Articles

Through its new Visiting Scientist Program and Digital Innovation Fellowship, Maven aims to improve its care model and continue improving prenatal health outcomes.

Maven Clinic announces new initiatives to improve maternal and family health care

A retrospective cross-sectional study has found that Medicaid expansion has increased the rates of autologous breast reconstruction in patients undergoing mastectomy.

Medicaid expansion and breast reconstruction

Podcasts

In this podcast episode, host Scott Kober is joined by experts Robert McDonald, MD, MBA, and Karla Loken, DO, OBGYN, FACOOG, to discuss ways that practicing ob-gyns can get involved in health coverage and reimbursement issues.

Becoming involved in health coverage and payer reimbursement issues

The CDC updated its guidelines for diagnosing and treating STIs, which included updates on the diagnosis and treatment of bacterial vaginosis (BV) in pregnant and nonpregnant women.

New guidelines for bacterial vaginosis diagnosis and treatment

The Centers for Disease Control and Prevention (CDC) updated its guidelines for the treatment of sexually transmitted infections (STIs), notably for Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis and pelvic inflammatory disease (PID).

Updated CDC guidelines: Diagnosing and treating STIs

Over the last year and a half, physicians around the world have been focused on managing patients, their teams, and themselves through the COVID pandemic. This has not been an easy time for physicians. 

Practical guidance for navigating complex world of insurance coverage, payer issues

An analysis of individual enrollment and premium data from California’s marketplace and the American Rescue Plan premium tax credit subsidy schedule has concluded that a smart default policy avoids defaulting lower-income marketplace enrollees to objectively inferior health care insurance plans and leads to large reductions in lower-income enrollees’ deductibles, copayments, and maximum out-of-pocket amounts. 

Smart default policy helps lower-income enrollees avoid inferior health plans

In addition to welcoming a newborn, parents may be unexpectedly billed for some hospitalization services, according to a research letter in JAMA Health Forum.

Surprise bills for childbirth

Scott Kober hosts this podcast in which he interviews Lisa Satterfield, senior director of health economics and practice management at the American College of Obstetricians and Gynecologists (ACOG). They discuss the tools and resources available to practicing ob-gyns that are focused specifically on payer and reimbursement issues.

Tools to use: ACOG’s payment advocacy and policy portal

Hear about tools and resources available to practicing ob/gyn to address payer and reimbursement issues.

ACOG‘s Payment Advocacy and Policy Portal with Lisa Satterfield

Telecontraception platforms generally screen adequately for contraindications to contraception and all online platforms offer oral contraceptives, while many also offer the contraceptive patch and contraceptive ring, according to the results of a study on the website of the Kaiser Family Foundation (KFF).

“Over the past several years, a growing number of companies have been providing contraception through online platforms, but there has been very little research on these businesses,” said principal investigator Brittni Frederiksen, MPH, PhD, a senior policy analyst at KFF in San Francisco. “When the COVID-19 pandemic started, we began tracking telecontraception companies because they were an option for people to access contraception when they could not visit a clinic in person.”

The study was conducted to better understand the policies and practices of telecontraception companies. A total of 10 companies participated in an online survey from November 2020 to January 2021.

“The pandemic has been an opportune time for growth in telecontraception,” Frederiksen told 

. “All of the companies we surveyed said their client volume increased during the pandemic, with the majority saying they had seen a client volume increase of over 50% in late 2020.”

The researchers also found that the majority of businesses accept some form of insurance, but only 2 said the majority of their clients use insurance to pay. “Three of these 8 companies said most of their clients use cash to pay, and 3 companies said half their clients use insurance and half their clients use cash,” Frederiksen said.

Frederiksen found it surprising that even when people have access to no-cost contraceptive services and supplies through their insurance, “they are still willing to pay out-of-pocket for the convenience of receiving their contraceptive care through telecontraception platforms, rather than going to an in-network provider.”

Online contraception platforms have created a new avenue for some women to access contraceptives easily and quickly, without having to visit a doctor’s office or leave their homes, according to Frederiksen. “But people could end up paying out-of-pocket for their contraceptives or the telecontraception consultation, when they could go to a clinic and receive no-cost contraceptive services with insurance,” she said.

