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Availability of pharmacist prescription of contraception in rural areas of Oregon and New Mexico
Journal Pre-proofs Brief Research Article Availability of pharmacist prescription of contraception in rural areas of Oregon and New Mexico Maria I. Rodriguez, Bharti Garg, Shannon M. Williams, Jessica Souphavong, Kaitlin Schrote, Blair G. Darney PII: DOI: Reference:
S0010-7824(19)30473-1 https://doi.org/10.1016/j.contraception.2019.11.005 CON 9359
To appear in:
Contraception
Received Date: Revised Date: Accepted Date:
8 August 2019 13 November 2019 13 November 2019
Please cite this article as: M.I. Rodriguez, B. Garg, S.M. Williams, J. Souphavong, K. Schrote, B.G. Darney, Availability of pharmacist prescription of contraception in rural areas of Oregon and New Mexico, Contraception (2019), doi: https://doi.org/10.1016/j.contraception.2019.11.005
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2019 Elsevier Inc. All rights reserved.
Availability of pharmacist prescription of contraception in rural areas of Oregon and New Mexico Maria I. Rodriguez MD MPH*, Bharti Garg, Shannon M. Williams, Jessica Souphavong, Kaitlin Schrote, Blair G. Darney
Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR 97239
Dr. Maria I. Rodriguez 3181 SW Sam Jackson Park Rd UHN 50 Portland, OR 97239 United States Phone: +0015034947921 Fax: not available E-mail: [email protected]
Abstract word count: 112 Manuscript word count: 950
*Corresponding author Maria I. Rodriguez 311 SW Sam Jackson Park Rd UHN 50 Portland OR 97239 [email protected] 503 494 7921 Abstract Objective: To determine the availability of pharmacist prescribing of hormonal contraception in rural areas of two states
Study design: Cross-sectional survey Results Overall, 42% of pharmacies prescribed contraception (Oregon: 46% and New Mexico 19%). A similar proportion of rural pharmacies reported offering pharmacist prescription of 37 contraception as urban locations (39% vs 46%, p = 0.26). Nearly 53% of rural and 45% of urban pharmacies report billing women, rather than insurance, directly for the cost of the pharmacist consultation. Over 80% of pharmacists in both rural and urban locations did not know if Medicaid covered the cost. Conclusion Pharmacists in rural areas are as willing as their urban counterparts to prescribe hormonal contraception. Financial barriers remain a concern. Keywords pharmacist, contraception, rural health
Introduction Nearly 75% of the land in the United States (US) is rural, with approximately a fifth of the rural population adult women (22.8%) [1]. Important disparities in reproductive health care are experienced by women living in rural areas, including access to effective contraception [1]. Women living in rural areas experience unique barriers to contraception that may not be an issue for their urban counterparts. Provider availability is more challenging: only 6.4% of practicing obstetrician gynecologists are in rural areas [1]. Distance to providers is also typically greater. A majority of rural women (87.6%) live more than an hour away from the nearest hospital [2]. Prescription of contraception by pharmacists is one strategy with promise to improve access to contraception for women [3]. Pharmacies have extended hours compared to clinics, do not commonly require appointments, and typically are located in the community they serve. However, prior research on pharmacist prescription of emergency contraception (EC) in rural areas suggested that rural and frontier pharmacies were less likely to offer EC due to a perceived lack of demand or training [4]. Oregon and New Mexico are two of eight states that have expanded the scope of pharmacists to directly prescribe hormonal contraception and have a large rural population. Oregon began the program January 1, 2016 and since program inception, Medicaid has covered for both the contraception and the pharmacist’s time to provide the service. New Mexico followed in June of 2017, but does not require insurance coverage for the pharmacist’s time to screen and counsel women. Pharmacists are able to prescribe the oral contraceptive pill (combined and progestin only), patch, ring and injectable. This is a promising strategy to reach new users of contraception, improve continuation rates, and avert unintended pregnancies [3, 5]. However, prior research suggested that rural pharmacists in Oregon were less likely to plan to prescribe HC than their urban counterparts [6]. We sought to understand practice (versus plan to
