Title X family planning clinics confront escalating costs,increasing needs

Since 1970, the Title X family planning program of the US Public Health Service act has helped low-income American women avoid unintended pregnancies, abortions, and unwanted births. In addition to averting a million pregnancies (and half as many abortions) each year, the 4400 Title X clinics provide an array of reproductive health services. Funding for the program, however, has never recovered from Reagan-era cuts, and President Clinton's proposal for a $25 million increase will only begin to allow the program to achieve Clinton-administration objectives. The clinics face a financial challenge in maintaining the full range of contraceptive choices, especially in light of the high up-front costs of long-acting contraceptives, such as Depo-Provera, which can consume 50% of a budget for 15% of the clients. New diagnostic technologies have made routine screening desirable but expensive, and clinics must struggle to maintain quality of care. Title X clinics also have a clear need to expand their service capacity to reach the million low-income women who continue to risk unintended pregnancy and to serve low-income salaried workers without health insurance. Currently, two-thirds of Title X clients are so impoverished that their care is totally subsidized, and only 20% are covered by Medicaid. A portion of the $25 million increase has also been earmarked to promote reproductive health among the hard-to-reach population, such as substance abusers and the homeless, and to expand service provision to males. While the increase is needed, it represents only a portion of the cost of facing these challenges.     

Comparison of adherence to Chlamydia screening guidelines among title x providers and non-title x providers in the california family planning, access, care, and treatment program

Abstract Background: Annual chlamydia screening is recommended for adolescent and young adult females and targeted screening is recommended for women ≥26 years based on risk. Although screening levels have increased over time, adherence to these guidelines varies, with high levels of adherence among Title X family planning providers. However, previous studies of provider variation in screening rates have not adjusted for differences in clinic and client population characteristics. Methods: Administrative claims from the California Family Planning, Access, Care, and Treatment (Family PACT) program were used to (1) examine clinic and client sociodemographic characteristics by provider group-Title X-funded public sector, non-Title X public sector, and private sector providers, and (2) estimate age-specific screening and differences in rates by provider group during 2009. Results: Among 833 providers, Title X providers were more likely than non-Title X public sector providers and private sector providers to serve a higher client volume, a higher proportion of clients aged ≤25 years, and a higher proportion of African American clients. Non-Title X public providers were more likely to be located in rural areas, compared with Title X grantees and private sector providers. Title X providers had the largest absolute difference in screening rates for young females vs. older females (10.9%). Unadjusted screening rates for young clients were lower among non-Title X public sector providers (54%) compared with private sector and Title X providers (64% each). After controlling for provider group, urban location, client volume, and percent African American, private sector providers had higher screening rates than Title X and non-Title X public providers. Conclusions: Screening rates for females were higher among private providers compared with Title X and non-Title X public providers. However, only Title X providers were more likely to adhere to screening guidelines through high screening rates for young females and low screening rates for older females.     

Availability of Services Related to Achieving Pregnancy in U.S. Publicly Funded Family Planning Clinics

BackgroundRecognizing that quality family planning services should include services to help clients who want to become pregnant, the objective of our analysis was to examine the distribution of services related to achieving pregnancy at publicly funded family planning clinics in the United States.MethodsA nationally representative sample of publicly funded clinics was surveyed in 2013–2014 (n = 1615). Clinic administrators were asked about several clinical services and screenings related to achieving pregnancy: basic infertility services, reproductive life plan assessment, screening for body mass index, screening for sexually transmitted diseases, provision of natural family planning services, infertility treatment, and primary care services. The percentage of clinics offering each of these services was compared by Title X funding status; prevalence ratios (PRs) and 95% confidence intervals (CIs) were estimated after adjusting for clinic characteristics.ResultsCompared to non-Title X clinics, Title X clinics were more likely to offer reproductive life plan assessment (adjusted PR [aPR], 1.62; 95% CI, 1.42–1.84), body mass index screening for men (aPR, 1.10; 95% CI, 1.01–1.21), screening for sexually transmitted diseases (aPRs ranged from 1.21 to 1.37), and preconception health care for men (aPR, 1.10; 95% CI, 1.01–1.20). Title X clinics were less likely to offer infertility treatment (aPR, 0.55; 95% CI, 0.40–0.74) and primary care services (aPR, 0.74; 95% CI, 0.68–0.80) and were just as likely to offer basic infertility services, preconception health care services for women, natural family planning, and body mass index screening in women.ConclusionsThe availability of selected services related to achieving pregnancy differed by Title X status. A follow-up assessment after publication of national family planning recommendations is underway.     

