Funding postabortal contraception for low income women in california by UCLA Luskin School of Public Affairs

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Funding Postabortal Contraception for Low-Income Women in California ! ! ! !

Jennifer Salcedo, MD, MPH and Andrea Sorensen, BA ! ! ! ! ! ! ! !

Funding Postabortal Contraception for Low-Income Women in California

Jennifer Salcedo, MD, MPH and Andrea Sorensen, BA

UCLA Luskin School of Public Affairs April 26, 2012

Disclaimer: This report was prepared in partial fulfillment of the requirements for the Master in Public Policy degree in the Department of Public Policy at the University of California, Los Angeles. It was prepared at the direction of the Department and of the UCSF Bixby Center for Global Reproductive Health. The views expressed herein are those of the authors and not necessarily those of the Department, the UCLA Luskin School of Public Affairs, UCLA as a whole, or the UCSF Bixby Center for Global Reproductive Health.

ACKNOWLEDGEMENTS Many individuals contributed to the content of this report. We would like to thank our Applied Policy Project advisor, Mark Peterson, Professor of Public Policy and Political Science at the UCLA Luskin School of Public Affairs, for his guidance and painstaking review of more drafts than we remember. We are also grateful for the advice of Rob Jensen, Associate Professor of Public Policy, and Mark Kleiman, Professor of Public Policy, for their assistance in reviewing our decision model and its assumptions. In addition, numerous individuals have been kind enough to share their valuable expertise on issues ranging from Markov modeling, the complexities of the Medi-Cal system, and administrative law, to the Affordable Care Act: M. Antonia Biggs, PhD - Senior Researcher, Family PACT Evaluation, Philip R. Lee Institute for Health Policy Studies E. Richard Brown, PhD - Founding Director Emeritus, UCLA Center for Health Policy Research Marianne Bruno, MPH, CHES - Title X Program Manager, UCLA Keri Castaneda – Health Administrator, Planned Parenthood Los Angeles Michael Dukakis, JD – Visiting Professor of Public Policy, UCLA Luskin School of Public Affairs Lisa Federer, MLIS, MA, AHIP – Associate Librarian, Louise M. Darling Biomedical Library, UCLA Diana Greene Foster, PhD - Associate Professor, Department of Obstetrics, Gynecology & Reproductive Sciences; Director of Research, Advancing New Standards in Reproductive Health (ANSIRH), UCSF Allison Hoffman, JD – Acting Professor of Law, UCLA Megan Kavanaugh, DrPH - Senior Research Associate, Guttmacher Institute Gerald Kominski, PhD - Associate Director, UCLA Center for Health Policy Research Maria Rodriguez, MD, MPH - Medical Officer, World Health Organization, Department of Reproductive health Sara Rosenbaum, JD – Professor and Founding Chair, Department of Health Policy, George Washington University Heike Thiel de Bocanegra, PhD, MPH - Director, UCSF Family PACT Program Support and Evaluation; Office of Family Planning, California Department of Public Health Kirsten Thompson, MPH - Project Director, Bixby Center for Global Reproductive Health We would also like to thank our peer reviewers, Lindsay Gilchrist, Maribel Angulo, and Ali Shefizadeh for their review and comments on numerous drafts.

Table of Contents Executive Summary…………………………………………………………………….i-iv Introduction…………...……………………………………………………………..….1-4 Medical Aspects of Postabortal Contraception……………………………………..…..4-7 Publicly-Funded Programs for Pregnancy and Contraception Care in California…...…7-8 Medicaid and Family Planning…….…………………………………………...…………9 Medi-Cal: California’s Medicaid Program……………………………...…………….9-10 Full-Scope Medi-Cal Program…………………………………………………..……10-11 Presumptive Eligibility and Limited Scope for Pregnant Women Programs………………………………………………………………………...……11-14 Coverage of Contraception: Family PACT Program…………………………..……15-22 Title X: Federal Funding for Family Planning Services…………….…………..……23-27 Political and Legal Issues Surrounding Abortion and Contraception……………..…27-29 Healthcare Legislation Impacting Abortion and Contraception…….…………..……29-33 Evaluation of Potential Public-Payer Cost Savings Associated with Immediate Provision of Postabortal Contraception…………………………………………………………33-40 Results from Decision Tree Analysis Public-Payer Cost Evaluation…………..….…40-45 Criteria for Choosing Among Policy Options...…….………………………..………45-47 Recommendations and Conclusions…………………………………………….……47-55

EXECUTIVE SUMMARY Approximately half of all pregnancies in the United States are unintended, and over forty percent of these pregnancies end in abortion. Low-income women have higher rates of unintended pregnancy and are consequently disproportionately represented among women seeking abortion. The provision of contraception at the time of abortion is within the medical standard of care and is desired by a high percentage of women. Additionally, provision of contraception at the time of abortion has been demonstrated to decrease rates of subsequent abortions compared to the planned provision of contraception at abortion follow-up. Despite these facts, as a result of the fragmentation of abortion and contraception services and policies that restrict federal funds from being used for abortions, less than one-third of high-volume abortion providers in the U.S. are able to offer placement of intrauterine devices (IUDs), a form of long-acting reversible contraception, at the time of abortion. In California, one of a minority of states to fund both abortion and contraception for low-income women, confusion over how healthcare providers may seek reimbursement for concurrently provided abortion and contraception services serves as a major barrier to womenâ&#x20AC;&#x2122;s access to immediate postabortal contraception. This is particularly true for women with incomes between 100% and 200% of the Federal Poverty Line (FPL) who receive abortion coverage under Presumptive Eligibility or Limited-Scope Medi-Cal, and contraception care under the separate Family PACT program. In 2007 this population of women represented 30,500 of the 80,069 publiclyfunded abortions performed in the state.

In this report, we analyze current barriers to the provision of immediate postabortal contraception for low-income women in California. Additionally, we create a decision analytic model to evaluate the potential cost-savings to public programs if immediate postabortal contraception was made available to low-income women undergoing abortion, compared to planned provision of contraception at abortion followup. Through these evaluations, we aim to provide recommendations to the UCSF Bixby Center for Global Reproductive Health (Bixby Center) regarding how California can best provide postabortal contraception to its low-income women in a way that: (1) is consistent with the medical standard of care, (2) reduces the number of unintended pregnancies and abortions, and (3) minimizes public program costs. The Bixby Center’s mission is to advance women’s health worldwide through research, training, policy analysis and services. Consistent with these goals, the Bixby Center provides ongoing evaluation of California’s Family PACT program to ensure its continued positive impact on health outcomes and cost-savings. FINDINGS !

In California, barriers to the provision of immediate postabortal contraception for low-income women persist despite lack of specific legal prohibitions that disallow concurrent billing for contraception funded by Family PACT and abortion services funded by Medi-Cal.

When considering only the future costs of contraception and pregnancy-related care for each woman undergoing a Medi-Cal funded abortion and desiring an IUD, California’s public programs would save $111 over one year if the IUD was provided at the time of the abortion, compared to planned placement at abortion

follow-up. After five years, Californiaâ&#x20AC;&#x2122;s public programs would be expected to save $4296 per woman, when considering direct medical costs of contraception and pregnancy, and additional public health insurance and social program costs of the woman and her children. This would result in a public program cost savings of $98 million, when accounting only for women with incomes 100 and 200% of the FPL. !

Provision of immediate postabortal IUDs, compared to planned placement at abortion follow-up, is anticipated to result in at least 2,294 fewer abortions annually for women with incomes 100 and 200% of the FPL in California.

RECOMMENDATIONS !

To decrease confusion among clinicians, office managers, and billing staff about the ability to obtain reimbursement from Family PACT for contraception services provided at the time of a Presumptive Eligibility or Limited-Scope Medi-Calfunded abortion procedure, we recommend that Family PACT amend its Policy & Procedures Manual to clarify the specific process by which to secure reimbursement for these services. We additionally advise that the Family PACT program expand its current legislatively-mandated training sessions to educate all Family PACT-participating clinicians and office managers about the current medical standard of care for the provision of immediate postabortal contraception and the appropriate mechanisms for seeking reimbursement for these concurrently provided services.

As a temporary mechanism, we recommend that the Family PACT program educate family planning clinic personnel about its new retroactive reimbursement

iii

provisions for contraceptive services provided to eligible women for the three months prior to their Family PACT enrollment. Additionally, we recommend that the Family PACT program establish a mechanism through which providers can seek retroactive reimbursement for eligible services billed to, but not yet paid for, by these women. !

As a longer-term goal, we recommend expanding Medi-Cal programs and formularies such that all versions of Medi-Cal provide coverage for the full range of FDA-approved methods of contraception so as to eliminate the fragmentation that surrounds family planning services in California. This change will require action from and support on the part of the California State Legislature.

INTRODUCTION: POSTABORTAL CONTRACEPTION FOR LOW-INCOME WOMEN IN CALIFORNIA California is one of few states to offer public funding for both abortion and contraception services to low-income women. It is one of thirteen states that funds all medically necessary abortions for low-income women, and one of 17 states that has a Medicaid 1115 Waiver or State Plan Amendment in place that allows for the provision of family planning services to low-income individuals who do not meet the strict eligibility criteria for Medicaid.1 In 2008, there were an estimated 7,680,396 women of reproductive age in California, 897,700 (12%) of whom became pregnant.2 Of these pregnancies, 214,190 (24%) resulted in an abortion, representing approximately one-fifth of the 1.2 million abortions performed nation-wide in 2008. ! In this same year, California had 522 abortion providers (including hospitals, clinics, and private physician locations), representing approximately 30% of the national total of 1,793." California has few abortion restrictions relative to other states. For example, California does not require parental notification for minors undergoing abortion, does not mandate specific content of pre-abortion counseling, and does not require a waiting period between a provider visit for pre-abortion counseling and the abortion procedure itself.# It is well documented that women can return to fertility within days of an abortion, which highlights the importance of providing prompt access to contraception 1

“State Policies in Brief: State Funding of Abortion Under Medicaid,” Guttmacher Institute, January 1, 2012, accessed January 21, 2012 <www.guttmacher.org/pubs/spib_SFAM.pdf>. 2 “State Facts About Abortion: California,” Guttmacher Institute, 2011, accessed January 17, 2012 <www.guttmacher.org/pubs/spib_SFAM.pdf>. 3 Ibid. “State Facts About Abortion: California,” 2011. 4 Ibid. “State Facts About Abortion: California,” 2011. 5 Ibid. “State Facts About Abortion: California,” 2011.

for this population of women.6 Providing immediate postabortal contraception is supported as a medical standard of care by the Centers for Disease Control and Prevention (CDC) in its U.S. Medical Eligibility Criteria for Contraceptive Use (MEC).7 Further, the immediate postabortal provision of intrauterine devices (IUDs) has been shown to decrease rates of repeat abortions compared to other contraception methods, and to yield a cost savings of seven dollars for every one dollar spent. 8 Importantly, when immediate postabortal IUD insertion is unavailable to women who desire the method, high no-show rates for planned follow-up visits are common and are associated with low rates of post-procedure IUD insertion. Specifically, of women who intend to obtain a postabortal IUD at follow-up, fewer than 20% obtain one by six weeks post-procedure, and only 32% obtain their planned IUD within six months.9 Despite the fact that immediate provision of postabortal contraception, including immediate postabortal IUD placement, complies with the medical standard of care, and that such provision produces significant cost savings, it is estimated that only one-third of high volume, non-hospital, abortion-providing facilities in the U.S. offer immediate postabortal insertion of IUDs.10 Postabortal contraception and its effect on womenâ&#x20AC;&#x2122;s health, including the avoidance of unintended pregnancy, is an issue of great concern to the University of 6

Stoddard A, Eisenberg DL. Controversies in family planning: timing of ovulation after abortion and the conundrum of postabortion intrauterine device insertion. Contraception 2011; 84: 119-121. 7 â&#x20AC;&#x153;U.S. Medical Eligibility Criteria for Contraceptive Use, 2010,â&#x20AC;? Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention, Vol. 59, May 28, 2010, accessed March, 13 2012, <www.cdc.gov/mmwr>. 8 Foster DG, Rostovtseva DP, Brindis CD, Biggs MA, Hulett D, Darney PD. Cost savings from the provision of specific method of contraception in a publicly funded program. American Journal of Public Health 2009; 99: 446-451. 9 Stanek AM, Bednarek PH, Nichols MD, Jensen JT, Edelman AB. Barriers associated with the failure to return for intrauterine device insertion following first-trimester abortion. Contraception 2009; 79: 216-220. 10 Kavanaugh ML, Jones RK, Finer LB. How commonly do US abortion clinics offer contraceptive services? Contraception 2010; 82: 331-336.

California, San Francisco (UCSF), Bixby Center for Global Reproductive Health (Bixby Center), the mission of which is to advance women’s health worldwide through research, training, policy analysis, and services. Among its many responsibilities, the Bixby Center is tasked with evaluating California’s Family PACT program by assessing its success in meeting the goals of increasing access to effective contraception for lowincome men and women, and preventing unintended pregnancies. Our intention is that the findings outlined in the report that follows will assist the Bixby Center in its work of improving access to contraception and reducing unintended pregnancy for women in California while also minimizing pubic program expenditures in the state. This analysis and the recommendations that follow are ours alone and are not intended to represent the views of the Bixby Center. Confusion over multiple funding sources for contraception and abortion care, complexities surrounding legal restrictions on the use of federal funds toward abortion services, delayed or inadequate reimbursement for contraception, and the lack of funds required to maintain a stock of contraceptive supplies have been found to contribute to the inability to provide immediate postabortal contraception.11 California is one such state that operates in an environment where multiple funding streams reimburse abortion and contraception services for its low-income population. For example, as we describe in detail below, the state’s Medicaid program, Medi-Cal, funds abortions through its FullScope, Presumptive Eligibility, and Limited-Scope (sometimes referred to as Emergency) programs, depending on a woman’s income eligibility, citizenship status, and stage in the

Kirsten Thomas, Personal interview, 23 February 2012; Heike Thiel, Personal interview, 7 March 2012; Kavanaugh ML, Jones RK, Finer LB. How commonly do US abortion clinics offer contraceptive services? Contraception 2010; 82: 331-336.

Medi-Cal application process. Contraceptive services for these same women, however, are funded through Full-Scope Medi-Cal, the Family PACT program, and Title X funds, also explained below. Consequently, a woman might have an abortion covered by the Medi-Cal Presumptive Eligibility program, and be asked to return for follow-up to enroll in the Family PACT program which would provide funding for her contraceptive services. Our goal is to determine how California can best fund postabortal contraception for its low-income women in a way that: (1) meets the medical standard of care, (2) minimizes public-payer costs, (3) decreases barriers to the immediate provision of postabortal contraception, and (4) decreases (or avoids increasing) the number of abortions. We will do so by evaluating in detail the current processes through which California funds abortion and contraception services for low-income women. We will also determine the effect on public expenditures of providing immediate postabortal contraception, specifically immediate postabortal IUDs, and will assess avenues for future changes in the provision of services.

MEDICAL ASPECTS OF POSTABORTAL CONTRACEPTION The Centers for Disease Control and Prevention (CDC) issues evidence-based recommendations for the medical safety of various contraceptive methods in particular circumstances and for women with particular medical conditions. The CDC publishes these recommendations in its U.S. Medical Eligibility Criteria for Contraceptive Use (MEC). The MEC is adapted from the World Health Organization (WHO) Medical Eligibility for Contraceptive Use to more specifically meet the needs of health care

providers in the United States by taking into account country-specific prevalence of diseases and standards of medical practice. The MEC is updated regularly and was released in its fourth edition in 2010. In the MEC, the use of a particular contraceptive method in a given circumstance is provided with a numeric classification ranging from one to four: “1 = A condition for which there is no restriction for the use of the contraceptive method. 2 = A condition for which the advantages of using the method generally outweigh the theoretical or proven risks. 3 = A condition for which the theoretical or proven risks usually outweigh the advantages of using the method. 4 = A condition that represents an unacceptable health risk if the contraceptive method is used.”12 The MEC provides a ‘1’ classification (a condition for which there is no restriction for the use of the contraceptive method) for contraceptive pills, patches, vaginal rings, injections (depot medroxyprogesterone acetate, DMPA), and implants (the progestincontaining single-rod 3-year contraceptive implant placed in a woman’s arm) immediately following first-trimester abortion, second-trimester abortion, and septic abortion (abortion in the setting of a pelvic infection). Additionally, the MEC provides a ‘1’ classification for the insertion of intrauterine devices (IUDs) immediately following first-trimester abortion, and a ‘2’ classification for immediate IUD insertion following second-trimester abortion. The ‘2’ classification for immediate IUD insertion following 12

second-trimester abortion (abortion after approximately 12 weeks of gestation) is provided due to the higher risk of IUD expulsion (the device spontaneously falling out) when placed in this circumstance. Immediate insertion of an IUD following septic abortion (abortion complicated by pelvic infection) is given a ‘4’ classification secondary to its potential to worsen the condition.13 Intrauterine devices are small t-shaped pieces of plastic that are placed directly into the uterus by a healthcare professional using a thin plastic insertion tube that is passed through the vagina and cervix. IUDs work to prevent pregnancy primarily by precluding the union of the male sperm and female egg (by increasing the thickness of cervical mucus and/or creating a local environment that impedes sperm).14 Two types of IUDs are currently FDA approved in the U.S. The hormonal Mirena® IUD (levonorgestrel-releasing intrauterine system, Bayer) is FDA approved for up to five years of contraceptive use and is associated with non-contraceptive benefits due to reduction in menstrual bleeding.15 The non-hormonal (copper-containing) ParaGard ® IUD (intrauterine copper contraceptive, Teva Women’s Health) is FDA approved for up to 10 years of contraceptive use.16 Compared to estrogen-containing methods of contraception, (such as commonly used contraceptive pills and all contraceptive vaginal rights and patches), which are contraindicated in women with a variety of medical conditions, neither FDA-approved IUD contains estrogen, making the IUDs medically

“U.S. Medical Eligibility Criteria for Contraceptive Use, 2010,” Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention, Vol. 59, May 28, 2010, accessed March 13, 2012, <www.cdc.gov/mmwr>. 14 “Intrauterine Devices: IUD,” American Pregnancy Association, accessed March 14, 2012, <http://www.americanpregnancy.org/preventingpregnancy/iud.html>. 15 Mirena, accessed 15 March 2012 <http://www.mirena-us.com/>. 16 Paragard, accessed 15 March 2012 <http://www.paragard.com/>.

appropriate for most women.17 The immediate provision of postabortal IUDs is associated with high continuation rates, low complication rates that are equivalent to those of IUD placement at times not associated with abortion, and low expulsion rates.18 PUBLICLY-FUNDED PROGRAMS FOR PREGNANCY AND CONTRACEPTION CARE IN CALIFORNIA Multiple public programs provide family planning services to low-income men and women throughout California. These programs include California’s Medicaid program, Medi-Cal, which has three sub-programs under which a pregnant woman might receive care: Full-Scope Medi-Cal, Presumptive Eligibility for Pregnant Women, and Limited-Scope Medi-Cal (sometimes referred to as Emergency Medi-Cal). In addition to these various programs within Medi-Cal, California’s Family PACT program, and supplemental funds from the federal Title X program also play an important role, primarily through their coverage of contraception. Thus, reimbursement for pregnancy and contraception care can often come from different funding streams depending on income levels, services required, and other eligibility-related issues.

