Dataset Information

Financial Implications of 12-Month Dispensing of Oral Contraceptive Pills in the Veterans Affairs Health Care System.

ABSTRACT: Importance:The Veterans Affairs (VA) health care system is the largest integrated health care system in the United States. Like most US health plans, the VA currently stipulates a 3-month maximum dispensing limit for all medications, including oral contraceptive pills (OCPs). However, 12-month OCP dispensing has been shown to improve continuation of use, decrease coverage gaps, and reduce unintended pregnancy in other practice settings. Objective:To estimate the financial and reproductive health implications for the VA of implementing a 12-month OCP dispensing option, with the goal of informing policy change. Design, Setting, and Participants:A decision model from the VA payer perspective was developed to estimate incremental costs to the health care system of allowing the option to receive a 12-month supply of OCPs up front, compared with the standard 3-month maximum, during a 1-year time horizon. A model cohort of 24?309 reproductive-aged, heterosexually active, female VA enrollees who wish to avoid pregnancy for at least 1 year was assumed. Probabilities of continuation of OCP use, coverage gaps, pregnancy, and pregnancy outcomes were drawn from published data. Costs of OCP provision and pregnancy-related care and the number of women using OCPs were drawn from VA administrative data. One-way and probabilistic sensitivity analyses were performed to assess model robustness. Main Outcomes and Measures:Incremental per-woman and total costs to the VA of allowing for 12-month dispensing of OCPs compared with standard 3-month dispensing. Results:The 12-month OCP dispensing option, modeled from the VA health system perspective using a cohort of 240 309 women, resulted in anticipated VA annual cost savings of $87.12 per woman compared with the cost of 3-month dispensing, or an estimated total savings of $2?117?800 annually. Cost savings resulted from an absolute reduction of 24 unintended pregnancies per 1000 women per year with 12-month dispensing, or 583 unintended pregnancies averted annually. Expected cost savings with 12-month dispensing were sensitive to changes in the probability of OCP coverage gaps with 3-month dispensing, the probability of pregnancy during coverage gaps, and the proportion of pregnancies paid for by the VA. When simultaneously varying all variables across plausible ranges, the 12-month strategy was cost saving in 95.4% of model iterations. Conclusions and Relevance:Adoption of a 12-month OCP dispensing option is expected to produce substantial cost savings for the VA while better supporting reproductive autonomy and reducing unintended pregnancy among women veterans.

SUBMITTER: Judge-Golden CP

PROVIDER: S-EPMC6618816 | biostudies-literature | 2019 Jul

REPOSITORIES: biostudies-literature

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Financial Implications of 12-Month Dispensing of Oral Contraceptive Pills in the Veterans Affairs Health Care System.

Judge-Golden Colleen P CP Smith Kenneth J KJ Mor Maria K MK Borrero Sonya S

JAMA internal medicine 20190901 9

<h4>Importance</h4>The Veterans Affairs (VA) health care system is the largest integrated health care system in the United States. Like most US health plans, the VA currently stipulates a 3-month maximum dispensing limit for all medications, including oral contraceptive pills (OCPs). However, 12-month OCP dispensing has been shown to improve continuation of use, decrease coverage gaps, and reduce unintended pregnancy in other practice settings.<h4>Objective</h4>To estimate the financial and repr ...[more]

PMID: 31282923

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Project description:ImportanceNineteen states have passed legislation requiring insurers to cover the dispensation of a 12-month supply of short-acting, hormonal contraception.ObjectiveTo determine whether 12-month contraceptive supply policies were associated with an increase in the receipt of 12-month or longer supply of contraception.Design, setting, and participantsThis retrospective cohort study included data from all female Medicaid enrollees aged 18 to 44 years who used short-acting hormonal contraception (ie, pill, patch, or ring) from 2016 to 2020.ExposuresEleven treatment states where legislation required insurers to cover a 12-month supply of contraception to continuing users and 25 comparison states without such legislation prior to December 2020.Main outcomes and measuresProportion of contraception months received via a single 12-month or longer fill.ResultsThis study included 48 255 512 months of dispensed oral pill, patch, and ring contraception prescription supply among 4 778 264 female Medicaid enrollees. The majority of months of supplied contraception were for the contraceptive pill rather than the patch or ring. In a staggered difference-in-differences model, the 12-month supply policy was associated with an estimated 4.39-percentage point (pp) increase (95% CI, 4.38 pp-4.40 pp) in the proportion of contraception dispensed as part of a 12-month or longer supply, from a mean of 0.11% in treatment states during the first quarter of the study period. Investigating the heterogeneity in policy association across states, California stood out with a 7.17-pp increase (95% CI, 7.15 pp-7.19 pp) in the proportion of contraception dispensed as a 12-month or longer supply; in the other 10 treatment states, the policy association was less than 1 pp.Conclusions and relevanceIn this cohort study of Medicaid recipients using short-acting hormonal contraception, the passage of a 12-month contraceptive supply policy was associated with a minimal increase in the proportion of contraception dispensed through a 12-month or longer supply.

