Pap Smear Ransom – Is It Ethical to Refuse to Refill a Patient’s Birth Control Until They Come in for Their Annual Exam?

Abstract

A review of the common but questionably ethical practice of refusing to refill a patient’s birth control prescription until they are seen in office for, and presumably pay for, a yearly examination. This forced decision between making time for the appointment or risking an unintended pregnancy is comically referred to as “Pap Smear Ransom.” This short review examines the limited data to support or decry this common practice.

Like death and taxes, a plethora of refill requests from all the major pharmacies in the area clogging up the fax machine of your office is completely inevitable for any busy OBGYN.

The most common of these requests for most OBGYNs is going to be birth control. With 62% of the reproductive age women in the United States currently using birth control,¹ and essentially 100% percent of pharmacies faxing over a request if the patient is more than 1 day late, the fax volume is bound to be substantial for any practice.

What varies widely, however, is what the response to those faxes is. For some providers, the faxes go directly into the shredder, feeling that any matter worth addressing is worth doing so only during a paid office visit, which certainly makes some sense. A fair number of these practitioners will probably trickle into the second group when pressed again on the subject, either by an irate patient or an impatient pharmacist, pandering them relentlessly to refill the prescription by phone. The second group is those providers with a philosophy that everything gets signed and faxed back on the spot, perhaps benevolently wanting to help eliminate all barriers to a patient's treatment, or perhaps just believing in the unquestionable wisdom of the requesting pharmacy. A passing glance to be sure that no controlled substances (which would be very rare in 2020), have found their way into the mix is usually in order.

It is the third group of practitioners that I would like to bring our attention to, namely those practitioners who use the faxes to encourage patients to present for their appointments by refusing to refill birth control until the patient is seen. This sets up a kind of "Pap Smear Ransom," as we fondly refer to it in my offices, where the patient must either risk pregnancy or present for a visit.

First, let us discuss the arguments against this practice. Approximately 45% of pregnancies in the United States are considered unplanned or unintended.² Of those pregnancies, approximately 42% will be aborted, and the majority of the rest will go to term.³ The average cost of an abortion service in the US is in the range of $470,⁴ and the cost of raising a child is clearly significantly higher. Therefore, one could argue that a practitioner who denies a birth control refill is selfishly placing an inappropriate burden on the US healthcare system to manage these unintended pregnancies, all for the hopes of charging a patient an additional annual exam fee, which averages less than $200.⁵

While, to the knowledge of this author, no major organization has directly issued a guideline or committee opinion on this particular practice,⁶ there has been one incidence where ACOG has come close. In 2014 ACOG released their "Statement on OTC Access to Contraception," which goes pretty far as to state that birth control should not require a prescription.⁷ While the statement also states that having access to OTC OCPs "does not obviate the need for women to see their gynecologist each year," it does logically seem to question the ethics of refusing a prescription for a drug that should not need a prescription in the first place.

This brings us to the arguments for the practice of withholding the refill until the patient is seen. The first argument would be concern for contraindications. If it's been more than a year since the prescription was written, what has changed? Are there new migraines with aura? Did the blood pressure creep up with the addition of a few more pounds? Has the patient started smoking? Clearly, these are concerns for the blind signer. There is a very reasonable concern for the possibility of liability. Are you responsible if the refilled OCP causes a stroke? You may have discussed the risk at the visit you prescribed it, but is there liability if it is refilled without seeing the patient? If not, would there be liability in refilling it for a third year, or for 10 years? Clearly, physicians are responsible, at least in part, for the medications they prescribe and refill, I will admit I was unable to find any cases of malpractice suits arising specifically from an OCP refill.

Last, if you do refill the prescription, will not it be less likely the patient will show up? What about all the other important components of the annual exam, the pap smear, the depression screen, the mammogram? Is not this care so important as to force the patient to come in with any means you have? Some would argue the moral high ground is in saving the woman from preventable cancer and diseases at the risk of an unintended pregnancy.

Of course, the obvious right answer here may be a mixed approach. I have overheard many of my colleagues receptionists saying something to the tune of "Okay but this is really the last refill until you come in for your exam, you are very overdue!" The idea being that maybe one or two additional months can be refilled as leeway to help accommodate the busy patient, with the understanding that this will not go on forever.

It is very likely that as we advance in eliminating barriers to women's healthcare, more ethical questions will be raised as to the safety and ethics of each decision. Finally, I would challenge each of my colleagues to consider the options fully, and be sure that their approach to the "Pap Smear Ransom" conundrum embodies the ethics and values that best represent their practice.