“U.S. Medical Eligibility Criteria for Contraceptive Use, 2010,” Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention, Vol. 59, May 28, 2010, accessed March 13, 2012, <www.cdc.gov/mmwr>. 18 Goodman S, Hendlish SK, Reeves MF, Foster-Rosales A. Impact of immediate postabortal insertion of intrauterine contraception on repeat abortion. Contraception 2008; 78: 143-148; Reeves MF, Smith KJ, Creinin MD. Contraceptive effectiveness of immediate compared with delayed insertion of intrauterine devices after abortion: a decision analysis. Obstet Gynecol 2007; 109: 1286-1294; Drey E, Reeves MF, Ogawa DD, Sokoloff A, Darney PD, Steinauer JE. Insertion of intrauterine contraceptives immediately following first- and second-trimester abortions. Contraception 2009; 79: 397-402.

Public Funding for Abortion and Contraception in California:19

California has multiple sources of public funding for abortion and contraception. Sources of abortion funding for low-income women include the Full-Scope, Presumptive Eligibility, and Limited-Scope (Emergency) Medi-Cal programs. Sources of contraception funding for low-income women in the state include Full-Scope Medi-Cal, the Family PACT program, and Title X.

MEDICAID Medicaid and Family Planning Medicaid funds a sizable percentage (about 60%) of all national family planning services.20 It operates as an entitlement program similar to Social Security and Medicare, meaning that Medicaid has no set budget so that funds can expand as needed depending on demand.21 Medicaid is funded through both the federal and state governments, with states funding approximately 43% of the costs of Medicaid services.22 Specifically, states support Medicaid services through the State General Fund while also receiving Medicaid matching funds from the Federal Government.23 In California in 2009, federal contribution to the state’s Medicaid system totaled $25,310,253,499, compared to the state contribution of 16,273,187,533; thus, California contributed 39% to the total funding of the program.24 Medi-Cal: California’s Medicaid Program Medi-Cal is California’s Medicaid program. Within Medi-Cal, women receive varying forms of coverage depending on health status, citizenship status, and income. Medi-Cal provides funding for abortion under three categories of coverage: its FullScope program, Presumptive Eligibility program, and Limited-Scope Medi-Cal. For

Rachel Benson Gold, “Stronger Together: Medicaid, Title X Bring Different Strengths to Family Planning Effort,” Guttmacher Institute, Vol. 10, No. 2. Spring 2007, accessed February 1, 2012, <www.guttmacher.org/pubs/gpr/10/2/gpr100213.html>. 21 Gold, Spring 2007. 22 “Medicaid and the Uninsured, Kaiser Commission on Key Facts,” Kaiser Family Foundation, January 2011, accessed February 13, 2012 <www.kff.org/medicaid/upload/8139.pdf>. 23 “Medicaid and the Uninsured, Key Questions About Medicaid and Its Role in State/Federal Budgets and Health Reform,” Kaiser Family Foundation, 1-3, January 2011, accesssed December 26, 2011, <www.kff.org/medicaid/upload/8139.pdf>. 24 “Federal and State Share of Medicaid Spending, FY 2009,” Kaiser Family Foundation, accessed March 11, 2012 <http://www.statehealthfacts.org/comparebar.jsp?ind=636&cat=4&sub=47&yr=90&typ=4&o=a>.

example, a woman with income below 100% of the Federal Poverty Line (FPL) might be covered under the Full-Scope Medi-Cal program. Alternatively, a woman with an income between 100% and 200% of the FPL would generally receive abortion services through the Presumptive Eligibility for Pregnant Women, or the Limited-Scope Medi-Cal program. The most recent year for which figures are available for Medi-Cal-funded abortions is 2007. In total, 80,069 abortions were funded through the state’s contribution to Medi-Cal that year. 25 This figure includes Medi-Cal managed care plans, standard fee-for-service Medi-Cal, and county-organized health systems.26 Specifically, 24,000 of these abortions were funded under Presumptive Eligibility Medi-Cal for U.S. citizens and qualifying legal residents, 6,500 were funded under Presumptive Eligibility and LimitedScope Medi-Cal for undocumented immigrants, and the remainder for U.S. citizens and legal residents under the Full-Scope Medi-Cal program.27 California, through its State General Fund, funds all abortion and delivery care for undocumented immigrants.28 Full-Scope Medi-Cal Program The Full-Scope Medi-Cal program provides comprehensive healthcare insurance to individuals who meet a number of income and other eligibility criteria. In order to qualify for California’s Full-Scope Medi-Cal program, a woman must be a U.S. citizen (verified through Social Security number), reside in California, have income less than 25

“Medi-Cal Funded Induced Abortions Calendar Year 2007,” California Department of Health Care Services, Research and Analytical Studies Section, 2, Revised 23 July 2009, accessed March, 1 2012, <http://www.dhcs.ca.gov/dataandstats/statistics/Documents/Induced_Abortions_2007.pdf>. 26 “Medi-Cal Funded Induced Abortions Calendar Year 2007,” California Department of Health Care Services, Research and Analytical Studies Section, 2, Revised 23 July 2009, accessed March 1, 2012, <http://www.dhcs.ca.gov/dataandstats/statistics/Documents/Induced_Abortions_2007.pdf>. 27 “Medi-Cal Funded Induced Abortions Calendar Year 2007,” California Department of Health Care Services, Research and Analytical Studies Section, 2-5, Revised 23 July 2009, accessed March 1, 2012 <http://www.dhcs.ca.gov/dataandstats/statistics/Documents/Induced_Abortions_2007.pdf>. 28 E. Richard Brown, Personal interview, 2 March 2012; Dylan Roby, Personal interview, 13 March 2012.

100% of the FPL, and be over the age of 21.29 In addition, a woman can qualify if she falls into one of the following categories: is blind or disabled (as defined by Social Security eligibility); is pregnant; receives CalWORKs; or is 65 or older.30 A person is also eligible for Full-Scope Medi-Cal if he or she is disabled and previously or currently receives SSI benefits.31 Those individuals who are eligible for this comprehensive version of Medi-Cal receive family planning services that include, for example, contraceptive drugs, family panning instruction, and lab procedures.32 Full-Scope Medi-Cal covers a limited selection of oral contraceptive pills, and does not cover contraceptive vaginal rings or patches.33 This formulary, with its limited selection of contraception methods, is determined by Medi-Cal administration, and is based on negotiated price reductions, and refunds, for example.34 [See Appendix, Exhibit A, for Medi-Cal Full-Scope contraceptive formulary]. Presumptive Eligibility and Limited-Scope Medi-Cal for Pregnant Women While the Full-Scope Medi-Cal program provides coverage for those who meet the strict eligibility criteria, the purpose of the Presumptive Eligibility program is to provide temporary assistance to low-income women who become pregnant but are

“Medi-Cal Flowcharts,” National Health Law Program, July 2006, accessed March 3, 2012, <healthconsumer.org/cs041Medi-CalFlowChart.pdf>; “At-a-glance Selected Eligibility Requirements and Benefits for Adults,” California Department of Public Health, October 2010, accessed March 10, 2012, <www.cdph.ca.gov/.../TBCB-MCalAt-a-GlanceEligibility-3Programs.pdf>. 30 “At-a-glance Selected Eligibility Requirements and Benefits for Adults,” California Department of Public Health, October 2010, accessed March 10, 2012 <www.cdph.ca.gov/.../TBCB-MCalAt-aGlanceEligibility-3Programs.pdf>. 31 “Medi-Cal Flowcharts,” National Health Law Program, July 2006, accessed March 3, 2012, <healthconsumer.org/cs041Medi-CalFlowChart.pdf>. 32 “State of California, Medicaid Demonstration Project For Family Planning, Access, Care, and Treatment Programs,” State of California Health and Human Services Agency, 2, April 23, 1999, accessed October 7, 2011, <http://www.dhcs.ca.gov/services/medi-cal/Documents/FPACTProposalI.pdf>. 33 Medi-Cal Formulary – Contraceptives. Provided by Marianne Bruno, UCLA Family Planning Clinic. 34 Heike Thiel, Personal interview, 7 March 2012.

ineligible for Full-Scope Medi-Cal.35 Specifically, the Presumptive Eligibility program exists “to grant immediate, temporary Medi-Cal coverage for ambulatory prenatal care and prescription drugs for conditions related to pregnancy to low-income, pregnant patients, pending their formal Medi-Cal application.”36 The Presumptive Eligibility program covers abortions, pregnancy tests, and prenatal care.37 Medi-Cal covers the cost of these services.38 While Presumptive Eligibility covers “most doctor, clinic and emergency room visits” it does “NOT cover hospital and delivery care or any other hospital in-patient care” nor does it cover contraception (emphasis in original document).39 In order to qualify for Presumptive Eligibility, women must meet the following criteria: they must be a resident of California, which is verified through a declaration of residency form (this does not require a social security number; to fulfill the state citizenship requirement, women must complete a Statement of California Residency

“Presumptive Eligibility: Presumptive Eligibility for Pregnant Women Provider Manual,” California Department of Health Care Services, September 1999, accessed December 18, 2012, <http://files.medical.ca.gov/pubsdoco/publications/masters-MTP/Part2/presum_m00o03p00.doc>. 36 “Presumptive Eligibility: Presumptive Eligibility for Pregnant Women Provider Manual,” California Department of Health Care Services, September 1999, accessed December 18, 2012 <http://files.medical.ca.gov/pubsdoco/publications/masters-MTP/Part2/presum_m00o03p00.doc>; “Information for Women Interested In Presumptive Eligibility (PE) For Pregnant Women,” California Department of Health Care Services, accessed March 7, 2012, <http://www.dhcs.ca.gov/services/medical/eligibility/Pages/PE_Info_women.aspx>. 37 “Pregnant Women’s Guide,” UCSF Center for the Health Professions, 1, accessed January 12, 2012, <cchealth.org/services/perinatal/pdf/pregnant_womans_guide.pdf>; “Presumptive Eligibility for Pregnant Women Program: Patient Fact Sheet,” State of California—Health and Human Services Agency, Department of Health Care Services, accessed December 26, 2011, <lacountyhelps.org/applications/English/EN_MC264PEFactSheet.pdf>; “Information for Qualified Providers for the PE Program: Provider Manual,” California Department of Health Care Services, 1, accessed January 7, 2012 <http://files.medical.ca.gov/pubsdoco/publications/masters-MTP/Part2/presum_m00o03p00.doc>. 38 “The Presumptive Eligibility for Pregnant Women Program, Provider Enrollment Information Package,” California Department of Health Care Services, 1, February 2012, accessed December 29, 2011, <www.dhcs.ca.gov/.../medi-cal/eligibility>. 39 “Presumptive Eligibility for Pregnant Women Program: Patient Fact Sheet,” State of California—Health and Human Services Agency, Department of Health Care Services, accessed March 7, 2012, <lacountyhelps.org/applications/English/EN_MC264PEFactSheet.pdf>.

form, which simply entails a woman documenting that she is in fact a state resident, and that she intends to remain in the state).40 In addition, women must not have any health insurance coverage, and must be pregnant. Finally, the woman’s family income, based on self-reporting by the woman, must not exceed 200% FPL. 41 Specifically, a woman could qualify if her monthly income does not exceed $2552 for a family of two (mother and unborn child).42 In some cases, it is also possible for a woman to obtain Presumptive Eligibility coverage for pregnancy if she has insurance, but has a high deductible and cannot afford prenatal care.43 If a woman does have private coverage, but has a very high deductible, the provider is allowed to process a “Presumptive Eligibility determination.”44 Women must submit their income (and the incomes of any other individuals in the household, such as parents if she resides with them), as well as a declaration of citizenship for the state of California.

“Information for Qualified Providers for the PE Program: Provider Manual,” California Department of Health Care Services, 3, accessed January 7, 2012, <http://files.medical.ca.gov/pubsdoco/publications/masters-MTP/Part2/presum_m00o03p00.doc>. 41 “Information for Qualified Providers for the PE Program: Provider Manual,” California Department of Health Care Services, 7, 13, accessed January 7, 2012, <http://files.medical.ca.gov/pubsdoco/publications/masters-MTP/Part2/presum_m00o03p00.doc>; “Presumptive Eligibility for Pregnant Women Program: Patient Fact Sheet,” State of California—Health and Human Services Agency, Department of Health Care Services, accessed December 26, 2011, <lacountyhelps.org/applications/English/EN_MC264PEFactSheet.pdf>; “Presumptive Eligibility Medi-Cal (PE) for Pregnancy,” Maternal and Child Health Access, March 2, 2011, accessed December 6, 2011, <www.mchaccess.org/.../Presumptive%20Eligibility%20Medi-Cal%20> and <www.mchaccess.org>. 42 “Presumptive Eligibility Medi-Cal (PE) for Pregnancy,” Maternal and Child Health Access, March 2011, accessed December 26, 2011, <www.mchaccess.org/.../Presumptive%20Eligibility%20Medi-Cal%20> and <www.mchaccess.org>. 43 “The Presumptive Eligibility for Pregnant Women Program, Provider Enrollment Information Package,” California Department of Health Care Services, 2, February 2012, accessed December 29, 2011, <www.dhcs.ca.gov/.../medi-cal/eligibility>. 44 “The Presumptive Eligibility for Pregnant Women Program, Provider Enrollment Information Package,” California Department of Health Care Services, 5, February 2012, December 29, 2011, <www.dhcs.ca.gov/.../medi-cal/eligibility>.

The Presumptive Eligibility application process does not require formal verification of income or U.S. citizenship.45 If, however, the woman desires to apply for Medi-Cal after receiving care under the Presumptive Eligibility program, she will be required to apply for state residency and show proof of U.S. citizenship at that time.46 The Presumptive Eligibility coverage is temporary, and lasts only until the end of the month following the initial enrollment date. Women, however, can apply for 60-day extensions by demonstrating that they have applied for Medi-Cal coverage.47 Costs incurred by undocumented immigrants through this program are funded entirely by the state .48 Women who begin pregnancy-related services under Presumptive Eligibility Medi-Cal, but who do not qualify for Full-Scope Medi-Cal, may receive the remainder of their care for that pregnancy (including remaining prenatal care, abortion, outpatient or inpatient care for delivery or other pregnancy outcomes) under the Limited-Scope MediCal program. This program, like Presumptive Eligibility (and unlike Full-Scope), does not cover contraception.49

“Presumptive Eligibility,” California Department of Health Care Services, 6, October 2011, accessed December 29, 2011, <files.medi-cal.ca.gov/pubsdoco/.../masters.../presum_m00o03p00.doc>; “Presumptive Eligibility Medi-Cal (PE) for Pregnancy,” Maternal and Child Health Access, March 2, 2011, accessed December 6, 2011 <www.mchaccess.org/.../Presumptive%20Eligibility%20Medi-Cal%20> and <www.mchaccess.org>. 46 “The Presumptive Eligibility for Pregnant Women Program, Provider Enrollment Information Package,” California Department of Health Care Services, 3, February 2012, accessed December 29, 2011, <www.dhcs.ca.gov/.../medi-cal/eligibility>. 47 “The Presumptive Eligibility for Pregnant Women Program, Provider Enrollment Information Package,” California Department of Health Care Services, 2-3, February 2012, accessed March 3, 2012, <www.dhcs.ca.gov/.../medi-cal/eligibility>. 48 E. Richard Brown, Personal interview, 2 March 2012. 49 Marianne Bruno, Personal interview, 16 March 2012.

