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Adolescent Pregnancy Prevention in Managed Care
Article Adolescent Pregnancy Prevention in Managed Care Joan Fine, MD Medical West Associates Chicopee, Massachusetts
T
he United States leads the industrialized world in adolescent pregnancy rates with a million pregnancies per year. Recent trends show an 8% drop in the adolescent birth rate from 1991 to 1995,1 although 10% of adolescent girls become pregnant every year and 85% of these pregnancies are unintended.2 This is an issue for which insurers, including managed care, have spent many health care dollars, yet they have not acknowledged this as an area of preventable or reducible expenditure.
ADOLESCENT PREGNANCY AS A WOMEN’S HEALTH ISSUE The government, employers, and the insurance industry recently have begun to address women’s health issues. Adolescent pregnancy generally is not considered a women’s health issue, yet avoiding pregnancy before an adolescent reaches womanhood is one of the best ways of safeguarding her health and well-being as a woman. According to a report prepared for the Robin Hood Foundation,3 more than 80% of mothers younger than age 18 continue to live in poverty or rely on welfare for years after the birth of their child. Most are unmarried, do not complete a high school education, and do not receive child support. They risk adverse health consequences for themselves and their offspring that would be less likely to occur if their first pregnancy was deferred until adulthood. As managed care grapples with other women’s health issues, adolescent pregnancy would be a very appropriate addition to the list.
ADOLESCENT PREGNANCY PREVENTION INITIATIVES There have been many adolescent pregnancy prevention programs, mostly in schools, community agencies, or through media campaigns, with a focus on education, self-esteem, assertiveness, or abstinence.4 Adolescent girls, rather than their partners, have been the main target of preventive efforts. In January 1997, U.S. Department of Health and Human Services (DHHS) Secretary Donna Shalala launched the National Strategy to Prevent Teen Pregnancy, a plan to prevent teen pregnancy by encouraging abstinence among 9 –14-yearold girls. The U.S. DHHS–supported teen pregnancy prevention programs reach 30% of communities in the United States. Unfortunately, a review for the National Campaign to Prevent Teen Pregnancy, a private, nonprofit organiza148
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© 1998 by the Jacobs Institute of Women’s Health Published by Elsevier Science Inc. 1049-3867/98/$19.00 PII S1049-3867(98)00002-4
tion founded in 1996, found that ‘‘there does not currently exist any published scientific research demonstrating that abstinence-only programs have actually delayed the onset of sexual intercourse or reduced any other measure of sexual activity.’’ In fact, this analysis of nearly 80 programs concludes that there have been too few studies to evaluate different approaches, many of the studies to date are limited by methodologic flaws, the results have been inconsistent from study to study, and results from even the best programs have not been replicated.5 Little has been published in regard to teen pregnancy prevention through medical intervention by health practitioners, either individually or in programs run by health organizations or clinics.
ADOLESCENT HEALTH INSURANCE STATUS Adolescents are medically underserved, with poorer access to medical care and insurance than other age groups. Between 1987 and 1993, the number of uninsured children and adolescents increased by nearly a million, with the greatest proportion of increase from ages 7 through 21, from 15.4% to 17.3% of all adolescents.6 At the same time, the percentage of children and adolescents covered by employer-based private insurance decreased significantly from 68% to 63%, mainly because of reductions in dependent coverage. Medicaid now insures more children and adolescents in the United States than any other public or private entity, providing health care to 22% of all children younger than 21 years of age. Of those adolescents covered by private insurance, there has been a shift from fee-for-service to managed care, including HMOs, preferred provider organizations, and point-of-service plans. Seventy percent of employees of firms with more than 200 workers and one third of Medicaid recipients now are enrolled in managed care. Managed care itself has undergone recent changes, with a movement away from group and staff model HMOs to IPAs and network model HMOs, from not-for-profit to large, national for-profit ownership. It is unclear how these changes in types of health insurance, and trends in insurance coverage will affect adolescents, especially in light of further threatened Medicaid cutbacks.
ADOLESCENT DEMOGRAPHICS AND PREGNANCY TRENDS U.S. Census data reports that there were 19 million adolescents aged 10 –14 and 18.4 million adolescents between 15 and 19 years of age in 1996. It is estimated that from 1995 to 2005, the numbers of 15–17-year-olds in the United States will rise by 15%, with the greatest increase in minority populations (Table 1).7 There may soon be more adolescent pregnancies on the basis of these demographics. However, if pregnancy prevention programs can be proven successful, pregnancy rates may decline despite an increasing adolescent population. The 1995 National Survey of Family Growth conducted by the U.S. DHHS’ National Center for Health Statistics showed a decline in the percentage of girls aged 15–19 who had ever had intercourse from 55% in 1990 to 50% in 1995. The survey showed an increase in the use of contraceptives at first intercourse due to a marked increase in condom use. In 1995, 90% of 18 –19-year-olds had received education on sexually transmitted diseases (STDs), safe sex, and abstinence. Although these results suggest that educational programs account for the recent declining birth rates, such an effect has yet to be documented in long-term studies. Information regarding current trends in adolescent pregnancy rates is hampered by limited abortion data. Data from the Centers for Disease Control
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Table 1. PROJECTED SHIFTS IN RACE/ETHNICITY OF U.S. CHILDREN UNDER AGE 18, 1995–2005 Ethnicity/race
1995
2005
Change, %
White Black Hispanic Asian and Pacific Islander Native American
45,732,900 10,178,500 9,599,700 2,555,600 673,300
44,208,100 11,013,000 12,466,800 3,563,000 713,000
3 8 30 39 6
Data from Kids Count Data Book: State profiles of child well-being. New York: The Annie E. Casey Foundation, 1997.
and Prevention from 1991 and 1992 lack adolescent abortion data from eight states because they do not report age-specific rates.8 An analysis for the Alan Guttmacher Institute reported adolescent abortion rates from surveys of all known abortion providers in the country. The number of stillbirths and miscarriages occurring after 6 –7 weeks gestation was estimated as 10% of abortions and 20% of births. As pregnancy losses are not reportable, this estimate more accurately reflects the total number of pregnant adolescents.9 This report documented the outcomes of adolescent pregnancies, showing a shift from abortions to live births. By 1992, almost 55% of teen pregnancies resulted in live birth compared to less than 50% throughout the 1980s. If trends persist toward increasing birth rather than abortion rates, then pregnancy-related costs will be disproportionately greater, as births are more costly than either terminations or miscarriages. However, if RU486 (‘‘the abortion pill’’) becomes available, more teens might choose abortion when a surgical procedure is not required, with the added benefit of greater privacy and confidentiality. Presumably, this would be a less expensive type of pregnancy termination, but as RU486 would not necessarily be dispensed in abortion clinics, statistics regarding the use of this method could be difficult to monitor.
