Inviting the pharmacist: a model for improved reproductive care access

Contraception 85 (2012) 2 – 4EditorialInviting the pharmacist: a model for improved reproductive care accessOn a Saturday afternoon in 1998, in a small town inWashington State, a 15-year-old young woman accompaniedby her friend enters a local pharmacy and walks up to thecounter. The tearful 15-year-old needs help and tells thepharmacist of being raped the night before. She expressedbeing too afraid to tell her parents, the police or her doctor.She decided to come to the pharmacy because it was “lessscary” and she was aware that pharmacists in the state couldprescribe emergency contraception. The pharmacist took thepatient to a private counseling room, prescribed andprovided her with emergency contraception, and gave her aglass of water to take the medication. After talking with thepharmacist, the patient agreed to have the pharmacist call alocal Title X clinic where the pharmacist had a preexistingcollaborative agreement; she was seen by clinicians thereshortly thereafter [1].1. Inviting the pharmacistWith myriad barriers preventing easy and timely access toeffective contraception, especially for youth, it is critical thatproviders utilize all available resources. Rarely, however, dononpharmacist health professionals and their respectiveorganizations consider the potential role pharmacists canplay in supporting access to care.Much of this underutilization stems from an outdatedview by other members of the health care team regardingwhat pharmacists do and what clinical roles they can play.Images of crowded retail pharmacy counters, with no privacyand little if any time or place to speak with patients,combined with unfortunate examples of pharmacists whohave refused to fill prescriptions for their patients onlyexacerbate this negative perception. Dismiss pharmacistsand you miss out on opportunities to provide better and moreaccessible reproductive health care. Many newly sexuallyactive youths have not yet been seen by a medical providerbut can and do walk into pharmacies. Private counselingrooms can and have been built. Youth- and adult-friendly,evidence-based reproductive health information and consumereducation portals and care can comprehensively beprovided. All of these can lead to important medical–pharmacy safety nets.2. Collaborative models of pharmacy practiceBeginning in 1979, Washington State pharmacists,physicians and nurse practitioners were legislatively empoweredto enter into legally binding, collaborative agreementsin order to extend the arm of health care [2]. Theseagreements establish mutually crafted care protocols toprovide a strong therapeutic bridge between patients,medical providers and pharmacists. In essence, they are theforerunners of the patient-centered medical home model. In1994, the Washington State Pharmacists Association and theUniversity of Washington School of Pharmacy, looking atstatewide low immunization rates, initiated a project to trainpharmacists to provide immunizations and other injectablemedications using the collaborative agreement mechanism[3]. This group then began to take this model “on the road” toeducate policy makers, medical providers, pharmacists andpatients on the value and mechanisms of these collaborations.The results of this innovative project are now seen inthe 50-state scope of pharmacist-provided delivery ofinfluenza, pneumococcal, shingles, HPV and many othervaccines. This new medical–pharmacy delivery model ofpreventative care has allowed women and men to access carewithout taking time off from work or school, as they can nowgo to a neighborhood pharmacy on evenings, weekends andholidays for their vaccinations.This same public health model — including a newpartner, PATH (formerly known as Project for AppropriateTechnologies in Health) — was expanded and utilized from1998 until the availability of emergency contraception (EC)over-the-counter (OTC), in order to train pharmacists in ninestates to provide EC to women under protocol. Access toprescription EC places an undue burden on women byrequiring them to obtain a prescription from a health careprovider — a system that is not accessible and not wellsuited for large-scale “urgent prevention” services. The15-year-old rape victim described above and the innumerablewomen who followed her benefit from this collaboration.This model played a part in moving EC OTC in the USand in the international movement to adopt direct access topharmacists to initiate contraceptive care [4,5].These services are only small examples of beneficialmedical–pharmacy collaborations. At least 45 states have0010-7824/$ – see front matter © 2012 Elsevier Inc. All rights reserved.doi:10.1016/j.contraception.2011.09.011

