Advancing Access to Contraception in States Through Quality Measures and Person-Centered Contraceptive Counseling

For nearly 30 years, experts have advocated for the importance of high-quality health care services, including the use of standardized performance measures to track effectiveness for providers and patients and to increase transparency.¹ The quality of contraceptive care is a key component of contraceptive access and reproductive health care overall.² Quality of care is a determining factor in women’s contraceptive decision-making, and research demonstrates that high-quality care is associated with an increase in contraception use and a decrease in unintended pregnancies.³ Contraceptive counseling and related services should be comprehensive and person-centered, meaning that women are advised of the full range of birth control methods in a nonjudgmental, noncoercive way that affirms their autonomy and reproductive decision-making power, as well as that of other people who may become pregnant.

To improve access to birth control and the provision of family planning and contraceptive services, states should adopt and implement contraceptive quality measures, or “performance measures,” where possible.⁴ Performance measures provide consistency and accountability to ensure that family planning services adhere to recognized standards and guidelines. These measures can be used to 1) drive improvement and adjustments in care, 2) inform consumers, and 3) influence payment and reimbursement to providers. For example, performance measures may be used to incentivize quality improvement through pay-for-performance initiatives, which aim to “achieve optimal outcomes for patients” by linking provider payment to demonstrated quality improvement.⁵

Contraceptive care quality measures are meant to serve a few main purposes. One purpose is to assess patient preference, ensuring that contraceptive decisions are rooted in the individual’s choice based on their own self-identified needs. Another purpose of quality measures is to focus on the most effective methods of birth control for preventing pregnancy. In 2016, the National Quality Forum (NQF)—a coalition of health care industry advocates and leaders that promotes evidence-based practices to advance patient protections and improve health care quality—endorsed contraceptive care quality measures developed by the U.S. Office of Population Affairs (OPA).⁶ These measures “assess the degree to which women access effective methods of contraception.”⁷ The move to endorse the quality measures would provide, for the first time, an important and previously overlooked assessment tool on accessibility and use of effective contraception that states can use in addition to their own Medicaid and health plan measures.⁸ At the same time, the quality measures’ emphasis on long-acting reversible contraceptives (LARCs) raised some concerns that patients could be pressed toward that method even if it is not the desired choice.

The NQF-endorsed contraceptive quality measures:⁹

To understand the concerns about noncoercive care and access to LARCS, it is critical to acknowledge that there is a deep history of unethical and coercive practices related to contraceptive use for low-income women and women of color, especially Black women.¹⁴ Throughout history, low-income women and women of color in the United States have been forced to undergo sterilization and other unethical practices, mistreatment, and experimentation related to reproductive health. That history continues to inform how women of color understand, navigate, and access contraceptive services today.¹⁵ Therefore, while the performance measures are designed to encourage providers to offer the full range of effective methods, the emphasis on LARCS as the most effective method has raised important questions on how best to implement such measures.¹⁶ Recognizing these dynamics, the American College of Obstetricians and Gynecologists recommends the use of a patient-centered reproductive justice framework along with a shared decision-making model for providing contraceptive counseling and care.¹⁷ Reproductive justice is a framework and advocacy movement with a set of core guiding principles that was created by a group of Black women advocates in the mid-1990s. The guiding principles are defined as “the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.”¹⁸ A promising approach with reproductive autonomy in mind that has gained traction over the past few years is the person-centered contraceptive counseling (PCCC) measure, which was also endorsed by the NQF in 2020.¹⁹

When it comes to contraceptive services and counseling, person-centered, contraceptive quality measures are particularly important due to the intimate nature of the visits.²⁰ Research demonstrates that women who receive contraceptive counseling place great importance on the effectiveness of a specified birth control method.²¹ One study asked 1,783 women in family planning and abortion clinics which characteristics of contraceptive methods were “extremely important” to them.²² A vast majority of respondents—89 percent—said that pregnancy prevention was “extremely important.” However, effectiveness is only one aspect of contraceptive decision-making. That same study found that the next most important factors were the method’s accessibility (81 percent), affordability (81 percent), and ease of use (80 percent). Additionally, research suggests that there are specific factors that influence women’s experiences and perspectives toward contraceptive visits, including “personalization of care,” the provider’s displays of empathy, “respect for women’s autonomy” and individual decision-making, accessibility, and more.²³ Unfortunately, many women report dissatisfaction with their contraceptive counseling, stating that visits are not tailored to their unique needs and circumstances.²⁴ All of these factors play into a patient’s assessment of the quality of services provided.

