One objective of quality family-planning services is to. Onsite Provision of Specialized Contraceptive Services: Does Title X Funding Enhance Access?

Transcription

1 JOURNAL OF WOMEN S HEALTH Volume 23, Number 5, 204 ª Mary Ann Liebert, In. DOI: 0.089/jwh Onsite Provision of Speialized Contraeptive Servies: Does Title X Funding Enhane Aess? Heike Thiel de Boanegra, PhD, MPH, Julie Cross Riedel, PhD, Mary Menz, PHN, Philip D. Darney, MD, and Claire D. Brindis, DrPH,2 Abstrat Bakground: This artile presents the extent to whih providers enrolled in California s Family Planning, Aess, Care, and Treatment (Family PACT) program offer ontraeptive methods onsite, thus eliminating one important aess barrier. Family PACT has a diverse provider network, inluding publi-setor providers reeiving Title X funding, publi-setor providers not reeiving Title X funding, and private-setor providers. We explored whether Title X funding enhanes providers ability to offer ontraeptive methods that require speialized skills onsite. Methods: Data were derived from,072 survey responses to a 200 provider-apaity survey mathed by unique identifier to administrative laims data. Results: A signifiantly greater proportion of Title X funded providers ompared to non Title X publi and private providers offered onsite servies for the following studied methods: intrauterine ontraeptives (90% Title X, 5% publi non Title X, 38% private); ontraeptive implants (58% Title X, 9% publi non Title X, 7% private); vasetomy (8% Title X, 4% publi non Title X, % private); and fertility-awareness methods (69% Title X, 55% publi non Title X, 49% private) (all p < 0.000). The assoiation between onsite provision and Title X funding remained after stratifying individually by lini speialty, faility apaity to provide reprodutive health servies (based on staffing), and rural/urban loation. Conlusions: Extra funding for publily funded family-planning programs, through mehanisms suh as Title X, appears to be assoiated with inreased onsite aess to a wide range of ontraeptive servies, inluding those that require speial skills and training. Introdution One objetive of quality family-planning servies is to provide aess to a broad range of ontraeptive methods so that women an hoose the method that best fits their preferene and lifestyle and be best prepared when and if they desire a pregnany.,2 The hoie of a method may be influened by its onsite availability, as women may hesitate to hoose a method that requires them to go to another site; thus, gaps in overage may our. In California, two ritial soures for publily funded family-planning servies have omplementary goals and a strong history of aring for California s low-inome residents. The first Title X of the Publi Health Servie At, a federal grant program established in 970 and administered by the Department of Health and Human Servies provides high-quality reprodutive healthare and ontraeptive servies to low-inome U.S. women and men. 3 The seond Mediaid, a joint federal-state program finanes health servies for low-inome individuals. Mediaid funding for family-planning servies ours through traditional fee-for-servie plans, managed-are Mediaid, or California s state family-planning expansion: Family Planning, Aess, Care, and Treatment (Family PACT). The Family PACT provider network inludes more than 2,000 publi governmental and not-for-profit providers (referred to here as publi providers ), as well as private group and individual medial praties. 4 A Family PACT provider is defined with a unique ombination of organizational National Provider Identifier (NPI), owner number, and loation number. All Title X funded failities are Family PACT providers. Bixby Center for Global Reprodutive Health, Department of Obstetris, Gyneology and Reprodutive Sienes, University of California, San Franiso, California. 2 Philip R. Lee Institute for Health Poliy Studies, University of California, San Franiso, California. 428

