Cuts Healing, But Scars Remain
Tex Med. 2013;109(11):20-26.
By Crystal Zuzek
By the time patients see obstetrician-gynecologist Lisa Hollier, MD, the opportunity for preventive care has passed. The high-risk Medicaid patients she predominantly sees are already pregnant and often suffer from a sexually transmitted infection (STI), chronic disease, or other complicating condition.
"When I ask patients if the pregnancy was planned, they often answer no. Access to preventive care is the biggest problem for low-income women," said Dr. Hollier, chair of the Texas District of the American Congress of Obstetricians and Gynecologists (ACOG).
Dr. Hollier practices in Houston, and like many Texas primary care physicians, she strives to provide first-rate care to women who have fallen through the state's tattered health care safety net.
"To have healthy babies, the moms need to be healthy," she said.
The state is in a prime position — a $200 million position — to improve access to preventive health care for low-income women through restored funding for women's health programs. Thanks to successful legislative advocacy by the Texas Medical Association and other organizations, the Texas Legislature appropriated $174 million in state funds for 2014-15 for preventive services. Additionally, clinics led by the Women's Health and Family Planning Association of Texas will receive $26 million in federal grants.
Texas Department of State Health Services (DSHS) Commissioner David Lakey, MD, says a comprehensive approach to family planning and preventive health care will help physicians improve the health of women.
"This funding will help reduce unintended pregnancies and will help physicians address women's chronic diseases and other health issues prior to pregnancy," Dr. Lakey said.
Texas can restore access to preventive care for the approximately 120,000 women who lost it following devastating cuts to the Texas family planning program in 2011. That year, the legislature drastically slashed funds for family planning services by 66 percent (from $111.5 million to $37.9 million) and further stressed the women's health infrastructure.
The restored funds represent the legislature's renewed interest in preventing unintended pregnancies and connecting women to vital primary health care services. Physicians say celebrating is premature, however. Texas now has the challenge of rebuilding the safety net and ensuring physician capacity to serve women's health needs. Even so, the restored funding levels only allow the state to serve about one-third of the women in need.
ACOG President-Elect John C. Jennings, MD, says Texas will have to scramble to repair the damage the 2011 family planning funding cuts caused.
"The legislature did the right thing by working with medicine to restore women's health funds. But in reality, we're still a long way from being able to provide the majority of low-income Texas women with preventive health care," said Dr. Jennings, chair of the Texas Medicine Editorial Board.
Sen. Jane Nelson (R-Flower Mound) says the 2011 funding cuts, which she describes as "too severe," inspired her as chair of the health and human services budget workgroup, to prioritize women's health funding this session. She adds that restoring women's health funding signals a common interest among legislators to ensure access to preventive health care for low-income women. In fact, Senator Nelson's Senate Health and Human Services Committee will study family planning access and programs before the legislature convenes in 2015. (See "Lawmakers to Study Family Planning Programs.")
"In the months ahead, we will continue to make a concerted effort to try and develop those common goals into legislative action," she said.
In the midst of the study, Texas physicians will scrutinize the programs' impact on the health care system for low-income women.
"I'll be looking for a reduction in unplanned pregnancies. I'll be looking for an increase in women who can identify a health professional who cared for them between pregnancies. That is going to indicate to me that the state has been successful with this funding," Dr. Hollier said.
Funding Women's Health
DSHS will receive $43 million in state funds for family planning services such as STI testing and treatment, contraception, health exams for men and women, clinical breast exams, Pap tests, and cholesterol and diabetes screenings. On top of that, the budget also adds $100 million to expand women's health services in the DSHS Expanded Primary Health Care Program, which contracts with community health clinics and nonprofit organizations to provide services for uninsured, poor Texans who don't qualify for other state health programs. The Expanded Primary Health Care Program differs from the department's traditional Primary Health Care Services Program in that it includes funding for family planning services.
DSHS estimates $60 million of the $100 million increase will fund family planning services. Additional funds in the Expanded Primary Health Care Program will allow DSHS to serve approximately 170,000 Texans annually by offering well-woman checks, cancer screenings, and family planning.
Lawmakers also allocated $71.3 million to fully fund the Texas Women's Health Program (TWHP), operated by the Texas Health and Human Services Commission (HHSC). The program gives low-income women aged 18 to 44 access to birth control, basic preventive health screenings, and STI treatment. Before 2013, the federal government provided 90-percent funding for the program, but last year the state opted to forgo federal funding so that it could exclude Planned Parenthood and affiliates of abortion providers.
