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Managed Care and Unintended Pregnancy:
Testing the Limits of Prevention

July 1997 - Number Three

By Julianna S. Gonen, PhD


As more and more Americans enroll in managed care plans, it becomes increasingly important to assess and identify how these plans can address the prevention of unintended pregnancy. Although managed care plans emphasize their commitment to preventive care, the extent to which preventing unintended pregnancy is included in their concept of such care is unclear. The Institute of Medicine, which issued a major report on this issue in 1995, stated that "the problem of unintended pregnancy is as much one of public policies and institutional practices as it is one of individual behavior." As organized delivery systems, managed care organizations (MCOs) are thus in a position to influence the rates of unintended pregnancy among their enrollees. This paper reviews data on family planning and contraceptive coverage, the effect of managed care on traditional and community-based family planning providers, the specific challenges of preventing unintended pregnancy among adolescents, the state of quality measurement for this issue,and relevant public policy.

Defining the Problem

An "unintended" pregnancy is one that a woman considers either mistimed or unwanted at the time of conception, and in the United States such pregnancies are widespread and on the increase. While the proportion of births from unintended pregnancies had decreased during the 1970s and early 1980s, the downward trend reversed in the late 1980s and 1990s. The national Healthy People 2000 goal is to reduce to 30% the proportion of all pregnancies that are unintended; currently the proportion stands at almost 60%. The problem affects all segments of society, not just teenagers and unmarried women, as is often thought. While a disproportionate share of women experiencing unintended pregnancies are unmarried or at either end of the reproductive age span, they do not by any means account for all such births.1

Public perception tracks the scope of the problem moderately well, with 60% of respondents in a 1994-95 Kaiser Family Foundation survey stating that they believed that unplanned pregnancy was a "very big problem."2 But in debates over teen pregnancy, out-of-wedlock childbirth, and abortion, the common element of pregnancy that is unintended at the time of conception is often overlooked.3 This oversight, combined with a tendency to focus only on particular vulnerable groups (such as young single women receiving public assistance) essentially ensures that efforts to address these problems will fail, as they do not address the underlying causes and associated issues.

Preventing unintended pregnancy enhances health prospects for mothers, children, and their families; improves prenatal outcomes; and reduces health care expenditures. Unintended pregnancy carries significant risks for women and their families beyond those that may already be present due to social and economic factors. Risks to the mother include health risks, violence, dissolution of a relationship, and interrupted educational and career goals. Other adverse outcomes are lack of preconception risk identification, delayed initiation of prenatal care, exposure of the fetus to alcohol, tobacco, drugs or medications, and increased likelihood that the child will be low birthweight, die in the first year of life, be abused, and not receive sufficient resources for healthy development. Unintended pregnancy also leads to approximately 1.5 million abortions annually in the United States; the ratio of abortions to live births here is significantly higher than in many other Western countries, despite the relatively greater ease of access to abortion in those countries.

A major cause of unintended pregnancy is failure to use contraception properly and consistently. The 21 million American women relying on reversible contraceptive methods and the 4 million not planning to become pregnant but not using contraception contribute roughly equally to the number of unintended pregnancies. Unwanted pregnancies may also result from non-consensual sexual intercourse.4 Contraceptive use and unintended pregnancy are influenced by access to and proficiency with contraception, personal feelings and attitudes, sexual behavior patterns, cultural, social, political and religious values and beliefs, racism and violence, and media messages.

A recently published study of data from the National Survey of Family Growth and the National Maternal and Infant Health Survey concluded that having private insurance does not guarantee access to family planning services.5 Trends in the 1980s indicated a modest decline in family planning visits, a marked reduction in public expenditures for contraceptive services, and an increase in the percentage of births from unintended pregnancies. The study suggested several steps to increase access to family planning services, including standardizing the types of family planning services available under all health insurance policies, increasing the availability of more effective prescription-based methods (which thus requires increased access to providers), removing financial barriers such as copayments, formally classifying family planning as a preventive service, and devoting more public funding to family planning services.