COVERAGE OF CONTRACEPTION: FAMILY PACT PROGRAM Similar to the Presumptive Eligibility and Limited-Scope Medi-Cal programs, the Family Planning, Access, Care and Treatment (PACT) program, established by the state of California, serves men and women who do not meet the strict eligibility criteria required for Full-Scope Medi-Cal. Family PACT is administered by the California Department of Public Health, Office of Family Planning.50 When the Office of Family Planning was established through state legislation in 1996 by the California State Legislature (1996-97 Budget Trailer Bill, Assembly Bill 3483), the UCSF Bixby Center for Reproductive Health was designated to provide monitoring and evaluation, as well as cost-benefit assessments of Family PACT and its services throughout the state. 51 The principal goals of the Family PACT program include: 1) preventing unintended pregnancy, 2) providing greater access to family planning services at no cost for underserved populations, and 3) improving both reproductive health and patient use of effective family planning methods.52 In California, approximately one-third of women with incomes of less than or equal to 200% of the FPL are of reproductive age.53 The number of California residents who utilize the services provided by the program has increased each year since the program’s inception. In FY 2009-10, 2.72 million men and

“Family PACT Program Report Fiscal Year 2009-2010,” University of California San Francisco (UCSF) Bixby Center for Global Reproductive Health, 1, accessed December 22, 2011, <bixbycenter.ucsf.edu/.../files/FPACT%20Program%20Report_09-10>. 51 “State of California, Medicaid Demonstration Project For Family Planning, Access, Care, and Treatment Programs,” State of California Health and Human Services Agency, 1, 7, 23 April 1999, accessed October 7, 2011 <http://www.dhcs.ca.gov/services/medi-cal/Documents/FPACTProposalI.pdf>; “Family PACT Program Report Fiscal Year 2009-2010,” UCSF Bixby Center for Global Reproductive Health, 1, accessed December 22, 2011 <bixbycenter.ucsf.edu/.../files/FPACT%20Program%20Report_09-10>. 52 “Fact Sheet on Family PACT: An Overview,” California Department of Health Services-Office of Family Planning, UCSF Bixby Center for Reproductive Health Research & Policy, updated May 2006, accessed February 13, 2012, <http://www.familypact.org/en/providers/fact-sheets.aspx> and <www.familypact.org/.../Fact%20Sheets/FS_FamPACToverview11-08>. 53 Ibid. “Fact Sheet On Family PACT: An Overview,” updated May 2006.

women were enrolled, 1.82 million of whom utilized its services.54 It is estimated that in 2007, 296,200 unintended pregnancies were avoided by low-income women, yielding a cost savings of $1.88 billion to the public sector.55 When the program was initially enacted in 1996, it was funded entirely by the California State General Fund.56 In 1999, the state received a Medicaid Section 1115(b) Waiver granted by what was then the Health Care Financing Administration (HCFA), now the Centers for Medicare and Medicaid Services (CMS).57 For the majority of its existence, Family PACT operated under this 1115 Medicaid Waiver, the purpose of which was, in this case, to assist the state in extending family planning services to individuals who are ineligible for Medicaid.58 The Medi-Cal Policy Division, specifically its Rate Development Branch, was charged with overseeing the administration of the Section 1115 Demonstration Waiver.59 Such waivers allow states to

Ibid. “Family PACT Program Report Fiscal Year 2009-2010,” 2, 7. “Cost-Benefit Analysis of the California Family PACT Program for Calendar Year 2007,” UCSF Bixby Center for Global Reproductive Health, 6, April 2010, accessed December 29, 2011, <bixbycenter.ucsf.edu/.../files/FamilyPACT_Cost-Benefit_2007.pdf>. 56 “Family PACT Program Report Fiscal Year 2009-2010,” UCSF Bixby Center for Global Reproductive Health, 1, accessed December 22, 2011, <bixbycenter.ucsf.edu/.../files/FPACT%20Program%20Report_09-10>. 57 “State of California, Medicaid Demonstration Project For Family Planning, Access, Care, and Treatment Programs,” State of California Health and Human Services Agency, 9, April 23, 1999, accessed October 7, 2012, <http://www.dhcs.ca.gov/services/medi-cal/Documents/FPACTProposalI.pdf>. 58 Medicaid Family Planning Eligibility Expansions, Guttmacher Institute, December 1, 2011, accessed February 2, 2012, <www.guttmacher.org/statecenter/spibs/spib_SMFPE.pdf>; Rachel Benson Gold, “Stronger Together: Medicaid, Title X Bring Different Strengths to Family Planning Effort,” Guttmacher Policy Review, Spring 2007, Volume 10, Number 2, accessed March 3, 2012, <www.guttmacher.org/pubs/gpr/10/2/gpr100213.html>. 58 “Cost-Benefit Analysis of the California Family PACT Program for Calendar Year 2007,” UCSF Bixby Center for Global Reproductive Health, 8, April 2010, accessed December 29, 2011, <bixbycenter.ucsf.edu/.../files/FamilyPACT_Cost-Benefit_2007.pdf>. 59 “State of California, Medicaid Demonstration Project For Family Planning, Access, Care, and Treatment Programs,” State of California Health and Human Services Agency, 10, April 23, 1999, accessed October 7, 2011, <http://www.dhcs.ca.gov/services/medi-cal/Documents/FPACTProposalI.pdf>. 55

receive federal matching dollars to experiment with innovative approaches to improve healthcare through experimentation with either the payment or the delivery system.60 To maintain this waiver, states must undergo an extensive evaluation and renewal process. Qualifying for such a waiver requires documentation of how the program will maintain budget neutrality, as well as clear documentation of the cost avoidance associated with the waiver.61 For the waiver received by Family PACT, this evaluation was conducted by the Bixby Center, which ensured that the program goals were met.62 As of July 1, 2010, the Family PACT program changed, and now operates under a State Plan Amendment (SPA) within the Medi-Cal State Plan.63 The purpose of this transition was to both simplify what had long been a complex and time consuming process to maintain the waiver, and to expand coverage to more individuals.64 These State Plan Amendment provisions grant states the authority to make family planning services available to more individuals than does any waiver program currently in place.65 Currently 74% of Family PACT funding comes from the federal level and the remaining

“Section 1115 Demonstration Waivers, Keeping America Healthy,” Centers for Medicare and Medicaid Services, accessed January 18, 2012, <http://www.medicaid.gov/Medicaid-CHIP-Program-Information/ByTopics/Waivers/1115/Section-1115-Demonstrations.html>. 61 “State of California, Medicaid Demonstration Project For Family Planning, Access, Care, and Treatment Programs,” State of California Health and Human Services Agency, 27-32, April 23, 1999, accessed October 7, 2011, <http://www.dhcs.ca.gov/services/medi-cal/Documents/FPACTProposalI.pdf>. 62 “State of California, Medicaid Demonstration Project For Family Planning, Access, Care, and Treatment Programs,” State of California Health and Human Services Agency, 37, April 23, 1999, accessed October 7, 2011, <http://www.dhcs.ca.gov/services/medi-cal/Documents/FPACTProposalI.pdf>. 63 “Family PACT Client Eligibility, Enrollment and Retroactive Eligibility,” Family PACT, Office of Family Planning, California Department of Public Health, Fall 2011, February 13, 2012, <20120113_ClientEligibilityNewsletter_FY10-11_508c.pdf>. 64 Adam Sonfield, Jennifer J. Frost and Rachel Benson Gold, “Estimating the Impact of Expanding Medicaid Eligibility For Family Planning Services: 2011 Update.” Guttmacher Institute, 3, January 2011, accessed January 17, 2012 <www.guttmacher.org/pubs/2006/08/16/or28.pdf>. 65 Sonfield, Frost, and Benson, January 2011, 3.

26% from the state level.66 State funding covers services for undocumented immigrants, or about 13.95% of the program’s funding, which comes from the State General Fund.67 As of 2011, California was one of 29 states to provide family planning services to individuals with incomes that exceed Medicaid eligibility levels, with seven of these 29 states doing so through a State Plan Amendment.68 In addition to this transition to a State Plan Amendment, a pending change to the program is Governor Brown’s 2012-2013 budget plan proposal to transfer the Family PACT program to the Department of Health Care Services from its current location in the California Department of Public Health.69 The stated purpose of this transfer is to increase efficiency by “placing direct health care service programs together.”70 Family PACT administrators expect this transfer to occur, but do not anticipate any significant changes to result from this transfer.71 Family PACT Eligibility and Enrollment In order to qualify for Family PACT, individuals must have incomes less than 200% of the FPL (gross family income), must be uninsured, and must have no alternative source of insurance that provides coverage for family planning or contraception services.72 While age (15-44 years old) dictated a person’s eligibility when the program operated under a waiver, eligibility under the new State Plan Amendment is now based

Heike Thiel, Personal interview, 7 March 2012. Heike Thiel, Personal interview, 7 March 2012. 68 “State Policies in Brief: Medicaid Family Planning Eligibility Expansions,” Guttmacher Institute, February 1, 2012, accessed February 13, 2012 <www.guttmacher.org/statecenter/spibs/spib_SMFPE.pdf>. 69 Laurie Weaver, “Governor’s Budget Proposal for FY 2012-13,” Family PACT, accessed February 10, 2012, <http://www.familypact.org/>. 70 Ibid. Weaver, 2012. 71 Heike Thiel, Personal interview, 7 March 2012. 72 “Fact Sheet on Family PACT: An Overview, Office of Family Planning,” California Department of Health Services, UCSF Bixby Center for Reproductive Health Research & Policy, updated May 2006, February 13, 2012, <http://www.familypact.org/en/providers/fact-sheets.aspx> and <www.familypact.org/.../Fact%20Sheets/FS_FamPACToverview11-08>; “Family PACT Program Report Fiscal Year 2009-2010,” UCSF Bixby Center for Global Reproductive Health, 3, accessed December 22, 2011. <bixbycenter.ucsf.edu/.../files/FPACT%20Program%20Report_09-10>. 67

on medical necessity, where medical necessity implies the potential to reproduce (thus women who have not reached menopause and have not had a hysterectomy or sterilization, and men who are sexually active).73 Besides these requirements, there are rare circumstances in which eligibility for Family PACT expands. A client who needs to maintain confidentiality from a spouse, for example, could be eligible for services. Also if an individual has Full-Scope Medi-Cal, but has an “unmet share” of cost burden that the client cannot afford when he or she is in need of family planning services can also serve as grounds for qualification.74 California’s Family PACT program has never, and does not currently, require documentation of U.S. citizenship, and thus has a history of serving a large undocumented immigrant population. 75 In order to decrease barriers to care, enrolling in the Family PACT program takes place on-site at the office or clinic where the woman seeks contraceptive services.76 This enrollment is done through the Health Access Programs (HAP) system, which provides clients with an HAP card.77 This process has gone primarily unchanged, even with the program’s transition from operating under a waiver to its current operations in the MediCal State Plan.78

Rachel Benson Gold, “CMS Guidance on Family Planning State Plan Amendments,” Guttmacher Institute, October 25, 2010, February 13, 2012, <www.guttmacher.org/pubs/Family-planning-SPA.pdf>. 74 “Family PACT Client Eligibility, Enrollment and Retroactive Eligibility,” Family PACT, Office of Family Planning, California Department of Public Health, Fall 2011, accessed February 13, 2012 <20120113_ClientEligibilityNewsletter_FY10-11_508c.pdf>. 75 Ibid. Family PACT Client Eligibility, Enrollment and Retroactive Eligibility, Fall 2011. 76 “Fact Sheet on Family PACT: An Overview, Office of Family Planning,” California Department of Health Services, UCSF Bixby Center for Reproductive Health Research & Policy, updated May 2006, accessed February 13, 2012, <http://www.familypact.org/en/providers/fact-sheets.aspx> and <www.familypact.org/.../Fact%20Sheets/FS_FamPACToverview11-08>. 77 Ibid. Family PACT Client Eligibility, Enrollment and Retroactive Eligibility, Fall 2011. 78 Ibid. Family PACT Client Eligibility, Enrollment and Retroactive Eligibility, Fall 2011.

Recent changes associated with the Family PACT program’s transition from the 1115 Medicaid Waiver to the State Plan Amendment include an important change that involves the ability to obtain reimbursement for services rendered in the three months prior to enrollment.79 This is consistent with ability to obtain retrospective reimbusement for other Medi-Cal-eligible services, a policy instituted as a result of a history of long delays in the processing of applications.80 Aside from these changes, eligibility for the Family PACT program has largely remained the same as it was under the waiver program.81 Services Covered by the Family PACT Program Family PACT provides coverage for all FDA-approved contraception methods.82 Currently, such contraceptive methods include oral contraceptive pills, contraceptive patches, contraceptive vaginal rings, dedicated emergency contraceptive pill products (ECPs), contraceptive injections, contraceptive implants, intrauterine contraception, barrier methods, and sterilization.83 In addition to contraception, the Family PACT program provides coverage for pregnancy testing, breast and cervical cancer screening, treatment for pre-cancerous conditions of the cervix, and screening and treatment for sexually transmitted infections (STIs), including chlamydia, gonorrhea, syphilis, HIV, genital warts, and genital herpes.84

Ibid. Family PACT Client Eligibility, Enrollment and Retroactive Eligibility, Fall 2011. Heike Thiel, Personal interview, 7 March 2012. 81 Ibid. Family PACT Client Eligibility, Enrollment and Retroactive Eligibility, Fall 2011. 82 “Cost-Benefit Analysis of the California Family PACT Program for Calendar Year 2007,” UCSF Bixby Center for Global Reproductive Health, 8, April 2010, accessed December 29, 2011, <bixbycenter.ucsf.edu/.../files/FamilyPACT_Cost-Benefit_2007.pdf>. 83 “Family PACT Program Report Fiscal Year 2009-2010,” UCSF Bixby Center for Global Reproductive Health, 21, accessed December 22, 2011 <bixbycenter.ucsf.edu/.../files/FPACT%20Program%20Report_09-10 >. 84 Ibid. “Family PACT Program Report Fiscal Year 2009-2010,” 16-17, 26. 80

Family PACT Program Service Providers and Reimbursement Policies Providers of Family PACT services may be publicly or privately employed, and can either be enrolled in Family PACT, or can provide services on a referral basis (while not being enrolled in the program). 85 In order to bill Family PACT for reimbursement (fee-for-service), providers must be enrolled in Medi-Cal.86 Providers, specifically a clinic administrator, must attend a one-time, legislatively-mandated orientation session before enrolling in the program; optional further training and updates are also offered.87 The rates at which providers are reimbursed reflect those of the Medi-Cal program.88 Because any provider of Medi-Cal can also participate in the Family PACT program, access to care has increased, as recipients of Family PACT services are not limited to seeking care only in community-based and public clinics.89 In total, 7,923 clinicians, pharmacies, and laboratories throughout the state were enrolled in the program as of 2009-2010, with most concentrated in highly populated areas.90 In 2009-2010, the total expenditures (provider reimbursement) of the Family PACT program were $597

“Family PACT Program Report Fiscal Year 2009-2010,” UCSF Bixby Center for Global Reproductive Health, 4-5, accessed December 22, 2011, <bixbycenter.ucsf.edu/.../files/FPACT%20Program%20Report_09-10>. 86 Ibid. “Family PACT Program Report Fiscal Year 2009-2010,” 6, 16. 87 “State of California, Medicaid Demonstration Project For Family Planning, Access, Care, and Treatment Programs,” State of California Health and Human Services Agency, 6, April 23, 1999, accessed October 7, 2011 <http://www.dhcs.ca.gov/services/medi-cal/Documents/FPACTProposalI.pdf>; Heike Thiel, Personal interview, 7 March 2012. 88 “State of California, Medicaid Demonstration Project For Family Planning, Access, Care, and Treatment Programs,” State of California Health and Human Services Agency, 4, April 23, 1999, accessed October 7, 2011, <http://www.dhcs.ca.gov/services/medi-cal/Documents/FPACTProposalI.pdf>. 89 “State of California, Medicaid Demonstration Project For Family Planning, Access, Care, and Treatment Programs,” State of California Health and Human Services Agency, 4-5, April 23, 1999, accessed October 7, 2011, <http://www.dhcs.ca.gov/services/medi-cal/Documents/FPACTProposalI.pdf>. 90 “Family PACT Program Report Fiscal Year 2009-2010,” UCSF Bixby Center for Global Reproductive Health, 2, December 22, 2011, <bixbycenter.ucsf.edu/.../files/FPACT%20Program%20Report_09-10 >.

million, while the average reimbursement per client served was $328 [See Appendix, Exhibit B, for fiscal year reimbursement trends].91 Cost Savings Attributable to Family PACT Evidence from cost-benefit analyses of the Family PACT program conducted by the Bixby Center suggests the program has achieved its goal in reducing unintended pregnancy and the high costs associated with that. Comparing results from cost-benefit reports in 2002 to those in 2007 reveals that savings to the public sector in the later year were nearly twice the savings attained in 2002. This increase in savings is due in part to enhancements in the program itself, such as elimination of costly laboratory tests, decreased use of unnecessary pregnancy tests, changes in contraception dispensing practices (such as dispensing 13 monthly packs of oral contraceptives at once, instead of 1 monthly pack at a time), and the continued increase in costs for pregnancy and delivery-related care.92

“Preliminary Program Report FY 2010-11,” UCSF Bixby Center for Global Reproductive Health, 5, November 1, 2011, accessed March 14, 2012, <www.familypact.org/.../Reports.../20111108_FamPACTPreliminary.pdf>. 92 “Cost-Benefit Analysis of the California Family PACT Program for Calendar Year 2007,” UCSF Bixby Center for Global Reproductive Health, 6-7, 9, April 2010, accessed December 29, 2011, <bixbycenter.ucsf.edu/.../files/FamilyPACT_Cost-Benefit_2007.pdf>.

