Rae Woods (00:02):
From Advisory Board, we are bringing you a Radio Advisory, your weekly download on how to untangle healthcare's most pressing challenges. My name is Rachel Woods. You can call me Rae. When we talk about women's health in America, we often focus specifically, in fact only, on maternal health, and some of this is for good reason.

(00:23):
In previous episodes of this very podcast, we've talked about the dangerous realities of maternal health, including maternal mortality and restrictions on abortion access. But women's health is so much bigger than just pregnancy. If we want to work towards better outcomes for women, we must stop conflating women's health with maternal health, and we need to invest in a more holistic approach in caring for women. But the financial realities of the healthcare industry today mean that any investment requires more than just a moral imperative. It requires a business case, and that's why today I've brought three advisory board women's health experts to describe that business case. I've brought Kara Marlatt, Gaby Marmolejos, and Ellie Wiles to talk about how health leaders should be thinking about the financial opportunities and the moral imperative of investing in women's health. Kara, Gaby, Ellie, welcome to Radio Advisory.

Kara Marlatt, PhD, MPH, MSCR (01:24):
Yes, thanks.

Rae Woods (01:25):
All right. This is our time. You can be mad at me if you want. We're having a conversation about women's health. I have only invited women onto this podcast. I regret this. I regret this decision. This is your time to yell at me. I wish we had included a man in this conversation, but you are the real experts who've been out there living and breathing this, right?

Kara Marlatt, PhD, MPH, MSCR (01:44):
Yeah.

Ellie Wiles (01:45):
Yes. But I also think people maybe would listen to us more if there was one man here.

Rae Woods (01:52):
If I'm honest about the healthcare industry. When we say women's health, we often actually only think about one thing, right? We think about maternal health. In this conversation I want to talk about how that is a incomplete response. But before we get to that, let's get out ahead of some immediate pushback that our listeners might have. With maternal mortality in true crisis mode, why is it so important that we shift away from this narrow focus from maternal health to women's health more broadly?

Kara Marlatt, PhD, MPH, MSCR (02:24):
I feel like it's not as much shifting away from maternal health, it's just adding on different points of conversation that have been lacking for a really long time. I don't mean to detract from the importance of maternal health, it's just that I think refocusing a little bit on other aspects is also important.

Gaby Marmolejos (02:43):
And honestly, I would add that it's not even detracting in any way. I think advancing women's health is, in fact, advancing maternal health.

Rae Woods (02:51):
Or perhaps not the opposite. If we only focus on maternal health, are we adequately then also advancing women's health?

Gaby Marmolejos (02:58):
Yeah, exactly.

Rae Woods (03:00):
Why do we need to do this now? I'm thinking about, again, in the context of maternal mortality, we've really seen a big change in the last year, in the last two years, which is capturing a lot of executive attention. Again, if we're going to convince folks that this is the conversation that they should be having headed into 2024, why is it important that we focus on women's health now?

Ellie Wiles (03:21):
I would almost argue that it's so long overdue that there's nothing about this year or even the past two or three years that make this an exceptional year. I think it's been long overdue for pretty much the entire existence of the US health system.

Rae Woods (03:37):
Yes. Yes, and that is because women experience health, women experience the healthcare industry differently than men. I'm thinking about the fact that, okay, men tend to have higher chronic disease prevalence, but isn't it true that women actually tend to have worse outcomes for those same conditions? That alone starts to describe the difference in the experience and the outcomes that women have. What are the big drivers for that differentiation between women and men?

Ellie Wiles (04:09):
It's not that women necessarily have worse outcomes across the board. That's true in a lot of cases, especially when we're thinking about comorbidities or outcomes associated with certain conditions. But I think as a whole, what we're seeing is that women have completely different experiences with the healthcare industry when they're seeking care, when they're seeking treatment, when they're trying to have their condition diagnosed. That's different from men. The entire experience is different from men. It's not just about the outcomes.

Rae Woods (04:39):
Can you give us an example of how the experience is different? This is an area where the four of us may have some lived experience here, but let's share that with our listeners.

