A qualitative study of clinicians' perspectives on a law that allows for a 12‐month supply of short‐acting contraceptives in Massachusetts: Barriers and facilitators to implementation

Abstract

Objective

To explore clinicians' perspectives regarding the Massachusetts 2017 law, ‘An Act Relative to Advancing Contraceptive Coverage and Economic Security in Our State’ (ACCESS), including awareness of the law, perceived barriers and facilitators to successful implementation, and recommendations to improve uptake. ACCESS requires all insurers, except self‐insured businesses, to cover short‐acting reversible contraceptives (SARCs) at no cost to patients and for a 12‐month supply to be prescribed/dispensed if desired after the completion of a three‐month trial.

Data Sources and Study Setting

We collected primary data from clinicians in Massachusetts from February 1 to July 31, 2021.

Study Design

Semi‐structured interviews of a purposeful sample of Massachusetts clinicians who provide primary and/or women's health care were conducted via Zoom.

Data Collection/Extraction Methods

Interview guide and codebook were created using the Theoretical Domains Framework. Interviews were analyzed using framework analysis, including deductive and inductive approaches. Major themes and subthemes were organized by a four‐level model of the health care system: patient, care team (clinician), organization, and environment.

Principal Findings

Most (58.1%) of the 31 participants were not aware of the law. Perceived advantages of this law included decreasing burden on patients, unnecessary clinical visits, and administrative burden on staff for refill requests. Perceived disadvantages focused on concerns that patients would lose their medications or devices (patient‐level) and decreased clinician contact with patients (provider‐level). Perceived organization‐ and environmental‐level barriers to implementation included lack of electronic medical record (EMR) prescription defaults and insurance coverage issues. Many felt EMR modifications and more training for clinicians and pharmacists could lead to a change in practice.

Conclusion

Our study identifies potentially modifiable barriers to the implementation of the ACCESS law. Massachusetts clinicians' lack of awareness of the law demonstrates the need for statewide education, which may allow more eligible patients to obtain a 12‐month SARC supply.

What is known on this topic

• Lack of access to contraception, including oral contraceptives and other SARCs, contributes to unintended pregnancy.

• Increasing the quantity of SARCs dispensed per prescription decreases rates of unintended pregnancy, increases continuation of contraception methods, and provides cost savings for health systems.

• Although many states have passed legislation to require insurance coverage for an extended 12‐month supply of contraception, barriers to implementation have limited the adoption of the practice and potential benefits to patients.

What this study adds

• This is the first study to examine clinicians' perspectives of the 2017 ACCESS Law in Massachusetts and describe clinicians' perceived barriers and facilitators to providing a 12‐month supply of SARCs to patients in the state.

• This study may inform implementation efforts to increase adoption of the extended supply provision in Massachusetts and provide guidance and key considerations for other states implementing similar legislation.

1. BACKGROUND

Limited access to contraception remains a major contributor to unintended pregnancy in the United States. ¹ Short‐acting reversible contraceptive methods (SARCs), including oral contraceptives, patches, vaginal rings, and injections, reduce unintended pregnancy and are used by approximately 26% of people of reproductive age who use contraception. ² SARCs are prescribed by most obstetrician‐gynecologists (OB‐GYNs) and nurse‐midwives and a smaller but substantial percentage of primary care clinicians. ³

One approach to improving contraception access has been to dispense a 12‐month supply of SARCs instead of the one to three‐month supply that many health insurers currently cover. In a large cohort study in California, members who received a 12‐month supply of SARCs were significantly less likely to become pregnant compared to those who received a shorter‐duration supply. ⁴ They were also more likely to refill their prescription more than a year after their initial prescription, and less likely to utilize emergency contraception. Another study from the Veterans Affairs (VA) health system demonstrated cost savings associated with a 12‐month supply of SARCS in addition to reducing unintended pregnancies among veterans. ⁵ The model from the VA payer perspective estimated savings of over $2 million annually when compared to three‐month dispensing. ⁵

