Health Care Reform Efforts Research Articles

The Kubler-Ross model, physician distress, and performance reporting

Physician performance reporting has been proposed as an essential component of health-care reform, with the aim of improving quality by providing transparency and accountability. Despite strong evidence demonstrating regional variation in practice patterns and lack of evidence-based care, public outcomes reporting has been met with resistance from medical professionals. Application of the Kubler-Ross 'five stages of grief' model--a conceptual framework consisting of a series of emotional stages (denial, anger, bargaining, depression, and acceptance) inspired by work with terminally ill patients--could provide some insight into why physicians are reluctant to accept emerging quality-reporting mechanisms. Physician-led quality-improvement initiatives are vital to contemporary health-care reform efforts and applications in urology, as well as other medical disciplines, are currently being explored.

Towards an expanded definition of value

Much of the change being sought in the United State's health-care system is predicated on improving value. Value is most simply defined as quality divided by cost, and physicians increasingly rely on the quality-adjusted life year as the numerical measure to justify their services. However, there are many other definitions of value being advocated by various stakeholders in the health-care reform effort. Incentive programs and pilot studies implemented by private and public payers are steering much of the current change. Expanding our understanding of how value is defined by health-care economists and policy makers can help spine providers navigate the evolving health-care landscape.

Delayed and Denied: Toward an Effective ERISA Remedy for Improper Processing of Healthcare Claims

The healthcare reform effort culminating in the Patient Protection and Affordable Care Act (PPACA) has focused, to date, on the plight of the uninsured and on barriers to insurance such as pre-existing condition exclusions. Reform efforts focus less often, however, on threats to healthcare benefits for people who do have health insurance. When insured individuals suffer a serious illness, does their insurance live up to its promise? One overlooked threat to the insured concerns administration of employer-sponsored health insurance plans. Specifically, participants' benefits are threatened by the lack of consequences when administrators of such plans improperly process claims for healthcare benefits by delaying the decision, failing to conduct a complete review, or simply denying the claim incorrectly.

The Future of Health Care Reform Remains in Federal Court

National Federation of Independent Business v. Sebelius did not mark the end of litigation challenging the Patient Protection and Affordable Care Act (PPACA) against constitutional attack. To the contrary, PPACA litigation continues apace and could well increase in the years to come as federal agencies seek to implement the health care reform law. This essay provides a brief overview of how continuing litigation in federal court will affect the implementation – and perhaps even the ultimate viability – of Congress’s latest and most ambitious health care reform effort. Topics discussed include legal challenges to the availability of tax credits in federally run health insurance exchanges and a requirement that group health plans cover contraception, and prospective challenges to the Independent Payment Advisory Board and revisions to the individual mandate penalty.

The Growing Shortage of Vascular Neurologists in The Era of Health Reform

The incidence of stroke has surpassed 800 000 cases each year, and acute stroke has become the leading cause of disability in the United States. Given that a person’s chronological age is a primary risk factor,1 and the United States will be experiencing exponential growth in the elderly population over the next 20 years, the incidence of stroke will grow substantially and the demand for dedicated stroke care will increase accordingly.2 In this report, we consider contemporary evidence-based practices for stroke care, the supply of vascular neurologists (VNs) and neurointerventionalists (NIs), potential causes for the supply–demand imbalance, and solutions aimed to increasing the supply of VNs within the ongoing healthcare reform effort. Evidence-based practices for stroke include medical interventions applicable to every patient and invasive endovascular interventions applicable only to a smaller subset of qualified patients. One of the most common evidence-based medical approaches for treating acute stroke includes use of recombinant tissue plasminogen activator in eligible patients given within 4.5 hours of when they were last seen normal,3 a treatment that is delivered most effectively within dedicated acute care stroke units with established clinical pathways for secondary prevention and management.4 In 2003, the Primary Stroke Center Certification program of the Joint Commission initiated an effort to increase the number of units with expertise in delivering evidence-based medical stroke care.5 A key component of these units is a stroke team, offering 24/7 coverage by physicians with advanced knowledge of evaluating and treating acute vascular diseases and who are able to recommend best emergent and preventive management.6 It has since become best practice in stroke treatment and management7 to incorporate these stroke units within a regional hub and spoke network in which the unit (ie, the hub) supports satellite clinics with video-based telemedicine8 …