Nonetheless, consumers might be willing to pay out-of-pocket for the ease of a quick consultation and having their contraception delivered directly to their home, without having to step foot in a clinic or schedule a telehealth appointment.

“Publicly funded clinics in the Title X program, as well as federally qualified health centers, offer no-cost and low-cost contraceptives for many uninsured and low-income people, but telecontraception may also be an affordable option for some uninsured individuals if they are unable to visit one of these clinics,” Frederiksen said.

Accepting both Medicaid and private insurance would decrease out-of-pocket costs for those using telecontraception services and could potentially increase their use and affordability for peopling seeking certain methods of contraception. “However, many of these companies reported that they have tried to work with Medicaid and private insurance companies, but experienced barriers,” Frederiksen said.

Despite the growing popularity of online contraception platforms, “brick-and-mortar clinics and certain providers will remain important for people with both private and public coverage to access the full range of contraceptive methods without cost-sharing, like long-acting reversible contraceptive (LARC) methods and for connecting individuals to other primary care services,” Frederiksen said.

Future studies should evaluate the impact of online contraception platforms on access to care and which populations are using these services, according to Frederiksen. “Another area of future research is assessing the quality of care provided by telecontraception providers and whether people can receive referrals to a clinic for their preferred contraceptive method, if it is not available through the telecontraception company, such as LARC methods,” she said.

Frederiksen reports no relevant financial disclosures.

Frederiksen B, Gomez I, Salganicoff A. Contraception 2.0: findings of a national study of online contraception platforms. Article appears on the Kaiser Family Foundation (KFF) website. Published online May 18, 2021. 

https://www.kff.org/womens-health-policy/issue-brief/contraception-2-0-findings-of-a-national-study-of-online-contraception-platforms/

“Over the past several years, a growing number of companies have been providing contraception through online platforms, but there has been very little research on these businesses,” said principal investigator Brittni Frederiksen, MPH, PhD, a senior policy analyst at KFF in San Francisco. 

Effectiveness of online contraception platforms

This podcast highlights the effectiveness of co-testing as it pertains to cervical cancer screening. 

Her Care is in Your Hands

During the first 2 years of Oregon’s Reproductive Health Equity Act (RHEA), immigrant women across the state used the expanded coverage to access abortion, indicating that the policy was fully enacted in metropolitan and nonmetropolitan areas alike, according to a research letter in 

Oregon’s RHEA, which took effect January 1, 2018, ensures coverage for family planning, including abortion and contraception, through state funds for all low-income state residents, regardless of citizenship status.

“Oregon leads the nation in innovative and progressive reproductive health policy.” said principal investigator Maria Rodriguez, MD, MPH, an associate professor of ob/gyn in the Section of Family Planning at Oregon Health & Science University in Portland. “My research centers on examining the intersection of policy, health and economics. In no other area of medicine is policy as critical to health as ob/gyn. It is essential to understand how policy can promote health, or perpetuate reproductive health disparities.”

The cross-sectional study of abortion services reimbursed under Oregon’s RHEA in 2018 and 2019 encompassed 11 standalone clinics statewide and one hospital-based clinic.

Oregon’s RHEA allowed for 625 abortions during the 2 years.

Nearly half (48.3%) of the abortions were for women aged 25 to 34 years (range, 15 to 46 years).

The vast majority of abortions (79.7%) were for women who resided in metropolitan zip codes.

Mirroring national trends, nearly all abortions (93.9%) occurred during the first trimester, and slightly more than half (57.3%) were surgical abortions.

But there was no difference in rates of second trimester abortion by residence: 5.6% metropolitan vs 6.3% nonmetropolitan (

Additionally, a vast majority of abortions (80%) were for women who had previously given birth.

The primary outcome of the study was the distance traveled to receive an abortion, which was a median distance of 8.73 miles, ranging from 0.42 miles to 124.44 miles.

Nearly a third of the women (30.2%) traveled less than 5 miles to receive abortion care, while 5.1% traveled 50 miles or more.

“Reproductive health is fundamental, to not just an individual’s health and rights, but also to the well-being of our communities,” Rodriguez told 

. “However, unintended pregnancy is becoming increasingly concentrated among people who are low-income or of color.”

