Apr. 6th, 2012

After my last entry about expecting another baby, it is very appropriate to have an entry about contraceptives, isn't it?

I was inspired by Val and Mary, who have written a bit about contraceptives in USA and Australia. When reading Val's entry, I was amazed that the prices of contraceptives in USA were so high, two or three times the prices in Norway.

One could think that Norway relied on heavy governmental sponsoring of contraceptives, since we have our evil socialist public health system. But alas. While we do have a good public health system, it does hardly cover contraceptives.

The health care system here seems rather similar to the Australian one, in that it is universal and private insurances covers extras. In our case they cover less extras than in Australia, as we have free ambulances everywhere, and there are not options to "upgrade" your hospital stay by paying extras. In some hospitals you may get a private room if your condition requires it (or if they simply can offer it to you), in other (like the one in my town, very recently built) all rooms are single rooms, so that's what you get (including internet and en suite bathrooms). What the private insurances do cover, though, is shorter waiting lists, usually maximum 3 or 4 weeks to start treatment. There are some exceptions, like major conditions that require "university hospital treatment" are not covered (because there are no private options the insurance company can buy us into for them), but most conditions people want speedy examinations for (including heart and cancer) are covered (you'll often be referred to the public system for treatment, but once they get you with a diagnosis and the necessary exams, they will often speed up, too), and also free physical treatment. Most of these insurances are paid for by employers, like my own. I have not used it, but I guess perhaps 25% of my colleagues have, most of them for physical therapy of one kind or another, and a few for surgeries. When I broke my back, all the emergency treatment was done by the hospital anyway, and physical treatment for 3 or 6 months was free since it was post-surgery. I considered using the insurance to remove the implants, because it might have given me a more fixed date for the surgery, but then I wanted "my" surgeon to do it so I stayed with the hospital.

The public health care system also buy some capacity in the private clinics, especially for image diagnostics and small surgeries (which does not require an overnight stay). Then the patient pay the same as she would in a public hospital, usually around $45. The government buy an annual fixed number of exams/operations from the private clinics, so sometimes you will get an examination far into the future after a referral from your GP, but with a note that if you will pay the clinic's full fee for it, you can have the same procedure immediately.

GPs are partly funded by the government. They have about 1500-2500 patients (lists with a maximum number of patients), and get a flat rate per patient per year to cover overhead expenses (office nurse, the office they rent, basic equipment, etc). Then there is a rate per patient visit, set by the government, which is shared with 2/3 paid by the government and 1/3 by the patient ("copay"). For office-hour appointments the copay is about $30, but maximum $380 per calendar year. Your copays (no medical information, just the amounts you have paid) are reported to the health care administration, and when you reach $380 you will receive a card that entitles you to free health care for the rest of the year (any excess you have paid will be reimbursed automatically if they have your bank account number).

The same policy is also valid for medicines for a lot of chronic conditions (i.e. most medical conditions that last more than a year, but not necessarily all kinds of drugs for that condition - new and usually very expensive drugs are often not covered), where you will get a "blue prescription" and pay 1/3 of the drug expenses until you reach the copay limit. You must choose the cheapest (usually generic) brand, but if medically indicated the doctor can say you must have a specific brand, and you can also pay the difference between generic and specific brands yourself. Usually the specific brand is rather similar in price to the generic, and most doctors will write the specific brand on the prescription and the pharmacy takes care of the substitution or the extra payment, as you like it.

When it comes to contraceptives they are not covered neither by the public health system or by insurances. They are however administered by regular GPs (or by your obgyn if you insist, but most women use their GP). You need an appointment with your GP, who will usually just talk a bit, check your blood pressure and do a pap smear (pelvic exam), if it's been more than 3 years since the last time (every 3 years is the recommended rate for women above 25, and you'll get a reminder from the cancer register if they haven't registered a new test within the last 3 years. You can opt out from that, though.). The pap smear is by no means compulsory. The doctor can refuse to write you a prescription for medical reasons, but I don't think refusing to do a pap smear is a valid reason for most doctors unless there are indications that you should do one now. The GP will usually give you a 1 year prescription (though prescriptions for contraceptives are valid for (and may be enough for) 3 years, but I guess doctors don't usually remember it since all other prescriptions are for 1 year only), and you can get all of it at the same time from the pharmacy if you want to. Getting a refill weeks or even months before you actually run out is not a problem, and I think most doctors will help you so you can be covered all your stay abroad to study, for instance. (Even if you can get a 3 year prescription, you should pop in to check your blood pressure from time to time. It can probably be done in the lab, though, or when you're there for other reasons.)

The price for an appointment to get contraceptives is about $30, plus about $10 extra for a pap smear (which covers gloves and equipment for the examination, the test itself is free) and $8 extra if you need to do any blood work (usually not).

If you are running out of contraception and the GP or you can't fit an appointment into the schedule in time, you can usually get a new supply for a short time by calling your GP, and they may also fax the prescription to your most convenient pharmacy for no (or a very low - like $2-3) extra fee (plus $7-8 for writing a prescription without an appointment). I have used this a couple of times when I have misplaced by pills.

Then you go to the pharmacy, queue up and have you pills or other medicines within 10 minutes. I have never heard of them being out of stock, and there is not bureaucracy beyond having to wait in a queue and then wait for the pharmacy technician to have her buddy check the package before you get it. You can get up to a year's worth of medicines at once, except when it's for chronic illnesses where the government covers 2/3 - then you can only have for 3 months at a time (there are also special rules for potentially abused drugs), so I usually got 12 boxes of contraceptive pills when I got mine since it was harder for me to displace them than a slip of paper. The pharmacy I usually use also offers to store the prescription for you, but I prefer to have the visual overview myself.

Women under 20 get free contraceptives, and can visit a school nurse or midwife in stead of their own doctor. They will usually only check medical history and blood pressure, since pap smears aren't recommended until you are 25 anyway. When saying "free" that means they get about $17 covered pr 3 months. With the prices of contraceptives here, that means free for most of them, and cheap for the rest.

Free contraceptives for women under 20 was introduced in 2002. Apparently the influence on the abortion rates haven't been quite as high as they expected/hoped when they started the project. But the abortion rates seem to have been reduced by about 20-40% for women under 20. There have been trials in a couple of cities with free contraceptives also to women between 20 and 24, and the abortion rates there were halved in that age group. The reason is probably that administration itself of contraceptives (including condoms) is harder the younger you are, it isn't easy to remember to take a pill every morning (especially if you don't want to put the pill sheet with your toothbrush in the family bathroom). The older the women are, the higher probability of having a life compatible with a daily pill at a set time. Ironically one of the political parties that are pro free contraceptives to women under 24 is the Christian Democratic party (Norwegian article). They argue that it will lower the abortion rates. The other political parties seem to be against the extension of the scheme, for economical reasons.

(Condoms can also be ordered online for free, and lots of organizations hand them out (including the student parish at university - I guess a few people have been surprised by their huge bowls of condoms in the common area. A friend of mine works for them, and she gets like 30,000 condoms delivered well before the annual AIDS day on 1 December. Which again means handicraft projects involving condoms and glue (not needles!) during our sewing circle meetings where about half the attendants belong to a, ehrm, slightly more conservative church.)

And then to the prices, the information from Val that inspired me to write this.
Most combination and mini-pills are in the $13 to $36 range for a 3 month prescription: Microgynon $13, Marvelon $20, Cerazette $28, Loette $36. There are also other options below $17, so there are a few to choose between also for those getting them for free. Not all pills work the same way for all women, so it's not like we could be done with having one brand for all. According to Val, it is possible to get a generic pill for $24/3 months in USA, but she has never paid less than $30 a month. It's a bit unclear if this was the copay she paid after insurance or if it was the actual price of the pill - I suspect the first, though.

NuvaRing is a low-dose alternative to oral estrogen that is inserted into the vagina and replaced once a month. They cost about $55 for 3 months in Norway. The price for Val was $45 per month - and that was the copay part of it! A Mirena IUD cost about $200, and will last for 5 years. It is usually inserted by your GP, so that's another $40. Another alternative to oral contraceptives are injections, Depo-Provera is about $15 for 3 months, and can be injected by the school nurse for free. Nexplanon, an implant for 3 years, is about $200 plus GP.

