The Community Pharmacy—Finding a way forward to bring health equity to all

Heather Clark, PharmD, RPh; Ashlyn Abell, BSc, IPG Health Expert

World Pharmacists Day occurs every year on September 25, highlighting the integral role pharmacists play in effective health systems. The International Pharmaceutical Federation (FIP), the largest global pharmacist advocacy organization, has appropriately themed 2023 as “Pharmacists strengthening health systems.” Pharmacists globally work hard every day to live up to this higher purpose, but they need like-minded partners and support to manage the major challenges they face.

Access to medication is so much more than cost

When most people think of “access,” they tend to focus on the financial aspects of cost and reimbursement. That is a pivotal aspect of the access story, but at its core, access means more than that. It is about health equity. True access is about empowering patients and providers, enabling health and healthcare education, and effectively communicating to address consumer learning limitations (eg, different reading levels, visual/auditory impairments, limited access to technology, etc). It is about clinical trials being representative of a diverse audience, so drug effectiveness can be assessed accurately to give all patients access to life-changing medications. And health access is about one’s ability to visit and talk to a healthcare professional where they work and live.
 

Healthcare deserts undermine access

The country is a currently going through a health access crisis driven largely by “healthcare deserts” that impact the health and wellness of communities across the United States.
 

What is a healthcare desert?

In LaFayette, Alabama, the only two primary doctors in this small town of 2,700 people announced their retirement. The nearest emergency room is in another town 20 minutes away along a rolling road.¹

That’s a healthcare desert. They are places where basic healthcare resources are lacking. The facts are hard to deny with 80% of the US population lacking adequate access to healthcare and over a third living in a county where there is inadequate access to primary care providers, pharmacies, hospitals, trauma centers, and/or low-cost health centers²:

• Over 9% of counties are primary care provider deserts, where there aren’t enough healthcare professionals to provide primary care for most of the local population
• Over 20% of counties are hospital deserts, where most people have to drive more than 30 minutes to reach the closest hospital, and nearly 47% of counties have fewer than two hospital beds per 1,000 people
• Over 45% of counties are low-cost health center deserts, where most people have to drive more than 20 minutes to reach federally funded community health-centers or services

What is even more concerning are the demographics of rural areas and their health status³:

• Rural populations usually have higher rates of chronic illness, which creates more demand
• Rural areas tend to have higher proportions of elderly residents, who typically require more care
• Rural populations tend to be poorer and may forego care due to cost

Revisiting where we started, what does this mean for LaFayette, Alabama?

The town is losing their only two doctors and the nearest in-person medical setting is over 20 minutes away. But what does this small town have? Two pharmacies!
 

Pharmacists play a vital role in helping people get access to their medications

Year after year, surveys report that community pharmacists are often considered the most accessible healthcare practitioners. We know that people visit pharmacies about 12 times more frequently than they do their own primary care provider. In fact, those with multiple disease states commonly report making visits to their community pharmacy up to 35 times per year!⁴ Access to pharmacy care is essential because regular engagement with pharmacists supports routine healthcare management, bridges gaps in care, and promotes preventative health in the communities they serve. Every visit to a pharmacy is an opportunity to optimize a patient’s health outcome.⁴

It’s also important to support pharmacists, like those in LaFayette, with tools and resources to enable them to excel in all the roles they fulfill beyond dispensing medications⁵:

• Immunizations and administration of other injectable products
• Hypertension screening
• Point-of-care testing
• Diabetes counseling
• HIV prevention
• Contraception
• Opioid addiction management (eg, naloxone dispensing)
• Buprenorphine for use in opioid use disorder

But what is the impact if a community also resides in a pharmacy desert?
 

Examining the pharmacy desert subtype

Here in the United States, most people probably think there is a pharmacy on every corner to meet patient healthcare needs. However, in many parts of the nation, this is not the case. There are many pharmacy deserts across the US.
 

What is a pharmacy desert?

Pharmacy deserts are defined as any area with restricted access to pharmacy services, fundamentally based on a person’s distance from the nearest pharmacy. For example, in urban settings, a pharmacy desert occurs when a patient lives over a mile away from the nearest pharmacy. The distance changes to two miles in suburban settings and 10 miles in rural settings.⁶

Additional factors may be used to define a pharmacy desert, including economic status, internet access, percentage of residents without health insurance or Medicare/Medicaid, geographic area-use location, and a region’s crime-risk score.⁶
 

Where do pharmacy deserts exist?

