Understanding pharmacists' role in contraceptive access

Transcript - Understanding pharmacists' role in contraceptive access

Dr. Mollie Scott: Pharmacists are the most accessible healthcare professionals and are very involved in prevention and managing chronic illnesses. And so it makes a lot of sense for us to contribute to the well-being of women and to increase access to contraception in our pharmacies.

Veronica Salib: Hello, everyone, and welcome back to Healthcare Strategies. My name is Veronica Salib, and I'm the associate site editor for Pharma Life Sciences. We are here today with Dr. Mollie Scott, a pharmacist, the regional associate dean of the University of North Carolina Eshelman School of Pharmacy, and the chair of the department of pharmacotherapy at Mountain Area Health Education Center.

Dr. Scott has been a champion for women's health and has advocated for pharmacist involvement in contraception prescribing. In today's episode, Dr. Scott will discuss the role of pharmacists in prescribing and how that impacts various healthcare stakeholders. Welcome, Dr. Scott, it's great to have you here today.

Dr. Scott: Thank you so much for having me. It's great to be here.

Salib: Awesome. So, to launch our conversation, can you begin by explaining what role pharmacists play in prescribing and how these roles might vary from state to state?

Dr. Scott: According to the American Pharmacists Association, there are 29 states that allow pharmacists to prescribe hormonal contraception. It does vary by state, and so depending upon what state you live in, you may be able to get the combined hormonal contraceptive pill or the progestin-only pill -- sometimes the contraception shot, the patch, or the ring, depending upon what the laws are in each state. Pharmacists are the most accessible healthcare professional and are very involved in prevention and managing chronic illnesses. And so it makes a lot of sense for us to contribute to the well-being of women and to increase access to contraception in our pharmacies.

Salib: We talked, when we were first discussing getting on this podcast, about how pharmacists are the primary point of contact for most patients with the healthcare system. I think it's an interesting point to make. Can you discuss a little bit about what the rules and regulations are that are in place regarding prescriptions written by a pharmacist?

Dr. Scott: Sure. Each state has its own Pharmacy Practice Act that governs the scope of practice for pharmacists. For instance, pharmacists can administer vaccines in every state across the country. In all states as well, we can practice under collaborative practice agreements with physicians where they're focusing on the diagnosis, and we're managing chronic diseases.

Vaccines are typically administered in community pharmacies, whereas collaborative practice agreements are often in physician practices like internal medicine or family medicine.

For contraception, again, it does depend on the state that the pharmacist is practicing in, but in most states, there had to be some kind of change to the Pharmacy Practice Act or an additional law that was passed, allowing pharmacists to prescribe contraception. So in North Carolina, we passed our law in 2021.

And then after you passed the law, the Board of Pharmacy here in North Carolina worked with the Board of Medicine, pharmacists, and physicians worked together with the Department of Health and Human Services to create statewide protocols for pharmacists to prescribe contraception, to kind of define exactly how we are providing that service and what the visit entails, what types of things we can prescribe, the information that we should give our patients to ensure that we're using evidence-based recommendations from the Centers for Disease Control and the medical eligibility criteria and that we have a standard approach to contraception care across our state.

Salib: Contraception right now is such an important discussion as policies change -- as rules and regulations change nationwide and within different states. And so I want to dig a little bit more into what you were just saying about collaboration between physicians and pharmacists. And could you discuss how that works when it comes to contraception and how we're ensuring that a patient is getting the right prescription for them based on their health background?

Dr. Scott: Yeah. It is very important that we give the appropriate medication for each patient, whether it's contraception or any other chronic illness or acute problems. So pharmacists are all about the safe and effective use of medications. Pharmacists prescribing for contraception is considered independent prescribing according to a statewide protocol or a standing order, depending upon the state.

And so in our state, we have a statewide protocol that outlines what we're able to do and what we're able to prescribe. When we do our assessment, we do ask the patient about past medical history because one of the things we want to make sure of is that there's not a contraindication to using estrogen-containing products like high blood pressure or a history of a blood clot.

