EXECUTIVE SUMMARY

Data from a recent study indicate allowing teens the option to obtain a long-acting reversible contraceptive (LARC) on the same day as their clinic visit could lead to significant cost savings.

• In comparison to the return-visit strategy, same-day LARC was associated with an unintended pregnancy rate of 14% vs. 48%.

• Abortion rates were 4% for same-day insertions, compared to 14% associated with subsequent visits.

• Analysis findings indicate that same-day LARC placement was associated with lower overall costs compared with placement at a subsequent visit.


When it comes to use of long-acting reversible contraception (LARC) in adolescents, the consensus among professional organizations is clear: Intrauterine devices (IUDs) and the contraceptive implant should be offered routinely as safe and effective birth control options.1 The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists both endorse the use of LARC, including IUDs, for teens, and the U.S. Medical Eligibility Criteria for Contraceptive Use ranks use of the IUD in adolescents as Category 2 (a condition for which the advantages of using the method generally outweigh the theoretical or proven risks).2-4

Both the IUD and the implant can be inserted at any time in the menstrual cycle, as long as pregnancy can be reasonably excluded, according to the U.S. Selected Practice Recommendations for Contraceptive Use.5 However, many clinics frequently require two visits to receive LARC methods, for reasons such as staffing/training issues and the cost of stocking the devices.

For teens, the delay in receiving IUDs and implants can result in missed protection against pregnancy. Research indicates that when LARC is not offered on the same day, more than half of women fail to return for the second visit for LARC placement.6

Data Back Same-Day Insertion

Data from a recent study indicate allowing teens the option to obtain a LARC on the same day as their clinic visit could lead to significant cost savings.7

Research has demonstrated that LARC is “highly effective” at preventing unintended pregnancy, says study co-author Brownsyne Tucker Edmonds, MD, MPH, MS, associate professor of obstetrics and gynecology and pediatrics at the Indiana University School of Medicine. Unintended pregnancy is associated with poor pregnancy outcomes, such as premature birth, which is a leading cause of infant mortality, Edmonds said in a statement.8 “Seeing as unintended pregnancy, premature birth, and infant mortality disproportionately impact women and infants of color and low-income populations, it stands to reason that by improving access to same-day LARC, Medicaid could not only cut costs, but could potentially also improve health disparities related to prematurity and infant mortality,” Edmonds noted.

Researchers analyzed Indiana Medicaid’s cost savings associated with providing teens same-day LARC insertion. Using data from August 2017 through August 2018, researchers developed a cost model to examine the anticipated outcome of providing LARC at the first visit compared with requiring a second visit for placement. Factors including costs and probabilities of clinic visits, devices, device insertions and removals, unintended pregnancy, and births, also were incorporated into the model.

“We thought about the typical young woman seeking contraception and drew a branching tree representing all of the things that might happen if she could or could not get it that day,” explained co-author Stephen Downs, MD, MS, Indiana University School of Medicine professor of pediatrics.8

Research has determined the potential outcomes, and medical claims demonstrate the potential cost, said Downs. By developing the model, the researchers could compare the average expected cost if one or two visits are required.

Analysis findings indicate that same-day LARC placement was associated with lower overall costs compared to placement at a subsequent visit ($2,016 per patient vs. $4,133 per patient over one year). Compared to the return-visit strategy, same-day LARC was associated with an unintended pregnancy rate of 14% vs. 48%. Abortion rates were 4% for same-day insertions, compared to 14% associated with subsequent visits.7

What Are the Next Steps?

Based on their analysis, the researchers offered four action steps for state Medicaid officials:

First, officials should offer bonus payments for clinicians to make same-day contraceptive access the most attractive payment option. These payments would dissipate the reimbursement-to-cost differential that leads to the two-visit strategy.

Second, by creating a single, uniform reimbursement structure, some of the procedural delays that occur when a device has to be ordered for an individual patient may be decreased.

Third, by moving toward purchasing LARC devices in bulk and distributing devices upfront to clinics, facilities could move toward same-day placement.

Finally, Medicaid officials should develop a policy whereby LARC devices that were ordered for a specific patient but were ultimately unused could be used for another patient.

“Access matters, and any barrier to access means that fewer people will actually get to that finish line,” said co-author Tracey Wilkinson, MD, MPH, Indiana University School of Medicine assistant professor of pediatrics. “When you have people who desire contraception not being able to access it, the outcomes of all our communities are less than ideal.”8

Remove the Barriers

In working with a LARC program, it is important to acknowledge that the high cost is a primary barrier for many women. The Colorado Family Planning Initiative (CFPI), which has had success in expanding access to long-acting methods, suggested the following ways to address cost barriers:

  • Put LARC devices on the same sliding fee scale as other contraceptive methods, and be sure that LARC removal is on the same sliding fee scale;
  • Double-check that all LARC methods are included in state Medicaid benefits and receive adequate reimbursement;
  • Ensure all LARC methods are included in private insurance benefits.

CFPI suggests that facilities partner with 340B health centers to ensure lower price devices. Look for federal funding sources, as well as state and county dollars, to fund LARC costs, and seek gifts, grants, and donations to supplement programs. (Visit the CFPI website, www.larc4co.com, to get further tips and information on building a successful LARC program.)

REFERENCES

  1. Committee on Practice Bulletins-Gynecology, Long-Acting Reversible Contraception Work Group. Practice bulletin 186: Long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol 2017;130:e251-e269.
  2. ACOG committee opinion no. 735 summary: Adolescents and long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol 2018;131:947-948.
  3. American Academy of Pediatrics. Contraception for adolescents. Pediatrics 2014;134:e1244-e1256.
  4. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. medical eligibility criteria for contraceptive use, 2016. MMWR Recomm Rep 2016;65:1-103.
  5. Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. selected practice recommendations for contraceptive use, 2016. MMWR Recomm Rep 2016;65:1-66.
  6. Bergin A, Tristan S, Terplan M, et al. A missed opportunity for care: Two-visit IUD insertion protocols inhibit placement. Contraception 2012;86:694-697.
  7. Wilkinson TA, Downs SM, Tucker Edmonds B. Cost minimization analysis of same-day long-acting reversible contraception for adolescents. JAMA Netw Open 2019;doi:10.1001/jamanetworkopen.2019.11063.
  8. Indiana University School of Medicine. Study shows cost savings from same-day long-acting reversible contraception. Sept. 11, 2019. Available at: https://bit.ly/35B48h2.