Restricting access to essential health care services, such as abortion, may perpetuate multigenerational cycles of poor health and inequity, according to Rodriguez. “It is important that Oregon implemented this equitably in rural and urban areas because all individuals need access to quality abortion care,” she said. “While the population of women who need the newly covered services is small, meeting the needs of this unique subpopulation is important for both the health of our community and achieving reproductive justice.”

Several other states also are intent on passing policies to promote reproductive health equity, including Virginia and New York.

“For ob/gyns and other providers focused on women’s or public health, the clinical and justice repercussions of restricting access to preventative and reproductive health care for low-income individuals on the basis of citizenship has always been clear: it is a lose-lose scenario,” Rodriguez said.

This picture perpetuates disparities in reproductive health care and has far-reaching consequences for communities, according to Rodriguez.

“The same is true from a policy perspective,” she said. “Limiting access to reproductive health care based on citizenship alone worsens health outcomes and increases system costs.”

Rodriguez said the challenge lies at the political level. “Also, the need for us as a society to recognize the benefit we all receive by providing essential health care services to all individuals who need it but cannot afford it,” she said.

Rodriguez reports no relevant financial disclosures.

Rodriguez MI, Skye M, Shokat M, et al. Women’s access to abortion care under Oregon’s Reproductive Health Equity Act. 

. Published online May 21, 2021. doi:10.1001/jamahealthforum.2021.0402

“My research centers on examining the intersection of policy, health and economics. In no other area of medicine is policy as critical to health as ob/gyn. It is essential to understand how policy can promote health, or perpetuate reproductive health disparities,” said principal investigator Maria Rodriguez, MD, MPH, an associate professor of ob/gyn in the Section of Family Planning at Oregon Health & Science University in Portland. 

Women’s Access to Abortion Care in Oregon

As screening rates went down for gonorrhea and chlamydia during the COVID-19 pandemic, weekly positivity rates increased, according to Quest Diagnostics’ 2020 Health Trends Study®. The results were published in the 

Harvey W Kaufman, MD, FCAP, senior medical director, and lead of Quest Diagnostics 2020 Health Trends®, conducted the study with colleagues. The study examined patients aged 14 to 49 years, with 1.36 million tests administered to female patients, and 4.7 million tests administered to male patients. Testing was conducted between January 2019 and June 2020 by a national reference clinical laboratory.

Researchers reported that testing for chlamydia and gonorrhea reached the lowest point in April of 2020, with rates in relation to baseline levels decreasing 59% for women and 63% for men.

 Both reductions in STI testing had a strong association with weekly positivity rates (chlamydia R2=0.96 and gonorrhea R2=0.85).1 Researchers said that an expected 26.4% (27,659) of chlamydia cases and 16.5% (5,577) of gonorrhea cases were possibly missed between March 2020 and June 2020.

Researchers said the COVID-19 pandemic’s effect on testing and infection rates warrants follow-up study to determine the long-term effects of missed chlamydia and gonorrhea screenings. “These findings should serve as a warning for the potential sexual and reproductive health implications that can be expected from the overall decline in testing and potential missed cases,” researchers concluded.

, Kaufman said this study is significant because it is thought to be the first nationally representative analysis of the pandemic’s effect on STI and cases. He said it comes after a CDC report issued last month that found STIs were at an all-time high in 2019, with 1 in 5 American young adults likely infected. “At a high level, the study finds that STI testing dramatically declined and never fully returned to pre-pandemic levels – between late February and late July 2020, likely resulting in higher positivity rates and a strong likelihood of missed cases, particularly in asymptomatic but potentially infectious individuals,” Kaufman said. He noted that while STIs are often asymptomatic, over time they can lead to adverse outcomes, including chronic pelvic inflammatory disease and infertility.

Kaufman said the study found STI testing decreased between late February 2020 to early April 2020 by 40% before returning to 85% of baseline by late June 2020. “Positivity rates for chlamydia increased from 4.7% in late February to as high as 5.9% in mid-April to 5.1% by late June,” he explained. He said similar patterns were observed in gonorrhea, “with increases from 1.4% to 2.4% in February to mid-April and back down to 1.9% by late June.” He added that for both chlamydia and gonorrhea, positivity rates remained higher than baseline 2019 levels by the end of the study.

