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Access to Removal of Long-acting Reversible Contraceptive Methods Is an Essential Component of High-Quality Contraceptive Care

  • Julia Strasser
    Correspondence
    Correspondence to: Julia Strasser, MPH, DrPH (c), Department of Health Policy, Milken Institute School of Public Health, The George Washington University, 950 New Hampshire Ave NW, 620L, Washington, DC 20052. Phone: (202) 994-4294; fax: (202) 994-3773.
    Affiliations
    Jacobs Institute of Women's Health, Milken Institute School of Public Health, George Washington University, Washington, DC

    Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, Washington, DC
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  • Liz Borkowski
    Affiliations
    Jacobs Institute of Women's Health, Milken Institute School of Public Health, George Washington University, Washington, DC

    Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, Washington, DC
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  • Megan Couillard
    Affiliations
    Jacobs Institute of Women's Health, Milken Institute School of Public Health, George Washington University, Washington, DC

    Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, Washington, DC
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  • Amy Allina
    Affiliations
    Jacobs Institute of Women's Health, Milken Institute School of Public Health, George Washington University, Washington, DC
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  • Susan F. Wood
    Affiliations
    Jacobs Institute of Women's Health, Milken Institute School of Public Health, George Washington University, Washington, DC

    Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, Washington, DC
    Search for articles by this author
      In the United States, nearly one-half of all pregnancies are unintended, at a rate of almost 3 million unintended pregnancies per year (
      • Finer L.B.
      • Zolna M.R.
      Declines in unintended pregnancy in the United States, 2008-2011.
      ). Although the rate of unintended pregnancy remains high, particularly in comparison to other developed countries, the United States has seen moderate declines in rates of both unintended pregnancy and abortion in recent years (
      • Finer L.B.
      • Zolna M.R.
      Declines in unintended pregnancy in the United States, 2008-2011.
      ). One important factor contributing to these declines is increased use of more effective methods of contraception such as subcutaneous hormone-releasing implants and intrauterine devices (IUDs), known as long-acting reversible contraceptive (LARC) methods (
      • Finer L.B.
      • Zolna M.R.
      Declines in unintended pregnancy in the United States, 2008-2011.
      ).
      Recent data show that approximately 7.2% of all U.S. women ages 15 to 44 used a LARC method in 2011 through 2013, up from only 1.5% in 2002 (
      • Branum A.M.
      • Jones J.
      Trends in Long-acting Reversible Contraception Use Among US Women Aged 15–44.
      ). Among women who used any method of contraception, 11.6% used a LARC method in 2009 through 2012, up from 2.4% in 2002 (
      • Kavanaugh M.L.
      • Jerman J.
      • Finer L.B.
      Changes in use of long-acting reversible contraceptive methods among U.S. women, 2009–2012.
      ). These recent increases took place despite persistent barriers, including high costs. In late 2012, the contraceptive coverage mandate of the Affordable Care Act (ACA) went into effect, requiring most insurers to cover all U.S. Food and Drug Administration–approved contraceptive methods without cost sharing. Although the policy was not specifically focused on LARC methods, it was designed to eliminate cost barriers associated with contraceptive methods, which is particularly important for LARC methods because of their high upfront costs. However, as of late 2015, LARC use had not increased significantly under the new policy (
      • Bearak J.M.
      • Jones R.K.
      Did contraceptive use patterns change after the Affordable Care Act? A descriptive analysis.
      ), and other barriers may still be playing a role in women's ability to use a LARC method.
      Barriers to removal may inhibit uptake of LARC methods. Although the relationship between access to removal and interest in obtaining a LARC method may not be immediately intuitive, impediments to LARC removal could discourage women from obtaining a LARC method because they lack assurance that removal will be an option when they want or need it. Unfortunately, many women encounter challenges to getting a LARC device removed. In particular, women may encounter resistance from providers—whether explicit or implicit—when they raise the possibility of removal, and barriers from insurers in covering this service. A central tenet of high-quality health care is respect and support for women's decisions, and this principle must apply to both starting and stopping any contraceptive method.