Pharmacy deserts are as likely to be found in major metropolitan areas as in rural settings. The most urban disparities were seen in Chicago, Los Angeles, Baltimore, Philadelphia, Milwaukee, Dallas, Boston, and Albuquerque. South Dakota, Montana, Nebraska, and Kansas are the states with the most counties with rural pharmacy deserts.
 

How do pharmacy deserts actually come about?

While pharmacy closures are the primary contributor to the growth of pharmacy deserts, lack of pharmacy access can occur for a variety of reasons.

In the United States, the healthcare payor system is structured so that pharmacy benefit managers (PBM) manage drug costs. The rise of PBMs have contributed to the rise of pharmacy deserts:

• PBMs create pharmacy networks for insurers that direct patients to use specific pharmacies. As a result, patients may not be permitted to fill their prescription using their insurance coverage at pharmacies that are the most convenient (ie, closest to their home) and, thus, they may allow their treatments to lapse
• PBMs also dictate how much money pharmacies will be paid (reimbursed) when they fill a prescription. The reimbursement amount may not be enough for the pharmacy to break even or make a profit filling certain medications. Eventually, the pharmacies might no longer be profitable and close down
   

Pharmacy deserts impact healthcare delivery and access

Pharmacists are at the forefront of healthcare delivery and improving health outcomes. But without local pharmacy care, patients may become less compliant in taking their medications as prescribed and may eventually drop the therapy altogether. When chronic conditions are not managed with medication adherence, patients can suffer severe and irreversible consequences. A 2016 study found that medication nonadherence costs the US around $528.4 billion, or approximately 16% of what is spent on healthcare.⁷

Pharmacists can also play a key role in helping to detect medical indications to drive earlier diagnosis and treatment. Therefore, pharmacy deserts may not only impact medication adherence but also access to medications and other important pharmacy services as mentioned above.

To learn more about what is being done to combat the growth of pharmacy deserts, please visit Support the Pharmacy Desert Act of 2023.

So, what can we do to help?

Fortunately, the potential impact of pharmacy deserts, as well as some possible solutions, are being acknowledged and recognized. In 2022, the Pharmacy Access Initiative was rolled out by the National Community Pharmacists Association (NCPA) and researchers at the University of Southern California (USC). They developed an interactive mapping tool to determine where pharmacy deserts exist and which areas require the greatest attention. The data can be presented to policymakers to improve regulation, transparency, and equitable reimbursement.

Brands can make a difference as well. Brands can be vital partners to pharmacies, providing tools and programs to support early intervention, optimal medication starts, adherence, and essential access in both brick and mortar and digital environments. In addition, brands can act as health equity champions, helping pharmacies to better reach the underserved and creating a win-win-win for patients, pharmacies that serve them, and the brands that aim to improve patient health. Brands leveraging white-space opportunities with pharmacists and pharmacies will find very capable and willing partners in combating healthcare deserts in a sustainable manner and ultimately improving healthcare access across the country.
 

Curbing the impact of chronic kidney disease (CKD)

Chronic kidney disease (CKD) is a common yet vastly underdiagnosed, progressive disease, typically presenting with no symptoms in the early stages. CKD generally becomes symptomatic when the disease progresses toward end-stage renal disease, by which point much of the kidney function cannot be recovered.⁷ Our client worked closely with IPG Health Expert to develop a community pharmacy screening program to detect CKD earlier so those who need further assessment and treatment can get it.  

The screening program, aptly called The CKD Pharmacy Toolkit, is an unbranded set of educational and practical tactics designed to upskill and empower pharmacists to positively impact the course of CKD through early identification and intervention.  

The program has already garnered success after being launched at FIP in May of 2023 and now can be accessed by pharmacists globally though the FIP website. Early reports suggest a high rate of adoption in some markets with the results and impact to communities being closely observed over the next several months to years.

This toolkit will no doubt have a positive halo effect on the early management of CKD and, most importantly, the health of CKD patients around the world. 
 

Leveraging pharmacies as an essential access point to healthcare services can impact the role of brands in patients’ lives and, ultimately, their health.

References

¹ With its two doctors planning to retire, an Alabama town patches together health care options

² Mapping healthcare deserts: 80% of the country lacks adequate access to healthcare

³ Rural healthcare workforce

⁴ Pharmacists as accessible health care providers: quantifying the opportunity

⁵ How pharmacy deserts are formed

⁶ Mapping healthcare deserts: 80% of the country lacks adequate access to healthcare

⁷ Cost of prescription drug–related morbidity and mortality