Introduction
Household planning companies, which embrace contraceptive companies and provides in addition to a broader set of companies associated to sexual and reproductive well being, are key preventive companies for girls. Most ladies (87%) use contraception in some unspecified time in the future and on common, ladies report utilizing 3.4 strategies of contraception all through their lifetime. For low-income ladies specifically, Medicaid performs a significant function in financing household planning companies. Recognizing the significance of contraception and household planning companies, federal Medicaid regulation classifies household planning companies and provides as a “obligatory” profit class that states should cowl. Federal Medicaid regulation has different protections that promote entry to household planning companies that:
- Prohibit suppliers from charging copayments or another type of affected person price sharing for household planning companies
- Set up a 90% federal matching price (FMAP) for the prices of companies labeled as household planning, a better price than for different companies
- Entitle beneficiaries to acquire household planning companies from any supplier that participates within the Medicaid program, referred to as free selection of supplier, together with for beneficiaries enrolled in managed care organizations (MCOs)
All states cowl prescription contraceptives for girls, however they might restrict entry by utilization controls. Moreover, about half of states provide a variety of household planning advantages together with contraceptive companies and provides to people who don’t in any other case qualify for full Medicaid protection. States can set up these household planning applications by receiving permission from the federal Facilities for Medicare and Medicaid Providers (CMS) by a Part 1115 waiver or by amending their Medicaid applications with a State Plan Modification (SPA). Recognizing the significance of contraceptive companies for girls, CMS just lately added two measures of contraceptive care to the core well being care high quality measures, often called the Grownup and Baby Core Units. These measures assess provision of essentially the most and reasonably efficient contraceptive strategies (i.e., sterilization, intrauterine gadgets (IUDs), implants, injectables (e.g., Depo-Provera), oral capsules, patch, or ring) to feminine beneficiaries.
Regardless of the particular standing of household planning companies below Medicaid, little or no is thought in regards to the provision of those companies to Medicaid beneficiaries. To higher perceive the extent of use of those companies and to discover the variation in utilization throughout states, we study the supply of contraceptive companies and provides, in addition to provision of household planning companies extra broadly to reproductive age ladies (ages 15 to 49) constantly lined by Medicaid in 2018. We current new nationwide and state-level knowledge by age in addition to comparisons by area. This evaluation relies on claims knowledge from the Remodeled Medicaid Statistical Info System (T-MSIS) and relies on knowledge from 43 states and the District of Columbia. Seven states are excluded attributable to considerations about knowledge high quality.
Findings
Amongst females ages 15-49 constantly enrolled in Medicaid in 2018, we checked out household planning service provision and contraceptive service provision (Desk 1). Contraceptive companies for this evaluation included medicine, gadgets, procedures, and counseling supposed to stop being pregnant. Household planning companies have been outlined to incorporate all contraceptive companies in addition to associated companies to stop and display for some sexually transmitted infections (STIs) and HIV, in addition to gynecological exams and Pap smears.
By service provision amongst those that have been constantly enrolled in Medicaid, we reduce the impression of protection churning, which might restrict entry to care.
One in 4 (25%) feminine Medicaid enrollees of reproductive age (ages 15 to 49) obtained at the least one contraceptive service in 2018.This share assorted significantly, starting from 18% in Arkansas and Arizona to 34% in Wisconsin (Determine 1). These percentages characterize the share of females general supplied these companies, which can embrace ladies who have been pregnant in the course of the yr and never in want of contraceptive companies.
Contraceptive provision was on common nearly twice as excessive amongst females ages 15-29 (32%) than females ages 30-49 (18%). There was appreciable variation in these charges by age throughout states with lower than 1 / 4 (22%) of females ages 15-29 in Texas receiving contraceptive companies in comparison with almost half of their counterparts in Vermont (46%). Amongst females ages 30-49, solely 9% acquired contraceptive companies in Arkansas in comparison with 1 / 4 (25%) in Wisconsin.
