Health Policy$ense

Fix Pennsylvania's Medicaid Policy on IUDs

Tangled Reimbursement Rules Deny Women Long-Acting Reversible Contraception After Childbirth

Cross-posted with the Philadelphia Inquirer

Imagine a woman in labor who goes to the hospital with a delivery plan she made in consultation with her obstetrician: yes to antibiotics in labor; no to an epidural for pain control; yes to neonatal circumcision; and yes to having an intrauterine device (IUD) placed immediately after childbirth.

Along with contraceptive implants, IUDs are a form of long-acting, reversible contraception (LARC) that is safe, effective, and convenient, whether placed after childbirth or at any other point. And more and more, obstetricians are offering placement of IUDs and implants while women are admitted to the hospital for childbirth. These postpartum IUDs and implants are part of a menu of methods that women can use to space their pregnancies, with other options available at a six-week followup visit that, unfortunately, only about half of women are able to attend.

Despite the woman's wishes, she does not get the IUD she wanted. Due to the way insurers pay for long-acting methods, hospitals often don't have IUDs and implants readily available. Because most insurers pay a lump sum intended to cover all childbirth costs, hospitals are paid the same amount whether they offer contraception or not. Since IUDs and implants are expensive - up to $850 per device - there is a major disincentive even to stock them at hospitals.
LARC is the most effective way, short of a permanent surgery, to prevent an undesired pregnancy. New research shows that women who choose to start LARC immediately after childbirth and in a hospital setting are more likely to use these methods up to a year longer than other women - suggesting that those who choose this option know what they want.
Ironically, if that same woman, a Medicaid patient, were to sign out of the hospital against medical advice, walk to her outpatient clinic provider, and ask for the same IUD to be inserted that day, it would be covered by her insurance. Hospitals, on the other hand, can provide LARC to Medicaid patients immediately after birth only by using piecemeal, short-term grants or by taking a financial loss - which means that they rarely provide the service at all.
Eleven states, including Georgia, Louisiana, South Carolina, and New York, have corrected this arbitrary distinction, allowing hospitals to be reimbursed for LARC provided to Medicaid patients at the time of delivery.
A broad coalition of providers, advocates, and policy experts in Philadelphia and beyond is calling for the same change to be made in Pennsylvania. This call has recently been supported by a report from the Philadelphia Department of Public Health's Maternal Mortality Review Committee. The committee believes that the lack of easy access to effective contraception following pregnancy has been a contributing factor to Philadelphia's high rate of 27 maternal deaths for every 100,000 pregnancies. When reviewed, these deaths are often associated with rapid, repeated, and potentially unintended pregnancies.
Such issues are complicated, but one simple way to improve the health of mothers right now is for individual states to add a supplemental billing code to the childbirth reimbursement package offered through Medicaid.
By not taking this action, Pennsylvania is missing out on a solution that would help more than half of the women who deliver in our state get better access to the contraception they choose when they want it. Making LARC more available would also save money: A statewide postpartum LARC program could save $2.94 for every dollar spent by the Medicaid program.
The cost of an unintended pregnancy soon after birth is high for everyone. Consider the woman we mentioned at the beginning of this article. There is no IUD available the day her baby is delivered. And she does not make it to her six-week postpartum visit. (With no child care or extra hands to help, she stays at home with her colicky newborn instead.) A key opportunity missed, the woman is pregnant again a year later. Unlike the previous one, this pregnancy was not planned.
This woman's story holds a lesson Pennsylvania's obstetricians already know well:
Most women with complicated lives know themselves best and may be ready to act immediately postpartum to protect their health and their families.
It is time for Pennsylvania's Medicaid program to support such foresight. Policymakers should act immediately to make this simple adjustment to state Medicaid policy now.

Pooja Mehta, MD is an LDI Fellow, Robert Wood Johnson clinical scholar and obstetrician-gynecologist at the University of Pennsylvania and the Department of Veterans Affairs. 

Melissa Weiler Gerber is president and CEO of Access Matters.