Freedom of choice: Medicaid, managed care, and California family planning clinics.

Access to out-of-plan family planning services for Medicaid beneficiaries enrolled in managed care plans in California has been limited by poor relationships between family planning clinics and contracting managed care plans. Plans either delay or fail to reimburse claims from non-network family planning agencies; family planning staff are unmotivated to identify managed care members through financial screening, to cover costs with other funds, or to refer members back to plan. In addition, plans and clinics fail to coordinate the care of managed care clients by sharing medical records. Based on findings from a pilot project, California will try to facilitate relationships between plans and family planning agencies rather than directly pay out-of-plan claims.

Barriers to prenatal care for low-income women.

Inadequate prenatal care is associated with poor birth outcomes. Recognizing barriers to care is necessary to improve results. Postpartum in-hospital interviews were conducted with women admitted through emergency departments with no physician of record (n = 69) in 8 Sacramento hospitals during April and May 1991. A focus group of local obstetrician-gynecologists was used to determine physicians' attitudes about caring for low-income women. We undertook the study in response to an increased number of "no doc" births. The inability to find a physician willing to accept them was reported by the women as the single largest barrier to obtaining care, cited by 64% of women overall and 96% of those who tried but were unable to obtain care. Transportation difficulties were a problem regardless of women's success in obtaining care and were ranked as the top barrier by women who never tried to obtain care. Physicians cited administrative difficulties and reimbursement levels of Medi-Cal plus extra care requirements and resource dependency of low-income patients as barriers to caring for this population. The value ascribed to prenatal care by women and physicians' perceptions of women's attitudes about care contrasted sharply. The link between poor women and physicians providing obstetric services can be fragile. The difficulty finding physicians willing to take them indicates that these women need special support services to ensure adequate care during pregnancy.

Will family physicians really return to obstetrics if malpractice insurance premiums decline?

BACKGROUND: The loss of family physicians as obstetrics providers during the last decade has had a significant impact on access to obstetric services, especially for rural populations. The expense of malpractice premiums has been cited often as a reason for physicians' discontinuation of this service. METHODS: Seventy-six family physicians in northern California who recently discontinued obstetrics were surveyed regarding their decisions related to obstetric practice. Those physicians who indicated that a decrease in malpractice premiums would allow them to consider resuming obstetrics were resurveyed by telephone the following year. This telephone survey occurred following a 25 percent decrease in malpractice premiums for obstetrics by the major malpractice insurance carrier for family physicians practicing obstetrics in the study area. RESULTS: Twenty-nine of the 76 physicians in the original survey who had recently discontinued obstetrics stated they would consider resuming if conditions changed. Twenty-six (90 percent) of these physicians indicated that malpractice premiums needed to change for them to consider resuming obstetrics. Following the reduction in premiums, none of these physicians reported plans to resume obstetrics or even a likelihood that they would be resuming obstetrics. CONCLUSION: This study found that family physicians who discontinued obstetrics and cited malpractice premiums as a barrier to resuming obstetrics are unlikely to resume when rates decline. This finding suggests that other issues might be equally or more important in this decision.

Trends in health care financing: opportunities for family planning agencies.

PIP: In response to spiraling health care costs in the US, several alternative health care delivery systems have evolved. The delivery of subsidized family planning services in particular is being affected by declining levels of government support. The most rapidly growing of alternative delivery systems is the health maintenance organization (HMO). HMOs provide a voluntarily enrolled population a guaranteed, specific range of physician and hospital services in return for a fixed periodic payment. There are 3 types of HMO: the group model, in which doctors are members of a partnership or service corporation that contracts with employers or individuals to provide medical services; the taff model, in which physicians are direct employees of the HMO; and the independent practice association (IPA) model, a physicians' group that enters into a contract with an HMO and receives reimbursement for every patient seen. In 1986, over 21 million Americans were enrolled in approximately 262 HMOs around the country. HMOs are unequaled in their success at reducing hospital utilization; they have achieved savings of hospital costs of 20-40%. Another system for delivering and financing health care is the preferred provider organization (PPO) under which patients are assigned to a designated panel of health care providers who offer services according to a discounted fee schedule. New hybrid systems that combine many of the features of both systems are emerging. Most of the newly organized health care delivery systems described focus on utilization control and keeping costs down. A common way of ensuring coordinated health care delivery is through primary care case management. To initiate or establish relationships with HMOs or other health care delivery systems, family planning agencies should consider such activities as: undertaking surveys to study the market; training new employees on developments in health care financing; and recruiting board members with HMO experience.^ieng

The Monterey County Health Initiative. A post-mortem analysis of a California Medicaid demonstration project.

Twenty months after the California State Department of Health Services turned its Medicaid program in Monterey County over to a local health care authority, the Monterey County Health Initiative (MCHI), the state terminated the pilot project in favor of a return to fee-for-service reimbursement. The MCHI, plagued from its inception with shaky provider support and a flawed program design, failed to demonstrate its anticipated cost savings. The key features of this failure were overly generous fees for primary case managers, inadequate utilization control measures, a general hesitancy to assume the necessary gatekeeper function, and a management information system that was not fully operational until well into the implementation of the program. Policy implications and recommendations for future state-sponsored Medicaid demonstration projects are discussed.

Patterns of contraceptive method of use by California family planning clinic clients, 1976-84.

Trends in contraceptive method of use by California family planning clients, 1976-84, are reviewed. Although use of foam and condoms doubled from 1976 to 1980 and was sustained, interest peaked but markedly declined for the diaphragm. Oral contraceptive (OC) use declined overall and most notably for older women, but there are indications in 1983 and 1984 of a slight OC "come back". Older women were more likely to choose methods free from medical side effects than were younger women.

Assessing the impact of copayment on family planning services: a preliminary analysis in California.

A legislatively mandated copayment system for California state-funded family planning services was evaluated after the first six months of experience. Most clients reportedly could make their payments, but three times as many providers suggested lowering the fees as suggested raising them, and one-third reported a decrease in client donations. While the majority of providers did not report a decrease in clients, 22 per cent did so. For these drop-outs, it is estimated that the State would pay approximately $3 million in costs associated with unintended pregnancies, or one and a half times the amount cut from the Family Planning budget.

Trends in contraceptive method of use by California family planning clinic clients aged 10-55, 1976-1979.

The types of primary contraceptive method chosen by women seeking services in California family planning clinics are reviewed for the years 1976-1979. Of most significance was the decline in the use of oral contraceptives (OC) and the concurrent rise in nonprescription methods at all ages. A striking difference in OC use between the earlier and latter time periods was noted for women age 40 and older.