Facilitators and Barriers to Implementation of Immediate Postpartum LARC Programs within Pennsylvania Hospitals 7 Years after PA Medicaid Reimbursement

Abstract

Objective:

To evaluate facilitators and barriers to implementation of immediate postpartum LARC (IPLARC) within Pennsylvania (PA) hospitals seven years after PA Medicaid adopted coverage of IPLARC outside the pregnancy care bundled payment, with particular attention to rural, small, or non-academic hospitals.

Study Design:

We conducted ten qualitative interviews representing ten unique hospitals from an opt-in subset of participants in our quantitative survey of clinician leaders at PA Labor and Delivery units. Transcripts were analyzed using grounded theory methodology. We coded and analyzed transcripts using MAXQDA software.

Results:

Several themes emerged from the data; three of which are novel. Firstly, that passage of Medicaid reimbursement was necessary but not sufficient for widespread implementation of IPLARC. We also found that hospital mergers and consolidations facilitated the capacity of smaller hospitals to implement and sustain IPLARC and that the Pennsylvania Perinatal Quality Collaborative was a utilized resource.

Conclusion:

Medicaid coverage of IPLARC is a necessary facilitator but not sufficient for all hospitals to implement this service. Smaller, non-urban hospitals may benefit more from network-level support and state Perinatal Quality Collaboratives than their larger, academic urban hospital counterparts.

Introduction

Increasing access to immediate post-partum long-acting reversible contraception (IPLARC) during the delivery hospitalization (initiation of intrauterine devices or contraceptive implants after delivery and before hospital discharge), is an evidence-based strategy to reduce subsequent adverse maternal and newborn outcomes due to short-interval pregnancies[1–3]. Champions, multidisciplinary engagement, enabling financial environments and healthcare support have been found to facilitate IPLARC implementation. [4–6]. IPLARC has been championed by some state Perinatal Quality Collaboratives (PQC). PQCs work in collaboration with their respective Maternal Mortality Review Committees (MMRC) to develop actionable initiatives to target the local drivers of maternal morbidity and mortality. Nationally, there are 36 Centers for Disease Control and Prevention (CDC) funded state PQC’s with eleven offering an IPLARC initiative [7].

Several barriers have limited the implementation of IPLARC services at hospitals. Financial considerations, especially reimbursement by insurance, are a recurring and prominent barrier across different studies. Hospitals are typically reimbursed for maternity care with a single negotiated bundled payment (i.e., the global maternity fee), resulting in a financial disincentive to provide IPLARC. To optimize IPLARC access, 45 states and D.C. have implemented new Medicaid rules to allow payment for LARC devices and/or insertions separate from the global maternity fee, including in Pennsylvania (PA) in 2016 [8–10].

The adoption of Medicaid policy that expands coverage for IPLARC has been hypothesized to be a critical element for IPLARC implementation because Medicaid covers 41% of births in the US and commercial insurance practices may be influenced by the practices of state and federal insurance programs[11]. Previous inquiries into the impact of Medicaid coverage for IPLARC have been contradictory; with some demonstrating more hospitals offering IPLARC regardless of patient insurance coverage,[12, 13] and some demonstrating no change [5]. Much of the literature surrounding IPLARC implementation is in the setting of well-supported pilot programs with the resources of academic hospitals [6, 8, 14–16]. Exploration of facilitators and barriers in non-academic hospitals are more limited. Smaller, rural or non-academic hospitals may require unique external support. Similarly, they may have unique, yet unknown barriers to implementation.

We sought to examine the “real world” implementation and sustainability of IPLARC across hospitals in PA seven years after Medicaid policy began covering IPLARC. We previously surveyed every PA hospital with a labor and delivery unit to quantitatively assess IPLARC patterns and rurality [17] and subsequently followed up with qualitative interviews with Labor and Delivery unit clinician-leaders. Our primary research objective was to explore facilitators and barriers to IPLARC implementation and sustainability at the hospital level in a Medicaid coverage environment, and secondarily consider interactions with hospital characteristics, such as rurality, academic status, and hospital ownership.

Methods:

We used the Consolidated Criteria for Reporting Qualitative Research Studies to present our methods and results[18]. The Penn State University Institutional Review Board granted IRB approval.

