Managed care is revolutionizing health care delivery in the United States. Its recent exponential growth stems largely from the fact that, increasingly, the nation's major purchasers of insurance coverage — employers in the private sector and governments in the public sector — are determined to hold down health care costs and are seeking to do so without sacrificing quality. This is the fundamental promise of managed care.
Already, traditional indemnity insurance covers fewer than six in 10 privately insured Americans; the rest — as well as one in four Medicaid enrollees — are covered by an array of highly diverse managed care plans, including four different types of Health Maintenance Organizations (HMOs) along with newer systems known as Preferred Provider Organizations (PPOs) and Point of Service (POS) networks.
Managed care has major implications for the delivery and receipt of reproductive health care. By the same token, because reproductive health is central to the lives and well-being of women and their families, and has major implications for overall societal health as well, people's reproductive health care needs have important implications for managed care.
This Issues in Brief — and the report on which it is based, Improving the Fit: Reproductive Health Services in Managed Care Settings — synthesizes and places in context key recent research efforts in an attempt to illuminate what is known about the critically important interaction between reproductive health and managed care. It addresses five major issues:
- the extent to which the range of reproductive health care services is covered in the various types of managed care plans;
- the extent to which key features of managed care may facilitate or impede access to reproductive health care services;
- whether the structure and functioning of managed care systems affect the ability of enrollees to obtain confidential reproductive health services;
- the lessons that may be learned from the experience with family planning service delivery in the context of Medicaid managed care; and
- how current monitoring efforts evaluate access to and quality of reproductive health services in managed care plans.
Background
A woman's reproductive years span, on average, half of her lifetime.
This is not a static period but, rather, one encompassing several
stages during which, as her reproductive goals change, so do her
health care needs. Because of these changing needs, comprehensive
coverage of the range of basic reproductive health care services
is critical. These services include: contraceptive services and
supplies (family planning); abortion services; voluntary sterilization
services; basic infertility services; screening for sexually transmitted
diseases, including HIV and cancers of the reproductive system;
preconceptional risk assessment and care; and maternity care,
including prenatal, delivery and postnatal care.
Adequately meeting the reproductive health care needs of diverse individuals over a period of many years has not been a strength of conventional health insurance, which emphasizes surgical care over nonsurgical procedures and curative care over preventive care. The historical origins and ongoing customs of managed care systems stand in sharp contrast, however, and their potential to make real progress toward that goal may be considerably greater.
It also must be recognized that there are tensions between some of the fundamental conventions of managed care and the notion not only that reproductive health services should be covered, but also that special efforts may be necessary to encourage appropriate use of these critical, but sometimes controversial, services.
Despite their differences, most managed care plans seek to fulfill their promise of maintaining quality while controlling costs in similar ways. In one way or another, all encourage use of a designated pool of providers, with some precluding payment for out-of-plan care entirely. Most rely on a system of primary care providers whose job it is to coordinate enrollees' overall care.
For some enrollees, these features may delay, impede or in some
cases even block access to needed care. Many reproductive health
services are highly time-sensitive; obtaining prior authorization
from a primary care provider may delay or deter care when time
is of the essence. Some primary care providers may have religious
or moral objections to providing or even referring for these services.
The coordination of care that is such a strength of managed care
systems may also threaten the patient confidentiality that is
critical to the willingness of some to seek sensitive services.
Similarly, limiting the pool of providers may preclude care from
community-based reproductive health clinics with whom patients
have long-standing, trusting relationships.
Managed Care and Reproductive Health Services Coverage
HMOs provide considerably more comprehensive coverage of the range
of reproductive health services than do traditional indemnity
plans. Newer types of managed care plans provide less extensive
coverage than do HMOs, with PPOs closest to indemnity plans in
coverage patterns.
Most plans, regardless of type, cover maternity care, induced abortion and sterilization. Coverage is less consistent when it comes to routine gynecologic care or reversible contraception. For example, only 15% of traditional indemnity plans cover all of the five most commonly used reversible medical methods (the IUD, diaphragm, Norplant, Depo Provera injection and pill); 49% of plans cover none of these methods. HMOs, however, provide somewhat more comprehensive coverage; 39% routinely cover all five methods and only 7% provide no contraceptive coverage.
Coverage of reversible contraception is less common among other types of managed care plans. Only 18% of PPOs and 33% of POS networks routinely cover all five reversible methods, with 49% of PPOs and 19% of POS networks routinely covering no contraceptive methods at all.
Moreover, many plans that cover prescription drugs in general
do not cover oral contraceptives.
