Women comprise 51% of the United States population. In 2010, the U.S. Census Bureau reported that women accounted for 59% of the population older than 65 and 67% of the population older than 85 (Federal Interagency on Age-Related Statistics, 2012; Werner, 2011). A closer look at the 2010 census data reveals a dramatic increase in the number of women between the ages of 45 and 65, reflecting the aging of the Baby Boomer generation and future Medicare beneficiaries (Howden & Meyer, 2011). By age 75, almost half of women live alone in the community (U.S. Administration on Aging, 2011). More problematic are factors that may require women to seek additional assistance as they age, including chronic health issues and functional limitations (Robinson, 2007).
Despite women claiming the majority of the older adult demographic, policy initiatives to address women’s health in general and the health of older women in particular have been lacking. It was not until the 1990s—after a 1985 report by a Public Health Service Task Force highlighted concerns that low levels of women’s health research were negatively impacting the quality of health care for women—that a rapid increase occurred in research and program development focusing on women’s health (Institute of Medicine [IOM], 2010). One of the first governmental actions to promote and guide research, policy, and programs focusing on issues in women’s health was to create the Office of Women’s Health within the U.S. Department of Health and Human Services (USDHHS, 2009). The most notable policy initiative for older women in the following years was to promote mammogram screening and include cancer screening as a biennial covered benefit for Medicare in 1991 (Barr et al., 2001).
In 2010, a major boost for women’s health care occurred as a result of the Patient Protection and Affordable Care Act (PPACA). Brody and Sullivan-Marx’s (2012) recent overview of the PPACA provided gerontological nurses with an explanation of the complicated law and implications for practice. The current article expands on the previous article by describing women-specific PPACA policy initiatives that promote the health of older women, encourage health care workforce development to meet the needs of the population of older women, and improve access to quality services for women and their families, including long-term care initiatives.
Older women are at higher risk for poverty than their male counterparts because the median working income of older women was often 25% lower than men and older women often had periods of nonpaid work while caring for family members during their working years (Bovbjerg, 2012; DaNavas-Walt, Proctor, & Smith, 2011). In addition, older women often have more chronic diseases; therefore, they have a disproportionate burden of higher health care costs (Salganicoff, Cubanski, Ranji, & Neuman, 2009). Medicare provides almost universal coverage for the 22 million women older than 65 (Kaiser Family Foundation, 2010b). The PPACA refocuses women’s health care on prevention and treatment of health problems.
Pre-retirement–age women lack health insurance more frequently than men because of the retirement of a spouse or because they experience a reduction in work hours or job loss. Prior to the PPACA, this group of women was often faced with higher insurance costs and benefit exclusions because of preexisting conditions, resulting in forgoing health care until Medicare eligibility at age 65 (Kaiser Family Foundation, 2009). The PPACA prohibits preexisting condition limitations and higher cost based on health status and gender (White House Council on Women and Girls, 2012). By expanding coverage to women and those with preexisting conditions, the PPACA will enable some women to purchase health insurance at a lower cost or to apply for Medicaid based on financial need (Prickett & Angel, 2011). After the Supreme Court decision on the constitutionality of the PPACA in June 2012 for women covered by Medicaid, benefits may vary by state. Historically, many state Medicaid programs were already covering preventive services (Johnson, 2012). Starting in 2013, the PPACA has built in financial incentives to encourage states to provide preventive services without copayment (Esponosa, 2010).
Evidence-Based Preventive Care
With the passage of the PPACA, women across all age, racial, and socioeconomic groups have access to specific preventive care without additional cost sharing. For both women younger than 65 and those covered by Medicare, there are specific changes leading to enhanced prevention and management of health problems. As of 2011, Medicare beneficiaries receive preventive care services without additional costs. Prior to the PPACA, when women older than 65 received preventive health services, Medicare only covered 80% of tests or services and the patient was responsible for the remaining 20% (IOM, 2011). Two government agencies will recommend preventive care that will not require a copayment: The U.S. Preventive Services Task Force (USPSTF) will address evidence-based screenings, and the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization will suggest routine immunizations (IOM, 2011). An important change for Medicare-insured women is that newly enrolled beneficiaries will have a “Welcome to Medicare Visit,” which has now been expanded to include an annual wellness visit without copayments (Kaiser Family Foundation, 2010a). The purpose of the wellness visit is to review personal and family health history, including medication use, identify the need for and planning of screening tests, and if needed, discussion of treatment options, including their risks and benefits (DiSantostefano, 2011).