In response to this evidence of health and economic benefits, at least 18 states have passed legislation to expand access to a 12‐month supply of SARCs. ⁶ In 2017, the Massachusetts legislature passed the ‘Act Relative to Advancing Contraceptive Coverage and Economic Security in Our State’ (ACCESS) law. ⁷ The law includes provisions that aimed to increase access to SARCs by requiring insurers to cover them at no cost to patients and to allow a 12‐month supply to be prescribed/dispensed. New prescriptions require a three‐month trial before 12 months can be prescribed and self‐insured employers are exempt from the law. Despite the passage of the law, only 300 of the one million reproductive aged women in the state who were covered by eligible insurance plans received a 12‐month SARC supply in 2020. ⁸ Past research has indicated that barriers to dispensing a 12‐month supply exist at several levels, including clinician knowledge and beliefs, state insurance policies, individual health center practices, and federal agency guidance. ⁹ This study aimed to understand the barriers and facilitators to prescribing a 12‐month supply from the perspective of clinicians in Massachusetts. This information would be critical to inform any implementation effort aimed at increasing adoption of the ACCESS law and maximizing its potential benefits.

2. OBJECTIVES

The goal of this qualitative study was to explore a diverse group of Massachusetts' clinicians' perspectives regarding the state's 2017 ACCESS law, including awareness of the law, perceived barriers and facilitators to successful implementation, and recommendations for improving uptake.

3. METHODS

We identified Massachusetts‐based clinicians through the authors' professional networks, snowball sampling, and postings in professional organization newsletters and listservs. We purposefully sampled clinicians based on medical specialty and geographic region of the state, aiming to include at least one participant from each county and for each medical specialty that routinely prescribes SARCs. ¹⁰ Interviews took place from February to July 2021. The methods follow the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (Appendix S2).

Two trained members of the research team (E.B. and P.D.) conducted semi‐structured one‐on‐one interviews via a secure online platform using a pre‐tested interview guide (Appendix S1). Field notes were taken during and immediately following the interviews to document impressions and observations. The interview guide was developed using the Theoretical Domains Framework (TDF) and the professional experience of the clinicians on the research team. ¹¹ TDF consists of 14 domains and has been used by researchers to evaluate and explain implementation problems and inform implementation interventions. ¹² , ¹³ REDCap, a secure, web‐based platform, was used to collect demographic information on gender, race/ethnicity, region of state, credentials, specialty, type of practice, and years in practice prior to the interview. ¹⁴ Interviews lasted approximately 30 min, were audio‐recorded, professionally transcribed, and uploaded to Dedoose (SocioCultural Research Consultants), a software program for qualitative analysis. ¹⁵ Interviews were conducted until there was at least one participant from each county, all specialties were represented, and thematic saturation was reached. ¹⁶ , ¹⁷ N.Q. met with interviewers weekly to discuss project status and emerging themes. Participants were offered a $25 cash card as an incentive. The study was approved by the Baystate Medical Center Institutional Review Board (BH‐21‐031).

We used the framework approach to analyze the data because it allows for prior knowledge to inform research questions and data analysis. This approach is commonly used for policy‐relevant qualitative research in which the objectives tend to be pre‐established and the data collection tends to be more structured than approaches such as grounded theory. ¹⁸ Coding team members read the first several interview transcripts to become familiar with the data, then developed a preliminary code book. The code book was refined iteratively during the open (line) coding process, with new codes agreed upon by two independent coders and the primary investigator (E.B., P.D., N.Q.). All transcripts were independently double coded by E.B. and P.D.; discrepancies were discussed and resolved by consensus with N.Q. making the final decision when needed. Utilizing the constant comparison process, excerpts were indexed by individual topics, then refined by grouping them into categories reflective of themes and subthemes. ¹⁸ Major themes and subthemes were identified deductively and inductively during the iterative process and finalized through further discussion.