Kaufman said that the most important aspect of the Health Trends® study is to remind providers to reinstate guideline-based STI screening. “Screening should not be performed based on symptoms alone,” he emphasized. He said that STI screening is important because many patients harbor infection without manifesting symptoms. “If left untreated, they may pass an STI unknowingly to others or experience adverse health outcomes, such as loss of fertility,” he said.

Kaufman noted that despite these risks, discussing this topic can be uncomfortable for the patient and the physician. “It is important for providers to start with the facts to lessen the discomfort of the conversation including the high prevalence of chlamydia and gonorrhea in the United States and that many STIs are asymptomatic. Messages that are judgement-free can help kick off the conversation,” Kaufman said.

He said that providers should stress medical testing guidelines to avoid stigma. “Instruct clinical staff to follow your lead because many patients will also see nurse practitioners or physician assistants as part of routine exams and it’s important that your practice is all on the same page. Direct discussions about STIs may be uncomfortable, but they are vital to protecting patient and public health,” he said.

Pinto CN, Niles JK, Kaufman HW, et al. Impact of the COVID-19 pandemic on chlamydia and gonorrhea screening in the U.S. 

The Quest 2020 Health Trends Study® has revealed declining rates in gonorrhea and chlamydia screenings, while positive tests increased, an issue that needs urgent public health attention.

Quest Study: Gonorrhea and Chlamydia Screenings Down, Infections Up During COVID-19 Pandemic

 is director of the division of gynecologic specialties and an associate professor of gynecology and obstetrics at 

Johns Hopkins University School of Medicine

 is a reproductive endocrinology and infertility specialist in the division of obstetrics and gynecology at the 

Host Scott Kober discusses the impact of sexually transmitted infections (STIs) on women’s fertility with experts Jenell Coleman Fennell, MD, MPH, and Molly Quinn, MD.

Impact of STIs on Women’s Fertility 

The 2020 Quest Health Trends Study® supports previous research that revealed co-testing for Pap and HPV is more effective in detecting cervical precancer and cancer in women aged 30-65. Harvey W Kaufman, MD, FCAP, senior medical director, and lead of Quest Diagnostics Health Trends® conducted the study with colleagues. The study examined 13.6 million women between 2010 and 2018. It was a heterogenous sample of the population of the United States. Women were co-tested and had a minimum of 1 biopsy before a cervical precancer or cancer diagnosis. Researchers reported 19 million co-testing data points and 625,000 co-tests that were followed by a minimum of 1 biopsy.

Researchers reported 94% of cervical cancers were found with co-testing <12 months to diagnosis, and 22.5% of diagnosed cancers would have remained undiscovered with HPV testing alone.1 In addition, 99.7% of precancers were identified with co-testing, 11% of which would not have been found with HPV testing alone.

For cancer outcomes for the 9-year duration of the study period, co-testing HPV and Pap found more cases of cancer: HPV alone identified 72%, Pap alone identified 74%, and co-testing identified 87%, researchers reported.1 The study found that adenocarcinoma rates are rising, and that individual testing of HPV or Pap did not identify 2 times as many women with this cancer as co-testing.

Researchers stressed that real-world comparisons confirm the effectiveness of co-testing. “This real-world study is more relevant to drive decisions about cervical cancer screening algorithms than data that includes a microcosm of patients,” Quest said in 

The research confirms several other studies on the subject. A 2018 study that performed a longitudinal, real-world analysis of data examined 186,000 women aged 30-65 in whom co-testing significantly reduced false negative results for cervical pre-cancer and invasive cervical cancer.

 This study said that for >12 months, 50% of women would not have had cancer identified with only HPV testing; that number was 24% for Pap only testing. In a 12-month period or longer for cervical intraepithelial neoplasia and adenocarcinoma in situ (CIN3+/AIS), the study found 46% of women would not have been diagnosed with HPV testing alone and 27% would not have been found with Pap alone.2 In addition, the rate of false positives was much lower in women who had undergone co-testing.

Researchers emphasized that co-testing is essential in 

, which also reported that screening intervals have increased over time. The release said these intervals are patient-age dependent, and include Pap alone every 3 years with co-testing every 5 years or HPV alone testing every 5 years. The release noted that in the US, “cervical cancer screening is opportunistic rather than routine,” and that the guidelines strongly support co-testing in women aged 30-65.

