After a long battle over Title X funding last October, Christ Community Health Services (CCHS) walked away with a contract to provide family-planning services to underserved women and men in Shelby County. After having received Title X funding directly from the state of Tennessee for more than 30 years, Planned Parenthood had been edged out.

But though the ink on Mayor Mark Luttrell's award letter to Christ Community had long since dried, the actual contract wasn't signed for another five months.

There are differing accounts of why the contract was delayed, but two things are certain: From October to March, Title X visits in Shelby County fell to an astonishingly low rate. And in that same period, in Tennessee's neediest county, more than $250,000 in Title X funding went unused.

Transition Time

By the time Christ Community's contract with the health department was finalized and signed on March 14th, Christ Community was averaging a mere 51 Title X visits a month, which pales in comparison to Planned Parenthood's 719 Title X visits in July 2011 and 841 visits in August of last year.

By the end of the fiscal year, Christ Community had only spent $143,361 of its $397,000 grant. Despite the fact that Shelby County receives the largest cut of Title X funding from the state, based on its population size and demonstrated need, the rest of the Title X money was untouched.

Title X grants are a federal program dedicated solely to providing comprehensive family planning and related preventive health services, with priority given to low-income individuals. According to a 2006 study by the Guttmacher Institute, Shelby County far outranks other counties in Tennessee for the number of women who need publicly supported contraceptive services and supplies. Shelby County has a total of 57,270 women in need of Title X services, nearly double the number in Nashville's Davidson County. According to the state health department, Shelby County's unused Title X funds were likely redistributed to other counties.

Nor does it appear that the Shelby County Health Department (SCHD), the only other local Title X service provider, picked up the slack. Title X visits to health department clinics from October to March hovered around the normal average of 500 to 600 per month.

So, what happened to the hundreds of Title X patients who typically visited Planned Parenthood each month? Where did they go for pap smears, breast exams, and birth control between October and March?

"I don't think they went anywhere," says Barry Chase, president of Planned Parenthood Greater Memphis Region. "Did they go to the county health department? Looking at the numbers, they did not. I'd say people just went without."

"That's a good question," says Shantelle Leatherwood, practice administrator at Christ Community Health Services. "That is a concern, but I'm not sure."

Nor does anyone seem to be completely sure why the contract took so long to be enacted. There are conflicting accounts from the health department and Christ Community Health Services.

Yvonne Madlock, director of the Shelby County Health Department, says the five-month lag time was a natural by-product of the transition from Planned Parenthood to Christ Community. Leatherwood says Christ Community was ready to go.

"It was the first year of a new approach to service delivery for Christ Community, so it takes awhile to staff up, gear up, etc.," Madlock says.

Meanwhile, Madlock instructed Barry Chase of Planned Parenthood to send Title X patients to Shelby County Health Department clinics, not Christ Community Health Services.

"They had to add staff. They had to build up protocols and procedures within their own organization," says Harvey Kennedy, chief administrative officer for Shelby County. "We sort of accepted that it would take them awhile to ramp up."

Kennedy also says threats from Nashville kept the contract from fully getting under way. "There was kind of a specter in Nashville that they were going to prohibit the awarding of [Title X funding to] a third party," he says. "Christ Community Health Services knew that was a possibility, so I think until the issue of the legislation and all, they really weren't into ramping up the whole services like they would have if they had the prospects for long term."

But Leatherwood has a different account. She says CCHS hired a Women's Health Services director, Tarsha Hubbard, formerly Yvonne Madlock's assistant, in January 2012. Beyond that, they incorporated the Title X program into the family-planning services they were already providing.

"We just brought on Tarsha, because we absorbed [Title X] into our clinic operations," Leatherwood says. "We were already providing family-planning services, so this was not really a difficult process for us to do with our existing staff."

"We didn't need to hire anyone to accommodate capacity. We were well-staffed," adds Jason Stevens, also of Christ Community.

What lies behind the low rate of Title X visits between October and March? (For example, Christ Community only saw 27 visits total at all four of its Title X locations in December.) Leatherwood insists that they served any and all Title X patients who came to their clinics.