The Impact of Reproductive Health Legislation on Family Planning Clinic Services in Texas

We examined the impact of legislation in Texas that dramatically cut and restricted participation in the state’s family planning program in 2011 using surveys and interviews with leaders at organizations that received family planning funding.Overall, 25% of family planning clinics in Texas closed. In 2011, 71% of organizations widely offered long-acting reversible contraception; in 2012–2013, only 46% did so. Organizations served 54% fewer clients than they had in the previous period. Specialized family planning providers, which were the targets of the legislation, experienced the largest reductions in services, but other agencies were also adversely affected.The Texas experience provides valuable insight into the potential effects that legislation proposed in other states may have on low-income women’s access to family planning services.Publicly funded family planning clinics have been a key component of the health care safety net for low-income women in the United States and will remain essential points of access under the Affordable Care Act.1,2 Title X, the federal program dedicated to family planning, provides crucial infrastructural support for a network of clinics and subsidizes the cost of family planning services for uninsured women. In many states, Medicaid family planning waivers or state plan amendments constitute another source of support, and they reimburse clinics for services provided to eligible women. These programs can help fill gaps in coverage for those who lose other insurance because of changes in income or employment or other life events.3However, the degree to which low-income women can rely on publicly funded providers for subsidized family planning services has become increasingly dependent on policies enacted by state legislatures, which recently have taken on a large role in determining not only the amount of funding that goes to family planning but also the types of organizations that are eligible to receive it. Since 2010, several states have made significant cuts to their family planning budgets, and in 5 states, funding for family planning services was disproportionately reduced relative to other health programs.4 Additionally, since 2011, 16 states have proposed legislation that effectively blocks specialized family planning providers from receiving any public funding such as Title X or bars those that also provide abortion services from receiving funds, including Medicaid.5,6 This legislation may be aimed at defunding entities providing abortion care, such as Planned Parenthood, even though federal dollars cannot be used to pay for abortions in almost all cases.One of the most striking examples of legislation affecting the delivery of publicly funded family planning services took place in Texas, which in 2011 both dramatically cut and restricted participation in the state’s family planning program. We examined the impact of the 2011 legislation on family planning providers in Texas. We have reported on our findings from surveys and in-depth interviews with leaders at organizations across the state that received public funding before the legislation and our analysis of state administrative data. The Texas experience provides valuable insight into the potential effects that legislation proposed in other states may have on low-income women’s access to family planning services.     

Results of the assessment of Kentucky's Medicaid home- and community-based services waiver

In states where a Home- and Community-based Services Waiver is operating under the Medicaid program, HCFA requires an independent assessment of the program. This paper reports on two assessments of the costs and use of services under Kentucky's HCBS waiver: one comparing waiver clients to a matched control group of regular Medicaid home health clients, and the other comparing elderly female waiver clients to a matched control group from nursing homes. Analyses of costs and use of home health services, hospital care, physician services, nursing home admission, and other services showed little difference between waiver clients and control groups. Waiver clients used more home health, but used other services at the same rate. Their costs were lower overall.     

Use of Health Insurance Among Clients Seeking Contraceptive Services at Title X–Funded Facilities in 2016

CONTEXT

As federal initiatives aim to fundamentally alter or dismantle the Affordable Care Act (ACA), evidence regarding the use of insurance among clients obtaining contraceptive care at Title X–funded facilities under ACA guidelines is essential to understanding what is at stake.

METHODS

A nationally representative sample of 2,911 clients seeking contraceptive care at 43 Title X–funded sites in 2016 completed a survey assessing their characteristics and insurance coverage and use. Chi‐square tests for independence with adjustments for the sampling design were conducted to determine differences in insurance coverage and use across demographic characteristics and facility types.

