Quality Family Planning (QFP)

Services: Addressing Provisions of the

ACA

Michael S. Policar, MD, MPH

Clinical Professor of Ob,Gyn, & RS

UCSF School of Medicine

policarm@obgyn.ucsf.edu

National Reproductive Health Conference

August 4, 2014, Orlando, FL

• There are no relevant financial

relationships with any commercial

interests to disclose

Objectives

• List 4 provisions of the ACA that deal with quality

of care and apply these sections to family planning

service delivery

• List 3 potential national family planning quality

metrics and explain how the numerator and

denominator for each metric could be computed

• List 5 commonly asked questions by clients

regarding why and how they should seek coverage

through mechanisms of the ACA available in the

state in which they reside.

• List the 8 categories services available to women

without cost-sharing for those who have non-

grandfathered health plans and how women can

access covered services if they are withheld by

their health plan.

So…What’s The “Big Deal” About The QFP?

• Completes, and ties together, the CDC “suite” of family

planning guidelines

• Defines and prioritizes the core content of contraceptive

services

• Defines the “borders” between family planning and other

preventive services

• Specifies which interventions are recommended for each of

the 7 family planning service types

• Emphasizes the role and content of contraceptive counseling

• Refines the content of male family planning services

The “Suite” of CDC

Family Planning

Recommendations

MMWR 2010,

59 (RR04):1-6

Focus on

safety in

women with

a variety of

medical

conditions

MMWR 2013;

62(5):1-60

Focus on

efficacy in

women and

men using

contraceptives

MMWR 2010; 59 (RR-12): 1

Updated Guidelines to Be Published in 2014

MMWR 2006;

55(RR-14):1-17

MMWR 2006; 55 (RR06): 1-23

Filling The “Gaps”• Pregnancy testing

and counseling

• Achieving pregnancy

• Basic infertility

• Preconception health

• Preventive health

screening of women

and men

• Contraceptive

counseling, incl

reproductive life plan

Framework

of the QFP

Core: Family planning

Related PHS: reproductive

health, but not core

family planning

Other PHS : not

reproductive health or

core family planning”

How Are Core Family Planning (FP)

Services Different from “Well Woman” Care?

• Core FP services focus upon

– Avoiding pregnancy or becoming pregnant

– Safe and effective contraceptive use

– Protection of reproductive health

• Additional preventive services may be performed by

– The patient’s primary care provider (PCP), or

– Her family planning clinic, in the absence of a PCP

• Given limitations of time and resources, provision of core

family planning services is our top priority!

Who Is the Target Audience?

Core FP Services Related PH Services Other PH Services

for primary care

providers

for women’s

health care

providers

“It depends on the

patient�”

Well Woman Preventive Services

• Recommended, but optional, related and other

preventive health services at any given visit based upon

– Individual client choice

– Avoidance of duplication of services performed by

the primary care provider or elsewhere

– Provider attitudes and preferences, as reflected in

site-specific policies and protocols

Other Preventive Health Services

Interventions unrelated to core family planning

Discuss

and

counsel

• Healthy diet counseling

• Dental health

• Injury prevention

• Breast cancer preventive medication

• Tobacco and drug use cessation interventions

• Administer vaccines: DTaP booster, influenza, rubella

Screening • Colorectal cancer screening

• DM, hyperlipidemia screening (unrelated to BCM)

• Skin cancer screening (high risk)

• Thyroid disease (high risk)

Test

• Bacteriuria screening with urinalysis

• Genital herpes screening

• Chlamydia screening in low risk women >26 and males of all ages

• Gonorrhea screening in low risk persons

• Syphilis screening in low risk persons

• Bacterial vaginosis and trichominiasis screening

• Hepatitis B screening

• Hepatitis C screening in low risk persons

• Ovarian cancer screening in low risk women

• BRCA mutation testing in low risk women

USPSTF: Routine Interventions to Avoid

Case Study

• 33 year old G3P3

established patient seen for family planning

health screening visit

• Using metformin for type 2 diabetes

• Mutually monogamous relationship

• Recent fasting lipid profile normal

• LMP 3 weeks ago; using condoms for contraception

• Cervical cytology test 2 years ago was negative

• Screened negative for HIV in each of her 3 pregnancies

Case Study

• Would like to start oral contraceptives…today if possible

– 13 cycles of monophasic dispensed

• Face-to-face time: 23 minutes; 18 minutes counseling

• What needs to be done in regard to…

– Counseling?

