For a brief overview of the laws and reporting requirements specific to abortion in different states see Chapter 1 Overview of Abortion Law, and for the most up-to-date information, go to the Guttmacher Overview of Abortion Law. Be aware that certain states require reporting of abortion complications and hospitalization. Consult your Department of Health for more information and reporting procedures.
- For reporting for statutory rape, abuse or incest, see https://rainn.org/statelaws.
- For child abuse and neglect, see https://www.childwelfare.gov/pubPDFs/manda.pdf.
- For sexually transmitted diseases, see http://www.cdc.gov/std/program/final-std-statutesall-states-5june-2014.pdf.
Obtaining affordable malpractice coverage is currently a challenge for clinicians in every area of medicine, and abortion services in particular. Although the financial risk to the insurer for abortion services is approximately one third that of obstetric services, insurance companies often “bundle” abortion with general Ob-Gyn coverage, in spite of much lower complication rates (Dehlendorf 2008). In addition, many insurance companies do not yet recognize abortion as a service that falls safely within the scope of practice of primary care providers, in spite of significant safety and efficacy data. Advocacy for improved regulation of the insurance industry could help ensure that clinicians trained and willing to provide services to their patients are not limited by the decisions of liability insurers.
The good news about malpractice is that federal and state lawmakers are moving toward considering legislation to help resolve this issue within the next few years. There have been a series of recent physician-led community efforts to help insurance companies understand the safety of covering abortion services, and others have identified sources of law that may limit insurers’ ability to deny coverage or charge high premiums for medical abortion. However, for most providers in private or small group practice there remains no easy, affordable solution. We therefore provide a list of options, along with the potential advantages and disadvantages of each.
There is currently no uniform code for insurance coverage. Not only do states differ in terms of whether they require you to have insurance coverage, but they also differ in which insurance companies they consider to be legitimate. Especially if you plan to purchase individual insurance, make sure to check with the insurance commissioner of your state that your carrier is on the approved list. No matter which option you choose, it is important to check that the coverage is adequate for your services.
A targeted, short-term fundraising campaign may be an option for raising the fee required for a rider. See fundraising suggestions on http://www.grassrootsfundraising.org.
|NAF Group coverage in progress (contact NAF for update or to join plan)||Large group of physicians ensures bargaining power.
Membership cost is pro-rated to procedure number performed.
|Clinic coverage only
Must be NAF member.
|Risk Retention Group||Allows providers to decide what to charge the group for premiums, what policies to adhere to, and what level of risk is acceptable.
Profit can be put back into premiums.
|Physicians within the group must be like-minded and share a similar level of risk.
Still may need to attract a secondary (excess) carrier.
|Commercially purchased insurance
(potential carriers include companies such as Chubb, Evanston, and Admiral)
|Risk is individually assessed,
which may be helpful for some.
Does not require organizing with other physicians.
|Most likely to be high-cost.|
|Going without (going “bare”)||No insurance premiums.
Does not require organizing with other physicians.
|May put personal assets at risk.
This option may not be legal in your state.
|Gap coverage||Covers services such as abortion that are not covered by Federal Tort Claims Act (FTCA) – FQHC 330 sites.
May already have in place for other services, like L&D or hospital rounding.
|May be expensive|
|Part-time policy||Less expensive in some cases than gap coverage, because it only covers the % time the physician is performing abortions.
May be particularly helpful for Federally Qualified Health Centers
|Safest to purchase alongside “entity coverage” that covers the clinic at all times.|
New providers should consider personal and online security precautions before beginning to provide services. See Chapter 9 Personal Security Section.
Security is an issue for any medical setting. You may already have security plans in place in your practice setting. This section is intended to help coordinate those plans with additional security concerns you may have for providing abortion care. When working with your staff, it may be helpful to put security into a larger framework (e.g. all clinics need to be prepared to handle fires or disruptive patient behavior, not just those that offer abortion services). If you do not have structured security preparedness training, then this section can help.
As with any good risk management program, security preparedness and violence prevention are important steps towards protecting your staff and patients. It is important to document any incident. A sample Incident Report Form (TEACH) sample is available online. For the most current information on incidence, go to NAF Violence Statistics and History.