2 ONSITE PROVISION OF CONTRACEPTION 429 As Family PACT reimburses its providers on a fee-forservie basis for family-planning servies to low-inome, uninsured lients, 5 Title X funded Family PACT providers an diret Title X funds toward enhanement of site effiieny, outreah, and liniian training. Family PACT providers an refer lients to another site to reeive ontraeptive methods that require speialized skills. 6 These methods inlude fertility-awareness methods (FAMs) to ahieve or prevent pregnany and highly effetive, user-independent methods, suh as long-ating reversible ontraeptive (LARC) methods inluding ontraeptive implants and intrauterine ontraeptives (IUCs) and vasetomies. A medial reord review of Family PACT laims has found that a large proportion of lients did not reeive neessary servies after referrals and resheduled appointments for IUC (59%) and vasetomy (36%). 7 Additionally, the review identified hallenges with aessing natural family-planning servies as indiated by repeat referrals and resheduled appointments. Despite high failure rates of natural methods, women who desire these methods are entitled to have aess to them. In this study, we determined whether Title X failities are more likely to provide these four speialized ontraeptive methods onsite, thus removing the aess barrier represented by a referral. Methods The data for this derived from a Family PACT provider survey and laims data. Inlusion riteria were to be an enrolled Family PACT provider with at least one laim in 2008, 2009, or 200. In 200, a survey was sent to eah of the 2,237 failities for ompletion by the medial diretor or a designee. Medial diretors who were responsible for more than one faility were asked to omplete a survey for eah unique billing NPI/owner/loation ombination, resulting in a single survey per faility. 8 There were no exlusion riteria. The survey assessed lini harateristis, inluding speialty, type, and apaity to provide reprodutive health servies. Respondents also indiated whether they offered FAM servies onsite to ahieve pregnany, as this familyplanning servie annot be identified through laims data. Information from responses to the survey was mathed to Family PACT laims data, using a unique identifier. For eah of the long-ating ontraeption methods (IUCs, implants, vasetomies), failities were onsidered to offer the servie if they had submitted at least one laim in Failities that had reeived more than 3 years of Title X funding were ategorized as a Title X provider, ensuring time for establishing improvements. Failities that had reeived Title X funding for 3 or fewer years were assigned to the group of publi providers not funded by Title X. Information on female sterilization was not inluded, beause onsite provision of female sterilization is influened by the faility s apaity for surgial interventions (tubal ligation) or the availability of speialized equipment (tubal olusion), and laims data do not always allow for the aurate distintion between onsite and referral-supported provision of female-sterilization servies. The primary outome of this study was to identify whether there was a differene in Title X funded failities ability to offer ontraeption methods requiring speial skills onsite when ompared to publi-setor providers without Title X funding and private-setor providers, whih are not eligible to reeive Title X funding. Seondary outomes explored this assoiation stratified by faility apaity, speialty, loation, or, for publi sites only, by offie type. Comparisons of proportions for the primary unstratified were made with the hi-square test. Stratified was performed using the Cohran-Mantel-Haenszel statisti to test for an assoiation between provider group (Title X funded, non Title X publi, or private) and their ability to offer Table. Number and Perent of Eah Provider Group by Demographi Charateristis Title X (n = 239) Provider group Non Title X publi (n = 308) Private (n = 525) Overall (n =,072) Demographi harateristi n % n % n % % p value a Faility apaity Low ( < 3 FTE) High ( 3 FTE) < Faility speialty Family planning/women s health Primary are/multispeialty < Loation Urban Rural < Offie type FQHC/Rural Health Clini/Indian Health Servies Clini Planned Parenthood County or ity health lini Hospital-based outpatient lini Other ommunity lini < a Based on hi-square test for differenes by provider group. FQHC, Federally Qualified Health Center; FTE, full-time equivalent.