– Method choice?

– Screening tests?

– Encounter coding?

– Out-of-pocket cost sharing (e.g., co-payment)?

Reproductive Life Plan Questions

• Do you hope to have any (more) children?

• How many children do you hope to have?

• How long do you plan to wait until you next become

pregnant?

• How much space do you plan to have between your

pregnancies?

• What do you plan to do until you are ready to become

pregnant?

• What can I do today to help you achieve your plan?

“One Key Question”

www.onekeyquestion.org

OC/P/R POP DMPA Impl LNG-

IUD

Cu-

IUD

Hx gestational diabetes 1 1 1 1 1 1

Nonvascular disease

i. Noninsulin-dependent 2 2 2 2 2 1

ii. Insulin-dependent 2 2 2 2 2 1

Nephropathy/retinopathy/

neuropathy

3/4 2 3 2 2 1

Other vascular disease or

diabetes of >20 yrs’

duration

3/4 2 3 2 2 1

US MEC 2010: Diabetes

SPR Appendix B: When To Start Using

Specific Contraceptive Methods

Method When to start Back-Up Exam

Cu-IUC Anytime none pelvic exam

LNG-IUS Anytime If >7d* Pelvic exam

Implant Anytime If >5d* none

Injection Anytime If >7d* none

CHC Anytime If >5d* BP

POP Anytime If >5d* none

* After the first day of menstrual bleeding

SPR Appendix C: Exams And Tests

Needed Before Method Initiation

Examination Needed for

Blood pressure OC, patch, ring

Clinical breast examination None

Weight (BMI) Hormonal methods

Bimanual examination, cervical inspection IUC, cap, diaphragm

Glucose, Lipids None

Liver enzymes None

Thrombogenic mutations None

Cervical cytology (Papanicolaou smear) None

STD screening with laboratory tests None

HIV screening with laboratory tests None

SPR Appendix D: Routine Follow-

Up After Contraceptive Initiation

IUC Implant Injectable CHC POP

Return any time X X X X X

Assess satisfaction at

routine visits

X X X X X

Asses for change in

health status (MEC 3,4)

X X X X X

Consider string check X

Consider assessing

weight change

X X X X X

Measure blood pressure X

CDC 2010: Routine STI Screening in Women

Age 18-20 21-25 26-29 30-39 40-49 50-59

CT (Both) Annually Hi risk

GC (Both) Hi Risk

HIV

Once, then

Hi risk only

Syphilis Hi Risk

Vag trich Hi Risk

Hepatitis C

- CDC 2012

Hi risk

Routine annual screening of sexually active women under 26

One time screening of adults born 1945-1965

Routine Cancer Screening in Women

Age 18-20 21-25 26-29 30-39 40-49 50-59

Cervix CA

•Cytology

•Co-testing

None

None

Q 3 yrs

Q5 yrs

CBE

•ACS

None Q 3 yrs X Annual

with MG

Mammogram

•ACS

•USPSTF

None Hi Risk

[I]

Annual

Q2y [C] Q2y [B]

Colorectal

cancer None Hi Risk [A]

ACOG: Am College of Ob-Gyn

ACS: American Cancer Society

CBE: Clinical breast exam

CDC: Centers for Disease Control

USPSTF: US Prev Services Task Force

Preconception Care for Diabetics

• Diabetes in pregnancy is associated with higher rates of

– Miscarriage

– Fetal malformations: esp cardiac and neural tube defect

– Pre-eclampsia, preterm labor

– Macrosomia, birth injury, and perinatal mortality

• Lower risk if optimal glycemic control, before & during pregnancy

– Insulin to achieve target blood glucose levels

– Use metformin as an adjunct or alternative

Mahmud M, Mazza D: Preconception care of women with diabetes: a review of

current guideline recommendations. BMC Women’s Health 2010 10:5

Preconception Care for Diabetics

Mahmud M, Mazza D: BMC Women’s Health 2010 10:5

Counseling

• Folate 5 mg daily pre-conceptually until 12 weeks gestation

• Inform about risk of miscarriage, congenital malformation and

perinatal mortality with poor metabolic control

• Inform re: how DM affects pregnancy and pregnancy affects DM

• Use effective contraception until target blood glucose is achieved

• Encourage smoking cessation and reduction in alcohol intake

• Encourage management of weight to achieve a BMI < 27

Contraindications to pregnancy

• HbA1C >10%

• Impaired renal function (increased risk of progression to dialysis)