Security drills help prepare staff to handle critical situations. They also help staff understand their role in keeping their workplace safe, express concerns, and know their fears are taken seriously.
The best preparedness training is achieved when scenarios are acted out and staff has to actually respond. Begin by telling staff you are going to run drills on a certain day. Include all staff, often in the roles they usually play on a given day. If you are in a larger practice it is helpful to break staff into two teams. One observes and later critiques, while the other does the drill. Observers can monitor communication, response, time it took to respond, and preparedness. There is new emphasis on closed-loop communications during emergencies. This is a technique used to avoid misunderstandings, such that when the sender gives a message, the receiver repeats it back.
During the debriefing, the whole team can assess what went well and areas for improvement, with attention spent on successful communication. We have included on five different security drills online.
If done well, adding EPL, medication or aspiration abortion into your practice should not cost you money in the long term. In time, all costs should be recoverable through proper billing and appropriate fee setting. But this information will help you make sure of this.
There are three main components of financial analysis for integration of EPL and abortion services: cost, revenue, and profit or loss. In addition, there are also many intangible benefits of integrating these services, including improved continuity of care, patient retention, and enhanced relationships with your patients.
Because of many one-time expenses, you may not be able to show a profit in the first year of service, especially if you are seeing a low volume of patients. However, over time – maybe 2 to 3 years – the variable supply costs should be very low, especially if you take advantage of group purchasing programs (for example through NAF membership, or HRSA 340b pricing for contraceptive supplies).
Facilities that receive federal funding, such as Title X or Section 330 funding (Federally Qualified Health Centers), are prohibited from using federal funds for abortion care. These facilities need to establish clear financial and administrative systems to ensure that abortion expenses and revenues are properly segregated from their federally funded services. An administrative guide (RHAP) outlines the key administrative and financial issues that federally funded facilities must take into account as they integrate abortion services.
Like any new service, you will need to cost out what it will take to provide an EPL or abortion care, then identify your revenue sources (e.g. cash, insurance revenue, state funds), and research what your competitive market will bear. Please refer to the Spreadsheet Tool. You can input your own variable and fixed costs and patient volume to determine your approximate cost per procedure.
Knowing how much you can expect to be paid for EPL and abortion services is another important step in developing your budget. EPL services should be reimbursed by all payors, including Medicaid. In 17 states, Medicaid will reimburse for abortion services in most circumstances. In other states, patients most often have to pay cash. (See Fee Setting below and Guttmacher State Policy Guide).
Because many of your patients are already insured, it will be beneficial to research if and how much those insurance plans will reimburse for EPL and abortion services. If you encounter plans that will not reimburse, consider negotiating contracts with those insurance companies with which you already have relationships. Be prepared to dedicate staff time to identifying and establishing new contracts. See FP Insurance Letter to use as blue print for contacting an insurance company.
With respect to abortion services, while some of your patients may be insured, it is important to note that approximately 40% of women who have insurance decline to use it for abortion services for privacy reasons.
When billing Medicaid or private insurance, use of proper billing codes is very important to getting accurate reimbursement. A list of the most common ICD-10 codes used for diagnosing and billing for early pregnancy loss, manual vacuum aspiration for abortion and medication abortion can be found here.
There are three considerations when setting your fee:
- What are your actual costs?
- What are your competitors charging?
- What is the value placed on it by patients?
In setting your fees, make sure to include:
- Pain medication
- The follow-up exam for medication abortion patients (if using office follow up)
The staff making the appointment should be able to articulate all the services in the visit. Evaluate whether patients can be separately covered for short and long acting birth control methods and emergency contraception. You can bulk bill for the office visit that includes abortion, or you can bill each item. For medication abortion, this especially makes sense because most primary care offices will be offering additional services on top of the abortion pill: contraceptive counseling, pap test, STI screening, even flu and HPV vaccination. So, in this case, some practices just bill the abortion pill ($90) and part of the provider time as the abortion part of the visit, and the rest as they would any primary care visit.