Ellie Wiles (04:51):
Yes. On average, women, they wait longer when they're in the emergency department, even when they're presenting with the exact same symptoms as men, they're more likely to be prescribed sedatives than pain medications when they're presenting with pain, they're more likely to be misdiagnosed or to wait longer for a diagnosis, things like that. Things that impact their entire care journey.

Gaby Marmolejos (05:14):
I also just think that women, when they present symptoms, they're often dismissed. So if you have side effects from some kind of medication that frankly isn't dosed for women to begin with-

Rae Woods (05:26):
Yeah, that women design for women. Yes.

Gaby Marmolejos (05:28):
Yeah, they'll just be like, "Oh, that's just you. At the end of the day, that's not normal. That shouldn't happen. You're just reading too much into it. It's all in your head. If you just believe in yourself, these symptoms will go away." I've definitely experienced that myself and I'm sure many women can talk about a situation where that's happened. I think that also just means that women are living with morbidities that a lot of men don't have to.

Rae Woods (05:55):
So there are challenges within the healthcare system. There are challenges in how women experience health and healthcare that are different, but there are also differences in how women experience the world, society outside of what we think of as healthcare. Women face unique social challenges. If we have to look beyond maternal health and kind of traditional OB-GYN care and think about something that's broader, do we need to think about some of these larger social challenges if we think about women's health?

Gaby Marmolejos (06:29):
I think the first thing that comes to mind is in our research that we recently did, we noticed that women are higher utilizers of certain services more than men, including behavioral health and then different kind of weight management services. And that's just because there's social pressures for them to receive care for these conditions, to lose weight or to receive mental health services, in a way that's not necessarily always the case for men. I'm sure, Kara, you can speak more to that too,

Rae Woods (06:57):
And I think they're seeking those services a lot more than men are.

Kara Marlatt, PhD, MPH, MSCR (07:00):
Yeah. I feel like whenever we talk about all the avenues of women's health beyond even just maternal health, my head just starts to swirl. I am listening to all the different things that we're listening for how women experience different levels of care, and I keep on going back to just differences in biology that make their symptoms present differently. An example of this is that for heart attack symptoms, they can have atypical presentation for how they come into the doctor's office. So they might not just have chest pain, they might have nausea or back pain or things that a doctor might not think are related to a heart attack but are, but they get pushed off or their care is delayed because they're misdiagnosed or they're not treated appropriately.

Rae Woods (07:53):
I feel like I have a good understanding of the problem. I don't know, yet, that I can name exactly where you want me and where you want the industry to go to next. What does it even look like to then provide comprehensive care for women? What's the goal that we should be aiming for?

Ellie Wiles (08:14):
I think part of it is just moving beyond what some researchers call the bikini approach. A woman's body is the entire body, not just like OB-GYN and breast health. So we can't forget cardiovascular health, we can't forget mental and behavioral health, we can't forget autoimmune conditions. All of these things that impact women's overall health, as well as things that affect their quality of life, childcare, menopause support services, flexible benefits through their employers, all of these things that collectively shape their health experience and their wellbeing.

Kara Marlatt, PhD, MPH, MSCR (08:49):
I think what's interesting to tie in here is that some of these services, how we treat women in healthcare beyond maternal health, it might be a little bit more limited because the research in those particular areas are lacking. I think that stems from the fact that women are harder to study and do research on than men because of the menstrual cycle.

Rae Woods (09:18):
When we think about designing medical clinical products, that's the reason why women are often excluded from the testing and clinical trial phase, at least to date. And I should say that there is a big push for more real-world data and evidence in product design that's not just about trying to include women, but also trying to include people of color, diverse populations, et cetera, et cetera.

