Myths die hard in medicine, and that’s certainly true when it comes to long-acting reversible contraceptives (LARCs).
Today LARCs are one of the safest and most-effective types of reversible birth control, but their reputation took a huge hit in the 1970s thanks to the Dalkon Shield intrauterine device (IUD). Memories persist of news reports about the shield’s many defects, which included triggering miscarriages and fatal infections, says Evelyn Delgado, president and executive director of Healthy Futures of Texas, a San Antonio nonprofit dedicated to reducing teen and unplanned pregnancies.
“What we hear sometimes from young women is that their mothers have told them that LARCs are not good because they’ll make them infertile or they can get cancer or things like that,” Ms. Delgado said. “And that probably is from that history way back when.”
This mistrust of LARCs — along with other obstacles to their wider use — hamper progress toward a wider goal for Texas medicine: improving maternal health and reducing maternal deaths across the state, says David Lakey, MD, vice chancellor for health affairs and chief medical officer at The University of Texas System.
That’s a serious concern for public health officials because maternal mortality rates are high both in Texas and the United States. Texas has the fourth-highest birth rate among U.S. states, and 31 percent of Texas women in 2016 reported their pregnancy was unintended, according to the Texas Department of State Health Services (DSHS). Unintended pregnancies have been tied to maternal illness and death, according to the U.S. Centers for Disease Control and Prevention (CDC), and have a deep impact on the state’s budget. (See “Maternal Health in Texas: By the Numbers,” page 28.)
“[LARCs are] preventing the cost to the state of these unplanned pregnancies, so the state can save money overall,” Ms. Delgado said, explaining that the cost of LARCS “is way less” than the cost of a Medicaid birth and the first year of a child’s life.
LARCs, which include IUDs and contraceptive devices implanted under the skin, are seen as an effective way to address these problems. In fact, the Texas Medical Association’s eight-point plan for reducing maternal mortality calls for legislation to make LARCs more easily accessible and for continuing medical education to increase both patient and physician awareness of LARCs (www.texmed.org/8PointPlan).
In 2017, Texas lawmakers ordered the Texas Health and Human Services Commission (HHSC) to produce a five-year strategic plan for improving LARC use among Texas women. The plan was written with input from the Texas Collaborative for Healthy Mothers and Babies, which includes TMA, and was designed to identify problems, look for ways to promote education about LARCs, and recommend policy changes. (See “LARC Strategy,” right).
“[Lawmakers] were very enthused [with data from other states showing] how LARCs were able to decrease teen pregnancies and decrease abortions and save the state money,” said Dr. Lakey, who helped write the recommendations.
LARCs are generally well-liked by patients who use them in part because, once inserted, they largely eliminate concerns about birth control for a long period of time. LARCs can last for up to three years, and they are 99 percent effective in preventing pregnancies.
Yet relatively few women currently use LARCs. Only 7.2 percent of U.S. women ages 15 to 44 use IUDs and 1.6 percent use implants, according to the Guttmacher Institute, which studies reproductive issues.
The biggest obstacle to LARC use is their high upfront costs to physicians, according to the HHSC strategic plan. Texas allows physicians to purchase LARCs two ways. The first is the buy-and-bill method. Physicians can buy LARCs upfront and then keep them on site until patients need them. However, LARC devices cost an average of $500 to $1,000 each. Also, state payment for Medicaid patients does not always keep up with the ever-rising cost of LARCs. Both problems discourage physicians from using buy-and-bill for LARCs, the plan says.
One possible solution is for Texas to develop a LARC purchasing model that mimics the successful Vaccines for Children program that has been in place since 1994, Dr. Lakey says.
“The state purchases vaccines and places them in physicians’ offices, and then when they’re used the physicians just bill for the administration, not for the vaccines themselves,” he said. “So is there a way to potentially do the same for LARCs?”
The second way physicians can obtain a LARC is from a specialty pharmacy for patients on Medicaid or Healthy Texas Women, the state’s family planning program for low-income women not eligible for Medicaid. However, the state’s strategic plan points out, this too has drawbacks. It forces the woman to order the LARC device during one appointment and come back for another appointment to have it inserted — a hassle that often discourages use.
