Results of immediate postpartum Long Acting Reversible Contraception provision after expanded reimbursement policy implementation at an academic medical institution

Abstract

Introduction:

Immediate postpartum (IPP) Long Acting Reversible Contraception (LARC) is effective in reducing short birth spacing, which is highest among minoritized and younger women with lower socioeconomic status. The structural barrier of cost for pregnant people who desire IPP LARC insertion was alleviated in 2016 when New York State provided statewide reimbursement for Medicaid recipients.

Methods:

Analyses of existing electronic medical records (EMR) were conducted on women who received IPP LARC between 3/2/17 and 9/2/19 at two hospitals after a term delivery, defined as gestational age 37 0/7 weeks or greater. Descriptive and bivariate statistics, including chi-square tests and Fischer’s exact tests, based on cell sizes, were calculated using SAS (version9.4).

Results:

Prior to the study period, IPP LARC was not placed in these hospitals. After reimbursement policy changes, electronic medical record data identified 501 women with full term delivery and IPP LARC placed, of which the majority were single (82.8%), Black (49.1%), and had public insurance (Medicaid and Medicaid Managed Care) (79.2%).

Discussion:

Removing structural economic barriers for people using public insurance may increase health equity in contraceptive access and choice.

Introduction

Clinical guidelines recommend the immediate postpartum (IPP) interval can be an ideal time to provide Long Acting Reversible Contraception (LARC); placement is safe and effective in this period(American College of Obstetricians and Gynecologists, 2016). While IPP LARC is recommended as a highly effective intervention for planning and appropriately spacing pregnancies, there are many access barriers, including lack of insurance coverage (American College of Obstetricians and Gynecologists (ACOG) Committee on Gynecologic Practice, 2009; Centers for Disease Control and Prevention, 2010; DeFranco et al., 2015; Washington et al., 2015). The impact of IPP LARC reimbursement policies, a structural barrier to contraceptive access, on unplanned and rapid repeat pregnancies are under-researched.

For patients with limited access to medical care, delivery provides an important opportunity to address the need for contraception(Grimes et al., 2002). Most non-lactating people resume menstruation within 45 to 64 days after delivery. Thirty to eighty percent of these cycles are anovulatory, which correlates to an average time of 45 to 94 days until first ovulation. However, ovulation has been demonstrated as early as 25 days postpartum(Jackson & Glasier, 2011). As fifty percent of women ovulate and 60% resume sex before six weeks postpartum, a woman returning for implant or IUD insertion four to eight weeks after delivery is therefore putting herself at risk for unintended pregnancy(B. P. Zhu, 2005; B.-P. Zhu et al., 1999). In addition, missing the postpartum visit is a significant barrier to postpartum contraceptive use with up to 35% of women not attending the postpartum visit. Insurance coverage is often an associated barrier as many women who had insurance to cover their pregnancy lose their insurance after they are no longer pregnant. Inserting a LARC method immediately postpartum is a way to overcome the barriers of changing insurance coverage and having to return for the postpartum visit before obtaining LARC(Ogburn et al., 2005; Speroff & Mishell, 2008). Timely access to postpartum contraception can prevent rapid repeat pregnancy, improve next pregnancy outcomes, and prevent abortion.

All forms of contraception have different efficacy rates. These rates are a function of not only how effective the method is, but also the ease of use. Given that short acting methods (oral contraceptive pills, contraceptive patches and vaginal rings), require patients to remember to take or use something, they have a different typical and perfect use rate. LARC methods have less user error as they are methods that while reversible, can be placed and “forgotten.” The effectiveness of LARC (IUDs, implants and injections) compared to short acting methods has been shown to be superior. Data from the Contraceptive Choice Project has shown that people are 20 times more likely to have an unplanned pregnancy using pills, patches or rings than while using a LARC method, and that people less than 21 years of age have almost twice the risk of unintended pregnancy as older people using that same method(McNicholas et al., 2014; Secura et al., 2010).

