The Hidden Economics of Women's Health

Dr. Jocelyn Fitzgerald:
This is a bit of a hot take, but if I ruled the world, we would divide OB and GYN into two separate specialties because I think that in a very practical sense, that is something we could do and we could fund, and that would inherently improve access to both of those things.

Jennifer Sargent:
Welcome to Maternity Reimagined, a podcast exploring the future of maternal healthcare through the lens of innovation and human connection. I'm Jennifer Sargent, and each episode I'll be speaking with healthcare leaders, providers, and changemakers who are working to transform how we support expecting parents and families. From hybrid care models and emerging technologies to policy shifts and real-world solutions, we'll uncover insights that are shaping a more connected, accessible future for maternal care. Whether you're a healthcare leader, provider, or just passionate about advancing maternal health, this podcast is for you. Join me as we reimagine what maternal healthcare can and should be.
Today I am thrilled to be joined by Dr. Jocelyn Fitzgerald, a nationally recognized urogynecologist surgeon and fierce advocate for equity in women's health, which I love. Dr. Fitzgerald is an Assistant Professor of Obstetrics, Gynecology, and Reproductive Sciences in the Division of Urogynecology and Reconstructive Pelvic Surgery at the University of Pittsburgh. She's not only a practicing clinician, but a powerful voice in the movement to reform how we reimburse, respect, and resource maternal and reproductive care in this country. Her insights on the economics of OBGYN care, pelvic floor recovery, and the long-overlooked disparities in clinical reimbursements are helping reframe how we think about value in women's health and who ultimately pays the price when that value is ignored. Jocelyn, welcome to Maternity Reimagined. I'm so excited for this conversation.

Dr. Jocelyn Fitzgerald:
Yeah, thank you so much for having me. I'm excited to be here.

Jennifer Sargent:
Great. I got the chance to hear you speak and meet you at a reimbursement summit in New York earlier this year, and so really excited that we can connect and go a little deeper on the work that you're doing. And you've spoken powerfully about how broken reimbursement models in women's health create ripple effects. Can you break down what this looks like on the ground for physicians and for the patients that you serve?

Dr. Jocelyn Fitzgerald:
Yeah, absolutely. So just a little bit of background. I don't think most people realize that OBGYN is the lowest reimbursed surgical specialty in medicine in terms of procedures and high stakes training and scope of practice that we have. And it's gotten steadily worse since the early '90s when the advent of Medicare and Medicaid came about and we developed a relative value system literally called a relative value unit, which is a code that's used to assign value to each procedure in medicine, and OB and GYN were really not at the table when those decisions were being made and were very much left behind. And subsequently, the total amount of reimbursement power that the Centers for Medicaid and Medicare Services will allow for procedures in medicine was then capped at a finite level that each year when we tried to reestablish valuation for something in medicine, has to come out to this net neutral number.
So basically over the past 30 years, we've been trying to make OBGYN worth more, but in order to do that, we have to make another specialty like urology or orthopedics worth less. So we haven't had a lot of success, and as more and more women have entered the field, the problem has gotten worse and worse as most professions that have an influx of women do. There's just a lot of sexism and gender discrimination when it comes to pay. So boots on the ground, the way that this works is women, when they walk into a hospital with a gynecologic problem like fibroids, like endometriosis, like pelvic organ prolapse, the medical and surgical care for that problem is worth a significantly less amount of money than both equivalent male procedures, which is what my research has shown. If you need a biopsy for a vulvar lesion versus a penile biopsy or a scrotal biopsy, you're going to get paid a lot more money for the penile or scrotal biopsy.
So walking in the door, you're sort of worth less money for equivalent procedures, but then it even gets worse when you look at surgeons with comparable expertise, comparable training, doing procedures that require a similar level of technical skill like in orthopedics, they're consistently generating a ton more money in the same amount of time for the same amount of effort for the hospital, which not necessarily in nefarious way, but in a sheer economics way, drives hospitals to throw their resources towards those conditions and away from women's health. So it really makes it hard for us to take care of our patients when we have less operating room time, we seen as less valuable by the hospital in terms of how much revenue and money can we make for them, and it just gets really difficult in terms of having us be accessible to patients with all the things they need over time, et cetera.

