Playing Catch-Up

Texas Expands Access to Family Planning and Preventive Health Services

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Cover Story — April 2016

Tex Med. 2016;112(4);22-29.

By Joey Berlin
Reporter

For advocates of women's health funding in Texas, the climb back from the depths of 2011 continues.

That year, the Texas Legislature sliced about two-thirds of the state's family planning budget, and the impact reverberated across the state. Obstetrician-gynecologist Janet Realini, MD, saw the effect of the cuts emerge in San Antonio. At the family planning clinic at University Health System, for example, making an appointment became extremely difficult for new patients, Dr. Realini says. More expensive contraceptives were no longer available.

"They had very limited funds," she said. "Here was a provider — they have comprehensive services available in their institution — and they also were not a Planned Parenthood [facility], and yet they had severe cuts to deal with. It was hard for women to get appointments. And when they did, the type of contraception that was really available was limited for a time."

Five years later, an infusion of new funding and a streamlined state approach to women's health have physicians optimistic. Physicians say Texas has made progress in addressing many of the issues those 2011 cuts created, such as decreased access to screenings and family planning services for low-income women and girls.

Texas Medical Association advocacy helped recoup a healthy amount of that funding during the 2013 legislative session, and last year's session brought an additional $50 million appropriation for 2016–17.

On July 1, the Texas Health and Human Services Commission (HHSC) will launch a consolidated program and a revamped one. HHSC is combining its Texas Women's Health Program (TWHP) with the Expanded Primary Health Care program (EPHC), which used to fall under Texas Department of State Health Services (DSHS) oversight. The new program, called Healthy Texas Women (HTW), will provide family planning services, screenings, and immunizations for low-income women and girls.

"I think definitely in our practice and across the Rio Grande Valley, and across Texas, when those cuts happened, a lot of providers definitely saw that women just didn't have the access to care anymore," said McAllen OB-Gyn Jennifer Almonte-Gonzalez, MD, a member of HHSC's Women's Health Advisory Committee. "This expansion will hopefully help some of those women get back into the program."

The Family Planning program, which moved from DSHS to HHSC last summer along with the expanded primary care program, will go into effect in a new, expanded form on July 1. Both HTW and the Family Planning program will boast wider age eligibility than their past incarnations.

"There are going to be people who fall through the cracks, obviously, for a variety of reasons," said John C. Jennings, MD, past president of the American College of Obstetricians and Gynecologists (ACOG) and chair of the Texas Medicine Editorial Board. "[But] it will bring us back up to a level [where] we're better off now than we were two years ago."

But concerns remain, and challenges lie ahead. For example, Austin OB-Gyn Amy Young, MD, chair of women's health at The University of Texas Dell Medical School, says she hopes the new programs increase access to contraception. She's concerned, however, that introducing "this many changes in this short of time has providers very confused about what they should do and who's eligible for what."

"I just think that a barrier to moving this forward quicker is that it's going to take providers a while to actually understand what the new 'new' is," Dr. Young said.

Serving Women and Girls

Though HTW and the Family Planning program will offer many of the same services, their requirements for eligibility will differ. Eligibility in HTW includes: 

  • Women and girls aged 15 to 44;
  • Those with an income at 200 percent of the federal poverty level or below;
  • U.S. citizens or legal immigrants; and
  • Those who are not pregnant. 

The inclusion of girls aged 15 to 17 is a key change from TWHP, for which only women aged 18 to 44 were eligible. Minors aged 15 to 17 who want contraceptive services through HTW will need parental consent. In 2013, according to U.S. Centers for Disease Control and Prevention data, Texas ranked second among all states in rate of births by mothers aged 15 to 17, trailing only New Mexico.

The new 200-percent maximum income also allows for greater eligibility for low-income women; TWHP allowed eligibility for women at or below 185 percent of the federal poverty level.

TWHP had a caseload of 114,441 women in fiscal year 2014, according to HHSC data. EPHC's caseload was 147,083 that year, while the Family Planning program had a caseload of 55,869.

The new version of the Family Planning program will be open to women and men who meet these criteria: 

  • Aged 64 and younger;
  • Income at 250 percent of the federal poverty level or below; and
  • Texas resident. 

Both programs will offer contraceptive services, screening and diagnostic services for breast and cervical cancer, screening for chronic conditions, and immunizations.

The Family Planning program also will provide limited prenatal services. Dr. Realini, vice chair of the Women's Health Advisory Committee and a consultant for TMA's Committee on Maternal and Perinatal Health, says the Family Planning program's availability to 64-year-old women will provide patients past reproductive age with screenings for breast and cervical cancer and chronic conditions.

HTW will be a fee-for-service-based operation, while the Family Planning program will be contract-based. Medicaid patients and physicians will have automatic enrollment into HTW, and the program will grandfather in physicians who are participating in TWHP.

"For physicians who are caring for Medicaid patients, if they would like to be Healthy Texas Women providers and continue with those patients in the [new] program, that can be now much more seamless," Dr. Realini said.

Although HHSC has determined the eligibility and basic services the programs will cover, rules for HTW and the Family Planning program still needed to go through the rulemaking process at press time. The Health and Human Services Council planned to examine proposed rules for the two programs at a meeting in late February. 