The average amount paid for a nonhospital abortion with local anesthesia at 10 weeks’ gestation was $480 in 2011-2012. The average amount paid for an early medication abortion before 10 weeks was $504. (Jerman 2014) Fee differences may impact on a woman’s choice or make her preferred procedure inaccessible. Therefore it is strongly advised to consider setting the same fee for aspiration and medication abortion.
PROFIT OR LOSS
While abortion provision is rarely motivated by finances, having an understanding of fiscal issues may help make the case for expanding services to your administration. For the first year, due to capital purchases, and assuming a low volume of patients, there may not be much profit, and may even be some loss. Be patient; we suggest a three year forecast to show a trend of breaking even, and eventual profitability.
While offering abortion services may only provide a health center with minimal profits, there are many non-financial reasons why offering the service may be worthwhile. A simple cost and expense analysis may not be enough to refute this argument. Be prepared to respond to these obstacles with your reasons for learning the procedure in the first place.
HELPING PATIENTS PAY FOR THEIR ABORTION
In many states Medicaid will not cover abortion care. Eleven states limit private insurance abortion coverage. Clinics can legally ask for payment at time of service, but cannot bill individual patients after the services are provided at a different rate than the standard billing rate set by the clinic. Paying at time of service for abortion services can be a financial challenge for some patients. Providers can connect with local and national abortion funds to help women pay for their abortion care. The National Network of Abortion Funds maintains a complete listing of state-based abortion funds. Planned Parenthood and the National Abortion Federation also offer patients financial support to cover their cost of their abortion.
DEVELOPING A NETWORK
Building a supportive community may be the key element to helping you build and sustain your abortion services. Building community support requires some advance planning, creativity, and courage.
Think of your support network in three key groups: core, usual suspects, and unusual suspects. Your core group might be made up of those people working with you to implement the services. Think of these people as your key stakeholders. Recall that stigma is an important predictor of satisfaction, burnout and compassion fatigue among abortion care providers (Martin 2014). So strengthening human resources for abortion care will help require stigma reduction efforts. An example, are the promising results from Provider Share Workshops showing reductions in stigma over time (Martin 2014).
The usual suspects might be the other local abortion providers, helpful listservs, local Planned Parenthood, reproductive health care providers known to refer for abortion (this may be a list that other abortion providers can help generate), and political organizations (NOW, NARAL, Physicians, League of Women Voters). See Chapter 9 for additional resource organizations.
Identifying your unusual suspects requires creativity and is specific to your community. This might include faculty at a university women’s studies department, women-owned businesses, community health care providers and educators, advocacy groups, high school nurses or guidance counselors.
Start with what is easy, and be encouraged whenever you make useful contacts. After identifying your core group, meet to decide what your goals or needs are in terms of support. If it seems that broader community support will be beneficial, identify and contact your usual suspects, inviting them to an informal discussion group. Consider inviting each person to talk about:
- The services or programs they offer.
- The patients they see
- How abortion touches the lives of their patients or their day-to-day work
- What kind of support they have needed and what kind they can offer
This is an important networking opportunity to discuss ways in which you can continue to support each other in the future. The local Planned Parenthood or political group might host this, to reduce your workload and to limit your exposure. You may want to go further in your search for community support. One suggestion would be to work with Planned Parenthood or another feminist group to set a panel discussion aimed at demystifying and normalizing abortion. Inviting you core and usual suspects along with some identified unusual suspect would be appropriate.
When you are trying to start EPL or abortion services, don’t be surprised that people within and outside your practice may throw you curveballs. For instance, if your head administrator or CEO is continuing to stall the initiation of abortion services, you may want to use some of the techniques in the Values Clarification Tool (NAF or RHAP) to discover her or his underlying concerns. Integrating abortion is much more than adding a service, or learning a new technique. It will require patience and determination to overcome obstacles at various steps of the way. Such barriers will vary with the existing culture of the practice, the level of knowledge and skill, as well as the attitudes and feelings of the staff and community.
Integration of broader reproductive health and abortion services is a process. As you move through it, your health center staff will begin to gain a more balanced understanding of pregnancy options and abortion access; enhancing their ability to handle divisive issues in a positive, patient-centered manner. Your patients will also gain greater access to these services in a safe, more private and familiar environment.