Jennifer Sargent:
Yeah, that's so helpful and I think such eye-opening information that I think a lot of people don't realize what those disparities in reimbursement really are. Can you maybe talk a little bit, go a layer deeper on what does that mean for the patient? I know there's less time, but how does that really impact the care that they can receive based on this reimbursement structure?

Dr. Jocelyn Fitzgerald:
Yeah, it happens in OB and GYN. I'll give you a concrete example of where I did my subspecialty training in Washington, D.C. at Georgetown University. They're affiliated with a healthcare system called MedStar Health. The surgery center where we did a lot of our prolapse and incontinence surgery, completely discontinued gynecologic surgical services a couple of years after the COVID pandemic hit because they wanted to recoup their financial losses as quickly as possible and gynecology was not the way to do it. So they totally canceled hundreds of women's surgeries and brought in more orthopedics, more urology, more plastic surgery, things that bill more, and all of those women had their surgeries delayed.
They had to be rescheduled at a different hospital. That's a very concrete way that happens. Or if I want new equipment to do more cystoscopies or be able to do more procedures in the office, they do a financial review of my department and say, "How much money is the urogynecology department making? Can we afford to buy them more equipment to see more patients?" If the answer is no, then patients wait longer for the same procedures that if they were higher paying procedures, there would be no issue with making that investment and buying more equipment.

Jennifer Sargent:
What would you maybe talk about related to maternal care specifically and how reimbursement structures impact the care that expectant and new parents get in the system?

Dr. Jocelyn Fitzgerald:
Yes, absolutely. So the same thing happens on the OB side. I also will just put in a plug that urogynecology is maternal care. 80% of pelvic floor disorders happen because women have had babies and having a baby is an injurious process by its nature. And so maternal care is not just the few years women spend pregnant, it's their whole life. You're postpartum from the minute you have a baby, it's not just a six week period. So I would argue that gynecologic surgery is maternal care, but specifically related to OB, the way that we reimburse for OB services is equally as awful as gynecology. And without going too far into the weeds on the way the system is set up, there's a committee that decides these codes every year, and OBGYN has one representative on the committee that mostly represents general OBGYNs, but it's for all of OBGYNs.
So one person is taking this finite number and splitting it up between OB and GYN, and they have very little to shift back and forth. And so all the time, women's health is getting the short shrift specifically for OB. Obstetrics is very high stakes, it's very expensive. There's a lot of critical care that's involved, a lot of one-on-one nursing that's required, just a of technical challenges that are involved in safely delivering a baby in a hospital. So it's expensive, but the reimbursement is very, very low. There's actually a set global fee for OB, so no matter how complicated a pregnancy is, there's a flat rate that a hospital will be reimbursed for that entire pregnancy, not just the delivery, but prenatal care to postnatal care. And hospitals cannot recoup those losses if they don't have ancillary services in the hospital that are being driven by OB.
So the best example is the NICU. Critical care time bills very well. So a NICU can be a very profitable entity for a hospital, but if you don't have a NICU, it almost becomes untenable to support a labor and delivery unit because you're losing money the whole time. You just can't recoup the facility losses. So as a result, only 50% of counties in the United States have any OBGYN and women are having to drive farther and farther to access an obstetrician, which becomes very unsafe. Anybody who takes care of obstetric and emergencies knows you don't have hours to deal with them, you have minutes to deal with them. And so it's causing harm to women, harm to babies, and that's the price and the non-profitability of obstetric care is being directly passed off to our communities.

Jennifer Sargent:
Agree. We certainly are keeping our eye on the maternal care deserts as we call it, and as we think about recent legislation as well and the continued impact that's going to have on access to OB services to people who really need it. I loved what you said about you're always postpartum. I had my last kiddo five years ago and I felt like heard and seen there in that. Maybe let's talk a little bit about the postpartum or the fourth trimester as it's been sort of termed. And weeks either immediately or sort of months after, it's really often overlooked in the care continuum. We talk a lot about postpartum and so much effort and focus happens when they're pregnant and people are supporting them and then they become postpartum. And especially I think for first time parents, it's a big change. What do you think in your experience are the biggest clinical and emotional needs during this period that go unmet?

