Providers’ Barriers to Offering Contraception in the Healthy Texas Women (HTW) Program

By: Kari White, Elizabeth Ela, Kristine Hopkins, and Joseph E. Potter

March 2019

The Healthy Texas Women (HTW) program was established in 2016 through the consolidation of the Expanded Primary Health Care program and the Texas Women’s Health Program. It is the third fee-for-service family planning program operated by the state of Texas since 2005.

HTW provides uninsured women with family planning and women’s health services, including contraception and screening for cervical cancer and sexually transmitted infections. Texas resident women who are between the ages of 15 to 44 years old, are US citizens or qualified immigrants, and have incomes at or below 200% of the federal poverty level are eligible for program services. The statewide network of participating providers includes county health departments and hospitals, Federally Qualified Health Centers, family planning clinics, group medical practices, private medical practices and rural health clinics.

To meet the program’s objective of increasing women’s access to services and preventing unintended pregnancies, providers participating in the HTW program must offer women a wide array of contraceptive methods and provide services in a timely manner.1

This brief reports on a survey we conducted with 114 HTW providers about their clinical practices related to the provision of common birth control methods. We present survey findings on the percentage of providers who follow four key clinical guidelines that facilitate women’s access to services ("Clinical Guidelines..." below). We also identify programmatic changes that would reduce barriers women may encounter when accessing care from HTW program providers.

Key Strengths of the HTW Provider Network

• HTW providers offer women multiple contraceptive methods on site at their practice or organization.
• The majority offer intrauterine devices (IUDs) and contraceptive implants, and few providers refer women elsewhere to get these highly effective, long-acting methods.

Key Challenges among Participating Providers

• Providers that do not receive other funding dedicated to the provision of family planning services, (e.g., federal Title X or state Family Planning Program) reported practices and barriers that may prevent women from getting their preferred contraceptive method in a timely manner.
  
  • HTW-only providers were far less likely to follow clinical guidelines for providing contraception and required women to make multiple medically unnecessary visits.
  • HTW-only providers more frequently reported cost-related barriers to offering long-acting reversible contraception, including difficulties stocking IUDs and implants and inadequate reimbursement for these devices.

Clinical Guidelines and Standards of Care for the Provision of Contraceptive Methods1–3

• Women can start using contraception on the same day as their office visit (i.e., Quick Start4), rather than waiting for their next menstrual period, if they are reasonably certain they are not pregnant.
• Women can delay having a physical exam, including cervical cancer screening, and do not need results from sexually transmitted infection (STI) testing before they can start using a method. Only women with active STI symptoms should delay having an intrauterine device (IUD) placed.
• IUDs and contraceptive implants are safe for most women, including adolescents and women who have not had children.
• Women are not required to make a follow-up visit after obtaining IUDs and implants.

Many providers offer on site methods that are the most effective for preventing pregnancy

Providers reported offering five different contraceptive methods, on average, at their clinical sites without requiring a referral to another provider. Nearly all providers (96%) offered the injectable contraceptive, Depo-Provera, on site (Figure 1). Approximately three quarters also offered contraceptive implants, hormonal IUDs, and the copper IUD on site, which are the most effective reversible birth control methods.

FIGURE 1: THE MAJORITY OF HTW PROVIDERS OFFER HIGHLY EFFECTIVE METHODS ON SITE

Providers without other family planning funding were the least likely to follow clinical guidelines

Over half (57%) of providers in the survey did not receive other funding dedicated to the provision of family planning services, such as federal Title X funding or state Family Planning Program (FPP) funding. Providers that only received HTW fee-for-service funding were the least likely to follow clinical guidelines for the provision of common birth control methods (Figure 2). Failure to follow these guidelines makes it difficult for women to get contraception in a timely manner and puts them at risk of unintended pregnancy.5,6

FIGURE 2: NOT ALL HTW PROVIDERS FOLLOW CLINICAL GUIDELINES FOR TIMELY INITIATION OF CONTRACEPTION

About half of providers that participated either in the HTW fee-for-service program only or were at organizations that received Family Planning Program (FPP) contracts reported that they were very likely to recommend women start using their method at any point in their menstrual cycle, compared to nearly all organizations that received Title X funding. HTW-only providers also were the least likely to allow women to delay or forgo cervical cancer screening when starting a contraceptive method or offer women same-day placements for the IUD and implant. More than two-thirds of providers - regardless of funding source - believed women needed a follow-up visit after having an IUD placed, even though it is not medically necessary.