HMOs and Reproductive Health Services Delivery
Recognizing that women view reproductive health care as central
to their primary care and women's strong desire to have direct
access to obstetrician-gynecologists who provide that care, 75%
of HMOs — comparable information is not available for other types
of managed care systems — have taken steps to make it easier for
women to obtain reproductive health care beyond that provided
by primary care physicians. Four in 10 plans (39%) allow women
to choose an obstetrician-gynecologist as a primary care physician
(often in addition to, rather than instead of, an internist or
family physician); 36% do not offer this option, but give women
at least some direct access to an obstetrician-gynecologist. However,
in those HMOs in which women may initiate a visit to a separate
provider of obstetric and gynecologic care, restrictions are often
placed on that privilege. Half of HMOs that allow women to self-refer
limit visits to one per year. (see Figure 1)
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Moreover, HMOs that permit some self-referral also commonly limit direct access by requiring prior authorization from the enrollee's primary care physician for services other than an annual gynecologic exam. Prior authorization is required by 31% of plans for routine obstetric care, 34% of plans for Norplant, 47% of plans for a contraceptive sterilization and 53% of plans for an abortion.
Prior authorization requirements and other enrollee care coordination features that are hallmarks of managed care can be barriers for some women seeking sensitive reproductive health services.
The purpose of prior authorization is to prevent unnecessary or excessive utilization of medical care and to ensure that an enrollee's condition is properly diagnosed and a referral for appropriate care is made. For most reproductive health services, these rationales rarely apply. It is generally the enrollee in accordance with personal goals, rather than the provider making a medical determination, who identifies a need for reproductive health services. It is the enrollee, for example, who must decide whether to take action to avoid unintended pregnancy or how to deal with an unplanned pregnancy should one occur. In these cases, over-utilization of care is not an issue, and prior authorization may only delay or impede access to appropriate care.
Prior authorization may also be difficult, if not impossible, to obtain in some cases, since definitions of appropriate care may be subject to the opinions and values of the gatekeeper. A referral for a teenager seeking contraceptives may be withheld as not appropriate, for example, because the primary care physician considers her sexual activity inappropriate. Or a referral for sterilization or abortion could be withheld because the primary care physician has moral or religious objections.
While coordinating an enrollee's total health care through the primary care physician is at the heart of managed care, this concept can pose serious confidentiality problems for some enrollees. These enrollees in some cases may not want their primary care physician, who may also care for their parents or spouse, to know that they need, or have obtained, certain sensitive services. Fear that their primary care physician will find out may result in care delayed, or foregone entirely. Abortion and contraception are obvious examples, but confidentiality could also be paramount for a woman seeking maternity care before her pregnancy becomes apparent.
Administrative Procedures and Patient Confidentiality
The billing and claims-processing procedures of all types of insurance
plans raise important concerns about confidentiality. Because
of the way in which HMOs function, they are well suited to address
these issues. For example, 71% of HMOs allow a spouse or other
dependent who is at least age 18 to receive confidential care;
in these instances, a dependent who can prove enrollment may obtain
services, either pay the copayment if one is required or elect
to be billed directly for the copayment amount, and ask that no
written statement be sent to the employee indicating that services
have been rendered.
Billing and claims — processing in other types of managed care plans, such as PPOs and POS networks, are similar to those in traditional indemnity plans, making confidentiality issues in these plans more difficult to address. Nonetheless, 10% of POS networks and 11% of PPOs have been able to do so.
Family Planning Clinics and Managed Care
The interaction of family planning clinics and managed care has
received considerable attention only in the context of the Medicaid
program. This experience has relevance for the private sector
as well.
The fact that Medicaid recipients continue to seek care at family planning clinics even though enrolled in managed care plans, and that most state programs have opted, even when not required to do so, to provide managed care enrollees with the freedom to choose family planning providers, suggests that clinics have much to offer managed care plans. They provide, at relatively low cost, the full range of reversible contraceptive methods within the context of preventive care. They have demonstrated expertise in reaching out to, and serving, vulnerable populations and are well-known in their communities for their history of protecting patient confidentiality. In addition, these clinics are accustomed to functioning as part of a larger health care system.
The Medicaid experience demonstrates that clinics with established contractual relationships with managed care plans are in an advantageous position compared with clinics that are theoretically guaranteed reimbursement but have to seek that reimbursement as out-of-plan providers. However, the short-term protection afforded family planning clinics when family planning services are carved out of capitation arrangements may have given family planning clinics scant incentive to involve themselves with managed care plans during a critical period in the growth of Medicaid managed care.
Family planning clinics may now be playing catch up, and will
need to vigorously seek out and market themselves to managed care
systems. This is indicated by the fact that, even as HMOs are
looking for ways to increase women's direct access to reproductive
health care providers, few have utilized community-based family
planning clinics as a means to accomplish that goal. Only 23%
of HMOs have a contract or reimbursement arrangement with either
a family planning or an abortion clinic, and 60% of these contract
only for abortion.
Assuring Access and Quality of Care
Although several efforts have been made to assess the quality
of health plans and the accessibility of the care they provide
to both private patients and Medicaid enrollees, none addresses
issues related to reproductive health care, other than maternity
care, in any depth. For example, HEDIS, the data set that has
become the standard information available in comparable form for
a wide array of health plans, contains no measures specific to
reproductive health except indicators for maternity care and cervical
cancer. Similarly, a parallel effort to develop measures for Medicaid
plans, while designed to "respond more directly to needs
of women and children who make up the majority of Medicaid managed
care enrollees," confines that additional attention almost
exclusively to care for pregnant women, as opposed to other aspects
of reproductive health care.
