When rural areas lose hospitals and primary care clinics, residents must turn to pharmacies to receive the care they need.
Health care deserts, which are areas with poor access to hospitals, clinics, primary care, and other health care services, are a growing problem. As the US population ages and shifts to more urban and suburban settings, rural areas are losing health care access.
When Kennett, Missouri, lost its only hospital in 2018, infant mortality increased, as did maternal mortality and deaths from cardiovascular causes, strokes, accidents, and other treatable events that had previously been handled in the emergency department, explained independent pharmacist Jenna Hawkins, PharmD. “If someone has a heart attack or a stroke, the nearest full-service hospital is an hour away,” Hawkins said. “Even if patients survive, the delay in care can impact them for life. [Patients with a] stroke may never get [tissue plasminogen activator] because they are so far beyond the 3-hour window by the time they finally get to a hospital that can administer it. We have babies born in parking lots, in cars, [or] in ambulances because mothers can’t get to a hospital in time.”
Access to nonurgent care plummeted as providers left the area. In turn, pharmacists are getting more questions about more severe symptoms from patients, many of whom are obviously sicker. “Too often it’s an emergency situation that is beyond our scope of practice,” Hawkins said. “Patients lean on their pharmacist and pharmacy staff more because they have lost that hospital access point of care.”
It’s a familiar problem for Tripp Logan, PharmD, vice president of SEMO Rx Pharmacies in Charleston and Sikeston, Missouri. “Our pharmacy staff are the only health care contacts many of our patients have,” Logan said. “We have entire counties where there is no hospital care, no primary care, no health care services at all—except maybe a pharmacy. And when the nearest hospital is an hour away, [patients] don’t always survive.”
Logan is part of a growing independent pharmacy community expanding and adapting services to fill the gap in health care deserts. It’s easy to think of medically underserved areas as a rural problem, he explained, but health care access can be just as difficult in urban neighborhoods lacking a nearby hospital or health clinic and poor public transportation. Pharmacies (typically independent pharmacies) may be the best and only health care facility within reach.
“I grew up in Nebraska, a very rural state,” said Joni Cover, vice president of strategic initiatives at the National Alliance of State Pharmacy Associations. “There are a lot of miles between [individuals] and a lot of communities that aren’t even served by public health departments. One good thing [to come out of] COVID-19 was the attention the pandemic brought to the need for more community-based providers. For a lot of communities, independent pharmacy was and remains the only entry point for health care services.”
There are no uniform definitions for the phrase health care desert. The Health Resources and Services Administration defines Health Professional Shortage Areas (HPSAs) and Medically Underserved Areas/Populations as areas or populations that have a shortage of primary, dental, or mental health providers largely by a population-to-provider ratio. The federal government provides bonus payments for some providers who are working in HPSAs or in designated critical access hospitals.
Using a combination of inadequate access to pharmacies, primary care, hospitals, trauma centers, and/ or low-cost health centers, GoodRx concluded that more than 80% of counties across the United States lack adequate access to care. The company estimated that approximately 121 million individuals live in a county defined as a health care desert, accounting for more than 37% of the US population.1
The Rural Policy Research Institute, based at the University of Iowa, has examined access to specific services, including pharmacies,2 nursing homes,3 hospitals,4 minoritized racial/ethnic groups,5 and ambulance services.6 Rural and urban areas both experience access barriers, but rural areas—including rural towns—are far more likely to have poor access compared with urban locales.
“Declining populations, high unemployment rates, high numbers of uninsured patients, and a high proportion of Medicare and Medicaid patients are important market factors [in hospital closures],” said George Pink, PhD, Humana Distinguished Professor in the Department of Health Policy and Management and senior research fellow at the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill.
“Hospital factors are things like low inpatient census, trouble getting physicians into the community or to cover the hospital, deteriorating physical facilities, technology, and occasionally fraud and patient safety,” he said. “Financial factors are the most important.” When a hospital closes, the community loses more than just inpatient and emergency department services, Pink explained. Physicians typically leave the community, along with nurses, dieticians, and others who depend on hospital employment or referrals. Local health department offices may also close.
More than 15 million individuals rely on independent pharmacies for access to care because there are no other providers in the area, according to Ronna Hauser, PharmD, senior vice president of policy and pharmacy affairs at the National Community Pharmacists Association.
