Enrollment barriers

All informants reported that there have been barriers to enrolling women in P4HB®. These barriers have caused a delay in women enrolling in P4HB^® and accessing P4HB® covered services. These barriers are associated with the following issues: 1) lack

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of awareness and understanding about the program; 2) burdensome documentation requirements; and 3) lack of presumptive eligibility.

As noted above, there remains a lack of awareness and understanding about P4HB^®. One provider said there is little outreach to providers or women about P4HB^®. She also thinks Title X providers aren’t doing enough to enroll clients. “I think that it (P4HB^®) has been perceived as a threat to them and that they were perceiving it as “oh this mean women come to us and we’ll lose head count.” The public health providers interviewed for this research have been providing information to their eligible clients about P4HB^®. As one public health provider stated “anyone we think might be eligible, we try and get them on the program” However, initially public health departments were instructed only to hand out brochures and flyers to eligible clients. Then, about nine months into the first year of P4HB^®, when DCH realized few women were enrolled in the program, public health departments were asked to take a more active role in assisting women to enroll in the program. All public health departments now provide women P4HB^® applications and instruct them about how to complete the application process.

Only two of the four public health providers interviewed for this study, however, fax completed applications to DCH for eligible clients. The other providers tell women they must either fax their applications, seek assistance through local welfare offices, or complete the P4HB^® application process online.

Representatives from all three CMOs acknowledged that the lack of awareness and understanding about P4HB^® is a problem and critical barrier to enrolling more women into the program. One CMO representative indicated that enrollment of IPC women is the plan’s main challenge. Even though the plan has instituted more on-site

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outreach and education at area hospitals, women are still not electing to enroll. These women “are not concerned about applying for a program that could possibly stop them, prevent them from having another pregnancy. They’re more concerned about the health of their baby at that time.” Another CMO representative echoed the same concern. This informant thinks women who are eligible for the IPC component have “competing

priorities..they have a preemie that they’re dealing with. They have all sorts of family and social issues that they are dealing with.” She confessed that her health plan is still trying to find a way to make more eligible women aware of P4HB^® and the IPC component and the value this new program offers them. The low IPC enrollment is a concern for another provider who feels that IPC enrollment be coordinated through NICU and perinatal health centers, while women are in the hospital and before they are discharged.

Burdensome documentation requirements: This barrier was most commonly identified by providers who have helped women enroll in P4HB^®. One representative of a public health department complained about the amount of paperwork women have to provide in order to apply for P4HB^®. This informant explained that women are required to provide original copies of their driver’s license and birth certificate, as well as copies of paystubs. Many women do not have these documents handy, and women complain about having to travel to multiple locations to get copies of the documents.

Transportation is a major problem for this population, and due to these barriers, women often don’t come back to complete their P4HB^® applications. Public health department providers also complained that initially they were not allowed to verify women’s documents (birth certificate, driver’s license). It wasn’t until the end of 2011 that DCH decided to allow these representatives to verify the documentation, which allowed for an

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easier and faster enrollment process. One social worker interviewed for this study helps women apply for the IPC component. She revealed that the IPC applications are often delayed because of the requirement to have the OBGYN sign off on the paperwork that verifies the woman’s VLBW delivery. This informant says that she wished the hospital and DCH data systems could “speak to one another, because all the information is already there” to verify this information.

Lack of Presumptive Eligibility: As noted above, several informants who were included in early discussions of P4HB^® expressed the desire to include presumptive eligibility in the enrollment process. As one public health clinic provider explained, being able to make a client presumptively eligible for P4HB^® at the time of her initial

appointment would allow the enrollment process to “speed up” but also could give the clinic the ability to be reimbursed for the services. Public health cannot be reimbursed retroactively for services provided to women who are eventually enrolled in P4HB^®. So essentially, public health clinics have to incur the costs, with their Title X money, for that initial set of services, which may include pregnancy testing and/or an annual exam.

Among the informants who advocated for presumptive eligibility, many could not understand why this option was available to women enrolled in RSM but not P4HB^®. One provider thought DCH decided not to seek presumptive eligibility because CMS was opposed to it. However, in an interview with a DCH official about this issue, presumptive eligibility “means that you receive services under the Fee-for-Service side. And since we had already structured this, that everything happens with the CMOs, we couldn’t have fee-for-service.” Therefore, due to the earlier decision to structure the P4HB^® program entirely through the CMO network, presumptive eligibility was not possible.

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Beginning in December 2011, after DCH realized that enrollment in P4HB^® was lower than anticipated, the program began auto-enrolling certain categories of DCH eligible clients into the program. That month, eligible women in RSM and Peach Care were auto enrolled in P4HB^®. For RSM clients, eligibility ends 60 days post-partum.

These women are notified in their eighth month of pregnancy and again one month post-partum about their auto enrollment in P4HB^®. Women are mailed letters from DCH and given the option to opt-out of the P4HB^® program. For women in Peach Care who are about to “age out” of the program (turn 18), similar letters are now sent to women a few months before their eligibility ends. In May 2012, 18 months after P4HB^® began, auto enrollment of IPC also took place. Many informants were pleased to learn that this auto enrollment process was occurring, including one advocate who said “I thought that was a smart thing to do.” Many informants, however are concerned about utilization. As

discussed below, utilization of P4HB^® services has been low, and many attribute this low utilization due to the lack of understanding and awareness about the program.