providing larcs in a federally qualified health center business model for ensuring access...
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Providing LARCs in a Federally Qualified Health Center
Is it financially viable? A case study
Lisa Maldonado, MA, MPH
Linda Prine, MD
Mission
The Reproductive Health Access Project trains and supports clinicians to make reproductive health care accessible to everyone.
We focus on three key areas:
abortion, contraception and miscarriage.
Community Health Centers
Year CHC Sites Patients Served
1990 1,400 5,000,000
2000 3,200 10,000,000
2010 8,000 20,000,000
2019 40,000,000
Family Planning Access in FQHCs
• More than 5.7 million women receive health care in FQHCs (2012).
• 2013 study found that 99.8% of FQHCs provided at least 1 contraceptive method…but only 19% of all FQHCs surveyed report offering comprehensive contraceptive options at their “largest” site. (1)
• The largest FQHCs sites: 36% offer the contraceptive implant, 56% offer the progestin IUD and 52% provide the copper IUD. (2)
1. Wood SF, Goldberg DG, Beeson T, Bruen BK, Johnson K, Mead KH, Shin P, Lewis J, Artis S, Hayes K, Cunningham
M, Lu X & Rosenbaum S. (2013). Health centers and family planning: results from a nationwide study. Health Policy
Faculty Publications.
2. Accessibility of Long-acting Reversible Contraceptives (LARCS) in Federally Qualified Health Centers (FQHCs)," Beeson
et al., Contraception, Oct. 3, 2013.
Common barriers to providing LARC in an FQHC
• Clinicians not trained to provide LARC
• “Procedure” interferes with patient flow
• Protocols out of date (eg, patient must be multiparous, currently having menses, etc.)
• Administrators won’t stock “expensive” items like IUDs and Implants.
• “Providing LARC is expensive, the health center will lose money.”
FQHCs serve low income populations
Source: Federally-funded health centers only. 2012 Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS.
Note: Federal Poverty Level (FPL) for a family of three in 2012 was $18,500. (See http://aspe.hhs.gov/poverty/12poverty.shtml).
Based on percent known.
Typical FQHC Payor Mix
*”Other public insurance” may include non-Medicaid SCHIP and state-funded insurance programs.
Source: Federally-funded health centers only. 2012 Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS.
One FQHC’s Experience
• Large, multi-site FQHC serving serving both inner-city, suburban and rural populations.
• 3 residency programs within the FQHC, all training family medicine residents to do LARC
• Most hiring for the FQHC comes from residency graduates, i.e. many trained providers
• Reproductive Health Fellowship has helped to expand training of residents and APCs
The bottom $$ line:
Benefits from:
• State Medicaid reimburses for device and insertion.
• Patient Assistance Program (ARCH and Paragard) for eligible uninsured.
• Special state Family Planning Benefit Program for uninsured/underinsured.
• 340b pricing for device
2012 2013
Mirena $304.75 $313.75
Paragard $185 $225.00
IUD Patient Assistance Programs
Paragard www.rxhope.com/PAP/pdf/duramed_paragard_0209.pdf
Mirena
ARCH Foundation
www.archfoundation.com
1st Quarter 2013
Number of IUDs inserted
Paragard Mirena Total
84 195 279
Revenue: 1st Quarter 2013
# patients Total Revenue Average per patient
Free Care 18 (6%) 0 0
Sliding Fee 27 (10%) $482.50 $20.10
Insurance * 234 (84%) $20,295.76 $86.73
Total 279 $20,778.26 $77.56
•includes Medicaid and private insurance plans
•No insurance reimbursement for insertion for 45 patients.
Insertion fees/Office visit collected
Revenue: one FQHC’s IUD experience
# patients
Total Revenue
Average revenue
per patient
Total cost (340b prices)
Net Profit
Paragard 84 $22,651.34 $269.66 $18,900.00 $3,751.34
Mirena 195 $72,896.48 $373.82 $61,181.25 $11,715.23
Total 279 $95,547.82 $342.46 $80,081.25 $15,466.57
Device fees collected
No insurance reimbursement for devices for 68 patients.
Net profit
Cost Revenue Net Profit
Devices $80,081.25 $95,547.82 $15,466.57
Visit* $39,060.00 $20,778.26 $18,281.74
Total $119,141.25 $116,326.08 $2,815.17
Wrap-around $4,972.13 $2,156.96
*$140.00 cost/visit
Additional Considerations • This data is pre-Obamacare.
• Changes made at FQHC due to this analysis:
– All patients now see social workers for insurance eligibility
– Billing department follows through on unpaid claims
– Contracts with insurances were addressed
• Many insurances actually pay a higher visit rate for IUD removals than for insertions.
Is this replicable in other states?
• National efforts to reform Medicaid
• States where Medicaid reform is working
• Other national issues to think about
• Clinicians have to become advocates regarding billing & reimbursement
• Special challenges for FQHCs, as opposed to other settings