Deductively derived major themes and subthemes were organized by the four‐level model of the health care system: patient, care team (clinician), organization (office, practice or individual pharmacy), and environment (political or economic setting, larger health system, insurers, regulations, etc.). ¹⁹ Reflexivity was considered throughout the design and execution of the study. Considerations included: N.Q. is a female OB‐GYN who specializes in family planning and has a background in policy implementation. These roles likely contributed to choices made when developing the interview guide and she may have more readily noted potential positive impacts of the ACCESS law over the potential downsides during data analysis. N.Q. knew some of the participants professionally; although she did not conduct interviews, participants may have consciously or subconsciously included or omitted certain perspectives during their interview due to this relationship. SG is a primary care pediatrician‐internist, public health professor, and health services researcher focused on implementation science and addressing health care inequities. In these roles, she sees the impact of unintended pregnancies on women and families and the disproportionate negative impact on members of minoritized communities and families with lower incomes. Her positionality may predispose her to be less critical in her support of health policy that aims to improve access to health care and addresses health care inequities and may have made her more attuned to the potential for bias in implementation of the ACCESS law. E.B. and P.D. are master's level research coordinators with training in community and behavioral health research. They work mostly on projects related to substance use, where they often see the impacts of negative patient experiences with medical care and policy barriers to receiving medication. This experience may have made them initially more attuned to the benefits of the ACCESS law on patients' ability to get contraception, which could have influenced the interview or analysis processes. They engaged in regular discussions that often included reflections on their efforts to maintain objectivity while acknowledging the role of their personal opinions and experiences in data collection and analysis.

4. RESULTS

We interviewed 31 clinicians from Massachusetts, all of whom cared for patients who were women of reproductive age. Most of the participants were female (87.1%) and White (83.9%); 61.3% were physicians (M.D. or D.O.); 22.6% were advanced practice registered nurses (APRNs); and 16.1% were certified nurse midwives (CNMs) (16.1%) (Table 1). The most common specialties represented were Family Medicine (29.0%) and OB‐GYN (29.0%). Most participants (58.1%) had not heard of the ACCESS law before being invited to participate in the study, and only one reported receiving training about the law. Approximately one third of the participants (35.5%) had ever prescribed a 12‐month supply of SARCs (Table 1). We noted some differences by specialty. More OB‐GYNs knew about the ACCESS law and its provisions compared to other specialties. None of the Pediatric‐Adolescent medicine physicians in our study cohort had tried to prescribe a 12‐month supply of a SARC while approximately half of participants in other specialties had tried to prescribe them.

TABLE 1.

Qualitative interview participant characteristics (n = 31)

Professional credential n (%)
Doctor of medicine (MD)/Doctor of osteopathy (DO)	19 (61.3)
Advanced practice registered nurse (APRN)	7 (22.6)
Certified nurse midwife (CNM)	5 (16.1)
Specialty, n (%)
Family medicine	9 (29.0)
Obstetrics/Gynecology	9 (29.0)
Midwifery	5 (16.1)
Pediatric and adolescent medicine	6 (19.4)
Internal medicine	1 (3.2)
Women's Health Nurse Specialty	1 (3.2)
Clinical setting, n (%)
Hospital‐based outpatient practice	12 (38.7)
Federally Qualified Health Center	6 (19.4)
Private practice	6 (19.4)
Other	7 (22.6
Gender, n (%)
Male	4 (12.9)
Female	27 (87.1)
Race, n (%)
White	26 (83.9)
Black	1 (3.2)
Asian	2 (6.5)
Mixed race	1 (3.2)
Other	1 (3.2)
Region, n (%)
West	11 (35.5)
Central	3 (9.7)
East	13 (41.9)
Cape	4 (12.9)
Heard of the contraception ACCESS law before the study? n (%)
Yes	13 (41.9)
No	18 (58.1)
Ever prescribed a 12‐month supply of contraception?
Yes	11 (35.5)
No	20 (64.5)
Ever received training about the contraception access law? n (%)
Yes	1 (3.2)
No	30 (96.8)

Findings were classified into three overarching themes: (1) perceived advantages and disadvantages of the ACCESS law (Table 2); (2) perceived barriers to implementation of the law, and suggestions to improve its implementation (Table 3); and (3) variation in clinicians' perspectives regarding the law. Themes 1 and 2 were deductively derived and Theme 3 was inductively derived. Themes 1 and 2 were further organized by level of the health care system, divided into patient‐, clinician‐, organization‐, and environmental‐ levels. Supportive quotations are presented in the Appendix with participants' clinical credentials and specialty (Appendix S3).

