This figure shows the percentage of women whose childbirth was paid for by Medicaid in a given month who received immediate postpartum long-acting reversible contraception (IPP-LARC) (panels A and B) and who had a short-interval birth (panels C and D). Short-interval birth is an indicator equal to 1 if there was less than a 21-month interval between delivery and subsequent birth. Each plot shows a trend line based on predicted values from 2 linear regression models (one line before the start of the Medicaid policy, from January 2010 through February 2012, and a second line starting the month after the policy change, from March 2012 through the end of the study period). The study period was January 2010 to December 2017 for IPP-LARC and from January 2010 to March 2016 for short-interval births. Vertical dotted lines at March 2012 represent the start of Medicaid’s IPP-LARC reimbursement policy change. Horizontal dotted lines represent a counterfactual postpolicy trend line that extends the linear prepolicy trend through the end of the study period. Percentage-point changes represent differences between the observed trend and the counterfactual trend during the last month of the study period. The percentage-point change in short-interval births is omitted for adults because no statistically significant change in trend in short-interval births was found for adults in regression analysis.
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Steenland MW, Pace LE, Sinaiko AD, Cohen JL. Association Between South Carolina Medicaid’s Change in Payment for Immediate Postpartum Long-Acting Reversible Contraception and Birth Intervals. JAMA. 2019;322(1):76–78. doi:10.1001/jama.2019.6854
Short interpregnancy intervals (defined variously as 6, 12, 18, or 24 months between pregnancies) are associated with adverse newborn outcomes.1 Immediate postpartum long-acting reversible contraception (IPP-LARC)—ie, receipt of an intrauterine device or contraceptive implant before hospital discharge following a birth—is recommended to reduce short interpregnancy intervals, but IPP-LARC use remains limited in the United States.2,3 Payers’ common practice of providing one global payment for all services during a delivery hospitalization may disincentivize IPP-LARC provision. In March 2012, South Carolina’s Medicaid program (covering 60% of the state’s births) began reimbursing hospitals for IPP-LARC separately from the global payment.4 We evaluated whether this change was associated with changes in IPP-LARC use and short-interval births.
We used inpatient Medicaid claims data for all childbirth hospitalizations for women and adolescent girls aged 12 to 50 years between January 2010 and December 2017 in South Carolina. We identified IPP-LARC placement by an insertion and/or device code for a LARC device during hospitalization. We defined short-interval births as subsequent childbirths within 21 months (12-month interpregnancy interval plus 9-month gestation); only births through March 2016 were included to allow 21 months of observation for subsequent births.
We graphed trends in use of IPP-LARC and short-interval births before vs after the reimbursement policy change. An interrupted time series linear regression model included a linear time trend, a postpolicy indicator, and an interaction term to test the change in trend in outcomes after the policy change. Analyses adjusted for seasonality and autocorrelation and were stratified by age group (adolescents [<20 years] and adults [20-50 years]). Data were analyzed using Stata version 15 (Stata Corp). A 2-sided P < .05 defined statistical significance. The study was deemed exempt by the Harvard T. H. Chan School of Public Health Institutional Review Board.
There were 242 825 childbirth hospitalizations, 5795 IPP-LARCs, and 21 372 short-interval births during the study. In January 2010, 0.07% of women received an IPP-LARC (Figure). Following the policy change, the trend in IPP-LARC increased relative to the prepolicy trend (difference in trends before vs after policy change, 0.07 [95% CI, 0.05-0.08; P < .001] percentage points each month among adults and 0.10 [95% CI, 0.07-0.13; P < .001] percentage points each month among adolescents) (Table). In December 2017, 5.65% of adults and 10.48% of adolescents received an IPP-LARC, which corresponds to increases of 5.00 (95% CI, 3.85-6.14; P < .001) percentage points in adults and 8.32 (95% CI, 6.45-10.18; P < .001) percentage points in adolescents relative to that expected without the policy change (Figure).
In January 2010, 10.61% of births by adults and 13.10% of births by adolescents were followed by a short-interval birth (Figure). Adolescent short-interval births were increasing before the policy change and flattened afterward (difference in trends, −0.09 [95% CI, −0.14 to −0.03; P = .002] percentage points each month) (Table). In March 2016, 16.60% of adolescent births were followed by a short-interval birth, corresponding to a decrease of 5.28 (95% CI, −8.34 to −2.22; P = .001) percentage points relative to that expected without the policy change (Figure). In March 2016, 11.59% of births by adults were followed by a short-interval birth; there was no statistically significant change in trend in short-interval births for adults following the policy change (Table).
South Carolina Medicaid’s shift to separate reimbursement for IPP-LARC was associated with increases in IPP-LARC initiation among adolescents and adults and flattening of the previously increasing trend in short-interval births among adolescents.
Limitations include that interrupted time series cannot exclude confounding due to other events occurring at the same time as the policy change. Data included Medicaid-funded services, and births paid by commercial payers could have been missed. Before the policy change, some IPP-LARC provision (ie, through training programs) could have occurred without claims. However, national survey data and reports from South Carolina support the finding of near-zero IPP-LARC use prior to the policy change.2
As of February 2018, 36 other states’ Medicaid programs have begun separately reimbursing for IPP-LARC,5 with calls for similar reforms from commercial payers.3 These findings suggest that IPP-LARC reimbursement could increase immediate postpartum contraceptive options and help adolescents avoid short-interval births.
Accepted for Publication: May 2, 2019.
Corresponding Author: Maria W. Steenland, SD, MPH, Population Studies and Training Center, Brown University, 68 Waterman St, Providence, RI 02912 (firstname.lastname@example.org).
Published Online: June 3, 2019. doi:10.1001/jama.2019.6854
Author Contributions: Dr Steenland had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Steenland, Cohen.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Steenland.
Critical revision of the manuscript for important intellectual content: Pace, Sinaiko, Cohen.
Statistical analysis: Steenland, Cohen.
Obtained funding: Steenland.
Administrative, technical, or material support: Steenland, Cohen.
Conflict of Interest Disclosures: None reported.
Funding/Support: The Eric M. Mindich Research Fund for the Foundations of Human Behavior provided funding to acquire the data used in this study. Dr Steenland was supported by National Institutes of Health (NIH) training grant T32 HD007338 and by other NIH support (P2C HD041020).
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.
Disclaimer: The findings and conclusions of this article are those of the authors and do not necessarily represent the official positions of the South Carolina agencies and programs from which the data originated.
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