As more physicians and women consider immediate postpartum insertion of an intrauterine device as a way to prevent rapid repeat pregnancy, the next step is getting the procedure covered by Medicaid.

Already, 12 state Medicaid agencies offer coverage for this procedure immediately postpartum, with California being the latest to join Alabama, Colorado, Georgia, Iowa, Louisiana, Maryland, Montana, New Mexico, New York, Oklahoma, and South Carolina.

The Association of State and Territorial Health Officials (ASTHO) has been working with state Medicaid agencies and physicians to expand that roster. So far, states have been receptive to the idea, said Dr. Lisa F. Waddell, ASTHO’s chief program officer for community health and prevention, adding that as more states make the necessary policy change to cover the device and insertion procedure, it becomes easier for other states to follow suit.

“Medicaid was a partner at the table and continues to be,” she said. “I really believe they’re wanting to get better outcomes for their dollars they are investing and therefore are opening up to listening to partners and the providers in the state.”

The key challenge is defining the economics of this policy change. Normally, birth services are paid under a flat fee, which does not include coverage of immediate postpartum IUD insertion.

“Any time you make any type of change where there is going to be a cost incurred, people want to know that there will be a return on investment,” Dr. Waddell said.

They are making the case from an outcomes perspective, arguing that the Medicaid program will save money by preventing unplanned rapid repeat pregnancies. And by paying physicians to insert immediate postpartum IUDs, it promotes planned pregnancies in the future, which in turn promotes healthy babies and mothers, another way to help reign in overall costs and improve overall outcomes, she said.

The other challenge is training physicians on the policies and codes in their state, as well the actual IUD insertion protocols.

“There is a lot of emphasis on provider training,” Dr. Waddell said.

Education has been a key emphasis in New Mexico, said Dr. Eve Espey , chair of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque, who noted that her university hospital is the only location in the state that “very routinely” does this procedure.

“What I’d like to do is through our perinatal collaborative is take the show on the road and talk to other hospitals about how to deal with the reimbursement mechanism and then train providers to be able to offer it to women with Medicaid,” Dr. Espey said. “Then I think an important next step is to talk to private insurers. We have a lot of work to do and I think starting with Medicaid does make a lot of sense.”

ASTHO is also focusing on gaining coverage in the Medicaid setting first. If they can help get the majority of state Medicaid agencies to cover the procedure, it will be easier to convince private insurers to follow suit, as coverage is also not common in the private sector, Dr. Waddell said.

In New Mexico, the state Medicaid program had covered IUD devices and insertion but didn’t pay for immediate postpartum insertion. But with “substantial” no-show rates for follow-up postpartum appointments to insert the devices, it became important to gain that coverage so that patients could have the procedure when they were the most motivated, Dr. Espey said.

In Georgia, the experience has been similar. Dr. Melissa Kottke , director of the Jane Fonda Center for Adolescent Reproductive Health at Emory University in Atlanta said there was a lot of hospital-level coordination needed once the state-approved coverage.

“The changes that have to get instituted are really at a particular institution or organizational level,” Dr. Kottke said. “There are a lot of stakeholders that need to be involved,” from clinicians to coding staff to electronic health record vendors and other key personnel.

“There is a lot of education and a lot of cooperation that is necessary, but it’s certainly something that’s definitely doable,” she said.

Dr. Kottke said there have not been any issues with the adequacy of payment for this procedure and the state Medicaid agency has been “really supportive of this approach,” particularly since there had already been a number of states that had instituted coverage and have seen improved outcomes, both clinical and financial.

“It’s a huge opportunity for taking really good care of women,” Dr. Kottke said. “We know that the immediate postpartum period is a time of unmet contraceptive need and to remove the financial barrier is really exciting to see.”


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