Investigating barriers to menopause care for Medicaid patients

During an EMT shift at her local ambulatory clinic, rising third-year Eri Maeda unlocked a new research interest: menopause health care dynamics in the U.S.—including how insurance status can shape access to menopause care.

After treating a female patient who had confused menopause-related signs with heart attack symptoms, Maeda—a neuroscience major on a pre-medicine track in the College of Arts & Sciences—felt called to explore the link between societal gaps in menopause awareness, the extent to which menopause management is prioritized in U.S. health care, and the factors that may prevent menopausal women from getting the care they need.

These curiosities, heightened by learning more about Medicaid in health care management courses at Penn, primed Maeda to pursue a Penn Undergraduate Research Mentoring Program (PURM) project examining patient access to Menopause Society Certified Providers (MSCPs) both in general and based on insurance type.

MSCPs are clinicians with specialized training and credentials in menopause care. However, there is a shortage of MSCPs in the U.S.—and many states have administrative barriers that can de-incentivize MSCPs from providing timely, affordable care, particularly to Medicaid patients. For example, Maeda notes that insurance status is a key indicator for hormone replacement therapy (HRT), which can be the first line of menopause care.

“Medicaid patients are 50% less likely to get HRT than privately insured counterparts,” says Maeda, who grew up in Menlo Park, California, and moved to Philadelphia during the COVID-19 pandemic.

The “secret shopper study” involved calling MSCP clinics while masked as prospective patients with different insurance types. This undercover approach has prepared Maeda—and her PURM faculty mentor, Arina Chesnokova, assistant professor in the Department of Obstetrics and Gynecology at the Perelman School of Medicine—to assess overall access to MSCPs, as well as compare how administrative and reimbursement differences in Medicaid programs by state can shape access.

PURM, organized by the Center for Undergraduate Research & Fellowships, enables students finishing their first or second year at Penn to pursue a 10-week summer research experience under the mentorship of a standing faculty member. Students receive $5,000 to support their program participation. Through her PURM project, Maeda can help inform state-based policies that enhance menopause management in the U.S. and improve access for Medicaid patients.

“Part of our analysis is seeing whether MSCPs say they accept Medicaid on their websites,” says Maeda. Using this data, she can gauge “realized access”—in this case, whether MSCPs follow through on providing Medicaid patients with menopause care.

Unmasking barriers to menopause care

To determine realized access, Maeda recorded various data when calling MSCPs, such as how soon patients can secure appointments; the length of time placed on hold; whether patients are seeking telehealth or in-person visits; the number of administrative tasks required of new patients; and whether they can book appointments at all.

One surprising observation, Maeda says, was that in many cases, prospective patients with Medicaid often “don’t get the appointment at all.” She notes how these patients are sometimes placed on hold for long periods of time or even transferred to other lines—which may push many to give up. Maeda found this happens regardless of whether Medicaid patients seek in-person or telehealth visits.

“I didn’t understand how disheartening this process can be until I actually began calling,” she says.

She also examined the impact of Medicaid reimbursement costs and administrative burdens unique to each state. Some U.S. states have higher claims denial rates, some take longer to reimburse clinicians, and some have lower reimbursement rates than others—even though all have lower reimbursement rates compared to private insurance. This can reduce the number of MSCPs willing to accept new Medicaid patients.

“We’re expecting to see a lot of claimed Medicaid providers not actually providing care,” Maeda says. “A big part of that is because even if they do accept Medicaid, they often put a limit on how many patients they are willing to have at one time with Medicaid. If their internal quota is already full, oftentimes they won’t be accepting any more.”

“We’re excited to see how much of a difference there is between states with high and low reimbursement costs,” Maeda says, compared to states with “high and low administrative burden.” Medicaid patients in states with high reimbursement costs and low administrative burdens may be more likely to access care.

The impact of PURM mentorship

Early in her PURM experience, Maeda struggled to focus the scope of her research. Chesnokova’s guidance, with an emphasis on thinking systematically and promoting autonomy, helped Maeda find a relevant and promising approach.

“She’s gaining a lot of valuable skills in terms of the basics of finding literature, compiling articles, finding software that helps you organize papers, [and] distilling information into words that are digestible,” Chesnokova says.

Maeda notes several paths forward for this research. One route, she says, involves a closer look at telehealth and “MSCP deserts.” These areas have a scarcity of MSCPs, partially due to state-based challenges in obtaining and maintaining credentials. MSCP deserts also tend to have higher poverty rates, more people using public insurance, and more rural-based populations who rely on telehealth services.

“I’m eager to see if [telehealth] could serve Medicaid patients in MSCP deserts, and this secret shopper approach could reveal many other hidden healthcare barriers,” Maeda says.

This research, Chesnokova says, can inform the development of the menopause care workforce in the U.S. and help prioritize expanded access to MSCP certification.

Chesnokova also notes that Maeda has already generated the data and evidence needed to be “immediately actionable from a policy standpoint.” She is ensuring Maeda has more opportunities to expand this research long after summer concludes—one of many long-term benefits that Penn undergraduates can gain from the PURM experience.