The report found that hospitals have little financial incentive to offer long-acting contraception right after birth if it is not covered separately. Family planning services are not part of standard quality measures, so it's hard to track how well providers are doing.
Research shows back-to-back pregnancies aren’t necessarily good for women or their children, so more experts support making access to long-acting reversible contraception (LARC) part of routine post-partum care. But in Medicaid, state-level policies and the cost of keeping expensive devices on hand can limit access to LARC for the women who most need it, a new report from the Kaiser Family Foundation has found.
The report, “Medicaid Managed Care and the Provision of Family Planning Services,” finds that the move toward bundled payments in pregnancy care can create little incentive for providers to make sure women get access to long-acting methods, such as an intrauterine device (IUD). As a result, a few states have started reimbursing for LARC separately. The findings come as efforts to repeal the Affordable Care Act (ACA), and transform Medicaid into a block grant program, could create greater variation in how poor women get access to contraception.
In recent years, CMS had taken steps to boost federal oversight of family planning policies in Medicaid, including an April 2016 rule that required managed care plans to have enough providers in their networks. But the Trump Administration has signaled that it will return more authority to the states. A separate state-by-state survey finds wide variation in what Medicaid covers: most of 41 states contacted cover basic prenatal care, deliveries, and breast pumps, but coverage for parenting classes, breastfeeding education, and lactation consulting is inconsistent.
Medicaid now pays for 49% of all births, and women of childbearing age account for 70% of all adult women in the program, so there are strong financial incentives to prevent unintended pregnancies. As of 2011, 77% of women in Medicaid were in managed care plans.
Key findings from the Kaiser report are:
· Medicaid managed care plans rely heavily on Federally Qualified Health Centers and low-cost clinics to offer comprehensive care, including family planning. Many plans report they have contracts with Planned Parenthood to offer family planning services. Currently, there are efforts in Congress to block $500 million in funding for Planned Parenthood, because some of its facilities offer abortion alongside other services. Federal funds cannot be used for abortion.
· State policies regulate what kind of contraceptives Medicaid clients receive, and some managed care plans offer methods beyond those available in fee-for-service. Women may not be aware of all the options available, and most plans will only cover birth control pills for 3 months on a single prescription, despite evidence that giving women a 6- or 12-month supply reduces the risk of unintended pregnancy.
· IUDs and implants cost up to $1000 to stock, but clinics are only paid after they are inserted, which makes it hard for clinics to keep them on hand. Health plans acknowledge that the financial risk associated with stocking long-term methods can prevent women from getting them the day they request them; some clinics have deals with local pharmacies to stock IUDs to guarantee access.
· Bundled payment policies for pregnancy that fold in the cost of LARC create little incentive for hospitals to make sure women receive these immediately after giving birth. The “churn” in Medicaid, in which members move in and out of eligibility based on work status, provides even more reason for plans to dodge paying for LARC within a bundle. Therefore, some states have started paying for LARC separately.
History plays a role in the lack of access to long-term contraception, as some health plans said they did not want to be associated with efforts to control the fertility of poor women, especially women of color. A century ago, the early birth control movement was associated with efforts to limit population growth among the poor and disabled, and federal dollars paid for sterilization programs in 32 states. The result of such variability in access could be a renewed uptick in unplanned pregnancies at a time when the rate of such pregnancy has reached a 30-year low, amid lingering disparities for the poor and minorities. Plans also reported they often lacked policies to stop religious providers who had contracts from blocking access to contraception, even though it is a mandatory benefit under Medicaid.
Finally, while plans collect some quality data, there are few measures that focus on family planning. The National Quality Forum has endorsed such a measure. While bundled payments save money, there are some concerns that they limit how much information comes from encounter data, and post-partum care in particular may be hard to track.
Rosenzweig C, Sobel L, Salganicoff A. Medicaid managed care and the provision of family planning services. Kaiser Family Foundation website. http://kff.org/womens-health-policy/report/medicaid-managed-care-and-the-provision-of-family-planning-services/. Published April 27, 2017. Accessed April 28, 2017.