How has managed care affected patient care?
If you haven’t dealt with managed care at your family planning facility, get ready. Three of four insured U.S. workers received health coverage through managed care in 1995, a number that jumped almost 25% in two years, according to a study released earlier this year.1 Also, the number of Medicaid enrollees in managed care has exploded, says Rachel Benson Gold, senior public policy associate at the Washington, DC, office of the Alan Guttmacher Institute. Many are young low-income women, a population traditionally served by public family planning clinics.
Managed care has the potential to deliver, and perhaps even improve, family planning services, says Gold, who co-wrote Improving the Fit, an in-depth look of reproductive health services and managed care.2 However, the road to managed care is not without its pitfalls, and in many cases, the potential to improve access to reproductive health care is not being met, she observes.
Almost half of Contraceptive Technology Update readers who participated in the 1997 Pill Survey say managed care has somewhat diminished’ patient care; 20% say it has seriously impacted’ services. (See chart, above right.) The response from Suzanne Presson, RNC, WHCNP, a nurse practitioner at Columbia Family Healthcare Center of Pampa (TX), is typical of those who see a negative impact: "My clients are indigent or Medicaid. Since we went from a state clinic to a private clinic, the push to see more patients in a limited time frame has reduced time for education. My solution to the education time frame is that I have received videos from the Association of Reproductive Health Professionals and [the manufacturer of] Depo-Provera in both English and Spanish. I have the patients watch videos and discuss side effects, missed pills, and periods [if using oral contraceptives] and verbally review warning signs. With return visits, I reinforce these things. If the patient is undecided, I spend as much time as I have to, which puts the clinic in chaos." (The Depo-Provera videos are no longer available. See resource box, p. 141, for details on videos from the Association of Reproductive Health Professionals.)
Susan Wysocki, RNC, BSN, NP, president of the National Association of Nurse Practitioners in Reproductive Health in Washington, DC, says managed care may send women to providers who aren’t prepared for the intimacy of reproductive care. "My concern is that you get a number of people, especially Medicaid patients, who are rerouted to services that aren’t necessarily geared for providing contraceptives or sexually transmitted disease services. There is this assumption that anybody can provide these services, and anybody can provide services to this population. I don’t think it’s true."
A study by Focus on Access, Information, and Reproductive Rights, a project of the Center for Reproductive Law and Policy in New York City, revealed that many plans failed to inform women they could refer themselves to providers outside the plan.3 And plan providers may not be prepared for many women when they do arrive, says Kathryn Lloyd-Watkins, BSN, NP. A women’s health care nurse practitioner at the South Austin (TX) Women’s Clinic. Her facility has been affected by a large influx of Hispanic immigrants, who desperately need basic, easy-to-understand anatomy and contraceptive information. Reaching these women is challenging, Lloyd-Watkins says, and the situation is compounded by the compressed time for education that results from "cranking out the numbers" in patient exams.
"There are a whole string of incentives that might mitigate against the sort of comprehensive, hands-on, labor-intensive care that many of us view as vital to providing good family planning service," Gold says. "I think that is a problem with which we all are all struggling. It is a place where both private doctors and family planning clinics alike are struggling in this adjustment to managed care."
If managed care has arrived, how can your facility maintain quality care? Adjustments must be made on both sides, Gold says. Managed care must expand covered options, and women must have access to those services. Managed care requirements should not limit confidential access when needed. Facilities must work closely with plans on quality issues, instituting monitoring mechanisms and addressing any problems they uncover.
If your state is moving toward Medicaid managed care, Gold says, work with state officials to determine which services are covered, address the need for patient confidentiality and proper handling of sensitive patient information, and check the policy on direct access to family planning.
As more Americans move to managed care coverage for their health needs, family planning facilities will have to find their niche. "The extent to which plans are contracting for family planning is not huge," Gold says. "It has grown, though, because family planning providers have really realized that this is here, this is happening, and if they want to remain viable players in the health care field, they need to work with it."
References
1. Jensen GA, Morrisey MA, Gaffney S, et al. The new dominance of managed care: insurance trends in the 1990s. Health Affairs 1997; 16:125-136.
2. Gold RB, Richards CL. Improving the Fit: Reproductive Health Services in Managed Care Settings. New York City: Alan Guttmacher Institute; 1996.
3. Center for Reproductive Law and Policy. Removing Barriers, Improving Choices: A Case Study in Reproductive Health Services and Managed Care. New York, NY; 1996.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content