FAMILY PLANNING

Notes:

^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.  ^a

^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. 

^d2005 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.     

INTRODUCTION

The Program currently has five performance measures that focus on increasing access and serving individuals and families from underserved, vulnerable and low-income populations, three gauging the extent to which the Program expands the availability of healthcare to the public and two measuring the limit to which preventive health care and chronic disease management services are utilized.  Each of the performance measures and the efficiency measure, guide the Program’s strategy, establish direction for technical assistance and direct revisions in program policies.  This enables the Program to better address program performance and facilitate methods to increase efficiency in the delivery of preventive healthcare services.  The Program’s major challenge to meeting its targets and maintaining a high-level of service delivery is the continued increase in medical care prices, which ultimately results in a decrease in clients served.  The Program’s main strategy to address this issue continues to be employing the use of focused training efforts, directing training funding and identifying National Training Priorities to address quality assurance, staffing patterns, procurement strategies and other areas related to improved clinic management, cost reduction and resource allocation.

DISCUSSION OF RESULTS AND TARGETS

36.II.A.1.  Increase the total number of unduplicated clients served in Title X clinics by 5% over five years.  (Indicator:  Total number of unduplicated clients served.)

In 2006, the most recent year for which Program data are available, 4.992 million unduplicated clients were served at 4,442 Title X clinics.  This represents a decrease of slightly less than a quarter percent in the number of clients served in 2006 over the number served in 2005. Of these, 95 percent were women and 5 percent were men.  The small decrease (1.49%) in overall users between 2004 and 2006 suggests a continuing leveling off trend in client numbers, following the more substantial gain experienced between 2000 - 2001 when additional funds were provided to the Program. The decrease is also a reflection of the continued increase in the cost of medical supplies and cost for services, including the rising cost of contraceptive supplies.  The FY 09 target is 4,985,000 unduplicated clients. 

36.II.A.2.  Maintain the proportion of clients served who are at or below 200 percent of the Federal poverty level at 90% of total unduplicated family planning users.

(Indicator: The proportion of clients with incomes at or below 200 percent of the Federal poverty level.)

Title X Family Planning clinics play a key role in providing family planning and related preventive health services to individuals who can least afford such services - low-income persons, many of whom have no insurance or lack insurance coverage for family planning and related preventive health care services. The Title X program provides family planning education and services to all persons who desire them and assures access by giving priority to low-income persons. The Program consistently maintains the proportion of clients who are at or below 200% of the Federal poverty level at 90% of the total unduplicated number of family planning clients.  In 2006 and historically, of the total number of unduplicated clients, 90 percent had incomes at or below 200 percent of the Federal poverty level. The Target for FY 09 is 90%.

36.II.A.3.  Increase the total number of unintended pregnancies averted by providing Title X Family Planning Services, with priority for services to low-income individuals.

(Indicator: Total number of unduplicated female clients served in Title X clinics multiplied by a factor of 20.65%; prior to the 2005 data the factor was 23.3%)

Each year, publicly-subsidized family planning services assist women in avoiding an estimated 1.3 million unintended pregnancies.  Title X is a major provider of publicly funded family planning services and offers a broad range of contraceptive methods and services, which enables men and women to plan pregnancies and space births, important elements in ensuring positive birth outcomes and a healthy start for children and families.  In FY 06, 975,080 unintended pregnancies were averted through the provision of family planning and related preventive health services in Title X clinics.  The FY 06 figure is less than the FY 05 actual and the FY 06 target largely due to the change in the multiplier used to determine this figure as well as a decrease in female users.  The initial FY 05 and 06 targets were established using the original multiplier which was higher than the most current multiplier.  (See section below on “Targets Substantially Exceeded or Not Met.”)  The FY 09 target is 978,000 unintended pregnancies averted. 

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.

(Indicator: The number of female clients ages 15-24 who received a Chlamydia test.)

Title X, through the provision of family planning and related preventive health services, has an impact in preventing infertility in women and ensuring their health, well-being and ability to have a healthy pregnancy. Based on Chlamydia prevalence data collected by the CDC Division of STD Prevention under the Infertility Prevention Program (IPP), the number of infertility cases prevented can be calculated.  IPP data collected over several years illustrates that there is a 5.9 percent positivity rate for Chlamydia in family planning clinics.  If left untreated, an estimated 10 - 40 percent of those cases would lead to pelvic inflammatory disease (PID).  Of those, an estimated 20 percent would become infertile due to the untreated infection. This calculation results in an estimated number of cases of infertility.   

