Contraception 89 (2014) 85 – 90
Original research article
Scope of family planning services available in Federally Qualified Health Centers☆ Susan Wood⁎, Tishra Beeson, Brian Bruen, Debora Goetz Goldberg, Holly Mead, Peter Shin, Sara Rosenbaum Department of Health Policy, The George Washington University School of Public Health and Health Service, Washington, DC 2006, USA Received 29 April 2013; revised 24 September 2013; accepted 24 September 2013
Abstract Objectives: Federally Qualified Health Centers (FQHCs) are a major and growing source of primary care for low-income women of reproductive age; however, only limited knowledge exists on the scope of family planning care they provide and the mechanisms for delivery of these essential reproductive health services, including family planning. In this paper, we report on the scope of services provided at FQHCs including on-site provision, prescription only and referral options for the range of contraceptive methods. Study Design: An original survey of 423 FQHC organizations was fielded in 2011. Results: Virtually all FQHCs reported that they provide at least one contraceptive method (99.8%) at one or more clinical sites. A large majority (87%) of FQHCs report that their largest primary care site prescribes oral contraceptives plus one additional method category of contraception, with oral contraception and injectables being the most commonly available methods. Substantial variation is seen among other methods such as intrauterine devices (IUDs), contraceptive implants, the patch, vaginal ring and barrier methods. For all method categories, Title-X-funded sites are more likely to provide the method, though, even in these sites, IUDs and implants are much less likely to be provided than other methods. Conclusion: There is clearly wide variability in the delivery of family planning services at FQHCs in terms of methods available, level of counseling, and provision of services on-site or through prescription or referral. Barriers to provision likely include cost to patients and/or additional training to providers for some methods, such as IUDs and implants, but these barriers should not limit on-site availability of inexpensive methods such as oral contraceptives. Implications: With the expansion of contraceptive coverage under private insurance as part of preventive health services for women, along with expanded coverage for the currently uninsured, and the growth of FQHCs as the source of care for women of reproductive age, it is critical that women seeking family planning services at FQHCs have access to a wide range of contraceptive options. Our study both highlights the essential role of FQHCs in providing family planning services and also identifies remaining gaps in the provision of contraception in FQHC settings. © 2014 Elsevier Inc. All rights reserved. Keywords: Family planning; Reproductive health services; Community health centers; Contraceptive methods
1. Introduction Federally Qualified Health Centers (FQHCs) are a major and growing source of primary care for low-income women of reproductive age. These FQHCs provide a wide range of primary care services to low-income and uninsured patients, more than 70% of whom have incomes below the federal
☆
Conflicts of Interest: The authors report no conflicts of interest. ⁎ Corresponding author. Tel.: + 1 202 994 4171. E-mail address: [email protected] (S. Wood).
0010-7824/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.contraception.2013.09.015
poverty level and are disproportionately represented from racial and ethnic minority populations [1]. In 2011, there were more than 8100 delivery sites nationwide that provided this health care to 20 million people as a result of 1128 FQHC grants [2,3]. It is clear that female patients rely on FQHCs for care and that their access to health care through FQHCs will increase in the future with implementation of the Affordable Care Act and through expansion of Medicaid coverage. Women comprised 59% of all people served by FQHCs, and women of childbearing age (15–44 years) represented 28% of the FQHC patient population in 2011. FQHCs served an
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estimated 24% of all low-income women of childbearing age in the United States, while the number of female patients of FQHCs who are women of childbearing age has doubled over the past decade from 2.8 million to 5.6 million [1,2]. Since the creation of FQHCs in 1974, “voluntary family planning” has been classified by the Bureau of Primary Health Care within the Health Resources and Services Administration (HRSA) as a required primary care service for FQHCs [4]. Though not specifically defined in FQHC guidelines, family planning and reproductive health funded through federal programs can include preconception and interconception care; screening and treatment of sexually transmitted infections; and education, counseling and provision of effective contraceptive methods for women who are sexually active and not seeking to be pregnant. However, few studies have been conducted on these family planning and reproductive health services provided at FQHCs. The Title X family planning program, also administered by the federal government, awards funding to a variety of clinical settings, including FQHCs and family planning clinics, for the purpose of training clinicians and providing family planning services. A 2010 Guttmacher Institute survey of family planning clinics, which included some FQHCs, noted that clinics focusing on primary care services were less likely to have protocols that support initiation and continuance of contraceptive methods [5]. The survey also found that Title-X-funded family planning clinics provided more contraceptive methods on-site than those without Title X funding [5]. Providing wider choices for women seeking care at FQHCs will promote adoption of the best method for women as well as continued use of the method over time [5–7]. This analysis focuses directly on the scope of contraceptive methods and sexually transmitted infections (STI)/HIV testing services provided at the nation's FQHCs. We report on the scope of services provided, including access to the range of contraceptive method categories through on-site provision, prescription only and referral options.
