- Email: [email protected]
Cost-Savings from the Provision of Specific Contraceptive Methods in 2009
Women's Health Issues 23-4 (2013) e265–e271
www.whijournal.com
Original article
Cost-Savings from the Provision of Specific Contraceptive Methods in 2009 Diana Greene Foster, PhD a, Maria Antonia Biggs, PhD a,*, Jan Malvin, PhD b, Mary Bradsberry, BS b, Philip Darney, MD, MSc b, Claire D. Brindis, DrPH b a
Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California at San Francisco, Oakland, California b Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California at San Francisco, San Francisco, California Article history: Received 27 March 2013; Received in revised form 22 May 2013; Accepted 23 May 2013
a b s t r a c t Background: Previous studies have shown that contraceptive provision generates significant public sector cost-savings by preventing health care and social service expenditures on unintended pregnancies. Over the past decade, women’s contraceptive options have expanded considerably, calling for the need to better understand the relative cost-benefit of new contraceptive methods. Methods: We estimated the number of pregnancies averted by each specific contraceptive method by subtracting the total number of pregnancies expected under Family PACT from the total number of pregnancies that would be expected if the program were not available. The cost of providing each method was compared with the savings in reduced public expenditures from averted pregnancies. A resultant cost–benefit ratio was calculated for 11 specific contraceptive methods provided to women under Family PACT. Results: Every contraceptive method studied saved more in public expenditures for unintended pregnancy than it costs to provide. Over half (51%) of the pregnancies averted in 2009 were attributable to the most commonly used method, oral contraceptives. Injectable methods accounted for 13% of averted pregnancies, followed by intrauterine contraceptives (12%), and barrier methods (9%). Intrauterine contraception and contraceptive implants had the highest costsavings with approximately $5.00 of savings for every dollar spent for users of these methods. Conclusions: Because no single method is recommended clinically for every woman, it is medically and fiscally advisable to offer women all contraceptive methods to enable them to choose methods that best meet their needs, increasing the likelihood of compliance with the method chosen and prevention of unintended pregnancies. Copyright Ó 2013 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.
Introduction Over the past decade, women’s contraceptive options have expanded considerably. The cost of providing newer and existing methods varies as widely as their effectiveness. Several studies have demonstrated that family planning programs generate significant public sector cost-savings as a result of preventing unintended pregnancies (Amaral et al., 2007; Forrest & Samara, 1996; Forrest & Singh, 1990; Frost, Finer, & Tapales, 2008). Studies of the cost-benefit of specific methods have demonstrated that the cost-savings varies by method type. An international
* Correspondence to: M. Antonia Biggs, PhD, Bixby Center for Global Reproductive Health, University of California, 3333 California Street, Suite 265, San Francisco, CA 94118. Phone: þ1 510 986 8961. E-mail addresses: [email protected], [email protected] (M.A. Biggs).
review of cost–benefit studies by specific methods across several developed countries found that sterilization and long-acting reversible contraceptive (LARC) methods were most costbeneficial, followed by other hormonal methods (Mavranezouli, 2009). In 1995, Trussell and colleagues (1995) showed the theoretical cost-effectiveness of 15 methods, not accounting for the costs of providing other method-related services, and found that all methods are cost-effective in relation to the high cost of an unintended pregnancy. Trussell and colleagues have continued to update and expand their economic analysis of contraceptive use over the years to account for cost updates, as well as the availability of new products, such as contraceptive implants (Chiou et al., 2003; Trussell, 2012; Trussell et al., 2009). The models presented by Trussell are based on hypothetical use for fixed periods of time, typically 1 and 5 years. These models do not take into account method switching and discontinuation. The purpose of this study was to examine the relative cost-benefit of specific
1049-3867/$ - see front matter Copyright Ó 2013 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.whi.2013.05.004
e266
D.G. Foster et al. / Women's Health Issues 23-4 (2013) e265–e271
methods, including new contraceptive products, when cost and dispensing data are derived from an established reproductive health program, the Family PACT Program. Introduced in 1997, Family PACT, California’s family planning program, serves uninsured reproductive age women and men at or below 200% of the federal poverty guidelines. The program recently converted from an 1115 Medicaid waiver to the State’s Medi-Cal Program via a State Plan Amendment in 2011. Family PACT currently provides contraception and other reproductive health services to more than 1.8 million clients per year (Bixby Center for Global Reproductive Health, 2012a). Methods available since the inception of the program include oral contraception, injectables, intrauterine contraception (IUC), sterilization, and barrier methods. As new and improved methods of contraception have become available, the Family PACT formulary has grown to include emergency contraception products (EC), added in 2000, the contraceptive patch and ring, added in 2002, the contraceptive implant as well as the permanent contraceptive device for tubal occlusion, both added in 2008. Cost–benefit analyses of the overall program show substantial reductions in public expenditures on unintended pregnancies attributable to pregnancies averted by the program (Amaral et al., 2007). A previous analysis using 2003 data demonstrated the cost-benefit of specific methods of contraception in Family PACT accounting for method switching and discontinuation (Foster et al., 2009). That analysis contributed to the literature because, unlike other studies, it included actual methods used by women in a program, and accounted for contraceptive discontinuation and switching. Findings from that study demonstrated that the highest savings were for implantable contraception and IUC with more than $7 of savings for every dollar spent on services and supplies. The present study offers an update to our previous paper using 2009 data. We examine the relative cost-benefit of specific methods and evaluate the relative contribution of each method to the number of unintended pregnancies averted within the Family PACT population. Unlike our previous analysis, this study includes some of the newly available methods (ImplanonÒ implantable contraception and EssureÒ, a tubal occlusion device for permanent contraception), while accounting for the changing costs of well-established methods.
Methods This analysis assessed the cost–benefit ratio for all methods that were provided to women and approved by the U.S. Food and Drug Administration at the time of the study (Table 1). The cost– benefit ratio of specific methods of contraception was estimated by assessing the cost of providing these methods through Family PACT and the averted pregnancy-related, public sector expenditures on unintended pregnancies borne by federal, state, and local governments. This analysis is based on services provided in 2009 to women aged 15 to 44. Few Family PACT female clients (<5%) are outside this age range and their fecundity is not well known (Bixby Center for Global Reproductive Health, 2012b). We used contraceptive dispensing data for 2009 and tracked IUC and contraceptive implant removals through the end of 2010. Contraceptive Coverage Using paid claims data, we estimated the number of months of contraceptive coverage provided under Family PACT based on the quantity and type of contraceptives dispensed. Coverage for long-acting methods, such as tubal ligations, IUCs, and implants, was capped at 2 years and calculated as the number of months between the provision date (anytime in 2009) and December 2010, unless the claims data suggested that the client discontinued the method earlier. This 2-year cap was used to avoid predicting pregnancies far into the future. Because clients may not use all the short-term contraceptive methods received (i.e., condoms, oral contraceptives), the number of months of contraceptive coverage for these methods was adjusted to account for method discontinuation. For example, we assumed that an oral contraceptive user who did not return for refills used half of the pills dispensed to her. We assumed that women who received one packet of EC used it. However, if women received more than one packet, we assumed that 50% used the second packet. The exact quantity of condoms and other contraceptive supplies dispensed on site was not available. Using data from the Family PACT Medical Record Review (Bixby Center for Global Reproductive Health, 2012b), we assumed that 2 months of contraceptive coverage was dispensed each time for barrier methods. We assumed 1 month
Table 1 Primary Contraceptive Methods Provided and Average Months of Protection for Family PACT Clients in 2009 Contraceptive Method
Interval tubal ligation* Tubal occlusion* Copper IUC* Hormonal IUC* Implant* Injectable Ring Patch Oral contraceptives Barriersy Emergency contraceptives All
Clients Aged 15–19
Clients Aged 20–44
Total
No. of Clients
Average Months of Protection per Client
No. of Clients
Average Months of Protection per Client
No. of Clients
Average Months of Protection per Client
Percentage of Total Months of Primary Contraceptive Protection Attributable to Method
0 0 1,399 2,905 1,361 29,160 15,913 11,099 116,251 85,466 22,034 214,856
d d 15.5 16.1 14.4 5.5 5.9 4.9 8.4 2.8 1.7 7.7
3,259 705 19,340 23,791 4,670 107,155 68,100 49,551 420,278 311,035 48,873 843,525
17.9 16.6 16.4 16.2 14.6 6.3 6.5 6.4 8.4 2.9 1.7 8.1
3,259 705 20,739 26,696 6,031 136,315 84,013 60,650 536,529 396,501 70,907 1,058,381
17.9 16.6 16.3 16.1 14.6 6.1 6.4 6.1 8.4 2.9 1.7 8.0
1 0 7 9 2 8 5 3 44 17 2 100
Abbreviation: IUC, intrauterine contraception. Columns add to more than the total because some women have visits for more than one primary method over the course of a year. * Assumes a 2-year cap on duration of contraceptive protection. y Barrier methods include onsite dispensing of male and female condoms, diaphragms, and spermicides.