When trying extra broadly at household planning companies together with screenings for sexually transmitted infections and cervical most cancers along with contraceptive companies, slightly below 4 in 10 females ages 15-49 (38%) have been supplied household planning companies. This ranged from a low of twenty-two% in Arkansas to a excessive of 49% in Connecticut (Determine 2). Youthful females ages 15-29 have been on common, 1.3 occasions extra prone to obtain household planning companies in comparison with these ages 30-49 (42% vs. 35%). Amongst females ages 15-29, household planning service provision ranged from a low of 27% in Texas to a excessive of 54% in Vermont. The vary was barely wider amongst females ages 30-49 with 14% receiving household planning companies in Arkansas in comparison with 46% in Connecticut.
Many elements can contribute to state degree variation in provision of companies, together with eligibility ranges, Medicaid utilization controls, entry to clinicians, the supply of companies, clinician practices, fee charges, beneficiaries’ wants and preferences, and extra.
Nationally, essentially the most generally supplied methodology of contraception to feminine Medicaid beneficiaries was oral contraceptives, which can also be essentially the most generally used reversible contraceptive amongst females within the basic inhabitants. Almost half of ladies supplied contraceptive companies in Medicaid in 2018 obtained contraceptive capsules (48%), adopted by injectable contraception (20%), after which intrauterine gadgets (12%) (Determine 3). Roughly one in 5 (21%) females obtained a long-acting reversible contraceptive (LARC) in 2018, which incorporates IUDs and implants.
Amongst these constantly enrolled in Medicaid, solely 4% of ladies had a analysis or process code for feminine sterilization in 2018. Since sterilization is a one-time process, ladies who have been sterilized in earlier years wouldn’t present up within the present measurement yr. Mixed with IUDs and implants, one quarter of contraceptive customers was supplied a “only” methodology in 2018 (e.g., sterilization, contraceptive implants, intrauterine gadgets or methods (IUD/IUS)). 5 p.c of females was supplied emergency contraceptive capsules. Lower than 5% of females have been supplied the opposite strategies – patch, ring, diaphragm, or fertility awareness-based counseling.
For the next figures on contraceptive methodology supplied, ladies may have a couple of methodology inside the yr.
Contraceptive provision differs by age. Youthful females of their teenagers and 20s had greater provision of oral contraceptives and decrease use of sterilization than females of their 30s and 40s. Preferences concerning the kind of contraceptive methodology typically differs by an individual’s age and the size of time they need to stop being pregnant. Not surprisingly, a bigger share of females ages 30-49 acquired a sterilization process within the yr, in comparison with females ages 15-29, who had greater use of reversible strategies reminiscent of contraceptive implants, injectables, and oral contraceptive capsules (Determine 4). Curiously, about one in 5 females in every age group obtained a LARC (IUDs and implants) in the course of the calendar yr. The supply of contraceptive patches and rings was equally low amongst each age teams. Lower than 1% of females in every age group have been supplied a diaphragm. Equally, a small share of females acquired fertility awareness-based counseling (1%) in every age group. Lastly, 5% of females ages 15-29 and 4% of females ages 30-49 have been supplied a prescription for emergency contraception capsules. Since emergency contraceptive capsules can bought over-the-counter with out a prescription, some ladies might have used the capsules however this might not be mirrored on this claims database. For Medicaid to cowl the prices of the capsules, nevertheless, enrollees must have a prescription.
There are some notable regional variations within the provision of contraceptive strategies, significantly for oral contraceptives, injectables, and emergency contraceptive capsules. We in contrast variations in forms of contraceptives that have been supplied within the 4 census areas: West, South, Midwest, and Northeast (Determine 5), excluding FL, KY, MS, NE, OK, UT, WY attributable to considerations about knowledge high quality. The share of ladies supplied sterilization in 2018 was highest within the South (5%), however related throughout areas (4% in Midwest, 3% in West, and three% in Northeast). The share of ladies supplied an intrauterine gadget was lowest within the South (9% in comparison with 11% in Midwest, 12% in Northeast, and 13% in West) and the share receiving a contraceptive implant was lowest within the Northeast (7% in comparison with 9% in Midwest, 9% in South, and 11% in West). The most important variations have been within the shares supplied injectable contraception, with the best share being within the South (27%) in comparison with 15% within the West. The share of ladies supplied contraceptive capsules was lowest within the South (42%) and highest within the Northeast (52%). The share of ladies supplied emergency contraception was decrease within the South (1%) in comparison with the West (7%), Midwest (5%), and Northeast (6%). There weren’t substantial regional variations within the shares of ladies supplied the contraceptive patch, contraceptive ring, diaphragm, and fertility awareness-based counseling.