participate was implied by completion of the survey questions. No further identifying information beyond participants' email addresses, professional titles and first names were stored. An incentive gift card of $50 was presented to each FQHC organization that participated in the survey. The largest primary care site was selected as an indicator of the widest range of services offered to patients of the FQHC grantee. An original survey was developed to obtain detailed information from FQHCs on their approach to family planning and primary reproductive health care, particularly pregnancy prevention and HIV testing and STI vaccine, testing and treatment. The research team focused on issues related to on-site care (including contraceptive dispensing), offsite referrals, patient care-seeking patterns, payment arrangements, staffing issues and informationsharing capabilities with offsite providers on family planning services. The FQHC survey was modified and adapted from existing Guttmacher Institute surveys of publically funded family planning clinics, and it was modified for the setting and services provided by FQHCs [8]. We also asked if the largest site participated in the Title X family planning program, as we hypothesized that FQHC sites with Title X additional targeted funds and program requirements may provide a broader range of services to women. The online survey using Survey Monkey was distributed by email in 2011 to the medical directors and chief executive officers of 959 federal FQHC grantees for whom we had current contact information made available from the HRSA Uniform Data System (UDS) out of a universe of 1128 FQHC grantees [2]. Follow-up emails and phone calls were placed to encourage completion. Weighting adjustments were utilized to account for the size and regional distribution of FQHC respondents by Census region (West, South, Midwest and East) [9]. Data on contraceptive method category were collected regarding the largest primary care site. Using data from the largest site provides a “best case” scenario that allows for better comparison across FQHCs.
2. Materials and methods 3. Results Following a meeting of an invited technical advisory panel comprised of individuals with expertise in reproductive health and FQHC domains, the project team developed and pretested a Web-based survey instrument of FQHCs focusing on two key levels of analysis: (a) respondents' overall approach to family planning across all sites within FQHCs and (b) the services specifically found at the responding center's largest primary care site. An FQHC designation is given to a health care entity (called a grantee) that may have multiple sites. The research proposal was reviewed by the Institution Review Board at the George Washington University Office on Human Research and was determined to be exempt from review. Information about the study was presented to all participants, and consent to
3.1. Description of FQHC grantee respondents We received responses from 423 grantees, for a 44% response rate, during a 6-month fielding period. These grantees that responded to our survey provide primary medical care at more than 1900 health care delivery sites. We categorized FQHCs as either small (less than 10,000 patients), medium (10,000–19,999 patients) or large (more than 20,000 patients) based on the annual patient volume reported in the UDS. Approximately 34% of respondents were categorized as small FQHCs, while medium and large FQHCs represented 29% and 37% of the sample, respectively. We observed that respondents were not significantly different from nonrespondents on most characteristics,
S. Wood et al. / Contraception 89 (2014) 85–90
including population of women of childbearing age, payer mix and regional distribution, except for size (respondents tended to be larger than nonrespondents) and geographic distribution (a slight overrepresentation in the Northeast and underrepresentation in the South). Twenty-nine percent of FQHCs self-reported that their largest sites received funding through the Title X Family Planning program. Table 1 summarizes the characteristics of the respondents. Nearly all of these FQHC grantees (99.8%) reported that they furnish some level of contraceptive services at one or more of their service sites, including at least one contraceptive method category, although we do not have site-specific data other than the largest primary care site. Respondents reported having an average of 4.5 primary care sites, while an average of 4.2 sites per grantee reported providing some level of family planning services, demonstrating that the vast majority of FQHCs' clinical sites provide certain reproductive health services, such as contraception and HIV/STI testing. Table 1 Characteristics of responding FQHCs
Total number of FQHCs Total number of primary care sites Total number of primary care sites providing family planning Organizational size (patient volume) Small Medium Large Region Northeast South Midwest West Not applicable Patient race/ethnicity African American Asian American/Pacific Islander American Indian/Alaska Native Hispanic/Latino White Other/more than one race Not reported Patient insurance status Uninsured Medicaid Medicare Other public Privately insured Financing at largest primary care site Title X recipient Title X nonrecipient Not reported Location of largest primary care site Urban Suburban Rural Not reported
Survey sample N (%)
FQHC population N (%)
423 1912 1756
1131
144 (34%) 122 (29%) 157 (37%)
525 (46%) 308 (27%) 298 (27%)
78 (18%) 129 (31%) 78 (18%) 128 (30%) 10 (2%)
201 (18%) 394 (35%) 210 (19%) 299 (26%) 27 (2%)
1,603,420 (18%) 322,041 (4%) 83,418 (1%) 3,171,972 (36%) 2,807,223 (32%) 64,102 (1%) 676,956 (8%)
3,786,257 (20%) 632,105 (3%) 186,182 (1%) 6,204,802 (33%) 6,384,182 (34%) 148,367 (1%) 1,411,913 (8%)
3,299,357 (38%) 3,304,909 (38%) 601,858 (7%) 324,106 (4%) 1,198,902 (14%)
7,157,037 (38%) 6,948,696 (37%) 1,363,744 (7%) 549,433 (3%) 2,734,948 (15%)
121 (29%) 294 (70%) 8 (2%) 217 (51%) 44 (10%) 158 (37%) 4 (1%)
87
3.2. Contraception availability at FQHCs Virtually all FQHCs reported that they provide at least one contraceptive method (99.8%) at one or more clinical sites. Among the 1912 health care delivery sites, 1756 (92%) provide at least one contraceptive method category. In addition, as required by federal law, all FQHCs are to maintain referral arrangements for contraceptive services not furnished on-site [10]. Among the responding FQHCs' clinical sites, 87% reported that they offer “typical” family planning services as defined below. 3.3. Identifying “typical” family planning services A component of our survey focused on determining what FQHCs usually provide at their service sites as an indicator of the typical package of family planning services a patient may access within an FQHC setting. Based on responses, a typical package of family planning was defined as follows: STI testing and treatment and prescription and/or dispensing of oral contraceptives plus one additional contraceptive method [e.g., injectables, intrauterine devices (IUDs), emergency contraception pills, condoms or hormonal implants]. Approximately half (51%) of responding FQHCs reported that, within this typical set of contraception services, they offer IUDs and/or implants as the additional contraceptive method (Fig. 1). We also examined the availability of these family planning services on-site, rather than having simply a prescription provided. Of the FQHCs that offer a typical set of family planning services, slightly more than half (52%) responded that they dispense oral contraceptives on-site, as opposed to offering just a prescription for oral contraceptives. More than one third (36%) reported that they make both oral contraceptives and IUDs and/or implants available on-site (Fig. 2). 3.4. Family planning characteristics of largest primary care sites Over half of FQHC respondents (52%) self-reported that their largest primary care site was in an urban location, while 48% self-reported their largest primary care site as either suburban or rural. In addition, 52% of FQHC organizations reported that their largest primary care site operated an open access model of care for women's health, described as any expanded model of scheduling and providing care by which patients are able to access services on the same day (e.g., walk-in, same day and phone appointments). 3.5. STI testing and treatment practices at largest primary care sites The overwhelming majority of FQHCs reported that their largest primary care site performs a set of selected testing and treatment services on-site. These include HIV testing (95%), STI testing (96%), STI treatment (98%), and human papillomavirus (HPV) vaccines (94%).
