Impact of the Affordable Care Act on the Diagnosis of Uterine Fibroids and Endometriosis

Derek van Amerongen, MD, MSc: Let’s look at fibroids, endometriosis, and racial disparities in maternal health. Passage of the Patient Protection and Affordable Care Act of 2010 expanded previously inaccessible insurance coverage for individuals. Dr. Hawkins, from your perspective, how has this impacted the diagnosis of patients with fibroids and endometriosis?

Dr. Soini Hawkins, MPH, FACOG: The Affordable Care Act has definitely made a big difference. By doing so, millions of Americans have access to more care. It included special provisions specific to women’s health, including maternal care screening, preventable screening, and contraception. This has given women more access to their health care providers, allowing them to answer questions about what is normal and what is not, simply by talking about their symptoms. It is hoped that this will allow more patients with endometriosis and fibroids to be diagnosed and treated, and hopefully to progress the disease more quickly. Doing so will increase their care options. It will give better results in the long run.

If they don’t go because they have a problem, at least we can catch them in the annual women’s exam. As a provider, we can put on our investigative hat and ask the right questions to make a faster diagnosis. As we find in every clinical condition we treat, the earlier we diagnose and understand the details of a patient’s disease process, the better the long-term outcome. The Affordable Care Act has definitely made a big difference. However, there is still work to be done.

Derek van Amerongen, MD, MSc: absolutely. We still have work to do. Studies have long demonstrated that black women are disproportionately affected by fibroids compared to white women. These usually begin at a younger age, with larger fibroids and greater disease burden. What is your experience with trends in surgical and uterine-sparing surgical recommendations?

Dr. Soini Hawkins, MPH, FACOG: I am happy to say that the trend is moving. That’s because of the technology and choices available to women today. It is possible to remove the fibroids in the uterus, but it is now possible to shrink the fibroids. We can potentially shrink them in a way that preserves fertility. This is the first concern of many women who visit their health care provider. We don’t have to offer them just a hysterectomy. Things are changing as patients are educating themselves further. They do a better job with her Google search. Google searches are fine as long as you talk about what you find or ask questions. Patients are arming themselves differently than ever before, advocating for themselves, their health and their choices much better than before. We are starting to see a change in hysterectomy rates, which were abnormal in the last few decades. I can’t make a shift. Lately, we’re starting to see improvements.

Derek van Amerongen, MD, MSc: Those are great points. Dr. Deans, medical planning has always viewed member education as an important part of its function and the services it provides to its members. What experience have you had in this area over the past few years?

Sharon Deans, MD, MPH, MBA: i am an obstetrician [obstetrician-gynecologist] 25 years at bedside. I was trained at Howard University, a historically black college. We have been trained to care for patients like ourselves and treat them as we treat family members. They visited us when I was in a private practice after training and recommended everyone to have a hysterectomy for fibroids. The reason we were suggesting uterus-sparing surgery was because we were trained to do so. Large uterine fibroids in many women can be affected early. As Dr. Hawkins said, we need women to understand the options available to them.

I focus on services available to commercial patients and Medicare and Medicaid patients. Part of my voice is making sure they match. Everything available to commercial patients, such as uterus-sparing and fertility-sparing surgery, should also be available to Medicaid patients. In addition, prior approval is required for hysterectomy. In light of the historic event in which a woman was sterilized without her knowledge, we are seeking the consent required by federal law. That form is required. We are looking for that shape.looking for a normal daddy [Papanicolaou] test. I am looking for an endometrial biopsy. However, from the perspective of obstetrics and gynecology, we are also considering whether surgery is necessary. Is there something different we can offer? Our staff are trained to examine the so-called gravitational equivalence of members who have previously performed other surgeries. How many times have they been pregnant? How many children have they given birth to? Is this the right next step for them? Doctors don’t like it. It’s a little invasive. But part of our role as Medicaid Medical Director is to advocate for our members and ensure they receive the right level of care at the right time.

Derek van Amerongen, MD, MSc: Dr. Wells, you oversee a large provider organization. Are you aware of this trend too?

Dr. Roxy Cannon Wells: I have. But listening to the panelists today, there’s a black woman who’s an obstetrician-gynecologist, two of hers, and they’re talking about black women and what it means to preserve black women’s fertility. I found myself eager to think about. In February, the results of a study were published in a journal. Journal of Minimally Invasive Gynecology. This was a retrospective cohort study of approximately 1300 women treated at a large US health center. It was her 2015-2020 period when they looked at these numbers. It was noted that black women were significantly more likely than white women to undergo hysterectomy or myomectomy, rather than minimally invasive surgery, to treat fibroids. He further noted that black women are more likely to undergo these surgeries by persons who are not necessarily gynecological surgeons trained in these techniques subspecialties. A lot of work has been done, but it’s clear from this study that we have miles of work to do before we go to sleep.

So I started looking at what was happening in rural America. If you’re a black woman living in rural America, three straight wins. If you are black, female, and live in rural America, your chances of undergoing minimally invasive surgery or even available drugs are greatly reduced. The biggest problem is traffic. Second, these areas are usually underserved.we don’t [as many] Obstetricians and gynecologists in those communities, as we would like. have to think about it. The second is that it takes a lot of intention and deliberation to convince women of their choice of uterine-sparing surgery. My colleagues here have done it well. But this research shows that we have a way forward. It’s important that we continue to do what you said from the payer side, what you said from the practitioner side. But it’s also our duty in the systems field to make sure we look at these things as well.

Derek van Amerongen, MD, MSc: This study is consistent with what we have been saying about racial disparities and their impact on women’s health. There is no question about it.

I edited the transcript for clarity.