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Contraception Editorial March 2008

The Continuum of Care: A Case for Pharmacists as Key
Members of the Reproductive Health Care Team

By: Nicole Monastersky Maderas, Sharon Cohen Landau, and Belle Taylor-McGhee

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The definition of primary care has evolved significantly in the United States over the past 30 years, shifting from a model based on clearly stratified clinical specialties and disciplines to a somewhat more loosely defined provider landscape centered on principles of leadership and teamwork.1,2,3 This trend — particularly in the United States — can be ascribed to a number of factors: concerns about access to care — especially among underserved populations, growing uncertainty about insurance coverage and medical society and academic efforts to evolve health professions training and education.4,5,6,7 These issues have created a platform for health care problem-solving, very often expressed through grassroots, academic, government or industry-driven efforts to provide the best possible care during an increasingly challenging situation.8 This evolution in the United States tracks the status quo in much of the rest of the world, where health care problem-solving in the face of various societal pressures and the reality of limited resources has often been creative and thoughtful.9,10,11

Patients and providers alike have become more resourceful in the face of increasing concerns about access to care and health insurance. Other factors add to the confusion: the explosion of health information — good and bad — on the Internet, sensationalized media coverage about drug side effects and the impact of direct-to-consumer advertising by the pharmaceutical industry.12,13,14 This relatively new way of looking at US health care provision has brought pharmacists centerstage. Their particular role in delivering high-quality health care is crucial, given the context of emergency contraception (EC), new vaccines and a renewed emphasis on preventive, patient-centered care — especially in the United States.15 So, how can we help patients get the reproductive health care they need? One answer is to enhance the key role played by all members of the health care team, including pharmacists.

The concept of strengthening all members of the health care team is not new or unique to the United States, but the time is ripe for introspection: the US health care industry is evolving and scientific leaders are scanning for new concepts to help improve patient care while also dealing with broken business models and all-too-real health care access issues.16 There is a clear place in this conversation for enhancing and solidifying the health provider role of pharmacists.

US case study: the impact of state and local pharmacist partnerships on EC provision 

Over the past decade, US pharmacists have had a profound effect on reproductive health in the area of EC. Many women, especially young women, are unfamiliar with EC or how it works.17,18 Organizational inroads at local and state levels have made a significant impact on awareness in individual communities.19

In the United States, with the introduction of a dedicated EC product in 1998, advocates and public health professionals have increasingly been promoting improved access to the medication.14,20 In order to motivate more obstetrician–gynecologists to aid in reducing the number of unintended pregnancies, the American College of Obstetricians and Gynecologists issued a call to action in the spring of 2001, requesting their 40,000 members to proactively discuss EC with their patients. The following year, the Reproductive Health Technologies Project and over 100 medical and women's health groups launched the “Back Up Your Birth Control” campaign to raise awareness about EC as a backup method of birth control.

While the US Food and Drug Administration (FDA) regulates the status of over-the-counter and prescription medications, each state may determine the authorizing prescribers for particular medications. Forty US states allow for collaborative practice agreements in which prescribers authorize pharmacists to engage in specified activities including initiating drug therapy, although the types of agreements vary by state.21 Many advances in EC access have occurred at the state level, allowing pharmacists to play a much more active role.

State-level policy allows for more localized advances in access, but it has also resulted in an uneven and inconsistent landscape, often confusing for the public, media and providers. Nine states have passed state laws or have regulations allowing for direct pharmacy access to EC (WA, CA, NM, AK, HI, ME, NH, MA, VT).22 Several other states (ID, MN, MO, NC, WI) are implementing EC pharmacy access provision under their state regulations; however, the application is not widespread or formalized throughout these states. Another 10 states have attempted to pass EC pharmacy access legislation.23

With funding from the William and Flora Hewlett Foundation,24 Pharmacy Access Partnership, launched a year-long “States Take Action Toward Advancing EC Services” (STATES) Re-Granting Program in the fall of 2005. The program goal was to provide direct financial support to advocates and organizations working at the state level to increase access to EC in pharmacies to initiate policy and practice change. To date, funding to support the advancement of pharmacies as points of access for clinical reproductive health services has been limited. Funding available through the STATES Re-Granting Program presented a first-time opportunity for several organizations to advance access to EC in pharmacies at the state level.

This approach was well-received on a national scale: 24 applications in 23 states were submitted representing state-level pharmacy and advocacy groups. Small grants (ranging from $5,000 to $20,000) were awarded to seven organizations that detailed how they could (1) effectively leverage momentum to promote increased access to EC in pharmacies achieved by current or past state-level activity, or (2) initiate new engagement among a cross-section of stakeholders if based in states where little activity had occurred.

