Women's Health: Approaches to Improving Unintended Pregnancy Rates in the United States

Contraception and reproductive health are important aspects of women's health and of comprehensive, patient-centered care.

This issue brief summarizes the consensus of key opinion leaders whom NCQA convened, with support from Bayer, for a 2014 meeting on evidence-based approaches to reduce barriers to utilization of the most effective birth control methods.

Table of Contents

1. Introduction to Women's Health and the Importance of Contraception
2. NCQA's Women's Healthcare Summit: Evidence-based Approaches to Reducing Barriers to Utilization of the Most Effective Methods of Birth Control
3. Understanding the Importance and Impact of Unintended Pregnancy
4. Summit Summary
Conclusion
References

1. Introduction to Women's Health and the Importance of Contraception

While women make up just over half the US population,1 medical research into their health needs has lagged. However, this has gradually been changing over the past 2 decades. In 1985, the Public Health Service Task Force on Women's Health Issues highlighted the need for research in women's health and issued the Women's Health: Report of the Public Health Service Task Force on Women's Health Issues.2 It concluded that the historical lack of research focus on women's health concerns had compromised the quality of health information available to women as well as the healthcare they receive.2

More recently, in the Consolidated Appropriations Act of 2008 (PL 110-161), Congress provided the US Department of Health and Human Services (HHS) Office on Women's Health (OWH) with funds for the Institute of Medicine (IOM) "to conduct a comprehensive review of the status of women's health research, summarize what has been learned about how to diseases specifically affect women, and report to the Congress on suggestions for the direction of future research." While the committee convened to perform this review identified a number of areas where either some progress had been made in women's health research, they also identified a number of conditions on which little progress had been made in reducing incidence, morbidity, or mortality. Unintended pregnancy and autoimmune disease were examples of conditions for which there had been little progress.2

Effective contraceptives are available to prevent pregnancy, and research has identified several risk factors for unintended pregnancy, but rates of unintended pregnancy have remained steady for decades. That unintended pregnancy continues to occur at a high rate points to the need for research on how to improve knowledge of contraceptive regimens and reduce barriers to contraceptive adherence, the need to develop contraceptives that are more acceptable to cultures in which unintended pregnancy occurs with greater frequency, and the need for social- and community-level interventions to decrease untended pregnancy.2

2. NCQA's Women's Healthcare Summit: Evidence-based Approaches to Reducing Barriers to Utilization of the Most Effective Methods of Birth Control

With support from Bayer, the National Committee for Quality Assurance (NCQA) convened a meeting of key opinion leaders (KOLs) for a consensus development conversation on clinical, evidence-based approaches to reduce barriers to utilization of the most effective methods of birth control. Specifically, the objectives of this Summit were to:

  • Identify areas of consensus that drive evidence-based interventions to reduce the barriers to utilization of the most effective contraception methods
  • Build upon current initiatives and guidelines to reduce the barriers to utilization of the more effective contraceptives for optimal family planning
  • Identify and prioritize actionable opportunities to address gaps in healthcare for patients, providers, and payers

The statements and views in this paper do not necessarily reflect the views of any particular participant or organization that participated in the Summit.

3. Understanding the Importance and Impact of Unintended Pregnancy 

Consistent with the identification of unintended pregnancy as a condition on which there has been little progress, a number of federal and local initiatives have been implemented to address opportunities that impact the issue. Of these, the Healthy People 2020 goal to improve pregnancy planning and spacing, and prevent unintended pregnancy has brought the issue to the nation's attention and provides the motivation to monitor progress toward achieving that goal.3,4 In addition, the implementation of the Affordable Care Act (ACA) helps make prevention affordable and accessible for all Americans by requiring health plans to cover preventative services and eliminating cost sharing for those services.5 Plans in the health insurance marketplace must cover contraceptive methods and counseling for all women, as prescribed by a healthcare provider.6 These plans must cover services without charging a copayment or coinsurance when they're provided by an in-network provider, including all US Food and Drug Administration (FDA)-approved contraceptive methods and sterilization procedures as well as patient education and counseling for all women with reproductive capacity.6

