Oct 11 2011

The Battle for Title X – Wrap-Up

Posted by Steve Ross in Shelby County, State Politics

Over the past week I’ve written several posts about the contract to provide Family Planning services to individuals in Shelby County. The first post dealt with the political issues involved. The second post took a look at the services to be provided and inconsistencies in scoring based on the quantity of those services. Yesterday I pointed out concerns relating to the ability and/or willingness of one of the potential contractors to fulfill the requirements of the Title X program. Unfortunately, the County didn’t respond to my inquiry about who asked the questions that would lead one to believe they could not fulfill these requirements on the grounds of their “ethical beliefs”.

On Sunday, Wendi Thomas at the Commercial Appeal wrote an article about the issue, and brought up some additional concerns. In that article, she quoted a previous article where the founding physician of CCHC indicated they would not follow the letter of the regulation relating to referrals for pregnancy termination. From her article:

“We really try to provide women with other options and make sure they have those possibilities. And if they at the end still want a pregnancy termination, we know they know where to go,” Rick Donlon told The Commercial Appeal last month. (Source)

There’s one simple truth about receiving public money for a service:

“Play by the rules, or the money goes away.”

For something like Family Planning, the cost of the money going away is huge. The thousands of people served by these funds would be left abandoned without the benefit of these services. If they go away that means a whole lot of women will get pregnant, quite possibly at a time when they aren’t ready. The pressures that unwanted pregnancy will place on them, and the community at large, are huge. Quite honestly, we can’t afford to play games with this money.

I understand there are those in state and local government that have a problem with PPGMR, who has been providing the services for some time in this community. I wish they would acknowledge that those problems have little to do with the actual services that PPGMR renders with this money, and more to do with a service they provide that the money doesn’t touch. Remember, no Federal money can go for providing abortions according to the Hyde Amendment.

That said, Title X funds recipients are bound by the terms of their contract to refer women who ask to a place that does provide abortion. Saying “I think they know where to go” doesn’t fit with the demands the money places on the provider.

There’s another issue that I haven’t touched on, and that’s of staffing. PPGMR already has staff in place to serve people under this program. They’ve been doing it for years, so of course they do. CCHS doesn’t. They explicitly list that they will have to hire 7 people just to execute the contract (you can find this on p. 14-15 of their proposal). That’s a huge problem. How long will it take to get that staff in place and trained? What makes CCHS so much different from the Health Department, who initially refused the money for the very same reasons? Why does CCHS think they can ramp up services quickly enough to be an effective provider?

Another really important question on this same line is why isn’t this weakness in the CCHS proposal reflected in the scores given by the 6 member ad-hoc purchasing panel? The RFP itself expressly states that the personnel must be in place. Here’s the section from page 15 of the RFP:

That this weakness in the CCHS proposal isn’t reflected in the scores, nor addressed in any official statement from the Shelby County Government, raises many questions about the fairness of the process. This is something that all the evaluators need to account for, as it is listed as a requirement, not a goal.

On Wednesday at 9:45 am the Health and Hospitals Committee will take this issue up again. As of right now there’s 1 hour scheduled for the discussion, though I feel certain that it will last much longer than that. I hope that the Commissioners give the issues I’ve raised over the past several posts a serious look. The lives of thousands of people in Shelby County are depending on them to exercise their oversight over the Administration, and get real answers.

Considering the challenges we already have in Shelby County with poverty, infant mortality and teen pregnancy, it hardly seems like a time to politicize a process that will directly impact some of the most at risk individuals in our community.

We’ll see on Wednesday.

Thanks again for reading.

Oct 10 2011

The Battle for Title X – Part 3

Posted by Steve Ross in Shelby County, State Politics

When we last left off, I had just finished taking a look at the proposed services to be provided by both PPGMR and CCHC. In addition, we took a look at the individual scores from the six evaluators. I raised some questions about their choices and noted that we’d talk about that more here. Well here we go.

As a part of just about every RFP I’ve ever seen, there is a question period where potential providers get to ask questions, and hopefully get them answered.

This RFP process was no different. Prospective contractors submitted 18 questions and, for the most part, got some answers. From the questions, I’m pretty sure at least one of the potential providers wasn’t too happy about the answers.

