Michelle Moniz: Q&A on coverage for immediate postpartum long-acting reversible contraception

But despite evidence that this service is associated with excellent outcomes for patients, improved population health and decreased healthcare costs, in practice it remains rarely available.

Michelle Moniz, M.D., M.Sc., assistant professor of obstetrics and gynecology, discusses what the evidence shows about the potential benefits of making immediate postpartum LARC more accessible to interested women, and the policy changes needed to make that happen.

What makes the immediate postpartum period an ideal opportunity for women considering longer-term contraception options? 

We know that LARC methods are highly effective and generally safe for most women, even those who have chronic medical conditions like hypertension or diabetes who may not be the best candidates for other types of contraception. Immediate provision of LARC methods during the hospital delivery stay is not only safe and effective, but can circumvent many of the potential barriers women face in accessing LARC methods postpartum.

The standard practice in the U.S. has been to have postpartum women wait and return to an outpatient office setting to receive one of these devices. Yet 40 percent of women never receive outpatient postpartum care, often due to challenges getting transportation, childcare, or time off from work. And even when women do return for LARC device placement, women may have already conceived.

Insurance coverage can also be an issue. Women who gain eligibility for Medicaid due to pregnancy often lose that coverage at 60 days postpartum and may no longer be able to afford LARC placement. Nearly half of all women, both publicly and privately insured, go through a period of uninsurance in the six months following delivery.

Many women like having the option to get one of these devices placed in the same procedure as their delivery, and under the same pain control they may be using for their delivery, rather than having a separate, sometimes painful procedure later in an office setting. And although we generally recommend that women wait to resume intercourse until they're seen at their postpartum checkup, not all women choose to wait, putting them at risk for unintended pregnancy. Providing these devices immediately after childbirth lets women turn on their birth control right away.

Of course, contraception is a preference-sensitive, individualized decision; LARC is not the right method for every woman, and even among women who want a LARC device, inpatient insertion may not be what they prefer. One potential downside to immediate postpartum IUD placement, for example, is that these devices are more likely to fall out than when we place an IUD later in the office. This or other factors may lead some women to choose IUD placement in the office.  Other women may want a totally different method of contraception.  Ultimately, the goal is to help each woman make an individualized decision. Immediate postpartum LARC access is just one more option to help women meet their reproductive life goals.

What are the guidelines for contraceptive care around childbirth?

The American College of Obstetricians and Gynecologists (ACOG), the American College of Nurse Midwives (ACNM), and the American Academy of Family physicians all support immediate postpartum LARC access as a best practice. National guidelines state that all women should be counseled about contraceptive options as part of their routine prenatal care. By the time each woman delivers, ideally, she and her provider would have engaged in shared decision-making process to come up with a plan for what her contraceptive method, if anything, is going to be. They should talk about whether she wants to be pregnant again in the next one to two years, and if not, review her options for what best meets her preferences, values, and needs.

Additionally, ACOG recommends that all hospitals that provide childbirth services should offer immediate postpartum LARC to interested, eligible women. Finally, when women want a LARC device in the outpatient setting, they should be offered same-day access at the routine postpartum visit.

Is there demand for these options from patients that’s not being met?

We know that the majority of pregnant women do not want to be pregnant again, right away. And from cohort studies we know that up to 40 percent of women are interested in using a LARC device. Yet only about 6 percent of postpartum women are using a LARC method at three months postpartum, compared to women who are not postpartum, about 12 percent of whom are using a LARC device. So, the fact that LARC use among postpartum women is much lower than the rate in the general population of women in the U.S., and much, much lower than the reported preferences for LARC among pregnant women, suggests that there's an access problem. Our research team has been talking with hospitals that have overcome challenges in making this service available. And at many of those sites as many as 25 percent of women are going home with a LARC device after their delivery. So, there's clearly demand.

Why is immediate postpartum LARC not routinely offered at most U.S. hospitals? 

Despite patient demand and guidelines from our major national organizations, most maternity hospitals nationally still do not offer immediate postpartum LARC care.

One reason is that offering inpatient LARC services is a heavy lift for hospitals.  It requires collaboration with pharmacy staff, billing staff, and clinicians. Hospitals have to get LARC methods on formulary, stock the devices on Labor & Delivery units, ensure that all staff are trained in immediate postpartum LARC insertion, and develop patient-centered processes for counseling about this option. It is a major undertaking for a hospital.

