Connors Center for Women’s Health
Policy Strategies
for Better Integration of
Education and Counseling
Primary Care
Policy Strategies for Better Integration
of Education and Counseling in Primary Care
One of the signature goals of the Patient Protection
and Affordable Care Act (ACA) is to transform the U.S.
health care system from a focus on treating the sick to a focus
on keeping people healthy. An integral part of this emphasis on
prevention is the requirement that all new health plans cover a
defined set of preventive services without cost-sharing. Among
the requirements are a set of preventive services specific to
women’s health needs, including a well-woman visit. National
guidelines call for education and counseling as important
components of this visit, along with medical history, physical
exam, age appropriate screenings, clinical tests and behavioral
risk assessments.1,2
Although there is ample evidence that providing education and
counseling during routine visits improves health outcomes and
is cost effective, it is not always a routine part of preventive
care. The well-woman visit provides an important opportunity
to improve the delivery of these services, but a number of
systemic barriers remain. This paper explores those barriers
and discusses policy approaches that could help ensure that
education and counseling services are successfully integrated
into women’s primary care.
Background: The Importance of Education
and Counseling
Many of the most common causes of disease, disability and
death for women in the United States are directly attributed
to health risk behaviors, such as smoking tobacco, the use of
alcohol or other substances, unhealthy diet, physical inactivity
and other factors such as interpersonal violence and sexual
assault.3,4 Behavioral counseling has proven to be effective
in modifying behavior and subsequently reducing the risk of
developing certain chronic illnesses.
Clinician advice targeted at lifestyle habits is associated with
increased patients’ efforts to change behavior.5,6 For women,
in particular, a “priming effect” results in patients being more
attuned to additional information that is consistent with
recommendations they have already heard from their provider.7
In addition, patient education has been shown to increase the
uptake of healthy behaviors, improve medication compliance
and assist with disease management.8,9,10
Research has demonstrated that evidence-based preventive
services, including education and counseling, can improve
population health and quality of life, often at little cost, and
should be a key element of health improvement strategies.11,12,13 Researchers have estimated that the increased
use of twenty preventive services, including immunizations,
screenings and counseling, would avert the loss of more than
2 million life-years annually, and, compared to 2006 utilization
of these services, could save $3.7 billion.14 Most of the leading
factors related to health disability in the US (including dietary
risks, tobacco smoking, high body mass index, high blood
pressure, high fasting plasma glucose, physical activity and
alcohol use15) can be addressed by education and counseling
interventions.16
Barriers to Education and Counseling
Although education and counseling is an important part of
women’s health care, it is not yet a routine part of women’s
health care. According to recent data, 81.5 percent of
obstetricians/gynecologists (OBGYNs) and 73.5 percent of
other primary care providers (PCPs) are not counseling their
patients on obesity, exercise, diet, or tobacco use.17 Similarly,
women report low rates of education and counseling services
during their doctors’ visits. For example, only 31 percent of
women report receiving counseling on alcohol and drug use
and only 41 percent report discussing their mental health with
their provider in the past year. Many documented barriers can
hinder the integration and implementation of education and
counseling in primary care settings, and thus account for such
low numbers. These barriers fall into five major categories:
time, reimbursement rates, patient perceptions, provider
perceptions, and lack of training.
Time
Many PCPs struggle with lack of time with when integrating
counseling more fully into their practice. In fact, researchers
from Duke University Medical Center found that
Policy Strategies for Better Integration of Education and Counseling in Primary Care
11 Dupont Circle NW, Suite 800, Washington, DC 20036 | 202.588.5180 Fax 202.588.5185 | www.nwlc.org
comprehensively providing all of the USPSTF-recommended
preventive services to an average patient panel would take
more than seven hours of the working day and over 1,700
hours annually.18 Having enough time with a patient is
essential to providing effective preventive care, but many
providers perceive time as a constraint to offering such care,
particularly because brief counseling services are not
separately reimbursed.19 Time constraints of the patient are
another important barrier to consider when discussing
education and counseling. Difficulty taking time off of work
or an expectation of long wait times prevents some patients
from even scheduling a well-woman visit with their provider.20
Reimbursement
Reimbursement rates also may be a disincentive to providing
education and counseling services. Many payers do not have
any formal coverage policies for counseling services. In
2006, the American Society of Clinical Oncology found
reimbursement to be a major barrier to the delivery of
preventive cancer education. Preventive counseling was
typically only reimbursed for patients with a precancerous condition or personal or family history of cancer.21
Additionally, reimbursement policies may make it harder for
practices to effectively utilize mid-level providers and other
non-traditional providers such as social workers and
behavioral change specialists who play an important role in
the delivery of education and counseling services, but who
are not separately reimbursed for these services.
