A California law that went into effect in 2016 allows pharmacists to prescribe, not just dispense, many forms of birth control. But three years in, only fifteen percent of pharmacies offer the option and too few women know about it.
Starting April 1, Medi-Cal will reimburse for the counseling fee that pharmacists typically charge, which is usually in the range of $45, for women who use the insurance plan for low-income people. Women’s health advocates are hopeful that will increase the number of pharmacists prescribing and the number of women who find and make use of the option.
“Absolutely many women don’t know this is possible,” said Sally Rafie, a pharmacist at UC San Diego Health and an assistant clinical professor at Skaggs School of Pharmacy and Pharmaceutical Sciences at UC San Diego.
“The state approved the expansion of the scope of practice for pharmacists but offered no help on expanding awareness among consumers,” Rafie said.
While the law allows pharmacists to prescribe birth control, it doesn’t require them to do it.
Unless they are currently enrolled in pharmacy school, where prescribing birth control is now taught, they must take an online or in person course at their own (or their employer’s) expense before they can begin prescribing contraceptives. Courses can cost several hundreds dollars.
Expanding access to birth control is critical, say advocates. A 2017 study commissioned by Planned Parenthood estimates that only about half of sexually active women between ages 15 to 39 received family-planning services in the year before the study. Improving the opportunity for women to learn about their birth control options could reduce unintended pregnancies by 64 percent.
“Reductions in unintended pregnancies and births mean fewer children born into poverty and fewer with negative birth outcomes such as low birthweight,” according to the report.
While there will never be just one solution to birth control access, Rafie said, pharmacies are often far more accessible than doctors’ offices or health clinics. “Barriers such as transportation, childcare and time off from work can make it hard for women to access clinics and doctors’ offices,” said Erin-Garner Ford, executive director of ACT for Women and Girls, a reproductive justice organization in the Central Valley. Garner-Ford will be working with Sally Rafie on a survey about access to pharmacies for birth control in the Central Valley this summer.
“These barriers most affect women who are already socioeconomically disadvantaged, making their lives even more difficult,” said Rafie.
Undocumented immigrants may also find pharmacies more accessible and less threatening than health clinics, Garner-Ford said.
According to Rafie, research shows that ninety percent of people in the U.S. live within five miles, or closer, to a pharmacy. Also, pharmacies are often open during the evening and on weekends, when women may have more time for a birth control appointment but clinics and doctors’ office may be closed.
In California, neither pharmacies nor the state have done much to advertise that pharmacists can now prescribe birth control. Rafie and some colleagues decided to raise that awareness themselves, creating a website called Birth Control Pharmacies that uses a map to mark pharmacies offering birth control in the six U.S. states where it is currently permitted. (Besides California, pharmacist prescribing of birth control is allowed by law in Oregon, Colorado, Hawaii, Maryland and New Mexico.)
Social media linked to the site keeps up the message that birth control prescriptions and counseling are available at pharmacies.
Ariel Genovese, 33, wishes she’d had access to the website a year after the law was implemented when she was an independent contractor with no health insurance. She called several pharmacies to find one near her that prescribed birth control, to no avail.
Genovese took a full time job in part because her health insurance would cover doctor’s visits for birth control prescriptions.
One reason the uptake has been slow is that pharmacies who decide to add the service must carve out time for the pharmacist to conduct a brief annual health check—required in the state law—with a woman who wants birth control.
Women fill out a health questionnaire to help determine their safest birth control option. A history of breast cancer, high blood pressure or migraine with aura, for example, rule out estrogen-based birth control, and women are then advised to choose a progestin based birth control which does not have the same health risks.
Pharmacists in the state can prescribe birth control pills, a patch, a shot and the vaginal ring.
Anu Gomez, director of the sexual health and reproductive equity program at UC Berkeley, is tracking the number of pharmacists who offer birth control prescribing. In 2017, she published a paper in JAMA, which found that of 1008 pharmacies surveyed, 11 percent had pharmacists who were prescribing birth control. That went up by four percentage points last year, said Gomez, who will soon publish that data.
California Health Report contacted several large chains who operate pharmacies in California, including Costco, Walgreens, CVS and Vons, all of whom had at least some pharmacists who can prescribe birth control.
Rafie advised using the Birth Control Pharmacies map and calling ahead, not just to ask if the option is available, but what days and what time the prescribing pharmacist is available.
The visit should take ten to thirty minutes and the prescription is good for a year. In addition, by law pharmacists can prescribe a year’s worth of birth control though some may only dispense smaller amounts. Health insurance will cover the cost of the birth control, but not necessarily the counselling fee.
To help increase pharmacist birth control prescribing, Rafie, together with Sheila Mody, the director of the Division of Family Planning in the obstetrics and gynecology department at UC San Diego, are about to start a study with forty pharmacists looking at different education modules to see which would give pharmacists the knowledge and comfort level to feel confident about prescribing birth control.
They hope to have results this spring and plan to share the results with the California Pharmacists Association, pharmacies and policy makers.
“Having pharmacists prescribe birth control can be particularly beneficial in rural areas,” said Rafie. For example, there are many migrant workers in rural areas who may be hesitant to go to a health clinic or may feel a stigma about going to a family planning clinic.
Jon Roth, the CEO of the California Pharmacists Association noted that a key obstacle to more pharmacists participating has been reimbursement. “The association supported the legislation because we see pharmacists as the face of neighborhood health care,” Roth said.
The primary objective of the legislation was to provide more options to underserved communities, Roth said. Once MediCal reimbursement starts, commercial insurance coverage for counselling will follow.