  • In 2008, there were 54 unintended pregnancies for every 1000 women aged 15-448
  • The proportion of women expected to have an abortion by age 45 is 3 in 10. Most abortions are the result of unintended pregnancies, and the continued overrepresentation of certain subpopulations among abortion patients would suggest that these groups have an unmet need for contraceptive and family planning services9
  • The US unintended pregnancy rate is significantly higher than the rates of many other developed countries10

Cost of Unintended Pregnancy

Taxpayers spend about $12 billion annually on publicly financed medical care for women who experience unintended pregnancies and on infants who were conceived unintentionally. After accounting for the fact that some of these pregnancies are merely mistimed while others are altogether unwanted, we also estimate that taxpayers would save about half of this amount if all unintended pregnancies could be prevented.11

  • In 2010, two-thirds (68%) of the 1.5 million unplanned births were paid for by public insurance programs, primarily Medicaid. In comparison, 51% of births overall and 38% of planned births were funded by these programs12
  • In 8 states and the District of Columbia, at least 75% of unplanned births were paid for by public programs. Mississippi was the state with the highest proportion (82%), and the District of Columbia's proportion was 85%12
  • Total public expenditures on unintended pregnancies nationwide were estimated to be $21.0 billion in 2010. Of that, $14.6 billion were federal expenditures and $6.4 billion were state expenditures12
  • In 19 states, public expenditures related to unintended pregnancies exceeded $400 million. Texas spent the most ($2.9 billion), followed by California ($1.8 billion), New York ($1.5 billion), and Florida ($1.3 billion)12

The human cost of unintended pregnancy is high. Women must either carry on unplanned pregnancy to term and keep the baby, make the decision for adoption, or choose to have an abortion.13 Women and their families may struggle with this challenge for medical, social, legal and financial reasons.13 However, a number of studies have shown that the prevalence can be curbed by policies such as evidence-based teen pregnancy prevention programs, expansions in subsidized family planning services, and media campaigns about contraceptive use.11 The NCQA Summit provided an opportunity to review emerging initiatives and offer insights and recommendations on how to reduce the barriers to utilization of the most effective methods of birth control as well as draw increased attention to the need to reduce unintended pregnancy rates.

4. Summit Summary

Recently, there has been a groundswell of support among researchers and advocates to shift contraception utilization to more effective methods. Multiple stakeholders see the value of long-acting reversible contraceptive (LARC) methods in reducing the high levels of unintended pregnancy. With the release of updated, aligned clinical guidelines and emergence of federal strategies to promote improvements in family planning, now is an opportune times to leverage existing research and inform recommendations about effective contraception.

In addition to the clinical guidelines supporting LARC use, the US Selected Practice Recommendations for Contraceptive Use indicate that contraceptive method effectiveness is critically important in minimizing the risk for unintended pregnancy, particularly among women for whom an unintended pregnancy would pose additional health risks. Methods that depend on consistent and correct use by clients have a wide range of effectiveness between typical and perfect users. IUDs and implants are considered LARCs; these methods are highly effective because they do not depend on regular adherence from the user. LARC methods are appropriate for most women, including adolescents and nulliparous women. All women wishing to prevent pregnancy should be counseled about the full range and effectiveness of contraceptive options for which they are medically eligible so that they can identify the optimal method in consultation with their healthcare provider.17

As with national clinical guidelines released with consistent recommendations around the use of LARCs, a number of state initiatives have emerged that show promise in addressing the system barriers. The following are brief summaries of each initiative that offer the potential for adoption and adaptation in additional settings and localities.

Illinois Family Planning/Healthy Women

Family Planning Action Plan: Increase access to family planning services for women and men in the Medicaid program by providing comprehensive coverage to ensure that every pregnancy is a planned pregnancy.18

Policy and Payment Changes18:

  • Increase reimbursement rates for insertion and removal of LARCs
  • Allow an evaluation/management visit on the same day as LARC insertion or removal
  • Allow fee-for-service billing for federally qualified health centers (FQHCs) and rural health centers for transcervical sterilization devices
  • Increase vasectomy reimbursement rates
  • Increase medical dispensing fee add-on for certain 340B birth control methods

North Carolina Pregnancy Medical Home (PMH)18

Goal: Improve the quality of care and outcomes as well as reduce costs in the pregnant Medicaid population. Incentives include a $150 payment for the postpartum visit if completed within 60 days of delivery.