TITLE X: FEDERAL FUNDING FOR FAMILY PLANNING SERVICES The Title X Family Planning program is a federal grant program that was established in 1970 as part of the Public Health Service Act with the intention of assisting women in obtaining high quality family planning services.93 It is administered by the Office of Population Affairs within the Department of Health and Human Services.94 Section 1008 of the law prohibits Title X funds from being used by providers towards abortion procedures.95 It is currently possible, however, for a provider to receive Title X funding and still perform abortion procedures. In order to do so, a provider must be able to demonstrate a clear distinction between family planning services and abortion services.96 In practice, what these legislative restrictions mean for high-volume clinics that perform abortions and prescribe contraception is that the clinic must be scrupulous in keeping separate the billing for abortion and contraception services. Some clinics use “Effort Reports” in order to substantiate that no federal funds are being used to support any abortion-related services.97 Other examples of how a clinic might maintain the separation of services include: 1) conducting abortions only on specific days of the week that are different from the days in which contraception-related visits take place, and 2) 93

PL 91-572; Rachel Benson Gold, “Title X: Three Decades of Accomplishment,” The Guttmacher Report on Public Policy, Guttmacher Institute, 5, February 2001, accessed March 8, 2012, <www.guttmacher.org/pubs/tgr/04/1/gr040105.pdf>. 94 Rachel Benson Gold, “Stronger Together: Medicaid, Title X Bring Different Strengths to Family Planning Effort,” Guttmacher Institute, Vol. 10, No. 2., 3, Spring 2007, accessed March 8, 2012, <http://www.guttmacher.org/pubs/gpr/10/2/gpr100213.html>; “Title X Statutes and Regulations,” U.S. Department of Health and Human Services, accessed February 25, 2012, <http://www.hhs.gov/opa/title-xfamily-planning/title-x-policies/statutes-and-regulations/>. 95 Ibid. “Title X Statutes and Regulations”; “Title X Family Planning,” Office of Population Affairs, U.S. Department of Health and Human Services, February 7, 2012, <http://www.hhs.gov/opa/title-x-familyplanning/>. 96 Ibid. “Title X Family Planning,” 3. 97 Marianne Bruno, Personal interview, March 29, 2012.

billing for concurrently provided abortion and contraception services under different encounters, as in treating one patient as if she were presenting for two different appointments. Following this procedure, the clinic can obtain reimbursement for both the abortion (under Medi-Cal) and the contraception (under Family PACT).98 This practice described above for successfully billing for same-day abortion and contraception is not in place at all clinics in California, however, as many high-volume abortion providers in the state operate under the assumption that because of the separateness of these programs, women must return for a follow-up visit in order to obtain Family PACT reimbursement for contraception when no longer covered by a version of Medi-Cal and no longer pregnant at the initiation of the encounter.99 It is important to note that in California one must be a Family PACT provider in order to apply for Title X funds.100 In addition, when a provider bills for an abortion under Medi-Cal or contraception under Family PACT, the reimbursement request is handled by the same office: the State’s Fiscal Intermediary.101 The federal government distributes Title X funds to state governments. States then allocate these funds to a variety of health care provider facilities.102 The California Family Health Council (CFHC) is a private organization that serves as the state’s primary

Thompson KMJ, Speidel JJ, Saporta V, Waxman NJ, Harper CC. Contraceptive policies affect postabortion provision of long-acting reversible contraception. Contraception 2011; 83: 41-47. 99 Heike Thiel, Personal interview, 7 March 2012; Kisten Thompson, Personal interview, 28 February 2012; Marianne Bruno, Personal interview, 15 March 2012; Kavanaugh ML, Jones RK, Finer LB. How commonly do US abortion clinics offer contraceptive services? Contraception 2010; 82: 331-336. 100 Heike Theil, Personal interview, 7 March 2012. 101 Laurie Weaver, Personal interview, 15 March 2012. 102 “Contraceptive Needs and Services, 2006,” Guttmacher Institute, 2009, accessed March 3, 2012 <http://www.guttmacher.org/pubs/win/allstates2006.pdf>.

Title X grantee and allocates funds throughout the state.103 More than 4,000 of these sites operate nationwide, and provide family planning care for approximately four million women.104 Evidence indicates that Title X funds reduce unplanned pregnancies and abortions.105 Moreover, because these funds serve predominantly low-income women, savings in medical and social program costs are also attained.106 Specifically, one in four low-income women receive their family planning care at a clinic that receives Title X funds.107 In addition to this important role in providing family planning services, Title X funds and the clinics they support often serve as the initial point of entry into more general medical services for these women.108 Analyses of estimated cost savings to the federal government resulting from Title X funds and their prevention of pregnancy suggest savings of $3.4 billion, or $3.74 for every one dollar spent.109 Unlike Medicaid in which reimbursement funds grow according to the demand of those entitled to coverage under the law, Title X funds are subject to annual appropriations and are dependent on current politics and funding decisions by

103

“State of California, Medicaid Demonstration Project For Family Planning, Access, Care, and Treatment Programs,” State of California Health and Human Services Agency, 9, April 23, 1999, accessed October 7, 2011, <http://www.dhcs.ca.gov/services/medi-cal/Documents/FPACTProposalI.pdf>. 104 Frost JJ, Henshaw SK and Sonfield A, “Contraceptive Needs and Services, National and State Data, 2008 Update,” Guttmacher Institute, 2010, accessed March 3, 2012, <www.guttmacher.org/pubs/win/contraceptive-needs-2008.pdf >. 105 Susan Cohen, “The Numbers Tell the Story: The Reach and Impact of Title X,” Guttmacher Policy Review, Volume 14, Number 2, Spring 2011, accessed February 16, 2012, <www.guttmacher.org/pubs/gpr/14/2/gpr140220.html>. 106 Susan Cohen, “The Numbers Tell the Story: The Reach and Impact of Title X,” Guttmacher Policy Review, Volume 14, Number 2, Spring 2011, 16 February 2012, <www.guttmacher.org/pubs/gpr/14/2/gpr140220.html>. 107 Gold RB et al., “Next Steps for America’s Family Planning Program: Leveraging the Potential of Medicaid and Title X in an Evolving Health Care System,” Guttmacher Institute, 2009, accessed March 3, 2012 <www.guttmacher.org/pubs/NextSteps.pdf>. 108 Susan Cohen, “The Numbers Tell the Story: The Reach and Impact of Title X,” Guttmacher Policy Review, Volume 14, Number 2, Spring 2011, accessed February 16, 2012, <www.guttmacher.org/pubs/gpr/14/2/gpr140220.html>. 109 Frost JJ, Henshaw SK and Sonfield A, “Contraceptive Needs and Services, National and State Data, 2008 Update,” Guttmacher Institute, 2010, accesseed March 3, 2012, <www.guttmacher.org/pubs/win/contraceptive-needs-2008.pdf>.

Congress.110 The use of Title X funds differs from that of Medicaid in that Title X funds are primarily intended for purposes such as outreach efforts to assist underserved populations, acquisition of non-contraceptive medical supplies, support of the salaries of clinic staff, and payment of utility bills, for example, whereas Medicaid funds are reserved only for direct clinical and medical purposes.111 A wide range of providers including hospitals, university health clinics, non-profit organizations, clinics, and community health centers are eligible for Title X funding.112 All women, not just those with income below a specified percentage of the FPL, are eligible to seek medical care at any facility that receives Title X funding.113 However, the fee that the clinic charges a woman for her care is based on income. Women with incomes above 250% of the FPL, for example, pay for their care in its entirety, while women with incomes below this level (100% to 250% of the FPL) pay based on a sliding scale.114 While available to all women, the majority of women who utilize services provided by Title X-funded family planning clinics are low-income, but are not eligible for Medicaid.115 Thus, much like the Family PACT program, Title X funds, and the provider facilities that are supported by these funds, are especially critical for the uninsured population.116 For those women who have low incomes, yet cannot

110

Rachel Benson Gold, “Stronger Together: Medicaid, Title X Bring Different Strengths to Family Planning Effort,” Guttmacher Institute, Vol. 10, No. 2., 3, Spring 2007, accessed March 8 2012 <http://www.guttmacher.org/pubs/gpr/10/2/gpr100213.html>. 111 Ibid. Rachel Benson Gold, Spring 2007. 112 “Title X Family Planning,” Office of Population Affairs, U.S. Department of Health and Human Services, accessed February 7, 2012 <http://www.hhs.gov/opa/title-x-family-planning/>. 113 Rachel Benson Gold, “Title X: Three Decades of Accomplishment,” The Guttmacher Report on Public Policy, Guttmacher Institute, 6, February 2001, accessed March 3, 2012, <www.guttmacher.org/pubs/tgr/04/1/gr040105.pdf>. 114 Rachel Benson Gold, “Title X: Three Decades of Accomplishment,” The Guttmacher Report on Public Policy, Guttmacher Institute, 6, February 2001, accessed March 3, 2012, <www.guttmacher.org/pubs/tgr/04/1/gr040105.pdf>. 115 Ibid. Rachel Benson Gold, February 2001, 6. 116 Ibid. Rachel Benson Gold, February 2001, 6.

meet the strict eligibility criteria for state Medicaid programs, these funds may provide their sole access to family planning care.117 This care reaches far beyond contraception alone.118 In fact, 90% of women who utilize Title X-funded services for contraception report receiving additional services, such as testing for STIs, cancer screenings, or other gynecologic care.119

POLITICAL AND LEGAL ISSUES SURROUNDING ABORTION AND CONTRACEPTION Legal restrictions are important to consider in the context of policies related to abortion and contraception. The politics surrounding abortion in recent years have substantially increased barriers for women seeking such services. Examples of such restrictions include the following: •

In 2011, Republicans succeeded in passing a bill in the House of Representatives that would not only eliminate all funding for Title X, but would prohibit any Planned Parenthood facility from being eligible for any federal funds such as Medicaid dollars for reimbursement. This legislation did not become law, however, as the Senate did not pass this bill.120

117

Ibid. Rachel Benson Gold, February 2001, 6.; “Title X Family Planning,” Office of Population Affairs, U.S. Department of Health and Human Services, accessed February 7, 2012, <http://www.hhs.gov/opa/title-x-family-planning/>; “Abortion and Title X: What Health Care Providers Need to Know,” National Abortion Federation, August 2007, accessed February 7, 2012, <http://www.prochoice.org/about_abortion/facts/abortion_title_x.html>. 118 Ibid. Rachel Benson Gold, February 2001, 7. 119 Ibid. Rachel Benson Gold, February 2001, 7. 120 Susan Cohen, “The Numbers Tell the Story: The Reach and Impact of Title X,” Guttmacher Policy Review, Spring 2011, Volume 14, Number 2, accessed February 16, 2012, <www.guttmacher.org/pubs/gpr/14/2/gpr140220.html>; Aimee Miles, “A Guide To GOP Proposals On Family Planning Funds,” Kaiser Health News, March 9, 2011, accessed March 11, 2012, http://www.kaiserhealthnews.org/Stories/2011/February/18/planned-parenthood-title-10.aspx.

•

In Indiana and Wisconsin, state funding for family planning services has been prohibited for any organization that performs abortions.121

•

In 33 states and the District of Columbia, public funds are not allowed to be used for abortion services, whether deemed medically necessary or not.122

The Hyde Amendment Following the Roe v. Wade Supreme Court decision in 1973, the politics and laws surrounding a woman’s right to an abortion have undergone frequent change, and in more recent years, have become increasingly restrictive. The Hyde Amendment has prohibited the use of federal dollars for abortion procedures since it was enacted in 1976.123 In its current form, the Hyde Amendment—part of the Consolidated Appropriations Act (H.R.2762)—also stipulates that no federal funds directed to managed care plans (e.g., by Medicaid) can be used to cover abortion services.124 Renewed every year by Congress through the appropriations process since its enactment in 1976, the Hyde Amendment—named after its main sponsor Rep. Henry Hyde (R-IL)—prohibits federal dollars from being used for abortions except in cases or rape or incest, or when it is determined that the pregnancy endangers the life of the mother defined as “physical disorder, physical injury, or physical illness, including a lifeendangering physical condition caused by or arising from the pregnancy itself.”$%#

121

“State Facts About Abortion: Wisconsin,” Guttmacher Insitute, March 11, 2012, <http://www.guttmacher.org/pubs/sfaa/wisconsin.html>; “State Facts About Abortion: Indiana,” Guttmacher Institute, March 11, 2012, <http://www.guttmacher.org/pubs/sfaa/indiana.html>. 122 Rebecca Wind, “States enacted 52 laws restricting abortion in 2005,” Guttmacher Institute, January 20, 2006, accessed January 16, 2012, <www.guttmacher.org/media/nr/2006/01/20/index.html>. 123 “The Hyde Amendment,” National Committee for a Human Life Amendment, April 2008, accessed January 21, 2012, <www.nchla.org/datasource/ifactsheets/4FSHydeAm22a.08.pdf>. 124 Ibid. “The Hyde Amendment,” April 2008. 125 Stanley K. Henshaw et al., “Restrictions on Medicaid Funding for Abortions: A Literature Review,” Guttmacher Institute, 3, June 2009, accessed February 13, 2012, <www.guttmacher.org/pubs/MedicaidLitReview.pdf>; Julie Rovner, “Abortion Funding Ban Has Evolved

California is one of 17 states that relies on state funds to cover “all or most medically necessary” abortions for Medicaid-eligible women, as determined by the healthcare provider.$%& This compares to 32 states that cover only abortions that result from rape or incest or pose danger to the health of the mother.$%' Despite the legal and programmatic complexities associated with the provision of abortion and contraception services to low-income women in California, legal restrictions alone do not serve as the primary barrier to the provision of immediate postabortal contraception. Specifically, neither the authorizing legislation for Medi-Cal or Family PACT programs, nor the Family PACT Policies, Procedures and Billing Instructions (PPBI) manual specifically prohibit seeking reimbursement for the concurrent provision of publicly-funded abortion and contraceptive services, a fact supported by our review of program authorizing legislation, interviews with experts at the UCLA School of Law, the Guttmacher Institute, the Family PACT Program, Planned Parenthood, and the UCSF Bixby Center.128 Instead, different interpretations of the Family PACT PPBI, which does not specifically state a protocol for addressing the concurrent provision of abortion and contraceptive services, has created a “gray area” in which some clinics have successfully

Over The Years,” December 14, 2009, accessed March 11, 2012, <http://www.npr.org/templates/story/story.php?storyId=121402281>. 126 Stanley K. Henshaw et al., “Restrictions on Medicaid Funding for Abortions: A Literature Review,” Guttmacher Institute, 3, June 2009, accessed February 13, 2012, <www.guttmacher.org/pubs/MedicaidLitReview.pdf>. 127 Stanley K. Henshaw et al., “Restrictions on Medicaid Funding for Abortions: A Literature Review,” Guttmacher Institute, 3, June 2009, accessed February 13, 2012, <www.guttmacher.org/pubs/MedicaidLitReview.pdf>. 128 Keri Castendeda, Personal interview, 29 February 2012; Allison Hoffman, Personal interview, 7 December 2011; Kirsten Thompson, Personal interview, 26 February 2012; Heike Theil, Personal interview 7 March 2012.

found ways to close the gap while others have not. 129 For instance, Planned Parenthood facilities throughout Southern California have implemented a way in which to secure reimbursement for the concurrent provision of abortion and contraceptive services, while a large, University of California-affiliated family planning clinic has not.135

ANTICIPATING CHANGES IN THE HEALTHCARE SYSTEM—THE PATIENT PROTECTION AND AFFORDABLE CARE ACT Continued access to contraception for low-income women undergoing abortions is also important to consider in the context of the implementation of the provisions in the Patient Protection and Affordable Care Act of 2010 (generally referred to as the Affordable Care Act or ACA), most of which will begin full implementation in 2014. Among the many anticipated changes to the medical system is the expansion of coverage to millions of currently uninsured Americans by expanding and standardizing eligibility of Medicaid to 133% of the FPL, and provision of subsidies for private health insurance coverage to those with incomes between 133% and 400% of the FPL.130 In fiscal year (FY) 2008, there were 10,669,800 individuals (29% of the population in California) enrolled in Medi-Cal.131 Specifically with regard to the expansion of Medicaid, researchers from the Urban Institute in affiliation with the Kaiser Family Foundation provide one estimate suggesting the Medicaid expansion will result in a 41.5% to 67.6% reduction of the uninsured in California, or that between two and three million people 129

Heike Thiel, Personal interview, March 7, 2012; “Family PACT Policies, Procedures, and Billing Instructions Manual,” Family PACT, accessed March 7, 2012 <http://www.familypact.org/en/providers/policies-procedures-and-billing-instructions.aspx>. 130 “The Health Reform Law’s Medicaid Expansion: A Guide to the Supreme Court Arguments,” Kaiser Family Foundation, March 2010, accessed March 16, 2012, <http://www.kff.org/healthreform/8288.cfm>; E. Richard Brown, Personal interview, 2 March 2012. 131 “Total Medicaid Enrollment, FY 2008,” Kaiser Family Foundation, accessed December 26, 2011 http://www.statehealthfacts.org/comparemaptable.jsp?ind=198&cat=4.

will become eligible for the Medi-Cal program.132 These numbers will depend largely on factors such as how effective outreach efforts are on the state and federal levels in actually enrolling newly-eligible individuals.133 The Kaiser Commission on Medicaid and the Uninsured estimates that 3.1 million California residents will remain uninsured even after the ACA provisions are implemented, 1.2 million of whom are anticipated to be undocumented immigrants.134 These estimates are important to consider for our analysis with regard to anticipating how the Family PACT program might change in terms of client composition in the coming years, and whether, with so many more individuals qualifying for Full-Scope Medi-Cal, the issue of immediate postabortal contraception will be substantially resolved, at least for those with incomes under 133% of the FPL. Undocumented immigrants in the healthcare system, both in California and the U.S. at large, present a complexity to the system, especially with the forthcoming changes that the ACA will bring. Since the Personal Responsibility and Work Opportunity Reconciliation ACT (PRWORA) welfare reform that was passed during the Clinton Administration in 1996, immigrants—whether documented or undocumented— have not been eligible to receive standard Medicaid benefits during their first five years

132

John Holahan and Irene Headen, “Medicaid Coverage and Spending in Health Reform: National and State-by-State Results for Adults at or Below 133% FPL,” Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation, 12-13, May 2010, accessed March 11, 2012, <www.kff.org/.../medicaid-coverage-and-spending-in-health-reform-national -and-state-by-state-resultsfor-adults-at-or-below-133-fpl.pdf>. 133 Ibid. John Holahan and Irene Headen, May 2010, 7. 134 “California’s Bridge To Reform Medicaid Demonstration Waiver,” Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation, 3, October 2011, accessed March 13, 2012, <www.kff.org/medicaid/upload/8197-R.pdf>.

of residing in the U.S.135 It is plausible that current Family PACT service recipients who are U.S. citizens might become eligible for Medi-Cal with the expansionary provisions. If that happens, the Family PACT program could become a program that serves primarily undocumented immigrants, and could consequently lose its support in the State Legislature and from other important stakeholders. However, we do not anticipate that an increase in the proportion of undocumented immigrant clients will result in dissolution of the Family PACT program in the foreseeable future, given that under the State Plan Amendment, eliminating the Family PACT program would require action on the part of the California State Legislature, which has generally supported providing publicly-funded medical care to undocumented immigrants that has proven cost saving (for example, prenatal care).136 While it is possible that the Family PACT program may note a decrease in clients upon the ACA expansion of Medicaid and creation of health insurance exchanges, or may lose support if it begins to serve a primarily undocumented immigrant population, we anticipate that the Family PACT program and the issue of postabortal contraception will remain relevant for several reasons. To begin, California is still anticipated to have a

135

Leighton Ku and Sheetal Matani, “Left Out: Immigrants’ Access To Health Care And Insurance,” Health Affairs, 247, January/February 2001, accessed January 3, 2012, <http://content.healthaffairs.org/content/20/1/247.abstract>; Shawn Fremstad and Laura Cox, “Covering New Americans: A Review of Federal and State Policies Related to Immigrants’ Eligibility and Access to Publicly Funded Health Insurance,” Center on Budget and Policy Priorities, 2004, March 7, 2012, <www.kff.org/.../Covering-New- Americans-A-Review-ofFederal.pdf>. 136 Allison Fee, “Forbidding States from Providing Essential Social Services to Undocumented Immigrants: The Constitutionality of Recent Federal Action,” Boston University Public Interest Law Journal, Vol. 7, No. 93, 1998, accessed 18 March 2012, <http://heinonline.org/HOL/LandingPage?collection=journals&handle=hein.journals/bupi7&div=11&id=& page=>.

rather large uninsured population.137 Additinally, evidence indicates that among men and women with incomes less than 200% of the FPL, half will bounce above and below the Medicaid cut-off of 133% of the FPL in a given year, creating an unmet need for healthcare services that may be met by programs such as Family PACT.138 Thus, we anticipate that a strategy for improving the provision of postabortal contraception for California’s low-income women will remain relevant in the years ahead.

