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Special Report: A Checkup on Women's Health

A national survey finds that many women are not getting preventive care or even birth control counseling at annual gynecological exams and that some women are skipping them altogether. For them, such visits are. . . : Hardly Routine


For women, the annual visit to the gynecologist has long been considered essential to good health. But many women are forgoing their annual checkups or, when they do get to the doctor, are not receiving basic preventive care recommended by medical experts.

A new national survey has found that among women who visited their gynecologist during the last two years, a startling 94% do not receive all the tests and counseling recommended for their age group.

That women often do not get all the care recommended by national guidelines is not surprising considering this: About half of those surveyed said they spent only 15 minutes or less with their doctor or other provider.

One in three women said they had not even had a routine gynecological exam in the last 12 months, while 16% have not had an exam in the last two years. Lack of insurance and time constraints were most often cited as the reasons for delaying care.

The results come from a nationwide poll conducted by the Henry J. Kaiser Family Foundation and the Los Angeles Times, with Essence and Latina magazines.

The telephone survey, conducted between Jan. 6 and Feb. 10, polled 2,241 women, ages 18 to 64, about reproductive health issues. The poll included interviews with 603 Latinas and 601 black women.

Health experts who analyzed the data for The Times said the gaps in care are likely explained by the large numbers of women without insurance, a lack of awareness among women about which services they should expect of their doctors, and frustration among gynecologists over the payment system used by many health insurers.

"What this survey points out is the amount of time that is spent with these women on such critical issues is a problem," says Julia Scott, president of the National Black Women's Health Project. She adds: "Women don't know what to expect or what particular concerns can be addressed by who."

Major groups, such as the American Medical Assn. and the American College of Obstetricians and Gynecologists, recommend an annual exam and have detailed guidelines specifying what should be covered. The survey, for example, showed that most women received a Pap smear and breast exam (94% and 88%, respectively).

But the poll also showed conflicts between what doctors aim to accomplish and what women say they want.

Only 42% of those surveyed were counseled on calcium to prevent bone loss, while a dismal 35% of women of childbearing age said they received counseling on birth control. Less than one-third of the women said they received counseling or screenings for sexually transmitted diseases.

Despite the well-known health benefits provided by hormone replacement therapy, only 66% of women ages 40 to 64 said they discussed menopause and hormone therapy with their doctors during their most recent exam.

"You would hope that for preventive services and routine services, women would have higher levels of care," said Alina Salganicoff, director of women's health policy for the Kaiser Family Foundation, a nonprofit national health care charity based in Menlo Park. (The foundation is not affiliated with Kaiser Permanente, the giant health care corporation.)

"I think women need to be more educated and informed about their health care and less afraid to ask their doctors questions," she said. "But we also have a system right now where doctors are under discounted service plans. They are paid to spend much less time with women."

HMO Payment System Is Cited

While the survey data indicate that doctors are not delivering all the recommended care to women, gynecologists have a different perspective. Many blame the payment system used by HMOs and other managed care plans in which doctors often are paid a fixed amount for taking care of patients--instead of being paid separately for each exam, test or procedure performed. They blame managed care for dramatically curtailing the services they can offer during the traditional gynecological visit.

"There is a tremendous discrepancy between what is ideal and what is practical," says Dr. Philip G. Brooks, a Los Angeles gynecologist and clinical professor at UCLA. "Insurers no longer demand, no longer expect and no longer reward physicians for being comprehensive. The reimbursements today are such that if you are not efficient and fast, you can have trouble covering your overhead."

Many health insurance plans offer an annual gynecological exam to women, sometimes called a "well woman" visit. But some plans will pay a gynecologist to provide only the essentials, such as a Pap smear and breast exam, says Dr. James Heaps, an assistant clinical professor at UCLA School of Medicine.

"The problem is: What is the definition of the annual exam? Insurance companies have introduced new terms, such as the 'well woman' or 'gynecological checkup,' which is very different from what a woman expects in an annual exam," Heaps says.

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