THE COSTS OF ADOLESCENT PREGNANCY A recent cost analysis of adolescent pregnancy by Gans et al10 showed an average of $440 for termination and an average $6,059 for hospital costs of deliveries that include a 17% cesarean section rate. They found an average cost of $25,000 per low birth weight (LBW) infant, which is the result of 9% of adolescent births. Although miscarriage costs are variable and difficult to calculate, they are at least as much as termination costs. A 1995 study of managed payment model costs for unintended pregnancies at all ages found the average cost of miscarriage to be $1,038.11 Of the total 37.4 million adolescents in the United States, approximately 30 million have health insurance coverage. Estimates range from 20% to 40% (6 –12 million) of insured adolescents who are covered under managed care through private insurance or Medicaid. Of adolescents insured by managed care, 25% (1.5–3 million) are girls 15–19 years of age. As 10% of these girls become pregnant each year, there are approximately 150,000 –300,000 adolescent pregnancies paid for by managed care insurance annually. Because approximately 50% of these pregnancies result in live birth, the average costs, assuming 40% of teens have managed care insurance, can be calculated as 150,000 3 $440 (termination or miscarriage unit cost) plus 150,000 3 $6,059 (delivery unit cost), plus .09 3 150,000 3 25,000 (LBW infant unit cost), and the total, which is an underestimate owing to more recent increases in costs, is $1–3 150
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billion (Table 2). This amount does not include costs of care for normal newborns or newborns with other health problems and or the children’s subsequent medical care, which generally is covered under the grandparent’s insurance. Total costs would be $656,175,000 if only 20% of teens are covered by managed care insurance. Thus, managed care has significant financial incentive for preventing teenage pregnancy.
MANAGED CARE PROGRAMS FOR ADOLESCENT PREGNANCY PREVENTION Unfortunately, teen pregnancy prevention seems to be an area almost untouched by both the medical and medical administration fields. In a symposium issue on adolescent health published in HMO Practice in 1993,12 a survey was sent to health care plans in the HMO Group, KaiserPermanente, and other managed care organizations. Of 19 HMOs responding, only four had adolescent medicine specialists on staff and none had specific programs for pregnancy prevention. A 1989 survey of the HMO Group13 showed similar results with no pregnancy prevention programs, although 8 of 11 respondents had some services for teens, such as a hotline, teen clinic, or teen prenatal program. Multidisciplinary adolescent clinics at Fallon Community Health Plan, Kaiser-Permanente, and Group Health Northwest have on-site mental health, nutrition, social, work, and educational services. These serve as a model for other health plans to emulate. Teen-tot programs that care for adolescent mothers and their babies generally have a component of repeat pregnancy prevention, and several HMOs, including Fallon and Group Health NW, have these clinics. At Kaiser-Permanente HMOs in California, there are several teen clinics at which many of their adolescent members receive care. A program has been underway at the Antioch center since 1996 in which all adolescents having negative pregnancy test results are immediately provided with birth control. A report from the Panorama City Medical Center of the Southern California Permanente Group indicates that patients seen in their Teen Center had a much higher percentage of adolescents electing to terminate their pregnancies than the national average.14 This suggests that in settings in which pregnancies are detected early and appropriate options counseling occurs, the ratio of terminations to live births might be increased. A 1995 report from Harvard Community Health Plan15 described a quality improvement team from the pediatrics and obstetrics and gynecology departments that studied their teenage pregnancies and devised interventions. They reviewed charts of positive pregnancy tests from 1992 in patients younger than 21 years of age and found that only 2 of 34 were planned. Twenty of the 34 had been seen for negative pregnancy testing in the year prior to the pregnancy, and the team believed that these were missed opportunities for prevention. There was little documentation of pregnancy option decision making, presumably indicating that little counseling occurred. The report describes inadequate prenatal care owing to unkept appointments and late initial visits. The team developed several interventions, including grouping adolescent appointments together for interdisciplinary care and coordinating postpartum care with pediatric visits to improve follow-up. None of these managed care programs has involved the entire enrolled teenage population seen within separate medical areas or different centers within the managed care plan. To be truly inclusive (and have the greatest overall impact) it would be important to involve all adolescent patients, both male and female, for which the managed care system is responsible. A
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Table 2. ANNUAL COSTS OF ADOLESCENT PREGNANCY IN MANAGED CARE (ASSUMING 40% OF ADOLESCENTS COVERED BY MANAGED CARE INSURANCE)
Deliveries Low birth weight infants Miscarriages and abortions
Patients, n
Unit cost, $
Total cost, $
150,000 13,500 150,000
6,059 25,000 440
908,850,000 337,500,000 66,000,000
comprehensive program would be far easier to implement in a staff-model HMO in which there are centralized medical records, coding, and departmental coordination. In IPAs and other less centralized types of managed care, it would be much more difficult to influence and monitor individual practitioner’s care of adolescents. Despite the fact that these forms of managed care are increasing in prevalence, there are no published studies of teen pregnancy prevention in these settings. At Medical West Associates, a Blue Cross and Blue Shield staff-model HMO in Massachusetts, the Quality Improvement team was formed in 1996 to study and devise interventions for preventing adolescent pregnancies within the entire HMO. Initial chart review revealed that only a minority of pregnant teenagers had been seen within a year prior to conception for nationally recommended annual routine examinations.16 However, most were seen shortly before the onset of pregnancy for a sick visit, at which time pregnancy risk factors were not discussed. Even at routine visits, there was poor provider compliance with recommended sexuality screening and referral for contraception. Postpartum teenagers rarely received contraception and had poor followup. Teenagers requesting pregnancy tests had no options counseling for a positive pregnancy or contraceptive counseling for a negative test. This poor standard of adolescent care is not unique and has been widely reported to be the norm in other practices.17 The team enacted several policy changes for the HMO as a whole, which would affect all enrolled teens. Annual physicals for teens were officially endorsed. At this visit, a sexuality questionnaire was distributed to all teens, with a section for provider scoring and documentation within the medical record. If a teen scored as high risk, she or he was referred to a trained birth control counselor at the time of the visit. Compliance was monitored and enforced through chart review. All teens requesting pregnancy testing were seen for appointments and immediate test results, allowing for contraceptive or options counseling at the testing visit. Obstetric patients selected a postpartum birth control method at the 28-week prenatal visit with provision of contraception before leaving the hospital at delivery. Various tracking procedures to ensure follow-up of all teens completing a pregnancy were arranged. Results are still preliminary but seem to indicate a lowering of teen pregnancy rates. These data will need to be compared to pending health department data on pregnancy rates for local adolescents to determine statistical significance of the program’s impact. However, lessons from the program are clear. There are many gaps in adolescent health care that can be filled by physicians and managed care organizations to reduce pregnancy rates and provide an optimal level of care for this age group. Departments such as pediatrics and obstetrics and gynecology, which traditionally have not coordinated care for adolescents, benefit both in increased efficiency and improved provision of services by working together. 152
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PROBLEMS AND SOLUTIONS FOR ADOLESCENT MEDICINE UNDER MANAGED CARE Rather than working within the managed care framework, it has been argued that teenagers would be more appropriately served by receiving their care in school-based health centers (SBHCs).18 School-based health care centers were developed to increase access to medical care for teenagers especially those who are uninsured or underinsured. There have been efforts to coordinate the services provided by SBHCs for teens covered by managed care. Unfortunately, there are several drawbacks to SBHCs, including no weekend, evening, or holiday coverage and no access for teenagers who poorly attend or who have dropped out of school. Many SBHCs do not allow provision of contraceptive services on-site, and others do not even allow discussion of contraception or pregnancy options. Enrollment in SBHCs is optional, based on parental consent. Thus, although SBHCs have been shown to be effective in the provision of many adolescent health services, they cannot be the sole answer to improving access for adolescents in managed care. The costs of raising the quality of adolescent care to optimal standards are not trivial. Because approximately half of adolescents are sexually active, this population would require yearly pelvic examinations, Papanicolaou smears, and STD testing. Current adolescent health care does not approach this standard. In a 1996 study of high school girls, 68% had never had a Papanicolaou smear and 96% said physicians had never recommended this test to them.19 If abstinence cannot be guaranteed, the best contraception for teens includes both condoms and a prescription method, such as the birth control pill or Depo-Provera (Pharmacia & Upjohn, Columbus, OH). Unfortunately, prescription contraceptives rarely are covered by health insurance. Only half of health insurance plans cover some contraceptive drugs or devices, and only one third cover the pill, despite the fact that 97% offer other prescription coverage.20 Teens who have the least financial resources would need health plans to supply condoms and other contraception free of charge or at greatly reduced prices to make their use of birth control feasible. A legislative bill introduced by U.S. Senators Olympia Snowe and Harry Reid in May 1997 would require insurance companies to cover contraception in the same way as other prescriptions. It is well documented that Catholic hospitals and other religious organizations have omitted certain benefits, such as contraception or abortion, from their insurance plans because of religious objections. Many private employers and state and local governments have the same exclusions. As insurance costs are based on claims experience, these carve-outs result in short-term cost containment. Occasionally, exclusions are based on political or religious beliefs of a benefits manager who thus can affect the health care options of many subscribers. In the state of Massachusetts, after many years of this type of policy, it required a legislative vote to reenact coverage for abortion for state employees in 1996. These exclusions can certainly not be justified on the basis of anything but initial cost-containment, as it is always less costly to provide abortion and contraceptive services than covering the costs of unplanned pregnancies.11 The group most affected by the lack of coverage is teenagers, who are most at risk medically and who have the least political clout to fight the system. Unlike adults, adolescents would not usually be able to pay out-of-pocket for uncovered items. Even when health plans ‘‘cover’’ contraception, their rationale usually is based on adult women, rather than the needs of adolescents. For instance, Blue Cross/Blue Shield of Massachusetts decided to cover Norplant (Wyeth-Ayerst Laboratories, Philadelphia, PA) with a pharmacy copay that would equal the copay for 5 years of birth control pills, with the rationale that the 5-year cost
