Right for Today...Ready for Tomorrow
In communities across the United States, the lives of nearly one and one half million women each year are positively affected by health care services provided or administered by private nonprofit family planning organizations. For many of these women, the services they receive would otherwise be unavailable to them because they are young, or poor, or living in medically underserved areas.
Now health care reform is underway, and the future of family planning services delivery is under consideration. In order to make a successful plan for the future, it is vital that public policy makers familiarize themselves with the major role that private nonprofit organizations currently play in the delivery of quality, cost-effective, comprehensive family planning services to low-income women in twenty states.
This document provides an overview of the private non-profit family planning organizations' current contributions, as well as a look at the unique strengths that make them ideally suited for playing an even more significant role in health care delivery in the years to come.
Historical Background
On June 7, 1965, the United States Supreme Court made a historic decision striking down the twenty-nine states' laws which had restricted women's access to contraceptives. At the same time, the Federal government committed to public support for family planning services as part of President Lyndon Johnson's War on Poverty. Through its Community Action Program, the Office of Economic Opportunity gave America's poor women the same opportunity as more affluent women to choose the number and spacing of their children.
In 1968, the Maternal and Child Health Program (Title V of the Social Security Act) mandated that six percent of Federal allocations to the states be spent on family planning services. This order was quickly followed by a requirement that state spending of funds received under Title IV-A (later known as the Title XX Social Services Block Grant) include provisions for family planning services for low-income women.
Later, preferential "match" requirements under Titles IV-A and XIX of the Social Security Act gave states an additional financial incentive to provide family planning services.
The limitations of providing family planning services under these arrangements soon became clear. The programs were largely state-controlled, and each state set different policies, priorities, eligibility criteria and reimbursement rates. The programs were operating without Congressional oversight and without its function in maintaining uniform standards of care.
It was not until 1970 that the system care that is in effect today was developed. At that time, the federal government passed the Family Planning Population Research Act creating Title X of the Public Health Services Act. For the first time, a nationwide network of family planning clinics was established. Title X expressly encourage, thecreation of private nonprofit organizations to make family planning available and readily accessible at local community level. (Click HERE for a description of family planning services.)
The Current Role of Private Nonprofit Organizations (PNOs)
Since the passage of Public Law 19-572 (also known as Title X of the Public Health Services Act) in 1970, grants and contracts have been made with a diverse group of public and private nonprofit organizations (PNOs) to foster family planning projects mostresponsive to local needs. Of the $139,925,224 allocated for directservices under Title X in FY 1992, $50,177,825--36 percent--was available to the PNOs through the private sector.
To the funding support that they receive from the Federal Department of Health and Human Services under Title X, PNOs add private dollars raised from their friends and members as well as fees received from patients and third-party payers. They then allocate these funds to delegate agencies within their states. In addition to distributing funds and monitoring expenditures, PNOs provide program coordination, quality assurance, staff training, technical assistance and data processing for their delegate agencies. Some also provide family planning services directly. Delegate agencies funded by the PNOs provide accessible, affordable family planning services to low-income women, either directly or by referral. Women with incomes below the Federal poverty level receive services free of charge. Others pay for services on a sliding fee scale that takes into account income and family size. Medical care is provided by nurse practitioners, physician assistants, certified nurse midwives and physicians. Counseling and education are provided by family planning counselors and other professionals.
Services provided go well beyond contraceptive counseling and dispensing of supplies to include a full range of services required by women in their reproductive years: complete medical examinations, breast and cervical cancer screenings, diagnosis and treatment of sexually transmissible diseases, and other primary and preventive health care. Some PNOs also provide services for young children, including Women, Infants and Children (WIC) nutrition programs, child health screenings and immunizations.
In fulfilling its responsibilities, the PNO serves several functions:
1. It is a provider of and an advocate for family planning services-first, for the women in need within its service area and second for the provider agencies it funds. The PNO identifies areas of special need among the communities it serves and secures and distributes funds to meet those needs. It also promotes public awareness of reproductive health care services and issues and reaches out to the women in need of reproductive health care.
