Access to High Quality Contraceptive Care at Community Health Centers: Current Practices, Barriers, and Facilitators for Providing a One-Year Supply of Oral Contraception On-Site Open Access
Downloadable ContentDownload PDF
Introduction. High quality family planning services help women achieve their preferred family size and birth spacing. Optimal birth spacing leads to improved health outcomes, better quality of life, and higher economic and educational achievement. Despite being a wealthy, developed nation, the United States consistently falls short in providing high quality contraceptive care and achieving optimal reproductive health outcomes. In particular, low-income women face substantial challenges in obtaining family planning care that could be easily accessible and beneficial. Equally important is ensuring that family planning services meet or exceed quality standards. Community Health Centers provide high quality primary care services, including contraceptive care, to millions of patients every year, regardless of their ability to pay. Six million women of reproductive age receive care at health centers every year, the vast majority of whom are low-income and either publicly insured or uninsured. Although health centers provide 30% of all publicly funded family planning care, they face substantial challenges in providing such care, including workforce shortages, threats to funding levels, and insufficient insurance reimbursement. Oral contraceptives (OCs) are the most common non-permanent method of contraception among health center patients and across the US. Women must use OCs continuously and correctly in order for them to be effective, but many women, especially low-income women, face barriers in obtaining a consistent supply of OCs. The Centers for Disease Control and Prevention (CDC) recommends providing or prescribing a one-year supply of OCs at a single visit. Similarly, the Providing Quality Family Planning Services (QFP) recommendations – jointly issued by the CDC and the Office of Population Affairs – include offering a broad range of FDA-approved contraceptive methods available on-site and ideally providing a full year’s supply of OCs. However, actual contraceptive practice patterns for dispensing OCs on-site and dispensing a one-year supply vary by provider type within the family planning safety net. This study focuses on both access and quality issues related to oral contraceptives for low-income women seeking care at Community Health Centers. It seeks to answer two research questions: Research Question 1: What proportion of health centers provide a one-year supply of oral OCs on-site, and what are the characteristics associated with providing a one-year supply of OCs on-site? Research Question 2: What are the barriers and facilitators for providing a one-year supply of OCs on-site at CHCs at the health center level and at the policy level?Methodology. This study employed a concurrent, mixed-methods approach. The primary source of quantitative data for this study was a survey conducted by researchers at The George Washington University and the Henry J. Kaiser Family Foundation in 2017. All 1,345 federally funded community health center grantees operating in the 50 states and the District of Columbia were invited to participate. The survey was conducted using SurveyMonkey between May and July 2017. Statistical analyses were conducted using Stata version 13 to examine the proportion of health centers meeting these two practices, as well as various characteristics associated with doing so. The first phase of qualitative data collection and analysis was a point-in-time environmental scan of state-level policies that may serve as either barriers or facilitators to providing a one-year supply of OCs. These policies included Medicaid coverage and private insurance coverage for OCs, including any recent state legislation. The second phase of the qualitative data collection and analyses was a series of semi-structured, in-depth interviews with key staff in four health centers located in three states, sampled using a maximum variation strategy. Interview transcripts were analyzed using thematic content analysis in QSR NVivo version 12. Results. Only one-half of health center sites surveyed provide OCs on-site, and of these, less than one-third offer a one-year supply at a time. In other words, approximately one-sixth of health centers provide a one-year supply on-site. Health centers are more likely to provide OCs on-site if they: receive Title X funding; participate in 340B; are large; are located in urban areas; or have a high proportion of women of reproductive age in their patient population. Health centers are more likely to offer a one-year supply on-site if they: participate in 340B; are large; or are located in states with policies that require coverage for a one-year supply under at least one coverage mechanism. Interviews with health center staff also provided insight into the barriers and facilitators at the health center level. Clinician and pharmacist preferences for providing OCs drive many of the policies and practices for dispensing OCs on-site. Often, these preferences reflected the leadership’s attitudes about family planning and the overall organizational approach to incorporating family planning into their other primary care services. The health centers that provided a one-year supply on-site included a leadership team and clinicians who prioritized family planning and made it a central part of their practice. In addition to the top-down effect from leadership, clinicians’ perceptions of the patient population and patient needs also influenced their preferences for providing a one-year supply on-site. When clinicians perceived that patients were less responsible or less likely to keep track of a full year of contraception at once, they did not express much enthusiasm for providing it, whereas clinicians who believed that a one-year supply would help their patient population to avoid an unintended pregnancy sought out ways to provide a one-year supply. In addition to these factors at the health center level, state and federal policy played a role in determining health centers’ practices, although the relationship between favorability of state policy and provision of a one-year supply was not always clear-cut. This study finds a rapidly shifting state policy environment for coverage of a one-year supply of OCs. While several states have recently passed legislation or implemented regulations requiring insurers to cover a one-year supply, the majority of states do not have such a requirement. In addition, most state Medicaid plans limit the supply of OCs to either one or three months. Only three states require coverage for a one-year supply under all coverage mechanisms examined here, with another 11 requiring coverage under at least one coverage mechanism. These findings reveal that women in most states do not have access to coverage for a one-year supply of OCs, whether through private insurance or Medicaid. Discussion. Although no previous studies have examined this exact topic, the majority of the findings presented here concur with existing research on related topics. Analyses of the QFP guidelines indicate that actual practice patterns vary significantly within the family planning safety net. Furthermore, other research suggests that providers base practice patterns on their own values and preferences, even when these contradict clinical guidelines. While the CDC and OPA have issued guidelines for family planning services that health centers may follow, there are very few practices that health centers must follow. As a condition of receiving Section 330 funding from the Health Resources and Services Administration (HRSA), health centers much provide “voluntary” family planning services. Yet the exact scope of these services, or even a set of quality guidelines for these services, is open to interpretation at the health center level. As a result, there are gaps in quality between best practices and actual practices among health centers. To remedy these gaps, HRSA could establish performance criteria for health centers, either through an independent process or by requiring adherence to existing guidelines, such as those outlined by the CDC or ACOG. Although this change would likely be effective in improving quality of care, it is not likely to manifest in the near future, as HRSA has not opted to impose specific requirements on family planning services since the initiation of the health center program.In the absence of specific requirements or guidance at the federal level, policy and practice change could instead take place at the regional, state, or health center level. As only 17 states (including DC) have instituted policies requiring private insurance coverage for a one-year supply, the remaining 34 would have to follow suit in order achieve coverage across the country. States with fee-for-service Medicaid could implement changes through updates to their provider manuals, and states with managed care could require coverage for a one-year supply in all managed care contracts. For health centers, Primary Care Associations (PCAs) could focus upcoming training efforts on implementing this practice or could offer technical assistance to health centers for doing so. In addition, addressing individual provider preferences and attitudes through continuing medical education and tailored provider training could change uptake of this practice. In the current political environment, threats to the family planning safety net persist and continue to develop. If family planning providers such as Planned Parenthood are either forced to close or to decrease services because of lost funding, health centers would be left to meet the increased demand among this population. However, health centers have indicated that most cannot absorb significant increases in patient load, and existing gaps in quality of family planning care between health centers and specialty family planning providers – such as the one explored in this study – will be exacerbated. Future research should monitor this practice over time. Additional research could also include examining this issue from the patient perspective, assessing health outcomes related to providing a one-year supply of OCs on-site, and updating/maintaining the state-by-state policy analysis as the policy environment continues to shift.