3 430 THIEL DE BOCANEGRA ET AL. Table 2. Number and Proportion of Respondents Providing the Servie Onsite by Faility Category and Stratified by Site Charateristis Title X (n = 239) Provider Group Non-Title X publi (n = 308) Private (n = 525) Servie provided n % n % n % Primary p value a Stratified p value b Fertility-awareness methods < Low apaity ( < 3 FTE) < High apaity ( 3 FTE) Family planning/women s health < Primary are/multispeialty Urban < Rural Contraeptive implants < Low apaity ( < 3 FTE) < High apaity ( 3 FTE) Family planning/women s health < Primary are/multispeialty Urban < Rural Intrauterine ontraeptives < Low apaity ( < 3 FTE) < High apaity ( 3 FTE) Family planning/women s health < Primary are/multispeialty Urban < Rural Vasetomy Low apaity ( < 3 FTE) < High apaity ( 3 FTE) Family planning/women s health Primary are/multispeialty Urban Rural a Based on hi-square test for differenes by provider group. b Based on Cohran-Mantel-Haenszel test for differenes by provider group, ontrolling for strata variable. Cell sizes are too small for signifiane testing. ontraeption methods onsite while adjusting for the individual strata variables. Statistial signifiane was set at p < Data was performed using Statistial Analysis System (SAS) version 9.2 (Cary, NC). Results The overall survey response rate was 48%; for Title X providers, it was 97%. The final sample of,072 inluded 239 Title X providers (out of a total of 246), 308 non Title X nongovernmental and not-for-profit publi sites (out of 66), and 525 private solo and group medial offies (out of,330). Overall, 63% of responding sites were low apaity (fewer than three full-time-equivalent (FTE) liniians providing obstetri, gyneologi, and/or family-planning servies), and this was more likely among private providers, of whih 83% were low apaity. Thirty-five perent of all respondents were at sites whose primary speialty was family planning, ob/gyn, or women s health, whereas only 6% of non Title X publi providers were family-planning/women s health speialists. Although the majority of sites (79%) were in urban loations, 47% of non Title X publi sites were rural. Of the publi providers (both Title X and non Title X), 49% were Federally Qualified Health Centers (FQHC), Rural Health Clinis, or Indian Health Servie linis; 2% were Planned Parenthood health enters; % were ounty or ity health sites; 4% were hospital-based outpatient linis; and 5% were shoolbased, ommunity linis, or neighborhood health enters. The majority of Planned Parenthood health enters were Title X funded, whereas only one-third of other publi sites were (Table ). A signifiantly greater proportion of Title X funded failities provided onsite servies for IUCs, ontraeptive implants, vasetomy, and FAMs: IUCs (90% Title X, 5% publi non Title X, 38% private); ontraeptive implants (58% Title X, 9% publi non Title X, 7% private); vasetomies (8% Title X, 4% publi non Title X, % private); and FAMs (69% Title X, 55% publi non Title X, 49% private) (all p < 0.000) (Table 2). The higher proportion of speialized ontraeptive methods offered onsite among Title X failities remained when

4 ONSITE PROVISION OF CONTRACEPTION 43 Table 3. Number and Proportion of Respondents Providing the Servie Onsite by Provider Group and Stratified by Offie Type Title X (n = 239) Provider group Non Title X publi (n = 308) Servie provided n % n % Primary p value a Stratified p value b Fertility awareness methods < FQHC/Rural Health Clini/Indian Health Servies Clini < Planned Parenthood County or ity health lini Hospital-based outpatient lini Other ommunity lini Contraeptive implants < FQHC/Rural Health Clini/Indian Health Servies Clini < Planned Parenthood County or ity health lini Hospital-based outpatient lini Other ommunity lini Intrauterine ontraeptives < FQHC/Rural Health Clini/Indian Health Servies Clini < Planned Parenthood County or ity health lini Hospital-based outpatient lini Other ommunity lini Vasetomy < 0.05 FQHC/Rural Health Clini/Indian Health Servies Clini Planned Parenthood County or ity health lini Hospital-based outpatient lini Other ommunity lini a Based on hi-square test for differenes by provider group. b Based on Cohran-Mantel-Haenszel test for differenes by provider group, ontrolling for strata variable. Cell sizes are too small for signifiane testing. stratifying by site apaity (by FTE), speialty, or rural/urban loation. Although subgroups for vasetomy were small, the trend was onsistent. Beause different types of publi failities have different infrastrutures, fous, and level of oversight and support, we also ategorized publi providers by offie type. In our sample, the majority of Planned Parenthood health enters had Title X funding for more than 3 years (85%), but only one-third of other offie types did. Trends toward higher proportions of onsite servies of LARC methods among Title X providers remained among all offie types. There were too few vasetomies for sub (Table 3). Disussion It is important in quality family