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Contraception Editorial October 2011

Strategies To Expand Contraception Coverage:

Another Tool In The Box

Emily M. Godfrey

Introduction 

Despite the extensive body of evidence about the health benefits and cost-savings of contraception coverage, women's health care advocates are bracing themselves for the possibility that contraceptive care will lose the political debate as a no cost-sharing preventive service under the Affordable Care Act (ACA). As a second alternative to no cost-sharing, the Health Resources and Services Administration (HRSA) may determine that contraceptive care under the ACA is an essential women's health preventive service that all health plans must cover, but with cost-sharing. Should HRSA decide to exclude comprehensive contraceptive coverage as an essential women's health preventive service altogether, strategists would likely attempt to (a) convince more states to classify contraceptive services as essential benefits that all health plans must cover (with cost-sharing) or (b) convince more employers to include contraceptive services as covered benefits in the health plans that they sponsor or participate in (with cost-sharing).

Yet, as a last resort to the strategies listed above, one additional strategy can be added to the mix — that of advocating for the development of a numerical International Statistical Classifications of Diseases (ICD) code for “unwanted fertility” — meaning one's desire to temporarily or permanently remove his or her state of fertility to prevent potential conception; as a diagnosis, unwanted fertility can be treated with contraception. The ICD system, which includes alphanumeric designations that serve to standardize various diseases, such as “diabetes,” or other problems, such as “nonspecific low blood pressure reading,” is required for billing and reimbursement. Health maintenance or preventive clinical visits use supplemental designations, referred to as “V codes” to identify encounters for reasons other than illness, injury or problems.1 All visits involving routine contraceptive care, be it counseling, prescribing or a device-insertion procedure, are coded for billing purposes with a preventive V code. Employers who, through their insurance benefit design, exclude most “preventive” visits are excluding not only the contraceptive method itself, but also office visits that include the use of the V code. Should attempts at advocating contraceptive care as essential preventive care with or without cost-sharing be unsuccessful, the generation of a numerical ICD code for unwanted fertility can potentially be used as a tool to compel health insurance plans to cover contraceptive services, drugs and devices as benefits, as they do for other diseases.

Although the presence of an ICD diagnosis code does not necessarily guarantee insurance coverage, the opportune time to consider the introduction of an ICD code for unwanted fertility may be sooner rather than later. It is the World Health Organization (WHO) that determines the ICD codes and the United States adapts them, referring to the adapted version as the “clinical modification” (CM). The current version of the US adapted ICD (or ICD-9-CM) was modified for use in 1979.2 A new generation and much larger code set, the US-adapted ICD-10-CM, will replace the current ICD-9-CM starting in 2013.3 WHO is currently working on the ICD-11, which is now undergoing field trials and slated to be submitted to the World Health Assembly for final approval by 2014.4 The changes that are occurring with the ICD-11 are significant because for the first time in history, WHO launched a major online project to revise the global standard for the ICD-11, inviting stakeholders to participate in the ICD revision through an internet platform. WHO states that this update is vital in order to keep up with recent progress in medicine, to monitor the use of health information technology and to improve the basis for international comparisons.5

The case for ICD diagnosis: meeting the aims of the update and revision process 

In the document put forth by the WHO that describes the revision process, WHO outlines the aims of the revision process of the ICD in which health information will be systematically reviewed using the following categories: (1) scientific evidence, (2) clinical utility and (3) health system utility and public health usefulness.4 The ICD diagnosis of unwanted fertility meets these aims in the following way. First, the measure “unmet need for contraception,” a synonym for unwanted fertility, has historical roots starting in the 1960s and remains an important indicator for monitoring family planning programs.6 Currently, the main information source for measuring unmet contraception need is the Demographic and Health Surveys (DHS), which provides information about married women or women living in a consensual union in more than 75 developing countries.6 By identifying countries with high levels of unmet need, governments and other organizations can target their resources to where they may be most effective. In addition, treatments for unwanted fertility, i.e., contraceptive methods, have a long-standing body of scientific evidence demonstrating the prevention of 188 million unintended pregnancies, which subsequently saves some 200,000 women from pregnancy-related deaths and contributes to the survival of a million infants annually.7

Second, unwanted fertility as a diagnosis has clinical utility, particularly in circumstances in which women may have significant underlying medical conditions. Both the WHO and the Centers of Disease Control and Prevention (CDC) Medical Eligibility Criteria for Contraception list medical conditions that will worsen with pregnancy.8, 9

Lastly, unwanted fertility as a diagnosis has significant public health usefulness. The National Center for Health Statistics (NCHS) collects annual data on conditions for which patients seek care, primarily using ICD codes. The existence of such a code could help augment current national survey collection standards of assessing unmet need for contraception and possibly improve accuracy and reliability of trends in its treatment within and between countries. Additionally, such information could be used to help countries understand how cultural and other local issues affect treatment of this health care problem.

