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Unintended pregnancies, which occur in almost half (45%) of all pregnancies in the United States, are associated with adverse health and social outcomes for the infant and the mother. The risk of unintended pregnancies is significantly reduced when women use long-acting reversible contraceptives (LARCs), namely intrauterine devices and implants. Although LARCs are highly acceptable to women at risk of unintended pregnancies, barriers to accessing LARCs hinder its uptake. These barriers are greater among racial and socioeconomic lines and persist within and across the intrapersonal, interpersonal, institutional, and policy levels. A synthesis of these barriers is unavailable in the current literature but would be beneficial to health care providers of reproductive-aged women, clinical managers, and policymakers seeking to provide equitable reproductive health care services. The aim of this narrative review was to aggregate these complex and overlapping barriers into a concise document that examines: (a) patient, provider, clinic, and policy factors associated with LARC access among populations at risk of unintended pregnancy and (b) the clinical implications of mitigating these barriers to provide equitable reproductive health care services. This review outlines numerous barriers to LARC uptake across multiple levels and demonstrates that LARC uptake is possible when the woman is informed of her contraceptive choices and when financial and clinical barriers are minimized. Equitable reproductive health care services entail unbiased counseling, a full range of contraceptive options, and patient autonomy in contraceptive choice.
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Policy Points Twelve states have yet to expand Medicaid under the Affordable Care Act (ACA). Louisiana offers a model of steps that states and counties can take to rapidly enroll eligible persons while balancing eligibility integrity and doing so within a limited administrative budget. In a post-COVID-19 health care landscape, Medicaid expansion can improve and protect population health and boost state economies, even amid budget shortfalls. Even though Louisiana compares well with other states in eligibility and enrollment efforts, future expansions may integrate other social support programs into their implementation strategies.
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COVID-19 , Medicaid , Determinación de la Elegibilidad , Humanos , Cobertura del Seguro , Louisiana , Patient Protection and Affordable Care Act , Estados UnidosRESUMEN
State payers may face financial incentives to restrict use of high-cost medications. Yet, restrictions on access to high-value medications may have deleterious effects on population health. Direct-acting antivirals (DAAs), available since 2013, can cure chronic infection with hepatitis C virus (HCV). With prices upward of $90,000 for a treatment course, states have struggled to ensure access to DAAs for Medicaid beneficiaries and the incarcerated, populations with a disproportionate share of HCV. Advance purchase commitments (APCs), wherein a payer commits to purchase a certain quantity of medications at lower prices, offer payers incentives to increase access to high-value medications while also offering companies guaranteed revenue. This article discusses the use of subscription models, a type of APC, to support increased access to high-value DAAs for treating HCV. First, the authors provide background information about HCV, its treatment, and state financing of prescription medications. They then review the implementation of HCV subscription models in two states, Louisiana and Washington, and the early evidence of their impact. The article discusses challenges to evaluating state-sponsored subscription models, and it concludes by discussing implications of subscription models that target DAAs and other high-value, high-cost medicines.