Through the STATES Re-Granting Program, participants created a network of colleagues throughout the country with whom they can collectively brainstorm and provide feedback about strategies to advance their work. Final reports from program participants indicated that for all seven of the grantee organizations, a broader and stronger network of professionals interested in increasing access to EC was fostered.25

Increasingly, physicians and pharmacists are forging links to improve patients' use of medications. In the states that had already changed their laws to permit direct EC pharmacy access, the pharmacy community actively collaborated with women's health advocates and health and medical providers including Planned Parenthood affiliates and community clinics. STATES Re-Granting Program participants learned the importance of identifying and cultivating meaningful, strategic relationships. The success of their projects required the support of a broad-based multidisciplinary coalition, beyond their traditional allies.26 For example, many Re-Granting participants established new relationships with unfamiliar or nontraditional partners including corporate pharmacy chains or pharmacy associations. Making connections with community pharmacies was highlighted as a successful method to engage community pharmacy stakeholders and gain new allies.27

The importance of establishing a network was demonstrated throughout the Re-Granting cycle. In particular, grantees leveraged their newly cultivated relationships with pharmacies and pharmacists when the FDA made the long-awaited decision to make Plan B available over the counter (OTC) for consumers 18 years and older, while maintaining prescription status for women younger than 18 years.27 For example, in Illinois, collaborating organizations coordinated strategic policy advocacy to formalize pharmacists' physician-delegated authority to dispense EC through collaborative agreements via a rulemaking process, and, in Vermont, collaborative partnerships were forged among pharmacy, health advocacy and medical communities in anticipation of the Vermont pharmacy access bill being signed into law.25

Support from the STATES Re-Granting Program helped seven pharmacist-oriented organizations achieve a number of positive outcomes. The grantees reported that 100,000 pharmacists, medical providers, legislators, students and activists participated in trainings, media outreach and presentations about EC in pharmacies nationwide during the grant cycle. Each grantee indicated that new coalitions were established, and that various organizational links, collaborative activities and legislative support with medical boards, pharmacy associations, schools of pharmacy and legislative members resulted from program funding, helping to increase access to reproductive health services (including EC) and supplies. Hundreds of pharmacists implemented EC pharmacy access services in their pharmacies as well. Five grantees conducted state-level research, including surveys with pharmacists in rural and urban parts of their states, in chain and community-pharmacy settings to understand and ascertain EC availability in their community and pharmacists' interest in EC provision and emerging health care issues.25

While Plan B is now available OTC for consumers ages 18 and older, direct pharmacy access to EC remains an important option for some women, particularly teens, those without proper proof of age, and women who rely on state-funded health insurance for EC services. In fact, when Plan B was approved for OTC sales, the FDA stressed in writing that EC pharmacy access programs are an important means to ensuring access for all women.28 Because adolescents were excluded from accessing EC as an OTC product, the FDA decision created new EC access barriers. Six of the seven grantees newly identified the importance of resources and educational tools targeted at adolescents and included teens as a target population in their strategic outreach efforts post Plan B OTC announcement.

The OTC decision also created an unintended barrier to EC access for low-income women: Medicaid typically does not cover the cost of OTC medications. Prior to its availability OTC, Medicaid and other state-funded health insurance programs helped make Plan B more widely accessible and in some instances recognized the benefits of the pharmacists' role in EC provision. For example, Washington state's EC pharmacy program saved the state nearly $22 million in Medicaid dollars related to pregnancies and infant care costs, indicating a financially sound and public health-minded motivation for recognizing pharmacists' role in EC provision.29

Since August 24, 2006, eight states (HI, IL, MD, NJ, NY, OK, OR, WA) successfully guaranteed Medicaid coverage of Plan B sold as an OTC product, while some other states have expressed interest in gaining this coverage as well. EC advocates have again unified forces nationwide to address Medicaid systems at individual state levels. In fact, a national Low-Income EC Access Coalition was formed with the general purpose of determining Medicaid coverage for Plan B in every state.

EC outreach and education for all health care providers and the public is still very necessary in an OTC environment.30 EC advocates are concerned that, with Plan B now available OTC, some providers (including pharmacists) may not be as interested in participating in direct pharmacy access programs or may not want to promote EC access to adolescents.25 Equally disconcerting is the fact that while some providers are not familiar with EC pharmacy access, there is a high level of awareness about the “pharmacist refusal” topic. Unfortunately, the media have paid a disproportionate amount of attention to a few, relatively rare incidents of pharmacists refusing to fill EC prescriptions based on ideological objections. This story line has trumped the very positive and significant increase in access to EC through pharmacists.31

Using a Re-Granting model to invest in state-level organizations proved to be a successful approach to advance pharmacies as an important point of access for reproductive health services and supplies. The Re-Granting funds allowed grantees to provide EC trainings to pharmacists including education on new EC access administrative rules and regulations, initiate targeted public education campaigns to increase EC awareness and dispel misconceptions and provide tools to pharmacists to offer and publicize EC pharmacy access, to name a few accomplishments.

Pharmacists have improved patient outcomes and reduced health care costs in states that have accommodated and supported pharmacists' involvement in patient care.29,32 Grantees demonstrated that, through collaboration, targeted capacity building at the pharmacy is worthwhile. The clinical role of the pharmacist continues to expand, offering more opportunities to improve reproductive health care and gain additional allies in pharmacy communities. Increased collaboration between pharmacists, the health care provider team and advocates can help achieve the common goal of improved access to reproductive health services.

The STATES Re-Granting Program is one illustration of the potential to enhance reproductive health care and access through pharmacists and pharmacies. This model reinforces the importance of the entire health care team — physicians, nurse practitioners, physician assistants, nurse midwives, nurses, health educators and pharmacists — working together to provide the best possible patient-centered health care.

Nicole Monastersky Maderas
Pharmacy Access Partnership
Oakland, CA

Sharon Cohen Landau
Pharmacy Access Partnership
Oakland, CA

Belle Taylor-McGhee
Pharmacy Access Partnership
Oakland, CA

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Used with permission from Elsevier, Inc.