Costs associated with pregnancy can be significant: $400- 500 for an induced abortion, over $1,000 for spontaneous abortion, nearly $5,000 for an ectopic pregnancy, and over $8,000 for a term pregnancy (assuming a private payer model). A recent comprehensive study in the American Journal of Public Health evaluated the clinical and economic impacts of 15 contraceptive methods.6 The study found that all 15 methods were more effective and less costly than no method. The most effective methods would in fact each save over $13,000 per person and prevent approximately 4.2 pregnancies per person over a five-year period. The study concluded that contraceptives save health care resources by preventing unintended pregnancies, and that up-front acquisition costs are inaccurate predictors of the total economic costs of competing methods. This sort of assessment is particularly pertinent for managed care, where cost considerations are either explicitly or implicitly included in coverage and treatment decisions.

The models used in the study suggest that although savings realized through contraception generally accrue to third-party payers, contraceptive costs are often not borne by these payers. It is not clear whether expanding contraceptive coverage would increase or decrease costs to payers, as this would depend on whether this coverage would simply replace individuals' out-of-pocket costs with expenditures by the payer, or whether better coverage would increase overall access and contraceptive use, thereby decreasing the number of unintended pregnancies and their associated costs. Since coverage does not guarantee use, or effective use, it does not guarantee a reduction in the rate of unintended pregnancy, but increased coverage should as least contribute to such a reduction.

Drs. Philip Lee and Felicia Stewart, then both of the U.S. Public Health Service, stated that "the most important conclusion drawn from this contraceptive model is that the high cost of non-use justifies large investments in outreach."7 Outreach to increase the use of clinical preventive services (such as immunizations, Pap tests, mammograms) is one area in which managed care plans have made particular efforts, and there is clearly both a need and an opportunity for extending such efforts to include contraceptive use. But health plans must first consciously define prevention of unintended pregnancy as a preventive service and commit to it as they do to other such services.

Family Planning and Contraceptive Services in Managed Care

Reproductive health services pose some challenges to traditional concepts of what is covered under health insurance in the United States. Prenatal care and abortion, for example, are episodic and time-sensitive, but not really "acute care," while a need for contraception may persist over many years without constituting a "chronic condition."8 The continuum of reproductive health care includes contraceptive services (including contraceptive sterilization), routine gynecologic care (including screening for sexually transmitted diseases [STDs] and cancer), preconception risk assessment, maternity care, abortion, and STD and infertility treatment. Traditionally, insurance has not treated these interrelated services as a discrete reproductive health package. In addition, the preventive nature of services has left them outside the sphere of traditional indemnity insurance coverage, which has focused principally on curative care.9 And despite improvements over fee-for-service, "the current 'fit' between reproductive health and managed care is not always a good one."10 Serious gaps in coverage remain, which may in fact reflect more the desires of health care purchasers than those of health plans. (The important role of health care purchasers was addressed at greater length in Insights #2.)

CoverageA 1993 study of private-sector insurance coverage of reproductive health services conducted by the Alan Guttmacher Institute (AGI) revealed significant differences among traditional indemnity plans, preferred provider organizations (PPOs), point-of-service (POS) networks, and health maintenance organizations (HMOs).11 Only 49% of large-group indemnity plans and 39% of small group plans covered annual gynecologic exams, compared with 64% of PPOs, 88% of POS networks, and 99% of HMOs.12 All plan types were more likely to cover specific medical procedures associated with such exams, including Pap tests and chlamydia cultures. Almost half of all typical large-group plans and PPOs did not cover any contraceptive methods, and only 15% covered all five reversible methods included in the study: intrauterine device (IUD) insertion, diaphragm fitting, Norplant insertion, Depo-Provera injection, and oral contraceptive prescriptions. (Blue Cross/Blue Shield plans, however, reported greater coverage levels than indemnity plans overall.) HMOs covered oral contraceptives at approximately the same rate that they covered other prescription drugs, at 84% and 89% respectively.