TABLE 2.

Perceived advantages & disadvantages of a 12‐month supply of contraception

Level	Subthemes
Patient	Advantages Lessens burden for patients Access to continuous supply decreases negative impacts of noncompliance Increases overall respect for patient autonomy	Disadvantages Risk of losing medication
Clinician	Advantages Improve compliance and prevent lapses that could lead to unintended pregnancy. Removes visits that may not be clinically beneficial. Decreased administrative burden on clinicians	Disadvantages Side effects or contraindications that might only be caught at follow‐up visits Decreased patient retention or missing the opportunity to discuss other topics or perform other health screenings Waste of unused medication if patients switch methods
Organizational
Office level	Advantages Decreased burden on office staff, mainly resulting from fewer refill requests	Disadvantages Administrative burden and call backs from pharmacists/insurance who are not used to covering 12‐months Loss of revenue from fewer visits and prescriptions
Pharmacy level	Advantages Fewer calls to pharmacies when a patient wanted to switch pharmacies or could not make it to pick up a prescription	Disadvantages Hesitancy to rely on pharmacists to provide adequate patient education about contraception
Environmental	Advantages Cost savings for the health care system resulting from preventing unintended pregnancies	Disadvantages Health care system waste due to unused medications

TABLE 3.

Barriers to implementation of the ACCESS law and suggestions for improvement

Level	Subthemes
	Barriers	Suggestions
Patient	More difficulty at the pharmacy Financial burden of higher co‐pay if coverage is denied	Patient education to avoid improper storage or waste
Clinician	Clinicians may be unwilling to prescribe extended supply due to lack of knowledge of up‐to‐date evidence Concerns were more at the pharmacy and insurance level, with many agreeing that they would need to be sure that patients are not going to face pushback	Provide patient education to address concerns around patients not being informed about side effects and contraindications Checklists or more standardized assessment tools for a 12‐month supply, particularly for higher‐risk patients
Organizational
Office level	Occasional resistance within the practice, among providers, office staff, or hospital systems It can be difficult to make changes to EMR systems	Engagement and education on the law and corresponding changes to prescribing for all office staff involved in prescription tasks Changes to the EMR systems Add a 12‐month supply to drop down menu or pop‐up alert in e‐prescribing Include patient insurance information in patient chart, including coverage details and cost to patient, so they have that information upfront and prescribe accordingly
Pharmacy level	Lack of awareness about law leading to refusal to dispense based on the belief that insurance would not cover extended supply Some pharmacists play a gatekeeper role based on individual opinions Lack of adequate supply	Pharmacists could help educate patients about the law, perhaps through advertisements at pharmacy or providing educational materials Pharmacists may be able to assist in educating clinicians about law/changes in policies that impact prescribing
Environmental	Variable insurance coverage makes it hard to know who is covered by the law	A more consistent way to get information about changes in state laws Education about contraception and reproductive health care generally for non‐specialists

4.1. Clinicians' perspectives related to the ACCESS law: advantages and disadvantages

4.1.1. Patient‐level advantages and disadvantages

A number of participants discussed barriers to patients coming to the office, such as busy lives and transportation challenges and how the 12‐month supply addresses barriers to have a consistent supply of their SARC. Many participants felt that the law has the potential to address common logistical barriers for patients such as when they switch pharmacies, move farther away, or travel, particularly for college.

Many participants believed that a longer‐term supply of SARCs would increase the likelihood that people could avoid lapses, ultimately reducing unintended pregnancies. They also discussed potential benefits beyond convenience and pregnancy prevention, such as improving patient engagement with health care by reducing the opportunities for unsatisfying interactions with the health care system.

Potential disadvantages of a 12‐month supply of SARCs described by participants included the risk of improper storage or losing the medication, and uncertainty as to whether insurers would pay for replacement medication. Despite these concerns, most participants felt comfortable prescribing a 12‐month supply if it was a patient's preference and believed that doing so would help to show more respect for patient autonomy, facilitating positive patient‐clinician relationships.

