Pharmacist-Prescribed Birth Control Still Hard to Find

Norra MacReady

April 17, 2018

One year after implementation of a California law permitting pharmacists to prescribe hormonal contraceptives directly to consumers, only a small proportion of pharmacists in a recent study were actually providing that service.

The law was intended to improve access to contraceptives, particularly for women in remote areas or of limited economic means, the study authors write. However, these findings suggest that this approach should be "just one part of a broader legislative strategy that will support access to birth control across the state."

Other legal measures should include mandating insurance coverage of pharmacist-prescribed contraceptives, pharmacist certification and credentialing, and ensuring that contraception providers are available in rural as well as nonrural areas, the authors explain.

The California bill was signed into law in October 2013 and went into effect in April 2016. It permits pharmacists to prescribe the contraceptive pill, patch, vaginal ring, or depot injection. Similar legislation has been passed in Oregon, Colorado, Hawaii, New Mexico, and Maryland, Priya Batra, MD, from the Center for Healthy Communities, University of California, Riverside, and colleagues write in an article published in the May 2018 issue of Obstetrics & Gynecology.

Between December 1, 2016, and April 1, 2017, Batra and coauthors conducted a cross-sectional telephone survey of a probability sample of pharmacies across the state. Of 480 pharmacies contacted, 457 (95.2%) responded.

"Secret Shopper" Survey Used

The researchers used a "secret shopper" design in which a study staff member posed as a nulliparous 16-year-old girl in good health with insurance coverage from California's Medicaid program.

The secret shopper would call the pharmacy and, reading from a script, ask about the availability of pharmacist-prescribed contraception services. Questions also covered issues such as the types of contraception available, whether the shopper could obtain contraceptives as a minor, what she should do when arriving at the pharmacy, and where she could go if the pharmacy did not offer those services.

Of the pharmacies reached by the secret shopper, 376 (78.3% of the original sample of 480) had a pharmacist or other staff member available to discuss the issue with her.

Of those 376 establishments, however, only 22 (5.9%) stated that they could actually provide contraceptives prescribed by a pharmacist. There were no significant differences between the proportions of rural vs nonrural or independent vs chain pharmacies that offered this service.

In addition, "Only five pharmacies (22.7% of those providing contraceptives by pharmacists) reported providing all four hormonal methods specified in the protocol," the authors write.

This contrasts with a slightly higher figure reported by another group in an article published in JAMA in December 2017. In this study, researchers posed as patients, calling more than 1000 pharmacies in California and asking whether they could obtain birth control without a physician's prescription. Pharmacist-prescribed contraception was available in 112, or 11%, of the stores, in this case.

Change Takes Time, Businesses Must Adapt

Although the law increased pharmacists' scope of practice to prescribe contraceptives, it did not require insurers to reimburse providers in that situation, nor did it include any other policies to facilitate adoption of this practice, Batra and coauthors add.

So it is possible that many pharmacies do not have enough of an economic incentive to offer the prescribing of contraceptives.

Business practices may also play a role. Large chain drugstores must conduct protocol development, legal review, and staff training across multiple locations, which can slow the implementation of any new policy. "With more time, it is expected that more pharmacists and pharmacies will participate," say the authors.

The findings also suggest that rapid changes in practice may require more than a single legislative measure, they write. Such efforts might be better supported by "a constellation of policies."

The secret shopper design might be one study limitation, as it might have limited the extent to which assessment of the services offered was possible, the authors point out.

However, they still felt this approach was valuable, "because it best reflected what a woman's true experience would be with respect to seeking these contraceptive services."

Also, the study was conducted only 8 to 12 months after the law went into effect, and "[t]he reality of implementing this type of practice change is that variation in communication regarding new services may persist for some time."

The small number of sample pharmacies that provided the service was yet another limitation and points to the need for follow-up in future studies as the program gains wider acceptance throughout the state.

These findings may offer a lesson to other states considering such legislation, the authors conclude.

Those states "might benefit from considering a package of policies that supports this complex practice change from start to finish."

Policies should take into account "reimbursement, pharmacist certification and credentialing, and access to this service in remote or rural areas. Other states might also consider evaluating the implementation of similar policies as they evolve over time."

The authors have disclosed no relevant financial relationships.

Obstet Gynecol. 2018;131:850-855. Abstract

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