PMH Care Pathways18:

  • Provide standardized clinical guidance to PMH providers statewide
  • Pathways for postpartum care and reproductive life planning/LARC to be released (date TBD)
  • Addresses the use of immediate and later postpartum LARCs and ensures receipt of a well-matched contraceptive method

St. Louis, Missouri Contraceptive CHOICE Project

Goal: Remove the financial barriers to contraception, promote the most effective methods of birth control, and reduce unintended pregnancy in the St. Louis area.19 The project provided no-cost, reversible contraception to participants for 2-3 years with the goal of increasing uptake of LARCs and decreasing unintended pregnancy in the area.20

CHOICE Successes:

  • Providing no-cost contraception to teens in the CHOICE Project dramatically reduced the teen pregnancy and abortion rate. Of the 1404 teens in the project, 72% chose a LARC method. The teen pregnancy rate was 34.0 per 1000 teens compared with the national average of 158.5 per 1000 teens. Additionally, the abortion rate for teens in the CHOICE project was 9.7 per 1000 teens compared with the national average of 41.5 per 1000 teens19
  • Researchers found that Hispanic women in the CHOICE Project were more likely to choose a LARC method when compared with non-Hispanic black and non-Hispanic white participants. Hispanic women also experienced high continuation and satisfaction rates with LARC methods, which is consistent with the findings from the entire CHOICE cohort19

Despite the recent release and updated reaffirmations of clinical guidelines, the rates of unintended pregnancy have remained stagnant. Thus, the Summit participants were asked to identify barriers at the various levels of the healthcare system.

Identified Barriers

There are numerous barriers in the healthcare system that have limited the ability to affect the unintended pregnancy rate. The panel tended to classify barriers in the following buckets: patient, provider, and system. The following are the barriers that garnered the most attention.

System Barrier: Operational/Process Issues

The most noted barrier to LARC usage was operational or administrative process issues, including financing, data capture, and opportunity for same-day insertion. Attendees agreed that there are systemic barriers that prevent women from receiving an IUD. While the panel agreed that LARCs should be offered to all women not considering pregnancy in the next 2 years, financial and logistical obstacles inhibit increased usage. Simplifying access to LARCs when patients want them would be a critical lever to increasing utilization. Dr. Hurtado commented, "You could talk in any context you want. You can talk as much as you want, but if you don't have the systems problems solved, you'll have an unhappy outcome."

Same-day insertion was a significant barrier discussed. As. Dr. Peipert said, "We learned from the CHOICE Project that you lose them (women) when you ask them to come back and rarely have another chance."

Added Joan Henneberry, "We all like to blame the insurance companies for making LARC utilization so difficult, but we also have to look at provider behavior. It is much easier for them to write a prescription and be done with it than go through the various steps to place an IUD."

In addition to access and convenience factors, operational barriers that were identified include:

  • Inventory/upfront costs to stock LARCs
  • Lack of clear understanding of billing/reimbursement processes
  • Reimbursement policies: inability to bill for the visit and placement on the same day
  • Abundance of paperwork
  • Required tests (PAP/sexually transmitted disease [STD]/pregnancy)
  • Lack of preparedness/resource availability to offer same-day placement

"I'm sure a minority of providers buy and bill because you have to have a very streamlined process to manage inventory, cost, and reimbursement and make sure the patient is covered. Using specialty pharmacies also has its hurdles. Bottom line: the process for access has to be made much easier," said Dr. Ahuja.

The group felt strongly that operational issues are the crux of the matter and that utilization will not increase dramatically until they are addressed, regardless of awareness, desire, and demand. While operational issues impose significant barriers to moving the needle on unplanned pregnancies, they are not the only issue impacting the problem.  

System Barrier: When the Message is Delivered

There are multiple times in a woman's reproductive life cycle where discussions about contraception are appropriate. The group was unanimous in agreeing that the postpartum approach to contraceptive care needs to be redesigned. Many women in both the commercial and Medicaid populations do not attend their 6-week postpartum visit, which is customary time to discuss and prescribe contraception.

As one participant said, "while most women don't come back for their postpartum visit, they do bring their babies in at 2 weeks for their well visits. There has to be a way to link these 2 together."