So, as part of our workflow, we do check the patient's blood pressure to make sure that's okay and, again, that the patient would be eligible for estrogen. It's also really important for us to partner with the patient and provide person-centered care and noncoercive care -- that we listen to what our patient is needing. Sometimes, patients are seeking contraception for birth control, but other times, they're seeking it for noncontraceptive benefits like management of heavy periods or acne.

And so understanding the patient's reproductive life goals and what their contraceptive and noncontraceptive goals are very important. And then in terms of partnership with physicians as well as other reproductive health stakeholders in the community, there will be things that will come up that will not be in our scope of practice. And so for instance, we do not do pap smears, and so it's important for women to have cervical cancer screening.

They might be at risk for sexually transmitted infections and need to see their physician for that, or perhaps personal preference or the best product for them for contraception is something that they would need to get from a physician, a nurse practitioner, or a [physician assistant] PA. And so having those relationships in the community so that we can refer them for other healthcare needs is really important.

Salib: You discussed a little bit about having that open conversation with patients, and like I mentioned before, especially community pharmacists, they're really pillars in the community. They are the people that we have the most contact with, especially if someone is struggling with a chronic condition or has a medication that they're taking regularly, like a contraceptive prescription. And I think that leads really well into my next question, which is: How does the pharmacist's ability to prescribe any medication, but specifically birth control, impact patients and public health?

Dr. Scott: Yeah, that's a great question. So, there is some data out of the state of Oregon about the positive impact of pharmacists-prescribed birth control. And so in the state of Oregon, as they were rolling out their initiative, they were finding that patients were definitely seeking out community pharmacists for contraception and that pharmacists were actually prescribing about 10% of all birth control prescriptions as they were getting started.

So it definitely shows that patients are open to the idea and that they are seeking out the pharmacists for that type of care. Their researchers in Oregon also demonstrated cost savings to Oregon Medicaid, and they demonstrated a cost savings of $1.6 million. And that is thought to be because sometimes unintended pregnancies are associated with negative outcomes, not all the time, but about half of pregnancies are unintended.

And we are concerned about increasing maternal mortality across the country for a variety of reasons, particularly in women of color. So being able to support women, families and communities as they are thinking about having a family, not having a family. We do have some really positive signs and outcomes from Oregon. One of the things that we know from some of our early data here in North Carolina is that we are serving women under the age of 18.

And so technically, according to our law, our legislation in North Carolina, if you're under 18, you do need consent from a parent or guardian. And what we're finding is that we have had young women come in with their parent or guardian to seek care, which is really terrific to see that level of support from parents and guardians for their young daughters. We also know that the most frequently prescribed product by pharmacists in North Carolina is the combined hormonal contraceptive pill, which makes sense.

That's one of the most frequent products that's prescribed by anyone in the U.S. And we also know that a large proportion of patients that have been seen in North Carolina actually don't have a primary care provider. And those are actually the patients that we're trying to reach.

We're trying to make it easy for patients to come into the pharmacy, have a short visit, walk out with a year's worth of birth control, and then be connected to a primary care provider if they don't have one, and connected to their primary care provider for follow-up care for things that we can't provide. So we are definitely seeing benefits. And one of the challenges right now is we want more people to know about this as an option. So we're really glad to be here with you today to talk about pharmacist-prescribed birth control.

Salib: Yeah. I think it's really important that more people know, and that's another challenge I'm assuming, is that because the laws vary so much from state to state, people aren't really sure what it is in their state, whether they can or cannot go to the pharmacy and just get the prescription or at least get a consultation or discuss something. So how would you suggest that, if someone is listening to this podcast and they don't know what the regulations are in the state, what's the best way to get the most accurate information?

