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FY 2009 Budget Justification

Family Planning

  FY 2007 Actual FY 2008
FY 2009
FY 2009 +/-
FY 2008
BA $283,146,000 $299,981,000 $299,981,000 ---
  42 42 45   +3

Authorizing Legislation: Title X of the Public Health Service Act

FY 2009 Authorization Expired 
Allocation Method Competitive Grant  

Program Description and Accomplishments
The Title X Family Planning program was enacted in 1970 as Title X of the Public Health Service Act. Title X is the only federal grant program dedicated solely to providing individuals with comprehensive family planning and related preventive health services. The Title X program is designed to provide access to contraceptive services, supplies and information to all who want and need them. By law, priority is given to persons from low-income families. Title X service funds are allocated to the ten Public Health Service (PHS) Regional Offices which, manage the competitive review process, make grant awards and monitor program performance. Services are provided through 88 service delivery grants that support a nationwide network of more than 4,400 clinics that provide services to approximately 5,000,000 persons annually. Historically, 90 percent of the clients served each year have incomes at or below 200 percent of the Federal poverty level. Family planning service grants are made to public and private not-for-profit organizations to support the provision of family planning clinical services and information.

Services are delivered through a network of community-based clinics that include State and local health departments, hospitals, university health centers, independent clinics, and public and nonprofit agencies. In FY 2003, nearly 75 percent of U.S. counties had at least one provider of contraceptive services that was funded by the Title X family planning program. Ninety percent of the program funds are used to provide clinical services. For many clients, Title X clinics provide the only continuing source of health care and/or health education.

The family planning program provides a broad range of effective and acceptable family planning methods and related preventive health services. The Title X program also supports three key functions aimed at assisting clinics in responding to clients’ needs: (1) training for family planning clinic personnel through ten regional general training programs, one national clinical training program, one national training center, and one national training program aimed at enhancing quality services for males in Title X projects; (2) information dissemination and community-based education and outreach activities; and (3) data collection and research to improve the delivery of family planning services.

The Title X Family Planning program addresses HHS Strategic Goal 3, “Increase the percentage of the Nation’s children and adults who have access to health care services, and expand consumer choice,” and supports the Secretary’s “500-Day Plan” by supporting community-based approaches to close the health care gap.

In 2006, the most recent data available, just over 975,000 unintended pregnancies were averted,
1.35 million screenings for Chlamydia infection in 15 – 24 year old females and 799 cases of invasive cervical cancer were prevented through the services provided by the Title X Program. All of these accomplishments were below their initial targets, mainly as a result of the increase in medical care prices for services, contraceptives and other medical supplies and diagnostic tests.

The Program under went its PART review in the Spring of 2005 and received a rating of Moderately Effective. The PART noted that the Program’s overall purpose, design and management are strong; that the clients who use Title X clinics receive better care than women who utilize private physicians or HMOs; and despite the collection of annual data, the Program lacked performance goals for some of its key program activities. As a result, the Program developed performance targets and goals for all of its main program activities and has planned and begun an independent evaluation of sufficient quality and scope which will examine and demonstrate the overall impact of the program.

Funding History

FY 2004 $278,283,000
FY 2005 $285,963,000
FY 2006 $282,907,000
FY 2007 $283,146,000
FY 2008 $299,981,000

Budget Request
The FY 2009 Budget Request is $299,991,000, which is equal to the FY 2008 funding amount. The request provides funding for family planning methods and related preventive health services, as well as related training, information and education, and research to improve family planning service delivery.

The program will continue to seek ways to increase efficiencies in order to maintain services despite the increasing costs of pharmaceuticals, providers, and screening and diagnostic technologies with the goal of maintaining the actual cost per client below the medical care inflation rate. In addition, the program will continue to seek ways to increase competition for family planning service funds, targeting areas that currently lack access to family planning services.

