A number of states are working to improve access to long-acting contraceptive methods such as intrauterine devices (IUDs) and implants for Medicaid patients at the urging of the federal government’s Centers for Medicare and Medicaid Services (CMMS).
Illinois and New York this summer joined a host of other states—from Louisiana to Texas—that are trying to help women prevent unintended pregnancies and save state money at the same time.
Long-acting reversible contraceptives (LARCs) have gotten a lot of attention in recent years because they are highly effective in preventing unintended pregnancy, safe for women of all ages, and last between three and ten years.
In fact, in 2012 the American Congress of Obstetricians and Gynecologists released an opinion saying that IUDs and implants should be among the first contraceptive options suggested to women, even adolescent women. “When choosing contraceptive methods, adolescents should be encouraged to consider LARC methods,” the opinion says. “Intrauterine devices and the contraceptive implant are the best reversible methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion in young women.”
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The American Academy of Pediatrics also suggested IUDs and implants as first-line contraceptive methods for sexually active teens, as Rewire reported, just this week.
Recent research has shown that when given information about and free access to LARCs, women opt for these methods and are satisfied with them.
The CHOICE Project at Washington University in St. Louis, Missouri, for example, began recruiting women ages 14 to 45 in 2007, and by September 2011 had closed the study having enrolled 9,256 women.
Women enrolled in the study received contraceptive counseling to help them choose a method and three years of contraceptive services for free. In a preliminary study of 5,086 participants, 70 percent chose a LARC method. Of those, 47 percent chose Mirena (a hormonal IUD), 11 percent selected ParaGard (the copper IUD), and 12 percent chose Implanon (the contraceptive implant).
Researchers followed participants and found that satisfaction and continuation rates among LARC users were higher than those of women using other methods. At 24 months, 77 percent of women who had chosen a LARC method were still using it, compared with 43 percent of those using the oral contraceptive pill, 40 percent of those using the contraceptive patch, 41 percent of those using the contraceptive ring, and 38 percent using the contraceptive shot. Continuation rates were higher for IUDs than implants.
Researchers concluded that participants who chose a LARC method at enrollment were at significantly lower risk of contraceptive method discontinuation compared with women who selected a non-LARC method. Not surprisingly, they were also at less risk of unintended pregnancy.
At the one year mark, pill, ring, and patch users were 20 times more likely to have had unintended pregnancy than LARC users.
Another intervention, the Colorado Family Planning Initiative (CFPI), sought to increase access to LARC methods by correcting misinformation, training providers, and providing these methods. This project worked with low-income women seeking services at Title X-funded clinics. CFPI began in 2009 and research found that by 2011, LARC use among women 15 to 24 had grown from 5 percent to 19 percent. By that point, one in 15 young, low-income women had received a LARC method, up from one in 170 in 2008.
The CFPI study also found that in 2011, the fertility rates among low-income women ages 15 to 19 were 29 percent lower than expected, and the rates among low-income women ages 20 to 24 were 14 percent lower.
Moreover, in those counties with a CFPI provider, abortion rates among women ages 15 to 19 fell 34 percent between 2009 and 2011, and rates for women ages 20 to 23 declined 18 percent. There was a 23 percent decline in infant enrollment in the federal WIC program (the Special Supplemental Nutrition Program for Women, Infants and Children) between 2010 and 2013.
While these results show how well LARCs can work in preventing unintended pregnancy and abortion, and helping women plan their families, LARCs remain underutilized by women across the country. Only 9 percent of contraceptive users are currently relying on these methods, according to the National Survey of Family Growth.
One of the barriers to use is the high upfront cost. An IUD can cost as much as $1,000, which includes the price of the device and the provider’s fee for insertion. When looked at over the long term, these methods are cost-effective—a woman who uses ParaGard for its full ten-year lifespan, for example, could pay as little as $4 a day—but with the whole fee due upfront, many women cannot afford it.
Though Medicaid pays for contraceptives, the reimbursement rules in many states make it difficult for participants to access IUDs and implants. The reimbursement rate in many states is less than the cost of the device, which means that providers lose money every time they do an insertion. Because the device itself is so expensive ($600 to $800) most providers do not keep it in stock in their offices.
Instead, they order it for an individual patient after she expresses interest. This means that women need to come to the office at least twice to receive the device. In some states the ordering process works like a prescription—once it is assigned to a patient, the device cannot be used on anyone else—if the woman does not come back for insertion, it gets thrown away.
This is one of the issues that states are addressing to make LARCs more affordable.
In Texas, Medicaid providers can order the devices from one of three pharmacies without any upfront costs. In South Carolina, one of the first states to expand LARC use, providers can get a LARC the day after it is requested and can keep it on hand for 30 days, at which time it must be returned.
The Illinois plan, which was introduced over the summer, would double doctor reimbursements for LARCs as well as vasectomies. The reimbursement rules in that state are also being revised so that women can ask for and receive the device in the same visit.
Rewire spoke with Dr. Rebekah Gee, the medical director for Medicaid in Louisiana, which is in the process of making similar changes. She explained that as of October 20, Medicaid in Louisiana will cover the cost of both the device and the office visit required to insert them. Gee explained that providers were losing $200 every time they inserted the device, and that 30 percent of the devices ordered were going to waste.
“Now, we match what it costs for people to buy it so providers can stock it in their offices,” Gee said.
The other important change that Gee and her colleagues have been working on is reimbursement for immediate postpartum insertion of an IUD.
Ensuring that women have access to contraception after they give birth is vital to their health and the health of their future children. Gee explained that spacing births by at least 18 months to allow the woman’s body to recover can reduce the risk that future pregnancies will end in premature delivery or low birth weight babies.
Though delivery can be an ideal time to insert an IUD, many providers are not doing so, in part because they do not get reimbursed. Medicaid rules in many states essentially pay providers a lump sum for all services done during delivery, which means again that a provider would lose money if he/she inserted a LARC at that time.
Though it might seem like merely an inconvenience to tell women they would have to schedule an office visit at a later time, it is a much bigger problem than that—about 70 percent of women, according to Gee, who are eligible for Medicaid during pregnancy don’t qualify for it otherwise.
Gee said that her state is working on postpartum insertion of IUDs because too many women don’t receive the implant when they go in and out of the Medicaid system. In July, New York announced that it would institute a fee-for-service payment schedule during delivery in order to encourage postpartum IUD insertion. Other states that have taken this step include Colorado, Georgia, Iowa, New Mexico, and South Carolina.
Colorado’s experience in particular has shown than increasing access to LARCs is an effective and cost-effective move for states. It has been suggested that the CFPI program saved Colorado $42.5 million in large part by helping to reduce the teen pregnancy rate.
Gee says for her it’s not about the money: “The motivation is to provide women with safe, effective, no cost, contraception that works for them so that their lives and their birth outcomes will be better.”