The cost of LARC devices is high, between $600–800 per device and while it does vary by the type of device, geographic area, and location placed, if not covered by insurance this can be a very high out of pocket cost(Trussell et al., 2013, 2015; Winner et al., 2012). The device and insertion costs are typically covered by insurance at the six-week postpartum visit as public health insurance programs, and now all ACA programs, mandate contraceptive coverage. When LARC is placed immediately postpartum as recommended by clinical guidelines, the costs are rolled into the global reimbursement for inpatient delivery which does not include the extra cost for the device or provider time, adding a financial barrier to the patient and/or the provider.

In 2014 the American Journal of Obstetrics and Gynecology published a study that poignantly demonstrated the cost savings of placing postpartum implants in the hospital prior to discharge when compared to women receiving routine postpartum contraception as an outpatient. Costs were then normalized to 1000 women using Medicaid reimbursement estimates. In this study, at six months, the expenditures of the IPP implant group exceeded the routine care group by 74K USD, however, by 12-, 18-, and 24-months projected savings would exceed 500.5 thousand, 2.5 million and 4.5 million USD respectively(Han et al., 2014). These numbers supported the justification of insurance companies covering the relatively small cost of a contraceptive device. As a response to these findings, beginning April 1, 2014, New York State (NYS) Department of Health (DOH) reimbursement policy was updated to begin providing reimbursement for the cost of LARC provided to Medicaid fee-for-service women during their postpartum inpatient hospital stay.

However, Medicaid Managed Care plans, which cover the majority of NYS women enrolled in public insurance, were excluded from the IPP LARC reimbursement policy with the expectation that these patients could have LARC placed at their six-week follow up appointment. To check this assumption, a review of billing records at the University of Rochester academic Medical Center (URMC) hospital-based clinic was conducted. Results showed a substantially high no-show rate (range 34–39% between 2013–2015) for the six-week follow up postpartum appointment, indicating a high proportion of all practice patients not receiving postpartum contraception.

Attempting to follow clinical guidelines and provide the full range of contraceptive options, URMC providers obtained a grant through the Ryan Residency Training Program to provide LARC devices for patients who requested IPP LARC and from 7/2015 – 5/2019 placed 217 grant-funded devices with the provider fee waived. The program was developed to expand training for nursing, medical students, residents and family planning fellows and to increase patient access to vulnerable populations in the IPP period. Their goals were to increase training in the evidence-based provision of LARC and to decrease financial barriers to patients accessing LARC. Eligibility requirements included patients with an income of less than or equal to 300% of the current Federal Poverty Level, no insurance coverage for LARC at the time of insertion, and less than 10 weeks postpartum. As NYS has excellent coverage for at risk populations to receive LARC at their postpartum visits, we used this grant to provide access in the IPP period. Patients who identified they desired an LARC device for postpartum contraception during their routine counseling were screened for inclusion criteria by our residents, NPs, and attendings. Patients were counseled that IPP contraception was possible, but they were also counseled that it would be an out-of-pocket cost if they didn’t qualify for the grant or there were no grant devices available. The grant only sent shipments of LARC devices every three months. As we typically ran out of devices in the first month, we had many patients requesting devices and not being able to get them.

On September 1, 2016, the NYS DOH amended the reimbursement policy to include Medicaid Managed Care plan enrollees, providing for IPP LARC placement reimbursement for those who request it, separate from global reimbursement for the inpatient delivery admission(Rodriguez et al., 2022). In May 2017, URMC implemented a policy change process for IPP LARC reimbursement for Medicaid patients, pilot testing each LARC device for payment processing using project champions (Hofler et al., 2017; New York State Department of Health, 2017). By December 2017, Excellus, United Healthcare, and MVP Health Care insurance companies, which are the main insurers in our area, had adjusted their systems to accommodate the new reimbursement (Figure 1). Since the reimbursement policy change, several hundred IPP LARC have been inserted at two URMC hospitals: Strong Memorial Hospital (SMH) and Highland Hospital (HH). This paper describes the experience of covering the cost of IPP LARC at two URMC hospitals in NYS after a reimbursement policy change.

Figure 1.