ADA 2014 Guidelines: Preconception Care

Maintain A1c levels as close to 7.0% as possible before conception

All women of childbearing

potential

Provide preconception counseling starting

at puberty

Evaluate and treat ( if

necessary) all women

contemplating pregnancy

• Retinopathy

• Nephropathy

• Neuropathy

• CVD

Evaluate and consider

risk/benefit profile of

medications used for DM

Contraindicated/not recommended

• Statins

• ACEIs (AT-converting enzyme inhibitor)

• ARBs (AT receptor blocker)

• Non-insulin therapy, except metformin

ADA, Diabetes Care 2014; 37 (supp 1): S14-S80

Summary of Patient Management

• QFP: review reproductive life plan; discuss all methods

• MEC: can use oral contraceptives with same day start

• SPR: assess BP, BMI only

• STD: no STI screening tests indicated

• HIV: screening not necessary

• Cancer screening: clinical breast exam Q 1-3 years

• Preconception care:

– Discuss preconception glucose control with all diabetics

• How should I code this visit???

Problem Oriented E/M Visits

HISTORY

EXAM

MEDICAL

DECISION

MAKING

TIME

Either:

•Composite of 3 key

components (Hx +

PE + MDM)

Or

• TIME, when greater

than 50% of time is

spent in

counseling

Problem Oriented E/M: Face-to-Face Time

E/M

new

Typical time

(min)

99201 10

99202 20

99203 30

99204 45

99205 60

E/M

established

Typical time

(min)

99211 5

99212 10

99213 15

99214 25

99215 40

Established client: seen within past 3 years

Established Time (typical)

99211 < 7 (5)

99212 8-12 (10)

99213 13-20 (15)

99214 21-33 (25)

99215 >33 (40)

New Time (typical)

99201 < 15 (10)

99202 16-25 (20)

99203 26-37 (30)

99204 38-53 (45)

99205 > 53 (60)

Problem Oriented E/M:

Face-to-Face Time “Midpoints”

Problem Oriented E/M Visit: Time Factor

• Average face-to-face (FTF) times listed for each level of E/M

• “Face-to-face Time” supersedes key indicators if > 50% of

total FTF time is spent in counseling & care coordination

– Includes time spent with patient and/ or family members

– Includes time spent on key components (e.g., exam)

– Excludes pre- and post-encounter time

– Excludes accommodation for disability or language

• Must document

– Total FTF time and counseling �me (or √ box for >50%)

– Counseled regarding outcome, risks, benefits of…

– Answered her questions regarding…

E/M: Preventive Medicine Services

Age New patient Established

12-17 yrs old 99384 99394

18-39 yrs old 99385 99395

40-64 yrs old 99386 99396

65 yo or older 99387 99397

• Preventive medicine: “check-up” visit

E/M: Preventive Medicine Services

• Components

– Comprehensive history and physical exam

– Counseling, anticipatory guidance, and risk reduction

– Order lab, diagnostic procedures

– Indicate immunizations with separate codes

• If insignificant or trivial problem(s) without extra work

to evaluate, do not add separate E/M

• If additional work-up for pre-existing or new problem,

may add problem-oriented E/M (-25)

Case Study: Answer

CPT code/HCPCS II code ICD9-CM

Procedure None

Supplies None

Drug S4993 (OCs) x 13 cycles V 25.01 (prescription of

oral contraceptives)

Lab None

E/M • 99214 (problem visit, 25 min)

or

• 99395 (preventive medicine

service,18-39 yo)

1o: V 72.31 (routine

GYN exam)

2o: V 25.01

(prescription of oral

contraceptives)

Which E/M Code to Use?

• Does the payer for this patient cover?

