JAN 12 1993

SUBJECT: Women's Health Issues

The quality and availability of health care for women is a top priority of the Department of Defense. The Defense Advisory Committee of Women in the Services (DACOWITS) requested clarification on the guidance we provide to the Services regarding several women's health care issues. Specifically, the issues are adequate access and timely notification of the results of mammography and Papanicolaou smears; the availability of obstetrical and gynecologic appointments for active duty women; and epidural analgesia for normal vaginal deliveries.

The Deputy Assistant Secretary of Defense (Health Affairs) for Professional Affairs and Quality Assurance convened a series of meetings with Tri-Service representatives regarding these women's health issues. The purpose of these meetings was to develop guidance on these health care issues for all active duty women and eligible beneficiaries. Correcting misperceptions and improving care for our women beneficiaries requires several initiatives. The first step was the development of an epidural analgesia option for normal deliveries as directed by my memorandum of 12 November 1992. As the next step in this Tri-Service effort, I am establishing the policies identified in the attachment.

These policies are effective on 1 July 1993. I expect the health care services required by these policies to be instituted without any additional cost to the Military Health Services System (MHSS). However, if additional costs are anticipated, you may identify them when you forward your implementing documents. Please provide me copies of your implementing documents by 1 March 1993. The point of contact on this matter is Lieutenant Colonel Gale Pollock, AN, (703) 695-7116.

Enrique Mendez, Jr., M.D.

Attachment:
As stated

HA POLICY 93-002

A. ANNUAL HEALTH MAINTENANCE EXAMINATIONS FOR WOMEN

All female beneficiaries 18 years old and older or who are sexually active should receive an annual health maintenance examination which includes, but is not limited to, the following services: 1) Papanicolaou smear; 2) pelvic examination; 3) breast examination; and, 4) blood pressure measurement. Family planning and contraceptive counseling will be made available for all eligible women who desire this service consistent with applicable DoD and Service regulations.

The results of the Papanicolaou smear shall be provided within 14 days except for those women located at isolated branch clinics and overseas locations where results shall be provided within 30 days. When a health care provider determines that a woman does not require a portion of the annual health maintenance examination, the provider shall discuss the basis for that recommendation and advise her of the time frame for, and the content of, the next examination.

B. MAMMOGRAMS

1. At the age of 40, a baseline mammogram shall be required for all active duty women and shall be offered to all other women who receive health care within the MHSS. In addition, mammography shall be provided for women at any age who have been identified by their health care provider as requiring additional screening as indicated by individual risk factors. For women over the age of 50, a screening mammography is recommended annually. The patient must have a referral from a health care provider for a mammogram to ensure that test results are tracked and the patient receives appropriate follow-up care. Appointment times shall be within four weeks for baseline or screening mammogram. Results shall be available to the patient within 14 days.

2. If evaluation by a health care provider requires mammography for diagnosis; e.g., for a lump, the test shall be provided within five working days of when it is ordered. Test results shall be available to the patient within 5 days of the test.

3. The mammogram location must be a certified location no later than 1 October 1994 to comply with the "Mammography Quality Standards Act of 1992" approved by Congress on 6 October 1992. Certification may be by either the American College of Radiology or the Department of Health and Human Services.

C. GYNECOLOGY SERVICES

The patient makes a judgment whether or not she will request care as an emergency, an urgent problem, or routine care. The patient care schedule below is based on the Coordinated Care Program Guidance memorandum No. 2, Provider Network Development, dated 8 January 1992.

1. Emergency rooms are available 24 hours a day for emergencies.

2. A woman with an urgent problem shall be seen by a health care provider within one working day for an initial evaluation. If the woman believes she cannot wait to be seen, she shall be advised that the emergency room is available to her.

3. For routine care, all women shall be seen within four weeks. If this cannot be accomplished, they shall be so advised and provided the option of going outside the medical treatment facility for care.