Direct economic burden of hepatitis B virus related diseases: evidence from Shandong, China

BackgroundAlthough the expenses of liver cirrhosis are covered by a critical illness fund under the current health insurance program in China, the economic burden associated with hepatitis B virus (HBV) related diseases is not well addressed. In order to provide evidence to address the economic disease burden of HBV, we conducted a survey to investigate the direct economic burden of acute and chronic hepatitis B, cirrhosis and liver cancer caused by HBV-related disease.MethodsFrom April 2010 to November 2010, we conducted a survey of inpatients with HBV-related diseases and who were hospitalized for seven or more days in one of the seven tertiary and six secondary hospitals in Shandong, China. Patients were recorded consecutively within a three-to-five month time period from each sampled hospital; an in-person survey was conducted to collect demographic and socio-economic information, as well as direct medical and nonmedical expenses during the last month and last year prior to the current hospitalization. Direct medical costs included total outpatient, inpatient, and self-treatment expenditures; direct nonmedical costs included spending on nutritional supplements, transportation, and nursing. Direct medical costs during the current hospitalization were also obtained from the hospital financial database. The direct economic cost was calculated as the sum of direct medical and nonmedical costs. Our results call for the importance of implementing clinical guideline, improving system accountability, and helping secondary and smaller hospitals to improve efficiency. This has important policy implication for the on-going hospital reform in China.ResultsOur data based on inpatients with HBV-related diseases suggested that the direct cost in US dollars for acute hepatitis B, severe hepatitis B, chronic hepatitis B, compensated cirrhosis, decompensated cirrhosis and primary liver cancer was $2954, $10834, $4552, $7400.28, $6936 and $10635, respectively. These costs ranged from 30.72% (for acute hepatitis B) to 297.85% (for primary liver cancer) of the average annual household income in our sample. Even for patients with health insurance, direct out-of-pocket cost of all HBV-related diseases except acute hepatitis B exceeded 40.00% of the patient’s disposable household income, making it a catastrophic expenditure for the household.ConclusionHepatitis B imposes considerable economic burden on a family. Our findings will help health policy makers’ understanding of the magnitude of the economic burden of HBV-related diseases in China. Evidence from our study also contributes to our understanding of potential benefits to society from allocating more resources to preventing and treating HBV infection, as well as increasing insurance coverage in China. These findings have important policy implications for health care reform efforts currently underway in China focusing on how to reduce the burden of catastrophic disease for its citizens.

Primary payer status is significantly associated with postoperative mortality, morbidity, and hospital resource utilization in pediatric surgical patients within the United States

PurposeCurrent healthcare reform efforts have highlighted the potential impact of insurance status on patient outcomes. The influence of primary payer status (PPS) within the pediatric surgical patient population remains unknown. The purpose of this study was to examine risk-adjusted associations between PPS and postoperative mortality, morbidity, and resource utilization in pediatric surgical patients within the United States. MethodsA weighted total of 153,333 pediatric surgical patients were evaluated using the national Kids' Inpatient Database (2003 and 2006): appendectomy, intussusception, decortication, pyloromyotomy, congenital diaphragmatic hernia repair, and colonic resection for Hirschsprung's disease. Patients were stratified according to PPS: Medicare (n=180), Medicaid (n=51,862), uninsured (n=12,539), and private insurance (n=88,753). Multivariable hierarchical regression modeling was utilized to evaluate risk-adjusted associations between PPS and outcomes. ResultsOverall median patient age was 12years, operations were primarily non-elective (92.4%), and appendectomies accounted for the highest proportion of cases (81.3%). After adjustment for patient, hospital, and operation-related factors, PPS was independently associated with in-hospital death (p<0.0001) and postoperative complications (p<0.02), with increased risk for Medicaid and uninsured populations. Moreover, Medicaid PPS was also associated with greater adjusted lengths of stay and total hospital charges (p<0.0001). Importantly, these results were dependent on operation type. ConclusionsPrimary payer status is associated with risk-adjusted postoperative mortality, morbidity, and resource utilization among pediatric surgical patients. Uninsured patients are at increased risk for postoperative mortality while Medicaid patients accrue greater morbidity, hospital lengths of stay, and total charges. These results highlight a complex interaction between socioeconomic and patient-related factors, and primary payer status should be considered in the preoperative risk stratification of pediatric patients.

