Abstract
This survey study estimates the extent to which pharmacies in California are making pharmacist-prescribed contraception available since it was permitted, but not required, in April 2016.
California is 1 of 4 states currently permitting—but not requiring—pharmacists to prescribe contraception. Since April 2016, patients can obtain hormonal contraceptive pills, injections, rings, and patches in California pharmacies offering this service. After patients complete a health questionnaire (and, for combined hormonal contraception, a blood pressure reading), trained pharmacists determine medical eligibility for methods, conduct counseling, and prescribe contraception. Although insurers are not required to reimburse pharmacies for this clinical service, pharmacies may charge patients fees.
To date, the extent to which pharmacies are making pharmacist-prescribed contraception available under these nascent policies has not been estimated; this study does so at 1 year after implementation began in California.
Methods
The Office for Protection of Human Subjects at the University of California, Berkeley, deemed this study to be nonhuman subjects research. A telephone audit study of a representative sample of California pharmacies was conducted between February 2017 and April 2017. A list of all licensed pharmacies (n = 7048) was obtained from the California State Board of Pharmacy in October 2016. Hospital, clinic, university, and specialty and other non–full-service pharmacies (eg, long-term care, mail order) were identified and excluded. A random sample of 20% of included pharmacies was used—stratified by urbanity (census tract designation) and pharmacy type (retail chain or independent, defined as <5 locations). With a power level of 0.85 and an α of .05, the minimum sample size required to detect an effect size of 0.1 in χ2 tests of independence comparing availability of pharmacist-prescribed contraception by urbanity or pharmacy type was 898.
To assess availability of pharmacist-prescribed contraception, trained interviewers used a structured data collection instrument. Posing as patients, interviewers called pharmacies and said: “I heard that you can get birth control from a pharmacy without a prescription from your doctor. Can I do that at your pharmacy?” If pharmacy staff responded affirmatively, interviewers inquired about service fees and method availability, documenting contraceptive methods spontaneously mentioned.
Proportions with 95% CIs, medians with interquartile ranges (IQRs), and χ2 tests comparing differences in availability by urbanity and pharmacy type were estimated using Stata (StataCorp), version 13.1. Statistical significance was set at 2-tailed P value of less than .05.
Results
The sampling frame included 5291 community-based, retail pharmacies. A random sample of 1058 pharmacies was drawn, with data collected from 1008 (95.2%). Most pharmacies were urban (85.7%) and affiliated with chains (70.3%) (Table 1). Pharmacist-prescribed contraception was available in 11.1% (95% CI, 9.3%-13.2%) of pharmacies, with no significant availability differences by urbanity or pharmacy type. Among pharmacies offering this service (n = 112), 67.9% (95% CI, 58.5%-75.9%) indicated a specific fee requirement (median, $45 [IQR, $40-$45]) (Table 2). Most chain pharmacies (86.3% [95% CI, 76.2%-92.6%]) had set fees compared with independent pharmacies (33.3% [95% CI, 20.2%-49.7%]) (P < .001). When queried about method availability, contraceptive pills were referenced most frequently (77.7%), followed by rings (40.2%), patches (38.4%), and injections (8.9%).
Table 1. Availability of Hormonal Contraception Prescribed by a Pharmacist in California Pharmaciesa.
| Total Pharmacies, No. (%) | Pharmacist-Prescribed Contraception Available, No. (%) [95% CI] | Pharmacist-Prescribed Contraception Not Available, No. (%) [95% CI] | P Value | |
|---|---|---|---|---|
| Overall | 1008 (100.0) | 112 (11.1) [9.3-13.2] | 896 (88.9) [86.8-90.7] | |
| Pharmacy type | ||||
| Chain | 709 (70.3) | 73 (10.3) [8.3-12.8] | 636 (89.7) [87.2-91.7] | .21 |
| Independent | 299 (29.7) | 39 (13.0) [9.7-17.4] | 260 (87.0) [82.6-90.3] | |
| Setting | ||||
| Urban | 864 (85.7) | 96 (11.1) [9.2-13.4] | 768 (88.9) [86.6-90.8] | >.99 |
| Nonurban | 144 (14.3) | 16 (11.1) [6.9-17.4] | 128 (88.9) [82.6-93.1] |
There were 1058 pharmacies sampled for inclusion. Data were not collected from 50 sampled pharmacies for the following reasons: no contact after 3 attempts (n = 22); pharmacy was permanently closed for business (n = 12); pharmacy did not offer contraception (n = 9); no working phone number (n = 5); and availability of pharmacist-prescribed contraception was indeterminate after the phone call (n = 2).
