Health Care Agency Blocks Planned Parenthood's Final Attempt to Secure County Funding

Health Care Agency Blocks Planned Parenthood's Final Attempt to Secure County Funding

After thirty years of working closely with the county and swooping in to absorb patients the county's shoddy public health care system could no longer treat, Planned Parenthood was forced to give up the county grant it has received for the past nine years. In a scathing letter written to the county Health Care Agency, CEO Jon Dunn ripped into the agency, and the board of supervisors, for blatantly erecting a series of barriers that have made it virtually impossible for the organization to receive the $290,000 allocation it was seeking for a new breast cancer treatment clinic.

Despite Planned Parenthood's long track record of working harmoniously with the county for decades, the Board of Supervisors "discovery" a few months ago that the non-profit received funds for sexual health training sessions and education (which many county employees benefited from) prompted a series of board meetings that eventually led to the yanking of Planned Parenthood's funds. After the funds were reinstated (because of the potential illegal move on the Board's part), the Health Care Agency enacted a new set of rules for all the community clinics receiving funding from the county. The new rules seemed specifically targeted at Planned Parenthood, with new caveats specifically targeted at clinics that performed abortions (county funds have never been used for abortion services at Planned Parenthood). Read the full back story here.

After several months of trying to comply with the Health Care Agency's new rules, Planned Parenthood gave up late last week after the agency asked that Planned Parenthood review and sign a proposed contract -- which would only pay half of the $290,000 allocation the clinic has traditionally received -- in less than 24 hours. "We told them we had to review it with our board and pleaded with them for more time, but they wouldn't give it to us," says Stephanie Kight, senior vice presidnet of Planned Parenthood OC. Without time to review the contract, the organization was forced to forfeit the grant, says Kight. 

"The barriers that the County erected for Planned Parenthood alone -- conditions it did not impose on other clinics -- have made it impossible for us to provide critical health care services to women in Orange County," wrote CEO Jon Dunn in a frustrated and biting letter sent to the board, the Health Care Agency, and cc'd to the ACLU on July 29. The letter lays out, in detail, the myriad barriers Planned Parenthood, unlike other clinics, faced in securing their funding.

Read the full contents of the letter after the jump....
July 29, 2009

Melissa J. Tober
Manager, Medical & Institutional Health Operations
County of Orange Health Care Agency
405 West 5th Street, Room 718
Santa Ana, CA  92701

Re:      Response to July 23, 2009 Letter Finally Rejecting Planned Parenthood's Breast Health Program

Dear Melissa:

Planned Parenthood could not sign and deliver the Tobacco Settlement Revenue contract you sent last Wednesday, July 23, 2009, within the 23-hour deadline you imposed. After eight years of providing vital health care to under-insured residents of Orange County, Planned Parenthood has been precluded from participating in the TSR community clinic program this year.  The barriers that the County erected for Planned Parenthood alone -- conditions it did not impose on other clinics -- have made it impossible for us to provide critical health care services to women in Orange County.

The long road we have travelled to this regretful conclusion started in March, with the Board of Supervisors' ideological assault on Planned Parenthood's participation in the TSR program.  In a plainly unconstitutional action, the Supervisors ordered the abrupt cancellation of our 2008 contract to provide sexual health education.  The Supervisors' comments left no doubt that the reason they were terminating the contract was because Planned Parenthood offered abortions, even though none of that care was funded through the TSR program.  In subsequently reinstating that contract, the Supervisors imposed a host of new restrictions on community clinics, gerrymandered to exclude Planned Parenthood alone from participating in the 2009-10 TSR program.

Although these new restrictions are also unconstitutional, Planned Parenthood decided to continue to serve under-insured patients rather than file a lawsuit.  We designed an innovative program to address a critical unmet need in Orange County: providing early diagnostic care and counseling to young women with potentially life-threatening breast cancer.

