JAMA Internal Medicine** just published a new study on the frictional effects of quarterly versus annual hormonal birth control prescriptions:
FINDINGS: In this economic decision model built from the Veterans Affairs health system payer perspective using a cohort of 24 309 women, adoption of a 12-month dispensing option for oral contraceptive pills is expected to produce substantial cost savings for the payer compared with standard 3-month dispensing, while reducing unintended pregnancies among women veterans….
RESULTS: Cost savings resulted from an absolute reduction of 24 unintended pregnancies per 1000 women per year with 12-month dispensing, or 583 unintended pregnancies averted annually. Expected cost savings with 12-month dispensing were sensitive to changes in the probability of OCP coverage gaps with 3-month dispensing, the probability of pregnancy during coverage gaps, and the proportion of pregnancies paid for by the VA. When simultaneously varying all variables across plausible ranges, the 12-month strategy was cost saving in 95.4% of model iterations.
This is fundamentally a story about administrative friction. Quarterly prescription requirements necessitate more individual management of interactions between the patient and the prescriber. There are also more interactions between the prescriber and the pharmacy where things can fall through the cracks when compared to a single, annual prescription. Similarly, one of the big advantages of Long Acting Reversible Contraception (LARC) like IUDs is that there is very little administrative management costs for the recipient after she gets the IUD.
It is a good thing that an annual prescription saves the VA money in nineteen out of twenty model runs as that gives us confidence that the proposal will increase female autonomy and reproductive choice but I don’t think cost-savings is a necessary requirement for these types of policy interventions. Instead, we should examine whether or not changing the prescription length produces desired clinical effects. And in this case, changing the prescription length produced a significant desired clinical effect of far fewer unintended pregnancies.
There are times when policy interventions can be clinically effective and value adding even if the total costs are slightly higher. Cost effective does not mean cost savings. We should buy cost-effective treatments and policy changes if the value of what we are buying is greater than the incremental price.
This is really cool that total costs are likely to go down for the VA but I don’t think it is necessary to do so in order to support these types of policy changes.
** Judge-Golden et al: