March 26, 2015 — Summary of "Potential Public Sector Cost-Savings From Over-the-Counter Access to Oral Contraceptives," Foster et al., Contraception, Feb. 27, 2015.
"[T]he need for a prescription to obtain a reliable contraceptive method is a barrier to use" for many women, according to researchers led by Diana Foster of the University of California-San Francisco's Bixby Center for Global Reproductive Health and Department of Obstetrics, Gynecology and Reproductive Science.
They noted that "inconsistent or lack of contraceptive use, rather than contraceptive method failure" is the leading cause of unintended pregnancy in the U.S. About half of U.S. pregnancies are unintended, a rate that "has remained steady ... for the past 2 decades," Foster and colleagues wrote.
According to the researchers, making oral contraceptive pills (OCPs) available over the counter (OTC) potentially could "increase contraceptive use and continuation rates by facilitating continuity of use and encouraging OCP use among women who currently do not use any method or use less effective methods."
In their study, Foster and colleagues examined the effects OTC OCPs would have on "use, unintended pregnancies and associated pregnancy and contraceptive costs."
Researchers used state and national data to predict how OTC OCPs could affect contraceptive use among low-income women who are at risk of unintended pregnancy.
Specifically, the researchers considered two possible scenarios -- high OCP adoption and low OCP adoption -- and predicted OCP adoption based on the out-of-pocket costs of each pill pack. They also predicted the number of unintended pregnancies in each scenario and "estimate[d] the public sector cost of providing OCPs and medical care for pregnancy under each scenario (no OTC access, low OTC use, high OTC use), effect on contraceptive failure rates (none, 50% reduction, 50% increase) and out-of-pocket costs for a pack of pills (from $0 to $50)."
The researchers found that among low-income women at risk of unintended pregnancy:
~ 21% reported being very likely to use OCPs if they were available OTC at drug or grocery stores;
~ 15% reported being somewhat likely to use OCPs in those circumstances;
~ 26% reported being unsure or not likely to use OCPs if they were available OTC; and
~ 39% reported having no interest in OCPs.
Further, the researchers found that "[t]he likelihood of using OCPs among low-income women who are somewhat or very interested in OTC OCPs varie[d] by price," ranging from 100% of women saying they would use the pills if a pack were available at no cost, to just 4% if a pack cost $50. As a result, Foster and colleagues concluded that making OCPs available OTC "would have almost no effect on the contraceptive method distribution if the out-of-pocket cost for an OTC pill pack is $50 and the most widespread adoption of OCPs if the OTC pack is entirely covered by insurance."
In addition, the researchers found that making OCPs available OTC without copayments would:
~ Decrease the share of low-income women using less-effective contraceptive methods from 31% to 18% under the high OCP adoption model and from 31% to 24% under the low-OCP adoption model;
~ Decrease the share of low-income women using no contraceptive methods from 18% to a range of 14% to 15%; and
~ Decrease the share of women using contraceptive methods more effective than OCPs from 17% to a range of 14% to 15%.
Low OCP Adoption Model
Under the low OCP adoption model with no copays, the number of OCP users would increase from 31% to 42%, with 63% of the new adopters switching from using a less effective method, 25% switching from using no contraception and 13% switching from a more effective method.
Further, the number of unintended pregnancies among low-income women would decrease by 11% (from 251 per 1,000 women annually to 223 per 1,000 women annually) if there are no changes to the OCP failure rate; by 15% (213 per 1,000 women) if OTC access reduced the failure rate; and by 7% (233 per 1,000 women) if OTC access increased the failure rate.
In addition, under the low OCP adoption model, contraception- and pregnancy-related medical costs covered by insurance would decrease by 1% without any change to the OCP failure rate and by 4% if the OCP failure rates decreased by 50%, while the amount would increase by 3% if the OTC access increased the OCP failure rate.
High OCP Adoption Model
Meanwhile, the researchers found that under the high OCP adoption model with no copays the number of OCP users would increase from 31% to 52%, with 62% switching from a less effective contraceptive method, 22% switching from using no contraception and 16% switching from a more effective method.
Further, the number of unintended pregnancies among low-income women "would decrease by 18% (204 per 1,000 women) with no changes to the pill failure rate, 25% (187 per 1,000 women) if the failure rate reduces by half and 12% (221 per 1,000 women) if the failure rate increases by half," they wrote.
Contraception- and pregnancy-related costs to insurers would decrease by 6% if there were no improvement in OCP failure rates, by 12% if OTC access decreased OCP failure rates by 50% and by less than 1% if such access increased OCP failure rates by 50%.
Overall, the researchers found, "Savings are maximized at an out-of-pocket cost per pack of $10-20 -- the price point where pill costs are offset by the copay but the copay is not so high as to discourage use." Specifically, the researchers wrote that a $10 copay would incur savings for insurers of "3-10% (low to high use models) on pregnancy and pill costs if there is no change in OCP failure rate, 6-15% if the OCP failure rate decreases and 0-5% if the OCP failure rate increases."
According to Foster and colleagues, the study shows "that OTC access to oral contraceptives is likely to increase low-income women's use of more effective contraceptive methods." In addition, if OCPs were available OTC without out-of-pocket costs, "there would be a significant drop in the number of low-income women at risk of unintended pregnancy using no method or a less effective method" of contraception. Accordingly, the rate of unintended pregnancy among low-income women would decline by 11% to 18% if OTC access did not affect OCP failure rates, by 15% to 25% if it decreased failure rates and by 7% to 12% if it increased failure rates.
Foster and colleagues suggested that "it is in the financial interest of public healthcare programs to cover a large portion of the cost of contraceptive pills." However, they noted that while "projected savings are maximized at $10-20 copay, the number of pregnancies averted is maximized at no out-of-pocket costs." Specifically, they wrote that "the proportion of women using OTC OCPs is directly correlated with out-of-pocket cost of the product," with "little advantage" conferred from OTC access among low-income women if the copays are more than $10.
Foster and colleagues concluded, "Removing the prescription barrier, particularly if pill packs are available at small or zero out-of-pocket cost, could increase the use of effective methods of contraception and reduce unintended pregnancy and healthcare costs."