Dr. Hollier says having more women's health funding programs calls for greater coordination.
"These programs each have different participation requirements and enrollment procedures. It would help to have standardization among the programs and a coordinating entity," Dr. Hollier said.
HHSC plans to hire a women's health coordinator to assess and oversee women's health services at HHSC, DSHS, the Texas Department of Family and Protective Services, the Texas Department of Aging and Disability Services, and the Texas Department of Assistive and Rehabilitative Services.
"The women's health coordinator will pursue ways to help women learn about the health services that exist and how to access them," said Linda Edwards Gockel, HHSC press officer.
Restoring women's health funding this session marks a shift in priorities for the Texas House and Senate, says Janet Realini, MD, chair of the Texas Women's Healthcare Coalition Steering Committee. TMA and 29 other organizations are members of the coalition, which works to improve the health of women and their families by ensuring they have access to preventive care. Dr. Realini says the case for funding women's health resonated with lawmakers for several reasons.
"Many lawmakers from both parties were distressed by the collateral damage of the family planning cuts of 2011. Two-thirds of the clinics that closed were not Planned Parenthood clinics, and many communities have been coping with a dramatic loss of preventive care," she said.
According to data from The University of Texas at Austin Population Research Center, 56 clinics closed following reductions in family planning funds.
Rep. Sarah Davis (R-Houston) played a pivotal role in garnering bipartisan support for restoring family planning funds in the 2014-15 budget. A breast cancer survivor, she has a personal connection to women's health.
"I understand that early detection is key, and my experience as a cancer survivor motivates me to prioritize funding for women's preventive health care," she said.
And it didn't hurt that the state had money in the budget to work with this session. In 2011, lawmakers faced a $27 billion shortfall, but this time around, they had an $8 billion surplus that Representative Davis says made it easier to gain broad support for replenishing the funds.
"I got a lot of calls from constituents who weren't happy with the family planning cuts last session. I worked with legislators to prevent debate over family planning funding on the House floor. It was important to me and to other lawmakers that the money allocated to women's health in the budget remain in the budget," Representative Davis said.
She says she'll fight to maintain family planning funding in future sessions.
"Preventive health care for women saves taxpayers money and results in better health outcomes. And I believe the only way we can repair the damaged health care safety net is by maintaining a consistent stream of revenue for family planning programs. We can't keep cutting money and adding it back in," she said.
Repairing the Safety Net
Dr. Realini says the restored women's health funding is a substantial step forward, but that challenges lie ahead.
"Texas built up the women's health care safety net over the course of 40 years but tore it down in just two years. It will be a huge challenge for Texas to restore services for several reasons," she said.
It will take time for clinics that closed to reopen. Plus, the network of physicians is now smaller due to the exclusion of Planned Parenthood clinics from women's health programs and reductions in services at other clinics serving low-income women.
"Large hospital systems and clinics that receive funding from multiple sources should be able to ramp up preventive services. It can be difficult for individual physicians and small clinics to prioritize prevention and achieve the efficiencies of the larger specialty clinics," Dr. Realini said.
Dr. Hollier worries clinic closures in rural areas won't be easily reversed.
"The restoration of funding is too little, too late. I'm concerned about the complexity in the distribution of the funding and the adequacy of the provider networks. I'm worried about accessibility of patients to the networks that we're building," Dr. Hollier said.
Whether Texas will have enough physicians to meet women's health needs is unclear, Dr. Realini says.
"It will be important to monitor these programs with regard to provider capacity and geographic reach," Dr. Realini said.
HHSC data for the first half of this year indicate lower service levels in TWHP, for instance.
As of June 1, HHSC had processed 79,663 TWHP claims, compared with 103,339 in 2012 for the same period. Ms. Gockel says the agency is confident it can "provide services for every woman who enrolls in the program," adding that the $71.3 million the legislature allocated to the program will allow HHSC to serve more than 110,000 women a year.
"If the demand for services is higher, we'll work with state leadership on our options," she said.
As of July, 2,636 physicians and providers participated in TWHP. Of those, 173 are family planning clinics, 169 are federally qualified health centers (FQHCs), 2,141 are physicians, 78 are rural health clinics, and 75 are physician assistants.
