On The Cover
Sonya Collins
During a routine comprehensive medication review at Brewster Family Pharmacy in rural Brewster, OH, a patient mentioned to pharmacist Chip Cather, PharmD, that he had been experiencing leg swelling, headaches, and eye pain, and was seeing spots.
“It sounded like he would have just let these things go until he could see a doctor if he hadn’t had this appointment at the pharmacy,” said Cather.
Cather contacted the patient’s doctor to get his blood pressure medication changed, which resolved the leg swelling. He also managed to get the patient in to see the doctor sooner than scheduled and got him to visit an ophthalmologist for the eye pain and spots.
Aside from the nursing home next door, Brewster Family Pharmacy provides the only health care available in the rural farming community of Brewster—a common scenario throughout rural America. The problem of limited health care resources is compounded by the fact that rural areas are often home to people with fewer economic and health resources.
Cather’s patient encounter is just one of countless stories in which rural patients rely on pharmacies for their primary health care. Pharmacies pick up the slack in American health care deserts, although many pharmacies struggle to keep their doors open in these underserved areas. However, some have found ways to thrive while addressing the urgent health care needs of their communities.
A picture of rural health
Nearly 80% of rural America has been designated by the federal government as medically underserved.
In Brewster, if patients don’t visit the one physician who is about a 10-minute drive from Brewster Family Pharmacy, Cather said, patients must drive 30 to 45 minutes to see a physician.
“In extremely underserved areas, access to specialists is particularly challenging, but even access to primary care is tough,” said Tripp Logan, PharmD, vice president of SEMO Rx Pharmacies, which owns and operates pharmacies in 3 rural counties in southeast Missouri (also called SEMO) and offers health care consulting services to pharmacies or other health care and social service organizations throughout the region.
The distance from a physician’s office makes collaborative practice agreements with pharmacists both a necessity and a challenge. Medicaid reimbursed Cather for providing comprehensive medication reviews
through a Medicaid/UnitedHealthcare Managed Care Organization pilot program. After the pilot program ended, Ohio Medicaid recognized Cather as a health care provider so that he could continue to provide medication reviews and bill for them.
But the state also required that Cather enter into a collaborative practice agreement with a physician, which was much easier said than done. “We don’t just have relationships with doctors right next door or across the street that we can collaborate with,” Cather said.
When he looked further afield for physicians with whom he might collaborate, he ran up against another systemic problem.
“So many of the private practices are being bought up by Cleveland Clinic,” he said.
When he approached providers in these practices about collaboration, they indicated that the request would have to be run up a very long chain of command in order to get approval. The response from the hospital was that they already had physician assistants and nurse practitioners in-house that provided the service Cather was proposing.
“They just don’t see the value in it—in doing the legwork required to start a collaborative practice agreement,” he said.
When physicians are hard to reach in a health system that’s difficult to navigate, patients are more likely to take their complaints to the local pharmacy or just defer care altogether, which leaves health problems to escalate.
SEMO Rx’s pharmacies are located in the Mississippi, New Madrid, and Scott counties of Missouri, which Logan explained “typically rank among the lowest in median household income and highest for infant mortality, diabetes, and cardiovascular disease. It’s a pretty challenging area [in which to receive health care].”
The low population density in rural areas means that these communities may often miss out on government-allocated resources. The state of Missouri, for example, sponsors large-scale free COVID testing sites, but these events do not reach rural communities.
“It’s free testing, which is amazing, but it doesn’t make sense to send testing resources to areas where there aren’t a whole lot of people,” Logan said. “So [some] people just don’t have access to COVID testing.”
Pharmacies are trying to pick up the slack in areas where life expectancy is shorter, health behaviors are worse, and death rates from the 5 leading causes of death (heart disease, cancer, accidental injury, chronic lower respiratory disease, and stroke) are higher.
Ailing health at rural pharmacies
Meanwhile, the health of rural pharmacies is at risk, too. Independently owned rural pharmacies have been steadily shuttering for the last two decades. According to the Rural Policy Research Institute, the United States lost 16.1% of its independent rural pharmacies—1,231 drug stores—between 2003 and 2018. In 2020 stresses piled onto the industry by the pandemic helped bring the total number of urban and rural independent pharmacies in the United States to below 20,000, according to the Drug Channels Institute.
Many rural independent pharmacists hold PBMs responsible for the field’s rapid decline. PBMs often require that health plan beneficiaries use the large chain pharmacies with whom the plans contract to get the lowest price on their prescription medications—a practice that hurts both pharmacies and their patients.
L&S Pharmacy in Charleston, MO, is located 20 miles from the nearest chain pharmacy, but many locals are forced to make the 40-mile round trip to pick up their prescriptions from the chain.