"Plan B" contraceptives (NorLevo) are available over the counter in stores that sell paracetamol, nasal spray, mild coughing mixtures etc (gas stations, supermarkets, kiosks), and in pharmacies. They are about $35 per pill. Since it's OTC the price may vary, but not very much (at least not if you compare pharmacies - everything is usually more expensive in a kiosk or gas station).

What is important to note here, is that ALL these prices are the prices of the market. They are not regulated by the government, but set by the manufacturer or their representative in Norway. The prices are regulated in the sense that they are fixed (not for OTC drugs) between all pharmacies, so there is no need to shop around to find the cheapest pharmacy - it's the same whether you are downtown Oslo or near North Cape. They may also be de facto regulated since the government pay for a lot of drugs for chronic illnesses, and have set maximum prices they will cover. But the manufacturer won't get any more money than the fixed price, it's not like the government buys a lot of these drugs for chronic patients in addition to giving money so they can keep the prices down, and the government regularly evaluates their maximum prices and have been pushing prices for branded drugs down when a cheap generic drug has become available. If a blood pressure medicine costs $20 a month, that's what the manufacturer are paid for it, no matter if the patient has a chronic diagnosis (and thus only pays about $6 copay for it) or is using it short term for some other non-chronic condition (and pays the full price of $20).

A few words on abortion, even if I don't think about it as a contraceptive. They are performed medically (before week 9) or surgically in public hospitals all over the country, with or without a referral from your GP (the hospitals prefer referrals through a GP and will probably urge you to see your GP first, but you can contact the hospital directly should you want to). As all exams and appointments related to an actual pregnancy are completely free of charge, this also goes for abortions. Travel costs above $50 to the hospital are covered. Abortions can be performed until week 12 after the last period. After that they can still be done, but it has to be due to a medical condition for either mother or fetus/baby, and the criterias are stricter the longer the pregnancy has lasted. After week 23-24 (when the foetus is considered viable) no abortions will be done no matter what (but birth will be induced to save a mother's life, the mother's life is always prioritized before the unborn child until the child is actually born). Vaginal ultrasounds are done, but only to confirm the length of pregnancy (and vaginally since that's the only practical way of doing it for most women before week 12), and the pregnant woman is by no means required to watch it.

Recently there as been a debate about doctors' rights with regard to abortions. Since our abortion law came into effect in 1972, doctors and nurses have been able to abstain from performing abortions if it's against their beliefs. The right to get an abortion is with the hospital, not with the individual doctors, so as long as the hospital is able to find other doctors to do it, the patients won't suffer and thus the government says it's ok for individuals to abstain. For large hospitals this is not a problem, but I have seen smaller hospitals adverting for doctors/nurses with a clause that the person must be able to perform abortions. As long as this clause is known before the medical staff is employed, it is allowed. The hospitals must also be able to have skilled doctors at any time in case of emergency, not just during office hours - after all the medical procedure is the same whether it's an abortion or a surgery to clean the linen of the uterus after a bad miscarriage.

The exceptions for hospital doctors haven't been much of an issue. Recently it was known that also GPs have been engaged under a no-referral-to-abortion clause (we're talking referrals, not performing them), which for many also included the right not to prescribe contraceptives (and also referring lesbians to IVF treatment). THIS engaged a debate. GPs are the first line in the health care system, the first person the patient sees. There are no ways to inform patients in advance about the doctor's consciousness about abortions and contraceptives, and while most doctors were able to deal with this quite easily by referring to other GPs, not all women (and men) were quite happy with this. Apparently it's wrong to sign the referral or prescription yourself, but they have no problems asking another GP to put her signature on the same paper - what's the logic here?

I don't know the prices of other prescription drugs in USA, and due to the insurance system it's apparently impossible to find any relevant prices of them either. OTC drugs seem quite a lot cheaper than here, so if the same price scheme was used the price the pharmaceutical company is paid for a prescription drug should be quite a lot less than here. And they might as well be, since I guess the insurance company takes quite a big share of the price on the way.



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