If you're going to MANDATE coverage, well . . .

. . . then NFP coverage should be mandated, too! A proposed amendment to the HHS Mandate:

Recognizing NFP as a legitimate form of family planning that would be covered by insurance would be of great benefit to Catholic couples and to the many “green-conscious” couples turning to NFP. . . . Physicians who provide patient education on NFP could be reimbursed for this service and have more of an incentive to recommend NFP if it was included as an option for family planning. If education and counseling for chemical and surgical methods of family planning are covered by insurance, it seems only fair that education for Natural Family Planning be covered as well.

http://www.hliamerica.org/truth-and-charity-forum/fair-is-fair-if-insurance-has-to-cover-chemical-and-surgical-family-planning-methods-it-should-cover-natural-ones-as-well/

Why the "counseling" aspect of NFP should be covered

Insurance companies might object that NFP should not be covered because they do not cover educational follow-ups. "Preventive" programs that emphasize sex ed only include a few classes, at most. Even for cases of diabetes, only an initial consultation with a dietician will be covered, not biannual or monthly consultations. Besides, artificial birth control requires only an initial consultation and rudimentary instruction, if that. Why pay for years of regular counseling?

But the analogies to diabetes and sex-ed do not hold. Creighton is not a "product" that you "use" after basic training. It is an ongoing practice of observation in consultation with a trained professional. As the Centers for Disease Control point out, the "counseling" aspect is essential to the method (see previous post).

Even though NFP counseling is repetitive, so are prescriptions. NFP counseling should be compared to the cost of artificial birth control prescriptions, not to the norms of health education programs.

And when you put NFP counseling and the Pill head-to-head on price, NFP wins.

How much counseling? That depends on the stage of life. Premarital and post-marital counseling will likely happen monthly as the woman (or couple) learns the system. Postpartum counseling is often monthly as the woman tries to prepare for the return of ovulation and understand a new pattern of cycles. But many women will only need a yearly consultation if all goes well, just like the annual "well visit" to the OB/GYN that most insurance plans cover. (Though some women with complicating conditions, such as continuous mucus, will need more frequent consultations.)

Monthly consultations with an experienced, licensed Creighton practitioner could cost $800/yr. A single annual consultation--which is all most women will eventually need--costs around $70. The price of artificial contraception varies, but the cheapest, generic Pill runs $9/mo. ($108/year), while some brand-name versions cost $90/mo. ($1080/yr.). (Source: http://theweek.com/article/index/225451/the-cost-of-birth-control-by-the-numbers).

The bottom line: even the most expensive method of NFP is cheaper than artificial contraception. And insurance companies like the bottom line!

*Need to do another post on the CDC's and WHO's comparison of NFP to artificial contraception on side effects and long-term health risks.

CDC on "Fertility Awareness-Based" (FAB) methods of contraception

"No medical conditions become worse because of use of FAB [Fertility Awareness-Based] methods. In general, FAB methods can be used without concern for health effects to persons who choose them. However, a number of conditions make their use more complex. The existence of these conditions suggests that 1) use of these methods should be delayed until the condition is corrected or resolved or 2) persons using FAB methods will require special counseling, and a more highly trained provider is generally necessary to ensure correct use."

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5904a9.htm

CDC on "choice," "acceptibility," and "counseling"

The Centers for Disease Control affirm that family planning outcomes improve when women and couples have choices about their methods of family planning, can rule out options that are not morally or medically acceptable to them, and have the benefit of counseling to help them successfully practice the method they choose.

Contraceptive Method Choice

Many elements need to be considered by women, men, or couples at any given point in their lifetimes when choosing the most appropriate contraceptive method. These elements include safety, effectiveness, availability (including accessibility and affordability), and acceptability. The guidance in this document focuses primarily on the safety of a given contraceptive method for a person with a particular characteristic or medical condition. Therefore, the classification of Category 1 means that the method can be used in that circumstance with no restrictions with regard to safety but does not necessarily imply that the method is the best choice for that person; other factors, such as effectiveness, availability, and acceptability, may play a key role in determining the most appropriate choice. Voluntary informed choice of contraceptive methods is an essential guiding principle, and contraceptive counseling, where applicable, may be an important contributor to the successful use of contraceptive methods.

