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Bullard KA, Hersh A, Caughey AB, Rodriguez MI. Expanding comprehensive pregnancy care for Emergency Medicaid recipients: a cost-effectiveness analysis. Am J Obstet Gynecol MFM 2024; 6:101364. [PMID: 38574857 PMCID: PMC11102284 DOI: 10.1016/j.ajogmf.2024.101364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Emergency Medicaid is a restricted benefits program for individuals who have low-income status and who are immigrants. OBJECTIVE This study aimed to compare the cost-effectiveness of 2 strategies of pregnancy coverage for Emergency Medicaid recipients: the federal minimum of covering the delivery only vs extended coverage to 60 days after delivery. STUDY DESIGN A decision analytical Markov model was developed to evaluate the outcomes and costs of these policies, and the results in a theoretical cohort of 100,000 postpartum Emergency Medicaid recipients were considered. The payor perspective was adopted. Health outcomes and cost-effectiveness over a 1- and 3-year time horizon were investigated. All probabilities, utilities, and costs were obtained from the literature. Our primary outcome was the incremental cost-effectiveness ratio of the competing strategies. RESULTS Extending Emergency Medicaid to 60 days after delivery was determined to be a cost-saving strategy. Providing postpartum and contraceptive care resulted in 33,900 additional people receiving effective contraception in the first year and prevented 7290 additional unintended pregnancies. Over 1 year, it resulted in a gain of 1566 quality-adjusted life year at a cost of $10,903 per quality-adjusted life year. By 3 years of policy change, greater improvements were observed in all outcomes, and the expansion of Emergency Medicaid became cost saving and the dominant strategy. CONCLUSION The inclusion of postpartum care and contraception for immigrant women who have low-income status resulted in lower costs and improved health outcomes.
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Affiliation(s)
- Kimberley A Bullard
- Department of Obstetrics and Gynecology, Center for Reproductive Health Equity, Oregon Health & Science University, Portland, OR (Drs Bullard, Hersh, Caughey, and Rodriguez); Department of Obstetrics and Gynecology, University of Tennessee College of Medicine Chattanooga, Chattanooga, TN (Dr Bullard)
| | - Alyssa Hersh
- Department of Obstetrics and Gynecology, Center for Reproductive Health Equity, Oregon Health & Science University, Portland, OR (Drs Bullard, Hersh, Caughey, and Rodriguez)
| | - Aaron B Caughey
- Department of Obstetrics and Gynecology, Center for Reproductive Health Equity, Oregon Health & Science University, Portland, OR (Drs Bullard, Hersh, Caughey, and Rodriguez)
| | - Maria I Rodriguez
- Department of Obstetrics and Gynecology, Center for Reproductive Health Equity, Oregon Health & Science University, Portland, OR (Drs Bullard, Hersh, Caughey, and Rodriguez).
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Paul PL, Pace LE, Hawkins SS. Impact of contraceptive coverage policies on contraceptive use and risky sexual behavior among adolescent girls in the USA. J Public Health (Oxf) 2023; 45:e121-e129. [PMID: 34850208 DOI: 10.1093/pubmed/fdab387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/30/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE This study used representative data to examine the impact of changes in contraceptive coverage policies (contraceptive insurance mandates and pharmacy access to emergency contraception) on contraceptive use and risky sexual behavior among adolescent girls. STUDY DESIGN Using 2003-17 Youth Risk Behavior Survey data on 116 180 adolescent girls from 34 states, we conducted difference-in-differences models to examine changes in contraceptive use and unprotected sexual intercourse with the implementation of contraceptive coverage policies. We also tested interactions between age and pharmacy access to emergency contraception. RESULTS Findings indicate that contraceptive insurance mandates and pharmacy access to emergency contraception were not associated with changes in contraceptive use or unprotected sexual intercourse among adolescent girls, although some changes were observed in specific age groups. Despite this, our results show an overall increase in reported use of birth control pills and longer-acting methods from 2003 through 2017. CONCLUSIONS Using representative data, this study lends support to existing evidence that increased access to emergency contraception does not impact contraceptive method used or unprotected sexual intercourse among adolescent girls. The results underscore the need for expanding access to a wide range of contraceptive options for adolescents, with a focus on safer and more effective longer-acting methods.
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Affiliation(s)
- Pooja L Paul
- School of Social Work, Boston College, Chestnut Hill, MA 02467, USA
| | - Lydia E Pace
- Division of Women's Health, Brigham and Women's Hospital, Boston, MA 02115, USA
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Policy impacts on contraceptive access in the United States: a scoping review. JOURNAL OF POPULATION RESEARCH 2023. [DOI: 10.1007/s12546-023-09298-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
AbstractContraceptive access is influenced by policy decisions, which can expand and constrict the contraceptive options available. This study explored the impact of recent US federal policies on contraceptive access by identifying and reviewing empirical literature, which is then presented and discussed using Levesque et al.’s (2013) healthcare access framework. A scoping review was conducted to identify empirical studies (N = 96) examining the impact of recent federal policy (passed from 2009 to 2019) on contraceptive access. Most identified studies examined the role of the Affordable Care Act (n = 53) and Title X of the Public Health Service Act (n = 25), showing many benefits of both policies for contraceptive access, particularly through improved affordability, availability, and appropriateness of contraceptive care. Other identified studies examined the impact of policies funding abstinence-only sex education (n = 2) and the Teen Pregnancy Prevention Program (n = 3), military policies related to the availability of contraception (n = 1), guidelines for quality contraceptive care (n = 3), Title IX of the Education Amendments (n = 4), the Violence Against Women Act (n = 1), and the Veterans Access, Choice, and Accountability Act (n = 4). Through increased outreach efforts, normalising of care, availability of services, cost subsidies, and provider competencies, recent federal policy has, overall, enhanced contraceptive access across the dimensions of healthcare access. Numerous policy and practice gaps and needs are identified, and future directions for research, policy, and practice are suggested.
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Swan LET. Policy impacts on contraceptive access in the United States: a scoping review. JOURNAL OF POPULATION RESEARCH 2023; 40:5. [DOI: https:/doi.org/10.1007/s12546-023-09298-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2022] [Indexed: 06/22/2023]
Abstract
AbstractContraceptive access is influenced by policy decisions, which can expand and constrict the contraceptive options available. This study explored the impact of recent US federal policies on contraceptive access by identifying and reviewing empirical literature, which is then presented and discussed using Levesque et al.’s (2013) healthcare access framework. A scoping review was conducted to identify empirical studies (N = 96) examining the impact of recent federal policy (passed from 2009 to 2019) on contraceptive access. Most identified studies examined the role of the Affordable Care Act (n = 53) and Title X of the Public Health Service Act (n = 25), showing many benefits of both policies for contraceptive access, particularly through improved affordability, availability, and appropriateness of contraceptive care. Other identified studies examined the impact of policies funding abstinence-only sex education (n = 2) and the Teen Pregnancy Prevention Program (n = 3), military policies related to the availability of contraception (n = 1), guidelines for quality contraceptive care (n = 3), Title IX of the Education Amendments (n = 4), the Violence Against Women Act (n = 1), and the Veterans Access, Choice, and Accountability Act (n = 4). Through increased outreach efforts, normalising of care, availability of services, cost subsidies, and provider competencies, recent federal policy has, overall, enhanced contraceptive access across the dimensions of healthcare access. Numerous policy and practice gaps and needs are identified, and future directions for research, policy, and practice are suggested.
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Bruce K, Stefanescu A, Romero L, Okoroh E, Cox S, Kieltyka L, Kroelinger C. Trends in Postpartum Contraceptive Use in 20 U.S. States and Jurisdictions: The Pregnancy Risk Assessment Monitoring System, 2015-2018. Womens Health Issues 2023; 33:133-141. [PMID: 36464580 DOI: 10.1016/j.whi.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 09/28/2022] [Accepted: 10/10/2022] [Indexed: 12/03/2022]
Abstract
INTRODUCTION In the last decade, state and national programs and policies aimed to increase access to postpartum contraception; however, recent data on population-based estimates of postpartum contraception is limited. METHODS Using Pregnancy Risk Assessment Monitoring System data from 20 sites, we conducted multivariable-adjusted weighted multinomial regression to assess variation in method use by insurance status and geographic setting (urban/rural) among people with a recent live birth in 2018. We analyzed trends in contraceptive method use from 2015 to 2018 overall and within subgroups using weighted multinomial logistic regression. RESULTS In 2018, those without insurance had lower odds of using permanent methods (adjusted odds ratio [AOR], 0.72; 95% confidence interval [CI], 0.53-0.98), long-acting reversible contraception (LARC) (AOR, 0.67; 95% CI, 0.51-0.89), and short-acting reversible contraception (SARC) (AOR, 0.61; 95% CI, 0.47-0.81) than those with private insurance. There were no significant differences in these method categories between public and private insurance. Rural respondents had greater odds than urban respondents of using all method categories: permanent (AOR, 2.15; 95% CI, 1.67-2.77), LARC (AOR, 1.31; 95% CI, 1.04-1.65), SARC (AOR, 1.42; 95% CI, 1.15-1.76), and less effective methods (AOR, 1.38; 95% CI, 1.11-1.72). From 2015 to 2018, there was an increase in LARC use (odds ratio [OR], 1.03; 95% CI, 1.01-1.05) and use of no method (OR, 1.05; 95% CI, 1.02-1.07) and a decrease in SARC use (OR, 0.97; 95% CI, 0.95-0.99). LARC use increased among those with private insurance (OR, 1.05; 95% CI, 1.02-1.08) and in urban settings (OR, 1.04; 95% CI, 1.02-1.07), but not in other subgroups. CONCLUSIONS We found that those without insurance had lower odds of using effective contraception and that LARC use increased among those who had private insurance and lived in urban areas. Strategies to increase access to contraception, including increasing insurance coverage and investigating whether effectiveness of existing initiatives varies by geographic setting, may increase postpartum contraceptive use and address these differences.