“Having pharmacists and their staff practicing to the full scope of their license is incredibly important, especially in health care deserts,” said Elizabeth Skoy, PharmD, professor of pharmacy practice and director of the Center for Collaboration and Advancement in Pharmacy at North Dakota State University School of Pharmacy. “Chronic disease management, screening for diabetes, and immunizations are all important. We are one of the states that not only allow pharmacy technicians to provide immunizations, but they can [also] immunize at a telepharmacy site. We are in the process of updating our rules to allow for point-of-care testing under the direction of a pharmacist, even remotely. Pharmacists have to be that connection for [patients] who otherwise wouldn’t receive care.”
In Missouri, the scope of pharmacy practice is more limited, so Logan works with local health departments to fund screening and referral initiatives. That has led to cross-training for pharmacy technicians as credentialed community health workers. “[Pharmacy technicians] work in pharmacy, but they also know where to get Meals on Wheels and other referrals, [as well as] how to integrate with other providers and services,” Logan said. “We now have electronic health record access with some of the larger providers, so we can read notes, make more useful recommendations, and provide more timely referrals.”
There are approximately 30 pharmacy technicians/community health workers across 16 counties in southeast Missouri, he added. Training costs were covered by state scholarships, workforce development funding, and the CDC. “There are a lot of state and federally appropriated funds for care coordination and patient education, vaccine hesitancy, and other programs that usually go to public health departments [who don’t have the same access to patients that pharmacists enjoy],” Logan said. “Those funds can just as easily go to community health workers. We are seeing a huge influx of dollars for pharmacies that are set up to provide those kinds of services.”
Logan pointed to other opportunities through the Community Pharmacy Enhanced Services Network (CPESN). He helped launch CPESN Health Equity, which is a specialized network focused on social determinants of health (SDOH) and community health workers nationwide. The network helps pharmacies plug into existing state and federal programs focused on community health and SDOH, tap into existing funding sources, and develop new programs.
There are also untapped resources within pharmacy—just not in filling prescriptions. Many clinical services can be submitted as medical claims. “The goal is to go directly to the medical side of an insurance company and not the pharmacy benefit manager side,” Hauser said. “Pharmacists can and should be partnering directly with the medical side of the benefit for administering vaccines, checking glucose levels [and] lipids, [and] testing for flu and strep.” Ramping up home delivery is another option to expand access to care, she added, and so is expanding long-term care pharmacy services to the home setting for patients who are eligible for a long-term care facility but prefer to remain at home.
And just as pharmacists should be practicing at the top of their state licensure, they should also be getting reimbursed at the top of their state program. “Some states provide higher dispensing fees in underserved areas,” said Dima M. Qato, PharmD, MPH, PhD, the Hygeia Centennial Chair and associate professor of clinical pharmacy, director of the Program on Medicines and Public Health, and senior fellow at the University of Southern California Leonard D. Schaeffer Center for Health Policy and Economics. “The state of Illinois has a critical access pharmacy program for independent pharmacies located in a medically underserved area modeled on the federal critical access hospital program with higher reimbursement rates.”
Qato also advised pharmacies to expand their hours of operation and boost their inventories. “It is critical to ensure that medications that [patients] can’t wait [for], such as naloxone, buprenorphine, contraception, and some cardiovascular and diabetes medications, are always in stock,” she said. “Urgent medications, EpiPens, and insulin should always be available, as well as [medications for] chronic diseases. Patients can’t afford to travel tens of miles only to be told to come back the next day or in 3 days because something isn’t in stock. They’re going to end up in an emergency [department] if they’re lucky.”
Qato emphasized the need for the entire pharmacy staff—not just pharmacists—to work at the top of their license. Whether through vaccination programs, medication management therapy, prescription contraception, or whatever other services your state allows, “provide every service, and bill for every service you provide,” Qato said. “COVID-19 showed us that we can think more innovatively about home care vs expecting [patients] to always come to the pharmacy.”
Collaborative practice is another avenue to expand pharmacy practice. In North Dakota, pharmacists can test for type 2 diabetes and hypercholesterolemia, then initiate metformin or statin therapy through collaborative practice agreements. “COVID-19 demonstrated just how ease of access to pharmacy can lead to better health outcomes,” Skoy said. “Not only in rural areas but [also] very much in urban areas. Collaborative practice isn’t about stepping on toes or even pitching your own services. It’s all about sitting down with other providers and talking about how we can work together to expand access to care.”