RESULTS

Most clients (71%) had some form of public or private health insurance, and most of these (83%) planned to use it to pay for their services. Foreign‐born clients were less likely than U.S.‐born clients to have coverage (46% vs. 75%) and to use it (78% vs. 85%). Clients with private insurance were less likely than those with public insurance to plan to use their insurance (75% vs. 91%). More than one‐quarter of clients not planning to use existing insurance for services indicated that the reason was that someone might find out.

CONCLUSION

Coverage gaps persist among individuals seeking contraceptive care within the Title X network, despite evidence indicating increases in health insurance coverage among this population since implementation of the ACA. Future research should explore the impact of altering or eliminating the ACA both on the Title X provider network and on the individuals who rely on it.     

上海市郊县妇女接受计划生育服务的质量评价

根据美国人口理事会Ｂｒｕｃｅ博士提出的服务质量六要素框架，从服务对象的角度，对上海市某郊县的３０岁以下已婚育龄妇女接受的计划生育服务进行了质量评价。对３１３例妇女的抽查结果表明，在过去一年中有２１４例妇女接受过计划生育服务，其中８８．３％的妇女选用宫内节育器，避孕针、药和男用避孕套的使用比例分别为１．９％、３．３％、６．５％；服务对象在就诊时获得过健康教育材料的仅为１０．７％，医生为之详细解释过所选避孕方法的比例不足１０％；知道放置宫内节育器后首次复诊时间的妇女不到４０％；有６０％多的对象认为所接受的服务总体上还是令人满意的，服务的可及性良好。认为在服务覆盖面良好的情况下，服务利用率的提高主要靠服务质量的改善，而确保妇女生殖健康，提倡知情选择的目标和要求更使计划生育的服务质量急待规范和提高。     

The availability and use of publicly funded family planning clinics: U.S. trends, 1994-2001

CONTEXT: It is important to monitor trends among publicly funded family planning clinics to determine where clinics are successfully meeting the contraceptive service needs of low-income women and where more effort is needed.
METHODS: Service data for all U.S. agencies and clinics providing subsidized family planning services were collected for 2001 and compared with similar data collected for 1997 and 1994. Trends reflecting clinic structure and capacity were analyzed at the national and state levels. Client numbers were compared with numbers of women needing publicly funded contraceptive services to create a measure of met need for states and groups of states, according to Medic-aid family planning waiver status.
RESULTS: In 2001, some 7,683 publicly funded family planning clinics provided contraceptive services to 6.7 million women–representing an 8% rise in clinics and a 2% increase in clients since 1994. Change varied by type of provider and clinic location. Health departments and Planned Parenthood affiliates served more clients at fewer sites; community health centers served fewer clients at more sites. One-third of states experienced growth in clinic capacity, with 5–65% increases in met need. In another third of states, met need declined by 5% or more. States with income-based Medicaid family planning waivers served 24% more clients, with met need increasing from 40% to 50%.
CONCLUSIONS: Among states, there has been tremendous variation in the ability of publicly funded family planning clinics to serve women. Implementation of income-based Medicaid family planning waivers in some states was associated with clinics' serving greater numbers of women. Further efforts are needed to ensure access to family planning services for low-income women in every state.     

Provider attitudes toward dispensing emergency contraception in Michigan's Title X programs

In 1997, the US Department of Health and Human Services instructed all Title X delegate agencies to provide emergency contraceptive pills as part of their standard family planning services. The results of a survey conducted in the state of Michigan in October 1996, prior to this policy development, elucidate potential obstacles to implementation of this directive. Questionnaires were completed by the family planning coordinator of all 53 Michigan health departments and Planned Parenthood affiliates that receive Title X funding. At the time of the survey, only 32 programs were providing emergency contraception and 27 of these agencies were offering the method to no more than one woman per month. 75% of providers agreed that poor or underprivileged women would benefit from more widespread access to emergency contraception through Title X programs. Barriers to translating this commitment into practice included inadequate staffing, the logistics of scheduling emergency appointments, lack of federal service guidelines, few client requests, and reservations about the impact on sexual risk-taking and contraceptive practice. In several cases, the decision not to dispense emergency contraception was made by a medical doctor or health officer who viewed the method's medicolegal status as unclear or considered the associated political risk too great. The subsequent marketing of a product specifically designated for emergency contraception should alleviate provider concerns about the method's status. The logistic concerns suggest a need to consider provision of emergency pills to clients in advance of actual need.     

