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Persistent Barriers to Affordable Contraception

Woman holds her head while listening to her doctorI thought the financial barriers to intrauterine device (IUD) access would disappear on August 1, 2012, with the implementation of the Affordable Care Act, which stipulates that all “FDA-approved contraception” will be covered without copayments. I was wrong. Since last summer I have often felt that helping my family-medicine patients get IUDs—the most reliable, reversible form of contraception—has become more time-consuming, and also potentially more expensive for them.

Because the IUD devices are so expensive, my office does not keep them in stock. Instead, for each patient who wants an IUD, we have to complete, fax and track a special pharmacy IUD order form. This can’t be done online, nor can we order the IUD from another pharmacy. In addition, the pharmacy has to talk with the patient to confirm the order and often to set up a payment plan if her insurance won’t cover the full cost of the expensive device. This process now seems to take weeks longer than it did before. And even when the device arrives, for some patients it’s the end of their waiting for an IUD but it’s not the end of their financial responsibilities.

Take, for example, a patient I’ll call Amy, a 24-year-old working woman who completed the numerous time-consuming steps needed to have her IUD sent to my office late last year. Amy paid the pharmacy in full for her IUD ($850) because it was not covered by insurance. Neither of us knew that her insurance wasn’t going to pay for the insertion of her IUD either. Last month she came back to me, angry and in tears. This young professional woman chose the most effective, reversible form of contraception, and none of the cost was covered by her commercial health insurance, even though abortion or prenatal care would have been.

Amy’s experience was almost the last straw for me. I have trouble justifying the time it takes my office to facilitate the ordering of the IUDs and the potential additional cost to patients. I think, “Why don’t I just send them all to the clinic downtown, which has IUDs in stock and a sliding-scale fee for insertion?”

And then the patients remind me of why I go on.

I offer them the referral option, but most of my patients feel strongly that they want to keep seeing their primary-care doctor in their primary-care office. They want their family physician to insert their IUD. I’m honored that patients value our doctor-patient relationship, so we proceed with filling out the IUD order form, faxing and calling. And my office staff and I go through these steps again and again. Some insurance covers the device; some patients set up a payment plan; others don’t get an IUD; a few go elsewhere.

There’s another reason I continue to offer and insert IUDs. I also work as a clinical researcher focusing on increasing the proportion of primary-care physicians who counsel adolescents about IUDs. Teen pregnancy continues to be a public health issue in the United States. Recent studies have shown that increasing IUD use decreases adolescent pregnancy and abortion rates.

As I’ve seen in my office, access to IUDs is a real issue. People want to receive care in a familiar place with a provider they know and trust. I believe that if we improve adolescents’ access to IUDs—in their usual primary-care sites as well as in specialty-care sites—then the adolescents will be more likely to use IUDs.

So this family physician/clinical researcher wonders: if I—who have a clinical and research interest in improved contraception access—feel frustrated and at times ready to give up on inserting IUDs, how can I expect other clinicians to continue fighting for access?

While I hope that in 2015, after full implementation of the Affordable Care Act, more of the financial barriers to full-scope reproductive healthcare, including IUD access, will disappear, I’m now more realistic. New barriers will emerge. But I can’t give up; I owe it to my patients.

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Susan E. Rubin, M.D.

Susan E. Rubin, M.D.

Susan E. Rubin, M.D. is assistant professor, Department of Family and Social Medicine at Albert Einstein College of Medicine and attending physician, Department of Family and Social Medicine, Montefiore Medical Center

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