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Affiliation(s)
- Katharine Bruce
- University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina; Louisiana Department of Health, Office of Public Health, Bureau of Family Health, New Orleans, Louisiana.
| | - Andrei Stefanescu
- Louisiana Department of Health, Office of Public Health, Bureau of Family Health, New Orleans, Louisiana
| | - Lisa Romero
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ekwutosi Okoroh
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Shanna Cox
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lyn Kieltyka
- Louisiana Department of Health, Office of Public Health, Bureau of Family Health, New Orleans, Louisiana; Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Charlan Kroelinger
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Swan LET, McDonald SE, Price SK. Pathways to reproductive autonomy: Using path analysis to predict family planning outcomes in the United States. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e6487-e6499. [PMID: 36317755 PMCID: PMC10092462 DOI: 10.1111/hsc.14094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 07/19/2022] [Accepted: 10/16/2022] [Indexed: 06/16/2023]
Abstract
In the United States, about half of pregnancies are unintended, and most women of reproductive age are at risk of unintended pregnancy. Research has explored predictors of contraceptive use and unintended pregnancy, but there is a lack of research regarding access to preferred contraceptive method(s) and the complex pathways from sociodemographic factors to these family planning outcomes. This study applied Levesque et al.'s (2013) healthcare access framework to investigate pathways from sociodemographic factors and indicators of access to family planning outcomes using secondary data. Data were collected at four time points via an online survey between November 2012 and June 2014. Participants were US women of reproductive age who were seeking to avoid pregnancy (N = 1036; Mage = 27.91, SD = 5.39; 6.9% Black, 13.6% Hispanic, 70.2% white, 9.4% other race/ethnicity). We conducted mediational path analysis, and results indicated that contraceptive knowledge (β = 0.116, p = 0.004), insurance coverage (β = 0.423, p < 0.001), and relational provider engagement (β = 0.265, p = 0.011) were significant predictors of access to preferred contraceptive method. Access to preferred contraceptive method directly predicted use of more effective contraception (β = 0.260, p < 0.001) and indirectly predicted decreased likelihood of experiencing unintended pregnancy via contraceptive method(s) effectiveness (β = -0.014, 95% confidence interval: -0.041, -0.005). This study identifies pathways to and through access to preferred contraceptive methods that may be important in determining family planning outcomes such as contraceptive use and unintended pregnancy. This information can be used to improve access to contraception, ultimately increasing reproductive autonomy by helping family planning outcomes align with patients' needs and priorities.
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Affiliation(s)
- Laura E. T. Swan
- Department of Population Health SciencesUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Shelby E. McDonald
- Virginia Commonwealth UniversityClark‐Hill Institute for Positive Youth DevelopmentRichmondVirginiaUSA
| | - Sarah K. Price
- Virginia Commonwealth UniversitySchool of Social WorkRichmondVirginiaUSA
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Swan LET, McDonald SE, Price SK. Pathways to reproductive autonomy: Using path analysis to predict family planning outcomes in the United States. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30. [DOI: http:/doi.org/10.1111/hsc.14094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 10/16/2022] [Indexed: 06/22/2023]
Affiliation(s)
- Laura E. T. Swan
- Department of Population Health Sciences University of Wisconsin‐Madison Madison Wisconsin USA
| | - Shelby E. McDonald
- Virginia Commonwealth University Clark‐Hill Institute for Positive Youth Development Richmond Virginia USA
| | - Sarah K. Price
- Virginia Commonwealth University School of Social Work Richmond Virginia USA
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Jalali FS, Bikineh P, Delavari S. Strategies for reducing out of pocket payments in the health system: a scoping review. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2021; 19:47. [PMID: 34348717 PMCID: PMC8336090 DOI: 10.1186/s12962-021-00301-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 07/28/2021] [Indexed: 11/24/2022] Open
Abstract
Background Direct out-of-pocket payments (OOP) are among the most important financing mechanisms in many health systems, especially in developing countries, adversely affecting equality and leading vulnerable groups to poverty. Therefore, this scoping review study was conducted to identify the strategies involving OOP reduction in health systems. Methods Articles published in English on strategies related to out-of-pocket payments were Searched and retrieved in the Web of Science, Scopus, PubMed, and Embase databases between January 2000 and November 2020, following PRISMA guidelines. As a result, 3710 papers were retrieved initially, and 40 were selected for full-text assessment. Results Out of 40 papers included, 22 (55%) and 18 (45%) of the study were conducted in developing and developed countries, respectively. The strategies were divided into four categories based on health system functions: health system stewardship, creating resources, health financing mechanisms, and delivering health services.As well, developing and developed countries applied different types of strategies to reduce OOP. Conclusion The present review identified some strategies that affect the OOP payments According to the health system functions framework. Considering the importance of stewardship, creating resources, the health financing mechanisms, and delivering health services in reducing OOP, this study could help policymakers make better decisions for reducing OOP expenditures.
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Affiliation(s)
- Faride Sadat Jalali
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Parisa Bikineh
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sajad Delavari
- Health Human Resources Research Center, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.
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Swartz JJ, Rowe C, Truong T, Bryant AG, Morse JE, Stuart GS. Comparing Website Identification for Crisis Pregnancy Centers and Abortion Clinics. Womens Health Issues 2021; 31:432-439. [PMID: 34266709 DOI: 10.1016/j.whi.2021.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 05/21/2021] [Accepted: 06/03/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Crisis pregnancy centers (CPCs) seeking to dissuade women from abortion often appear in Internet searches for abortion clinics. We aimed to assess whether women can use screenshots from real websites to differentiate between CPCs and abortion clinics. METHODS We conducted a cross-sectional, nationally representative online study of English- and Spanish-speaking women aged 18-49 years in the United States. We presented participants with screenshots from five CPCs and five abortion clinic websites and asked if they thought an abortion could be obtained at that center. We scored correct answers based on clinic type. Outcomes included ability to correctly identify CPCs and abortion clinics as well as risk factors for misidentification. The survey also included five questions about common abortion myths and a validated health literacy assessment. RESULTS We contacted 2,223 women, of whom 1,057 (48%) completed the survey and 1,044 (47%) were included in the analysis. The median score for correctly identifying CPCs as facilities not performing abortion was 2 out of 5 (Q:1 0, Q:3 4). The median score for correctly identifying abortion clinics as facilities performing abortion was 5 out of 5 (Q:1 3, Q:3 5). Those less likely to endorse abortion myths had higher odds of correctly identifying CPCs (adjusted odds ratio, 2.43; 95% confidence interval, 1.78-3.32). A low health literacy score was associated with decreased odds of correct identification of CPCs (adjusted odds ratio, 0.39; 95% confidence interval, 0.25-0.59). CONCLUSIONS Websites of CPCs were more difficult for women to correctly identify than those of abortion clinics. Women with limited knowledge about abortion and low health literacy may be particularly susceptible to misidentification of CPC websites.
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Affiliation(s)
- Jonas J Swartz
- Division of Women's Community and Population Health, Department of OBGYN, Duke University Medical Center, Durham, North Carolina; Division of Family Planning, Department of OBGYN, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Carly Rowe
- Division of Family Planning, Department of OBGYN, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Tracy Truong
- Department of Biostatistics & Bioinformatics, Duke University of Medical Center, Dueham, North Carolina
| | - Amy G Bryant
- Division of Family Planning, Department of OBGYN, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Jessica E Morse
- Division of Family Planning, Department of OBGYN, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Gretchen S Stuart
- Division of Family Planning, Department of OBGYN, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Darney BG, Biel FM, Rodriguez MI, Jacob RL, Cottrell EK, DeVoe JE. Payment for Contraceptive Services in Safety Net Clinics: Roles of Affordable Care Act, Title X, and State Programs. Med Care 2020; 58:453-460. [PMID: 32049877 PMCID: PMC7148195 DOI: 10.1097/mlr.0000000000001309] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We describe payor for contraceptive visits 2013-2014, before and after Medicaid expansion under the Affordable Care Act (ACA), in a large network of safety-net clinics. We estimate changes in the proportion of uninsured contraceptive visits and the independent associations of the ACA, Title X, and state family planning programs. METHODS Our sample included 237 safety net clinics in 11 states with a common electronic health record. We identified contraception-related visits among women aged 10-49 years using diagnosis and procedure codes. Our primary outcome was an indicator of an uninsured visit. We also assessed payor type (public/private). We included encounter, clinic, county, and state-level covariates. We used interrupted time series and logistic regression, and calculated multivariable absolute predicted probabilities. RESULTS We identified 162,666 contraceptive visits in 219 clinics. There was a significant decline in uninsured contraception-related visits in both Medicaid expansion and nonexpansion states, with a slightly greater decline in expansion states (difference-in-difference: -1.29 percentage points; confidence interval: -1.39 to -1.19). The gap in uninsured visits between expansion and nonexpansion states widened after ACA implementation (from 2.17 to 4.1 percentage points). The Title X program continues to fill gaps in insurance in Medicaid expansion states. CONCLUSIONS Uninsured contraceptive visits at safety net clinics decreased following Medicaid expansion under the ACA in both expansion and nonexpansion states. Overall, levels of uninsured visits are lower in expansion states. Title X continues to play an important role in access to care and coverage. In addition to protecting insurance gains under the ACA, Title X and state programs should continue to be a focus of research and advocacy.