Editorial / Contraception 85 (2012) 2–43legislation that enables pharmacists and medical providers toenter into collaborative agreements [6]. These collaborations,when fully utilized, are a terrific example of how toestablish a patient-centered medical home that is inclusive ofpharmacists. Patients in traditional allopathic medicalpractices, not open on weekends or after hours, now haveimmediate access to contraceptive care and vaccinations.Think of patients who need access to their 3-month Depo-Provera injection or their second and third HPVvaccination, yet cannot get to a clinic during traditionalbusiness hours. Think also of a 20-year-old patient whoneeds EC on a weekend but the OTC product is out of reachfinancially. A pharmacist prescribing this EC rather thanselling it OTC can bill the patient's insurance without thepatient deductible or co-pay [7].3. Barriers and solutions to accessAccess to reproductive and sexual health care isdetermined by many factors. Among the influences affectingboth consumers and providers are age, geographic location,personal reproductive health literacy, family, money,insurance, culture, religion, country, public policy, healthsystem fragmentation, provider time constraints, productavailability, local and national standards of care, peerpressure, the time of day, the day of the week and urgencyof need. Each of us has the ability to positively impact one ormore of these access issues — pharmacists are no exception.Uniquely placed in small towns and in inner cities, theirwalk-in access, their extended hours and their clinicaleducation put pharmacists in a position to impact access toreproductive health in ways that may be inherently difficultfor other providers to attain on their own.Successful pharmacy partnership solutions may involve,but are not at all limited to, the following examples:• Pharmacists engaged as consultant partners or asprofessional staff members/employees in reproductivehealth clinics and school-based health centers. Theseprimarily nondispensing pharmacy partnerships supportkey health messages to patients, assist ineliminating medication issues (i.e., refills, insurance,drug interactions, adherence, etc.) and help clinics tomeet or exceed their ever-increasing quality assurancerequirements [8].• Pharmacists, using collaborative agreements with localphysicians or Advanced Registered Nurse Practitioners,initiating hormonal contraception as a briefbridge for women without ready access to a medicalprovider [5]. Long-acting reversible contraception maybe the ultimate objective for many women, butcontraception initiated at the pharmacy may be avital temporary solution. Pharmacists using collaborativeagreement protocols with local medical providerscan establish formal referral pipelines for cancer, rapeand sexually transmitted infection screenings, not tomention improving access to EC and hormonalcontraception pills, patches, rings and injectables.• Development of youth-friendly pharmacies to helpyouth access objective reproductive health informationand to help facilitate medical referrals. The PharmacyAccess Partnership program, supported by reproductivehealth visionaries such as Dr. Felicia Stewart,Dr. Jane Boggess, Belle Taylor-McGhee, Dr. PhilipDarney and Sharon Landau, among others, has helpedus to better understand the reproductive healthaccess needs of youth and the role that enlightenedpharmacists can play in removing access barriers.Advocates for Youth in Washington, DC, continuesthis work by embracing pharmacists as key reproductivehealth partners.• Pharmacists providing Depo-Provera injections, asstated previously, after initial evaluation by a medicalclinician. HPV injections can similarly be provided,and there may be additional opportunities for collaborationwith other important adherence medications.• Pharmacists stocking free or low-cost contraceptivesacquired from local clinics or by 340B purchasingagreements, a national medication discount programdesigned for patients of Federally Qualified HealthCenters. This model utilizes medical–pharmacy collaborativeprotocols to provide low- or no-costcontraceptive access to patients who are uninsured orunderinsured. Nonemancipated youth without accessto their parent's insurance can also benefit by thesepharmacy partnerships. Low-income patients needingan urgent refill of their hormonal contraception orperhaps EC can access these services under a specificprotocol even when their medical provider is temporarilyunavailable.