Pharmacists can prescribe contraceptives in half the US, but doing so often loses them money

Pharmacists can prescribe and dispense self-administered hormonal contraception—think pills, patches, shots, and rings—thanks to laws in 24 states and Washington, DC, aimed at making contraceptives more accessible.

At least 5,538 pharmacies across the US prescribe birth control, according to self-reported data compiled by the Birth Control Pharmacist project, which provides education and training to pharmacists who prescribe birth control. And that number could grow, as 11 other states have introduced bills this year to expand pharmacists’ prescribing powers.

The only problem? Many pharmacists don’t want to dole out the goods over concerns that it could lose their pharmacies money.

“The single greatest barrier to pharmacists doing any prescribing at all is that the practice setting in community pharmacy has not adjusted the business model to accommodate it so it’s sustainable,” Tom Wadsworth, executive associate dean and associate professor at Idaho State University’s College of Pharmacy, told Healthcare Brew.

A losing business model

Often, the amount a pharmacy pays to acquire a drug is more than the pharmacy benefit manager reimburses to dispense it, Michael Murphy, advisor for state government affairs at the trade group American Pharmacists Association, told Healthcare Brew.

Pharmacists also don’t get paid for the time it takes to prescribe a medication. When a provider prescribes a drug, they have to conduct a clinical assessment to decide if it’s necessary and figure out how to prescribe it in a safe and effective way, Murphy said.

But many insurers don’t recognize pharmacists as medical providers for such services—and they don’t reimburse for it, he said. Those rates also vary by state and insurer.

“Even with adequate coverage by a health plan to dispense medicine, without reimbursement for pharmacists’ cognitive services to prescribe a medication, pharmacists cannot sustainably serve their communities,” Murphy said.

Some states have also passed laws to improve PBM pricing transparency and require that PBMs provide reasonable reimbursement—elements that could affect how much a pharmacy makes or loses from birth-control prescriptions.

Instead of trying to increase the number of contraception pharmacists dispense, pharmacies often focus on providing more billable healthcare services—like administering vaccines or Covid-19 tests—because “that’s where the revenue is,” Wadsworth said.

Case study: Oregon

Oregon became the first state to allow pharmacists to prescribe contraception in 2016.

Six months after the program’s implementation, 19.4% of Oregon zip codes housed a pharmacist certified to prescribe birth control. Within a year, that figure grew to 63% of zip codes, according to a 2018 study from researchers at Oregon Health and Science University. But 76% of the 121 Oregon pharmacists surveyed reported that they wrote fewer than 10 prescriptions a month.

There may not be adequate financial incentives to encourage more Oregon pharmacists to prescribe birth control, according to Joshua Free, president of Nelco Advisory, a pharmacy consulting firm.

Oregon pharmacists have provider status, which allows them to get Medicaid reimbursement at the same rate as a physician for the contraceptive consultation.

The reimbursement pharmacists receive for the birth control consultation is not “super lucrative,” Free said.

Prescribing birth control can also impede a pharmacy’s efficiency, he said.

“For a pharmacy to do this well, they’ve got to figure out their own workflow behind it, how they’re going to staff it, do they have an appropriate space to do it. You don’t want to have this interaction next to the cash register at the counter,” Free explained.

Pharmacists still want prescribing power

Despite the lack of financial incentive, many pharmacists approve of legislation that allows them to prescribe contraception. For example, Connecticut pharmacists voiced their support in March for a new bill that would improve access to hormonal contraception.

But “even in very progressive states, nobody knows that [these laws allowing pharmacists to prescribe birth control] exist,” Kelsey Grimes, senior counsel on reproductive rights and health at The National Women’s Law Center, told Healthcare Brew.

Besides the “needless restrictions” that limit access to contraception, many of these laws lack enforcement mechanisms, such as tracking and reporting how many pharmacies have opted into the program, Grimes said.

To make the laws effective in their mission to increase contraceptive access, pharmacies need financial incentives, according to Wadsworth. And the public needs to know that going to their pharmacist to get birth control is even an option in the first place, Grimes explained.

“We’re not trying to invade primary care; we’re not trying to become a replacement for your ob-gyn,” Free said. “We’re trying to create another point of access that fulfills an important purpose.”