This study began with a quantitative survey introduced to all PA Labor and Delivery units querying their IPLARC practices (results previously reported) [17]. At the completion of the survey, all participants were asked about their willingness to be contacted for a qualitative interview, creating an initial convenience sample that was further expanded with snowball sampling wherein our initial respondents were able to recommend further obstetric leaders in Pennsylvania. Each hospital was represented by a single interview of an L&D nurse or physician leader with programmatic and procedural knowledge. The investigators developed an interview guide based on prior IPLARC implementation research[4]. Participants were asked about institutional characteristics, how their labor and delivery unit has approached practice changes broadly, and then specifically regarding IPLARC (See Appendix for interview guide). Interviews were conducted by three of the investigators (SH, GF, EG) and a single investigator conducted each interview based on availability. SH and GF are physicians and EG is a medical student; all identify as cis-women and received training in qualitative interviewing before conducting interviews. Interviews were typically performed to accommodate schedules; however, care was taken to avoid interview dyads where the interviewee had an existing relationship with the interviewer. Interviews were performed on the Zoom platform (https://zoom.us/) and ranged from 30–90 minutes in length. Participants received $50 as compensation for their time. All interview recordings and transcripts were deidentified and stored on a protected online folder.

Following the conclusion of data collection, interviews were transcribed and cleaned for analysis. All four study team members reviewed all transcripts to create a storyline, or a short overview of the data. Researchers then met to discuss their storylines. All team members analyzed the transcripts using grounded theory methodology, wherein we approached the data without hypotheses and inductively created codes, and iteratively re-examined the data until codes and themes were finalized. All four team members initially coded the data, and two team members (SH and CB) performed the in-depth coding. For the in-depth coding, interrater reliability had a kappa coefficient >0.70. After all transcripts were coded, the research team met to identify emergent themes; any disagreement was discussed as a group until we reached consensus. Demographic data for each interview had previously been collected in the quantitative portion of the study. We conducted analyses using MAXQDA software

We projected conducting approximately 20 interviews with the goal of reaching thematic saturation.

Results

Overall, of our 51 quantitative survey respondents, 15 (29.4%) expressed a willingness to be contacted for a follow-up interview. We achieved thematic saturation at ten interviews and ended interviews for data collection due to timeframe constraints; if we had not achieved thematic saturation there were additional participants for interviews available. Our participant hospitals were mostly non-rural, community hospitals with Labor and Delivery units staffed by a single-employed hospital group. Number of deliveries varied from 530–3800 annually. Seven of our ten interviews were at sites that were currently providing IPLARC services (See Table 1). The interviewees consisted of 4 physicians and 6 nurses. Three hospitals were rural by Pennsylvania Center for Rural Health criteria, though six of our hospitals self-identified as non-urban: four hospitals self-identified as being rural and two more self-identified as being suburban.

Table 1.

IPLARC qualitative interviewee characteristics (N=10, PA 2023)

ID	Rurality	Academic status	Deliveries	Employment	Implementation status	PA PQC
48	No	Academic	3800	Both	Implementer	Y
52	No	Academic	2200	Hospital	Sustainer	Y
49	No	Hybrid	3500	Hospital	Sustainer	Y
61	Yes	Community	530	Hospital	Implementer	Y
64	Yes	Community	980	Hospital	Sustainer	Y
02	No	Academic	2300	Hospital	Non-implementer	Y
06	No	Community	800	Hospital	Non-implementer	N
62	No	Community	960	Private	Non-implementer	Y
22	No	Academic	3000	Hospital	Implementer	N
29	Yes	Community	1600	Both	Implementer	Y

ID = Participant identification number, only one participant per hospital was interviewed. Rurality was determined by the Center for Rural Pennsylvania definitions. Deliveries = annual delivery volume. Employment = hospital employed obstetric physicians, private physician group, or both. Implementer = IPLARC began within the past two years, sustainer = IPLARC > 2 years, Non-implementer = no IPLARC. PA PQC = Pennsylvania Perinatal Quality Collaborative; Y = active involvement before, during, or after implementation, N = considering involvement or never heard of the program.

Several themes emerged from the data; three of which are new to the literature: Medicaid was necessary but not sufficient for widespread IPLARC implementation, hospital mergers and consolidations facilitated the capacity of smaller hospitals to implement and sustain IPLARC and finally, that the Pennsylvania Perinatal Quality Collaborative (PAPQC) was a well-utilized resource. Otherwise, our participants largely echoed pre-existing findings regarding facilitators and barriers of IPLARC.

Hospital mergers and acquisitions can facilitate IPLARC implementation

Differences between urban academic centers and rural community hospitals were highlighted by the interviewees and presented unique considerations in the “real world” implementation of IPLARC. One participant from a community hospital described their physician-owned practices and the dilemma of providing IPLARC in their private practice versus the hospital-employed physicians in the “city,”

“So, there’s really no benefit for them [private physicians] to do it in the hospital instead of waiting until they’re postpartum and having them come into the office and get a place there… The other doctors, the hospital took on and they own those practices [hospital-owned practice], so the hospital had agreed to provide this service. So it’s a little bit of a different situation up at [city] than it is for me down here. I need to know how am I going to entice my doctors? And they have great hearts, and maybe they’ll do it for the good of the community, but people want to get paid for their services, something.”