Person-centered contraceptive counseling and care

Person-centered care should be the standard of care.²⁵ The University of California, San Francisco (UCSF) describes the person-centered contraceptive counseling measure as “a patient-reported outcome performance measure” that assesses “the person-centeredness of contraceptive care.”²⁶ In other words, the measure centers patient experience and satisfaction and seeks to provide a counterbalance and complement to existing contraceptive provision measures, which already assess the percentage of patients receiving evidence-based contraceptive care. PCCC experts describe person-centered services as:

Treating each person as a unique individual with respect, empathy and understanding, providing accurate, easy to understand information about contraception based on the patient’s needs and goals, and assisting patients in selecting a contraceptive method that is the best fit for their individual situation in a manner that reflects the patients’ preferences for decision making.²⁷

The PCCC measure helps narrow in on patients’ preferences, beyond just “pregnancy intentions,” to ensure they have a comfortable experience and can meet their own family planning and contraceptive goals.²⁸

The PCCC was derived from years of contraceptive research and is actually the shortened version of a larger scale used to assess patient experience.²⁹ The UCSF recommends that the PCCC measure be used either as a standalone measure of patient experience or alongside other measures endorsed by the National Quality Forum to optimize access to all methods while monitoring patient experience.³⁰ Using a 5-point Likert scale, with answers ranging from 1 to 5, the PCCC measure requires that patients are asked about their health care visit prior to leaving the facility. The measure is then calculated as a percentage of patients who scored their experience as a 5 at either the individual provider or facility level.

The specific questions include whether their provider:

1. Respected them as a person
2. Let them say what mattered to them about their birth control method
3. Took their preferences about their birth control seriously
4. Gave them enough information to make the best decision about their birth control method

Contraceptive quality measures such as these can help providers, managed care organizations, and state agencies assess patients’ reproductive preferences and the effectiveness of contraceptive care, as well as prevent providers from coercing women into using certain types of contraceptives.

There is a multitude of avenues states can pursue to implement contraceptive quality measures. There is no established method for states to decide on and implement changes to family planning standards and guidelines. Additionally, because states are not required—only encouraged—to adopt and report on the measures, states and, subsequently, health care providers have considerable discretion and flexibility in what they choose to envelop in their family planning services. The following case studies are not designed to be comprehensive, but they do demonstrate some notable trends in implementation—and the recommendation section includes additional statistics from states to further explain the need for certain changes.

Illinois

Illinois has been a national leader in adopting progressive reproductive health policies. The state has made considerable and significant progress in improving access to contraceptives, including eliminating cost sharing for contraceptives, allowing for multimonth dispensing, and making long-acting reversible contraceptives more accessible over the past decade. This included the passage of the Illinois Contraceptive Coverage Act in 2016.³³ Nonetheless, some estimates indicate that nearly 800,000 people in the state are in need of publicly funded contraceptives due to myriad barriers such as immigration status, restrictions in religiously affiliated health centers, confidentiality concerns, problems with insurance, and more.³⁴ In 2021, Illinois launched a five-year statewide initiative called Illinois Contraceptive Access Now (ICAN!), which is a working group helping to address unmet contraceptive need in the state.³⁵ A key part of the new initiative is assessing patients’ reproductive goals and the extent to which patients feel respected, supported, and informed enough to make decisions about whether, when, and under what circumstances to become pregnant or a parent.

