National Partnership for Women & Families

Monthly Women's Health Research Review

Study Examines Relationship Between Patients' Out-of-Pocket Costs and LARC Use

Summary of "The Relationship Between Long-Acting Reversible Contraception and Insurance Coverage: A Retrospective Analysis," Broecker et al., Contraception, Nov. 11, 2015.

"Despite implementation of the Affordable Care Act [PL 111-148] ... out-of-pocket cost for contraceptives may be a barrier for many privately insured and uninsured women," according to Jane Broecker of Ohio University Heritage College of Osteopathic Medicine's Department of Obstetrics and Gynecology and colleagues.

The researchers explained that, under the ACA, insurers must cover FDA-approved contraceptives and services without cost-sharing, although some plans are exempt, grandfathered or "simply violate the ACA requirements." According to the researchers, "Out-of-pocket costs are of particular concern for long-acting, reversible contraceptive (LARC) methods," which are "significantly more effective than shorter-acting contraceptives" but are also "more expensive to initiate."

Although "there is momentum to increase utilization of LARC methods, cost may be a significant barrier," the researchers wrote. For their study, the researchers "hypothesized that women [in Ohio] requesting LARC methods would be less likely to follow through for placement if they were required to pay some or all of the cost." According to the researchers, Ohio's Medicaid program covers 100% of the cost of LARC, while private insurance coverage ranges from 0% to 100%.

Methods

The researchers analyzed data on patients who were "prescribed either an implant ... or an IUD between December 2011 and July 2013" at Athens Medical Associates Obstetrics and Gynecology. According to the study, patients had private insurance, Medicaid coverage or were uninsured.

The researchers explained that patients were counseled about their contraceptive options, and those who expressed an interest in LARC were prescribed the device and given cost information. Patients decided how to proceed "with placement of the device based on cost information or other factors, such as choosing another method after more consideration."

Among other factors, researchers examined patients' demographic data, coverage status, prescribed LARC method, contraceptive method used during the prescriptive visit, the patients' decision on whether to have the prescribed LARC method placed and the total out-of-pocket cost for the device and device placement.

Results

The final study sample included 571 patients.

The researchers found that, at the time of the prescriptive visit, 47.8% of patients were not using birth control. Meanwhile, the most common methods used among patients on birth control at the time of the prescriptive visit were oral contraception and injections. According to the researchers, 60.4% of patients were prescribed intrauterine devices and 39.6% were prescribed implants. They found that the out-of-pockets costs for LARCs ranged from $0 (68.8%) to between $1,200 and $1,299.

The researchers found that, "[c]ompared to patients already using a LARC method at the prescriptive visit, the odds of switching to a LARC method decreased for patients using birth control pills/injections, for patients using condoms and for patients not using any method."

Meanwhile, "For every additional $100 patients had to pay in out-of-pocket expenses, the decision to use a LARC method also decreased." According to the researchers, "There is a dramatic drop in the percentage of patients who chose to use LARC methods when the expense was equal to or above $200." Specifically, the researchers found that "only 27.8%" of privately insured patients whose out-of-pocket expenses were at least $200 opted to have the device placed, compared with 86.6% of privately insured patients with out-of-pocket costs less than $200. Meanwhile, 78.2% of patients with Ohio Medicaid "followed through with LARC placement."

The researchers also looked at contraceptive outcomes among patients who did not choose LARC in spring of 2015. The researchers found that:

  • 52% of patients opted for hormonal contraception;
  • 4.8% opted for condoms;
  • 4.1% opted for sterilization; and
  • 18.5% opted not to use a specific method.

Meanwhile, 1.4% of patients became pregnant and 19.2% did not return after the prescriptive appointment where they had shown interest in using LARC.

Discussion

"This study demonstrates that for women interested in LARC methods, out-of-pocket cost is a significant barrier to patient utilization of the most effective methods of reversible contraception: IUDs and implants," the researchers wrote. They added, "If patients have to pay $200 or more out of pocket, they are less likely to follow through for placement of a device even if their financial responsibility is only a small proportion of the actual cost."

The data showed patients who had expressed interest in LARC "had a fairly high follow through for placement when cost was not a barrier," the researchers noted. They also noted that the study's "findings in an Appalachian population have some overlap with the findings of the Contraceptive CHOICE Project, which included women in an urban environment." According to the researchers, there were "fairly high device placement rates (77.9%) for patients with Medicaid living in Appalachia," which is significant because such patients "are more likely to live in poverty and often face other barriers to placement such as inadequate transportation and lower level of education." In turn, the researchers urged "work[ing] toward same-day placement whenever possible and continu[ing] to identify and break down barriers to LARC provision."

The researchers noted that some factors influencing a woman's decision to use LARC that were not considered in the study included "lack of transportation, fears about the insertion procedure and side effects, and concern about confidentiality." They wrote, "Outreach services to rural locations and patient-physician discussion of women's concerns about LARC may provide greater access to contraceptive services and help women to make more informed choices."

According to the researchers, "[s]ignificant differences in LARC placement were found when [the researchers] stratified by contraceptive status." They found that the highest rate of follow through for LARC device placement was among current LARC users, "followed by those using pill/injection, with the lowest follow through rates for those patients using no method or condoms." The researchers listed several possible explanations for the results, such as how women using LARC might already be satisfied with LARC methods or how women who are less likely to follow through with placement might have fewer financial resources.

In terms of study limitations, the researchers noted that because of the study location in rural Appalachia, "patients were mostly white, and [their] findings may not be generalizable to other populations." Further, the researchers pointed out "a lack of information on women's annual income ... which may have been significant when assessing for whom cost was a barrier." They added that they "also lacked detailed information regarding reasons why women who requested a LARC method did not ultimately have one placed."

The researchers wrote, "The study clearly demonstrates that out of pocket cost is a barrier to placement of a desired LARC device." According to the researchers, "employers could have an impact on the unintended pregnancy rate of their employees by ensuring low- or no-cost provision of LARC methods by offering new insurance plans which cover contraceptive services at no cost to the patient and phasing out older grandfathered plans which are not required to comply with the requirement of no-cost contraceptive services."

The researchers noted that while "the ACA will likely result in an increasing number of patients choosing LARC methods," providers in the immediate future must "continue to help [uninsured or underinsured] patients find affordable LARC placement whether through Title X programs, patient assistance programs, use of new lower-cost IUDS or othe[r]" means. Meanwhile, providers "must continue to work toward lowering the costs of [LARC] and advocate for no-cost contraceptive coverage for all."