The case for ICD diagnosis: defining unwanted fertility as a medical problem 

For those who are involved in the revision process, WHO has provided a working definition of disease or health-related problem to include (1) symptomatology/manifestations, (2) etiology, (3) course and outcome, and (4) treatment response. By using this working definition for disease, the WHO states that it will be better able to classify whether the condition is a disease or other entity. Unwanted fertility has the potential to meet WHO's working definition of a health care problem.

Manifestation 

Unwanted fertility is a manifestation of a woman who may present with regular menstrual cycles, has current sex partner(s) who has the potential to cause pregnancy and has an expressed desire to avoid pregnancy. Unwanted fertility may not be unlike a current manifestation and diagnosis, called “infertility,” defined by the failure to achieve a successful pregnancy after 12 months or more of regular unprotected intercourse.10

Etiology 

While underlying causes of unwanted fertility may not be due to anatomical or organic dysfunction, its etiology may stem from having a significant underlying medical condition and being informed that the condition will severely worsen with pregnancy and possibly endanger the life and health of the patient; other causes may be genetic, endangering the health and life of the potential fetus, or may be social, familial or economical.

Course and outcome 

The course in not treating unwanted fertility is clear — pregnancy will occur in approximately 85 of every 100 untreated women in 1 year. In the US, lack of treatment of unwanted fertility has led to an epidemic of unintended pregnancy, with approximately half of all pregnancies each year as unintended.11

Treatment response 

Unwanted fertility is treated with an effective method of contraception. The range of contraceptive methods approved by the US Food and Drug Administration are all highly effective to treat unwanted fertility and prevent unwanted pregnancy. Long-acting contraceptive methods, such as sterilization, the IUD and the implant, are the most effective methods, reducing unwanted pregnancy by more than 99%. Injectable and contraceptive pills are slightly less effective in preventing unwanted pregnancy because of the difficulties some women experience using contraception consistently and correctly when they miss or delay receiving an injection or taking a pill. Despite some imperfect treatment responses, using any contraceptive method to treat unwanted fertility, and thus protect against unwanted pregnancy, is far better than using no method at all.12

Conclusion 

An abundance of evidence and reasonable arguments exists behind the notion that contraceptive care is a critical preventive health service for women, but many individual and small group plans, as well as some of the larger employer-based insurance plans, manage to finagle their way out of paying for this important health care service. While women's health care advocates anxiously await the decisions from HRSA, they must continue to devise multiple strategies to expand contraceptive coverage including convincing more states to pass laws that require insurers to either cover or offer coverage for contraceptive care or convincing more employers to include contraceptive services as covered benefits in their health plans. If none of these strategies succeeds, advocate organizations should consider sponsoring a request to WHO for the development of a numerical ICD code for unwanted fertility. While an ICD code for unwanted fertility may not eradicate coverage exclusions, it may be yet another tool in the box to compel health insurance plans to cover contraceptive services, drugs and devices as benefits, as they do for other diseases.

Acknowledgments 

The author would like to thank Dr. Michael Policar of the Bixby Center for Global Reproductive Health at the University of California, San Francisco, for his critical review of this editorial.

Emily M.Godfrey
Association of Reproductive Health Professionals
Washington, DC
Department of Family Medicine
University of Illinois-Chicago
Chicago, IL

References

  1. National Center for Health Statistics . ICD-9-CM Official Guidelines for Coding and Reporting (Effective October 1, 2010)
  2. National Center for Health Statistics . International Classification of Diseases, Ninth Revision (ICD-9). Available at: 2009;
  3. National Center for Health Statistics . International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). Available at:
  4. World Health Organization . Production of ICD-11: the overall revision process. Available at 2007;
  5. World Health Organization . WHO uses web-based approach to revise global disease standards. Available at:
  6. Mills S, Suzuki E. Unmet need for contraception. World Bank; 2010;
  7. Cohen SA. In: Family planning and safe motherhood: dollars and sense, Guttmacher Policy Review. New York: Guttmacher Institute; 2010;p. 12–16
  8. Centers for Disease Control and Prevention . U S. Medical Eligibility Criteria for Contraceptive Use, 2010. MMWR Recomm Rep.2010;59:1–86
  9. World Health Organization . Medical eligibility criteria for contraceptive use – 4th ed, Rev. 1. Geneva: WHO Press; 2010;
  10. Practice Committee of the American Society for Reproductive Medicine . Definitions of infertility and recurrent pregnancy loss.Fert Steril. 2008;90:S60
  11. Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health. 2006;38:90–96
  12. Trussell J. Contraceptive failure in the United States. Contraception. 2011;83:397–404

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Used with permission from Elsevier, Inc.