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Improving Contraceptive Care In Medicaid and CHIP The Council of State Governments October 4, 2016 Lekisha Daniel-Robinson, MSPH Coordinator, CMCS Maternal Infant Health Initiative 2 CMCS Maternal and Infant Health Initiative (MIHI) In July

  2. Improving Contraceptive Care In Medicaid and CHIP The Council of State Governments October 4, 2016 Lekisha Daniel-Robinson, MSPH Coordinator, CMCS Maternal Infant Health Initiative 2

  3. CMCS Maternal and Infant Health Initiative (MIHI) In July 2014, CMCS launched a Maternal and Infant Health Initiative in collaboration with states to: 1) Increase the rate and content of postpartum visits; and 2) Increase access to effective methods of contraception in Medicaid and CHIP. This initiative builds on the work of an Expert Panel that identified strategies CMS and states could undertake to improve maternal and infant outcomes in Medicaid and CHIP. 3

  4. Exploring Payment Strategies • Informational Bulletin released on 4/8/16 identified emerging promising payment approaches to increase access to long- acting reversible contraceptives (LARC) • Key strategies: • Timely, patient-centered comprehensive coverage • Increasing payment rates for contraceptive devices to ensure access to the range of methods available • Reimbursement for Immediate Postpartum LARC by “unbundling” payments for LARC from payment for labor and delivery services • Removing logistical barriers for supply management (e.g., addressing supply chain, stocking cost and disposal cost issues). • Removing administrative barriers to access for LARC (e.g. minimize preauthorization and “step therapy” requirements) 4

  5. Medicaid Managed Care Final Rule • The Medicaid Managed Care Final Rule (81 FR 27498) promotes access to family planning services and effective contraception methods, including LARC. Specifically, the rule promotes: • Choice – reiterates enrollees right to directly access family planning providers without need for referral (42 CFR 438.10(g)(2)(vii)) • Non-discrimination of providers – MCOs cannot discriminate in the participation, reimbursement or indemnification of any providers acting within the scope of their licensure or certification (42 CFR 438.12 and 438.214) • Utilization management – clarifies that “step therapy” utilization methods cannot be applied to contraceptive methods (42 CFR 438.210(a)(4)(ii)(C)) • Cost-sharing for family planning services and/or items – stipulates that any cost-sharing imposed on Medicaid enrollees must be in accordance with Medicaid’s cost-sharing regulations (42 CFR 438.108 and 447.50 et seq.) 5

  6. Policy Guidance • State Health Official Letter, 6/14/16, clarified family planning regulations and offered additional options for increasing accessibility of LARC • Application of Family Planning Policy to Fee-for-Service and Managed Care • Clarification of the Purpose of the Family Planning Visit • Access to Services and Supplies • Additional Strategies to improve access to LARC, including an 1115 demonstration project 6

  7. Measuring Contraception Access • There are two Contraceptive Care MIHI measures - global and postpartum - that are stratified by age and have multiple rate categories • The global measure includes a total of 4 rates: • Provision of most effective or moderately effective FDA-approved methods of contraception for ages 15–20 and ages 21–44. • Provision of long-acting reversible method of contraception (LARC) for ages 15–20 and ages 21–44. • The postpartum measure includes a total of 8 rates: • Provision of most effective or moderately effective FDA-approved methods within 3 days postpartum for ages 15–20 and ages 21–44. • Provision of most effective or moderately effective FDA-approved methods within 60 days postpartum for ages 15–20 and ages 21–44. • Provision of LARC within 3 days postpartum for ages 15–20 and ages 21–44. • Provision of LARC within 60 days postpartum for ages 15–20 and ages 21–44. 7

  8. Measuring Contraception Access: MIHI Grantees 8

  9. Next Steps • Work with states to explore payment that supports high quality prenatal, postpartum, and inter-conception care. • Continue to explore policy options to address effective contraceptive counseling and removal. • Identify innovative care delivery models that have demonstrated promising results in improving outcomes, but do not have a sustainable source of funding. • Consider how contracting, alternative payment bundles and other models may be applied to contraceptive care services. 9

  10. South Carolina Birth Outcomes Initiative Long Ac(ng Reversible Contracep(on: Why Support LARC Policy Ms. Melanie “BZ” Giese, BSN, RN Director, South Carolina Birth Outcomes Ini(a(ve SC Department Health & Human Services October 4, 2016

  11. Ques(ons • How do you change and implement the state policy for inpa(ent inser(on reimbursement for the LARC device? • Is suppor(ng coverage of LARCs cost effec(ve to the state and improve health outcomes? • What other reimbursement methodologies are effec(ve to increase overall LARC u(liza(on and how is the policy implemented? South Carolina Birth Outcomes Initiative 11