Patient Perceptions
Patients may not be inclined to ask for advice from their
provider, even when they want to. Qualitative research
has shown that patients want preventive counseling during
preventive health visits, but perceive a number of barriers to
asking for and receiving advice.22,23 Studies have confirmed
that patients expect their providers to educate them on key
behaviors including diet, exercise, and substance abuse,
but may be hesitant to bring these counseling topics up
themselves.24 As a result, providers may believe that there
is low demand for behavioral counseling because patients
may not think to ask for information on these topics, or are
uncomfortable or ambivalent about requesting information
on ways to improve their own health.25
Provider perceptions
Providers’ perceptions of certain conditions as well as
their perception of patients’ willingness to change may
influence whether or not they provide education and
counseling. According to several studies, providers often
believe that behavior change is predicated on the patient’s
willingness to change. In many cases, providers viewed
patients as either compliant or noncompliant but did not
consider issues that impacted patients’ ability to change
their behavior, such as self-efficacy or personal resources.26
Providers also believed that their recommendations lacked
the power to motivate the patient to change behaviors.27
These beliefs reinforce the perception of low demand for
preventive counseling: patients are looking to their provider
to counsel them on behavior change but providers believe
patients need to express a willingness to change their
behavior in order for providers’ recommendations to be
effective.
Lack of effective interventions and training
In addition, some providers do not have confidence in
the effectiveness of available education and counseling
interventions. For example, qualitative studies of barriers
to interpersonal violence (IPV) screening find that
providers’ greatest concern is a lack of effective interventions for patients after they had been screened for IPV.28
Specifically, physicians described feelings of “powerlessness”
in knowing how to direct patients experiencing IPV to other
services or their own ability to “fix” the problem. Related to
inadequate training, providers believed their inability to
address IPV stemmed, in part, from their own lack of
education on the issue.29 In other areas significant to
women’s health, such as sexual health counseling, medical
and nursing students are often taught how to initiate a topic
but not how to effectively continue the conversation.30 In
addition, less than one in five OB-GYN residents receive
training in menopause medicine, which leaves them without
the tools they need to educate patients about this life
transition.31
Policy Strategies
These systemic barriers to the increased use of
education and counseling services require broad-based
solutions – while individual physicians may use effective
counseling techniques, and practices may reorganize to
improve the availability of these services, these barriers
will remain an impediment to the increased delivery of education and counseling. Strategies that address long-standing
problems in our health care delivery system, such as better
integration of care, increased use of mid-level health
professionals, and payment reforms, would also improve the
availability of education and counseling in primary care.
Policy Strategies for Better Integration of Education and Counseling in Primary Care
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Case Study:
Group Prenatal Care
Ludlow Street Newark Community Health Center
in Newark, New Jersey began it’s Centering
Pregnancy group prenatal care program in 2009.
Over the course of 10 visits, led by a midwife,
women record and report their own vital signs and
then share their experiences in a facilitated group
discussion. All of the women in the group sessions
live at or below the poverty line, putting them at
increased risk for pre-term births and low-birth
weight babies. But in 2013, none of the women
participating in the Centering Pregnancy program
delivered preterm and nearly all had babies
who were healthy weights.38
Integrate alternative care models in clinical settings serving
predominantly low-income, minority women
Alternative care models, such as group prenatal care, have
been found to improve education and counseling for women.
