August 10, 2020
3 min read
Rodriguez reports receiving research funding from Arnold Ventures for this grant, as well as research funding from Arnold Ventures, Merck and NIMHD outside of this grant. She also reports receiving consulting fees from ACOG, Bayer, Merck and the World Health Organization outside of this work.
Implementing a program-level incentive metric may increase use of effective contraceptives among Medicaid beneficiaries, according to results from a study published in JAMA Network Open.
The study evaluated the impact of the effective contraceptive use (ECU) incentive metric in Oregon’s Medicaid program. The metric assessed the percentage of reproductive-aged women who were at risk for unintended pregnancy and who were provided an effective contraceptive, including an intrauterine device, progestin injectable, contraceptive implant, pull, patch, ring, diaphragm or sterilization.
Researchers said the ECU metric was one of 17 quality metrics in a bonus pool for coordinated care organizations in Oregon, which provide care to more than 90% of Medicaid beneficiaries in the state.
In the claims-based cohort study, researchers used a comparative interrupted time series to assess whether the implementation of the incentive metric in 2015 was associated with changes in contraceptive use among Medicaid enrollees compared with commercially insured women.
A total of 532,337 Medicaid person-years and 1,131,738 privately insured person-years were included in the final analyses.
Researchers found that use of effective contraceptives among Medicaid enrollees of all ages increased by 3.6% (95% CI, 3.1-4.1) after 1 year, 7.5% (95% CI,6.8-8.2) after 2 years, and 11.5% (95% CI, 10.5-12.4) after 3 years.
According to the researchers, contraceptive use rates in the youngest cohort of Medicaid enrollees — who were aged 18 to 24 years — were decreasing before the quality metric was used but increased steadily after its implementation. After 3 years, the use of effective contraceptives increased by 16.5 percentage points (95% CI;14.4-18.6) in this age group.
The greatest increase in contraceptive use 1 year after the program was implemented was among women aged 30 to 34 years (4.9%; 95% CI, 3.4-6.3).
Healio Primary Care spoke with study author Maria I. Rodriguez, MD, MPH, associate professor of obstetrics and gynecology at the Oregon Health and Science University School of Medicine, to learn more about the incentive metric and the importance of effective contraception use.
Q: What prompted you to conduct this study?
A: The decision on if and when to become pregnant has huge implications for the individual, their family, and our community. Unintended pregnancy impacts approximately 2.7 million U.S. women and costs an estimated $4.6 billion annually. While we are overall seeing a national reduction in unintended pregnancy, we are seeing that unintended pregnancy is increasingly becoming more common among people with low incomes and people of color. Unintended pregnancy has multigenerational effects; it carries health and social risks for the woman as well as the child, if the pregnancy results in a birth. Contraception is an effective strategy to prevent unintended pregnancy, but multiple barriers limit access.
Q: What incentives were used to increase contraceptive use, and why are they needed?
A: When we talk about reproductive health and incentive metrics, it is incredibly important to be aware of the reality of reproductive coercion both in the U.S. and globally. Implementing a financial incentive at the individual (for the patient or physician) or clinic level to increase contraceptive use would be unethical. This incentive was based at the program level; the coordinated care organizations (CCO) that organizes service delivery needed to meet goals for a pool of quality metrics that were developed and implemented by the state’s health authority to receive their full budget. The ECU metric was a key quality metric in the pool. A portion of each CCO’s budget was held back and dispensed when each CCO demonstrated that they had achieved success on a majority of the metrics in that year’s pool. CCO’s could choose how to spend the funds. This incentivized them to develop the infrastructure needed to improve access to contraceptive methods and care, and to achieve the ECU metric.
Q: Why is it important for physicians to increase contraception use in the Medicaid population?
A: All individuals have the right to decide if or when to become pregnant. Access to reproductive health care, in particular contraception, is essential to both health and rights. It is important for all individuals — not just Medicaid, but those who are uninsured or have private insurance — to have access to a full range of contraceptive methods and information. We focused on the Medicaid population, because this is where the incentive metric was applied, but want to emphasize the importance of ensuring access to affordable, acceptable and quality contraceptive services for all women.
Reproductive health care is increasingly legislated and controlled by policy driven by ideology, not science. It is important for physicians and all health care providers to recognize and support women’s health and autonomy by ensuring access to contraceptive choice.
Q: Based on the findings, should these incentives be implemented nationwide? If so, how soon could they be implemented?
A: National efforts to equitably provide high quality reproductive health care, included contraception are urgently needed. Based on our findings, an incentive at the state or program level to support developing contraceptive infrastructure or delivery is one possible solution. The ability to implement this nationally would depend on political will and require clear and careful guidance to ensure the incentives are ethically aligned.