"We didn't turn anyone away," she says. "We continued to see patients even though the contract wasn't finalized."

County commissioner Steve Mulroy, who requested Christ Community's Title X numbers from the Shelby County Health Department, finds this troubling. "There was a substantial decline [in Title X visits], and that was a red flag to me," he says. "I didn't think it suddenly, magically meant the need for reproductive services had declined in Shelby County. So, was there confusion about where to go? Or were people for some reason reluctant to go to CCHS? That would be a cause for concern about our decision to go with CCHS over Planned Parenthood."

Indeed, the Title X contract requires that the Title X contractor "establish and implement planned activities whereby their services are made known to the community."

Christ Community and the health department say they have attended health fairs with brochures. Madlock also noted that the information is available on the county health department website.

"I think that is something we will be working on collaboratively," Madlock says. "And now that we are through a year of essentially transition, we will have and make and create opportunities to sit down and talk about where there are opportunities for them and for the health department to really push information about Title X services out into the community."

Mulroy, one of the nine commissioners who voted in favor of the contract with Christ Community last October, has expressed concerns over the slow implementation of the contract.

"My memory of the debate was that assurances were made that [Christ Community] would promptly staff up, that they had the capacity to ramp up quickly, and that outreach efforts would be made to the customer base that there's been a change, and they needed to go to a different place," he says. "So, while maybe some reduction is inevitable in any transition period, I don't know if it adequately explains the level of reduction that we saw in these numbers."

The last time the county confronted a potential interruption of Title X services was July 2011, when the health department issued Planned Parenthood a short-term buffer contract to cover Title X services during the subcontract bidding process. Yet they had no such back-up plan for this transition period, which quickly became a five-month service gap before the actual contract went into effect.

"Looking back on it, that probably wouldn't have been a bad idea," Kennedy says. "If we had known that it was going to take awhile to get through the process, we might have put that little buffer contract for a longer period of time. But hindsight is perfect."

Political Football

In the spring of 2011, word came from the state health department that it would no longer contract with Planned Parenthood for Title X services. With only a few months notice, the state would require the Shelby County Health Department to take on the entirety of the $1,345,000 Title X grant.

Without the staff or the infrastructure to absorb more than double the Title X caseload it had previously seen, the health department pushed back, until the state came up with a compromise: SCHD would have to take on all of the Title X funding but would be allowed to subcontract with a third-party provider.

"They were trying to defund Planned Parenthood, and they had some sort of legal problems doing it. At the end of the legislative session, they said, rather than requiring the county health department to take all of it on themselves, we'll allow them to subcontract on the local level," Mulroy says.

For the next three months, things moved quickly. The county health department issued a request for proposals, evaluated the proposals with a committee of county administrators, and made a recommendation to the county commission. Christ Community received its award letter from the county mayor's office on September 2nd and received approval for the contract in a final vote in the county commission on October 17th.

"No one can deny, and I'm not sure the administration would deny, that this was somewhat rushed because of the action in Nashville," Mulroy says. "Clearly, amidst a climate of Nashville signaling hostility to Planned Parenthood, nobody can deny that occurred."

Questions immediately emerged about the bidding process. In the committee meeting, Christ Community had touted six locations and a mobile-unit van. The reality is that only four locations were Title X clinics and the mobile van was not a certified Title X location.

The original request for proposals had called for proposers to prove they had sufficient, competent, and skilled staff to take on the services. Christ Community's proposal called for hiring a new women's health director and six family-planning coordinators. A women's health director was hired; the six additional family-planning coordinators were not.

And while Christ Community was touted as offering multiple clinic locations as opposed to Planned Parenthood's one central location — a benefit that seemed to suggest greater access to a greater number of patients — Planned Parenthood had proposed to see 3,500 Title X patients, 75 percent more than Christ Community's proposal to treat 2,000 Title X patients.