System Barrier: Lack of Quality Measure

Measuring and reporting on healthcare quality is extremely important; it gives consumers and employers the ability to make informed choices and pursue the best available care.21 But healthcare quality assessment is about more than just informing buyers and consumers of their options.21 It's also about giving feedback to health plans, medical groups, and doctors that they can use to address quality issues and improve over time.21 Although the Center for Medicaid and CHIP Services (CMCS) Maternal and Infant Health Initiative, which focuses largely on women's health, will start collecting a voluntary contraception utilization measure from state Medicaid agencies in early 2015,22 there is not a currently endorsed and implemented quality measure assessing family planning. KOLs support the development and implementation of measures that will offer opportunities for both quality improvement and accountability at various levels of the healthcare system. However, one of the key obstacles to measure implementation is the availability of data necessary to capture the key aspects of care that are being measured. The group acknowledged that electronic health records (EHRs) and current claims data will not support a robust measure that could motivate change in clinical practice. One of the concepts that the panel embraced is the consideration of family planning as a "vital sign" and requirement for annual patient evaluations. This "vital sign" could be built into EHRs and should be promoted by reimbursement policies in order to support the data collection necessary to implement appropriate quality measures.

Provider Barrier: Current Counseling Approach

Research evidence indicates that there are strong positive relationships between a healthcare team member's communication skills and a patient's willingness to follow through with medical recommendations, self-manage a chronic medical condition, and adopt preventive health behaviors. The group agreed that an evidence-based approach that takes into account patient preferences, health literacy, and cultural beliefs would be advantageous.

The KOLs acknowledged that the lack of current counseling approach between a clinician and patient is a significant barrier. They indicated that current messaging is often not framed in the right way, strong enough to stress the importance of contraception decisions, or communicated in terms that warrant serious consideration of more effective methods of contraception. In addition, there was a discussion about educating women on the risks of pregnancy and various contraceptive methods. Dr. Ahuja spoke of the economics of pregnancy. He felt it was critical that during counseling, women be educated that having a child is probably the most important economic decision of their life and that having a child changes their whole life's course.

According to a 2011 Brookings Institute Brief, unintended pregnancy is also associated with an array of negative outcomes for the women and children involved. For example, relative to women who become pregnant intentionally, women who experience unintended pregnancies have a higher incidence of mental health problems, less stable romantic relationships, experience higher rates of physical abuse, and are more likely to have abortions or to delay the initiation of prenatal care. Children whose contraception was unintentional are also at greater risk than children who were conceived intentionally of experiencing negative physical and mental health outcomes and are more likely to drop out of high school and to engage in delinquent behavior during their teenage years.11

The term "family planning" was also disputed as effective since it literally denotes planning for a family and excludes women who are not planning a family. Instead of focusing on the phrase "planning to get pregnant," the provider should focus on the patient's feelings about pregnancy. As a mechanism to move toward informed decision making, the group discussed the possibility of clinicians extending the conversation beyond pregnancy to focus on the lifelong responsibilities of being a parent, including financial obligations.

Patient Barrier: Message Delivery and Understanding

Summit attendees indicated an emerging shift in where, and by whom, women's healthcare is delivered. As the healthcare landscape changes, primary care will be the primary point of care for many women, including their reproductive care. This shift is also influenced by the guidelines related to cervical cancer screening. Since current guidelines do not recommend annual cervical cancer screening, there isn't an opportunity for other services, such as family planning. Increasingly, other providers beyond OB/GYNs will be critical to LARC counseling, prescribing, and placement. This trend is being pushed by the release of the American Academy of Pediatrics (AAP) guidelines; however, pediatricians may be ill suited to provide the full spectrum of family planning services. This evolution in healthcare delivery necessitates that contraceptive counseling and understanding of referral options be core components of primary care training.

Meeting participants agreed that a key barrier to LARC utilization is ineffective patient communication and counseling at various stages of the patient journey. Who delivers the message is also influenced by social and cultural norms for some women. Physicians and the healthcare system are not always the most trusted source of information and understanding disparities in contraception care will be important in changing patient behavior.

As Dr. Peipert discussed, "there isn't a uniform approach to contraceptive counseling. Providers have very personal, unique approaches to the conversation, which can be problematic to providing optimal contraceptive care." 

