Pharmacists’ Public Health Role Grows as Birth Control Prescribing Authority Expands

An increasing number of pharmacists are now prescribing birth control, further expanding their role as public health service providers.

Lincoln Alexander, PharmD, residency program director in Portland, Oregon, for Albertsons Companies, has been prescribing birth control for just over 5 years and has received a positive response from his patients.

“Patients are highly appreciative of the service. Nowadays, [pharmacists prescribing birth control] seems like second nature to many, which is a testament to the effective rollout we have had here in Oregon,” said Alexander, who is also president-elect of Oregon State Pharmacy Association.

Oregon isn’t alone. Allie Jo Shipman, PharmD, MBA, director of state policy for the National Alliance of State Pharmacy Associations, said 13 states and the District of Columbia currently allow pharmacists to prescribe oral contraceptives independently.

“There are also 13 states with legislation pending this session that would allow for the same thing,” she said.

Although the prescriptive authority, age limits, and requirements for each state vary, the overall message is clear: Pharmacies in all practice settings are stepping up to the challenge.

Differences Among States

In 2013, California became the first state to pass a bill allowing pharmacists to “furnish” contraception without a physician prescription. However, Oregon was the first state to implement independent pharmacist-prescribed contraception.

“We had a physician legislator, Dr [Knute] Buehler, who just decided this is an access issue for patients,” said Paige Clark, RPh, director of alumni relations and professional development at Oregon State University College of Pharmacy in Corvallis.

According to Shipman, state policies are typically structured using 1 of 3 types of prescriber authority:

• General prescriber authority, where the pharmacist is the prescriber of record
• Statewide protocol, where the pharmacist serves as the prescriber of record but the overall protocol is developed and approved by a state pharmacy board
• A statewide standing order

Under the last option, the state offers a statewide blanket prescription issued by a medical official in the department of health, who is often the chief medical officer. That official is considered the prescriber of record, but pharmacists are responsible for consulting and making clinical decisions.

Although some states have no age limits in place, Shipman said others only allow pharmacists to prescribe to those 18 years or older. Alternatively, they may allow prescribing to patients younger than 18 only if they have had a previous contraception prescription.

Capitalizing on a Need for Public Health Service Providers

A growing number of states are exploring options that go beyond collaborative practice agreements for birth control prescribing. The move follows a larger trend of enlisting pharmacists to provide public health services to patients for areas that don’t require a diagnosis.

“I think the pandemic has shown just how pharmacists have shined in
a time of a public health emergency where pharmacies have stayed open...when other providers have closed,” said Veronica Vernon, PharmD, an assistant professor of pharmacy practice at Butler University in Indianapolis, Indiana. “We have seen during the pandemic that access to contraception has been a significant concern.”

Pharmacists can bring their unique set of skills to address what Vernon referred to as “contraception deserts,” geographic regions where access to birth control prescribers might be limited. They can also save states significant money in public costs.

One study examined the policy’s impact on Oregon’s Medicaid program in the first 2 years since it went into effect in 2016. According to the results, published in Obstetrics & Gynecology, pharmacist prescription of contraception averted more than 50 unintended pregnancies and saved the state an estimated $1.6 million in public costs.¹

Payment Challenges

Pharmacist contraception prescription may come with big benefits, but it also brings its own set of challenges. Not least among these is ensuring that pharmacists are getting paid for their services.

“We want to remove barriers for patients and we can be a more cost-effective approach for patients when accessing contraception, but you want to make sure you are not giving away the service for free,” Vernon said.

Clark said that in Oregon the Medicaid system has put pharmacists in the provider lane, allowing them to use billing codes that are also available to physicians and physician assistants. However, to date, their adoption hasn’t been widespread because of the systems many pharmacies need to put into place in order to process medical billing.

“There are some hoops they have to jump through, and there are some connectivity issues,” she said.

Vernon said patient consultations and assessments can last up to 20 minutes or more. This makes it essential that pharmacists are paid not only for dispensing the medication but also for their time to properly assess the patient.

“If you are going to do this, make sure there is a payment pathway in place and that you are meeting with insurance companies in your state to talk about what this would look like...The states that have been most successful in pharmacists’ prescribing of contraception have ensured that there is a pathway for payment for pharmacists’ time,” she explained.

Putting It Into Practice

Vernon recommends having a designated space within the pharmacy to conduct patient assessments in community pharmacy settings.

She also stressed the need to evaluate the workflow within the pharmacy to manage day-to-day responsibilities and billing. It will most likely mean using technicians to their highest skill levels to increase overall efficiency.

“I think including them in your workflow so that the pharmacist can step away from checking prescriptions and counseling on other prescriptions to spend time with the patient...would be really helpful,” Vernon said.

For example, one pharmacy she talked with had tasked their lead technician with medical billing to streamline the workflow. Alexander echoed Vernon’s comments, saying one of the biggest challenges he has seen in practice is adapting the workflow.

“Time constraints with performing a contraceptive consultation with the patient can sometimes make this service a challenge to fit into the workflow, especially with the ongoing COVID-19 pandemic and vaccination efforts,” he said.

To accommodate all the workflow demands, Alexander said he has done his best to educate patients on the best time of day to come to the pharmacy for prescribing services, such as in the mornings when there is pharmacist overlap. However, he has also found that patients are generally “amenable [to] a short wait” if he clearly communicates to them the other demands going on at the time.

“It starts with treating each person that walks through our doors with courtesy, dignity, and respect,” he noted. He also stressed the importance of training pharmacy technicians, interns, and other associates on workflow procedures.

“Though these associates cannot make prescribing or consultation decisions, they are very helpful in onboarding the patient,” he said. He added that they can check IDs, gather insurance cards, or ask the patient to begin by filling out a self-screening questionnaire.

As an employee of the public state university in Oregon, Clark and her team were tasked with developing a thorough training program for pharmacists in the state and other areas. She recommends that pharmacists who assume the new role invest in an educational program, even if it isn’t specifically required in their state.

“We have a 4-hour course that literally [covers] the entire process from the beginning of that patient walking in the door all the way through all the safety guidelines,” she said. The course makes it very doable for frontline pharmacists to begin offering the service, she added.

When working with patients, Vernon said, most states require pharmacists to follow the CDC’s US Medical Eligibility Criteria (US MEC) for Contraceptive Use, 2016 and the US Selected Practice Recommendations For Contraceptive Use, 2016 to guide patient eligibility and selection.

Many states also require pharmacists to administer a patient questionnaire that can be a “great jumping off point” to begin a conversation with the patient, she continued.

“The best option is what the patient decides on, and so using a shared decision-making approach with the patient is really crucial,” she said. Having patient buy-in on the product will likely increase consistent adherence, she pointed out.

The last step is to find ways to successfully advertise the new services.

“It’s not if you build it, they will come, you also have to let patients know that you are doing this,” Vernon said.

Reference

1. Anderson L, Hartung DM, Middleton L, Rodriguez MI. Pharmacist provision of hormonal contraception in the Oregon Medicaid population. Obstet Gynecol. 2019;133(6):1231-1237. doi:10.1097/AOG.0000000000003286