Women's Perspectives on Family Planning Service Quality: An Exploration of Differences by Race, Ethnicity and Language

CONTEXT: Despite calls to make family planning services more responsive to the values, needs and preferences of clients, few studies have asked clients about their experiences or values, and most have used surveys framed by researchers', rather than clients', perspectives.
METHODS: Forty in-depth interviews exploring lifetime experiences with and values regarding services were conducted with 18–36-year-old women who visited family planning clinics in the San Francisco Bay Area in 2007. Women were categorized as black, white, English- or Spanish-speaking Latina, or of mixed ethnicity to allow examination of differences by racial, ethnic and language group. Interviews were audiotaped, transcribed and coded thematically; matrices were then used to compare the themes that emerged across the subgroups.
RESULTS: Eight themes emerged as important to women's views of services: service accessibility, information provision, attention to client comfort, providers' personalization of care, service organization, providers' empathy, technical quality of care and providers' respect for women's autonomy. Women reported that it was important to feel comfortable during visits, to feel that their decision-making autonomy was respected, to have providers show empathy and be nonjudgmental, and to see the same provider across visits. The only notable difference among racial, ethnic and language groups was that Spanish-speaking Latinas wanted to receive language-appropriate care and contraceptive information.
CONCLUSIONS: Future surveys of family planning service quality should include measures of the factors that women value in such care, and efforts to improve providers' communication and counseling skills should emphasize the personalization of services and respect for clients' autonomy.     

Incentives in a Medicaid carve-out: impact on children with special health care needs

Objective. To evaluate whether a specialty care payment "carve-out" from Medicaid managed care affects caseloads and expenditures for children with chronic conditions.
Data Source. Paid Medicaid claims in California with service dates between 1994 and 1997 that were authorized by the Title V Children with Special Health Needs program for children under age 21.
Study Design. A natural experiment design evaluated the impact of California's Medicaid managed care expansion during the 1990s, which preserved fee-for-service payment for certain complex medical diagnoses. Outcomes in time series regression include Title V program participation and expenditures. Multiple comparison groups include children in managed care counties who were not mandated to enroll, and children in nonmanaged care counties.
Data Collection/Extraction Methods. Data on the study population were obtained from the state health department claims files and from administrative files on enrollment and managed care participation.
Principal Findings. The carve-out policy increased the number of children receiving Title V-authorized services. Recipients and expenditures for some ambulatory services increased, although overall expenditures (driven by inpatient services) did not increase significantly. Cost intensity per Title V recipient generally declined.
Conclusions. The carve-out policy increased identification of children with special health care needs. The policy may have improved children's access to prevailing standards of care by motivating health plans and providers to identify and refer children to an important national program.     

Peer Reviewed: Optimizing Women��s Health in a Title X Family Planning Program, Baltimore County, Maryland, 2001-2004

Background

Although women usually obtain family planning services during their reproductive years, their need for comprehensive preventive services that promote wellness beyond reproductive health is often ignored.

Community Context

The Maryland Department of Health and Mental Hygiene sought to improve the general health of women and reduce their risk for adverse pregnancy outcomes by integrating women''s health services into the Baltimore County Title X program. Title X is a federal family planning grant program primarily serving low-income, uninsured people.

Methods

After completing a needs assessment, we addressed gaps in women''s wellness services in 3 family planning clinics. On-site services included counseling, screening, and referral for nutrition and physical activity, adult vaccination, depression, domestic violence, smoking cessation, substance abuse, and general medical disorders. A local multidisciplinary task force provided leadership for the clinical infrastructure of the project and served as a resource for women''s health referrals.

Outcome

Every staff person surveyed reported that the project had a positive effect on the community and should be continued. Clients identified non–reproductive health services they needed but would not have received otherwise. During the 3-year period, patient volume increased 28% for the pilot sites, compared to 1% for the state family planning program overall.

Interpretation

With collaboration from a multidisciplinary community task force, the Title X family planning program can help provide needed preconception, interconception, and general women''s health services, especially for women who have difficulty accessing care.     