– Preventive services [check-up visit] (99395)

– Problem oriented visit, established (99214)

• What are the comparative reimbursement rates for the

covered codes? Code for the highest supported code

• If only problem oriented visit codes (9920x, 9921x) are

covered, code for the higher E/M level

– By the 3 key components, or

– Time

� Specified preventive services must be covered with no

cost-sharing (no out-of-pocket costs)

� Applies to private and public programs

– (New) Private insurance policies 2010

– Medicare, Medicaid 2011

– State insurance exchanges 2014

� Improves coverage for preventive services in many

individual and small group plans

� Preventive services include all services

– USPSTF grade [A] or [B] recommendations

– AAP Bright Futures recommendations for adolescents

– CDC ACIP vaccination recommendations

� IOM recommended to HRSA additional women’s

prevention benefits not addressed by USPSTF…intended

to “close the gaps”

Institute of Medicine

� Committee on Preventive

Services for Women

� “Closing the Gaps” released

July 20, 2011

� 16 member panel

� 8 additional preventive

services recommended

Reproductive Health Cancer Healthy

Behaviors

Pregnancy

related

Immunizations Chronic

conditions

STI and HIV

counseling ; all

sexually active F)

Breast Cancer

•Mammography

Alcohol S&C •Alcohol S&C •TdaP, Td booster,

•MMR, varicella

CV: HTN,

lipids

Ct, GC, Syphilis

screening

•Genetic S&C Tobacco C&I •Tobacco C&I Influenza T2DM screen

HIV screening (adults

at HR; all sexually

active F)

•Preventive

medication

counseling

Diet

counseling if

CVD risk

•Folic acid

supplement

•Hepatitis A, B

•Meningococcal

Depression

screen

Contraception

(women w/repro

capacity

Cervix:

• Cytology

• HPV + cytology

Interpersonal

and DV S&C

•GDM screen

•Rh screen

•Anemia

screen

•HPV

(women 19‐26)

Osteo‐

porosis

screen

Colorectal:

• FOBT,

• Colonoscopy,

• Sigmoid

Well‐woman

visits

•STI screen

•Bacteruria

screen

•Pneumococcal

•Zoster

Obesity

screen; C&I if

obese

•Lactation

Supports

S&C: screening and counseling C&I: counseling and interventions

Women's Preventive Services

HHS Guideline for

Insurance CoverageFrequency

Well-woman visits annually

including preconception and

prenatal care

• Several visits may be needed to

obtain all recommended services,

depending on health status,

health needs, and other risks

Women's Preventive Services

HHS Guideline for Insurance Coverage Frequency

All FDA approved contraceptive methods,

sterilization procedures, and patient education &

counseling for women with reproductive capacity

As

prescribed

• Limited exclusion for religious institutions (e.g., churches)

from providing contraceptive coverage for insured employees

• DHHS “accommodation” extended to religion-affiliated non-

profits employers and certain for-profit companies (Burwell

vs. Hobby Lobby, USSC, 2014)

Can Plans Limit Contraceptives

Covered Without Cost-Sharing?

• Plans must cover all of FDA-approved methods, but not all

products

• “Reasonable medical management techniques” are allowed

– Cost-sharing for brand-name drugs

– Cost-sharing for out-of-network services

– Prescription for over-the-counter methods

• The “Waiver Process”

– Allows women to access medically appropriate method

without cost-sharing if plan typically imposes cost-sharing

– Usually done through pharmacy pre-authorization

How Do You Know If You

Have First Dollar Coverage

for Contraceptives?

• Call “Member Services” at you health plan…the

number is on your health insurance card

• If you feel you are not receiving benefits to which you

are entitled, contact the National Women’s Law Center

– 1-866-PILL4US

– pill4us@nwlc.org

• Six CDC-developed evidence based guidelines are now

available that cover most clinical circumstances that occur in

family planning clients

• The QFP fill in gaps left between the guidelines and then

“ties” all the guidelines cohesively

• Most family planning services will be coded based on client

counseling, not on physical assessment or lab testing

• Most women covered by commercial health insurance,

Medicaid, state FP programs, and Title X will have no out-of

pocket costs for contraceptives

Clinical Pearls