title: The relationship between long-acting reversible contraception and insurance coverage: a retrospective analysis.
abstract: OBJECTIVE
  The objective was to determine if there is a relationship between patients' financial responsibility (out-of-pocket expenses) and placement of long-acting, reversible contraceptive (LARC) methods among girls and women living in Appalachia who expressed interest in LARC device placement.
  
  
  METHODS
  A retrospective chart analysis of patients prescribed an intrauterine device (IUD) or an etonogestrel implant between December 2011 and July 2013 in an Appalachian private practice was performed. Of the 571 identified patients aged 13 to 50, the majority were Caucasian (98.7%) and using Medicaid (53.2%). Outcomes measured the patients' decision regarding whether to use LARC after being informed of out-of-pocket expenses.
  
  
  RESULTS
  There was a dramatic increase in the proportion of patients who had LARC methods placed if expense was under $200 (p<.001). Placement rate for privately insured patients was 86.6% for those who paid less than $200 compared to 27.8% for those who paid $200 or more. Medicaid patients, for whom the device was free, had a 78.0% placement rate. For every additional $100 patients had to pay out of pocket, the odds of deciding to use the prescribed LARC method decreased.
  
  
  CONCLUSIONS
  LARC methods are utilized significantly more often when out-of-pocket cost is low. Cost appears to be a significant barrier to device placement for the group of privately insured Appalachian patients with out-of-pocket expenses over $200. Despite the improvements in coverage for many women provided under the Affordable Care Act, cost may remain a barrier for privately insured women who are required to pay some or all of the cost of LARC methods.
  
  
  CONCLUSIONS
  Unintended pregnancy rates in the United States remain high, especially in Appalachia. One contributing factor is reliance on user-dependent methods which have significantly high typical use failure rates. Placement of LARC methods for more patients could decrease unintended pregnancy, but device costs may be one barrier to utilization, even for those with private insurance.
authors.affiliation: Department of Obstetrics and Gynecology, Ohio University Heritage College of Osteopathic Medicine, Athens, OH, United States. Electronic address: broecker@ohio.edu.
authors.forename: Jane
authors.initials: J
authors.lastname: Broecker
authors.affiliation: Department of Social and Public Health, Ohio University, Athens, OH, United States.
authors.forename: Joan
authors.initials: J
authors.lastname: Jurich
authors.affiliation: Department of Obstetrics and Gynecology, Ohio University Heritage College of Osteopathic Medicine, Athens, OH, United States.
authors.forename: Robin
authors.initials: R
authors.lastname: Fuchs
mesh_terms: D000293:Adolescent; D000328:Adult; D001061:Appalachian Region; D003267:Contraception / Q000379:methods; D003271:Contraceptive Agents, Female / Q000191:economics*; D003365:Costs and Cost Analysis; D017135:Desogestrel / Q000008:administration & dosage / Q000191:economics; D004343:Drug Implants; D005260:Female; D006801:Humans; D019458:Insurance Coverage / Q000191:economics*; D007434:Intrauterine Devices; D008875:Middle Aged; D011247:Pregnancy; D049168:Pregnancy, Unplanned; D012189:Retrospective Studies; D055815:Young Adult
chemical_list: D003271:Contraceptive Agents, Female; D004343:Drug Implants; C044815:etonogestrel; D017135:Desogestrel
keywords: Affordable Care Act; Appalachia; Contraception; Insurance coverage; Long-acting, reversible contraceptive (LARC) methods; Unintended pregnancy