Project description:BackgroundWomen veterans who use the Veterans Affairs Healthcare System theoretically have access to the full range of contraceptive methods. This study explores match between currently used and self-reported "ideal" methods as a potential marker of contraceptive access and preference matching.MethodsThis mixed methods study uses data from a nationally representative survey of reproductive-aged women veterans who use the Veterans Affairs Healthcare System for primary care, including 979 participants at risk of unintended pregnancy. Women reported all contraceptive methods used in the past month and were asked, "If you could choose any method of contraception or birth control to prevent pregnancy, what would be your ideal choice?" and selected a single "ideal" method. If applicable, participants were additionally asked, "Why aren't you currently using this method of contraception?" We used adjusted logistic regression to identify patient-, provider-, and system-level factors associated with ideal-current method match. We qualitatively analyzed open-ended responses about reasons for ideal method nonuse.ResultsOverall, 58% were currently using their ideal method; match was greatest among women selecting an IUD as ideal (73%). Non-White race/ethnicity (adjusted odds ratio, 0.68; 95% confidence interval, 0.52-0.89) and mental illness (adjusted odds ratio, 0.69; 95% confidence interval, 0.52-0.92) were negatively associated with ideal-current match in adjusted analyses; the presence of a gynecologist at the primary care site was associated with an increased odds of match (adjusted odds ratio, 1.35; 95% confidence interval, 1.03-1.75). Modifiable barriers to ideal method use were cited by 23% of women, including access issues, cost concerns, and provider-level barriers; 79% of responses included nonmodifiable reasons for mismatch including relationship factors and pregnancy plans incongruent with ideal method use, suggesting limitations of our measure based on differential interpretation of the word "ideal."ConclusionsMany women veterans are not currently using the contraceptive method they consider ideal. Results emphasize the complexity of contraceptive method selection and of measuring contraceptive preference matching.

Project description:ImportanceAs prescription drug costs rise, it is important to understand attitudes among primary care physicians and nurse practitioners (NPs) towards generic drugs.ObjectiveWe aimed to examine the generic skepticism index (GSI) among primary care clinicians, and their willingness to discuss and prescribe generic antidepressants (ADs) and generic oral contraceptives (OCPs).DesignWe used a factorial vignette design survey to test 4 factors: message source, message, brand preference, and drug class. Participants were randomized to different combinations of factors.SettingThis was a cross-sectional study.ParticipantsPhysicians registered with the American College of Physicians (ACP) and NPs registered with the American Association of Nurse Practitioners (AANP) participated in the study.Main measuresThe primary outcomes were generic skepticism as measured using the generic skepticism index (GSI), and clinician willingness to discuss and prescribe generics.ResultsSurveys were completed by 56% of physicians (n = 369/661) and 60% of NPs (n = 493/819). Compared with physicians, NPs were younger (p < 0.001), predominantly female (p < 0.001), and differed in the race (p < 0.001). According to the GSI, 16% (n = 138/862) were identified as generic skeptics (18.5% of NPs and 12.7% of physicians, p = 0.023). Generic skeptics had lower odds of willingness to discuss switching (OR 0.22, 95% CI (0.14-0.35), p < 0.001) or prescribe (OR 0.18, 95% CI (0.11-0.28), p < 0.001) generic OCPs. Participants had lower odds of willingness to prescribe generic drugs to patients with brand preference compared with brand-neutral patients (OR 0.64, 95% CI 0.50-0.82, p < 0.001).Conclusions and relevanceGeneric skepticism was associated with lower willingness to discuss or prescribe generic drugs. Clinicians reported lower willingness to discuss switching or prescribe generics for OCPs than for ADs. Patient brand preference hindered generic prescribing. Message source and message type were not significantly associated with outcomes.

Project description:OBJECTIVES:To evaluate safety outcomes from clinical studies of a 12-month contraceptive vaginal system (CVS) releasing an average of segesterone acetate (SA) 150 mcg and ethinyl estradiol (EE) 13 mcg daily. STUDY DESIGN:We integrated clinical safety data from nine studies in which women used the CVS for 21 consecutive days and removed it for 7?days of each 28-day?cycle. Four studies used the final manufactured CVS, including a 1-year pharmacokinetic study, two 1-year phase 3 trials and a second-year treatment extension study. We assessed safety by evaluating adverse events women reported in a daily diary. We also included data from focused safety studies evaluating endometrial biopsies, vaginal microbiology and liver proteins from one of the phase 3 studies. RESULTS:The combined studies included 3052 women; 2308 women [mean age 26.7±5.1?years; mean body mass index (BMI) 24.1±3.7?kg/m2] received the final manufactured CVS, of whom 999 (43.3%) completed 13?cycles of use. Women using the final CVS most commonly reported adverse events of headache (n=601, 26%), nausea (n=420, 18%), vaginal discharge/vulvovaginal mycotic infection (n=242, 10%) and abdominal pain (n=225, 10%). Few (<1.5%) women discontinued for these complaints. Four (0.2%) women experienced venous thromboembolism (VTE), three of whom had risk factors for thrombosis [Factor V Leiden mutation (n=1); BMI>29?kg/m2 (n=2)]. During 21,482 treatment cycles in the phase 3 studies evaluable for expulsion, women reported partial expulsions in 4259 (19.5%) cycles and complete expulsions in 1509 (7%) cycles, most frequently in the initial cycle [499/2050 (24.3%) and 190/2050 (9.3%), respectively]. Safety-focused studies revealed no safety concerns. CONCLUSION:The 1-year SA/EE CVS has an acceptable safety profile. Additional studies are warranted in obese women at higher risk of VTE. IMPLICATIONS:This 1-year contraceptive vaginal system represents a new long-term, user-controlled and procedure-free option with a safety profile similar to other combination hormonal contraceptives. The same precautions currently used for combination hormonal contraceptive prescriptions apply to this new contraceptive vaginal system.