Cost, Coverage, and Comparative Effectiveness Research: The Critical Issues for Oncology

A new national initiative in comparative effectiveness research (CER) is part of a broad and long-term evolution toward greater reliance on scientific evidence in clinical practice and medical policy. But CER has been controversial because of its high profile in the health care reform effort, its instantiation in a prominent new national research institute, and lingering concerns that the ultimate goal of CER is to empower the government and private insurers to reduce health care costs by restricting access to expensive new medical tests and treatments. This article presents an analysis of the policy development behind CER and focuses on its potential impact on insurance coverage and payment for oncology services. By itself, CER will not solve the tension that exists between the goal of innovative, personalized care and the eroding affordability of cancer treatment in the United States. But CER does offer an important opportunity for progress. Oncologists have taken important first steps in acknowledging their responsibility for addressing cost issues; as a professional society, they should now move forward to assume leadership in the effort to integrate clinical evidence with considerations of cost effectiveness to guide clinical practice and insurer policies.

Audiology Groups Alert Members to Service Delivery Changes

You have accessThe ASHA LeaderASHA News1 Oct 2012Audiology Groups Alert Members to Service Delivery Changes Ingrida Lusis Ingrida Lusis Google Scholar More articles by this author https://doi.org/10.1044/leader.AN2.17122012.7 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In Audiologists need to prepare for changes in audiology service delivery models that may affect the way they operate their practices, according to the three national organizations representing audiologists. That’s the message conveyed in an August letter [PDF]—signed by the leaders of ASHA, the American Academy of Audiology, and the Academy of Doctors of Audiology—sent to audiology members of all three organizations. The letter urges audiologists to review their current delivery systems as consumer-driven health care takes center stage in recent federal health care reform efforts. The organizations developed the joint letter in response to the growing number of consumers who purchase hearing aids online or from their health insurance companies. The letter provides a list of questions audiologists can use to assess their current practice models: What role does the sale of hearing aids play in your practice model? Do you have options in place to accommodate consumers who arrive at your practice with a hearing aid purchased elsewhere? Are the costs associated with the care you provide transparent to the patient? If appropriate, do you itemize the cost of your services? When discussing amplification and other treatment, do you offer patients options? Do you engage family and others to support the patient with hearing loss? Do you charge your patients appropriately for the products and services that you provide? Are you familiar with policies of competitive entities in your immediate locale? Are your services clearly defined and valued in your contracts with payer groups? Do you provide treatment for hearing loss that reflects the full scope of practice for audiology? Do you provide information on hearing assistive technology, listening training, and counseling—all of which could expand and enhance the service delivery model for your patients? How do you plan to engage consumers to facilitate and enhance access to your services? Do you use or have you considered employing audiology assistants to provide appropriate care under your supervision, thereby enabling you to expand professional services for your patients? Are you aware of your professional code of ethics, state licensure rules, and legal and regulatory guidelines that affect your specific practice setting (e.g., anti-trust policy, coding and billing practices)? Do you employ established best practices (verification, counseling, etc.) to ensure and improve patient outcomes? Do you measure patient satisfaction? The letter also provides a list of resources to help clinicians navigate changes. The Hearing Loss Association of America (HLAA), the nation’s leading organization representing people with hearing loss, issued a press release praising the three organizations for supporting consumer needs and setting a path for audiologists to evaluate how their practices will respond to and operate in a new hearing health care delivery system. Brenda Battat, HLAA executive director, called the letter a “watershed event for consumers” that validates HLAA’s advocacy for accessible and affordable hearing health care. For more information about changes in hearing health care service delivery, contact Pam Mason, MEd, CCC-A, director of audiology professional practices, at [email protected]. Author Notes Ingrida Lusis, director of federal and political advocacy, can be reached at [email protected]. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 17Issue 12October 2012 Get Permissions Add to your Mendeley library History Published in print: Oct 1, 2012 Metrics Current downloads: 44 Topicsasha-topicsleader_do_tagasha-article-typesleader-topicsCopyright & Permissions© 2012 American Speech-Language-Hearing AssociationLoading ...