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Affiliation(s)
- Blair G Darney
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
- National Institute of Public Health, Population Research Center (INSP/CISP), Cuernavaca, Morelos, Mexico
- OHSU-PSU School of Public Health
| | - Frances M Biel
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | - Maria I Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | | | | | - Jennifer E DeVoe
- Department of Family Medicine, Oregon Health and Science University, Portland, OR
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MacCallum-Bridges CL, Margerison CE. The Affordable Care Act contraception mandate & unintended pregnancy in women of reproductive age: An analysis of the National Survey of Family Growth, 2008-2010 v. 2013-2015. Contraception 2019; 101:34-39. [PMID: 31655071 DOI: 10.1016/j.contraception.2019.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 09/06/2019] [Accepted: 09/08/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE(S) The Affordable Care Act contraception mandate could reduce unintended pregnancies by increasing access and affordability of contraceptive resources, e.g., long-acting reversible contraceptives (LARCs). We assessed: (1) whether unintended pregnancies decreased post-mandate, and (2) whether this decrease differed by demographic characteristics. STUDY DESIGN We used data from the National Survey of Family Growth (unweighted n = 7409) in logistic regression analyses to compare odds of unintended pregnancy pre-mandate (2008-2010) vs post-mandate (2013-2015), overall and stratified by demographic characteristics. RESULTS Paralleling an increase in long-acting reversible contraceptive use (p < 0.01), post-mandate, the odds of experiencing unintended pregnancy in the prior year decreased 15% overall (OR: 0.85, 95% CI: 0.62, 1.17), with the greatest reduction observed among women with government-sponsored insurance (OR: 0.63, 95% CI: 0.41, 0.97). CONCLUSIONS Unintended pregnancy decreased following the contraception mandate, although possibly due to chance. The short study period relative to the mandate could under-estimate the mandate's effect.
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Affiliation(s)
- Colleen L MacCallum-Bridges
- Department of Epidemiology and Biostatistics, Michigan State University, 939 Fee Road, East Lansing, MI 48825, United States.
| | - Claire E Margerison
- Department of Epidemiology and Biostatistics, Michigan State University, 939 Fee Road, East Lansing, MI 48825, United States
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Cost Sharing and Utilization of Postpartum Intrauterine Devices and Contraceptive Implants Among Commercially Insured Women. Womens Health Issues 2019; 29:465-470. [PMID: 31495642 DOI: 10.1016/j.whi.2019.07.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 07/09/2019] [Accepted: 07/26/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Cost sharing may impede postpartum contraceptive use. We evaluated the association between out-of-pocket costs and long-acting reversible contraceptive (LARC) insertion among commercially insured postpartum women. METHODS Using the Clinformatics Data Mart, we examined out-of-pocket costs for LARC insertions at 0 to 3 and 4-60 days postpartum among women in employer-sponsored health plans from 2013 to 2016. Patient costs were estimated by summing copayment, coinsurance, and deductible payments for LARC services (device + placement). Multivariable logistic regression evaluated the association between plan cost sharing for LARC services (at least one beneficiary with >$200 cost share) and LARC insertion by 60 days postpartum (yes/no). RESULTS We identified 396,073 deliveries among women in 51,797 employer-based plans. Overall, LARC placement by 60 days postpartum was observed after 5.2% (n = 20,604) of deliveries. Inpatient LARC insertion (n = 233; 0.06% of deliveries) was less common than outpatient LARC insertion (n = 20,375; 5.14% of deliveries). Cost sharing was observed in 23.4% of LARC insertions (inpatient IUD: median, $50.00; range, $0.93-5,055.91; inpatient implant: median, $11.91; range, $2.49-650.14; outpatient IUD: median, $25.00; range, $0.01-3,354.80; outpatient implant: median, $27.20; range, $0.18-2,444.01). Among 5,895 plans with at least one LARC insertion and after adjusting for patient age, poverty status, race/ethnicity, region, and plan type, women in plans with cost sharing of more than $200 demonstrated lower odds of LARC use by 60 days postpartum (odds ratio, 0.74; 95% confidence interval, 0.71-0.77). CONCLUSIONS Cost sharing for postpartum LARC is associated with use, suggesting that out-of-pocket costs may impede LARC access for some commercially insured postpartum women. Reducing out-of-pocket costs for the most effective forms of contraception may increase use.
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Bell KN, Meyn LA, Chen BA. Long-Acting Reversible Contraceptive Uptake before and after the Affordable Care Act Contraceptive Mandate in Women Undergoing First Trimester Surgical Abortion. Womens Health Issues 2018; 28:301-305. [PMID: 29853173 DOI: 10.1016/j.whi.2018.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 03/27/2018] [Accepted: 04/20/2018] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To compare long-acting reversible contraceptive (LARC) uptake before and after the Affordable Care Act (ACA) contraceptive mandate among women undergoing a first trimester surgical abortion. STUDY DESIGN We conducted a retrospective chart review of 867 women undergoing a first trimester surgical abortion at an academic gynecology practice between December 2010 and December 2014 (excluding August to December 2012) to evaluate intrauterine device and contraceptive implant uptake before and after the ACA contraceptive mandate. RESULTS Before the ACA contraceptive mandate, 79% of privately insured women (213 of 271) had full LARC coverage (no out-of-pocket costs) compared with 92% (298 of 324) after the mandate (p < .001). We found no difference in postabortal LARC uptake before and after the ACA in women with private insurance, Medicaid, or overall. Among all women, 46% chose a postabortal LARC method before the mandate as compared with 48% after the mandate (p = .63). Among privately insured women, 45% used a postabortal LARC method before the mandate as compared with 50% after the mandate (p = .25). One-half of privately insured women (268 of 534) with full or partial LARC coverage used a postabortal LARC method compared with 32% of privately insured women (18 of 56) with no LARC coverage after implementation of the ACA contraceptive mandate (p = .01). CONCLUSIONS Despite the significant increase in full coverage of LARC among privately insured women, there was no change in postabortal LARC use after the ACA. However, privately insured women with full or partial LARC coverage were more likely to use a postabortal LARC method compared with privately insured women with no LARC coverage after the implementation of the ACA contraceptive mandate.
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Affiliation(s)
- Kimberly N Bell
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Leslie A Meyn
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Beatrice A Chen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Magee-Womens Research Institute, Pittsburgh, Pennsylvania.
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Jones RK. Is pregnancy fatalism normal? An attitudinal assessment among women trying to get pregnant and those not using contraception. Contraception 2018; 98:255-259. [PMID: 29792840 DOI: 10.1016/j.contraception.2018.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/15/2018] [Accepted: 05/16/2018] [Indexed: 10/16/2022]
Abstract
OBJECTIVES To assess factors associated with pregnancy fatalism among U.S. adult women. STUDY DESIGN I used data from the Change and Consistency in Contraceptive Use study, which collected information from a national sample of 4634 U.S. women aged 18-39 at baseline (59% response rate). I assessed pregnancy fatalism based on agreement with the statement: "It doesn't matter whether I use birth control, when it is my time to get pregnant, it will happen." I compared fatalism among all respondents to fatalism among respondents who were trying to get pregnant and those who did not want to get pregnant but were not using contraception. I used logistic regression to assess associations between nonuse of contraception and pregnancy fatalism at baseline and whether respondents were trying to get pregnant 6 months later. RESULTS Overall, 36% of the sample expressed some degree of pregnancy fatalism, and proportions were higher for respondents trying to get pregnant (55%) and those not using contraception (57%). The association between pregnancy fatalism and trying to get pregnant was maintained after controlling for other characteristics [odds ratio (OR) 1.4, p=.01], as was the association for nonuse of contraception (OR 2.08, p<.001). Contraceptive nonusers at baseline were more likely than users to be trying to get pregnant 6 months later, especially if they expressed a fatalistic outlook at baseline. CONCLUSIONS Pregnancy fatalism may be a common outlook among women who are trying to get pregnant. Associations between fatalism and nonuse of contraception may be more complex than previously recognized. IMPLICATIONS Gaining a better understanding of the dynamics of pregnancy planning might inform our understanding of why some women do not use contraception.