Project description:Both oral contraceptive pills (OCPs) and estradiol (E2) valerate have been used to schedule gonadotropin-releasing hormone (GnRH) antagonist in vitro fertilization (IVF) cycles and, consequently, laboratory activities. However, there are no studies comparing treatment outcomes directly between these two pretreatment methods. This randomized controlled trial was aimed at finding differences in ongoing pregnancy rates between GnRH antagonist IVF cycles scheduled with OCPs or E2 valerate.Between January and May 2012, one hundred consecutive patients (nonobese, regularly cycling women 18-38 years with normal day 3 hormone levels and <3 previous IVF/ICSI attempts) undergoing IVF with the GnRH antagonist protocol were randomized to either the OCP or E2 pretreatment arms, with no restrictions such as blocking or stratification. Authors involved in data collection and analysis were blinded to group assignment. Fifty patients received OCP (30 ?g ethinyl E2/150 ?g levonorgestrel) for 12-16 days from day 1 or 2, and stimulation was started 5 days after stopping OCP. Similarly, 50 patients received 4 mg/day oral E2 valerate from day 20 for 5-12 days, until the day before starting stimulation.Pretreatment with OCP (mean±SD, 14.5±1.7 days) was significantly longer than with E2 (7.8±1.9 days). Stimulation and embryological characteristics were similar. Ongoing pregnancy rates (46.0% vs. 44.0%; risk difference, -2.0% [95% CI -21.2% to 17.3%]), as well as implantation (43.5% vs. 47.4%), clinical pregnancy (50.0% vs. 48.0%), clinical miscarriage (7.1% vs. 7.7%), and live birth (42.0% vs. 40.0%) rates were comparable between groups.This is the first study to directly compare these two methods of cycle scheduling in GnRH antagonist cycles. Our results fail to show statistically significant differences in ongoing pregnancy rates between pretreatment with OCP and E2 for IVF with the GnRH antagonist protocol. Although the study is limited by its sample size, our results may contribute to a future meta-analysis. An interesting future direction would be to extend our study to women with decreased ovarian reserve, as these are the patients in whom an increase in oocyte yield-due to the hypothetical beneficial effect of steroid pretreatment on follicular synchronization-could more easily be demonstrated.ClinicalTrials.gov http://NCT01501448.

Project description:ImportanceEighteen states, including Oregon, have passed legislation requiring insurers to cover dispensation of a 12-month supply of short-acting, hormonal contraception.ObjectiveTo determine whether Oregon's 2016 12-month supply law was associated with an increase in contraceptive supply received.Design setting and participantsThis retrospective cohort study of hormonal contraceptive users using Oregon's All Payer All Claims database examined the quantity of contraceptive supply dispensed 3 years before and 3 years after the 2016 policy change. We also assessed changes among patients attributed to Title X clinics.ExposuresLegislation requiring insurers in Oregon to cover a 12-month supply of contraception to continuing users.Main outcomes and measuresReceipt of a 12-month supply of hormonal contraception.ResultsThis cohort study of insured users (mean [SD] age, 27.4 [2.1] years) of short-acting hormonal contraception included 639 053 contraceptive prescriptions. Results indicated that more than 80% of prescriptions for contraceptives cover 3 months or fewer. Most women in the study population used the oral contraceptive pill, lived in a metropolitan area, and were privately insured. We did not observe a significant association between the passage of the 12-month supply policy and receipt of a 12-month supply (aOR, 1.01; 95% CI, 0.74-1.38). Receipt of a 12-month supply was more common for Medicaid recipients than the privately insured (aOR, 9.40; 95% CI, 6.62-13.34). We did find a shift from 1 month to 2 to 3 months supply being dispensed. The policy change was associated with a small, overall increase in quantity dispensed (0.27 months supply; 95% CI, 0.15 to -0.38). Title X clinics prescribed 3 months more of contraceptive supply than non-Title X clinics (3.03 months supply; 95% CI, 2.64-3.41). However, the policy change was not associated with increased contraceptive supply dispensed at Title X clinics.Conclusions and relevanceIn this cohort study of insured users of short-acting hormonal contraception, the passage of a 12-month contraceptive supply policy was not associated with an increase in contraceptive supply dispensed.

Dataset Information

Financial Implications of 12-Month Dispensing of Oral Contraceptive Pills in the Veterans Affairs Health Care System.

Publications

Financial Implications of 12-Month Dispensing of Oral Contraceptive Pills in the Veterans Affairs Health Care System.

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