A 12-month supply of birth control pills could be a huge benefit to many people, particularly those who live in areas where it is difficult to see prescribers and pick up prescriptions.1,2 It could help people stay on the contraceptive of their choice and reduce discontinuation rates.
One reason for high discontinuation rates with short-acting contraception is because of users’ difficulty in obtaining a consistent supply. A 12-month prescription could remove that barrier.2
Massachusetts passed the 2017 Act Advancing Contraceptive Coverage and Economic Security in Our State (ACCESS) to ensure access to a 12-month supply of birth control pills, patches, vaginal rings, and other short-acting contraception.1
When researchers studied whether people were interested in the one-year supply of contraception and whether they were using it, they found that interest was high at 93% — and actual use was only 9%.1
Investigators identified various obstacles to women obtaining a 12-month supply. They interviewed clinicians and pharmacists and conducted a consumer survey for answers. Some of the concerns raised were insurers’ reliability in paying for the longer prescription despite the law and hassle of claim denials. There also were concerns about patients not following up with their provider if they had any problems with their contraceptive method, says Neena Qasba, MD, MPH, lead study author and an assistant professor at the University of Connecticut School of Medicine in Farmington, CT. Qasba was an assistant professor at the University of Massachusetts when conducting research for the study.
“Massachusetts passed the ACCESS Law in 2017, and it had several components,” Qasba says. “One of which is mandating insurances in the state to cover a 12-month supply of short-acting contraceptive methods — things like birth control pills, birth control patches, birth control vaginal ring, and self-administered birth control injection.”
When Qasba moved to Massachusetts in 2015, and the law passed a couple of years later, she noticed that clinicians were not prescribing the one-year supply of contraceptives.
“I did some preliminary conversations with people in my institution and noticed there were a lot of logistical hurdles that were not addressed or specified in the law,” Qasba explains. “There was poor awareness among pharmacists about this provision, so I received some funding from my previous institution to do stakeholder analyses.”
Awareness of the law was another obstacle. “Clinicians were also concerned if pharmacies knew about it, and they were getting feedback that pharmacists were not accepting a 12-month prescription,” Qasba says.
Research suggests that many clinicians are not even aware of the Massachusetts law that allows patients to receive a 12-month supply of birth control pills. Clinicians were concerned that patients would lose their medications or devices, and decreased clinician contact.3
From the pharmacists’ perspective, there were logistical issues. While birth control pills are a common prescription, many pharmacies would not have 12-month packs on hand. In one study, pharmacists told investigators they were not trained on the ACCESS Law.4
Pharmacists also were concerned about stocking the 12-month packs and being unable to fill a 12-month supply at a single visit. They worried about whether they could provide a 12-month supply with an expiration date long enough for the patient to complete using it.
“There also were concerns about insurance,” Qasba says. “They were questioning whether there would be an increased administrative burden if the prescription was denied.”
The law itself also created an obstacle. “It’s important to note that the law in Massachusetts made a three-month trial period for every new user,” Qasba explains. “If you are using the pill, patch, ring, or injection for the first time, your first prescription could only be a three-month supply.”
The reason for this is insurance companies wanted to prevent medication wastage. “However, between clinicians and pharmacists, they expressed confusion about who was supposed to be keeping track of that,” Qasba says. “Is it the clinician keeping track? Is the pharmacist keeping track of it?”
When this type of bill is written, it seems simple to just add a three-month prescription for new users. But with a healthcare system that is not unified or connected, it becomes complex. “If a patient fills the prescription at CVS, will Walgreens know that?” Qasba asks. “If the patient changes doctors, will the new doctor only do it for three months?”
These logistical issues seemed to make both clinicians and pharmacists hesitant. “How can laws and policy be written so they have implementation in mind? I think a lot of these things sound simple, but on the ground, it means something different,” Qasba says.
Any of these changes a patient makes — in pharmacy, clinician, and insurer — could create an obstacle.
On the other hand, longer supplies of contraception bring positive outcomes. “I know that different insurers are moving toward 90-day supplies and longer supplies,” Qasba says. “We know that giving people a longer supply improves compliance.”
Contraception users voiced their own concerns, including where to safely store a 12-month supply of pills and how to maintain their privacy. “Some were concerned when stashing a larger supply — they didn’t want people to accidentally find it,” Qasba says.
Increased awareness and provider training could help reduce the obstacles to longer prescriptions for contraceptives. The Massachusetts Department of Public Health is addressing this issue by investing funds to increase awareness.
“They also have training for continuing medical education credits for clinicians and pharmacists,” Qasba explains. “I think the other piece of it is coordinating with insurers. That’s some of the work that advocacy groups have done.”
Along with increasing the public’s awareness of the 12-month supply of contraceptives, there should be some effort to help people walk through local implementation.
“Help people think about what we should do,” Qasba says. “Some pharmacists said the most likely scenario is the patient presents the prescription and then comes back in a day or two for the 12-month supply.”
If that would work best logistically for pharmacies, then contraception users need to know that they may not receive their 12-month supply on the day they renew their prescription. Consumers are becoming more accustomed to waiting a few days for prescriptions, so this obstacle may not be as challenging as everyone becomes used to the process for obtaining a 12-month supply of birth control.
For health systems with electronic medical records (EMRs), some institutions have created a default for all contraception prescriptions to a 12-month supply, which makes it more automatic in the EMR.
“It’s important to understand the importance of writing health policy and legislation, thinking about how it translates on the ground,” Qasba says. “It is about putting deliberate planning and thinking about implementation and oversight.”
Legislation should have oversight specified in the law to make it easier to ensure implementation, Qasba adds.
REFERENCES
- Qasba NT, Wallace KF, Yu V, et al. Online survey of consumer awareness and perceptions of a Massachusetts law for 12-month-supply of contraception. Contraception 2023 Aug 6;110138. doi: 10.1016/j.contraception.2023.110138. [Online ahead of print].
- Day SL, Qasba N, Goff S. Twelve-month contraception dispensing advances access and equity. Health Affairs. April 21, 2023.
- Qasba NT, Dowd P, Bianchet E, Goff SL. A qualitative study of clinicians’ perspectives on a law that allows for a 12-month supply of short-acting contraceptives in Massachusetts: Barriers and facilitators to implementation. Health Serv Res 2023;58:498-507.
- Qasba N, Wallace KF, Sopko J, et al. Twelve-month supply of short-acting contraception methods: Pharmacists’ perspectives on implementation of new state law. J Am Pharm Assoc (2003) 2022;62:1296-1303.e2.
A 12-month supply of birth control pills could be a huge benefit to many people, particularly those who live in areas where it is difficult to see prescribers and pick up prescriptions. It could help people stay on the contraceptive of their choice and reduce discontinuation rates.
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