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Affiliation(s)
- Rachel K Jones
- Guttmacher Institute, 125 Maiden Lane, New York, NY 10038.
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15
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Snyder AH, Weisman CS, Liu G, Leslie D, Chuang CH. The Impact of the Affordable Care Act on Contraceptive Use and Costs among Privately Insured Women. Womens Health Issues 2018; 28:219-223. [DOI: 10.1016/j.whi.2018.01.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 01/19/2018] [Accepted: 01/22/2018] [Indexed: 11/26/2022]
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16
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Pace LE, Dusetzina SB, Keating NL. Early Impact Of The Affordable Care Act On Oral Contraceptive Cost Sharing, Discontinuation, And Nonadherence. Health Aff (Millwood) 2018; 35:1616-24. [PMID: 27605641 DOI: 10.1377/hlthaff.2015.1624] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The oral contraceptive pill is the contraceptive method most commonly used by US women, but inconsistent use of the pill is a contributor to high rates of unintended pregnancy. The relationship between consumer cost sharing and consistent use of the pill is not well understood, and the impact of the elimination of cost sharing for oral contraceptive pills in a mandate in the Affordable Care Act (ACA) is not yet known. We analyzed insurance claims for 635,075 women with employer-sponsored insurance who were initiating use of the pill, to examine rates of discontinuation and nonadherence, their relationship with cost sharing, and trends before and during the first year after implementation of the ACA mandate. We found that cost sharing for oral contraceptives decreased markedly following implementation, more significantly for generic than for brand-name versions. Higher copays were associated with greater discontinuation of and nonadherence to generic pills than was the case with zero copayments. Discontinuation of the use of generic or brand-name pills decreased slightly but significantly following ACA implementation, as did nonadherence to brand-name pills. Our findings suggest a modest early impact of the ACA on improving consistent use of oral contraceptives among women initiating their use.
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Affiliation(s)
- Lydia E Pace
- Lydia E. Pace is an associate physician in the Division of Women's Health at Brigham and Women's Hospital and an instructor in medicine at Harvard Medical School, both in Boston, Massachusetts
| | - Stacie B Dusetzina
- Stacie B. Dusetzina is an assistant professor of pharmacy and public health in the Eshelman School of Pharmacy and the Gillings School of Public Health, both at the University of North Carolina at Chapel Hill
| | - Nancy L Keating
- Nancy L. Keating is a professor of health care policy and medicine in the Department of Health Care Policy at Harvard Medical School and the Division of General Internal Medicine at Brigham and Women's Hospital
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17
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Johnston EM, Adams EK. State Prescription Contraception Insurance Mandates: Effects on Unintended Births. Health Serv Res 2017; 52:1970-1995. [PMID: 29130270 PMCID: PMC5682137 DOI: 10.1111/1475-6773.12792] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To test the effects of state prescription contraception insurance mandates on unintended, mistimed, and unwanted births in a sample of privately insured recent mothers. DATA We pooled Pregnancy Risk Assessment Monitoring System (PRAMS) data from 1997 to 2012 to study 209,964 privately insured recent mothers in 24 states, 11 of which implemented prescription contraception coverage mandates between 2000 and 2008. STUDY DESIGN Individual-level difference-in-differences models compare the probability of unintended birth among privately insured recent mothers in state-years with mandates to those in state-years without mandates. Additional models use aggregate data to estimate the effect of mandates on states' number of unintended births. PRINCIPAL FINDINGS State mandates are associated with decreased probability of unintended birth (1.58 percentage points) among privately insured women in the second year of implementation, driven by decreased probability of mistimed birth (1.37 percentage points or 614 births per state-year) in the second year of implementation. We find no effects in the first year of implementation or on the probability of unwanted birth. Unexpectedly, recent mothers without private insurance experienced declines in unintended birth, but among unwanted, rather than mistimed, births. CONCLUSIONS State prescription contraception insurance mandates are associated with reduced probability of unintended and mistimed births among privately insured women.
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Affiliation(s)
| | - E. Kathleen Adams
- Department of Health Policy and ManagementRollins School of Public HealthEmory UniversityAtlantaGA
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18
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Wu JP, McKee KS, McKee MM, Meade MA, Plegue MA, Sen A. Use of Reversible Contraceptive Methods Among U.S. Women with Physical or Sensory Disabilities. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2017; 49:141-147. [PMID: 28514522 DOI: 10.1363/psrh.12031] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 02/28/2017] [Accepted: 03/01/2017] [Indexed: 06/07/2023]
Abstract
CONTEXT Women with disabilities experience a higher rate of adverse pregnancy outcomes than women without disabilities. Preventing or delaying pregnancy when that is the best choice for a woman is a critical strategy to reducing pregnancy-related disparities, yet little is known about current contraceptive use among women with disabilities. METHODS A cohort of 545 reproductive-age women with physical disabilities (i.e., difficulty walking, climbing, dressing or bathing) or sensory disabilities (i.e., difficulty with vision or hearing) was identified from among participants in the 2011-2013 National Survey of Family Growth. Those at risk for unplanned pregnancy were categorized by whether they were using highly effective reversible contraceptive methods (IUD, implant), moderately effective ones (pill, patch, ring, injectable), less effective ones (condoms, withdrawal, spermicides, diaphragm, natural family planning) or no method. Multinomial regression was conducted to examine the association between disability and type of contraceptive used. RESULTS Some 39% of women with disabilities were at risk of unplanned pregnancy, and 27% of those at risk were not using contraceptives. The presence of disability was associated with decreased odds of using highly effective methods or moderately effective methods, rather than less effective ones (odds ratio, 0.6 for each), but had no association with using no method. CONCLUSION There is a significant need to reduce contraceptive disparities related to physical or sensory disabilities. Future research should explore the extent to which contraceptive use differs by type and severity of disability, as well as identify contextual factors that contribute to any identified differences.
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Affiliation(s)
- Justine P Wu
- Assistant professor, Departments of Family Medicine and Obstetrics and Gynecology, The University of Michigan, Ann Arbor
| | - Kimberly S McKee
- Research fellow, Department of Family Medicine, The University of Michigan, Ann Arbor
| | - Michael M McKee
- Assistant professor, Department of Family Medicine, The University of Michigan, Ann Arbor
| | - Michelle A Meade
- Associate professor, Department of Physical Medicine and Rehabilitation, The University of Michigan, Ann Arbor
| | - Melissa A Plegue
- Lead statistician Department of Family Medicine, The University of Michigan, Ann Arbor
| | - Ananda Sen
- Professor, Department of Family Medicine, The University of Michigan, Ann Arbor
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19
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Borrero S, Callegari LS, Zhao X, Mor MK, Sileanu FE, Switzer G, Zickmund S, Washington DL, Zephyrin LC, Schwarz EB. Unintended Pregnancy and Contraceptive Use Among Women Veterans: The ECUUN Study. J Gen Intern Med 2017; 32:900-908. [PMID: 28432564 PMCID: PMC5515789 DOI: 10.1007/s11606-017-4049-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 01/24/2017] [Accepted: 03/13/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Little is known about contraceptive care for the growing population of women veterans who receive care in the Veterans Administration (VA) healthcare system. OBJECTIVE To determine rates of contraceptive use, unmet need for prescription contraception, and unintended pregnancy among reproductive-aged women veterans. DESIGN AND PARTICIPANTS We conducted a cross-sectional, telephone-based survey with a national sample of 2302 women veterans aged 18-44 years who had received primary care in the VA within the prior 12 months. MAIN MEASURES Descriptive statistics were used to estimate rates of contraceptive use and unintended pregnancy in the total sample. We also estimated the unmet need for prescription contraception in the subset of women at risk for unintended pregnancy. For comparison, we calculated age-adjusted US population estimates using data from the 2011-2013 National Survey of Family Growth (NSFG). KEY RESULTS Overall, 62% of women veterans reported current use of contraception, compared to 68% of women in the age-adjusted US population. Among the subset of women at risk for unintended pregnancy, 27% of women veterans were not using prescription contraception, compared to 30% in the US population. Among women veterans, the annual unintended pregnancy rate was 26 per 1000 women; 37% of pregnancies were unintended. In the age-adjusted US population, the annual rate of unintended pregnancy was 34 per 1000 women; 35% of pregnancies were unintended. CONCLUSIONS While rates of contraceptive use, unmet contraceptive need, and unintended pregnancy among women veterans served by the VA are similar to those in the US population, these rates are suboptimal in both populations, with over a quarter of women who are at risk for unintended pregnancy not using prescription contraception, and unintended pregnancies accounting for over a third of all pregnancies. Efforts to improve contraceptive service delivery and to reduce unintended pregnancy are needed for both veteran and civilian populations.