Dialogue
Given the central function of Medicaid in financing household planning companies for low-income ladies, it is very important perceive what household planning service and contraceptive service provision appears to be like like throughout states. Whereas these are vital companies for a lot of ladies, not all ladies want or need to use contraception. Our general discovering that 25% of reproductive age ladies have been supplied a contraceptive service is in step with charges just lately revealed by CMS, the place 25.3% of ladies ages 21 to 44 vulnerable to unintended being pregnant have been supplied a “only” or “reasonably efficient” methodology of contraception. It’s unclear whether or not the remaining ladies, who characterize the vast majority of reproductive age ladies on Medicaid encounter entry boundaries or an absence of availability, or whether or not they really feel they don’t want or don’t want to use contraceptive companies, or another cause. A few of these ladies could also be pregnant or attempting to get pregnant and don’t want contraception. Others could also be utilizing over-the-counter strategies reminiscent of condoms or spermicide.
It’s notable that there are appreciable variations in provision of household planning and contraceptive companies and provides by age. The next share of ladies of their teenagers and 20’s acquired contraceptive and household planning companies in comparison with ladies over the age of the 30. This might partially be defined by greater shares of ladies over age 30 having had sterilization procedures in earlier years in addition to higher reliance on longer performing contraceptive strategies, like IUDs which might last as long as 10 years relying on the kind of IUD. No matter age, contraceptive capsules stay essentially the most ceaselessly supplied contraceptive methodology inside Medicaid general, adopted by injectable contraception (e.g., Depo-Provera).
One other notable discovering is the substantial state variation within the share of ladies supplied contraceptive and household planning companies. Much like our findings, an evaluation of contraceptive utilization in 37 states utilizing the 2019 Behavioral Danger Issue Surveillance System (BRFSS) amongst ladies with completely different insurance coverage sorts discovered decrease contraceptive use amongst ladies aged 18-49 within the South in comparison with the West. A few of the states that we discovered to have the best and lowest shares of contraceptive use amongst ladies with Medicaid have been additionally discovered to have greater and decrease shares of contraceptive use within the BRFSS knowledge, together with greater shares in Wisconsin and decrease shares in Arizona and Arkansas.
These variations by state may replicate the variation within the adoption of insurance policies and applications to extend entry to contraception, together with these from public well being practitioners, clinicians, and state and federal policymakers. Many initiatives to develop contraceptive entry have centered on increasing entry to postpartum LARCs. Notably, many states revised their fee insurance policies to make it simpler for suppliers to get reimbursed for quick postpartum LARCs outdoors of the worldwide maternity care payment. For instance, Louisiana and South Carolina, states that applied a separate fee construction for postpartum LARC insertions have been discovered to have the best charges of efficient contraceptive provision 60 days postpartum amongst Medicaid enrollees in 2016. These states additionally had significantly greater contraceptive provision than their neighboring states in our evaluation.
Moreover, state adoption of utilization management insurance policies can even form entry and availability of contraceptive strategies. These insurance policies embrace prior authorization for sure strategies like emergency contraception, step remedy that require beneficiaries to make use of contraceptives off a Most popular Drug Listing earlier than with the ability to use one other methodology of selection and limiting the quantity of provide a beneficiary can obtain at one time, reminiscent of a 1-month or 3-month provide somewhat than the beneficial 12-month provide.
