By Rebecca H. Allen, MD, MPH, Editor
Synopsis: In this national retrospective cohort study of patients on Medicaid, states with 12-month hormonal contraceptive supply policies increased their 12-month dispensing by only 4.39% compared to the pre-policy period. The majority of this increase was contributed by the state of California.
Source: Rodriguez MI, Meath TH, Daly A, et al. Twelve-month contraceptive supply policies and Medicaid contraceptive dispensing. JAMA Health Forum. 2024;5(8):e242755.
The authors of this study sought to assess whether policies mandating that health insurers allow dispensing of a full 12-month supply of short-acting hormonal contraceptives (pill, patch, or ring) made a difference for patients. A total of 19 states have enacted these policies to date. These policies are designed to allow patients to pick up a 12-month supply of contraceptives at a time and have the full year covered by insurance.
This was a national retrospective cohort study from 2016 to 2020 of national Medicaid claims and enrollment data. The cohort was divided into treatment states, which had legislation or guidance directing Medicaid to cover a 12-month supply of contraception, and comparison states. The period was divided into the pre-policy period from Jan. 1, 2016, to the state’s policy compliance date and the post-policy period from the compliance date to Dec. 31, 2020.
Comparison states did not have a policy prior to Dec. 31, 2020. Three states (Washington, Oregon, and South Carolina) were excluded because they had implemented a policy prior to 2016. Twelve states (Alaska, Florida, Maine, Minnesota, Mississippi, North Carolina, Ohio, Rhode Island, Colorado, Wisconsin, Kansas, and Nebraska) were excluded because of various data quality reasons.
With 36 states remaining, there were 10 states (Vermont, California, Hawaii, New York, Nevada, Delaware, Massachusetts, Maryland, New Hampshire, and New Mexico) and the territory of Washington, DC, in the treatment group and 25 remaining states in the control group.
The data collected included all short-acting contraceptive prescriptions to female Medicaid enrollees aged 18 to 44 years including age, type of contraceptive, and months of supply received. The primary outcome was the proportion of total months of contraception supplied during a quarter, provided in a single 12-month or longer supply.
The study authors identified 48,255,512 months of pill, patch, and ring prescriptions to 4,778,264 Medicaid participants during the study period in the 11 treatment and 25 comparison states. Most prescriptions were for oral contraceptive pills (87.8% in treatment states and 90.1% in comparison states), followed by the ring (6.8% in treatment states and 5.6% in comparison states) and the patch (5.5% in treatment states and 4.3% in comparison states).
At study start, in treatment states, a one-month supply was dispensed 58.1% of the time, followed by a two- to three-month supply 41.5% of the time. A 12-month or more supply was dispensed only 0.1% of the time.
At the end of the study, in treatment states, the one-month supply was 31.2%, two- to three-months’ supply was 60.9%, and 12-month or more supply was 6.2%. In comparison states, one-month supply was 82.7% at study start and 51.5% at study end while a two- to three-months’ supply was 17.1% at study start and 48.4% at study end. There were no 12-month supplies dispensed in comparison states.
On average, the policies were associated with a 4.39% increase (95% confidence interval [CI], 4.38 to 4.40) in treatment states for 12-month supplies of contraceptives. California contributed the highest increase with a 7.17% increase (95% CI, 7.15, 7.19). The remaining 10 treatment states demonstrated less than a 1% increase.
Commentary
The unintended pregnancy rate in the United States (defined as unwanted or mistimed pregnancies) is around 45%.1 Access to contraception is critical to reducing the unintended pregnancy rate and improving the health of individuals. The Affordable Care Act has mandated since 2012 that all U.S. Food and Drug Administration-approved contraceptives be covered by health insurers without cost-sharing. While some private employers have been able to opt out of this coverage, Medicaid does cover contraception.
The American College of Obstetricians and Gynecologists recommends that a full year of contraception be prescribed by clinicians, dispensed by the pharmacy, and covered by health insurers.2 Studies have shown that a 12-month supply of short-acting contraceptive methods (pill, patch, or ring) can improve adherence and continuation rates.3 A frequent reason why these shorter-acting methods fail is the need to obtain a new prescription and/or go to the pharmacy every month for a refill.
To confront the barriers to continued contraceptive use with these short-acting methods, policy makers and state legislatures have enacted 12-month supply policies in 19 states. This study showed, unfortunately, that at least among Medicaid recipients, these policies were only associated with a very small increase in 12-month contraceptive supplies, except in California, which demonstrated a 7% increase.
The authors speculated multiple reasons for their findings. For the policy to work, patients need to know they can receive 12 months at one time, prescribers need to write a prescription for 12 months, pharmacists must dispense a 12-month supply, and health insurers must cover it. The authors noted that prescribers and pharmacists may not be up to date on these new policies. California likely was the most successful because the state has a large publicly supported family planning clinic network where information can be disseminated easily, and practice change can occur.
The study was limited by using claims data, which did not allow access to other variables that may influence contraceptive prescribing on an individual level. Not all patients want or need 12 months of a contraceptive in their medicine cabinet, for example. In addition, information about whether prescriptions were new or when they would expire was not available. Nevertheless, this study highlights the fact that when policies are enacted, they are not automatically followed or implemented in real-world settings. Additional education, dissemination, monitoring, and enforcement is always needed.
It is important for us as prescribers to do our part and provide patients with prescriptions that last 12 months and allow the pharmacist to dispense a 12-months’ supply of a contraceptive if that is what the patient desires.
Rebecca H. Allen, MD, MPH, is Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, RI.
References
1. Guttmacher Institute. Unintended pregnancy in the United States. Published January 2019. https://www.guttmacher.org/fact-sheet/unintended-pregnancy-united-states
2. American College of Obstetricians and Gynecologists. Access to contraception. Committee Opinion Number 615. Published January 2015. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2015/01/access-to-contraception
3. Foster DG, Parvataneni R, Thiel de Bocanegra H, et al. Number of oral contraceptive pill packages dispensed, method continuation, and costs. Obstet Gynecol. 2006;108(5):1107-1114.
In this national retrospective cohort study of patients on Medicaid, states with 12-month hormonal contraceptive supply policies increased their 12-month dispensing by only 4.39% compared to the pre-policy period. The majority of this increase was contributed by the state of California.
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