(ID 62, nurse leader, non-rural community hospital)

This participant was challenged by both financial incentives for their physicians, but also by their lack of resources.

“We don’t have as much support here because we’re a smaller hospital. They [larger hospitals] have a lot of different levels of management and support and everything.

(ID 62, nurse leader, non-rural community hospital)

Acquisition of smaller hospitals by larger networks has created a pathway to overcome hurdles in implementation via the sharing of protocols, EMR order sets, billing pathways etc.

“Locally, what items do you need to be able to insert these? What did the providers need? Did they have specific preferences? What patient education do we need to be able to hand out for pre and then post? That was all worked out within the service line so that it was almost like a package. So it made it super easy for us to then at each entity roll it out.”

(ID29, nurse leader, non-rural community hospital)

“ …the hospital president has a say in what we do, but most of it is actually driven from the overarching hospital. We’re part of a service line, so the company that owns us in [city] pretty much drives a lot of the policies, procedures, and protocols to all of their 13 delivering sites so that we’re all doing the same thing.”

(ID64, nurse leader, rural community hospital )

Implementation in the environment of changing hospital ownership is bi-directional as communication occurs from local hospital to larger network and back.

“They would… stamp…the areas that needed to change, the areas we could keep the same as we chose them, so that we can make that work. Because it’s a pretty large, almost statewide, entity, we really try and keep some things local, where we can, for the culture.”

(ID48, physician, academic non-rural hospital)

The dynamic landscape of large hospital networks acquiring smaller hospitals in the community has created unique conditions in the healthcare environment. Competition between networks can be a positive force in creating an incentive for IPLARC implementation.

“I think it helped at a higher up scale, right? The physicians do not care, but at a higher up scale, there’s a lot of competition between these two networks…But at any time you can come to someone higher administration and say, “Well, they’re doing this already.” “

(ID49, physician, non-rural hybrid hospital)

“Seeing the success at other institutions and how it’s really impacted their healthcare and their change… being able to see all of their information was a really big driver to say, “Okay, we can do it here, and it can be successful.”

(ID61, nurse leader, rural community hospital)

The Pennsylvania Perinatal Quality Collaborative (PAPQC) is a practical and important resource

The PAPQC introduced an IPLARC initiative in 2020 and was cited by eight of our 10 participants as a known resource; two already had IPLARC programs before the PAPQC initiative was launched and two cited the PAPQC as the primary inspiration for beginning their program.

“So we participate with the PA PQC, and that’s what drove this initiative for us to start this IPP LARC.”

(ID 61,nurse leader, rural community hospital))

Medicaid coverage of IPLARC is a necessary facilitator but not sufficient

Passage of Medicaid coverage was a facilitator of IPLARC implementation. Having a consistently covered payer in Medicaid allows for initiation of IPLARC programs, but the uncertainty of commercial payer coverage continues to be a major obstacle for sustainability of IPLARC provision and patient access. Inconsistency in insurance coverage obstructs the ability of providers to counsel patients universally about IPLARC,

“Do I counsel everyone about it? Not as much … But anyone who is eligible for it from an insurance standpoint, I’ll let them know about it.”

(ID49 physician, non-rural hybrid hospital).

Unpredictable insurance coverage also confounds the capacity of hospitals to incorporate IPLARC as a covered service,

“It would be really great if it didn’t matter who I could offer and counsel with, but unfortunately, in hospital has made that a reality that we’ve had to limit our subset.”

(ID48, physician, academic non-rural hospital).

Participants also shared many of the same themes surrounding implementation of IPLARC previously seen in the literature, including the need for clinical champions, multi-disciplinary support (especially pharmacy and electronic medical record expertise) and the challenges of insurance coverage and reimbursement. Participants provided examples of providers being challenged by biases in their knowledge about IPLARC (concerns about safety, expulsion and coercion) and concerns about financial incentives for themselves. However, overall, individual providers and staff are ultimately motivated by the benefit and convenience IPLARC provides to the patient.