Although oral contraceptives are the reversible method most commonly used in the United States, only 33% of large group plans covered them, despite the fact that 97% of such plans typically cover other prescription drugs. Similarly, while these plans routinely cover other medical devices, fewer than a quarter covered IUDs, diaphragms, and Norplant. Forty-one percent of PPOs routinely covered oral contraceptives, although 99% cover prescription drugs in general. At the other end of the spectrum, only 7% of HMOs covered no contraceptives, and 39% routinely cover the five reversible methods in the study. HMOs covered oral contraceptives at approximately the same rate that they covered other prescription drugs, at 84% and 90% respectively. POS networks fell between HMOs and the indemnity and PPO plans, with 19% offering no contraceptive coverage, 60% routinely covering some oral contraceptives, and 33% covering all five methods.

Surgical reproductive procedures were well covered, in keeping with traditional insurance's emphasis on surgical procedures in general. Tubal ligation was covered in 86% of large-group indemnity plans, PPOs, and HMOs, and in 90% of POS networks. Vasectomies were also routinely covered by between 85 and 90% of each plan type.

The AGI study also inquired about coverage for spouses and other dependents of policyholders. Although the federal Pregnancy Discrimination Act requires employers who provide maternity benefits to employees to provide them for spouses also, the same does not apply to other reproductive services. For example, slightly fewer plans cover oral contraceptives for policyholder dependents; 86% of PPOs, 89% of large-group indemnity plans, 91% of HMOs, and 95% of POS networks provided this coverage to spouses. The numbers are slightly lower for contraceptive coverage for other dependents: 82% of PPOs, 84% of large-group plans, and 91% of POS networks and HMOs.

A 1994 survey of HMOs, conducted by the Group Health Association of America (GHAA, now the American Association of Health Plans) and the Kaiser Family Foundation, examined management of reproductive health in GHAA member health plans.13 Regarding specific contraceptive/family planning services, 90% of HMOs covered IUD insertion and removal, 93% covered diaphragm fitting, 77% covered Norplant insertion and removal, and 97% covered vasectomies and tubal ligations (while less than 10% covered reversals of these two procedures). The majority of plans that covered these services required some form of enrollee copayment. For prescription contraceptives, 87% of plans covered oral contraceptives, 83% Depo-Provera, and 70% diaphragms. Again, most plans required some enrollee copayment.

ConfidentialityConfidentiality is critical in reproductive health services. A small number of plans in the AGI study (6% of large-group indemnity and PPOs, 5% of POS networks, and 4% of HMOs) notify employers about specific individuals receiving specific services. Under the claims system of indemnity insurance, dependents may encounter difficulty receiving confidential services if a policyholder signature is required on a claim form or if the Explanation of Benefits (EOB) is sent to the policyholder. The majority of large-group, PPO, and POS plans did not require a policyholder signature for claim form submission, with more plans requiring the signature for minors than for non-minor dependents. Most plans, however, do send the EOB directly to the policyholder; less than 15% of the three plan types using claim forms would send the form directly to the dependent who received the care. Confidentiality was more assured in HMOs, which typically do not use claim forms, because the care is prepaid except for the visit copayment. Seventy-one percent of HMOs said that they do not send the employee a statement of services received by dependents, while some will do so under certain circumstances. Lack of confidentiality assurances in non-HMO plan types may mean that some individuals either finance reproductive health services out-of-pocket or forego them altogether.

Plans in the GHAA/Kaiser study were asked if they required special confidentiality protections for family planning services. Only 4% of plans had such protections; less than 2% required separate billing procedures for family planning services to protect patient confidentiality. Approximately 85% did not require parental notification or consent when providing family planning services to minors.