  12. South Carolina Medicaid Numbers • FY2017 Total Expenditures $7.1 billion • Covers 57% of all births in the state • 90% of teen births • 60% of all children are on Medicaid • 90% of all Medicaid births are covered under 5 MCOs in state South Carolina Birth Outcomes Initiative 12

  13. Unintended Pregnancy by Age United States vs South Carolina 100% 77% 74% 80% 57% 60% 50% 35% 40% 20% 25% 0% 15-19 20-24 25-44 SC US Source: Based on 2010 PRAM data South Carolina Birth Outcomes Initiative 4

  14. Percent of Unintended Pregnancies • 50% of all pregnancies in the U.S. are unintended. However, use of LARCs are low – only 11% of women use LARCs • Most women (79%) who defined their pregnancy as “unintended” had their births covered by Medicaid Source: h\p:www.gu\macher.org/statecenter/unintended-pregnancy/SC 5 South Carolina Birth Outcomes Initiative

  15. Unplanned Births & Costs Specific to SC • 78.6% of unplanned births were publically funded compared with 68% na^onally • The federal & state government spent $411.2 million on unintended pregnancies • The total public costs for unintended pregnancies was $443/woman aged 15-44 vs $201/woman na^onally Source: PRAMS 2010 South Carolina Birth Outcomes Initiative 6

  16. South Carolina Birth Outcomes Ini(a(ve • Launched in July 2011 • Housed at the SC Department of Health & Human Services • 6 Workgroups Meet Monthly • Access to Care & Coordina(on • Quality & Safety • Health Dispari(es • Baby Friendly & Safe Sleep • Behavioral Health • Data South Carolina Birth Outcomes Initiative 16

  17. South Carolina Birth Outcomes Initiative 17

  18. Changing FFS Medicaid IPI LARC Policy • In most states, the Medicaid Director has the authority • CMS approval not needed • Medicaid Bulle^n issued & Provider Manual Changed • Iden^fying a Clinical Champion for implementa^on in the hospital is cri^cal • Educa^onal & strategic component of policy success is described in detail in the SC Postpartum LARC Toolkit on the ChooseWell SC website. South Carolina Birth Outcomes Initiative 18

  19. SC MCO LARC Policy Coverage • Device inser^on and removal costs included in the MCO capita^on rate • All five MCOs par^cipate in IPI, White-Bagging/ Specialty and Out pa^ent policy South Carolina Birth Outcomes Initiative 19

  20. Sell the Benefits of IPI LARC • Likely to reduce # of repeat and unintended births due to convenience of inpa^ent inser^on versus outpa^ent • Removes barriers to receiving appropriate contracep^ve care due to missed post-partum appointments at 6 weeks (55% miss it in SC Medicaid) • Improve provider rela^onships and address another iden^fied barrier, i.e. reimbursement amount for the device which was below cost to purchaser (outpa^ent & inpa^ent adjusted up) South Carolina Birth Outcomes Initiative 20

  21. Sell the Benefits cont. • Cost for Medicaid is a 90/10 match as Family Planning service • Offer 3 different ways to get LARCs so women have op^ons • IPI • OPI • White-bagging/Specialty South Carolina Birth Outcomes Initiative 21

  22. LARC Reimbursement Update: Effec(ve July 1, 2016 HCPCS HCPCS Name Name Current Current New Rate New Rate J7300 ParaGard $745.00 $804.50 J7301 Skyla $655.52 $707.96 J7302 Mirena/Lile\a N/A- Terminated Code J7307 Nexplanon $777.69 $839.91 J7297 Lile\a $630.00 $680.40 J7298 Mirena $816.99 $882.35 South Carolina Birth Outcomes Initiative 22

  23. Support LARCs Cost-Effec(veness & Improve Outcomes South Carolina Birth Outcomes Initiative 23

  24. SC Medicaid MCO and FFS LARCs Claim Volume 16% Inpa(ent 84% Outpa(ent Source: Data through June 2015 South Carolina Birth Outcomes Initiative 24

  25. Success of SC IPI LARCs • There was a 96% increase associated with IPI LARCs for females below the age of 18 from FY2012- FY2015 • There was a 74% increase associated with IPI LARCs for females above the age of 19 from FY2012- FY2015 South Carolina Birth Outcomes Initiative 25

  26. LARC IP Inser(ons and Avoided Births • There were 984 pa^ents with a LARC inserted in FY2014 • Over a 21 month period aker FY14, those pa^ents had a pregnancy rate 5.65% lower than the all-state rate. • This represents 52 subsequent births that were avoided South Carolina Birth Outcomes Initiative 26

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