Will rising prices limit the options for patients at family planning clinics?
Providers may need to make hard choices to add new methods to list
Your fellow clinicians are buzzing about the new methods of contraception that have emerged this summer, and patients are talking about stories in the popular press touting the contraceptive patch and the vaginal ring. But when it comes to stocking your clinic’s pharmacy shelves with these new options, will your facility’s budget be able to cover these choices?
According to Joan Malin, president and chief executive officer of Planned Parenthood of New York City (PPNYC), the biggest challenge her organization faces is providing new options to clients who come in under the agency’s sliding-fee scale. Since the public dollars that fund the sliding-scale program have been curtailed for so long, the agency has had to absorb some amount of the costs to purchase and provide new technologies for low-income and uninsured women, she explains.
Through private funds and general funds received by the agency, PPNYC plans to subsidize the extra costs to add the Evra contraceptive patch (Ortho-McNeil Pharmaceutical, Raritan, NJ) and the NuvaRing (Organon, West Orange, NJ) because it believes availability of such options for all women is crucial, says Malin.
Malin is preparing cost figures to present to state and regional funding agencies to request their help in meeting the funding shortage.
"We are really at loggerheads on how to do this, because we want to make the new options available," she notes. "Women should be able to make the best decision for themselves, as opposed to what it costs."
It’s all about money
While Ortho-McNeil Pharmaceuticals has made significant concessions in negotiating a Title X price of $9.90 for each box of Evra patches, agencies still must look at their finite dollars and balance their budgets based on the projected numbers of clients served, observes Judith DeSarno, chief executive officer of the Washington, DC-based National Family Planning and Reproductive Health Association (NFPRHA). And when administrators look at the numbers, $9.90 remains seven times higher than the $1.25 public sector price for a monthly supply of oral contraceptives, she concludes.
DeSarno praises Ortho-McNeil for working with family planning advocates in reaching the Title X price, which is lower than the estimated $40 retail cost. Discussions have just begun with Organon on public pricing for the NuvaRing, which is scheduled to hit retail pharmacy shelves later this summer.
The contraceptive patch and the vaginal ring represent important new birth control options for women, since they do not rely on daily pill-taking for their efficacy, says DeSarno. However, the higher costs of the drugs will lead clinics to offer limited availability to them, she predicts. (Get in-depth coverage of both options in the Contraceptive Technology Reports supplements inserted in Contraceptive Technology Update. Check the May 2002 issue for "A Transdermal Delivery System Examined: Ethinyl Estradiol and Norelgestromin for Contraception" and the February 2002 issue for "The Vaginal Contraceptive Ring— Efficacy, Caution, and Instructions.")
NFPRHA has launched a public campaign in the wake of its recent annual meeting to seek increased funding for the Title X program, the only federal program that provides categorical funding for family planning. Annual Title X appropriations have been flat or declining since 1982.1 Medicaid has replaced Title X as the largest source of agency funding.2
While some clinics are able to raise dollars through private funding, those who are able to do so already have tapped into available funds, says DeSarno. With the advent of the two new contraceptive methods, there are no new sources of private monies to augment agencies’ public dollars, she notes.
Don’t expect increased state funding for family planning, DeSarno says. States that can run budget deficits already are in the red, and those states required by law to run balanced budgets have had to make major funding cuts, she states.
"I find it very unlikely that we are going to see big increases in the states that have family planning budgets," observes DeSarno. "What we have been seeing is the opposite: We have been seeing cuts."
In the United States, nearly 25% of women who obtain contraceptive services from a medical provider receive their care from clinics run by publicly funded agencies.3 It is estimated that publicly funded family planning clinics serve more than 7 million contraceptive clients per year.3 To ensure that all women have access to the full range of reproductive health care, more federal dollars must be mandated for family planning, DeSarno urges.
"We have got to get this funding level [for Title X] to at least $325 million, or frankly, we have to serve far less women so that we do not have two standards of care," she says.
Add education costs
Adding any new contraceptive method represents additional costs in staff training and patient education, says Margie Fites Seigle, chief executive officer of the California Family Health Council in Los Angeles.
The council has just developed informed consent forms and informational materials in 13 written languages, with three of those language options also presented in audio tapes for those who cannot comprehend their written language, she notes.
"So in fact, we have about 15 core languages now that we work with in California," says Seigle. "It becomes an incredible challenge."
Staff training and client education for any method of birth control should be tailored so that the most appropriate method is chosen for the patient, she says. Proper patient education improves success with complicated regimens and explains anticipated or possible side effects, which can help decrease anxiety and increase success with the method.
Check group purchasing
Look to the power of group purchasing as one option to stretching clinic dollars, says Seigle. She and Sue Speth, director of the council’s cooperative programs, presented tips on how to manage the rising costs of contraceptives at the recent NFPRHA conference.
The council administers two programs, the Family Planning Cooperative Purchasing Program and the Cooperative Purchasing Network. The programs are funded by a Title X federal family planning grant. They assist agencies in managing their higher-cost/usage products and services, and they have approximately 600 agencies with 2,000 clinic sites across the country. The agencies include state, county, multisite, and single-site nonprofit facilities. The Family Planning Cooperative-Purchasing Pro-gram has existed for more than 10 years and supports locations that receive Title X funding. The Cooperative Purchasing Network spread nationwide in 2002 and is available to all nonprofit, licensed locations that don’t receive Title X federal funding.
Membership in the Family Planning Cooperative Purchasing Program and the Cooperative Purchas-ing Network is entirely voluntary. Participation in the Family Planning Cooperative Purchasing Pro-gram is free; an annual membership fee of $199 is required for the Cooperative Purchasing Network.
Administrators also may want to look at more than just method costs when examining funding options, says Seigle. Facilities should check their cost of disposables; a cost savings in this area may allow a clinic to add more dollars for contraceptive supplies, she suggests.
DeSarno says NFPRHA has met with its members, which include Planned Parenthood affiliates, state health departments, and family planning councils, to examine how agencies are going to meet the reproductive health needs of uninsured patients while spending more money on screening and treatment with limited federal assistance. Clinics funded with public dollars face a significant challenge, she asserts.
"Are there other places we could make some changes to get more money available for clinical services? And the fact of the matter is that this program is so severely underfunded, that we can’t," comments DeSarno.
References
1. Alan Guttmacher Institute. Fulfilling the Promise: Public Policy and U.S. Family Planning Clinics. New York City; 2000.
2. Finer LB, Darroch JE, Frost JJ. U.S. agencies providing publicly funded contraceptive services in 1999. Fam Plann Perspect 2002; 34(1):15-24.
3. Frost JJ. Public or private providers? U.S. women’s use of reproductive health services. Fam Plann Perspect 2001; 33(1):4-12.
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