planning that lients be able to hoose their preferred method of ontraeption and that providers offer a variety of methods onsite to help redue aess barriers. One barrier having to be referred elsewhere for speifi servies an lead to lak of follow-through or reeipt of a less suitable method. Extra funding, through suh mehanisms as Title X, appears to be assoiated with improved onsite aess to the full range of ontraeptive servies. This study omplements other reent national reports on family-planning servies offered onsite that demonstrate the benefit of providing the wraparound servies allowed by Title X. In a 200 national survey examining provision of a wide range of reversible ontraeptive methods among Title X lini providers and offie-based physiians, Moskosky et al. found that a greater proportion of Title X providers reported onsite availability of all methods studied, exept the Levonorgestrel-releasing IUD. 9 This survey did not, however, examine onsite provision of vasetomy or FAMs. The Guttmaher Institute reported on a 200 national survey of publily funded family-planning linis and found that regardless of the faility s servie fous, those that reeived Title X funds were more likely than those not funded through the program to provide more ontraeptive methods onsite. 0 The survey did not, however, find signifiant differenes in the onsite provision of IUCs and implants or vasetomy between linis that reeived Title X funding and publily funded linis that did not have Title X support. The survey did not inlude private medial offies. We report muh higher proportions of onsite provision of LARC methods among Title X providers in the California data than was found nationally. In the California sample, 90% of Title X providers offered IUCs onsite ompared to 47% 65% nationally (depending on IUC type). Also, 58% of Title X providers in the California sample offered ontraeptive implants onsite ompared to 36% 38% nationally. This

5 432 THIEL DE BOCANEGRA ET AL. differene ould be due to several fators. First, we lassified as Title X sites only those with more than 3 years of funding in order to ensure time for improvements to be implemented and hanges established. Additionally, beause the Family PACT program reimburses for most of the family-planning servies at Title X funded failities, Title X money is free to be used in other ways, inluding the hiring and training of liniians in speialized family-planning servies. Finally, some of the differene ould be aounted for by offie type. Nationally, more than half (56%) of the Title X supported sites are health departments. In the Family PACT sample presented here, 40% of Title X funded sites are Planned Parenthood health enters, 37% are Federally Qualified Health Centers/Rural Health Clinis/Indian Health Servie linis, and only 2% are health departments. As Planned Parenthood health enters have a strong fous on familyplanning servies, the higher perentage of Planned Parenthood sites in our sample (40% ompared to 3% in the national survey) may partly explain the higher provision of onsite servies. Failities fae obstales to offering servies onsite. Time to teah FAMs is required, and there is a shortage of liniians qualified to provide these servies. Although IUCs and implants are among the most effetive methods available, their provision requires extra skill and training, suffiient volume to maintain a high skill level, and initial work under the mentorship of a senior liniian. Lak of training is one of the main reasons liniians mention as barriers to inserting IUCs. 2 Title X funded providers may be more likely to train their liniians to offer FAMs or long-ating ontraeption or to employ senior liniians to offer mentorship, whih avoids the need to go to another site and hene removes a ruial barrier to are. The findings presented here have several limitations. Although the overall response rate of 48% is similar to response rates reported in similar surveys, 9 the response rate for both the non Title X (47%) and private sites (40%) was onsiderably lower than the response rate for Title X providers (97%). Based on laims, nonresponders served fewer Family PACT lients, on average, than did survey respondents; in partiular, greater proportions of nonrespondents than of respondents saw fewer than 30 Family PACT lients a year. In addition, nonresponders were more likely than respondents to serve Hispani Family PACT lients and individuals whose primary language was Spanish; private medial offies that did not respond were more likely than those that did to serve males. Differenes in servie provision between survey respondents and nonrespondents ould lead to a false interpretation of the importane of Title X funding. Beause information on FAMs was obtained from the provider survey, potential differenes in patterns of provision between responders and nonresponders ould not be determined. However, an of laims data by responders and nonresponders showed no differene in the provision of vasetomy; responders