As a first-time mom at age 42, Michele Garcia calls her infant son “a very happy surprise.” But, baby love aside, Garcia is sure she does not want another child.
“I would like to say, ‘One and done,’” said Garcia, a Weslaco resident.
Before her son was born in May, she made her wishes known during a prenatal visit with her doctor, Saul Rivas, an obstetrician-gynecologist with Doctors Hospital at Renaissance in Edinburg. Rivas, also a clinical assistant professor at the University of Texas Rio Grande Valley School of Medicine, talked to Garcia about Immediate Postpartum Long-Acting Reversible Contraception, also called IPLARC.
For some hospitals, implementing a IPLARC program is not so simple.
IPLARC is one of the most effective ways to prevent unplanned pregnancy, but it’s also one of the most under-used — not just in Texas but in other states. Hospitals face a variety of hurdles with IPLARC, which involves placing an intrauterine device within 15 minutes of delivery or implanting Nexplanon under the skin in the arm before a woman is discharged.
IUDs that release hormones can protect against pregnancy for three to five years, according to the Journal of the American Medical Association. The copper, hormone-free IUD protects for 10 years; while progestin implants like Nexplanon are effective for three years.
Garcia wanted to avoid hormones and opted for longest-acting IUD, which likely will be the last form of birth control she’ll ever need. The device was placed immediately after she delivered her baby.
“It was a great experience,” she said. “How easy is it just after delivering your child to have an IUD put in?”
What hasn’t been easy is launching — and sustaining — hospital-based IPLARC programs.
Divya Patel, Ph.D., an epidemiologist and assistant professor of population health in the office of health affairs at The University of Texas System, spent more than a year researching obstacles to IPLARC programs and patient adoption. They include training staff, educating patients and obtaining reimbursement for IPLARC, she said.
“What we really found is that it was challenging for hospitals to convince their leadership this was something that is financially viable,” Patel said. “Hospitals are always concerned about reimbursement … (Hospitals) that had funding sources to offset costs, they were ones able to keep things up and running.”
As for training, residents learn how to implant IUDs but not all are trained to do it immediately after delivery, she said. And many women simply don’t know about IPLARC. Mounting a statewide public education campaign isn’t a solution, though, when only a few hospitals in Texas are set up to provide IPLARC, Patel said.
State officials are helping to solve the reimbursement problem, but Tony Ogburn, M.D., a professor and chair of the obstetrics and gynecology program at the Rio Grande Valley medical school, said there’s still work to be done.
“Nirvana,” he said, “is still a distant glimmer on the horizon.”
No “One Size Fits All”
Lesley French, J.D., Texas Health and Human Services Commission deputy executive commissioner for health, developmental and independence services, agreed. “It’s been a bumpy ride for folks,” but it’s getting better, she said.
“Texas doesn’t have a one-size-fits-all billing process,” she explained. “We have 21 (Medicaid) managed care organizations across the state, and then there are almost 400 birthing hospitals.”
The state’s Medicaid program began coverage in January 2016, but managed care plans pay hospitals varying reimbursements — if they pay at all — for IPLARC. As a result, a hospital getting paid for these services depends on which MCO a Medicaid patient uses. In addition, hospitals have faced technical problems setting up billing systems for the program, she said. As with all Medicaid-covered services, contracted hospitals receive negotiated reimbursement from managed care plans, which leads to reimbursement variation among payers.
Only about a dozen hospitals in Texas have IPLARC programs, French said. She is working with a statewide committee on developing solutions to help hospitals be successful.
At Baylor Scott & White – Temple, staff were committed to IPLARC and spent many hours creating an automated billing system, including a method for splitting payments to cover fees for doctors, pharmacies and other sources, said Nathan Drever, M.D., the hospital’s medical director of labor and delivery.
IPLARC is a way to address Texas’ high repeat teen pregnancy rate, Drever explained. He championed the program’s launch. “We all believe in this, and we were all excited,” he said. “We see recurrent teen pregnancies all the time, and it’s heartbreaking.”
As the program has matured, reimbursements are proving to be a problem the hospital has yet to overcome. “We were losing $100 or so dollars per patient and … it’s cost-prohibitive.”
For now, the program has been halted, but Drever said he hopes to see it resurrected, even if he has to create a charity to sustain it.
“We all see the benefit of this program,” he said.
Many Unplanned Pregnancies
Unintended pregnancies are expensive — and common — with 45 percent of all pregnancies in the United States unplanned, according to the Guttmacher Institute. In Texas, 54 percent of all pregnancies are unplanned.
Nearly three-fourths of Texas’ unintended pregnancies are paid for by the state’s Medicaid program, according to the Guttmacher Institute. As Texas has made progress in reducing its teen birth rate, the public savings resulting from the decline in 2015 was $418 million, according to Power to Decide, a national campaign to prevent unintended pregnancies. And that is a conservative estimate. It accounts for the cost of pregnancy and just the first year of the child’s life. Many babies born with Medicaid funds receive publicly financed health care throughout childhood.
As Medicaid costs rise, Texas has a strong interest in reducing unplanned pregnancies. The Texas Legislature has directed that use of long-acting reversible contraception increase 10 percent annually, according to a 2018 report by Texas Health and Human Services Commission. IPLARC costs hundreds of dollars versus thousands for a pregnancy.
Implanting an IUD or Nexplanon at the hospital is important. While postpartum at the hosptial, new moms are a captive audience as patients with attention called to their immediate health needs but they may not be able to afford the time for a follow-up appointment. Additionally, some Medicaid patients quickly lose coverage with no way to pay for IPLARC.
Beyond that, there are other compelling reasons for IPLARC, said David Lakey, M.D., vice chancellor for health affairs and chief medical officer at The University of Texas System. “The ability for women to control when they get pregnant has a dramatic impact on their health and the health of their child,” said Lakey, former commissioner of the Texas Department of State Health Services.
Further, unplanned pregnancies are associated with premature births and related problems for newborns, said Lakey, who strongly supports and promotes IPLARC.
Successful programs most often have a champion at the hospital — usually a physician leader or an administrator.
Lyndon B. Johnson Hospital and Ben Taub Hospital in Houston are known for having highly successful programs and passionate champions and receive many inquiries from other Texas hospitals about IPLARC.
“It’s always a challenge” to start a new program, said Carey Eppes, M.D., master of public health, and chief of obstetrics at Ben Taub. But her hospital and LBJ had some built-in advantages that did not require creating an IPLARC program from scratch, she said.
For one thing, both hospitals are part of the Harris Health System, a longtime supporter of family planning services. They began providing IPLARC services before the state agreed to cover reimbursement for Medicaid patients. For another, the hospitals have long received grants that help offset program costs, Eppes said.
At her hospital, IPLARC is a team sport, involving trained physicians, nurses and other staff. The team educates patients early on in pregnancy, Eppes said. Because it’s a safety-net hospital, almost all of Ben Taub’s deliveries are covered by Medicaid.
“We keep this as one of the highest priorities,” Eppes said. “Most of our patients lose insurance coverage when they’re not pregnant.”
The Rio Grande Valley didn’t have a program until February 2017, Ogburn said, but now has a dozen or so doctors trained to provide IPLARC so it is offered 24 hours a day, seven days a week. The residents work with physicians in the community on planning for such deliveries, he said.
In addition, the nursing staff has been trained, and the hospital has been able to keep a supply of birth-control implants on hand, Ogburn said.
But even there, reimbursement remains the biggest problem, he said. “We have some HMOs working smoothly and others we’re having discussions with,” he said.
For now, the hospital is using a grant to help cover IPLARC when insurance programs don’t, Ogburn said.