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would be the same for both methods and women would recognize this and find it acceptable. However for teens, the 5-year cost, which has to be paid before insertion, makes the method completely financially unavailable. One abortion equals the pharmacy cost of Norplant. It would make financial sense for the health plan to cover this medication even if an adolescent contributes no copay. The same is true for all the contraception and abortion exclusions by employers, and many health plans have decided to cover costs for these items. The chief obstacles to adolescent reproductive health care are lack of confidentiality and difficulties with access. Managed care insurance, with its organizational structure, has the potential to obviate both these concerns. Computerized subscriber information that avoids the need for an adolescent to present her ‘‘insurance card,’’ allows a teen to make her own appointments without parents being aware. However, medical offices frequently have policies to call or send reminder notices about appointments to diminish their no-show rate. If an office staff is sensitive to the confidential needs of teens, this mechanism can be selectively ‘‘unplugged.’’ When contraceptive services and visits are covered, there is no need for bills to be sent home. Nevertheless, many insurances including both fee-for-service and managed care send an ‘‘explanation of benefits’’ statement to the insurance holder. Even when a service is covered fully, it is thought to be beneficial to notify policyholders. Thus, in Massachusetts and several other states where a teen may receive legal permission from the court for an abortion without parental notification, the parent may be mailed a summary of services provided at the abortion clinic. This backfiring of the system can be rectified by a manual workaround by the central business unit, but a nonautomated method is prone to failure. Again, modifications require ongoing education and sensitivity to the unique concerns of adolescents. Finally, providers of adolescent health care need to be cognizant of and respectful of a teen’s confidentiality. Two recent studies show that this is not usually the case. A survey of 93 Pennsylvania gynecologic providers revealed that they ‘‘did not have a clear understanding of the laws related to teens and confidentiality.’’21 A survey of Texas physicians found that half only saw their adolescent patients with parents in the room, thus prohibiting any opportunity for confidentiality.22 In managed care, there should be ways to educate physicians and monitor their compliance with confidential patient history, such as the use of confidential adolescent reproductive health questionnaires, which have been distributed nationally by the Association of Reproductive Health Professionals. The use of screening tools can be documented in the medical record as proof that screening occurred. Access is sometimes worsened in a managed care situation, with a restriction of providers. Unaccompanied teens with limited transportation and resources may find restricted sites impossible to access. Community agencies and managed care organizations have provided vans for senior transportation, which are cost-effective by increasing access to primary-care providers and keeping elders from unnecessary emergency room visits and hospitalizations. The same principle would apply to adolescents, who could be provided with transportation from high schools or teen centers with preauthorized parental approval. Teen clinics with a social worker and teen hotlines that have been piloted in some HMOs, could coordinate such programs. However, as an adolescent is unlikely to read the managed care literature mailed to the subscriber, they will be unaware of the programs unless the managed care organization also does outreach and advertising. The advantage of managed care is that they do have the organizational structure to be able to make special arrangements for adolescents if they are so motivated. Another major obstacle to ideal adolescent health care is the lack of age-appropriate care for teens because of providers being unknowledgeable or 154
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feeling constraints of inadequate time or reimbursement. A good example of inappropriate care in regard to pregnancy prevention is the widespread practice of offering pregnancy testing to teens without immediate counseling. Adolescents who have a negative pregnancy test are soon likely to become pregnant, and it has been recommended that all teens requesting a pregnancy test be seen for an appointment and counseled about birth control if their test is negative.23 If they have a positive test, immediate options counseling should be done, rather than having a teen be given erroneous advice from friends and relatives before speaking with a provider. Another example of care that is not only acceptable in an older age group but lauded as a convenience for both physicians and patients, is treating uncomplicated bladder infections by telephone. In teens, a urinary tract infection is usually the sign that sexual activity has commenced, and thus other issues such as birth control and a pelvic examination must be addressed. As teens are concerned about confidentiality, and have no idea where to go for reproductive care, they are unlikely to spontaneously request contraception when being seen for another problem. Sometimes managed care can be too ‘‘macromanaged’’ to provide individualized care for teens. Many managed care organizations have contracted with national or regional nurse telephone triage companies for more costeffective and consistent telephone screening. Although national protocols have been made with hundreds of possible algorithms for most common health problems, they usually are divided into broad categories such as pediatrics, adult medicine, and reproductive care. Teens fit somewhere in between all three of these categories, and it is often an uneven fit. Recommending home pregnancy tests for diagnosis of pregnancy is reasonable for adult women but totally inappropriate for a 14-year-old girl. Asking an adult woman to use over-the-counter antifungal cream for a presumptive yeast infection is also reasonable but not for a teen who has more likelihood of an STD and undisclosed sexual activity. Although pediatric algorithms are used in both children and adolescents, a common complaint such as abdominal pain has a different set of diagnostic possibilities in a sexually active adolescent female than in a younger child, and questions to rule out diagnoses such as pelvic inflammatory disease (PID) must be included but generally are not. The sales representatives of these triage companies have impressive presentations to the medical staff of managed care groups to convince them that all age groups and most health issues have been addressed by experts in the field. However, a true assessment of whether adolescents are appropriately served is only possible by painstaking review of algorithms for all age groups that might include teens. These telephone services focus on self-care and justify their services as cost-saving by allowing more patients to treat themselves without an office visit. This approach can have the opposite effect for teens who have difficulty in articulating their needs. Their complaints may be transmitted inaccurately or second-hand by a parent who is not aware of the full situation. There is less chance for openness without the benefits of continuity that a personal relationship with a provider can offer. Lack of sufficient screening for the sake of expediency also can prove costly to teens. A study of older women in a managed care setting revealed that for those who are identified as high risk and screened for chlamydia, the incidence of subsequent PID was lower than in women who were not adequately tested.24 This effect is even more likely in teens in whom the incidence of STDs is highest and for whom PID would have the most long-ranging and costly consequences, including infertility and ectopic pregnancy, as well as the immediate costs of hospitalization. Although managed care classically is supposed to be more involved in preventive medicine than is indemnity insurance, the benefits of many types of
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preventive efforts take years to occur and are not seen as immediately cost-effective by health care administrators. Preventing adolescent pregnancy is a rare instance of preventive service that would have immediate, costeffective results. Given that 90% of girls become pregnant in a year of unprotected sexual activity, there are few other preventive efforts that could deter such an expensive annual ‘‘morbidity.’’ Despite national recommendations for yearly health examinations for teens, most health plans do not have a policy requiring this. Many teenagers obtain a cursory sports physical that is provided free of charge by schools and does not typically cover any sexuality issues. Some insurances do not cover yearly physicals for adolescents and many do not cover yearly gynecologic examinations. Some types of managed care restrict access to gynecologic providers or make this a referral requiring notification of the pediatrician. If there are no standards within the managed care plan for confidential care and referrals, then an adolescent will have little hope of navigating through the system herself. Standards have not been established for the time it takes to do a comprehensive adolescent examination, although estimates of the time necessary to do this kind of examination range from 30 to 47 minutes.25 Health plans do not generally allow longer time slots for well-adolescent than well-child visits (usually 15–20 minutes), and thus clinicians have inadequate time for full screening, including sexuality screening, in adolescents. Also, correct procedural terminology coding may not allow adequate reimbursement for adolescent visits. It is difficult to code adequately for a pelvic examination, which is frequently an adolescent’s first gynecologic experience and requires a lengthy visit, or for extensive contraceptive counseling involving patient and parental education and mediation.
