Summary of "Provider Opinions Regarding Expanding Access to Hormonal Contraception in Pharmacies," Rafie et al., Women's Health Issues, November 2015.
"Pharmacist-initiated hormonal contraception presents an opportunity for safely increasing access for all women, particularly women with lower socioeconomic status who are at greatest risk for unintended pregnancies," according to Sally Rafie of the University of California-San Diego's Skaggs School of Pharmacy and Pharmaceutical Sciences and colleagues.
According to the researchers, "Pharmacist-initiated contraception has the potential to prevent one-half of a million unintended pregnancies and save nearly $250 billion in public funds each year." However, they noted that "[f]or such a change to occur, support from women, pharmacists, and prescribing providers is needed."
For this study, the researchers "conducted a national survey of reproductive health care providers to assess their opinions on pharmacist-initiated hormonal contraception, as well as behind-the-counter access (BTC) and over-the-counter access (OTC)."
Methods
For the study, the researchers developed a 27-item survey, which was offered to 3,194 physician providers and advanced practice clinicians or midlevel providers in 2009.
The survey asked participants about "sociodemographic, professional, and practice characteristics, as well as provider views about various models of expanded access to hormonal contraceptives in pharmacies, including OTC, BTC, and pharmacist-initiated access, impact of expanded access on patients and providers, pharmacist training issues, and policy implications."
Results
The final sample included responses from 482 participants, of whom 60% were physicians and 40% were midlevel practitioners.
Expanding Access to Hormonal Contraception
The survey found that "74% of respondents supported pharmacist-initiated access" for oral contraception, the patch and the ring; 45% supported BTC access to these three methods; and 28% supported OTC access. The report also found that 67% of respondents supported pharmacist-initiated access to injectable progestin contraceptives, while 38% and 17% supported BTC and OTC access, respectively, to the injectable.
The survey also found that, in terms of the reasons why practitioners supported pharmacist-initiated access:
- 92% of physicians and 85% of midlevel practitioners selected "'important to expand access and reduce barriers for women'";
- 91% of physicians and 88% of midlevel practitioners selected "'preventing unintended pregnancies is an important health issue'";
- 83% of physicians and 73% of midlevel practitioners selected "'greater accessibility for the adolescent population'";
- 80% of physicians and 73% of midlevel practitioners selected "'providing uninsured/underinsured women with an additional point of access'"; and
- 58% of physicians and 58% of midlevel practitioners selected "'important to foster a multidisciplinary approach to public health.'"
Further, according to the survey, 73% of respondents -- 78% of physicians and 65% of midlevel practitioners -- said they were "very or somewhat comfortable with pharmacists authorizing refills for contraception originally initiated by another authorized prescriber."
Effects of Expanded Access
The survey also found that:
- 43% of physicians and 58% of midlevel practitioners believed OTC contraceptive access would negatively affect their relationship with the patient;
- 35% of physicians and 45% of midlevel practitioners believed BTC access would negatively affect the patient-provider relationship; and
- 18% of physicians and 24% of midlevel practitioners believed pharmacist-initiated access would have a negative effect on providers' relationships with patients.
Further, according to the survey, more than 70% of respondents -- 67% of physicians and 79% of midlevel practitioners -- thought "expanding access to hormonal contraception would significantly decrease Pap, pelvic, and breast examinations, as well as sexually transmitted infection screenings, assuming no screening at the pharmacy." Meanwhile, "[w]ith regard to patient out-of-pocket expenses, providers generally anticipated no changes for patients with private (54%) and state-funded family planning or Medicaid insurances (66%)."
Pharmacist Training and Protocols
The researchers also found that:
- 79% of physicians and 66% of midlevel practitioners "were confident or neutral regarding patients' correct use of contraceptive method following education and counseling by a pharmacist";
- 67% of respondents were confident or neutral regarding "pharmacists' ability to identify patients for whom hormonal contraception is contraindicated";
- 62% of respondents were confident or neutral regarding patients' ongoing use of contraception and their ability to follow-up at a pharmacy;
- 52% of respondents were confident or neutral on the ability of pharmacies "to provide confidentiality and privacy"; and
- 48% were confident or neutral about pharmacists' ability to "manage side effects or refer as appropriate."
However, according to the study, few respondents said they were confident that a sufficient number of pharmacists would participate to bolster contraceptive access.
When asked about additional training for pharmacists who opt to provide contraception, the majority of respondents (75%) said pharmacists should take "an intensive training course on hormonal contraception and other reproductive health issues/services." Meanwhile, 61% of respondents said they would be "somewhat or very comfortable" referring a patient to a trained pharmacist for contraception.
According to the survey, 69% of respondents expressed support for a statewide collaborative protocol between the state medical and pharmacy boards for pharmacist-initiated hormonal contraceptive services, 25% said they were opposed and 6% were neutral. Meanwhile, 66% of respondents said they were interested "in signing a collaborative protocol with an individual pharmacist to provide hormonal contraceptive services."
Discussion
"The majority of providers supported pharmacist-initiated access, followed by BTC and then OTC," the researchers wrote, noting that providers' "support for expanded access to hormonal contraception decreased as the level of required pharmacist oversight decreased."
However, the researchers noted that despite "support for expanded access, a majority of providers ... believed that Pap smears, pelvic examinations, breast examinations, and [STI] screening rates would decrease." The researchers noted that while "pelvic and breast examinations are not medically necessary before prescription of hormonal contraception," nonetheless, providers' concerns about maintaining the patient-provider relationship and "timely screening examinations" must be addressed if contraceptive access is expanded.
According to the researchers, "the pharmacy is a cost-effective point of service." Although pharmacies currently "are primarily billing for the cost of the medications themselves, along with a small dispensing fee," proposed legislation that would require Medicare to recognize pharmacists as providers "would allow for reimbursement of pharmacist services for selected patient populations beyond medication dispensing," the researchers wrote.
In terms of a pharmacy access model, the researchers noted that pharmacists would ideally be able "to obtain reimbursement from insurers for contraception services and other services the same way other health care providers do." Meanwhile, patients "should expect to pay the same service fees when obtaining the same service at either a doctor's office, clinic, or pharmacy." Under an OTC model, the researchers added that policy makers would have to ensure affordable contraceptive access as "insurers may not cover the cost of the medication" in such a system.
The researchers also proposed several policy solutions to providers' concerns about pharmacists having the time and training to evaluate and monitor patients for contraindications or side effects, such as self-screening patient questionnaires. Further, the researchers wrote that provider concerns about ensuring adequate pharmacist training for selecting the best contraceptive method and providing patient privacy could be addressed, respectively, through allowing medical boards to "dictate what type of training would be required before participating in the statewide collaborative protocol" and establishing consulting rooms in pharmacies.
Despite these concerns, the researchers noted that providers "were not only supportive of collaborative protocols with the respective state boards, but also willing to sign collaborative protocols with individual pharmacists and refer patients to a trained pharmacist." Further, the researchers found that physicians and midlevel practitioners "believe pharmacists are adequately trained to accurately identify women who are not candidates for hormonal contraception." In addition, according to the researchers, "[p]harmacists are well-poised to help assuage women's fears of the safety of birth control, consult on proper use as well as how to handle missed doses and adverse events."
The researchers wrote that the survey was conducted before California and Oregon enacted laws "granting pharmacists the authority to furnish hormonal contraceptives to patients." As a result, the survey "can serve as a baseline to any changes in provider opinions with the progress on pharmacist-initiated and OTC access," the researchers noted.
The researchers concluded, "Overall, providers support expanding access to hormonal contraception through pharmacists and pharmacies are well-positioned to expand into this niche of preventative care."
