In Western North Dakota, Jody Doe, RPh, has spent the past 23 years operating the Killdeer Drug Store in the small town of Killdeer, population under 1,000.
“This is the only pharmacy in the whole county—it’s more than an hour away from the next one—and it’s a service that’s needed here,” Doe says. “I enjoy providing the service and helping people out. I’m here every day so I know what’s going on and I can provide a personal touch that those in other areas of the country can’t.”
After pharmacy school, Doe worked as a pharmacist in bustling Portland, OR, but returned to rural North Dakota because he missed the small-town atmosphere he was raised in.
Independent pharmacists in rural America like Doe are vital to the residents who live in these small communities. But they are becoming increasingly rare, as challenges force them to shut down.
The RUPRI Center for Rural Health Policy Analysis at the University of Iowa released a policy brief this year that revealed more than 16% of the independently owned rural pharmacies in the United States closed between March 2003 and March 2018, lowering the number to just 6,393.
Among the worrisome findings of the report was the disappearance of retail pharmacies in some rural communities altogether, with the data showing that 630 rural communities that had at least one retail pharmacy in March of 2003 no longer had one in March of 2018.
Recent analysis by the National Council for Prescription Drug Programs revealed that independent pharmacies, which represent 52% of all rural retail pharmacies, are often the only operating pharmacy in a community, with the data showing that more than 1,800 independent community pharmacies are the lone source in a particular rural area. And because 1,231 independently owned rural pharmacies have closed over the last 16 years, this is alarming.
And it’s not just the independent rural pharmacies suffering. Many rural hospitals and chains are finding it hard to find staff pharmacists willing to live in rural areas.
Rural Pharmacy Challenges
Rural pharmacies are forced to shut their doors for many reasons. Keith Mueller, PhD, director of the RUPRI Center for Rural Health Policy and principal investigator in rural pharmacy closures, says for one, the costs they pay to drug manufacturers per prescription are higher than their urban counterparts. This is because they purchase less at a time, and since they tend to sell less volume as well, their profits tend to be smaller. Plus, with increasing competition from internet suppliers, where prices are lower because they deal in bulk supplies, many are not getting the customer base needed to survive, he says.
Mike Swanoski, PharmD, BCGP, FASCP, associate professor of pharmacy practice and pharmaceutical sciences, University of Minnesota College of Pharmacy, says the decline in rural pharmacies is primarily due to declining reimbursements for medications dispensed as reimbursement rates are often barely enough to cover the cost of the medication.
Still, he says, the rural pharmacy is a lifeblood of small-town America.
“The pharmacists practicing in rural pharmacies serve an important role in assuring that not only their patients’ medication needs are met, but also in providing important information regarding health conditions that can be appropriately treated with OTC treatments and when patients should be referred to their medical provider,” Swanoski says.
Mueller agrees that reimbursement is a problem, both for community pharmacies and rural hospitals.
Maintaining in-stock medications, when the costs to the pharmacy are rising faster than changes in reimbursement based on average wholesale prices, is challenging, he says, adding that weak negotiation position with insurance plans, including those participating in Medicare Part D, is also a factor.
Jennifer Laws, BSPS, CPhT, is supervisor of the pharmacy department at Scotland County Hospital in Memphis, MO, a city with a population of 1,822.
“The main challenge is the lack of pharmacists willing to move to rural areas,” she says. “Unless they have a tie to the specific rural area, most pharmacists will take higher paying jobs in metropolitan areas,” she says. “Rural pharmacies also struggle with declining reimbursement amounts from PBMs, which is another detriment.”
Nicholas Herrmann, PharmD, pharmacist in charge at Memphis Community Pharmacy in Memphis, MO, agrees staffing is a huge challenge.
“It is even more difficult to find part time or per diem staff,” he says. “If a position doesn’t offer enough guaranteed hours, sometimes the closest people you can find are from more metropolitan areas, which means paying higher rates for things like drive time and hotel accommodations.”
Reimbursement and staffing aren’t the only challenges rural pharmacists face. Many feel isolated because they are often the lone person working, and there are rarely colleagues nearby to share information and talk about what’s happening in the pharmacy industry, according to Mueller.
He adds it’s also harder to get time off to go to a conference or attend advanced educational classes with fellow pharmacists because there’s no one to cover the time away and the venues are usually too far for a quick trip anyway.
On Page 2: Overcoming Barriers & the Draw to Rural Pharmacy...