Dr. Jocelyn Fitzgerald:
Oh my God. I mean, how much time do you have? I mean, I also just really briefly do want to bring this back to the reimbursement piece and that global fee that I mentioned for pregnancy, because again, you get paid one flat fee for the entire pregnancy and postpartum period, and that includes, there's these sort of special codes that delineate whether or not a specialist is within the realm of OBGYN and urogynecology is considered to be part of that. So all of this is to say that if you have a baby, and then, it depends on what state you live in, but whatever your postpartum period is, doctors don't get reimbursed for any of the additional care that you get. So they're not really incentivized to bring you back to the hospital for pelvic floor care, for emotional care. If you get a consultation from a psychiatrist, that's different. They bill separately.
But any care that is provided by somebody under the same taxonomy code it's called, under OBGYN, is like nobody's getting paid for that service. So I think that has a lot to do with why maybe services are not as encouraged or as accessible. In terms of your question, what are the biggest needs? I mean, I think as a urogynecologist, I'm a hammer, everything's a nail. The physical aspect of recovery, whether you've had a vaginal delivery or C-section, both of those can be very, very physically challenging. A C-section is major abdominal surgery. Any other major abdominal surgery that you would have done that, I mean, there is no abdominal surgery that goes through more layers of your abdomen than a C-section. No hernia surgery, nothing that any general surgeon does is as invasive as a C-section. And you would get 12 weeks off from any hernia surgery or any open abdominal exploratory surgery outside of pregnancy, bar none.
That would just be, you would have a doctor's note to have eight to 12 weeks off of work. But we don't do that for obstetrics in this country. Women often have to go back to work at six or eight weeks and they've just had major abdominal surgery. So that of course brings on the huge fatigue, exhaustion, mental health issues, just from being completely physically depleted and suddenly having this enormous new responsibility. All of these new anxieties, I mean, we don't even come close to physically and mentally supporting and rehabbing women after they have brought a whole new person into the world. And the last thing, I guess I'll say, and there's a million others I could, but I mentioned pelvic floor, but pelvic floor therapy. Like, getting a patient who's, regardless of their delivery route, getting them hooked up with pelvic floor rehabilitation outside of a surgical intervention like me. I mean, we want to restore function and coordination to this very complex body part that has just gone through a sort of dynamic change unlike any other part of the body will ever experience.

Jennifer Sargent:
Kind of on the pelvic floor topic, why do you feel like it's such a hidden or underused resource in postpartum care? What would help it become more part of a standard practice of care?

Dr. Jocelyn Fitzgerald:
I think there's so many reasons. Accessibility is one. Simply the supply and demands are very imbalanced. There's a huge demand for pelvic floor therapist time. They're all booked out for months, so that can be really challenging. There's another reimbursement piece there actually in their own field. So if you need to get physical therapy on your knee or something, if anyone listening has ever done that, your therapist is seeing multiple patients at a time. They can see four patients at once who are all having hips, knees, shoulder, whatever. But if you're doing pelvic floor, that's obviously very sensitive. You need a private room, you can only see one patient at a time.
So you're making one quarter of the amount of revenue in that moment as somebody doing orthopedic PT. So that's a reason that a facility might not want to invest in a pelvic floor therapist, which leads more, I'd say a pelvic floor therapists to go into a more private practice, cash-based setting, which can be financially not attainable by patients. And then because we don't really in this country support new parents by giving parental leave, women are often after one or two weeks, alone or with some help of piecemeal from a family member to raise this child and to say, "Okay, now you just had a C-section, throw your new baby in the car and drive to pelvic floor therapy." Is an impossible ask. So I think the barriers are pretty infinite.

Jennifer Sargent:
Thank you for explaining why pelvic floor therapy isn't always accessed. It sounds like there's a lot of opportunity to improve that, but do you think that stigma or discomfort around these topics plays a role in why care isn't accessible or even accessed if there is the availability for a therapist? What would help change that?

