Free means free.

The Obama administration said Monday that health plans must offer for free at least one of every type of prescription birth control — clarifying regulations that left some insurers misinterpreting the Affordable Care Act’s contraceptive mandate.

“Today’s guidance seeks to eliminate any ambiguity,” the Health and Human Services Department said. “Insurers must cover without cost-sharing at least one form of contraception in each of the methods that the Food and Drug Administration has identified … including the ring, the patch and intrauterine devices.

The ruling comes after reports by the Kaiser Family Foundation and the National Women’s Law Center, an advocacy group, found many insurers were not providing no-cost birth control for all prescription methods. (KHN is an editorially independent project of the Kaiser Family Foundation.)

Gretchen Borchelt, a vice president with the women’s law center, applauded the guidance.

“Insurance companies have been breaking the law and, today, the Obama Administration underscored that it will not tolerate these violations,” she said. “It is now absolutely clear that ‘all’ means ‘all’— ‘all’ unique birth control methods for women must be covered.”

The law requires that preventive services, such as contraception and well-woman visits, be covered without out-of-pocket expenses, such as a co-pay or deductible.

While HHS said insurers must offer for free at least one version of all 18 FDA approved contraceptives, the plans may still charge fees to encourage individuals to use a particular brand or generic. For example, a generic form might be free, while a brand name version of the drug can include cost sharing, HHS said.

The administration Monday said insurers could have misinterpreted prior rules to mean they only had to offer certain types of contraception without cost-sharing. Plans have until July to implement the policy, which will generally not take effect until a new plan year begins. That means for most people the new rule will start in January.

Cecile Richards, president of Planned Parenthood Action Fund, the political arm of Planned Parenthood of America, thanked the administration.

“This is a victory for women and the more than 30,000 Planned Parenthood supporters who spoke out to ensure all women, no matter what insurance they have, can access the full range of birth control methods without a copay or other barriers,” she said. “We know that increased access to birth control has helped bring teen pregnancy rates to a 40-year low and we must continue to drive forward policies that build on this progress.”

The Kaiser study  — which looked at a sample of 20 insurers in five states — found one that simply didn’t cover the birth control ring (NuvaRing) at all and four that “couldn’t ascertain” whether they covered such birth control implants. More commonly, insurers would restrict access to certain contraceptives when they believed a cheaper, equally effective way for patients to get the same treatment was available.

The report by the health law center, which analyzed coverage from 100 insurance companies during 2014 and 2015, found that 15 plans in seven states failed to cover all FDA-approved methods of birth control. Among the companies named as not complying with the law’s requirements in some states are Aetna, Cigna, Physicians Plus and Anthem Blue Cross Blue Shield.

The insurance industry disputes the reports’ conclusions that the problem is widespread. “This report presents a distorted picture of reality,” Karen Ignagni, president and CEO of America’s Health Insurance Plans, the industry’s primary trade group, said when the report came out.

AHIP did not have an immediate comment Monday on the federal guidance.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

NEWPORT BEACH, Calif.— Hoag Memorial Hospital Presbyterian, one of the largest and most respected facilities in Orange County, needed to move quickly.

A big insurer had warned that its maternity costs were too high and it might be cut from the plan’s network. The reason? Too many cesarean sections.

“We were under intense scrutiny,” said Dr. Allyson Brooks, executive medical director of Hoag’s women’s health institute.

The C-section rate at the time, in early 2012, was about 38 percent. That was higher than the state average of 33 percent and above most others in the area, according to the California Maternal Quality Care Collaborative, which seeks to use data to improve birth outcomes.

Within three years, Hoag had lowered its cesarean section rates for all women to just over a third of all births. For low-risk births (first-time moms with single, normal pregnancies), the rate dropped to about a quarter of births. Hoag also increased the percentage of women who had vaginal births after delivering previous children by C-section.

In medicine, this qualifies as a quick turnaround. And the story of how Hoag changed sheds light on what it takes to rapidly improve a hospital’s performance of crucial services, to the benefit of patients, insurers and taxpayers.

Decreasing C-sections results in “better health to mothers and better health to babies and lower costs,” said Stephanie Teleki, senior program officer at the California HealthCare Foundation, which helped fund the data collection and analysis by the California Maternal Quality Care Collaborative. “That’s like a nirvana moment in health care.”

