Women’s Health: Part II

Show Notes

May is Women’s Health month, and Daniel sat down with Dr. Joanne Armstrong, Chief Medical Officer for Women's Health & Genomics at CVS Health, for both a tactical and macro-level look at how we all measure up to the rest of the world in this area — including prenatal, maternal, and postpartum care, as well as breast cancer and the latest studies on unconscious bias.

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Dr. Joanne Armstrong:
What we have done is essentially create a plumbing system, a system that sort of takes the patients right through to pre-screening, to counseling, to testing, to interpretation, closing the loop, making it personalized. It brings it right down to where you are, right here in your living room. You can do this. It is useful and it's based and grounded. It is low cost and it stays within the healthcare system. We think that's an example of trying to sort of live this mission in a complicated area that really needs some right sizing.

Dr. Daniel Kraft:
The plus side of all this, it really engages the individual, the new drug is the empowered patient who hopefully owns their data, understands that they're in partnership whether it's their OBGYN or their primary care doc or their oncologist.
Welcome to Healthy Conversations. I'm Dr. Daniel Kraft and I'm in conversation today with Dr. Joanne Armstrong. She's the Chief Medical Officer for Women's Health and Genomics at CVS Health.
Maybe tell us a little bit about your background and how you as an obstetrician and gynecologist sort of evolved into the field of women's health itself.

Dr. Joanne Armstrong:
So I'm an OBGYN by training. I've also been practicing OBGYN for a number of decades now and have always done that. So I've had the experience of working at the individual patient level, sort of always, but also always at a population level. They sort of go from micro to macro all the time. So then when you think about what is women's health, a lot of people think that it's just OBGYN care. It's really broader than that. It's sort of thinking about women over the course of their lifetimes. Much of it sits in reproductive health, but there's also this issue of more chronic disease care and women have, I think, some unique challenges when they access care.

Dr. Daniel Kraft:
Sort of my medical training it wasn't often that you'd see for women versus men that you need to differentiate drug selection or dosing. Now are you starting to see this concept of precision medicine meets women's health?

Dr. Joanne Armstrong:
Back in the day, women weren't even necessarily intentionally included in clinical trials. All the findings, how we think about heart disease, drugs, et cetera, we learned it on men. We assume that it applied evenly to women. That has disadvantaged women to really understand why their physiology might be different, why their disease presentation might be different. You start thinking about systems, again, going up to the macro level. What is it that's different about women's lives that can make it much harder to access care? I've got kids and parents, both of whom need a lot of attention and care from me. A one size fits all solution, whether it's actually addressing right at the physiology level or even the systems of care that we all have to navigate are unique for women compared to men. So this is evolution that we're actually thinking about all these things.

Dr. Daniel Kraft:
So that might tie into your new role at CVS Health as Chief Medical Officer for women's health. That's a pretty large purview.

Dr. Joanne Armstrong:
It is huge. It takes on average about 17 years for a clinical guideline to get into practice. 17 years. That's kind of crazy. Why does that happen? Some of it is just the total amount of knowledge that's being poured at us, at physicians. It's hard. How do you personalize it? The right person in the right place. We are also thinking about what role the patient plays.
So one of the examples that I'm working on now with a team of creative people at CVS Health is to look at this issue of a disease in pregnancy that's called preeclampsia. So preeclampsia is this kind of weird form of hypertension. It only happens in pregnant women and the only treatment for it is delivery. It's a major cause of preterm birth and low birth weight and a significant driver of maternal death in the country. What's neat about this is the preventive step for preeclampsia is low dose aspirin, 81 milligrams of aspirin. It costs three or $4 for an entire treatment course. It is safe, it is readily available.
So what we are doing is putting that educational focus on the patient. We can identify women who have risk for preeclampsia and send them both educational probation about risk factors and symptoms, but also give them the bottle of aspirin. So there's one simple gap that you close. It's, here it is, it's in your hands.
And then one of the areas that we're iterating on as it relates to preeclampsia is looking at it through the lens of disparities because preeclampsia is all also more common in black women, and black women tend to have more severe disease.

Dr. Daniel Kraft:
Preeclampsia has multiple factors from socioeconomic elements to racial, and one of your lead areas is genomics. Is that starting to integrate into care and now that you might be able to get your genetic test at your corner CVS?

