Ob/Gyn Alignment Revisited as a Critical Channel for Health Systems

Alignment with generalist obstetricians and gynecologists (ob/gyns) has traditionally been relegated to the back burner. There are two reasons for this. First, in the fee-for-service environment, OB has little or negative direct contribution margin. Second, dwindling gynecology inpatient volumes may appear to undermine the need for alignment with ob/gyn generalists.

There is, however, good reason to solidify your relationship with generalist ob/gyns. Most obvious, women’s health is a core element of your portfolio of services, which means that aligned ob/gyn generalists are requisite to your organization.

It’s not just about obstetrics and gynecology, though. Generalist ob/gyns are a critical channel, even in the fee-for-service landscape; ob/gyns generate significant downstream revenue from their referrals (eg, mammograms), outpatient services and neonatology volume. In fact, ob/gyns provide 44% of preventive services in the US. As organizations evolve their priorities to take a System of CARE approach, address consumer needs, lay out a primary care strategy and adopt an emphasis on value, generalist ob/gyns will become more integral to a health system.

Health Care Trends Challenge Ob/Gyn Roles
While general ob/gyns are increasingly important to health systems’ long-term goals, trends impacting health care business and clinical practices are challenging those relationships and, in some cases, changing ob/gyn roles.

  • Long-standing practice patterns are evolving with the advent of evidence-based preventive care guidelines, surgical options and protocols, and shifting sites of care.
  • The workforce continues to change with an emphasis on physician employment, often in larger practices, and the desire for predictable work hours.
  • Practice expenses, including EMR and malpractice insurance, and changes in payment models are threatening independent practices.
  • Market consolidation, portfolio management decisions for obstetrics and neonatal levels of care, and payment model changes shake the health system community and even employed ob/gyns’ trust and understanding of their role within that system.

These challenges can all be overcome, but to form an effective alignment strategy that serves the organization and the community, a health system executive must understand how the landscape has created the uncertainty that threatens generalist ob/gyn practices.

Clinical Services Continue to Evolve (or “I don’t need a Pap smear this year?!”)
Generalist ob/gyns play a number of roles in your organization and for their patients—primary care physician, obstetrician and gynecologic surgeon.

Each of these areas has been subject to recent guideline shifts (eg, revised cervical screening guidelines from the American Congress of Obstetricians and Gynecologists and a recommendation against routine pelvic examination from the American College of Physicians), which have impacted the practice makeup of a general ob/gyn.

  • Annual screening for cervical cancer (eg, Pap testing) is no longer recommended, and age parameters on who should get routine screenings have tightened. (Screening is now recommended every three to five years for women age 21 to 65; routine screening for women under 21 and over 65 is no longer recommended.) Adoption of revised recommendations for screening and increasing vaccination of young women against HPV will diminish the rates of unnecessary treatment for pap smear abnormalities.
  • Routine pelvic examination in low-risk, asymptomatic women has questionable yield. Although the recommendation is contentious, even advocates concede there is little evidence demonstrating that this aspect of the physical exam has any benefit.

Changes in Pap test frequency and questions surrounding the need for pelvic exams actually call into question the “annual well-woman exam” and create confusion in what used to be a source of regular, consistent contact with women. In fact, it threatens to erode the relationship between generalist ob/gyns and their patients.

Even if well-woman exams are threatened, a generalist ob/gyn’s practice is not at risk. For one, ob/gyns still maintain their role as the primary, consistent source of care for many women, particularly those of reproductive age. Even if some ob/gyns are not their patients’ regular source of primary care, they are often still responsible for working with primary care providers in managing care for women.

Additionally, while hospital volume has and continues to decline for gynecology, ambulatory procedures are increasing. In the short-term, coverage expansion and a rebound from the recession will increase demand for services for benign gynecologic conditions. Many procedures, such as endometrial ablation, are shifting into the physician’s office, eliminating the dependence on a hospital and increasing the physician’s revenue.

Workforce changes are afoot, which may mean, depending on the market, new ob/gyn pressures and a decreased workforce incapable of addressing those pressures. Examples of the changing workforce that impact workload include: general ob/gyns electing to work fewer and/or more consistent hours, an increase in subspecialists (meaning a decrease in new generalists) and a decreased role of family practitioners in obstetrics and gynecologic care.

Health Systems Benefit From Alignment With Ob/Gyn Generalists
Generalist ob/gyns will remain clinically requisite to health systems because they provide comprehensive obstetrical care, procedural expertise, understanding of female reproductive physiology and familiarity with guidelines for evidence based-gynecologic care. In a fee-for-service model, ob/gyn alignment is critical as a channel, and increasingly with risk-based contracts, ob/gyns will be a tool to manage the health of the female population.

Ob/gyn generalists are an important source of health maintenance and preventive care, particularly for younger women, who may be less likely to have a relationship with a primary care provider. As ob/gyns emphasize health maintenance—smoking cessation, for example—they improve health outcomes in general and reproductive outcomes in particular.

Ob/Gyn Alignment: Strategize Carefully
Key considerations when including or assessing generalist ob/gyn alignment as part of an organizational strategy are as follows:

  • Measure the impact of ob/gyns as a channel.
    • Provided services (eg, deliveries, gynecologic procedures)
    • Referred services (eg, mammography, urogynecology, maternal-fetal medicine)
    • Leverage the relationship ob/gyns have with women in the community to engage patients and educate women (eg, for appropriate breast cancer screening).
    • Optimize relationships between primary care providers and ob/gyns, recognizing the unique hybrid role that an ob/gyn plays in managing care and identifying risk.
    • Include ob/gyns in primary care strategy, but be mindful of their true role in primary care when defining which metrics are appropriate.
    • Deploy generalist ob/gyns rationally with clinical counterparts, but with physician buy-in.
      • Advanced practitioners
      • Standardized referral pathways for subspecialists
      • Inpatient coverage options, such as laborists

Rational deployment of the generalist ob/gyn depends on market supply, organizational employment structure, status of risk-contracting and participation in population health initiatives. With our service line forecasting, Ambulatory Market Share data and other analytic tools, Sg2 is well positioned to help you navigate your relationship with women’s health providers so that you can best meet your organizational goals while also serving your community.

Sg2 Associate Vice President Rebecca Limestall contributed to this post.

Sources: The Obstetrician-Gynecologist Workforce in the United States. The American Congress of Obstetricians and Gynecologists: 2011; Stormo AR et al. Women’s clinical preventive services in the United States: who is doing what? JAMA Intern Med. 2014;174:1512–1514.


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