Discussion:

The healthcare landscape in Pennsylvania and nationally has trended towards hospital closures, consolidation, and mergers since the mid-1990s, largely driven by the financial distress of smaller and often rural hospitals[19]. These closures create reproductive healthcare challenges such as obstetric care deserts and limited patient access to specialty services[20]. These structural changes often result in 3–5 dominant players in a region and can result in increased costs without an accompanying increase in quality[21]. Our finding that hospital consolidations facilitated IPLARC implementation via provision of resources from the larger hospital system is novel and relevant as we strive to optimize quality and outcomes in a dynamic commercial environment.

Our previously published quantitative survey revealed that rural hospitals are less likely to offer IPLARC, even controlling for academic or non-academic hospital type [17]. This qualitative data provides further context for this finding. Our respondents were mostly non-rural by Center for Rural Pennsylvania classification, however interestingly many of them self-identified as non-urban in the interviews- we may need to consider different definitions of rurality that may better reflect the experiences of these hospitals.

It is easy to conflate rurality and hospital type, especially as rural hospitals close or shutter their L&Ds and rural-adjacent health systems absorb larger rural populations. Indeed, some of our interviewees identified as rural even when they did not meet technical criteria as such. Our data bears evidence that non-rural, but smaller hospitals, community hospitals, non-network affiliated hospitals, and hospitals with significant presence of privately owned physician groups may be challenged in implementing IPLARC in ways that their larger, urban, academic counterparts are not. These hospitals share a tendency toward fewer resources and more financial vulnerability. Non-hospital owned physician groups, “private groups”, can be more sensitive to revenue considerations for clinical practice. National trends in physician employment show increasing hospital or health system ownership of physician groups; however consistent with the challenges cited by our rural hospital, rural hospitals were less likely than urban hospitals to be affiliated with a broader health care system [22].

Moniz and colleagues identified three “Essential conditions for success”: 1) Effective implementation champions 2) Enabling financial environment 3) Hospital administrator engagement”[4]. Passage of Medicaid coverage in Pennsylvania was necessary for expansion of IPLARC but not sufficient for successful implementation nor sustainability in Pennsylvania despite seemingly fulfilling the “essential condition” of “enabling financial environment.” Hospitals continued to cite reimbursement concerns as a barrier to provision of IPLARC given inconsistent and unpredictable coverage from commercial insurers. Participants cited an ironic “reverse inequity” of being able to offer the service to Medicaid patients but not to commercially insured patients. This is concerning in both directions, as those with Medicaid may feel coerced by being offered LARC that are not being offered to their commercially insured counterparts.

Our “real world” examination of IPLARC implementation also revealed that the PAPQC was a significant motivator and support resource for hospitals to offer IPLARC implementation. PQCs offer programs that are data driven from the state Maternal Mortality Review Committees and hospitals are incentivized to participate in projects. They provide actionable initiatives with toolkits, tailored educational and practical support, and metrics for success and sustainability. Multiple institutions in our study chose to implement IPLARC because it was a PAPQC initiative, and nearly all hospitals were aware of it as a resource. We suggest that state PQC initiatives may be a powerful driver for increased national access to IPLARC.

A strength of our study is our “real world” examination of IPLARC implementation outside of the academic setting. Our sample echoed the same types of facilitators and barriers to overall implementation as previous pilot studies, suggesting an increased generalizability of their findings. Our study has several important limitations. Our sample size is small, and skews towards hospitals that offer IPLARC provision. Our sample well represents community hospitals, but not rural hospitals by Center for Rural PA classifications, limiting our ability to draw conclusions based on rurality. We tried to enrich our sample with representatives from rural hospitals, but our attempts were not successful. Our interviewers were medical professionals and may have positively biased participants towards IPLARC. Finally, our results may not be generalizable to states without Medicaid coverage of IPLARC, or a PQC- two defining characteristics of the environment in Pennsylvania.

In conclusion, continued work is needed with the goal of universal access to IPLARC for all birthing people. Medicaid coverage alone is insufficient, and commercial payers must cover IPLARC to incentivize hospitals to provide this service, thereby addressing a serious “reverse inequity” in access to IPLARC and critical postpartum healthcare. Moments of change in hospital ownership, especially acquisition by a larger network, may be a prime opportunity to implement IPLARC at a smaller hospital by taking advantage of protocols, workflows and administrative support offered by the primary network hospital. Finally, state PQCs are an effective resource for hospitals, and we encourage them to champion IPLARC initiatives as a critical tool to combat maternal and neonatal morbidity and mortality.

Implications:

Medicaid coverage of IPLARC was a necessary facilitator but not sufficient for all PA hospitals to implement this care. Internal support from larger hospital systems via buyouts/mergers and external support programs (state Perinatal Quality Collaboratives) may play a larger role in implementation at smaller, rural, or non-academic hospitals.