Timeline of immediate postpartum (IPP) long acting reversible contraception (LARC) access before and after the policy change within the catchment area of the University of Rochester Medical Center (URMC) in New York (NY) State

Methods:

The CTSI Informatics Service request was used to pull data from the electronic medical record (EMR) on women who received IPP LARC between 3/2/17 and 9/2/19 at SMH or HH after a term delivery, defined as gestational age 37 0/7 weeks or greater. Data were recorded through FlowCast, using CPT codes for copper (ParaGard) and Levonorgestrel IUD (Liletta/Mirena) and Etonogestrol implants. Specifically, CPT codes (IUDs: J7300, J7301, J7297, J7298, 58300, Z30.430, Z30.433, 0UH97HZ; Implants: J7306, J7307, Z30.017, 0JHF3HZ, 11981, PRO75B, PRO75C, PRO75D, J7307, S0180) included the full range of LARC available at URMC.

The study population included patients admitted to the hospital for delivery who also had IPP LARC (defined as IUD placement within 10 minutes of the placenta and/or Etonogestrol implant placement prior to discharge) by comparing dates of delivery and LARC placement. IPP LARC was verified by triangulating financial, insurance and EMR data, using appointment notes for confirmation. Descriptive statistics were calculated on sociodemographic variables including age (<=19, 20–24, 25–29, 30–34, 35–39, 40+ years), marital status (divorced, legally separated, life partner, married, single, unknown, widowed), race (Black, white, none of the above), insurance type (private, public, other), gravidity (one, two, three or more), and parity (one, two, three or more). Bivariate statistics were conducted dichotomizing each variable by the type of LARC (IUD or implant), including two-tailed chi-square tests and Fischer’s exact tests, based on cell sizes, using SAS (version9.4). Statistical significance was determined using an alpha level of 0.05. This study was determined to be IRB exempt by the University of Rochester’s Research Review Board and has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Due to the retrospective data pull, informed consent was not collected from participants.

Results:

One thousand one hundred twenty four women had a term delivery between 3/2/17 and 9/2/19, of which 501 (44.6%) had a LARC placed ≤3 days after delivery (mean[SD]=0.8[0.9]day, median=1). Of these, 73.7% (n=369) delivered at SMH and 26.4% (n=132) delivered at HH. Yearly distribution of IPP LARC was 21.4% in 2017, 44.7% in 2018, and 33.9% in 2019. Implants comprised 59.3% while IUDs comprised 40.7% of IPP LARC. Women who received IPP LARC had a mean age of 26.4 years ([SD:5.6], median=26.2, range 13.7–43.9); 13% of women were ≤19 years. Mean[SD] gravidity and parity were 3.2[2.0] and 2.4[1.4], respectively. The majority of women were single (82.8%), Black (49.1%), and had public insurance (79.2%, Table 1).

Table 1.

Demographic characteristics of women receiving immediate postpartum long acting reversible contraception insertion, academic Medical Center, 2017–2019.

	IUD		Implant		Total
	n=204 [40.7%]		n=297 [59.3%]		n=501 [100%]
Characteristic	n	%	n	%	n	%
Age
<=19	21	10.3	44	14.8	65	13.0
20–24	56	27.5	89	30.0	145	28.9
25–29	74	36.3	91	30.6	165	32.9
30–34	35	17.2	56	18.9	91	18.2
35–39	15	7.4	13	4.4	28	5.6
40+	3	1.5	4	1.4	7	1.4
Marital status
Divorced	2	1.0	4	1.4	6	1.2
Legally Separated	2	1.0	4	1.4	6	1.2
Life Partner	1	0.5	2	0.7	3	0.6
Married	24	11.8	34	11.5	58	11.6
Single	171	83.8	244	82.2	415	82.8
Unknown	4	2.0	9	3.0	13	2.6
Widowed	0	0.0	0	0.0	0	0.0
Race*
Black	87	42.7	159	53.5	246	49.1
None of the above	44	21.6	63	21.2	107	21.4
White	73	35.8	75	25.3	148	29.5
Delivery type*
Vaginal	123	60.3	212	71.4	335	66.9
Cesarean	81	39.7	85	28.6	166	33.1
Insurance type
Other	0	0.0	1	0.3	1	0.2
Private	40	19.6	63	21.2	103	20.6
Public	164	80.4	233	78.5	397	79.2
Gravidity*
1	31	15.2	84	28.3	115	23.0
2	45	22.1	61	20.5	106	21.2
3+	125	61.3	146	49.2	271	54.1
missing	3	1.5	6	2.0	9	1.8
Parity*
1	47	23.0	114	38.4	161	32.1
2	69	33.8	79	26.6	148	29.5
3+	85	41.7	98	33.0	183	36.5
missing	3	1.5	6	2.0	9	1.8