Access and Care Coordination.   Coverage is not the only factor that affects access to reproductive services. The time-sensitive nature of services such as prenatal care, abortion, and contraception make them particularly subject to the potentially adverse effects of managed care mechanisms such as preauthorization requirements. The rationale for prior authorization is to ensure that services sought are necessary and appropriate, but these terms have less meaning in the context of reproductive services, particularly contraception, where the decisions about use lie solely with the enrollee and the need for services or prescriptions is not strictly "medical." Allowing women to choose ob-gyns as primary care providers may enhance access to contraceptive and reproductive care, but even ob-gyns do not all perform the full range of such services, necessitating referral to other providers in such cases. Care coordination, another managed care component, may prove a threat to individuals seeking confidential treatment for sensitive reproductive health needs. But while 59% of plans in the GHAA/Kaiser HMO survey reported that family planning providers and primary care physicians had access to one another's records, 40% of plans did not report this access, which seems to run counter to the care coordination purported to be a hallmark of managed care plans.

A potential issue related to availability of contraceptive and family planning services is the growing role of Catholic-affiliated hospitals and clinics. A recent study conducted at Johns Hopkins University for the Henry J. Kaiser Family Foundation found that Catholic hospitals and health systems were involved in about 18% of the nation's hospital affiliations (mostly mergers and acquisitions) between 1990 and 1996, and that a key factor motivating these affiliations was increased competition in local markets resulting from the growth of managed care. In case studies of four successful affiliations between Catholic and non-Catholic providers, no evidence was found that the affiliations resulted in reduced availability of contraceptive services (including emergency contraception and sterilization). In these cases, contraception was viewed as an issue best considered within individual physician-patient relationships, and no organizational policies restricting physicians' ability to prescribe contraception were observed. But only one of the case study sites showed evidence of actively promoting family planning services. Thus, although the market for contraceptive services was not ignored by these providers, their ethical and religious values influenced the context within which services were organized.14 Catholic ownership of entire health plans is not evident, but the existence of Catholic institutions within managed care networks, particularly limited networks, could pose barriers to some enrollees seeking family planning services.

Medicaid and Traditional Community Providers

Medicaid is the largest source of public funding for contraceptive services and supplies, accounting for half of the public dollars spent in the United States. Medicaid now pays for more family planning services than does Title X, which funds nearly 4,000 family planning providers serving low-income patients.15 In 1981, states were given the option of applying for 1915 waivers which allowed them to set up Medicaid managed care programs without giving enrollees open access to providers of their choice, a requirement of the federal Medicaid statute. But problems arose under these waivers as enrollees continued to seek family planning services from community-based providers who were not part of managed care networks and thus were often not reimbursed. Patients sought to continue using these providers out of a desire for confidentiality, preference, and comfort, and to avoid service delays encountered within their health plans. As a result, Congress mandated in 1986 that plans operating under 1915 waivers must restore the freedom-of-choice provision for family planning providers.

This ameliorated the situation to some extent, but a George Washington University study identified several persistent problems: the lack of a uniform definition of family planning services, the failure of the 1986 law to prohibit plans from requiring prior authorization before seeking out-of-plan services (effectively nullifying the freedom-of-choice guarantee), and the range of reimbursement mechanisms used for family planning providers. While some are compensated directly by the state, others must seek reimbursement from the managed care plans; without a formal contract, these providers often go unpaid. The study concluded that carving family planning services out of Medicaid managed care plan capitation rates may have afforded providers temporary protection. But it may also have deprived them of incentives to enter into arrangements with managed care plans during a time of dynamic change in the Medicaid program, forcing them now to play "catch-up" and aggressively market themselves to managed care plans.16

Recent surveys bear this out. The GHAA/Kaiser survey inquired about HMO contracts with outside family planning providers such as Planned Parenthood, school-based clinics, community health centers, and other family planning agencies. Twenty-three percent reported contracts or reimbursement arrangements with Planned Parenthood, 14% with community health centers, and less than 3% with school-based clinics. Many reported no interest in establishing such arrangements. Some family planning agencies have entered into collaborative arrangements with managed care, with varying degrees of success. The viability of these arrangements tends to depend on the level of managed care penetration in the local health care market, the clinic's patient profile, applicable government regulations, and the political environment.17