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S. Wood et al. / Contraception 89 (2014) 85–90 99.8%
100.0%
87.0%
80.0% 60.0%
51.0%
40.0% 20.0% 0.0% Provide One or More Contraceptive Methods
Provide "Typical" Family Planning†
Provide "Typical" Family Planning PLUS IUDs and/or Implants††
†Percent of health center grantee’s primary medical care sites that offer at least STI testing/treatment, oral contraceptives, plus one other contraceptive method (e.g. injectables, IUDs, emergency contraception pills, condoms, hormonal implants). †† Percent of health center grantee’s primary medical care sites that offer at least STI testing/treatment, oral contraceptives, plus IUDs and/or hormonal implants, plus one other contraceptive method.
Fig. 1. Health center provision of family planning services.
3.6. Contraception prescribing and dispensing practices at largest primary care sites Our findings demonstrate the wide variation in the availability of select contraceptive methods at FQHCs' largest primary care sites. FQHCs were asked to indicate whether each contraceptive method was available by prescription (only), prescription and delivery/dispensing on-site, or through referral or another mechanism. They then indicated the standard practice if a contraceptive method was only available by prescription. Methods include oral and extended oral contraceptives, emergency contraceptives, Mirena and Paragard IUDs, implants, injectables, patches, vaginal rings, diaphragms, sponges, male condoms, female condoms, spermicides and natural family planning instruction. Fig. 3 shows that, in the case of oral contraceptives, 62% of FQHCs' largest primary care sites report that they are both prescribed and dispensed on-site, while 36% of sites provide a prescription only. While the majority of FQHCs' largest primary care sites report prescription and on-site insertion of IUDs (59%), 8% of sites only prescribe IUDs and 34% of sites simply refer the patient out for this method. Sites that only prescribe IUDs often provide the prescription; then the client obtains the contraceptive method from an outside source (e.g., retail pharmacy) and returns to the clinic for administration or insertion, as applicable [12]. An even smaller proportion of FQHCs' largest primary care sites 100%
80%
60%
52%
36%
40%
20%
0% Provide "Typical" Family Planning with Oral Contraceptives On-site
Provide "Typical" Family Planning with Oral Contraceptives, IUDs and/or Implants On-site
Fig. 2. Health center provision of on-site family planning services.
deliver contraceptive implants on-site (36%), while the majority (57%) refer patients to other providers for this service. In contrast, 81% of FQHCs report that their largest primary care site both prescribes and delivers injectable contraceptives on-site, with only 7% of FQHCs referring out for this method. There is substantial variation in other methods such as the patch or vaginal ring, other barrier methods and emergency contraception (Fig. 3). Only 19% of FQHCs report that they make all method categories available on-site through prescription and delivery, insertion and/or dispensing. Fig. 4 shows the difference between FQHCs' largest sites that participate in and are funded through the Title X Family Planning Program and those that do not. Less than one third (29%) of FQHCs received funding through Title X. Nearly all Title-X-funded (95%) and non-Title-X-funded (92%) primary care sites provide injectable contraceptives. Similarly, 99% of Title-X-funded and 97% of non-Title-Xfunded largest primary care sites prescribe or offer oral contraceptives on-site. Title-X-funded sites are more likely to provide all other method categories, though, even in these sites, IUDs and implants are much less likely to be provided than other method categories.