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Hepatitis C Crónica , Hepatitis C , Humanos , Estados Unidos , Hepacivirus , Antivirales/uso terapéutico , Hepatitis C Crónica/tratamiento farmacológico , Hepatitis C/tratamiento farmacológico , Hepatitis C/epidemiología , Costos de los MedicamentosRESUMEN
BACKGROUND: Unintended pregnancies, occurring in nearly 1 out of every 2 (45%) pregnancies in the United States, are associated with adverse health and social outcomes for the infant and the mother. The risk of unintended pregnancies is significantly reduced when women use long-acting reversible contraceptives, namely intrauterine devices and implants. Inadequate reimbursement for long-acting reversible contraceptive devices may be an access barrier to long-acting reversible contraceptive uptake. In 2014, the Louisiana Department of Health Bureau of Health Services Financing implemented a policy change that increased the Medicaid reimbursement rates for acquiring long-acting reversible contraceptive devices to the wholesale acquisition cost. OBJECTIVE: To examine the association of a Medicaid policy change that increased the long-acting reversible contraceptive device reimbursement rate to the wholesale acquisition cost (ie, price set by the manufacturers) on long-acting reversible contraceptive uptake among women at risk for unintended pregnancy. MATERIALS AND METHODS: This retrospective, repeated cross-sectional study used 2013-2015 Louisiana Medicaid claims data and contraceptive provision measures to assess associations between patient (age, race, urban/rural residence, postpartum status) and provider (urban/rural location, specialty) characteristics and long-acting reversible contraceptive uptake among contraceptive users (N = 193,623) using bivariate and logistic regression analyses. RESULTS: After long-acting reversible contraceptive reimbursement increased, there was a 2-fold likelihood increase in use in 2015 vs 2013 (odds ratio, 2.08; 95% confidence interval, 1.69-2.55). Long-acting reversible contraceptive uptake was more likely across all patient and provider subgroups in 2015 vs 2013 but notably among patients receiving contraceptive care from family planning clinics (odds ratio, 3.93; 95% confidence interval, 2.34-6.62). CONCLUSION: Removal of a provider-level financial barrier to long-acting reversible contraceptive provision was associated with increased long-acting reversible contraceptive uptake among women at risk for unintended pregnancy. Efforts to improve long-acting reversible contraceptive access should focus on equitable healthcare reimbursement for healthcare providers of reproductive-aged women.
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Política de Salud , Anticoncepción Reversible de Larga Duración/estadística & datos numéricos , Mecanismo de Reembolso , Adolescente , Adulto , Estudios Transversales , Femenino , Humanos , Anticoncepción Reversible de Larga Duración/economía , Louisiana , Medicaid , Mecanismo de Reembolso/legislación & jurisprudencia , Estudios Retrospectivos , Estados Unidos , Adulto JovenRESUMEN
Rates of short-interval pregnancies that result in unintended pregnancies remain high in the United States and contribute to adverse reproductive health outcomes. Long-acting reversible contraception methods have annual failure rates of <1%, compared with 9% for oral contraceptive pills, and are an effective strategy to reduce unintended pregnancies. To increase access to long-acting reversible contraception in the immediate postpartum period, several State Medicaid programs, which include those in Iowa and Louisiana, recently established reimbursement policies to remove the barriers to reimbursement of immediate postpartum long-acting reversible contraception insertion. We used a mixed-methods approach to analyze 2013-2015 linked Medicaid and vital records data from both Iowa and Louisiana and to describe trends in immediate postpartum long-acting reversible contraception provision 1 year before and after the Medicaid reimbursement policy change. We also used data from key informant interviews with state program staff to understand how provider champions affected policy uptake. We found that the monthly average for the number of insertions in Iowa increased from 4.6 per month before the policy to 6.6 per month after the policy; in Louisiana, the average number of insertions increased from 2.6 per month before the policy to 45.2 per month. In both states, the majority of insertions occurred at 1 academic/teaching hospital. In Louisiana, the additional increase may be due to the engagement of a provider champion who worked at both the state and facility level. Recruiting, training, engaging, and supporting provider champions, as facilitators, with influence at state and facility levels, is an important component of a multipart strategy for increasing successful implementation of state-level Medicaid payment reform policies that allow reimbursement for immediate postpartum long-acting reversible contraception insertions.
