Impact of no cost contraception on utilization and direct medical expenditures
As of January 1, 2014, the Patient Protection and Affordable Care Act (ACA) required all commercial, employer-based health plans to cover contraception counseling and methods without patient copayments except for certain religious organizations. Fifty-eight percent of women in the United States are enrolled in such health plans. Ongoing debate would benefit from a clearer understanding of how eliminating patient cost-sharing for contraceptive-related visits and contraceptive methods impacts contraception use patterns, pregnancies, and health care spending. Unintended pregnancy is a serious maternal-child health problem with potentially long-term burdens not only for women and families, but also for society. Unintended pregnancies generate an estimated $4 billion in direct and indirect costs for the U.S. health care system, and approximately 30% end in abortion. Studies have consistently concluded that contraception is cost effective from both a health plan and a societal perspective. Our proposal is innovative in its framing around value-based insurance design (VBID) principles as a strategy to decrease unintended pregnancy. Under VBID principles, health plans should implement policies that encourage the delivery of evidence-based services. In this instance, the elimination of cost-sharing under the ACA for contraceptive-related services aligns patient financial incentives with clinical goals. Previous studies have suggested that contraceptive use patterns, such as method choice and consistency of use, can be improved by eliminating out-of-pocket costs. However, their findings are not easily generalizable to the ACA context. We will use the natural experiment of the ACA?s implementation to observe real-time changes in patient cost sharing, method use, and direct medical spending during the mandate?s implementation in a large, national administrative claims database to meet the following aims: 1)To determine whether the elimination of patient cost-sharing is associated with changes in contraception-related office visits. 2a) To determine whether the elimination of patient cost-sharing is associated with changes in contraception method use patterns, including method type, consistency of use and method switching. Our primary analysis we be conducted at the patient level to estimate the effect of cost-sharing on our outcomes. A second analysis will examine the impact of the mandate?s implementation at the plan level using the following sub-aim: 2b) To determine whether the implementation of the contraception mandate is associated with changes in aggregate contraceptive method use patterns. We will also examine the relationship between the elimination of cost-sharing and patient and plan medical spending with the following aim: 3) To examine whether the elimination of cost-sharing is associated with changes in related medical spending (i.e., outpatient contraceptive-visits, pregnancy care, births and drug spending).
Agency for Health Care Research and Quality, HHS
(1 R01 HS 023784 01 A1)
Funding Period: 9/1/2015 to 6/30/2019