D.G. Foster et al. / Women's Health Issues 23-4 (2013) e265–e271
of protection for every 10 condoms dispensed by pharmacies. Each injection of depot medroxyprogesterone acetate was assumed to provide 3 months of contraceptive coverage. Pregnancies Averted To estimate pregnancies averted, we employed the same methodology that we have previously used (Foster et al., 2011). For each method, the pregnancies averted calculation is the number of pregnancies expected despite contraceptives received through Family PACT subtracted from the pregnancies expected in the absence of the program. Pregnancies Expected Under Family PACT The number of pregnancies expected among Family PACT clients was estimated by modeling the month-by-month experience of a woman at risk for pregnancy, beginning with the month when the contraceptive was dispensed and ending with the last month of contraceptive coverage. For each month, we calculated the probability that the woman would become pregnant based on the published “typical use” failure rate of the method used (Trussell, 2011) and the estimated probability of pregnancy in previous months. Rather than assume a year of coverage for each client, modeling pregnancies by month allowed us to use specific contraceptive dispensing data on months of coverage. This model also allowed for repeat pregnancies within a year, a common outcome among women who use low-efficacy methods and terminate pregnancies in abortion (Lewis, Doherty, Hickey, & Skinner, 2010; Osler, David, & Morgall, 1997). Based on published estimates for unintended pregnancies in California, we assumed that 47% of pregnancies are carried to term, 42% end in abortion, and 11% in fetal loss (Finer & Kost, 2011). Pregnancies in the Absence of Family PACT To estimate the probability of pregnancy in the absence of contraceptives provided through Family PACT, we used a program-wide fertility rate from client reports of contraceptive use before Family PACT enrollment, determined from a review of medical records of 440 new female clients in 2009 who were not seeking pregnancy (Bixby Center for Global Reproductive Health, 2012b). We employed the same methodology described to assess the number of pregnancies that would have been experienced in the absence of Family PACT. Costs of Family PACT Services We calculated the costs of providing contraceptive services for each method by assigning each visit in which a contraceptive was dispensed, a primary method. Each visit was assigned the most effective method dispensed in the following order: Female sterilization, IUCs, implants, injectables, vaginal ring, patch, oral contraceptives, barrier methods, and EC. In addition to the cost of the contraceptive supplies, all subsequent clinician visits, laboratory tests, and pharmacy claims, including services related to pregnancy testing or sexually transmitted infections, were attributed as costs of providing that method. For clinician visits, laboratory or pharmacy claims in which no method was dispensed, the primary method of the last clinician visit was assigned. Therefore, if a client received oral contraceptives, all her subsequent clinician visits and laboratory and pharmacy
e267
claims would be attributed to the cost of providing oral contraceptives until she is dispensed or provided another method of contraception. For long-term methods like sterilization, implants, and IUCs, a clinical visit for screening and counseling might be scheduled a few weeks before the method is actually provided. We attributed the cost of visits in which no method was dispensed, but that occurred within 40 days before initiation of a long-term method of contraception (sterilization, IUCs, and implants) to that long-term method. In 2009, there were $443 million in Family PACT expenditures for female clients ages 15 to 44 who were dispensed a contraceptive method. This represents 78% of the total program costs for 2009 ($569 million). The other 22% were spent on other services (e.g., sexually transmitted infection testing and treatment, cervical cytology screening) for women who did not get a method of contraception, women outside the age range, and men. Rebates for prescription drugs dispensed at pharmacies reduced the total cost of the program by 5% to 8%. Information on the amount of the rebates by drug type is not available and is not included in this analysis, an omission that may cause our analysis to underestimate the cost-benefits of oral contraceptives, patch, and ring. Costs of Unintended Pregnancies The public cost of an unintended pregnancy was estimated for up to 2 years after a birth as part of the 2007 cost–benefit study for the Family PACT evaluation (Biggs, Foster, Hulett, & Brindis, 2010). Secondary data sources provided quantitative information on health and social service programs available to pregnant or parenting women at or below 200% of the federal poverty level in California. The costs of participation in each public program were adjusted to account for the probability that a Family PACT female client would qualify for each program on the basis of the program’s income, age, and citizenship status eligibility requirements, as well as the anticipated participation rate among eligible women and children. Finally, an adjustment was made to the total cost per pregnancy to account for whether the costs associated with a pregnancy were entirely prevented versus delayed. We assumed that the public saves the entire cost of 50% of pregnancies to adults and 62% of pregnancies to adolescents. This is the percentage of pregnancies that are unwanted and would never occur and the percentage that are delayed, but are not expected to incur public costs in the future. Some pregnancies are not expected to incur public costs in the future if, by delaying a pregnancy, a woman is likely to be financially self-sufficient by the time she becomes pregnant again. For the remaining pregnancies, however, the public saves the difference between paying for services now versus paying at the time when women wish to have their pregnancies. Data for this adjustment came from exit interviews conducted with 1,497 Family PACT clients after their family planning visit in 2007. Family PACT clients ages 20 to 44, on average, wished to delay their first or repeat pregnancies by 3.7 years, and adolescents wanted to wait an average of 6.6 years to have their first or another child (Biggs, Rostovtseva, & Brindis, 2009). Using this methodology, we updated the 2007 figures for 2009, using the medical care price index, yielding $5,469 per pregnancy for adults and $11,077 for adolescents. From 2007 to 2008, the consumer price index for medical costs increased 3.7%. From 2008 to 2009, the increase was 3.2%. The cost for adolescents is higher because they are more likely to carry a pregnancy to term, to have delayed rather than prevented pregnancies,
e268
D.G. Foster et al. / Women's Health Issues 23-4 (2013) e265–e271
and to qualify for public programs owing to their age, income, and immigration status. By updating the figures to 2009 costs, we estimated that each pregnancy averted by Family PACT saved the public sector an estimated $1,266 for adult women and $1,644 for adolescents in medical costs alone for a woman from conception through delivery or termination. Sensitivity Analyses
limited data on exact quantities dispensed, we estimate that barrier method users received 2.9 months of contraceptive protection. Women using EC as their primary method received 1.7 months of protection, although these women may have received other primary methods over the course of the year.
Pregnancy Rates in the Absence of Family PACT
Because our model makes some assumptions that may impact the relative cost-benefit of particular methods, we conducted two sensitivity analyses to investigate the impact of changing these assumptions on our results. In our first sensitivity analysis, we reran our model without adjusting the months of protection from short-term methods, allowing women to use all the methods dispensed. Second, we examined the short-term return of contraceptive provision examining the medical savings through delivery or termination as opposed to 2 years after birth.
Before receiving Family PACT contraceptive services, 25% of adolescent and 20% of adult female clients were using no method of contraception, and 1% were using behavioral methods, such as periodic abstinence and withdrawal. Nearly half of women (47%) were using condoms, 3% were not sexually active, and the remaining 28% were using hormonal methods or IUCs. Based on these data, we estimated that, in the absence of the Family PACT Program, women would become pregnant at an annual rate of 43% among women ages 15 to 19 and 38% among women ages 20 to 44 (data not shown).
Results Pregnancies Averted Contraceptives Dispensed to Women in 2009 More than 1 million women received contraceptive methods through Family PACT in 2009 (Table 1). More women were dispensed oral contraceptives than any other method (136,315), followed by barrier methods and injectable contraceptives. There were about 84,000 women who received the vaginal contraceptive ring and 61,000 who received the contraceptive patch. Long-acting methods, such as implants, IUCs, and sterilization, were provided to over 57,000 women. The contraceptive methods dispensed provided women with an average of 8 months of contraceptive coverage. Long-acting methods, such as tubal ligation, implant, and IUCs provided the greatest number of months of protection, even with the 2-year duration cap. Women who received implants received 14.6 months of protection, women who received IUCs or a sterilization procedure got more than 16 months of protection (Table 1). Among short-term methods, oral contraceptives provided the longest protection (8.4 months), followed by the ring (6.4 months), injectable, and the patch (each 6.1 months). With
Based on the quantity and type of contraceptive methods dispensed and because of method failure and noncompliance that is considered typical among contraceptive users, we estimated that women participating in Family PACT experienced almost 50,000 pregnancies during the time they were covered by Family PACT contraceptives. If these women had been using the methods used before enrollment in Family PACT, they would have experienced approximately 250,000 pregnancies. The difference, approximately 200,000 pregnancies, is an estimate of the number of pregnancies averted through the provision of specific contraceptive methods provided in the Family PACT program in 2009 (Table 2). Modeling pregnancies averted by method reveals that just over half (51%) of the pregnancies averted (102,000) were attributable to oral contraceptive use, 13% (26,000) to injectable use, 12% (24,000) to IUC provision, 9% (18,000) to barrier methods, and 5% (9,000) to the patch. Implants prevented around 3,000 pregnancies (1%) and female sterilization (both tubal ligation and tubal occlusion) prevented 2,100 pregnancies (1%) over 2 years.
