British Columbia’s Contraception Access Subsidy (BCAS) The Contraception Access Research Team 2018 Contraception Cost-Effectiveness in British Columbia 2018 June 22 Prepared by the UBC Contraception Access Research Team, Contraception Cost-Effectiveness Modelling Study Investigators Principal Investigators: Wendy V. Norman, MD, MHSc Stirling Bryan, PhD Principal Knowledge User: Dr. Bonnie Henry and recognizing the input over many years of her predecessor, Dr. Perry Kendall, who are the current and most recent Provincial Health Officers, Government of BC Investigators: Saied Samiedaluie, PhD (primary model development and testing); Steven Shechter, PhD (modeling oversight and expert lead); Janusz Kaczorowski, PhD; Rollin Brant, PhD; Sheila Dunn, MD, MSc; Jean Shoveller, PhD; Gina Ogilvie, MD, DrPH; Jan Christilaw, MD, MHSc. This model incorporates data collected through the 2015 BC Sexual Health Survey. See our separate report of CSHS results 2017 June 15, http://cart-grac.ubc.ca/research/current-projects/. Contents EXECUTIVE SUMMARY IV SIMULATION ResULTs 9 A Policy Tool for British Columbia IV Simulation Results with No Policy Change 9 A model to simulate health outcomes and Health System Costs for All Women Under Status Quo 9 health systems costs resulting from policy interventions to reduce unintended pregnancy IV Simulation Results with Implementation of a New BC Contraception Access Subsidy (BCAS) Policy 10 Is it more expensive for a health system to pay for the care of unintended pregnancies, or Reduction in Pregnancies, by Number and Percent 10 to subsidize contraception? IV Costs for all Women under Status Quo and BCAS Policies, for Pregnancy Care, Contraception DEVELOPING THE MODEL 1 and Total 11 Project Overview 1 SUMMARY 13 Background 1 Project Components 4 APPENDIX I 15 Research Question 4 Costs Related to Pregnancy Care and Contraception by Responsible Government Division 15 Aim 4 Costs for Status Quo 15 Objectives 4 Costs for BCAS Policy Options 15 The 2015 BC Sexual Health Survey 4 Costs Differences when Comparing BCAS Policy to Status Quo 16 THE SIMULATION MOdeL DECISION SUPPORT TOOL 6 How the Simulation Model Works 6 APPENDIX II 20 Model Parameters 7 References 20 Model Assumptions 7 Simulation Model Inputs 8 Cost for Contraceptive Methods 8 Cost for Pregnancy Outcomes 8 Executive Summary A Policy Tool for British Columbia A model to simulate health outcomes and health survey throughout BC to collect high quality population systems costs resulting from policy interventions to data to determine the indicators of pregnancy intention, reduce unintended pregnancy contraceptive method use, and sexual activity. We used these data as inputs for a simulation model to ascertain Unintended pregnancy is common in British Columbia (BC) provincial health system costs and outcomes associated with where 40 % of pregnancies, including a third of all births, are unintended pregnancy and project costs associated with unintended at the time of conception. Compounding the contraceptive subsidy. Simulation models were developed burden and system costs of managing unintended pregnancy by UBC faculty of the Sauder School of Business, the School is the significant equity gradient between families able, and of Population and Public Health and Center for Clinical those who face challenges, to time and space their births. Epidemiology and Evaluation. Vulnerable populations with the least favourable social determinants of health are the most likely to experience unintended pregnancy, and the most likely to have that pregnancy result in an unplanned birth, and yet conversely have the fewest resources to manage the additional demands of an unplanned birth. Consumer cost for contraception is the Providing most commonly cited barrier to achieving desired pregnancy complete subsidy timing and spacing. Government has an opportunity to for highly effective improve outcomes and reduce costs by reducing the rate contraception to all female of unintended pregnancy when providing subsidy for the residents of BC would reduce most effective contraception. This policy results in the lowest overall health system cost. pregnancies by an average of 12.8% annually within four years Is it more expensive for a health system to pay for (including 21.0% fewer pregnancies the care of unintended pregnancies, or to subsidize among those under age 30), contraception? with cost equilibration after two years, and Canadian health systems have not been able to answer this savings of $27M question as neither pregnancy intention nor contraception annually starting method use prevalence has previously been measured. To answer this question for BC, we conducted a door-to-door in year four. IV British COLUmbia’S Contraception Access SUbsidY (BCAS) Cost