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Division of General Medicine and Clinical Epidemiology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North CarolinaDepartment of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Correspondence to: Vanessa K. Dalton, MD, MPH, Program on Women's Health Care Effectiveness Research, Department of Obstetrics and Gynecology University of Michigan Medical School, 1500 E. Medical Center Dr., L4000 Women's Hospital, Ann Arbor, MI 48109. Phone: 734-930-5610; fax: 734-647-9726.
The Patient Protection and Affordable Care Act of 2010 (ACA) eliminates patient cost sharing for a variety of women's preventive health services, including breast and cervical cancer screening, prenatal care, and contraceptive methods and counseling. Based on recommendations by the Committee on Preventive Services for Women in their 2011 report for the Institute of Medicine, first-dollar coverage of contraceptive methods, including sterilization, and related contraceptive counseling services, is now required of new insurance plans (
). Further, the public discourse has focused almost exclusively on these moral debates, while considerably less consideration is dedicated to the potential impact the mandate has on the larger population of American women, most of whom use contraception at some point in their lives (
). In particular, whereas many privately insured women already have some level of coverage for contraceptive methods, there is a dearth of information on the out-of-pocket cost burden of contraceptive methods for this group, making it difficult to estimate the mandate's impact on women currently receiving private insurance benefits.
More than half of U.S. women are enrolled in employer-based insurance plans. Although it seems to be true that the vast majority of employer-based health plans already cover contraception (
), there are few data reporting the out-of-pocket costs incurred by insured American women for specific contraceptive methods. Moreover, there has been limited discussion of the ACA's impact on women's choice of contraceptive method among the many available alternatives. This is critically important, because contraceptive methods differ significantly in effectiveness and price, to both the patient and the health plan. Short-acting contraceptives include pills, patches, rings and injectables. Short-acting methods have lower initiation costs (i.e., amount someone would have to pay to start using their chosen method) than other prescription methods. However, their effectiveness is largely user-dependent and failure rates are almost 10% in the first year of typical use (
). In contrast, long-acting reversible contraception (LARC), including implants and intrauterine contraception, have a failure rate of well under 1% in the first year of typical use largely because they do not rely on the user to be effective (
). Although LARC methods eventually have lower average costs of use (e.g., they can remain in place for 3 to 10 years after initial placement, compared with most short-term methods that require payments for each month of use;
), they are considerably more expensive to initiate. Given our clinical and public health goals to reduce unintended pregnancy and its consequences, it is important to clearly understand the extent of the burden that copayments present to women, and how copayments might drive contraceptive method choice.
There is some evidence to support the notion that cost might drive some women to choose less expensive and less effective methods. For instance, a recent study in a cohort of low-income women reports that eliminating out-of-pocket costs may increase the proportion of women who choose LARC methods (
). In another study, procurement of LARC methods increased significantly after cost sharing was eliminated in a large health maintenance organization. In this study, the authors calculated a 137% increase in couple-years of protection from intrauterine contraception, versus only a 16% increase in (couple-years of protection) from short-acting hormonal methods (
). Findings from these two studies are difficult to generalize to the broader population and there are no similar studies among other commercially insured women.
A more accurate picture of baseline expenditures made by both insured women and their health plans is a necessary first step to inform the debate on the potential impact of the ACA mandate on contraception use, method choice, and medical costs. To estimate the beneficiary and health plan expenditures made for contraceptive methods, we used the Truven Health MarketScan Commercial Claims and Encounters database. This data source represents over 50 million nonretired employees and their dependents enrolled in commercial health insurance plans sponsored by over 100 large or medium sized U.S.-based employers. The data include monthly enrollment, inpatient and outpatient medical claims, outpatient prescription drug claims, and reimbursed amounts paid by the health plan and patient for services billed. We examined women aged 14 to 45 with prescription drug coverage and at least 1 year of continuous health plan enrollment who used any contraceptive services between 2007 and 2010 (n = 3,746,785).
To estimate the costs that a patient might take into consideration when choosing a method, we examined the mean initiation costs of reversible contraceptive methods across health plans in each year. For branded oral contraceptives, generic oral contraceptives, vaginal rings, and transdermal patches we estimated reimbursement for a single fill, standardized to a 28-day supply. For injectables, implants, and intrauterine devices (IUDs) we estimated reimbursements for one injection or implant/IUD placement. These reimbursed amounts represent the amounts paid by the health plan and the patient for initiating a selected contraceptive method. Although we included expenditures associated with device placement, reimbursements for office visits were not included. All costs are inflation-adjusted to 2010 dollars using the medical component of the Consumer Price Index.