Also, if a woman does not use the device for some reason, it cannot be transferred to another patient, says Nichole Van de Putte, MD, a San Antonio obstetrician-gynecologist and member of TMA’s Committee on Reproductive, Women’s, and Perinatal Health.
“I have at least 40 devices sitting in my office because the device was ordered for the patient, and then they never came back for insertion,” she said. “The device belongs to that particular patient, and it just sits there on the shelf.”
Unclaimed devices must be either destroyed or returned to the specialty pharmacy for a refund, the HHSC strategy plan says.
LARC devices and their insertion generally are covered for patients on private insurance and Medicaid. However, contraception is not covered for women who are on the Children’s Health Insurance Program. Also, women on Medicaid who have just given birth sometimes don’t understand that their coverage runs out within 60 days of giving birth, Dr. Van de Putte says.
“If she scheduled an appointment for insertion but is unable to make that appointment, and Medicaid expires prior to her rescheduled appointment, then the insertion will often not occur,” she said. “The out-of-pocket insertion cost is simply too high, and the patient will opt to not have the device inserted.”
Bureaucratic problems in hospitals also hamper LARC use. To prevent unwanted pregnancies in women who’ve had a child, the ideal time to insert a LARC is immediately after birth, says Ms. Delgado. That ensures she’s discharged with a nearly foolproof method of contraception. However, the birth is billed as an inpatient procedure, inserting the LARC is billed as an outpatient procedure, and many hospital billing systems are not equipped to file inpatient and outpatient claims on the same day.
“There have been a lot of efforts on the part of the state to work with hospital systems [to ease this problem],” Ms. Delgado said. “But apparently the hospitals and [electronic medical records] that work on the hospital level aren’t set up to do immediate post-partum LARCs.”
Many of these hindrances can be remedied without help from the Texas Legislature. However, Texas lawmakers are likely to take up bills this session that will directly promote LARC use, for example by allowing physicians to reuse unclaimed LARCs. Other bills could boost LARCs indirectly by improving Medicaid coverage, Dr. Lakey says.
“The extension of Medicaid for the full year after the delivery of a baby [instead of 60 days] so that we can better address the health of moms, I think will be a very important issue to watch,” he said.
LARC learning curve
Physician education is another major solution to enhance LARC use, especially in rural areas, says Dr. Van de Putte. OB-Gyns are trained on educating patients about LARCs and inserting LARCs. But Texas’ long-running shortage of physicians has left many rural areas without OB-Gyns. The job of addressing LARC use, education, and insertion is left to primary care physicians in rural communities, and many of them have not had the opportunity for adequate training, she says.
“We need to increase availability and education so that LARCs are just not something an obstetrician-gynecologist can place but any adequately trained family or nurse practitioner,” Dr. Van de Putte said.
HHSC’s education efforts include a LARC toolkit for physicians and health care workers as well as bimonthly meetings with groups like TMA that have members who educate patients about LARCs. (See “LARC Resources,” page 28.)
The best patient-centered education takes place directly between a woman and her physician in the exam room, Ms. Delgado says. Most women know about the pill, but many are unaware of LARCs, how they work, possible side effects, and their effectiveness.
“That’s why the education of women by their providers is important,” she said.
Dr. Van de Putte says LARCs come with potential side effects, such as cramping, irregular uterine bleeding, and insertion risks, and physicians need to educate patients about those risks. But most side effects are manageable and temporary, and most patients report they’re glad to be done with the pill and other forms of birth control.
“They like the long-term consistency and reliability,” she said. “Overall, women tend to be very satisfied.”
Check out the American College of Obstetricians and Gynecologists’ library of resources on long-acting reversible contraceptives (LARCs), including free videos, materials for physicians and their patients, and a free e-newsletter. Also see the Texas Health and Human Service Commission’s LARCs toolkit.
Tex Med. 2019;115(1):26-29
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