Let’s make this easy and start with the first question.

Q: In providing information about pregnancy termination, is it sufficient to have the referral information in writing?

A: No

The rest of the answer goes on to say that patients need to be counseled, not handed a card and sent on their way.

The next question follows the same theme:

Q: If the information about pregnancy termination is provided, is the contractor allowed to indicate in wiriting (NOT coerce) – on a referral sheet or in the office- that
a. it does not provide that service because of its beliefs.
b. or, is the contractor never allowed to indicate its position or why it does not offer the service.

A: (to both questions) No, followed by a long paragraph about the importance of face to face counseling and how the “beliefs of the contractor about pregnancy termination should not be part of a process.”

Whoever asked this question wants to say they don’t believe in abortion to their patients and thinks that will somehow not be coercive? When did medicine become about beliefs? Last time I checked abortion was a medically approved and legal procedure. If a contractor doesn’t feel comfortable referring out, then maybe they shouldn’t be considered. In any case, it seems pretty clear from the way these first two questions were asked that they came from the same prospective contractor.

The next interesting question is number 13.

P.12, paragraph 5: If a contraceptive method is not provided on site by a provider because of the provider’s ethical beliefs, can the provider refer the client to another Title X provider who offers this method? If so, does the referring provider have to pay for the service?

Wait, wait, wait… Contraceptive method? A contraceptive method is against the providers ethical beliefs? Why would they want to engage in this line of work if a medically accepted form of contraception is against their “ethical beliefs”?

To be honest, these three questions left me flabbergasted. Certainly individuals and associations of people are allowed to hold their own beliefs. Certainly, different physicians and networks of physicians have different preferred treatment plans. There’s plenty of room for this diversity out there in the private sector. However, when you choose to enter the public sector by seeking a contract for public dollars, you are bound by the requirements those public dollars place on you. If those requirements are unpalatable to you, then perhaps you shouldn’t seek them.

The questioners aren’t identified so I asked the woman with the Shelby County Government who received the questions if she could identify the questioners for me. Unfortunately, I never received a response to my request. In fact, I never even got a response saying a response couldn’t be provided.

Since I didn’t get an answer from the County on this issue, I decided to take a look at the mission statements of the contractors. Maybe that holds the key to making an educated guess about who asked these questions. Here’s the first one.

Christ Community Health Services will provide high-quality health care to the underserved in the context of distinctively Christian service. We recognize that Jesus Christ is the true healer of individuals and their communities and the source of our ability to serve. (Source)

What’s interesting is neither of the other two potential contractors have anything about “belief” in their mission statements. Here’s Memphis Health Center, and PPGMR.

Now look, I don’t think an organizations beliefs excludes them from serving. They may choose, based on those beliefs, that they don’t want to perform the service or receive the funds. However, I don’t think that being a religious organization is an automatic exclusion. From a practical standpoint, it can’t be. That said, the three questions listed above leave some serious doubt that whoever asked them can provide the services required by Title X.

Nowhere in the RFP is it noted that questions are confidential, or whether or not they will be considered in the evaluation process, so it’s interesting that the County hasn’t responded to my request. The questions are, no doubt, subject to public disclosure. In the interest of full disclosure and the public interest the Administration should list which prospective contractors asked which questions, and whether or not those questions were considered in the evaluations of the proposals.

Of course, had the questions been considered in the evaluation process, it still might not have changed the outcome. The way the score sheets are structured there are 52 points up for grabs in very subjective categories, and no listed benchmarks to be met. That leaves a lot of wiggle room to let your “beliefs” guide you.

As we saw in the previous post, there was a great deal of variation in the scoring, particularly from political appointees. Because specific benchmarks for the scoring of these 52 points are not explicitly laid out in the RFP its hard to know what metrics were used, or explain this variation in any way other than personal preference. Further, because there is such variation in the number of services to be provided, one is left to conclude again that personal preference played a greater role in the process than we’ve been led to believe.

