Pharmacist's Order: Birth Control Without The Doctor
Advocates say increasing access to hormonal contraceptives could help reduce unplanned pregnancies. One legislative proposal considered earlier this year aims to do just that by allowing patients to skip a physician's visit and head straight to a pharmacist. But it is having trouble catching on in Illinois.
For some users of hormonal contraceptives, getting into a doctor's office to receive a prescription can take weeks and, in some instances, even months.
"I have seen many women over my years of practice who have had an unplanned pregnancy, and it's often because their prescription ran out and they weren't able to get a new one without a long wait," said Dr. Maura Quinlan, an obstetrics and gynecology specialist in Chicago. She said for others, birth control goes beyond family planning: Many women have issues with polycystic ovary syndrome - a hormonal disorder - and others suffer debilitating menstrual cramps.
In most of these cases, Quinlan said, an invasive evaluation isn't always needed. "My specialty has made it clear that it is not medically necessary to have a routine pelvic exam before starting contraception," she said.
Five states -- including California and Oregon -- allow their pharmacists to prescribe birth control, cutting out the need for a physician's visit. Four other states -- Hawaii, Maryland, Ohio, and Tennessee -- recently passed legislation, while several other states are currently considering similar initiatives.
But in Illinois, not everyone is convinced about the approach. A proposal allowing pharmacists to dispense birth control through a standing order -- similar to what pharmacists use to give vaccines -- did not get sufficient votes during the spring legislative session. Some lawmakers had personal concerns about morality and birth control use; other groups said they worried with giving pharmacists too much power. Others said they were worried about the overall safety of contraceptives without a physician's direct involvement.
State Rep. Michelle Mussman, a Schaumburg Democrat and sponsor of the legislation, said she's been in close communication with advocates from California and Oregon to learn how to improve her proposal and convince her colleagues in the General Assembly.
California's law went into effect in 2016, and so far, the biggest challenge for the state has been finding more pharmacists willing to offer the birth control service. As with the Illinois proposal, the California law is an opt-in program.
Sally Rafie, a pharmacist based in California, has been working to educate women and pharmacists on the initiative. She is the founder of Birth Control Pharmacists, a one-stop shop for California pharmacists to learn about training and for women to find pharmacies.
Despite the implementation challenge, she said, what matters is that the option is there when needed. "The way I think about it is, it all comes down to patient access. It's all about having different options for women so they can choose what works best for them."
In Illinois, that's exactly what Mussman, said she wants to offer. "Access is an issue in rural communities and in urban communities. Lack of transportation, lack of insurance can be a huge problem, and lack of consistency leads to unplanned pregnancies," she said.
Under her proposal, a physician within the Illinois Department of Public Health would provide a standing order that pharmacists can use to fill prescriptions. "Pharmacists would voluntarily go and have enhanced training to be able to have better understanding of how to dispense this more authoritatively," she said.
The California law, for example -- gives pharmacists full prescribing power. That means a pharmacist's name is one on the prescription. That state's law doesn't depend on a statewide standing order as the Illinois proposal outlines. But those are just the technicalities.
In both scenarios, a patient would still meet one-on-one with a trained pharmacist for a consultation. Patients fill out a risk evaluation, where health issues, like high blood pressure, are disclosed. Unless any other red flags come up, a pharmacist is able to go ahead with dispensing the patient's birth control of choice. In some situations, a pharmacist might recommend a patient check in with a physician before moving forward with any medications.
Mussman said all of these steps are outlined and approved by the Centers for Disease Control and Prevention. "Certainly, we've always been concerned about making sure that we're indicating all the safety procedures that were in place," she said.
Still, opponents say they believe risks exist by skipping out on the regular office visit and giving pharmacists too much power. State Rep. Tony McCombie, a Savanna Republican, said during a House debate she worries about the possible side effects if a woman is not properly evaluated by a pharmacist. "I think it just really could open up a huge can of worms," she said. She then voted against the measure.
Republican state Rep. Jeanne Ives of Wheaton agreed. She said complications could result if someone with high blood pressure takes hormonal birth control. "This bill is not at all ready for main stream pharmacists to be prescribing to young, adolescent girls."
Sally Rafie, the California pharmacist, said the training she and colleagues have received prepares them to spot any potential complications. She expects Illinois pharmacists would follow the same standards. The health risk questionnaire used by a pharmacist is similar to the one a physician would use.
"We wouldn't want to give patients anything that would be unsafe for them," Rafie said.
Yet -- unlike in Illinois, some of California's medical associations have been onboard with the idea and supportive of pharmacists filling those prescriptions.
The Illinois State Medical Society is the group representing doctors in the state. The organization supports increased access to contraceptives, but not so much handing pharmacists full prescribing power. The group worked with Mussman to make sure that power is restricted to a prescribing physician at the Department of Public Health.
In its annual legislative update, the Illinois State Medical Society, referring to the measure, wrote: "While pharmacists are experts in drugs and an essential part of the health care team, they are not experts in diagnosing and treating conditions, diseases and other maladies of the human body. Pharmacists and physicians have very distinct roles in our health care system; blurring these roles is not in the best interest of patient safety and will only increase episodic care."
Mussman says she plans to continue discussions, not just with the medical society, but also with other groups, like the Illinois Insurance Association and Blue Cross Blue Shield of Illinois -- two groups that also oppose the measure. These insurance companies would need to cover pharmacists for their one-on-one consultation with a patient.
A spokesperson for Blue Cross Blue Shield of Illinois declined to offer specifics on their opposition.
"That's what we're working out now," Mussman said, "We believe that for the most part most these things are addressed, and again - it's just a matter of now getting the bill an opportunity."
She said the measure could come up again during the fall veto session.
Ultimately, many advocates would like to see full over the counter access for contraceptives in the future. But that's up to the Federal Drug Administration to decide. Meanwhile, companies are finding different ways to increase access. In Illinois and in other states, companies are already offering online access to birth control through tele-health consultations with physicians.
But for many, the issue of safety remains when a physician isn't directly involved.
Advocates like Dr. Maura Quinlan, the Chicago obstetrician-gynecologist, says she wants to help dispel the myths.
"It's important to remember that these methods are safe, safer than any other medications we can get over the counter," she said.
"And as a physician I know too well that hormonal contraception is safer than being pregnant."
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Illinois Issues is in-depth reporting and analysis that takes you beyond the headlines to provide a deeper understanding of our state. Illinois Issues is produced by NPR Illinois in Springfield.