In rural and small-town America, independent pharmacies play a vital role for the customers who rely on them. However, U.S. rural pharmacies are dwindling. Since 2003, about 16 percent of independent rural pharmacies — or…
In rural and small-town America, independent pharmacies play a vital role for the customers who rely on them. However, U.S. rural pharmacies are dwindling. Since 2003, about 16 percent of independent rural pharmacies — or roughly 1,230 stores — have closed, with fewer than 6,400 remaining, according to figures released in July.
In some areas, no pharmacies exist whatsoever. According to statistics from the RUPRI Center for Rural Health Policy Analysis, 630 rural communities that had at least one independent, chain or franchise retail pharmacy in 2003 had none by March 2018. Residents may need to travel far to fill prescriptions, or turn to mail-order arrangements without the benefit of in-person counseling or easy ability to ask questions about taking medications safely.
As rural hospitals close, and with a shortage of primary care providers, pharmacists are sometimes the only health professionals serving area residents. If they go, it leaves a void.
To beachgoers, Easton, Maryland (population: 16,000), is a small Eastern Shore town en route to Ocean City. To the staff at Hill’s Drug Stores, two independent family-owned pharmacies, Easton is home. This week, the East Dover Street shop marks its 90-year anniversary.
“My grandfather started it in 1928,” says Mimi Shannahan, co-owner of Hill’s Drug Stores along with her siblings. “Then my father took over, when he got back from World War II.” Carrying on family tradition, she and her sister went on to pharmacy school (while their brother branched out into dentistry).
Remnants of an apothecary era persist. The old-fashioned soda fountain, with its original marble counter, still serves customers. In addition to the usual prescriptions, specially trained pharmacists mix individualized prescriptions in a separate compounding laboratory.
Independent pharmacies used to thrive in the historic downtown location. “There were five or six little pharmacies when I grew up,” Shannahan says. “We’ve been the only one now for at least 20 or 25 years.”
The setting for the second Hill’s Drug Store, less than a mile away, is much different. Launched in 1987, the larger Cynwood Drive location includes a drive-through window and home health division. Inside, a robotic packaging machine can sort a customer’s entire medication regimen into separate, time-of-day packs to help ensure that prescriptions are taken correctly and prevent medication mix-ups at home.
The sharpest drop in independently owned rural pharmacies happened between 2007 and 2009, according to the RUPRI brief. However, a slower decline continues into 2018.
“The biggest spike in rural pharmacy closures occurred a few years ago, after the full implementation of Medicare Part D,” says Keith Mueller, director of the RUPRI Center, which is based at the University of Iowa and supported by the Federal Office of Rural Health Policy.
Pharmacists are important resources for people in rural America, Mueller says. “The problem is, even when you lose a smaller number of pharmacies a year, you’re still losing a point of access to that professional,” he says. “In some communities, they may be the sole source of any kind of clinical advice.”
Mueller’s team previously looked at the effects for rural residents after their only nearby pharmacy closed. “We found some combination of turning to mail order, or a pharmacy located as far away as 30 or 40 miles might do once-a-week or twice-a-week deliveries in the community,” he says. In some states, systems involving pharmacists, pharmacy technicians and telepharmacy technology enable prescriptions to be dispensed in areas where providers are scarce.
Rural and small-town pharmacies like Hill’s have long faced competitive pressure. Drug Fair (now defunct) was the first pharmacy chain to come along, Shannahan recalls. “Then it was Walmart and all the chains like CVS and Walgreens, and now it’s Target and Harris Teeter.”
Reimbursement changes have affected the entire pharmacy industry, possibly hitting small independent drug stores the hardest. “It’s why we’re losing a lot of rural pharmacies,” Shannahan says. “I can’t tell you how many times we have refilled a prescription where we are reimbursed less than our costs,” she says. “Also, it goes to get processed and we don’t get paid for 30 days. When we do get reimbursed above costs, sometimes it’s 1 percent or 5 percent.”