®, Kaufman emphasized that “co-testing is the most sensitive and best approach to identify cervical cancer. A departure from co-testing will likely lead to more women being diagnosed with cervical cancer and possibly lead to more deaths.” When asked about the next steps to be taken, Kaufman said that models for cervical testing need to consider the rate of the disease’s progression and endeavor to identify women who develop cancer more quickly. “As the interval between screening events increases, so will the likelihood of women whose cervical disease progresses quickly between screening events,” he said. He added that more women are likely to be diagnosed with cancer and more advanced cancer as screening intervals are extended.

Kaufman also noted the need to recognize racial and ethnic disparities. “Black, non-Hispanic women are more likely to develop cervical cancer than White non-Hispanic women. Further, 56% of Black, non-Hispanic women will survive cervical cancer after 5 years compared with 68% of White non-Hispanic women,” he explained. He stressed the importance of cancer screening programs addressing the observed reality of each population. “They should not be based on the average woman, because she may not represent women at higher risk such as Black, non-Hispanic women,” Kaufman said. He also noted that more than 20% of cancer diagnoses are higher in women over 65 because fewer women are having hysterectomies. In addition, he said some younger women have more aggressive cancer. He stressed the need of screening programs to monitor both of these populations.

“Pap is one of the most remarkable tests used to dramatically decrease incidence of a cancer. Great strides forward should not be reversed without careful deliberation that remains missing in the current guideline development process,” Kaufman told 

®. “We are deeply concerned that the haste to embrace guidelines that support primary HPV screening will lead to an increase in cervical cancer deaths, especially among minority and both young and older women.”

Kaufman HW, Alagia DP, Chen Z, Onisko A, Austin RM. Contributions of liquid-based (papanicolaou) cytology and human papillomavirus testing in cotesting for detection of cervical cancer and precancer in the United States. 

. 2020;154(4):510-516. doi:10.1093/ajcp/aqaa074

Austin RM, Onisko A, Zhao C. Enhanced detection of cervical cancer and precancer through use of imaged liquid-based cytology in routine cytology and HPV cotesting. 

. 2018;150(5):385-392. doi:10.1093/ajcp/aqy114

A Quest Diagnostics 2020 retrospective, longitudinal Health Trends Study® adds to previous research that shows co-testing is more effective than single testing alone.

Study: Co-testing Pap and HPV Finds More Precancer and Cancer than Single Testing

This podcast features Oluwatosin Goje, MD, an ob/gyn at the Cleveland Clinic in the Department of Obstetrics and Gynecology. 

April is STI Awareness Month, and as such, we are focusing on testing and increase of STDs in the pandemic, especially how women and minorities are affected. 

Testing protocols and general prevalence of STIs during COVID-19

Prescription and illicit drug testing rates declined during the COVID-19 pandemic in 2020, according to a study published in the journal 

Many in-person health services were unavailable following pandemic stay-at-home orders, including in-person drug testing, to prevent the spread of the virus.

Harvey W Kaufman, MD, MBA, FCAP, senior medical director, information ventures and office of chief medical officer at Quest Diagnostics conducted the study along with colleagues. The authors analyzed changes in testing patterns for prescription and illicit drugs at Quest Diagnostics, a national clinical laboratory. Researchers compared data sets from before and during the COVID-19 pandemic by examining urine specimen results from Quest Diagnostics medMATCH® reporting method, which indicates whether provider-prescribed or other drugs are found in the samples.

Study authors used specimens collected between January 1, 2019 and May 16, 2020. Specimens that had no record of age, or that were collected from patients under 18 years of age were excluded. Researchers also excluded specimens with abnormal specimen validity testing results and those that tested negative for drugs. The authors noted that not all specimens were tested for all drugs as choice of test varied among medical providers. A total of 872,762 specimens were used in the study; specimens came from all 50 US States and the District of Columbia.