Leveraging Opportunities

With the current alignment of clinical guidelines (American Congress of Obstetricians and Gynecologists [ACOG], American Academy of Family Physicians [AAFP], AAP), Centers of Disease Control and Prevention (CDC) and Centers for Medicare & Medicaid Services (CMS) initiatives, and the prominence of LARCs on the World Health Organization's (WHO) birth control effectiveness scale, there appears to be a strong opportunity and even momentum for change and improvement. In order to promote these initiatives at the patient and provider levels, the group agreed that there needs to be substantial improvement in the what, how, and where of LARC message delivery to women. The principal point is to shift the contraceptive conversation from the least effective to most effective method, and understand the patient's reproductive plans and needs.

The group discussed at length the stubborn unintended pregnancy rate, which hovers at 50%. The unintended pregnancy rate has been immovable in the United States for decades, even with an increase in fundings, educational programs, and the availability of effective birth control options. As with the barrier conversation, participants discussed where there were levers or opportunities to change provider, patients, and system behaviors.

1. Care Coordination

Given the shift in the United States to a more primary-care-based model (ie, PCMH), the focus of contraceptive care counseling is likely to shift from OB/GYNs to pediatricians, family physicians, internists, and other healthcare professionals, such as nurse practitioners (NPs) and physician assistants (PAs). With this shift, it is plausible that other than obstetrical care, the primary care office may have increased responsibilities for contraception care as well as women's preventive care, including breast and cervical cancer screening. Thus, there would be an increased need for coordination between the OB/GYN and primary care practices, with the latter reinforcing the need for LARCs and helping to remind patients to continue ongoing care with OB/GYN practices for contraceptive management. The group agreed that contraceptive counseling should be taking place in the primary care setting (eg, medical homes, FQHCs). The group also discussed that the provider may not necessarily be the one having the conversation -- other clinicians in the practice can have the conversation (eg, medical assistants, PAs, NPs). This might be advantageous for a host of reasons, including cultural relevance as well as time and cost efficiencies.  

There was unanimous agreement that pediatricians, internal medicine, and family practice providers should be providing contraceptive counseling at various points in the patient's journey. However, since the primary care practitioners are not always well versed in reproductive care, training and education need to be instituted regarding contraceptive care. In order to ensure the success of a collaborative model of care, the experts recommended the development of a clinical care pathway that would start with primary care education, move through the most effective counseling approaches, and ultimately to training on LARC placement or referral, where appropriate. There are existing pathways in other practice areas that could serve as the basis for a Family Planning Pathway. For example, in behavioral healthcare, there is an emergence toward integrated care where services span both the primary care and specialty arenas. Dr. Ahuja talked about University Hospital's approach to integrating pediatric practices into the gynecological pathway. "The facility has a coordinated effort to educate pediatricians and offer support and referrals when necessary. Some of this can be incorporated into a roadmap that highlights a standardized pathway." 

Performance or quality measures can be useful for assessing and monitoring the success of practice patterns, guideline recommendation implementation, and quality improvement initiatives. There was agreement that a quality measure would also be beneficial in making a model successful.

2. Solving Access Barriers and Promoting Consistent Messaging

As summarized earlier, the Summit participants provided direction on the key concepts they felt needed to be addressed to overcome contraception barriers. These included defining and mapping a care coordination pathway that includes:

  1. Primary care and general practitioner training on contraceptive care and counseling
  2. A step-by-step process on how to ask about pregnancy planning that includes a standardized, validated questionnaire about readiness and intent for pregnancy, provides contraceptive recommendations based on identified patient needs, and offers a road map on how to manage the patient and connect them with an OB/GYN for placement
    1. Similar to depression and substance abuse screening and brief interventions, a uniform approach should be implemented whereby providers ask a series of questions to understand the patient's life course and needs, which will drive contraceptive offerings. The consensus was that if the patient is not planning to have a child in the next 2 years, LARCs should always be offered as an option. Some counseling questions could progress as follows:
      • Are you sexually active?
      • Do you plan to be pregnant in the next year?
      • How would you feel if you became pregnant in the next year?
      • Do you plan to be pregnant in the next 2 years?
      • How would you feel if you became pregnant in the next 2 years?
      • Are you ready to be a parent and responsible for a child?
      • Are you ready to be financially responsible for a child?

