Family planning centers are the main interface with the health care system for many of the clients they serve. Increasingly, centers are leveraging that reality to connect clients not only to insurance coverage but also to needed health care beyond what the centers provide directly. This unique role could serve as a critically important stepping stone toward a sustainable path for the family planning provider network in the emerging health care landscape.
The nationwide network of more than 8,000 publicly funded family planning centers provides contraceptive and related services to more than seven million women a year.1 One in four women who obtain contraceptive services in the United States—including half of poor women accessing contraceptive care—does so at a publicly funded family planning center. These women receive other important, related care as well, including Pap tests, breast exams, and testing and treatment for STIs. One in three women who get tested for HIV does so at a family planning center.
It is therefore not at all surprising that six in 10 women who obtain care at a family planning center describe it as their usual source of medical care.1 In fact, in many cases it may be their exclusive source of care: according to one study conducted at Planned Parenthood centers in Los Angeles, 29% of adults and 19% of teens said the center was their only source of medical care.2 In other words, family planning centers are a significant entry point to the health care system in the United States.
Connecting Clients to Coverage
Because the door to the family planning center may be the only door to the health care system they have walked through, clients come into centers with a multiplicity of needs. But they also often come in eligible for insurance coverage for which they have not yet enrolled. Through their years of experience with state Medicaid family planning expansions, centers have developed a range of innovative approaches to assist clients in enrolling (related article, Spring 2008, page 7).
Some centers assist clients in applying for coverage on-site. Planned Parenthood of New York City (PPNYC), for example, aided more than 2,500 clients in enrolling in the state's Medicaid family planning expansion last year alone.3 When a client calling for an appointment indicates that he or she is uninsured and needs financial assistance, the telephone operator also schedules an appointment with an entitlement counselor as part of her visit and gives her the list of required documentation to bring. (Entitlement counselors are on-site at all the agency's clinical centers during all operating hours.) During the visit, if the client appears eligible, the counselor assists him or her in filling out the application; the counselor also attests that he or she has viewed original copies of the materials necessary to document citizenship. Then center staff send the completed application to the Department of Social Services for processing.
Once the application is approved, PPNYC bills the state program, which will reimburse providers for care retroactively back to the date on which the application was filed. Given the high approval rate that PPNYC receives for their submitted applications, the agency is comfortable providing the service prior to obtaining a final decision. Social Services sends the enrollment card directly to the client at the mailing address she has specified. The cost of the entitlement counselors is made up many times over by the savings from reducing the number of uninsured clients, according to Alice Berger, vice president of health care planning.
Three states with Medicaid family planning expansions—California, Iowa and Oregon—have moved beyond point-of-service application to actual point-of-service enrollment. In these states, the process begins much as it does at PPNYC. Clients calling to schedule an appointment are screened to determine whether they might be eligible, asked if they are interested in applying and, if so, given a list of the documentation they will need to bring to their visit. Once they arrive, center staff guide them through the application process. When the application is complete, the client signs a hard copy and the staff verify any required documentation and enter the client's information into a state-developed Web-based eligibility system. During the course of the visit, this system can generate an eligibility determination and the client can leave the visit enrolled in the program, which enables the center to be reimbursed for the care provided.
Clients come into centers with a multiplicity of needs, but they also often come in eligible for insurance coverage for which they have not yet enrolled.
