Medicaid payments for immediate postpartum LARC

Since 2012, when South Carolina's Medicaid program became the first state Medicaid program to separate payment for the immediate postpartum placement of long-acting reversible contraception (LARC) from global maternity payment, a significantly greater number of mothers are using LARC, especially among adolescents.

“For adults, this increase was accompanied by a decrease in tubal ligation, so the policy did not actually increase overall use of the most effective methods of contraception, like tubal ligation, intrauterine devices (IUDs) and implants,” said Maria Steenland, SD, a health scientist and research assistant professor of maternal and reproductive health policy at Brown University in Providence, Rhode Island. “However, for adolescents, the policy increased overall use of the most effective methods of contraception.”

Steenland is principal investigator of a study of LARC use in South Carolina, before and after the policy change, published in the journal Health Affairs.

“As recently as about 10 years ago, there were a lot of policy-related barriers to LARC access in the United States, and relatively few women used LARC methods,” Steenland told Contemporary OB/GYNÒ. “For immediate postpartum LARC, lack of separate payment was considered to be a major barrier, so understanding how removal of reimbursement-related barriers to immediate postpartum LARC provision affects the availability of these methods is an important policy question.”

The authors obtained all Medicaid claims data from South Carolina for inpatient, outpatient and pharmacy services from 2010 to 2014. For each childbirth, they measured the method of postpartum contraception.

Before the start of the policy change, 59% of births were followed by no most effective or moderately effective method of contraception in the 8 weeks after delivery.

Short-acting methods were the most common postpartum method choice, embraced by roughly 22% of mothers, followed by 13% sterilization.

Although 7% of births were followed by a postpartum outpatient LARC method, immediate use of this method was adopted by less than 1% of mothers.

Furthermore, postpartum LARC placement was concentrated in only five facilities in South Carolina. Among the 42 facilities conducting deliveries in the state, 57% had no patients with immediate postpartum LARC insertions after the policy change, and an additional 31% provided immediate postpartum LARC after fewer than 1% of births.

The remaining facilities offered an immediate postpartum LARC to between 1% and 20% of women.

“Before the study, I had not thought very much about the counterfactual for women who adopt a LARC,” Steenland said. “I had assumed that an increase in postpartum LARC adoption would lead to an increase in use of highly effective methods and a decrease in short birth intervals. But the effect of an increase in immediate postpartum LARC on use of the most effective methods depends on the type of method that women would have used without the policy.”

Steenland noted the motivation for immediate postpartum LARC payment should be to expand patient choice rather than reduce pregnancy and health system costs. “Ultimately, this is a service that Medicaid pays for in outpatient settings, and if offering the service before leaving the hospital better meets some patient's needs, then it makes sense to make this service available,” she said.

Incomplete payments from Medicaid, such as reimbursement for some but not all of the immediate postpartum LARC provided, is a major concern of providers, according to Steenland. “Whether this results from hospital billing errors or Medicaid payment practices, the consistency of this finding indicates that earlier investment in creating and disseminating clear billing guidelines and making sure that the billing system can accommodate these changes is critical,” she said.

Because the upfront cost of purchasing LARCs is high, “any doubt about prompt and complete reimbursement could make hospitals reluctant to start to provide this service,” Steenland said.

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Steenland reports no relevant financial disclosures.

Steenland MW, Pace LE, Sinaiko AD, et al. Medicaid payments for immediate postpartum long-acting reversible contraception: evidence from South Carolina. Health Aff. 2021 Feb;40(2):334-342.

doi:10.1377/hlthaff.2020.00254