In addition, the CDC has produced a Guide to Taking a Sexual History (http://www.cdc.gov/std/treatment/sexualhistory.pdf) that could be used as a starting point for conversation.

Consistent with the recommendation of this Summit panel, in a recent ACOG Committee on Health Care for the Underserved Women Opinion, the Committee recommended the following actions to address access issues:

  • Full implementation of the ACA requirement that new and revised private health insurance plans cover all FDA-approved contraceptives without cost sharing, including nonequivalent options from within one method category (eg, levonorgestrel as well as copper IUDs)13
  • Easily accessible alternative contraceptive coverage for women who receive health insurance through employers and plans exempted from the contraceptive coverage requirement13
  • Confidential, comprehensive, contraceptive care and access to contraceptive methods for adolescents without mandated parental notification or consent, including confidentiality in billing and insurance claims processing procedures13
  • The right of women to receive prescribed contraceptives or an immediate informed referral from all pharmacies13
  • Prompt referral to an appropriate healthcare provider by clinicians, religiously affiliated hospitals, and others who do not provide contraceptive services13
  • Institutional and payment policies that support immediate postpartum and postabortion provision of contraception, including reimbursement for LARC devices separate from the global fee for delivery, and coverage for contraceptive care and contraceptive methods provided on the same day as an abortion procedure13
  • Inclusion of all contraceptive methods, including LARCs, on all payer and hospital formularies13

A key theme of the conversations was the need to change the conversation (ie, messaging) around how healthcare providers interact with their patients and that such changes could potentially result in improved access to the most effective contraceptive methods. Additional concepts the KOLs suggested related to messaging included:

  • Introducing LARCs as low maintenance contraception for young women compared with the pill, which requires daily actions
  • Modeling interventions after the successful Text4Baby model for reminders on appointments and reinforcing the need for follow-up care, which could reduce no show rates
  • Ensuring messaging modalities cater to the appropriate audience and recognizing how specific populations want to learn (eg, use of texting, social media)
  • Promoting the use of more acceptable/less offensive terminology during counseling. For example, "placement" instead of "insertion: and "permanent birth control" instead of "sterilization"

3. Promoting Every Opportunity to Counsel and Educate

There are numerous opportunities in the care continuum for reproductive health and family planning to address patient barriers that may be contributing to the unintended pregnancy rate. When assessing intervention opportunities, it is useful to consider key points in the reproductive cycle or care delivery where women access the healthcare system.

Key concepts for ensuring appropriate intervention at the various access points include:

  • Counseling: Having the provider gain an understanding of the patient's intent and feelings about pregnancy at a specific time periods (the Summit KOLs suggested accessing the patient's intent and feelings about pregnancy in current and annual increments)
  • Education: Ensuring the patient and their partner understand contraception options, their level of effectiveness, and the level of commitment from the patient to ensure optimal use
  • Referrals: While conversations may start in the primary care setting and with the recommendation that primary care providers become well versed in contraception issues, there should always be an option for referral to an OB/GYN for LARC placement
  • Increase reimbursement rates for insertion and removal of LARCs
  • Allow an evaluation/management visit on the same day as LARC insertion or removal

In addition to identifying key intervention approaches, there is an opportunity to expand the number of opportunities to engage patients in understanding their contraception options:

  • Baby well visits: As pediatricians screen for postpartum depression in new mothers, they can also provide contraception counseling and prescribing
  • Postdelivery counseling: Provide contraceptive counseling postdelivery while they are still in the hospital. Similar to how breastfeeding guidance is provided postdelivery, before they leave the hospital. One advantage to this is that their partner is also there, so they can confer with their partner right then and make a decision together
  • Discussions with male patients: As with STDs, there is male responsibility that must be acknowledged and providers should recognize that the male partners may also be a part of the decision process
  • Preventative care: Unintended pregnancy rates are high in teenagers and very young adults; thus, starting the conversation and education about effective birth control early is important
  • Support in making informed decisions: In the new world of the ACA, there are other providers who provide contraceptive and parenting/specialty settings, such as public health nurses with nurse-family partnerships in home and group settings. Alternative professional roles in home visitation programs have the potential to be of great value in supporting women in making informed decisions