Experts have long been troubled by the wide variation of C-sections among hospitals nationally. (In California, the rates range from 18 percent to 56 percent.)  Certainly there are instances in which C-sections are typically recommended – such as a baby in breech position. But the disparities suggest that decisions are being driven by factors other than medical necessity – such as doctors’ time constraints and malpractice concerns.

Over the past few years, there has been a coordinated push to cut C-section rates in other states and in births covered by Medicaid, the health coverage program for low-income Americans.

Across California, data publicly released by the California HealthCare Foundation, the Pacific Business Group on Health and others in the past few years have underscored the differences in how hospitals handle maternity care. http://www.chcf.org/publications/2014/11/tale-two-births  http://www.pbgh.org/storage/documents/PBGH_C-Section_NTSV_Variation_Report.pdf

Despite the increased transparency, however, many hospitals don’t act until dollars are at stake, said Dr. Elliott Main, medical director of the California Maternal Quality Care Collaborative. That’s what happened with Hoag, which Main said is now becoming a model for others.

“In quality improvement, we call it ‘the burning bridge,’” he said. “You can’t just stay still. You’ve got to move.”

Focus on Physicians

At Hoag, where more than 6,000 babies are born each year, Brooks and other administrators knew that they had to focus on changing the mindset and behavior of physicians. “Hospitals don’t do C-sections, doctors do,” she said.

So they took some aggressive steps. First, they shared the data with all the physicians in the department without names — then decided to reveal the names. Suddenly, everyone knew who had exceeded or come in under the average.

“There was a lot of upheaval,” Dr. Jeffrey Illeck, a community OB-GYN and the hospital’s obstetrics department chair. “None of us want to look bad in front of our peers. … And some looked horrible.”

Some physicians reacted with surprise and frustration. Initially, many attributed the high rates to the patients, saying they were older, had more complicated pregnancies or demanded scheduled C-sections.

Dr. Amy VanBlaricom, an OB-GYN who delivers about 25 to 30 babies a month, said she wasn’t opposed to sharing the data. But she said doctors were worried that the rates would be used to penalize them rather than to drive improvement.

“It’s very heated,” she said. “We should use this data as an opportunity rather than a polarizing topic.”

VanBlaricom already tracked her own rates, which she said fell in the middle of the pack, and has only seen a small drop since. But she said being aware that Hoag is monitoring the C-sections has changed how she thinks about her practice and has encouraged her to let women remain in labor longer.

That’s what Hoag administrators were aiming for – a realization among doctors that C-sections should not be undertaken lightly. They carry surgical risks, including serious infection and blood clots, and require longer hospital stays.

“Doctors and patients look at cesareans as an easy way to time the birth,” said Dr. Marlin Mills, chief of perinatology at the hospital. “But a C-section is not benign. It’s a big surgery.”

The costs are also well-documented. Surgical births cost nearly $19,000, compared to about $11,500 for vaginal births, according to the Pacific Business Group on Health, an organization of employers that is also working to bring down C-section rates around the state.

The business group worked with the hospital on the financial side. It enlisted the help of some of the biggest local employers, including Disney, and another insurer, Blue Shield, to adjust payments so the hospital didn’t earn more from elective C-sections than vaginal births.

In addition, the hospital set new scheduling rules. In the past, doctors could simply call in with the woman’s due date and schedule the birth. Now, they would have to fill out a detailed form, with some requests needing special approval.

The hospital also stepped up its patient education, encouraging women to wait for labor to come naturally.  If patients did want an elective C-section, they would have to sign an easy-to-understand consent form in the doctor’s office that detailed the risks.

The nurses received end-of-year bonuses if they helped the hospital reach certain goals on reducing surgical births.

The hospital opened an obstetrics emergency department and gave more responsibility to “laborists,” doctors who were there around the clock to respond to emergencies, monitor women in labor and deliver babies.

Dr. Alex Deyan, who delivered more than 500 babies at the hospital last year, used to turn away patients who wanted vaginal births after cesarean sections. With a busy private practice, Deyan said he couldn’t always be immediately available if labor didn’t go as expected and a woman needed a C-section. That changed with the laborist program.

