A Review of the HHS Family Planning Program Mission, Management, and Measurement of Results (2009) / Chapter Skim
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4 Program Management and Administration
4 Program Management and Administration
Pages 101-144
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From page 101... ...
2008. By statute, at least 90 percent of that appropriation must be used for family planning services.
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From page 102... ...
. The first six sections review in turn the roles and relationships of the Central Office, Regional Offices, grantees, and delegates; the application process for grants and contracts; the types and distribution of grantees and delegates; and the services provided by, oversight of, and funding of grantees and delegates (including coordination with other federal sources of funding for family planning services)
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From page 103... ...
It has developed an array males; family planning services to couples; organizational approaches to integrated services; translation of research into practice; increasing costs and their impact; and the effectiveness of Title X informational and educational activities. In addition to research covered by the standing announcement, research is currently being conducted through cooperative agreements with three grantees to analyze data on family planning needs and services over time using wellestablished formulas and databases; develop tools to assess and improve the quality of care in family planning clinics based on clinic data collection by a network of service providers; and analyze an array of national survey data sets to better understand the determinants of unintended pregnancy and childbearing.
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. Delegate agencies for family planning services must be appropriately licensed health care facilities that agree to provide services in accordance with Title X guidelines and applicable federal, state, and local laws; report data for the Family Planning Annual Report (FPAR)
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By statute, public or nonprofit private entities can receive grants or contracts to offer family planning services, provide training, conduct research, and develop and distribute informational and educational materials. Providers of family planning services must offer a "broad range of acceptable and effective medically approved family planning methods" and provide services without coercion and "in a manner which protects the dignity of the individual" (42 CFR § 59.5 [a]
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From page 106... ...
The notices are published online at www.grants.gov. Applications for service grants are submitted to the Office of Grants Management for Family Planning Services at the Central Office, but applications are reviewed and decisions made about the awarding of grants, their duration, and their amount at the regional level.
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From page 107... ...
Grantee Funding Each region receives a core allocation of regular service funds by the Central Office, based on a historical formula that measures each region's need according to three data sets -- the Guttmacher Institute's Women in Need of Contraceptive Services and Supplies (hereafter referred to as Women in Need) (Guttmacher Institute, 2008b)
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From page 108... ...
; a historical formula to assess the needs of the community (e.g., Women in Need, state and federal health statistics, needs assessments, National Survey of Family Growth) ; the number of Title X program users and the size of the grantee; and the resources and history of the grantee in the Title X program.
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The Lewin Group (2009) reports that some grantees use the annual needs assessment to identify areas with an unmet need for family planning services, but that there is significant variability in the methodology used by grantees in distributing funds to delegates.
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From page 110... ...
poverty level) • Base starting amount is $80,000 • Take into account all of a • Take into account: program's income from fees and -- Number of users public and private insurance -- Number of warning letters • Set goals for how much money (compliance)
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. As noted earlier, some grantees provide family planning services them selves, but most contract with delegates in whole or in part.
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As noted above, most current grantees have been Title X grantees for many years. Most of the state health departments that emerged as grantees from the consolidation of grants at the state level in the early 1980s have remained in that role.
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. The Program Guidelines apply to all clinical family planning services provided by a recipient of Title X funds, even if services are not paid for by those funds and even if those funds represent only a small portion of a grantee's or delegate's budget (see the discussion below)
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can obtain educational materials free of charge from the OPA Clearinghouse, which collects, develops, and distributes publications on family planning, sexual health, and reproductive health. (The Clearinghouse also provides a database and directory of family planning grantees, delegates, and clinics, and provides referrals to clinics and government sources of information pertaining to family planning and related health issues.)
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Consultants are professionals with direct experience with Title X and may previously have served, for example, as nurses in Title X clinics or have worked for grantee or delegate agencies. In addition to visiting the grantee's offices, the review team visits one to three delegate agencies and/or clinics overseen by the grantee (although grantees have primary responsibility for monitoring delegates and clinics)
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From page 116... ...
The analysis is updated annually and helps inform decisions regarding priorities for the next year's activities. Funding of Grantees and Delegates Congress has mandated that 90 percent of Title X appropriations be used to support Section 1001, the establishment and operation of voluntary family planning programs.
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From page 117... ...
Non–Title X Family Planning Funding Sources Medicaid and Medicaid Waivers As noted earlier, while Title X remains the centerpiece of family planning, funding for family planning services through the Medicaid program now exceeds that from Title X. The federal government pays 90 percent of each state's Medicaid expenditures for family planning services and sup 11 ocial S Services block grants, through Title XX of the Social Security Act, provide funds to state social services agencies to reduce individuals' dependence on public assistance and can be spent for family planning services.
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. As discussed in Chapter 2, in 1993, the Medicaid Waiver program was instituted to allow states to waive normal Medicaid eligibility requirements to cover family planning services for those low-income individuals who otherwise would not qualify.
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From page 119... ...
However, in using MCH block grant funding, states are required by law to contribute 3 state dollars for every 4 federal dollars; there are no such requirements for Social Services funds. In FY 2006, MCH and Social Services block grants provided close to $23 million and more than $28 million, respectively, for family planning services (RTI International, 2008)
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From page 120... ...
, state appropriations for family planning services have remained flat. Summary In summary, Medicaid now pays for approximately 70 percent of publicly funded family planning services, with Title X accounting for approximately 12 percent, state and local governmental funds 13 percent, MCH block grants 2 percent, and Social Services block grants and TANF 3 percent (Guttmacher Institute, 2008a)
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From page 121... ...
Critical to achieving the program's goal of providing family planning services to lower-income individuals is making those services available at no cost to persons with incomes up to 100 percent of the federal poverty level and at discounted prices to those whose income is less than 250 percent of that level (42 CFR § 59.5(a)
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. Title X clinics therefore meet the reproductive health care needs of adolescents, men, recent legal immigrants, and the undocumented,16 who might otherwise forego family planning services.