These systems offer a route to enrollment in states' Medicaid family planning expansions, which cover contraceptive services and related medical care, such as treatment for STIs. A program initiated by Tapestry Health—an agency that provides family planning, STI and HIV counseling and testing, WIC and needle-exchange services in western Massachusetts—as part of the state's health care reform efforts goes a giant step further to assist clients, and members of the community who are not seeking family planning services, to apply for full-benefit coverage through the state's health insurance exchange (related article, Summer 2009, page 2). The effort has assisted more than 2,000 individuals in accessing coverage since 2007.4
Tapestry Health staff are certified to access the state's Web-based Virtual Gateway, which allows them to assist clients in assessing their options, as well as in applying for either Medicaid or subsidized private coverage. Trained staff assist clients in completing the application and view the required documentation. They then help clients with choosing a specific plan that best meets their needs, and often with selecting a primary care provider in the health plan in which they have enrolled. Because many of the clients are new to the health care system or to health insurance, the conversations often include basic education on the different types of service providers and the mechanics of insurance coverage (such as how to find providers in the plan's network and submit claims), as well as health care terminology (such as "deductible" and "co-pay") that is often unfamiliar and intimidating. Over the course of 2010, Tapestry Health staff assisted 451 individuals in applying for coverage; 384 of these applications have been approved and 67 are still pending.4
The assistance provided by Tapestry Health staff goes well beyond initial enrollment. Clients are able to assign the staff ongoing rights to view insurance information through the system. This allows staff to provide continuing support with paperwork and documentation critical to maintaining coverage as clients' life circumstances change. They can also provide assistance with reenrollment when a client loses coverage because of changes in eligibility or other administrative pitfalls. The system enables the Tapestry Health staff to be an ongoing interface between clients and a bureaucracy that is new and daunting to many clients, but well-known to the staff. Of the individuals assisted in 2010, 100 returned for some type of additional assistance with insurance enrollment or coverage.4
Connecting Clients to Care
Family planning centers can provide clients with the contraceptive services and related care they are seeking, and often, that is the only care needed. But many clients, especially those new to the health care system, come to a family planning visit with needs beyond the scope of services centers provide. They may need treatment for conditions as diverse as bronchitis and eye infections, or they may have issues related to dental health, mental health or substance abuse. In fact, significant medical concerns are frequently identified in the course of a family planning visit. "They come in thinking that they need to get their Pap smear, or they're interested in a family planning method," says Karen Klauss, a nurse midwife at Unity Health Care, a community health center Washington, DC. "But as soon as I see them, I see that their blood pressure is completely out of control, or based on the family history that I've gathered, they're at really high risk for diabetes and I check their blood sugar and it's sky high."5
Title X, the federal legislation that organizes and gives shape to the national family planning network, has long required family planning centers to have procedures for referring clients for additional care when needed. These requirements apply to most of the nationwide network of family planning centers; two-thirds of clients obtaining care at a family planning center do so at a site that receives some funding through the program.1 Both Unity Health Care in Washington, DC, and Tapestry Heath in western Massachusetts are grantees under the program.
According to program guidelines, Title X projects are required to maintain a list of local health care providers, health and human services departments, hospitals, and other providers and agencies for referral purposes.6 Some Title X grantees require more specific protocols. The Texas Department of State Health Services, for example, requires family planning programs to establish communication with community health centers or other state-funded organizations providing primary care or services for breast or cervical cancer within their service area.7
But many family planning providers have gone further to establish linkages with local providers. For example, the Family Planning Association of Maine, the state's only Title X grantee, maintains an extensive referral protocol.8 For conditions that do not appear serious, such as a mild rash, the client is referred to another provider. For so-called second-tier conditions, such as an abnormal Pap test result or an STI, the staff will offer to make an appointment for care. For top-tier acute conditions, such as a suspected ectopic pregnancy or a breast lump, according to Senior Vice President Evelyn Kieltyka, "we'll make sure you get in and we'll make sure you get there."
Maternal and Family Health Services, a Title X grantee in northeastern Pennsylvania, used funding from a private foundation to hire a social worker to do initial client intake and coordinate with other agencies.9 This case manager can help make sure that women get the follow-up care they need and work to ease any impediments, such as transportation, that can make getting services difficult for clients. In recent years, the agency moved from providing referrals for colposcopies when an abnormality is discovered through a Pap test to contracting with private physicians to offer colposcopy services on-site at some of its centers; this arrangement has also made it easier for women to keep appointments and access needed follow-up care. The agency has also been working closely with a local community health center to develop more meaningful linkages for clients to be able to get them into their system when needed.
Tapestry Health combines connecting clients to insurance coverage with connecting them to health care they may need by integrating this handoff into the agency's enrollment and patient navigation system. If a client needs follow-up care, the staff will assist her with insurance enrollment if she is not already covered. They can also refer the client to a provider in the community that will take clients while their insurance enrollment is pending. For a more immediate health care need, the staff will make the actual appointment when a client says that would be helpful or welcome. Long-standing relationships with local providers enable the staff to arrange an expedited appointment, sometimes as early as the next day for an urgent need.
The goal, says the staff, is to ensure that a client needing follow-up care leaves with a plan for both coverage and follow-up care; absent that, "there are just too many cracks for clients to fall through," says Ann Poole, the agency's insurance enrollment and client navigation manager.4 Doing so not only helps put a client at ease during a stressful time, but also is most efficient for the agency. The medical staff can liaise with the referring medical provider to convey whatever medical information is needed. But the client navigator does the work on the administrative side, either securing coverage or making the actual arrangements for an appointment. The navigator can also ensure that medical records are transferred, as appropriate and as consented to by the client, and work to make sure that appropriate records come back, so that the client's chart at Tapestry reflects the resolution of the issue.
