Cost-benefit analysis of state and hospital funded postpartum intrauterine contraception for recent immigrants to the United States

Transcription

1 2010 Contraception Outstanding Article September 23, 2010 Cost-benefit analysis of state and hospital funded postpartum intrauterine contraception for recent immigrants to the United States Maria Rodriguez, Aaron Caughey, Alison Edelman, Philip Darney and Diana Greene Foster

2 Maria Rodriguez, MD MPH Obstetrics & Gynecology Residency, OHSU Family Planning Fellow, UCSF ( ) Medical Officer, World Health Organization (2010- present) Economics and politics profoundly impact public health in our country. As public health professionals it is incumbent upon us, to understand these relationships and advocate for interventions and legislation that maximize health, regardless of partisan politicking. September 2010 Slide 2

3 Work on family planning policies and immigrants Some of the most interesting work on provision of family planning services to immigrants has come out of Oregon Why? Maria Rodriguez and colleagues California has more immigrants but also a more liberal approach to providing services September 2010 Slide 3

4 Immigrants and Medicaid Emergency Medicaid covers life threatening conditions or an obstetrical delivery. Immigrants are eligible only for Emergency Medicaid for first 5 years of legal residence Undocumented immigrants are always only eligible for Emergency Medicaid September 2010 Slide 4

5 Oregon s waiver program Adults and teens <185% of the Federal Poverty Line Provides access to contraception, annual exams, STI screening, and cervical cancer screening Network of 160 clinics 200,000 client visits annually. Angus, L. Health Affairs, 2010 September 2010 Slide 5

6 The Deficit Reduction Act Requires proof of citizenship and identity prior to receiving care in public health clinics. September 2010 Slide 6

7 Oregon and DRA: Results Percent change in visits by age Angus L, Devoe J. Evidence that the citizenship mandate curtailed participation in Oregon's Medicaid family planning program. Health Affairs. Apr;29(4):690-8 September 2010 Slide 7

8 Oregon and DRA: percent change in visits by ethnicity No statistical difference Angus L, Devoe J. Evidence that the citizenship mandate curtailed participation in Oregon's Medicaid family planning program. Health Affairs. Apr;29(4):690-8 September 2010 Slide 8

9 Emergency Medicaid and unintended pregnancy 82% of EM claims are for obstetrical diagnoses Previous work by Dr. Rodriguez found that covering access to postpartum sterilization for new immigrants would likely reduce hospital losses. What about long acting reversible methods of contraception? DuBard CA, Massing MW. Trends in emergency Medicaid expenditures for recent and undocumented immigrants. JAMA 2007 Mar 14;297(10): Rodriguez MI, Edelman A, Wallace N, Jensen JT. Denying postpartum sterilization to women with Emergency Medicaid does not reduce hospital charges. Contraception 2008 Sep;78(3): Rodriguez MI, Jensen JT, Darney PD, Little SE, Caughey AB. The financial effects of expanding postpartum contraception for new immigrants. Obstet Gynecol Mar;115(3):552- September 2010 Slide 9

10 Cost benefit of offering IUDs to women with Emergency Medicaid Retrospective cohort study Followed a postpartum group of EM patients Cost benefit analysis: Compared costs of offering a postpartum IUD with baseline policy of covering only the delivery Costs and repeat admissions from hospital records Rodriguez, M. Contraception, 2010 September 2010 Slide 10

11 Estimated pregnancies in the absence of an IUD program Pregnancies per 1000 women based on return obstetrical visits among 1,037 women with EM who delivered at OHSU in ,000 women delivering in Year 0 would return to the same hospital with 258 pregnancies over the next four years Year 1 Year 2 Year 3 Year September 2010 Slide 11

12 Conservative model of a postpartum IUD program Year 1 Year 2 Year 3 Year 4 Expulsion rate 10% 3% 2% 1% Discontinuation rate 17% 19% 17% 12% Pregnancies* women discontinuing/expelling Pregnancies* women continuing use Total pregnancies with IUD program* * Per 1,000 women With an IUD program, 1,000 women delivering in Year 0 would return to the hospital to with 140 pregnancies over the next four years September 2010 Slide 12

13 Obstetrical costs to state and hospital Cost to state Net cost to hospital Cesarean section $6128 $1848 Vaginal delivery $4146 $16 Vaginal delivery with sterilization $5629 $1371 Ectopic pregnancy $5915 $3614 Spontaneous abortion Threatened abortion $1291 $3281 $2026 $1557 Normal newborn $3316 -$1495 September 2010 Slide 13

14 Cost Benefit ratio for an IUD program 258 pregnancies in the absence of an IUD program -140 pregnancies with an IUD program 118 pregnancies averted per 1,000 women who accept an IUD Cost of excess pregnancies Cost of an IUD program Every dollar spent on an IUD program saves Hospital $99,000 $328,000 $0.30 State $964,000 $328,000 $2.94 September 2010 Slide 14

15 Conservative estimate of cost benefit ratio to state Repeat pregnancies to other hospitals not included Assumes women give birth in their first year in the country (after 5 years, a birth to a legal immigrant on Medicaid would cost more to the state) Only direct costs for obstetrical diagnoses no other costs for infants. All infants assumed to be born healthy. September 2010 Slide 15

16 Sensitivity of our results An IUD program is cost effective to the state unless IUD discontinuation reaches 90% or expulsion reaches 70%. September 2010 Slide 16

17 Conclusions Restricting access to contraception by citizenship hurts families and increases financial losses for the state. Contraception is fundamental to social justice. Policy must be socially and fiscally responsible. Future work -- personal, social and economic benefits of family planning Given the critical importance of family planning in maintaining healthy families and reducing health disparities, as well as conserving public funds, I urge you to join me in demanding that politicians neither politicize contraception nor demonize immigrants as we reshape health care in the United States. return to awards September 2010 Slide 17