4.1.2. Clinician‐level advantages and disadvantages

At the clinician level, study participants believed that prescribing a 12‐month supply could save them time by reducing administrative burdens and decreasing visits that were not clinically necessary or valuable to patients.

Although many participants felt that an extended supply is beneficial and safe to prescribe, several had concerns about missing opportunities to assess side effects or identify contraindications. Others were accustomed to using the refill requests as a reminder to monitor other health concerns, particularly for populations at higher risk of adverse side effects from a SARC.

Many participants agreed with the requirement that patients be on a SARC for 3 months before receiving a 12‐month supply because they felt that it was important to ensure that the contraception method was the right fit for the patient first.

4.1.3. Organization‐level advantages and disadvantages

At the organization level, participants shared mixed feelings about how the law could impact their practices. Although some participants thought the law has the potential to improve workflow by reducing the number of refill requests and appointments, many felt that the lack of system‐wide preparation to implement the law would result in more time spent managing pushback from insurance companies or pharmacies who were unaware of the law. A small number of participants described pressure by their administrators to see a high volume of patients and related concern about the repercussions of the potential decrease in office visits, even though they were not personally driven by ‘making money’.

4.1.4. Environment‐level advantages and disadvantages

The most commonly discussed potential disadvantage from an environment or health systems perspective was the potential for waste if people were prescribed 12‐months of contraception and did not use all of it. Participants did not necessarily see this as a drawback to the law but did feel the requirement to start with a shorter supply could reduce waste. Potential cost savings to the health care system and society conferred by prevention of additional unintended pregnancies was also noted.

4.2. Clinicians' perceived barriers to implementation of the ACCESS law and suggestions to improve practice

4.2.1. Patient‐level barriers and suggestions

At the patient level, participants identified several barriers patients may encounter when filling a prescription for a 12‐month SARC supply. Several expressed concern that pharmacists may be unaware of the law and would refuse to fill the prescription. Even though the ACCESS law requires that patients not be charged for contraception, some participants expressed concern that higher costs could potentially be burdensome for patients, either from copays or if coverage is denied.

Some participants hypothesized that clinicians' concerns about waste and lack of follow‐up opportunities could be addressed by providing the patient educational materials about potential side effects or contraindications to the SARC.

4.2.2. Clinician‐level barriers and suggestions

Most participants felt confident they could determine if a patient is a good candidate for a 12‐month SARC supply and that barriers to implementing the ACCESS law are largely located at the organizational and environmental levels. The few perceived clinician‐level barriers to implementation included that clinicians might be hesitant to prescribe a 12‐month supply due to lack of guidelines that summarize the risks, benefits, and contraindications to providing a 12‐month SARC supply. Suggestions to address this potential barrier included development and use of checklists or standardized assessments, particularly for higher risk patients, to help assuage concerns about potential clinical complications.

4.2.3. Organization‐level barriers and suggestions

A potential barrier at the organizational level was resistance within practices among clinicians, office staff, or hospital systems. An unwillingness to change prescribing practices or, as one NP described, pressure by supervising physicians to prescribe a certain way, was believed to lead to resistance in change in practice. A nurse midwife was concerned that any additional administrative burden caused by prescribing as 12‐month supply would result in pressure from management not to do it.

Many participants felt that providing education about the law to all staff involved in prescription tasks (e.g., nurses, receptionists) could prevent resistance and facilitate implementation. Another recommendation made by many participants was making changes to electronic medical record (EMR) systems. They suggested using existing tools, such as adding a 12‐month supply option in drop‐down menus, or a pop‐up alert when e‐prescribing to alert the prescriber to consider a 12‐month supply. One participant thought that making insurance information about SARC costs to patients readily available in the EMR, as it is for other medications, could facilitate prescribing a 12‐month supply. However, some participants also described how difficult it can be to make changes to their EMR system.