Kara Marlatt, PhD, MPH, MSCR (09:38):
What I find really fascinating is that when I was doing clinical research in women's health, specifically around menopause for years and I worked at obesity and diabetes research center where there were tons of high-powered studies that really would set the tone for how women and men could be treated throughout the course of their life, I could not find one study that actually tracked a woman's cycle or that measured their hormones. It was amazing to see that because it just shows you, even for people that know how to do research studies really well, they do not track things according to a menstrual cycle, which can be very important when you're trying to look at the impacts of certain levels of care of drugs that you give women. There's shortcomings there that we're still dealing with.

Rae Woods (10:40):
And what you're getting at, I think, Kara, is that holistic women's health is not just something about care delivery. It is not something that is limited to when you happen to be in the moment with a patient. We have to think about the care delivery and we have to think about some of the things that happen upstream, some of the things that happen downstream, and those are things that we need to change in order to see better outcomes for women, more holistic care for women. I want to stop here and ask the question that I am positive someone on the line is thinking about. Why should we be doing this for women and not doing it for men?

Gaby Marmolejos (11:19):
Whenever you ask this question, I always get angry. But anyway, honestly, the way I see it is the way I see equity, any kind of equity initiative you would do, I always hear the analogy of a wheelchair ramp. We build a wheelchair ramp for a specific purpose. We're trying to make buildings more accessible for people in wheelchairs, but everybody benefits from a wheelchair ramp. If you ever move into an apartment building with a heavy box, it's really nice to have a ramp. And so, at the end of the day, it might've been intentionally designed for a specific population to meet their need, but everybody can benefit.

(11:52):
I think the same is true. If you invest in women's health, you could actually design something that everybody else benefits from. So like childcare, for instance. I'm sure many women would benefit from childcare during their doctor's appointments, but I'm sure many men and non-binary people would also benefit from having childcare available, even if it was designed for women.

Rae Woods (12:13):
And because you brought up equity, I'm also going to just name intersectionality here that we are talking about women as a whole group, but we do know that within the group that is women, there are differentiated experiences, there are differentiated outcomes, and addressing the most vulnerable group ultimately helps everyone, to your point, Gaby.

Ellie Wiles (12:36):
I also think it's worth saying that the way that the US health care system is structured already serves men as the default. That doesn't mean that they don't have health needs that should be addressed or that they shouldn't have resources dedicated to men's health, but I feel like there's not an equity issue there to begin with for men because they've kind of been the model patient and the model. They're the standard we think of when we're learning what conditions look like, what research looks like, so there's just not as much of a gap to be filled.

Rae Woods (13:11):
Yes, that comes back to Kara's point. And we are not saying do less for men. We are saying that we need to add to an underserved, vulnerable population and not take away from another population that we happen to be serving well, to your point, Ellie. I hope that at this point in our conversation, our listeners are on board with the idea of holistic women's health, more comprehensive women's health, women's health beyond the bikini, beyond maternal health.

(13:43):
But the reality for our listeners for healthcare is that financials are tough, trade-offs are always difficult, priorities always need to be made, and it is not so easy to allocate dollars without a business case. So what would you say to a listener who's working with limited resources and maybe believes in holistic women's health, but doesn't necessarily see the sustainable way forward to actually invest here? What is the business case for investing in women's health?

Kara Marlatt, PhD, MPH, MSCR (14:15):
At the end of the day, investing in women's health is important because right now, women could be considered the chief medical officers of their family's care, and healthy women are the cornerstone of really healthy societies. And so if it can extend to a woman's spouse or their children or their family, their spouse's family, they're really the caregivers of the family unit.

Rae Woods (14:45):
And the decision makers, often. We have data that they are the decision makers.

Kara Marlatt, PhD, MPH, MSCR (14:49):
Absolutely. And so, if you want to focus on somebody who can really shift care for the entire family, it's focusing on the women of the family.

Gaby Marmolejos (14:59):
And that's a great way to build loyalty, I think, within a family, especially if you already know that this is a key decision maker, and now you are making their lives easier in receiving care at your hospital or your health system. That can help build loyalty so that they want to come back with other people that they're caring for.

