Cases in Cost Conscious Care

Cristina Zottola
czottola@gwmail.gwu.edu
Mentor: Dr. Jennifer Keller, MD

Clinical Scenario A
A 26 year-old nulliparous woman calls your office to schedule an appointment to discuss having an IUD placed.  The scheduling department obtains the woman’s insurance information and, prior to her appointment, seeks pre-approval for an IUD because of the woman’s interest.  Your office also sends her educational information in advance of her appointment. The patient is monogamous with a male partner and is using OCPS for contraception.  Her LMP was 7 days ago.  During the appointment you review with her the information she read on IUDs, explain the risks and benefits, give anticipatory guidance on possible menstrual changes, and answer her questions.  After your discussion, she decides that she would like to have the Mirena IUD inserted.  You proceed with the insertion of the IUD that day.  There are no complications. 

Clinical Scenario B
A 26 year-old nulliparous woman calls your office to schedule an appointment to discuss having an IUD placed.  She is scheduled for a contraception consult visit. The patient is monogamous with a male partner and is using OCPS for contraception.  Her LMP was 7 days ago.  You review with her the information she obtained on her own about IUDs, provide pamphlets reviewing contraceptive options, explain the risks and benefits, as well as possible menstrual changes that might occur with IUDs, and answer all of her questions.  After your discussion, she decides that she would like to have the Mirena IUD inserted.  You perform a cervical swab for Gonorrhea and Chlamydia and a serum pregnancy test.  You inform her that she will need to schedule another appointment for the insertion

Three days later the office informs the patient that her test results were negative and that her insurance approved the IUD, but should come in for insertion while menstruating.  One week later, the women returns to clinic for insertion, she signs the IUD consent form, and the IUD is inserted with no complications.

Discussion Questions 

  1. What are some potential barriers to the same day IUD insertion method?
  2. What practices can be implemented to help reduce the costs of IUD insertion?
  3. Should every patient have an STI screen and pregnancy test prior to IUD insertion?

Costs Scenario A
Level III E/M visit, new patient with -25 modifier: $236
Mirena IUD Device: $826.72
IUD placement: $128.14
Total: $1,190.86

Costs Scenario B
Level III E/M visit, new patient: $236
Gonorrhea Test: $91.00
Chlamydia Test: $95.00
Serum Pregnancy test: $38.00
Mirena IUD Device: $826.72
IUD placement: $128.14

Total: $1,304.86

(The costs listed for the Level III New Patient visit, the gonorrhea test and serum pregnancy test are provided by Healthcarebluebook.com.  Healthcarebluebook.com states a “Fair price” expected for medical services, which is calculated from actual amounts health plans have paid on claims.  The cost listed for chlamydia test is provided by clearhealthcosts.com, which uses Medicare prices as the stated prices because they are the closest thing to a publicly available fixed price in this marketplace.  The other costs are the contracted rate paid by an insurance company for services at the George Washington Medical Facility Associates Department of OBGYN.

Teaching Moment:
Long Acting Reversible Contraception, such as IUD’s, has been recommended by ACOG as the most effective reversible contraceptive option for women.  Same day IUD insertion is not only cost conscious, but it also increases uptake rates, saves patients from additional office visits, and ultimately improves patient care.  It is essential to consider the cost of an unplanned pregnancy in patients who do not return for the second visit.  A failed two-visit IUD insertion model is not only costlier, but the patient also may have to deal with the emotional, physical, and health concerns associated with an unplanned pregnancy.

Potential barriers to same day IUD insertion include:

  • Checking Insurance reimbursement/benefits
  • Verifying that the patient is not currently pregnant
  • Performing STI screening 

One way to facilitate same day insertion and reduce costs is by seeking pre-approval from the patient’s insurance prior to her appointment to discuss contraceptive options.  A script you can give to the staff in your office who schedules appointments is available at: http://larcprogram.ucsf.edu/appointmentTo facilitate same day placement, providers are encouraged to stock IUDs in their office.  To help providers and practices considering stocking IUDs the CAI LARC modeling Tool (http://www.caiglobal.co/larc/ ) was established to gather information about a practices projected LARC demand, possible payers, and the rates of reimbursements and costs.  