The goal is to ensure that a client leaves with a plan for both coverage and follow-up care; absent that, ‘there are just too many cracks for clients to fall through.’
This kind of coordinated approach also makes sense for the overall health care system. The average wait at comprehensive providers in some communities served by Tapestry could be up to three months if the client were to call on his or her own. Clients unable to secure appointments on their own would likely, in the absence of the assistance provided by Tapestry, seek much more expensive, but more immediate, care at hospital emergency rooms instead.
Strategic Pathway
Clearly, many family planning centers are already taking important steps to serve as a gateway to the health care system in their communities, either to insurance coverage or health care or, in some cases, both. But moving forward, they would be wise to consider how to consolidate those efforts and forge them into an identifiable, recognizable and, perhaps most critically, recognized, role for family planning programs. Doing so could be a key strategy for both improving access to needed services and for giving these providers a unique and vital role in the health care landscape that is evolving as we move toward health care reform.
Solidifying this role as an entry point to care has the potential to expand the ability of family planning providers to reach into their communities, perhaps in ways that they have not been able to do before. Having the ability to connect people to full-benefit health coverage has enabled Tapestry Health's staff to reach out to some of the "off-the-grid" people in their community, individuals such as waitresses or domestic employees who may not have formal connections or channels to access coverage on their own. They have also been able to reach out to men in the community by doing outreach in places such as delis and construction sites. Although conversations may initially be about accessing insurance coverage, they provide an opportunity to discuss contraceptive needs as well.
At the same time, by offering access to full-benefit coverage, Tapestry Health staff have been able to connect with groups such as local chambers of commerce and labor unions in ways not previously possible. In doing so, they have been able to rely on their reputation in the community as a place where people can discuss sensitive issues, secure that conversations will be confidential, whether they are about reproductive and sexual health needs or perhaps individuals' discomfort at needing help, possibly for the first time in their lives.
Because of the high-quality, low-cost, confidential contraceptive services they offer, family planning centers have long had a door to the health care system that some individuals are willing to walk through, even though they may not be willing to go through other doors. Consolidating this track record into an identifiable role in the health care system holds the potential for a sustainable path for family planning centers going forward. Doing so can serve as a compelling argument for policymakers to continue to fund these centers, even as they increase resources available to comprehensive service providers, such as community health centers. This role gives health plans a reason to bring family planning centers into their networks so that enrollees who enter through that door can more easily navigate the system once inside. And, finally, it offers comprehensive providers a clear rationale for why entering into collaborations with family planning providers is an effective strategy for meeting their common goal of ensuring that all in their communities can access the services they need as quickly, effectively and efficiently as possible. In short, it has enormous potential to be a wise move for individuals, communities and the family planning provider network going forward
REFERENCES
1. Gold RB et al., Next Steps for America's Family Planning Program: Leveraging the Potential of Medicaid and Title X in an Evolving Health Care System, New York: Guttmacher Institute, 2009.
2. Sugerman S et al., Family planning clinic clients: their usual health care providers, insurance status, and implications for managed care, Journal of Adolescent Health, 2000, 27(1):25–33.
3. Berger A, Planned Parenthood of New York City, New York, personal communication, Apr. 13, 2011.
4. Smith S, Poole A and Stewart R, Tapestry Health, Florence, MA, personal communication, Apr. 11, 2011.
5. Rovner J, At-risk federal funds cover far more than the pill, National Public Radio, Apr. 1, 2011, <http://www.npr.org/2011/04/01/ 135018313/at-risk-federal-funds-cover-far-more-than-the-pill>, accessed May 9, 2011.
6. Office of Population Affairs (OPA), U.S. Department of Health and Human Services, Program Guidelines for Project Grants for Family Planning Services, Bethesda, MD: OPA, 2001.
7. Texas Department of State Health Services, Fiscal Year 2011 Policy and Procedure Manual for Title V, Title X and Title XX Family Planning Services, 2011, <http://www.dshs.state.tx.us/WorkArea/linkit.aspx?LinkIdentifier=id&Item…;, accessed May 9, 2011.
8. Kieltyka E, Family Planning Association of Maine, Augusta, ME, personal communication, Apr. 4, 2011.
9. Saxton B, Maternal and Family Health Services, Wilkes-Barre, PA, personal communication, Apr. 6, 2011.
