South Carolina Finds Winning Strategy to Reducing Unintended Pregnancies in its Medicaid Population

Posted March 01, 2016 by Wendy Loveland

Pregnant Woman Visiting DoctorIn South Carolina, half of all pregnancies in 2010 were unintended, primarily due to either lack of or failed contraceptives. Within the South Carolina Medicaid population, almost 79 percent of women defined their pregnancy as unintended. This is particularly troubling because births resulting from unintended pregnancies are linked to adverse maternal and child health outcomes and myriad social and economic challenges.

To reduce this percentage, South Carolina Medicaid began a policy change in 2012 aimed at increasing the use of immediate postpartum inpatient insertions of long-acting, reversible contraceptives (LARCs). LARCs are safe, highly effective, recommended first-line methods of pregnancy prevention for most women. Immediate postpartum insertion not only helps reduce the cost of care, but gives women more control over their reproductive health, leading to better birth spacing.
Between 2013 and 2015, South Carolina had a 110 percent increase in LARC inpatient insertions, and a 10 percent increase in LARC utilization for outpatient insertion. These impressive results also reflect improved pre- and interconception care, a strategy of NICHQ’s signature infant health initiative—The Collaborative Improvement and Innovation Network to Reduce Infant Mortality (IM CoIIN).

“This initiative has required engagement on all levels of the hospital as well as from clinical physician champions and nurses,” says Melanie “BZ” Giese BSN, RN, director of the South Carolina Birth Outcomes Initiative at the South Carolina Department of Health and Human Services. “Changing a policy and the reimbursement mechanism won’t work if you simply issue a Medicaid bulletin.”

Forge active partnerships
South Carolina’s LARC policy is centered on LARC insertion in the immediate inpatient setting, before the mother leaves the hospital. This is because 55 percent of mothers on Medicaid weren’t showing up to their first postpartum visit where contraception options were most likely offered. The initiative not only required a policy change, but a change in reimbursement and billing procedures. Partnerships, data collection, and spreading the policy—both within a hospital and to other hospitals—were key to the South Carolina initiative, which is seeing extraordinary results to date.

Giese developed a 20-member “Visions Team” within the state’s Birth Outcomes Initiative (SCBOI) to be a sounding board for all their initiatives, including LARCs. It includes representatives from various stakeholders—such as the state Hospital Association, Department of Public Health, Medicaid managed care organizations (MCOs), Blue Cross Blue Shield of South Carolina and the American Congress of Obstetricians and Gynecologist.

“You cannot make effective change without clinical champions and administrative buy-in,” says Giese. “Get your Medicaid systems department and the Medicaid directors of the MCOs there on day one. It takes time for everyone to adjust their claims system so that the transition runs smoothly.”

The Vision Team and SCBOI meet monthly to discuss their objectives. Learning what works or doesn’t work in one area leads to brainstorming about how the team can do things better, says Giese.

“We can also share in the excitement and passion for our accomplishments, which gives us momentum to continue,” she says.

Collect the right data
To determine where improvement is needed and to measure success, the team has to collect data from multiple sources. According to Giese, the following are the most important data to collect:

  • Percent of actual utilization, from the day the policy starts, then again at 6 months and 12 months
  • Continuation rate, which doubles as a patient satisfaction rate
  • Increases and decreases in outpatient and inpatient insertions
  • Utilization of LARC on MCO encounter data (although encounter data is only as good as what the author writes on the form)
This data is important for three reasons, according to Giese.
  1. It can be used to determine the patients’ and the physicians’ satisfaction of the convenience of the inpatient insertion policy/option.
  2. It can assess the effectiveness of inpatient versus outpatient LARC by tracking “next birth” post insertion in regards to birth-spacing.
  3. Tracking the continuation rate at 6 and 12 months can be used as evidence to dispel the myth that inpatient insertion is not favored as much as outpatient.
“We have seen a 110 percent increase in inpatient LARC utilization from FY13-FY15,” says Giese. “Overall, usage inpatient has gone from ~0 percent to 17 percent of moms getting their LARC immediate postpartum.”

Spreading success
Giese’s team has found that the toughest barriers to adoption are reimbursement concerns from hospitals and the educational process that must occur along the various participants in the hospital who are needed to make the policy work.

“Physicians and hospitals do not want to change their policy and claims process unless it is worth their while financially,” says Giese. “We had to make sure that we educated them on the increased reimbursement rate in the new policy, and how to bill outside the DRG for additional fee-for-service reimbursement.” (DRG stands for diagnosis-related group, a system of classifying inpatient stays into groups for payment.)

Physician champions can address any concerns such as possible bleeding or identify inaccurate information about LARCs that the mom may have received. To overcome lactation consultant concerns that LARCs inserted postpartum may affect breastfeeding, information was provided showing LARCs’ lack of effect on breastfeeding outcomes and that the advantages of LARC insertion generally outweigh the risks.

“Collaboration and coordination are the keys, as is making the policy a living document,” says Giese. “Without our team collaboration and commitment, the policy would just end up in a binder on a shelf.”


Other Key Buy-In Strategies Used by the South Carolina Team:
  • Referencing that the CDC and ACOG support immediate postpartum LARC insertion with few contraindications
  • Positioning the policy as a Healthcare Effectiveness Data and Information Set (HEDIS) measurement such as how well the provider is doing with post-partum contraception
  • Providing a return on investment data on LARC cost versus oral contraception: South Carolina’s model shows that the first year cost of oral contraception is twice as much as LARCs.
  • Educating clinicians, administrators and the billing department via webinars (with influential guest speakers), newsletter articles, research papers, physician-to-physician demonstrations of insertion process, educational conference calls and Q&A opportunities.
  • Providing a “tackle box” on the labor and delivery floor with everything a clinician needs for LARC insertion and a postpartum toolkit.
  • Demonstrating LARC insertions at other hospitals. 


Learn more about the IM CoIIN initiative and how you can get involved.


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