The 1994 National Survey of Women's Health Centers also explored the emerging relationships between these niche and community-based service providers and MCOs.18 Reproductive health centers constitute just over 70% of the estimated 3,600 women's health centers operating in 1993, and many women rely on these centers as their usual source of care.19 Primary care and reproductive health centers were found to be the least likely to have contracts with MCOs, and among all the centers with managed care contracts, reproductive health centers had the smallest average percentage of patients enrolled in managed care and derived the least amount of revenue from managed care. A primary strategy adopted by reproductive health centers was to expand into primary care or midlife women's health services in order to qualify as a primary care provider. Centers undergoing such transitions face staff resistance to changing the organizational mission, staff retraining and client education needs, marketing issues, and questions about maintaining confidentiality.

Adolescents

Although unintended pregnancy affects women of all ages, it is of particular importance among adolescents. One in 10 adolescent American girls will give birth by the time she reaches 18. In 1992, the total annual costs of obstetric services for adolescents was estimated at more than $4 billion. Approximately 9% of adolescents who gave birth in 1992 delivered a low-birthweight infant, at an additional annual cost of $1.5 billion.20 There is a scarcity of information on the use of managed care systems by adolescents, an underserved population with a tendency to be reticent about seeking services, and indications are that few MCOs specifically address either the prevention or the outcomes of teenage pregnancy.21

School-based health centers (SBHCs) have emerged recently to increase access to health care services among adolescents, particularly those who have low income or lack sufficient insurance coverage and others means of receiving care.22 While these centers offer a range of services, "a relatively small proportion [18.5%] of student visits to SBHCs are for reproductive and sexual health needs." One of the major reasons for the success of SBHCs is their ability to provide confidential services, an issue with particular salience for sexuality and contraception.

With the advent of Medicaid managed care programs, these centers have begun to face issues similar to those faced by women's health centers, family planning clinics, and other community-based providers. There are examples of SBHCs working with MCOs, either joining the network and sharing in capitation payments, establishing reimbursement mechanisms for specific services, or developing formal referral and treatment protocols between the managed care plan providers and the SBHCs. Some MCOs are now beginning to take steps to improve service delivery to adolescents in a manner similar to the SBHC approach. Group Health Northwest in Spokane, Washington, has a birth control case management program, in which nurses monitor sexually active teens to encourage and facilitate their continued use of contraceptives. Many Kaiser Permanente sites in California have established separate and confidential teen health clinics.

Adolescent pregnancy presents some unique challenges, as many of the most effective interventions may lie outside the traditional health system. Few health plans or individual providers have instituted programs to address adolescent pregnancy prevention, but it is an area in which organized providers have a great deal of opportunity to have a positive impact.23 Medical West Associates, a multispecialty group practice affiliated with the Blue Cross and Blue Shield of Massachusetts HMO, formed a quality improvement team in 1996 specifically to lower the adolescent pregnancy rate among enrollees. The team consists of providers, nurses, and receptionists from the ob-gyn, pediatrics, home health care, and mental health departments of all five Medical West sites. In a retrospective chart review, the team found that most pregnant teens had been seen for a sick visit in the year before conception, but that only half had received physicals, and most of those did not receive contraception counseling. The team recommended annual physicals for teens and the implementation of a modfied teen sexuality questionnaire for confidential use at every visit. Birth control counselors from the provider and nursing staff were trained to be available for immediate contraceptive counseling. A protocol was also established to increase the use of postpartum birth control.

Other steps that managed care plans could take to address unintended teen pregnancy include creating screening, outreach, and education programs, documenting education and outreach services requested and provided to discern patterns of need, developing prevention programs and guidelines, creating teen clinics, improving accessibility by reducing waiting times for contraceptive appointments, decreasing the cost of contraception, establishing confidentiality protocols, contracting with SBHCs, and training primary care physicians to counsel patients about birth control.24