The majority of providers believed IUDs and implants are safe and appropriate for many women, but some would not recommend an IUD to suitable candidates (Figure 3). One in four providers considered IUDs to be unsuitable for teens age 15 to 19 and one in eight considered the method unsuitable for young adults age 20 to 29. More than one third of HTW-only providers considered IUDs to be unsuitable for women who have not had a child, and this view was less common among providers at Title X- and FPP-funded organizations.

FIGURE 3: SOME HTW PROVIDERS WOULD NOT RECOMMEND IUDS TO SUITABLE CANDIDATES

Providers report barriers to offering long-acting reversible contraception

Providers reported several barriers to providing IUDs and implants on site, and the barriers were similar for both of these long-acting methods (Figure 4). The most common barrier was having an insufficient number of devices on site to meet patient demand, but this was largely a challenge for HTW-only providers and less often cited by providers at Title X- and FPP-funded organizations. Nearly one in four providers indicated that reimbursement is inadequate and stated they had concerns about insurance claims being denied.
Providers also reported a lack of clinicians at their practices trained to place IUDs (22%) and implants (11%) or who were not adequately trained to remove these devices (12%).

FIGURE 4: PROVIDERS COMMONLY EXPERIENCE BARRIERS TO OFFERING IUDS AND IMPLANTS

Conclusions and Recommendations

Providers reported offering multiple methods on site at their practice locations. The majority offered IUDs and implants, which are the most highly effective reversible methods of birth control. However, cost and insurance barriers, as well as provider practices that are inconsistent with current clinical guidelines, may prevent women from obtaining these, and other, contraceptive methods in a timely manner. In addition, providers that have other sources of funding, such as Title X or the Family Planning Program, have greater availability of devices, which allows them to provide same-day IUD and implant placements for women who want these methods.
Several measures could be taken to improve the capacity of the HTW provider network and improve women’s timely access to contraception:

• Conduct professional education for HTW providers around current clinical guidelines for the provision of contraceptive methods and the broad range of women who are eligible for IUDs and implants.
• Implement programmatic changes that allow HTW providers, particularly those lacking Title X and FPP funding, to purchase and stock IUDs and implants in advance of women’s request for these methods.
• Offer additional training opportunities for providers to gain competence in both inserting and removing IUDs and implants.

Methods

We obtained a list of providers enrolled in the HTW program as of November 2017. We grouped providers into practice sites and organizations based on addresses and organizational names and removed providers that were unlikely to provide contraceptive services (e.g., laboratories, other clinical specialties). From 1,053 organizational sites based in Texas, we sampled a total
of 215 practice locations, including organizations that received Title X funding and any participating organization that received state funding for family planning services since 2013; we also sampled 150 HTW-only providers, selecting sites in all health service regions based on the number of reproductive-aged women in each area.

In May 2018, we mailed sampled providers a letter inviting them to complete an online survey and sent an email if an email address was available. All letters included a two-dollar incentive, and providers who completed the survey were entered into a raffle to receive one of ten fifty-dollar Amazon gift cards. We made follow-up phone calls and sent follow-up letters and emails encouraging providers to participate. Between May and December 2018, 114 providers (53%) completed the survey.

TABLE 1: PROVIDER CHARACTERISTICS (N=114)

References

1.    Texas Health and Human Services Commission Women’s Health Services Division. Policy and procedure manual for Healthy Texas Women (HTW) 2017 [Internet]. 2017 [cited 2019 Mar 1];Available from: https://hhs.texas.gov/sites/default/files/documents/laws-regulations/handbooks/htw/healthy-texas-women-provider-manual.pdf
2.    Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. selected practice recommendations for contraceptive use, 2016. Morb Mortal Wkly Rep Recomm Rep 65(RR-4):1–66.
3.    American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 186: Long-acting reversible contraception: Implants and intrauterine devices. Washington, D.C.: American College of Obstetricians and Gynecologists; 2017.
4.    Westhoff C, Kerns J, Morroni C, Cushman LF, Tiezzi L, Murphy PA. Quick Start: a novel oral contraceptive initiation method. Contraception 2002;66(3):141–5.
5.    Leeman L. Medical barriers to effective contraception. Obstet Gynecol Clin North Am 2007;34(1):19–29.
6.    Lesnewski R, Prine, Linda. Initiating hormonal contraception. Am Fam Physician 2006;74:105–12.

The Texas Policy Evaluation Project (TxPEP), based at the Population Research Center at The University of Texas at Austin, is a collaborative group of university-based investigators who evaluate the impact of legislation in Texas related to women’s reproductive health. The project is supported by grants from the Susan Thompson Buffett Foundation and the Society of Family Planning. Infrastructure support for the Population Research Center is provided by a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Funders of the Texas Policy Evaluation Project have no role in the design and conduct of the research, interpretation of the data, approval of the final manuscript or decision to publish.