Difference between Status Quo and the BCAS Policy for Pregnancy, Contraception, and Overall, by year Cost Difference Between Status Quo and BCAS Policies BCAS Policy Policy 1 Policy 2 45 35 25 Contraception Cost Difference (Dashed) 15 5 - 5 Total Net Difference (Solid) Cost Neutrality For BCAS vs Status Quo Cost (Millions of Dollars) - 1 5 Among All Women -2 5 -3 5 Pregnancy Cost Difference -4 5 (Dotted) 1 2 3 4 Year Status Quo: Results expected with no policy change indicated by the Red Line of Zero Cost Difference BCAS 1: Results expected with a policy of subsidy for contraception for all BC residents BCAS 2: Results expected with a policy of subsidy for contraception among BC residents under age 30 years Contraception Cost-EFFectiveness in British COLUmbia 2018 V Developing the Model Project Overview Our team developed a simulation model predicting the achieve their goals for timing and spacing pregnancies. occurrence and outcomes of pregnancies in BC and the We have incorporated new primary data from BC, collected associated costs, which is suited to inform decision-making through a high quality representative sample household relating to the provision of subsidy for contraception. The survey, as well as secondary evidence from existing tool is intended to support evidence-informed policy research by members of the team, and from the highest development to equitably support British Columbians to quality evidence available in published literature. Background Decision makers in health care are frequently expected to informed decision making on contraception access for BC make choices in an evidentiary and analytic vacuum. This is populations. The CART-CCM policy-research partnership an unacceptable state of affairs and one that the BC Ministry collaborated with BC Ministry of Health, Population and of Health is working to address across the health sector Public Health division staff to determine the evidence policy broadly. (2) Our project’s starting point was policy making makers require to support policy-making. This report details relating to access to contraception, with a particular focus on our findings with respect to the potential for cost-aversion the needs of vulnerable subgroups and the unique features strategies to support the equitable provision of affordable, of British Columbian contexts. The Contraception Access effective, accessible and culturally-appropriate contraception. Research Team (CART) Contraception Cost-effectiveness The BC Ministry of Health has identified the need to improve Modelling Study (CART-CCM, funded by MSFHR and CIHR) access to contraception as a key health priority. The Provincial was undertaken to address this gap and foster evidence- Health Officer’s report “The Health and Well-being of Women Contraception Cost-EFFectiveness in British COLUmbia 2018 1 in British Columbia” released in Dec. 2011(3) highlighted among this group indicating income and education among summary recommendations including: the highest levels in Canada, withdrawal was the third most commonly reported method of contraception among those • Improve access to contraception, especially long-acting at risk for pregnancy but not desiring to conceive, with 15% of reversible contraception; the same group reporting no contraceptive use at all. • Improve access to and coverage of sex education services, The Black findings are consistent with gaps identified by the principles of which should include the following: Access knowledge user partners and community stakeholders to contraception is unimpeded or even free. across BC(23, 47, 48, 90-92) indicating (even among our most Family planning is acknowledged to be one of the top affluent citizens) consumer cost of contraception influences ten public health advances of the millennium.(4) Health consumer preference for the least effective (and least costly) policy supporting accessible family planning has proven methods, in turn generating health system costs for provision value, leading to population-level gains in terms of health of abortion and management of unintended births. In high equity in high-income countries around the world.(5-22) income countries the rate of unintended pregnancy resulting Disadvantaged and vulnerable populations, particularly in birth is roughly equal to those resulting in abortion.(41, 42, 60, 62, youth, those of low socio-economic status or subjected 65, 93) In Canada, a third of women have at least one abortion.(89) to Adverse Childhood Experiences (ACES) and/or intimate Further, unintended pregnancies resulting in birth are partner violence, those living with substance use and associated with higher rates of smoking and substance use mental health disorders, residents in rural and remote during pregnancy, lower rates of breastfeeding,