The Breast Health Program grew directly out of research by the Epidemiology Department at the University of California, Irvine and the Orange County Affiliate of Susan G. Komen for the Cure indicating an acute need for the services we proposed.  The researchers found that the populations Planned Parenthood serves -- women under age 40, women without health insurance, and women living in neighborhoods with the lowest socioeconomic status -- were more likely to be diagnosed with breast cancer at a late stage, when the disease is particularly fatal.  The researchers recommended interventions to help women overcome obstacles to early diagnosis and treatment, such as child care needs, scheduling, and financial constraints.  The researchers also recommended centralizing breast cancer screening, diagnosis, and treatment in a single location.

In crafting a proposal in accordance with these recommendations, Planned Parenthood complied with the County's requirements for TSR-funded programs, including the requirement that TSR funding not be used for abortions, abortion referrals, abortion counseling or the promotion or advocacy of abortion as a means of family planning.  In addition, Planned Parenthood guaranteed that it would separate the Breast Cancer Program, both physically and financially, from any abortion-related services.

Planned Parenthood was thus surprised when the County rejected its proposal to provide diagnostic care and counseling to young women at high risk for breast cancer.

For more than two months following the initial rejection, Planned Parenthood worked with the County in an effort to understand the basis for the rejection, respond to the County's repeated questions -- questions not posed to any other community clinics -- and identify a workable solution so that the women of Orange County could receive the valuable health services that the researchers had recommended.

In response, the County placed obstacle after obstacle in Planned Parenthood's path, ultimately making it impossible to implement the Breast Health Program.

·        The County refused to fund Planned Parenthood's nurse case manager.  The nurse case manager was a critical component of the Breast Health Program.  The nurse would have helped young women navigate the daunting system of care for breast cancer patients.  The County refused to fund the nurse, stating it was not a "direct medical service," and there was "no billable medical procedure code."  That was false: we explained that there was a billing code, that the position would be staffed by a licensed RN, and that researchers consider the nurse case manager a medically necessary component of the Breast Health Program.  The County still refused, so Planned Parenthood sought and obtained outside funding from the Komen Foundation to subsidize the nurse case manager.

·        The County refused to fund the Breast Health Program at reasonable rates.  The County offered, at one point, to provide funding, but only at $76 per visit.  Planned Parenthood explained that the average rate per visit under its Breast Health Program was $373.58 because the program involved specialized services including breast exams, radiology and mammography.  Planned Parenthood developed this rate by pricing its in-house services at MediCal rates and external referrals at the lowest community pricing levels it could find.

Planned Parenthood nevertheless revised its proposal, offering to provide the Breast Health Program to the County for $289 per visit.  The County countered by offering only $184 per visit, cutting the budget in half while requiring Planned Parenthood to see the same number of patients.  Not only was the County ungrateful that Planned Parenthood raised private funds to pay for the nurse case manager, a critical component of the Program, but it also demanded that Planned Parenthood subsidize each individual visit to the Breast Health Program.  As Planned Parenthood is a nonprofit organization already operating under tight fiscal constraints, the County clearly knew that Planned Parenthood could not offer the Breast Health Program under these conditions.

·        The County held Planned Parenthood to different accounting standards than other clinics.  The County repeatedly required Planned Parenthood to explain how it would financially separate the Breast Health Program from abortion-related services, even though Planned Parenthood said it would adhere to financial separation standards, established by the federal government under Title X, as Planned Parenthood has done for years.  There has been no suggestion that Planned Parenthood has ever improperly mingled funds or services under the TSR program, and no reason to impose additional requirements now.

Without addressing these points, the County simply said in response that financial separation would be accomplished through fixed per-visit rates.  Subsequently, the County backtracked.  Unlike the conditions it imposed on every other community clinic, it added yet another requirement for Planned Parenthood: the agency would not only have to track the number of visits but also record exactly what services were provided using detailed billing codes.  As the County no doubt understood, Planned Parenthood would have to incur an additional $5,000 in unreimbursed costs to comply with the County's record keeping demands.  This was a wasteful administrative burden not placed on any other clinic.