A Social Justice Perspective on Medicare Part D in an Age of Reform: Critical Implications of Trends in Health Care Policy and Advocacy

This article examines the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) in its current form and explains why a critical perspective is useful when analyzing the policy and reform efforts. Using this approach, we consider the development of the policy and describe ways that gender and racial differences may hinder equal access to medications for some of the most vulnerable older adults. This article explores the implications of gender and racial disparities under the MMA and ramifications of health care reform efforts that could potentially impede, rather than promote, a social justice agenda. Beyond the political advantage of the MMA's current structure, reconsideration should include the potentialfor disproportionate negative economic and health effects for women and people in historically disadvantaged minority groups.

Understanding the Failure of Health-care Exceptionalism in the Supreme Court's Obamacare Decision

On June 28, 2012, a mere century after the first presidential proposal for national health insurance, the Supreme Court issued a resounding victory for President Obama and for health-care reform generally, upholding the Patient Protection and Affordable Care Act against a serious constitutional challenge. Nevertheless, the Court also struck a potential blow to future health-care reform efforts in refusing to accept the solicitor general's argument that health care is a unique market with unique regulatory needs that justify special constitutional treatment. The failure of health-care exceptionalism in the Court's opinion might render future reform efforts more difficult than they would have been if the solicitor general's argument had carried the day. This commentary seeks to shed light on the Court's hesitation to recognize the uniqueness of health insurance and health care, noting that market-based exceptionalism in constitutional law has a long, dark history that the Court was understandably loath to repeat. Although the result of Chief Justice John Roberts' one-size-fits-all approach to constitutional analysis in this case is an odd holding that elides some genuine uniqueness of American health care, the alternative of health-care exceptionalism might have been much worse for our overall constitutional system.

Value Generation and Health Reform in Emergency Medical Services

American Emergency Medical Services (EMS) agencies largely have been untouched by the dramatic health care reform efforts underway, although change seems imminent. Clarifying the role of the modern EMS system, and the yardsticks used to evaluate its performance, will be a challenge.This paper introduces the concept of value (or outcomes to cost ratio) in EMS, and offers value assessment as a means by which reform decisions can be framed. The best reform decisions are those that optimize both costs and outcomes. This includes: (1) attention to the patient experience; (2) disallowing the provision of unhelpful, harmful or disproven prehospital care; and (3) expanding patient dispositions beyond Emergency Departments. Costs of care will need to be tracked carefully and acknowledged. Value generation should serve as the goal of ongoing EMS reform efforts.

The value of health information exchange

The value of health information exchange Joshua E Richardson, Erika L Abramson, Rainu KaushalCenter for Healthcare Informatics and Policy, Weill Cornell Medical College, New York, NY, USAAbstract: Health information exchange (HIE) is a key component of health care reform that enables clinical data sharing between providers, patients, and health care organizations. The value of HIE rests in the promise that more efficient and effective access to clinical data will improve patients&rsquo; condition-specific outcomes relative to the costs. For example, improvements in outcomes may result from fewer medical errors and improved adherence to evidence-based recommendations, whereas reductions in costs may result from fewer duplicate tests and improved care coordination. However, even though health care reform efforts promote HIE as a way to improve care and curb costs, few studies demonstrate these results. We have organized the available evidence at national and regional levels to report on costs and benefits associated with HIE, and identify potential areas of future research.Keywords: health information exchange, interoperable systems, health information technology, economic assessment, evaluation

Advancing primary care to promote equitable health: implications for China

China is a country with vast regional differences and uneven economic development, which have led to widening gaps between the rich and poor in terms of access to healthcare, quality of care, and health outcomes. China's healthcare reform efforts must be tailored to the needs and resources of each region and community. Building and strengthening primary care within the Chinese health care system is one way to effectively address health challenges. This paper begins by outlining the concept of primary care, including key definitions and measurements. Next, results from a number of studies will demonstrate that primary care characteristics are associated with savings in medical costs, improvements in health outcomes and reductions in health disparities. This paper concludes with recommendations for China on successfully incorporating a primary care model into its national health policy, including bolstering the primary care workforce, addressing medical financing structures, recognizing the importance of evidence-based medicine, and looking to case studies from countries that have successfully implemented health reform.