Physician extender services in family planning agencies: issues in Medicaid reimbursement

The US Social Security Amendments of 1972 mandated the inclusion of family planning services in state Medicaid plans, authorized 90% of reimbursements for family planning care, and imposed financial penalties for failure to provide these services to Medicaid-eligible clients. On the other hand, many states have retrictive policies regarding Medicaid reimbursements to family planning agencies for services provided by physician extenders (e.g.s nurse practitioners and physician assistants). There is concern that such restrictions greatly reduce accessibility to family planning services. Reasons that hae been suggested as causes of such restrictive policies include physician concern over loss of income, the uncertain status of physician extenders in some states, a fear that this step will lead to a demand for reiimbursement for the services of other allied health care providers such as social workers, and concern that care for the indigent will lead to an expensive increase in state reimbursement for family planning services. However, a review of relevant federal law and regulations indicates that Medicaid reimbursement for services provided to eligible patients by physician extenders has never been prohibited or discouraged. Physician supervision is required in reimbursement cases, but this does not mean that a physician must be on the premises while services are delivered. The Medicaid program actually allows significant latitude in establishing administrative policies and procedures. Rather, problems faced by family planning agencies in receiving Medicaid reimbursements for physician extenders' services are due to restrictions in state laws and staff misinterpretations of policy. Research has demonstrated that physcian extenders can contribute significantly to cost effectiveness, while providing types of care in localities such as rural areas that physicians tend to avoid. Given the importance of family planning services to Medicaid-eligible clients, unwarranted policy restrictions contrary to congressional intent should be eliminated.     

Care Coordination Impacts on Access to Care for Children with Special Health Care Needs Enrolled in Medicaid and CHIP

Children with special health care needs (CSHCN) often require services from multiple health care providers. This study’s objective is to evaluate whether CSHCN, enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) and receiving care coordination services, experience improved access to mental and specialty health care services. Using data from the 2009–2010 National Survey of Children with Special Health Care Needs, two separate outcomes are used to evaluate children’s access to care: receipt of needed mental and specialty care and timely access to services. Using propensity score matching, CSHCN propensity for receiving care coordination services is derived and an assessment is made of care coordination’s impact on the receipt of health care and whether care is delayed. Results demonstrate that care coordination is positively associated with whether a child receives the mental and specialty care that they need, regardless of whether or not that coordination is perceived to be adequate by parents. However, receiving care coordination services that parents perceive to be adequate has a larger impact on the timeliness in which care is received. This study indicates that care coordination is associated with an increased ability for CSHCN to access needed mental and specialty care. States should consider offering care coordination services that support provider communication and fulfill families’ coordination needs to the CSHCN enrolled in their Medicaid and CHIP programs.     

Home alone: unmet need for formal support services among home health clients

In order to remain in the home without family or other informal support, home health clients must have access to essential formal services such as nutritional support and homemaking chores to supplement medical and nursing care. In this study, we looked at client-related factors associated with the need for formal support services, and factors associated with whether those needs are adequately met. Data were collected from 2,013 home health clients in Massachusetts. According to the assessment of the skilled nurses treating them, 85 percent of the clients needed one or more support services; some or all needs were not adequately met in nearly half. Significant factors contributing to unmet need included: being non-white, having Medicaid as payer, being in a health maintenance organization, having AIDS, receiving maternal/child health services, and having an acute condition. This research suggests that even clients receiving skilled nursing care may not have many or most of their supportive needs met, and that there are identifiable factors which decrease the likelihood of having adequate care provided.     

Public funding of contraceptive, sterilization and abortion services, 1982

The federal government and the states spent $328 million to support the provision of contraceptive services in fiscal 1982, 13 percent less than they had spent the previous year. Federal funds for family planning services came from Title X of the Public Health Service Act, Title XIX of the Social Security Act (Medicaid), and the Maternal and Child Health (MCH) and Social Services block grants, which are administered by the states. Title X continued to provide the largest, although a diminishing, share of public funds for contraceptive services--36 percent of all such funds in 1982. (In 1980, Title X had accounted for 44 percent of public funding.) Medicaid expenditures for family planning totaled $94 million; $17 million was spent under the MCH block grant, and $46 million under the Social Services block grant. State governments contributed an additional $53 million, about the same figure reported for the previous year, indicating that the states did not use their own funds to soften the impact of cuts in federal expenditures for contraceptive services in 1982. The federal government and the states spent an estimated $55 million, almost all of it through Medicaid, to provide sterilization services for poor women. The states spent $67 million and the federal government spent $1 million to provide abortions for 210,000 indigent women. These figures come from the 11th annual survey of state health and welfare agencies and state Medicaid programs by The Alan Guttmacher Institute (AGI). The AGI conducted this survey in January 1983 to determine the levels and sources of public funding for contraceptive, sterilization and abortion services in each state during FY 1982.     