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5904a1.htm

Why randomized trials of NFP are rare

Here is an explanation of why randomized trials are rare, from a 2007 analytical study of a fairly large set of observational studies. (Hilgers et al.--the basis of Creighton--are "observational studies"):

"While we recognize that critics may argue that this study was not a randomized controlled trial, it should be recognized that very few FAB method studies are randomized controlled trials. The majority are observational studies. This study was a prospective cohort study which could be seen to be placed from an evidence-based perspective, between the retrospective case-control studies and the randomized clinical trials. The only randomized clinical trials on methods of NFP (Wade et al., 1981; Medina et al., 1980) are of limited use: they showed huge recruitment problems and retention as well as having a very strong selection bias (participants had to agree to expect quite high failure rates while attracted by free medical care at study entry), their results are therefore very questionable (Grimes et al. 2004). Randomized controlled trials are rarely used to investigate other family planning methods either because most couples have a preference for a certain method or do not wish to be randomized. In addition with most family planning methods, it is impossible to blind the couples from the allocated method unless comparing certain different hormonal contraceptives or intrauterine devices."
(P. Frank-Herrmann, et al., "The effectiveness of a fertility awareness based method to avoid pregnancy in relation to a couple's sexual behaviour during the fertile time: a prospective longitudinal study,"

Hum. Reprod. (2007) 22 (5): 1310-1319. doi: 10.1093/humrep/dem003)

This article argues that its own analytical method could be the best possible way of establishing evidence-based guidelines--but still not nearly as reliable as randomized trials.

Let's hope the good people at The Cochrane Collaboration find ways to analyze the evidence that do not require randomized trials!

Evidence-based Guidelines

Insurance companies typically decide what to insure and what not to insure based on medical consensus. The consensus on diagnosis and treatments is formalized by institutions that aggregate and analyze medical research to determine whether the evidence for particular diagnoses and treatments is sufficient to recommend them in mainstream care. Two of the most important such institutions are The Cochrane Collaboration, The Center for Disease Control, and the World Health Organization.

A recent Cochrane study searched the internet for randomized trials of "fertility awareness-based" (FAB) methods of contraception, and only found three such studies. The methods in these studies were "too weak" to analyze the data. http://summaries.cochrane.org/CD0048...lity-awareness

Therefore Cochrane does not consider NFP currently eligible for recommendation as an evidence-based guideline.

Women need choices

We are hoping to achieve coverage for NFP even in the absence of a related health condition, simply to use NFP as an alternative to artificial contraception and fertility treatments, as part of a suite of reproductive health services that empower women to make informed and healthy choices about family planning and their bodies.

The Typical Situation for Reimbursements

According to a Creighton Model Fertility Care Practitioner, most reimbursements for NFP occur in the following type of situation:

1. Your Fertility Care Practitioner (FCP) is working in a clinic or hospital setting (such as this)
2. Your physician (likely an NFP-trained doctor) diagnoses you with a condition requiring regular charting and consultation, such as PCOS, repetitive miscarriage, vaginal discharge, PMS, infertility, etc.
3. Your physician prescribes NFP for you using one of the diagnostic/billing codes, along with a diagnosis code for the condition being treated.

Sound good? But we think coverage should extend further (see next post) . . .

Minnesota State Law

A 1994 Minnesota law requires that insurance companies that cover family planning services cannot decline to cover NATURAL family planning services:

The Law (62Q.14) simply states that:

No health plan company may restrict the choice of an enrollee as to where the enrollee receives service related to:

1. The voluntary planning of the conception and bearing of children, provided that this clause does not refer to abortion services;
2. The diagnosis of infertility;
3. the testing and treatment of a sexually transmitted disease; and
4. the testing for AIDS or other HIV-related conditions.

The directive to implement the law was issued jointly by the State Department of Commerce and the Department of Health in September, 1996 and included some very decisive language. For example, the directive states as follows:

Health plan companies cannot use credentialing requirements to restrict where enrollees choose to receive 62Q.14 services. For example, if health plan companies cover family planning services, then health plan companies must pay for NFP services. Therefore, regardless of where or from what type of provider, the enrollee receives natural family planning services, the health plan company must pay for these services.

This info was provided in the context of the first successful attempt by a diocese (St. Cloud, MN) to have their insurer cover NFP.

It DOES happen!

There are internationally recognized diagnostic codes NFP services:
V25.04 Counseling and instruction in natural family planning to avoid pregnancy
V26.41 Procreative counseling and advice using natural family planning
(Source: ICD-9 Code List) See also the info at fertilitycare.org.*

These are also the codes that insurance companies use to recognize services provided and to reimburse them.

According to personal sources, more than 100 insurance plans, including most the most prominent American companies, have reimbursed for services at NFP clinics using either of codes above. (We'll hopefully be able to provide more details on this soon.)

In at least some cases these insurance companies are providing the insurance for a Catholic employer such as a diocese or university.

*While the ICD-9 codes are still in use, American health care is transitioning to the ICD-10 (2007) or the forthcoming ICD-11. The ICD-10 does not specify natural family planning, as far as I can tell. Perhaps code Z.30.0--"General Counselling and Advice on Contraception / Family Planning Advice NOS"--would be the right one? Can anybody help clarify this?

Intro

We want our health insurance company to cover our Natural Family Planning services. Here we will blog about the process as we research the issues and advocate for coverage with our employer and our insurance company.

We encourage others to chime in and share advice and information.