Long-Acting Reversible Contraception in Medicaid: Where Do We Go From Here?

The Medicaid program funds more than 75% of public family planning expenditures and provides care to nearly 20 million individuals child-bearing age (Hasstedt et al., 2017Hasstedt K. Sonfield A. Gold R. Public funding for abortion services, FY 1980–2015. Guttmacher Institute, 2017www.guttmacher.org/report/public-funding-family-planning-abortion-services-fy-1980-2015Google Scholar). has will continue play a fundamental role in ensuring that all the United States, regardless income, can access services. Currently, 40 states contract with managed organizations (MMCOs) provide contraception enrollees (Medicaid.gov, 2020Medicaid.govMedicaid Managed Care.www.medicaid.gov/medicaid/quality-of-care/medicaid-managed-care-quality/index.htmlDate: 2020Google MMCOs are integral program's ability Compared traditional fee-for-service models, frequently able innovate launch context-specific initiatives (Rosenzweig 2017Rosenzweig C. Sobel L. Salganicoff Moore J. Gray provision Henry Kaiser Family Foundation, 2017http://files.kff.org/attachment/Report-Medicaid-Managed-Care-and-the-Provision-of-Family-Planning-ServicesGoogle Long-acting reversible (LARC) comes two forms, intrauterine device single-rod contraceptive implant. LARC been longtime focus is heralded its high efficacy ease use both patient provider (ACOG Contraceptive Working Group, 2015ACOG GroupIncreasing implants devices reduce unintended pregnancy.www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2015/10/increasing-access-to-contraceptive-implants-and-intrauterine-devices-to-reduce-unintended-pregnancyDate: 2015Google By nature being costly requires trained insertion removal, poses unique challenges those enrolled compared commercially insured (Institute Innovation, 2020Institute InnovationAdvancing person-centered among population.2020www.medicaidinnovation.org/_images/content/2020-IMI-Advancing_Person-Centered_LARC_Access_in_Medicaid-Report.pdfGoogle However, since Center CHIP Services launched maternal health initiative 2014, multiple state agencies have implemented policies programs aimed at improving (Wachino, 2016Wachino V. State payment approaches improve long-acting contraception. Medicare Services, 2016www.medicaid.gov/sites/default/files/Federal-Policy-Guidance/Downloads/CIB040816.pdfGoogle There still long road ahead ensure LARC, along other forms contraception, equitably available Medicaid. COVID-19 pandemic highlighted enduring ongoing reckoning about racism States underscored importance care. This commentary describes barriers prevent outlines opportunities stakeholders consider as looks ahead. Immediate postpartum refers an or implant immediately after childbirth before hospital discharge Committee on Obstetric Practice, 2016ACOG PracticeCommittee opinion 670: contraception.2016www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2016/08/immediate-postpartum-long-acting-reversible-contraceptionGoogle placement also occur visit outpatient setting. 40% birthing do not receive because problems transportation, childcare, employment (White 2015White Teal S. Potter Contraception delivery short interpregnancy intervals women States.Obstetrics Gynecology. 2015; 125: 1471-1477Crossref PubMed Scopus (85) Google In Medicaid, immediate may be especially crucial many people lose coverage 60 days unable afford without any form insurance (Wilkinson 2019Wilkinson B. Ascha M. Verbus E. Montague Morris Mercer Arora receipt interval contraception.Contraception. 2019; 99: 32-35Abstract Full Text PDF (8) Over past decade, altered their reimbursement access. Traditionally, covered within global maternity pays Forty-two District Columbia now specific device, procedure, South Carolina, quantitative analyses showed modest increases population carve-out policy was enacted 2012 (Liberty 2020Liberty Yee Darney Lopez-Defede Rodriguez Coverage improved birth at-risk populations.American Journal Obstetrics & 2020; 222: 886e1-886e9Abstract (5) Scholar; Steenland 2019Steenland Pace Sinaiko Cohen Association between Carolina Medicaid’s change intervals.Journal American Medical Association. 322: 76-78Crossref (14) finding suggests important first step creating viable option Policy alone far from definitive solution. Implementing challenging often concentrated efforts players Hospital systems reported difficulty configuring billing, inaccurate coding, poor communication relevant parties (Brown 2020Brown Greenfield Rapkin Special report: Florida.American S906-S909Abstract (4) Harper 2020Harper Loper Louison Morse Stage-based implementation using reproductive justice framework.American S398-S905Google Lacy 2020Lacy Baird Scott T. Barker Zite N. Statewide quality improvement implement contraception.American S910e1-S910e8Abstract Hospitals were successful implementing had establish partnerships addition working directly providers, pharmacists, billing coding departments, administration A recent study took, average, 200 hours dedicated staff time would cost $10,000 $20,000. These estimates include costs required secure stock which $1,000 dollars per (Ling 2020Ling Levi Harrington Rivas Dalton Moniz care: multisite economic analysis resource recommended programmes.BMJ Quality Safety. ([Epub print] https://doi.org/10.1136/bmjqs-2020-011111)Crossref (2) Wachino, If only made intense financial human investments, safety-net hospitals low-income rural areas less likely offer these services (Palm 2020Palm H. Degnan Biefield Reese Espey Hofler An New Mexico.American S911e1-S911e7Abstract (7) gap increase disparities outcomes. opportunity learn replicate initiatives. nonprofit convened 170 clinics, payers, clinicians, community address system-wide service challenges, including For successfully reimburse MMCOs, administration, staff, pharmacy clinicians come together multiday workshop To mitigate expense stocking MMCO Washington, DC, partnered private sector create automated storage dispensing unit devices. Stocked units provided free charge clinics bill separately procedure. currently used but potential adapted inpatient setting Moving forward, diverse settings needed. includes hospitals, freestanding centers choose outside need meaningfully engaged throughout process. yet adopted should encouraged so, knowledge this Historically, consistently favored rights autonomy typically abled White bodies over groups. Government-sponsored sterilization forced control against Black, Indigenous, People Color into twenty-first century (Thorburn Bogart, 2005Thorburn Bogart Conspiracy beliefs control: Barriers pregnancy prevention African Americans age.Health Education Behavior. 