Table 2. Characteristics of Pharmacist-Prescribed Hormonal Contraception in California Pharmacies.
| Characteristics | Pharmacies Offering Pharmacist-Prescribed Contraception, No. (%) [95% CI] (n = 112) |
P Value |
|---|---|---|
| Pharmacy Service Fees for Prescribing Contraception | ||
| Pharmacies with established fee requirementsa | 76 (67.9) [58.5-75.9] | |
| Fee requirements by pharmacy type | ||
| Chain | 63 (86.3) [76.2-92.6] | <.001 |
| Independent | 13 (33.3) [20.2-49.7] | |
| Fee requirements by urbanity | ||
| Urban | 65 (67.7) [57.6-76.4] | .93 |
| Nonurban | 11 (68.8) [42.2-86.9] | |
| Fee, median (IQR), $ | 45.0 (40.0-45.0) | |
| Fee amounts | ||
| <$45 | 27 (35.5) [25.4-47.1] | |
| $45 | 43 (56.6) [45.0-67.4] | |
| >$45 | 6 (7.9) [3.5-16.7] | |
| Available Contraceptive Methods Spontaneously Mentioned by the Pharmacy Staffb | ||
| Oral contraception | 87 (77.7) [68.9-84.5] | |
| Vaginal ring | 45 (40.2) [31.4-49.6] | |
| Patch | 43 (38.4) [29.7-47.8] | |
| Injectable contraception | 10 (8.9) [4.8-15.9] | |
| Otherc | 16 (14.2) [8.9-22.2] | |
| Do not know | 5 (4.4) [1.8-10.4] | |
Abbreviation: IQR, interquartile range.
To assess fees for obtaining pharmacist-prescribed contraception, interviewers said, “I know my insurance covers birth control, but do I have to pay anything upfront?” When a fee range was provided, the midpoint was used to estimate the median. Data were missing for 6 pharmacies. In an additional 3 pharmacies, the staff member did not know whether a fee was required or not. Other responses were given by 5 pharmacies (4 indicated that the fees were dependent on insurance coverage; 1 pharmacy had not yet determined the fee amount).
To assess available contraceptive methods, interviewers said, “What type of birth control can I get?” and documented methods spontaneously mentioned. Availability of each method was not ascertained. Data were missing for 4 pharmacies.
Other responses included all methods; a method the caller had used in the past; and availability of methods will be determined based on health questionnaire responses.
Discussion
One year after California pharmacists were permitted to prescribe contraception, a minority of pharmacies offered this service. Previous research highlights barriers to implementation, including concerns about training, liability, and staffing. Most pharmacies offering pharmacist-prescribed contraception required a fee for this service, particularly retail chains. Even when contraception is available in pharmacies, it may not be economically accessible because of fees. In California, lack of insurance reimbursement may undergird low availability of pharmacist-prescribed contraception. Additional legislation (effective in July 2017) requires California's Medicaid program to reimburse for pharmacist services by July 2021; the implementation timeline and lack of private insurance coverage may still present barriers to increasing availability of this service.
The strengths of this study include use of a large, representative sample of pharmacies and the high response rate. Limitations are assessment of service availability via phone and inclusion of only 1 state. Additionally, availability of each method was not systematically ascertained.
Pharmacist-prescribed contraception could facilitate contraceptive use for many women. With at least 9 states implementing or considering allowing pharmacist-prescribed contraception, continued research is needed to identify barriers to accessibility of this clinical service.
Section Editor: Jody W. Zylke, MD, Deputy Editor.
References
- 1.National Alliance of State Pharmacy Associations Pharmacists authorized to prescribe birth control in more states. https://naspa.us/2017/05/pharmacists-authorized-prescribe-birth-control-states/. Accessed August 19, 2017.
- 2.California State Board of Pharmacy Self-Administered Hormonal Contraception Protocol for Pharmacists. Sacramento, CA: California State Board of Pharmacy; 2016. [Google Scholar]
- 3.California Legislative Information Senate bill no. 493. http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201320140SB493. Accessed November 7, 2017.
- 4.Gonsalves L, Hindin MJ. Pharmacy provision of sexual and reproductive health commodities to young people. Contraception. 2017;95(4):339-363. [DOI] [PubMed] [Google Scholar]
- 5.Rodriguez MI, McConnell KJ, Swartz J, Edelman AB. Pharmacist prescription of hormonal contraception in Oregon. J Am Pharm Assoc (2003). 2016;56(5):521-526. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.California Legislative Information Assembly bill no. 1114. https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201520160AB1114. Accessed November 7, 2017.