Initiation costs of using contraceptives varied by method and over time. Figure 1 presents the mean payments made by health plans and patients when initiating a contraceptive method in 2010. In 2010, patient out-of-pocket costs for initiating contraceptives was $10 (standard deviation [SD], $6) for generic oral contraceptives, $112 (SD, $156) for IUDs, and $116 (SD, $180) for implants. There was considerable variation in initiation costs. The 10th and 90th percentiles for patient out-of-pocket contraceptive initiation costs were $5 and $17 for generic oral contraceptives, $0 and $305 for IUDs, and $0 and $308 for implants.
Between 2007 and 2010, total reimbursements increased for each contraceptive method with the exception of generic oral contraceptives and injectable contraceptives. Patient out-of-pocket expenditures increased for LARC methods by approximately 40% for IUDs and 60% for implants between 2007 and 2010. This was driven by both an increase in the total reimbursed amounts for these methods and by an increase in the proportion of total reimbursements paid by the patient. For example, patients paid 13.8% of the reimbursed amounts of an IUD in 2007, and approximately 17.5% in 2010.
Unintended pregnancy incurs about $4.6 billion in direct medical costs per year (
). Our findings suggest that, although many insured women have access to relatively low-cost contraceptive options, such as generic oral contraceptives, there is considerable variability in cost sharing by plan and by contraceptive method. The out-of-pocket cost for a woman to initiate LARC methods—recognized as most effective, but also most expensive in the short-term—was 10 times higher compared with a 1-month supply of generic oral contraceptives.
Unintended pregnancy is a major problem in the United States; half of all pregnancies are unintended (
). Results from the Contraception CHOICE Project suggest that patient cost sharing may be an important barrier to intrauterine contraception and implant use for some women. In that study, 75% of participants chose a LARC method when financial barriers were eliminated and differences in the effectiveness of various contraceptive methods were discussed (
). Based on these initial studies, the elimination of copayments certainly seems to have potential. More work is needed to fully understand its benefits.
Out-of-pocket payments faced by privately insured women for contraception vary greatly and can be substantial. Initiation costs for the most effective methods are particularly high. These findings begin to inform a more rational debate on the potential value—in terms of a reduction in unintended pregnancy and its consequences, including abortion—of mandating full first dollar coverage for a wide range of contraceptive methods. Regardless of one's view of the ACA's mandate, the argument that the cost of contraceptive methods to patients is unimportant seems overstated. Monitoring the impact of the ACA's coverage of contraceptive products on method choice will help to define the extent to which costs have served as barriers to use or drivers of method selection. This understanding in turn can help to guide rational policies to promote women's health.
Dr. Dalton's effort in part was supported by grant number 1 K08 JS015491 from the Agency for Healthcare Research and Quality. Dr. Dalton is a Nexplanon Trainer for Merck. Drs. Dalton and Fendrick have also served on an advisory board for McNeil. No other authors have funding or conflicts to disclose.
Extending contraceptive coverage under the Affordable Care Act saves public funds.
Stacie B. Dusetzina, PhD, is an Assistant Professor in the Division of General Medicine and Clinical Epidemiology and the Department of Health Policy and Management at the University of North Carolina at Chapel Hill. She is a pharmacoepidemiologist by training and has expertise in the design and conduct of secondary database analyses.
Vanessa K. Dalton, MD, MPH, is an Associate Professor in the Department of Obstetrics and Gynecology and directs the department’s Program on Women’s Health Care Effectiveness Research. Her research focuses on the delivery of family planning services.
Michael E. Chernew, PhD, is a Professor of Health Care Policy in the Department of Health Care Policy at Harvard Medical School. Dr. Chernew’s research examines several areas related to controlling health care spending growth while maintaining or improving the quality of care.
Lydia E. Pace, MD, MPH, is a hospitalist and fellow in Global Women’s Health at Brigham and Women’s Hospital. She works part of the year for the Women’s Health Program of Partners in Health, in Rwanda.
Grace Bowden, graduated from the University of Michigan in 2012 with a degree Women's Studies. She is currently enrolled in the Scripps Post-Baccalaureate Premedical Program and is particularly interested in women's reproductive health policy.
A. Mark Fendrick, MD, is the Director of the Value Based Insurance Design Center at the University of Michigan and has appointments in the Departments of Internal Medicine and Health Management and Policy. Dr. Fendrick's research focuses on the clinical and economic assessment of medical interventions with special attention to how technological innovation influences clinical practice, benefit design, and health care systems.