Finding Ways to Save Rural Pharmacies

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...

Overcoming Barriers

Herrmann notes there are some benefits to pharmacists who work in these areas.

“It allows the pharmacist to take a more prominent place in the community as a whole,” he says. “Also, it makes knowing your patients that much easier and more important.”

As for the financial challenges, Swanoski says pharmacists in these areas should consider expanding the scope of healthcare provided at their pharmacies to include: comprehensive medication management, which is a covered service under Part D Medicare, immunizations, and medical supplies.

“They should explore opportunities for providing medications to patients residing in assisted living or skilled nursing facilities,” he says. 

Pharmacists in rural areas might also consider how to expand their offerings by using technology. When telepharmacy became legal in North Dakota, Doe opened two remote locations there: one, 56 miles away in the city of Beach and the other, 95 miles away in the city of New England.

Thanks to his live video sessions, Doe can have face-to-face interactions with customers and monitor and supervise an onsite pharmacy technician at each location who is tasked with counting and distributing the medications.
“It’s been a good thing, and people support it well,” he says. “It’s like I’m virtually there, and it’s a service that was desperately needed.” 

Rural Pharmacists Explain the Draw

Jennifer Laws, BSPS, CPhT, grew up in a town of 1,822 people and started volunteering in a rural hospital pharmacy in high school. Although she headed to Kansas City to begin her career, she always knew she wanted to come home and work in a friendlier, more deep-rooted community.

“I worked in the Kansas City area for 11 years before moving back to my hometown and am currently working in a neighboring critical access hospital,” she says. “The benefits of rural areas are getting to know more about your customers and having a presence in the community. The biggest con is the lack of coverage for days off and vacations, so it becomes a 24/7 job.”
When Laws does need time away, a pharmacist in the general vicinity covers her shifts.

The career of Mike Swanoski, PharmD, BCGP,  FASCP,  includes more than 20 years of practicing in a small town or neighborhood pharmacy.

The biggest payoff, he says, was getting to know his customers extremely well. “The trust and confidence my patients placed in me as their pharmacist was the highest honor I could ever hope to achieve and one that I was professional obligated to continually and consistently earn,” he says. “I was fortunate to practice in a setting in which I was able to spend the necessary time with each patient to assure their needs were met and there questions answered.”

Keith Loria has been writing for major newspapers and magazines for nearly 20 years.