4. Discussion There is clearly wide variability in the delivery of contraceptive services at FQHCs in terms of methods available and provision of services on-site or through prescription and referral. While virtually all FQHCs made some form of contraceptive method available either through prescription or on-site delivery, the range of comprehensiveness of methods varies substantially among FQHC respondents. While many FQHCs make several contraceptive methods available and many of these methods are available on-site to varying degrees, a considerable proportion of FQHCs offered less than the fullest level of contraceptive methods at their largest primary care sites. Some reproductive and sexual health services such as HIV
S. Wood et al. / Contraception 89 (2014) 85–90 Prescribed and Dispensed 100%
80%
2% 36%
Prescription Only 7%
10%
12%
34%
9% 14%
40%
81%
59%
20%
66%
28%
7% 62%
23%
34%
57% 8%
60%
89
Available by Referral or Other
76% 56%
14%
49%
36% 19%
0%
Fig. 3. Family planning prescribing and dispensing, health centers' largest site.
services than may be provided at other primary care sites, and it may also not be representative of the patient population served by the larger FQHC entity. In addition, the data are largely self-reported by either the medical director or chief executive officer. Finally, this study does not reflect any measures of patient preference or other measures of quality health care delivery. Family planning has been recognized as one of the great public health achievements of the 20th century [19]. With the expansion of contraceptive coverage under private insurance as part of preventive health services for women [20], along with expanded coverage for the currently uninsured, and the growth of FQHCs as a source of health care for women of reproductive age, it is critical that women have access to a wide range of contraceptive options that are appropriate for their health needs [21]. Access to method category options, counseling and reduction of cost barriers have been shown to shift selection from less effective methods to more effective methods [11,22].
testing and treatment, HPV vaccination and pregnancy testing are nearly universally provided, demonstrating successful uptake of best practices [11–13]. However, the lack of uniform provision of on-site oral contraception or a wide range of contraceptive choices for women clearly needs to be addressed. Though access to additional targeted funds through the Title X family planning program is associated with expanded services, few Title-X-funded FQHCs provide access to the full spectrum of contraceptive methods on-site. Those centers without Title X funding are even less likely to provide a wide range of method categories. Barriers to provision likely include cost to the patient and/or additional training of providers for some methods, such as IUDs and implants; however, these barriers should not limit on-site availability of inexpensive methods such as oral contraceptives and emergency contraception [14–18]. This study is limited as the data represent the largest primary care sites, which could bias the results in a variety of ways. The largest sites may present a broader range of Health Center Sites w/out Title X
100%
97% 99%
92% 95%
80%
Health Center Sites w/ Title X 100%
95%
93%
88%
87%
85%
71% 60%
57%
60%
52%
38%
40%
27%
20% 0% OCs & Injectable extended OCs
Patch & Ring Emergency Other Barrier contraception Methods
IUDs
Implant
All Categories
Fig. 4. Contraception prescribing and dispensing by receipt of Title X funding.
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The goal of all FQHCs to provide comprehensive primary care is challenged when the scope of services for family planning and reproductive health is not a uniform set of services or not defined through either guidelines or standards of care within the FQHC network. The Office of Population Affairs (OPA) within the US Department of Health and Human Services is expected to issue new guidelines in the near future defining high-quality family planning services that will go beyond the role of regulatory guidelines for specifically funded Title X family planning clinics. These guidelines will also establish a high standard of care for quality that can be adapted for use by any provider of family planning services. Although OPA does not have regulatory authority over FQHCs, these anticipated guidelines can serve as the basis for the development of adapted standards of care for FQHCs. FQHCs can build on the success of those centers that have overcome barriers or developed effective strategies to provide a full range of family planning services and can adapt these practices to individual FQHC circumstances in order to expand family planning options for women who seek care.
References [1] Shin P, Rosenbaum S, Paradise J, Beeson T, Shirac J. Community Health Centers the challenge of growing to meet the need for primary health care in medically underserved communities. Washington, DC: Kaiser Family Foundation; 2012. [2] Uniform Data System: 2000–11. Washington (DC): Health Resources and Services Administration (U.S.); 2011. [3] Rosenbaum S, Shin P, Paradise J. Community health centers: the challenge of growing to meet the need for primary care in medically underserved communities. Kaiser Commission on Medicaid and the Uninsured. Available at: http://www.kff.org/uninsured/upload/8098-02.pdf. [4] 42 U.S.C. §254b(b)(1)(A)(i)(III)(gg). [5] Westhoff C, Heartwell S, Edwards S, Zieman M, Cushman L, Robilotto C, et al. Initiation of oral contraceptives using a quick start compared with a conventional start: a randomized controlled trial. Obstet Gynecol 2007;109(6):1270–6. [6] Foster DG, Hulett D, Bradsberry M, Darney P, Policar M. Number of oral contraceptive pill packages dispensed and subsequent unintended pregnancies. Obstet Gynecol 2011;117(3):566–72.