These approaches can be applied to the well-woman visit,
particularly for women who lack a regular source of care and
are therefore significantly less likely to receive preventive and
counseling services.32 The CenteringPregnancy (CP) model,
which emphasizes health assessment, education, and support
through group prenatal care, has served as a health system
entry point for diverse groups, including low-income Latinas,
adolescents, and Black women.33 Participants in CP pilot
programs have increased health care utilization during
pregnancy and the postpartum period, resulting in improved
perinatal health outcomes.34
The patient-centered medical home (PCMH) is another delivery
system reform that offers new opportunities for specialized
populations – particularly individuals with chronic illness – to
receive education and counseling services in primary care settings that engage them in better managing their health.35 Care
coordination is a particularly important element of PCMH for
women.36 In fact, women benefit from the medical home’s
assistance navigating the health care system: they remain
integrated in care, are more likely to form trusting relationships
with a provider, and utilize education and counseling services.3
Enhance counseling instruction during clinical training and
offer continuing education opportunities
Inadequate physician training and knowledge and physician
attitudes towards the efficacy of education and counseling
should be addressed beginning in medical school and
throughout a medical career. Physicians consistently report
lacking sufficient training to offer their patients motivational and
educational counseling services.39 Not surprisingly, health
professionals who receive specific, extensive, training on
utilizing behavioral counseling in patient visits are more likely
to provide this counseling. For example, physicians who learn
about obesity counseling in school or during residency are
more likely to discuss diet and exercise with their obese
patients compared to those who did not receive training – and
are more likely to report success in their weight counseling
efforts. Overall, evidence suggests that providers who are
extensively trained are more likely to educate and counsel
their patients, which is related to improved patient health
outcomes. In addition to emphasizing training for medical
students and young professionals, continuing medical education credits for skill-building workshops on the core principles
of evidence-based counseling may be helpful for mid-career
professionals, particularly on women’s health issues and
USPSTF-recommended preventive health services.40
Case Study:
Domestic Violence Training
Continuing Medical Education courses can be
effective way of providing physicians with more
training inpatient education and counseling. For
example, a study of California physicians who took
a “Respond to Domestic Violence” online course
found that the course significantly increased
providers’ understanding and awareness of
interpersonal violence issues. Nearly 80 percent
of course participants said they would make
practice changes for handling suspected
interpersonal violence. On physician responded,
“I thought I was aware of the general problem of
IPV, but this course startled me with how much I
am likely overlooking. I’ve already asked my office
manager to set up an in-service
for my office staff.”41
Policy Strategies for Better Integration of Education and Counseling in Primary Care
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Reform scope-of-practice laws
Restructure payer policies
The core principles of the ACA include provision of preventive care and improved health system quality and efficiency.
Mid-level practitioners (i.e., advanced practice nurses and
physician assistants) are more likely to provide education
and counseling services than physicians,42 and can thus help
fulfill these objectives of the ACA. However, scope-of-practice
(SOP) laws limit the effective use of the current and projected
workforce.43 Reforming state SOP laws may help to combat
inefficiencies, particularly in underserved regions. Currently,
32 states require physician involvement to diagnose, treat, or
prescribe medication, with 7 of these states requiring physician
oversight only for nurse practitioners’ prescribing authority.44
Mid-level providers are highly accepted by the majority of
U.S. consumers45 and achieve health outcomes and quality
measures equivalent to those of physicians.46 Improving
mid-level provider’s autonomy may prove an important
component of improving women’s health, and promoting
education and counseling.
While differing reimbursement levels do not drive providers’
willingness to counsel patients and the amount of time they
spend counseling, the reimbursement structure itself does
make a difference. For example, studies found no significant
difference in the average length of a visit or the likelihood
of patients receiving preventive health counseling when
comparing safety net patients to those with private insurance.49
However, physicians who receive capitated or salary-based
payments are more flexible in their allocation of time and have
greater motivation to offer counseling on a larger number of
patient health concerns than those who are reimbursed on a
fee-for-service basis.50 Alternatively, separate payment for
education and counseling services would provide greater
flexibility and accountability for providing education and
counseling for health care providers who are reimbursed
on a fee-for-service basis.
