Study finds Medicaid billing policies boost postpartum LARC use

Use of long-acting reversible contraceptives (LARCs) immediately postpartum (IPP) is increased by Medicaid billing policies allowing for separate reimbursement of LARC from the global fee, according to a recent study in JAMA Health Forum.¹

Reproductive autonomy and health are supported by full and informed choices of contraceptive methods in the postpartum period, with postpartum contraception linked to reduced risks of maternal and infant morbidity. Postpartum contraception reduces short interpregnancy intervals and unintended pregnancy, which are linked to adverse maternal health.

The Office of Disease Prevention and Health Promotion has listed delays in initial prenatal care, reduced odds of breastfeeding, increased maternal depression risk, and increased violence risk as adverse outcomes of unintended pregnancy.² Children born from unintended pregnancy are also at increased risk of poor physical and mental health.

The risks of unintended pregnancy and short interpregnancy interval are increased among Medicaid patients, with postpartum contraception use falls beneath goals among this population.¹ While Medicaid beneficiaries can receive permanent and short-acting contraception, billing procedure prevent IPP LARC access.

In 2012, some billing policies have been changed to allow LARC costs to be separated from the obstetric global fee. However, there is little data about the impact of these policy changes.

Investigators conducted a cohort study to evaluation the impact of changes in Medicaid policy allowing separate billing for IPP LARC on LARC receival within 7 days of delivery and 60 days postpartum. Data about Medicaid pharmacy, inpatient, and other service claims and enrollment from 2016 to 2018 and from 2019 were included in the analysis.

The treatment group included states that implemented IPP LARC separate billing between January 2017 and October 2019, while the control group included states without the policy as of October 2019. Documents from the Medicaid and Children's Health Insurance Program were evaluated to determine policy implementation date.

State exclusion criteria included implementing IPP LARC separate billing before January 2017, falling outside the treatment and control group definitions, and having high concern or unusable data. Five waves of billing were identified: January 2017, July 2017, January 2018, July 2018, and October 2018.

Delivery encounters for postpartum Medicaid enrollees aged 18 to 44 years living in a treatment or control state were included in the analysis. An IPP LARC receipt was the primary outcome of the analysis, defined as an indicator for LARC insertion within 7 days postpartum.

Secondary outcomes included LARC receipt within 60 days, immediate postpartum permanent contraception receipt, and immediate most or moderately effective contraception receipt. Covariates included age, medical complexity, diabetes without chronic hypertension, depression, complicated hypertension, drug misuse, obesity, and chronic pulmonary disease.

There were 1,378,885 delivery encounters for 1,197,287 Medicaid enrollees included in the final analysis. Patients were aged a mean 27 years at delivery, and rates of obesity, chronic pulmonary disease, and hypertension were increased in states that implemented the IPP LARC policy.

IPP LARC rates remained relatively stable prior to policy implementation in most waves, with a baseline 60-day LARC use of 10.44% before implementation and 11.72% after the implementation. A mean increase of 0.74% was reported for IPP LARC receipt following policy implementation.

An association was identified between policy implementation and gradual rate increases based on monthly estimates. When stratifying by implementation wave, only waves 1, 3, and 5 displayed significant associations.

A 1.58% increase in the 60-day postpartum rate was reported from implementation of the IPP LARC billing policy, as well as a 0.92% increase for most or moderately effective contraception receipt. No changes in 7-day postpartum sterilization rates were identified.

These results indicated an increase in IPP LARC use among Medicaid recipients following implementation of a billing policy allowing separate reimbursement of LARC devices from the obstetric global fee. Investigators stated, “future research should center on who is using IPP LARC and why.”

Reference

1. Rodriguez MI, Meath THA, Watson K, Daly A, McConnell KJ, Kim H. Medicaid policy change and immediate postpartum long-acting reversible contraception. JAMA Health Forum. 2024;5(6):e241359. doi:10.1001/jamahealthforum.2024.1359
2. Healthy People 2030 goals: family planning. Office of Disease Prevention and Health Promotion. 2020. Accessed June 12, 2024. https://www.healthypeople.gov/2020/topics-objectives/topic/family-planning