The PPACA has already improved access to preventive services by older women for mammograms, well-woman visits, Pap smears, glucose testing, bone density screening, and other preventive care at no extra cost (IOM, 2011) (Table).
Table: Recommended Preventive Testing and Screening for Women Older than 65 Under the Patient Protection and Affordable Care ACT
Developing New Models of Care
With growth in the 65 and older population and the addition of the Welcome to Medicare and annual wellness visits, demand for primary care services will significantly increase. Now that the PPACA has added preventive services to the Medicare benefit, discussing the risks and benefits of recommended screening examinations or tests, tracking of results, and coordinating recommended follow-up care will expand the activities of primary care offices. Adding to the complexity of the shared decision-making process is that, although the PPACA utilized the USPSTF guidelines, many health professional organizations, including the American Geriatrics Society, have different screening recommendations (Bernstein, DeJoseph, & Buchanan, 2010). Although the USPSTF recommended prevention assessments are evidence-based, another concern is, that as a woman ages, she may experience multiple health issues that may alter the benefits of screening and may add to her health risks, such as complications from a screening assessment (Nicholas & Hall, 2011). To date, there has been limited research on older populations to inform some preventive interventions (IOM, 2008). The USPSTF is aware that their recommendations for older women should be tailored to reflect the variation in the aging process among women. The USPSTF is currently working on creating a framework that will incorporate varied factors of aging into their models, such as comorbidities and limitations in activities of daily living, and will include more patient-focused outcomes, such as quality of life (Leipzig et al., 2010). Information on preventive services can be downloaded to a mobile device from http://epss.ahrq.gov/PDA/index.jsp.
To explore solutions to both old and new health issues, the PPACA created the Center for Medicare & Medicaid (CMS) Innovation. The goal of CMS Innovation is to advance quality patient care in the areas of “safety, effectiveness, patient centeredness, timeliness, efficiency, and equity” (p. 7, IOM 2001; CMS Innovation, 2012a). Some programs focusing on improving access to care are already in development, such as Accountable Care Organizations (ACOs), Medicaid incentives for prevention of chronic diseases, Partnerships for Patients, and patient-centered medical homes (PCMHs) (CMS, 2012; Webb & Marshall, 2010). PCMHs complement ACOs and are smaller care delivery units contained within an ACO, a federally qualified health center, or a community private medical practice. Given the variation in practice styles throughout the United States, many unique practice models that provide care to older women are likely to evolve. Key elements in a PCMH include (“Patient-Centered Medical Homes,” 2010):
- Patients are assigned a personal physician/health care provider with a team practice who provides care coordination.
- Health information technology facilitates, communicates, and evaluates the care provided.
- Financial incentives for achieving improved patient and practice management goals are provided.
Access to a PCMH and health insurance has been shown to significantly improve client health and reduce disparities in health outcomes (Berenson, Doty, Abrams, & Shih, 2012). A variation on PCMH is home-based primary care. Home-based care is especially important for older women who commonly experience multiple chronic health conditions. By focusing on women with chronic disease in the home setting, the primary care provider has a more complete understanding of not just the illness, but other environmental and social factors that may influence the success of the treatment plan. As with the PCMH, the primary care provider assumes greater accountability for all aspects of the patient’s care (CMS Innovation, 2012b).
Researchers, using different aging models, forecast that over the next 30 years, the frail older adult population (having at least one activity of daily living limitation) will continue to increase, with women accounting for more than 60% of those experiencing functional limitations (Johnson, Toohey, & Wiener, 2007). Models also suggest that long-term care will increase by two thirds, with paid home care increasing by 75% (Johnson et al., 2007). These statistics highlight the need to significantly expand the gerontological nursing workforce to provide care to older women and their support systems (IOM, 2008). Since 1996, the John A. Hartford Foundation (JAHF) has supported the development of the geriatric nurse workforce by providing financial support for the education, research, and practice of nurses (Fagin & Franklin, 2005). Responding to the imbalance between the future aging population and the geriatric nursing workforce, in 2000 the JAHF partnered with the American Academy of Nursing to develop the Building Academic Geriatric Nursing Capacity Program (Fagin & Franklin, 2005). The innovative effort has made progress in building the geriatric nursing workforce. Specific to older women’s health, the Association of Women’s Health, Obstetrical and Neonatal Nurses (2009) received funding to educate the membership of the organization about older women’s health issues. The Association used annual meetings, journals, and a web page to share current practice in addressing older women’s health issues, such as fall prevention, pain management, and sexual health.