The FY 2009 funding level is expected to support family planning services for approximately 4,985,000 persons, with at least 90 percent of clients having incomes at or below 200 percent of the federal poverty level. In addition, it is forecasted that around 978,000 unintended pregnancies will be averted, 1.349 million screenings for Chlamydia infection in 15 – 24 year old females and 798 cases of invasive cervical cancer be prevented in FY 2009 through the services provided throughout the Title X Program. These services include the provision of family planning methods, education, counseling and related preventive health services. The annual targets for FY 2008 and FY 2009 reflect the increase and subsequent level amount of funding. Although the program will continue to emphasize being as efficient as possible, rising costs of medical care will make it difficult to maintain service delivery at FY 2008 levels. The revised targets for both FY 2008 and FY 2009 still represent aggressive figures based on the significant increases in medical costs, the current program’s appropriation, grantee revenue from other sources and forecasted trends for the future.

Despite the rise in medical care costs, the family planning program has been able to maintain the average cost per Title X clients below the medical rate of inflation, although the program has observed a slight decrease in the number of overall clients served. To address this decrease, the program’s main strategy in FY 2007 was to increase clinic efficiency through a concentrated training effort. The Office of Family Planning (OFP) identified and provided to each of the ten Regional Training Centers (RTCs) funding to address a National Training Priority area: providing training to Title X providers on improving clinic efficiency in an effort to address increasing costs of health care without sacrificing quality. This concerted training effort and the development of region-specific plans to address clinic efficiency, quality assurance/continuous quality improvement, appropriate staffing patterns and purchasing strategies, various methods of cost analyses and other areas were aimed at developing processes to more effectively address client needs and mitigate the effects of medical cost increases. The OFP continues to emphasize the need for clinic efficiency and to support provide technical assistance to improve clinic management, cost reduction strategies and more efficient resource allocation.

Additionally, the OFP has awarded a 1% evaluation task order entitled, “An Analysis of the Effectiveness of Title X Family Planning Providers’ Use of the 340B Drug Pricing Program.” The purpose of this evaluation is to document the successes, challenges/obstacles and trends of Title X providers’ use of the 340B Drug Pricing Program. Better insight into this and other drug pricing programs will help Title X clinics provide better care to their clients, serve them more efficiently and lower costs in an effort to improve health care access and quality and promote preventive health practices.

# Key Outcomes a,b FY 2004 Actual FY 2005 Actual FY 2006 FY 2007 FY 2008 Target FY 2009 Target Out-year Target
Target Actual Target Actual
Long-Term Objective: Expand the availability of healthcare, particularly to undeserved, vulnerable and special populations.
36.II .A.1 Increase the total number of unduplicated clients served in Title X clinics by 5% over five years. 5,067,785 5,002,961 5,162,000 4,992,498 5,162,000 Jul-08 5,000,000 4,985,000 2010: 4,975,000
36.II .A.2 Maintain the proportion of clients served who are at or below 200% of the Federal poverty level at 90% of total unduplicated family planning users. 91% 90% 90% 90% 90% Jul-08 90% 90% 2010: 90%
36.II .A.3 Increase the number of unintended pregnancies averted by providing Title X family planning services, with priority for services to low-income individuals. c 1,125,300 978,845 d 1,142,608 975,080 1,012,655 Jul-08 981,000 978,000 2010: 976,000
Long-Term Objective: Increase the utilization of preventive health care and chronic disease management services, particularly among underserved, vulnerable, and special needs populations.
36.II .B.1 Reduce infertility among women attending Title X family planning clinics by identifying Chlamydia infection through screening of females ages 15-24. e Not Collected 1,349,884 1,398,000 1,353,319 1,398,000 Jul-08 1,352,000 1,349,000 2010: 1,347,000
# Key Outcomes a,b FY 2004 Actual FY 2005 Actual FY 2006 FY 2007 FY 2008 Target FY 2009 Target Out-year Target
Target Actual Target Actual
36.II .C.1 Increase the number of unduplicated female clients who receive a Pap test. f Not Collected 2,447,498 2,450,000 2,324,488 2,450,000 Jul-08 2,372,000 2,365,000 2010: 2,361,000
36.II .C.2 Reduce invasive cervical cancer among women attending Title X family planning clinics by providing Pap tests. g Not Collected 808 809 799 809 Jul-08 800 798 2010: 796