Table 2 Estimated Number of Pregnancies Averted and Cost-Savings for Each Contraceptive Method Provided by Family PACT, 2009 Contraceptive Method
No. of Pregnancies in Absence of Method
No. of Pregnancies with Method
No. of Pregnancies Averted
Costs Associated with Method Provision ($ in Thousands)
Cost-Savings per Dollar Expenditure ($)
Tubal ligation* Tubal occlusion* Copper IUC* Hormonal IUC* Implant* Injectable Ring Patch Oral contraceptives Barriersy Emergency contraceptives All
1,788 360 10,472 13,463 2,812 29,993 16,177 11,277 128,923 29,704 4,588 249,557
23 5 208 66 3 3,940 3,246 2,272 26,350 12,139 1,263 49,516
1,766 355 10,264 13,396 2,808 26,053 12,931 9,005 102,573 17,564 3,325 200,041
2,692 1,226 11,905 16,900 3,819 43,869 38,872 27,113 208,676 77,545 9,828 442,443
3.59 1.59 5.07 4.89 5.06 4.00 2.20 2.12 3.37 1.58 2.56 3.04
Abbreviation: IUC, intrauterine contraception. * Assumes a 2-year cap on duration of contraceptive protection. y Barrier methods include onsite dispensing of male and female condoms, diaphragms, and spermicides.
D.G. Foster et al. / Women's Health Issues 23-4 (2013) e265–e271
Cost-savings Expenditures on all contraceptive methods studied result in cost-savings when accounting for the cost of the unintended pregnancies they avert (Table 2). The contraceptive implant and copper IUC have the highest rate of return (just over $5 in averted public expenditures per dollar spent on family planning services). The hormonal IUC saves almost $5 per $1 spent on family planning services ($4.89). Among short-term methods, injectable contraceptives have the highest savings at $4.00 saved per $1 in expended services. The remaining short-term hormonal methods, in order of cost-savings are oral contraceptives ($3.37), EC ($2.56), the ring ($2.20), and the patch ($2.12). Barrier methods and spermicides alone have lower cost-savings at $1.58 and $1.22 per $1 spent on services, respectively. Tubal ligation averts an estimated $3.59, and the new outpatient sterilization procedure, tubal occlusion, saves $1.59 in pregnancy related costs for every $1 spent in prevention services Figure 1 presents expenditures on Family PACT services and the number of pregnancies averted. Sensitivity of Results Our first sensitivity analysis examined the pregnancies averted without the adjustment for method discontinuation on the ring, patch, oral contraceptives, and barrier methods. The costbenefit of the whole program would be 16% higher ($3.51) without this adjustment. Even without the adjustment, the three most cost-beneficial methods are the IUCs (copper and hormonal) and implant. As shown in Table 3, if women used all the oral contraceptives they were dispensed, the savings from oral contraceptive provision would be higher than that of injectables and would become the most cost-beneficial shortterm method of contraception. Without the adjustment for discontinuation, barrier methods are comparable to the cost– benefit ratio of the contraceptive patch ($2.19 compared with $2.51). Even when we assume women use all supplies they are dispensed, the level of savings from condoms and spermicides remains lower than it is for hormonal methods. Our second sensitivity analysis examined the short-term return of providing contraceptives. By limiting the cost associated with unintended pregnancy to just those medical expenditures that occur up to delivery or termination, we have a conservative measure of the short-term returns of contraception. One dollar spent on contraceptives provided through the program saves an estimated $0.61 when just including the
Figure 1. Cost efficiency of contraceptive methods provided by California’s Family PACT program, 2009.
e269
medical costs related to pregnancy. For the program as a whole, the IUCs and implant recoup the cost of provision even when limiting the savings to just medical care through the end of pregnancy (Table 3). Discussion Our findings support previous research and demonstrate that every contraceptive method studied saves more in public expenditures for unintended pregnancy than it costs to provide. These results must be interpreted while considering their limitations. This study makes assumptions which have the effect of reducing the cost-savings associated with very long-acting and very short-term contraceptive methods. The cap of 2 years on the effect of long-acting methods underestimates the costsavings from these methods because women may use them for many years in the future. We cannot know how long women will use these methods, or when they might decide to become pregnant, cease sexual activity, or become infecund. So, we conservatively limit the time period to 2 years. These long-term methods already achieve a positive cost–benefit ratio within 2 years and are more cost-beneficial than short-term methods. It is cost-beneficial to offer these long-acting methods even to women desiring a short interval of protection from pregnancy. For barrier methods, we may have underestimated the duration of contraceptive coverage. Without knowledge of the actual number of months of protection from the actual provision of barrier methods through clinic dispensing, we cannot know the true coverage provided by this method. Furthermore, using claims data we cannot tell whether contraceptive supplies that were dispensed were actually used. We conservatively assume that half of supplies are used. If actual use is lower, the cost effectiveness of condoms, pills, patches, and rings would be inflated relative to injectables and long-acting methods. We have not precisely captured the cost of providing some contraceptives because we do not include rebates from pharmaceutical companies on contraceptives dispensed at pharmacies. The rebates reduce the dispensing costs of oral contraceptives, rings, and patches. We underestimate the cost effectiveness of these methods because we cannot attribute the drug rebate amounts to specific methods. Our model of the fertility rate in the absence of Family PACT is based on the contraceptive use among women who were new to Family PACT. Specifically, the model includes methods they report using before enrollment, according to a medical record review (Bixby Center for Global Reproductive Health, 2012b). For one in five medical records, the contraceptive method used before enrollment was not noted in the chart. To the extent providers may be less likely to record no method as opposed to a specific method of contraception, we may have overestimated contraceptive use in the absence of Family PACT by underestimating noncontraceptive use in the absence of Family PACT and therefore, underestimated pregnancies averted by Family PACT services. The results are similar to our past findings (Foster et al., 2009) with a couple of key differences. 1. The cost-savings from every method and of the program as a whole has dropped from $3.52 to $3.04. This is largely owing to more current data on the methods women would choose in the absence of the program. Whereas we calculated that 43% of women would become pregnant in the absence of the program in 2003, we calculated that 39% of
e270
D.G. Foster et al. / Women's Health Issues 23-4 (2013) e265–e271
Table 3 Sensitivity Analyses of Method-Specific Savings from Preventing Unintended Pregnancies Contraceptive Method
Tubal ligation Tubal occlusion Copper IUC Hormonal IUC Implant Injectable Ring Patch Oral contraceptives Barriers Emergency contraceptives All
Base Case Cost-Savings per Dollar Expenditure ($)
3.59 1.59 5.07 4.89 5.06 4.00 2.20 2.12 3.37 1.58 2.56 3.04
Scenario 1: Women Use All Methods Dispensed
Scenario 2: Medical Costs Through End of Pregnancy Only
Cost-Savings per Dollar Expenditure ($)
Percentage Change from Base Case
Cost-Savings per Dollar Expenditure ($)
Percentage Change from Base Case
3.59 1.59 5.07 4.89 5.06 4.00 2.60 2.51 4.08 2.19 2.56 3.51
0 0 0 0 0 0 18 18 21 39 0 16
0.83 0.37 1.12 1.04 1.00 0.80 0.45 0.44 0.67 0.31 0.48 0.61
77 77 78 79 80 80 80 79 80 80 81 80
Abbreviation: IUC, intrauterine contraception.
women would become pregnant in the absence of the program in 2009. That change may reflect real increases in condom use and reductions in the proportion of couples who would use no method of contraception. 2. The provision of EC is more cost-beneficial than was documented in the previous analysis. Whereas EC was the least cost-beneficial method in 2003, it is substantially more costbeneficial than barrier methods, and even more costbeneficial than the patch and ring in 2009. Because our estimate of the effectiveness of EC has not changed, the difference may be a function of the lower cost of providing women with EC. That lower cost may be owing to success in getting women who use EC to switch to a more effective method of contraception. If women who are dispensed EC are given other primary methods, the cost of subsequent visits are attributed in the analysis to the more effective primary method, thereby reducing the cost of visits for EC primary users. 3. Our differentiation between types of female sterilization and types of IUCs indicates that the copper IUC is slightly more cost-beneficial than the hormonal IUC. A substantial price increase for the hormonal IUC in 2010 had not been implemented in 2009, our study year. The hormonal IUC would have been less cost-beneficial than the copper IUC with this price increase. 4. Tubal occlusion for female sterilization is notably less costbeneficial than surgical tubal ligation because of the higher cost of the device. We find all contraceptive methods dispensed to women through Family PACT to be cost-beneficial. The greatest savings were observed among LARC methods. This finding is also echoed in a recent economic analysis, which attributes the greater savings generated from LARC methods to improved contraceptive adherence and resulting in a reduction in unintended pregnancies (Trussell et al., 2013). Barrier methods and spermicides tend to yield the lowest savings per dollar expenditure owing to their relatively low efficacy and short duration of use. Higher costs and fewer months of contraceptive protection from the contraceptive patch and ring result in lower cost-savings than for oral contraceptives. Tubal occlusion sterilization is less cost-beneficial than traditional tubal ligation, primarily owing to high product cost. Tubal occlusion is less cost-beneficial than all but one
contraceptive method (spermicides). Despite underestimating the cost-savings from permanent methods by limiting their duration to 2 years, tubal occlusion saves more in pregnancy expenditures than it costs to provide. It also seems to be attracting women to sterilization who might not have been interested in a tubal ligation. Tubal occlusion does represent a cost-beneficial choice to the extent that women might not otherwise use alternative methods of contraception.