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Affiliation(s)
- Sonya Borrero
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive (151 C), Building #30, Pittsburgh, PA, 15240, USA. .,Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Lisa S Callegari
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Obstetrics & Gynecology, University of Washington School of Medicine, Seattle, WA, USA
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive (151 C), Building #30, Pittsburgh, PA, 15240, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive (151 C), Building #30, Pittsburgh, PA, 15240, USA.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive (151 C), Building #30, Pittsburgh, PA, 15240, USA
| | - Galen Switzer
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive (151 C), Building #30, Pittsburgh, PA, 15240, USA.,Departments of Medicine, Psychiatry and Clinical and Translational Science, University of Pittsburgh, Pittsburgh, PA, USA
| | - Susan Zickmund
- VA HSR&D Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Laurie C Zephyrin
- Women's Health Services, Department of Veterans Affairs, Washington, D.C., USA.,Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY, USA
| | - E Bimla Schwarz
- Division of General Internal Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
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20
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Bearak JM, Jones RK. Did Contraceptive Use Patterns Change after the Affordable Care Act? A Descriptive Analysis. Womens Health Issues 2017; 27:316-321. [PMID: 28284588 DOI: 10.1016/j.whi.2017.01.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 01/13/2017] [Accepted: 01/18/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND The Affordable Care Act (ACA) substantially increased rates of insurance coverage within the first year of implementation, including among women of reproductive age. The ACA also requires that private insurance plans cover contraceptives without any out-of-pocket costs. These provisions may have led more women to start using prescription contraception. STUDY DESIGN We conducted two cross-sectional studies, collecting data from 8,062 women aged 18 to 39 in the fall 2012 and spring 2015. We examined contraceptive use patterns during both time periods. We used logistic regression to determine whether differences between the two time periods were significant, adjusting for the demographic characteristics of respondents. RESULTS We observed no changes in contraceptive use patterns among sexually active women. However, use of the pill nearly doubled, from 21% to 40%, among young women aged 18 to 24 who had not had sex in the last month. Many of these women cited benefits of the pill in addition to pregnancy prevention. CONCLUSIONS It may be that the ACA has yet to affect contraceptive use patterns, and it is possible that it will do so in the future, but the evidence thus far suggests the importance of further research into contraceptive access and sources of care.
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21
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Hubacher D, Spector H, Monteith C, Chen PL, Hart C. Long-acting reversible contraceptive acceptability and unintended pregnancy among women presenting for short-acting methods: a randomized patient preference trial. Am J Obstet Gynecol 2017; 216:101-109. [PMID: 27662799 DOI: 10.1016/j.ajog.2016.08.033] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 08/12/2016] [Accepted: 08/25/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Measures of contraceptive effectiveness combine technology and user-related factors. Observational studies show higher effectiveness of long-acting reversible contraception compared with short-acting reversible contraception. Women who choose long-acting reversible contraception may differ in key ways from women who choose short-acting reversible contraception, and it may be these differences that are responsible for the high effectiveness of long-acting reversible contraception. Wider use of long-acting reversible contraception is recommended, but scientific evidence of acceptability and successful use is lacking in a population that typically opts for short-acting methods. OBJECTIVE The objective of the study was to reduce bias in measuring contraceptive effectiveness and better isolate the independent role that long-acting reversible contraception has in preventing unintended pregnancy relative to short-acting reversible contraception. STUDY DESIGN We conducted a partially randomized patient preference trial and recruited women aged 18-29 years who were seeking a short-acting method (pills or injectable). Participants who agreed to randomization were assigned to 1 of 2 categories: long-acting reversible contraception or short-acting reversible contraception. Women who declined randomization but agreed to follow-up in the observational cohort chose their preferred method. Under randomization, participants chose a specific method in the category and received it for free, whereas participants in the preference cohort paid for the contraception in their usual fashion. Participants were followed up prospectively to measure primary outcomes of method continuation and unintended pregnancy at 12 months. Kaplan-Meier techniques were used to estimate method continuation probabilities. Intent-to-treat principles were applied after method initiation for comparing incidence of unintended pregnancy. We also measured acceptability in terms of level of happiness with the products. RESULTS Of the 916 participants, 43% chose randomization and 57% chose the preference option. Complete loss to follow-up at 12 months was <2%. The 12-month method continuation probabilities were 63.3% (95% confidence interval, 58.9-67.3) (preference short-acting reversible contraception), 53.0% (95% confidence interval, 45.7-59.8) (randomized short-acting reversible contraception), and 77.8% (95% confidence interval, 71.0-83.2) (randomized long-acting reversible contraception) (P < .001 in the primary comparison involving randomized groups). The 12-month cumulative unintended pregnancy probabilities were 6.4% (95% confidence interval, 4.1-8.7) (preference short-acting reversible contraception), 7.7% (95% confidence interval, 3.3-12.1) (randomized short-acting reversible contraception), and 0.7% (95% confidence interval, 0.0-4.7) (randomized long-acting reversible contraception) (P = .01 when comparing randomized groups). In the secondary comparisons involving only short-acting reversible contraception users, the continuation probability was higher in the preference group compared with the randomized group (P = .04). However, the short-acting reversible contraception randomized group and short-acting reversible contraception preference group had statistically equivalent rates of unintended pregnancy (P = .77). Seventy-eight percent of randomized long-acting reversible contraception users were happy/neutral with their initial method, compared with 89% of randomized short-acting reversible contraception users (P < .05). However, among method continuers at 12 months, all groups were equally happy/neutral (>90%). CONCLUSION Even in a typical population of women who presented to initiate or continue short-acting reversible contraception, long-acting reversible contraception proved highly acceptable. One year after initiation, women randomized to long-acting reversible contraception had high continuation rates and consequently experienced superior protection from unintended pregnancy compared with women using short-acting reversible contraception; these findings are attributable to the initial technology and not underlying factors that often bias observational estimates of effectiveness. The similarly patterned experiences of the 2 short-acting reversible contraception cohorts provide a bridge of generalizability between the randomized group and usual-care preference group. Benefits of increased voluntary uptake of long-acting reversible contraception may extend to wider populations than previously thought.
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22
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Durante JC, Woodhams EJ. Patient Education About the Affordable Care Act Contraceptive Coverage Requirement Increases Interest in Using Long-Acting Reversible Contraception. Womens Health Issues 2017; 27:152-157. [PMID: 28063850 DOI: 10.1016/j.whi.2016.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 11/23/2016] [Accepted: 11/29/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND The Patient Protection and Affordable Care Act (ACA) requires health insurance to cover all Food and Drug Administration-approved contraceptives at no cost to patients, including highly effective long-acting reversible contraception (LARC). Our objective was to determine whether a brief educational intervention about these provisions would increase interest in LARC use. METHODS This is a cross-sectional survey of women seeking contraceptive care in an urban outpatient obstetrics/gynecology clinic. We collected baseline contraceptive attitudes and knowledge of the ACA's contraceptive coverage provisions before the intervention. Our primary outcome was interest in using a LARC method before and after reading a short description of the ACA's contraceptive coverage provisions. RESULTS Surveys were completed by 316 participants. Most participants (52.8%) could not correctly identify any of the contraception coverage stipulations protected under the ACA. We observed a significant increase in LARC interest after the intervention in all participants (37.3% vs. 44.3%; p = .038), primarily among participants who did not originally identify any ACA provisions correctly (n = 167; 38.3% vs. 48.5%; p = .030). This subset also demonstrated a greater adjusted odds ratio of post-intervention LARC interest (odds ratio, 2.889; 95% CI, 1.234-6.723; p = .014). Interest in short-acting reversible contraception and contraception overall remained unchanged. CONCLUSIONS Most women seeking birth control lack comprehensive understanding of the contraceptive coverage protected by the ACA. Incorporating patient education about the ACA's no-cost contraception provision into routine contraceptive counseling may increase interest in LARC use and better enable women to make informed family planning decisions unrestrained by financial considerations.
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Affiliation(s)
- Julia C Durante
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.
| | - Elisabeth J Woodhams
- Thomas Jefferson University, Department of Obstetrics and Gynecology, Philadelphia, Pennsylvania
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23
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Armstrong MA, Postlethwaite DA, Darbinian JA, McCoy M, Law A. Are Health Plan Design and Prior Use of Long-Acting Reversible Contraception Associated with Pregnancy Intention? J Womens Health (Larchmt) 2016; 26:450-460. [PMID: 27753522 DOI: 10.1089/jwh.2014.5146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND In 2007, high-deductible plans were added to the primarily nondeductible Kaiser Permanente Northern California (KPNC) integrated health plan, which had covered 100% of device and procedure costs of long-acting reversible contraception (LARC) for members regardless of prescription/visit copay amount. We hypothesized that nondeductible plans and prior LARC use decreased unintended pregnancy. OBJECTIVE The purpose of this study was to determine if health plan design (nondeductible vs. deductible) and LARC use before pregnancy were associated with pregnancy intention. METHODS In this retrospective cohort study, women aged 15-44 as of the index date of June 30, 2010 were followed from January 1, 2010 to December 31, 2012 for evidence of pregnancy (n = 65,989). Health plan design, copays, contraceptive method used most recently before the pregnancy, and self-reported pregnancy intention status (intended, mistimed, unwanted) were obtained from electronic medical records. Logistic regression models were developed to determine if various health plan designs, copays, or prior LARC use were associated with pregnancy intention, controlling for potential confounders such as age, race/ethnicity, marital status, education/income, parity, and comorbidities. RESULTS In all models, LARC use before pregnancy versus non-LARC use was significantly related to intended pregnancies (all models: odds ratio [OR] = 2.26, 95% confidence interval [CI] 2.06-2.48). Women with deductible plans with healthcare spending accounts (HSA) were more likely to report intended pregnancies versus women with nondeductible plans (all models: OR = 1.2, 95% CI 1.04-1.30). In stratified analyses, high income/high education was a significant predictor of intended pregnancy regardless of race/ethnicity. CONCLUSION LARC use before pregnancy and having an HSA were associated with intended pregnancy.