“Having in-house doctors 24/7 is a huge benefit,” Deyan said. “I can be a little more patient.”

Good for Patients Too

Holly Grim appreciated Hoag’s approach. She knew she didn’t want a C-section with her second baby. Her first labor at another hospital in December 2013 was long and painful and ended with a cesarean section that kept her in the hospital for days. Her son was healthy, but she said, “this wasn’t exactly how I had it planned – not even close.”

This time, she needed to get back on her feet quickly so she could chase after her 16-month-old. She decided to switch doctors and hospitals. And in early April, she got her wish — giving birth naturally to an 8-pound girl, Agnes, at Hoag.

The day after Agnes was born, the family was packing up to go home. She didn’t have any restrictions on lifting or driving, and she wasn’t in severe pain. This, she said, is how childbirth is supposed to be.

“I’m feeling really good,” she said as she nursed Agnes, wrapped in a blanket decorated with pastel footprints. “I’m relieved I’ll be able to run around after my son.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

CLEVELAND — It’s difficult to imagine that a seven-story glass building will soon take the place of what’s now a vast hole near the corner of Carnegie Avenue and 105th Street in Cleveland. But Cliff Kazmierczak, who is with Turner Construction and overseeing the transformation, points to the gray sky, tracing a silhouette with his fingertips. In two years, he says, the Cleveland Clinic’s nearly $300 million cancer center is slated to open here.

“The big thing is to make the patient comfortable with the treatments that they’re going through,” he says of the building’s design. “So lighting, light colors, [and] as much natural light as possible are always very important to cancer patients.”

Kazmierczak came to this project after overseeing construction of the cancer hospital at Ohio State University a few hours south of here. All around the U.S., the health care industry is building up to take care of an expected influx of cancer patients.

Ohio is not alone in this building boom. The Advisory Board Company, a firm that does health care consulting, works with hospitals and doctors. Last year it found that about 25 percent of its members that have oncology departments were either constructing a cancer center, or had built one in the past three years. The Advisory Board’s Deirdre Fuller says people are more likely to get cancer as they get older.

“Now that everyone is looking forward and seeing the aging of the baby boomers,” she says, “it’s certainly adding some fuel to that fire.”

And most boomers will get health insurance through Medicare — which is a steady paycheck for hospitals.

Dr. Brian Bolwell heads the Cleveland Clinic’s cancer institute. He says hospitals have to meet the need.

“In the past five years, volumes go up, depending on location, between 5 and 10 percent a year,” Bolwell says. “And there’s no end in sight to that volume of growth.”

The Cleveland Clinic, along with its local competitor, University Hospitals, treat about 70 percent of the region’s cancer patients. And when the Cleveland Clinic opens its new center, the two will be located within a five minute drive of each other.

Historically, state governments have required hospitals to meet a certificate of need before building a hospital. But beginning in the late 1980s, states across the country began deregulating. Ohio’s certificate of need requirements for hospitals ended in the late 1990s, though it still requires it for long-term care facilities.

Dr. Nathan Levitan, who heads the cancer center at University Hospitals, doesn’t seem worried about the competition. His 4-year-old hospital, he says, is mostly full every day.

“We discharged over 11,000 patients with cancer in 2014,” Levitan says, “which is about a 20 percent increase over just a few years beforehand.”

He says that’s because both hospitals employ and contract with thousands of doctors. And in the world of cancer care, doctors have a lot of influence.

People usually don’t shop for cancer treatment until they are diagnosed, and at that moment their doctor’s advice on where to go matters a lot.

Bill Ryan leads a hospital advocacy group in Cleveland. He says that with so many expected patients, building is good for a hospital’s bottom line and good for patients.

“If you can run enough procedures through a facility, you’re going to get some economies of scale that will generate [a profit] margin,” he says. “The other thing you get when you run enough procedures through a facility, is a level of expertise that improves the quality of care that the individual gets.”

And when talking about the future of cancer care, hospital leaders tend to talk about quality. They insist that focusing on the quality of care will eventually lower the cost to patients, too.

This story is part of a reporting partnership with NPR, WCPN and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.