Disclosure

The authors report no conflicts of interest in this work.

References

1. Hurt KJ, Guile MW, Bienstock JL, Fox HE, Wallach EE. The Johns Hopkins Manual of Gynecology and Obstetrics. Lippincott Williams & Wilkins; 2012. 2. Sawhill IV, Guyot K. Preventing Unplanned Pregnancy: Lessons from the States. 2019. 3. Finer LB, Zolna MR. Declines in unintended pregnancy in the United States, 2008–2011. N Engl J Med. 2016;374(9):843–852. doi:10.1056/NEJMsa1506575 4. Jones RK, Upadhyay UD, Weitz TA. At what cost? Payment for abortion care by US women. Womens Health Issues. 2013;23(3):e173–e178. doi:10.1016/j.whi.2013.03.001 5. Marchand GJ, Sainz KM. A Simple and Novel Technique for Cleaning Up after the Ovarian cystectomy of a dermoid cyst. J Minim Invasive Gynecol. 2018;25(7):S239–S240. doi:10.1016/j.jmig.2018.09.617. 6. Machlin S, Chowdhury S. Expenses and Characteristics of Physician Visits in Different Ambulatory Care Settings, 2008. Agency for Healthcare Research and Quality; 2011. 7. ACOG. ACOG statement on OTC access to contraception. American College of Obstetrics and Gynecology. September 9, 2014. Available from: www.acog.org.AccessedApril3, 2020.

