Providing LARCs in a Federally Qualified Health Center Is it financially viable? A case study. Lisa Maldonado, MA, MPH Linda Prine, MD

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1 Providing LARCs in a Federally Qualified Health Center Is it financially viable? A case study Lisa Maldonado, MA, MPH Linda Prine, MD

2 Mission The Reproductive Health Access Project trains and supports clinicians to make reproductive health care accessible to everyone. We focus on three key areas: abortion, contraception and miscarriage.

3 Community Health Centers Year CHC Sites Patients Served ,400 5,000, ,200 10,000, ,000 20,000, ,000,000

4 Family Planning Access in FQHCs More than 5.7 million women receive health care in FQHCs (2012) study found that 99.8% of FQHCs provided at least 1 contraceptive method but only 19% of all FQHCs surveyed report offering comprehensive contraceptive options at their largest site. (1) The largest FQHCs sites: 36% offer the contraceptive implant, 56% offer the progestin IUD and 52% provide the copper IUD. (2) 1. Wood SF, Goldberg DG, Beeson T, Bruen BK, Johnson K, Mead KH, Shin P, Lewis J, Artis S, Hayes K, Cunningham M, Lu X & Rosenbaum S. (2013). Health centers and family planning: results from a nationwide study. Health Policy Faculty Publications. 2. Accessibility of Long-acting Reversible Contraceptives (LARCS) in Federally Qualified Health Centers (FQHCs)," Beeson et al., Contraception, Oct. 3, 2013.

5 Common barriers to providing LARC in an FQHC Clinicians not trained to provide LARC Procedure interferes with patient flow Protocols out of date (eg, patient must be multiparous, currently having menses, etc.) Administrators won t stock expensive items like IUDs and Implants. Providing LARC is expensive, the health center will lose money.

6 FQHCs serve low income populations Source: Federally-funded health centers only Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS. Note: Federal Poverty Level (FPL) for a family of three in 2012 was $18,500. (See Based on percent known.

7 Typical FQHC Payor Mix * Other public insurance may include non-medicaid SCHIP and state-funded insurance programs. Source: Federally-funded health centers only Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS.

8 One FQHC s Experience Large, multi-site FQHC serving serving both inner-city, suburban and rural populations. 3 residency programs within the FQHC, all training family medicine residents to do LARC Most hiring for the FQHC comes from residency graduates, i.e. many trained providers Reproductive Health Fellowship has helped to expand training of residents and APCs

9 The bottom $$ line: Benefits from: State Medicaid reimburses for device and insertion. Patient Assistance Program (ARCH and Paragard) for eligible uninsured. Special state Family Planning Benefit Program for uninsured/underinsured. 340b pricing for device Mirena $ $ Paragard $185 $225.00

10 IUD Patient Assistance Programs Paragard Mirena ARCH Foundation

11 1 st Quarter 2013 Number of IUDs inserted Paragard Mirena Total

12 Revenue: 1 st Quarter 2013 Insertion fees/office visit collected # patients Total Revenue Average per patient Free Care 18 (6%) 0 0 Sliding Fee 27 (10%) $ $20.10 Insurance * 234 (84%) $20, $86.73 Total 279 $20, $77.56 includes Medicaid and private insurance plans No insurance reimbursement for insertion for 45 patients.

13 Revenue: one FQHC s IUD experience Device fees collected # patients Total Revenue Average revenue per patient Total cost (340b prices) Net Profit Paragard 84 $22, $ $18, $3, Mirena 195 $72, $ $61, $11, Total 279 $95, $ $80, $15, No insurance reimbursement for devices for 68 patients.

14 Net profit Cost Revenue Net Profit Devices $80, $95, $15, Visit* $39, $20, $18, Total $119, $116, $2, Wrap-around $4, $2, *$ cost/visit

15 Additional Considerations This data is pre-obamacare. Changes made at FQHC due to this analysis: All patients now see social workers for insurance eligibility Billing department follows through on unpaid claims Contracts with insurances were addressed Many insurances actually pay a higher visit rate for IUD removals than for insertions.

16 Is this replicable in other states? National efforts to reform Medicaid States where Medicaid reform is working Other national issues to think about Clinicians have to become advocates regarding billing & reimbursement Special challenges for FQHCs, as opposed to other settings