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Finding 4-2. While family planning services are funded through a variety of sources, which may vary from state to state, Title X plays a special role by covering services that other payers do not, clients who do not qualify for other coverage and cannot afford services, infrastructure, and expenses associated with program development and service delivery that other sources do not reimburse.
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. Regional Offices and Grantees: Structure and Relationships Staff and participants at the federal, regional, and state levels generally view the decentralized, regional structure of the Title X program as beneficial.
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The regional system for managing and administer ing the Title X program often serves varying needs across regions effectively and is an important function of the program, but there is room for improvement. Grantees and Delegates: Service Delivery The network of clinics supported by Title X delivers crucial family planning services for communities and populations that are underserved and would otherwise lack medical care.
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These challenges relate to the following: • Overall funding limitations and rising costs • Management of multiple funding sources • Program guidelines • Procedural requirements • Communication • Staffing • Informational and educational materials • Challenges of serving populations that are the focus of Title X • Provision of culturally appropriate care • Provision of services that meet client needs Funding Limitations and Rising Costs As is true for much of the nation's stressed health care system, funding for the Title X program is severely constrained. Shortly after the program was established, Congress dramatically expanded its funding, which ultimately peaked in constant dollars in 1980.
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Title X has inadequate financial resources to pro vide comprehensive care to patients and communities at a high level of professional standards or to exercise leadership in family planning. Many Title X clinics obtain contraceptive products through the Office of Pharmacy Affairs' 340B drug pricing program18; consortia, cooperatives, or other groups of individual providers (such as Planned Parenthood)
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Management of Multiple Funding Sources As discussed earlier, Title X clinics rely on funds from a number of sources, necessitating coordination and management of multiple funding sources at the federal, state, and local levels to operate a comprehensive 19 A product may become unavailable after just a few months since the list changes quarterly. 20 ccording to American Cancer Society guidelines, screening should be done every year A with the regular Pap test or every 2 years using the newer liquid-based Pap test.
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. Coordinating the many requirements for the multiple federal programs involved in the provision of family planning services could reduce the administrative burdens and costs borne by grantees and delegates.
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, restriction of services under the Medicaid Waiver program (individuals with third-party health insurance of any kind are disqualified from participation in the program, even if that insurance exempts coverage of family planning services [Sonfield et al., 2008b]
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By not reviewing and updating the Program Guidelines for clinical, behavioral, and educational services to reflect the most current professional standards, OPA is creating a critical problem for health professionals in Title X clinics that represents a serious failing of the program. Providers are
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Likewise, Title X recipients that focus on providing family planning should develop networks to refer patients who have other health care needs. Procedural Requirements Procedural requirements of OPA and the other entities that govern the functioning of Title X grantees present additional administrative challenges.
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While OFP communicates regularly by e‑mail and conference calls with RPCs, who in turn communicate with grantees, the process does not provide grantees with information they desire about program decisions. In addition, grantees do not believe that they have adequate input into such decisions or that their concerns reach the Central Office.
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The limited pool of qualified professionals has been an ongoing problem for the Title X program.21 This problem will become greater with the 21 arlier, E Title X funded certificate Women's Health Care Nurse Practitioner education programs located in geographically diverse regions (at Planned Parenthood in Philadelphia, Emory University Medical School in Atlanta, University of Texas Southwestern Medical School in Dallas, and Harbor UCLA in Los Angeles) to provide access for participants from Title X programs.
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Informational and Educational Materials During the committee's site visits, in testimony provided by grantees and delegates, and in the Membership Survey of the National Family Planning and Reproductive Health Association (NFPRHA) , several issues regarding informational and educational materials were raised.
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, the demand for family planning services has increased. While funding is a core issue that affects the ability of Title X clinics to provide care for all who seek it, the situation poses particular challenges concerning the special needs of target populations such as adolescents, men, and people with limited English proficiency.
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From page 137... ...
found that comprehensive programs, which include education about delaying sexual activity and decreasing the number of sexual partners as well as information about contraception, were considerably more effective overall than those focused on abstinence-only education in encouraging positive reproductive health behaviors and showed no significant negative effects. In addition, many private foundations are investing in research aimed at identifying ways to improve the family planning and reproductive health care available to low-income women, including teens.
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From page 138... ...
. As discussed in Chapter 3, HHS's Guidance Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons also requires agencies that receive federal funding from HHS to ensure that clients with limited English proficiency have access to services the agencies provide.
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From page 139... ...
The program structure and funding also limit the ability of Title X clinics to provide important services relevant to healthy pregnancies and birth outcomes. These services include pre- and interconception care (to improve, respectively, the health of women who are considering pregnancy and attention to issues between pregnancies that may affect birth outcomes)
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The committee offers the following recommendations for achieving these improvements: Recommendation 4-1: Increase program funding so statutory responsibilities can be met. Title X should receive the funds needed to fulfill its mission of providing family planning services to all who cannot obtain them through other sources and to finance such criti cal supplemental services as infrastructure, education, outreach, and counseling that many other financing systems do not cover.
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Recommendation 4-5: Reduce the administrative burden on Title X clinics. OPA should work with other HHS agencies sup porting family planning to coordinate patient fee schedules and record-keeping and reporting requirements.
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Finally, timely updated guidelines could be used for all federal health care programs. In this way, clinical and quality advances achieved in Title X could be used to inform other HHS family planning efforts.
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Recommendation 4-9: Assess workforce needs. With the help of an independent group, OFP and other agencies within HHS should conduct an analysis of family planning workforce projections for the United States in general and for the Title X program specifi cally.
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