July | August 2017







States Successful at Reducing Unintended Pregnancies

By Debra Miller, CSG health policy director
Two years ago, Colorado reported success in dramatically reducing the state’s teen birth and abortion rates by 48 percent from 2009 to 2014 through a privately funded initiative that provided long-acting reversible contraception, known as LARCs.
LARCs—intrauterine devices, or IUDs, and subdermal contraceptive implants—are highly effective forms of birth control, with a pregnancy rate of less than 1 percent within the first year according to the Centers for Disease Control and Prevention. For comparison, oral contraceptive pills have a pregnancy rate of 9 percent and male condoms have a pregnancy rate of 18 percent in the first year. The LARC devices are effective for three to 10 years.
In the last days of budget negotiation in Colorado in early April, legislators approved $2.5 million in state funding to provide LARCs to low-income women.
A five-year, $25 million grant from the Susan Thompson Buffett Foundation for a pilot program ended in 2014. A measure to appropriate public funds in the 2015 legislature failed and private contributions were cobbled together to continue LARC funding.
“There were two primary reasons the 2015 funding measure failed,” said Colorado Rep. Susan Lontine. “Some argued that funding was no longer needed, that women could access services in other ways through the Affordable Care Act. For others, LARCs are seen as abortifacients, especially IUDs.”
“What changed from 2015 to 2016,” Lontine said, “was the growing acceptance that this is good public policy. It will save social services dollars in the long run.”
Rep. Tracy Kraft-Tharp said she thinks data from the five-year pilot was persuasive and it hit home for many of her colleagues as they learned more.  According to Kraft-Tharp, Colorado had one of the highest rates of teen pregnancy in the nation before the LARC initiative. The drastic decrease was impressive.
“While the idea of kids and birth control isn’t ideal for some, we have an opportunity to make a huge difference with LARC,” she said.
South Carolina, as part of a larger birth outcomes initiative beginning in 2011, was the first state to develop and implement a Medicaid payment policy to eliminate financial disincentives and to increase LARC placements for low-income women and at-risk adolescents.
The state’s efforts are highlighted in an April 2016 informational bulletin from the federal Center for Medicaid and CHIP Services.
South Carolina has addressed LARC access barriers in both inpatient and outpatient health settings. Policy changes include providing reimbursement of LARC insertion immediately after the birth of a child outside of the bundled fee—called a DRG, or diagnosis-related-group—for an inpatient birth and full reimbursement of the cost of the LARC device. Without adding an additional fee for the LARC insertion, there is no incentive for the provider to offer this contraceptive method. To streamline the internal process for hospitals and clinicians, the state also eliminated prior-authorization or step-therapy requirements. Prior-authorization means securing approval in advance—usually by phone—of a certain treatment or medication. Step-therapy may require the use of less expensive, often generic, products, before stepping up to brand-name or more expensive treatment. These cost-saving practices by the health insurance industry can be time consuming and expensive for health care providers.
South Carolina closely monitored the implementation of the policy changes. After the first year, the state learned that hospitals were not receiving full payment for LARC-associated expenses. The state worked with hospitals to ensure they understood billing procedures and captured all expenses eligible for reimbursement.
In the outpatient setting, South Carolina’s Medicaid program worked to ease the LARC process as well. The device is shipped directly to the outpatient clinician and billed through the pharmacy benefit so the clinician does not incur the up-front cost of the device pending reimbursement. The clinician has 30 days to insert the LARC and bill for the insertion fee or to return the unopened device to the state’s Medicaid specialty pharmacy.
Initial data show that the rate of voluntary election of inpatient insertion of LARC devices increased from none to 16 percent in the first two years. Between 2013 and 2015, South Carolina has seen a doubling of inpatient LARC utilization immediately following birth.
The April 2016 informational bulletin highlights the 12 additional states that have developed policies to remove barriers to the utilization of LARC methods for Medicaid-eligible women.
Colorado is one of the 13 states making full use of Medicaid funds for LARC. As the LARC pilot program proved its effectiveness, Colorado changed Medicaid policies in 2013 to fully reimburse hospitals for post-delivery LARC insertion and to reimburse rural health centers for outpatient insertion.
“After the delivery of a young mother’s first baby, providing highly effective contraception can make a big difference in making life better and opening opportunities for the parents and the infant,” Kraft-Tharp said.
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