Although still in its infancy, ICAN! could provide a great model for how to integrate quality measures into existing systems and how to get providers on board. For example, the state has plans to create a quality hub network, which would be a collaborative of federally qualified health centers (FQHCs), pharmacy allies, and managed care organization partners, to solicit patient feedback and utilization patterns that will deepen the field’s understanding of what it means to provide high-quality contraceptive care. Specifically, ICAN! plans to create a digital platform to expand access by partnering with local community health providers to strengthen the provision of reproductive health care. It will directly connect users to a telehealth or in-person appointment with skilled providers equipped to offer same-day access to all methods without financial barriers. The platform will incorporate patient experience metrics by asking users to complete the survey after appointments.³⁶

Mississippi

As noted in many studies, access to quality, affordable health care in Mississippi—and access to contraception in particular—is not equitably distributed across the state.³⁷ Many people face economic and geographic barriers to get contraceptive care. 2022 data show that more than 208,000 low-income women—that is, those living at or below 250 percent of the poverty level—in Mississippi live in contraceptive deserts.³⁸

Mississippi Converge is the state’s first Title X grantee that is not the state’s health department, and it began administering Title X in 2022.³⁹ Quality of care is one of the organization’s five-year strategic priorities, with the aim to “promote the inclusion of patient experience as a key indicator of quality.”⁴⁰ Converge works closely with the state’s public health agency to champion quality improvement activities in family planning services.⁴¹ As part of its mission to ensure that people have access to high-quality family planning care, Converge partners with many organizations to provide continuing education for providers and advocates on person-centered care. They also recently endorsed the Self-Identified Need for Contraception-based contraceptive performance measures.⁴² While the impact of Mississippi’s emphasis on quality care is not yet known, future monitoring and evaluation to generate lessons learned could be valuable for other states looking to do similar activities.

New Jersey

In 2010, more than half of unplanned births in New Jersey—52.4 percent—were publicly funded, and the state spent $477.1 million on unintended pregnancies, with $186.1 million paid by the state and $291 million using federal funds.⁴³ Additionally, New Jersey had a low rate of use for the most effective contraceptive methods. For example, in 2016, 13 percent of Title X clients were using the most effective methods, and approximately only 1 percent of Medicaid beneficiaries used LARCs from 2015 to 2017.⁴⁴

Given these challenges, New Jersey was one of the first states to add quality measures to support access and quality contraceptive services. In 2019, NJ FamilyCare added two measures to the set of core measures for Medicaid MCOs: contraceptive care for postpartum women and contraceptive care for all women.⁴⁵ Because the National Quality Forum endorsed the four contraceptive care measures, New Jersey policymakers were able to use that data to understand the effectiveness of different contraceptive methods for preventing pregnancy, with the intent to encourage providers to offer their patients a range of effective methods.⁴⁶ These efforts highlight alignment across stakeholders in the state to maximize the use of measures to improve contraceptive access.

New York

New York has championed reform to its health care payment and delivery systems for more than a decade, aiming to improve access and quality of care for patients. The state has developed several priorities and goals related to its transition to value-based payment arrangements. For example, in 2022 it introduced the postpartum contraceptive measure in its maternity care VBP arrangement as a pay-for-reporting measure.⁴⁷ The maternity care quality measures were created in collaboration with the state’s clinical advisory groups and the New York State Department of Health.⁴⁸

State health departments and advocates of health care payment and delivery reform who want to pilot the implementation of the PCCC measure could model their reform after New York City’s recently developed program proposal to implement new standards for sexual and reproductive health care services across the city.⁴⁹ As part of its Quality Improvement Network for Contraceptive Access, the New York City Department of Health and Mental Hygiene identified and refined four key steps to provide high-quality contraceptive care and includes implementation of the PCCC measure as one tactic to achieve the city’s goals. One strategy that may be useful to successful implementation is extensive planning and preparation. The New York program and concept paper could offer a useful roadmap for implementing a PCCC pilot, with specific relevance pertaining to programmatic eligibility, which includes but is not limited to abortion providers, FQHCs, family planning providers, and hospital outpatient clinics.

Because the contraceptive quality measures are relatively new, there is still a gap in the understanding of how to best implement them at the state level, making it challenging to know exactly what barriers states may face when implementing such measures. Below are some common challenges to implementation that policymakers must be aware of and work to address. This is not an exhaustive list and is meant to create an informative foundation that states can build on to plan and create new programs and improve existing programs.

Challenge: Provider training, education, and awareness

The implementation of contraceptive quality measures relies partly on providers being informed and educated on contraceptive quality measures as well as being incentivized to adopt them into practice. The quality measures themselves are insufficient without the necessary support from providers.

Specifically, states can take the following steps to ensure that providers are adequately trained on quality measures:

• Collaborate with training and technical assistance providers. Partnering with a technical assistance provider may help states anticipate common questions and give providers a direct source of information to lean on during implementation.

