Providing LARCs in a Federally Qualified Health Center

Is it financially viable? A case study

Lisa Maldonado, MA, MPH

Linda Prine, MD

Mission

The Reproductive Health Access Project trains and supports clinicians to make reproductive health care accessible to everyone.

We focus on three key areas:

abortion, contraception and miscarriage.

Community Health Centers

Year CHC Sites Patients Served

1990 1,400 5,000,000

2000 3,200 10,000,000

2010 8,000 20,000,000

2019 40,000,000

Family Planning Access in FQHCs

• More than 5.7 million women receive health care in FQHCs (2012).

• 2013 study found that 99.8% of FQHCs provided at least 1 contraceptive method…but only 19% of all FQHCs surveyed report offering comprehensive contraceptive options at their “largest” site. (1)

• The largest FQHCs sites: 36% offer the contraceptive implant, 56% offer the progestin IUD and 52% provide the copper IUD. (2)

1. Wood SF, Goldberg DG, Beeson T, Bruen BK, Johnson K, Mead KH, Shin P, Lewis J, Artis S, Hayes K, Cunningham

M, Lu X & Rosenbaum S. (2013). Health centers and family planning: results from a nationwide study. Health Policy

Faculty Publications.

2. Accessibility of Long-acting Reversible Contraceptives (LARCS) in Federally Qualified Health Centers (FQHCs)," Beeson

et al., Contraception, Oct. 3, 2013.

Common barriers to providing LARC in an FQHC

• Clinicians not trained to provide LARC

• “Procedure” interferes with patient flow

• Protocols out of date (eg, patient must be multiparous, currently having menses, etc.)

• Administrators won’t stock “expensive” items like IUDs and Implants.

• “Providing LARC is expensive, the health center will lose money.”

FQHCs serve low income populations

Source: Federally-funded health centers only. 2012 Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS.

Note: Federal Poverty Level (FPL) for a family of three in 2012 was $18,500. (See http://aspe.hhs.gov/poverty/12poverty.shtml).

Based on percent known.

Typical FQHC Payor Mix

*”Other public insurance” may include non-Medicaid SCHIP and state-funded insurance programs.

Source: Federally-funded health centers only. 2012 Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS.

One FQHC’s Experience

• Large, multi-site FQHC serving serving both inner-city, suburban and rural populations.

• 3 residency programs within the FQHC, all training family medicine residents to do LARC

• Most hiring for the FQHC comes from residency graduates, i.e. many trained providers

• Reproductive Health Fellowship has helped to expand training of residents and APCs

The bottom $$ line:

Benefits from:

• State Medicaid reimburses for device and insertion.

• Patient Assistance Program (ARCH and Paragard) for eligible uninsured.

• Special state Family Planning Benefit Program for uninsured/underinsured.

• 340b pricing for device

2012 2013

Mirena $304.75 $313.75

Paragard $185 $225.00

IUD Patient Assistance Programs

Paragard www.rxhope.com/PAP/pdf/duramed_paragard_0209.pdf

Mirena

ARCH Foundation

www.archfoundation.com

1st Quarter 2013

Number of IUDs inserted

Paragard Mirena Total

84 195 279

Revenue: 1st Quarter 2013

# patients Total Revenue Average per patient

Free Care 18 (6%) 0 0

Sliding Fee 27 (10%) $482.50 $20.10

Insurance * 234 (84%) $20,295.76 $86.73

Total 279 $20,778.26 $77.56

•includes Medicaid and private insurance plans

•No insurance reimbursement for insertion for 45 patients.

Insertion fees/Office visit collected

Revenue: one FQHC’s IUD experience

# patients

Total Revenue

Average revenue

per patient

Total cost (340b prices)

Net Profit

Paragard 84 $22,651.34 $269.66 $18,900.00 $3,751.34

Mirena 195 $72,896.48 $373.82 $61,181.25 $11,715.23

Total 279 $95,547.82 $342.46 $80,081.25 $15,466.57

Device fees collected

No insurance reimbursement for devices for 68 patients.

Net profit

Cost Revenue Net Profit

Devices $80,081.25 $95,547.82 $15,466.57

Visit* $39,060.00 $20,778.26 $18,281.74

Total $119,141.25 $116,326.08 $2,815.17

Wrap-around $4,972.13 $2,156.96

*$140.00 cost/visit

Additional Considerations • This data is pre-Obamacare.

• Changes made at FQHC due to this analysis:

– All patients now see social workers for insurance eligibility

– Billing department follows through on unpaid claims

– Contracts with insurances were addressed

• Many insurances actually pay a higher visit rate for IUD removals than for insertions.

Is this replicable in other states?

• National efforts to reform Medicaid

• States where Medicaid reform is working

• Other national issues to think about

• Clinicians have to become advocates regarding billing & reimbursement

• Special challenges for FQHCs, as opposed to other settings