ANALYSIS: EVALUATION OF POTENTIAL PUBLIC-PAYER COST SAVINGS ASSOCIATED WITH THE IMMEDIATE PROVISION OF POSTABORTAL CONTRACEPTION Our findings highlight how restrictions imposed by legislation such as the Hyde Amendment, with its implications for Title X and Medicaid funds, complicates the billing process for abortion and contraception services provided to low-income women. The fact that clinic managers and billing staff in California are often confused about their ability to seek reimbursement for abortion and contraception services provided concurrently to low-income women highlights the complex nature of the current reimbursement system.139 Based on our findings that the challenge in providing immediate postabortal contraception to low-income women in California is not an issue of administrative law, the following section of our report addresses the potential public cost savings associated

137

“California’s Bridge To Reform Medicaid Demonstration Waiver,” Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation, 3, October 2011, accessed March 13, 2012, <www.kff.org/medicaid/upload/8197-R.pdf>. 138 Benjamin Sommers and Sara Rosenbaum 2011, “Issues In Health Reform: How Changes In Eligibility May Move Millions Back And Forth Between Medicaid And Insurance Exchanges,” Health Affairs, February 2011, March 13, 2012, <http://content.healthaffairs.org/content/30/2/228.abstract>. 139 We base these discoveries on information gathered during interviews with billing experts, clinic staffs, and researchers at the Bixby Center and Family, as well as literature reviews.

with the provision of immediate postabortal contraception, compared to the current default strategy of planned contraception provision at the time of abortion follow-up. Given that immediate provision of postabortal contraception is both in line with the medical standard of care and not specifically prohibited for low-income women receiving services under the Medi-Cal and Family PACT programs, we aimed to determine if immediate provision of postabortal contraception would be cost saving from a public-payer perspective, compared to planned provision of contraception at abortion follow-up. In order to evaluate the financial feasibility and potential cost savings associated with immediate postabortal contraception, we chose to perform a cost analysis by creating a decision-analytic model with TreeAge 2011 software (TreeAge Software, Williamstown, MA). We designed the model to consider theoretical cohorts of women who experience different contraceptive methods and fertility outcomes. The sequence of the model begins with a woman undergoing a surgical abortion funded by Medi-Cal who desires postabortal IUD placement [See Appendix, Exhibit C, for model diagram]. For several reasons IUDs serve as a particularly good contraceptive method for which to begin evaluating potential public sector cost savings of providing immediate postabortal contraception, compared to planned provision of contraception at the abortion follow-up visit. Intrauterine contraception has demonstrated the greatest cost savings among available methods, saving more than seven dollars for every dollar spent on method-related costs.140 The higher cost-savings of IUDs compared to other contraceptive methods stems primarily from the high efficacy of the method. Specifically, the IUD as a method fails, resulting in pregnancy, at an annual rate of 140

Foster DG, Rostovtseva DP, Brindis CD, Biggs MA, Hulett D, Darney PD. Cost savings from the provision of specific method of contraception in a publicly funded program. American Journal of Public Health 2009; 99: 446-451.

approximately 0.5% per year.141 Importantly, for IUDs the typical use failure rate (the rate of method failure resulting in pregnancy when the contraceptive method is used by women under real-world conditions with the potential for imperfect use) is essentially equivalent to the perfect use failure rate (the rate of method failure when used perfectly under research study conditions) because the woman does not need to take action to continue using the IUD device once it has been inserted [See Appendix, Exhibit D, for contraception method failure rates]. These results differ substantially from other methods, such as oral contraceptive pills, where the perfect use failure rate is similar to the IUD at 0.3%, while the typical use failure rate is approximately 8%.142 Immediate postabortal IUDs have also been demonstrated to decrease the number of subsequent abortions.143 Aside from these inherent features of IUDs, the additional factors outlined below provide further reasons to use IUDs as a method for which to begin evaluating potential policy changes. !

While the IUD device is generally inserted as an office procedure without the administration of medications for pain or sedation, its placement does involve a brief mild to moderate level of discomfort, which may be avoided when the IUD is administered at the conclusion of an abortion procedure when medications for sedation and pain have been administered for the purpose of the abortion.144 For

141

Trussell J. Contraceptive efficacy. In Hatcher RA, Trussell J, Nelson AL, Cates W, Stewart FH, Kowal D. Contraceptive technology. 19th revised ed. New York, NY: Ardent Media; 2007) 142 Ibid. Trussell, 2007. 143 Foster DG, Rostovtseva DP, Brindis CD, Biggs MA, Hulett D, Darney PD. Cost savings from the provision of specific method of contraception in a publicly funded program. American Journal of Public Health 2009; 99: 446-451. 144 Maguire K, Davis A, Rosario Tejeda L, Westhoff C. Contraception. 2012 Feb 9. [Epub ahead of print] Intracervical lidocaine gel for intrauterine device insertion: a randomized controlled trial.

this and other reasons, two-thirds of women offered IUD insertion at abortion follow-up express a preference for immediate postabortal insertion.145 !

Immediate postabortal IUD insertion has been found to have very low complication rates, such as pelvic infection and uterine perforation (displacement of the IUD through the wall of the uterus or cervix into the abdominal cavity) that are equivalent to those of IUD placement at the time of a follow-up appointment.146

IUDs have demonstrated higher uptake rates in U.S. women undergoing abortion when cost barriers are removed and the IUD is offered immediately at the time of abortion, compared to at a follow-up appointment.147 For instance, in the Contraceptive CHOICE study, women seeking abortion who were offered immediate access to the full spectrum of FDA-approved contraceptive methods selected IUD placement 75% of the time, compared to 59% of women offered the full range of contraceptive methods at the time of their abortion follow-up visit.148 Consequently, the cost-effectiveness of the IUD in preventing unintended

pregnancy, its low and user-independent failure rates, and effectiveness in decreasing the number of subsequent abortions, make this method an ideal contraceptive approach for

145

Stanek AM, Bednarek PH, Nichols MD, Jensen JT, Edelman AB. Barriers associated with the failure to return for intrauterine device insertion following first-trimester abortion. Contraception 2009; 79: 216-220. 146 Goodman S, Hendlish SK, Reeves MF, Foster-Rosales A. Impact of immediate postabortal insertion of intrauterine contraception on repeat abortion. Contraception 2008; 78: 143-148; Reeves MF, Smith KJ, Creinin MD. Contraceptive effectiveness of immediate compared with delayed insertion of intrauterine devices after abortion: a decision analysis. Obstet Gynecol 2007; 109: 1286-1294.; Drey E, Reeves MF, Ogawa DD, Sokoloff A, Darney PD, Steinauer JE. Insertion of intrauterine contraceptives immediately following first- and second-trimester abortions. Contraception 2009; 79: 397-402.; Bednarek PH, Creinin MD, Reeves MF, Cwiak C, Espey E, Jensen J (for the Post Aspiration IUD Randomization (PAIR) Study Trial Group). Immediate versus delayed IUD insertion after aspiration. NEJM 2011; 364: 2208-2217. 147 Thompson KMJ, Speidel JJ, Saporta V, Waxman NJ, Harper CC. Contraceptive policies affect postabortion provision of long-acting reversible contraception. Contraception 2011; 83: 41-47. 148 Madden T, Secura GM, Allsworth JE, Peipert JF. Comparison of contraceptive method chosen by women with and without a recent history of induced abortion. Contraception 2011; 84: 571-577.

which to evaluate a change in policy from planned provision of contraception at the time of follow-up to immediate provision of postabortal contraception. Our model compares the strategy of delaying the insertion of a desired postabortal IUD until a planned follow-up visit to the strategy of immediate postabortal IUD insertion for women desiring the method. We employed a Markov recursive model [See Appendix, Exhibit E, for additional information regarding model assumptions] to analyze the difference in public program costs between the two strategies at both one and fiveyear postabortal time points, considering three different sets of costs. First, we considered only direct medical costs associated with the provision of contraception services and pregnancy outcomes (delivery, abortion, miscarriage, or an ectopic pregnancy). Second, we considered the direct costs of contraception and pregnancyrelated care, as discussed above, as well as the public health insurance costs of Medi-Cal and similar programs that a woman and child would qualify for following a delivery [See Appendix, Exhibit E, for additional cost information]. Third, we considered direct medical costs of contraception and pregnancy care, additional public health insurance costs for the woman and child(ren) following a delivery, and additional social program costs for which a woman and child(ren) would be eligible for following a delivery. Such social programs include, for example, California Children’s Services, Cal-Works Cash Grants for mother and child, Food Stamps, and Head Start [See Appendix, Exhibit F, for full list of programs].149 In our model, we assumed that in each year a woman could become pregnant or avoid pregnancy. If pregnancy was avoided, we assumed that she could become pregnant 149

in the next cycle. If she became pregnant, she could experience a delivery, abortion, miscarriage, or an ectopic pregnancy. An ectopic pregnancy occurs when a fertilized egg, which typically attaches and develops in the uterus, instead attaches elsewhere in the body (such as in a uterine tube or ovary), resulting in a nonviable pregnancy that usually requires medical or surgical treatment.150 We assumed that delivered pregnancies took place at term and resulted in healthy newborns. We assumed that all women in the theoretical cohort remained eligible for the Family PACT program throughout the five years of the model, which is consistent with the fact that women remain enrolled in the Family PACT program for an average of four years.151 Sterilization was not considered in the model because it represents only 0.3% of annual claims paid by the Family PACT program and would subsequently exclude women in the model from program eligibility.152 Whenever possible, assumptions required for the model were chosen with the intention of arriving at the most conservative estimate of potential cost savings associated with the immediate provision of postabortal IUDs. We obtained probability inputs from a comprehensive search of the medical literature using PubMed for original research, review articles, and commentaries related to postabortal provision of IUDs and other contraception. Reference lists were searched to find additional relevant articles. We then contacted authors for clarification when necessary. In addition, we referenced published reports from the UCSF Bixby Center and Family PACT programs, and again contacted

150

“Ectopic Pregnancy,” The Mayo Clinic, 13 February 2012 <http://www.mayoclinic.com/health/ectopicpregnancy/DS00622>. 151 Heike Thiel, Personal interview, 7 March 2012. 152 “Cost-Benefit Analysis of the California Family PACT Program for Calendar Year 2007,” UCSF Bixby Center for Global Reproductive Health, 8, April 2010, accessed December 29, 2011, <bixbycenter.ucsf.edu/.../files/FamilyPACT_Cost-Benefit_2007.pdf>.

program staff for clarification when necessary [See Appendix, Exhibit G, for details about model input assumptions and data sources]. Following delivered pregnancies in the model, women and their resultant child(ren) were considered to be eligible for public health insurance at rates consistent with their anticipated income eligibility. All eligible women and children were assumed to participate in public health insurance programs for which they are eligible. This assumption is consistent with exceedingly high rates of documented participation by eligible parties and is consistent with the ACA's individual insurance mandate.153 Social program costs were calculated per year following delivery based on the proprotion of women and children anticipated to meet eligibility requirements and anticipated to participate in programs for which they are eligible.154 Finally, we converted all costs in our model to 2011 dollars and future costs were discounted at a rate of 3% per year. We performed one-way sensitivity analyses on all major probability and cost inputs for the one-year model duration [See Appendix, Exhibit H, for sensitivity analysis information]. We then calculated threshold values for all major model inputs in order to determine the value at which a change in the variable would alter which timing of immediate postabortal versus planned placement at abortion follow-up is cost saving from a public-payer perspective. We then performed bivariate (two-way) sensitivity analyses to determine whether simultaneous changes in two variables would significantly affect the results of our analysis. To test the overall robustness of our model to

153

“Cost-Benefit Analysis of the California Family PACT Program for Calendar Year 2007,” UCSF Bixby Center for Global Reproductive Health, 8, April 2010, accessed December 29, 2011, <bixbycenter.ucsf.edu/.../files/FamilyPACT_Cost-Benefit_2007.pdf>. 154 “Cost-Benefit Analysis of the California Family PACT Program for Calendar Year 2007,” UCSF Bixby Center for Global Reproductive Health, 8, April 2010, accessed December 29, 2011, <bixbycenter.ucsf.edu/.../files/FamilyPACT_Cost-Benefit_2007.pdf>.

simultaneous variation of all model inputs, we performed probabilistic sensitivity analysis using Monte Carlo simulation.

RESULTS FROM DECISION TREE ANALYSIS Immediate postabortal IUD insertion, compared to planned IUD insertion at the time of abortion follow-up, is cost saving from the perspective of public program expenditures when only direct medical costs of contraception and pregnancy-related care are considered for one year following the initial abortion. Specifically, immediate postabortal IUD insertion, compared to planned IUD insertion at the time of abortion follow-up, is anticipated to save $111 per woman in public program expenditures when only direct medical costs of contraception and pregnancy-related care are considered for one year following an initial abortion. This is anticipated to reduce public expenditures in California by $2.00 million to $2.54 million per year, when only women undergoing abortions funded by the Presumptive Eligibility and Limited-Scope Medi-Cal programs are considered.155 One-way sensitivity analysis demonstrates that these results are robust over a wide range of model inputs. For instance, the strategy of immediate IUD insertion is cost saving compared to the strategy of planned IUD placement at follow-up until the cost of an IUD exceeds $808, the probability of immediately placed IUD expulsion exceeds 30.9%, the annual probability of IUD failure surpasses 8.1%, or the cost of prenatal, delivery, and postpartum care for a term delivery is less than $4170 [See Appendix, Exhibit H, for one-year sensitivity analyses]. Probabilistic sensitivity analysis

155

Madden T, Secura GM, Allsworth JE, Peipert JF. Comparison of contraceptive method chosen by women with and without a recent history of induced abortion. Contraception 2011; 84: 571-577; Thompson KMJ, Speidel JJ, Saporta V, Waxman NJ, Harper CC. Contraceptive policies affect post-abortion provision of long-acting reversible contraception. Contraception 2011; 83: 41-47.

using Monte Carlo simulation demonstrates that the strategy of immediate postabortal IUD placement is cost saving over planned IUD placement at the abortion follow-up visit in 60.5% of trials [See Appendix, Exhibit H]. Further, the immediate provision of postabortal IUDs is anticipated to prevent 1,834 pregnancies per 10,000 women over one year, compared to planned placement at abortion follow-up, as well as 817 deliveries per 10,000 women over one year. Additionally, immediate provision of postabortal IUDs, compared to planned provision at the time of abortion follow-up, would avert approximately 752 abortions per 10,000 women over one year. This would result in approximately 2,294 fewer abortions per year among low-income women in California. When direct costs of contraception and pregnancy-related medical care are considered at five years following an initial abortion, the strategy of immediate postabortal IUD provision, compared to planned IUD placement at abortion follow-up, results in a cost savings of $810 per woman. This would result in a public program cost savings in California of approximately $14.58 million to $18.53 million over five years. In this case, probabilistic sensitivity analysis using Monte Carlo simulation demonstrates that the strategy of immediate postabortal IUD placement is cost saving over planned IUD placement at the abortion follow-up visit in 83.8% of trials [See Appendix, Exhibit H]. When the costs of public insurance coverage for eligible women and their delivered children are additionally considered, the anticipated cost savings of immediate postabortal IUD placement increases to approximately $1956 per woman, or approximately $35.2 million to $44.74 million in Californiaâ&#x20AC;&#x2122;s public program expenditures over 5 years. Further, when the costs of public programs such as income support, public day care, and nutrition support programs for which a proportion of

women anticipated to be eligible for (and seek services from) following a delivery are additionally considered, immediate postabortal IUD insertion is expected to save $4296 per woman, or approximately $77.31 million to $98.27 million over five years in California. When costs of public health insurance and social programs are considered, immediate postabortal IUD placement is cost saving in 88.4% and 90.2% of trials, respectively. Additionally, over 5 years, the strategy of immediate postabortal IUD placement is anticipated to result in more than 4,000 averted pregnancies and 1,600 averted abortions per 10,000 low-income women undergoing abortion and receiving an immediate postabortal IUD, compared to planned IUD placement at abortion follow-up [See Appendix, Exhibit H]. The model indicates that when direct medical costs of contraception and pregnancy-related care, public health insurance costs, and social program costs are considered for five years following an abortion, immediate postabortal IUD placement is cost saving over planned IUD placement at follow-up until the rate of abortion reaches 85.9%, the probability of expulsion of an IUD placed immediately postabortal exceeds 89.1%, or the annual continuation rate of an IUD placed immediately postabortal is less than 9.3%. In addition, sensitivity analysis results indicate cost savings until the cost of the IUD exceeds $1807 when considering costs of only contraception and pregnancy; $3444 when considering costs of contraception, pregnancy, and public insurance; and $6787 when considering costs of contraception, pregnancy, public insurance, and social programs [See Appendix, Exhibit I, for five-year sensitivity analyses].

