July | August 2017







States Move to Expand Access to Long-Acting Reversible Contraception

By Lisa McKinney, CSG communications associate
To reduce unintended pregnancies and the costs associated with them, some states are implementing policies to increase the use of long-acting reversible contraception, or LARCs, among Medicaid enrollees. LARCs—such as intrauterine devices and subdermal contraceptive implants—are highly effective forms of birth control, with pregnancy rates of less than 1 percent within the first year, according to a Washington University School of Medicine study. Experts and policymakers discussed successful initiatives to expand LARC use during a recent CSG eCademy webcast, Adopting Medicaid Policies to Encourage Long-Acting Reversible Contraception.
South Carolina found success reducing unintended pregnancies and Medicaid costs through the South Carolina Birth Outcomes Initiative, which focuses on improving outcomes for newborns not only in the Medicaid program but throughout the state’s population, including preventing unintended pregnancies through enhanced Medicaid coverage for postpartum birth control. The initiative was launched in July 2011 and is housed at the South Carolina Department of Health and Human Services.
“We were very fortunate with our previous director here to support a collaborative effort between not only Medicaid, but different stakeholders in the state, which includes Blue Cross Blue Shield, our largest private payer, and many others to address maternal and child health,” said Melanie “BZ” Giese, director of the South Carolina Birth Outcomes Initiative.
Medicaid covers 57 percent of all births in the state and 90 percent of teen births. Nearly all—90 percent—of Medicaid births are covered under five managed care organizations, or MCOs, in the state. In South Carolina, 50 percent of all pregnancies are unintended; however, only 11 percent of women use LARCs. Most women in the state—79 percent—who define their pregnancy as unintended had their births covered by Medicaid.
In most states, the Medicaid director has the authority to enhance coverage of LARCs, according to Giese. “When we started we were able to move this rapidly to change the provider manual and issue a Medicaid bulletin stating that we were going to update this policy,” she said.  
In 2012, South Carolina was the first state in the nation to pay outside of the diagnosis-related group, or DRG, for full reimbursement of a LARC device postpartum. LARC device insertion and removal costs are included in the MCO capitation rate and all five MCOs allow for inpatient, outpatient and specialty pharmacy dispensing directly to doctors for insertion, which is known as white-bagging.
Giese emphasized the importance of selling the benefits of inpatient LARC insertion, providing the device to new mothers while they are still receiving postpartum care in the hospital.  
“The reason for inpatient insertion is strictly convenience,” said Giese. “The mom delivers the baby and within 10 minutes she is onboard with protection for the future and she can go home and concentrate on the baby and the family and not have to worry about coming up with an unintended pregnancy. There is so much going on when a mom brings a baby home that often they just don’t get around to coming back to the postpartum visit, which is the normal time in the past that contraception has been discussed.”
About 55 percent of new mothers enrolled in Medicaid in South Carolina miss their six-week postpartum visit.
The policy initiative has saved $1.7 million from January 2012 to May 2016. It is important to note this is just the savings for births after inpatient LARC insertion and that LARC expansion outside of inpatient insertion could have a much larger impact, according to Giese. South Carolina’s model shows the first-year cost, including costs of unintended pregnancy, for LARC users was $596.66 versus $1,180.56 for oral contraceptive users.
Illinois also found success developing statewide Medicaid policy to support quality family planning and reproductive health services through the state’s Department of Healthcare and Family Services’ Illinois Family Planning Initiative.
“Illinois Medicaid pays for 52 percent of all births, covers 92 percent of all teen births in Illinois, and pays for a disproportionate share of non-normal births,” said Linda Wheal, maternal health program manager at the Illinois Department of Healthcare and Family Services. “We believe providing quality, comprehensive family-planning services is key to making the needle move on these outcomes.”
The state developed the Illinois Family Planning Action Plan, or IFPAP, to increase access to family planning services for women and men in the Medicaid program by providing comprehensive and continuous coverage to ensure that every pregnancy is a planned pregnancy. IFPAP’s recommendations included increasing reimbursement rates for LARC insertion and removal, allowing payment to providers for two services on same day when one is a LARC procedure and increasing the dispensing fee for effective contraceptives. They also developed a new policy for postpartum LARC insertion that unbundles payments, allowing providers to bill separately for the LARC insertion when they bill for the delivery.
Wheal said they arrived at these recommendations after intensive sessions with different stakeholders. “Engaging practicing clinicians is critical in order for them to identify policy gaps and payment and service barriers,” she said.  
IFPAP showed the value of its recommendations to the Department of Healthcare and Family Services by demonstrating a positive return on investment. “Often I get asked how we convinced the department to increase costs and pay for more services when our state is in such a dire budget crisis,” said Wheal. “My response has always been, ‘why would you not want to buy into something when you know you will get a significant return on investment?’”
The state also took an innovative approach to increasing access to LARCs by working with the pharmaceutical industry. Their goal was to provide devices at clinic sites without incurring high upfront costs so that an inventory would be available for same-day insertion. Pharmaceutical companies Bayer and Teva Pharmaceutical Industries agreed to participate in a pilot project.
“One company declined, but the two others developed systems that are still in the pilot testing phase,” said Wheal. “Basically these pharmaceutical companies provide inventory upfront without billing providers. Providers don’t get billed until they insert the device. Once inserted, they bill Medicaid and we pay them within 30 days and then the providers pay the pharmaceutical companies within the 90-day billing window from insertion.”
In July 2014, the Center for Medicaid and CHIP Services, or CMCS, launched a Maternal and Infant Health Initiative, or MIHI, in collaboration with states to increase access to effective methods of contraception in Medicaid and CHIP.
“While Medicaid programs are required to provide family planning benefits, program organization, delivery and financing are, as most of you know, very state specific,” said Lekisha Daniel-Robinson, a coordinator of the MIHI. “So our efforts on the initiative have been to maximize opportunities, to improve access and reach of patient-centered services.”
Their strategies mirror many of those taken by South Carolina and Illinois, including timely, patient-centered comprehensive coverage of the full range of contraceptives; increasing payment rates for contraceptive devices to ensure access to the range of methods available; reimbursement for immediate postpartum LARC by unbundling payments for LARC from payment for labor and delivery services; removing logistical barriers for supply management by addressing supply chain, stocking cost and disposal cost issues; and removing administrative barriers to access for LARC.
Daniel-Robinson said most of MIHI’s key strategies can be implemented within existing state authority. 
“The other area we are working on with states is on collecting data in a standardized way to evaluate the effect of policies but also to look for places that may need some additional help in terms of increasing access,” said Daniel-Robinson. The initiative is working with 13 states to use contraceptive care measures developed by the Office of Population Affairs and the Centers for Disease Control and Prevention to measure the success of their policies and look for additional opportunities for improving access.
The full webcast is available online in the CSG Knowledge Center at http://knowledgecenter.csg.org/kc/content/adopting-medicaid-policies-encourage-long-acting-reversible-contraception.