Participants anticipated that inadequate supplies, lack of awareness about the law, and belief that the 12‐month supply would not be covered by insurance would cause pharmacists to refuse to dispense the medication. They also recounted experience with pharmacists exerting personal discretion when filling prescriptions and having to redirect patients to go to another pharmacy to get it filled.

However, participants also saw pharmacies and pharmacists as potentially playing an important role in improving implementation of the provision. An OB‐GYN physician suggested that the pharmacist, the pharmacy techs, and the people at checkout could help educate patients about the law through word‐of‐mouth, advertisements in the stores, or patient education materials. Others pointed out that pharmacists could also help to educate clinicians about the law, as well as changes in policies that impact prescribing generally.

4.2.4. Environment‐level barriers and suggestions

The most often mentioned perceived barrier to widespread implementation was insurance coverage. The concern was largely twofold: the variability of insurance coverage; and the question of whether insurance would cover the 12‐monthly supply, even though nearly all insurers are mandated to pay for and allow disbursement of a 12‐month supply of SARCs. Participants stated that the variable and unclear coverage could be mitigated by previously mentioned changes to the EMR to include details about coverage in patient charts. However, participants felt limited in actions they could take because they felt practice‐level initiatives like this are controlled by larger institutional structures and “actual implementation…is really out of the hands of doctors.”

Some participants believed that the ACCESS law could increase access to SARCs for patients with public insurance, but they were skeptical that it will do the same for patients with private insurance coverage, despite the law's provisions that all insurers except self‐insured businesses comply with the law. This potential issue was seen as problematic by a participant because it is nearly impossible to keep track of variation in coverage for medication, so the default is to prescribe in way that is consistent with most insurers' rules.

Most participants felt that implementation of the 12‐month SARC supply provision would be improved if information about the ACCESS law is more consistently and clearly distributed to clinicians, and if more basic education about contraception care and reproductive health care was available for general practitioners.

4.3. Variation in clinicians' perceptions regarding the law

Inductive analysis of interview data suggested variation in perceptions and experiences across participants which provided an opportunity to theorize explanations for the variation noted. All study participants provided primary and/or reproductive health care to women of reproductive age but brought varied training, experience, scope of practice, and practice cultures or philosophies to their clinical practice. None of the participants expressed opposition to this law and generally perceived the law as advantageous, particularly around lessening patient burden. However, participants generally spent more time discussing perceived disadvantages, largely focused on concerns about potential time spent managing insurance.

Differences noted across participants included the level of concern about a patient's capacity to keep track of 12 months' worth of medication, with some trusting patients to manage this task adequately and others being concerned that patients would ‘lose’ their medication. A related difference was in concerns about patients not being required to come into the office every 3 months to refill their SARC prescription. One participant commented that the high rates of obesity and smoking in their patient population made them feel their patients were at risk if they did not require them to come in, while other providers felt it would be better for patients to have more autonomy in managing their reproductive health. Pediatric‐Adolescent medicine physicians expressed concerns about decreased patient contact more than participants in other specialties. Some providers also wanted to ‘protect’ patients from unanticipated costs or embarrassment if the pharmacy would not fill the prescription. These differences in perceptions of the clinician's role and their responsibilities raise questions about the tension between patient autonomy and paternalism as well as the potential for implicit bias influencing decisions about which patients can and cannot ‘handle’ a 12‐month supply of SARCs.

Differences were also noted in the degree of control participants felt they had over their decision to offer a 12‐month supply of a SARC and the capacity to make changes in their practice in general. Several participants felt that insurers, pharmacists, information technology specialists, and administrators had greater control over decision making about 12‐month SARC prescriptions than they did at the clinician, organization, and environment levels while other participants felt they could provide a 12‐month SARC supply if it was what a patient desired. This difference may also relate to experiences within specific discipline's training and practice or may signal a diminished feeling of professional autonomy and self‐efficacy in a system in which health care is a commodity. Experience prescribing SARCs may also influence clinician's perceived control over prescribing decisions, with OB‐GYNs and CNMs having the highest level of experience.