• Pharmacists prescribing EC, under a collaborativeagreement protocol, to undocumented immigrants andwomen under 17 years of age needing a prescriptionfor EC. Currently, this can only happen in the ninestates with pharmacist authority to initiate EC careservices, but many other states could be added to thelist. Pharmacists prescribing EC under a collaborativeagreement protocol to women 17 years of age andolder who technically have access to OTC EC butrequire EC to be prescribed for insurance coverage.With no co-pay for prescription contraceptives, thiswould eliminate cost barriers for many women.4. Conundrums, compensation and considerationsPharmacists, like other medical providers, have aninherent conflict of interest when they simultaneouslyprovide clinical interventions, yet profit from the sale oftheir own medications. Unfortunately, the compensationmodel for pharmacists is historically dependent on product

4 Editorial / Contraception 85 (2012) 2–4sales. Similar to the necessary change in medical providerpayment from procedure-based to patient outcomes-basedcompensation, pharmacists must move away from productbasedcompensation in order to free themselves of thisconflict of interest and to use their clinical education andexpertise to better effect.The collaboration opportunities outlined in this editorialare not limited to reproductive health care. Outcomes frommedical–pharmacy collaborations in diabetes, asthma,hypertension, heart disease, anticoagulation and otherchronic problems are extremely encouraging for their effecton patient outcomes and health costs and for their positiveeffect on medicine's ability to meet quality assurancestandards [9–11].Pharmacy schools graduate pharmacists not only withextensive knowledge of medications but also with excellentknowledge of prevention-based interventions, chronicdisease medication management, management of patienthealth behaviors and patient counseling/education, all ofwhich are currently subjugated to filling one moreprescription in order to survive. Pharmacists engaged inbest reproductive care practices must find ways to balancetraditional dispensing obligations and embrace outcomesbasedincentives as part of a patient-centered health careteam. Many new pharmacy graduates are consideringforgoing any connection with prescription sales andpreparing to be the medication use provider on their diversehealth care team.It is not that pharmacists can be and do everything; it isthat patients deserve better than what each of us can provideon our own. When pharmacists are engaged as importantpartners, rather than dismissed as inconsequential (or worseas competitors or care obstructionists), history has shownthat women have greatly benefitted. When awareness, policyand leadership come together, we can all participate increating radically new care delivery opportunities.ReferencesDon DowningDepartment of PharmacyUniversity of WashingtonBox 357630Seattle, WA 98195-7630, USAE-mail address: dondown@u.washington.edu[1] Consultation phone call to Don Downing by pharmacist during thepatient encounter, 1998.[2] 1979 Revised Code of Washington (RCW) 18.64.011(23) and 1980Washington Administrative Code (WAC) 246-863-100.[3] Hogue MD, Grabenstein JD, Foster SL, Rothholz MC. Pharmacistinvolvement with immunizations: decade of postgraduate training.J Am Pharm Assoc 2006;46:168–82.[4] Wells ES, Hutchings J, Gardner JS, et al. Using pharmacies inWashington State to expand access to emergency contraception. FamPlann Perspect Special Report 1998;30:288–90.[5] Gardner JS, Miller L, Downing DF. Pharmacist prescribing ofhormonal contraceptives: results of the Direct Access Study. J AmPharm Assoc 2008;48:212–21.[6] American Pharmacists Association. Issue brief: collaborative drugtherapy management. Accessed from: http://www.pharmacist.com/AM/Template.cfm?Section=Home2&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=16882.[7] DeNoon DJ. No more co-pay for birth control. WebMD. Accessed from:http://women.webmd.com/news/20110801/no-more-copay-forwomens-wellness-birth-control.[8] Bunting BA, Smith BH, Sutherland SE. The Asheville Project: clinicaland economic outcomes of a community-based long-term medicationtherapy management program for hypertension and dyslipidemia. J AmPharm Assoc 2008;48:23–31.[9] Patient-centered Primary Care Collaborative. The patient-enteredmedical home: integrating comprehensive medication management tooptimize patient outcomes. Accessed from: http://www.pcpcc.net/files/medmanagepub.pdf. Accessed 8-27-2011.[10] Nichol A, Downs GE. The pharmacist as physician extender in familymedicine office practice. J Am Pharm Assoc 2006;46:77–83.[11] Blumenthal D, Tavenner M. The “meaningful use” regulation forelectronic health records. N Engl J Med 2010;363:501–3.