Migration, remittances, and health care utilization in Ecuador

To examine the relationship between migration and migrant remittances and health care utilization in Ecuador, and to identify any potential equalizing effects. Using data from the 2004 National Demographic and Maternal & Child Health Survey (ENDEMAIN), a multilevel multivariate analysis was conducted to assess the relationship of two migrant predictors (households with an international migrant; use of migrant remittances) with use of preventive care, number of curative visits, hospitalization, and use of antiparasitic medicines. Relevant predisposing, enabling, and need factors were included following Andersen's Model of Health Care Utilization Behavior. Interaction terms were included to assess the potential equalizing effects of migration and remittances by ethnicity, area of residence, and economic status. Migrant predictors were strongly associated with use of antiparasitic medicines, and to a lesser extent, with curative visits, even after adjusting for various predisposing, enabling, and need factors. Interaction models showed that having an international migrant increased use of these services among low-income Ecuadorians (quintiles 1 and 2). No significant relationship was found between migrant predictors and use of preventive services. Migration and remittances seem to have an equalizing effect on access to antiparasitic medicines, and to a lesser extent, curative health care services. Health care reform efforts should take into account the scope of this effect when developing public policy.

Hospital Religious Affiliation and Outcomes for High-Risk Infants

The effect of hospital organizational affiliation on perinatal outcomes is unknown. Using the 2004 American Hospital Association Annual Survey and Healthcare Cost and Utilization Project State Inpatient Databases, the authors examined relationships among organizational affiliation, equipment and service availability and provision, and in-hospital mortality for 5,133 infants across five states born with very low and extremely low birth weight and congenital anomalies. In adjusted bivariate probit selection models, the authors found that government hospitals had significantly higher mortality rates than not-for-profit nonreligious hospitals. Mortality differences among other types of affiliation (Catholic, not-for-profit religious, not-for-profit nonreligious, and for-profit) were not statistically significant. This is encouraging as health care reform efforts call for providers at facilities with different institutional values to coordinate care across facilities. Although there are anecdotes of facility religious affiliation being related to health care decisions, the authors did not find evidence of these relationships in their data.

Do You Know Quality Care When You See It?

The mission of the Oncology Nursing Society (ONS) is to promote excellence in oncology nursing and quality cancer care, but have you ever considered how that mission comes to life in your daily practice? Just as it can be challenging to describe the essence of nursing practice beyond listing specific tasks we perform each day, it may be difficult to routinely identify high-quality care. Our time is often drawn to clearly problematic areas of clinical care. Although this always will be necessary, changes associated with healthcare reform, reimbursement, and accreditation efforts highlight the need to also demonstrate consistently good clinician performance and patient outcomes. Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), defined healthcare quality as “getting the right care to the right patient at the right time—every time” (AHRQ, 2009, “What Is Quality?” para. 1). Do you know what the “right care” is? Can you demonstrate that it consistently is provided in your practice? Although many nurses might reply that they simply recognize good care when they see it, standards of care should be derived from a strong evidence base; high-quality care that achieves those standards can be quantified and compared across organizations through use of nationally tested quality measures. Evidence-based nursing practice (EBP) is not a new concept, and the link between EBP and quality cancer care is a critical one. In “Advocating for Quality Cancer Care: Making Evidence-Based Practice a Reality,” ONS member Kathi Mooney noted the need to transform the nursing role from a traditional “doer” based on local policy or personal preferences to one of a clinical “knowledge worker” with an everchanging evidence base (Mooney, 2001). Without a doubt, keeping abreast of rapidly changing clinical information is a daunting task. ONS strives to provide a wide range of resources to help keep nurses up to date on the latest evidence important to those providing care to patients with cancer. The 2012–2016 ONS Strategic Plan addresses four pillars on which to focus efforts—knowledge, leadership, technology, and, for the first time, quality. Resources from all four areas provide oncology nurses what they need to recognize and illustrate high-quality cancer care (see Figure 1). a ONS Research Agenda and ONS Foundation grant-making EBP—evidence-based practice; ONS—Oncology Nursing Society; PEP—Putting Evidence Into Practice

Quality and Safety in Medical Care: What Does the Future Hold?