Public cost savings per woman undergoing abortion & desiring an IUD if immediate postabortal IUDs are provided, compared to planned IUD insertion at abortion follow-up

Total anticipated public cost savings in California**

$111

$2.00 million - $2.54 million

$810

$14.58 million - $18.53 million

5 years, considering direct medical costs of contraception and pregnancyrelated care, and public health insurance costs for the woman and child(ren) following delivered pregnancies

$1,956

$35.2 million - $44.74 million

5 years, considering direct medical costs of contraception and pregnancyrelated care, public health insurance costs for the woman and child(ren) following delivered pregnancies, and social program costs related to delivered pregnancies

$4,296

$77.31 million - $98.27 million

Model 1 year, considering direct medical costs of contraception and pregnancy-related care 5 years, considering direct medical costs of contraception and pregnancyrelated care

* All figures in $2011 ** Based on the number of abortions funded through Presumptive Eligibility & Limited-Scope MediCal programs in 2007 (excludes abortions funded through Full-Scope MediCal ). The ranges reflect the different uptake rates for IUDs at the time of abortion, depending on whether the IUD is offered immediate postabortal or at the time of abortion follow-up. Madden T, Secura GM, Allsworth JE, Peipert JF. Comparison of contraceptive method chosen by women with and without a recent history of induced abortion. Contraception 2011; 84: 571-577; Thompson KMJ, Speidel JJ, Saporta V, Waxman NJ, Harper CC. Contraceptive policies affect post-abortion provision of long-acting reversible contraception. Contraception 2011; 83: 41-47.

Our model is likely to underestimate the public cost savings of the strategy of immediate postabortal contraception provision relative to planned contraception provision at abortion follow-up for several reasons. First, our model considers only postabortal IUD provision. The anticipated cost savings if the other methods of contraception were also included would clearly be expected to increase, particularly given the low follow-up rates of abortion patients documented in the medical literature.156 Additionally, in our model we assumed that annual rates of contraceptive failure for women with a history of abortion were equal to those reported in the literature for the population as a whole, a fact that is inconsistent with higher rates of contraception failure for women with a history of abortion, as documented in the literature. Further, our calculated cost savings for California included only women whose abortions were funded by Presumptive Eligibility and Limited-Scope Medi-Cal programs. Greater cost savings would be anticipated if Full-Scope Medi-Cal enrollees were additionally considered. Lastly, deliveries that took place within the model were assumed to be term (of at least 37 weeks gestation) and uncomplicated, an assumption that is conservative given the higher rates of pregnancy complications reported in the medical literature for unplanned pregnancies.157 A potential limitation of our cost estimates relates to the distinction of pregnancies that are entirely avoided versus pregnancies that are simply delayed as a result of public funding for contraception. Three potential outcomes are possible for low-

156

Stanek AM, Bednarek PH, Nichols MD, Jensen JT, Edelman AB. Barriers associated with the failure to return for intrauterine device insertion following first-trimester abortion. Contraception 2009; 79: 216-220. 157 Shah PS, Balkhair T, Ohlsson A, Beyene J, Scott F, Frick C, Intention to become pregnant and low birth weight and preterm birth: a systematic review, Matern Child Health Journal, 2011 205-216.

income women seeking publicly-funded contraception: 1) a women could avoid an unplanned and unwanted pregnancy, thereby saving both medical and social services costs to the public-payer system; 2) a woman could avoid becoming pregnant in the current time period, and might improve her socioeconomic situation such that if she becomes pregnant in the future, she would not be reliant on the public system; and 3) a woman could avoid pregnancy in the current period, but sill become pregnant in the future. If the womanâ&#x20AC;&#x2122;s economic situation has not improved, public funding would simply be delayed, and not altogether avoided, reducing the public cost savings for these pregnancies to the funds saved by delaying the expense. A conservative estimate is that half of all adult pregnancies considered in the model are truly averted, with the remainder only delayed. Consequently, considering this limitation in our model would not be expected to reduce our estimated public cost savings by more than 50%. 158 CRITERIA FOR CHOOSING AMONG POLICY OPTIONS Recommendations for how California can best fund postabortal contraception for its low-income women should be based on goals of: decreasing barriers to immediate postabortal provision of contraception in a manner consistent with medical standards of care, decreasing the number of annual unintended pregnancies and abortions in the state, and minimizing public program expenditures. Recommendations for programmatic changes should also aim to minimize administrative burdens for women, medical office staff, and public program staff by using preexisting structures and systems whenever possible. Additionally, we strive for policy recommendations with the potential for

158

Amaral G, Foster DG, Biggs A, Jasik CB, Judd S, Brindis CD. Public savings from the prevention of unintended pregnancy: a cost analysis of family planning services in California. Health Services Research 2007; 42: 1960-1980.

implementation at an administrative level in order to minimize political conflicts, which could potentially compromise California’s current public funding for abortion and contraception for low-income women. Because women in California between 100% and 200% of the FPL are at particularly high risk for gaps in postabortal contraception coverage due to their need to pursue abortion and contraception services under two distinct programs (Presumptive Eligibility or Limited-Scope Medi-Cal and the Family PACT program), we focus our recommendations towards programmatic changes that would decrease barriers to the provision of immediate postabortal contraception for this population specifically. The following recommendations—revising the Family PACT Policies, Procedures and Billing Instructions Manual to specifically address women receiving abortion services under the Presumptive Eligibility and Limited-Scope Medi-Cal programs, coupled with an education campaign to make clinicians and office staff aware of how to concurrently bill for abortion and contraceptive services; expanding use of the new Family PACT retroactive reimbursement feature to secure reimbursement for contraception provided at the time of abortion; and reforming Medi-Cal to include contraception under all versions of the program—offer potential means by which to close this coverage gap While we believe that all three of these recommendations should be pursued, as they are not mutually exclusive, we acknowledge that our third recommendation— altering the state Medi-Cal system—represents a longer-term goal because it requires action on the part of the State Legislature and would bring attention to the currently politically-charged issues of publicly-funded abortion and contraception. As the UCSF Bixby Center for Global Reproductive Health is not directly involved in the

administration of the Family PACT or Medi-Cal programs, but instead serves in a general advisory capacity to these and related programs, we recommend that the Bixby Center bring the information and recommendations contained in this report to the attention of stakeholders such as: Family PACT administrators; the California Department of Health Care Services, which oversees Medi-Cal; and advocacy groups concerned with lowincome womenâ&#x20AC;&#x2122;s access to reproductive health services.

RECOMMENDATIONS AND CONLUSIONS 1) Amend the Family PACT Policies, Procedures and Billing Instructions (PPBI) Manual to explicitly address the issue of immediate postabortal contraception and address inconsistencies surrounding the issue of eligibility for women who are pregnant. Update required training to reflect these changes. We recommend that the Family PACT program amend its Policies, Procedures and Billing Instructions (PPBI) Manual, and update its established training programs, to specifically address the coverage of immediate postabortal contraception, including IUDs and implants, in order to eliminate confusion and inconsistent practices among clinicians, office managers, and billing staff in seeking reimbursement from Family PACT for contraception services provided at the time of a Medi-Cal-funded abortion procedure. Currently, a woman who intends to receive services covered by Family PACT must have her eligibility status verified by medical office personnel at each appointment. If office personnel determine the woman to be ineligible for Family PACT, the womanâ&#x20AC;&#x2122;s Health Access Program (HAP) card, which grants her coverage for Family PACT services, must

be deactivated.159 At this time, however, the Family PACT PPBI is inconsistent in outlining the criteria for HAP card deactivation. Specifically, the Client Eligibility Certification and HAP Card Activation section of the PPBI provides for the following deactivation codes: (1) Not resident of California (2) Over 200 percent of the federal poverty level (3) Sterilized, no longer contracepting (4) Health insurance coverage for family planning services (5) Full-Scope Medi-Cal (does not have an unmet Share of Cost) (6) Permanent deactivation of HAP card (lost/stolen) 160 Under the above criteria for deactivation, a woman obtaining abortion services funded through the Presumptive Eligibility or Limited-Scope Medi-Cal programs, by nature of having neither Full-scope Medi-Cal nor health coverage for family planning services, would meet criteria for maintaining HAP card activation, and would thereby be eligible to receive contraception at the time of her abortion through the Family PACT program. In the same section of the PPBI, however, the HAP Card Deactivation sub-section includes a segment titled “Deactivation for Pregnancy.” This section states that if a client becomes pregnant, she is no longer eligible for Family PACT services and that “The HAP card must be deactivated using deactivation code ‘05’ on the day following the visit

159

Client Eligibility Determination, Family PACT Policies, Procedures and Billing Instructions Manual, Department of Health Care Services, accessed April 21, 2012. < http://files.medical.ca.gov/pubsdoco/manual/man_query.asp?wSearch=%28%23filename+*f00*.doc+OR+%23filename+*f 00*.zip%29&wFLogo=Family+PACT+Policies%2C+Procedures+and+Billing+Instructions%3C%2Fi%3E +Manual&wFLogoH=54&wFLogoW=281&wAlt=%3Ci%3EFamily+PACT+Policies%2C+Procedures+an d+Billing+Instructions+Manual&wPath=N>. 160 Client Eligibility Certification and HAP Card Activation, Family PACT Policies, Procedures and Billing Instructions Manual, Department of Health Care Services, 4, accessed April 21, 2012.

the diagnosis of pregnancy was determined. The HAP card may be retained in the client’s file for possible future use by the client. Clients who become ineligible due to pregnancy may be recertified when they are no longer pregnant.” The “Deactivation for Pregnancy” section thus provides criteria for HAP card deactivation that are inconsistent with information contained in earlier sections of the same document and fails to consider that use of deactivation code ‘05’ fails to account for women who receive pregnancyrelated care through the Presumptive Eligibility and Limited-Scope Medi-Cal programs. Additionally, the requirement to deactivate the HAP cards of pregnant women seeking abortion “the day following the visit diagnosis of pregnancy was determined” is nonsensical, as these women would be expected to have regained their non-pregnant status by that time. Current inconsistencies in criteria for HAP card deactivation have led many providers, such as the UCLA-affiliated family planning clinic, to deactivate the HAP cards of all women undergoing abortions under Presumptive Eligibility and LimitedScope Medi-Cal programs, and to reactivate them only when abortion follow-up is completed, thereby prohibiting the clinic from offering contraception through the Family PACT program at the time of abortion. At UCLA, this decision has been made primarily due to concerns over the potential for clinic audits brought on by billing Medi-Cal programs and Family PACT for concurrently provided services.161 We recommend amending the PPBI manual to address the population of women who receive pregnancy-related services through the Presumptive Eligibility and LimitedScope Medi-Cal programs, and who thereby maintain a need for contraception services provided through the Family PACT program. Specifically, we recommend that the PPBI 161

Marianne Bruno, Personal interview, 19 March 2012.

manual state that these women should maintain activation of their HAP cards in order to ensure eligibility for contraception provided at the time of an abortion (or during the postpartum period). The PPBI manual’s section entitled Claim Completion: CMS-1500 provides detailed examples of how billing managers should complete reimbursement forms depending on the services rendered to the patient. Some of these examples involve situations where a patient might present for two distinct services, such as a surgical procedure from a referred provider combined with provision of contraception.162 An example that provides clinic personnel with guidance as to how to bill for an abortion funded by Medi-Cal and contraception funded by Family PACT would presumably aid in reducing confusion over this issue. The PPBI manual should also clarify that since Family PACT is not a health insurance program, women may be concurrently enrolled in a health insurance programs (such as Presumptive Eligibility or Limited-Scope Medi-Cal) and the Family PACT program when other criteria for eligibility are met. Such amendments to the PPBI manual would be consistent with clearly stated Family PACT program goals of 1) preventing unintended pregnancy, 2) providing greater access to family planning services at no cost for underserved populations, and 3) improving both reproductive health and patient use of effective family planning methods.163 Additionally, as we have discussed earlier in our report, such a change would allow publicly-funded contraception to be provided at the time of a publicly-funded abortions 162

Claim Completion: CMS-1500, Family PACT Policies, Procedures and Billing Instructions Manual, Department of Health Care Services, accessed April 21, 2012. <cal.ca.gov/pubsdoco/manual/man_query.asp?wSearch=%28%23filename+*f00*.doc+OR+%23filename+ *f00*.zip%29&wFLogo=Family+PACT+Policies%2C+Procedures+and+Billing+Instructions%3C%2Fi%3 E+Manual&wFLogoH=54&wFLogoW=281&wAlt=%3Ci%3EFamily+PACT+Policies%2C+Procedures+a nd+Billing+Instructions+Manual&wPath=N>. 163 “Fact Sheet on Family PACT: An Overview,” California Department of Health Services-Office of Family Planning, UCSF Bixby Center for Reproductive Health Research & Policy, updated May 2006, accessed February 13, 2012, <http://www.familypact.org/en/providers/fact-sheets.aspx> and <www.familypact.org/.../Fact%20Sheets/FS_FamPACToverview11-08>.

for women who fall between 100% and 200% of the FPL, as it currently is for women who receive services under the Full-scope Medi-Cal program. Further, as demonstrated through our decision analysis, such a change would be anticipated to result in substantial decreases in public program expenditures. Under current regulations providers must attend a legislatively-mandated orientation session before enrolling in the Family PACT program.164 These mandated orientations could provide an efficient means by which to educate providers about the ability of eligible, low-income women to obtain contraception through the Family PACT program at the time of a Presumptive Eligibility or Limited-Scope Medi-Cal-funded abortion. The orientations could also provide information regarding the advantages of long-acting reversible contraception (LARC) methods (IUDs and implants) and recommendations surrounding the provision of immediate postabortal contraception, such as the CDC MEC. Currently, clinical providers are not required to attend this mandated orientation, and is most frequently attended by office medical directors. Also, while clinical practice alerts and information on additional voluntary training opportunities are sent to the person who attends the original training, no subsequent training or reorientation sessions are required.165 We recommend that the impact of required Family PACT training be optimized by requiring the participation of all clinical providers (physicians, nurse practitioners, etc.), in addition to at least one office manger per site, and by requiring periodic training updates.

164

â&#x20AC;&#x153;State of California, Medicaid Demonstration Project For Family Planning, Access, Care, and Treatment Programs,â&#x20AC;? State of California Health and Human Services Agency, 6, 23 April 1999, 7 October 2011 <http://www.dhcs.ca.gov/services/medi-cal/Documents/FPACTProposalI.pdf>. 165 Heike Thiel, Personal interview, 7 March 2012.

2) Amend the Family PACT Policies, Procedures and Billing Instructions (PPBI) Manual to specify the ability of providers to seek retroactive reimbursement for contraceptive services provided to a woman prior to Family PACT enrollment, in order to facilitate immediate postabortal contraception provision. Under the State Plan Amendment, as of April 1, 2011, individuals who enroll in Family PACT are able to seek reimbursement for eligible expenses related to family planning services that he or she incurred in the three months before enrollment in the program.166 However, as currently described in the PPBI manual, the ability to seek retroactive reimbursement may be limited to payments the client has already made (or payments that have been made on the client’s behalf by another individual). The ability of clinical providers to seek retroactive reimbursement for contraceptive services that have been billed, but have not yet been paid, is not discussed in the PPBI manual and is consequently less clear. We recommend that the Family PACT program, through amendments to its PPBI manual, clarify how women or providers can pursue retroactive reimbursement for eligible contraceptive services rendered prior to Family PACT enrollment that have been billed, but have not yet been paid. In this way, a woman may receive contraception, such as an IUD, at the time of a Presumptive Eligibility or Limited-Scope Medi-Cal funded abortion, and then subsequently enroll in the Family PACT program and seek retroactive reimbursement for her immediate postabortal contraception. Introducing this practice into clinics would also require educational outreach to increase awareness among 166

“Family PACT Client Eligibility, Enrollment and Retroactive Eligibility,” Family PACT, Office of Family Planning, California Department of Public Health, Fall 2011, 13 February 2012 <20120113_ClientEligibilityNewsletter_FY10-11_508c.pdf>.

providers of their ability to obtain retroactive reimbursement for immediate postabortal provision of contraception. While we acknowledge that this recommendation is not an ideal long-term solution, it would be useful as an additional route through which barriers to the provision of immediate postabortal contraception can be reduced until all versions of Medi-Cal can be changed to cover all FDA-approved contraceptive methods (our next recommendation outlined below). 3) Include the full range of FDA-approved contraceptive methods in all versions of Medi-Cal. As a long-term solution, we recommend that the coverage schemes for all forms of Medi-Cal, specifically Medi-Calâ&#x20AC;&#x2122;s Presumptive Eligibility and Limited-Scope MediCal programs, be amended to include the full range of FDA-approved contraceptive methods. As discussed earlier in this report, only the Full-Scope version of Medi-Cal currently does so. If contraceptive services could be covered under all Medi-Cal versionsâ&#x20AC;&#x201D;not strictly the Full-Scopeâ&#x20AC;&#x201D;programmatic barriers to the provision of immediate postabortal contraception would be avoided. This recommendation is complicated, however, because achieving this solution would not fall within the authority of the current Medi-Cal Department Secretary, but would instead require securing enough votes from the California State Legislature.167 Although California has a history of supporting publicly-funded family planning services, including services for its undocumented immigrants, the current political environment and recent tension surrounding abortion and even contraception highlights the delicate nature of this subject. We therefore recommend that these legislative changes be pursued

167

E. Richard Brown, Personal interview, 2 March 2012; Dylan Roby, Personal interview, 14 March 2012; Michael Dukakis, Personal interview, 12 March 2012.

only after full evaluation of the support of various stakeholders, and in the context of broader healthcare reform efforts. Conclusion Our findings suggest that California has a rare opportunity to both increase the quality of reproductive healthcare and significantly decrease public program expenditures by taking steps to eliminate barriers to the provision of immediate postabortal contraception to its low-income women. While providing all family planning services through a single funding stream would create the greatest efficiency, the state—despite the fragmented funding of abortions and contraception—is currently in a position to achieve a solution that meets the standard of medical care, achieves public-payer cost savings, and reduces the number of abortions. Our recommendations to improve contraception access for low-income women receiving abortion care in California by amending the Family PACT PPBI, increasing the intensity of required Family PACT provider training, and extending retroactive reimbursement to providers for eligible family planning services provided to women in prior to Family PACT enrollment (while awaiting an appropriate policy window to address expanding all versions of Medi-Cal to include contraception), present a rare opportunity for a universal ‘win’ in the health care policy arena. First, such changes would be expected to decrease the number of abortions in California by more than 2,000 annually, and to save public programs more than $4,000 over five years for each woman undergoing abortion and desiring an IUD, when just considering women between 100% and 200% of the FPL. Second, these changes would bring California closer to the medical standard of care for postabortal contraception, as

set forth by the World Health Organization and the Centers for Disease Control and Prevention. Third, the changes are anticipated to increase the satisfaction of both lowincome women and reproductive health care providers in the state. Fourth, our recommendations can be addressed within existing systems and are clearly in line with the goals of the Family PACT program. Further, the recommendations we put forth would have benefits that extend beyond low-income women undergoing abortion in California. These recommendations would help address gaps in contraception coverage for low-income women who obtain their pregnancy-related care though Presumptive Eligibility and Limited-Scope Medi-Cal programs, but who have other pregnancy outcomes, such as delivery, miscarriage, and ectopic pregnancy. 168 Finally, our analysis of potential policy changes to decrease barriers to the immediate provision of postabortal contraception would be expected to apply not only in California, but throughout the U.S. as well.