Kara Marlatt, PhD, MPH, MSCR (15:20):
In this case, I feel like a great example is a woman in their midlife. They have kids that are getting older and have responsibilities to manage their child's care going off to college, but then they're also caring for their ailing parents. And when that happens, you're caring for multiple generations of people, but then that woman can also put off her own care because she's taking care of so many other things. And so that leads to delayed care for that particular person. So investing in women's health is really investing in all women in society.

Rae Woods (16:01):
So when it comes to the business case, it sounds like there's an actual financial opportunity. There's a share-of-wallet opportunity to try to capture as many dollars as possible from not just an individual consumer, but from their family unit and capture as much of that over the course of their life. That's really what we're talking about here. And by the way, that is something that exists in all business models in healthcare. But I have to believe there's another side of the coin to the financial opportunity that is specific to those who are moving into alternative payment models. I'm talking about value-based care, value-based payment, here. Why does women's health matter there?

Gaby Marmolejos (16:43):
I think part of any value-based payment model is trying to reduce total cost of care, most of the time by reducing risk, by better providing higher quality care. And so if you improve the quality of care for women, in many cases, you're reducing the risk of a lot of comorbidities and a lot of higher acuity cases, and so you can help reduce the total cost of care by better treating their needs and tailoring your interventions to meet them.

Kara Marlatt, PhD, MPH, MSCR (17:13):
Yeah. And if we're speaking through the lens of value-based care, it makes sense to invest in women's health, specifically for midlife women's health. Because if I think of a condition like when women experience menopause, there's this confluence of different symptoms and physical changes that arise during a consolidated period of time that makes women at increased risk for cardiovascular disease. And so you would hope that she would be surrounded with services that could help her navigate that time period, because then that will improve her care overall. But I don't think that's really what happens, and that's not what a lot of women experience right now.

Rae Woods (18:01):
I don't think that's what happens. I don't think that's what we think about when we think about the specific work that's required to reduce the risk of a population or keep somebody in the rising-risk category and not in the high-risk category. I'm not sure that that is something that even really savvy and sophisticated population health managers are thinking about when they think about the menopause experience that happens with women.

Kara Marlatt, PhD, MPH, MSCR (18:23):
I think of, too, when anybody gets hired at a certain organization, you always hear about the maternal benefits, how much time you get off if you have a baby, or do they support IVF, and all those things. But I've never seen any sort of information about the midlife transition and what happens after that. I have never seen an organization say, "Here's how we support you as you age out of your fertility years."

Rae Woods (18:49):
The fact that all women will experience that medical event and not all women will experience the medical event that is having a child. Which brings us back to the very first thing that we said, and actually brings me to another point of pushback. I just feel like I keep channeling the folks that are going, "But what about this? But what about this?" And I'm happy to take that job in today's conversation, but if I'm honest, this is actually a question that I have.

(19:19):
We're talking about investing in services beyond maternal health, and yet I keep hearing and seeing headlines about labor and delivery units closing, about this really creating more care gaps, particularly in more rural populations. How are we supposed to reconcile in a world of limited investment and where we have to make trade-offs and have to focus on our priorities where we've already made the leap to say, "Okay, we need to think beyond maternal care." But also, there's this second layer where what happens when L&D units are closing? Why then is it still so important that we think beyond maternity care, beyond labor and delivery?

Gaby Marmolejos (20:05):
It's especially important now if you're talking about L&D units. I mean, the reason they're closing is mainly because we have lower rates of pregnancies in a lot of these rural communities, and we're seeing a higher proportion of people with high-risk pregnancies. And so many hospitals can't handle the small volumes of high-risk cases, and they don't really have the infrastructure for that. And so I think now is especially the time that we need to reduce risk.

Rae Woods (20:34):
For women, period.

Gaby Marmolejos (20:36):
Yes. For women, period, and again, like I said, they're related. Maternal health and women's health, intricately related. If you care about one, you care about the other. I talked to a health system recently that was working on trying to reduce the risk of women so that when they came into their facility, now they don't have to deal with as many high-risk pregnancies. I think most health systems I talked to right now have a lot of high-risk pregnancies that they're dealing with more than before. So now is especially the time to be focusing on women's health specifically.