4. Identification and Development of Quality Measures/ Quality Improvement Programs

The development and implementation of quality measures to assess and drive quality improvement in reducing unintended pregnancy was of great interest to the Summit participants. Current measurement approaches are developing and include the previously mentioned Healthy People 2020 goal as well as related objectives. In addition, CMCS has launched a maternal and infant health initiative that focuses on state collaboration to improve maternal and child health outcomes in Medicaid and CHIP. There are 2 specific areas of focus22:

  • Increasing the rate and content (ie, reproductive planning services, counseling) of postpartum visits
  • Increasing the rate of pregnancies that are intended

These goals consider the critical benefits that can be realized when women receive appropriate and timely postpartum care. Regular postpartum visits have positive implications for the woman's health, infant's care and health, and also subsequent pregnancies. In addition, reproductive planning that includes access to contraception, either during the immediate postpartum period or during any other time in the reproductive continuum, allows for appropriate birth spacing and improved access to services that can, in turn, improve perinatal outcomes.22

The initiative has identified that current public and private reimbursement mechanisms do not align well with achieving good perinatal outcomes. Subsequently, CMCS is promoting payment program and coverage policies to enhance provider service delivery for the use of effective contraception and timely postpartum care to increase access. Progress is to be assessed through voluntary reporting of quality measures.22

While there is not a current Healthcare Effective Data and Information Set (HEDIS®) measure focused specifically on contraception use, there is a measure on postpartum care that is used for health plan reporting as well as included in the Medicaid Adult Core Set of Measures: Percentage of Medicaid/CHIP deliveries of live births between November 6 for the year prior to the measurement year and November 5 of the measurement year that had a postpartum visit on or between 21 and 56 days after delivery.18

5. Conclusion

Unless coordination and collaborative efforts are made to address unintended pregnancy and thus make progress toward improving this critical aspect of women's health, the needle will not move below a rate of 50% of pregnancies being unintended. With the emergence of federal, state, and local initiatives, as well as convergence of clinical guideline recommendations across specialties, it appears that there is sufficient evidence as will to support major changes in the delivery of reproductive and family planning care in the United States. However, success will be highly dependent on a commitment to promoting these guidelines and the use of effective counseling and education, especially in primary care.

As ACOG outlined earlier, there are various reimbursement, payment, and product availability challenges that should be prioritized. The Summit attendees also had some ideas on potential methods to overcome operational barriers. These included:

  • Promote care pathways across primary care and specialties and integration into PCMHs or other recognition programs
  • Implement payment mechanisms/reimbursement strategies that allow postpartum/postdelivery visit LARC placement
  • Drive payment reform, especially through the Medicaid and CHIP programs, including pay-for-performance programs based on measures of family planning (which may foster similar actions from private payers)
  • Incentivize Health Resources and Services Administration to enforce family planning data reporting requirements of FQHCs and link reporting to reimbursement

NCQA acknowledges the presence of quality gaps in regards to unintended pregnancy and use of effective contraception and encourages the use of nationally endorsed clinical guidelines through recognition programs and clinical quality measures. Aligned with NCQA's mission to improve the quality of healthcare, NCQA is interested in understanding how to close these gaps in women's health, including those related to family planning. NCQA's PCMH Recognition Program is a practice-based evaluation for clinicians who provide care in primary care specialties. A requirement for PCMH Recognition is for practices to select clinical conditions (eg, acute, chronic, preventive, behavioral health) and appropriate clinical guidelines aligned with those conditions to guide clinical care. While NCQQA does not prescribe specific guidelines for practices to select for their quality improvement efforts, the PCMH program narrative contains examples for consideration. As NCQA continues exploring mechanisms to drive quality improvement for women's health, this may be one way to promulgate the importance of family planning in the primary care specialties.

NCQA is aware of postpartum measure development under way by federal agencies. Given that contraceptive usage is not a one-size-fits-all concept and is driven by highly personal religious and cultural values, it would be very difficult to develop measurement standards that capture the level of risk or benefit of contraceptives to the individual. It is especially important to take a multistakeholder approach into consideration for all measure development processes.

References

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