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Impact of Affordable Care Act on Diagnosis of Uterine Fibroids and Endometriosis
Early detection of uterine fibroids and endometriosis has been powered by the Affordable Care Act, ultimately improving prognosis for patient outcomes.
Derek van Amerongen, MD, MS: Let’s turn our attention to racial disparities in uterine fibroids, endometriosis, and maternal health. The passage of the 2010 Patient Protection and Affordable Care Act expanded coverage for individuals who previously did not have access. Dr Hawkins, from your perspective, how did this impact the diagnosis of patients with uterine fibroids and endometriosis?
Soyini Hawkins, MD, MPH, FACOG: The Affordable Care Act definitely moved the needle. In doing so, it gave more access to care to millions of Americans. It had special provisions in it that were specific to women’s health, including maternal care screening, preventable screening, and contraception. It has given women more access to their health care providers, so they can simply speak about their symptoms and get questions answered about what’s normal and what’s not normal. That absolutely allows us to diagnose and reach more patients with endometriosis and fibroids, hopefully sooner in their disease process. Doing so is going to give them more options in their care. It’s going to give them better outcomes in the long run.
If they don’t go because they’re having a problem, at least we’re catching them at their annual women’s exams. As providers, we’re able to put on our investigation hats and ask the right questions to get to a quicker diagnosis. As we know with every clinical state that we treat, the earlier we diagnose and understand the specifics of the disease process for our patients, the better outcomes they will have in the long run. The Affordable Care Act has definitely moved the needle. We still have work to do, though.
Derek van Amerongen, MD, MS: Absolutely. We still have work to do. The studies have long demonstrated that Black women are disproportionately impacted by fibroids compared with White women. They typically present at a younger age, with larger fibroids and a higher disease burden. What has been your experience with the trends in terms of recommending surgical vs uterine-sparing operations?
Soyini Hawkins, MD, MPH, FACOG: I’m excited to say that the trends are moving, and that’s because of the technology and the options that we now have available for women. We can remove fibroids in uteruses, but now we can shrink fibroids. We can shrink them in a way that’s potentially fertility sparing, which is the first thing on the minds of many women when they come to their health care providers. We don’t have to offer them only a hysterectomy. It’s shifting because patients are educating themselves more. They’re doing a better job with their Google searches. We’re OK with Google searches as long as you speak with us about what you’ve found and ask questions. Patients are arming themselves differently and advocating for themselves, their health, and their options much better than they’ve done in the past. We’re starting to see shifts in our hysterectomy rates, which were outlandish in previous decades. We haven’t been able to make a shift. Lately, we’re starting to see improvement.
Derek van Amerongen, MD, MS: Those are great points. Dr Deans, health plans have always looked at member education as a key part of their function and the service that they delivered to their members. What has been your experience in this area over the last few years?
Sharon Deans, MD, MPH, MBA: I’m an ob-gyn [obstetrician-gynecologist] with 25 years at the bedside. I trained at Howard University, a historically Black university. We were trained to take care of patients who look like us and treat them as we would treat our family. When I went into private practice after training, and they were offering everybody hysterectomies for fibroids, they came to see us. We were offering uterine-sparing surgeries because that’s how we were trained. Large fibroids in many women can be impacted earlier. As Dr Hawkins mentioned, we need to make sure women understand the options available to them.
I look at services that are available to our commercial patients and our Medicare and Medicaid patients. Part of my voice is to make sure they’re aligned. Everything that’s available to our commercial patients—uterine-sparing and fertility-preserving surgeries—also needs to be available to our Medicaid patients. In addition, we have a requirement for prior authorization for a hysterectomy. We’re looking for consent that’s required by federal law because of historical events, when women were surgically sterilized without their knowledge. That form is required. We’re looking for that form. We’re looking for a normal Pap [Papanicolaou] test. We’re looking for an endometrial biopsy. But from the ob-gyn point of view, I’m also looking to see if surgery is necessary. Is there something different we can offer? We have staff trained to look at whether they’ve done other surgeries before, to looking at what we call the gravity and parity of the member. How many pregnancies have they had? How many children have they delivered? Is this the right step for them next? The doctors don’t like it. It’s a little invasive. But part of our role as Medicaid medical directors is advocacy for our members and making sure they’re getting the right level of treatment at the right time.
Derek van Amerongen, MD, MS: Dr Wells, you oversee a large provider organization. Have you noticed these trends as well?
Roxie Cannon Wells, MD: I have. But in listening to our panelists today, I see 2 Black women who are obstetrician-gynecologists, and they are attuned to thinking about Black women and what it means to preserve fertility for Black women. In February, a study was released in the Journal of Minimally Invasive Gynecology. It was a retrospective cohort study of about 1300 women who were treated at a large health center in the United States. It was from 2015 to 2020 that they looked at these numbers. It noted was that Black women are significantly more likely than White women to undergo hysterectomy and myomectomy rather than minimally invasive surgery for the treatment of fibroids. In addition, it noted that Black women are also more likely to have these procedures performed by individuals who aren’t necessarily gynecologic surgeons with subspecialty training in these techniques. A lot of work has been done, but from this study, there are clearly miles and miles of work to go before we sleep.
That makes me pivot to what happens in rural America. If you’re a Black woman in rural America, then you win the trifecta. If you’re Black, you’re a woman, and you live in rural America, the likelihood of you being able to get minimally invasive procedures or even medications that are available decreases significantly. The No. 1 issue is transportation. No. 2, those areas are typically underserved. We don’t have [as many] ob-gyns in those communities as we’d like. We have to think about that. The other piece is that we have to be very intentional and deliberate when it comes to making sure women understand their choices for uterine-sparing procedures. My colleagues here have done a good job of that. But this study shows that we have a way to go. It’s important that we continue to do the things you’ve spoken about from a payer side, the things you talked about from a private practitioner’s side. But it’s also incumbent on us in a systems area to make sure we’re looking at these things as well.
Derek van Amerongen, MD, MS: That study is in line with what we’ve been talking about in terms of racial disparities and their impact on women’s health. There’s no question about that.
Transcript edited for clarity.