Kaufman and colleagues said the volume of weekly drug testing declined by 70% from the baseline of January 1, 2019 to March 29, 2020 before rebounding in the following weeks. Testing showed increases in substance use during the pandemic: positive tests for non-prescribed fentanyl rose by 35%, and positive tests for heroin rose by 44%. In addition, the authors reported that “Positivity for non-prescribed fentanyl increased significantly among patients positive for other drugs: by 89% for specimens positive for amphetamines; 48% for benzodiazepines; 34% for cocaine; and 39% for opiates (

for all comparisons).”1 There also was an increase in dangerous drug combination use, the authors said. Researchers suggested these rates are a direct result of the COVID-19 pandemic, and said that social distancing, stress, loneliness, depression, and job loss contributed to increases. They also said isolation makes drug use more dangerous during this time, as it decreases the chances of a bystander being present to call for help or administer naloxone in the event of an overdose.

Test positivity rates stayed the same for many other non-prescribed drugs or decreased when compared to patterns seen prior to COVID-19. “Models adjusting for potential confounding variables, including medication-assisted treatment and treatment at a substance use disorder facility indicated that the risk for non-prescribed fentanyl positivity rose by more than 50% during the pandemic,” study authors said.1

They also reported an increase in submissions to the Overdose Mapping Application Program (ODMAP); suspected overdose deaths rose 18% in March, 29% in April, and 42% in May when compared to the same period in 2019. ODMAP also reported an overall 11.4% increase in overdose deaths and an 18.6% increase in non-fatal overdoses in 2020.

® Kaufman said an important takeaway for providers is that “the pandemic and the associated social restrictions and stresses may have led many patients to engage in potentially dangerous drug behaviors.” He said that in June and September 2020 the American Society of Addiction Medicine (ASAM) issued guidance suggesting other ways of monitoring drug adherence that could be used instead of laboratory testing. “Predicting which patients are taking drugs can be challenging.Patient evaluation and drug testing, especially urine drug testing, are critical tools to help establish what drugs patients may be using,” Kaufman said.

For important steps that need to be taken following this study, Kaufman told 

® that providers “need to re-engage with patients who have skipped or delayed healthcare. Although this specific study focused on the epidemic of drug misuse, patients have postponed many healthcare visits.” He said that to get patients active in their care again, “we need to find creative ways, such as with telemedicine, to check in with patients who remain hesitant or in denial.”

in a separate Quest Diagnostics Health Trends

™ survey, researchers worked with the Harris Poll and found that 2 in 5 patients were concerned they had an undiagnosed medical condition. “With delayed care, some patients will present at more advanced stages of disease, will require more aggressive therapy, and have worse outcomes. We have observed decreases in cancer diagnoses, testing for sexually transmitted infections, and most other routine laboratory testing,” Kaufman explained in the interview.

“We recognize the role that women often have as the central caregiver in their immediate and extended families. Women are more likely to prioritize others’ health over their own. We need to address their needs so they can be healthy themselves and can continue to support their families and communities,” Kaufman told 

®. He said the pandemic has illuminated health inequities and collaboration is needed to find new ways to provide health care services to all who are in need.

"And we must not forget ourselves,” Kaufman stressed.“As healthcare providers, we need to take care of ourselves including addressing our personal needs for healthcare and need to take time to recuperate – to avoid burnout.”

He said drug use may be in response to the stresses everyone faces, and the pandemic has exacerbated these stresses.“Medical evaluation, testing, and treatment are critical if we are to combat the drug epidemic now and moving forward as we continue to battle with COVID-19.”

Niles JK, Gudin J, Radcliff J, Kaufman HW. The opioid epidemic within the COVID-19 pandemic: drug testing in 2020. 

 2021;24(S1):S43-S51. doi:10.1089/pop.2020.0230

Lower levels of testing and higher positivity rates, higher rates of dangerous drug combination use, and increases in fatal and non-fatal overdoses during the coronavirus disease 2019 (COVID-19) pandemic reveal a need for more resources to address the opioid epidemic in the United States.

Reduced Testing, Higher Positivity Rates for Prescription and Illegal Drugs During the COVID-19 Pandemic in 2020

This KCast features Jeanne Sheffield, MD, Director of Maternal-Fetal Medicine at John Hopkins Medicine, and Aparna Sridhar, MD, MPH, an ob/gyn at UCLA Health as they discuss COVID's impact on testing, telehealth, and care accessibility.

COVID Impact on Testing, Role of Telehealth and How that is Impacting Access to Care

Have payer disparities seemed to grow worse during the pandemic, especially with telehealth? 

Take the poll now.

Have payer disparities seemed to grow worse during the pandemic, especially with telehealth?

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