Implications for Policy These results continue to reinforce the need for the wide availability of all U.S. Food and Drug Administration-approved contraceptive methods to women. The broader the array of method choices, the greater the likelihood that women will find a method that meets her specific needs. Because each method has been shown to be cost effective, all these methods are fiscally responsible choices. Our findings give support for the use of LARC methods as the most cost-beneficial option. Yet, less costeffective options remain more popular than LARC. The high upfront cost of LARC can be a formidable barrier to LARC provision and use (Thompson et al., 2011; Gariepy, Simon, Patel, Creinin, & Schwarz, 2011). Efforts to ensure that provider reimbursement for methods keeps pace with the costs of providing them, has the potential to result in substantial future savings and a reduction in unintended pregnancies. Identifying strategies to reduce the high upfront costs required to stock contraceptive devices may help to facilitate provision of these methods. Furthermore, tailored training approaches aimed at sites not offering certain methods would help to reach providers who would benefit from such training and could include hands-on LARC training, dispelling misconceptions about LARC, and special training for newer methods. Although one study has shown that clients demonstrate some awareness that LARC methods are more cost effective when compared with oral contraceptives, many continue to hold inaccurate perceptions inhibiting their use (Callegari, Parisi, & Schwarz, 2013). Women may benefit from counseling aimed to increase knowledge about the advantages of LARC methods, dispelling common misperceptions about LARC, and being offered LARC as a first-line contraception option. As new methods become available and clinical protocols and recommendations evolve, it will be important to continuously ensure that providers are supported
D.G. Foster et al. / Women's Health Issues 23-4 (2013) e265–e271
with the latest information and training so that they can deliver the highest quality contraceptive care. References Amaral, G., Foster, D. G., Biggs, M. A., Jasik, C. B., Judd, S., & Brindis, C. D. (2007). Public savings from the prevention of unintended pregnancy: A cost analysis of family planning services in California. Health Services Research, 42(5), 1960–1980. Biggs, M. A., Foster, D. G., Hulett, D., & Brindis, C. D. (2010). Cost-benefit analysis of the California Family PACT Program for calendar year 2007. San Francisco: University of California, San Francisco. Biggs, M. A., Rostovtseva, D. P., & Brindis, C. D. (2009). Findings from the 2007 Family PACT client exit interviews. San Francisco: Bixby Center for Global Reproductive Health, University of California, San Francisco. Bixby Center for Global Reproductive Health. (2012a). Family PACT program report, FY10/11. Sacramento: University of California, San Francisco. Bixby Center for Global Reproductive Health. (2012b). 2011 Family PACT medical record review. Sacramento: University of California, San Francisco. Callegari, L. S., Parisi, S. M., & Schwarz, E. B. (2013). Perceptions of intrauterine contraception among women seeking primary care. Contraception. S00107824(13)00048–6. Chiou, C. F., Trussell, J., Reyes, E., Knight, K., Wallace, J., Udani, J., et al. (2003). Economic analysis of contraceptives for women. Contraception, 68(1), 3–10. Finer, L. B., & Kost, K. (2011). Unintended pregnancy rates at the state level. Perspectives on Sexual and Reproductive Health, 43(2), 78–87. Forrest, J. D., & Samara, R. (1996). Impact of publicly funded contraceptive services on unintended pregnancies and implications for Medicaid expenditures. Family Planning Perspectives, 28(5), 188–195. Forrest, J. D., & Singh, S. (1990). Public-sector savings resulting from expenditures for contraceptive services. Family Planning Perspectives, 22(1), 6–15. Foster, D. G., Biggs, M. A., Rostovtseva, D., de Bocanegra, H. T., Darney, P. D., & Brindis, C. D. (2011). Estimating the fertility effect of expansions of publicly funded family planning services in California. Womens Health Issues, 21(6), 418–424. Foster, D. G., Rostovtseva, D. P., Brindis, C. D., Biggs, M. A., Hulett, D., & Darney, P. D. (2009). Cost savings from the provision of specific methods of contraception in a publicly funded program. American Journal of Public Health, 99(3), 446–451. Frost, J. J., Finer, L. B., & Tapales, A. (2008). The impact of publicly funded family planning clinic services on unintended pregnancies and government cost savings. Journal of Health Care for the Poor and Underserved, 19(3), 778–796. Gariepy, A. M., Simon, E. J., Patel, D. A., Creinin, M. D., & Schwarz, E. B. (2011). The impact of out-of-pocket expense on IUD utilization among women with private insurance. Contraception, 84(6), e39–e42. Lewis, L. N., Doherty, D. A., Hickey, M., & Skinner, S. R. (2010). Implanon as a contraceptive choice for teenage mothers: A comparison of contraceptive choices, acceptability and repeat pregnancy. Contraception, 81(5), 421–426. Mavranezouli, I. (2009). Health economics of contraception. Best Practice & Research. Clinical Obstetrics & Gynaecology, 23(2), 187–198. Osler, M., David, H. P., & Morgall, J. M. (1997). Multiple induced abortions: Danish experience. Patient Education and Counseling, 31(1), 83–89.
e271
Thompson, K. M., Speidel, J. J., Saporta, V., Waxman, N. J., & Harper, C. C. (2011). Contraceptive policies affect post-abortion provision of long-acting reversible contraception. Contraception, 83(1), 41–47. Trussell, J. (2011). Contraceptive failure in the United States. [Review]. Contraception, 83(5), 397–404. Trussell, J. (2012). Update on and correction to the cost-effectiveness of contraceptives in the United States. Contraception, 85(6), 611. Trussell, J., Henry, N., Hassan, F., Prezioso, A., Law, A., & Filonenko, A. (2013). Burden of unintended pregnancy in the United States: Potential savings with increased use of long-acting reversible contraception. Contraception, 87(2), 154–161. Trussell, J., Lalla, A. M., Doan, Q. V., Reyes, E., Pinto, L., & Gricar, J. (2009). Cost effectiveness of contraceptives in the United States. Contraception, 79(1), 5–14. Trussell, J., Leveque, J. A., Koenig, J. D., London, R., Borden, S., Henneberry, J., et al. (1995). The economic value of contraception: A comparison of 15 methods. American Journal of Public Health, 85(4), 494–503.
Author Descriptions Diana Greene Foster, PhD, is an Associate Professor in the UCSF Bixby Center for Global Reproductive Health. She is a demographer who uses quantitative analyses to evaluate the effectiveness of family planning policies and the effect of unintended pregnancy on women’s lives.
M. Antonia Biggs, PhD, is a researcher at the UCSF Bixby Center for Global Reproductive Health. Her research focuses on the evaluation of reproductive health programs, access to family planning services, and unintended pregnancy.
Jan Malvin, PhD, is a researcher at the UCSF Bixby Center for Global Reproductive Health. Her research interests include prevention of adolescent risk behavior and unintended pregnancy, and evaluation of family planning programs.
Mary Bradsberry, BS, is a Statistician with the University of California, San Francisco, with an interest in analysis of publicly funded family planning programs.
Philip Darney, MD, MSc, is a Distinguished Professor of Obstetrics, Gynecology and Reproductive Sciences at the University of California, San Francisco, where he directs the Bixby Center for Global Reproductive Health. He works in contraceptive and abortion development and evaluation.
