Service utilization barriers

A majority of the informants felt that P4HB^® is underperforming as a program because women are not being enrolled and thus not accessing the covered services. As one informant stated, “Medicaid simply thought, ‘if you build it, they will come…well, they haven’t come.” Some informants indicated that even participants who are enrolled in P4HB^® are not using the services, which several feared is because these participants do not know they are enrolled in the program or do not understand what services are covered in the program. As identified earlier, many informants feel that there is a lot of confusion

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about the nature and scope of P4HB^®, that it markets a false identity as a maternal and child health or “healthy babies” program and that women do not know that it provides family planning and inter-pregnancy care services. One informant stated that the name Planning for Healthy Babies^® is “awful.” Originally the name discussed for the program was “Family Planning for Healthy Babies,” but for political reasons the term ‘family planning was omitted.” The informant further stated “we believe it (the name) is

deceptive in terms of people who don’t want to be pregnant…why would they ever think I need to enroll in a program called “Planning for Healthy Babies^®.’?

A couple of public health providers explained how the confusion over the name of the program has led to delay in utilization of services. One public health provider

mentioned that several clients were approached about applying for P4HB^® but declined, stating “they’re not interested in NOT having babies.” So there is a population of women who do not want to postpone their pregnancies, that do want to have a baby. Another public health provider echoed a similar problem, that women come to her clinic already enrolled in P4HB^®. These women come in for pregnancy testing, most already knowing they are pregnant, and then have to be disenrolled from P4HB^® after their pregnancy test is positive. “There’s a good many women that are coming in who think it is just for not planning and spacing their babies, but to help them have a healthy baby.” Therefore, these women think P4HB^® is for women who are pregnant.

In addition to confusion over the name and scope of the P4HB^® program, several providers reported that very few P4HB^® women sought health care during the first year of implementation. One public health provider indicated she only began to see P4HB^® clients at her clinic in June 2012, 18 months after the implementation of the program.

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Another public health provider feels that perhaps P4HB^® clients switched initially to seeing private health care providers the first year, and then after being unhappy with their care or simply not having the same kind of relationship with their private physician as they did with their public health nurse, that these clients then came back to public health, but after the first year of P4HB^®.

Informants shared many other concerns about the coverage of services under P4HB^®. Informants from two public health clinic described the problem of not being able to provide services to clients who were accepted into P4HB^® but not yet assigned to a CMO. In these situations, though women can receive services, the clinic will not be reimbursed by Medicaid, so they have to use their public health (Title X) funds for such services. One public health clinic provider complained that follow-up services to an abnormal pap is not covered under the program, so women must either pay out of pocket for a biopsy or ultrasound, or the clinic has to find other funding to pay for the P4HB^® client’s diagnostic service. This provider also wished the program paid for other related services, such as lab tests (blood and urine) and calcium pills, which are prescribed for women who take Depo as their birth control. Another provider who works with IPC women explained that sterilization is a problem for these women. IPC women do not know that if they get a tubal ligation while enrolled in P4HB^®, that their eligibility will then be terminated. The provider feels that women should be kept in this component of P4HB^® to promote overall women’s health. She also feels that providers do not

understand how to code for P4HB® services, and therefore, the low utilization rates may reflect errors in coding on behalf of the participating providers. Coding was identified

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early in the P4HB^® implementation process as a concern that many providers felt and still feel is a hindrance to successful utilization of the program.

A few informants have worried that the Resource Mother services have not been well executed under the IPC component of P4HB^®. One provider was concerned about the nature of the Resource Mother-client interaction when it was first described to the LBW work group. The provider did not feel that a telephone-based Resource Mother system was a good way to maintain contact with the new mothers. According to the Resource Mother interviewed for this study, she makes two attempts to follow up with IPC eligible women if they refuse her services. If after the second attempt to contact the woman by phone, the woman still refuses to enroll in P4HB^®, the Resource Mother terminates the client from her roster. Another informant was concerned about the type of person the CMOs would hire as Resource Mothers. Indeed, CMOs have each hired Resource Mothers with different professional backgrounds: one CMO has hired former DFACS workers as Resource Mothers, another CMO uses social workers, and a third CMO uses nurses.

Two informants expressed concern about the lack of IPC enrollment and

utilization. One of these informants knew that few IPC women were enrolled in the first year. This informant said that original estimates of IPC enrollment was supposed to be 120 (per quarter), and while he did not know that only 27 IPC were enrolled in the first year, the informant knew the real numbers “were nowhere near” the 120 per quarter estimate. The other informant, an advocate, heard that 20 women had been enrolled in IPC in the first year. This informant wanted to “understand what are the reasons for not enrolling..not utilizing” these services.

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Informants also expressed concern that the lack of provider understanding of the program may result in low utilization of services. As one informant stated, while auto enrollment has been a positive step toward improving enrollment into P4HB^®, “if our providers don’t know anything about the program, how are they going to encourage women to seek services.” One advocate feels that DCH should have an advisory board that consists of providers who can learn more about the program but also provide input about the problems they are facing with enrolling and serving women in the program.

This advocate felt strongly about engaging providers in order to improve the P4HB^® program. Finally, one state agency representative cautioned against using enrollment as a measure of success for P4HB^®. This representative is concerned that with the auto enrollment of women into P4HB^®, that this was going to be used by DCH to show the program has been a success. “Utilization needs to be the measure of the program, not enrollment. It is standard for other programs to use enrollment or referrals as measures of a program’s success…but it is not.”