There were also concerns about Christ Community's ability to provide certain Title X services and counseling, due to the organization's stated opposition to abortion and the "morning after" pill, also known as "Plan B."

While Title X funds cannot be used to conduct abortions, providers are required by federal law to provide accurate, non-directive information about how to procure abortion services when such information is requested. Rick Donlon, associate executive director for CCHS, was less committed to providing this information, saying in a Commercial Appeal article last October: "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."

More recently, Donlon was quoted in a post on The Commercial Appeal's "Faith in Memphis" blog on August 10th, comparing the practice of abortion to the mass shooting at the Aurora, Colorado, movie theater.

Christ Community also announced it would send patients to an off-site, third-party provider for patients wanting morning-after contraception or "Plan B." In an October 17th article in The Commercial Appeal, Shantelle Leatherwood reportedly cited religious reasons for the organization's decision. However, Leatherwood has since backed off from the religious grounds, saying in a recent interview, "I don't even know if I recall saying that actually. I don't think I actually explicitly said that to anyone."

When asked what a Christ Community clinician might say when asked why emergency contraception is delegated to an off-site provider, Leatherwood responded, "I just believe that what we would say is that it's our belief that, well, actually I'm not sure what we would say to the patient. Just that this is our decision, that we've provided it through a voucher through these particular entities, and that they could go through Kroger or Walgreens to get the emergency contraception."

Citing a statement from Christ Community's medical director, David Pepperman, Leatherwood said the organization's choice was an "operational decision to provide the ECP [emergency contraception] vouchers off-site" and "was the best decision for us as an entity." Leatherwood would not speak to the operational differences between providing monthly oral contraception and the morning-after pill.

Politics played a large role in last fall's bidding. During committee proceedings on October 12th, Commissioner Terry Roland invited Governor Haslam to listen to the proceedings via conference call. He somewhat ominously reminded the room that "Nashville is listening to our proceedings."

The panel selected to review the proposals was composed entirely of members of the county administration, many of them Luttrell's appointees.

"If you looked at the actual individual ratings, scores that were given by the different people, the disparity between CCHS and Planned Parenthood varied depending on how political the scorer was, the proximity of the scorer to the mayor," Mulroy says. "When you looked at the raw scores, it did seem like there was a correlation between the closer they were to the top of the administration, the more they were putting their thumb on the scale towards CCHS."

Future Funding

The scale tipped back in Planned Parenthood's favor in July, when the organization was notified it would receive $395,000 in Title X funding directly from the federal government.

Since then, Planned Parenthood, which had only been accepting teenage Title X patients and paying for them out of pocket ("It's our policy to never turn a teenaged patient away," Chase says), is once more offering family-planning services. Although the grant amount is half of what the group requested, Chase was pleased with the development and says they will continue to apply for funding from the federal government.

Yvonne Madlock says she has not yet been notified of Shelby County's Title X award amount for fiscal year 2013 but that the state has received $302,000 less in Title X funding than last year. Meanwhile, since signing the Title X contract in March, Christ Community's Title X visits have increased to nearly 300 per month. Although that rate is still only around half of Planned Parenthood's average Title X monthly visit rate from 2011, Leatherwood is satisfied with the progress.

"From our vantage point, we feel that the first year has gone pretty well, as we have served a number of men as well as women throughout this year. I believe the health department has been pleased with our performance. We've submitted all of our reports and invoices on time, and we are in constant communication with them about the program and training to be provided to the staff. For us, we believe we've done pretty well."

According to the contract signed on March 14th, Christ Community has the option to renew the Title X subcontract each year for three years. Madlock anticipates sticking with CCHS.

"Assuming that Christ Community Health Services will have performed adequately and has been compliant with its contract in terms of the quality of services provided, we would anticipate entering into another contract with them for this fiscal year," she says. "We haven't yet consummated the contract or received a written confirmation of what the amount of the contract is going to be for this year. I am very, very hopeful that we will not see any lessening of the contract amount, because we would certainly contend that the need in Shelby County for Title X services to low-income women remains very, very strong. And this is a resource that is of great value to this community."