Because of the way the proposals are structured, there’s no way for the evaluations to be “blind”. This, of course, means that anyone with a predisposition against one of the prospective providers would be free to exercise that perspective. Further, because the questions submitted during the Q & A period were apparently not included in the evaluations, the evaluators may not have been aware of the depths of “belief” or ethical conflicts that exist with, what is most likely only one of the prospective contractors. This seems like a huge oversight and opens many potential problems for the County and the people who receive these Title X services.

Tomorrow morning I’ll wrap up my coverage of this issue, with a recap of what we’ve seen thus far, and some additional information that has come my way in the past few days.

Thanks for reading.

Oct 05 2011

The Battle for Title X – Part 2

Posted by Steve Ross in Shelby County, State Politics

As noted in my last post, there has been a great deal of politicization of this issue, not just at the state and local level, but nationally. What gets lost in this political tug of war are the people who stand to benefit most from the family planning services that would be provided. This issue is more than just about unplanned pregnancies and STD’s, its also about arming people with the information that will help them reach their fullest potential educationally and professionally.

Study after study has shown that women who have children before they complete their education are far less likely to do so. This negatively impacts their income potential, and in the long run, many more things.

From this frame, the importance of family planning takes on a different character. Family planning is not just about stopping unwanted pregnancy or slowing the rate of STD infection, but it also is a workforce development strategy. The fewer unintended pregnancies that occur in women at an early age, the more likely they are to finish High School, College, and perhaps more.

With all this in mind, the numbers matter, and that’s what we’re going to look at today.

Going by the numbers

The RFP’s presented by Planned Parenthood and Christ Community Health Center (ed note: CCHC also has this program work plan that wasn’t included in my copy) detail the services each group plans to provide and the means by which they intend to proved them.

While both plans deal with many of the same things the quantities are different. The following table is a breakdown of the services that both organizations offer, and the quantities.

Services Planned Parenthood Christ Community
Health Center
Proposed number of Clients to be served over the 9 month period of the contract 3500

Reference – p. 19


Reference – p.1 CCHC work plan

Provide Preventative health care services (includes testing for breast cancer, cervical cancer, STD, and HIV) 2000 HIV tests
6000 Gonorreah tests
30 Gardasil vaccinations
2500 Clinical Breast Exams
2500 Pap tests
95 colposcopy
10 cryotherapy

Reference p. 18,19

No number given
Contraception 130+ Long Acting Reversible Contraception
650 Emergency Contraception
130 IUD
30 Implanton
20 IUD
20 Implanton

No other mention of contraception in the work plan

Pregnancy Testing 5000 pregnancy tests None listed
Other Services listed 3000 3 month supplies of 400 mcg folic acid

It should be noted that in the actual RFP, Christ Community lists that some 3375 individuals will be served over the 9 month period of the contract, however, their work plan lists 2000. This inconsistency should have caused a good deal of confusion with the individuals scoring the proposals. However, the score sheets show no markdown for this inconsistency.

Another thing of concern in the CCHC proposal is the absence of current Family Planning staff. Both the narrative and the work plan list that staff will be hired upon receiving the contract. This should have raised serious questions by the evaluators, yet this, again, is not evidenced by the score sheets.

So what of those score sheets? You can see them here, and that’s where we take back up the political angle of this story.

Confronting the Judges

From looking at the information provided above, it appears that there might have been a mistake, to put it mildly, but it was noted in the County Commission meeting on September 21st that Planned Parenthood had lodged a complaint and that complaint was found to be without merit. One of the Commissioners characterized this as a contractor that was just complaining because they didn’t win, but it seems like there’s a little more to it than that.

In order to really get at the judging, you need to know who the judges were. Here’s the list:

Yvonne Madlock – Director of the Shelby County Health Department
Harvey Kennedy – Shelby County CAO
Bill Powell – Shelby County Criminal Justice Coordinator
Kim Hackney – Shelby County Director of Legislative Affairs/Sr. Policy Advisor
Dr. Kenneth Robinson – Shelby County Public Health Policy Advisor
Dr. Helen Morrow – Acting Shelby County Health Officer

First and foremost, I don’t want to besmirch the names of these individuals. They are all serving the public in their official capacities and I’m sure they’re good people. Some have medical or public health training, others do not. Some are appointees from the current administration, others are holdovers. I’m not interested in attacking anyone, but I do think there is a good deal of cause to question the choices made by some of these evaluators. So, rather than make a claim I’ll try to either ask a question or point out an interesting pattern.

