Cost savings from same-day long-acting reversible contraception

Published today in the journal JAMA Network Open, the study was the work of three IU School of Medicine faculty -- Tracey A. Wilkinson, MD, MPH, Stephen M. Downs, MD, MS, and Brownsyne Tucker Edmonds, MD, MPH, MS.

In the study, the researchers worked to determine what the cost savings would be by providing same-day access to long-acting reversible contraception, from the perspective of insurance companies, in particular, Medicaid, to adolescents. Considered the most effective contraception for adolescents, long-acting reversible contraception, or LARC, include intrauterine contraceptives (IUCs) and implants.

According to Wilkinson, who joined the faculty at IU School of Medicine four years ago, the lack of clinics in Indiana offering same-day access to these contraceptives came as a surprise when she began her work in the state as a health services researcher.

"When I landed in Indiana, I quickly realized there were very few clinical sites providing same-day LARC. They are more expensive, but they are very effective, because they don't require any user dependence in order to work," Wilkinson said. "As I started to piece together what the barriers were, one of the biggest seemed to be cost."

Teaming with Downs and Tucker Edmonds, Wilkinson said the group set out to create a cost minimization model to determine the cost to an insurance company when a patient is required to come back to the clinic for subsequent visits to receive their desired contraceptive.

Drawing on their work as members of the Medicaid Medical Advisory Cabinet at IU School of Medicine -- a group of physicians who provide research-based policy advice to Indiana's Office of Medicaid Policy and Planning -- Downs and Tucker Edmonds joined Wilkinson in compiling data that would help them come up with a policy that could show a cost savings to Medicaid.

Using data from previous studies, the group worked through all of the scenarios that could result from an adolescent seeking same-day LARC. With each step, the group calculated what the cost would be to the payer -- looking into the cost of the device, the cost of delivering a baby, the cost of an annual visit, and so on.

"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," Downs said. "The research literature tells us how likely all of those things are, and we know from medical claims how much they cost. With the resulting tree we can compare the average cost we'd expect if contraception is immediately available or not."

Through their work, the group found that same-day LARC placement led to overall lower costs to the payer -- $2,016 on average -- compared with placement at a later visit -- $4,133 on average. Additionally, they found that the numbers of unintended pregnancies and abortions decreased in association with providing same-day placement.

A cost-saver for the insurance companies and Medicaid, Tucker Edmonds asserted that the practice of providing patients access to same-day LARC also could help improve Hoosier health.

"We know that LARC is highly effective at preventing unintended pregnancy. Unintended pregnancy is associated with poor pregnancy outcomes, such as premature birth, which is a leading cause of infant mortality," said Tucker Edmonds. "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."

In the paper, the researchers came up with four recommendations for state Medicaid officials from the data compiled through their study:

• Provide bonus payments for clinicians to incentivize same-day contraceptive access. Doing so would overcome the reimbursement-to-cost differential that leads to the two-visit strategy and mitigate carrying-cost concerns.
• Create a single, uniform reimbursement structure, preferably as a medical benefit, to mitigate some of the procedural delays that occur when a device has to be ordered for an individual patient as opposed to being used for any presenting patient.
• Pursue a strategy to purchase LARC devices in bulk and distribute devices up front to clinics desiring to provide same-day LARC access.
• Develop a policy whereby LARC devices that were ordered for a specific patient but ultimately unused after a certain time could be used for another patient.

Moving forward from the study, Wilkinson said she hopes the findings will help push the needle forward in helping provide access to same-day contraceptives of all kinds to women when and if they need it.

"Access matters, and any barrier to access means that fewer people will actually get to that finish line," Wilkinson said. "When you have people who desire contraception not being able to access it, the outcomes of all our communities are less than ideal. Planned pregnancies are healthier pregnancies, so having same-day access to all forms of contraception is vital."