[7] Stuart JE, Secura GM, Zhao Q, Pittman ME, Peipart JF. Factors associated with 12-month discontinuation among contraceptive pill, patch, and ring users. Obstet Gynecol 2013;121(2):330–6. [8] Frost J, Gold R, Frohwirth L, Blades N. Variation in service delivery practices among clinics providing publicly funded family planning services in 2010. Guttmacher Institute: Washington (DC); 2012. [9] Census regions and divisions. [Internet] Washington, DC: Bureau of Labor Statistics; 2001. Available from: http://www.bls.gov/lau/laurd.htm. [10] 42 U.S.C. §254b(b)(1)(A)(ii). [11] Henderson JT, Sawaya GF, Blum M, Stratton L, Harper CC. Pelvic examinations and access to hormonal contraception. Obstet Gynecol 2010;116(6):1257–64. [12] Westhoff CL, Jones HE, Guiahi M. Do new guidelines and technology make the routine pelvic examinations obsolete? J Women's Health 2011;20(1):5–0. [13] The American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 463: cervical cancer in adolescents: screening, evaluation, and management. Obstet Gynecol 2010;116(2 Pt 1): 469–72. [14] Eisenberg D, McNicholas C, Peipert JF. Cost as a barrier to long-acting reversible contraceptive (LARC) use in adolescents. J Adolesc Health 2013 Jan;52:S59–63. [15] Beeson T, Wood S, Bruen B, Goldberg DG, Mead H, Rosenbaum S. Accessibility of long acting reversible contraceptives (LARCs) in Federally Qualified Health Centers (FQHCs). Contraception 2014;89(2):91–6. [16] Harper CC, Blum M, de Bocanegra HT, Darney PD, Speidel JJ, Policar M, et al. Challenges in translating evidence to practice: the provision of intrauterine contraception. Obstet Gynecol 2008;111(6): 1359–69. [17] Foster DG, Raine TR, Brindis C, Rostovtseva DP, Darney PD. Should providers give women advance provision of emergency contraceptive pills? A cost-effectiveness analysis. Women's Health Issues 2010;20 (4):242–7. [18] Harper CC, Henderson JT, Raine TR, Goodman S, Darney PD, Thompson KM, et al. Evidence-based IUD practice: family physicians and obstetrician-gynecologists. Fam Med 2012;44(9):637–45. [19] Ten great public health achievements — United States, 1900–1999. Atlanta (GA): Centers for Disease Control and Prevention (U.S.). MMWR 1999;48(12):241–3. [20] Institute of Medicine. Clinical preventive services for women: closing the gaps. Washington (DC): The National Academies Press; 2011. [21] Lesnewski R, Maldonado L, Prine L. Community health centers' role in family planning. J Health Care Poor Underserved 2013;24(2): 429–34. [22] Huber LRB, Hogue CJ, Stein AD, Drews C, Zieman M, King J, et al. Contraceptive use and discontinuation: do side effects matter? Am J Obstet Gynecol 1998;179:577–82.
Original research article
Scope of family planning services available in Federally Qualified Health Centers☆ Susan Wood⁎, Tishra Beeson, Brian Bruen, Debora Goetz Goldberg, Holly Mead, Peter Shin, Sara Rosenbaum Department of Health Policy, The George Washington University School of Public Health and Health Service, Washington, DC 2006, USA Received 29 April 2013; revised 24 September 2013; accepted 24 September 2013
Abstract Objectives: Federally Qualified Health Centers (FQHCs) are a major and growing source of primary care for low-income women of reproductive age; however, only limited knowledge exists on the scope of family planning care they provide and the mechanisms for delivery of these essential reproductive health services, including family planning. In this paper, we report on the scope of services provided at FQHCs including on-site provision, prescription only and referral options for the range of contraceptive methods. Study Design: An original survey of 423 FQHC organizations was fielded in 2011. Results: Virtually all FQHCs reported that they provide at least one contraceptive method (99.8%) at one or more clinical sites. A large majority (87%) of FQHCs report that their largest primary care site prescribes oral contraceptives plus one additional method category of contraception, with oral contraception and injectables being the most commonly available methods. Substantial variation is seen among other methods such as intrauterine devices (IUDs), contraceptive implants, the patch, vaginal ring and barrier methods. For all method categories, Title-X-funded sites are more likely to provide the method, though, even in these sites, IUDs and implants are much less likely to be provided than other methods. Conclusion: There is clearly wide variability in the delivery of family planning services at FQHCs in terms of methods available, level of counseling, and provision of services on-site or through prescription or referral. Barriers to provision likely include cost to patients and/or additional training to providers for some methods, such as IUDs and implants, but these barriers should not limit on-site availability of inexpensive methods such as oral contraceptives. Implications: With the expansion of contraceptive coverage under private insurance as part of preventive health services for women, along with expanded coverage for the currently uninsured, and the growth of FQHCs as the source of care for women of reproductive age, it is critical that women seeking family planning services at FQHCs have access to a wide range of contraceptive options. Our study both highlights the essential role of FQHCs in providing family planning services and also identifies remaining gaps in the provision of contraception in FQHC settings. © 2014 Elsevier Inc. All rights reserved. Keywords: Family planning; Reproductive health services; Community health centers; Contraceptive methods
1. Introduction Federally Qualified Health Centers (FQHCs) are a major and growing source of primary care for low-income women of reproductive age. These FQHCs provide a wide range of primary care services to low-income and uninsured patients, more than 70% of whom have incomes below the federal
☆
Conflicts of Interest: The authors report no conflicts of interest. ⁎ Corresponding author. Tel.: + 1 202 994 4171. E-mail address: [email protected] (S. Wood).