# Key Outputs FY 2004 Actual FY 2005 Actual FY 2006 FY 2007 FY 2008 Target FY 2009 Target Out-year Target
Target Actual Target Actual
Efficiency Measure
36,E Maintain the actual cost per Title X client below the medical car inflation rate. h i $193.92 $200.81 $223.97 $215.56 $233.73 July-08 $243,92 $254.55 2010:
  Appropriated Amount ($ Million) 278.283 285.963   282.907   283.146 299.981 299.981  


a Data Source for the performance table: Family Planning Annual Report (FPAR). The FPAR consists of 14 tables in which grantees report data on user demographic characteristics, user social and economic characteristics, primary contraceptive use, utilization of family planning and related health services, utilization of health personnel, and the composition of project revenues. Table 4 collects information on the unduplicated number of family planning users by income level.
b Data Validation: The responsibility for the collection and tabulation of annual service data from Title X grantees rests with the Office of Population Affairs (OPA), which is responsible for the administration of the program. Reports are submitted annually on a calendar year basis (January 1 - December 31) to the regional offices. Grantee reports are tabulated and an annual report is prepared summarizing the regional and national data. The annual report describes the methodology used both in collection and tabulation of grantee reports, as well as the definitions provided by OPA to the grantees for use in completing data requests. Also included in the report are lengthy notes that provide detailed information regarding any discrepancies between the OPA requested data and what individual grantees were able to provide. Data inconsistencies are first identified by the Regional Office and then submitted back to the grantee for correction. Additionally, discrepancies found by the contractor compiling the FPAR data submits these to the Office of Family Planning (OFP) FPAR data coordinator who works with the Regional Office to make corrections. All data inconsistencies and their resolution are noted in an appendix to the report. These are included for two reasons: (1) to explain how adjustments were made to the data, and how discrepancies affect the analysis and (2) to identify the problems grantees have in collecting and reporting data, in hope of improving the process.
c Using population-based data from the National Survey of Family Growth (NSFG), contraceptive use, and contraceptive method failure rates to estimate the rate of pregnancies averted, it is calculated that pregnancies averted are 20.65% of the number of women who receive publicly funded family planning services. This multiplier factor was changed for 2005 based on updated data from NSFG. This percentage is applied to the total number of females served in Title X clinics (FPAR) to arrive at the number of pregnancies averted as a result of the Title X program. Increasing the number of clients is contingent on increased efficiency within the Title X service delivery system, and will be addressed through technical assistance and training.
d 2005 Actual data represents the first year that the described updated multiplier is being used.
e Based on changes from CDC based on the positivity rate for Chlamydia in Title X clinics, targets and results may be adjusted accordingly.
f The baseline was determined using data from the 2005 FPAR.
g The baseline was determined by applying the formula for determining the projected cases of invasive cervical cancer to the 2005 FPAR Data using the # of unduplicated female users who received a Pap test. Methodology – The range in number of cases of invasive cervical cancer prevented will be estimated using accepted estimates of the number of cases of invasive cervical cancer that would result if women were screened annually and if they were screened every three years (33 cases per 100,000 women screened in an annual Pap test and 96 cases per 100,000 women screened every three years).
h Data Source: Consumer Price Indexes of Medical Care (CPI)/U.S. Department of Commerce, Bureau of Labor Statistics
i Targets for FY 06, 07 and 08 are based on forecasted CPI. The targets are determined as a product of the baseline figure (1999 actual cost per client) and the corresponding year’s CPI for medical care prices. The target for future years is determined as a product of the prior year’s target and the forecasted CPI for the year based on historical data. The targets will be recalculated to reflect the actual CPI once the data are available. The measure allows the Program to quantify the efficiency of the services while controlling for the cost of medical care using the consumer price index (CPI). As a result, preventive services and related reproductive health outcomes can be assessed with respect to cost per client compared to the CPI of Medical Care.