As a result, there has been no systematic monitoring of the quality
of reproductive health care provided by managed care plans, and
no mechanism to improve the ability of patients or payers to make
informed decisions about this area of health care in either the
private or public sector.
Recommendations
Managed care may hold significant potential for improving the
delivery of reproductive health services in the United States
beyond the level of care that traditional indemnity insurance
mechanisms have been able to achieve. There are inherent tensions,
however, between some of the characteristics of managed care plans
and appropriate access to reproductive health care services for
all who want and need them. The challenge is to resolve these
tensions without compromising managed care's basic emphasis on
care coordination and cost efficiency. The following steps would
go a long way toward optimizing the potential of managed care
systems to deliver high-quality reproductive health care to their
enrollees:
- As a prerequisite for making managed care work for reproductive
health services, all managed care systems should cover the
full range of reproductive health services for all enrolled individuals
and all dependents of reproductive age. Ensuring full coverage
is as much a responsibility of public- and private-sector purchasers
of insurance as it is a responsibility of the plans themselves.
- Because of the sensitive nature of reproductive health services,
plans should actively inform all enrollees, including dependents
of reproductive age, of the specific services to which they are
entitled under the plan and that, for religious or personal reasons
some plan providers may not provide or refer for all of these
covered services; plans must have a bypass mechanism to help enrollees
access covered services. Allowing dissatisfied enrollees to
change primary care providers, while important for other reasons,
is insufficient to accomplish this objective.
- Because of the importance of confidentiality in reproductive
health, an enrollee unwilling to seek a specific service or
a referral from a primary care physician should be able to obtain
a confidential referral directly from the plan. In the interest
of care coordination, information regarding services sought or
received from plan providers generally should be included in an
enrollee's formal medical record to which other plan providers
have access; however, when confidentiality is specifically requested
by the enrollee, information concerning a reproductive health
service should not be entered into that person's medical record.
- Billing and claims-processing mechanisms should be adjusted
to ensure that confidentiality is not breached unwittingly through
the plan's administrative procedures. Key to this recommendation
is the establishment of appropriate procedures for plan enrollees
to demonstrate enrollment in the plan without having to involve
a parent or spouse.
- Because reproductive health services are critical primary care
services, their use should be encouraged, with direct access provided
whenever possible. Plans should permit women either to choose
an obstetrician-gynecologist as a primary care physician or to
have direct access to a separate provider of such services; prior
authorization requirements should be limited to those reproductive
health services for which inappropriate or excessive utilization
can be demonstrated.
- Community-based family planning clinics have a tradition of
providing high-quality, cost-effective, confidential contraceptive
care that is targeted to young women of modest means (including,
but not limited to, teenagers and Medicaid enrollees); these facilities
can be a valuable resource for managed care plans. Managed
care plans should give careful consideration to including community-based
family planning clinics as in-plan providers, and clinics seeking
inclusion should strive to accommodate the administrative needs
of managed care systems whenever possible. Because of the
importance of the nationwide network of subsidized family planning
clinics to vulnerable population groups, government should
ensure the viability of the clinic system until such time as the
reproductive health needs of the population groups that clinics
serve can be assured through managed care plans or other insurance
mechanisms.
- Ongoing quality assurance and accreditation provide the managed care industry with the opportunity to establish and enforce meaningful standards of care. The industry's accreditation standards and uniform data sets should be modified to include specific measures relating to the quality and accessibility of reproductive health services. In monitoring that involves review of medical charts, care must be taken to preserve confidentiality. Governments have a responsibility to use these accreditation standards and uniform data sets to ensure that reproductive health services are available and accessible to Medicaid beneficiaries enrolled in managed care plans.
This Issues in Brief is based on a 1996 AGI report,
Improving the Fit: Reproductive Health Services in Managed Care Settings,
which was supported in large part by a grant from the Henry J.
Kaiser Family Foundation, Menlo Park, California. The recommendations
in the report are solely those of the authors and AGI.
Major Sources for Improving the Fit include:
AGI, Uneven and Unequal: Insurance Coverage and Reproductive
Health Services, New York, 1994 and "Survey of Private-Sector
Insurance Coverage of Reproductive Health Services," New
York, 1993.
A.B. Bernstein, T.H. Dial and M.D. Smith, "Women's Reproductive
Health Services in Health Maintenance Organizations," Western
Journal of Medicine, 163(Supplement):15-19, 1995; and Fact
Finders, "GHAA/Kaiser Family Fdn. Survey of Reproductive
Benefits, Background Volume," Albany, N.Y., 1994.
S. Rosenbaum, et al., Beyond the Freedom to Choose: Medicaid
Managed Care and Family Planning, George Washington University
Center for Health Policy Research, Washington, D.C., 1994 and
"Beyond the Freedom to Choose-Medicaid, Managed Care and
Family Planning," Western Journal of Medicine, 163(Supplement):33-39,
1995.
For more information about the data presented, contact the Washington Office at (202) 296-4012. Multiple copies of this Issues in Brief may be purchased for a small charge.