Expanding Patient Access to Hormonal Birth Control Through Pharmacist-Led Initiatives

Kayla McFeely and April Wolski, PharmD Candidates Class of 2017 Lauren J. Jonkman, PharmD, MPH, BCPS

University of Pittsburgh School of Pharmacy, Pittsburgh, PA

BACKGROUND

PRESCRIBING PROCESS MAP

ADVANTAGES AND DISADVANTAGES

REFERENCES

• The demand for physicians is projected to steeply increase over the next decade 11

• Prior to the Affordable Care Act being established, the average cost for a primary care visit for an uninsured patient was $160 8

• Physicians tend to practice in upscale and urban environments, making access an issue for many low income, and rural dwelling patients 12

PROBLEMS: COST AND ACCESS • Family planning is key to slowing unsustainable population growth, which causes

negative effects on the economy, environment and development efforts

• Research has shown that there is causal link between closely spaced pregnancies and three key birth outcome measures: low birth weight, preterm birth, and small size for gestational age.

• There is an association between unintended pregnancies and delayed initiation of prenatal care, which leads to less than optimal outcomes

• Evidence has shown that women who experience unplanned pregnancies are more likely to experience physical and sexual abuse

• Women with incomes below the federal poverty level have more than five times the unintended pregnancy rate of women at 200% poverty and greater

• By preventing unintended pregnancy, contraception prevents deaths in mothers and children, and reduces the ned for unsafe abortion

CONSEQUENCES OF INADEQUATE ACCESS 5

OBSTACLES

Patient request

Screen (PMH, BP)

Discuss and Write Script

Dispense and

Counsel

In Oregon, patients must be over the age of 18, and will complete a brief screening completed by the pharmacist. They are also required to fill out a questionnaire concerning their health and medical history 3

ACKNOWLEDGEMENTS

There has recently been a great push in the medical community to increase access to birth control through legislative action. In several states such as California and Oregon, recent legislation has passed that allows women to obtain birth control without a doctor’s prescription.

In Oregon, with these new regulations in place as of 01 Jan 2016, patients will be able to receive both a prescription and a 1-year supply of the medication itself directly from the pharmacist. In Oregon, this is limited to only oral contraceptives and patches, and age 18 and older. In California, no such limits are in place. Oregon law also requires pharmacists to complete specialized training, to ensure a standardized and safe process.2,3

The goal of this legislature is to minimize the barriers between the patient and birth control, while also making the process more cost and time effective.

STUDENTS SPEAK MEASURABLE OUTCOMES

Patient Utilization

Patient Satisfaction

Surveys

Short Term

Unintended Pregnancy Decrease

Decreased risk of ovarian and endometrial

cancers

Long Term

NEXT STEPS FOR PA

Collaborative Practice Agreement Pilot

Legislative Action Large Scale

Implementation

INCREASED ACCESS

DECREASED COST TO SOCIETY

DECREASED DEPENDENCE

ON PHYSICIANS

IMPROVED HEALTH

OUTCOMES

CONS PROS • Lack of physician oversight may be problematic if patients have additional health concerns or questions regarding pregnancy, STDs, or maintenance screenings.

• Average wait time for physicians is over 19 minutes, and average wait time to obtain an appointment is 18.5 days nationwide 4, 14

• Pharmacists are the most accessible health care professionals 13

• Would pharmacists be reimbursed for their time

dedicated to providing this service?

• If so, would it be an out-of-pocket cost to the patient,

or covered by insurance, as the medication is?

• Many community pharmacies are understaffed: Do pharmacists have time to provide the service requirements?

• Would another pharmacist have to be hired/on duty at all times in case a patient required extra OC counseling and screening?

• Lack of knowledge on pharmacist

training/qualifications • Suspicions that patients

would not go in for their yearly screenings (lacking

evidence6) • Possible decrease in

revenue • Suspicions that the doctor-

patient relationship would be negatively impacted

• The process is lengthy, and there has not been much of a push from PA legislature to make a move on this issue.

• PA is more conservative than some of the western states when it comes to pharmacy law.

• Ethical and religious complications delaying action further.

LEGISTLATIVE BARRIERS

PHYSICIAN RESISTANCE

REIMBURSEMENT QUESTIONS

PHARMACIST TIME

CONSTRAINTS

Percentage of Female Students Aged 20-24 Who Would Utilize Pharmacist-

Prescribed Contraceptives

Data collection should occur at this step to test and prove value

The authors would like to thank Lauren J. Jonkman, PharmD, MPH, BCPS for her advice and input on their project.

1. Shotorbani S, et al. Contraception 2006;73:501–6. 2. Geggel, L. New Oregon Law Allows Pharmacists to Prescribe Birth Control Pills. Yahoo. January 5, 2016. (Accessed Jan 16, 2016). 3. Oregon Pharmacists Tasked to Improve Access to Hormonal Birth Control. Oregon State Pharmacy Association. (Accessed Jan 16, 2016). 4. Physician Appointment Wait Times and Medicaid and Medicare Acceptance Rates. 5. Family planning/contraception. World Health Organization. May 2015. (Accessed Jan 19, 2016). 6. Over-the-Counter Access to Oral Contraceptives. The American Congress of Obstetricians and Gynecologists. December 2012. (Accessed Jan 16, 2016). 7. Foster DG, et al. Obstet Gynecol. 2011; 117:566-72. 8. Saloner B, et al. Most. Health Aff. 2015; 34:773-80. 9. Fees for Services. Planned Parenthood of Western Pennsylvania. (Accessed Jan 17, 2016). 10. Expenditures on Children by Families, 2013. United States Department of Agriculture. August 2014. (Accessed Jan 17, 2016). 11. Physician Supply and Demand Through 2015: Key Findings. Association of American Medical Colleges. (Accessed Jan 18, 2016). 12. Rosenblatt RA, et al. West J Med. 2000; 173:348-51. 13. The Role of the Pharmacist in the Health Care System. Essential Medicines and Health Products Information Portal. 1994. (Accessed Jan 19, 2016). 14. Hutkin E. Patients can address doctor’s office wait times. The San Diego Union-Tribune. April 7, 2015. (Accessed Jan 19, 2016).

• 50% of all pregnancies in the United States are unplanned 6

• The average cost of raising a child from birth to 18 years is $241,080, not including the cost of college, and costs taxpayers an estimated $11.1 billion each year 10

• Receiving an abortion in PA can cost upwards of $1,000 without insurance, while an annual supply of “the pill” ranges from $160-600 9

• The risk of VTE is much lower in women receiving OCs (3-10.22/10,000 women-years) versus the risk during pregnancy (5-20/10,000 women-years) or in the post-partum period (40-65/10,000 women-years) 6

• Compared to women that receive only a 1-3 month supply of birth control at a time, women that receive a full year supply reduce their chances of pregnancy by 30% in the subsequent year, and demonstrate a 46% reduction in the odds of having an abortion7

• In a study that compared current family planning clients’ self-assessment of contraindications with clinical assessment, greater than 90% of participants (females aged 15–45 years) and health care provider pairs obtained agreement on medical eligibility criteria 1,6