Broaden payers’ definitions of ‘primary care providers’
to include mid-level providers
Integrating behavioral health services in well-woman care
helps target the underlying cause of 70 percent of primary care
visits.51 Many primary care providers report being ill-equipped
or lacking the time to address the wide range of psychosocial
issues that patients present.52 Research suggests that primary
care providers can facilitate behavioral health care. Integrated
care can enhance access to this important service by making it
more readily available, less stigmatized, more community-centered, and cost-effective.53 One promising model of integrated
care includes a trained behavioral health specialist within
women’s health care teams to provide education and counseling services. Behavioral health specialists are typically trained
at the Master’s degree level and are qualified to treat a range
of conditions commonly found in the primary care setting (e.g.,
depression, anxiety, relationship problems, and insomnia).54
Behavioral health specialists have been found to increase
efficiency, increase patient and provider satisfaction, and
improve co-morbid physical and mental health conditions.55
Co-locating, which removes geographic distance between a
behavioral health specialist and the well-woman care team and
improves daily interaction, increases the likelihood that women
will receive education and counseling. Medicaid’s system of
prospective, cost-based payment for health centers supports
funding of this model.56
Payers can determine which services mid-level providers are
paid for, reimbursement rates, whether they are paid directly,
and whether they can be designated as primary care providers and assigned their own patient panels. Stricter SOP laws
are usually correlated with the level of autonomy granted to
mid-level providers through public and private payers, but
payers often impose additional restrictions.47 For example,
in Arkansas and Indiana, state law restricts nurse practitioners (NPs) from practicing independently of physicians, even
though they may provide essential services to their patients.
In these states, Medicaid does not recognize NPs as primary
care providers, and on these grounds, will not reimburse
preventive services performed by NPs.48 In addition, many
commercial health plans will not directly pay for primary care
services provided by NPs. By including mid-levels in the
definition of “primary care provider,” the scope and settings
in which they practice can be broadened. Payer policy reforms
may facilitate women receiving the care that they need, as
mid-level providers are more likely to educate and counsel
during the well-woman visit and work in underserved settings.
Supplement behavioral change specialists on well-woman
visit teams
Policy Strategies for Better Integration of Education and Counseling in Primary Care
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Conclusion
Diabetes Educators
Education is an important part of diabetes
management, but this kind of intensive education
is time consuming for providers and often requires
a referral for specialized outpatient education. To
address these barriers, the University of Pittsburgh
Diabetes Institute implemented the Chronic Care
Model in several rural Pennsylvania primary care
practices. This model places certified diabetes
educators (CDEs) in the practices on specified
days. The CDEs rotate among the 17 participating
practices and provide diabetes self-management
education (DSME) to patients as the point of
service, so they do not require a referral outside
the practice. Individuals who received the DSME
saw decreases in their A1C levels as well
as their LDL cholesterol levels.57
Patient education and counseling is an important but often
underused aspect of well-woman care. Barriers such as time
constraints, payment mechanisms, and patient and provider
perceptions often impede the delivery of these services, but
there are a number of policy solutions and other systemic
approaches that could better integrate education and
counseling into women’s primary care. Policies that make it
easier for practices to utilize mid-level providers, rely on
specialized staff such as certified educators and social
workers, and spend more time with patients increase the
chance that education and counseling will be delivered
effectively. In addition, strategies that provide health care
professionals with greater expertise and counseling skills or
promote alternative delivery systems that make education
and counseling a central component of their patient
engagement emphasis can improve access to key
education and counseling services. These changes
could lead to great improvements in women’s health,
which should be a key consideration for policymakers as
our health care system continues its movement towards
preventing disease and disability and lowering costs.
1American College of Obstetricians and Gynecologists. (2012). Well-Woman Care: Assessments & Recommendations. Obstet Gynecol, 120, 421-4.
2Riley, M., Dobson, M., Jones, E. & Krist, N. (2013). Health Maintenance in Women. American Family Physician, 87(1), 30-37.
3McGinnis, J. M., & Foege, W. H. (1993). Actual Causes of Death in the United States. Journal of the American Medical Association, 270(18), 2207-2212.