0010-7824/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.contraception.2013.09.015
poverty level and are disproportionately represented from racial and ethnic minority populations [1]. In 2011, there were more than 8100 delivery sites nationwide that provided this health care to 20 million people as a result of 1128 FQHC grants [2,3]. It is clear that female patients rely on FQHCs for care and that their access to health care through FQHCs will increase in the future with implementation of the Affordable Care Act and through expansion of Medicaid coverage. Women comprised 59% of all people served by FQHCs, and women of childbearing age (15–44 years) represented 28% of the FQHC patient population in 2011. FQHCs served an
86
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estimated 24% of all low-income women of childbearing age in the United States, while the number of female patients of FQHCs who are women of childbearing age has doubled over the past decade from 2.8 million to 5.6 million [1,2]. Since the creation of FQHCs in 1974, “voluntary family planning” has been classified by the Bureau of Primary Health Care within the Health Resources and Services Administration (HRSA) as a required primary care service for FQHCs [4]. Though not specifically defined in FQHC guidelines, family planning and reproductive health funded through federal programs can include preconception and interconception care; screening and treatment of sexually transmitted infections; and education, counseling and provision of effective contraceptive methods for women who are sexually active and not seeking to be pregnant. However, few studies have been conducted on these family planning and reproductive health services provided at FQHCs. The Title X family planning program, also administered by the federal government, awards funding to a variety of clinical settings, including FQHCs and family planning clinics, for the purpose of training clinicians and providing family planning services. A 2010 Guttmacher Institute survey of family planning clinics, which included some FQHCs, noted that clinics focusing on primary care services were less likely to have protocols that support initiation and continuance of contraceptive methods [5]. The survey also found that Title-X-funded family planning clinics provided more contraceptive methods on-site than those without Title X funding [5]. Providing wider choices for women seeking care at FQHCs will promote adoption of the best method for women as well as continued use of the method over time [5–7]. This analysis focuses directly on the scope of contraceptive methods and sexually transmitted infections (STI)/HIV testing services provided at the nation's FQHCs. We report on the scope of services provided, including access to the range of contraceptive method categories through on-site provision, prescription only and referral options.
participate was implied by completion of the survey questions. No further identifying information beyond participants' email addresses, professional titles and first names were stored. An incentive gift card of $50 was presented to each FQHC organization that participated in the survey. The largest primary care site was selected as an indicator of the widest range of services offered to patients of the FQHC grantee. An original survey was developed to obtain detailed information from FQHCs on their approach to family planning and primary reproductive health care, particularly pregnancy prevention and HIV testing and STI vaccine, testing and treatment. The research team focused on issues related to on-site care (including contraceptive dispensing), offsite referrals, patient care-seeking patterns, payment arrangements, staffing issues and informationsharing capabilities with offsite providers on family planning services. The FQHC survey was modified and adapted from existing Guttmacher Institute surveys of publically funded family planning clinics, and it was modified for the setting and services provided by FQHCs [8]. We also asked if the largest site participated in the Title X family planning program, as we hypothesized that FQHC sites with Title X additional targeted funds and program requirements may provide a broader range of services to women. The online survey using Survey Monkey was distributed by email in 2011 to the medical directors and chief executive officers of 959 federal FQHC grantees for whom we had current contact information made available from the HRSA Uniform Data System (UDS) out of a universe of 1128 FQHC grantees [2]. Follow-up emails and phone calls were placed to encourage completion. Weighting adjustments were utilized to account for the size and regional distribution of FQHC respondents by Census region (West, South, Midwest and East) [9]. Data on contraceptive method category were collected regarding the largest primary care site. Using data from the largest site provides a “best case” scenario that allows for better comparison across FQHCs.
2. Materials and methods 3. Results Following a meeting of an invited technical advisory panel comprised of individuals with expertise in reproductive health and FQHC domains, the project team developed and pretested a Web-based survey instrument of FQHCs focusing on two key levels of analysis: (a) respondents' overall approach to family planning across all sites within FQHCs and (b) the services specifically found at the responding center's largest primary care site. An FQHC designation is given to a health care entity (called a grantee) that may have multiple sites. The research proposal was reviewed by the Institution Review Board at the George Washington University Office on Human Research and was determined to be exempt from review. Information about the study was presented to all participants, and consent to
3.1. Description of FQHC grantee respondents We received responses from 423 grantees, for a 44% response rate, during a 6-month fielding period. These grantees that responded to our survey provide primary medical care at more than 1900 health care delivery sites. We categorized FQHCs as either small (less than 10,000 patients), medium (10,000–19,999 patients) or large (more than 20,000 patients) based on the annual patient volume reported in the UDS. Approximately 34% of respondents were categorized as small FQHCs, while medium and large FQHCs represented 29% and 37% of the sample, respectively. We observed that respondents were not significantly different from nonrespondents on most characteristics,