168

Rodriguez MI, Caughey AB, Edelman A, Darney PD, Foster DG. Cost-benefit analysis of state- and hospital-funded postpartum intrauterine contraception at a university hospital for recent immigrants to the United States. Contraception 2010; 81: 304-308.; Rodriguez MI, Jensen JT, Darney PD, Little SE, Caughey AB. The financial effects of expanding postpartum contraception for new immigrants. Obstet Gynceol 2010; 115: 552-558.

Funding Postabortal Contraception for Low-Income Women in California APPENDIX

Jennifer Salcedo, MD, MPH and Andrea Sorensen, BA

EXHIBIT A: Full-Scope Medi-Cal Formulary for Contraception Desogestrel and Ethinyl Estradiol

Monophasic: Desogen, Ortho-Cept, Apri Biphasic: Mircette, Kariva Triphasic: Cyclessa, Velivet Emergency Contraception Levonorgestrel (Plan B, Next Choice) Levonorgestrel Estradiol Ethynodiol Diacetate and Ethinyl Estradiol Monophasic: Demulen, Zovia, Kelnor Etonorgestrel Implanon (Contraceptive Implant) Monophasic: Alesse, Levlen, Nordette, Lutera, Levlite, Levonorgestrel and Ethinyl Estradiol Aviane, Lessina, Lovera, Portia Triphasic: Trivora, Triphasil, Tri-Levlen, Enpresse Medroxyprogesterone Provera Depo-Provera (Contraceptive Injection) Nonoxynol 9 Spermicide Norethindrone Micronor NOR-QD Camilla Errin Monophasic: OvCon, Brevicon, Modicon, Necon, Norinyl, Norethindrone and Ethinyl Estradiol FemCon Fe Triphasic: Tri-Norinyl, Ortho-Novum, Nortel, Necon Norethindrone Acetate and Ethinyl Estradiol Monophasic: Microgestin Fe, Junel Fe, Loesterin Fe Triphasic: Estrostep Fe, Tri-Legest Fe Norethindrone and Mestranol Norgestimate and Ethinyl Estradiol Norgestrel and Ethinyl Estradiol Octoxynol 9

Monophasic: Necon 1/50, Norinyl 1+50, Ortho-Novum 1/50 Triphasic: Ortho Tri-Cyclen, Tri-Sprintec, Trinessa Monophasic: Lo/Ovral, Low-Ogestrel, Cryselle, Ovral, Oegstrel Spermicide

Full-Scope Medi-Cal (SML) does NOT cover: Drospirenone and Ethinyl Estradiol Etonogestrel and Ethinyl Estradiol Norelgestromin and Ethinyl Estradiol

Yaz, Yasmin NuvaRing (Vaginal Contraception) Ortho-Evra (Contraceptive Transdermal Patch)

Norgestimate and Ethinyl Estradiol

Monophasic: Ortho-Cyclen, Sprintec, Mononessa, Previfem Triphasic: Ortho Tri-Cyclen Lo

Levonorgestrel and Ethinyl Estradiol Extended Cycle Adapted from www.medi-cal.gov in consultation with Marianne Bruno, MPH, CHES - Title X Program Manager, UCLA, February 10, 2012.

Seasonale, Seasonique

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EXHIBIT D:

Summary Table of Contraceptive Efficacy

Method No method Spermicides Withdrawl Fertility awareness-based methods Standard Days method Two Day method Ovulation method Sponge Parous women Nulliparous women Diaphragm Condom Female (Reality) Male Combined pill and progestin-only pill Evra Patch NuvaRing Depo-Provera IUD ParaGard Mirena Implanon Female Sterilization Male Sterilization

Percent of Women Experiencing an Unintended Pregnancy within the First Year of Use -

Percent of Women Experiencing an Unintended Pregnancy within the First Year of Use - Perfect Use

Typical Use 1

Percent of Women Continuing Use at One Year 3

85% 29% 27% 25% 32% 16% 16% 21% 15% 8% 8% 8% 3% 0.80% 0.20% 0.05% 0.50% 0.15%

85% 18% 4% 5% 4% 3% 20% 9% 6% 5% 2% 0.30% 0.30% 0.30% 0.30% 0.60% 0.20% 0.05% 0.50% 0.10%

42% 43% 51% 46% 57% 57% 49% 53% 68% 68% 68% 56% 78% 80% 84% 100% 100%

Source: Trussell J. Contraceptive efficacy. In Hatcher RA, Trussell J, Nelson AL, Cates W, Stewart FH, Kowal D. Contraceptive Technology: Nineteenth Revised Edition. New York NY: Ardent Media, 2007 1 - Among typical couples who initiate use of a method (not necessarily for the first time), the percentage who experience an accidental pregnancy during the first year if they do not stop use for any 2 - Among couples who initiate use of a method (not necessarily for the first time) and who use it perfectly (both consistently and correctly), the percentage who experience an accidental pregnancy 3 - Among couples attempting to avoid pregnancy, the percentage who continue to use a method for 1 year.

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

Henshaw SK, Unintended pregnancy in the United States. Fam Plann Perspect. 1998 Jan-Feb;30(1):24-9, 46.; Saraiya M, Berg CJ, Shulman H, Green CA, Atrash HK, Estimates of the annual number of clinically recognized pregnancies in the United States, 1981-1991. Am J Epidemiol. 1999 Jun 1;149(11):1025-9. 2 Robert Hatcher et al., Contraceptive Technology, Revised 20th edition, (Bridging the Gap Foundation, 2011). H!S%2'+#!EF8!J..$:)+41!XY8!F#&&%*!K8!F'..%+$3#*!XQ8!D%-(%+4!XI;!K1%!=)*4+#2%(4-,%!=ZU@=Y!D+)P%24[! +%&'2-*5!0#++-%+$!4)!.)*5C#24-*5!+%,%+$-0.%!2)*4+#2%(4-)*;!JXUE!>\<\]!>\H[!<<L;%<C^;! O!_I#3-./!DJ=K!D+)5+#3!R%()+4!I-$2#.!`%#+!>\\aC>\<\8b!A=SI!"-V0/!=%*4%+!6)+!E.)0#.!R%(+)&'24-,%! Z%#.418!>>!B%2%30%+!>\<>!c!"#!$%&'(&)*+%,-*&.+/***/-"0&,/123456782)9:);<678=&>9)(?8@AB8d;!! 5 “Family PACT Program Report Fiscal Year 2009-2010,” UCSF Bixby Center for Global Reproductive Health, 22 December 2012 <bixbycenter.ucsf.edu/.../files/FPACT%20Program%20Report_09-10>. 6 Backman 2004 (not on reference list)

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

D("*(,0%&"(%!,2)+3,(%R),(%GQQA4%S,+%L(,+-1#-"4%!M7%S/601$$)3%$"%$:)%!,21&"(+1,%K)',($0)+$%"&%D/621-% ;),2$:4%T&&1-)%"&%L,012.%D2,++1+*%K151#1"+7%M'(12%GQCQ7%O1<6.%!)+$)(%&"(%P2"6,2%U)'("3/-$15)%;),2$:4% J+15)(#1$.%"&%!,21&"(+1,4%S,+%L(,+-1#-"V%S,+%L(,+-1#-"4%!M7% G%O1**#%EM4%L"#$)(%KP4%;/2)$$%K4%O(1+31#%!7%>GQCQB7%!"#$FO)+)&1$%M+,2.#1#%"&%$:)%!,21&"(+1,%L,012.%DM!N%

D("*(,0%&"(%!,2)+3,(%R),(%GQQA4%S,+%L(,+-1#-"4%!M7%S/601$$)3%$"%$:)%!,21&"(+1,%K)',($0)+$%"&%D/621-% ;),2$:4%T&&1-)%"&%L,012.%D2,++1+*%K151#1"+7%M'(12%GQCQ7%O1<6.%!)+$)(%&"(%P2"6,2%U)'("3/-$15)%;),2$:4% J+15)(#1$.%"&%!,21&"(+1,4%S,+%L(,+-1#-"V%S,+%L(,+-1#-"4%!M7% 3 Ibid. Biggs MA, Foster DG, Hulett D, Brindis C (2010).

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

EXHIBIT F:

Public Health Insurance Costs For Women & Children Following Delivered Pregnancies

Public Health Insurance Costs, Year Following Delivery 1st year following delivered pregnancy 2nd year following delivered pregnancy 3rd year following delivered pregnancy 4th year following delivered pregnancy Note - Programs considered include: Medi-Cal for woman, Infant MediCal, Infant Healthy Families Source: â&#x20AC;&#x153;Cost-Benefit Analysis of the California Family PACT Program for Calendar Year 2007,â&#x20AC;? UCSF Bixby Center for Global Reproductive Health, 8, April 2010, accessed December 29, 2011, <bixbycenter.ucsf.edu/.../files/FamilyPACT_Cost-Benefit_2007.pdf.

Average Cost per Delivered Pregnancy $2011 $ 4847 $ 1511 $ 407 $ 407

EXHIBIT F:

Social Program Costs for Pregnancies Resulting in Delivery

Program California Childrens' Services Early Start-LEAs/SELPAs Early Start-Regional Centers SSI Cal-Works Cash Grants-Woman Cal-Works Cash Grants-Child Cal-Works Employment Services Cal-Works Special Pregnancy Payment Food Stamps (2 people) WIC - Woman WIC - Child Child Care-CalWORKS Stage 1 Child Care-CDE Programs CDE State Preschool Foster Care Early Head Start (age 0-2) Head Start (age 3) Head Start (age 4)

Percent Eligible

Percent Eligble Who Enroll

1% 0.4 % 2% 1% 64 % 64.4 %

100 % 100 % 100 % 100 % 24 % 24 %

64 % 64 % 96 % 100 % 100 % 64 % 100 % 100 % 100 % 85.9 % 86 % 86 %

Number of Average Cost per Years for which Program Delivered Applies Pregnancy ($2011)

Cost per Year of Program ($2011) $ 3.01 $ 19.00 $ 43.98 $ 23.22 $ 102.99 $ 103.64

$ 15.03 $ 57.01 $ 131.95 $ 116.09 $ 411.97 $ 414.54

5 3 3 5 4 4

24 %

$ 1106.94

$ 276.74

24 % 50 % 82 % 82 % 10 % 51 % 65 % 1% 46 % 46 % 46 %

$ 47 $ 1326.25 $ 491.08 $ 392.64 $ 442.79 $ 2674.14 $ 2744.91 $ 185.08 $ 3376.75 $ 3380.68 $ 3380.68

1 5 1.5 5 2 3 2 5 2 1 1

$ 47.00 $ 265.25 $ 327.39 $ 78.53 $ 221.40 $ 891.38 $ 1372.46 $ 37.02 $ 1688.38 $ 3380.68 $ 3380.68

EXHIBIT G

Decision Analysis Model Inputs

IUD device cost

Abortion cost

Baseline Value

Average annual reimbursement for Family PACT clients $

Delivery cost

650

631

349

5523

Highest Value used in Probabilistic Sensitivity Analysis

Lowest Value used in Probabilistic Sensitivity Analysis

325

316

175

2762

1300

1262

698

11046

Source Peipert JF, Zhao Q, Allsworth JE, Petrosky E, Madden T, Eisenberg D, Secura G., Continuation and satisfaction of reversible contraception. Obstet Gynecol. 2011 May;117(5):1105-13. UCSF Bixby Center for Global Reproductive Health. CostBenefit Analysis of the California Family PACT Program for Calendar Year 2007. UCSF Bixby Center for Global Reproductive Health. CostBenefit Analysis of the California Family PACT Program for Calendar Year 2007. UCSF Bixby Center for Global Reproductive Health. CostBenefit Analysis of the California Family PACT Program for Calendar Year 2007.

Notes Weighted cost of levonorgestrel and copper IUDs based on frequency with which the two types of IUDs are selected.

Includes services other than contraception, such as STI testing and treatment and screening for cervical and breast cancer. All pregnancy outcome costs (delivery, abortion, miscarriage) include prenatal/preoperative care, inpatient or surgical care, and postpartum/postoperative care. These costs consider reimbursement for MediCal feefor-service and managed care plans. Delivery costs reflect costs of term deliveries.

UCSF Bixby Center for Global Reproductive Health. CostBenefit Analysis of the California Family PACT Program for Calendar Year 2007.

Average annual reimbursement for Family PACT barrier method clients $

215

108

430

Ectopic pregnancy cost

3113

1557

6226

Miscarriage cost

931

466

1862

Probability of IUD failure

0.005

0.002

0.01

Probability of abortion (given pregnancy)

0.41

0.21

0.61

Probability of delivery (given pregnancy)

0.45

Probability of ectopic pregnancy (given pregnancy)

0.01

0.0033

0.03

IUD users were considered to incur annual FamilyPACT costs of barrier method users after separately accounting for the cost of the IUD device. This was chosen to account for provision of non-contraceptive services (i.e. STI screening and treatment, cancer screening, follow-up IUD visits, as well as common dual-method use [IUD and condoms]).

UCSF Bixby Center for Global Reproductive Health. CostBenefit Analysis of the California Family PACT Program for Calendar Year 2007. UCSF Bixby Center for Global Reproductive Health. CostBenefit Analysis of the California Family PACT Program for Calendar Year 2007. Trussell J. Contraceptive efficacy in Hatcher RA, Trussell J, Nelson AL, Cates W, Stewart FH, Kowal D. Contraceptive Technology: Nineteenth Revised Edition. New York NY: Ardent Media, 2007. SK Henshaw. Fam Plan Perspect (1998); DG Foster, MA Biggs, et al. Perspectives for Sexual and Reproductive Health 38 (2006). SK Henshaw. Fam Plan The probability of delivery Perspect (1998); DG Foster, MA given pregnancy was used as a Biggs, et al. Perspectives for complementing probability in Sexual and Reproductive Health the model such that the all 38 (2006). delivery outcomes summed to 100%. SK Henshaw. Fam Plan Perspect (1998); DG Foster, MA Biggs, et al. Perspectives for Sexual and Reproductive Health 38 (2006).

Probability of miscarriage (given pregnancy)

0.13

0.03

0.23

Probability an IUD planned to be placed at abortion follow-up is placed

0.3

0.19

0.75

Annual probability an IUD placed at follow-up is continued

0.8

0.6

0.95

Annual probability an IUD placed at follow-up is expelled

0.03

0.06

Annual probability an IUD placed at the time of abortion is expelled

0.07

0.3

Annual probaility an IUD placed immediately post abortion is continued

0.8

0.6

0.95

SK Henshaw. Fam Plan Perspect (1998); DG Foster, MA Biggs, et al. Perspectives for Sexual and Reproductive Health 38 (2006). M Cremer et al. Contraception 83 (2011); AM Stanek et al. Contraception 79 (2009); A ElTagy, E Sakr et al. Contraception 67 (2003). Hatcher RA, Trussell J, Nelson After accounting for rates of AL, Cates W, Stewart FH, IUD expulsion. Kowal D. Contraceptive Technology: Nineteenth Revised Edition. New York NY: Ardent Media, 2007. PH Bednarek, MD Creinin NEJM 364 (2011); A Gocmen et al.. Clin Exp Obstet Gyecol 2002; JF Peipert, Q Zhao, JE Allsworth et al. Obstet Gyncecol 117 (2011) P Pakarinen et al. Contraception Values adjusted to 0.03, 0, and 68 (2003); A Gocmen, N 0.1, respectively for use in the 5Demirpolat, H Aysin. Clin Exp year Markov model to account Obstet Gyecol 2002; Stud Fam for the fact that IUDs placed Plann. 1983 Apr;14(4):99-108. immediately postabortal have a IUD insertion following higher rate of expulsion, termination of pregnancy: a compared to IUDs placed at clinical trial of the TCu 220C, abortion follow-up, only in the Lippes loop D, and copper 7. first year following placement. [No authors listed]. PH Bednarek, MD Creinin NEJM 364 (2011) Trussell J. Contraceptive After accounting for rates of efficacy. In Hatcher RA, IUD expulsion. Trussell J, Nelson AL, Cates W, Stewart FH, Kowal D. Contraceptive technology. 19th revised ed. New York, NY: Ardent Media; 2007)

PH Bednarek, MD Creinin NEJM 364 (2011); M Cremer et al. Contraception 83 (2011); insert reference for FPACT 2010 & prelim 2011 reports; Goodman et al. Contraception 2008.