practice) after the policy change permitting pharmacists to prescribe contraception. Our objective was to determine the availability of pharmacist prescription of hormonal contraception in rural versus urban areas in Oregon and New Mexico. Materials and Methods We conducted a phone audit of a random sample of all Oregon and New Mexico pharmacies between April and May 2019. We obtained a list of all licensed pharmacies for each state from the respective board of pharmacies in March 2019. The institutional review board at Oregon Health & Science University approved this study. We focused our study population on retail pharmacies in the community: hospital, clinic, university, and other specialty pharmacies were excluded. We used the pharmacy ZIP code to determine rural status, and stratified pharmacies by urban and rural location. Our sampling frame included 702 Oregon and 192 New Mexico pharmacies. We drew a random sample of 300 pharmacies balanced on urban and rural status (rural pharmacies oversampled). This sample gave us 80% power to detect a 15% difference in our outcome, pharmacist-prescribed contraception by rural/urban location. To assess availability of pharmacist-prescribed contraception, trained interviewers called pharmacies and used a structured data collection instrument. Interviewers asked: “I heard that you can get birth control from a pharmacy without a prescription from a doctor. Can I do that at your pharmacy?” If the response was affirmative, callers asked questions about the availability of methods, whether an appointment was needed, and whether insurance could be billed. We used descriptive statistics to characterize our study population by rural status. We used chi squared tests to evaluate the proportion of rural pharmacies offering pharmacist prescribed contraception as compared with urban pharmacies. All analyses were conducted in Stata version 16.0 (StataCorp LP, College Station, TX, USA; 2015). Results Overall, 42% of pharmacies prescribed contraception (Oregon: 46% and New Mexico 19%; data not shown by state). A similar proportion of rural pharmacies reported offering pharmacist prescription of contraception as urban locations (Table 1 39% vs 46%, p = 0.26). The majority of pharmacies offering the service were chain pharmacies in both rural (68% vs 32%,p <0.001) and urban locations (75% vs 25%, p <0.001, data not shown).
Pharmacies reported offering all methods pharmacists are able to prescribe, although the oral contraceptive pill was the most commonly reported available method (Table 1). No difference in method availability was noted by rural location. We examined other barriers to access including requiring an appointment and cost of services (drug and consultation). Among pharmacies offering pharmacist prescription of contraception, a minority in both rural (12%) and urban (7%) required an appointment for services. Financial barriers remain a consideration in both rural and urban locations. Nearly 53% of rural and 45% of urban pharmacies report billing women directly, rather than insurance, for the cost of the pharmacist consultation. Nearly half the pharmacies (47%) in rural and just over half (55%) in urban locations, the cost of the contraceptive drug was covered by insurance when prescribed by a pharmacist. Over 80% of pharmacists in both rural and urban locations did not know if Medicaid covered pharmacist prescription of contraception. Conclusion We found that pharmacies in rural areas were as likely as their urban peers to have pharmacists available to prescribe contraception. This suggests that pharmacists may have an important role to play in contraceptive provision for underserved women in rural areas. Our study is not without limitations. We are underpowered to detect less than a 15% difference in pharmacist prescription of contraception by rural location. Importantly, we may over estimate the availability of pharmacist prescription of contraception. Our callers queried whether the store had a pharmacist able to prescribe contraception. We did not elicit information as to whether all pharmacists were trained, or available throughout all pharmacy business hours. Secondly, differential implementation by states may affect our results. Oregon’s pharmacists have been prescribing contraception since January 2016, and Medicaid has reimbursed for the service from the start. New Mexico began services 18 months later, and does not require state Medicaid to cover the cost of the pharmacist consultation. We were not adequately powered to examine differences in pharmacist knowledge of insurance coverage by state. It is not currently known to what extent private insurance plans cover reimbursement for the consultation by the pharmacist, as this requires insurance plans to contract with pharmacies directly. Lack of reimbursement by insurance for pharmacist consultations has previously been described as a key