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including population of women of childbearing age, payer mix and regional distribution, except for size (respondents tended to be larger than nonrespondents) and geographic distribution (a slight overrepresentation in the Northeast and underrepresentation in the South). Twenty-nine percent of FQHCs self-reported that their largest sites received funding through the Title X Family Planning program. Table 1 summarizes the characteristics of the respondents. Nearly all of these FQHC grantees (99.8%) reported that they furnish some level of contraceptive services at one or more of their service sites, including at least one contraceptive method category, although we do not have site-specific data other than the largest primary care site. Respondents reported having an average of 4.5 primary care sites, while an average of 4.2 sites per grantee reported providing some level of family planning services, demonstrating that the vast majority of FQHCs' clinical sites provide certain reproductive health services, such as contraception and HIV/STI testing. Table 1 Characteristics of responding FQHCs
Total number of FQHCs Total number of primary care sites Total number of primary care sites providing family planning Organizational size (patient volume) Small Medium Large Region Northeast South Midwest West Not applicable Patient race/ethnicity African American Asian American/Pacific Islander American Indian/Alaska Native Hispanic/Latino White Other/more than one race Not reported Patient insurance status Uninsured Medicaid Medicare Other public Privately insured Financing at largest primary care site Title X recipient Title X nonrecipient Not reported Location of largest primary care site Urban Suburban Rural Not reported
Survey sample N (%)
FQHC population N (%)
423 1912 1756
1131
144 (34%) 122 (29%) 157 (37%)
525 (46%) 308 (27%) 298 (27%)
78 (18%) 129 (31%) 78 (18%) 128 (30%) 10 (2%)
201 (18%) 394 (35%) 210 (19%) 299 (26%) 27 (2%)
1,603,420 (18%) 322,041 (4%) 83,418 (1%) 3,171,972 (36%) 2,807,223 (32%) 64,102 (1%) 676,956 (8%)
3,786,257 (20%) 632,105 (3%) 186,182 (1%) 6,204,802 (33%) 6,384,182 (34%) 148,367 (1%) 1,411,913 (8%)
3,299,357 (38%) 3,304,909 (38%) 601,858 (7%) 324,106 (4%) 1,198,902 (14%)
7,157,037 (38%) 6,948,696 (37%) 1,363,744 (7%) 549,433 (3%) 2,734,948 (15%)
121 (29%) 294 (70%) 8 (2%) 217 (51%) 44 (10%) 158 (37%) 4 (1%)
87
3.2. Contraception availability at FQHCs Virtually all FQHCs reported that they provide at least one contraceptive method (99.8%) at one or more clinical sites. Among the 1912 health care delivery sites, 1756 (92%) provide at least one contraceptive method category. In addition, as required by federal law, all FQHCs are to maintain referral arrangements for contraceptive services not furnished on-site [10]. Among the responding FQHCs' clinical sites, 87% reported that they offer “typical” family planning services as defined below. 3.3. Identifying “typical” family planning services A component of our survey focused on determining what FQHCs usually provide at their service sites as an indicator of the typical package of family planning services a patient may access within an FQHC setting. Based on responses, a typical package of family planning was defined as follows: STI testing and treatment and prescription and/or dispensing of oral contraceptives plus one additional contraceptive method [e.g., injectables, intrauterine devices (IUDs), emergency contraception pills, condoms or hormonal implants]. Approximately half (51%) of responding FQHCs reported that, within this typical set of contraception services, they offer IUDs and/or implants as the additional contraceptive method (Fig. 1). We also examined the availability of these family planning services on-site, rather than having simply a prescription provided. Of the FQHCs that offer a typical set of family planning services, slightly more than half (52%) responded that they dispense oral contraceptives on-site, as opposed to offering just a prescription for oral contraceptives. More than one third (36%) reported that they make both oral contraceptives and IUDs and/or implants available on-site (Fig. 2). 3.4. Family planning characteristics of largest primary care sites Over half of FQHC respondents (52%) self-reported that their largest primary care site was in an urban location, while 48% self-reported their largest primary care site as either suburban or rural. In addition, 52% of FQHC organizations reported that their largest primary care site operated an open access model of care for women's health, described as any expanded model of scheduling and providing care by which patients are able to access services on the same day (e.g., walk-in, same day and phone appointments). 3.5. STI testing and treatment practices at largest primary care sites The overwhelming majority of FQHCs reported that their largest primary care site performs a set of selected testing and treatment services on-site. These include HIV testing (95%), STI testing (96%), STI treatment (98%), and human papillomavirus (HPV) vaccines (94%).
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S. Wood et al. / Contraception 89 (2014) 85–90 99.8%
100.0%
87.0%
80.0% 60.0%
51.0%
40.0% 20.0% 0.0% Provide One or More Contraceptive Methods
Provide "Typical" Family Planning†
Provide "Typical" Family Planning PLUS IUDs and/or Implants††
†Percent of health center grantee’s primary medical care sites that offer at least STI testing/treatment, oral contraceptives, plus one other contraceptive method (e.g. injectables, IUDs, emergency contraception pills, condoms, hormonal implants). †† Percent of health center grantee’s primary medical care sites that offer at least STI testing/treatment, oral contraceptives, plus IUDs and/or hormonal implants, plus one other contraceptive method.
Fig. 1. Health center provision of family planning services.
3.6. Contraception prescribing and dispensing practices at largest primary care sites Our findings demonstrate the wide variation in the availability of select contraceptive methods at FQHCs' largest primary care sites. FQHCs were asked to indicate whether each contraceptive method was available by prescription (only), prescription and delivery/dispensing on-site, or through referral or another mechanism. They then indicated the standard practice if a contraceptive method was only available by prescription. Methods include oral and extended oral contraceptives, emergency contraceptives, Mirena and Paragard IUDs, implants, injectables, patches, vaginal rings, diaphragms, sponges, male condoms, female condoms, spermicides and natural family planning instruction. Fig. 3 shows that, in the case of oral contraceptives, 62% of FQHCs' largest primary care sites report that they are both prescribed and dispensed on-site, while 36% of sites provide a prescription only. While the majority of FQHCs' largest primary care sites report prescription and on-site insertion of IUDs (59%), 8% of sites only prescribe IUDs and 34% of sites simply refer the patient out for this method. Sites that only prescribe IUDs often provide the prescription; then the client obtains the contraceptive method from an outside source (e.g., retail pharmacy) and returns to the clinic for administration or insertion, as applicable [12]. An even smaller proportion of FQHCs' largest primary care sites 100%
80%
60%
52%
36%
40%
20%
0% Provide "Typical" Family Planning with Oral Contraceptives On-site
Provide "Typical" Family Planning with Oral Contraceptives, IUDs and/or Implants On-site
Fig. 2. Health center provision of on-site family planning services.
