COMMENTARY

Long-acting Reversible Contraceptives Under the ACA: How to Help Patients Get Coverage

Lin-Fan Wang, MD, MPH

Disclosures

March 12, 2014

In This Article

Accessing LARCs

Women face multiple barriers to accessing the contraceptive method of their choice, particularly long-acting reversible contraceptives (LARCs). Misbeliefs about LARC methods are persistent among both patients and providers, some of whom hold outdated and misguided ideas about which populations of women can safely use LARCs.

Cost is another deterrent. LARC methods are highly effective and take little effort to continue, but they have high up-front costs. The Affordable Care Act (ACA) addresses this financial barrier and expands options for women by requiring insurance coverage for all FDA-approved contraceptive methods, including LARCs, without additional out-of-pocket costs. However, some health insurance plans may inappropriately implement this part of the law and continue to charge women for contraceptives,[1] making it necessary for physicians to intervene.

Benefits of Insurance Coverage for LARCs

The ACA added contraceptive counseling and supplies to their list of preventive services for women, on the basis of recommendations by the Institute for Medicine.[2]

The ACA includes coverage of LARCs, which is good news for women. LARCs have many advantages. They have low failure rates (less than 1%) and high continuation rates.[3] There are very few contraindications to use.[4]

Nulliparous and adolescent women are excellent candidates for LARC methods.[5,6] They can be inserted immediately after abortion or miscarriage, and immediately postpartum.[4] In addition, copper intrauterine devices (IUDs) are the most effective form of emergency contraception.[7]

The safety of IUDs for nulliparous and adolescent women is supported by recent research. Owing to the strength of the evidence, the recommendation for use only in parous women was removed from the package insert for the Paragard™ CuT380A. The manufacturer of the Mirena™ levonorgestrel intrauterine system (LNG-IUS) has not applied for an update to the package insert, despite the available safety data.[8] The Skyla® LNG-IUS is a newer IUD that is approved by the US Food and Drug Administration for use in nulliparous women.

Both the Mirena™ LNG-IUS and the Paragard™ CuT380A are acceptable to nulliparous and adolescent women. Young and nulliparous women have high satisfaction and continuation rates, although they may experience more discomfort during insertion compared with older, parous women.[5,6]

Fear of discomfort can be addressed with a discussion of pain control options, including supportive care, nonsteroidal anti-inflammatory drugs or paracervical blocks.[9] Although providers may be concerned that insertion is more technically difficult in nulliparous women, insertion is often successful.[5] Expulsion rates are low in these populations; a study of 1133 women found that the expulsion rate among nulliparous and adolescent women was similar to that among older, parous women.[10]

Good evidence supports that adolescent and nulliparous women are not at increased risk for pelvic inflammatory disease (PID) or infertility with IUD use.[5,6] Multiple studies, including a large study by the World Health Organization and the Women's Health Study, have demonstrated that modern IUDs, which contain monofilament strings, do not increase the risk for PID besides the slightly higher relative risk in the first 20 days after IUD insertion.[5,9] The LNG-IUS may lower the risk for PID.[5,9]

On the day of insertion, asymptomatic women should be screened for gonorrhea and chlamydia, according to current guidelines from the Centers for Disease Control and Prevention. IUDs should not be inserted if active cervicitis or PID is suspected.[9] IUDs do not increase the risk for infertility; fertility returns rapidly after IUD removal.[5]

Removing financial barriers to use of LARCs increases uptake and results in healthcare savings.[11] These devices cost approximately $500 or more.[12] In contrast, not providing contraceptive coverage in health plans has been estimated to cost employers 15%-17% more, after the direct and indirect costs of pregnancy are taken into account.[11]

The Contraceptive CHOICE project in St. Louis offered all contraceptive methods at no cost and used a standardized script informing women that LARC methods are the most effective. They recently published their analysis of the first 2500 participants.[13]

Women were recruited using a convenience sample from university-affiliated clinics and providers, 2 facilities providing abortion services, and community clinics. Most participants were non-Hispanic white or black. The average age was 25 years (range, 14-45 years). Four out of 10 participants were uninsured, and over one-half had significant financial difficulties. Four out of 10 were nulliparous.

Seventy-five percent of women chose a LARC method,[13] compared with 8.5% among women nationally.[14] Although there were statistically significant differences in LARC users in terms of race, marital status, number of lifetime partners, reproductive history, and parity, the associations were small, suggesting that women with diverse backgrounds, including adolescent and nulliparous women, desire LARC methods.

Of note, a subsequent analysis of 9256 women who participated in the study between August 2007 and September 2011 found that women who chose LARCs had lower rates of unintended pregnancy than women who used pills, patches, or rings.[15]

Physicians can improve uptake by providing comprehensive information about LARC and dispelling myths. Younger, unmarried women are less likely to be aware of LARC methods, and many of those who are aware have misbeliefs about who can safely use LARCs and their efficacy, side effects, and risks.[16] Physicians and other health professionals are the most trusted source of accurate information for young women; however, these women are more likely to hear about LARC through the media.[16]

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