The provider is reimbursed for the same day insert at the same rate as if they performed the insert at a separate appointment provided they use the -25 modifier, which is to show that a separately identifiable E/M service was performed on the same date as a procedure.

Women at high risk for STI’s, women under 25 or who have multiple sexual partners, should be screened prior to insertion, although this sample may be collected at the time of IUD insert.  ACOG does not recommend screening for STI’s in women who are low risk.

The CDC recommends a pregnancy test prior to IUD insertion only if the provider is uncertain of the patient’s pregnancy status. Insertion of an IUD does not require a patient to be menstruating, as studies have shown no added benefit from insertion while menstruating and could be the cause of an additional barriers.

The physician should provide a thorough explanation of IUDs; especially the risks and benefits, common complications, and alterations to menstruation.  If well prepared, this counseling process can effectively occur during the same visit as insertion.  Same day IUD insertion is not only more cost effective, but it can also significantly improve woman’s reproductive health.

References:
Armstrong, Erin, Mara Gandal-Powers, Sharon Levin, Amanda Kimber Kelinson, Alicia Luchowski, and Kirsten Thompson. "Intrauterine Devices and Implants: A Guide to Reimbursement." (2015): Http://larcprogram.ucsf.edu. Apr. 2015. <http://larcprogram.ucsf.edu/>.

Bergin, Ashlee, Sigrid Tristan, Mishka Terplan, Melissa L. Gilliam, and Amy K. Whitaker. "A Missed Opportunity for Care: Two-visit IUD Insertion Protocols Inhibit Placement." Contraception 86.6 (2012): 694-97.

Curtis, Kathryn M., PhD. "U.S. Selected Practice Recommendations for Contraceptive Use, 2013: Adapted from the World Health Organization Selected Practice Recommendations for Contraceptive Use, 2nd Edition." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 20 June 2013. Web. 15 July 2016. 

"Intrauterine Devices & Implants: A Guide to Reimbursement-Forecasting." Intrauterine Devices and Implants: A Guide to Reimbursement. UCSF Bixby Center for Global Reproductive Health, 6 Apr. 2016. Web. 29 July 2016. <http://larcprogram.ucsf.edu/forecasting/>. 

"Intrauterine Devices and Implants: A Guide to Reimbursement Second Edition." Intrauterine Devices and Implants: A Guide to Reimbursement (2015): 1-36. LARC Program- UCSF, 2015. <http://larcprogram.ucsf.edu/>.

IUD and Implant Reimbursement Under Medicaid in New York State: A Primer (2016): 1-7. LARCTaskfroce.org. Reimbursement Workgroup of the New York City LARC Access Taskforce. Web. <http://larctaskforce.org/sites/default/files//sites/all/themes/pika/IUD_TaskForce_Docs/
LARC%20Coverage%20Under%20Medicaid%20in%20NYS-%20A%20Primer.pdf>.
 

Papic, Melissa, Nan Wang, Sara M. Parisi, Erin Baldauf, Glenn Updike, and Eleanor Bimla Schwarz. "Same-Day Intrauterine Device Placement Is Rarely Complicated by Pelvic Infection." Women's Health Issues 25.1 (2015): 22-27. 

"Practice Bulletin No. 121: Long-Acting Reversible Contraception: Implants and Intrauterine Devices." Obstetrics & Gynecology 118.1 (2011): 184-96. 

"Same-Day IUD Insertion." IUD Taskforce Frequently Asked Questions (Nov. 2014): IUDTaskforce.org.

 

Published Date: 8/5/16

American Congress of Obstetricians and Gynecologists
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