Original research articleA comparison of contraceptive procurement pre- and post-benefit change☆
Introduction
Half of all pregnancies in the United States are unintended [1]. This percentage has not changed since 1994 despite an increase in the variety of contraceptive methods available. Mandates to include contraceptive coverage in insurance benefit packages have been recently passed in 26 of the 50 states in this country [2], but the impact on contraceptive use and unintended pregnancy is not proven. In 2002, 27% of women at risk for unintended pregnancy were using oral contraceptives (OCs), 5% were using injectables and only 2% were using intrauterine contraceptives (IUCs) [3]. However, the annual risk of pregnancy for OCs is 8%, as compared with 3% for injectables and less than 1% for IUCs [4]. Among women having abortions, 28% reported using male condoms in the month pregnancy occurred and 14% reported using OCs; in contrast, only 0.1% of women reported IUC use [5]. IUCs, contraceptive implants and injectables have been well documented to be the most cost-effective reversible methods of contraception [6], [7], [8].
In 2002, the Kaiser Foundation Health Plan in California changed its coverage policy to include universal 100% coverage (no co-payment) for the most effective forms of contraception (copper and levonorgestrel IUCs, injectables and implants but not OCs) and for emergency contraceptive pills (ECPs). The benefit change was advocated by Kaiser Permanente Medical Group physician leaders throughout the system as an effort to promote more effective contraceptive use and thereby reduce unintended pregnancies. Prior to this coverage change, contraceptive devices and injections were stocked in the pharmacy and had large co-payments. For example, if the co-payment for a monthly contraceptive was US$5, then a 5-year contraceptive method (e.g., levonorgestrel IUC or contraceptive implant) would cost the member US$300 (60 months in 5 years×US$5/month). A second appointment was often necessary for the member to receive these services because of the inconvenience of purchasing the device from the pharmacy. This requirement would lead to additional visits with an additional co-payment as well as inconvenience. After the change in coverage, other system changes resulted from the removal of the need to collect payment for contraceptives. Injections and devices were stocked in the medical offices and there was no pharmacy co-pay; hence, same-day administration of these methods was made possible and encouraged.
In 2002, the California Department of Managed Care issued a mandate to health maintenance organizations that ECPs be made more widely available [9]. In addition to removing the financial barrier imposed by the pharmacy co-pay, stocking ECPs in the medical offices for direct dispensing increased the likelihood that women would get them in a timely manner.
In this article, we assessed the impact of the contraceptive benefit change by analyzing pharmacy procurement data before and after the change using a novel evaluation approach. Pharmaceutical procurement at Kaiser Permanente is based on several factors including current and projected utilization patterns, as well as strict protocols concerning expiration dating of items to be purchased. These factors minimize overstock or drug destruction due to expired product.
Kaiser Permanente Northern California (KPNC) has over 3 million members, approximately 660,000 of whom are women of reproductive age. Traditionally, 96% of all members have KPNC pharmacy benefits, an incentive to have prescriptions filled at KPNC pharmacies. Overall, female members aged 20–44 are primarily employed (89%), middle income and educated (38% with some college or more); approximately 55% are White non-Hispanic, 7% African American, 16% Latino, 19% Asian, 1.3% Native American and less than 1% Pacific Islander [10].
The research questions were the following: (a) does removing the cost of contraception as a potential barrier to utilization lead to change in the mix of contraceptive methods purchased by a large health plan? and (b) could the changes in prescribing that are reflected in contraceptive procurement theoretically result in averting a greater number of unintended pregnancies?
The measurable study objectives included the following:
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Identifying the portfolio of contraceptive medications and devices procured each year by KPNC from 2000 through 2004
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Estimating the couple-years of protection (CYP) for hormonal methods and IUCs for the years 2000–2004
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Estimating unintended pregnancies averted per year based on the estimated CYP
Section snippets
Methods
This study was approved by the Kaiser Permanente Institutional Review Board (IRB) for Human Subjects. Funding for the project was provided by the Kaiser Permanente Women's Health Research Institute.
Results
Procurement data for the period 2000 to 2004 are shown in Table 1. Membership of women aged 15–44 remained relatively level over the 5-year study period; there was a decline of 1% between 2001–2002 and 2004–2005 (Table 2). In contrast, there was a 28% increase in CYP from hormonal methods and IUCs: an increase of 137% from IUCs, 32% from injectables and 16% from OCs, patch and ring (Table 2). The estimated annual contraceptive failure rate among users of these methods fell from 7.0% to 6.4% due
Discussion
This study provides evidence that a change in benefit structure to include 100% coverage of long-acting reversible contraceptive methods and removal of other barriers to their use resulted in increased procurement of these methods (which reflects increased prescribing of the methods).
Several factors affected the available contraceptive options over the 5-year period of study. Distribution of the monthly injectable, the 1-year IUC and the 5-year implant was discontinued. The contraceptive patch
References (22)
- et al.
Economic analysis of contraceptives for women
Contraception
(2003) - et al.
Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomized trial
Lancet
(2002) - et al.
Efficacy and safety of a contraceptive vaginal ring (NuvaRing) compared with a combined oral contraceptive: a 1-year randomized trial
Contraception
(2005) - et al.
Advanced provision of emergency contraception does not reduce abortion rates
Contraception
(2004) - et al.
Advanced provision of emergency contraception to postnatal women in China makes no difference in abortion rates: a randomized controlled trial
Contraception
(2005) - et al.
Intrauterine contraception: study to evaluate clinician practice patterns in Kaiser Permanente, Northern California
Contraception
(2007) - et al.
Disparities in rates of unintended pregnancy in the United States, 1994 and 2001
Perspect Sex Reprod Health
(2006) Insurance coverage of contraceptives. State policies in brief
(2007)- et al.
Use of contraception and use of family planning services in the United States: 1982–2002. Advance data from vital and health statistics, no 350
(2004) Contraceptive efficacy
Contraceptive use among U.S. women having abortions in 2000–2001
Perspect Sex Reprod Health
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Financial support for the study was provided by Kaiser Permanente, Women's Health Research Institute.