Measuring Quality in Reproductive Health

The Health Plan Employer Data and Information Set (HEDIS), a project of the National Committee for Quality Assurance (NCQA), is the predominant set of performance measures for evaluating managed care plans. The latest iteration, HEDIS 3.0, includes several measures related to reproductive health, but few that relate specifically to unintended pregnancy. HEDIS 3.0, which contains measures for both commercial and Medicaid plans, assesses arrangements with public health and other social service entities (including family planning), and availability of family planning services (Medicaid only). The measure of family planning services for Medicaid enrollees is a descriptive measure of the plan's family planning network for Medicaid members. NCQA's Committee on Performance Measurement, which selects measures to include in HEDIS, concedes that family planning services are significant and relevant to commercial populations as well, but determined that further assessment of this measure as applied to Medicaid only was needed before broadening it to include other populations. Given that unintended pregnancy is not a problem only of teens and low-income women, this measure and indeed additional measures, such as the rate of unplanned pregnancy within a health plan, could be implemented for all managed care enrollees.

There are always operational difficulties to overcome when devising ways to assess health care quality accurately. Quality is a nebulous concept, subject to myriad definitions. When evaluating the quality of care that plans deliver, it is important to ensure that plans are assessed on elements over which they have at least some control, such as the composition of provider networks or covered services, not those outside their control, such as enrollees' family and socioeconomic characteristics that might affect their health status. For preventive services, there is the additional challenge of measuring an outcome that is essentially a non-event for the individual enrollee. Reductions in rates of preventable illnesses or conditions can, however, be measured over time for a given population.

McGlynn (1995) outlined a number of quality measures related to reproductive health that could be implemented in evaluating health plans.25 Those focusing on prevention of unintended pregnancy include number of qualified family planning providers per 1,000 enrollees, average length of time to obtain an appointment for family planning services, proportion of health professionals who have accurate information about adoption opportunities (for patients with unintended pregnancies and those experiencing infertility), proportion of primary care physicians who have accurate knowledge about preconception planning and feel comfortable providing counseling in this area, proportion of adolescents who indicate that they have talked to or would be willing to talk to a health professional in the plan about sexual practices and conception, proportion of sexually active adolescents (younger than 19) using combined method contraception, satisfaction with the technical and interpersonal quality of family planning services (among those who have used services), and proportion of sexually active women who have discussed contraceptive options with a health professional within the past 5 years.

Public Policy

Numerous bills proposed in the 105th Congress have addressed health insurance and managed care in particular. Some are general consumer protection bills, while others focus on discrete areas of care. An example of the latter is S. 766, introduced in May by Senators Olympia Snowe (R-ME) and Harry Reid (D-NV), entitled the Equity in Prescription Insurance and Contraceptive Coverage Act of 1997, or EPICC. The bill is designed to achieve parity between coverage of family planning and coverage of other basic medical care services under private insurance plans. The legislation is depicted by its sponsors as a matter of basic equity for women, the premise being that plans that cover basic medical services should cover services related to contraception, and plans that cover prescription drugs should also cover contraceptive drugs and devices. Cost-sharing requirements for contraceptive services and supplies could not, under this legislation, be different from those for other services.

Conclusion

With an emphasis on prevention and population-based health care, and with ever-increasing numbers of enrollees, managed care stands in a position to influence the high rate of unintended pregnancy. Managed care has already demonstrated improvements in contraceptive coverage and in confidentiality protections. Focused quality improvement efforts aimed at reducing unintended pregnancy rates present an opportunity for health plans not only to reduce their own costs but to contribute to the amelioration of a substantial public health problem.

Many questions remain, including the following:

  • If managed care plans were to treat prevention of unintended pregnancy as they do other preventive services, could they effect a significant reduction in such pregnancies?

  • Given that many factors that contribute to unintended pregnancy fall outside of a health plan's purview, what interventions can plans use most effectively to enable women and their partners to make informed and healthy decisions regarding contraception and pregnancy? 

  • What tensions exist between managed care's coordination of services and the need for confidentiality in reproductive care? How can these tensions be addressed effectively?

  • Do the obstacles to quality measurement around unintended pregnancy prevention differ from those for other preventive services? 