2005; 32: 474-487Crossref (95) Recent reports hysterectomies Immigration Customs Enforcement detention no exception (Capelouto, 2020Capelouto Whistleblower Georgia claims number ICE facility.2020www.npr.org/2020/09/16/913448209/whistleblower-in-georgia-claims-high-number-of-hysterectomies-at-ice-facilityGoogle confront history commit addressing racism. Racism seen counseling. Research found that, women, Hispanic non-Hispanic Black feel pressured by another (Yee Simon, 2011Yee L.M. Simon Perceptions coercion, discrimination negative experiences counseling minority women.Journal Health Care Poor Underserved. 2011; 22: 1387-1400Crossref (60) practice particularly problematic period where, owing inadequate prenatal care, during shortly delivery. help providers comprehensively counsel patients Pennsylvania coalition women's champions community-based organizations. They in-network education Other approach support comprehensive Person-centered means discontinue method penalty (Strasser 2017Strasser Borkowski Couillard Allina Wood Access removal methods essential component high-quality care.Women’s Issues. 2017; 27: 253-255Abstract Qualitative research demonstrates experience significant anxiety when how removed if they coverage, common who (Mann 2019Mann Rogers P. Gomez Patients’ Carolina’s policy.Contraception. 100: 165-171Abstract (27) dedicate equal effort promoting removals insertions. interim better small changes racial disparities. instance, Tennessee Program (TennCare) reminds done whenever desired. danger losing TennCare information resources where status (Lacy Sexual choices influenced wide variety social, historical, political, factors. factors trauma, opportunities, education, lack food, housing, transportation (Holt 2020Holt Reed Crear-Perru Wulf Dehlendorf Beyond same-day access: framework advancing high-quality, equitable care.American 222 (S878.E1–S878.E6)PubMed Maness Buhi, 2016Maness Buhi Associations social determinants young people: systematic review published 25 years.Public Reports. 2016; 131: 86-99Crossref (17) permeates through (Centers Disease Control Prevention, 2020Centers PreventionSocial health: Know what affects health.www.cdc.gov/socialdeterminants/index.htmDate: As considers institutional systemic clinical realm understood. More intersection outcomes needed guide going forward. adolescent faces accessing well-positioned address. Adolescent-specific concerns fears breach confidentiality, inaccessible clinic hours, methods, misinformed inadequately teen issues (Daley, 2014Daley What influences adolescents’ decision-making? meta-ethnography.Journal Pediatric Nursing. 2014; 29: 614-632Abstract (15) Kavanaugh 2013Kavanaugh Jerman Ethier Moskosky Meeting needs teens adults: Youth-friendly U.S. facilities.Journal Adolescent Health. 2013; 52: 284-292Abstract (90) Paul 2020Paul Huysman Maddipati Madden Familiarity acceptability choice.American 884e1-884e9Abstract Addressing confidentiality teen-friendly options relatively straightforward solutions. 23 explicit allowing minors consent parent guardian consent. unintentionally broken explanation benefits sent adolescent's home (Guttmacher 2020Guttmacher InstituteMinors’ services.https://guttmacher.org/state-policy/explore/minors-access-contraceptive-servicesDate: Many requirement sensitive such planning, pregnancy-related sexually transmitted infections Those follow example while advocating expanded minor laws level. evaluate list, adolescents older individuals. this, school-based worked advocate teen-only Teens risk victims coercion (Vyas 2018Vyas Landry Masselink Mead Ku George Washington University Milken Institute School Health, Planning Community assessment DC Project (DCFPP). Area Women’s Foundation (WAWF), 2018https://media.thewomensfoundation.org/wp-content/uploads/2018/09/10202208/WAWF_Report_FamilyPlanning-Assessment_Final_Web.pdfGoogle Therefore, it trainings stage psychological development (Committee Adolescence, 2014Committee AdolescenceContraception adolescents.Pediatrics. 134: e1244-e1256Crossref (259) Establishing youth-centered youth-led serve enhance efforts. York partnering nonmedical established relationships community. Adolescents interested could then referred adolescent-oriented (Aligne 2020Aligne Phelps VanScott Korenes Greenberg Impact Rochester Initiative utilization (31–36): S890PubMed adults, report ambivalence—mixed feelings becoming pregnant (Higgins 2012Higgins Popkin Santelli Pregnancy ambivalence adults States.Perspectives Reproductive 2012; 44: 236-243Crossref (96) lower academic higher levels perceptions perceived greater opportunities. youth much (Minnis 2013Minnis Marchi Ralph Biggs Combellick Arons Braveman Limited socioeconomic Latina childbearing: qualitative structural affecting future expectations.Journal Immigrant Minority 15: 334Crossref (33) Vyas When designing adolescents, acknowledge stark impact Funders researchers alongside discussions given reevaluate planning. Providing way person centered remain key priority. agencies, employees, collaborate Collaboration programs, racism, tailor adolescents. Because meaningful collaboration, smaller players, investment, funders put forward new ways place voices forefront development. Collectively, proper make truly enrollees. Megan F. Fuerst, MD, MPH, Fellow Innovation. She recently received her medical degrees began ob/gyn residency Oregon Science University. health, policy. Karen George, FACOG, Women's Director Subcommittee Associate Professor OB/GYN Jennifer Moore, PhD, RN, FAAN, founding executive director Innovation Michigan. Her focuses mortality morbidity, access,