Approachability and Access
Access is a big part of what rural pharmacies offer. “Anywhere you go, pharmacists are so approachable,” says Bree Watzak, a clinical associate professor of pharmacy practice in the College of Pharmacy and the Rural and Community Health Institute at Texas A&M University. “You can walk in to buy a candy bar and then go talk to a pharmacist.”
Overall, rural residents tend to be older and therefore more likely to have chronic diseases, Watzak notes. Medication management becomes more complicated. “I’ve seen pharmacists doing counseling at nursing homes and seniors centers where they help with streamlining of medication,” she says. If indicated, the pharmacist can discuss deprescribing unneeded drugs with the patient’s doctor.
Convenience, or lack thereof, affects whether people take prescription drugs as recommended. “If you have to drive 60 miles to pick up your drug, you’re not going to get your refills on time as often as you should,” Watzak says. “Whereas, if it’s right there where you live, that makes it easier for you to take the medications that you need.”
Rural pharmacists play an important role in patient safety, Watzak says. “You don’t necessarily have specialists in small towns,” she says. “So you may go to a big city for your cardiologist and another big city for your orthopedic surgeon. You may go to another big city for after your stroke.”
As a result, medications may overlap. “That pharmacist in your town is the one who sees everything that’s going on — not necessarily the specialist in the city where you went,” Watzak says. “It’s very important to have eyes on the different medications you’re taking, to make sure they’re optimized and there won’t be duplications or side effects.”
Pharmacies sometimes serve as rural telehealth sites. Patients can come in to have their vital signs taken or for blood glucose monitoring, Watzak says. That information is immediately transmitted to the patient’s physician onscreen. “Physicians can then talk with patients while pharmacists can be hands-on,” she says.
Patients have benefited from Medicare changes in terms of affordable medications, says Michael Swanoski, a senior associate dean and associate professor with the University of Minnesota College of Pharmacy. However, he also notes the effects of low reimbursement rates on pharmacies.
“It’s harder for an independent pharmacy to get enough revenue from other types of transactions to keep the lights on,” Swanoski says. Larger chain pharmacies and big box stores can better absorb reimbursement changes, he says. “In independent pharmacies in smaller communities, the patient base is smaller,” he says. “For independent pharmacies that are surviving, the secret sauce is: They either have to get bigger or they have to offer more services.”
In Minnesota, for instance, some rural pharmacies have developed collaborative-practice agreements with primary care clinics, allowing pharmacists to manage conditions like high blood pressure and start, stop or adjust patients’ therapy, Swanoski says. These arrangements improve patients’ access, increase pharmacy revenue and help address the primary care provider shortage for nonurgent patients with chronic conditions, he says.
Jennifer Harrison, pharmacy manager for Hill’s Drug Stores, has personally been serving local customers for more than 30 years. “A lot of people view mom and pop stores — the older independents — in a certain way,” Harrison says, but she emphasizes these pharmacies are much more than “sweet little shops.”
Services go beyond the ordinary. For instance, some customers have diabetes, putting them at risk for serious health issues affecting their feet. The home health division offers a diabetic shoe service for customers who bring in prescriptions from their doctors. “They are fitted by certified diabetic shoe-fitters,” Harrison explains. “The shoes are specially ordered for that individual. Their foot is measured like the old days when you went into a shoe store.”
Now it’s flu season and Harrison and a pharmacist colleague are taking flu-shot clinics on the road. Last week, that included a trip to a senior facility where older adults received immunizations. “When we got there, we had a few people call and say, ‘We really need a flu shot, but we’re shut-ins and can’t get out,'” she says. “So we went out to their homes and did their flu shots for them.”
On occasion, Shannahan will go to the pharmacy in the middle of the night to respond to an Easton neighbor’s urgent need. “What really sets us apart is caring and customer service,” Shannahan says. “We’re from the community. Our lives are here.”