“LET’S INCREASE OUR USE OF IMPLANTS AND DMPA AND IMPROVE CONTRACEPTIVE EFFECTIVENESS IN THIS COUNTRY”
(SEPTEMBER 2012) ROBERT L. BARBIERI, MD (EDITORIALS)
LARC shouldn’t be bundled into the global obstetric fee
I appreciate Dr. Barbieri’s very timely editorials on long-acting reversible contraception (LARC). He mentioned a recent study by Tocce and colleagues, in which new mothers were offered a choice between insertion of an etonogestrel implant before hospital discharge or initiation of any contraceptive at the postpartum follow-up visit.1 The women who chose the implant had a lower rate of pregnancy at 6 months than the women who deferred contraception to the postpartum visit (0% vs 9.9%).
Interestingly, I had recently been in contact with Dr. Tocce when I read Dr. Barbieri’s editorials. I was concerned about insurance companies’ bundling of the charge for LARC into the global obstetric fee. I have given a copy of the study by Tocce and colleagues to two large insurers in our community, arguing that it is cost-effective to unbundle this service. In addition, as Dr. Barbieri noted, the initiation of LARC immediately postpartum would help reduce the rate of unintended repeat pregnancy. I plan to send the insurers a copy of Dr. Barbieri’s editorials as well.
If insurers are willing to change their policy, perhaps Medicaid will follow their lead.
Kenneth R. Kahn, MD
Buffalo, New York
Reimbursement for LARC is too low
I am an ObGyn in private practice, and I am absolutely in favor of LARC. I am probably one of the few ObGyns in my area who actually encourage patients to get an intrauterine device (IUD). I believe the reason that many docs do not recommend the IUD is the fact that reimbursement is less than the cost!
If private insurers and Medicaid would increase reimbursement, I am certain that more docs would encourage patients to use LARC. For some docs in private practice, however, it comes down to the bottom line. I’m sure we all appreciate the value of these contraceptives, but many of us just cannot absorb the cost.
Jennifer Nguyen, MD
Dr. Barbieri responds In some locales, reimbursement for LARC is inadequate
I thank Dr. Kahn and Dr. Nguyen for their important commentary on barriers they face in using LARC. In my editorial, I neglected to mention that the reimbursement practices of commercial insurers, Medicaid, and Medicare often create barriers to optimal patient care. In some locales, insurance practices, such as refusing to pay for the true cost of the contraceptive, discourage the use of LARC, especially in private office settings.1 Advocacy and high-quality outcomes data2 are sometimes effective in changing insurers’ reimbursement practices, and likely are our best hope for advancing the health of our patients.
“HOW TO AVOID MAJOR VESSEL INJURY DURING GYNECOLOGIC LAPAROSCOPY”
MICHAEL BAGGISH, MD (AUGUST 2012)
Controlled trocar insertion can avert vascular injury
I commend Dr. Baggish on his thoughtful, well-organized, and complete review of trocar injuries. I also would like to point out that proper insertion of the trocar means that it barely enters the peritoneal cavity. For vascular injury to occur (with any means of trocar insertion), the trocar not only would have to enter the peritoneal cavity but would need to pass through it entirely and impale vessels against the posterior abdominal wall. That is not a controlled entry, but a completely uncontrolled entry, involving too much momentum and muscle strength and too little precision.
My experience with residents and others learning laparoscopy has revealed two common errors that may lead to loss of control of the trocar:
- failure to incise the fascia sufficiently, which can cause the trocar to hang up on the fascia. When this occurs, the fascial defect should be enlarged, but some physicians apply more pressure to the trocar instead, increasing the risk of injury.
- a tendency to put the shoulder above the elbow when inserting the trocar, to gain more “oomph” at the cost of losing control.
As Harry Reich, MD, has often noted, if one jams a trocar into a hard surface, such as a table (or bone), one hears two taps in quick succession rather than a single tap. Presumably, this phenomenon arises when the energy behind the insertion leads to a rebound bounce. Clinically, that suggests that when trocar injury occurs, and a vessel perforation is found, the surgeon needs to look for that second-bounce perforation!
William J. Mann Jr., MD
Neptune Township, New Jersey