Rae Woods (21:13):
Which I actually think is counterintuitive to what most folks think of when they think about the maternal health risk and the L&D shortage, especially in rural areas.

Ellie Wiles (21:24):
Kind of along the same lines, that argument could be made broadly for almost any specialty care area or service area. When you're investing resources into preventive care and maintenance and services that will support women's well being, there will be less of an overall risk for more complicated and more expensive health needs down the line.

Rae Woods (21:50):
Back to our value-based care argument. I see, I see.

Kara Marlatt, PhD, MPH, MSCR (21:53):
Just on top of what we've been talking about, it might be blunt, but I really just truly think it's unacceptable to say that there aren't enough resources, because we have resources and maybe we just need to reallocate those. I'm thinking of, I could see a world where organizations engage women better across the healthcare ecosystem or their particular ecosystem and ask them where they could improve their care delivery, because maybe there's some inefficiencies of where they're delivering care and they could improve. And so, if we're going to get better at delivering care, I guess one way is that why don't you ask women where you can be of better service to them? Maybe that's easier said than done.

Ellie Wiles (22:40):
I actually completely agree. I feel like there's no need to make assumptions about what female consumers need when you could just ask them. That's really all there is to it.

Gaby Marmolejos (22:50):
To add on to the business case we were talking about, people always say OB-GYN is an unprofitable service line, but guess what? People think of cardiovascular and oncology and a few other service lines as profitable service lines, and guess who receives care in all of these profitable service lines? Women. So like we were saying, if you ask them what would make this experience better, you can better serve them within those other service lines.

Rae Woods (24:12):
Throughout this conversation, we've mostly talked about the care delivery side and what change needs to happen in order to provide comprehensive care for women. We touched on the role of life sciences here. Kara mentioned the fact that clinical products are developed on a homogeneous population, a population that tends to be white men, and that needs to change so that we know if our clinical products are effective, are safe, are creating the same desirable outcome in different populations, including populations of women. What are other stakeholders that we need to give voice to? What's the opportunity for health plans employers to support women's health?

Kara Marlatt, PhD, MPH, MSCR (24:55):
One thing that I think is really interesting is that over the last several years around COVID, the FemTech industry just ballooned. And that really was a signal that consumers were demanding more from the healthcare system and there's unmet need. And so, no matter where that comes from, it needs to come from somewhere. And so it can come from multiple different places, it doesn't just have to come from one particular avenue. It's like the women have spoken, they've said that they want these different resources, and that's why so many startups happened in the first place,

Rae Woods (25:33):
Which by the way, it probably comes back to the, why now? There are so many healthcare and other industry stories of outsider notices a gap, moves to fill that gap. That's what disruption is, even though I'm so sick of that term, at this point. But hey, you want a reason to act now? Look at this entire portion of the technology industry that is saying, "Hey, there's not enough for women here and I actually see my profit." Talk about a business case.

Kara Marlatt, PhD, MPH, MSCR (26:00):
Yep, absolutely. I always remember women coming into the clinic talking about how they just felt like their care at a doctor's visit wasn't met, and they need additional resources or they need additional education on particular topics because a 10 to 15-minute appointment with their doctor is not going to cut it, and they need support elsewhere.

Gaby Marmolejos (26:28):
These FemTech startups, for the most part, they're partnering with employers. That is actually their main audience. They're partnering with employers, they're partnering with health plans because they're realizing there is a gap in care provided. So there's a lot of startups that are focusing on niche, I put quotes, with niche women's topics. There's startups that are focused on menopause specifically, so they offer care coordination services, they offer education, they create these forums for women to talk about the different symptoms they're experiencing and be able to talk to one another. And so employers can either partner with them or they can just look at their own existing benefit packages, look at where are the gaps? Are we assuming that women only want child-related or pregnancy-related needs? What are other things that women are looking for? And as Ellie said, you should just ask them what they want, rather than assuming.