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Affiliation(s)
| | | | | | - Mark McCoy
- 2 Bayer HealthCare Pharmaceuticals Inc. , Whippany, New Jersey
| | - Amy Law
- 2 Bayer HealthCare Pharmaceuticals Inc. , Whippany, New Jersey
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24
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Pace LE, Dusetzina SB, Keating NL. Early Impact of the Affordable Care Act on Uptake of Long-acting Reversible Contraceptive Methods. Med Care 2016; 54:811-7. [PMID: 27213549 PMCID: PMC4982821 DOI: 10.1097/mlr.0000000000000551] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Affordable Care Act (ACA) required most private insurance plans to cover contraceptive services without patient cost-sharing as of January 2013 for most plans. Whether the ACA's mandate has impacted long-acting reversible contraceptives (LARC) use is unknown. OBJECTIVE The aim of this article is to assess trends in LARC cost-sharing and uptake before and one year after implementation of the ACA's contraceptive mandate. DESIGN A retrospective cohort study using Truven Health MarketScan claims data from January 2010 to December 2013. SUBJECTS Women aged 18-45 years with continuous insurance coverage with claims for oral contraceptive pills, patches, rings, injections, or LARC during 2010-2013 (N=3,794,793). MEASURES Descriptive statistics were used to assess trends in LARC cost-sharing and uptake from 2010 through 2013. Interrupted time series models were used to assess the association of time, ACA, and time after the ACA on LARC cost-sharing and initiation rates, adjusting for patient and plan characteristics. RESULTS The proportion of claims with $0 cost-sharing for intrauterine devices and implants, respectively, rose from 36.6% and 9.3% in 2010 to 87.6% and 80.5% in 2013. The ACA was associated with a significant increase in these proportions and in their rate of increase (level and slope change both P<0.001). LARC uptake increased over time with no significant change in level of LARC use after ACA implementation in January 2013 (P=0.44) and a slightly slower rate of growth post-ACA than previously reported (β coefficient for trend, -0.004; P<0.001). CONCLUSIONS The ACA has significantly decreased LARC cost-sharing, but during its first year had not yet increased LARC initiation rates.
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Affiliation(s)
- Lydia E. Pace
- Division of Women’s Health, Department of Internal Medicine, Brigham and Women’s Hospital, 1620 Tremont Street, 3 Floor, Boston, MA, 02120, Phone: 415-465-7223, Fax 617-525-7746
| | - Stacie B. Dusetzina
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 2203 Kerr Hall, CB# 7573, Chapel Hill, NC 27599, Phone: 919-962-5355
| | - Nancy L. Keating
- Division of General Internal Medicine, Department of Internal Medicine, Brigham and Women’s Hospital, Department of Health Care Policy, Harvard Medical School, Boston, MA, Phone: 617-432-3093
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25
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Arora P, Desai K. Impact of Affordable Care Act coverage expansion on women's reproductive preventive services in the United States. Prev Med 2016; 89:224-229. [PMID: 27235601 DOI: 10.1016/j.ypmed.2016.05.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 05/21/2016] [Accepted: 05/23/2016] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The Affordable Care Act (ACA) expansion mandated the private health plans to cover women's preventive services starting August 2012. With limited and contradictory evidence, this study intends to assess the impact of ACA on the utilization rates and the cost burden of women's reproductive preventive service. METHODS A pre-post analysis was conducted using a nationally representative sample of females (aged 15-44years, n=4397) participating in the 2011-2013 National Survey of Family Growth. The utilization rates and cost burdens were compared for six services using bivariate and multivariable logistic regression models. RESULTS After the ACA expansion, there wasn't a significant increase in the utilization rates of birth control/prescription (33.7% vs. 30.7%), birth control counseling (17.7% vs. 16.9%), sterilization counseling (3.3% vs. 3.5%), STI counsel/test/treat (15% vs. 14.6%) and HIV screening (24.1% vs. 23.1%). Respondents paying through insurance increased after ACA, but out-of-pocket spending (cost-sharing) didn't decrease for respondents. Type of insurance was an important predictor of utilization rates with publicly insured having significantly higher Odds Ratio (OR) or likelihood of receiving birth control counseling (OR:1.71), sterilization counseling (OR:2.67), STI counsel/test/treat (OR:1.54) and HIV screening (OR:1.69) compared to privately insured. CONCLUSIONS The early-on impact of ACA expansion on utilization rates of women's reproductive preventive services didn't appear to be significant. Private health plans, however, might have expanded their coverage but burden of cost sharing still existed. Future research should evaluate the long term impact of ACA expansion on women's health and the economic gains.
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Affiliation(s)
- Prachi Arora
- Social and Administrative Sciences Division, University of Wisconsin-Madison School of Pharmacy, 777 Highland Ave., Madison, WI 53705-2222, USA.
| | - Karishma Desai
- Surgical Health Services Research Unit, Department of Surgery, Stanford School of Medicine, 291 Campus Drive, Stanford, CA 94305, USA
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26
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Trends in direct-to-consumer advertising of prescription contraceptives. Contraception 2016; 93:398-405. [DOI: 10.1016/j.contraception.2016.01.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 01/20/2016] [Accepted: 01/20/2016] [Indexed: 11/22/2022]
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Kim TY, Dagher RK, Chen J. Racial/Ethnic Differences in Unintended Pregnancy: Evidence From a National Sample of U.S. Women. Am J Prev Med 2016; 50:427-435. [PMID: 26616306 DOI: 10.1016/j.amepre.2015.09.027] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 09/15/2015] [Accepted: 09/22/2015] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Racial and ethnic minorities experience greater burden of unintended pregnancy in the U.S. This study examined the factors associated with racial and ethnic disparities in unintended pregnancy among women in the U.S. using the social ecological model. METHODS This study utilized the National Survey of Family Growth data from 2006 to 2010. Data were analyzed in Autumn 2014 and Winter 2015. Decomposition analyses examined which intrapersonal, interpersonal, institutional, community, and public policy factors explained racial and ethnic disparities in unintended pregnancy. RESULTS Unadjusted analyses found that black and Hispanic women had a greater likelihood of unintended pregnancy compared with white women. Decomposition models explained 51% of the disparity in unintended pregnancy between black and white women and 73% of that between Hispanic and white women. Factors contributing to the disparity between black and white women included age, relationship status, respondent's mother's age at first birth, Federal Poverty Level, and insurance status. Between Hispanic and white women, these factors included age, U.S.-born status, education, and relationship status. CONCLUSIONS Given that the results showed factors at different levels of the social ecological model contribute to racial and ethnic disparities in unintended pregnancy, interventions that aim to reduce these disparities should target at-risk groups of women such as younger, unmarried, lower-income, less-educated, non-U.S. born women and uninsured or publicly insured women.
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Affiliation(s)
- Theresa Y Kim
- Department of Health Services Administration, School of Public Health, University of Maryland, College Park, Maryland.
| | - Rada K Dagher
- Department of Health Services Administration, School of Public Health, University of Maryland, College Park, Maryland
| | - Jie Chen
- Department of Health Services Administration, School of Public Health, University of Maryland, College Park, Maryland
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Bearak JM, Finer LB, Jerman J, Kavanaugh ML. Changes in out-of-pocket costs for hormonal IUDs after implementation of the Affordable Care Act: an analysis of insurance benefit inquiries. Contraception 2016; 93:139-44. [PMID: 26386444 PMCID: PMC4780678 DOI: 10.1016/j.contraception.2015.08.018] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 08/17/2015] [Accepted: 08/24/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Affordable Care Act (ACA) requires that privately insured women can obtain contraceptive services and supplies without cost sharing. This may substantially affect women who prefer an intrauterine device (IUD), a long-acting reversible contraceptive, because of high upfront costs that they would otherwise face. However, imperfect enforcement of and exceptions to this provision could limit its effect. STUDY DESIGN We analyzed administrative data for 417,221 women whose physicians queried their insurance plans from January 2012 to March 2014 to determine whether each woman had insurance coverage for a hormonal IUD and the extent of that coverage. RESULTS In January 2012, 58% of women would have incurred out-of-pocket costs for an IUD, compared to only 13% of women in March 2014. Differentials by age and region virtually dissolved over the period studied, which suggests that the ACA reduced inequality among insured women. CONCLUSIONS Our findings suggest that the cost of hormonal IUDs fell to US$0 for most insured women following the implementation of the ACA. IMPLICATIONS Financial barriers to one of the most effective methods of contraception fell substantially following the ACA. If more women interested in this method can access it, this may contribute to a decline in unintended pregnancies in the United States.
