Depo-Provera: Costs eat up clinic contraceptive budgets
Few price concessions lead to hard choices for clinic administrators
Teen-age girls may consider Depo-Provera the dream method for birth control, but many publicly funded clinic administrators are finding the contraceptive injectable a purchasing nightmare as they try to balance fixed budgets with an upsurge in demand.
Since its U.S. introduction in 1993, increasing numbers of adolescents have moved to Depo-Provera, according to Jacqueline Darroch, PhD, senior vice president and vice president for research with the Alan Guttmacher Institute in New York City.
The upswing has been noted by Contraceptive Technology Update readers as well. Seventeen percent of adolescent patients chose Depo-Provera in 1997, jumping from an 11% increase in 1996, CTU readers noted in the newsletter’s annual contraceptive survey. (See the November 1997 issue, pp. 133-136, for full results.)
During the 1980s, more sexually active teens began using birth control, primarily in the form of oral contraceptives (OCs), notes Darroch. How ever, between 1988 and 1995, while the overall level of contraceptive use remained stable, the use of such long-acting methods as Depo-Provera and the Norplant implant showed a steep increase, she explains.
While the use of any form of effective birth control is a positive step, the switch to Depo-Provera has resulted in a serious budget crunch for those publicly funded family planning clinics struggling with the cost of the injections and climbing patient demand.
Depending on the negotiated price, OCs may cost a clinic $2 per cycle, for an annual per-patient cost of $24. Depo-Provera, in contrast, may cost a clinic $15 per quarterly shot for an annual per-patient cost of $60. For clinics such as Family Planning Services of Lorain County in Elyria, OH, the increase has "destroyed whatever concept I had of having a budget," says executive director Ellen Bricmont.
Family Planning Services’ problems began in July 1997, when the clinic went from about 70 injections per month, to 90, 110, and then 120, notes Bricmont. The Title X-funded facility services an area outside Cincinnati with the ninth-highest level of teen pregnancy in the state.
"It happened in the last quarter of 1997, and by then I had already set my budget and the board had voted on it," says Bricmont. "We are already $5,000 over budget in our contraceptive account, and that is just through the end of September."
The Family Planning Council of Philadelphia, which serves as the federal Title X grantee for 70 clinics in southeastern Pennsylvania, spends 50% of its budget on the 15% of its patients who use Depo-Provera, confirms Dorothy Mann, executive director. "It is by far the most expensive method, and so we make it available within the confines of our financial resources," she says. "For the last two years, we have put a cap on the amount of money that we would spend on Depo, and the only way we will get through this year is if the price reduction holds."
Depo-Provera, manufactured by Pharmacia and Upjohn of Bridgewater, NJ, is the sole injectable method available in the United States. The company reports that the product recorded $62.2 million in global sales as of the third quarter of 1998, compared to $50.7 million in the same quarter of 1997. The company does offer what it terms "substantial" discounts to clinics, government programs, and Title X programs in the form of free goods based on purchases, confirms Daniel Watts, media relations manager. It also offers support through sales representatives and telemarketing techniques to check clinic stock and patient education and support material, he says. While public clinics are an important market segment for Depo-Provera, they do not represent the total market, he notes, adding that the company plans no further price reductions outside of its current pricing strategy.
That strategy is much the same as a "buy three, get one free" pyramid scheme, since clinics have to purchase more in order to get the discounted goods, contends Jeffrey Zonis, MBA, MPA, president and chief executive officer of the Family Health Council of Central Pennsylvania in Camp Hill, PA.
Initial subsidies dropped
When Depo-Provera was first introduced, Family Health Council offered a subsidy to its 47 family planning clinics to help boost use of the method. When the demand began to outstrip the council’s resources, the organization turned to Pharmacia and Upjohn for relief in the form of reduced prices. The result was the current incentive program. Family Health Council since has ended its subsidies to its clinics.
"We did see then a dramatic drop-off — not actually a reduction, but the growth has stopped," Zonis says. "There are some new patients, but the method is not going to grow the way it has been, and it is a cost issue."
The first year Depo-Provera was listed as a contraceptive method in the National Survey of Family Growth was 1995. That survey is conducted by the National Center for Health Statistics in Hyattsville, MD, a division of the Atlanta-based Centers for Disease Control and Prevention, In 1995, Depo-Provera was named by 19% of non-Hispanic blacks and slightly less than 10% of white and Hispanic adolescent females as the method used by those who were sexually active and using a contraceptive method, says Darroch.
According to a 1998 analysis released by the Alan Guttmacher Institute, between 1991 and 1996, the teen-age birthrate in the United States declined from a 20-year high of 62.1 births per 1,000 females ages 15 to 19 to 54.4 per 1,000.1 While such a drop cannot not be attributed to any one factor, family planners say that Depo-Provera definitely has made an impact.
While there are still too many sexually active adolescents who are not using a contraceptive method, Darroch says the net move has been to long-acting methods that don’t require any action from the teen. Depo-Provera eliminates the need to remember a daily pill or hide contraceptive supplies, and its use results in absence of menstrual periods. These are all benefits teens like — and report to their friends.
"It is incredibly popular with adolescents," says Bricmont. "If I only had a dime for every time someone called and said, "I want the shot,’ and when I ask how old they are, they say, I’m 15, and my friend has it.’"
Swaying teens from a mindset of "got to have the shot" is problematic for Family Planning Services providers, says Bricmont. Those first-time patients who request Depo-Provera are now counseled with, "We’d like to try you on the pill and see how you do on it."
The clinic operates a monthly waiting list for Depo-Provera, with patients instructed to call at a certain time of the month. Within minutes, the limited slots are filled, Bricmont reports. "The clinicians hate having to be restrictive. They understand it is a strictly financial decision."
Hard choices are facing all publicly funded clinics. With budget cuts looming for the family planning program for the San Antonio Metropol itan Health District, administrators are unsure whether resources will allow Depo-Provera to be provided to all who want it in the upcoming fiscal year, says Janet Realini, MD, MPH, medical director.
"If we need to limit the number of patients we supply with Depo-Provera in our clinics, we will give teens priority," Realini affirms. "San Antonio’s teen birth rate is over 50% higher than the national rate for ages 15 to 17 and nearly twice the national rate for young adolescents ages 10 to 14."
1. Donovan P. Falling teen pregnancy, birthrates: What’s behind the declines? The Guttmacher Report on Public Policy 1998; 1(5).