University of Michigan Medical School, and the Department of Obstetrics and Gynecology, Institute for Healthcare Policy and Innovation, and the Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan.
Obstet Gynecol. 2018 May;131(5):843-849. doi: 10.1097/AOG.0000000000002567.
To evaluate changes in out-of-pocket cost for intrauterine device (IUD) placement before and after mandated coverage of contraceptive services and to examine how changes in out-of-pocket cost influence IUD insertion as a function of baseline cost.
We conducted a cross-sectional pre-post analysis at the plan level using a large deidentified medical claims database to analyze our primary outcome, new IUD insertions among women enrolled in employer-sponsored health plans in 2009 and 2014, and our secondary outcome, out-of-pocket cost. Patient costs and utilization were aggregated by plan and year to conduct a plan-specific analysis. Plans were classified by mean out-of-pocket cost level: no out-of-pocket cost, low out-of-pocket cost (less than the 75th percentile), and high out-of-pocket cost (75th percentile or greater). A generalized estimating equation was used to evaluate average plan utilization of IUD services in 2009 and 2014 as a function of plan cost category and year.
Overall, average plan utilization of IUD services demonstrated a significant increase between 2009 (12.5%, 95% CI 11.6-13.4%) and 2014 (13.8%, 95% CI 13.0-14.7%; P<.001). When plans were grouped by out-of-pocket cost level, significant differences in plan utilization over time were observed. Plans that went from high out-of-pocket cost in 2009 to no out-of-pocket cost in 2014 saw a higher average increase in the rate of plan IUD insertions over time (2.4%, 95% CI 0.04-4.5%) compared with plans with no out-of-pocket cost in both 2009 and 2014 (-1.0%, 95% CI -3.3 to 1.4%, P=.02). Among all women in all plans, the 75th percentile of out-of-pocket cost in 2009 was $368; this number dropped to $0 in 2014.
Women in plans with the greatest reduction in out-of-pocket cost after mandated coverage of contraception had the greatest gains in IUD insertion. This suggests that baseline cost should be considered in evaluations of this policy and others that eliminate patient out-of-pocket cost.
评估避孕服务强制覆盖前后宫内节育器（IUD）放置的自付费用变化，并研究自付费用的变化如何影响 IUD 的插入，作为基线成本的函数。
我们在计划层面上进行了一项大型、匿名医疗索赔数据库的横断面、前后分析，以分析我们的主要结果，即 2009 年和 2014 年参加雇主赞助的健康计划的女性中新的 IUD 插入情况，以及我们的次要结果，自付费用。按计划和年份汇总患者费用和使用情况，以进行特定计划的分析。根据平均自付费用水平对计划进行分类：无自付费用、低自付费用（低于第 75 百分位数）和高自付费用（第 75 百分位数或更高）。使用广义估计方程评估 2009 年和 2014 年 IUD 服务的平均计划使用率，作为计划费用类别的函数。
总体而言，IUD 服务的平均计划使用率在 2009 年（12.5%，95%CI 11.6-13.4%）和 2014 年（13.8%，95%CI 13.0-14.7%；P<.001）之间显著增加。当按自付费用水平对计划进行分组时，观察到随着时间的推移计划使用率的显著差异。与 2009 年和 2014 年均无自付费用的计划相比，2009 年高自付费用的计划在 2014 年转变为无自付费用的计划，其 IUD 插入率的平均增长率更高（2.4%，95%CI 0.04-4.5%），而 2009 年和 2014 年均无自付费用的计划则下降（1.0%，95%CI -3.3 至 1.4%，P=.02）。在所有计划中的所有女性中，2009 年自付费用的第 75 百分位数为 368 美元；这一数字在 2014 年降至 0 美元。
在避孕服务强制覆盖后自付费用降幅最大的计划中的女性，其 IUD 插入量的增加幅度最大。这表明，在评估这项政策和其他消除患者自付费用的政策时，应考虑基线成本。