Ellie Wiles (27:25):
The role of health plans in all this comes back to the whole value-based care argument in preventing downstream costs, which is what health plans already do. So their role will continue to be to support more preventive and routine healthcare costs to prevent more costly and more complicated conditions down the line. And eventually that will mean partnering with organizations to support those kinds of services.

Rae Woods (27:56):
We've talked about a lot in today's conversation. We spent a lot of time talking about the why. Why does holistic care for women matter? We talked a lot about the business case, and what I'm hearing loud and clear is that there are a lot of different layers and there are a lot more opportunities on the business side than I think most folks are paying attention to. I want to talk about what our listeners should do next. Is there a key question that you want them to bring back to their leadership teams? Or is there a specific next step that you want them to take as they navigate all of the trade-offs on their to-do list headed into 2024?

Gaby Marmolejos (28:33):
Well, I always have a cop-out answer to any question about what to do next, and it's always, how does this fit into your strategic plan?

Rae Woods (28:41):
Not a cop-out answer a good one, actually.

Gaby Marmolejos (28:44):
It's not. It's not. I agree, it's not. But people think it is, but it's not. And I think it's just because your organization's strengths, your organization's resources, you know what you're already investing in, and there's a way for you to take advantage of what you're already focused on and try to add another component where you're addressing the needs of women.

(29:09):
A lot of organizations have some kind of telehealth strategy. Women are some of the highest users of telehealth compared to men. So now you have an opportunity to say, "Okay, how are we designing these platforms, this program, to better meet the needs of women? How can we ensure that we have the right specialists offering care via telehealth?" And so I think, depending on your organization's infrastructure and capacity and strategic plan, that's the place to tap into and to see, "Where are some areas where we can better meet the needs of women?"

Kara Marlatt, PhD, MPH, MSCR (29:40):
And you can't even begin to solve any of those problems if you don't have the right people at the table. You need to find the people that can help you solve all of those problems to address those gaps. And it's not just specific women at the table. You can have any sort of person at the table, sex, gender, race, ethnicity. You need everybody to come together because it requires everybody. It requires a comprehensive solution.

Ellie Wiles (30:11):
I truly think the place for every single stakeholder to start is just to ask women in their target populations what they need, whether that's health plans, whether that's life science research companies, whether that's provider organizations. The best place to start is by meeting the needs of your community.

Rae Woods (30:33):
I'm going to cheat and add my own takeaway, which I don't often do, but it relates to every single thing that you all said, which is you have to have the right data or you have to look at your own data and make sure that you're cutting it so that you can see where your gaps exist, so that you can see where the disparities are, so where you can see where the needs are. Ellie, Kara, Gaby, thank you so much for bringing such an important conversation to Radio Advisory.

Ellie Wiles (30:57):
Thank you so much for having us.

Kara Marlatt, PhD, MPH, MSCR (30:59):
Yes. No, it was great. Always love having these conversations.

Gaby Marmolejos (31:03):
Completely agree.

Kara Marlatt, PhD, MPH, MSCR (31:08):
I bet you think that that was a hard conversation, and honestly, it's because it was. Every time we talk about disparities, social determinants of health, every time we acknowledge the gaps and vulnerabilities in our own delivery system, in our own healthcare ecosystem, that's a hard conversation. But, it is a necessary one. There's a lot that you can do to advance women's health. There's a lot that everyone can do, not just care delivery. And remember, as always, we are here to help.

(31:47):
If you like Radio Advisory, please share it with your networks. Subscribe wherever you get your podcasts, and leave a rating and a review. Radio Advisory is a production of Advisory Board. This episode was produced by me, Rae Woods, as well as Abby Burns, Kristin Myers, and Atticus Raasch. The episode was edited by Katy Anderson with technical support provided by Dan Tayag, Chris Phelps, and Joe Shrum. Additional support was provided by Carson Sisk, Leanne Elston, and Erin Collins. Thanks for listening.