Dr. Jocelyn Fitzgerald:
I think so. I mean, it's so hard. I think sometimes maybe I spend a lot of time in a very pro-physical therapy bubble on the internet, so I feel as though there is this really big demand from patients and it's becoming less and less stigmatized and that women are very aware of their pelvic floor. This sort of generation of millennial moms seems to be way more all over it than my mom's generation. But yes, you're absolutely right that there's a lot of people who are embarrassed or concerned about saying, "Oh my God, I had my baby and things are still not back to normal. I don't feel right down there. I'm leaking urine or I'm having even bowel accidents if I had a bad tear or it hurts to have sex."
Those things make you feel like maybe your body wasn't built for childbearing. People really take that on. They're like, "Oh, I'm not going to say anything because everyone thinks I should just be able to do this." Or, "I think I should just be able to do this." Until you realize that almost every single woman's body saved for a few people who are, I guess just blessed or built different do not come out of birth unscathed. So I don't know. I think I would just say that, that so many women, most of them need some help.

Jennifer Sargent:
Yeah, I agree. And I think it's changing. When I reflect on my own journey and becoming a new mom for the first time, I think that the, no one told me what it was going to be like afterwards, and I'm glad people are starting to talk about it now. And I didn't have any major complications, but no one once mentioned like, "Oh, maybe you should consider pelvic floor therapy or anything." So I'm glad the conversation is happening more. It sounds like there's room to improve that and make sure there's enough therapists and ability to get care, because that can make such a big impact.

Dr. Jocelyn Fitzgerald:
Absolutely.

Jennifer Sargent:
Yeah. Maybe shifting a bit, this is kind of a big question, but if you could redesign the maternal care system from scratch and maybe even focusing on the postpartum piece, you had a magic wand, what would that look like?

Dr. Jocelyn Fitzgerald:
Obviously there would be plenty of OBGYNs for everyone and plenty of pelvic floor therapists for everyone. We would pay these people appropriately and we wouldn't gatekeep the number of them that can be trained and where they would work. That would be one thing. This is a bit of a hot take, but if I ruled the world, we would divide OB and GYN into two separate specialties because I think that in a very practical sense, that is something we could do and we could fund, and that would inherently improve access to both of those things. And that isn't to say that those two specialties would be unlinked. Obviously they're very related, but there's lots of specialties in medicine where things are very related, but you still do a different residency and you kind of are hired into different departments and it ends up making more accessibility and not less. So I think we'd have just more obstetricians.
For example, my residency program at Johns Hopkins, there were 10 of us, and I believe only two of the 10, maybe three, do any type of obstetrics. Two of them are high risk obstetricians, so they don't really deliver that much. I think mostly they do ultrasound and high risk consultations. There is one general OBGYN out of all 10 of us, and the other seven are specialists like me. They're urogynecologists, they do gynecologic cancer surgery, they do infertility, and they do minimally invasive gynecologic surgery like fibroids and endometriosis. So we're spending a lot of money in this country training obstetricians, but we're not generating enough obstetricians, so we really have to separate it.
And what's also happening is when you have a general OBGYN, they're not getting trained in really high level complex female pelvic surgery. So then we have to do these extra fellowships, which decreases the numbers of surgeons that are able to provide a good surgery to patients. So if I ruled the world and redid the whole system, that is the first thing I would do. And then I would go forth and have, expand the programs, have more of them, provide incentives so that we have people on the ground in rural areas that can provide excellent high level obstetric care outside of urban areas, which right now is where most of the good women's healthcare is concentrated.

Jennifer Sargent:
I love that. You said it was a hot take. Is there a disagreement across the provider community on whether OB and GYN should be split up?

