Immediate Postpartum Long-Acting Reversible Contraceptive Use Following State-Specific Changes in Hospital Medicaid Reimbursement

Abstract

ImportanceFacilitating access to the full range of contraceptive options is a health policy goal; however, inpatient provision of postpartum long-acting reversible contraceptive (LARC) methods has been limited due to lack of hospital reimbursement. Between March 2014 and January 2015, the Medicaid programs in 5 states began to reimburse hospitals for immediate postpartum LARC separately from the global maternity payment.ObjectiveTo examine the association between Medicaid policies and provision of immediate postpartum LARC, and to examine hospital characteristics associated with policy adoption.Design, Setting, and ParticipantsThis cross-sectional study used interrupted time series analysis. The setting was population-based in Georgia, Iowa, Maryland, New York, and Rhode Island. Participants included individuals who gave birth in these states between 2011 and 2017 (n = 3 097 188). Statistical analysis was performed from June 2021 to August 2022.ExposuresChildbirth after the start of Medicaid’s reimbursement policy.Main Outcomes and MeasuresImmediate postpartum LARC (outcome), teaching hospital, Catholic-owned or operated, obstetrical care level, and urban or rural location (hospital characteristics).ResultsThe study included a total of 1 521 491 births paid for by Medicaid and 1 575 697 paid for by a commercial payer between 2011 and 2017. Prior to Medicaid reimbursement changes, 489 389 of 726 805 births (67%) were to individuals between 18 and 29 years of age, 219 363 of 715 905 births (31%) were to non-Hispanic Black individuals, 227 639 of 715 905 births (32%) were to non-Hispanic White individuals, 155 298 of 715 905 births (22%) were to Hispanic individuals, and 113 605 of 715 905 births (16%) were to individuals from other non-Hispanic racial groups. Among Medicaid-paid births, the policies were associated with an increase in the rate of immediate postpartum LARC provision in all states, although results for Maryland were not consistent across sensitivity analyses. The change in trend ranged from a quarterly increase of 0.05 percentage points in Maryland (95% CI, 0.01-0.08 percentage points) and 0.05 percentage points in Iowa (95% CI, 0.00-0.11 percentage points) to 0.82 percentage points (95% CI, 0.73-0.91 percentage points) in Rhode Island. The policy was also associated with an increase in immediate postpartum LARC provision among commercially paid births in 4 of 5 states. After the policy, only 38 of 366 hospitals (10%) provided more than 1% of birthing people with immediate postpartum LARC. These adopting hospitals were less likely to be Catholic (0% [0 of 31] vs 17% [41 of 245]), less likely to be rural (10% [3 of 31] vs 33% [81 of 247]), more likely to have the highest level of obstetric care (71% [22 of 31] vs 29% [65 of 223]) and be teaching hospitals (87% [27 of 31] vs 43% [106 of 246]) compared with nonadopting hospitals.Conclusions and RelevanceThis cross-sectional study’s findings suggest that Medicaid policies that reimburse immediate postpartum LARC may increase access to this service; however, policy implementation has been uneven, resulting in unequal access.

Immediate Postpartum Long-Acting Reversible Contraception: An Effective and Underutilized Strategy

“…Factors associated with nonadoption of the policies included rural and Catholic hospitals. These findings highlight that the actualization of this policy across communities is low and uneven and that many birthing people continue to miss out on this key health strategy …”

“…Importantly, while these findings are substantial and encouraging, the analysis by Steenland et al 1 highlights ongoing barriers to full implementation of these policies. 1 Notably, while substantial improvements occurred, they were mainly driven by a small proportion of hospitals that implemented IPP-LARC; after the policy only 10% of the hospitals provided more than 1% of birthing people with IPP-LARC. Factors associated with being an adopter of IPP-LARC included hospitals that have the highest level of obstetric care and those that are teaching hospitals.…”

“…These findings highlight that the actualization of this policy across communities is low and uneven and that many birthing people continue to miss out on this key health strategy. 1 The association of high acuity obstetrical services and teaching hospitals as adopters is likely strongly correlated as many teaching hospitals offer higher level care. In a qualitative study examining facilitators and barriers to IPP-LARC implementation, 2 the authors found that the adopters were often at teaching hospitals and efforts were attributed to faculty stakeholders who may be fellowship trained in Complex Family Planning and are committed to ensuring access to this policy.…”

“…Initially, some state Medicaid agencies offered this option, but with a payment model that included coverage within the global fixed delivery reimbursement. This payment model led to ongoing barriers to implementing IPP-LARC given hospital reluctances to cover the high upfront costs of LARC devices …”

“…Since 2012, many state Medicaid agencies began providing separate reimbursement for inpatient LARC delivery. In their study, Steenland and colleagues set out to determine whether Medicaid payments for IPP-LARC have increased the availability and use of LARC across multiple states and hospital settings. Not surprisingly, they found such state funding was associated with increased LARC uptake among Medicaid recipients and, by proxy, for commercial insurance patients in states and specifically hospitals that offered IPP-LARC.…”