Logistics slow rollout of Ore. contraceptive-access program

BEND, Ore. (AP) — In 2016, Oregon became the first state to allow pharmacists to prescribe birth control to consumers in an effort to increase access to contraception and reduce unintended pregnancies. But while the state has made great progress in training and certifying pharmacists to provide the service, significant logistical hurdles remain, blunting the early impact of the effort.

Many women don’t know they can get birth control at pharmacies, and even those who do may have trouble finding a pharmacist who prescribes. And while the cost of the birth control is usually covered by insurance, in most cases, the pharmacist consultation needed to get a prescription is not. This can leave women with significant out-of-pocket costs.

“It should be another option for people that makes it easier,” said Hannah Rosenau, a program director with NARAL Pro-Choice Oregon. “But when there’s barriers like cost or they can’t find out who is actually participating, I think it remains to be seen whether it’s impacting the people who would like to use this option.”

The bill establishing the program, sponsored by state Rep. Knute Buehler, R-Bend, and passed by the Legislature in 2015, authorized pharmacists to prescribe hormonal birth control pills and patches after completing a five-hour training program. In 2017, the Legislature expanded pharmacists’ prescribing authority to include injectable contraception and birth control rings.

“I think it’s rolled out very well,” Buehler said. “This is a complex undertaking, not done before.”

After passage of the legislation, the Oregon Board of Pharmacy had to write the rules for the program, and pharmacists had to undergo training. The Oregon State University School of Pharmacy created a curriculum for the training and a certification process to show who had completed it. Insurance plans had to develop ways to pay pharmacists for their services, and pharmacies had to figure out how to include prescribing into their work flows.

“For all of that to be done within a year and half of rolling out,” Buehler said, “I think it’s impressive.”

The training for pharmacists is voluntary, and there is as yet no public registry where consumers can look up what pharmacies in their community are participating. Proponents of the measure say that a public registry isn’t crucial as major pharmacy chains in Oregon — including Albertsons/Safeway, Costco, Fred Meyer, Target/CVS and Rite Aid — have moved quickly to get their pharmacists trained.

“With those chains, you’ve covered literally the entire state,” said Paige Clark, director of alumni relations and professional development at Oregon State University, who oversees the training program.

But in an informal survey last fall, NARAL asked volunteers to call 50 pharmacies in Deschutes, Jefferson, Crook, Lane and Jackson counties to inquire about getting birth control prescriptions. In total, 70 percent of pharmacists reached were not able to write prescriptions, mostly because they had not completed the training. Seven pharmacists said it was against store policy. Two-thirds of the pharmacists who were unable to write prescriptions referred callers to other pharmacies who could.

Nearly half of the pharmacists said they could not bill insurance for the consult, and so charged customers fees ranging from $15 to $50.

The Bulletin contacted 11 chain pharmacies in Bend and Redmond last week, finding that six offered the service, with a consult fee ranging from $35 to $45.

“Implementation of any kind of policy is always a much slower process than most people realize. Just because a policy is on the books doesn’t mean it’s fully enacted,” said Dr. Maria Rodriguez, an assistant professor of obstetrics and gynecology at Oregon Health & Science University. “I think things in Oregon have really been a case example for the nation in terms of the smoothness and how well it’s been implemented.”

Rodriguez will soon publish research showing that as of last fall, 1,300 of the estimated 1,600 retail pharmacists in Oregon have been certified, and that 68 percent of Oregon ZIP codes have at least one pharmacist who has completed the training.

In contrast, a University of California, Berkeley, study found that in California, which implemented a similar law in April 2016, only 11 percent of the state’s community-based retail pharmacies offered birth control prescriptions after the first year of the program.

“Training the pharmacists, that’s been easy to do. But the billing and reimbursement mechanism is harder, because it requires pharmacies to contract with the insurance companies,” Rodriguez said. “One of the reasons it’s been highest among chain pharmacies is just because of all the infrastructure that goes into having all of this in place.”

The Oregon Health Plan is supposed to cover the pharmacy consult fee for its members, but Clark said not all of the regional coordinated care organizations, which provide care to OHP members, do. Many private insurance plans are also still considering whether to reimburse pharmacists for their time.

“We have all worked very hard to take care of the underserved population,” Clark said. “But the service should be paid for by the commercial plan. Is it? Well, we’re not quite there yet.”

Clark says for women with private health plans, the convenience of being able to get contraception at a pharmacy, rather than having to make an appointment with a doctor, offsets the cost of the consult fee.

“I would whip out my checkbook and, darn right, I would write a $30 check,” she said. “Are you kidding me? That is well worth the time, energy and effort.”

Buehler said he would consider proposing further legislative changes to require coordinated care organizations to cover the consult fee.

“We all know this is going to save dollars, so for a system that’s supposed to be focused on prevention and care coordination among ancillary providers, we’ve been a little puzzled that CCOs have not embraced this right away,” he said.

Hong Nguyen, a clinical staff pharmacist with Fred Meyer Stores, said nearly all of the pharmacists in the chain’s 50 Oregon pharmacies have been trained and can now write prescriptions. They wrote 587 contraceptive prescriptions in 2016 and 1,093 prescriptions in 2017. But Nguyen said few customers seem to know about the service.

“Some people have been in, but it hasn’t been directly put out there in a big push in Oregon,” Nguyen said. “We need more from the state.”

The chain is unable to promote the service in its weekly flyers because they go to four different states. Meanwhile, it recently had to pull in-store advertising after people complained the woman on the poster looked too promiscuous.

Albertsons Companies is close to having at least one trained pharmacist in each of its Albertsons and Safeway pharmacies in Oregon.

“They really become the experts in providing that service,” said Kimberly Hecht, patient care services coordinator for the company.

Customers might not happen upon that pharmacist when they walk up to the counter, but staff are instructed to direct them to other locations or other times when the prescribing pharmacist will be working.

“We’ve seen a decent amount of demand for the service,” Hecht said. “I think the biggest piece right now is people don’t necessarily equate needing a prescription for birth control with going to your pharmacy.”

Similar problems occurred when pharmacists started providing flu shots. It took major advertising campaigns to get customers into pharmacies for flu season. That experience, however, has prepared pharmacists for an expanded role and has helped pave the way for customers to see pharmacies as a source of health services.

“It definitely showed the public. that we could do more than just count pills, put them in a bottle and give you advice,” Hecht said.

Some women’s health advocates have been pushing for hormonal contraceptives to be offered over the counter to increase access. But that move would require a lengthy and costly process to get Food and Drug Administration approval, and in most cases, health insurance plans won’t cover the cost of an over-the-counter product. Those additional costs can wind up being a barrier, particularly for low-income women who can least afford an unintended pregnancy.

“Cost is a major barrier for women in terms of gaining contraception and using it,” Rodriguez said. “And pharmacist prescription of hormonal contraception is also important because it ensures that access is covered by insurance.”

Pharmacies are also open later and on weekends, so women don’t have to take time off of work to see their doctor.

Other states have followed Oregon’s example, including Colorado, Maryland, New Mexico, Utah and the District of Columbia. Buehler said he’s spoken to officials from other states interested in recreating the program.

“Being one of the first states means that other states get to learn from the Oregon experience,” said Elizabeth Nash, senior state issues manager for the Guttmacher Institute. “And I’m observing that much more information could be made publicly available.”

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Information from: The Bulletin, http://www.bendbulletin.com