  • What are the potential threats to making the full range of pregnancy prevention options available posed by the growing role of Catholic-affiliated hospitals and clinics? 

  • What is the role of family planning clinics in managed care? Do they provide an incentive for plans not to provide these services, or do they increase access to services? Do they improve women's health or contribute to its continuing fragmentation?


Endnotes

1. Brown S and Eisenberg L, eds. The Best Intentions--Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: National Academy Press, 1995.

2. Delbanco S et al. Public knowledge and perceptions about unplanned pregnancy and contraception in three countries. Family Planning Perspectives 1997;29:70-75.

3. Brown S and Eisenberg L, eds., 1995.

4. See, for example, Holmes MM et al. Rape-related pregnancy: estimates and descriptive characteristics from a national sample of women. Am J Obstet Gyn 175:320-325.

5. Mitchell JB and McCormack LA. Access to family planning services: relationship with unintended pregnancies and prenatal outcomes. J Health Care for the Poor and Underserved 1997;8:141-152.

6. Trussell J et al. The economic value of contraception: a comparison of 15 methods. Am J Public Health 1995;85:494-503.

7. Lee P, Stewart F. Editorial: failing to prevent unintended pregnancy is costly. Am J Public Health 1995;85:479-480.

8. The Alan Guttmacher Institute. Uneven and Unequal--Insurance Coverage and Reproductive Health Services. 1994.

9. The Alan Guttmacher Institute, 1994.

10. Gold R, Richards C. Improving the fit--Reproductive Health Services in Managed Care Settings. The Alan Guttmacher Institute, 1996.

11. The Alan Guttmacher Institute, 1994. The survey focused on six types of insurance: small-group (under 100 employees) indemnity, large-group indemnity, self-insured indemnity, PPO, POS, and HMO. Since little difference was found between the three types of indemnity insurance, results in the study are generally reported for large-group indemnity plans.

12. HMOs combine the financing and delivery of health care to a defined population for a fixed prepayment; all care is provided through a limited network of health plan providers. PPOs are networks of providers that provide services to enrollees in an insurance companies managed care plan for discounted fees. POS plans or networks function similarly to HMOs but enrollees retain the option of receiving care outside the plan network at an increased cost-sharing level. See Insights #2 (May 1997) for further explanation.

13. Group Health Association of America/The Henry J. Kaiser Family Foundation. 1994 Market Survey--Final Report. April 6, 1997.

14. Weisman CS, Khoury AJ, Sharpe VA, Cassirer C, and Morlock LL. Affiliations Between Catholic and Non-Catholic Health Care Providers and the Availability of Reproductive Health Services. Final Report to the Henry J. Kaiser Family Foundation, March 1997.

15. Delbanco S, Smith MD. Reproductive health and managed care--an overview. West J Med 1995;163 [suppl]:1-6.

16. Rosenbaum S, et al. Beyond the Freedom to Choose: Medicaid Managed Care and Family Planning. George Washington University Center for Health Policy Research, 1994.

17. Orbovich C. Case studies of collaboration between family planning agencies and managed care organizations. West J Med 1995;163 [suppl]:39-44.

18. The experiences of primary care centers were reviewed in Insights #2 (May 1997).

19. Weisman C, Curbow B, Khoury A. Women's health centers and managed care. Women's Health Issues 6:5;1996.

20. Cited in Brindis C. Promising approaches for adolescent reproductive health service delivery--the role of school-based health centers in a managed care environment. West J Med 1995; 163 [suppl]:50-56.

21. Brindis C, Peterson SA, Brown S. Complex Terrain: Charting a Course of Action to Prevent Adolescent Pregnancy. Report submitted to the California Wellness Foundation, May 1997.

22. Brindis C, 1995.

23. Conversation with Joan Fine, MD, Medical West Associates, Chicopee, Massachusetts, May 28, 1997.

24. Brindis C, Peterson SA, Brown S; 1997.

25. McGlynn EA. Quality assessment of reproductive health services. Western J Med 1995; 163 [suppl]:19-27.