Claire D. Brindis, DrPH, is a Professor of Pediatrics and Health Policy at the University of California, San Francisco, where she is a Director of the Bixby Center for Global Reproductive Health and also Director of the Philip R. Lee Institute for Health Policy Studies. Her research interests are in the area of reproductive health, program evaluation, and the translation of research findings into evidence-based policy.
www.whijournal.com
Original article
Cost-Savings from the Provision of Specific Contraceptive Methods in 2009 Diana Greene Foster, PhD a, Maria Antonia Biggs, PhD a,*, Jan Malvin, PhD b, Mary Bradsberry, BS b, Philip Darney, MD, MSc b, Claire D. Brindis, DrPH b a
Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California at San Francisco, Oakland, California b Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California at San Francisco, San Francisco, California Article history: Received 27 March 2013; Received in revised form 22 May 2013; Accepted 23 May 2013
a b s t r a c t Background: Previous studies have shown that contraceptive provision generates significant public sector cost-savings by preventing health care and social service expenditures on unintended pregnancies. Over the past decade, women’s contraceptive options have expanded considerably, calling for the need to better understand the relative cost-benefit of new contraceptive methods. Methods: We estimated the number of pregnancies averted by each specific contraceptive method by subtracting the total number of pregnancies expected under Family PACT from the total number of pregnancies that would be expected if the program were not available. The cost of providing each method was compared with the savings in reduced public expenditures from averted pregnancies. A resultant cost–benefit ratio was calculated for 11 specific contraceptive methods provided to women under Family PACT. Results: Every contraceptive method studied saved more in public expenditures for unintended pregnancy than it costs to provide. Over half (51%) of the pregnancies averted in 2009 were attributable to the most commonly used method, oral contraceptives. Injectable methods accounted for 13% of averted pregnancies, followed by intrauterine contraceptives (12%), and barrier methods (9%). Intrauterine contraception and contraceptive implants had the highest costsavings with approximately $5.00 of savings for every dollar spent for users of these methods. Conclusions: Because no single method is recommended clinically for every woman, it is medically and fiscally advisable to offer women all contraceptive methods to enable them to choose methods that best meet their needs, increasing the likelihood of compliance with the method chosen and prevention of unintended pregnancies. Copyright Ó 2013 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.
Introduction Over the past decade, women’s contraceptive options have expanded considerably. The cost of providing newer and existing methods varies as widely as their effectiveness. Several studies have demonstrated that family planning programs generate significant public sector cost-savings as a result of preventing unintended pregnancies (Amaral et al., 2007; Forrest & Samara, 1996; Forrest & Singh, 1990; Frost, Finer, & Tapales, 2008). Studies of the cost-benefit of specific methods have demonstrated that the cost-savings varies by method type. An international
* Correspondence to: M. Antonia Biggs, PhD, Bixby Center for Global Reproductive Health, University of California, 3333 California Street, Suite 265, San Francisco, CA 94118. Phone: þ1 510 986 8961. E-mail addresses: [email protected], [email protected] (M.A. Biggs).
review of cost–benefit studies by specific methods across several developed countries found that sterilization and long-acting reversible contraceptive (LARC) methods were most costbeneficial, followed by other hormonal methods (Mavranezouli, 2009). In 1995, Trussell and colleagues (1995) showed the theoretical cost-effectiveness of 15 methods, not accounting for the costs of providing other method-related services, and found that all methods are cost-effective in relation to the high cost of an unintended pregnancy. Trussell and colleagues have continued to update and expand their economic analysis of contraceptive use over the years to account for cost updates, as well as the availability of new products, such as contraceptive implants (Chiou et al., 2003; Trussell, 2012; Trussell et al., 2009). The models presented by Trussell are based on hypothetical use for fixed periods of time, typically 1 and 5 years. These models do not take into account method switching and discontinuation. The purpose of this study was to examine the relative cost-benefit of specific
1049-3867/$ - see front matter Copyright Ó 2013 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.whi.2013.05.004
e266
D.G. Foster et al. / Women's Health Issues 23-4 (2013) e265–e271
methods, including new contraceptive products, when cost and dispensing data are derived from an established reproductive health program, the Family PACT Program. Introduced in 1997, Family PACT, California’s family planning program, serves uninsured reproductive age women and men at or below 200% of the federal poverty guidelines. The program recently converted from an 1115 Medicaid waiver to the State’s Medi-Cal Program via a State Plan Amendment in 2011. Family PACT currently provides contraception and other reproductive health services to more than 1.8 million clients per year (Bixby Center for Global Reproductive Health, 2012a). Methods available since the inception of the program include oral contraception, injectables, intrauterine contraception (IUC), sterilization, and barrier methods. As new and improved methods of contraception have become available, the Family PACT formulary has grown to include emergency contraception products (EC), added in 2000, the contraceptive patch and ring, added in 2002, the contraceptive implant as well as the permanent contraceptive device for tubal occlusion, both added in 2008. Cost–benefit analyses of the overall program show substantial reductions in public expenditures on unintended pregnancies attributable to pregnancies averted by the program (Amaral et al., 2007). A previous analysis using 2003 data demonstrated the cost-benefit of specific methods of contraception in Family PACT accounting for method switching and discontinuation (Foster et al., 2009). That analysis contributed to the literature because, unlike other studies, it included actual methods used by women in a program, and accounted for contraceptive discontinuation and switching. Findings from that study demonstrated that the highest savings were for implantable contraception and IUC with more than $7 of savings for every dollar spent on services and supplies. The present study offers an update to our previous paper using 2009 data. We examine the relative cost-benefit of specific methods and evaluate the relative contribution of each method to the number of unintended pregnancies averted within the Family PACT population. Unlike our previous analysis, this study includes some of the newly available methods (ImplanonÒ implantable contraception and EssureÒ, a tubal occlusion device for permanent contraception), while accounting for the changing costs of well-established methods.
Methods This analysis assessed the cost–benefit ratio for all methods that were provided to women and approved by the U.S. Food and Drug Administration at the time of the study (Table 1). The cost– benefit ratio of specific methods of contraception was estimated by assessing the cost of providing these methods through Family PACT and the averted pregnancy-related, public sector expenditures on unintended pregnancies borne by federal, state, and local governments. This analysis is based on services provided in 2009 to women aged 15 to 44. Few Family PACT female clients (<5%) are outside this age range and their fecundity is not well known (Bixby Center for Global Reproductive Health, 2012b). We used contraceptive dispensing data for 2009 and tracked IUC and contraceptive implant removals through the end of 2010. Contraceptive Coverage Using paid claims data, we estimated the number of months of contraceptive coverage provided under Family PACT based on the quantity and type of contraceptives dispensed. Coverage for long-acting methods, such as tubal ligations, IUCs, and implants, was capped at 2 years and calculated as the number of months between the provision date (anytime in 2009) and December 2010, unless the claims data suggested that the client discontinued the method earlier. This 2-year cap was used to avoid predicting pregnancies far into the future. Because clients may not use all the short-term contraceptive methods received (i.e., condoms, oral contraceptives), the number of months of contraceptive coverage for these methods was adjusted to account for method discontinuation. For example, we assumed that an oral contraceptive user who did not return for refills used half of the pills dispensed to her. We assumed that women who received one packet of EC used it. However, if women received more than one packet, we assumed that 50% used the second packet. The exact quantity of condoms and other contraceptive supplies dispensed on site was not available. Using data from the Family PACT Medical Record Review (Bixby Center for Global Reproductive Health, 2012b), we assumed that 2 months of contraceptive coverage was dispensed each time for barrier methods. We assumed 1 month
Table 1 Primary Contraceptive Methods Provided and Average Months of Protection for Family PACT Clients in 2009 Contraceptive Method
Interval tubal ligation* Tubal occlusion* Copper IUC* Hormonal IUC* Implant* Injectable Ring Patch Oral contraceptives Barriersy Emergency contraceptives All
Clients Aged 15–19
Clients Aged 20–44
Total
No. of Clients
Average Months of Protection per Client
No. of Clients
Average Months of Protection per Client
No. of Clients
Average Months of Protection per Client
Percentage of Total Months of Primary Contraceptive Protection Attributable to Method
0 0 1,399 2,905 1,361 29,160 15,913 11,099 116,251 85,466 22,034 214,856
d d 15.5 16.1 14.4 5.5 5.9 4.9 8.4 2.8 1.7 7.7
3,259 705 19,340 23,791 4,670 107,155 68,100 49,551 420,278 311,035 48,873 843,525
17.9 16.6 16.4 16.2 14.6 6.3 6.5 6.4 8.4 2.9 1.7 8.1
3,259 705 20,739 26,696 6,031 136,315 84,013 60,650 536,529 396,501 70,907 1,058,381
17.9 16.6 16.3 16.1 14.6 6.1 6.4 6.1 8.4 2.9 1.7 8.0
1 0 7 9 2 8 5 3 44 17 2 100
Abbreviation: IUC, intrauterine contraception. Columns add to more than the total because some women have visits for more than one primary method over the course of a year. * Assumes a 2-year cap on duration of contraceptive protection. y Barrier methods include onsite dispensing of male and female condoms, diaphragms, and spermicides.