4Centers for Disease Control and Prevention. (2013). Leading Causes of Death in Females, United States, 2009. Retrieved from
http://www.cdc.gov/women/lcod/2009/index.htm
5Whitlock, E. P., Orleans, C., Pender, N., & Allan, J. (2002). Evaluating Primary Care Behavioral Counseling Interventions: An Evidence-based Approach.
American Journal of Preventive Medicine, 22(4), 267-284.
6Balasubramanian, B.A., Cohen, D.J., Clark, E.C., Isaacson, N.F., Hung, D.Y., Dickinson, L.M., Fernald, D.H., Green, L.A., Crabtree, B.F. (2008). Practice-Level Approaches
for Behavioral Counseling and Patient Health Behaviors. American Journal of Preventive Medicine, 35(5s): S407-S413.
7 Krueter, M., Chedda, S., & Bull, F. (2000). How does physician advice influence patient behavior? Archives of Family Medicine, 9(5, 426-433.
8Hartley, B.M. & O’Connor, M.E. (1996). Evaluation of the ‘Best Start’ breast-feeding education program. Archives Pediatric Adolescent Med, 150, 868-871.
9J. Hill, H. Bird, S. Johnson (2001). Effect of patient education on adherence to drug treatment for rheumatoid arthritis: a randomised controlled trial. Ann Rheum
Dis, 60,869–875.
10Ghisi GL, Abdallah F, Grace SL, Thomas S, and Oh P. (2014). A systematic review of patient education in cardiac patients: Do they increase knowledge and promote
health behavior change? Patient Education and Counseling, 95(2),160-174.
11 Maciosek MV, Coffield AB, Flottemesch TJ, Edwards NM, Solberg LI. (2010). Greater Use Of Preventive Services In U.S. Health Care Could Save Lives At Little Or No
Cost. Health Affairs, 29(9), 1656-1660.
12Centers for Disease Control and Prevention. (2009). The Power of Prevention. CDC: Atlanta, GA. Retrieved from
http://www.cdc.gov/chronicdisease/pdf/2009-power-of-prevention.pdf
13 Goetzel RZ. (2009). Do Prevention Or Treatment Services Save Money? The Wrong Debate. Health Affairs, 28(1), 37-41.
14 Maciosek, M.V., Coffield, A.B., Flottesmesch, T.M., Edwards, N.M. & Solberd, L.I. (2010). Greater use of preventive services in U.S. health care could save lives at little
or no cost. Health Affairs, 29(9), 1656-1660.
15US Burden of Disease Collaborators. (2013). The state of US health: 1990-2010. Burden of Diseases, Injuries, and Risk Factors. Journal of the American
Medical Association, 360(6), 591-608.
16U.S. Preventive Services Task Force (USPSTF). (2012). Guide to Clinical Preventive Services. Retrieved from
http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide/guide-clinical-preventive-services.pdf
17 Stormo, A., Saraiya M, Hing E, Henderson JT, Sawaya GF. (2014). Women’s Clinical Preventive Services in the United States: Who Is Doing What?
JAMA Internal Medicine [epub ahead of print].
18Primary care: Is there enough time for prevention. Kimberly, SH et al, 2003. 93(4), American Journal of Public Health. 635-641.
19Mirland, A., Beehler, G., Kuo, C. & Mahoney, M. (2002). “Physician Perception of Primary Prevention.” BMC Public Health, 16(2).
20Wolff, L. S., Massett, H. A., Weber, D., Mockenhaupt, R. E., Hassmiller, S., & Maibach, E. W. (2010). “Opportunities and barriers to disease prevention
counseling in the primary care setting: a multisite qualitative study with US health consumers.” Health Promotion International; 25(3), 265-276.
Policy Strategies for Better Integration of Education and Counseling in Primary Care
11 Dupont Circle NW, Suite 800, Washington, DC 20036 | 202.588.5180 Fax 202.588.5185 | www.nwlc.org
21Zon, R., Towle, E., Ndoping, M., Levinson, J., Colbert, A. & Williams, C. (2006). “Reimbursement for Preventative Counseling Services.” Journal of Oncology Practice,
2(5), 214-218.