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Crissman HP, Hall KS, Patton EW, Zochowski MK, Davis MM, Dalton VK. U.S. Women's Intended Sources for Reproductive Health Care. J Womens Health (Larchmt) 2016; 25:91-8. [PMID: 26501690 PMCID: PMC4741210 DOI: 10.1089/jwh.2014.5116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION The current sociopolitical climate and context of the Affordable Care Act have led some to question the future role of family planning clinics in reproductive health care. We explored where women plan to get their future contraception, pelvic exam/pap smears, and sexually transmitted infection testing, with a focus on the role of family planning clinics. METHODS Data were drawn from a study of United States adults conducted in January 2013 from a national online panel. We focused on English-literate women aged 18-45 years who answered items on intended sources of care (private office/health maintenance organization [HMO], family planning clinic, other, would not get care) for reproductive health services. We used Rao-Scott F tests to compare intended sources across sociodemographic groups, and logistic regression to model odds of intending to use family planning clinics. Probability weights were used to adjust for the complex sampling design. RESULTS The response rate was 61% (n = 2,182). Of the 723 respondents who met the inclusion criteria, approximately half intended to use private offices/HMOs. Among some subgroups, including less educated (less than high school), lower annual incomes (<$25,000) and uninsured women, the proportion intending to use family planning clinics was higher than the proportion intending to use private office/HMO in unadjusted analyses. Across all service types, unmarried and uninsured status were associated with intention to use family planning clinics in multivariable models. CONCLUSIONS While many women intend to use private offices/HMOs for their reproductive health care, family planning clinics continue to play an important role, particularly for socially disadvantaged women.
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Affiliation(s)
- Halley P. Crissman
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Kelli Stidham Hall
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Elizabeth W. Patton
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Melissa K. Zochowski
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Matthew M. Davis
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan
| | - Vanessa K. Dalton
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
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Weisman CS, Lehman EB, Legro RS, Velott DL, Chuang CH. How do pregnancy intentions affect contraceptive choices when cost is not a factor? A study of privately insured women. Contraception 2015; 92:501-7. [PMID: 26002807 DOI: 10.1016/j.contraception.2015.05.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 05/11/2015] [Accepted: 05/13/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective was to test the hypothesis that among privately insured women who have contraceptive coverage without cost-sharing, using prescription contraception is predicted primarily by pregnancy intentions. STUDY DESIGN Participants are 987 women ages 18-40 who wish to avoid pregnancy for at least the next 12 months and are enrolled in Highmark Health plans in Pennsylvania. Data are from the baseline survey of MyNewOptions, an ongoing randomized controlled trial testing an intervention to help insured women make optimum contraceptive choices. Primary type of contraception used [categorized as long-acting reversible contraception (LARCs), other prescription methods, nonprescription methods or no method] is modeled using multinomial logistic regression, with predictors representing the timing and strength of pregnancy intentions, pregnancy history, pregnancy risk exposure and sociodemographics. RESULTS LARCs were used by 8.4% of the sample; other prescription methods (primarily oral contraceptives), 49.6%; nonprescription methods (primarily condoms), 30.4%; and no method, 11.5%. Pregnancy intentions predicted use of LARCs and other prescription methods compared with no method. The most consistent predictors of using all categories of contraception were pregnancy risk exposure measures (partnership type and frequency of sexual intercourse). CONCLUSIONS In the absence of cost-sharing for contraception, women's choice of prescription contraception was a function primarily of pregnancy risk exposure rather than pregnancy intentions. IMPLICATIONS This study is among the first to examine privately insured women's contraception choices in the context of contraceptive coverage without cost-sharing; it shows that use of prescription contraception is predicted by pregnancy risk exposure and pregnancy intentions.
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Affiliation(s)
- Carol S Weisman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA; Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, PA, USA.
| | - Erik B Lehman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Richard S Legro
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA; Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, PA, USA
| | - Diana L Velott
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Cynthia H Chuang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA; Division of General Internal Medicine, Penn State College of Medicine, Hershey, PA, USA
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Abstract
Long-acting reversible contraceptive (LARC) methods are underutilized in the adolescent population despite their superior efficacy over non-LARC methods. The purpose of this article is to discuss the barriers that lead to underutilization of these methods and present an evidence-based approach for the use of LARC methods among adolescents in the primary care setting.
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Foster DG, Biggs MA, Phillips KA, Grindlay K, Grossman D. Potential public sector cost-savings from over-the-counter access to oral contraceptives. Contraception 2015; 91:373-9. [PMID: 25732570 DOI: 10.1016/j.contraception.2015.01.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 11/25/2014] [Accepted: 01/12/2015] [Indexed: 12/01/2022]
Abstract
OBJECTIVE This study estimates how making oral contraceptive pills (OCPs) available without a prescription may affect contraceptive use, unintended pregnancies and associated contraceptive and pregnancy costs among low-income women. STUDY DESIGN Based on published figures, we estimate two scenarios [low over-the-counter (OTC) use and high OTC use] of the proportion of low-income women likely to switch to an OTC pill and predict adoption of OCPs according to the out-of-pocket costs per pill pack. We then estimate cost-savings of each scenario by comparing the total public sector cost of providing OCPs OTC and medical care for unintended pregnancy. RESULTS Twenty-one percent of low-income women at risk for unintended pregnancy are very likely to use OCPs if they were available without a prescription. Women's use of OTC OCPs varies widely by the out-of-pocket pill pack cost. In a scenario assuming no out-of-pocket costs for the over-the counter pill, an additional 11-21% of low-income women will use the pill, resulting in a 20-36% decrease in the number of women using no method or a method less effective than the pill, and a 7-25% decrease in the number of unintended pregnancies, depending on the level of use and any effect on contraceptive failure rates. CONCLUSIONS If out-of-pocket costs for such pills are low, OTC access could have a significant effect on use of effective contraceptives and unintended pregnancy. Public health plans may reduce expenditures on pregnancy and contraceptive healthcare services by covering oral contraceptives as an OTC product. IMPLICATIONS Interest in OTC access to oral contraceptives is high. Removing the prescription barrier, particularly if pill packs are available at low or zero out-of-pocket cost, could increase the use of effective methods of contraception and reduce unintended pregnancy and healthcare costs for contraceptive and pregnancy care.
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Affiliation(s)
- Diana G Foster
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, and the Department of Obstetrics, Gynecology & Reproductive Science, University of California, San Francisco, San Francisco, CA 94143, USA.
| | - M Antonia Biggs
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, and the Department of Obstetrics, Gynecology & Reproductive Science, University of California, San Francisco, San Francisco, CA 94143, USA; Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA 94143, USA
| | - Kathryn A Phillips
- UCSF Center for Translational and Policy Research in Personalized Medicine (TRANSPERS Center), Department of Clinical Pharmacy, University of California, San Francisco, CA 94143, USA; Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA 94143, USA
| | | | - Daniel Grossman
- Ibis Reproductive Health, Oakland, CA 94612, USA; Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA 94143, USA
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Stern LF, Simons HR, Kohn JE, Debevec EJ, Morfesis JM, Patel AA. Differences in contraceptive use between family planning providers and the U.S. population: results of a nationwide survey. Contraception 2015; 91:464-9. [PMID: 25722074 DOI: 10.1016/j.contraception.2015.02.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 02/06/2015] [Accepted: 02/16/2015] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To describe contraceptive use among U.S. female family planning providers and to compare their contraceptive choices to the general population. STUDY DESIGN We surveyed a convenience sample of female family planning providers ages 25-44 years, including physicians and advanced practice clinicians, via an internet-based survey from April to May 2013. Family planning providers were compared to female respondents ages 25-44 years from the 2011-2013 National Survey of Family Growth. RESULTS A total of 488 responses were eligible for analysis; 331 respondents (67.8%) were using a contraceptive method. Providers' contraceptive use differed markedly from that of the general population, with providers significantly more likely to use intrauterine contraception, an implant, and the vaginal ring. Providers were significantly less likely to use female sterilization and condoms. There were no significant differences between providers and the general population in use of partner vasectomy or the pill. Long-acting reversible contraception (LARC) use was significantly higher among providers than in the general population (41.7% vs. 12.1%, p<.001). These results were consistent when stratifying by variables including self-identified race/ethnicity and educational level. CONCLUSIONS The contraceptive choices of this sample of female family planning providers differed significantly from the general population. These findings have implications for clinical practice, patient education, and health policy. IMPLICATIONS Family planning providers report higher use of LARC than the general population. This may reflect differences in preferences and access. Providers might consider sharing these findings with patients, while maintaining patient choice and autonomy.