driver of low pharmacist participation in prescribing contraception [7, 8]. These two factors may explain why a higher proportion of pharmacies in Oregon offer the service. Cost has long been recognized as a significant barrier to contraceptive use. We found that nearly half the time, women in both urban and rural locations were billed directly for contraceptive medications when prescribed by a pharmacist, suggesting that a large proportion of pharmacies are not billing insurance for any part of the visit. While pharmacist prescription of contraception has promising potential to meet the needs of underserved women in rural areas, there is a possibility of improving geographical access but introducing financial barriers with increased out of pocket costs as compared to clinics. Equitable reimbursement for pharmacist prescription of contraception with no cost-sharing by women must be ensured. Acknowledgments: None Funding: This work was supported by a grant from the Laura and John Arnold Foundation. References 1. ACOG Committee Opinion No. 586: Health disparities in rural women. Obstet Gynecol. 2014;123(2 Pt 1):384-8. 2. Brems C, Johnson ME, Warner TD, Roberts LW. Barriers to healthcare as reported by rural and urban interprofessional providers. J Interprof Care. 2006;20(2):105-18. 3. Anderson L, Hartung DM, Middleton L, Rodriguez MI. Pharmacist Provision of Hormonal Contraception in the Oregon Medicaid Population. Obstet Gynecol. 2019;133:1231-1237. 4. Bigbee JL, Abood R, Landau SC, Maderas NM, Foster DG, Ravnan S. Pharmacy access to emergency contraception in rural and frontier communities. J Rural Health. 2007;23(4):294-8. 5. Rodriguez MI, Hersh A, Anderson LB, Hartung DM, Edelman AB. Association of Pharmacist Prescription of Hormonal Contraception With Unintended Pregnancies and Medicaid Costs. Obstet Gynecol. 2019; 133:1238–46 6. Rodriguez MI, Anderson L, Edelman AB. Prescription of Hormonal Contraception by Pharmacists in Oregon: Implementation of House Bill 2879. Obstet Gynecol. 2016;128(1):168-70. 7. Gomez AM. Availability of Pharmacist-Prescribed Contraception in California. JAMA. 2017;318(22):2253-4. 8. Gomez AM, McCullough C, Fadda R, Ganguly B, Gustafson E, Severson N, et al. Facilitators and barriers to implementing pharmacist-prescribed hormonal contraception in California independent pharmacies. Women Health. 2019; Jul 2:1-11.
Table: Rural pharmacies are as likely as their urban counterparts to offer pharmacist prescription of hormonal contraception Rural Urban 51%
49%
(n= 154)
(n=146 )
%
%
Pharmacist prescription of contraception*
39%
46%
Among those pharmacies that provide contraception, N=127
n=60
n=67
60%
69%
Among all pharmacies, N=300
Contraceptive methods Oral contraceptive pill Patch
32%
33%
Ring
30%
28%
Injection
25%
24%
Depends on consultation
12%
10%
12%
7%
Yes (consult and medication)
17%
12%
Yes (medication only)
47%
55%
No
2%
3%
Don’t Know
10%
4%
Yes (consult and medication)
7%
6%
Yes (medication only)
5%
12%
No
3%
0%
Don’t Know
85%
82%
Appointment required Covered by insurance
Covered by Medicaid
*At least one pharmacist employed who is able to prescribe hormonal contraception No significant differences (p < 0.05) noted
S0010-7824(19)30473-1 https://doi.org/10.1016/j.contraception.2019.11.005 CON 9359
To appear in:
Contraception
Received Date: Revised Date: Accepted Date:
8 August 2019 13 November 2019 13 November 2019
Please cite this article as: M.I. Rodriguez, B. Garg, S.M. Williams, J. Souphavong, K. Schrote, B.G. Darney, Availability of pharmacist prescription of contraception in rural areas of Oregon and New Mexico, Contraception (2019), doi: https://doi.org/10.1016/j.contraception.2019.11.005
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2019 Elsevier Inc. All rights reserved.
Availability of pharmacist prescription of contraception in rural areas of Oregon and New Mexico Maria I. Rodriguez MD MPH*, Bharti Garg, Shannon M. Williams, Jessica Souphavong, Kaitlin Schrote, Blair G. Darney
Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR 97239
Dr. Maria I. Rodriguez 3181 SW Sam Jackson Park Rd UHN 50 Portland, OR 97239 United States Phone: +0015034947921 Fax: not available E-mail: [email protected]
Abstract word count: 112 Manuscript word count: 950
*Corresponding author Maria I. Rodriguez 311 SW Sam Jackson Park Rd UHN 50 Portland OR 97239 [email protected] 503 494 7921 Abstract Objective: To determine the availability of pharmacist prescribing of hormonal contraception in rural areas of two states
Study design: Cross-sectional survey Results Overall, 42% of pharmacies prescribed contraception (Oregon: 46% and New Mexico 19%). A similar proportion of rural pharmacies reported offering pharmacist prescription of 37 contraception as urban locations (39% vs 46%, p = 0.26). Nearly 53% of rural and 45% of urban pharmacies report billing women, rather than insurance, directly for the cost of the pharmacist consultation. Over 80% of pharmacists in both rural and urban locations did not know if Medicaid covered the cost. Conclusion Pharmacists in rural areas are as willing as their urban counterparts to prescribe hormonal contraception. Financial barriers remain a concern. Keywords pharmacist, contraception, rural health