5. DISCUSSION

This qualitative study explored primary care and OB‐GYN clinicians' perspectives regarding the ACCESS law in Massachusetts, including perceived advantages and disadvantages of the law, barriers and facilitators to implementing the law, and recommendations to address barriers. Less than half of the participants in the study knew about the law, only one recalled receiving any training about the law, and approximately one third had written a prescription for a 12‐month supply of a SARC since the law was passed. Most participants identified perceived advantages and disadvantages of the law at patient, clinician, organization, and environmental levels. Perceived disadvantages largely focused on potential waste and decreased opportunity for clinicians to monitor patients. Several of the perceived disadvantages demonstrated unfamiliarity with the specific provisions of the law and/or a more paternalistic practice style. Barriers to implementation and suggestions to address them mainly focused on concerns regarding organization‐ and environmental‐level issues such as insurance coverage, the potential utility of EMR prescription defaults, and a need for more training for clinicians and pharmacists. Many of these findings such as decreasing patient burden, concerns with decreased patient contact, and issues with insurance coverage were consistent with a study of Massachusetts pharmacists' perspectives on the ACCESS law. ²⁰ Inductively derived sub‐themes identified opportunities to further explore the potential role of paternalism, implicit bias, and patient autonomy in SARC prescribing decisions and clinicians' perceived autonomy in decision making with patients in relation to clinician's specialty. In a post‐Roe era, facilitating access to reproductive health care is a critical public health intervention, and policy alone is likely not enough to change practice; implementation requires intentional policy analysis, education, and stakeholder engagement.

Potential waste of unused SARC medications was a commonly cited potential disadvantage of prescribing a 12‐month supply, a concern that has been raised in other studies. ²¹ A large cohort study of the California family planning program looked at the number of oral contraceptive pill packs dispensed or prescribed on method continuation, correct use, consistent use, and pill wastage, defined as method‐switching and pill‐oversupply waste. ²¹ This study found that pill continuation increased with the number of packs prescribed but was also associated with more pill wastage. ²¹ People who were dispensed 13 cycles worth of pills at their first visit wasted almost one cycle (6.5% of total cycles dispensed) over the course of the year while people who were dispensed one or three cycles at a time wasted less (2% and 2.4% respectively) of the total cycles dispensed. ²¹ Despite this wastage, an extended supply of pills was still found to be cost effective for the program. Moreover, when controlling for age, race or ethnicity, and previous pill use, dispensing a 12‐month supply of pills is associated with a 30% reduction in the odds of conceiving an unintended pregnancy compared with dispensing one to three packs and a 46% reduction in the odds of obtaining an abortion. ²² Although concerns around wastage are not unfounded, overall savings for the health care system outweighed this risk, a sentiment that was shared by many participants in the current study. Since several participants described wastage as a potential barrier, ensuring that key stakeholders (e.g., prescribers, pharmacists, health care administrators, insurers) are aware of these data could be important in an educational campaign to improve implementation of the law. Understanding different stakeholders' perspectives on the acceptability of wastage will also provide a more holistic view of the issue.

Some participants in the current study felt that adding an option to prescribe a 12‐month supply to existing options in EMRs could facilitate increased access to a 12‐month supply of a SARC. ²³ A single institution study evaluated the change in the proportion of SARC prescriptions sent as a 12‐month supply after a change in the EMR. The EMR defaulted the prescribed quantity to 360–365 pills, 36 patches, or 12 rings. Provision of 12‐month prescriptions by OB‐GYN clinicians, who had the highest baseline prescribing rate, increased by 27% after the EMR change. Comparatively, non‐OB‐GYN clinicians increased their 12‐month prescriptions by 360% following the EMR change. ²³ Our study participants agreed that this simple, automated, EMR change across the health system could facilitate provider prescribing and increase access to a 12‐month supply of SARCs, but shorter‐duration prescriptions should remain available to meet all patient's preferences.