      Providers’ Role in Ensuring Reproductive Autonomy

      Patient-centered counseling is a critical part of contraceptive care for all women. Research suggests that women prefer to control the ultimate selection of their contraceptive method and to receive providers’ input in ways that prioritize and value their goals and preferences (
      • Dehlendorf C.
      • Levy K.
      • Kelley A.
      • Grumbach K.
      • Steinauer J.
      Women's preferences for contraceptive counseling and decision making.
      ). Dehlendorf and others have encouraged taking a “shared decision making approach” for choosing a particular method (
      • Dehlendorf C.
      • Krajewski C.
      • Borrero S.
      Contraceptive counseling: best practices to ensure quality communication and enable effective contraceptive use.
      ). The same must be true for removing a method as well.
      Although LARC methods are effective for 3 to 12 years, there is no medical reason to require someone using a LARC method to keep the device to the end of its effective life. However, interviews with women who considered elective IUD removal within 9 months of insertion found many of the study participants “reported that their providers communicated a preference, explicitly or implicitly, for them to keep the IUD” (
      • Amico J.R.
      • Bennett A.H.
      • Karasz A.
      • Gold M.
      “She just told me to leave it”: Women’s experiences discussing early elective IUD removal.
      ). Participants' comments suggest that providers may have been concerned about patients using less effective methods in place of the LARC method or may have predicted that side effects would subside after several months of use (
      • Amico J.R.
      • Bennett A.H.
      • Karasz A.
      • Gold M.
      “She just told me to leave it”: Women’s experiences discussing early elective IUD removal.
      ). Although such concerns may be rooted in desires to help patients avoid unintended pregnancy, patients who reported that their providers resisted removal were less likely to be satisfied with the visit and more likely to experience frustration (
      • Amico J.R.
      • Bennett A.H.
      • Karasz A.
      • Gold M.
      “She just told me to leave it”: Women’s experiences discussing early elective IUD removal.
      ). Women seeking LARC methods may want a highly effective method for only a year or a few years, and a LARC method may be the best option for women in these circumstances. Providers must respect women's preferences about the timing of contraceptive method use, as well as the selection of the type of method.
      Reports of clinician bias toward keeping LARC methods are particularly concerning among vulnerable populations.
      • Gomez A.M.
      • Fuentes L.
      • Allina A.
      Women or LARC first? Reproductive autonomy and the promotion of long-acting reversible contraceptive methods.
      note that “the long-standing devaluation of the fertility and childbearing of young women, low-income women and women of color in the United States, and the perception that these women have too many children” may implicitly or explicitly result in practices or policies that encourage these populations to obtain and keep LARC methods, regardless of patient preferences. A recent survey focusing on women of color found that 3% of participants reported that IUDs had been misused against people in their communities, and 9% reported that to be the case for the contraceptive implant (
      • Burns B.
      • Grindlay K.
      • Dennis A.
      Women’s awareness of, interest in, and experiences with long-acting reversible and permanent contraception.
      ).
      Populations who have historically experienced the most severe restrictions on reproductive autonomy in the United States may consider the ability to stop using contraception at any time particularly important (
      • Strasser J.
      • Borkowski L.
      • Couillard M.
      • Allina A.
      • Wood S.
      Long-acting reversible contraception: Overview of research & policy in the United States (Bridging the Divide).
      ).
      • Jackson A.V.
      • Karasek D.
      • Dehlendorf C.
      • Foster D.G.
      Racial and ethnic differences in women’s preferences for features of contraceptive methods.
      found that non-Hispanic Black, Latina, and Asian Pacific Islander women seeking services from abortion and family planning clinics were more likely to report that being able to stop using a method at any time was an “extremely” important contraception feature than were non-Hispanic White women. Providers must acknowledge and respond to these preferences and concerns in ways that recognize their validity as factors in a woman's contraceptive decision making.

      Costs and Insurance Coverage for Removal

      High costs associated with LARC methods may affect both patients' and providers’ approaches toward removal. ACA regulations currently remove the financial barrier of cost-sharing for contraception for most women with private insurance and some women covered by Medicaid (
      • Becker N.V.
      • Polsky D.
      Women saw large decrease in out-of-pocket spending for contraceptives after ACA mandate removed cost sharing.
      ,

      HealthCare.gov. (2016). Available at: https://www.healthcare.gov/. Accessed: April 13, 2016.