Dr. Joanne Armstrong:
Yeah. We've done some really exciting work in this space. One of them is in the pregnancy area and one is in the area of breast cancer. A small but important proportion of all breast cancer is due to an inherited predisposition to cancer through something called B-R-C-A, BRCA gene. In the case of B-R-C-A testing and breast cancer, it is recommended that women get genetic counseling before they get tested and that they get post-test counseling to make sure that they use the results well. And the reason for that is the test results are associated with pretty severe clinical actions. Say you have breast cancer, the right surgical procedure may actually be a bilateral mastectomy and an oophorectomy, having your ovaries removed, at the same time. So it's really important that this is a coordinated function.
We have surveyed using our own members and our own data looking at what percent of women actually have genetic counseling before they get tested, and the answer is more than half of them do not. Why is that? And it turned out it's just the geographic distance between the provider and the genetic counselor. So if I see one, if I know one, I'll use them. In reaction to that, what we did first was develop a network of genetic counselors to make it telephonic, make it available all day on Saturday and bilingual, and then look for opportunities to sort of push that in.
So one of the things that we have done is to sort of take this model and think about other areas and that next place is in reproductive genetics. In pregnancy, women are recommended to get preconception counseling for a few different diseases like cystic fibrosis and SMA. So what we have developed this year, actually it just launched, is a genetic counseling and testing offering that's called Guided Genetic Health, which basically puts a series of pre-screening questions in front of patients that based on the answer, automatically takes them to a genetic counseling offering that is telephonic, and from there right into genetic testing, all at a very low cost.
What we have done is essentially create a plumbing system, a system that sort of takes the patients right through to pre-screening, to counseling, to testing, to interpretation, closing the loop, making it personalized. It brings it right down to where you are right here in your living room. You can do this. It is useful and it's based and grounded. It is low cost and it stays within the healthcare system. We think that's an example of trying to sort of live this mission in a complicated area that really needs some right sizing.

Dr. Daniel Kraft:
The plus side of all this, it really engages the individual. The new drug is the empowered patient who hopefully owns their data, understands it, they're in partnership, whether it's their OBGYN or their primary care doc or their oncologist here in the United States, very developed nation, but we're still quite low down on the spectrum in terms of risks and outcomes and both prenatal, postpartum care. Maybe you can help frame the crisis where we are now and where we need to go to improve outcomes. Particularly for those who have challenges with health equity.

Dr. Joanne Armstrong:
We rank somewhere around 35 in the world in maternal mortality, while it is not that common, there really should be zero. Right behind every maternal death is a huge hole left in a family, in a community and a whole ecosystem. So it's really devastating and that's just the leading edge of poor quality. So we are not doing well. Our maternal mortality rate is actually increasing compared to other countries.
For almost every measure of maternal and child health, black women perform worse. We have about three times the rate of maternal death. Twice the rate of infant death. Their children have twice the rate of preterm birth, which can have lifelong consequences for developmentally for a baby, higher rates of low birth weight for infants. So we're just really doing poorly overall and poorly in the area of disparities.
There is the other piece, which is the health care delivery system in this country is pretty fractured. A lot of women don't have care at all. There are 45 million American women, half of the pregnancies in this country are not planned. And when they're not planned, it means you lose your opportunity to optimize diabetes and your hemoglobin A1C, which is associated with birth defects and all sorts of bad things. You lose your ability to control hypertension, weight, connective tissue disorders, and a whole range of things.
When you look at what women tell us about their ability to get a visit for family planning, about one third of them say they have problems either because of cost or access, the amount of time it takes to get in. It turns out that for contraception planning, it also is one of the causes of maternal death actually, about 15% happen early in pregnancy through ectopic pregnancies and other sort of early pregnancy issues. So for CVS Health, we are, I think the only company whose pharmacists we've developed sort of at scale of pharmacy prescribing of contraception.
So a woman can walk into CVS to the pharmacy, fill out a phone survey that assesses for risk, and a pharmacist can prescribe it right there, no time wasted. Similarly, MinuteClinics in 33 states plus Washington DC have as one of their service's contraception planning. Something like eight out of every 10 individuals lives within 10 miles of a CVS, which means that contraception planning can go right down to the community level. So those are some of the ways that we're thinking about sort of public health, women's health and the capabilities that we have deep down in communities to really elevate women's health and solve problems that are real.

Dr. Daniel Kraft:
And it seems like an opportunity from preconception all the way through delivery and beyond, you have an opportunity to connect the dots for evaluation and guidance.

Dr. Joanne Armstrong:
So we don't envision it as a substitute for prenatal care at all. The blood work can get started, the evaluation can take place, and then those patients are referred to physicians in their town. The other thing that happens in that, it may not be called a preconception visit, but the question is, what's your intention this year? Why don't we get that A1C optimized? Let's think about other things that we can do here because we are capturing you right now. You know, you have to take advantage of the opportunity you have in front of you. And if one of those things is, I'm coming in for a pregnancy test, let's talk about it.

Dr. Daniel Kraft:
We're also seeing other, not new players, but doulas for example, have been around for a long time, but haven't got a huge amount of attention. Have you seen that changing?