2. It is a coordinator and technical assistance provider. The PNO works to enhance coordination and cooperation among its delegate agencies and the community it serves, encouraging the sharing of resources and information. It identifies, develops and implements programs of training, education and research in areas of reproductive health care. For example, the Family Planning Association of Maine has utilized focus groups with teens to create a 26-lesson curriculum on AIDS education for area eleventh and twelfth grade classes. Fourteen high schools have implemented the program, and the U.S. Center for Disease Control has expressed an interest in its national replication.
3. It is a management agency. The PNO works to secure and distribute funding for direct services, training, education and research in reproductive health care. As a recipient of Title X funds, the PNO is responsible for the quality, cost, accessibility and acceptability of the services provided by its delegate agencies. It establishes standards, monitors the quality of both medical and administrative contracted services, and ensures programmatic and financial compliance by the agencies it funds. The PNO grantee in Los Angeles is in the process of designing an accessible service delivery model for disabled women. This model will be replicated in reproductive health service systems throughout the United States. The project includes the development of self-assessment materials for use by clinics in evaluating their own accessibility to disabled women. It also includes instructional tools which will increase the ability of family planning staff to relate and respond to the special needs of disabled women.
4. It is a not-for-profit corporate agency. As such, the PNO must be organized and managed effectively. It is responsible for demonstrating accountability to its funding sources, for providing management controls for its delegate agencies, and for ensuring that its providers and its service community have input into the decision-making processes surrounding its service delivery.
5. It is locally-controlled. The PNO is open to maximum community involvement. This often results in maximum flexibility in general program operations.
Strengths of the Private Nonprofit Organizations in the Title X Delivery System
Use of private nonprofit organizations to receive and disseminate family planning funds and oversee the provision of reproductive health care services has several important advantages. A discussion of these advantages follows.
Self-Determination. In contrast to the State grantee system, a PNO is both flexible in its programming and insulated from unwarranted political and legislative influences on its activities. The statutory framework of a PNO enables it to function by self-determination. It need look only to its enabling documents for the legal authority to achieve its purposes and carry out its functions. This ability permits a PNO to legally receive multiple funding streams and to perform multiple service activities in an often less regulated environment than that imposed by State governments on their agencies.
Efficient New Program Development. The organizational structure of PNOs at the executive management level is designed to support the quick and efficient implementation of contracts with other agencies and individuals, ensuring that a full range of services can be provided to meet each community's needs.
PNOs have historically utilized this capability to bring together a variety of related services-- including medical care, research and training and to bring new and innovative opportunities to the delivery of health care for low-income women. For example, in certain states, PNOs have helped secure State approval for clinic staff to begin offering such new services as early prenatal care for pregnant women; colposcopy, which facilitates early and accurate detection of cervical cancer, and cryotherapy, an efficient and cost effective treatment for the same disease. The PNO grantee in Philadelphia has developed a special response to the HIV/AIDS epidemic by creating a Pediatric AIDS Program which utilizes the agency's resources and family planning care network to address a major community problem.
Program Accountability. PNO grantees are subject to a number of State and Federal regulation governing the content and quality of care that they provide. These controls are different from those found in State grantees. Together with the commitment of PNO providers to providing quality care, these guidelines have historically assured PNOs' patients of both safe and effective services. Each PNO has a well-functioning quality assurance program which meets Department of Health and Human Services guidelines. PNOs evaluate agencies and provide technical assistance as needed. Visits to delegate agency sites are regularly made by PNO administrators to verify that quality standards are being met. Patient care audits and education audits are also routinely conducted to ensure the quality of medical care and counseling services funded through PNOs.