RECOMMENDATIONS AND FUTURE RESEARCH IN ADOLESCENT PREGNANCY PREVENTION If a health plan were to establish an ongoing teen pregnancy prevention program, it should not rely entirely on volunteer effort from teams or committees but should devote paid time or possibly hire an adolescent health care coordinator to track teen care within the plan, educate staff, and arrange and enforce protocols. As such a position has never been studied, it would be important to learn whether its cost could be justified and whether there would be acceptance and compliance by the medical staff. Also, there are no studies on consumer satisfaction with a health plan’s teen pregnancy prevention program, despite surveys showing widespread public support for the concept of lowering adolescent pregnancy rates. Both patient satisfaction and costeffectiveness would need to be demonstrated for health plans to enact a pregnancy prevention program. The federal government, which has earmarked so many dollars for community-based adolescent pregnancy prevention, should consider funneling some of these funds to study medically based prevention efforts. Unlike other women’s health issues, such as mammography screening for breast cancer for which there is no political dissent except surrounding cost, teen pregnancy prevention is an explosive political topic. Although there is almost universal agreement on the need to prevent adolescent pregnancy, the method to do so is hotly debated. Vocal conservative and religious groups support abstinence as the only route, and they would be quite opposed to provision of contraception or confidential services for teens. Managed care would justifiably be concerned that their preventive efforts could cause a backlash of disapproval. Nevertheless, in Europe, where teen pregnancy rates are much lower than in the United States despite similar sexual activity, both 156
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government and health care vigorously espouse contraception for teens, and there has been public acceptance. Possibly, media campaigns in the United States could similarly affect public attitudes. There have been some attempts at quality indicators regarding adolescent sexuality. For example, inclusion of an STD-related quality indicator, namely the percentage of women (including sexually active adolescents) from age 15 to 25 who have had annual chlamydia screening, is being considered as a Health Plan Employer Data Information Set (HEDIS) measure.26 Such a performance measure would also boost pregnancy prevention, as condom use and other contraception could be discussed at this preventive visit. Although there are no standardized practice guidelines regarding teen pregnancy prevention, these could be developed from such a set of quality indicators. Other cost-saving initiatives that managed care has undertaken could be applied to adolescents as well. Many health plans have case management programs for intensive follow up of chronically ill patients or patients who use a disproportionate amount of health care services based on hospitalizations or emergency room visits. Pregnant adolescents could certainly fit within these guidelines, as one of the highest risk factors for an adolescent pregnancy is a previous pregnancy. Typically, adolescents have not been included in these programs based on pregnancy, but it would be useful to study whether case management could be effective in reducing repeat adolescent pregnancies. Recommendations to the entire managed care industry regarding adolescent pregnancy prevention must start with the recognition that teen pregnancy is a costly, avoidable condition and that optimal adolescent care should be age-appropriate, confidential, and follow specific national guidelines. There are policy statements and guidelines from the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists that specifically address issues of adolescent sexuality screening, pregnancy testing, options counseling, and confidential contraceptive provision. These policies should be endorsed and enforced by managed care. Adolescents should receive care from primary care providers who have special training in this age range and have their care centralized and coordinated. Managed care organizations should monitor their teen pregnancy rates and identify areas requiring intervention. They should analyze teen pregnancy prevention programs in their own setting for effectiveness and choose the most effective interventions based on cost and medical outcome rather than on political viewpoint. Interventions should begin in preadolescence before high-risk sexual behaviors have occurred and continue throughout the adolescent years with yearly education and support for abstinence, as well as providing specific programs that address both access and confidentiality for sexually active teens who require contraception. Although teen pregnancy in the United States is largely a societal problem, and its reduction will require many types of solutions, health practitioners are a resource that has been largely overlooked. As more adolescents become covered by managed care organizations, the financial costs that this industry bears will increase for this preventable health problem. There are many steps the industry could take that would simultaneously improve the health care for their adolescent patients and decrease unnecessary health care expenditure. Although the federal government has recently become acutely aware of the need for preventing adolescent pregnancy, leaders in the managed care field have not shown a similar awareness. It will take pressure from consumers, governmental agencies, and health care providers to effect policy changes. Health care practitioners and the health care industry must join the effort to reduce teen pregnancy and its associated costs, which are ultimately paid for by all of society.
