Clinic Provision of Contraceptive Services to Managed Care Enrollees. (Articles).

Context: Since the initiation of managed health care, little information has been available on whether family planning agencies are seeking ways to serve (and obtain reimbursement for serving) the growing number of clients who are managed care enrollees.

Methods: A 1995 mail survey sought information from a nationally representative sample of publicly funded family planning agencies about the agencies' involvement with managed health care plans and related clinic services, policies and practices. Completed surveys were received from 603 agencies, for an overall response rate of 68%.

Results: One-half of ail publicly funded family planning agencies had served known enrollees of managed care plans. One-quarter (24%) had served managed care enrollees under contract, while others sought out-of-plan reimbursement for services provided to enrollees (13%) or used other sources to cover the cost of these services (12%). Family planning clinics administered by hospitals and community health centers were more likely than other types of clinics to have contracts to provide full primary-care services to managed care enrollees, whereas Planned Parenthood affiliates were more likely to have contracts that covered the provision of contraceptive care only. Clinics administered by health departments rarely had secured managed care contracts (10%), and only 36% reported even serving managed care enrollees.

Conclusions: The challenges presented by managed care, and agencies' responses to these challenges, vary according to the type of organization providing contraceptive care. Family planning agencies need to seek relationships with managed care organizations based on those services that their clinics can best supply. Family Planning Perspectives, 1998, 30(4):156-162

In recent years, enrollment in both private and publicly funded managed health care plans has escalated. By the mid-1990s, nearly three-quarters (73%) of insured private-sector employees and 40% of all Medicaid recipients were enrolled in some form of managed health care. (1)

Given these trends, the contraceptive clients served at publicly funded family planning clinics are increasingly likely to be enrolled in a wide variety of managed health care plans. The coverage of many preventive and reproductive health care services, such as annual gynecologic exams and reversible contraceptive methods, is generally better among managed care plans than among traditional indemnity insurance plans. (2) Therefore, agencies that operate clinics providing contraceptive services have an added incentive to negotiate with managed care plans for coverage of services, even if they have rarely billed traditional indemnity plans for services provided to insured clients.

Providers of all types increasingly are finding ways to serve clients enrolled in managed care. Most private physicians have contracts with managed care plans to serve enrollees, as either primary care or specialty physicians. In 1996, 88% of all physicians and 94% of obstetrician-gynecologists reported having managed care contracts. (3) However, for a number of reasons, family planning agencies and other public-sector providers have been slower than private providers to become involved in managed care, and have been less actively pursued by the managed care organizations. Consequently, some family planning agencies may face reduced caseloads if their clients switch to physicians in managed care plans. Some agencies' revenues may also be cut if clinics continue to serve managed care enrollees without contracts and cannot obtain reimbursement for the services they provide.