Ms. Gockel says comparing the number of physicians and providers to the previous year is difficult because 2012 data include duplicates. HHSC said last year that the Women's Health Program had 2,562 physicians and providers. (See "A Steep Price," July 2012 Texas Medicine, pages 18-25.)
Since the exclusion of Planned Parenthood clinics, Ms. Gockel says many other clinics in the program now serve a "significant number of women." She cites a capacity survey HHSC conducted last year of TWHP providers in areas Planned Parenthood previously served. In 2012, Planned Parenthood and others served 80,127 women. The survey found that physicians and providers in those areas can serve 147,513 TWHP clients this year. HHSC continues to recruit doctors and clinics to TWHP. She says HHSC has identified 4,000 OB-Gyns for potential recruitment in the program, for example.
Innovative Funding Approach
Immediately following the 2011 legislative session, Dr. Lakey began meeting with legislators and their staff members throughout the state to develop a plan for funding women's preventive health care, including family planning.
"People weren't happy with the cuts in 2011. We needed a solution. The feedback from lawmakers was that they felt comfortable focusing on funding for comprehensive care that addressed not only contraception but also prevention," he said.
Dr. Lakey says the $100 million investment the legislature made in the department's Expanded Primary Health Care Program will help the state rebound from the big family planning cuts in 2011. Now, he says, DSHS needs to deliver on its promise to save the state money while improving health.
Had lawmakers opted not to restore funding for women's health, they would have faced daunting financial implications. HHSC's Legislative Appropriations Requests estimate additional Medicaid births would cost Texas taxpayers $136 million from 2013 to 2015. Allocating funds to family planning and preventive health care is an investment that will save the state money in the long run, Dr. Lakey says.
"We need to make sure we demonstrate that the investment made a difference. We're building this program to be cost neutral through savings in the Medicaid program. If we can demonstrate cost savings, we'll have a platform with bipartisan support that we can strengthen in future sessions," he said.
Dr. Hollier says Dr. Lakey's vision for expanding the Primary Health Care Services Program is a good example of increasing access to preventive care to help rein in costs.
"We need more innovative programs, and we need to encourage physicians, Medicaid, and health systems to develop new women's health initiatives," she said.
The Expanded Primary Health Care Program will serve an estimated 170,000 women aged 18 and older annually. In 2012, the Primary Health Care Services Program served about 46,000 women out of 64,338 clients.
Before this legislative session, the program operated on a $12 million annual budget and provided services to patients through 57 contracts with FQHCs, local health departments, hospitals, hospital districts, and nonprofit organizations. Texas residents at or below 150 percent of the federal poverty level (FPL) — a monthly income of $2,943 for a family of four — were eligible for the program. The Expanded Primary Health Care Program is open to residents at or below 200 percent FPL, or a monthly income of $3,925 for a family of four.
Carrie Williams, DSHS press officer, says those interested in participating in the Expanded Primary Health Care Program submitted applications, which DSHS was reviewing at press time. Ms. Williams says most contracts took effect Nov. 1. To accelerate patient access, the hospital districts in Houston, Dallas, Fort Worth, and San Antonio, and The University of Texas Medical Branch in Galveston started providing services under the expanded program in September.
Contractors receive payments through a voucher system, and DSHS is developing a fee-for-service system, which Ms. Williams says should be available in 2015.
"DSHS will allow a hybrid contract with both voucher-based and fee-for-service reimbursements if the contractor chooses this option," she said.
DSHS conducted nine public regional meetings for interested parties across Texas in April and May. Attendees included current and potential physicians and providers, TMA, the Texas Association of Community Health Centers, the Texas Association of Local Health Officials, other professional and community organizations, and women's health advocates. The department used its input to make program decisions, such as opting to keep the Primary Health Care Services Program and the new Expanded Primary Health Care Program separate.
Ms. Williams says many participants in the Primary Health Care Services Program voiced concerns about the expanded program. For example, some rural organizations worried they didn't have a large enough demand to justify fully dedicating 60 percent of funds to family planning services.
"Ultimately, DSHS wanted to give local communities options in how to provide primary health care services. Keeping the two programs separate allowed those communities that wanted to participate in the new expanded program to take on the new funds. Smaller communities could choose to remain in the traditional Primary Health Care Services Program," Ms. Williams said.
More information on the Expanded Primary Health Care Program is on the DSHS website.
Crystal Zuzek can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email.