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REFERENCES 1. National Center for Health Statistics. Recent declines in teenage birth rates in the United States: variation by state, 1990 –94. Monthly Vital Statistics Report, Hyattsville (MD): NCHS, 1996;45 Suppl 5. 2. Alan Guttmacher Institute. Sex and America’s teenagers. New York: AGI, 1994. 3. Maynard RA. Kids having kids: a Robin Hood Foundation special report on the costs of adolescent childbearing. New York: 1996. 4. Frost J, Forrest J. Understanding the impact of effective teenage pregnancy prevention programs. Fam Plann Perspect 1995;27:188 –95. 5. Kirby D. No easy answers: research findings on programs to reduce teen pregnancy. The National Campaign to Prevent Teen Pregnancy. Washington (DC): 1997. 6. Yudkowsky BK, Tang SS. Children at risk: their health insurance status by state. Pediatrics 1997;99:e2– 8. 7. Kids Count data book: state profiles of child well-being. New York: The Annie E. Casey Foundation, 1997. 8. Centers for Disease Control and Prevention. State-specific pregnancy and birth rates among teenagers: United States, 1991–1992. MMWR Morb Mortal Wkly Report 1995;44:677– 84. 9. Henshaw SK. Teenage abortion and pregnancy statistics by state, 1992: Fam Plann Perspect 1997;29:115–22. 10. Gans JE, Alexander B, Chu RC, Elster A. The cost of comprehensive preventive medical services for adolescents. Arch Pediatr Adolesc Med 1995;149:1226 –34. 11. Trussell J, Leveque JA, Koenig JD, et al. Am J Public Health 1995;85:494 –503. 12. Berman HS. Risky business: providing health care to teens in the 90s. HMO Pract 1993;7:149 –50. 13. Fine JS. The practice of adolescent medicine in staff-model HMOs. HMO Pract 1989;3:16 –21. 14. Klitsner IN. Meeting the challenge of adolescent health care in a group practice HMO. HMO Pract 1993;7:151– 6. 15. Marshall R. Eye on improvement 1995;2:6 – 8. 16. Elster AB, Kuznets NJ, editors. AMA guidelines for adolescent preventive services (GAPS): Baltimore (MD): Williams & Wilkins, 1994. 17. Braverman P, Strasburger V. Office-based adolescent health care: issues and solutions. Adolescent Medicine State-of-the Art Reviews. Philadelphia (PA): Hanley & Belfus, 1997. 18. 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 – 6. 19. Najem GR, Batumen F, Smith AM. Papanicolaou test status among inner-city adolescent girls. Am J Prev Med 1996;12:482– 6. 20. The Alan Guttmacher Institute. Uneven and unequal: insurance coverage and reproductive health services. New York: AGI, 1994. 21. Reidel CW, Scott CS, Waxman A. Confidentiality and minors: poster presentation. Annual meeting of North American Society for Pediatric and Adolescent Gynecology, April 7, 1997. 22. Purcell J, Hergenroeder A, Kozinetz C, et al. Interviewing techniques with adolescents in primary care. J Adolesc Health 1997;20:300 –5. 23. Zabin LS, Emerson MR, Ringers PA, Sedivy V. Adolescents with negative pregnancy test results: an accessible at-risk group. JAMA 1996;275:113–7. 24. Scholes D, Stergachis A, Heidrich F, et al. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med 1996;334:1362– 6. 25. Knishkowy B, Palti H. GAPS: Where are the gaps? Arch Pediatr Adolesc Med 1997;151:123– 8. 26. Eng TR, Butler WT. The hidden epidemic: confronting sexually transmitted diseases. Washington (DC): National Academy Press, 1997.
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he United States leads the industrialized world in adolescent pregnancy rates with a million pregnancies per year. Recent trends show an 8% drop in the adolescent birth rate from 1991 to 1995,1 although 10% of adolescent girls become pregnant every year and 85% of these pregnancies are unintended.2 This is an issue for which insurers, including managed care, have spent many health care dollars, yet they have not acknowledged this as an area of preventable or reducible expenditure.
ADOLESCENT PREGNANCY AS A WOMEN’S HEALTH ISSUE The government, employers, and the insurance industry recently have begun to address women’s health issues. Adolescent pregnancy generally is not considered a women’s health issue, yet avoiding pregnancy before an adolescent reaches womanhood is one of the best ways of safeguarding her health and well-being as a woman. According to a report prepared for the Robin Hood Foundation,3 more than 80% of mothers younger than age 18 continue to live in poverty or rely on welfare for years after the birth of their child. Most are unmarried, do not complete a high school education, and do not receive child support. They risk adverse health consequences for themselves and their offspring that would be less likely to occur if their first pregnancy was deferred until adulthood. As managed care grapples with other women’s health issues, adolescent pregnancy would be a very appropriate addition to the list.
ADOLESCENT PREGNANCY PREVENTION INITIATIVES There have been many adolescent pregnancy prevention programs, mostly in schools, community agencies, or through media campaigns, with a focus on education, self-esteem, assertiveness, or abstinence.4 Adolescent girls, rather than their partners, have been the main target of preventive efforts. In January 1997, U.S. Department of Health and Human Services (DHHS) Secretary Donna Shalala launched the National Strategy to Prevent Teen Pregnancy, a plan to prevent teen pregnancy by encouraging abstinence among 9 –14-yearold girls. The U.S. DHHS–supported teen pregnancy prevention programs reach 30% of communities in the United States. Unfortunately, a review for the National Campaign to Prevent Teen Pregnancy, a private, nonprofit organiza148
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© 1998 by the Jacobs Institute of Women’s Health Published by Elsevier Science Inc. 1049-3867/98/$19.00 PII S1049-3867(98)00002-4
tion founded in 1996, found that ‘‘there does not currently exist any published scientific research demonstrating that abstinence-only programs have actually delayed the onset of sexual intercourse or reduced any other measure of sexual activity.’’ In fact, this analysis of nearly 80 programs concludes that there have been too few studies to evaluate different approaches, many of the studies to date are limited by methodologic flaws, the results have been inconsistent from study to study, and results from even the best programs have not been replicated.5 Little has been published in regard to teen pregnancy prevention through medical intervention by health practitioners, either individually or in programs run by health organizations or clinics.
ADOLESCENT HEALTH INSURANCE STATUS Adolescents are medically underserved, with poorer access to medical care and insurance than other age groups. Between 1987 and 1993, the number of uninsured children and adolescents increased by nearly a million, with the greatest proportion of increase from ages 7 through 21, from 15.4% to 17.3% of all adolescents.6 At the same time, the percentage of children and adolescents covered by employer-based private insurance decreased significantly from 68% to 63%, mainly because of reductions in dependent coverage. Medicaid now insures more children and adolescents in the United States than any other public or private entity, providing health care to 22% of all children younger than 21 years of age. Of those adolescents covered by private insurance, there has been a shift from fee-for-service to managed care, including HMOs, preferred provider organizations, and point-of-service plans. Seventy percent of employees of firms with more than 200 workers and one third of Medicaid recipients now are enrolled in managed care. Managed care itself has undergone recent changes, with a movement away from group and staff model HMOs to IPAs and network model HMOs, from not-for-profit to large, national for-profit ownership. It is unclear how these changes in types of health insurance, and trends in insurance coverage will affect adolescents, especially in light of further threatened Medicaid cutbacks.
ADOLESCENT DEMOGRAPHICS AND PREGNANCY TRENDS U.S. Census data reports that there were 19 million adolescents aged 10 –14 and 18.4 million adolescents between 15 and 19 years of age in 1996. It is estimated that from 1995 to 2005, the numbers of 15–17-year-olds in the United States will rise by 15%, with the greatest increase in minority populations (Table 1).7 There may soon be more adolescent pregnancies on the basis of these demographics. However, if pregnancy prevention programs can be proven successful, pregnancy rates may decline despite an increasing adolescent population. The 1995 National Survey of Family Growth conducted by the U.S. DHHS’ National Center for Health Statistics showed a decline in the percentage of girls aged 15–19 who had ever had intercourse from 55% in 1990 to 50% in 1995. The survey showed an increase in the use of contraceptives at first intercourse due to a marked increase in condom use. In 1995, 90% of 18 –19-year-olds had received education on sexually transmitted diseases (STDs), safe sex, and abstinence. Although these results suggest that educational programs account for the recent declining birth rates, such an effect has yet to be documented in long-term studies. Information regarding current trends in adolescent pregnancy rates is hampered by limited abortion data. Data from the Centers for Disease Control
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Table 1. PROJECTED SHIFTS IN RACE/ETHNICITY OF U.S. CHILDREN UNDER AGE 18, 1995–2005 Ethnicity/race
1995
2005
Change, %
White Black Hispanic Asian and Pacific Islander Native American
45,732,900 10,178,500 9,599,700 2,555,600 673,300
44,208,100 11,013,000 12,466,800 3,563,000 713,000
3 8 30 39 6
Data from Kids Count Data Book: State profiles of child well-being. New York: The Annie E. Casey Foundation, 1997.
and Prevention from 1991 and 1992 lack adolescent abortion data from eight states because they do not report age-specific rates.8 An analysis for the Alan Guttmacher Institute reported adolescent abortion rates from surveys of all known abortion providers in the country. The number of stillbirths and miscarriages occurring after 6 –7 weeks gestation was estimated as 10% of abortions and 20% of births. As pregnancy losses are not reportable, this estimate more accurately reflects the total number of pregnant adolescents.9 This report documented the outcomes of adolescent pregnancies, showing a shift from abortions to live births. By 1992, almost 55% of teen pregnancies resulted in live birth compared to less than 50% throughout the 1980s. If trends persist toward increasing birth rather than abortion rates, then pregnancy-related costs will be disproportionately greater, as births are more costly than either terminations or miscarriages. However, if RU486 (‘‘the abortion pill’’) becomes available, more teens might choose abortion when a surgical procedure is not required, with the added benefit of greater privacy and confidentiality. Presumably, this would be a less expensive type of pregnancy termination, but as RU486 would not necessarily be dispensed in abortion clinics, statistics regarding the use of this method could be difficult to monitor.