Below is a spreadsheet with all the evaluators scores for both PPGMR and CCHC. Each organization’s scores are on their own sheet.

What is, perhaps, most interesting about these scores is that the three top political appointees for the administration on this evaluation team scored Planned Parenthood in the 80’s, despite far more bang for the buck in terms of service delivery. The primary determinant is the “Clinical Services” section listed on page 29 of the RFP. While the CCHC scores show little variation, the PPGMR scores vary wildly with a 10 point range. That’s some serious disagreement.

So what does “Clinical Services” refer to? Let’s take a look:

Now, it could be argued that because CCHC has six locations, they should have been scored higher. I would agree with you if they had staff currently in place, but as I noted before, they do not. Six locations, with no staff to serve these individuals is about like having zero locations or six “potential” locations. Why on earth would anyone rate that unfulfilled potential between 5 and 10 points higher than a provider that has one location that is, you know, actually functioning.

“Project Approach” is the other area of variation. The section is too lengthy to quote or screen cap, but you can find it on page 26 of the RFP.

This seems to be directly related to the services that the prospective contractors will provide. As I showed above, PPGMR proposes to provide a good deal more to more people than CCHC, so one has to wonder why PPGMR was rated below CCHC?

I’m not going to lob any charges at anyone. I don’t know these people. But I am going to say that it might be a good idea for them to start thinking about how they’re going to explain these scores if the process was truly unbiased, as asserted in the Committee meeting on September 21. It doesn’t seem very likely that some of the highest ranking people in the current administration would miss these huge discrepancies in services, and rank the vendor that proposes to provide less higher, but either they did, or they went in with a purpose in mind. In either case, this certainly doesn’t instill much faith in the process.

This has been a long post, and of course, there’s more to it that what I’ve presented so far. That said, in the area of pure levels of service, PPGMR has proposed to do much more than CCHC. On that account alone there are some serious questions to be raised about the scoring process. At the end of the day the big goal should be the number of people served. That’s the thing that will combat teen pregnancy, infant mortality, and an increase in the incidence of STD’s. Based on the information I’ve reviewed, I’m not seeing that CCHC is providing more of anything.

What’s worse, there are more questions about CCHC, like just how committed they are to following through will delivering all the accepted methods of family planning.

That’s coming up in my next post.

Oct 04 2011

The Battle for Title X – Part 1

Posted by Steve Ross in Shelby County, State Politics

The political fight has been going on for months now. Since February as a matter of fact. But it all really culminated with an attempt at the state level to prevent Planned Parenthood from receiving funds for Title X Family Planning.

This could either be the most frightening, or happy day of your life.

The move was thwarted, amid calls of sabotage, and perhaps folks felt comforted by Harwell and Ramsey calling on all parties to just say bygones and move on.

While some may have thought it was over at that, the administration of Governor Bill Haslam still sought to send all the Title X funds to the Shelby County Health Department rather than contract directly with Planned Parenthood of Greater Memphis, as they had in previous years.

In the wake of the political posturing that would have prevented PPGMR, and its Davidson County counterpart from receiving Federal dollars through the state the Governor began an effort to pressure local officials to take the funds, even though local capacity didn’t exist. They were eventually accepted, with the condition that the local Health Department could contract with PPGMR.

An RFP was issued, and three organizations: Planned Parenthood of Greater Memphis, Christ Community Health Center, and Memphis Health Center submitted responses.

In mid-September, the winner was announced, and it was not Planned Parenthood. This caused a bit of a stir at the County Commission a few days later, as they chose to defer voting on the contract until some questions could be answered.

I was at the County Commission that day, and observed as some called legitimate concerns surrounding this issue “political posturing”. Family Planning has been politicized, but not just at this point in the process. It’s been politicized for decades. What’s happening here is just one more stop on a long journey that has not only put the future of Title X funding in question, but the health of the thousands of women who benefit from the Family Planning services provided.

The Issues

Aside from the national and statewide issues surrounding the politicization of Title X, there are quite a few issues that pertain to the local funds that would go for that service. Today, in the first of a series of posts, some of these issues will be introduced. Most of them deserve and will get a deeper look in the coming days.

