Aug. 12--It's the controversy that's gotten the most coverage.

The portion of the Affordable Care Act that took effect Aug. 1 requires insurers to cover, without a patient co-pay, all U.S. Food and Drug Administration-approved contraceptive methods for women, sparking a heated debate resulting in exemptions for religious employers.

But this small piece of the broad, multiyear ACA also includes seven more categories of "preventive" services women can now get without a co-pay, including testing for the virus thought to cause cervical cancer, HIV tests, and consultation and certain supplies to help women successfully breast-feed.

The U.S. Department of Health and Human Services estimates 47 million women whose insurance policies renew on or after Aug. 1 are now "guaranteed access" to services without a co-pay. It cites a 2009 study that found more than half of women delayed or avoided necessary care because of cost.

'People are dying'

Obstetrician/gynecologist Dr. Michael Caudle, director of women's health services for Cherokee Health Systems, has seen these women. Patients who are unemployed or earning minimum wage have little money for even modest co-pays, he said. By the time they get care, he said, their problems are severe, more expensive to treat and have less chance of being treated successfully.

Caudle said he's seen 10 patients recently who have cancer.

"I'm not talking about pre-cancer, I'm talking about real, invasive cancer," he said. "And their stories are disheartening. They're people who didn't get their Pap smear for 25 years because they said they couldn't afford to go to the doctor. They're people who had an abnormal Pap smear and got it treated and got no follow-up, and now this has come back, and it's invasive. ... It's going to kill them.

"People are dying because of a lack of access to health care. They will die. They die every year."

What could make a difference? Preventive care, he said, but in a busy practice, "we can't get back to preventive medicine because we're dealing with bad bleeding, bad infection, psychological and emotional situations that are almost in crisis state."

HHS tasked the Institute of Medicine to conduct a scientific review of evidence-based medicine and then recommend specific measures that keep women healthier.

They mesh nicely with what Cherokee is already doing. Six months ago, Cherokee began a women's clinic that integrates physical and mental health, with Caudle, nurses, case workers, a psychologist and a psychiatrist practicing in the same clinic. It accepts private insurance, TennCare or the uninsured (on a sliding scale).

With that model, Caudle said, the clinic can treat, for example, drug-addicted pregnant women, or women at risk for postpartum depression. If it works as well as he expects, Caudle hopes to present the model to the American Congress of Obstetricians and Gynecologists as a method for private practices like the hospital-affiliated group he practiced with for 25 years.

Specifics unknown

Cherokee routinely offered some services that are part of the new guidelines -- screening for domestic violence, for instance. In theory, providers can now submit that for reimbursement.

In practice, it probably won't be that simple. So far, few specifics have been passed to providers or clients about how the guidelines are to be implemented. Must domestic violence screening be administered by a master's-level counselor? Must a specific test be used?

These are questions Sherri Hedberg, clinical director for Lisa Ross Birth and Women's Center, has. The center has routinely screened for domestic violence for years but never billed for it. And since the free-standing birth center has made it a mission to help women breast-feed -- even starting an East Tennessee Breastfeeding Center and piloting a program where rural women can get lactation consultation via Skype -- it potentially stands to benefit from the coverage of breast-feeding supplies and consultation.

Yet at this point, Hedberg hasn't found clarification on which supplies are covered, in what cases. Some insurers already cover pumps if an infant is particularly small, or counseling if the lactation consultant is, like the ones at LRBWC, board-certified. Hedberg also can't find a reimbursement rate.

"There are still a lot of questions," Hedberg said, though there's no question she finds the requirements encouraging. "Other than (prenatal care), breast-feeding is really that crucial first step in prevention. We need to look at it not as lifestyle choice but as a health issue, because it saves us all money."

Like Caudle, Hedberg sees an opportunity to make sure women are healthy before they get pregnant. Though the government has recommendations for women of childbearing age, "you can't even have those discussions if the people aren't coming in the door," Hedberg said.

The trade-off for some small practices will be a longer wait for reimbursement, because they won't get immediate co-pays for those services, said LRBWC Executive Director Carmen Pitt. And because the changes don't take right away if a policy was renewed before Aug. 1, it will take some time to figure out when patients qualify, she said.

Other issues

Dr. Leonard Brabson, who has an OB/GYN practice affiliated with Tennova Healthcare and serves as vice president for the state chapter of ACOG, said most women he sees had no trouble getting preventive services before the ACA guidelines took effect. Still, "it's very positive," he said. ACOG called the guidelines "a victory for women."

Physicians' concerns, he thinks, are largely with other provisions of the ACA, such as the Independent Payment Advisory Board, which dictates Medicare payment and program rules.

Caudle thinks some doctors will take issue with the government imposing on what services patients need -- or what physicians and other medical service personnel have time to provide.

"I think we have a shortage of providers providing true preventive medicine," he said. "It's been embraced by (ACOG), but in practice, in a busy OB/GYN practice ... you're doing deliveries, you're doing surgeries ... and it's difficult to focus on all of it."

At Cherokee, Caudle no longer delivers babies. Though he misses it.

"That's just one day out of their life," he said. "The rest of their life is more important to me."

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