  One lesson learned from the Maternal and Infant Health Initiative was the importance of state technical assistance. Many states requested technical assistance with the Centers for Medicare & Medicaid Services’ new core sets to ask questions and implement these measures effectively. Additionally, the MIHI states and technical assistance providers used a “co-design” model so that states could be involved in refining the technical aspects of implementing measures.⁵⁰ This type of co-design model may be useful especially for providers within each state for contraceptive care measures.

• Require ongoing training for providers and staff to help them meet the standards of the measures. Having regular training sessions can help equip providers with the tools and information they need to provide high-quality contraceptive care and stay up to date with changing guidelines and standards.

  Not all health care providers receive extensive formal training on contraceptive care. Some health care providers report experiencing barriers and feeling ill-prepared to provide contraceptive counseling.⁵¹ This lack of formal training may negatively affect patients and, particularly, low-income women and women of color who may disproportionately receive lower quality reproductive health care and face poor reproductive health outcomes. Some research suggests that women who receive poorer quality care may have a higher risk of unintended pregnancies and less likelihood of using the most effective methods of contraception.⁵² Research suggests that the higher the quality of care at the onset of a contraceptive method, the higher the likelihood of continued use of that contraceptive method at a follow-up visit.⁵³

  Power to Decide advocates that trainings should be offered annually and as guidelines are released to cover topics “critical to effective delivery of high-quality contraceptive care.”⁵⁴ As noted by Power to Decide and affirmed by Families USA, at minimum, training topics should include cultural humility and health equity; person-centered counseling and contraceptive care; youth-friendly clinical practices; ways to prevent reproductive coercion; pregnancy-intention screening; the National Culturally and Linguistically Appropriate Services Standards in Health and Health Care; insertion and removal of long-acting reversible contraception, as well as troubleshooting in complicated cases; and billing and coding procedures to maximize patient confidentiality and contraceptive access.⁵⁵

  Additionally, the aforementioned New York program would prioritize allocating funding to providers familiar with a reproductive justice framework and with at least five years of experience providing care to the communities that have the greatest needs, or both.⁵⁶ In fact, in 2022, the American College of Obstetricians and Gynecologists issued new guidance on contraceptive counseling that emphasizes patient-centered care through a reproductive justice lens.⁵⁷

Challenge: Integrating quality measures into existing reproductive health services, programs, and practices

There is an opportunity for states to explore how to integrate contraceptive quality measures into other commonly used programs and services to both broaden their reach and meet statewide family planning goals to reduce unintended pregnancies and support women to plan their pregnancies if, when, and how they choose.

Accordingly, states must:

• Investigate ways to integrate quality measures into existing reproductive health services, programs, and practices. For example, postpartum and post-abortion access to contraception are often overlooked areas of family planning need. Integrating contraceptive quality measures into these and other pregnancy-related services may help to mitigate this issue and ensure that people are able to achieve their family planning goals. Increasing postpartum contraceptive access is an important method for helping people achieve their family planning goals and reduce rates of unintended pregnancies.⁵⁸ In fact, the postpartum period is an optimal time to address contraceptive care, as women are recommended to visit their health care provider in the first few weeks after birth.⁵⁹ However, many women face extensive barriers to care and do not make it back to visit their provider within the recommended timeframe.

  Furthermore, some states have changed their payment policies to facilitate payment to providers to increase access to contraceptive care in the immediate postpartum period.⁶⁰ To successfully implement these policies and models of care, state Medicaid and Children’s Health Insurance Program initiatives would need to also implement complementary administrative changes related to provider credentialing, payment, and administrative procedures.