Introduction Nearly 75% of the land in the United States (US) is rural, with approximately a fifth of the rural population adult women (22.8%) [1]. Important disparities in reproductive health care are experienced by women living in rural areas, including access to effective contraception [1]. Women living in rural areas experience unique barriers to contraception that may not be an issue for their urban counterparts. Provider availability is more challenging: only 6.4% of practicing obstetrician gynecologists are in rural areas [1]. Distance to providers is also typically greater. A majority of rural women (87.6%) live more than an hour away from the nearest hospital [2]. Prescription of contraception by pharmacists is one strategy with promise to improve access to contraception for women [3]. Pharmacies have extended hours compared to clinics, do not commonly require appointments, and typically are located in the community they serve. However, prior research on pharmacist prescription of emergency contraception (EC) in rural areas suggested that rural and frontier pharmacies were less likely to offer EC due to a perceived lack of demand or training [4]. Oregon and New Mexico are two of eight states that have expanded the scope of pharmacists to directly prescribe hormonal contraception and have a large rural population. Oregon began the program January 1, 2016 and since program inception, Medicaid has covered for both the contraception and the pharmacist’s time to provide the service. New Mexico followed in June of 2017, but does not require insurance coverage for the pharmacist’s time to screen and counsel women. Pharmacists are able to prescribe the oral contraceptive pill (combined and progestin only), patch, ring and injectable. This is a promising strategy to reach new users of contraception, improve continuation rates, and avert unintended pregnancies [3, 5]. However, prior research suggested that rural pharmacists in Oregon were less likely to plan to prescribe HC than their urban counterparts [6]. We sought to understand practice (versus plan to
practice) after the policy change permitting pharmacists to prescribe contraception. Our objective was to determine the availability of pharmacist prescription of hormonal contraception in rural versus urban areas in Oregon and New Mexico. Materials and Methods We conducted a phone audit of a random sample of all Oregon and New Mexico pharmacies between April and May 2019. We obtained a list of all licensed pharmacies for each state from the respective board of pharmacies in March 2019. The institutional review board at Oregon Health & Science University approved this study. We focused our study population on retail pharmacies in the community: hospital, clinic, university, and other specialty pharmacies were excluded. We used the pharmacy ZIP code to determine rural status, and stratified pharmacies by urban and rural location. Our sampling frame included 702 Oregon and 192 New Mexico pharmacies. We drew a random sample of 300 pharmacies balanced on urban and rural status (rural pharmacies oversampled). This sample gave us 80% power to detect a 15% difference in our outcome, pharmacist-prescribed contraception by rural/urban location. To assess availability of pharmacist-prescribed contraception, trained interviewers called pharmacies and used a structured data collection instrument. Interviewers asked: “I heard that you can get birth control from a pharmacy without a prescription from a doctor. Can I do that at your pharmacy?” If the response was affirmative, callers asked questions about the availability of methods, whether an appointment was needed, and whether insurance could be billed. We used descriptive statistics to characterize our study population by rural status. We used chi squared tests to evaluate the proportion of rural pharmacies offering pharmacist prescribed contraception as compared with urban pharmacies. All analyses were conducted in Stata version 16.0 (StataCorp LP, College Station, TX, USA; 2015). Results Overall, 42% of pharmacies prescribed contraception (Oregon: 46% and New Mexico 19%; data not shown by state). A similar proportion of rural pharmacies reported offering pharmacist prescription of contraception as urban locations (Table 1 39% vs 46%, p = 0.26). The majority of pharmacies offering the service were chain pharmacies in both rural (68% vs 32%,p <0.001) and urban locations (75% vs 25%, p <0.001, data not shown).