Lawmakers to Study Family Planning Programs
The Senate Health and Human Services Committee, chaired by Sen. Jane Nelson (R-Flower Mound), will review family planning access and programs before the 2015 legislative session. She said in September the committee is monitoring the implementation of family planning programs supported by the approximately $200 million infusion of new funds.
Extending services to women in rural and underserved areas will be a priority for the committee.
"Texas spreads health care resources over a more populated, diverse, and expansive area than any other state, so we must continue to find better ways to deliver services in places that are difficult to reach," Senator Nelson said.
Janet Realini, MD, chair of the Texas Women's Healthcare Coalition Steering Committee, says the coalition, of which TMA is a member, has requested the study focus on:
- The ability of family planning funding programs to achieve their goals of providing preventive health care to women and save money for the state;
- Ways to better coordinate the various programs to increase the number of women served, ensure an adequate number of providers, and maximize savings to the state;
- The ability of the family planning programs and agencies to provide statewide access to services across several payer sources;
- How the 2011 cuts to the Department of State Health Services family planning program affects access to family planning services statewide and the prevalence of unintended pregnancy, number of births, and Medicaid costs to the state; and
- The effect of excluding affiliates of abortion providers from the Texas Women's Health Program on access to family planning services statewide, and on the prevalence of unintended pregnancy, number of births, and Medicaid costs to the state.
Rep. Sarah Davis (R-Houston) says she'll participate in the interim study.
"I'm hopeful the study will show the family planning programs are cost-effective and need to be continually funded," she said.
Lisa Hollier, MD, chair of the Texas District of the American Congress of Obstetricians and Gynecologists, says the bipartisan interest in family planning is encouraging.
"The interim study provides an opportunity for legislators to learn about the real problems confronting women in their districts. I hope the information gathered through the study leads to practical solutions, not partisan politics," she said.
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Texas Enacts Strict Abortion Measure
In July, Gov. Rick Perry signed a law that bans abortions at or after 20 weeks postfertilization and subjects physicians to stiff penalties for violating the law. The legislature passed the measure despite concerns from the Texas Medical Association and heated debates that dragged the issue out into two special sessions.
House Bill 2 includes 20-week postfertilization abortions in the Texas Medical Board's list of prohibited practices by physicians or license applicants and assesses administrative penalties for physicians distributing or prescribing abortion-inducing drugs in certain situations. The law restricts use of RU-486, an abortion-inducing drug approved by the U.S. Food and Drug Administration for use by women who seek an abortion; requires abortion providers to have hospital privileges; and requires abortion facilities to meet ambulatory surgical center standards.
Governor Perry said at the HB 2 bill-signing ceremony that the law "ensures that anyone performing abortions in Texas is doing so in a facility that is safe, clean, and prepared to deal with any emergencies that might occur — a reasonable, common-sense expectation for those caring for the health and safety of Texans."
TMA didn't take a position in the debate but was concerned with the legislative intrusion into the patient-physician relationship and the practice of medicine and with a legislatively created standard of care. "This bill includes determinations that should be made by the medical community and science, not by the legislature," TMA President Stephen L. Brotherton, MD, wrote to the House State Affairs Committee.
TMA warned the bill could have a chilling effect on physicians' ability to use their best judgment in treating pregnant patients, resulting in access-to-care issues and potential risks for both the mother and the fetus. TMA also worries the law is overly broad in that it requires physicians or other health care personnel to be available 24 hours a day, possibly indefinitely, to assist patients with pregnancy complications and provide potentially unprecedented access to medical records.
Planned Parenthood, women's health organizations, and abortion rights groups filed a lawsuit Sept. 27 that seeks to block two provisions of HB 2 that were scheduled to take effect Oct. 29. At issue in the suit are the law's restrictions on the use of abortion-inducing drugs and the requirement that abortion providers have hospital privileges. Plaintiffs also argue that the inevitable closure of abortion clinics will limit women’s access to the procedure.
The lawsuit doesn’t challenge the ban on 20-week postfertilization abortions or the requirement that abortion facilities meet ambulatory surgical center standards.
All articles in Texas Medicine that mention Texas Medical Association's stance on state legislation are defined as "legislative advertising," according to Texas Govt. Code Ann. §305.027. That law requires disclosure of the name and address of the person who contracts with the printer to publish the legislative advertising in Texas Medicine: Louis J. Goodman, PhD, Executive Vice President, TMA, 401 W. 15th St., Austin, TX 78701.
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