Dr. Scott: One of the easiest things to do would be to ask your pharmacist if this is a service that they provide, and if they don't, to ask them if they know someone in the community who does provide the service. There are also some places that patients can go to find out where pharmacist-prescribed birth control might be in their community. And so one of those is Birth Control Pharmacist out of California.

They have a website that you can go to and then narrow it down to your state and then to your town and see if there's a Birth Control Pharmacist near you. And services are being provided by chain pharmacies as well as small independent family-owned pharmacies. And then in our state, we also have a website with the North Carolina Association of Pharmacists to find a pharmacist who is providing services.

Some states also have a logo. So we have a logo in North Carolina that folks can look for in the pharmacy or on the pharmacy website. And then Birth Control Pharmacist also has a logo that they use. And so that enables us to tell patients that we're there and available to provide that service for them.

Salib: So we discussed a bunch of different things about the benefits of pharmacist prescribing, and I think you started hinting at some of the potential challenges. Can you discuss a little bit more about what the drawbacks might be or what the challenges have been so far from right now where certain states currently can have pharmacists prescribing birth control? And then I know since you had a really big hand in advocating for these policies, if you could discuss what the challenges were when you were advocating for them?

Dr. Scott: One of the main challenges is that this isn't happening in every single state across the country like it is for vaccine administration. And so one of the things that we hope is that getting your birth control from your pharmacist will become as commonplace as getting your flu shot from your pharmacist every year. So we do have states that have not yet implemented any legislation or haven't even introduced anything yet to allow pharmacists to provide that level of care.

So, the collaboration with physicians and other reproductive health stakeholders remains important just to make it even a thing in some states. Some of our larger chain pharmacies have shared that one of the things they're waiting on to be able to provide the service are standardized workflows at their corporate level. For instance, if you own just a small pharmacy in a small town, it's easier for you to do something creative and innovate it and roll it out in your own community pharmacy.

But if you're part of a network of hundreds or even thousands of stores, then the large corporate office has to figure out how to implement that in the same way across all of those stores. Also, recognizing that the rules are different in every state. So that has been a challenge.

I think also incorporating birth control visits into workflow. Pharmacists are very busy, and of course right now it is flu and COVID vaccine season, and they're very busy on the phone working with insurance companies, counseling patients, working with people at the window, and keeping up with all the metrics that are important for community pharmacy performance.

And so that has been a challenge, supporting pharmacies as they figure out how I might incorporate this into my existing workflow. So one of the things that we have done to support pharmacies as they're implementing birth control services is for them to think through how they use student pharmacists or interns or their technicians to greet the patient, have them do the paperwork, complete the blood pressure assessment, and then have the pharmacists go in with all of that information to talk with the patient about what their preferences are, what their goals are, and then ultimately make the decision together about what product might best suit them.

And of course, that takes some time, but most of the visits are around 10 to 15 minutes. So they're not very long, especially if someone else like a technician or a student is collecting that data on the front end. And I would say the final challenge is something that faces community pharmacists everywhere they practice, and that is reimbursement for clinical pharmacy services.

So pharmacists are paid for medications that they dispense, although the reimbursement that we get from insurance companies has been really challenging over the past years because of decreasing reimbursement rates. And so in order for small pharmacies to stay open, it's really important for them to be able to maintain their business model, which is difficult if they're providing services where they are not reimbursed. So physicians, PAs, and nurse practitioners are not going to provide clinical services without a reimbursement model from insurance companies.

So one of the things that we are doing at the state and national level is working with third-party payers, insurance companies, and state Medicaid plans to ensure that there is a payment model where pharmacists get paid for their time just as a physician or a nurse practitioner, PA, would be paid for their time. So in North Carolina, we do have a payment model with North Carolina Medicaid, which enables the pharmacists to be reimbursed for their clinical time, which helps with the finances and the financial sustainability of a program like that.

Salib: Yeah, I think the reimbursement part is so critical, and it's definitely a whole beast of a challenge, I would say, especially as you mentioned, with smaller pharmacies, they need that reimbursement to keep them running financially. And these are the pharmacies in the communities with people who aren't getting as much contact with the healthcare system in more rural areas.

