A shortage of pharmacies in rural areas has made it harder for people to fill prescriptions and to access other critical services.
Roughly 450,000 adults in Washington live in what are called pharmacy deserts, according to the University of Washington. An interactive map by the telepharmacy software company TelePharm illustrates the shortage, showing 86 towns in Washington are more than 10 miles from the nearest pharmacy.
The disparities are partly the result of a national shortage of pharmacists and barriers that make it difficult for independent pharmacies to operate.
Erik Nelson, who owns pharmacies in Spokane; Moscow, Idaho; and the Suncrest area in Stevens County just northwest of Spokane, said rural pharmacies act as a health care point of contact for their communities.
“The pharmacist is the most accessible health care provider in America,” he said, “because you can walk into pretty much any pharmacy and talk to a pharmacist in less than a minute.”
Smaller communities tend to use pharmacy services more, particularly if there are no other health care providers nearby. So when a pharmacy closes, it can lead to a health care shortage.
“It’s really the first line of defense for most of these people’s health care,” Nelson said.
Insurance companies make it difficult for some smaller independent pharmacies to survive, through reduced or “negative reimbursements” for medications, Nelson said.
“Probably 50% of the time, the prescriptions that we fill are paid below our acquisition costs,” Nelson said. “So, we are losing money. It’s not a sustainable business model.”
At the same time, the pandemic prompted many pharmacists to retire, and not enough new professionals are entering the field. In a competitive market with sign-on bonuses, rural pharmacies are often left out.
A new program at the Washington State University College of Pharmacy and Pharmaceutical Sciences plans to address these challenges by supporting rural pharmacies and increasing the number of rural pharmacists over the next 10 years.
An anonymous $2.2 million donation last year helped kick-start the Rural Health Initiative, which will train pharmacy students to specialize in rural health care.
The program, based at WSU’s Spokane and Yakima campuses, will operate as a special track under the pharmacy school. Along with regular coursework, the curriculum emphasizes rural health topics, hands-on experiences in rural clinics and a capstone project focused on improving an aspect of rural health care.
Students accepted into the program are eligible to receive a $10,000-a-year scholarship. In return, they make a commitment to practice for at least three years in rural Washington after graduation.
The program can help provide a path for students who want to return to their hometowns but don’t see enough opportunity, said Megan Undeberg, WSU’s director of rural health curriculum.
Students from rural backgrounds are especially encouraged to apply.
“We believe that students from rural areas are more likely to return to those communities after graduation,” said Angela Stewart, WSU’s associate dean for rural health.
Students apply to join during their first year at the pharmacy school. Five students were selected for the inaugural class.
Catalina Yepez, a member of the first cohort of students, joined the program because she wants to continue living and working in Prosser, the Central Washington town where she grew up.
“I always wanted to work in rural health, I just didn’t know where,” she said.
Yepez still lives in Prosser and commutes an hour to the Yakima campus. Her main interest is to study, treat and prevent type 2 diabetes in the Hispanic and agricultural communities. She said the disease is common in her family.
When Yepez was growing up, her mother would take her out of school so she could help translate at doctor appointments.
“I hope that the rural health track will allow me to become a stronger liaison for Spanish-speaking and underserved communities while bridging the health care gap,” she said.
Michael Sauseda, an Army veteran, wants to help tribal nations and veterans in rural areas.
“I really want to continue serving the underserved,” he said.
Sauseda spent part of his 20-year military career as a Special Forces medical sergeant, serving tours in Afghanistan, Iraq and the Philippines.
During training, he spent two months on the Sioux Indian Reservation in Rosebud, South Dakota. That experience impressed upon him “how certain communities are more impoverished than others here in the U.S.”
The rural health track begins in the classroom, where students learn the basics of rural health and research methods. They also learn entrepreneurial skills.
Then they go into the field. Each student will partner with a rural pharmacy and work to solve a high-priority issue based on their interests.
During the summers and their final year, students complete clinical rotations so they can experience pharmacies in various settings, including a rural hospital, a community pharmacy and an outpatient clinic.
Students also can choose elective rotations not limited to rural settings, such as a compounding pharmacy where medications are made from scratch.
After earning their doctor of pharmacy degree, some may choose to do a residency for a year or two in another community where they can continue research.
In addition to recruiting and educating new pharmacists, another goal of the Rural Health Initiative is to directly support rural pharmacies in Central and Eastern Washington by establishing residency programs. The Rural Health Initiative will embed faculty in these communities, where they can guide recent graduates through their residencies, provide additional care and develop new business and practice models.
Because the program is new, the school is still working to develop some of these partnerships. They are seeking additional funding sources to support the program.
The professors emphasized a shift for pharmacists to focus on clinical care.
“Pharmacists are recognized as some of the most accessible providers,” Stewart said. “You don’t need an appointment to access pharmacy care or advice. A lot of these rural residents, when they are experiencing something new with their health, the pharmacy might be the first place they go for help and advice, for recommendations in terms of self-care and even perhaps for initiating clinical services or for referral, if necessary.”
Because of recent law changes, pharmacists can now bill for clinical services. This could be a way to offset reimbursement losses from prescriptions.
“Margins are very slim, and so a lot of the independent community pharmacies are being forced to close these days because they just can’t sustain their business with reimbursements for their prescription services,” Stewart said. “What needs to grow then is the ability of pharmacists to be paid for the clinical services they provide, the patient care that they provide beyond just the dispensing of the prescription.”
Pharmacists can provide an array of clinical services. These include screening and testing for disease, running lab tests, treating minor illnesses and prescribing medication.
Pharmacists are especially well-positioned to manage chronic conditions such as hypertension, diabetes, cardiovascular disease and asthma.
Besides providing medication, pharmacists can counsel patients on lifestyle, diet and exercise. They can do frequent follow-ups, monitoring the condition over time and adjusting dosage, without the patient needing to return to a primary care provider.
For these reasons, telepharmacy and mail-order prescriptions are no replacement for in-person care, said Julie Akers, WSU’s associate dean for external relations and a co-lead of the Rural Health Initiative.
Still, amid the pharmacist shortage, more robotic pharmacists will pop up at some locations.
“It’s like a vending machine with a screen,” Akers said. A pharmacist somewhere else counsels the patients through a screen, then dispenses their medication.
“That’s a solution for some of the rural communities,” Akers said, “but I don’t think it’s the best solution, because it’s a way for them to get their medications, but they are still not getting access to a care provider.”
Pharmacists are trusted community members who form relationships with patients that foster honest communication, Akers said.
Nelson pointed out another downside to mail-order prescriptions, which are becoming more common.
“Say you are sick or need a dental procedure or something like that. You don’t have time to wait three or four days for (medication) to show up in the mail.”
Before the pandemic, Akers said, there were too many pharmacists. News reports at the time discouraged people from entering the field because there weren’t enough jobs. They did not take into account that many older pharmacists would soon retire.
Now it will take a while to reverse the trend.
“Probably for the next 10 years, I foresee we are going to have a fairly critical pharmacist shortage,” she said.
Over that time, the Rural Health Initiative intends to scale up and make a difference across the state and beyond.
“We recognize our students come from all over the country and there are pharmacy deserts all over the county,” Stewart said. “I think there’s potential for spreading what we learn and what’s successful beyond Washington eventually.”