Probability of pregnancy the first year following abortion if a planned IUD is not placed

0.31

0.09

0.85

Annual probability of pregnancy for Family PACT clients

0.17

0.01

0.85

Annual probability of pregnancy when a planned IUD is placed at abortion follow-up, is not expelled, and is continued through the first model cycle.

0.04

Annual probability of pregnancy when a planned IUD is not placed at abortion followup

0.17

Average public health insurance costs for a woman and each delivered pregnancy $

4966

Average social program costs for a woman and each delivered pregnancy $

9639

0.003

0.08

2483

4819

0.62

9933

19278

Women who did not receive a planned IUD were assumed not to use an IUD or contraceptive implant in the first year following abortion, and were considered to have pregnancy rates consistent with the weighted distribution of Family PACT methods excluding IUDs and implants. In subsequent years of the model, women for whom a planned postabortal IUD was not placed were assumed to have pregnancy rates consistent with the annual probability of pregnancy for Family PACT clients. â&#x20AC;&#x153;Family PACT Program Report Calculated based on the Fiscal Year 2009-2010,â&#x20AC;? UCSF percentage of FamilyPACT Bixby Center for Global clients using various primary Reproductive Health, 1, methods of contraception and accessed December 22, 2011, the respective typical use failure <bixbycenter.ucsf.edu/.../files/F rates of these methods. PACT%20Program%20Report_ 09-10>; Hatcher RA, Trussell J, Nelson AL, Cates W, Stewart FH, Kowal D. Contraceptive technology. 19th revised ed. New York, NY: Ardent Media; 2007. Used in the 5-year Markov model and adjusted to account for annual rates of IUD expulsion, failure, and continuation. Used in the 5-year Markov model and adjusted to account for typical use failure rates of the spectrum of contraception methods. Used in the 5-year Markov model and averaged to account for deliveries taking place in various years of the model. Used in the 5-year Markov model and averaged to account for deliveries taking place in various years of the model.

!"#$%$&'#(')*+,-.-/-.0'1+230,-,'$+45672.-5+'' ! "#$%&'&(&')!*$*+)%#%!,-.(&/#!&$%&01'!&$'.!1.2!3451!(*-&.4%!,*-*3#'#-%!.6!'1#! 3./#+!2.4+/!$##/!'.!51*$0#!%451!'1*'!'1#!.(#-*++!3./#+!-#%4+'!51*$0#%78!!9.-#! %,#5&6&5*++):!*!4$&(*-&*'#!;.$#<2*)=!%#$%&'&(&')!*$*+)%&%!&++4%'-*'#%!'1#!#66#5'!'1*'! *+'#-&$0!.$#!,*-'&54+*-!(*-&*>+#!;5.%'!.-!,-.>*>&+&')=!&$!'1#!3./#+!2&++!1*(#!.$!'1#! .(#-*++!3./#+!-#%4+'%7?!!"&3&+*-+):!*!>&(*-&*'#!;'2.<2*)=!%#$%&'&(&')!*$*+)%&%!*++.2%! 6.-!'1#!(*+4#%!.6!'2.!.-!3.-#!(*-&*>+#%!;5.%'%!.-!,-.>*>&+&'&#%=!&$!'1#!3./#+!'.!>#! (*-&#/!%&34+'*$#.4%+)!&$!.-/#-!'.!*%%#%%!'1#!,.'#$'&*+!5.3>&$#/!#66#5'%!.$!'1#! .(#-*++!3./#+!-#%4+'%7@!! ! A-.>*>&+&%'&5!%#$%&'&(&')!*$*+)%&%!;A"B=:!,#-6.-3#/!(&*!9.$'#!C*-+.! %&34+*'&.$!&$!.4-!3./#+:!&%!*!3#'1./!.6!#(*+4*'&$0!'1#!.(#-*++!-.>4%'$#%%!.6!3./#+! >)!%&34+'*$#.4%+)!(*-)&$0!*++!3./#+!&$,4'%!2&'1&$!%,#5&6&#/!-*$0#%7!!A"B!-#%4+'%! ,-.(&/#!'1#!,#-5#$'*0#!.6!'-&*+%!;/4-&$0!21&51!*++!5.%'%!*$/!,-.>*>&+&'&#%!*-#!(*-&#/! %&34+'*$#.4%+)=:!/4-&$0!21&51!*!0&(#$!%'-*'#0)!&%!,-#6#--#/!;&$!.4-!3./#+:!'1#! ,#-5#$'*0#!.6!'-&*+%!&$!21&51!&33#/&*'#!,.%'*>.-'*+!DEF!,-.(&%&.$!&%!5.%'!%*(&$0! 5.3,*-#/!'.!,+*$$#/!DEF!&$%#-'&.$!*'!*>.-'&.$!6.++.2<4,=7!!G#!#3,+.)#/!8H:HHH! '-&*+%!6.-!.4-!9.$'#!C*-+.!%&34+*'&.$%7!!I.-!A"B:!2#!4%#/!'-&*$04+*-!/&%'-&>4'&.$%!6.-! 5.%'!*$/!,-.>*>&+&')!&$,4'%:!&$!21&51!'1#!3.%'!+&J#+):!+.2#%'!-#*%.$*>+#:!*$/!1&01#%'! -#*%.$*>+#!(*+4#%!2#-#!4%#/:!5.$%&%'#$'!2&'1!,4>+&%1#/!+&'#-*'4-#!;*$/!#K,#-'! .,&$&.$!21#$!,4>+&%1#/!+&'#-*'4-#!2*%!4$*(*&+*>+#=7! ! D$!.4-!/#5&%&.$!3./#+:!9*-J.(!3./#+&$0!*++.2%!*!'1#.-#'&5*+!5.1.-'!.6! 2.3#$!'.!5)5+#!'1-.401!(*-&.4%!%#'%!.6!.4'5.3#%!6.-!#*51!.6!'1#!6&(#!)#*-<+.$0! 5)5+#%!.6!'1#!3./#+7!!L1#-#!&%!$.!#$'-)!.-!#K&'!6-.3!'1&%!3./#+!.(#-!'1#%#!6&(#!)#*-%7!! I.-!#K*3,+#:!&$!#*51!.$#<)#*-!5)5+#!.6!'1#!3./#+:!*!2.3*$!5.4+/!#&'1#-!>#5.3#! ,-#0$*$'!.-!$.'7!L1#!.4'5.3#!&$!'1#!,-&.-!)#*-<+.$0!5)5+#!/.#%!$.'!1*(#!*$!#66#5'!.$! '1#!.4'5.3#!&$!'1#!54--#$'!.-!%4>%#M4#$'!5)5+#%:!*$/!,-.>*>&+&'&#%!-#3*&$!'1#!%*3#! *5-.%%!*++!'&3#!,#-&./%!%,#5&6&#/!&$!'1#!3./#+7N!!!! ! !

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Edith Stokey and Richard Zeckhauser, A Primer for Policy Analysis, (New York: Norton & Company, 1987) 233-236. 2 “What is sensitivity analysis?” Health Economics, www.whatisseries.co.uk, April 2009, 2-3, accessed 15 March 2012, <www.medicine.ox.ac.uk/bandolier/painres/.../What_is_sens_analysis.pdf.> 3 “What is sensitivity analysis?” Health Economics, www.whatisseries.co.uk, April 2009, 4, accessed 15 March 2012, <www.medicine.ox.ac.uk/bandolier/painres/.../What_is_sens_analysis.pdf.> 4 Edith Stokey and Richard Zeckhauser, A Primer for Policy Analysis, (New York: Norton & Company, 1987) 98-101 and 109-10.

EXHIBIT H:

Threshold Values for One-Year Model Inclusive of Costs of Contraception and Pregnancy-Related Care Model Input

Threshold Value

IUD device cost

less than or equal to $807.88

abortion cost

NA*

average annual reimbursement for Family PACT clients

greater than or equal to $85.07

delivery cost

greater than or equal to $4,170.29

average annual reimbursement for Family PACT barrier method clients ectopic pregnancy cost miscarriage cost probability of IUD failure probability of abortion (given pregnancy) probability an IUD planned to be placed at abortion follow-up is placed annual probability an IUD placed at follow-up is continued probability an IUD placed at follow-up is expelled during the first year of use probability an IUD placed immediately post abortion is expelled during the first year of use annual probaility an IUD placed immediately post abortion is continued

less than or equal to $435.36 NA* NA* less than or equal to 8.1% less than or equal to 53.5% less than or equal to 90.0% NA* NA* less than or equal to 30.9% greater than or equal to 59.4%

probability of pregnancy the first year following abortion if a planned IUD is not placed

greater than or equal to 25.1%

annual probability of pregnancy for Family PACT clients

less than or equal to 38.9%

Notes Weighted cost of levonorgestrel and copper IUDs based on frequency with which the two types of IUDs are selected.Obstet Gynecol. 2011 May;117(5):1105-13. Continuation and satisfaction of reversible contraception. Peipert JF, Zhao Q, Allsworth JE, Petrosky E, Madden T, Eisenberg D, Secura G. Model is not sensitive to this input. There is no value of this input at which the strategy of planned IUD placement at the time of abortion follow-up is cost saving over the strategy of immediate postabortal IUD placement. Includes services other than contraception, such as STI testing and treatment and screening for cervical and breast cancer. All pregnancy outcome costs (delivery, abortion, miscarriage) include prenatal/preoperative care, inpatient or surgical care, and postpartum/postoperative care. These costs consider reimbursement for MediCal fee-for-service and managed care plans. Delivery costs reflect costs of term deliveries. IUD users were considered to incur annual FamilyPACT costs of barrier method users after separately accounting for the cost of the IUD device. This was chosen to account for provision of noncontraceptive services (i.e. STI screening and treatment, cancer screening, follow-up IUD visits, as well as common dual-method use [IUD and condoms]).

After accounting for rates of IUD expulsion. After accounting for rates of IUD expulsion. Women who did not receive a planned IUD were assumed not to use an IUD or contraceptive implant in the first year following abortion, and were considered to have pregnancy rates consistent with the weighted distribution of Family PACT methods excluding IUDs and implants .PH Bednarek, MD Creinin NEJM 364 (2011) and M Cremer et al. Contraception 83 (2011). Goodman et al. Contraception 2008. Calculated based on the percentage of FamilyPACT clients using various primary methods of contraception and the respective typical use failure rates of these methods.

**All costs in $2011. ** The threshold values present costs/probabilities for which the strategy of immediate postabortal IUD insertion is cost saving relative to the strategy of planned IUD insertion at abortion follow-up. * NA indicates that the the model is not sensitive to changes in this input.

!"#$%$&'()'*+,-$&$.$&/'0,12/-$-'3,45671&$5,'

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EXHIBIT I:

Threshold Values for Five-Year Model Inclusive of Costs of Contraception and Pregnancy-Related Care Model Input

Threshold Value

IUD device cost abortion cost

less than or equal to $1807.41 NA*

average annual reimbursement for Family PACT clients

NA*

delivery cost

NA*

average annual reimbursement for Family PACT barrier method clients probability of IUD failure probability of abortion (given pregnancy) probability an IUD planned to be placed at abortion follow-up is placed annual probability an IUD placed at follow-up is continued probability an IUD placed at follow-up is expelled during the first year of use probability an IUD placed immediately post abortion is expelled during the first year of use annual probaility an IUD placed immediately post abortion is continued

less than or equal to $631.50 NA* less than or equal to 85.4% less than or equal to 94.7% NA* NA* less than or equal to 58.8% greater than or equal to 35.4%

probability of pregnancy the first year following abortion if a planned IUD is not placed

NA*

annual probability of pregnancy for Family PACT clients

less than or equal to 58.2%

Notes Weighted cost of levonorgestrel and copper IUDs based on frequency with which the two types of IUDs are selected.Obstet Gynecol. 2011 May;117(5):1105-13. Continuation and satisfaction of reversible contraception. Peipert JF, Zhao Q, Allsworth JE, Petrosky E, Madden T, Eisenberg D, Secura G. Includes services other than contraception, such as STI testing and treatment and screening for cervical and breast cancer. All pregnancy outcome costs (delivery, abortion, miscarriage) include prenatal/preoperative care, inpatient or surgical care, and postpartum/postoperative care. These costs consider reimbursement for MediCal fee-for-service and managed care plans. Delivery costs reflect costs of term deliveries. IUD users were considered to incur annual FamilyPACT costs of barrier method users after separately accounting for the cost of the IUD device. This was chosen to account for provision of non-contraceptive services (i.e. STI screening and treatment, cancer screening, follow-up IUD visits, as well as common dual-method use [IUD and condoms]).

**All costs in $2011. ** The threshold values present costs & probabilities for which the strategy of immediate postabortal IUD insertion is cost saving relative to the strategy of planned IUD insertion at abortion follow-up. * NA indicates that the the model is not sensitive to changes in this input.

EXHIBIT I:

Threshold Values for Five-Year Model Inclusive of Costs of Contraception, Pregnancy-Related Care, & Public Health Insurance Model Input

Threshold Value

IUD device cost abortion cost

less than or equal to $3444.09 NA*

average annual reimbursement for Family PACT clients

NA*

delivery cost

NA*

average annual reimbursement for Family PACT barrier method clients less than or equal to $1220.48 probability of IUD failure NA* probability of abortion (given pregnancy) less than or equal to 85.7% probability an IUD planned to be placed at abortion follow-up is placed less than or equal to 96.0% annual probability an IUD placed at follow-up is continued NA* probability an IUD placed at follow-up is expelled during the first year of use NA* probability an IUD placed immediately post abortion is expelled during the first year of use less than or equal to 75.4% annual probaility an IUD placed immediately post abortion is continued greater than or equal to 21.2%

probability of pregnancy the first year following abortion if a planned IUD is not placed NA* annual probability of pregnancy for Family PACT clients

less than or equal to 64.2%

Notes Weighted cost of levonorgestrel and copper IUDs based on frequency with which the two types of IUDs are selected.Obstet Gynecol. 2011 May;117(5):1105-13. Continuation and satisfaction of reversible contraception. Peipert JF, Zhao Q, Allsworth JE, Petrosky E, Madden T, Eisenberg D, Secura G. Includes services other than contraception, such as STI testing and treatment and screening for cervical and breast cancer. All pregnancy outcome costs (delivery, abortion, miscarriage) include prenatal/preoperative care, inpatient or surgical care, and postpartum/postoperative care. These costs consider reimbursement for MediCal fee-for-service and managed care plans. Delivery costs reflect costs of term deliveries. IUD users were considered to incur annual FamilyPACT costs of barrier method users after separately accounting for the cost of the IUD device. This was chosen to account for provision of non-contraceptive services (i.e. STI screening and treatment, cancer screening, follow-up IUD visits, as well as common dual-method use [IUD and condoms]).

** All costs in $2011. ** The threshold values present costs & probabilities for which the strategy of immediate postabortal IUD insertion is cost saving relative to the strategy of planned IUD insertion at abortion follow-up. * NA indicates that the the model was not sensitive to changes in this input.

EXHIBIT I:

Threshold Values for Five-Year Model Inclusive of Costs of Contraception, Pregnancy-Related Care, Public Health Insurance, & Social Programs Model Input

Threshold Value

Notes

Weighted cost of levonorgestrel and copper IUDs based on frequency with which the two types of IUDs are selected.Obstet Gynecol. 2011 May;117(5):1105-13. Continuation and satisfaction of reversible contraception. IUD device cost less than or equal to $6786.50 Peipert JF, Zhao Q, Allsworth JE, Petrosky E, Madden T, Eisenberg D, Secura G. abortion cost NA* average annual reimbursement for Family PACT clients NA* Includes services other than contraception, such as STI testing and treatment and screening for cervical and breast cancer. All pregnancy outcome costs (delivery, abortion, miscarriage) include prenatal/preoperative care, inpatient or surgical care, and postpartum/postoperative care. These costs consider reimbursement for MediCal fee-for-service and managed care plans. Delivery delivery cost NA* costs reflect costs of term deliveries. IUD users were considered to incur annual FamilyPACT costs of barrier method users after separately accounting for the cost of the IUD device. This was chosen to account for provision of non-contraceptive services (i.e. STI screening and treatment, cancer average annual reimbursement for Family PACT barrier method clients less than or equal to $2423.27 screening, follow-up IUD visits, as well as common dual-method use [IUD and condoms]). probability of IUD failure NA* probability of abortion (given pregnancy) less than or equal to 85.9% probability an IUD planned to be placed at abortion follow-up is placed less than or equal to 96.7% annual probability an IUD placed at follow-up is continued NA* After accounting for rates of IUD expulsion. probability an IUD placed at follow-up is expelled during the first year of use NA* probability an IUD placed immediately post abortion is expelled during the first year less ofthan use or equal to 89.1% annual probaility an IUD placed immediately post abortion is continued greater than or equal to 9.3% After accounting for rates of IUD expulsion. Women who did not receive a planned IUD were assumed not to use an IUD or contraceptive implant in the first year following abortion, and were considered to have pregnancy rates consistent with the weighted distribution of Family PACT methods excluding IUDs and implants .PH Bednarek, MD Creinin NEJM 364 (2011) and M Cremer et al. Contraception 83 (2011). probability of pregnancy the first year following abortion if a planned IUD is not placed NA* Goodman et al. Contraception 2008. Calculated based on the percentage of FamilyPACT clients using various primary methods of contraception and the respective annual probability of pregnancy for Family PACT clients less than or equal to 70.7% typical use failure rates of these methods.

*All costs in $2011. ** The threshold values present costs & probabilities for which the strategy of immediate postabortal IUD insertion is cost saving relative to the strategy of planned IUD insertion at abortion follow-up. * NA indicates that the the model was not sensitive to changes in this input.