For gerontological nurses, especially those working with under-served women who have chronic diseases, many provisions in the PPACA, although not specifically tailored to older women, will help increase the size and skill of the nursing workforce and improve access to and the quality of care for women. New primary care scholarships and loans for nurses are available under the PPACA. Increased funding for the National Health Service Corps (NHSC) will support expansion of both clinicians and clinical sites, and $1.5 billion has been authorized for the NHSC loan repayment and scholarship programs for which nurses can apply (CMS, 2011). To meet the growing need for clinicians with older women’s health expertise, advanced practice dual adult-gerontology/women’s health nurse practitioner educational programs are emerging (MGH Institute of Health Professions, 2012). To increase access to primary care services, the PPACA also provided $50 million to expand nurse-managed health centers (NMHC) (Naylor & Kurtzman, 2010). Similar to federally qualified health centers and PCMHs, NMHCs are staffed by advanced practice nurses and provide individualized primary care, often serving as a safety net for vulnerable women (Pohl, Tanner, Pilon, & Benkert, 2011).
Managing Cost and Maintaining Quality
Quality is essential for any health care program with the goal of promoting health of older women. The PPACA aligns many quality measures with financial risks and rewards. For gerontological nurses, some of the most important changes under the PPACA are focused on managing the cost of care for Medicare beneficiaries while providing quality nursing care. Starting in October 2012, Medicare began introducing a 1% penalty on hospitals with the highest 30-day readmission rates for patients with heart failure, heart attack, and pneumonia. The penalty will increase annually until it reaches 3% in 2014 (Rau, 2012). To assist agencies and providers who care for recently discharged Medicare patients, the community-based Transitions Program within the program Partnership for Patients was created through a public-private partnership in 2011. Specific to Medicare patients, the program is focused on improving transitions from the hospital to another setting with the goal of reducing readmissions and improving patient outcomes (CMS Innovation, 2012c). Hospitals, especially safety net hospitals that serve the most vulnerable patients, have expressed concern that they will need to add discharge programs, but experience reduced revenues (Rau, 2012). Others are worried that limited evidence supports the interventions being proposed to reduce readmissions (Crocker, Crocker, & Greenwald, 2012).
Long-term care is an important issue for women because of chronic health conditions and the need for assistance to maintain functioning. The Community Living Assistance Services and Supports program (CLASS Act) under the PPACA was designed to address the issue of improving access to affordable, voluntary, long-term care insurance. However, not all programs legislated by the PPACA have been actualized. Because the program was controversial from the start, the USDHHS placed its development on hold because of many funding issues. Later, with bipartisan support, Congress repealed the CLASS Act (Parkinson, 2012). Although the repeal of the CLASS Act was a setback, there is continued funding of model programs to provide quality care to clients with chronic health conditions. Community Health Teams, led by nurses, is one such program adopted by the state of Vermont. Funded by CMS, this public-private partnership provides community health teams to communities for care coordination and other services, such as electronic medical records, to improve the coordination and delivery of chronic care services (Bielaszka-DuVernay, 2011).
PPACA is a significant advance for women under Medicare. Access to preventive care will provide women and their health care providers with the ability to choose recommendations that best fit individual needs. CMS Innovation will provide detailed information on demonstration projects, so that replication of successful programs will not only improve access and cost but also outcomes of care. Gerontological nurses, collaborating with others in the care of older women, will be in the forefront of educating the health care workforce, conducting research into best practices, and setting quality standards. Framing older women’s health as a policy and research priority presents challenges for gerontological nurses, but is also an opportunity to refine models of health care delivery for older women.
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Recommended Preventive Testing and Screening for Women Older than 65 Under the Patient Protection and Affordable Care ACT
|Annual wellness visit||Bone density screenings every 24 months|
|Cardiovascular disease screening||Immunizations: flu, pneumonia, hepatitis B|
|Blood pressure (annual) and lipid profile (every 5 years)||Annual tobacco use/cessation counseling|
|Mammogram (biennial), ages 55 to 74||Annual substance abuse screening|
|Counseling and screening for BRCA gene mutation, as needed||Body mass index evaluation and diet counseling|
|Colorectal screening, ages 50 to 75||Fall prevention and intervention|
|Screening for diabetes||Glaucoma testing|
|STI/HIV counseling and screening, as needed||Annual depression and cognitive screening|
|Pap test, varied by risk factors||Intimate partner violence/elder abuse screening|