But before we get in to the specifics of proposals, scoring methodologies, and the politics of it all, I think its important to understand what Title X is, and more importantly, what it isn’t.

Here’s what HHS says it is:

The Title X program also supports three key functions, authorized under the Title X statute aimed at improving the quality of family planning services and assisting clinics with responding to client needs. These functions include: (1) training for family planning clinic personnel through ten regional general training programs and three national training programs that focus on clinical training, enhancing quality family planning services for males, and/or coordination of training activities on the national level; (2) data collection and family planning research aimed at improving the delivery of family planning services; and, (3) information dissemination and community based education and outreach activities. These functions help to ensure that family planning services are evidence-based and of high quality. (Source)

Title X funds are bound by the Hyde Amendment, meaning they cannot be used for abortion. However, because abortion is a medically accepted and legal procedure, clinics that utilize Title X funds are required to refer patients to clinics that provide abortion if they make a request. That doesn’t mean the Federal government will pay for the abortion. It just means they’re required to make a referral.

Of the three organizations that made proposals to the Shelby County Government, only Planned Parenthood provides abortion services. Abortion opponents charge that because Planned Parenthood offers abortion services, any public dollars spent are by default supporting abortion. What these advocates ignore is that Family Planning services are not exactly money makers, as Shelby County CAO Harvey Kennedy noted in his presentation to the County Commission about this issue on September 21st. Further, no one using Title X funds can suggest abortion as a default. The patient must request an abortion referral. It is also important to note that family planning is the single best way to prevent abortion, a fact that is often conveniently ignored.

The reality of all this, in a county that has massive poverty, that family planning is a big deal. Unwanted pregnancies are preventable via many means. Preventing unwanted pregnancies is an effective measure to stem the tide of poverty. All too often, particularly with teens, an unplanned pregnancy means the end of their education, which can significantly limit potential. Title X family planning funds seek to help women and men make the right choices to not only prevent unwanted pregnancies, but also slow the rate of STD infection, which is unacceptably high, and rising as more and more teens engage in unprotected sex.

You may be asking yourself why all this family planning money hasn’t been more effective to date. There are no easy answers, but the politicization of the issue plays a role. By continually shifting focus from proven methods, to methods that rely on people to fundamentally act out of character, specifically for a political purpose, the entire franchise of family planning, and the lives of people who could most benefit from it, are put at risk.

This reality is something that should remain in the back of your mind as this discussion moves forward.

In a series of forthcoming posts we’ll take a look at the RFP, and the proposals submitted by the two highest scoring agencies, PPGMR and Christ Community Health Center and do a little compare and contrast, highlighting the services each agency seeks to provide.

Stay tuned…

Aug 21 2009

Two Events, One Perspective

Posted by Steve Ross in City of Memphis, Shelby County

I spent the day today getting ready to go see my brother and niece, and attending events around Memphis.

The first event was the Mid-Southerners for Choice Luncheon hosted by Planned Parenthood of Greater Memphis featuring Jeanne Richardson (HD-89).

It was an inspiring event, attended by people who firmly believe in protecting a women’s right to reproductive healthcare. Jeanne gave a great presentation and even brought up Rep. Karen Camper whose alias I will not reveal. Jeanne talked about SJR127 and the urgency of organization and action in the coming years.

Later in the day I went to the Shelby Co. Young Democrats Mixer at SOLE in the new Westin Hotel near the Forum. This was a well organized, well attended meet and greet. Lots of people I didn’t know and unfortunately, didn’t get to meet, that’s how thick it was. Good on the organizers and the SCDP for organizing it.

What was missing? YOU WERE.

I don’t know all my readers, but I know a bunch of them, and I didn’t see all of you.

I know you’re out there, and I love you for reading, but I’d love you more for being out there. Come join me at these events.

I’m taking a break for the weekend to see my family. The next few weeks are going to be pretty crazy around here with the special election looming and maybe as many as 40 candidates running for Mayor, a possible Metro Charter Commission, and the Senate 31 race, which will no doubt be interesting.

Rest up, we’re all gonna need it.