The Future of Family Planning in Post-COVID America


What is the future of telemedicine in family planning? What have been the financial implications of telemedicine so far? And what as been telemedicine impact on quality of care in family planning? At the September CT conference,[2] Contraceptive Technology author, Michael Policar, MD, MPH, interviewed experts Alina Salganicoff, PhD, Senior Vice President and Director of Women’s Health Policy at Kaiser Family Foundation in San Francisco, and Maria I. Rodriguez, MD, MPH, Associate Professor of Obstetrics and Gynecology at Oregon Health and Sciences University,  Medical Director for the state of Oregon’s Title X program, and Deputy Editor of the Cochrane Fertility Regulation Group.

Michael Policar: With the advent of the public health emergency, most family planning clinics have implemented at least some telemedicine capabilities. What do you think is the future of telemedicine visits for family planning services once the public health emergency is over?

Alina Salganicoff:  Telemedicine is adding an interesting new wrinkle that has a lot of positive possibilities in terms of providing family planning and contraceptive care, as well as new challenges. The pandemic has really resulted in a major explosion of telemedicine as a delivery system, and this is actually largely only possible because now we’re we have become so accustomed to communicating and getting goods and services through our phones for online services. Healthcare in fact is now no different, so there’s really been kind of a very layered and complicated change that’s been happening in our field that’s shaped by funding, earlier changes in medical standards of care, choices that people make, and how and where they get their contraceptive care. We’ve also seen an increase in LARC use, changes in standards around Pap smears and how often women should get them. All of those are affecting revenue and patient visits for family planning providers. Telemedicine is now going to be layered on top of that.

There really is a growing number of vendors of these applications. Most of most of them all offer generic oral contraceptives, the ring, the Patch, emergency contraception, and some others are vendors that are offering home STI tests. During the COVID lockdown, many women still had a need for contraception, but for many reasons relating to the availability of care, and concern about infection and PPE, these apps have really become very appealing. Anecdotal conversations we’ve had with some of these vendors have shown anywhere from a 20% to 40% spike in utilization over the past 6 months. The online platforms use an online questionnaire with, sometimes, a video consultation, and the provider determines the patient’s eligibility for contraception. After assessing eligibility, they can either give you a prescription that you send directly to your pharmacy, or—how they mostly make their money—through an online pharmacy. Some of the issues have been worrisome. There is no formalized referral. They have very limited contraceptive counseling. It works very well if you know what you want, but if you want counseling—not so much. Again, that really depends on the app. Some have age restrictions for teens.

You need to have a credit or a debit card for payment. And there’s very limited participation with insurance plans and Medicaid. As we know, paying for contraception is critically important to the patients that many of us serve. Many of [the apps] charge a membership fee or they have some type of a one which is [about] $100; some of them have a $10 or $30 fee each time that you use the method. Then the other thing which a lot of people don’t think about is that a lot of folks, particularly low-income folks, have online systems that are basically by-the-minute. They don’t have very generous data programs, so that using these types of services can be incredibly expensive. So for some, this is a really great option, but for others, it becomes much more difficult.

Mike Policar: What have been the financial implications, whether or not that’s causing a compromise in the income or the financial solvency of family planning clinics?

Alina Salganicoff: A couple of factors that really affect this—do Medicaid programs and the private plans reimburse for telemedicine? And we’ve had some emergency actions on the state level, and some plans have actually come forward and said “Yes, we’re going to pay for that.” But the other issue is parity­—do you get paid the same amount that you would have for an in-person visit? There’s another level that I call, for lack of a better analogy, the restaurant factor. Like you go to the restaurant and the restaurant doesn’t just make their money on the meal; it’s the drinks before, the bottle of wine, and the dessert. Think about the different types of services that we also offer: the medical tests and the labs that we offer our patients. We’ve heard that the no-show rate is much lower for telemedicine visits. The patients seem to like having this type of access, but whether this is going to change practice is an open question right now, during the pandemic in terms of the bottom-line, and then afterwards.

Mike Policar:  What’s your overall sense of whether or not you think the quality of care provided in these telemedicine visits is as good as what would be provided in an in-person visit?

Maria Rodriguez: It depends. First, I think it’s incredibly important overall that we have different points of access as a way to protect reproductive health and rights in the current very challenging policy environment we face. As far as the quality of telemedicine and the reason I said “it depends” is because there are a lot of positives for it, to a certain extent. I really like the interactions we have. Telemedicine feels a lot less rushed. I feel like I have more chances to talk with people. A lot of times, women are more comfortable in their own homes. You get to see a lot of babies you delivered who are better now and considerably older. You get to meet people’s pets, and it feels more relaxing for them. I’ve noticed that younger people, particularly adolescents, seem to be a more comfortable with it, too. I think that’s partially their familiarity with technology, but also perhaps, that the possibility of an exam is off the table. Some people are intimidated by the idea of a gynecological exam.

On the negative side—is it going to promote equitable access, or is this just going to be for the people that are already really dialed into the health care system? That’s a major concern, especially for our patients who don’t speak English as a first language. I think we have to be really thoughtful about how we structure the technology, so that there’s a video interpreter dialed into the call, so that it doesn’t exacerbate existing disparities within the healthcare system.

Mike Policar: In your department at OHSU, are you doing any things like prenatal care visits, infertility services, menopause services?

Maria Rodriguez: Absolutely, and in fact, I think we’re in a position of advantage because [we serve] a rural state. We already had a lot of the telemedicine consultations in place for reaching out to more isolated communities. We were also part of the Telabortion study… so we had mechanisms in place for providing abortion care remotely. [Because of COVID], what happened though is that instead of the slow ramp-up over years that the University had been talking about, [we had to] immediately [move] to everybody being able to provide telemedicine. I actually think that despite the speed at which it occurred, we all got good training on how to use the software and technology. Currently we’re doing staggered visits for antenatal care: some visits are virtual and some in-person. The closer woman gets to term, the more important it is that they’re coming in every visit. We also do a lot of consultations by telemedicine: menopause is a great one that we can talk to women about; some basic infertility workups, just in terms of getting the history; tubal ligation consults. I think is also helpful to have that first conversation done by video, where you’re talking about all different options, efficacy, how the scheduling process works. So there’s quite a lot that can be done.

[1] Policar M, Salganicoff A, Rodriguez MI. The future of family planning service delivery in a post-COVID, post-election America. Presented at the Contraceptive Technology virtual conference, Sept. 23-25, 2020.

[2] Policar M, Salganicoff A, Rodriguez MI. The future of family planning service delivery in a post-COVID, post-election America. Presented at the Contraceptive Technology virtual conference, Sept. 23-25, 2020.