The rules were to appear in the Texas Register on April 1 and remain open for public comment until May 2.

Dr. Realini acknowledges while much remains unknown about the parameters of what HTW will cover, HHSC has already decided it will cover "the core family planning services that we know from the family planning programs of old," including a history and physical exam, an assessment of a woman's contraceptive needs, and screening for breast and cervical cancers, infections, hypertension, diabetes, and high cholesterol. 

In comments TMA and other organizations submitted to HHSC's Women's Health Advisory Committee in November, TMA requested treatment of hypertension and diabetes be covered benefits in both programs to improve women's health and birth outcomes for women who plan future pregnancies. 

"When we're talking about contraceptive services, we're talking about high-quality [services], lots of the different methods available, good information about them, a system so that women can hear about all those that they may be interested in, and to hear especially about those highly effective methods that they might be interested in," Dr. Realini said.

Lesley French, HHSC's associate commissioner for women's health services, said the agency is committed to women's health.

"The Women's Health Advisory Committee has been essential to the design of the new Healthy Texas Women and Family Planning programs," she said. "These programs will provide access for thousands of Texas women because they were designed by doctors for doctors. Having provider support is crucial for the programs to be successful."

More Coverage, More Services?

During the past two legislative sessions, TMA and other organizations convinced lawmakers to replenish state funding for women's health after the Texas Legislature's deep cuts of 2011. That year, the legislature slashed funding for family planning services by about 66 percent, from more than $111 million to less than $40 million.

"That took out the only funding that these ladies had," said Odessa OB-Gyn Moss Hampton, MD, chair of the Texas District of ACOG. "It wasn't like, 'Oh, I lost my insurance; I'll just pay cash today.' They lost their insurance and couldn't get the services. It was a very devastating effect. A lot of women went without care, or if they received care, a lot of times it was through the emergency room for problems. ... It was a very devastating cut for those of us who serve the uninsured and underinsured."

A Texas Policy Evaluation Project (TxPEP) report later showed a seismic impact on the number of women receiving those services. The TxPEP study, which appeared in the March 2015 issue of the American Journal of Public Health, looked at the effect of the 2011 cuts to women's health funding. Organizations that received family planning funding served 54 percent fewer clients during 2012–13 than they did in 2011.

In that same 2011 session, the legislature targeted Planned Parenthood, directing HHSC to ensure funds for the state's Medicaid Women's Health Program wouldn't go toward the controversial family planning services provider. The next year, those changes resulted in the Centers for Medicare & Medicaid Services phasing out federal funding for the Women's Health Program, which became a fully state-funded program in 2013 under its new name, the Texas Women's Health Program. Enrollment in the women's health program fell by 9.1 percent from fiscal year 2011 to fiscal year 2013, according to a report HHSC released in 2015. Use of services fell by more than 25 percent, declining in 10 of 11 HHSC state regions.

Advocacy by TMA and other stakeholders engineered a promising bounce-back for women's health funding in 2013, with the legislature appropriating $174 million for preventive services that year, including $71.3 million in funding for TWHP. (See "Cuts Healing, But Scars Remain," November 2013 Texas Medicine, pages 20–26.) 

Last year's legislature transferred the Family Planning program and EPHC from DSHS to HHSC effective Sept. 1, 2015. HHSC already oversaw TWHP. The Sunset Advisory Commission recommended consolidating those three programs into two.

"Sunset found that it was confusing for women to try and navigate multiple programs spread out across two state agencies," said Sen. Jane Nelson (R-Flower Mound), a previous chair of the Senate Health and Human Services Committee. "We moved them together at HHSC under the Healthy Texas Women umbrella to make it easier for women to connect with these services. So far, it has been a seamless transition, and we are monitoring closely to make sure the additional funding we approved this session gets out into the field in an efficient manner."

Senator Nelson notes total women's health funding is "far and away above where we were during the recession." HHSC received $262 million in general revenue funds for women's health and family planning for 2016–17, bringing total women's health funding to about $285 million for the biennium — about $84 million more than during fiscal year 2010–11, prior to the cuts. (See "Funding Women's Health.") The additional $50 million this year was subject to Legislative Budget Board approval at press time.

"Funding is at an all-time high, and we have more than tripled provider enrollment to make sure that women in every corner of the state can access services," Senator Nelson said.

"The legislature has reached out through the health department; the health department has come to the physicians who actually do the work and asked for advice," Dr. Jennings said. "[TMA has] had people sitting on the Women's Health Advisory Committee for the state, and it's resulted in these programs that I think are going to be very effective."

Senator Nelson told Texas Medicine the political reality of how Texans want their tax dollars spent with regard to women's health is often mischaracterized.

"The fact is both parties want a robust women's health system, which is exactly what we are building in Texas," she said.

Challenges Await

Maximizing the effectiveness of the programs will be challenging.

Dr. Realini says HTW will likely have trouble enlisting enough participating practitioners to take the program "where it needs to be."

"And of course, Texas has ruled out certain providers that have historically provided not only the most services under the women's health program, but also taking care of finding who's eligible and getting them signed up, and all that sort of administrative work we need," she said.

