Payer considerations regarding unintended pregnancy is discussed by Maria Lopes, MD, MS, and Kevin Stephens Sr., MD, JD.
Neil Minkoff, MD: One thing that comes up a lot—especially for someone like Kevin, Maria, or me— when we talk to the ultimate purchasers, the employers buying these, about OB-GYN issues is unintended pregnancy, between the costs associated with it, the work-ups, and so on. Maria, can you comment a little on the different issues around the economics from a payer or employer point of view, not to mention the patient and the family of unintended pregnancy? Some of these issues play a role in unintended pregnancy because of difficulties around tracking periods and so on.
Maria Lopes, MD, MS: With fibroids, if you have a pregnancy, there’s a higher risk of miscarriage, dystocia, C-section, bleeding, and probably other conditions, including abruption. There are all these predisposed maternal complications but also NICU [newborn intensive care unit] costs if you have a preterm birth. On the infertility side, endometriosis as well as fibroid can contribute to infertility. The issue then becomes how you address that, especially with fibroids. If you have a surgical approach, that also increases the potential risk of complications, including uterine dehiscence. The approach, especially if you’re contemplating pregnancy in the short term, is an interesting one with fibroids.
With endometriosis, you may find that women may present within infertility 10% or 15% of the time, and then it becomes incidental. Not every woman with endometriosis is symptomatic. Many times, they present with ovarian cysts or at the time of a laparoscopic evaluation because you’re looking at fallopian tubes, ovaries, and the pelvis in general, identifying adhesions and endometriosis. At that point, you’re trying to look at what can be done in terms of options to obtain a pregnancy success.
As a payer, we’re concerned about the whole aspect of not only unintended pregnancies but the high risk and high cost associated with maternal child complications, particularly NICU costs. Then there’s the infertility component. Not all states have robust benefit designs around infertility, but the work-up and cost associated with assisted reproductive technology, the medications associated with ovarian stimulation, and the consequences of hyperstimulation are very much a real concern.
Neil Minkoff, MD: Let me step back for a second. We talked a little about endometriosis. You talked a little about fibroids and unintended pregnancies. We’re going to get back to all these things and get a little deeper. One question I want to ask Kevin and Maria—I should probably weigh in as well, but I don’t have to because I’m the moderator—is what it would take for payers to be more on top of these issues, to get patients into medical solutions before getting into surgery. You’re going to hate this idea. Should there be more precertifications around surgery to make sure patients have maxed out their medical options? Where are we with that? Do payers need to be pushing surgery off to go along with what Steven said earlier? He said that surgery is the last resort. Should the payers try to reinforce that?
Kevin Stephens Sr., MD, JD: I can take a stab at it first. We have criteria, whether it’s…for prior authorization that we use in terms of size of fibroids for myomectomy, length, and those things. There are safety nets in place to make sure everyone who walks into an office doesn’t end up with a scalpel in the surgeon’s hand. On the other hand, I like to rely on the judgment of the gynecologist or ob-gyn who’s managing the patient and the judgment of the patient. When you see 1 patient, you have seen 1 patient. They all look different. They all have different concerns. They all have different tolerance levels. Pain is subjective. We’ve all seen it. We’ve seen patients with minimal pelvic disease in whom the pain is astronomical.
Neil Minkoff, MD: It’s just unbelievable. Right.
Kevin Stephens Sr., MD, JD: Yes. Then we’ve seen the other realm. I’ve seen a patient who had a fibroid as big as a basketball who had no pain. It was just an incidental finding. I said, “How can you not feel a big basketball?” But that’s the whole point. It’s a tough space to be in. In the managed care arena, we try to give as much freedom and flexibility to the provider to make the best decisions for that patient, not to intervene but to make sure we help support them.
Neil Minkoff, MD: Maria, do you have anything to add to that?
Maria Lopes, MD, MS: I agree. There’s a fine line between what payers do and the practice of medicine. We also tend to focus on things like regional variations in care. Hysterectomy has been a topic of focus. It may be totally appropriate for some but not for others. Things that drive change for payers is when something becomes a quality measure. Because only at that point do we apply data to understand or even predict what may be the next procedure, and frankly, what can be done about that.
I love Dr [Steven] McCarus’s approach, an algorithm around frequent fliers who end up in the ED [emergency department] and imaging. These are things that payers are concerned about and drive costs. If you’re discharged from the ED without follow-up, you’re probably going to end up back in the ED. The other area is opioid. Opioid substance use disorder is a hot topic in terms of how we do a better job in patient care, care coordination, follow-up, and reduce the risk of addiction and use of opioids in general.
Neil Minkoff, MD: But like everything else we’re talking about, even that’s a double-edged sword. You have patients who might do very well with opioids for 2 days a month—I’m making that up for the sake of the argument—who are now being targeted because they’re chronic opioid users. We go back and forth on this. One thing that I feel that we end up doing is when we try to follow guidelines, whether it’s on the provider or payer side, we get castigated for not taking into account the patient who doesn’t fit into the guideline. When we don’t follow guidelines, we get yelled at for not following guidelines. What do we do?
Transcripts edited for clarity.