Pharmacy Deserts

Mickie Cathers

The number of pharmacies closing nationwide continues, mostly in communities of color, contributing to pharmacy deserts. An APhA2024 session on pharmacy deserts explored the research and possible solutions.

Pharmacy deserts are defined as communities with restricted or low access to local pharmacies and when at least one-third of residents live over a mile from a pharmacy, said Dima Mazen Qato, PharmD, an associate professor at the Mann School of Pharmacy at the University of Southern California, who shared over 12 years of research and publications on pharmacy deserts.

Between 2010 and 2015, the trend was pharmacy growth. However, in 2018, it all changed.

“For the first time in 20 years, you see a decline in pharmacies; closing at rates exceeding them opening,” said Qato.

In a 2021 research study published in Health Affairs, Qato and colleagues revealed that while 30 of the most populous U.S. cities showed an increase in the total number of pharmacies, disparities persisted in low-income, Black, and Hispanic neighborhoods. Some neighborhoods lost their only pharmacies. Independent pharmacies were two times more likely to close than community retail pharmacies.

“We realized we can’t ignore closures when evaluating pharmacy deserts,” said Qato. “Because of closures, it’s getting worse in certain neighborhoods, and that’s a problem because it leads to nonadherence and to disparities.”

Closures were often concentrated in low-income neighborhoods, and disproportionately affected Black and Hispanic communities. Among low-income neighborhoods, 47.7% were pharmacy desert neighborhoods.

Pharmacy closures impact access to medications, pharmacist consultation, convenient access to produce, health care services, and health navigation and literacy, as well as socialization and exercise for seniors. Even a half-mile distance between pharmacies can pose a significant barrier for older adult patients, those with disabilities, or individuals who lack reliable transportation.

Impact on health equity

The greatest incidence of HIV and a higher unmet need for PrEP was seen within pharmacy deserts, according to a study by Qato and colleagues published in the July 2020 issue of Health Affairs.

“If you overlay pharmacy deserts and those who need PrEP, they match,” said Qato. “Many pharmacies don’t even stock or carry PrEP.”

In Los Angeles, only 26 out of 1,600 pharmacies offered pharmacist-prescribed PrEP and less than 20% stocked it.

In Philadelphia, which saw one of the first statewide orders for naloxone, less than a third of pharmacies offered it without a prescription. And of that third, only 40% of those pharmacies had naloxone in stock.

According to Qato’s research, contraception access was also affected by closures and pharmacy deserts in Los Angeles. In neighborhoods with the highest teen birth rates—mostly Hispanic and Black communities—about half the pharmacies only had Plan B in stock. To make matters worse, they required identification, said Qato, even though it’s over the counter and identification isn’t necessary.

However, she added, expanding services won’t address barriers in a pharmacy desert. “If there’s no pharmacy there, that gap in care potentially worsens teen birth rates or pregnancy rates. This is especially obvious when pharmacies close.”

Payor mix implications

Neighborhood pharmacies that rely on Medicaid or Medicare, rather than commercial insurance, were more likely to close than other pharmacies, according to a study by Qato and colleagues published in the January 2020 issue of JAMA Internal Medicine.

“We saw that payor mix influences closures,” said Qato. Community retail pharmacies were closing in Black and Hispanic communities—communities where patients were predominately publicly insured.

“Pharmacies are reimbursed less due to many system-level factors, including lack of PBM transparency, and low pharmacy reimbursement,” said Qato. “For large businesses or chain pharmacies that have the power to decide where and when to close, they often close the stores where they aren’t reimbursed as much. For independent pharmacies, however, they are often forced to close.”

Closures due to PBMs’ harmful practices — Some closures are directly related to PBMs’ harmful practices such as spread pricing, claw backs, and lack of transparency in payment. Pharmacies are being reimbursed below cost more often than not, putting them at a financial loss, due to the actions of PBMs. APhA continues to advocate every day at state and federal levels to prohibit PBM practices that undermine the sustainability of community pharmacies and lead to these closures. Visit www.endpbmsnow.com/ to learn more and join in APhA’s efforts to help.

Possible solutions

Potential policy and patient-centered remedies to address pharmacy deserts involve focusing on equitable access. The goal is to ensure all patients have access to prescription medications regardless of where they live, said Qato.

Efforts to reduce closures and pharmacy deserts may involve payment reform, including increases in Medicare and Medicaid pharmacy reimbursement rates—especially for critical access pharmacies most at-risk. Qato said this means considering preferred status for those pharmacies, particularly independents, at risk for closure in low-access neighborhoods.

Other options include awareness and advocacy through town halls held in affected communities and pilot interventions such as transportation vouchers, telepharmacy, and home-delivery, as well as pharmacists partnering with their state pharmacy associations to work out agreements with the federal government. ■