deliver contraceptive implants on-site (36%), while the majority (57%) refer patients to other providers for this service. In contrast, 81% of FQHCs report that their largest primary care site both prescribes and delivers injectable contraceptives on-site, with only 7% of FQHCs referring out for this method. There is substantial variation in other methods such as the patch or vaginal ring, other barrier methods and emergency contraception (Fig. 3). Only 19% of FQHCs report that they make all method categories available on-site through prescription and delivery, insertion and/or dispensing. Fig. 4 shows the difference between FQHCs' largest sites that participate in and are funded through the Title X Family Planning Program and those that do not. Less than one third (29%) of FQHCs received funding through Title X. Nearly all Title-X-funded (95%) and non-Title-X-funded (92%) primary care sites provide injectable contraceptives. Similarly, 99% of Title-X-funded and 97% of non-Title-Xfunded largest primary care sites prescribe or offer oral contraceptives on-site. Title-X-funded sites are more likely to provide all other method categories, though, even in these sites, IUDs and implants are much less likely to be provided than other method categories.
4. Discussion There is clearly wide variability in the delivery of contraceptive services at FQHCs in terms of methods available and provision of services on-site or through prescription and referral. While virtually all FQHCs made some form of contraceptive method available either through prescription or on-site delivery, the range of comprehensiveness of methods varies substantially among FQHC respondents. While many FQHCs make several contraceptive methods available and many of these methods are available on-site to varying degrees, a considerable proportion of FQHCs offered less than the fullest level of contraceptive methods at their largest primary care sites. Some reproductive and sexual health services such as HIV
S. Wood et al. / Contraception 89 (2014) 85–90 Prescribed and Dispensed 100%
80%
2% 36%
Prescription Only 7%
10%
12%
34%
9% 14%
40%
81%
59%
20%
66%
28%
7% 62%
23%
34%
57% 8%
60%
89
Available by Referral or Other
76% 56%
14%
49%
36% 19%
0%
Fig. 3. Family planning prescribing and dispensing, health centers' largest site.
services than may be provided at other primary care sites, and it may also not be representative of the patient population served by the larger FQHC entity. In addition, the data are largely self-reported by either the medical director or chief executive officer. Finally, this study does not reflect any measures of patient preference or other measures of quality health care delivery. Family planning has been recognized as one of the great public health achievements of the 20th century [19]. With the expansion of contraceptive coverage under private insurance as part of preventive health services for women [20], along with expanded coverage for the currently uninsured, and the growth of FQHCs as a source of health care for women of reproductive age, it is critical that women have access to a wide range of contraceptive options that are appropriate for their health needs [21]. Access to method category options, counseling and reduction of cost barriers have been shown to shift selection from less effective methods to more effective methods [11,22].
testing and treatment, HPV vaccination and pregnancy testing are nearly universally provided, demonstrating successful uptake of best practices [11–13]. However, the lack of uniform provision of on-site oral contraception or a wide range of contraceptive choices for women clearly needs to be addressed. Though access to additional targeted funds through the Title X family planning program is associated with expanded services, few Title-X-funded FQHCs provide access to the full spectrum of contraceptive methods on-site. Those centers without Title X funding are even less likely to provide a wide range of method categories. Barriers to provision likely include cost to the patient and/or additional training of providers for some methods, such as IUDs and implants; however, these barriers should not limit on-site availability of inexpensive methods such as oral contraceptives and emergency contraception [14–18]. This study is limited as the data represent the largest primary care sites, which could bias the results in a variety of ways. The largest sites may present a broader range of Health Center Sites w/out Title X
100%
97% 99%
92% 95%
80%
Health Center Sites w/ Title X 100%
95%
93%
88%
87%
85%
71% 60%
57%
60%
52%
38%
40%
27%
20% 0% OCs & Injectable extended OCs
Patch & Ring Emergency Other Barrier contraception Methods
IUDs
Implant
All Categories
Fig. 4. Contraception prescribing and dispensing by receipt of Title X funding.
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The goal of all FQHCs to provide comprehensive primary care is challenged when the scope of services for family planning and reproductive health is not a uniform set of services or not defined through either guidelines or standards of care within the FQHC network. The Office of Population Affairs (OPA) within the US Department of Health and Human Services is expected to issue new guidelines in the near future defining high-quality family planning services that will go beyond the role of regulatory guidelines for specifically funded Title X family planning clinics. These guidelines will also establish a high standard of care for quality that can be adapted for use by any provider of family planning services. Although OPA does not have regulatory authority over FQHCs, these anticipated guidelines can serve as the basis for the development of adapted standards of care for FQHCs. FQHCs can build on the success of those centers that have overcome barriers or developed effective strategies to provide a full range of family planning services and can adapt these practices to individual FQHC circumstances in order to expand family planning options for women who seek care.
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