Community Involvement. Historically, from the 1700s through the 1930s, the entire human services delivery system in the United States was based on the initiative and involvement of private citizens rather than government institutions. Government involvement became more evident during the 1940s and 1950s with the advent of such initiatives as the New Deal and the Hill-Burton Act. With the startup of President Johnson's War on Poverty, government became a significant force in the design of health and welfare programs. Yet, even then, our country's historical commitment to the "maximum feasible participation" of consumers in the design and operation of service systems was emphasized.
Today, it is the private sector grantees in the provision of family planning services who are most responsive to the health care needs and demands of the communities they serve. PNOs are more likely to have a greater degree of consumer participation than public grantees for several reasons:
Cost-Effective, Efficient Service Delivery
Private nonprofit agencies operate from year to year with no tax-based safety net. They must augment their fixed amounts of Title X grant revenues with income derived from fee-for-service payments from patients or third parties and with capitation payments. To survive, PNOs must perform. They must operate full-scale clinic networks which provide services in quantity and of a quality consistent with a certain standard of care. State grantee budgets are derived from tax-based revenue. Increasing tax revenues boosts their budgets from year to year; improving performance does not. State grantees do not have such incentives to develop cost-effective, efficient delivery systems.
Required to perform cost-effectively in order to survive, PNOs have implemented numerous administrative cost control techniques. For example, PNOs employ state-of-the-art technology in program operations such as centralized purchasing, planning and care coordination; total quality management strategies; and bulk-purchasing agreements with pharmaceutical firms that enable even the smallest rural clinics to enjoy low, high-volume prices. PNOs' emphasis on preventive health care also permits tremendous long-term cost savings to be achieved with no sacrifice whatsoever in quality of care. Breast and cervical cancer screenings, child immunizations, prenatal care and nutrition programs, smoking cessation classes and STD screenings are just some of the many preventive health care services available along with family planning at PNO supported clinics.
Regional Training Services for the Public and Private Sectors. In order to ensure that family planning program has skilled and knowledgeable personnel, Title X supports 10 general training centers and five projects training over 250 OB/GYN Advanced Nurse Practitioners annually. In funding all fifteen training programs the Department of Health and Human Services chooses PNOs to organize and deliver these vital training services.
Research to Improve the Quality and Efficiency of Patient Care. Because of their programming flexibility, PNOs are uniquely suited to carrying out programs of applied research. These programs are designed to enhance PNOs' and other providers' ability to provide the widest possible variety of quality, cost-effective, coordinated family planning services to the greatest possible number of women in need. Demonstration and research projects conducted by PNOs have included chlamydia control plans; breast and cervical cancer screening programs; research on new methods of contraception such as Norplant, Depo-Provera and cervical caps; teen pregnancy prevention projects; studies of HIV transmission among high-risk women; and studies involving integration of programming with managed care programs and others.
Community Outreach. PNOs carry out community education programs which serve to inform the public of the availability of their services and to promote community-wide understanding of the benefits of family planning. Representatives of PNOs and their delegate/contract agencies advertise in local media, participate in community activities such as health fairs, and speak to local school, professional and social groups.
Benefits of Family Planning Services
The benefits of family planning services are significant, measurable and many. Family planning services:
Private Nonprofit Organizations and the Future of Family Planning in America
Nonprofit Grantees and Service Integration. While not a new concept in care delivery, service integration recently has become much more widely discussed. Scarce resources and being responsive to client needs both demand that categorical programs like family planning find ways of participating in comprehensive service systems. PNOs are much better suited than state grantees to quickly and decisively make the changes in family planning service delivery that will be needed to achieve integration. They are also much better able to provide and oversee family planning services within an integrated system. Consider, for example, care management, a process which is critical to an integrated service system. A public grantee may find itself forbidden to make certain referrals or to perform certain counseling functions due to legislative limitations or political imperatives. The PNO, however, bound solely by its corporate mission and the by-laws determined by its Board of Directors, finds itself unencumbered in meeting the needs of the women it serves.Additionally, a state grantee is be part of a large, ponderous institutional system. As such, it may forced to consider political compromises and proper bureaucratic approaches before taking any significant action. But the PNO, with its smaller number of decision makers and its more focused commitment to providing family planning care, is streamlined, responsive, and able to react very quickly to changes in the needs of its clients and the demands of its care delivery system.