      ). Private insurance plans are required to cover insertion, follow-up management, and removal of contraceptive devices, including LARC methods, although insurers may impose “reasonable medical management” strategies (). Before the enactment of the ACA, however, the cost of LARC methods was a significant barrier to use (
      • Gariepy A.M.
      • Simon E.J.
      • Patel D.A.
      • Creinin M.D.
      • Schwarz E.B.
      The impact of out-of-pocket expense on IUD utilization among women with private insurance.
      ), and studies have found that in the first few years after implementation of the law, coverage for LARC methods varied from plan to plan owing to the imposition of medical management techniques (
      • Sobel L.
      • Salganicoff A.
      • Kurani N.
      Coverage of contraceptive services: A review of health insurance plans in five states.
      ). As a result, women may continue to face significant financial barriers to obtaining a LARC method or having one removed.
      Medicaid coverage of LARC removal varies from state to state. Some states implement payment policies that, in effect, deny reimbursement for removal by imposing additional requirements or cost-sharing regulations (
      • Armstrong E.
      • Gandal-Powers M.
      • Levin S.
      • Kimber Kelinson A.
      • Luchowski A.T.
      • Thompson K.
      Intrauterine devices and implants: A guide to reimbursement.
      ). A recent study found that at least four states restrict Medicaid coverage for removal of IUDs, and three states do so for implants (
      • Walls J.
      • Gifford K.
      • Ranji U.
      • Salganicoff A.
      • Gomez I.
      ). The most common restriction was to limit coverage to removals deemed “medically necessary,” with only one state explicitly allowing coverage for IUD removal to allow pregnancy.
      Furthermore, at least one state has implemented a policy denying Medicaid reimbursement for implant removal if the woman is seeking to become pregnant. South Dakota Medicaid's 2016 billing manual states, “The removal of an implant is only reimbursable by South Dakota Medicaid when due to infection, rejection or when determined medically necessary. South Dakota Medicaid will not reimburse for the removal of the implant if the intent is for the recipient to become pregnant” (
      South Dakota Department of Social Services
      South Dakota Medicaid professional services billing manual.
      ). To address policies like this one, a June 2016 letter from Centers for Medicare and Medicaid Services to state health officials explicitly instructs that state Medicaid programs’ reimbursement to providers for LARC methods must include both insertion and removal of the devices. It also encourages states to “avoid practices that … impose medically inappropriate quantity limits, such as allowing only one long acting reversible contraceptive (LARC) insertion every five years, even when an earlier LARC was expelled or removed” (
      Centers for Medicare and Medicaid Services
      Medicaid family planning services and supplies. (CMS Informational Bulletin).
      ). However, as of early 2017, South Dakota has not changed its policy on reimbursement for removal.
      Although the ACA regulation has removed or reduced the cost barrier to LARC methods for many patients, costs for providers nonetheless remain high and may influence providers' attitudes toward removal. LARC insertion costs for providers are high for two reasons: 1) stocking the devices requires a substantial upfront cost of up to $1000 per device (
      • Eisenberg D.
      • McNicholas C.
      • Peipert J.F.
      Cost as a barrier to long-acting reversible contraceptive (LARC) use in adolescents.
      ), and this cost can only be recouped when the device is inserted, and 2) the value of the clinical time spent inserting them is high compared with, for example, birth control pills, which require no clinician time for regular use. Also, some providers’ reluctance to remove LARC methods may stem from concerns that their patients will not be able to get another LARC device without incurring significant out-of-pocket costs owing to a lack of insurance coverage or insurer policies that limit the number of IUDs a woman can obtain during a certain timeframe (
      • Armstrong E.
      • Gandal-Powers M.
      • Levin S.
      • Kimber Kelinson A.
      • Luchowski A.T.
      • Thompson K.
      Intrauterine devices and implants: A guide to reimbursement.
      ). Thus, improving insurance reimbursement policies goes hand in hand with changing provider attitudes toward removal.
      Private insurance and Medicaid coverage for removal are essential to ensuring that any woman who wants to stop using a LARC method can do so. At the same time, policymakers should develop pathways for women to have LARC devices removed even if they become uninsured. Without such assurances, women with a history of unstable insurance coverage may be understandably reluctant to begin using a LARC device, even if an IUD or implant would otherwise be their preferred method. Conversely, creating a system that makes LARC removal easy at any time and allows for use for 1 to 2 years could result in more women seeing these highly effective forms of contraception as viable options.

      Ensuring Autonomy

      Improving access to LARC methods for women who wish to obtain them is an essential component of providing high-quality contraceptive care. Equally essential is improving access to LARC removal. Providers should respect patient preferences for removal of LARC methods, and insurers should provide coverage for removal without imposing administrative, financial, or medical barriers. Additionally, the Centers for Medicare and Medicaid Services should continue to instruct state Medicaid agencies to provide complete coverage for removal without any restrictions, and states should update policies as necessary to ensure compliance. As the health care landscape continues to shift over the next several years, we must build and improve on policies that provide women with access to the methods they want and respect their decisions to switch or stop using a method when they choose to do so.