• States can integrate the person-centered contraceptive counseling measure into their Medicaid and health plan programs’ quality measurement to incentivize providers to utilize the measure in addition to other quality measures endorsed by the National Quality Forum.
  • Medicaid managed care organizations: Although coverage varies from state to state, many Medicaid beneficiaries receive coverage through an MCO. Contracted health plans may have annual reporting requirements that solicit feedback from beneficiaries. This would be an opportunity to receive feedback from people who received contraceptive counseling through the PCCC measure and others.
  • Patient-centered medical homes (PCMHs): PCMHs use a team-based care delivery model to provide continuous and coordinated care throughout a patient’s lifetime and help move away from the traditional fee‐for‐service model. PCMH practices cover a wide range of services, including primary and pediatric care, family medicine, and ambulatory visits. Providers are assessed based on quality, use, and efficiency performance metrics. They also survey patients for their experiences and quality of care.
  • Maternal, infant, and early childhood home visiting programs:⁶¹ States with home-visiting programs have some flexibility in the way they operate their programs. However, awardees must report on their program’s performance for 19 measures across six statutorily defined benchmark areas and demonstrate improvements in at least four benchmark areas.⁶² When clients are connected to such services, the state should require that the providers offering this care utilize the PCCC measure to ensure they are providing care that is patient-centered and high quality.
• States may also consider tying the measure to their existing state or federal grants partnerships, including as a requirement for partnership with the state in applications to the Title X program.

Challenge: Patient awareness and empowerment

In quality of care, the importance of the patient’s perspective and experience cannot be overstated. A patient’s agency should be the foundation on which care decisions are made, and importantly, patient experiences should inform and drive changes in the U.S. health care system. All too often, patients are not centered in their own care, nor are they provided resources that support their autonomy and agency.

Moving forward, states should:

• Invest in decision support tools to improve quality of care and affirm patients’ autonomy in their contraceptive care. One way to do this is to incentivize health care facilities to adopt and use these tools regularly in their practices.⁶³

As recommended by Families USA, states may find it helpful to invest in decision support tools that increase patient autonomy in contraceptive appointments.⁶⁴ Decision support tools inform patients of the range of contraceptive options, determine which factors are most important to them when seeking contraceptive care, and support shared decision-making between patients and providers during visits.⁶⁵ Utilizing decision support tools helps address challenges posed by short clinic visits by offering patients tailored information about contraceptive options that suit their needs and values; sharing these preferences with their providers; and establishing effective, patient-centered communication between patients and providers.⁶⁶

For example, the University of California, San Francisco’s Bixby Center developed a tablet-based decision support tool and conducted a pilot study of its ability to aid women in their contraceptive decisions.⁶⁷ Ninety-six percent of patients reported the tool helped them select a method and provided satisfactory information. Another study of the tool showed that patients who used the tool had higher levels of counseling quality and increased knowledge of contraception options and side effects—and they felt more empowered to ask questions of their provider than patients in the control group.⁶⁸

• Partner with providers to implement electronic health record measures that ensure that patients receive comprehensive, patient-centered resources on contraceptive options available to them.⁶⁹

  As recommended by Families USA, Medicaid agencies can work with providers to implement an electronic health record measure “that tracks the delivery of evidence-based, patient-centered resources on contraception options.”⁷⁰ This measure can help enhance patients’ knowledge of how to use contraception by making information easily accessible. It helps ensure that providers are consistently providing contraceptive information to patients.

Challenge: Optimizing the use of quality measures

To optimize the use of quality measures and better assess the quality of contraceptive care, states should explore using more than one quality measure concurrently. This approach may provide a more holistic picture of service provision and help states identify and assess issues in care. Indeed, as recommended by the Coalition to Expand Contraceptive Access (CECA), using existing measures in concert can help expound on the complex and “multi-dimensional nature of quality as it relates to contraceptive care [and counseling].”⁷¹

States can explore the following options:

• Use existing measures in concert with new contraceptive measures.
• Explore both patient and provider aspects of quality of care.

The CECA notes:

Using both the provision measures and PCCC in tandem [can create] a ‘balancing measure’ to counteract the potential inappropriate consequences of the provision measures. Tandem use can address two types of ‘coercion’: 1) indirect/structural coercion through lack of access, and 2) direct coercion through provider bias.⁷²

Contraceptive quality measures have the potential to exponentially improve the way women access and experience contraceptive care and counseling. Contraceptive care should be affirmative of women’s and all people’s agency and personal needs, and providers must be supported in adopting these complex measures. Implementing quality measures is one way to ensure that patients’ family planning needs are being met and to incentivize providers to offer quality care by focusing on the whole person.

The author would like to thank Osub Ahmed, Bela Salas-Betsch, Amina Khalique, Maggie Jo Buchanan, Emily Gee, and Tara Mancini for their contributions to and reviews of this series.