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the Body Politic
Vol. 08, No. 03 - May/Jun 1998, Page 30
Copyright © 1998 by the Body Politic Inc.

Is Managed Care Caring for Women?

By Alexander C. Sanger,
President of Planned Parenthood of New York City

Most American women are enrolled in a managed care plan -- yet if New York is any indicator of the national picture, those plans are endangering women's health by failing to provide timely and accurate information about reproductive health care.

Planned Parenthood of New York City's (PPNYC) three-part Reproductive Health and Managed Care Policy Series reveals that Managed Care Organizations (MCOs) and Primary Care Physicians (PCPs) often fail to provide women with vital reproductive health care information. Yet, as detailed in PPNYC's third and final report, MCOs could realize substantial savings by supplying women with the preventative care they need to safeguard their sexual and reproductive health.

PPNYC's first report, Do Managed Care Organizations Inform Members About the Free Access and Direct Access Laws, shows how 46 to 59 percent of the time member service information help lines in New York City routinely gave callers incorrect information about pregnancy tests, abortion, birth control and treatment for sexually transmitted infections (STIs). Each of the 22 MCOs surveyed gave out information at odds with state and federal laws.

In New York, two laws specifically protect a woman's right to go directly to her ob/gyn without a referral from her PCP. The Direct Access law mandates that health maintenance organizations (HMOs) tell commercially-insured members they can self-refer to any ob/gyn in their plan for two visits per year. However, PPNYC callers were told "all tests must be made through the primary care doctor or with a referral" and "maybe you should look up 'pregnancy' in the Yellow Pages and find a clinic where they will give you a free pregnancy test." Callers who identified themselves as enrollees in a commercial plan were given incorrect information 59 percent of the time.

The Free Access law in New York gives members of Medicaid managed care plans the right to go outside their plan to any doctor or clinic for family planning services -- without a referral or approval from their primary care provider -- as long as that provider accepts Medicaid. But callers were told "there is no way you can get birth control without going to your PCP." Medicaid managed care subscribers were given misleading information 46 percent of the time.

The study also examined the information given to adolescents in light of federal statutes guaranteeing adolescents access to confidential family planning services, and New York state law which states that minors have a right to confidential reproductive health care, including family planning and abortion, without parental consent or notification. Despite such legal guarantees, adolescents were routinely given advice such as, "You cannot get [birth control] without your primary care doctor writing the prescription and telling your mother." Another service representative told a caller that she might need her parents' permission to get a pregnancy test and that she needed to be accompanied by an adult to get an abortion.

Customer services representatives also exhibited an alarming lack of knowledge about basic reproductive health care terms and services. For example, two representatives from different Medicaid managed care plans asked a caller to explain what was an STI.

While first source of information -- or misinformation -- about managed care services is usually customer service representatives, PPNYC also found that doctors primarily responsible for ensuring women's overall health are failing to provide basic reproductive health care.

PCPs are often granted nearly exclusive control over patient's health care, including whether or not a patient's condition warrants visiting a specialist. But PPNYC's second report, The Transition to Managed Care: Experiences of Planned Parenthood Patients, found that most women are not receiving critical reproductive health tests, counseling or prevention information about sexually transmitted infections, including HIV/AIDS, breast exams, pap smears or birth control from their PCP.

Medicare Managed Care Respondents
Chart

PPNYC interviewed 115 women and adolescents in managed care programs who came to our clinics seeking reproductive health care. An alarming 66 percent of those surveyed had never even heard the term "primary care doctor." Furthermore, many women had never had an appointment with their PCP -- in fact, 40 percent of Medicaid managed care respondents had yet to have an appointment, and of those, 65 percent had been in their current plan for more than a year. Of the women who had seen their PCP, few had received reproductive health care information, education, counseling or treatment during their visit.

Doctors simply aren't discussing reproductive health care with their patients. Sixty-six percent of Medicaid managed care respondents and 13 out of 19 commercial managed care respondents had never discussed sexually transmitted infections with their PCP. Sixty percent of Medicaid managed care respondents and 12 out of 19 commercial managed care respondents had never discussed HIV/AIDS with their PCP, and 44 percent of Medicaid managed care respondents and 9 out of 19 commercial managed care respondents had never discussed a pap smear with their PCP. In addition, 36 percent of Medicaid care respondents and 9 out of 19 commercial managed care respondents had never discussed birth control with their PCP.

Furthermore, many women are not aware of the range of services available to them. Twenty-one percent of the Medicaid managed care respondents surveyed said one of the reasons they came to PPNYC was because they did not think any other doctor in their plan would provide contraceptive services. Of these respondents, twice as many came to PPNYC for contraception as for abortion. An overwhelming majority also said they came to PPNYC rather than their PCP due to confidentiality concerns.

Among PPNYC's most notable findings were that for every 1,000 members who receive contraception, the MCO will save $1.2 million (net) in costs annually for pregnancy-related care averted...

To encourage MCOs to train customer service representatives and doctors to help women get the reproductive health care they need and to which they are entitled, PPNYC's final report details the cost-savings of preventative reproductive health care. Prevention Pays: A Cost-Effective Analysis of Preventive Reproductive Health Care for Managed Care Organizations, shows how private MCOs can save millions of dollars within one to two years by providing members with contraceptive care such as screening for cervical cancer and explaining how to properly use a condom.

Among PPNYC's most notable findings were that for every 1,000 members who receive contraception, the MCO will save $1.2 million (net) in costs annually for pregnancy-related care averted; that for every 1,000 members who receive contraception plus Emergency Contraceptive Pills as back-up, the MCO will save $1.4 million (net) in costs for pregnancy-related care averted; and for every 1,000 members who receive early detection and necessary treatment for chlamydia, the MCO will save $71,000 (net) in curative care averted.

After releasing the three reports, PPNYC attempted to work with MCOs and better the quality of care for New York women. We forwarded copies of all three reports, including our recommendations, to all major New York City MCOs. We offered free education and training classes about the Free Access and Direct Access laws, in addition to confidentiality rules. We secured prominent media placements detailing the results of our series. But based upon our response -- few MCOs responded to our offer for free trainings, and approximately ten MCOs solicited further information regarding the third report -- the managed care community has yet to prioritize women's health.

Managed care organizations face a legal and professional obligation to provide women and adolescents with unhindered access to vital reproductive health care. According to PPNYC's series and the experiences of millions of women nationwide, misinformation results in delayed care, more costly services and increased health risk.

As more and more women are enrolled in private MCOs, and more Medicaid recipients are enrolled in managed care, women's health advocates must be alert to make sure that government agencies monitor MCO-compliance with local and national laws and ensure MCOs do not overlook the real dollar return on providing comprehensive, reliable preventive reproductive health care.

What's good medicine for women can be good fiscal medicine for MCOs.

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