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Affiliation(s)
- Lisa F Stern
- Planned Parenthood Federation of America, New York, NY, USA.
| | | | - Julia E Kohn
- Planned Parenthood Federation of America, New York, NY, USA
| | - Elie J Debevec
- Planned Parenthood Federation of America, New York, NY, USA
| | | | - Ashlesha A Patel
- Division of Family Planning, Department of Obstetrics and Gynecology, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
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Hubacher D, Spector H, Monteith C, Chen PL, Hart C. Rationale and enrollment results for a partially randomized patient preference trial to compare continuation rates of short-acting and long-acting reversible contraception. Contraception 2014; 91:185-92. [PMID: 25500324 DOI: 10.1016/j.contraception.2014.11.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 10/16/2014] [Accepted: 11/08/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Most published contraceptive continuation rates have scientific limitations and cannot be compared; this is particularly true for dissimilar contraceptives. This study uses a new approach to determine if high continuation rates of long-acting reversible contraception (LARC) and protection from unintended pregnancy are observable in a population not self-selecting to use LARC. STUDY DESIGN We are conducting a partially randomized patient preference trial (PRPPT) to compare continuation rates of short-acting reversible contraception (SARC) and LARC. Only women seeking SARC were invited to participate. Participants chose to be in the preference cohort (self-selected method use) or opted to be randomized to SARC or LARC; only those in the randomized cohort received free product. We compared participant characteristics, reasons for not trying LARC previously and the contraceptive choices that were made. RESULTS We enrolled 917 eligible women; 57% chose to be in the preference cohort and 43% opted for the randomized trial. The preference and randomized cohorts were similar on most factors. However, the randomized cohort was more likely than the preference cohort to be uninsured (48% versus 36%, respectively) and to cite cost as a reason for not trying LARC previously (50% versus 10%) (p<.01 for both comparisons). In the preference cohort, fear of pain/injury/side effects/health risks were the predominant reasons (cited by over 25%) for not trying LARC previously (p<.01 in comparison to randomized cohort). CONCLUSIONS Enrollment was successful and the process created different cohorts to compare contraceptive continuation rates and unintended pregnancy in this ongoing trial. The choices participants made were associated with numerous factors; lack of insurance was associated with participation in the randomized trial. IMPLICATIONS This PRPPT will provide new estimates of contraceptive continuation rates, such that any benefits of LARC will be more easily attributable to the technology and not the user. Combined with measuring level of satisfaction with LARC, the results will help project the potential role and benefits of expanding voluntary use of LARC.
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Affiliation(s)
- David Hubacher
- FHI 360, 359 Blackwell Street, Suite 200, Durham, NC 27701, USA.
| | - Hannah Spector
- Planned Parenthood of Central North Carolina, PO Box 3258, Chapel Hill, NC 27515, USA
| | - Charles Monteith
- Planned Parenthood of Central North Carolina, PO Box 3258, Chapel Hill, NC 27515, USA
| | - Pai-Lien Chen
- FHI 360, 359 Blackwell Street, Suite 200, Durham, NC 27701, USA
| | - Catherine Hart
- FHI 360, 359 Blackwell Street, Suite 200, Durham, NC 27701, USA
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Sonfield A, Tapales A, Jones RK, Finer LB. Impact of the federal contraceptive coverage guarantee on out-of-pocket payments for contraceptives: 2014 update. Contraception 2014; 91:44-8. [PMID: 25288034 PMCID: PMC4712914 DOI: 10.1016/j.contraception.2014.09.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 09/10/2014] [Accepted: 09/10/2014] [Indexed: 11/17/2022]
Abstract
Background The Affordable Care Act requires most private health plans to cover contraceptive methods, services and counseling, without any out-of-pocket costs to patients; that requirement took effect for millions of Americans in January 2013. Study design Data for this study come from a subset of the 1842 women aged 18–39 years who responded to all four waves of a national longitudinal survey. This analysis focuses on the 892 women who had private health insurance and who used a prescription contraceptive method during any of the four study periods. Women were asked about the amount they paid out of pocket in an average month for their method of choice. Results Between fall 2012 and spring 2014, the proportion of privately insured women paying zero dollars out of pocket for oral contraceptives increased substantially, from 15% to 67%. Similar changes occurred among privately insured women using injectable contraception, the vaginal ring and the intrauterine device. Conclusions The implementation of the federal contraceptive coverage requirement appears to have had a notable impact on the out-of-pocket costs paid by privately insured women, and that impact has increased over time. Implications This study measures the out-of-pocket costs for women with private insurance prior to the federal contraceptive coverage requirement and after it took effect; in doing so, it highlights areas of progress in eliminating these costs.
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Gomez AM, Fuentes L, Allina A. Women or LARC first? Reproductive autonomy and the promotion of long-acting reversible contraceptive methods. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2014; 46:171-5. [PMID: 24861029 PMCID: PMC4167937 DOI: 10.1363/46e1614] [Citation(s) in RCA: 259] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
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Making the most of the Affordable Care Act's contraceptive coverage mandate for privately-insured women. Womens Health Issues 2014; 24:465-8. [PMID: 25128037 DOI: 10.1016/j.whi.2014.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 07/16/2014] [Accepted: 07/17/2014] [Indexed: 11/23/2022]
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Jones RK, Lindberg LD, Higgins JA. Pull and pray or extra protection? Contraceptive strategies involving withdrawal among US adult women. Contraception 2014; 90:416-21. [PMID: 24909635 DOI: 10.1016/j.contraception.2014.04.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 04/22/2014] [Accepted: 04/29/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Research assessing contraceptive use often focuses on the most effective method used and suggests that very few women rely on withdrawal. We adopted a new measurement strategy in an attempt to measure contraceptive practices and withdrawal in particular. STUDY DESIGN We collected data from a national sample of 4634 US women aged 18-39; the survey was administered online in November and December 2012. We obtained information about recent use of hormonal methods and coital methods using two separate items, and we placed withdrawal first on the list of coital methods. The analysis examines several measures of withdrawal use in the last 30 days: most effective method used, any use, use with other methods and withdrawal "method mix." RESULTS Among women at risk of unintended pregnancy, 13% reported that withdrawal was the most effective method used in the last 30 days, but 33% had used withdrawal at least once. Most women who used withdrawal had also used a hormonal or long-acting method (13% of the sample) or condoms (11%) in the last 30 days, and a minority reported using only withdrawal (12%). Younger women, women in dating relationships and women strongly motivated to avoid pregnancy had some of the highest levels of "dual" use of withdrawal with condoms or highly effective methods. CONCLUSION Many women and couples in our sample used withdrawal in combination, or rotation, with condoms and highly effective methods. Findings suggest that some people who use withdrawal may be more versus less vigilant about pregnancy prevention. IMPLICATIONS Health care providers who discuss contraception should include withdrawal in these conversations. A substantial minority of individuals has used it recently, and many appear to be using it as a backup or secondary method. If dual use were more widespread, it could help reduce the incidence of unintended pregnancy.
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Affiliation(s)
- Rachel K Jones
- Guttmacher Institute, 125 Maiden Lane, New York, NY 10038.
| | | | - Jenny A Higgins
- Department of Gender and Women's Studies, University of Wisconsin, Madison
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Donnelly KZ, Foster TC, Thompson R. What matters most? The content and concordance of patients' and providers' information priorities for contraceptive decision making. Contraception 2014; 90:280-7. [PMID: 24863169 DOI: 10.1016/j.contraception.2014.04.012] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 04/17/2014] [Accepted: 04/20/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE(S) The objective of this study was to identify women's and health care providers' information priorities for contraceptive decision making and counseling, respectively. STUDY DESIGN Cross-sectional surveys were administered online to convenience samples of 417 women and 188 contraceptive care providers residing in the United States. Participants were provided with a list of 34 questions related to the features of contraceptive options and rated the importance of each. Participants also ranked the questions in descending order of importance. For both women and providers, we calculated the mean importance rating for each question and the proportion that ranked each question in their three most important questions. RESULTS The average importance ratings given by women and providers were similar for 18 questions, but dissimilar for the remaining 16 questions. The question rated most important for women was "How does it work to prevent pregnancy?" whereas, for providers, "How often does a patient need to remember to use it?" and "How is it used?" were rated equally. The eight questions most frequently selected in the top three by women and/or providers were related to the safety of the method, mechanism of action, mode of use, side effects, typical- and perfect-use effectiveness, frequency of administration and when it begins to prevent pregnancy. CONCLUSION(S) Although we found considerable concordance between women's and provider's information priorities, the presence of some inconsistencies highlights the importance of patient-centered contraceptive counseling and, in particular, shared contraceptive decision making. IMPLICATIONS This study provides insights into the information priorities of women for their contraceptive decision making and health care providers for contraceptive counseling. These insights are critical both to inform the development of decision support tools for implementation in contraceptive care and to guide the delivery of patient-centered care.
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Affiliation(s)
- Kyla Z Donnelly
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH, USA
| | - Tina C Foster
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH, USA; Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Rachel Thompson
- The Dartmouth Center for Health Care Delivery Science, Dartmouth College, Hanover, NH, USA.
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