As a result of private nature of reproductive well being care decisions together with contraceptive use and the historical past of reproductive coercion in lots of communities within the US, there is no such thing as a agreed upon benchmark for contraceptive provision and methodology combine. Nonetheless, details about the supply of companies and the way use varies by state and populations supplies policymakers and clinicians vital insights in regards to the variations throughout states and units a baseline for the examine of future coverage modifications and initiatives.
Strategies
This evaluation relies on claims knowledge from the Remodeled Medicaid Statistical Info System (T-MSIS) Analysis Identifiable Information (RIF). Knowledge for 2018 have been from the ultimate model (Launch 1) of those information. This evaluation was restricted to females ages 15-49 constantly enrolled in Medicaid with not more than a 45-day hole in enrollment in the course of the yr. This definition of steady enrollment was chosen to align with CMS’ Grownup and Baby Set Core Measures, particularly, these round contraceptive provision, and to present folks ample time in Medicaid to entry contraceptive and household planning companies.
We excluded the next states from our evaluation attributable to considerations with the standard of their enrollment knowledge: Florida, Kentucky, Mississippi, Nebraska, Oklahoma, Utah, and Wyoming. We relied on knowledge high quality assessments from DQ Atlas to exclude states based mostly on knowledge high quality scores of the next indicators: (1) Enrollment Benchmarking: Medium concern for Whole Medicaid and CHIP Enrollment (Mississippi, Nebraska, and Kentucky), (2) Enrollment Patterns Over Time: Variety of Enrollment Spans – % of Beneficiaries with Solely One Enrollment Span in 12 months ≥ 99.8 (Florida, Wyoming), (3) Enrollment Patterns Over Time: Variety of Enrollment Spans – % Beneficiaries with 3 or Extra Enrollment Spans in 12 months ≥ 5% (Oklahoma). Moreover, we excluded Utah due to a considerably decrease price of steady enrollment, which can be attributable to an administrative error the place a lot of enrollees have been disenrolled from April 31, 2018 to June 1, 2018. The evaluation was restricted to 2018 claims, so enrollees that will have been enrolled within the earlier or subsequent yr however had a couple of 45-day hole in enrollment in 2018 have been truncated and excluded from the constantly enrolled inhabitants for the 2018 calendar yr. Knowledge replicate enrollment in any eligibility pathway in addition to any fee construction (FFS, managed care, and so on.)
Contraceptive claims have been captured from the 2018 T-MSIS header and line information for “different companies” claims and prescription drug claims, in addition to the header information for inpatient claims for provision of feminine sterilization, intrauterine gadgets (IUDs), contraceptive implants, injectables, contraceptive capsules, contraceptive patches, contraceptive rings, diaphragms, female and male condoms, emergency contraception, counseling for fertility-awareness based mostly strategies, contraceptive counseling, and contraceptive administration and surveillance of different contraceptives. Household planning companies included any contraceptive claims, in addition to claims for sexually transmitted an infection (STI) screening, gynecological exams and pap smears, Human Immunodeficiency Virus (HIV) counseling and screening, and Human Papillomavirus (HPV) screening. In response to the DQATLAS, the next states had unusable knowledge for a number of information: Rhode Island (inpatient claims quantity), Tennessee (inpatient analysis codes), Maryland (inpatient process codes), and Utah (different companies skilled process codes). Because the different knowledge, significantly for the “different companies” information and RX information the place the vast majority of household planning and contraceptive service claims are discovered, we didn’t exclude any states based mostly on these scores.
The share of beneficiaries supplied contraceptive companies included any feminine ages 15-49 constantly enrolled in Medicaid with at the least one contraceptive service declare in 2018. The share supplied household planning companies included any feminine ages 15-49 constantly enrolled in Medicaid with at the least one declare for contraceptive companies, sexually transmitted an infection (STI) screening, gynecological exams and pap smears, HIV counseling and screening, and HPV screening. A listing of analysis, process, and drug codes that have been used for this evaluation can be found upon request.
Appendix Tables