Nonprofit Grantees and Health Care Reform. The next few years will most likely see dramatic changes in this country's health care environment. Changes involving expansion and coordination of services, health care financing, cost containment programs, managed care projects and national health insurance efforts will all shape the way that reproductive health care services are provided and funded. Reproductive health care services are changing, too, in their focus and scope. Health screenings for reproductive system cancers and sexually transmitted diseases are increasingly utilized. HIV prevention, testing and counseling services are in ever greater demand. STD treatment services are expanding to include male sexual partners. A rise in the incidence of cervical dysplasia has resulted in a greater need for colposcopy services. New contraceptives including Norplant contraceptive implants, injectable Depo Provera, female condoms, and low dose contraceptive pills are providing new options for women who wish to delay child-bearing and those whose families are complete. Co-location of family planning and related services-in some cases including prenatal care, nutrition services for women and children, and immunization for young children--is making a broad array of important basic health care services readily accessible to women who previously had none.
The existing network of private non-profit family planning providers represents an effective national health care infrastructure that is prepared to play a vital operational role in health care reform. Should Congress decide to add new delivery dimensions-such as enhanced community education, special teen projects, or school clinics--to the Title X categorical programs, this infrastructure will readily accommodate them. Strategic planning, venture capitalization, wise allocation of limited resources, performance appraisal, rapid program development and responsiveness to community needs will all be required of the grantees that will successfully integrate family planning into a new comprehensive service system. All are routine functions for today's PNOs.The family planning delivery system of the future will most likely be a public/private partnership of some type. The private nonprofit family planning organizations are ready to contribute significantly to that partnership, both as models of successful program administration and management and as funders of high quality, well-coordinated, responsive health care services for the nearly one and one half million women they already serve each year and the millions more still in need.
FAST FACTS
What people have to say about private nonprofit family planning agencies...
"For more than twenty years, nonprofit Family Planning Councils have played an important role in women's health care. They have worked hard to insure that low-income, high-risk women and teenagers have meaningful access to high-quality reproductive health care. I appreciate and support their efforts." --Former Senate Majority Leader George Mitchell (D-Maine)
"I enthusiastically support the work of the Los Angeles Regional Family Planning Council. For more than 25 years, the Council has provided reliable and accurate information on human reproduction, not only to pregnant women but to the entire community. It has been my honor to cooperate with the Council in its noble efforts. I look forward to continued cooperation with this most worthwhile organization.." --Congressman Henry A. Waxman (D-California) .
"I value and support the work of Family Planning Councils because they are based in the community, are flexible and responsive, and assure that my constituents receive the services they need." -- State Rep. Vincent Hughes (D-Philadelphia) Chair, Pennsylvania, Legislative Black Caucus
"The nonprofit organizations that exist as Title X grantees represent a unique federally funded health care delivery system that is cost-effective, responsive and flexible. They provide a valuable and needed range of health services to millions of American women."-- U.S. Senator Tom Harkin (D-Iowa)
"The private, nonprofit Family Planning councils have shown how successful private/public partnerships can be. Hundreds of thousands of women have been the beneficiaries." -- Judith DeSarno Executive Director, National Family Planning and Reproductive Health Association (NFPRHA)
"Family Planning Councils in this country are a long standing example of what we should strive for in health care reform. The Councils'effective administration has helped to guarantee cooperation, cost effectiveness and the quality of family planning programs and a myriad of related programs for women and children." -- Susan Wysocki, RNC, BSN, NP Executive Director National Association of Nurse Practitioners in Reproductive Health (NANPRH)
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