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Política de Salud , Anticoncepción Reversible de Larga Duración/estadística & datos numéricos , Periodo Posparto , Intervalo entre Nacimientos , Femenino , Humanos , Iowa , Louisiana , Medicaid , Embarazo , Embarazo no Planeado , Mecanismo de Reembolso/legislación & jurisprudencia , Estados UnidosRESUMEN
Introduction In 2012, the Louisiana (LA) Department of Health and Hospitals revised the LA birth certificate to include medical reasons for births before 39 completed weeks' gestation. We compared the completeness and validity of these data with hospital discharge records. Methods For births occurring 4/1/2012-9/30/2012 at Woman's Hospital of Baton Rouge, we linked maternal delivery and newborn birth data collected through the National Perinatal Information Center with LA birth certificates. Among early term births (37-38 completed weeks' gestation), we quantified the reasons for early delivery listed on the birth certificate and compared them with ICD-9-CM codes from Woman's discharge data. Results Among 4353 birth certificates indicating delivery at Woman's Hospital, we matched 99.8% to corresponding Woman's administrative data. Among 1293 early term singleton births, the most common reasons for early delivery listed on the birth certificate were spontaneous active labor (57.5%), gestational hypertensive disorders (15.3%), gestational diabetes (8.7%), and premature rupture of membranes (8.1%). Only 2.7% of births indicated "other reason" as the only reason for early delivery. Most reasons for early delivery had >80% correspondence with ICD-9-CM codes. Lower correspondence (35 and 72%, respectively) was observed for premature rupture of membranes and abnormal heart rate or fetal distress. Discussion There was near-perfect ability to match LA birth certificates with Woman's Hospital records, and the agreement between reasons for early delivery on the birth certificate and ICD-9-CM codes was high. A benchmark of 2.7% can be used as an attainable frequency of "other reason" for early delivery reported by hospitals. Louisiana implemented an effective mechanism to identify and explain early deliveries using vital records.
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Costo de Enfermedad , Reforma de la Atención de Salud/métodos , Salud Pública/economía , Mejoramiento de la Calidad/estadística & datos numéricos , Estadísticas Vitales , Femenino , Reforma de la Atención de Salud/economía , Registros de Hospitales/estadística & datos numéricos , Humanos , Clasificación Internacional de Enfermedades/estadística & datos numéricos , Louisiana/epidemiología , Parto Normal/economía , Parto Normal/estadística & datos numéricos , Vigilancia de la Población/métodos , Embarazo , Nacimiento Prematuro/epidemiología , Salud Pública/métodos , Salud Pública/estadística & datos numéricos , Estadística como Asunto/métodosRESUMEN
Objectives Determine trends in incidence and expenditure for perinatal drug exposure and neonatal abstinence syndrome (NAS) among Louisiana's Medicaid population. We also describe the maternal characteristics of NAS affected infants. Methods Retrospective cohort analysis using linked Medicaid and vital records data from 2003 to 2013. Conducted incidence and cost trends for drug exposed infants with and without NAS. Also performed comparison statistics among drug exposed infants with and without NAS and those not drug exposed. Results As rate of perinatal drug exposure increased, NAS rate per 1000 live Medicaid births also increased, from 2.1 (2003) to 3.6 (2007) to 8.0 (2013) (P for trend <0.0001). Total medical cost paid by Medicaid also increased from $1.3 million to $3.6 million to $8.7 million (P for trend <0.0001). Compared with drug exposed infants without NAS and those not drug exposed, infants with NAS were more likely to be white, have feeding difficulties, respiratory distress syndrome, sepsis, and seizures, all of which had an association at P < 0.0001. Over one-third (33.2%) of the mothers of infants with NAS had an opioid dependency in combination with a mental illness; with depression being most common. Conclusions for Practice Over an 11-year period, NAS rate among Louisiana's Medicaid infants quadrupled and the cost for caring for the affected infants increased six-fold. Medicaid, as the predominant payer for pregnant women and children affected by substance use disorders, must play a more active role in expanding access to comprehensive substance abuse treatment programs.
