The Affordable Care Act (ACA) gave millions of uninsured Americans health coverage. But it couldn’t conjure enough primary care physicians to serve this new patient population. Even before the ACA passed, some 65 million Americans lived in areas with primary care shortages: Doctors were too few, too far apart, or too overbooked to provide sufficient care. The U.S. Department of Health and Human Services predicts that by 2020, the United States will have a shortage of about 20,400 physicians.
A California bill (SB-493) passed in 2013 is going into effect that will allow the state’s trained pharmacists to provide some basic care. With additional training, they would be able to prescribe birth control pills and some other drugs directly to patients without having to go through a doctor. (Like medical doctors, all pharmacists hold a doctorate degree. Their degree gives them an expert knowledge of prescription medications, allowing them to counsel their patients on the proper use of drugs.)
More than two thirds of Californians live in areas with healthcare provider shortages, according to the bill’s sponsor, Senator Ed Hernandez, who is an optometrist.
Contraception, Over the Counter
With additional training, California pharmacists will be able to prescribe hormonal birth control to women, including pills, patches, rings, and injections.
“As a pharmacist, it's hard to send my patient elsewhere for care when I know I have the knowledge and skills to help her with her birth control,” said Sally Rafie, PharmD., assistant clinical professor of health sciences at the University of California, San Diego Skaggs School of Pharmacy & Pharmaceutical Sciences, in an interview with Healthline. “This new law allows me to take care of my patients while still collaborating with other healthcare providers.”
Pharmacists would perform an eligibility screening that meets rigorous guidelines called the United States Medical Eligibility Criteria for Contraceptive Use before prescribing contraceptives. These ensure that the woman doesn’t have any health conditions and isn’t taking any other medications that might make it dangerous to use hormonal contraception.
The bill aims to reduce unwanted pregnancies, which account for more than half of all pregnancies in the United States. Unwanted pregnancies disproportionately occur among low-income and minority women.
One study suggested that if contraception were available over the counter (OTC), an additional 11 to 21 percent of low-income women would use it, resulting in a 7 to 25 percent decrease in the number of unintended pregnancies. Another study compared women who received birth control from clinics in El Paso with women who got their medication over the counter in Mexico. It found that women who got their birth control from clinics were about 25 percent less likely to continue using the medication long-term.
But widening access to effective contraceptives remains a controversial issue, even beyond the usual right wing objections. The California Medical Association, which opposed previous versions of the bill, was unavailable for comment. But the group and other critics of the bill have asked: Will women still have preventative health screenings done if they don’t have to go to a doctor to get birth control?
Another study by the El Paso/Mexico research group found that preventative healthcare rates don’t fall very far, however. “Our research in El Paso found that U.S.-resident women who accessed their oral contraceptives OTC in Mexico had very high rates of preventive screening,” said Kristine Hopkins, Ph.D., research assistant professor of sociology at the University of Texas at Austin, in an interview with Healthline. “For instance, 91 percent of women who got their oral contraceptives OTC had a recent Pap smear. This is higher than the national average of 85 percent of women of reproductive age.”
Among women who didn’t get tested, the top two reasons were price and convenience.
“This is a big concern, but it comes back to trusting women,” said pharmacist Rafie. “We can't hold the birth control hostage or as a carrot to get them to come in for their other unrelated health screenings. If women don't value these services, we need to increase awareness and education, rather than punishing women by withholding another important service.”
Additional Power of the Pad Under SB-493
Although any pharmacist can be trained to prescribe contraceptives, the bill also creates a new level of training and licensing for pharmacists: advanced practice pharmacist (APP).
Pharmacists with an APP license will be able to perform a physical assessment and refer patients to other care providers. They will be able to prescribe certain basic drugs, such as smoking cessation and travel-related medications. They will be able to order tests related to drugs that require regular monitoring and adjust patients’ medications based on those test results.
At each step of the way, the pharmacist should work with the patient’s primary care physician, keeping lines of communication open to best serve the patient’s needs.
“You can imagine a community pharmacist working very closely with a primary care provider or practice, and as an access point could order tests specific to making sure a medication is safe,” said Lisa Kroon, PharmD., chair of the department of clinical pharmacy at the University of California, San Francisco School of Pharmacy, in an interview with Healthline. “For example, a lot of blood pressure medications can cause electrolyte disturbances, like low potassium or low sodium. As part of the dispensing process, the pharmacist could order those tests.”
Kroon doesn’t worry that being able to get certain prescriptions from pharmacists will cause people to stop seeing their doctors. In fact, she hopes to see the opposite.
“If the pharmacist has someone coming to them, and they share that they either don’t have a primary care provider or they haven’t seen their primary care provider for awhile, that pharmacist could actually help connect them back into the healthcare system,” she said. “All the pharmacists and pharmacy students that I train – that’s really our approach to care, that we’re a member of a team, and that we’re not just practicing out there on our own.”
Kroon hopes that giving pharmacists more authority will expand healthcare access in rural areas. Rural and economically disadvantaged urban areas have less than half the rate of primary care physicians than wealthier urban areas, meaning that patients often have to travel long distances or wait for months to see their doctor.
“Community pharmacists are one of the most accessible healthcare providers out there,” Kroon said. “Not only for low-income people who may not have a designated primary care provider, but also in more rural areas where physician practices may require a person to drive a significant way, while a pharmacy may be nearby. It’s a nice access point to healthcare that the community pharmacy will be able to provide.”
Footing the Bill
The California bill is relying on insurers to cover the additional services that the pharmacists would be providing. It doesn’t compel insurers to do so, but it designates pharmacists as healthcare providers, a status that health insurance companies require in order to cover medical services.
So far, those using these services are having to open their own wallets.
“Insurance companies, including state and federal programs, are currently not reimbursing pharmacists for this service. Women should be prepared to pay a small fee for this service at the pharmacy” said Rafie. She added: “If you feel strongly that the insurance companies should reimburse pharmacists for this service as they would reimburse a physician or nurse practitioner for the exact same service, please make sure your insurer hears your voice on this issue!”
Kroon thinks it would be to the benefit of the insurance companies to offer coverage.
“A lot of the health insurance companies and medical groups need to meet certain quality measures. Pharmacists can help them achieve those measures,” she said. “There’s a win-win and return on investment in terms of paying the pharmacists to provide the services. Ultimately, of course, we would like to see pharmacists getting paid for [their] professional services just like our physician colleagues are.”
The California Pharmacists Association is also working on a bill that would add pharmacist services to be covered under Medical, the state’s version of Medicaid.