Pharmacies reported offering all methods pharmacists are able to prescribe, although the oral contraceptive pill was the most commonly reported available method (Table 1). No difference in method availability was noted by rural location. We examined other barriers to access including requiring an appointment and cost of services (drug and consultation). Among pharmacies offering pharmacist prescription of contraception, a minority in both rural (12%) and urban (7%) required an appointment for services. Financial barriers remain a consideration in both rural and urban locations. Nearly 53% of rural and 45% of urban pharmacies report billing women directly, rather than insurance, for the cost of the pharmacist consultation. Nearly half the pharmacies (47%) in rural and just over half (55%) in urban locations, the cost of the contraceptive drug was covered by insurance when prescribed by a pharmacist. Over 80% of pharmacists in both rural and urban locations did not know if Medicaid covered pharmacist prescription of contraception. Conclusion We found that pharmacies in rural areas were as likely as their urban peers to have pharmacists available to prescribe contraception. This suggests that pharmacists may have an important role to play in contraceptive provision for underserved women in rural areas. Our study is not without limitations. We are underpowered to detect less than a 15% difference in pharmacist prescription of contraception by rural location. Importantly, we may over estimate the availability of pharmacist prescription of contraception. Our callers queried whether the store had a pharmacist able to prescribe contraception. We did not elicit information as to whether all pharmacists were trained, or available throughout all pharmacy business hours. Secondly, differential implementation by states may affect our results. Oregon’s pharmacists have been prescribing contraception since January 2016, and Medicaid has reimbursed for the service from the start. New Mexico began services 18 months later, and does not require state Medicaid to cover the cost of the pharmacist consultation. We were not adequately powered to examine differences in pharmacist knowledge of insurance coverage by state. It is not currently known to what extent private insurance plans cover reimbursement for the consultation by the pharmacist, as this requires insurance plans to contract with pharmacies directly. Lack of reimbursement by insurance for pharmacist consultations has previously been described as a key
driver of low pharmacist participation in prescribing contraception [7, 8]. These two factors may explain why a higher proportion of pharmacies in Oregon offer the service. Cost has long been recognized as a significant barrier to contraceptive use. We found that nearly half the time, women in both urban and rural locations were billed directly for contraceptive medications when prescribed by a pharmacist, suggesting that a large proportion of pharmacies are not billing insurance for any part of the visit. While pharmacist prescription of contraception has promising potential to meet the needs of underserved women in rural areas, there is a possibility of improving geographical access but introducing financial barriers with increased out of pocket costs as compared to clinics. Equitable reimbursement for pharmacist prescription of contraception with no cost-sharing by women must be ensured. Acknowledgments: None Funding: This work was supported by a grant from the Laura and John Arnold Foundation. References 1. ACOG Committee Opinion No. 586: Health disparities in rural women. Obstet Gynecol. 2014;123(2 Pt 1):384-8. 2. Brems C, Johnson ME, Warner TD, Roberts LW. Barriers to healthcare as reported by rural and urban interprofessional providers. J Interprof Care. 2006;20(2):105-18. 3. Anderson L, Hartung DM, Middleton L, Rodriguez MI. Pharmacist Provision of Hormonal Contraception in the Oregon Medicaid Population. Obstet Gynecol. 2019;133:1231-1237. 4. Bigbee JL, Abood R, Landau SC, Maderas NM, Foster DG, Ravnan S. Pharmacy access to emergency contraception in rural and frontier communities. J Rural Health. 2007;23(4):294-8. 5. Rodriguez MI, Hersh A, Anderson LB, Hartung DM, Edelman AB. Association of Pharmacist Prescription of Hormonal Contraception With Unintended Pregnancies and Medicaid Costs. Obstet Gynecol. 2019; 133:1238–46 6. Rodriguez MI, Anderson L, Edelman AB. Prescription of Hormonal Contraception by Pharmacists in Oregon: Implementation of House Bill 2879. Obstet Gynecol. 2016;128(1):168-70. 7. Gomez AM. Availability of Pharmacist-Prescribed Contraception in California. JAMA. 2017;318(22):2253-4. 8. Gomez AM, McCullough C, Fadda R, Ganguly B, Gustafson E, Severson N, et al. Facilitators and barriers to implementing pharmacist-prescribed hormonal contraception in California independent pharmacies. Women Health. 2019; Jul 2:1-11.
Table: Rural pharmacies are as likely as their urban counterparts to offer pharmacist prescription of hormonal contraception Rural Urban 51%
49%
(n= 154)
(n=146 )
%
%
Pharmacist prescription of contraception*
39%
46%
Among those pharmacies that provide contraception, N=127
n=60
n=67
60%
69%
Among all pharmacies, N=300
Contraceptive methods Oral contraceptive pill Patch
32%
33%
Ring
30%
28%
Injection
25%
24%
Depends on consultation
12%
10%
12%
7%
Yes (consult and medication)
17%
12%
Yes (medication only)
47%
55%
No
2%
3%
Don’t Know
10%
4%
Yes (consult and medication)
7%
6%
Yes (medication only)
5%
12%
No
3%
0%
Don’t Know
85%
82%
Appointment required Covered by insurance
Covered by Medicaid
*At least one pharmacist employed who is able to prescribe hormonal contraception No significant differences (p < 0.05) noted