And so it's all kind of intertwined in a way. So thank you so much for describing that factor. I want to move on a little bit and discuss the regulatory landscape and how it's continuing to change. How do you see this field of birth control prescribing, pharmacist prescribing evolving as the regulatory landscape continues to evolve and change?

Dr. Scott: One thing that I'm seeing that I think is very encouraging is the new over-the-counter Opill product. That's the first over-the-counter hormonal contraceptive. It's a progestin-only product, and you can go to your pharmacy to purchase it. It's around $20. And so that's another thing that has happened with the FDA and with regulations, allowing that medication to go from a prescription-only product to an over-the-counter product in order to increase access to care.

So I think that is a good step forward. The American College of Ob-Gyns has been very supportive of over-the-counter birth control for years, and there's a host of organizations, such as Free The Pill, that have supported having increased access just over-the-counter without having to do any kind of assessment. And the patient then has a responsibility to read the package insert, the packaging to determine if it's safe for them or not, just like they would any other over-the-counter medication.

There are also some opportunities for pharmacists to now be involved in dispensing of Mifepristone for medication abortion. That has not had a wide uptake, but there are some opportunities now for pharmacists to be engaged in that space. And it's certainly something that we're teaching our student pharmacists about so that they're aware of all the different opportunities and options that there are for women in their reproductive health lifespan, including contraception as well as abortion care.

Salib: Well, my next question kind builds off of that, but are there any policies or bills or anything of that nature that we should be keeping an eye out that may impact pharmacists prescribing?

Dr. Scott: I don't think there's anything out there right now at the federal level that I'm aware of regarding contraception, but it's certainly something that we'll be watching as we head into 2025. One of the things we would like to see as pharmacists again is new policies, regulations, and legislation around reimbursement for clinical services.

I think that's really important so that we can continue to spread this model. And there is another over-the-counter product that has estrogen and progestin in it that's being considered by the FDA as a prescription to over-the-counter switch. So that might be something for us to look for in the next year or so.

Salib: Awesome. Well, my final question before we close is if you could give any tips, tricks, or ideas to pharmacists who are living in states that have not approved pharmacist prescribing or are not quite as far along as your state, what would they be?

Dr. Scott: Yeah, that's a great question. My biggest piece of advice for other states has been to see this as a reproductive health initiative and not a pharmacy initiative. There are a host of other healthcare professionals and reproductive health experts who were working in this area to increase access to hormonal contraception for women to ensure that women's health stays accessible. And so partner with them, thinking about ob-gyns and family docs and midwives.

Those are great partners for pharmacists. We're not trying to take other people's patients. We're trying to have one more door that we can open to increase access to care so that women who live a distance away from an ob-gyn or have to take off work to go to their family doctor and need childcare or transportation that might be easier for them. It might be simpler for them because the vast majority of Americans live within a couple of miles of a pharmacy.

And I would also say partner with your legislators and educate them about all that pharmacists are doing around prescribing in other areas. Often, legislators in the public think of us dispensing medications, and they might not realize that pharmacists can actually prescribe to some degree in all states. Educating them, advocating for patients, and letting them know how we can all work together to improve women's health, I think, is the advice that I would give. Don't try to go it alone. Work with those who are already in this space.

Salib: Awesome. Well, thank you so much for joining us today, Dr. Scott. It was a great conversation. For our listeners, we would love to hear from you. Feel free to reach out with any healthcare-related questions or subjects that you think we should cover by emailing me at [email protected]. And if you liked this episode, please consider rating and reviewing us on Apple Podcasts, Spotify, or wherever you're listening. Thank you so much for listening.

Kelsey Waddill: Music by Vice President of Editorial Kyle Murphy, and production by me, Kelsey Waddill. This is an Informa TechTarget production

Veronica Salib has covered news related to the pharmaceutical and life sciences industry since 2022.