Implementation Process

There are many documents that describe the outreach and enrollment process for P4HB®. The Concept Paper was the first P4HB^® document to describe the enrollment

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process. This document explains that eligible women will be enrolled “through the DCH Enrollment Process administered by the Georgia Department of Human Services. Point of service enrollment will not be utilized.” Therefore, the document explains that Medicaid affiliated enrollment brokers will be used and that presumptive eligibility (otherwise known as point-of-service) is not an option in the program. In the Medicaid statute, the enrollment process is described in detail, including where applications are to be made available (at DFACS and public health offices) and how applications should be submitted (by DCAFS to PSI), or through the P4HB® online system. In these documents, the eligibility criteria for each component of the program is also explicitly stated.

The client brochures and post cards also provide information about how to apply online or where to pick up applications if preferable (public health departments and DFCS offices). Only the P4HB^® application provides detailed information about the documentation that is required for application (proof of income, child support. This document also asks applicants to describe their pregnancy status, history of preterm births, health insurance status, and citizenship status.

Outreach efforts are described in the statute, Provider Outreach Plan, and CMO provider materials. These documents describe different elements of the outreach, however. For instance, the Medicaid statute details the outreach that is provided RSM enrollees during their pregnancy and includes information about the post cards and letters that are sent to these eligible women. The Provider Outreach Plan indicates that each CMO will “outreach to its provider network to build their P4HB® provider network.” No further information is given, however, about how this outreach is defined and will be provided. The November 2010 Communications Plan provides the first details of the

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P4HB® marketing plan, and is described in two phases. The first phase includes

production of postcards and posters, as well as paid radio ads to be conducted over give weeks. A second marketing phase provides funds for billboards and all health districts and bus and train advertisements over the course of six months. Additionally, this

document reflects a give phase marketing strategy of outreach and education to providers, CMOs, and consumers. This marketing strategy later develops into the P4HB®

Communications Plan, which is followed and reported on in each of the P4HB®

quarterly reports to CMS. DCH provides detailed information about how each phase of this marketing strategy was employed and what strategies are still ongoing.

4.5.5 Access and Utilization

In the 2009 Concept Paper, data were provided that reflected estimated enrollment in P4HB.^® According to this document, the eligible population in Georgia is 276,548 women and is based on 2007 Georgia Population Survey data. The Paper then assumes that 50% of this population will enroll, and of these women, only 50% will utilize P4HB^® covered services. The Paper cites the South Carolina Family Planning Waiver as support for this estimation. Interestingly, the document also provides estimates for first, second, and third year enrollment and utilization, citing data provided by the Department of Public Health (DPH). For the first year, which the document states has typically low usage (1.5-2%), DPH data indicates that 40% of eligible women will enroll and 30% will use waiver services. Therefore, approximately 110,620 women will enroll and 33, 186 will use services (DCH, 2009; pg. 7). The document later identified about 244 low birth weight deliveries per year. However, this document does not explicitly estimate how

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many of these mothers of LBW babies will enroll in the IPC component of the program.

The document does, however, provide estimates of how many births will be averted through the implementation of this program and uses Pregnancy Risk Assessment and Monitoring System (PRAMS) data to provide these estimates. The estimation reflects the number of births from an unwanted or mistimed pregnancy that results from not using birth control at the time of pregnancy. In the first year, the number of projected births that would be averted is 2,571.

According to a review of the DCH P4HB^® quarterly reports for 2011 and the DCH Annual Report, actual enrollment and service utilization fell short of the estimates provided initially in the Concept Paper. As the Annual Report states, while the number of women deemed eligible for the FP component grew steadily in the first year, from 3,000 to over 21,000 women, “only 7,566 women or 6.8% of the 110, 620 women projected to be enrolled were actually enrolled” (pg. ii). The number of women deemed eligible for the IPC component also grew during the first year, but at a slower pace, from 0 to 19 women. All 19 women were enrolled in the IPC component of P4HB^®. Despite

“multiple engagement efforts,” the FP enrollment data represents about 5.3% of the eligible population and the IPC enrollment figures are only 1% of the expected population. The Annual Report, and quarterly reports too, acknowledge the need for enhanced provider and patient outreach.

The CMOs conducted two client and provider surveys during the first 18 months of the program. Findings from the client (or member) surveys suggest that P4HB^® provides most women the opportunity to access primary care services (54%) and birth control and family planning services. Clients also reported that P4HB^® has allowed them

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to use access preventive care, such as Pap smears and family planning counseling (83%), wider choice of birth control methods (49%), and access family planning at no cost (54%). Members also describe learning about P4HB^® through word of mouth from health department staff or at WIC offices (28%), and from mailings (22%).