Another reason is that most private insurers and Medicaid programs historically have not provided specific reimbursement for LARC services in the inpatient setting, whereas they generally do provide reimbursement in the outpatient setting. Currently, most health insurance plans pay a bundled rate for all services provided during a labor and delivery admission. Typically, the LARC device and the placement procedure, which are covered in an outpatient clinic visit by most public and private insurers, are not reimbursed in addition to this global fee for delivery if placed immediately postpartum in the hospital. Hospitals have the potential to lose a lot of money if they start providing this care on the inpatient side where they don't get paid, and that has been a really big financial disincentive.

How have reimbursement policies changed in recent years, and how has implementation been going in those states where it's a newly covered option?

The research clearly shows that immediate postpartum LARC improves health outcomes while reducing healthcare expenditures. Unbundling payment for immediate postpartum insertion of LARC from other inpatient services is a great opportunity for payers to incentivize high-value care, and multiple studies demonstrate the cost-effectiveness of this approach. To date, 37 states have implemented changes to their Medicaid policies to reimburse immediate postpartum LARC separately from the global fee for delivery. This is a major step towards increasing LARC access for postpartum women, and hopefully other payers will follow suit.

Importantly, reimbursement alone will not be sufficient to meaningfully guarantee access for women. Hospitals may need technical assistance as they implement this new care service. Hospitals have to manage supply chain and revenue cycle challenges. Hospitals have to train all their providers in how to offer this care in a safe, effective, ethical, patient-centered way. Changing the way billing mechanisms work and processing claims for reimbursement around this service can be challenging. And, ideally, women are receiving counseling in the outpatient setting, and those preferences are being communicated to the inpatient providers, while what happens in labor and delivery is also being communicated to the outpatient postpartum care team – all of this takes a tremendous amount of coordination.

So even in states that have implemented changes to Medicaid reimbursement policies for immediate postpartum LARC, not all of their hospitals have adopted the services because of these challenges.

What’s going on in Michigan?

Beginning in October 2018, Michigan Medicaid began paying for immediate postpartum LARC outside the global fee. That's a really exciting opportunity for the 80+ maternity hospitals in Michigan to offer this care.

I’m partnering with some of our colleagues who are quality improvement experts in the state with Medicaid, with other payer groups, with our Hospital Association, and many other stakeholders to develop a robust plan for implementing this care across our state. We're hoping to do this, thoroughly and effectively, to make sure that women have access to this service wherever they present for their maternity care in our state.

At Michigan Medicine, we currently offer immediate postpartum LARC, and we've worked very hard over the past year to make sure it’s available universally to anyone who wants it, regardless of her insurance status and any other considerations other than her medical conditions and her preferences.  We are thrilled that women interested in immediate postpartum LARC can come to Michigan Medicine for childbirth, knowing that this option is available to them here.

What can be done to help overcome some of the remaining barriers to implementing this service?

Number one, we need to continue to build an enabling reimbursement landscape. Hospitals have to be reassured that they will, in fact, be adequately reimbursed for the care they're providing. We need to continue to strive for value-based insurance design in Medicaid agencies and commercial payers. This means providing reimbursement for high-value services, like immediate postpartum LARC, that are safe and evidence-based, and that are clearly linked to better outcomes and can lower healthcare costs overall.

We also need to help hospitals implement this care. Our team is currently working on developing tools that will make it easier for hospitals to implement this care. And some of our colleagues on the public health side are working to help state-level policymakers help facilitate implementation. It really takes a lot of coordination across different stakeholders to help roll out these services.

And finally, my hope would be that women would feel empowered to ask for this service. It is something that national guidelines recommend should be widely available. We now have this enabling reimbursement landscape. And I think women can really help motivate their clinicians to make this more widely available by voicing their preference for this service. Maternity care providers care very deeply about empowering women and helping them meet their reproductive life goals. And so women expressing a preference for this is a really powerful motivator for hospitals to start to undertake the hard work to make this available to the patients they care for.

For more information, read Dr. Moniz's brief on the topic of immediate postpartum LARC.