Like death and taxes, a plethora of refill requests from all the major pharmacies in the area clogging up the fax machine of your office is completely inevitable for any busy OBGYN. The most common of these requests for most OBGYNs is going to be birth control. With 62% of the reproductive age women in the United States currently using birth control,¹ and essentially 100% percent of pharmacies faxing over a request if the patient is more than 1 day late, the fax volume is bound to be substantial for any practice. What varies widely, however, is what the response to those faxes is. For some providers, the faxes go directly into the shredder, feeling that any matter worth addressing is worth doing so only during a paid office visit, which certainly makes some sense. A fair number of these practitioners will probably trickle into the second group when pressed again on the subject, either by an irate patient or an impatient pharmacist, pandering them relentlessly to refill the prescription by phone. The second group is those providers with a philosophy that everything gets signed and faxed back on the spot, perhaps benevolently wanting to help eliminate all barriers to a patient’s treatment, or perhaps just believing in the unquestionable wisdom of the requesting pharmacy. A passing glance to be sure that no controlled substances (which would be very rare in 2020), have found their way into the mix is usually in order. It is the third group of practitioners that I would like to bring our attention to, namely those practitioners who use the faxes to encourage patients to present for their appointments by refusing to refill birth control until the patient is seen. This sets up a kind of “Pap Smear Ransom,” as we fondly refer to it in my offices, where the patient must either risk pregnancy or present for a visit. First, let us discuss the arguments against this practice. Approximately 45% of pregnancies in the United States are considered unplanned or unintended.² Of those pregnancies, approximately 42% will be aborted, and the majority of the rest will go to term.³ The average cost of an abortion service in the US is in the range of $470,⁴ and the cost of raising a child is clearly significantly higher. Therefore, one could argue that a practitioner who denies a birth control refill is selfishly placing an inappropriate burden on the US healthcare system to manage these unintended pregnancies, all for the hopes of charging a patient an additional annual exam fee, which averages less than $200.⁵ While, to the knowledge of this author, no major organization has directly issued a guideline or committee opinion on this particular practice,⁶ there has been one incidence where ACOG has come close. In 2014 ACOG released their “Statement on OTC Access to Contraception,” which goes pretty far as to state that birth control should not require a prescription.⁷ While the statement also states that having access to OTC OCPs “does not obviate the need for women to see their gynecologist each year,” it does logically seem to question the ethics of refusing a prescription for a drug that should not need a prescription in the first place. This brings us to the arguments for the practice of withholding the refill until the patient is seen. The first argument would be concern for contraindications. If it’s been more than a year since the prescription was written, what has changed? Are there new migraines with aura? Did the blood pressure creep up with the addition of a few more pounds? Has the patient started smoking? Clearly, these are concerns for the blind signer. There is a very reasonable concern for the possibility of liability. Are you responsible if the refilled OCP causes a stroke? You may have discussed the risk at the visit you prescribed it, but is there liability if it is refilled without seeing the patient? If not, would there be liability in refilling it for a third year, or for 10 years? Clearly, physicians are responsible, at least in part, for the medications they prescribe and refill, I will admit I was unable to find any cases of malpractice suits arising specifically from an OCP refill. Last, if you do refill the prescription, will not it be less likely the patient will show up? What about all the other important components of the annual exam, the pap smear, the depression screen, the mammogram? Is not this care so important as to force the patient to come in with any means you have? Some would argue the moral high ground is in saving the woman from preventable cancer and diseases at the risk of an unintended pregnancy. Of course, the obvious right answer here may be a mixed approach. I have overheard many of my colleagues receptionists saying something to the tune of “Okay but this is really the last refill until you come in for your exam, you are very overdue!” The idea being that maybe one or two additional months can be refilled as leeway to help accommodate the busy patient, with the understanding that this will not go on forever. It is very likely that as we advance in eliminating barriers to women’s healthcare, more ethical questions will be raised as to the safety and ethics of each decision. Finally, I would challenge each of my colleagues to consider the options fully, and be sure that their approach to the “Pap Smear Ransom” conundrum embodies the ethics and values that best represent their practice. Disclosure The authors report no conflicts of interest in this work. References [RAW_REF_TEXT] 1. Hurt KJ, Guile MW, Bienstock JL, Fox HE, Wallach EE. The Johns Hopkins Manual of Gynecology and Obstetrics. Lippincott Williams & Wilkins; 2012. [/RAW_REF_TEXT] [RAW_REF_TEXT] 2. Sawhill IV, Guyot K. Preventing Unplanned Pregnancy: Lessons from the States. 2019. [/RAW_REF_TEXT] [RAW_REF_TEXT] 3. Finer LB, Zolna MR. Declines in unintended pregnancy in the United States, 2008–2011. N Engl J Med. 2016;374(9):843–852. doi:10.1056/NEJMsa1506575 [/RAW_REF_TEXT] [RAW_REF_TEXT] 4. Jones RK, Upadhyay UD, Weitz TA. At what cost? Payment for abortion care by US women. Womens Health Issues. 2013;23(3):e173–e178. doi:10.1016/j.whi.2013.03.001 [/RAW_REF_TEXT] [RAW_REF_TEXT] 5. Marchand GJ, Sainz KM. A Simple and Novel Technique for Cleaning Up after the Ovarian cystectomy of a dermoid cyst. J Minim Invasive Gynecol. 2018;25(7):S239–S240. doi:10.1016/j.jmig.2018.09.617. [/RAW_REF_TEXT] [RAW_REF_TEXT] 6. Machlin S, Chowdhury S. Expenses and Characteristics of Physician Visits in Different Ambulatory Care Settings, 2008. Agency for Healthcare Research and Quality; 2011. [/RAW_REF_TEXT] [RAW_REF_TEXT] 7. ACOG. ACOG statement on OTC access to contraception. American College of Obstetrics and Gynecology. September 9, 2014. Available from: www.acog.org.AccessedApril3, 2020. [/RAW_REF_TEXT]

References

1. Hurt KJ, Guile MW, Bienstock JL, Fox HE, Wallach EE. The Johns Hopkins Manual of Gynecology and Obstetrics. Lippincott Williams & Wilkins; 2012.

2. Sawhill IV, Guyot K. Preventing Unplanned Pregnancy: Lessons from the States. 2019.

3. Finer LB, Zolna MR. Declines in unintended pregnancy in the United States, 2008–2011. N Engl J Med. 2016;374(9):843–852. doi:10.1056/NEJMsa1506575

4. Jones RK, Upadhyay UD, Weitz TA. At what cost? Payment for abortion care by US women. Womens Health Issues. 2013;23(3):e173–e178. doi:10.1016/j.whi.2013.03.001

5. Marchand GJ, Sainz KM. A Simple and Novel Technique for Cleaning Up after the Ovarian cystectomy of a dermoid cyst. J Minim Invasive Gynecol. 2018;25(7):S239–S240. doi:10.1016/j.jmig.2018.09.617.

6. Machlin S, Chowdhury S. Expenses and Characteristics of Physician Visits in Different Ambulatory Care Settings, 2008. Agency for Healthcare Research and Quality; 2011.

7. ACOG. ACOG statement on OTC access to contraception. American College of Obstetrics and Gynecology. September 9, 2014. Available from: www.acog.org.AccessedApril3, 2020.