Provider responses to the survey indicated some uncertainty about the nature of the program as well as the eligibility criteria and scope of covered services. Only 61%

(38 out of 62 survey respondents) knew about P4HB^®. Among these providers, most learned about the program from their contracted CMO. Also a majority of these participating providers (79%, or 30 out of the 28 respondents) provided some type of covered service to P4HB^® clients. However, only seven of these 30 respondents knew the service was explicitly covered as a P4HB^® service, suggesting there is some uncertainty of the program and its scope of services.

Utilization data were first reported in the quarterly reports to CMS by using CMO participation rates. In the first Quarterly Report, data indicated that while 45 FP

participants were enrolled (total), only 19 of these enrollees utilized P4HB^® covered services. There were no IPC enrollees in this first quarter. The Quarterly Report

identified several potential barriers to enrollment (delays in the application procedures), but not in the low utilization rates. By June 2011, the enrollment jumped significantly across all three CMOs, to 1,249 women. Active participation, however, fell short again to about 50% utilization of services. One CMO, however, indicated that its utilization rate was 100%, which was later considered to be a reporting error. IPC enrollment was also still delayed by this time, with only 2 enrollees. This second Quarterly Report also

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indicates that CMOs were still hiring Resource Mothers, so it is likely that CMOs were not prepared for this component of the program.

By the 3rd Quarterly report, enrollment of FP clients into P4HB^® had jumped to 1,898 women total in the FP (1,892) and IPC (6) components. As noted, however, this was a third of the women deemed eligible. Also only 56% of these women were enrolled in a CMO, indicating a delay in women choosing or being assigned to the CMO. As a result, active participation/utilization of P4HB^® fell short in the third quarter, to only 39%. So despite improvements in enrollment, the implementation of P4HB^® was delayed in large part to difficulties in the CMO selection process. Outreach and education to provides continued through this period, and RSM Outreach workers were used to advertise the P4HB^® at multiple health fairs and community events through the state.

Interestingly, starting in the 4^th Quarterly Report, utilization/participation data were no longer reported by DCH. Instead, only the eligibility and enrollment data were provided. By December 2011, 20, 185 women were deemed eligible for P4HB^®, but only 7,403 actually enrolled in a CMO. Of those enrolled, 21 were enrolled in the IPC

component. This Quarterly Report finds that delays existed in the program eligibility determination process and CMO selection process. As a results, the Report explains that auto-enrollment of FP women began in early December to facilitate enrollment of women in RSM and Peach Care.

4.5.6 Barriers

The only barriers described in this review of documents are those found in the DCH Quarterly Reports and 2011 Annual Report. As stated above, the barriers include

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enrollment, CMO selection, and Resource Mother services, as well as lack of

understanding of the program and its scope of services. In the Annual Report, data are provided about the delays in applications received by DCH for P4HB^®. According to this document, the average number of days from application to referral to a RSM outreach worker for processing the initial application increased from 12.5 days in January 2011 to 16.4 days in December 2011. The Annual Report suggests several reasons for these delays: 1) women’s’ provision of required documentation; verification of documents by designated agencies, women’s selection of a CMO, and communication of that selection the Medicaid agency, and administrative processing the application and enrollment. As noted earlier, DCH changed its policy towards the end of 2011 to allow public health providers the capability to verify certain documents to assist with the application process.

Findings from the client surveys suggest several barriers to P4HB^®. The three most prevalent problems experienced by P4HB^® clients were not getting the family planning services they needed (22%), not getting the referrals or follow-up care that was needed (18%), and not being able to find a doctor or nurse willing to take P4HB^®. Provider responses also denote certain barriers to the program, including a lack of understanding about program eligibility (40%) and a lack of covered services (range of 23-44% providers answered correctly about P4HB^® scope of services). Providers also expressed concern that there were certain major barriers for P4HB^® participation, including that the program does not cover the full scope of family planning services (13%), does not cover referrals or follow-up care (19%) and does not cover complications of family planning services (17%).

137 4.6 Summary of Document Review Results

A review of key policy and program documents provide useful information about the design and implementation of P4HB. We learned that several guidelines were

developed to describe the program, but these descriptions varied in both the content of the information and ways in which the information was provided. We also note that the DCH Concept Paper, rather than the Medicaid statute appears to be the main legal document that guided the development and implementation of P4HB. We also learned that certain enabling factors, including provider availability and enrollment processes, influence the implementation process. Lack of provider understanding about the program and cumbersome application procedures may have resulted in low enrollment and service utilization. These barriers were noted in particular in the P4HB evaluation reports (DCH quarterly reports and 2011 Annual report), which also suggested strategies for

overcoming these barriers (e.g., enhancing consumer and provider outreach).