^*p<0.05

^†Where Public= Medicaid, CHIP, Indian Health Service (IHS), Prenatal Care Assistance Program; Other= self-pay, Tri-care, uninsured

Forty-eight (9.6%) of women had >1 delivery and IPP LARC placed in this time period, mean[SD] age 25.4[4.8]. Statistically significant differences between IUD and implant distribution were seen for race, delivery type, gravidity, and parity, with women identifying as Black, with vaginal deliveries, gravidity one and/or parity one choosing implants over IUDs (p<0.05).

Discussion:

Women who received IPP LARC at two URMC hospitals between 2017 and 2019 were most often single or Black, and enrolled in public insurance, an indicator of low socioeconomic status. These results are consistent with demographics of women more likely to have rapid repeat pregnancy, giving optimism that providing IPP LARC might begin to address health inequities by enabling these women to have subsequent pregnancies with more optimal spacing (Baldwin & Edelman, 2013; Thiel de Bocanegra et al., 2014). Written clinical notes were used to verify actual LARC placement during the delivery hospital stay, but limitations inherent in merging financial, insurance and EMR data to identify IPP LARC placement may have resulted in undercounting of those who actually had LARC placed.

In our medical system, postpartum contraception is part of our “pregnancy check-list.” Due to the importance of birth spacing intervals, all options are reviewed with patients during their prenatal care course. Patients who select an implant or an IUD are counseled regarding the option of placement IPP or at the traditional postpartum visit. If they chose the former, it is documented and they are consented prior to hospital admission. Once admitted, if they again voice interest in IPP LARC and haven’t been consented, a form is reviewed and signed with them. All patients receive additional postpartum contraceptive options in a pamphlet within their admission packets. Our patient educational and contraceptive selection tools and handouts list all options based on typical use efficacy as to have scientific evidence of efficacy lead the discussion rather than provider bias.

Next steps are to conduct an observational cohort study to compare the prevalence of rapid repeat pregnancy and/or birth. Additional research will explore any potential coercion or bias in postpartum contraception counseling, as historical data have illustrated racist coercive systems and recent research has shown links between Black women, women with social determinants of health, those with inadequate prenatal care, and public insurance are more likely to choose LARC methods(Liberty et al., 2020; Oduyebo et al., 2019; Roberts, 1998).

The no-show rates for six-week postpartum visits have averaged about 35% over the last two years (2020 and 2021) at URMC, highlighting the importance of IPP LARC reimbursement policy implementation for identifying women who may have limited access to postpartum obstetric visits for obtaining their choice of postpartum contraceptive methods. Removing this structural barrier has been instrumental in increasing access to postpartum contraceptive choice for pregnant people in URMC’s catchment area.

Significance.

Implementing different reimbursement policies takes time and effort of multiple stakeholders throughout an institution. This effort is justified when disenfranchised patients become eligible for additional services due to the removal of structural financial barriers. Over a 30-month time period, 397 additional women using public insurance with a term delivery had LARC placed due to the new reimbursement policy, increasing autonomy of these people to plan their next pregnancy. Removing economic structural barriers increases health equity.

Availability of data:

Data are available on reasonable request. Given the identifying and potentially stigmatizing nature of the data in this study, analyses are provided in this paper to support its conclusions, although datasets are not publicly available. Interested investigators can request data from the corresponding author.