In the last legislative session the Texas Health and Human Services Commission (HHSC) was charged with developing a five-year strategic plan to reduce barriers to accessing Long-Acting Reversible Contraception (LARC) for women on Medicaid and other state-funded health programs. The plan, which was released in November, was developed in collaboration with a range of experts and stakeholders, including the Texas Collaborative for Healthy Mothers and Babies, whose specific recommendations are included in an appendix.
TCHMB News spoke to Lesley French, deputy executive commissioner of Health, Developmental and Independence Services at HHSC, about the strategic plan, the state’s commitment to women’s health, and the broader context of LARCs. French, who leads HHSC’s LARC efforts, was previously the director of the HHSC Women's Health Services Division and the Office of Women’s Health at the Department of State Health Services. In her current position she oversees 615 employees across 40 programs, as well as the programs’ budgets, legislative requests and office logistics.
She received her Bachelor of Science from The University of Texas at Austin and her Juris Doctor from Regent University School of Law.
TCHMB News: What is a LARC?
Lesley French: It stands for Long Acting Reversible Contraception. And it’s what it sounds like, contraception that works for a long period of time and is reversible. There are now six different products on the market, which fall into two types, an intrauterine device (IUD) and a subdermal contraceptive device, more commonly known as “the implant.” The implants are inserted under the skin of a woman’s arm. Both types of device protect women from getting pregnant for 3-10 years, depending on the device, and can be easily removed.
The Texas Health and Human Services Commission recently published a five-year strategic plan to increase the availability and use of LARCs in Texas. What is the main problem, or challenge, that this plan is intended to address?
In Texas roughly a third of pregnancies are unplanned, and of the 36% of women who report unintended pregnancy, more than half (according to at least one study I’ve seen) were using some form of birth control. So these women want to have control over their pregnancies, and are willing to take responsibility for birth control. But not all forms of birth control were created equal.
We’ve now had about a decade to track the safety and effectiveness of LARCs. What we have learned is that they are safe and are 99.9% effective. Other methods can be effective, but it is a challenge to take a pill every single day, or to remember to change your patch every week. In practice, other forms of birth control, including the pill, can be around 90% effective..
LARCs remove user error. They are life changers for women, removing that chance of unintended pregnancy. Now you have six different LARC options for women, which allows for even more tailoring to woman’s needs, depending on her age and pregnancy history, whether she is an 18-year-old who intends to have children but is not ready yet, or a 44-year-old woman who knows that she is done with pregnancy.
They are also a cost-saver for the state of Texas. Texas has 400,000 births a year, and Medicaid pays for over 200,000 of those, at a cost of about $15,000 per birth. If a third of those are unintended, and that may be an underestimate, that means 60-70,000 women every year in Texas who weren’t intending to have a pregnancy. The research shows that for every dollar invested in family planning programs, you get about a $7 savings.
The overall goal is to empower women to have control over their reproductive lives, and the new generation of LARCs are by far the best opportunity we have to do that.
How long has this strategic plan been in the making?
As more and more evidence came in showing that these contraceptives were safe and effective, the legislature wanted to make sure that Texas was doing what it could and should to make this amazing development for women’s health care available and accessible.
This has evolved over a few legislative sessions. Initially, we were tasked by the legislature with redesigning the overall women’s health care plan for Texas, and it was important to make sure LARCs were an element of that overall plan. That began the planning. Since then we have been working with a wide variety of stakeholders and experts, in particular through our bimonthly LARC working group, to develop a much better sense of the obstacles in the way of women accessing LARCs, and to propose solutions. More recently we have been collaborating with the Texas Collaborative for Healthy Mothers and Babies. The strategic plan is the product of all of these years of work.
So what are the challenges?
There are basically two contexts in which women might get LARCs. One is the more routine clinical visit with an obstetrician, before a woman is pregnant or between pregnancies. The other is immediately postpartum, within 15 minutes of giving birth, in the case of the IUDs, or before discharge for the implants.
In either context we need to make sure that women and providers are informed about LARCs, and that providers are trained to insert them, if that is what their patients want. The new LARCs only came onto the market in the mid-2000s, so there are a lot of women, and some providers, who don’t have all the information about their safety and effectiveness. There are also misconceptions still floating around that are based on an IUD that came on the market in the late 1970s and was used into the 1980s. That device caused irreparable damage to many women’s uteruses. These new LARCs are different devices with different mechanisms, and are only inserted by providers who have been trained to do so, but not everyone is informed on where we are now.