Dr. Joanne Armstrong:
Because they are not licensed and credentialed they're not providers under health plans. Yet the services are valuable. So there have been two Cochrane reviews and they are associated with lower rates of C-sections, higher rates of spontaneous deliveries, one good quality study that showed that they were associated with lower rates of preterm birth. And where they seem to be most helpful, it's not rocket science, is that they're most helpful for people who have the least amount of support. So it can be younger patients, poorer patients and black patients or other patients have difficulty navigating the system because the system treats them sort of unfairly and makes them invisible, doesn't hear them. For just our employer group for CVS Health, we actually started covering them as part of a wellness benefit this January, so our employees can use that to cover doula services.

Dr. Daniel Kraft:
I wonder if there's opportunity for the father doula to help integrate into the whole thing.

Dr. Joanne Armstrong:
Well, there is an opportunity for father doula. Part of our evaluation is to see what kind of support people have at home, including what fathers need. Everybody needs more help, and I think in this environment it's just laid bare how much support we really need to get through key medical events in life.

Dr. Daniel Kraft:
Clearly race is one component, but maybe you could help us dissect what, beyond the core racial element, really drives the disparities and potentially some of the ways to address them.

Dr. Joanne Armstrong:
I will say though, the drivers of the difference in clinical outcomes in maternal and child health is explained only partially by risk factors, underlying risk factors. It's also only partially explained by the systems of care that patients' access. It is also explained by bias and racism and there's now a decent amount of literature that sort of points to that. It is at the individual level, it is unconscious bias. I think few physicians, no physician would wake up saying, "I'm going to treat this person differently", but we come into life with our ingrained assumptions. These are unconscious at the individual level, but when you roll it all up, what the patient's experience is a systematic level of racism. So how do you address those things? Obviously paying attention to underlying risk factors is important. Looking at the systems of care, that is harder.
There's even data that shows, it's not explainable, but black children have worse outcomes when cared for by white physicians. But as you get to this issue of unconscious bias, our own assumptions about patients, assumptions about pain, there's literature that says that the physicians assume black patients can handle more pain. So what happens in a delivery environment? You say your eight centimeters dilated, you don't need an epidural because I think you can handle it. I've seen that before. That's how it plays out. Certainly training is needed, but we also need to give patients tools so that they can recognize that, get some allies and sort of fight through it. At a system level we are also embarking on non-biased training for our clinical people.
So we have a long way to go in this country. I think there's a lot of data now coming out to help us understand what bucket this dynamic sort of lives in. So it's going to take a lot of work.

Dr. Daniel Kraft:
And that sort of comes back to, I guess, as you mentioned, our medical education.

Dr. Joanne Armstrong:
Unconscious bias means we're not even thinking about it, but we are acting that way. But it really is an individual responsibility. My own personal experience is that we think we live in somebody else's shoes, but we really don't. So we've had this really amazing experience here at CVS Health. We have worked with our black colleague resource group. We call it a BCRG.
We sent out an email to our BCRG members to ask if anyone would be willing to have a conversation just to share their birth stories with us. Within about two hours, 40 people wrote to say, "I have a story." By about five days we had something like 95 women say, "I want to share with you my story." That's unheard of. I've been here a long time, I've never seen that.
We organize forums of patients and of employees and their stories are painful, and the themes that come out of that are that care is not personalized. They are not seen as sort of individuals. They kind of represent a motif of a patient, but not an actual individual patient. Two respondents were actually physicians here in the company who said that they experience it themselves. They hold their physician credentials back to see how they're treated, and then they have to pull out that card to say, no, this conversation is not okay. And again, it's part of this non-conscious bias. We think we know, but we don't.

Dr. Daniel Kraft:
Are there any other tools that you've seen that are really help work?

Dr. Joanne Armstrong:
I am finding personally that just sharing stories is very powerful. So we need a forum and we're creating that here to bring physicians in and others in to sort of learn about this. One comment that one person made, her child died shortly after birth, and she told us, and this happened 20 years ago, that she's carried this, how she was treated, and she felt that she was sort of held accountable for this infant's death. She's carried this with her for 20 years.
This forum, talking about it in the presence of other people, including physicians. And she always thought it was on her. And somebody else, another participant said, "I felt the same thing, but what I'm realizing is that the system failed me." That's not the same as policy changes, but personalizing each other. Seeing each other as a full human sort of starts with just asking, "Tell me about you and I mean you, not a concept of you but you."

Dr. Daniel Kraft:
So wrapping up, speaking directly to healthcare providers, anything you'd like to add?

Dr. Joanne Armstrong:
We are very interested in working with physicians to figure out how we can speed that 17 year cycle to get to best practice and working with professional colleges and others to help us get there.

Dr. Daniel Kraft:
Thank you very much for joining us in Healthy Conversations and all your work. It's a time where we can really, I think, start to converge the players, the payers, the technology, the patients to really impact maternal health, women's health probably around the planet. So thanks for everything you're doing.

Dr. Joanne Armstrong:
Thank you.