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The Impact of Out-of-Pocket Costs on the Use of Intrauterine Contraception Among Women With Employer-sponsored Insurance

Pace, Lydia E. MD, MPH*; Dusetzina, Stacie B. PhD†,‡; Fendrick, A. Mark MD§,∥; Keating, Nancy L. MD, MPH¶,#; Dalton, Vanessa K. MD, MPH**

doi: 10.1097/MLR.0b013e3182a97b5d
Brief Reports

Background: Long-acting reversible contraception (LARC) is highly effective but also has higher initiation costs than oral contraceptive methods, which may contribute to relatively low use. The Affordable Care Act requires most private insurance plans to cover contraceptive services without patient cost-sharing. Whether this mandate will increase LARC use is unknown.

Objective: To assess the relationship between cost-sharing and use of LARC among privately insured women.

Design: Cross-sectional analysis using Truven Health MarketScan data from January 2011 to December 2011.

Subjects: Women aged 14–45 years with continuous insurance coverage enrolled in health plan products that covered branded and generic oral contraceptive pills (OCPs) and intrauterine devices (IUDs). We selected women using OCPs and IUDs as these are the most commonly used short-acting and long-acting reversible methods, respectively (N=1,682,425).

Measures: Multivariable regression was used to assess the association of the level of out-of-pocket costs for IUDs for each patient’s plan and IUD initiation, adjusting for out-of-pocket costs for branded and generic OCPs and patient characteristics.

Results: Overall, 5.5% of women initiated an IUD in 2011. After adjustment, IUD initiation was less likely among women with higher versus lower co-pays (adjusted risk ratio=0.65; 95% CI, 0.64–0.67). Women who saw an obstetrician/gynecologist during 2011 were more likely to initiate an IUD (adjusted risk ratio=2.49; 95% CI, 2.45–2.53).

Conclusions: Rates of IUD use are low among privately insured women in the United States, and higher cost-sharing is associated with lower rates of IUD use. Together with other measures to promote LARC use, eliminating co-pays for contraception could promote the use of these more effective and cost-effective methods.

*Department of Internal Medicine, Division of Women’s Health, Brigham and Women’s Hospital, Boston, MA

Division of General Medicine and Clinical Epidemiology, School of Medicine

Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC

Departments of §Internal Medicine

Health Management & Policy, Center for Value-Based Insurance Design, University of Michigan, Ann Arbor, MI

Department of Health Care Policy, Harvard Medical School

#Department of Internal Medicine, Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA

**Program on Women’s Health Care Effectiveness, Research, Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI

L.E.P.’s effort was supported by the Global Women’s Health Fellowship, Connors Center for Women’s Health and Gender Biology, Brigham and Women’s Hospital. V.K.D.’s effort in part was supported by grant number 1 K08 JS015491 from the Agency for Healthcare Research and Quality. She is a Nexplanon Trainer for Merck. She also served on an advisory board for McNeil Consumer Healthcare.

The authors declare no conflict of interest.

Reprints: Stacie B. Dusetzina, PhD, Division of General Medicine and Clinical Epidemiology, School of Medicine, University of North Carolina at Chapel Hill, 5034 Old Clinic Building, Chapel Hill, NC 27599. E-mail:

© 2013 by Lippincott Williams & Wilkins.