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Gastos en Salud/estadística & datos numéricos , Gastos en Salud/tendencias , Medicaid/economía , Madres/estadística & datos numéricos , Síndrome de Abstinencia Neonatal/economía , Síndrome de Abstinencia Neonatal/epidemiología , Complicaciones del Embarazo/epidemiología , Adulto , Femenino , Humanos , Incidencia , Lactante , Recién Nacido , Louisiana/epidemiología , Masculino , Medicaid/estadística & datos numéricos , Embarazo , Estudios Retrospectivos , Estados UnidosAsunto(s)
COVID-19 , Urgencias Médicas , Reforma de la Atención de Salud/legislación & jurisprudencia , Cobertura del Seguro/estadística & datos numéricos , Seguro de Salud/estadística & datos numéricos , Medicaid/legislación & jurisprudencia , Humanos , Patient Protection and Affordable Care Act , Estados UnidosAsunto(s)
Sistemas Electrónicos de Liberación de Nicotina/normas , Aromatizantes/normas , Guías como Asunto , Industria del Tabaco/legislación & jurisprudencia , Industria del Tabaco/normas , Sistemas Electrónicos de Liberación de Nicotina/estadística & datos numéricos , Humanos , Estados Unidos , United States Food and Drug AdministrationAsunto(s)
Infecciones por Coronavirus , Tormentas Ciclónicas , Planificación en Desastres , Planificación en Salud , Política de Salud , Pandemias , Neumonía Viral , Betacoronavirus , COVID-19 , Tormentas Ciclónicas/historia , Programas de Gobierno , Historia del Siglo XXI , Humanos , Louisiana/epidemiología , SARS-CoV-2RESUMEN
Over the past 3 decades, major changes enhanced Medicaid's role in improving the health of women and perinatal outcomes. Reforms in the 1980s and 1990s had impact not only on coverage but also on current policy debates. Whether or not states expand eligibility under the Affordable Care Act, Medicaid is important. Increased coverage for well-woman visits, preconception care, and contraceptive methods are opportunities in gynecology. As a critical source of maternity coverage, Medicaid can improve prenatal care, reduce preterm births, limit early elective deliveries, and increase postpartum visits. Obstetrician-gynecologists play a role in translating coverage into access to quality services.
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Accesibilidad a los Servicios de Salud/normas , Medicaid , Patient Protection and Affordable Care Act , Atención Perinatal , Atención Preconceptiva , Servicios de Salud para Mujeres , Adulto , Determinación de la Elegibilidad/tendencias , Femenino , Humanos , Recién Nacido , Medicaid/normas , Medicaid/tendencias , Atención Perinatal/legislación & jurisprudencia , Atención Perinatal/normas , Atención Perinatal/tendencias , Atención Preconceptiva/métodos , Atención Preconceptiva/organización & administración , Embarazo , Mejoramiento de la Calidad , Estados Unidos , Salud de la Mujer , Servicios de Salud para Mujeres/economía , Servicios de Salud para Mujeres/normasRESUMEN
The US government developed a Medicaid Consent to Sterilization form in the mid-1970s to protect vulnerable populations from coerced sterilization. US health care practices have evolved significantly since that time. The form, however, has not changed, and may be preventing access to desired services for the same vulnerable populations it was originally created to protect. This paper discusses the relevant historical, practical use, ethical, and advocacy considerations of the Medicaid sterilization consent form and proposes changes to make the form more pertinent to today's medical environment.
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Política de Salud , Salud Reproductiva , Esterilización Reproductiva , Femenino , Regulación Gubernamental , Política de Salud/historia , Política de Salud/legislación & jurisprudencia , Historia del Siglo XX , Humanos , Masculino , Defensa del Paciente/tendencias , Salud Reproductiva/ética , Salud Reproductiva/historia , Esterilización Reproductiva/ética , Esterilización Reproductiva/historia , Esterilización Reproductiva/legislación & jurisprudencia , Esterilización Reproductiva/métodos , Estados UnidosRESUMEN
OBJECTIVE: To determine the contribution of monozygotic twining to in vitro fertilization multiple births. STUDY DESIGN: We performed a retrospective analysis of the incidence of monozygotic twining in multiple births resulting from fresh embryo transfers using 2006-2010 data from the Society for Reproductive Technology Clinic Outcome Reporting System. RESULTS: The number of embryos transferred were fewer than the number of births in 0.5% (223/40950) of twin, 29% (659/2289) of triplet, and 64% (43/67) of quadruplet births resulting from transfer of fresh embryos from 2006 to 2010. In 2010, 37% of triplets and 100% of quadruplet births occurred when fewer than 3 and fewer than 4 embryos respectively were transferred. CONCLUSION: Monozygotic twinning plays a key role in the development of triplet and quadruplet pregnancies achieved through in vitro fertilization.