·        The County refused to pay Planned Parenthood the same way it paid other clinics.  Every other clinic was offered an annual grant, to be paid up front in twelve equal monthly installments.  Only Planned Parenthood was required to seek reimbursement every month on a fee-for-service basis. This would increase Planned Parenthood's administrative burdens and costs and delay its receipt of funds.  Again, the County provided no explanation for these additional requirements, presumably because there is none.

·        The County suggested the Breast Health Program duplicated a Komen Foundation program, and should not be funded.  Still seeking a way out, the County demanded detailed information about the relationship between a Komen Foundation program and Planned Parenthood's Breast Health Program.  The request was irrelevant: the relevant requirement under Measure H is that TSR funds may not supplant any existing funding for an applicant, and Planned Parenthood complied with that requirement.  Komen does not provide direct services, so the programs were not comparable, and we understand Komen's was not funded anyway.  Moreover, no other grantee was singled out for such scrutiny.  Yet Planned Parenthood agreed to provide the information, much of which was already provided in the revised proposal, which the County apparently had not read.

·        The County refused to negotiate and imposed an unworkable deadline.  Planned Parenthood submitted its proposal to provide services on a fee-per-visit basis, as the County requested, on June 18.  Almost a month later, on July 13, 2009, the County responded by cutting Planned Parenthood's proposed average fee-per-visit in half, finally offered Planned Parenthood a contract, containing many of the problems described above, and required Planned Parenthood to sign and return the contract by July 23, 2009 at 4:00 p.m. or be denied TSR funding for the 2009-2010 contract year.  When Planned Parenthood requested additional time to investigate whether providers would accept the low-ball reimbursement rates imposed by the County, the County refused.  When Planned Parenthood pointed out that it was being treated differently than other clinics with respect to the fee-for-service payment mechanism, the County denied it.

The County then backtracked after the close of business on the evening before the July 23 deadline.  The County offered Planned Parenthood a revised contract that was now supposedly "consistent with that used in the other clinic agreements."  Planned Parenthood again asked for more time to review the contract, which its red-line revealed had substantial changes.

The County refused, the deadline passed, and the women of Orange County are the ones who will pay the price.

To implement the Breast Health Program in its stripped-apart form, Planned Parenthood would have had to subsidize the program, take a financial loss of more than $50,000 a year and comply with a host of burdensome administrative procedures imposed on no other clinic.  In the end, that was neither appropriate nor feasible.  This is especially true when the County is sitting on more than $2 million in unspent TSR funds from prior years.

The real reason behind this parade of barriers, unreasonable deadlines and refusals to negotiate has nothing to do with providing vital health care to the uninsured women of Orange County.  It is because Planned Parenthood offers abortion-related services, wholly independent from any services funded through TSR either in the past or contemplated.  The County obviously wants to use any excuse imaginable to preclude Planned Parenthood from participating in the TSR program due to its opposition to abortion.

The real losers in this attack on Planned Parenthood, of course, are the medically underserved men, women, and children who live in Orange County.  The elimination of all health education will inevitably result in more people with obesity, diabetes, and cancer, as well as HIV and other sexually transmitted infections.  The increased administrative costs of complying with wholly unnecessary new restrictions on clinics that offer family planning counseling will divert resources from patient care.  And, finally, young women with aggressive breast cancers will suffer delayed -- perhaps tragically delayed -- access to care.

When the voters passed Measure H, they envisioned tobacco settlement money going directly to hospitals, doctors, and clinics serving the uninsured, without political interference.  The Supervisors and Health Care Agency have tampered needlessly with a system that was working well to expand access to health care for the medically underserved.  In your effort to eliminate Planned Parenthood from the TSR program, you have eliminated critical health education programs, created barriers to critically needed care, and increased the cost of providing health services for all community clinics.  You will be held accountable for your reckless and irresponsible actions.


Jon Dunn

President and CEO

Cc:       David Riley, HCA Director

Robert Gates, HCA Deputy Agency Director

Isabel Becerra, CEO, Coalition of Orange County Community Clinics

Beth Parker, Arnold & Porter LLP

Maggie Crosby, American Civil Liberties Union


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