The rapid changes in health care policy, embracing quality and safety mandates, have culminated in programs and initiatives under the Patient Protection and Affordable Care Act. To review the context of, and anticipated quality and patient safety mandates for, delivery systems, incentives under health care reform, and models for future accountability for outcomes of care. Assessment of the provisions of Patient Protection and Affordable Care Act, other reform efforts, and reform initiatives focusing on future quality and safety provisions for health care providers. Health care reform and other efforts focus on consumerism in the context of price. Quality and safety efforts will be structured using financial incentives, best-practices research, and new delivery models that focus on reaching benchmarks while reducing costs. In addition, patient experience will be a key component of reimbursement, and a move toward "retail" approaches directed at the individual patient may supplant traditional "wholesale" efforts at attracting employers. Quality and safety have always been of prime importance in medicine. However, in the future, under health care reform and associated initiatives, a shift in the paradigm of medicine will integrate quality and safety measurement with financial incentives and a new emphasis on consumerism.

American Diabetes Association Postgraduate Meetings—2011

At the American Diabetes Association(ADA) Postgraduate Meetings held 25–26 February 2011 in New York, a discussion of health-care reform and diabetes was opened by Herbert Pardes, chief executive officer of New York-Presbyterian Hospital, who stated that “the focus on health care by the entire country … and the world has never been so great.” His medical center is one of the largest hospital networks in the country, with 2,300 beds and two medical schools, and is the largest private enterprise in New York. He discussed the Naomi Berry Diabetes Center, treating >10,000 diabetic individuals, with one of the largest pediatric diabetes practices in the U.S. At the Weill Cornell Hospital, surgical treatment for diabetes is being studied. Safety programs are being developed in hand washing and in error prevention. Information technology is being expanded, with (as an example) software tools to reduce deep vein thrombosis. More online access to medical records by patients and initiatives such as health information exchanges are being studied to avoid “costly, redundant tests.” Hospitals around the country are, along with politicians and the general public, focusing on health-care reform because of increasing costs, large numbers of uninsured individuals, and increasing numbers of individuals with chronic diseases, in part because of increasing longevity. Cost-effectiveness is an issue, with the U.S. ranking first in per capita spending but far lower in health outcomes. “A lot of populations,” Pardes said, “are not getting the kind of care that they should.” Health-care reform efforts include measures to increase coverage, eliminate exclusions for preexisting illnesses and “lifetime caps,” allow older dependent children to remain on parents’ plans, and to eliminate costs to patients for annual preventive care. All these concepts are relevant to the treatment of diabetes. Quality has also become an important focus, with proposals that “the provider needs …

Access to Care for Women Veterans: Delayed Healthcare and Unmet Need

Timely access to healthcare is essential to ensuring optimal health outcomes, and not surprisingly, is at the heart of healthcare reform efforts. While the Veterans Health Administration (VA) has made improved access a priority, women veterans still underutilize VA healthcare relative to men. Eliminating access disparities requires a better understanding of the barriers to care that women veterans' experience. We examined the association of general and veteran-specific barriers on access to healthcare among women veterans. Cross-sectional, population-based national telephone survey of 3,611 women veterans. Delayed healthcare or unmet healthcare need in the prior 12 months. Of women veterans, 19% had delayed healthcare or unmet need, with higher rates in younger age groups (36%, 29%, 16%, 7%, respectively, in 18-34, 35-49, 50-64, and 65-plus age groups; p < 0.001). Among those delaying or going without care, barriers that varied by age group were: unaffordable healthcare (63% of 18-34 versus 12% of 65-plus age groups); inability to take off from work (39% of those <50); and transportation difficulties (36% of 65-plus). Controlling for age, race/ethnicity, regular source of care, and health status, being uninsured (OR = 6.5; confidence interval [CI] 3.0-14.0), knowledge gaps about VA care (OR = 2.1; 95% CI 1.1-4.0), perception that VA providers are not gender-sensitive (OR = 2.4; CI 1.2-4.7), and military sexual assault history (OR = 2.1; CI 1.1-4.0) predicted delaying or foregoing care, whereas VA use and enrollment priority did not. Both general and veteran-specific factors impact women veterans' access to needed services. Many of the identified access barriers are potentially modifiable through expanded VA healthcare and social services. Health reform efforts should address these barriers for VA nonusers. Efforts are also warranted to improve women veterans' knowledge of availability and affordability of VA healthcare, and to enhance the gender-sensitivity of this care.