THE COSTS OF ADOLESCENT PREGNANCY A recent cost analysis of adolescent pregnancy by Gans et al10 showed an average of $440 for termination and an average $6,059 for hospital costs of deliveries that include a 17% cesarean section rate. They found an average cost of $25,000 per low birth weight (LBW) infant, which is the result of 9% of adolescent births. Although miscarriage costs are variable and difficult to calculate, they are at least as much as termination costs. A 1995 study of managed payment model costs for unintended pregnancies at all ages found the average cost of miscarriage to be $1,038.11 Of the total 37.4 million adolescents in the United States, approximately 30 million have health insurance coverage. Estimates range from 20% to 40% (6 –12 million) of insured adolescents who are covered under managed care through private insurance or Medicaid. Of adolescents insured by managed care, 25% (1.5–3 million) are girls 15–19 years of age. As 10% of these girls become pregnant each year, there are approximately 150,000 –300,000 adolescent pregnancies paid for by managed care insurance annually. Because approximately 50% of these pregnancies result in live birth, the average costs, assuming 40% of teens have managed care insurance, can be calculated as 150,000 3 $440 (termination or miscarriage unit cost) plus 150,000 3 $6,059 (delivery unit cost), plus .09 3 150,000 3 25,000 (LBW infant unit cost), and the total, which is an underestimate owing to more recent increases in costs, is $1–3 150
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billion (Table 2). This amount does not include costs of care for normal newborns or newborns with other health problems and or the children’s subsequent medical care, which generally is covered under the grandparent’s insurance. Total costs would be $656,175,000 if only 20% of teens are covered by managed care insurance. Thus, managed care has significant financial incentive for preventing teenage pregnancy.
MANAGED CARE PROGRAMS FOR ADOLESCENT PREGNANCY PREVENTION Unfortunately, teen pregnancy prevention seems to be an area almost untouched by both the medical and medical administration fields. In a symposium issue on adolescent health published in HMO Practice in 1993,12 a survey was sent to health care plans in the HMO Group, KaiserPermanente, and other managed care organizations. Of 19 HMOs responding, only four had adolescent medicine specialists on staff and none had specific programs for pregnancy prevention. A 1989 survey of the HMO Group13 showed similar results with no pregnancy prevention programs, although 8 of 11 respondents had some services for teens, such as a hotline, teen clinic, or teen prenatal program. Multidisciplinary adolescent clinics at Fallon Community Health Plan, Kaiser-Permanente, and Group Health Northwest have on-site mental health, nutrition, social, work, and educational services. These serve as a model for other health plans to emulate. Teen-tot programs that care for adolescent mothers and their babies generally have a component of repeat pregnancy prevention, and several HMOs, including Fallon and Group Health NW, have these clinics. At Kaiser-Permanente HMOs in California, there are several teen clinics at which many of their adolescent members receive care. A program has been underway at the Antioch center since 1996 in which all adolescents having negative pregnancy test results are immediately provided with birth control. A report from the Panorama City Medical Center of the Southern California Permanente Group indicates that patients seen in their Teen Center had a much higher percentage of adolescents electing to terminate their pregnancies than the national average.14 This suggests that in settings in which pregnancies are detected early and appropriate options counseling occurs, the ratio of terminations to live births might be increased. A 1995 report from Harvard Community Health Plan15 described a quality improvement team from the pediatrics and obstetrics and gynecology departments that studied their teenage pregnancies and devised interventions. They reviewed charts of positive pregnancy tests from 1992 in patients younger than 21 years of age and found that only 2 of 34 were planned. Twenty of the 34 had been seen for negative pregnancy testing in the year prior to the pregnancy, and the team believed that these were missed opportunities for prevention. There was little documentation of pregnancy option decision making, presumably indicating that little counseling occurred. The report describes inadequate prenatal care owing to unkept appointments and late initial visits. The team developed several interventions, including grouping adolescent appointments together for interdisciplinary care and coordinating postpartum care with pediatric visits to improve follow-up. None of these managed care programs has involved the entire enrolled teenage population seen within separate medical areas or different centers within the managed care plan. To be truly inclusive (and have the greatest overall impact) it would be important to involve all adolescent patients, both male and female, for which the managed care system is responsible. A
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Table 2. ANNUAL COSTS OF ADOLESCENT PREGNANCY IN MANAGED CARE (ASSUMING 40% OF ADOLESCENTS COVERED BY MANAGED CARE INSURANCE)
Deliveries Low birth weight infants Miscarriages and abortions
Patients, n
Unit cost, $
Total cost, $
150,000 13,500 150,000
6,059 25,000 440
908,850,000 337,500,000 66,000,000
comprehensive program would be far easier to implement in a staff-model HMO in which there are centralized medical records, coding, and departmental coordination. In IPAs and other less centralized types of managed care, it would be much more difficult to influence and monitor individual practitioner’s care of adolescents. Despite the fact that these forms of managed care are increasing in prevalence, there are no published studies of teen pregnancy prevention in these settings. At Medical West Associates, a Blue Cross and Blue Shield staff-model HMO in Massachusetts, the Quality Improvement team was formed in 1996 to study and devise interventions for preventing adolescent pregnancies within the entire HMO. Initial chart review revealed that only a minority of pregnant teenagers had been seen within a year prior to conception for nationally recommended annual routine examinations.16 However, most were seen shortly before the onset of pregnancy for a sick visit, at which time pregnancy risk factors were not discussed. Even at routine visits, there was poor provider compliance with recommended sexuality screening and referral for contraception. Postpartum teenagers rarely received contraception and had poor followup. Teenagers requesting pregnancy tests had no options counseling for a positive pregnancy or contraceptive counseling for a negative test. This poor standard of adolescent care is not unique and has been widely reported to be the norm in other practices.17 The team enacted several policy changes for the HMO as a whole, which would affect all enrolled teens. Annual physicals for teens were officially endorsed. At this visit, a sexuality questionnaire was distributed to all teens, with a section for provider scoring and documentation within the medical record. If a teen scored as high risk, she or he was referred to a trained birth control counselor at the time of the visit. Compliance was monitored and enforced through chart review. All teens requesting pregnancy testing were seen for appointments and immediate test results, allowing for contraceptive or options counseling at the testing visit. Obstetric patients selected a postpartum birth control method at the 28-week prenatal visit with provision of contraception before leaving the hospital at delivery. Various tracking procedures to ensure follow-up of all teens completing a pregnancy were arranged. Results are still preliminary but seem to indicate a lowering of teen pregnancy rates. These data will need to be compared to pending health department data on pregnancy rates for local adolescents to determine statistical significance of the program’s impact. However, lessons from the program are clear. There are many gaps in adolescent health care that can be filled by physicians and managed care organizations to reduce pregnancy rates and provide an optimal level of care for this age group. Departments such as pediatrics and obstetrics and gynecology, which traditionally have not coordinated care for adolescents, benefit both in increased efficiency and improved provision of services by working together. 152