D.G. Foster et al. / Women's Health Issues 23-4 (2013) e265–e271
of protection for every 10 condoms dispensed by pharmacies. Each injection of depot medroxyprogesterone acetate was assumed to provide 3 months of contraceptive coverage. Pregnancies Averted To estimate pregnancies averted, we employed the same methodology that we have previously used (Foster et al., 2011). For each method, the pregnancies averted calculation is the number of pregnancies expected despite contraceptives received through Family PACT subtracted from the pregnancies expected in the absence of the program. Pregnancies Expected Under Family PACT The number of pregnancies expected among Family PACT clients was estimated by modeling the month-by-month experience of a woman at risk for pregnancy, beginning with the month when the contraceptive was dispensed and ending with the last month of contraceptive coverage. For each month, we calculated the probability that the woman would become pregnant based on the published “typical use” failure rate of the method used (Trussell, 2011) and the estimated probability of pregnancy in previous months. Rather than assume a year of coverage for each client, modeling pregnancies by month allowed us to use specific contraceptive dispensing data on months of coverage. This model also allowed for repeat pregnancies within a year, a common outcome among women who use low-efficacy methods and terminate pregnancies in abortion (Lewis, Doherty, Hickey, & Skinner, 2010; Osler, David, & Morgall, 1997). Based on published estimates for unintended pregnancies in California, we assumed that 47% of pregnancies are carried to term, 42% end in abortion, and 11% in fetal loss (Finer & Kost, 2011). Pregnancies in the Absence of Family PACT To estimate the probability of pregnancy in the absence of contraceptives provided through Family PACT, we used a program-wide fertility rate from client reports of contraceptive use before Family PACT enrollment, determined from a review of medical records of 440 new female clients in 2009 who were not seeking pregnancy (Bixby Center for Global Reproductive Health, 2012b). We employed the same methodology described to assess the number of pregnancies that would have been experienced in the absence of Family PACT. Costs of Family PACT Services We calculated the costs of providing contraceptive services for each method by assigning each visit in which a contraceptive was dispensed, a primary method. Each visit was assigned the most effective method dispensed in the following order: Female sterilization, IUCs, implants, injectables, vaginal ring, patch, oral contraceptives, barrier methods, and EC. In addition to the cost of the contraceptive supplies, all subsequent clinician visits, laboratory tests, and pharmacy claims, including services related to pregnancy testing or sexually transmitted infections, were attributed as costs of providing that method. For clinician visits, laboratory or pharmacy claims in which no method was dispensed, the primary method of the last clinician visit was assigned. Therefore, if a client received oral contraceptives, all her subsequent clinician visits and laboratory and pharmacy
e267
claims would be attributed to the cost of providing oral contraceptives until she is dispensed or provided another method of contraception. For long-term methods like sterilization, implants, and IUCs, a clinical visit for screening and counseling might be scheduled a few weeks before the method is actually provided. We attributed the cost of visits in which no method was dispensed, but that occurred within 40 days before initiation of a long-term method of contraception (sterilization, IUCs, and implants) to that long-term method. In 2009, there were $443 million in Family PACT expenditures for female clients ages 15 to 44 who were dispensed a contraceptive method. This represents 78% of the total program costs for 2009 ($569 million). The other 22% were spent on other services (e.g., sexually transmitted infection testing and treatment, cervical cytology screening) for women who did not get a method of contraception, women outside the age range, and men. Rebates for prescription drugs dispensed at pharmacies reduced the total cost of the program by 5% to 8%. Information on the amount of the rebates by drug type is not available and is not included in this analysis, an omission that may cause our analysis to underestimate the cost-benefits of oral contraceptives, patch, and ring. Costs of Unintended Pregnancies The public cost of an unintended pregnancy was estimated for up to 2 years after a birth as part of the 2007 cost–benefit study for the Family PACT evaluation (Biggs, Foster, Hulett, & Brindis, 2010). Secondary data sources provided quantitative information on health and social service programs available to pregnant or parenting women at or below 200% of the federal poverty level in California. The costs of participation in each public program were adjusted to account for the probability that a Family PACT female client would qualify for each program on the basis of the program’s income, age, and citizenship status eligibility requirements, as well as the anticipated participation rate among eligible women and children. Finally, an adjustment was made to the total cost per pregnancy to account for whether the costs associated with a pregnancy were entirely prevented versus delayed. We assumed that the public saves the entire cost of 50% of pregnancies to adults and 62% of pregnancies to adolescents. This is the percentage of pregnancies that are unwanted and would never occur and the percentage that are delayed, but are not expected to incur public costs in the future. Some pregnancies are not expected to incur public costs in the future if, by delaying a pregnancy, a woman is likely to be financially self-sufficient by the time she becomes pregnant again. For the remaining pregnancies, however, the public saves the difference between paying for services now versus paying at the time when women wish to have their pregnancies. Data for this adjustment came from exit interviews conducted with 1,497 Family PACT clients after their family planning visit in 2007. Family PACT clients ages 20 to 44, on average, wished to delay their first or repeat pregnancies by 3.7 years, and adolescents wanted to wait an average of 6.6 years to have their first or another child (Biggs, Rostovtseva, & Brindis, 2009). Using this methodology, we updated the 2007 figures for 2009, using the medical care price index, yielding $5,469 per pregnancy for adults and $11,077 for adolescents. From 2007 to 2008, the consumer price index for medical costs increased 3.7%. From 2008 to 2009, the increase was 3.2%. The cost for adolescents is higher because they are more likely to carry a pregnancy to term, to have delayed rather than prevented pregnancies,
e268
D.G. Foster et al. / Women's Health Issues 23-4 (2013) e265–e271
and to qualify for public programs owing to their age, income, and immigration status. By updating the figures to 2009 costs, we estimated that each pregnancy averted by Family PACT saved the public sector an estimated $1,266 for adult women and $1,644 for adolescents in medical costs alone for a woman from conception through delivery or termination. Sensitivity Analyses
limited data on exact quantities dispensed, we estimate that barrier method users received 2.9 months of contraceptive protection. Women using EC as their primary method received 1.7 months of protection, although these women may have received other primary methods over the course of the year.
Pregnancy Rates in the Absence of Family PACT
Because our model makes some assumptions that may impact the relative cost-benefit of particular methods, we conducted two sensitivity analyses to investigate the impact of changing these assumptions on our results. In our first sensitivity analysis, we reran our model without adjusting the months of protection from short-term methods, allowing women to use all the methods dispensed. Second, we examined the short-term return of contraceptive provision examining the medical savings through delivery or termination as opposed to 2 years after birth.
Before receiving Family PACT contraceptive services, 25% of adolescent and 20% of adult female clients were using no method of contraception, and 1% were using behavioral methods, such as periodic abstinence and withdrawal. Nearly half of women (47%) were using condoms, 3% were not sexually active, and the remaining 28% were using hormonal methods or IUCs. Based on these data, we estimated that, in the absence of the Family PACT Program, women would become pregnant at an annual rate of 43% among women ages 15 to 19 and 38% among women ages 20 to 44 (data not shown).
Results Pregnancies Averted Contraceptives Dispensed to Women in 2009 More than 1 million women received contraceptive methods through Family PACT in 2009 (Table 1). More women were dispensed oral contraceptives than any other method (136,315), followed by barrier methods and injectable contraceptives. There were about 84,000 women who received the vaginal contraceptive ring and 61,000 who received the contraceptive patch. Long-acting methods, such as implants, IUCs, and sterilization, were provided to over 57,000 women. The contraceptive methods dispensed provided women with an average of 8 months of contraceptive coverage. Long-acting methods, such as tubal ligation, implant, and IUCs provided the greatest number of months of protection, even with the 2-year duration cap. Women who received implants received 14.6 months of protection, women who received IUCs or a sterilization procedure got more than 16 months of protection (Table 1). Among short-term methods, oral contraceptives provided the longest protection (8.4 months), followed by the ring (6.4 months), injectable, and the patch (each 6.1 months). With
Based on the quantity and type of contraceptive methods dispensed and because of method failure and noncompliance that is considered typical among contraceptive users, we estimated that women participating in Family PACT experienced almost 50,000 pregnancies during the time they were covered by Family PACT contraceptives. If these women had been using the methods used before enrollment in Family PACT, they would have experienced approximately 250,000 pregnancies. The difference, approximately 200,000 pregnancies, is an estimate of the number of pregnancies averted through the provision of specific contraceptive methods provided in the Family PACT program in 2009 (Table 2). Modeling pregnancies averted by method reveals that just over half (51%) of the pregnancies averted (102,000) were attributable to oral contraceptive use, 13% (26,000) to injectable use, 12% (24,000) to IUC provision, 9% (18,000) to barrier methods, and 5% (9,000) to the patch. Implants prevented around 3,000 pregnancies (1%) and female sterilization (both tubal ligation and tubal occlusion) prevented 2,100 pregnancies (1%) over 2 years.
