Global Fee Prohibits Postpartum Provision of the Most Effective Reversible Contraceptives

Early postpartum access to highly effective reversible contraceptives (intrauterine contraceptives (IUCs) and the implant) and sterilization is key to helping women prevent unintended pregnancy.[1] Yet most current hospital reimbursement policies deny postpartum women access to IUCs and implants prior to hospital discharge. For women whose deliveries are covered by private insurance or Medicaid, hospitals receive a global fee based on the diagnosis-related group (DRG) for all delivery-related care. Postpartum sterilization is carved out by insurance companies and Medicaid as a procedure that may be billed separately from the global fee, which in turn means that hospitals are not financially driven to deny such procedures. In contrast, in most states, postpartum IUCs and implants are not carved out for separate reimbursement and the costs of the devices must be deducted from the DRG payment. Since the wholesale acquisition costs for IUCs and implants range from $600 to $775, covering those costs would be fiscally rash. Consequently, most hospitals do not permit postpartum placement of the most effective reversible methods, a policy that not only hinders women’s ability to space their pregnancies but also prohibits an important option for those who have completed childbearing but do not wish to be sterilized. Equally, for women who are covered by Medicaid and desire postpartum sterilization, the twin requirements of a minimum 30-day waiting period after signing the consent form and having that form present in the delivery room still inhibit access.[2] For these women, postpartum placement of IUCs and implants would be a valuable alternative. Although the Affordable Care Act (ACA) may go a long way towards expanding outpatient access to the most effective methods of contraception, it does not specifically facilitate inpatient access to IUC or the implant for new mothers prior to hospital discharge.

Placement of IUCs immediately after placental delivery or an implant before hospital discharge is attractive because motivation to use is high, timing is convenient for the woman and provider, and the woman is obviously known not to be pregnant. As Rodriguez and colleagues extensively document in their Commentary in this issue, postpartum placement of these products is also safe for the woman and there are no adverse effects on breastfeeding.[3] (We note, however, that in one study, women in whom the levonorgestrel IUC was placed immediately postpartum were more likely to discontinue breastfeeding than were mothers who delayed placement until 6–8 weeks postpartum.[4]) There is also good evidence of high continuation rates at 6 and 12 months following immediate IUC placement[5,6,7] and of a reduction in the likelihood of repeat pregnancy within 24 months following placement of implants prior to discharge.[8]

Perhaps the most compelling reason to provide highly effective reversible contraceptives to new mothers prior to hospital discharge is that women themselves want to use them but often face significant barriers to access. In their article in this issue, Potter and colleagues demonstrated substantial unmet demand for postpartum IUCs and implants. Thirty-four percent of women desired either an IUC or implant (a further 44% desired female or male sterilization), yet only 13% were using IUCs or the implants at 6 months postpartum. Among women who desired an IUC or implant and who wanted more children, 48% ended up using a method as or less effective than condoms at 6 months post-delivery.[9]

In addition to improving women’s health, a major advantage of facilitating postpartum placement of IUCs and implants is the potential to save money by preventing unintended births. The reason is that IUCs and implants are the most effective reversible contraceptives; they are in the top-tier effectiveness category [10] because they require no adherence on the part of the woman. Significant cost savings to the Colorado Medicaid program were demonstrated for adolescent mothers receiving postpartum implants: $0.78, $3.54 and $6.50 per dollar spent at 12, 24 and 36 months postpartum.[11] Likewise, immediate postpartum placement of IUCs in women covered by Emergency Medicaid (for undocumented immigrants and legal immigrants with less than five years of legal residence) in one Oregon hospital was estimated to save three dollars for every dollar spent.[12] That hospital lost money on women whose obstetrical care was covered by Emergency Medicaid, so in theory it might save money by preventing further such losses. However, in fact it would not save money by using its own funds to cover postpartum IUCs because too few of these women return to it for subsequent obstetrical care.

There are of course other obstacles to providing immediate postpartum IUDs and implants to women who are suitable candidates. Catholic hospitals, which provide one-sixth of hospital beds in the United States, do not allow placement of IUCs or implants for contraception. Other difficulties include ensuring an adequate stock of devices, the need for provider training, and the task of coordinating a sufficient volume of skilled providers to be available when required. Yet without the ability for hospitals to bill for postpartum placement separately from the global fee, there is no incentive for these issues to be addressed.

Separate billing for postpartum implants and IUCs for women covered by Medicaid is now permitted in ten states (Colorado, Georgia, Iowa, Louisiana, Mississippi, New Mexico, New York, Oklahoma, South Carolina, and Tennessee). No legislative action is needed, just regulatory changes and short-term investments.[3] If this progressive Medicaid policy is adopted in all other states, and should private insurance plans as well as Emergency Medicaid allow separate billing for postpartum IUCs and implants, women and their families will benefit from fewer unintended pregnancies, and health care dollars will be saved.