In FY 05, the baseline as well as future targets were established regarding the number of females ages 15 - 24 years screened for Chlamydia.  In FY 06, 1,353,000 screenings for Chlamydia were conducted.  While the number of screenings in FY 06 was more than in FY 05, the targets for FY 06 were not met.  The decrease in the number of female clients is the primary reason for this occurrence.  The target for FY 09 is 1,349,000.

36.II.C.1.  Increase the number of unduplicated female clients who receive a Pap test.  

(Indicator: Number of unduplicated female clients who receive a Pap test.)

Title X funded agencies are required to perform Pap tests according to nationally recognized standards of care, to document these results in the client’s record and to have a system to track or monitor follow-up care for abnormal results.  The frequency of Pap testing varies based on individual circumstances, but current recommendations stipulate screening every one to three years.  Beginning in 2005, data was collected on the number of unduplicated clients receiving a Pap test in order to better understand and monitor the scope of cervical cancer screening in Title X projects. In FY 06, 2,324,488 unduplicated women received a Pap test, about 5% lower than the previous year. The decrease in the number of female clients as well as less frequent screening in accordance with current medical standards are the primary reasons for this occurrence.  The target for FY 09 is 2,365,000. 

36.II.C.2.  Reduce invasive cervical cancer among women attending Title X family planning clinics by providing Pap tests.   

(Indicator: The projected cases of invasive cervical cancer avoided based on the number of unduplicated female users in Title X who received a Pap test.)

Based on Title X clinics providing Pap tests for their female clients and using accepted estimates of the number of cases of invasive cervical cancer that would result if screening did not occur (33 cases per 100,000 women screened annually and 96 cases per 100,000 women screened every three years), the number of invasive cervical cancer cases prevented can be calculated.  In FY 05, the FPAR began collecting data on the unduplicated number of women receiving Pap test in Title X projects.  Using this figure, the range of invasive cancer cases prevented by Pap testing in Title X clinics can be calculated.

In FY 06, at least 799 cases of invasive cervical cancer were prevented as a result of the number of women who attended and received a Pap test at a Title X clinic,  slightly lower than the number of cases prevented in FY 05.  The target for FY 09 is 798.

1.E Maintain the actual cost per Title X family planning client below the medical care inflation rate.

(Indicator: The actual cost per client is derived by dividing the total revenue by the total number of individuals served, and then factoring in the annual medical care Consumer Price Index (CPI).) 

It is vital that family planning clinics maximize the number of patients served.  Tracking the average cost per client, and factoring the medical care price index, is an appropriate process to assess efficiency. The program is able to measure and set targets for the average cost per client using the FPAR data and comparing the annual rate of growth of actual expenditures to the baseline amount forecasted using the CPI for medical care prices. 

In 2006 the actual cost per client was $215.56, $8.41 less than the targeted projection.  This resulted in cost avoidance of approximately $42 million in client costs.  The Program has consistently met or come under the annual target for this measure and historically has kept its increase in total cost per client below that of the CPI for medical care costs. The Target for FY 09 is $254.55.

TARGETS SUBSTANTIALLY EXCEEDED OR NOT MET

Measure:  Increase the number of unintended pregnancies averted by providing Title X family planning services, with priority for services to low-income individuals.

            FY 06 target: 1,142,608

            FY 06 result:    975,080

The performance result was substantially lower than the target for FY 06.  This outcome was primarily due to the change in the multiplier used to determine the number of unintended pregnancies averted through the Title X Family Planning Program.  The initial targets were developed using the original multiplier, approximately 11% higher than the current figure, thus establishing an inflated target figure.  In addition, the decrease in the unduplicated number of female clients seen contributed to the target not being met, but to a much lesser degree.  The out-year targets have been adjusted downward to reflect the change in multiplier and the forecast in unduplicated clients.

The crisis of unintended pregnancy continues to exist, despite advances in preventive health care practice and medical advances.  The Program’s mission to continue to provide education and preventive health care services, especially to the underserved, vulnerable, low-income and others who are disproportionately affected, is essential given the continued decline in preventive health indicators and widening of health-related disparities. The performance measure is an effective indicator of the Program’s effectiveness and reflects a positive health outcome for the mission of and the preventive health services performed by the Program.