Dr. Jocelyn Fitzgerald:
There is. I apologize to anyone listening if they disagree with this, but my experience has been that specialty gynecologic surgeons like myself could not be more in favor of having a separate residency in gynecologic surgery, very similar to urology. But there are some people who really do love the combination of obstetrics and office-based gynecology or less surgically complex gynecology. I don't think that would need to be taken away. I actually have a, I can't talk about it too much. It's embargoed at the moment, but a paper coming out where me and one of my colleagues outline our whole plan for doing this, but there definitely is some pushback where people have lots of criticisms where they say, "What would you do in a rural community if somebody needs a hysterectomy at the time of a C-section? If you're not trained in OB and GYN, how would you know how to do that?"
Well, that's a straw man's argument because we would have gynecologic surgeons there as well. That's the whole point of expanding the workforce and making it bigger. So gynecologic surgeons and obstetricians would still train together. They would still have that overlapping training. Right now, they don't really have that training. Most general, modern OBGYNs are not doing a huge, horrible postpartum hysterectomy. Some of them are, it depends. It's very geographic. And then a lot of times trauma surgeons are helping. It would expand the scope of OBGYN in a way that other specialties would become more attuned to the specific needs of women's health, because right now it is so siloed that we are shooting ourselves in the foot and also makes for anything that's for women, mostly done by women, is very easy to look down upon by those who are on the outside and don't really understand it. Very much seen as women's work.
And if obstetrics and gynecologic surgery become part of general surgery and part of trauma surgery, I think it just improves the care for women across the board because a wider diversity of physicians understand what's really happening with pregnancy physiology. So yeah, it's a bit of a hot take. There are some people who disagree and think it would completely upend the way we train, but respectfully, that's the point, so I'm sticking by it.

Jennifer Sargent:
That's great. Well, we look forward to seeing that paper come out and reading through it. Last question for you. We've talked a lot about things that need to change and opportunities to improve, but what gives you hope right now in the system?

Dr. Jocelyn Fitzgerald:
Oh, I mean, there are a lot of things that give me hope. I mean, women's health has never been a more popular topic than it is right now. I am so grateful for platforms like this one. The internet for all of its good and bad has overall for equity issues been a real equalizer, has given women in particular a platform and a voice and a way to come together in a way that was not previously possible in hierarchical systems. So I think just the general awareness of these issues that as women continue to have, and not just women, men, of course, people who see women's health as valuable have influence in their own realms, in their own systems, their own hierarchies, their own connections can bring this topic up in rooms where it matters. So having these kinds of conversations gives me a ton of hope.
I think just having women in other specialties of medicine gives me a lot of hope because they really care about the things in OB and GYN that were previously being ignored because they didn't, I don't know if people didn't want to think about them, but for example, cardiology didn't really used to think about women's health very much, but now there's a lot more women in cardiology. And all of a sudden we have this whole new field of medicine called cardio-obstetrics where we're looking at how things like preeclampsia and just pregnancy in general, remodels the heart, same thing for the brain. And we didn't know anything about any of that before. So now we're really starting to, and there's these whole huge areas of research that are opening up. And I think also women have always had to be resourceful. Women's health has never been very well funded, even though funding for research across the board is being slashed right now.
Women's health already was finding other ways because the NIH wasn't really giving us money to begin with. So I think that has just strengthened and organized the coalitions around this. And I mean, a lot of this does come down to money, as I've said, and one of the greatest transfers of wealth that has ever happened in the history of the world is going to happen in the next decade or so between the baby boomers and the millennials and a lot of women will have control of some serious money for the first time in history. And I think they're ready to spend it on the overlooked issues we've talked about today. So that gives me a lot of hope too.

Jennifer Sargent:
Couldn't agree more. Well, Dr. Fitzgerald, thank you for joining us today. And thank you so much for all of your advocacy in this space. It's going to take all of us to keep things moving the way that they need to be. So appreciate you joining us here on Maternity Reimagined.

Dr. Jocelyn Fitzgerald:
Yes, absolutely. Thank you for having me. It was lovely.

Jennifer Sargent:
Thank you for listening to Maternity Reimagined. I'm your host, Jennifer Sargent. If today's conversation resonated with you, please subscribe and listen wherever you get your podcasts. And be sure to share this episode with those who, like us, are passionate about reshaping the future of maternal health. Until next time, as we continue to build bridges and transform maternal care together.