Lessons Learned: The Managed Care Experiences of Family Planning Providers.

This article examines key opportunities and obstacles facing community-based family planning agencies seeking to be "players" in the provision of contraceptive and related services in the managed care context. Based on telephone interviews with people working in or closely with a range of family planning provider agencies in five states, it identifies a range of innovative strategies that family planning providers have developed in pursuing arrangements with managed care organizations. It further identifies five difficult issues that have arisen repeatedly in the course of negotiating or implementing those arrangements.

Key words: family planning agencies, family planning services, managed care, Medicaid

IN THE COURSE of just a few years, managed care has revolutionized the delivery of medical care in the United States. Its growth has been astonishing. Between 1993 and 1995, the percent of insured, private-sector employees enrolled in conventional, fee-for-service plans plummeted from 49 percent to 27 percent, while the market share of managed care plans skyrocketed from 51 percent to 73 percent. (1) Managed care has arrived in the public sector as well; in 1983, only 3 percent of Medicaid enrollees were enrolled in managed care plans; that figure rose to 40 percent in 1996. (2)

The managed care marketplace is by no means monolithic. The country's near 3,000 managed care organizations (MCOs) come in at least three different basic types, each of which has distinct organizational principles. (3) Most MCOs, however, employ similar means of seeking to fulfill managed care's fundamental promise: controlling costs while maintaining quality. In one way or another, all encourage the use of a designated pool of providers assembled through an intricate web of contracts and subcontracts and establish strong financial incentives for their enrollees to obtain care only from these providers. Some go so far as to preclude payment for care that is obtained outside the plan. Most rely on a system of primary care providers (PCPs) whose job it is to coordinate enrollees' overall care and ensure that they receive an appropriate level of care--that is, neither too much nor too little--by managing referrals to specialty providers.

The varying types of managed care systems--ranging from the more traditional health maintenance organizations (HMOs) to newer versions such as preferred provider organizations (PPOs) and point-of-service (POS) networks--also differ, sometimes markedly, in their coverage of reproductive health services. While most plans, regardless of type, cover maternity care, induced abortion, and sterilization, coverage is less consistent when it comes to routine gynecologic care, especially reversible contraception. In general, the newer system types--which are also those growing the fastest--offer less generous coverage than do traditional HMOs.

As these new systems continue to expand and reach for even greater market share and as both the purchasers and consumers of health care become increasingly aware of the importance of basic reproductive health care to the health and well-being of their enrollees, the ability of these systems to provide key services such as contraception to their enrollees is likely to grow in importance. (4) Thus far, however, few managed care plans have developed contractual relationships with community-based clinics to provide contraceptive services. In 1994, only 23 percent of HMOs had an existing contract or reimbursement arrangement with a family planning or abortion clinic. Moreover, 60 percent of these HMOs contracted only for abortion. While 33 percent contracted for some other services along with abortion, only 8 percent contracted exclusively for reproductive health care services other than abortion. (4)

A more recent study of family planning agencies confirms the paucity of contracting between managed care plans and community-based family planning providers--and highlights a key problem facing providers in the absence of contracts. Half of all family planning agencies provide contraceptive services and supplies to enrollees of managed care plans, despite the fact that only one in four has negotiated a contract with an MCO to do so. (5)