A new approach to the assessment of aged community service users

ABSTRACT: This paper was written in response to the recognition of problems with multiple assessment of frail aged clients wishing to access various rural community services. Primarily under the Home and Community Care program, these offer a range of services with the aim of maintaining independence and preventing premature admission into long-term residential care. To gain access, each service conducts an assessment—some of which have been shown to be lengthy and detailed, with some bordering on invasion of privacy. Research has shown that multiple assessment of clients by multiple agencies can be threatening to the client and can give them the feeling they are being judged. Further, there appears to be poor coordination and liaison between service agencies which exacerbates the problems inherent in multiple assessment, and provides an avenue for overservicing. This paper presents a solution to these problems. A pilot project is foreshadowed whereby the Aged Care Assessment Team (ACAT) undertakes all assessments and enters the details into a communal database for access by all care providers via computer network. The paper suggests that such a multiscreen database with service provider access codes to ensure confidentiality would markedly reduce client stress. It is shown that community service administrative costs would be reduced enabling funds to be directed to actual field hours. Some redefining of staff roles and redeployment of staff would be necessary and these issues are discussed.
The writer recognises that the proposal is somewhat idealistic. However it does address some significant problems with the current methods of client assessment. Potential solutions are offered and may provide a useful basis for future development.     

Family planning clinics--a story of growth and conflict

During the 1960s, as demand for effective contraceptives increased and women expressed a desire for smaller families, an "odd lot" of groups came together to press for federally supported family planning services for low-income women. The drive culminated in 1970 with the passage of Title X of the Public Health Service Act, which authorized the funds that fed a network of family planning clinics. At the height of the national family planning program, approximately 2,500 agencies were operating clinics at more than 5,000 sites, providing services annually to almost five million patients. As part of the screening for medical methods of birth control, family planning clinics have provided basic physical examinations and related tests to millions of low-income women and teenagers who might not otherwise have had access to those services. Clinics have also been heavily utilized for pregnancy tests, screening for sexually transmitted diseases (STDs), infertility screening and referral for abortion, adoption and sterilization services. Other desired achievements have been more elusive and difficult to document--reductions in the number of high-risk and unintended pregnancies and in poverty rates, for example. The program's role in providing contraceptive services to teenagers and its involvement in the abortion controversy have led to a number of political, legislative and judicial skirmishes with conservatives, Congress and the Reagan administration. Funding for Title X declined during the 1980s and is now surpassed by Medicaid as the largest source of family planning dollars. Diminishing funds at a time when some expenses--for supplies, malpractice insurance and treatment of STDs, for example--are increasing have resulted in fewer clinic sites and other service cutbacks. The suggestion has been made that it is time to eliminate categorical funds for family planning and integrate all services into the general medical care system. Family planning providers say an integrated arrangement would not meet the needs of much of their patient population and would not provide the special attention they feel is needed for successful contraceptive practice among low-income, high-risk women. Instead, they suggest expanding the scope of services in family planning clinics, out of an awareness that the continuing high prevalence of unintended childbearing, among the young and disadvantaged in particular, is part of a larger problem of living in a desolate social environment.     

Integrating HIV prevention and care services: the Seattle "Collaboration Project".

The "Collaboration Project" explored whether human immunodeficiency virus (HIV) prevention providers in Seattle-King County refer their HIV+ clients into care services and whether HIV care service providers discuss sex and drug use risk reduction or make referrals for clients with ongoing risk reduction needs. Data uncovered demographic disparities between provider populations that may impact cross-system collaboration, particularly regarding provider demographic reflectiveness of the consumers being served. Ninety percent of prevention providers referred clients to care services; only one quarter discussed sexual risk reduction, while half discussed drug use risk reduction. Knowledge of cross-system resources was generally high, although gaps emerged between providers in several resource areas. Based on these findings, several key changes have been implemented.