“They have to drive past the closest pharmacy to go to another one because it is mandated by their health plan,” Logan said.
Collaboration is key
Many pharmacists are working to solve some of the problems that face their patients and their pharmacies in order to help them navigate a complicated health care system, get their medications at a more affordable price, and keep their care in their community.
For all the challenges they face, in many ways rural pharmacies are uniquely positioned to help resolve some of the health care challenges that rural Americans face.
At one of SEMO Rx’s pharmacies in Missouri, a patient had qualified for a follow-up consultation with a pharmacist after discharge from the hospital as part of a program for individuals at high risk for hospital readmission. The patient had been discharged into the care of a local health clinic, but when the pharmacy followed up the clinic said the patient had not come in for his appointment. The hospital did not know the patient’s whereabouts, either.
“It was as if the patient had fallen off the face of the earth,” Logan said.
SEMO Rx’s pharmacy team knew the patient’s family, and they knew that the daughter was the primary caregiver. The hospital and clinic had been coordinating with another family member who was not responsible for the patient to make follow-up appointments. The pharmacy was able to quickly contact the daughter, loop her in on the missed follow-up appointments, and help her schedule new appointments.
“The pharmacy team knew the patient and daughter simply because they are embedded in the rural community,” Logan said. “That’s what happens in [pharmacies] with people who have been working there forever.”
SEMO Rx harnesses this community connection and trains pharmacy technicians to double as community health workers. The organization has recently developed a formula curriculum for the training.
“A community health worker is a local liaison who understands the community and can help somebody navigate the health care system on a peer-to-peer level without the ‘white coat’ intimidation,” Logan said.
A legion of pharmacy technicians turned community health workers in southeast Missouri now address many of the health care problems that patients face. They help patients get their medications at a more affordable price; screen patients for certain health risks; make referrals, sometimes to other community health workers with different expertise; and connect them with health care and services in the community. Their status as community members means they do not breed the distrust and intimidation that physicians and other clinicians from outside the area might.
The key to providing the necessary health care to rural Americans, Logan said, is forming expansive reciprocal networks with other health and service organizations.
“In rural areas where there’s a lot of distance between providers, everybody has a challenge or a need and other people have solutions,” Logan said. “We have to coordinate with these entities rather than seeing it as infringing on someone else’s territory.”
This type of coordination and reciprocity is the backbone of New Mexico–based Project ECHO, which helps support coalitions in rural and underserved areas so that patients can be treated locally for chronic complex diseases rather than travel long distances to see a specialist.
In this model of collaboration between university-based specialists and a variety of rural clinicians, “all teach and all learn,” said Paulina Deming, PharmD, assistant director of viral hepatitis programs for Project ECHO and associate professor of pharmacy practice and administrative sciences at the University of New Mexico College of Pharmacy.
Through Project ECHO, clinicians in underserved areas—including rural pharmacists—present cases via videoconference to a remote team of specialists who are often located at academic medical centers. The local clinician can then learn how to manage the patient and, in many cases, eliminate the need to refer them out of town for further care. That’s how the program accomplishes its mission of “moving knowledge, not people.”
“This oftentimes results in a more culturally appropriate manner of care by keeping the care local,” Deming said.
Deming, like Logan, stresses the importance of reciprocal collaboration. The objective is not for big-city specialists to teach rural clinicians in a one-way transaction. “We as hub experts may have input on how to manage the disease, but we may have a rural clinical site that knows how to access the medications or how to navigate patient assistance programs.”
One of Deming’s favorite ECHO success stories is of a Native American pharmacist in Montana’s Indian Country who learned how to manage patients with hepatitis C through the program. While he is employed by Indian Health Service, he is now also an expert faculty member in Project ECHO’s Indian Country ECHO.
“He had a number of patients who had been infected and no one was able to provide care for them, so he decided he would take it upon himself to figure out how to get it done—and he did it,” Deming said. In Indian Country, she added, pharmacists are often the only clinicians consistently available to the community on an ongoing basis. “They identify various needs in the community and some of the work they are doing is phenomenal.”
A multi-pronged approach
Project ECHO has brought medical expertise to underserved areas across the United States and in 93 other countries. But, Deming said, it’s not “the answer” to all that ails rural America; it’s simply one approach to one of many challenges. SEMO Rx’s community health worker program is another. But many approaches are needed to begin to eliminate health disparities and close life expectancy gaps in rural areas. Among them, there’s a role for pharmacists.
“It’s taking a challenge and turning it into an opportunity,” Logan said. “There’s a lot of opportunity in rural areas to collaborate with partners outside of the pharmacy.” ■