Table 2 Estimated Number of Pregnancies Averted and Cost-Savings for Each Contraceptive Method Provided by Family PACT, 2009 Contraceptive Method
No. of Pregnancies in Absence of Method
No. of Pregnancies with Method
No. of Pregnancies Averted
Costs Associated with Method Provision ($ in Thousands)
Cost-Savings per Dollar Expenditure ($)
Tubal ligation* Tubal occlusion* Copper IUC* Hormonal IUC* Implant* Injectable Ring Patch Oral contraceptives Barriersy Emergency contraceptives All
1,788 360 10,472 13,463 2,812 29,993 16,177 11,277 128,923 29,704 4,588 249,557
23 5 208 66 3 3,940 3,246 2,272 26,350 12,139 1,263 49,516
1,766 355 10,264 13,396 2,808 26,053 12,931 9,005 102,573 17,564 3,325 200,041
2,692 1,226 11,905 16,900 3,819 43,869 38,872 27,113 208,676 77,545 9,828 442,443
3.59 1.59 5.07 4.89 5.06 4.00 2.20 2.12 3.37 1.58 2.56 3.04
Abbreviation: IUC, intrauterine contraception. * Assumes a 2-year cap on duration of contraceptive protection. y Barrier methods include onsite dispensing of male and female condoms, diaphragms, and spermicides.
D.G. Foster et al. / Women's Health Issues 23-4 (2013) e265–e271
Cost-savings Expenditures on all contraceptive methods studied result in cost-savings when accounting for the cost of the unintended pregnancies they avert (Table 2). The contraceptive implant and copper IUC have the highest rate of return (just over $5 in averted public expenditures per dollar spent on family planning services). The hormonal IUC saves almost $5 per $1 spent on family planning services ($4.89). Among short-term methods, injectable contraceptives have the highest savings at $4.00 saved per $1 in expended services. The remaining short-term hormonal methods, in order of cost-savings are oral contraceptives ($3.37), EC ($2.56), the ring ($2.20), and the patch ($2.12). Barrier methods and spermicides alone have lower cost-savings at $1.58 and $1.22 per $1 spent on services, respectively. Tubal ligation averts an estimated $3.59, and the new outpatient sterilization procedure, tubal occlusion, saves $1.59 in pregnancy related costs for every $1 spent in prevention services Figure 1 presents expenditures on Family PACT services and the number of pregnancies averted. Sensitivity of Results Our first sensitivity analysis examined the pregnancies averted without the adjustment for method discontinuation on the ring, patch, oral contraceptives, and barrier methods. The costbenefit of the whole program would be 16% higher ($3.51) without this adjustment. Even without the adjustment, the three most cost-beneficial methods are the IUCs (copper and hormonal) and implant. As shown in Table 3, if women used all the oral contraceptives they were dispensed, the savings from oral contraceptive provision would be higher than that of injectables and would become the most cost-beneficial shortterm method of contraception. Without the adjustment for discontinuation, barrier methods are comparable to the cost– benefit ratio of the contraceptive patch ($2.19 compared with $2.51). Even when we assume women use all supplies they are dispensed, the level of savings from condoms and spermicides remains lower than it is for hormonal methods. Our second sensitivity analysis examined the short-term return of providing contraceptives. By limiting the cost associated with unintended pregnancy to just those medical expenditures that occur up to delivery or termination, we have a conservative measure of the short-term returns of contraception. One dollar spent on contraceptives provided through the program saves an estimated $0.61 when just including the
Figure 1. Cost efficiency of contraceptive methods provided by California’s Family PACT program, 2009.
e269
medical costs related to pregnancy. For the program as a whole, the IUCs and implant recoup the cost of provision even when limiting the savings to just medical care through the end of pregnancy (Table 3). Discussion Our findings support previous research and demonstrate that every contraceptive method studied saves more in public expenditures for unintended pregnancy than it costs to provide. These results must be interpreted while considering their limitations. This study makes assumptions which have the effect of reducing the cost-savings associated with very long-acting and very short-term contraceptive methods. The cap of 2 years on the effect of long-acting methods underestimates the costsavings from these methods because women may use them for many years in the future. We cannot know how long women will use these methods, or when they might decide to become pregnant, cease sexual activity, or become infecund. So, we conservatively limit the time period to 2 years. These long-term methods already achieve a positive cost–benefit ratio within 2 years and are more cost-beneficial than short-term methods. It is cost-beneficial to offer these long-acting methods even to women desiring a short interval of protection from pregnancy. For barrier methods, we may have underestimated the duration of contraceptive coverage. Without knowledge of the actual number of months of protection from the actual provision of barrier methods through clinic dispensing, we cannot know the true coverage provided by this method. Furthermore, using claims data we cannot tell whether contraceptive supplies that were dispensed were actually used. We conservatively assume that half of supplies are used. If actual use is lower, the cost effectiveness of condoms, pills, patches, and rings would be inflated relative to injectables and long-acting methods. We have not precisely captured the cost of providing some contraceptives because we do not include rebates from pharmaceutical companies on contraceptives dispensed at pharmacies. The rebates reduce the dispensing costs of oral contraceptives, rings, and patches. We underestimate the cost effectiveness of these methods because we cannot attribute the drug rebate amounts to specific methods. Our model of the fertility rate in the absence of Family PACT is based on the contraceptive use among women who were new to Family PACT. Specifically, the model includes methods they report using before enrollment, according to a medical record review (Bixby Center for Global Reproductive Health, 2012b). For one in five medical records, the contraceptive method used before enrollment was not noted in the chart. To the extent providers may be less likely to record no method as opposed to a specific method of contraception, we may have overestimated contraceptive use in the absence of Family PACT by underestimating noncontraceptive use in the absence of Family PACT and therefore, underestimated pregnancies averted by Family PACT services. The results are similar to our past findings (Foster et al., 2009) with a couple of key differences. 1. The cost-savings from every method and of the program as a whole has dropped from $3.52 to $3.04. This is largely owing to more current data on the methods women would choose in the absence of the program. Whereas we calculated that 43% of women would become pregnant in the absence of the program in 2003, we calculated that 39% of
e270
D.G. Foster et al. / Women's Health Issues 23-4 (2013) e265–e271
Table 3 Sensitivity Analyses of Method-Specific Savings from Preventing Unintended Pregnancies Contraceptive Method
Tubal ligation Tubal occlusion Copper IUC Hormonal IUC Implant Injectable Ring Patch Oral contraceptives Barriers Emergency contraceptives All
Base Case Cost-Savings per Dollar Expenditure ($)
3.59 1.59 5.07 4.89 5.06 4.00 2.20 2.12 3.37 1.58 2.56 3.04
Scenario 1: Women Use All Methods Dispensed
Scenario 2: Medical Costs Through End of Pregnancy Only
Cost-Savings per Dollar Expenditure ($)
Percentage Change from Base Case
Cost-Savings per Dollar Expenditure ($)
Percentage Change from Base Case
3.59 1.59 5.07 4.89 5.06 4.00 2.60 2.51 4.08 2.19 2.56 3.51
0 0 0 0 0 0 18 18 21 39 0 16
0.83 0.37 1.12 1.04 1.00 0.80 0.45 0.44 0.67 0.31 0.48 0.61
77 77 78 79 80 80 80 79 80 80 81 80
Abbreviation: IUC, intrauterine contraception.
women would become pregnant in the absence of the program in 2009. That change may reflect real increases in condom use and reductions in the proportion of couples who would use no method of contraception. 2. The provision of EC is more cost-beneficial than was documented in the previous analysis. Whereas EC was the least cost-beneficial method in 2003, it is substantially more costbeneficial than barrier methods, and even more costbeneficial than the patch and ring in 2009. Because our estimate of the effectiveness of EC has not changed, the difference may be a function of the lower cost of providing women with EC. That lower cost may be owing to success in getting women who use EC to switch to a more effective method of contraception. If women who are dispensed EC are given other primary methods, the cost of subsequent visits are attributed in the analysis to the more effective primary method, thereby reducing the cost of visits for EC primary users. 3. Our differentiation between types of female sterilization and types of IUCs indicates that the copper IUC is slightly more cost-beneficial than the hormonal IUC. A substantial price increase for the hormonal IUC in 2010 had not been implemented in 2009, our study year. The hormonal IUC would have been less cost-beneficial than the copper IUC with this price increase. 4. Tubal occlusion for female sterilization is notably less costbeneficial than surgical tubal ligation because of the higher cost of the device. We find all contraceptive methods dispensed to women through Family PACT to be cost-beneficial. The greatest savings were observed among LARC methods. This finding is also echoed in a recent economic analysis, which attributes the greater savings generated from LARC methods to improved contraceptive adherence and resulting in a reduction in unintended pregnancies (Trussell et al., 2013). Barrier methods and spermicides tend to yield the lowest savings per dollar expenditure owing to their relatively low efficacy and short duration of use. Higher costs and fewer months of contraceptive protection from the contraceptive patch and ring result in lower cost-savings than for oral contraceptives. Tubal occlusion sterilization is less cost-beneficial than traditional tubal ligation, primarily owing to high product cost. Tubal occlusion is less cost-beneficial than all but one
contraceptive method (spermicides). Despite underestimating the cost-savings from permanent methods by limiting their duration to 2 years, tubal occlusion saves more in pregnancy expenditures than it costs to provide. It also seems to be attracting women to sterilization who might not have been interested in a tubal ligation. Tubal occlusion does represent a cost-beneficial choice to the extent that women might not otherwise use alternative methods of contraception.