"LARCs remove user error. They are life changers for women, removing that chance of unintended pregnancy."
There is also the issue of cost. LARCs are not cheap, $500-$1,000 per device, which means that they’re not the type of thing most hospitals or clinics or doctor’s offices are just going to have on hand. In the routine setting, this is less of a problem. The insertion visit can be scheduled after the device has been delivered, and insurance is typically good about reimbursing. Even in this case, there can be problems if a visit is cancelled after the device is ordered; right now a provider cannot re-assign that device, which requires a prescription, to another woman, so they have to return it to the manufacturer to destroy it. Also, it is always preferable to have the device on-hand if possible, so that women don’t have to return for another visit if they’re ready to have the device inserted.
In the immediate postpartum context, it can get even more complicated. Women don’t know when they’re going to go into labor, and the window of insertion is short. So hospitals would need to have the devices available not knowing when they’ll be necessary or how many they’ll need.
There have also been issues with reimbursement, particularly in the immediate postpartum period. Until relatively recently, insurers were reimbursing in a bundle for the whole delivery regardless of whether there was a LARC insertion or not. Insurers would reimburse for the device, but not extra for the doctor’s LARC services, so doctors were being asked to do additional work for no additional payment.
This has been fixed. The LARC insertion is now reimbursed separately from the delivery, and the evidence is that insurers and Medicaid have been good about reimbursing. But providers don’t always know this. So we need to make sure the providers and their billing departments are informed.
In addition to that change in reimbursement policy, what are some of the other solutions that are being proposed or developed or implemented?
I mentioned the changes to reimbursement policies. Hospitals can now receive reimbursement separate from the main delivery bundle. Federally qualified health centers (FQHCs) and rural health clinics (RHCs) can also now receive reimbursement for a LARC device in addition to payments for the basic clinical encounter.
In 2016 we released the Texas LARC Toolkit, which offers education to providers about LARCs, and we updated the toolkit in June of this year. The toolkit, which is part of a larger statewide outreach campaign, includes materials on patient counseling strategies, billing and reimbursement, and other key resources. Texas was actually the first state in the nation to release a comprehensive toolkit on LARCs. The strategic plan is also the first of its kind in the nation.
We have provided in-person and online training to women's health contractors and providers, including training on LARC counseling and clinic skills and an insertion practicum for providers. We are working with our partners at DSHS and stakeholders to identify additional opportunities for trainings.
We have also begun calculating new contraceptive care measures for all state Medicaid programs, which is allowing us to identify barriers to LARC provision in Medicaid overall and among specific providers, programs, and regions.
We also have a really strong partnership with the device manufacturers, who are the ones who conduct trainings for providers on LARC insertion. These companies have a vested interest in making sure the products are safe and reliable, and in increasing the pool of providers who are well-trained to insert them. Of course they have a monetary incentive, but they have been excellent partners with us in making sure that the priority is always women’s control over their own reproductive lives and providing women the freedom to choose their own preferred contraception method.
There are a number of LARC bills that are going to be filed in the upcoming legislative session, so there may be more on the near horizon.
Is the overall effort working? Is usage of LARCs going up? Is it saving money for the state.
The simple answer is yes. In each of the three state-funded programs that cover LARCS (Medicaid, Healthy Texas Women, and the Family Planning Program), the numbers and percentages have gone up over the last three years. More women are taking advantage of the LARC option. And it is saving the state money, not just on deliveries but on things like NICU stays and other things may come up in that first year postpartum. We have been able to track that dollar to dollar.
What else do we need to do, going forward?
We have to continue our patient and provider outreach, education, and training. Continue working with stakeholders and partners to expand services and awareness. Update the LARC toolkit as needed.
The Texas Department of State Health Services (DSHS) has been working to promote the One Key Question (OKQ) program, which promotes clinician use of a screening question to assess the patient’s pregnancy intention. We want to support those efforts.
The biggest cost challenge that remains unsolved involves closing the gap between the value to women and providers of having LARCs on hand and the cost to providers of stocking them. Providers would like to be able to provide LARCs to women who want them, without the delay of ordering them, but it is expensive to do so.
The good thing, on all these fronts, is that there is a lot of momentum around LARCs, and support from legislators, stakeholders, providers, and others.