Policy changes alone are unlikely to promote widespread change in clinical practice. Our study demonstrated suboptimal awareness of this law among clinicians participating in the study. This experience is similar to other states. ²⁴ , ²⁵ For example, Oregon passed a similar 12‐month supply provision into law in January 2016 and disseminated information about this policy change to its network of publicly funded contraceptive clinics. ²⁶ Only 3.7% of SARC users in Oregon received a 12‐month supply after the policy change (compared to 3.5% prior to policy). ²⁷ Similarly, in Washington, which implemented the 12‐month provision in 2014, only one in seven people received a 12‐month supply of oral contraceptive pills the year after the law's establishment. ²⁸ Studies of implementation of other family planning initiatives, such as immediate postpartum long‐acting reversible contraception, suggested technical assistance and stakeholder outreach, public health education programs, and social media campaigns were critical for success. ²⁹ Likewise, stronger public and clinician education programs may be needed to promote practice of prescribing a 12‐month supply. ³⁰

In our inductive analysis, we identified subthemes related to the potential effects of paternalism and implicit bias on equitable access to 12‐month supply of a SARC method. Contraceptive choice is a preference‐sensitive decision and discussion should be centered around patient's preferences, values, and priorities. ³¹ People generally desire more autonomy in their contraceptive decisions compared to decisions about other general health care issues. ³² In pediatric and adolescent health care, the tension between protection of a minor's wellbeing versus emerging patient autonomy is more evident. ³³ It is imperative that those who provide contraception recognize potential bias, provide scientifically accurate information, and apply patient‐centered approaches. ³⁴

The findings of our study should be viewed considering its strengths and limitations. To our knowledge, this is the first study to examine clinicians' perspectives regarding the implementation of the 2017 ACCESS law in Massachusetts. Strengths of the study include having clinicians from all geographic regions of the state and a diversity of specialty, credentials, and practice settings. Most of the participants were White and female and different perspectives may have been obtained from clinicians in different gender and racial/ethnic groups. However, all but two of the disciplines included in the study are majority female ³⁵ , ³⁶ , ³⁷ and most clinicians in the United States are White. ³⁸ Approximately one third of the study participants reported prescribing a 12‐month supply at least once, which may be higher than expected due to sampling strategies and self‐selection for the study. Since prescribing rates for a 12‐month supply of SARCs are low overall in Massachusetts, some participants in this study may have been more knowledgeable about the law than the general population of providers who prescribe SARCS. This could suggest an even greater need for provider education and support for fully implementing the law.

Non‐clinicians conducted the interviews, which may have reduced bias in responses to interview questions, but also may have resulted in less nuanced discussions than a clinician‐interviewer may have had. Finally, other stakeholders' perspectives (e.g., patients, clinical staff, administrators, pharmacists, legislators, insurers) are needed to develop a more complete understanding of the barriers and facilitators to uptake of the ACCESS law's 12‐month SARC provision.

Our study gives a strong signal that there are numerous potentially modifiable barriers to implementation of the 12‐month SARC provision that states enacting such laws may want to consider during implementation. First, clinicians' lack of awareness of the ACCESS law suggests the need for statewide outreach and education on this law's provisions as well as promoting patient‐centered contraception counseling to minimize potential bias. Second, in addition to developing a better understanding of all stakeholders' perspectives, implementation interventions that further identify effective ways to address multi‐level and interprofessional barriers are needed. Finally, technological supports, such as EMR defaults may make it easier to prescribe a 12‐month supply. The study also raised important perceived potential negative implications of the law, such as loss of contact with patients, that should be considered when evaluating the law's effectiveness. State‐academic‐clinical partnerships may be best suited to address the barriers to effective policy implementation highlighted in this study, which may allow more eligible patients to obtain a 12‐month supply of their short‐acting birth control method.

FUNDING INFORMATION

This study supported by Baystate Medical Center Research Pilot Award Program (RPAP‐701‐21031).

Supporting information

Appendix S1. Supporting Information.

Appendix S2. Supporting Information.

Appendix S3. Supporting Information.

Qasba NT, Dowd P, Bianchet E, Goff SL. A qualitative study of clinicians' perspectives on a law that allows for a 12‐month supply of short‐acting contraceptives in Massachusetts: Barriers and facilitators to implementation. Health Serv Res. 2023;58(2):498‐507. doi: 10.1111/1475-6773.14105