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PROBLEMS AND SOLUTIONS FOR ADOLESCENT MEDICINE UNDER MANAGED CARE Rather than working within the managed care framework, it has been argued that teenagers would be more appropriately served by receiving their care in school-based health centers (SBHCs).18 School-based health care centers were developed to increase access to medical care for teenagers especially those who are uninsured or underinsured. There have been efforts to coordinate the services provided by SBHCs for teens covered by managed care. Unfortunately, there are several drawbacks to SBHCs, including no weekend, evening, or holiday coverage and no access for teenagers who poorly attend or who have dropped out of school. Many SBHCs do not allow provision of contraceptive services on-site, and others do not even allow discussion of contraception or pregnancy options. Enrollment in SBHCs is optional, based on parental consent. Thus, although SBHCs have been shown to be effective in the provision of many adolescent health services, they cannot be the sole answer to improving access for adolescents in managed care. The costs of raising the quality of adolescent care to optimal standards are not trivial. Because approximately half of adolescents are sexually active, this population would require yearly pelvic examinations, Papanicolaou smears, and STD testing. Current adolescent health care does not approach this standard. In a 1996 study of high school girls, 68% had never had a Papanicolaou smear and 96% said physicians had never recommended this test to them.19 If abstinence cannot be guaranteed, the best contraception for teens includes both condoms and a prescription method, such as the birth control pill or Depo-Provera (Pharmacia & Upjohn, Columbus, OH). Unfortunately, prescription contraceptives rarely are covered by health insurance. Only half of health insurance plans cover some contraceptive drugs or devices, and only one third cover the pill, despite the fact that 97% offer other prescription coverage.20 Teens who have the least financial resources would need health plans to supply condoms and other contraception free of charge or at greatly reduced prices to make their use of birth control feasible. A legislative bill introduced by U.S. Senators Olympia Snowe and Harry Reid in May 1997 would require insurance companies to cover contraception in the same way as other prescriptions. It is well documented that Catholic hospitals and other religious organizations have omitted certain benefits, such as contraception or abortion, from their insurance plans because of religious objections. Many private employers and state and local governments have the same exclusions. As insurance costs are based on claims experience, these carve-outs result in short-term cost containment. Occasionally, exclusions are based on political or religious beliefs of a benefits manager who thus can affect the health care options of many subscribers. In the state of Massachusetts, after many years of this type of policy, it required a legislative vote to reenact coverage for abortion for state employees in 1996. These exclusions can certainly not be justified on the basis of anything but initial cost-containment, as it is always less costly to provide abortion and contraceptive services than covering the costs of unplanned pregnancies.11 The group most affected by the lack of coverage is teenagers, who are most at risk medically and who have the least political clout to fight the system. Unlike adults, adolescents would not usually be able to pay out-of-pocket for uncovered items. Even when health plans ‘‘cover’’ contraception, their rationale usually is based on adult women, rather than the needs of adolescents. For instance, Blue Cross/Blue Shield of Massachusetts decided to cover Norplant (Wyeth-Ayerst Laboratories, Philadelphia, PA) with a pharmacy copay that would equal the copay for 5 years of birth control pills, with the rationale that the 5-year cost
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would be the same for both methods and women would recognize this and find it acceptable. However for teens, the 5-year cost, which has to be paid before insertion, makes the method completely financially unavailable. One abortion equals the pharmacy cost of Norplant. It would make financial sense for the health plan to cover this medication even if an adolescent contributes no copay. The same is true for all the contraception and abortion exclusions by employers, and many health plans have decided to cover costs for these items. The chief obstacles to adolescent reproductive health care are lack of confidentiality and difficulties with access. Managed care insurance, with its organizational structure, has the potential to obviate both these concerns. Computerized subscriber information that avoids the need for an adolescent to present her ‘‘insurance card,’’ allows a teen to make her own appointments without parents being aware. However, medical offices frequently have policies to call or send reminder notices about appointments to diminish their no-show rate. If an office staff is sensitive to the confidential needs of teens, this mechanism can be selectively ‘‘unplugged.’’ When contraceptive services and visits are covered, there is no need for bills to be sent home. Nevertheless, many insurances including both fee-for-service and managed care send an ‘‘explanation of benefits’’ statement to the insurance holder. Even when a service is covered fully, it is thought to be beneficial to notify policyholders. Thus, in Massachusetts and several other states where a teen may receive legal permission from the court for an abortion without parental notification, the parent may be mailed a summary of services provided at the abortion clinic. This backfiring of the system can be rectified by a manual workaround by the central business unit, but a nonautomated method is prone to failure. Again, modifications require ongoing education and sensitivity to the unique concerns of adolescents. Finally, providers of adolescent health care need to be cognizant of and respectful of a teen’s confidentiality. Two recent studies show that this is not usually the case. A survey of 93 Pennsylvania gynecologic providers revealed that they ‘‘did not have a clear understanding of the laws related to teens and confidentiality.’’21 A survey of Texas physicians found that half only saw their adolescent patients with parents in the room, thus prohibiting any opportunity for confidentiality.22 In managed care, there should be ways to educate physicians and monitor their compliance with confidential patient history, such as the use of confidential adolescent reproductive health questionnaires, which have been distributed nationally by the Association of Reproductive Health Professionals. The use of screening tools can be documented in the medical record as proof that screening occurred. Access is sometimes worsened in a managed care situation, with a restriction of providers. Unaccompanied teens with limited transportation and resources may find restricted sites impossible to access. Community agencies and managed care organizations have provided vans for senior transportation, which are cost-effective by increasing access to primary-care providers and keeping elders from unnecessary emergency room visits and hospitalizations. The same principle would apply to adolescents, who could be provided with transportation from high schools or teen centers with preauthorized parental approval. Teen clinics with a social worker and teen hotlines that have been piloted in some HMOs, could coordinate such programs. However, as an adolescent is unlikely to read the managed care literature mailed to the subscriber, they will be unaware of the programs unless the managed care organization also does outreach and advertising. The advantage of managed care is that they do have the organizational structure to be able to make special arrangements for adolescents if they are so motivated. Another major obstacle to ideal adolescent health care is the lack of age-appropriate care for teens because of providers being unknowledgeable or 154
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feeling constraints of inadequate time or reimbursement. A good example of inappropriate care in regard to pregnancy prevention is the widespread practice of offering pregnancy testing to teens without immediate counseling. Adolescents who have a negative pregnancy test are soon likely to become pregnant, and it has been recommended that all teens requesting a pregnancy test be seen for an appointment and counseled about birth control if their test is negative.23 If they have a positive test, immediate options counseling should be done, rather than having a teen be given erroneous advice from friends and relatives before speaking with a provider. Another example of care that is not only acceptable in an older age group but lauded as a convenience for both physicians and patients, is treating uncomplicated bladder infections by telephone. In teens, a urinary tract infection is usually the sign that sexual activity has commenced, and thus other issues such as birth control and a pelvic examination must be addressed. As teens are concerned about confidentiality, and have no idea where to go for reproductive care, they are unlikely to spontaneously request contraception when being seen for another problem. Sometimes managed care can be too ‘‘macromanaged’’ to provide individualized care for teens. Many managed care organizations have contracted with national or regional nurse telephone triage companies for more costeffective and consistent telephone screening. Although national protocols have been made with hundreds of possible algorithms for most common health problems, they usually are divided into broad categories such as pediatrics, adult medicine, and reproductive care. Teens fit somewhere in between all three of these categories, and it is often an uneven fit. Recommending home pregnancy tests for diagnosis of pregnancy is reasonable for adult women but totally inappropriate for a 14-year-old girl. Asking an adult woman to use over-the-counter antifungal cream for a presumptive yeast infection is also reasonable but not for a teen who has more likelihood of an STD and undisclosed sexual activity. Although pediatric algorithms are used in both children and adolescents, a common complaint such as abdominal pain has a different set of diagnostic possibilities in a sexually active adolescent female than in a younger