Implications for Policy These results continue to reinforce the need for the wide availability of all U.S. Food and Drug Administration-approved contraceptive methods to women. The broader the array of method choices, the greater the likelihood that women will find a method that meets her specific needs. Because each method has been shown to be cost effective, all these methods are fiscally responsible choices. Our findings give support for the use of LARC methods as the most cost-beneficial option. Yet, less costeffective options remain more popular than LARC. The high upfront cost of LARC can be a formidable barrier to LARC provision and use (Thompson et al., 2011; Gariepy, Simon, Patel, Creinin, & Schwarz, 2011). Efforts to ensure that provider reimbursement for methods keeps pace with the costs of providing them, has the potential to result in substantial future savings and a reduction in unintended pregnancies. Identifying strategies to reduce the high upfront costs required to stock contraceptive devices may help to facilitate provision of these methods. Furthermore, tailored training approaches aimed at sites not offering certain methods would help to reach providers who would benefit from such training and could include hands-on LARC training, dispelling misconceptions about LARC, and special training for newer methods. Although one study has shown that clients demonstrate some awareness that LARC methods are more cost effective when compared with oral contraceptives, many continue to hold inaccurate perceptions inhibiting their use (Callegari, Parisi, & Schwarz, 2013). Women may benefit from counseling aimed to increase knowledge about the advantages of LARC methods, dispelling common misperceptions about LARC, and being offered LARC as a first-line contraception option. As new methods become available and clinical protocols and recommendations evolve, it will be important to continuously ensure that providers are supported
D.G. Foster et al. / Women's Health Issues 23-4 (2013) e265–e271
with the latest information and training so that they can deliver the highest quality contraceptive care. References Amaral, G., Foster, D. G., Biggs, M. A., Jasik, C. B., Judd, S., & Brindis, C. D. (2007). Public savings from the prevention of unintended pregnancy: A cost analysis of family planning services in California. Health Services Research, 42(5), 1960–1980. Biggs, M. A., Foster, D. G., Hulett, D., & Brindis, C. D. (2010). Cost-benefit analysis of the California Family PACT Program for calendar year 2007. San Francisco: University of California, San Francisco. Biggs, M. A., Rostovtseva, D. P., & Brindis, C. D. (2009). Findings from the 2007 Family PACT client exit interviews. San Francisco: Bixby Center for Global Reproductive Health, University of California, San Francisco. Bixby Center for Global Reproductive Health. (2012a). Family PACT program report, FY10/11. Sacramento: University of California, San Francisco. Bixby Center for Global Reproductive Health. (2012b). 2011 Family PACT medical record review. Sacramento: University of California, San Francisco. Callegari, L. S., Parisi, S. M., & Schwarz, E. B. (2013). Perceptions of intrauterine contraception among women seeking primary care. Contraception. S00107824(13)00048–6. Chiou, C. F., Trussell, J., Reyes, E., Knight, K., Wallace, J., Udani, J., et al. (2003). Economic analysis of contraceptives for women. Contraception, 68(1), 3–10. Finer, L. B., & Kost, K. (2011). Unintended pregnancy rates at the state level. Perspectives on Sexual and Reproductive Health, 43(2), 78–87. Forrest, J. D., & Samara, R. (1996). Impact of publicly funded contraceptive services on unintended pregnancies and implications for Medicaid expenditures. Family Planning Perspectives, 28(5), 188–195. Forrest, J. D., & Singh, S. (1990). Public-sector savings resulting from expenditures for contraceptive services. Family Planning Perspectives, 22(1), 6–15. Foster, D. G., Biggs, M. A., Rostovtseva, D., de Bocanegra, H. T., Darney, P. D., & Brindis, C. D. (2011). Estimating the fertility effect of expansions of publicly funded family planning services in California. Womens Health Issues, 21(6), 418–424. Foster, D. G., Rostovtseva, D. P., Brindis, C. D., Biggs, M. A., Hulett, D., & Darney, P. D. (2009). Cost savings from the provision of specific methods of contraception in a publicly funded program. American Journal of Public Health, 99(3), 446–451. Frost, J. J., Finer, L. B., & Tapales, A. (2008). The impact of publicly funded family planning clinic services on unintended pregnancies and government cost savings. Journal of Health Care for the Poor and Underserved, 19(3), 778–796. Gariepy, A. M., Simon, E. J., Patel, D. A., Creinin, M. D., & Schwarz, E. B. (2011). The impact of out-of-pocket expense on IUD utilization among women with private insurance. Contraception, 84(6), e39–e42. Lewis, L. N., Doherty, D. A., Hickey, M., & Skinner, S. R. (2010). Implanon as a contraceptive choice for teenage mothers: A comparison of contraceptive choices, acceptability and repeat pregnancy. Contraception, 81(5), 421–426. Mavranezouli, I. (2009). Health economics of contraception. Best Practice & Research. Clinical Obstetrics & Gynaecology, 23(2), 187–198. Osler, M., David, H. P., & Morgall, J. M. (1997). Multiple induced abortions: Danish experience. Patient Education and Counseling, 31(1), 83–89.
e271
Thompson, K. M., Speidel, J. J., Saporta, V., Waxman, N. J., & Harper, C. C. (2011). Contraceptive policies affect post-abortion provision of long-acting reversible contraception. Contraception, 83(1), 41–47. Trussell, J. (2011). Contraceptive failure in the United States. [Review]. Contraception, 83(5), 397–404. Trussell, J. (2012). Update on and correction to the cost-effectiveness of contraceptives in the United States. Contraception, 85(6), 611. Trussell, J., Henry, N., Hassan, F., Prezioso, A., Law, A., & Filonenko, A. (2013). Burden of unintended pregnancy in the United States: Potential savings with increased use of long-acting reversible contraception. Contraception, 87(2), 154–161. Trussell, J., Lalla, A. M., Doan, Q. V., Reyes, E., Pinto, L., & Gricar, J. (2009). Cost effectiveness of contraceptives in the United States. Contraception, 79(1), 5–14. Trussell, J., Leveque, J. A., Koenig, J. D., London, R., Borden, S., Henneberry, J., et al. (1995). The economic value of contraception: A comparison of 15 methods. American Journal of Public Health, 85(4), 494–503.
Author Descriptions Diana Greene Foster, PhD, is an Associate Professor in the UCSF Bixby Center for Global Reproductive Health. She is a demographer who uses quantitative analyses to evaluate the effectiveness of family planning policies and the effect of unintended pregnancy on women’s lives.
M. Antonia Biggs, PhD, is a researcher at the UCSF Bixby Center for Global Reproductive Health. Her research focuses on the evaluation of reproductive health programs, access to family planning services, and unintended pregnancy.
Jan Malvin, PhD, is a researcher at the UCSF Bixby Center for Global Reproductive Health. Her research interests include prevention of adolescent risk behavior and unintended pregnancy, and evaluation of family planning programs.
Mary Bradsberry, BS, is a Statistician with the University of California, San Francisco, with an interest in analysis of publicly funded family planning programs.
Philip Darney, MD, MSc, is a Distinguished Professor of Obstetrics, Gynecology and Reproductive Sciences at the University of California, San Francisco, where he directs the Bixby Center for Global Reproductive Health. He works in contraceptive and abortion development and evaluation.
Claire D. Brindis, DrPH, is a Professor of Pediatrics and Health Policy at the University of California, San Francisco, where she is a Director of the Bixby Center for Global Reproductive Health and also Director of the Philip R. Lee Institute for Health Policy Studies. Her research interests are in the area of reproductive health, program evaluation, and the translation of research findings into evidence-based policy.