22Wolff, L. S., Massett, H. A., Weber, D., Mockenhaupt, R. E., Hassmiller, S., & Maibach, E. W. (2010, April 22). Opportunities and barriers to disease prevention
counseling in the primary care setting: a multisite qualitative study with US health consumers. Health Promotion International, 25(3), 265-276.
23Whitlock, E. P., Orleans, C., Pender, N., & Allan, J. (2002). Evaluating Primary Care Behavioral Counseling Interventions: An Evidence-based Approach. American
Journal of Preventive Medicine, 22(4), 267-284.
24Ibid.
25Wolff, L. S., Massett, H. A., Weber, D., Mockenhaupt, R. E., Hassmiller, S., & Maibach, E. W. (2010, April 22). Opportunities and barriers to disease prevention counseling in the primary care setting: a multisite qualitative study with US health consumers. Health Promotion International, 25(3), 265-276.
26Mirland, A., Beehler, G., Kuo, C. & Mahoney, M. (2002). Physician Perception of Primary Prevention. BMC Public Health, 16(2).
27Ibid.
28Waalen, J. et al. (2000). “Screening for Intimate Partner Violence by Health Care Providers: Barriers and Interventions.” American Journal of Preventative Medicine,
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29Sugg, N. & Inui, T. (1992). “Primary Care Physicians’ Response to Domestic Violence.” Journal of the American Medical Association, 267 (23), 3157-3160.
30Ford, J., Barnes, R., Rompalo, A. Hook, E. (2013). Sexual Health Training and Education in the U.S. Public Health Reports, 128 (1), 96-101.
31 Lazarou, J. (2013). “What do Ob/Gyns in training learn about menopause? Not nearly enough, new study suggests.” Johns Hopkins Medicene. Retrieved on August
28, 2013 from http://www.eurekalert.org/pub_releases/2013-05/jhm-wdo050113.php.
32Miller NA, Kirk A, Alston B, Glos L. (2013). Effects of gender, disability, and age in the receipt of preventive services. The Gerontologist; 54(3): 473-487.
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35Nielsen M, Olayiwola JN, Grundy P, Grumbach K. (2014). The Patient-Centered Medical Home’s Impact on Cost & Quality: An annual update of the evidence, 20122013. Patient-Centered Primary Care Collaborative: Washington, DC.
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38
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40Jay MR, Gillespie CC, Schlair SL, Savarimuthu SM, Sherman SE, Zabar SR, Kalet AL. (2013). The impact of primary care resident physician training on patient weight
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44Cassidy A. (2013). Nurse practitioners and primary care. Health Affairs, Policy Brief.
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49Bruen et al 2013
50Tai-Seale & McGuire 2012
51Robinson, P., and J. Reiter. (2007). Behavioral Consultation and Primary Care: A Guide to Integrating Services. New York: Springer.
52Collins C, Hewson DL, Munger R, Wade T. (2010). Evolving models of behavioral health integration in primary care. New York: Milbank Memorial Fund.
53Funk, M. and G. Ivbijaro, eds. (2008). Integrating Mental Health into Primary Care: A GlobalPerspective. Geneva, Switzerland: World Health Organization and London,
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54 Reitz R, Fifield P, Whistler P. (2011). Integrating a behavioral health specialist into your practice. Family Practice Management, 18(1), 18-21.
55Baik SY, Bowers BJ, Oakley LD, Susman JL. (2005). The recognition of depression: the primary care clinician’s perspective. Ann Fam Med, 3(1), 31–37.; Younes N,
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56The Kaiser Commission on Medicaid and the Uninsured. (2014). Integrating physical and behavioral health care: Promising Medicaid models. Washington, DC:
Kaiser Family Foundation.
57
http://ndep.nih.gov/media/NDEP37_RedesignTeamCare_bw_508.pdf?redirect=true
Policy Strategies for Better Integration of Education and Counseling in Primary Care
11 Dupont Circle NW, Suite 800, Washington, DC 20036 | 202.588.5180 Fax 202.588.5185 | www.nwlc.org