      References

        • Amico J.R.
        • Bennett A.H.
        • Karasz A.
        • Gold M.
        “She just told me to leave it”: Women’s experiences discussing early elective IUD removal.
        Contraception. 2016; 94: 357-361
        • Armstrong E.
        • Gandal-Powers M.
        • Levin S.
        • Kimber Kelinson A.
        • Luchowski A.T.
        • Thompson K.
        Intrauterine devices and implants: A guide to reimbursement.
        ACOG, NFPRHA, NHeLP, NWLC, UCSF, 2015 (Available at: http://www.healthlaw.org/publications/browse-all-publications/LARC-Report-2015-R5. Accessed: April 25, 2017)
        • Bearak J.M.
        • Jones R.K.
        Did contraceptive use patterns change after the Affordable Care Act? A descriptive analysis.
        Women’s Health Issues. 2017; 78: 284-289
        • Becker N.V.
        • Polsky D.
        Women saw large decrease in out-of-pocket spending for contraceptives after ACA mandate removed cost sharing.
        Health Affairs (Project Hope). 2015; 34: 1204-1211
        • Branum A.M.
        • Jones J.
        Trends in Long-acting Reversible Contraception Use Among US Women Aged 15–44.
        NCHS Data Brief. 2015; : 1-8
        • Burns B.
        • Grindlay K.
        • Dennis A.
        Women’s awareness of, interest in, and experiences with long-acting reversible and permanent contraception.
        Women’s Health Issues. 2015; 25: 224-231
        • Center for Consumer Information & Insurance Oversight
        Affordable Care Act Implementation FAQs: Set 12.
        2013 (Available at:) (Accessed: April 3, 2017)
        • Centers for Medicare and Medicaid Services
        Medicaid family planning services and supplies. (CMS Informational Bulletin).
        Centers for Medicare and Medicaid Services, Baltimore, MD2016 (Available at:) (Accessed: April 25, 2017)
        • Dehlendorf C.
        • Krajewski C.
        • Borrero S.
        Contraceptive counseling: best practices to ensure quality communication and enable effective contraceptive use.
        Clinical Obstetrics and Gynecology. 2014; 57: 659-673
        • Dehlendorf C.
        • Levy K.
        • Kelley A.
        • Grumbach K.
        • Steinauer J.
        Women's preferences for contraceptive counseling and decision making.
        Contraception. 2013; 88: 250-256
        • Eisenberg D.
        • McNicholas C.
        • Peipert J.F.
        Cost as a barrier to long-acting reversible contraceptive (LARC) use in adolescents.
        Journal of Adolescent Health. 2013; 52: S59-S63
        • Finer L.B.
        • Zolna M.R.
        Declines in unintended pregnancy in the United States, 2008-2011.
        New England Journal of Medicine. 2016; 374: 843-852
        • Gariepy A.M.
        • Simon E.J.
        • Patel D.A.
        • Creinin M.D.
        • Schwarz E.B.
        The impact of out-of-pocket expense on IUD utilization among women with private insurance.
        Contraception. 2011; 84: e39-e42
        • Gomez A.M.
        • Fuentes L.
        • Allina A.
        Women or LARC first? Reproductive autonomy and the promotion of long-acting reversible contraceptive methods.
        Perspectives on Sexual and Reproductive Health. 2014; 46: 171-175
      1. HealthCare.gov. (2016). Available at: https://www.healthcare.gov/. Accessed: April 13, 2016.

        • Jackson A.V.
        • Karasek D.
        • Dehlendorf C.
        • Foster D.G.
        Racial and ethnic differences in women’s preferences for features of contraceptive methods.
        Contraception. 2016; 93: 406-411
        • Kavanaugh M.L.
        • Jerman J.
        • Finer L.B.
        Changes in use of long-acting reversible contraceptive methods among U.S. women, 2009–2012.
        Obstetrics & Gynecology. 2015; 126: 917-927
        • Sobel L.
        • Salganicoff A.
        • Kurani N.
        Coverage of contraceptive services: A review of health insurance plans in five states.
        2015 (Available at:) (Accessed: April 25, 2017)
        • South Dakota Department of Social Services
        South Dakota Medicaid professional services billing manual.
        2016 (Available at:) (Accessed: April 25, 2017)
        • Strasser J.
        • Borkowski L.
        • Couillard M.
        • Allina A.
        • Wood S.
        Long-acting reversible contraception: Overview of research & policy in the United States (Bridging the Divide).
        2016 (The George Washington University: Jacobs Institute of Women’s Health. Available at:) (Accessed: April 25, 2017)
        • Walls J.
        • Gifford K.
        • Ranji U.
        • Salganicoff A.
        • Gomez I.
        Medicaid coverage of family planning benefits: Results from a state survey.
        2016 (Available at:) (Accessed: April 25, 2017)

      Biography

      Julia Strasser, MPH, DrPH (c), is a doctoral candidate and Senior Research Associate in the Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University. Her interests include reproductive health, safety net services, and public financing.

      Biography

      Liz Borkowski, MPH, is managing editor of Women's Health Issues and a researcher in the Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University. Her interests include reproductive health, paid leave, and the Affordable Care Act.

      Biography

      Megan Couillard, BS, is an MPH student in Health Promotion at the Milken Institute School of Public Health at the George Washington University. Her interests include reproductive health, reproductive justice, and community health.

      Biography

      Amy Allina, BA, is a senior leader in policy advocacy and program development with expertise in women's health and rights, regulation of drugs and medical devices, and health care coverage. She works with Bridging the Divide, Jacobs Institute of Women's Health.

      Biography

      Susan F. Wood, PhD, is Associate Professor of Health Policy and Management and Environmental and Occupational Health and Director of the Jacobs Institute of Women's Health, Milken Institute School of Public Health, George Washington University.