were more likely than nonresponders to provide reversible methods. Beause most of the nonresponders were non Title X linis, it is likely that had data from the nonresponders been inluded, the differenes between the Title X and non Title X groups would have been even greater than reported here. Additionally, although the number of Title X nonresponding providers was small, a similar pattern of servies was seen among nonresponders, with a higher proportion of Title X providers offering vasetomy and reversible ontraeptive servies. In both the survey data and the laims data, the reasons that a method was not available onsite ould not be identified. Finally, it is not possible to rule out potential seletion bias among sites: Failities that apply for Title X funding likely already have a stronger ommitment to providing more omprehensive family-planning servies, and the award of funding allows them to fulfill this ommitment. Conlusions The provision of a variety of ontraeptive methods (sterilization, IUCs, ontraeptive implants, and behaviorbased methods in partiular) requires more training and skills than the provision of hormonal ontraeptive methods and, for this reason, are frequently referred out to other sites. Lak of onsite provision poses barriers to these methods, whih may negatively impat their timely adoption and, as a onsequene, lead to gaps in ontraeptive overage or the use of ontraeptive methods that may not be the ideal hoie for a given lient. Conerns about aess to reprodutive health servies are partiularly important with expeted inreases in demand for family-planning servies owing to hanges with the Affordable Care At and newly insured low-inome women. These results have impliations for healthare reform, as inlusion of ontraeption as a preventive servie under the Affordable Care At will inrease demand for aess to the full range of methods. In addition to reimbursing diret linial servies, there will ontinue to be a need to provide funding for infrastruture enhanements, inluding liniian training in LARC insertion, either through ontinuation of the Title X program or through new ways of reimbursing for these aspets of quality are. Aknowledgments We would like to thank our olleagues Fran Maguire and Shantha Rao for their work in the preliminary stages of this study. This researh was supported by the Department of Health and Human Servies, Offie of Population Affairs (DHHS-OPA), Grant No. FPRPA All analyses, interpretations, and onlusions reahed are of the University of California, San Franiso, not DHHS-OPA. Author Dislosure Statement No ompeting finanial interests exist. Referenes. Frost JJ, Darroh JE, Remez L. Improving ontraeptive use in the United States. Issues Brief (Alan Guttmaher Inst) 2008;: Frost JJ, Lindberg LD. Reasons for using ontraeption: Perspetives of US women seeking are at speialized family planning linis. Contraeption 203;87: Butler AS, Clayton EW, eds. A review of the HHS Family Planning Program: Mission, management, and measurement of results. Washington, D.C.: Institute of Mediine, National Aademies Press, Bixby Center for Global Reprodutive Health. Family PACT program report, FY San Franiso: University of California, 202. Available at:

6 ONSITE PROVISION OF CONTRACEPTION 433 publiations/files/fpact_programreport_0-.pdf (aessed June 3, 203). 5. Bixby Center for Global Reprodutive Health. Family PACT: An overview. San Franiso: University of California, 202. Available at: publiations/files/fpact_overview_202.pdf (aessed June 3, 203). 6. Family PACT poliies, proedures, billing and instrution manual. Saramento: California Department of Publi Health, Offie of Family Planning, Available at: (aessed June 3, 203). 7. Thiel de Boanegra H, Rostovtseva D, Menz M, Karl J, Darney P. The 2007 Family PACT medial reord review: Assessing the quality of servies. Saramento, CA: Bixby Center for Global Health, University of California, San Franiso, Available at: MRR%20Full%20Report.pdf (aessed June 3, 203). 8. Thiel de Boanegra H, Maguire F, Hulett D, Horsley K, Puffer MJ, Brindis C. Enhaning servie delivery through Title X funding: Findings from California. Perspet Sex Reprod Health 202;44: Moskosky SB, Zapata LB, Whiteman MK, et al. Contraeptive methods available to patients of offie-based physiians and Title X linis: United States, MMWR Morb Mortal Wkly Rep 20;60: Frost JJ, Gold RB, Frohwirth L, Blades N. Variation in servie delivery praties among linis providing publily funded family planning servies in 200. New York: Guttmaher Institute, 202. Available at: (aessed June 3, 203).. Cohen SA. The numbers tell the story: The reah and impat of Title X, gpr40220.html (aessed June 3, 203). 2. Harper CC, Blum M, Thiel de Boanegra H, et al. Challenges in translating evidene to pratie: The provision of intrauterine ontraeption. Obstet Gyneol 2008;(6): Address orrespondene to: Heike Thiel de Boanegra, PhD, MPH University of California, San Franiso /o Offie of Family Planning MS 8400, P.O. Box Saramento, CA thielh@obgyn.usf.edu