A Bundled Payment System for Constraceptive Coverage

Unintended pregnancy remains a persistent public health challenge in the United States. Publically funded family planning services prevented 17,400 unintended pregnancies in 2014. However, almost half of all pregnancies in Missouri are still unintended at a cost of $518 million to the state and federal governments. Improved provision of contraceptive services has the potential to decrease the number of unintended pregnancies. This paper focuses on an innovative, bundled payment model that has the potential to improve delivery of contraceptive services, and reduce unintended pregnancies.

A contraceptive delivery model focused on patient education and removal of access barriers has been shown to increase the uptake of IUDs and implants, the most effective contraceptive methods, and reduce unintended pregnancy. This paper describes to construct a feasible bundled payment for initiation of reversible contraception and ongoing contraceptive care provided within a specified episode of care (90 days). The goal of the bundled payment is to improve the provision of contraceptive services and ultimately reduce health care expenditures. The proposed bundled payment model would provide reimbursement for health care providers to provide comprehensive contraceptive counseling in addition to contraceptive care. Bundled payment models have been shown to increase quality and decrease costs and may offer improvement over the current fee-for-service system.

The paper outlines the data and methods used to construct the costs for the bundled payment model. In particular, a cost savings analysis was performed in order to estimate the total expected cost savings to Missouri Medicaid under the bundled payment model. Outcomes from participants in the Contraceptive Choice Center’s (C3) intervention were compared to what method they would choose under a counterfactual scenario, estimated using a model from the 2013-2015 National Survey of Family Growth. For both scenarios, contraceptive effectiveness was obtained from Trussell (2011) and because costs differ based on the selected method, expected costs were calculated for each type of reversible contraception. For women, the costs of initiation and the contraceptive device were accounted for. For women who experience a pregnancy, the costs associated with four outcomes of pregnancy were taken into account: Live birth, miscarriage, ectopic pregnancy, and induced abortion.

The proposed bundled payment provides incentives to improve outcomes and reduce costs, since reductions in unintended pregnancy and birth has potential to significantly reduce public expenditures. The payment model outlined here results in cost savings for Missouri Medicaid of roughly $19 million relative to current practice due to a reduction in unintended births. However, actual cost savings may be even higher as a result of factors not taken into account in our analysis such as poorer infant health outcomes from unintended pregnancies, including increased rates of preterm and low birth weight births.