child, and questions to rule out diagnoses such as pelvic inflammatory disease (PID) must be included but generally are not. The sales representatives of these triage companies have impressive presentations to the medical staff of managed care groups to convince them that all age groups and most health issues have been addressed by experts in the field. However, a true assessment of whether adolescents are appropriately served is only possible by painstaking review of algorithms for all age groups that might include teens. These telephone services focus on self-care and justify their services as cost-saving by allowing more patients to treat themselves without an office visit. This approach can have the opposite effect for teens who have difficulty in articulating their needs. Their complaints may be transmitted inaccurately or second-hand by a parent who is not aware of the full situation. There is less chance for openness without the benefits of continuity that a personal relationship with a provider can offer. Lack of sufficient screening for the sake of expediency also can prove costly to teens. A study of older women in a managed care setting revealed that for those who are identified as high risk and screened for chlamydia, the incidence of subsequent PID was lower than in women who were not adequately tested.24 This effect is even more likely in teens in whom the incidence of STDs is highest and for whom PID would have the most long-ranging and costly consequences, including infertility and ectopic pregnancy, as well as the immediate costs of hospitalization. Although managed care classically is supposed to be more involved in preventive medicine than is indemnity insurance, the benefits of many types of
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preventive efforts take years to occur and are not seen as immediately cost-effective by health care administrators. Preventing adolescent pregnancy is a rare instance of preventive service that would have immediate, costeffective results. Given that 90% of girls become pregnant in a year of unprotected sexual activity, there are few other preventive efforts that could deter such an expensive annual ‘‘morbidity.’’ Despite national recommendations for yearly health examinations for teens, most health plans do not have a policy requiring this. Many teenagers obtain a cursory sports physical that is provided free of charge by schools and does not typically cover any sexuality issues. Some insurances do not cover yearly physicals for adolescents and many do not cover yearly gynecologic examinations. Some types of managed care restrict access to gynecologic providers or make this a referral requiring notification of the pediatrician. If there are no standards within the managed care plan for confidential care and referrals, then an adolescent will have little hope of navigating through the system herself. Standards have not been established for the time it takes to do a comprehensive adolescent examination, although estimates of the time necessary to do this kind of examination range from 30 to 47 minutes.25 Health plans do not generally allow longer time slots for well-adolescent than well-child visits (usually 15–20 minutes), and thus clinicians have inadequate time for full screening, including sexuality screening, in adolescents. Also, correct procedural terminology coding may not allow adequate reimbursement for adolescent visits. It is difficult to code adequately for a pelvic examination, which is frequently an adolescent’s first gynecologic experience and requires a lengthy visit, or for extensive contraceptive counseling involving patient and parental education and mediation.
RECOMMENDATIONS AND FUTURE RESEARCH IN ADOLESCENT PREGNANCY PREVENTION If a health plan were to establish an ongoing teen pregnancy prevention program, it should not rely entirely on volunteer effort from teams or committees but should devote paid time or possibly hire an adolescent health care coordinator to track teen care within the plan, educate staff, and arrange and enforce protocols. As such a position has never been studied, it would be important to learn whether its cost could be justified and whether there would be acceptance and compliance by the medical staff. Also, there are no studies on consumer satisfaction with a health plan’s teen pregnancy prevention program, despite surveys showing widespread public support for the concept of lowering adolescent pregnancy rates. Both patient satisfaction and costeffectiveness would need to be demonstrated for health plans to enact a pregnancy prevention program. The federal government, which has earmarked so many dollars for community-based adolescent pregnancy prevention, should consider funneling some of these funds to study medically based prevention efforts. Unlike other women’s health issues, such as mammography screening for breast cancer for which there is no political dissent except surrounding cost, teen pregnancy prevention is an explosive political topic. Although there is almost universal agreement on the need to prevent adolescent pregnancy, the method to do so is hotly debated. Vocal conservative and religious groups support abstinence as the only route, and they would be quite opposed to provision of contraception or confidential services for teens. Managed care would justifiably be concerned that their preventive efforts could cause a backlash of disapproval. Nevertheless, in Europe, where teen pregnancy rates are much lower than in the United States despite similar sexual activity, both 156
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government and health care vigorously espouse contraception for teens, and there has been public acceptance. Possibly, media campaigns in the United States could similarly affect public attitudes. There have been some attempts at quality indicators regarding adolescent sexuality. For example, inclusion of an STD-related quality indicator, namely the percentage of women (including sexually active adolescents) from age 15 to 25 who have had annual chlamydia screening, is being considered as a Health Plan Employer Data Information Set (HEDIS) measure.26 Such a performance measure would also boost pregnancy prevention, as condom use and other contraception could be discussed at this preventive visit. Although there are no standardized practice guidelines regarding teen pregnancy prevention, these could be developed from such a set of quality indicators. Other cost-saving initiatives that managed care has undertaken could be applied to adolescents as well. Many health plans have case management programs for intensive follow up of chronically ill patients or patients who use a disproportionate amount of health care services based on hospitalizations or emergency room visits. Pregnant adolescents could certainly fit within these guidelines, as one of the highest risk factors for an adolescent pregnancy is a previous pregnancy. Typically, adolescents have not been included in these programs based on pregnancy, but it would be useful to study whether case management could be effective in reducing repeat adolescent pregnancies. Recommendations to the entire managed care industry regarding adolescent pregnancy prevention must start with the recognition that teen pregnancy is a costly, avoidable condition and that optimal adolescent care should be age-appropriate, confidential, and follow specific national guidelines. There are policy statements and guidelines from the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists that specifically address issues of adolescent sexuality screening, pregnancy testing, options counseling, and confidential contraceptive provision. These policies should be endorsed and enforced by managed care. Adolescents should receive care from primary care providers who have special training in this age range and have their care centralized and coordinated. Managed care organizations should monitor their teen pregnancy rates and identify areas requiring intervention. They should analyze teen pregnancy prevention programs in their own setting for effectiveness and choose the most effective interventions based on cost and medical outcome rather than on political viewpoint. Interventions should begin in preadolescence before high-risk sexual behaviors have occurred and continue throughout the adolescent years with yearly education and support for abstinence, as well as providing specific programs that address both access and confidentiality for sexually active teens who require contraception. Although teen pregnancy in the United States is largely a societal problem, and its reduction will require many types of solutions, health practitioners are a resource that has been largely overlooked. As more adolescents become covered by managed care organizations, the financial costs that this industry bears will increase for this preventable health problem. There are many steps the industry could take that would simultaneously improve the health care for their adolescent patients and decrease unnecessary health care expenditure. Although the federal government has recently become acutely aware of the need for preventing adolescent pregnancy, leaders in the managed care field have not shown a similar awareness. It will take pressure from consumers, governmental agencies, and health care providers to effect policy changes. Health care practitioners and the health care industry must join the effort to reduce teen pregnancy and its associated costs, which are ultimately paid for by all of society.
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