TWHP had a total of 3,853 participating health professionals as of June 2014, according to an HHSC report released in early 2015. That count included 2,705 physicians (combined MDs and DOs), 635 physician groups, 194 federally qualified health centers, and 189 family planning clinics. More recently, a November 2015 HHSC report pegged the total number of TWHP health professionals for fiscal year 2015 at 4,603.

A major opportunity exists for many practitioners and health organizations that participate in family planning programs to increase their patient volume by participating in HTW, Dr. Realini says. But she adds HTW will need greater involvement from private practice physicians to thrive. 

The "limited package of services" HTW will offer creates a challenge in attracting physicians, she says, because of liability concerns if doctors don't offer uncovered services the patient may need. Stakeholders were still trying to determine which, if any, chronic conditions HTW will cover.

"And that creates a difficult tension in the program because the program is designed to save the state money by reducing the unplanned Medicaid births, and that's where its funding comes from," Dr. Realini said. "But the diagnosis and treatment of chronic conditions are much more expensive than the smaller costs, like family planning services.

"If you get into doing too much treatment, you're not going to be able to do as much family planning. The program will not be able to pay for itself because the funds will be spent on unplanned Medicaid pregnancies. That's the tension."

Another challenge in HTW: The state's eligibility system doesn't allow teens who are enrolled in the Children's Health Insurance Program (CHIP) to have simultaneous enrollment in HTW. CHIP does not cover contraceptive services. 

Alice Bufkin, director of policy and advocacy for the Texas Women's Healthcare Coalition, says that mutual exclusion "creates a challenge because we know a lot of the girls who would most benefit from having services within the Healthy Texas Women program won't be able to participate because they're getting CHIP services."

"CHIP is great; it's more comprehensive than what Healthy Texas Women offers," Ms. Bufkin said. "But it does not provide contraceptive care through the program."

Increasing access and awareness of long-acting reversible contraceptives (LARCs) has been a TMA priority, and HTW and the new Family Planning program will cover those services. Effective Jan. 1, 2016, Medicaid patients can already receive immediate postpartum LARC implantation.

Claims for LARCs, including intrauterine devices and birth control implants, fell sharply after the state excluded Planned Parenthood from receiving public funds, according to a report released in the New England Journal of Medicine last February. The report examined the effects of the exclusion on low-income childbirths and contraception. The study used data from the Women's Health Program in the two years before and two years after it became the Texas Women's Health Program on Jan. 1, 2013.

Claims for LARCs during 2013–14 fell by more than 35 percent, according to the study, and claims for injectable contraceptives dropped by 31 percent.

"These methods have high satisfaction, and they can lower rates for teen and unplanned pregnancy," Dr. Realini said of LARCs. "Making those methods accessible … is really, really important."

TMA is offering a continuing medical education course on LARCs at TexMed 2016 April 29–30 at the Hilton Anatole in Dallas. (See "Learn About LARC Access at TexMed.")

The New England Journal of Medicine study also found in the 23 Texas counties that had clinics affiliated with Planned Parenthood, Medicaid-covered births increased by 1.9 percent. Those 23 counties were home to 60 percent of women aged 18 to 44 who were at or below the 185-percent federal poverty line threshold.

In a Better Position

The boosted dollars and the expanded approach don't give medicine everything it needs for women's health services. But many echo Dr. Young when she says the programs represent "a step in the right direction."

Dr. Realini acknowledges the state has a long way to go but says Texas is "poised to make huge progress in helping women and men plan their families, avoid unplanned pregnancy, reduce state costs … and reduce teen pregnancy dramatically. We're really poised to make a lot of progress, and these programs will likely be part of that."

Dr. Hampton says he's happy to have additional funding for women's health care. "I think we're going to be able to put together a good program. Could we have used more money? Absolutely. There are many more women out there who could utilize our services than we've got money to pay for in the current program, but it's a start."

The trick, Dr. Jennings says, will be "getting the word out and getting people back into the system at the places where these services are provided. I'm very encouraged by the fact that we've got that program in place and coming out," he said. "Obviously, the quicker we can roll it out and the more advertising that can be done, and the more placement there can be of the people in the services, the better."

Joey Berlin can be reached by phone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.

SIDEBAR

Learn About LARC Access at TexMed

Through a continuing medical education (CME) course available at TexMed 2016, physicians can learn the importance of and keys to improving patient access to intrauterine devices (IUDs) and birth control implants, collectively known as long-acting reversible contraceptives (LARCs). Improving Women's Access to IUDs & Implants will teach participants to: 

  • Explain the public health implications of the increased use of highly effective contraceptives;
  • Identify common misinformation about LARCs;
  • Identify key counseling points for LARCs;
  • Identify the absolute contraindications to IUD initiation;
  • Discuss strategies for management of difficult insertions; and
  • Demonstrate ways to address common patient concerns for LARC methods.

Primary care physicians, nonphysician practitioners, and office managers can benefit from the course. Find more information on and register for TexMed 2016, which will take place April 29–30 at the Hilton Anatole in Dallas. You can also contact the TMA Knowledge Center at (800) 880-7955. 

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