Friction and birth control

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: JAMA Intern Med. Published online July 8, 2019. doi:10.1001/jamainternmed.2019.1678






36 replies
  1. 1
    laura says:

    Man, that heading gives me the uh-oh feeling in the no-no spot.

  2. 2
    Betty Cracker says:

    @laura: Heh! Glad I’m not the only one!

  3. 3
    Steeplejack says:

    I came for the boom-chicka-mao-mao music. Why is there no boom-chicka-mao-mao music?!

    (Obligatory boom-chicka-mao-mao music.)

  4. 4
    mere mortal says:

    This is a hilariously inappropriate title.

    Also, I’ve got some Internal Medicine for you right here, baby.

    Yes, I am twelve, how did you know?

  5. 5
    TenguPhule says:

    hey David, this sounds a bit up your alley.

    Trump to order overhaul of organ transplant and kidney dialysis systems

    What fresh hell is this?

  6. 6
    Ruckus says:

    I’ve wondered how effective this might be for a lot of prescriptions. Every prescription I have is a 90 day because that’s how the VA works. Yet I see my docs on a 6 month schedule. So I’m having to interact with the pharmacy twice as often as my docs, making twice as much work for them. Don’t really see the point.

  7. 7
    TomatoQueen says:

    I like interacting with my pharmacist. She has a great sense of humor and will give me a flu shot at 8 am on a Saturday morning, no appointment needed.

  8. 8
    Adam L Silverman says:

    @laura: @Betty Cracker:

  9. 9
    Brachiator says:

    @mere mortal:

    This is a hilariously inappropriate title.

    At first, I didn’t think about it.

    Now I’m having all kinds of crazy thoughts.

    Friction and birth control: Hunka Hunka Burning Love

  10. 10
    Adam L Silverman says:

    @TenguPhule: Maybe if you’d actually read the article you’d know. I just read it. And, as my father died of end stage kidney disease, was on dialysis for five years, and was denied the chance for a transplant not because he didn’t qualify or hadn’t done everything his nephrologist had told him to do to get on the list, but because the junior backup surgeon on the transplant team didn’t want to risk his success rate, while the devil will be in the details here, I didn’t see anything in the article that is out of line.

  11. 11

    I think he means friction in the economic sense not the physics sense.

  12. 12
    Brachiator says:

    OT. Ross Perot has died

    Billionaire businessman, philanthropist and independent presidential candidate Ross Perot is dead at 89, CNBC has confirmed.

    Perot, who ran for president in 1992 and 1996, died after a five-month battle with leukemia, said James Fuller, a representative for the Perot family.

  13. 13
    Adam L Silverman says:

    @Brachiator: Is this good news for John McCain?

  14. 14
    Mandalay says:

    @Adam L Silverman:

    Maybe if you’d actually read the article you’d know.

    You must be new here. Welcome to Balloon Juice.

  15. 15
    The Lodger says:

    @schrodingers_cat: You physicists… obviously, he’s speaking in the biological sense.

  16. 16
    Brachiator says:

    @Adam L Silverman:
    This was a sad and sobering story about your father.

    Yesterday, a talk radio host mentioned that Stevie Wonder announced that he would be getting a kidney transplant in October. The show producer talked about his own experiences in having a pancreas and kidney transplant nine years ago. The discussion was unexpectedly illuminating, especially for talk radio.

  17. 17
    Adam L Silverman says:

    @Brachiator: It was what it was. I would have liked to have had him around a lot longer. But he went peacefully, at home, two weeks after seeing my brother get married. He basically just stopped. Like his battery had finally run down. Had gone into my parents’ bedroom after dinner to watch TV and my mom found him about a 1/2 later after she’d finished cleaning up. He basically just drifted off.

  18. 18
    Adam L Silverman says:

    @Mandalay: What was I thinking?//

  19. 19
    TenguPhule says:

    @Adam L Silverman: I could not find the catch. And there is ALWAYS a catch when Trump does anything that remotely sounds not evil.

  20. 20
    Adam L Silverman says:

    @TenguPhule: We won’t know if there is one until the actual policy details are released and actual subject matter experts can review it.

  21. 21

    @TenguPhule: The way that we pay for kidney disease treatment in the US is jacked up and both expensive and less than optimal from a care point of view. There is a lot of money available for dialysis and not enough for either transplants or pre-ESRD maintenance treatments.

    This is a problem that needs to be worked on.

  22. 22

    @schrodingers_cat: I’ve been spending a lot of time in the administrative friction space with a paper accepted, another paper in round 2 of revision and a brand new project that all touch on this literature.

  23. 23
    Mohagan says:

    The conclusions of the article seem a bit Duh to me, but I ‘m glad the obvious was proved so the VA can start giving out annual prescriptions, and saving everyone a lot of unnecessary trouble

  24. 24
    Steeplejack says:

    @schrodingers_cat:

    You’d better duck so the joke can go safely over your head.

  25. 25
    Baud says:

    @laura:

    At least he didn’t go with “traction.”

  26. 26
    Baud says:

    @Mandalay:

    Yeah, I usually don’t even finish reading the tweet before commenting. Article? Pshaw.

  27. 27
    cmorenc says:

    @David Anderson:
    Coming from any other poster than you, the thread title “Friction and Birth Control” would elicit quite a different off-the-cuff anticipation for what sort of content awaits the reader. But somehow, I knew your post wasn’t going to be about e.g. the insane high amounts insurers were being billed for K-Y lubricant.

  28. 28
    catclub says:

    @mere mortal: I have always enjoyed the word ‘lubricity’.
    The heck with friction

  29. 29
    burnspbesq says:

    I wonder how many white male Republican members of Congress will see a reduction in unintended pregnancies as a good thing.

  30. 30
    Walker says:

    Birth control is such a sh*tshow even when insurance covers it properly. Insurance is always after cost savings, so they will deny specific prescriptions and direct people to generics or alternatives. But womens’ bodies are so complex that just minor differences in the formula (even in the “inactive” ingredients) can cause major quality of life differences. My wife gave up on using insurance for birth control and moved to out-of-pocket for exactly this reason.

  31. 31
    cmorenc says:

    @burnspbesq:

    I wonder how many white male Republican members of Congress will see a reduction in unintended pregnancies as a good thing.

    Only when they have an unmarried young female daughter and it finally dawns on them it’s beyond their control that she’s probably having sex with her current boyfriend, and they have to get real about shit.

  32. 32
    boatboy_srq says:

    @burnspbesq: The GOTea will no doubt find some new dogwhistle to rephrase rhe complaint that better birth control results prevents Righteous Xtianist slvt-shaming, and therefore said improved birth control is to be prohibited.

  33. 33
    Yutsano says:

    @boatboy_srq: That already exists. It’s already RWNJ dogma that oral birth control causes abortions. And that’s really the only birth control you can get prescribed like that. So that’s already long out the barn door.

  34. 34
    TomatoQueen says:

    @David Anderson: SSDI/Medicare kicks in automagically for End Stage Renal Disease patients, while those not at that point get to….go through the worst of everything our system has to throw at them. I wonder what might happen if we loosened eligibility just a bit, say making it automatic for stage 3 instead of stage 4.

  35. 35
  36. 36
    EthylEster says:

    If there’s no friction, then no birth control needed.

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