Pharmacy Deserts and the Community Pharmacy

What Is A Pharmacy Desert? 

In 2014 Dr. Dima M. Qato PharmD, MPH, PhD coined the term “Pharmacy Desert” to describe geographic areas with low access to pharmacy services. Derived from the USDA’s term for low food access areas, “pharmacy deserts” are 1) urban areas that are at least one mile from a pharmacy or 2) rural areas that are at least 10 miles from a pharmacy.¹ 

The Role of the Community Pharmacy 

Understanding the role of the community pharmacy is essential to recognizing the scope of the pharmacy desert problem. Pharmacy services vary widely depending on the type of pharmacy, but may include:

• Vaccine administration  
• Medication therapy review 
• Filing of insurance requests  
• Over-the-counter drug advice 
• Education on prescription and over the counter medications 
• Point-of-care testing  
• Blood pressure, blood sugar and cholesterol measurements 
• Prescription delivery 
• Prescription compounding 

The role of the pharmacist is constantly growing so this list is not exhaustive. When pharmacies close and patients lose access to these services, their medication adherence suffers.² This can lead to increased  risk of adverse events from untreated conditions, increased emergency room visits, longer hospital stays and overall poorer patient outcomes.  

How Are Pharmacy Deserts Created? 

Pharmacy deserts occur when a pharmacy closes in an area, leaving its residents with reduced access to  pharmacy services.

Challenges facing pharmacies which can lead to closures include staffing,  competition from other pharmacies and reimbursement rates.² The biggest of these problems by far are the reimbursement rates, which are systemically lowered by Pharmacy Benefits Managers (PBMs).

PBMs are companies that manage prescription drug benefits for sponsors such as employers, health insurers and Medicare Part D plans (ie. Caremark, Aetna, Express Scripts, OptumRx etc.). These PBMs generate revenue through a complex system of negotiating rebates, modifying administration fees and controlled charges to the sponsor.^3,4

Unfortunately, very little of this revenue makes it to the pharmacy or the beneficiaries. PBM profits are maintained, but the pharmacy may be forced to operate at a loss. This financial pressure forces pharmacies out of communities and leaves little motivation for these services to return.

Who Is Affected By Pharmacy Deserts? 

Research on pharmacy deserts has been sparce, making it difficult to draw conclusions from available data. Three studies of note include a population study in Chicago, Illinois, a population study in Philadelphia and a more general tool that identifies pharmacy deserts across the U.S.

In 2014, Dr Qato  and colleagues performed a revealing observational study assessing urban pharmacy access. According to their data, roughly one million Chicagoans live in pharmacy deserts, many of whom live in low income and racially segregated communities. 54% of segregated Black communities were pharmacy deserts. By comparison, 34% of segregated Hispanic communities, 29% of integrated communities and 5% of segregated white communities were pharmacy deserts.⁵ The highest risk group as identified by this study were people in low income, segregated Black communities. 

A 2018 study in Pennsylvania focused on elderly individuals who are enrolled in a State Pharmaceutical Assistance Program (SPAP). Pharmacy deserts were much more prevalent in rural areas than urban areas, but contained a lower proportion of individuals in the SPAP program. The researchers found that 40% of the 172,967 enrollees lived in pharmacy deserts.⁶ The highest risk group as identified by this study were non-Hispanic white, married males in urban areas. As the study scope was limited to SPAP enrollees, this may not be representative of the Pennsylvania population as a whole. 

In 2018, TelePharm in Iowa mapped pharmacy deserts across the U.S. by identifying locations with between 500 and 5,000 people who were ten or more miles from the nearest retail pharmacy.⁷ The objective of this project was only to map the pharmacy deserts, therefore no additional conclusions were drawn about affected populations. 

How To Address These Disparities 

With much of the financial pressure centered around reimbursement, it is essential for public health policy makers to take a serious look at PBMs.

Regulations to create fair reimbursement plans and promote transparency of PBM revenue streams will go a long way toward stabilizing the loss of pharmacy services. Other options include subsidies, telehealth and mail-order pharmacy.^1,2 Each of these solutions has pros and cons. Government subsidies would help motivate pharmacies to move back into under-served areas. Getting pharmacies back into communities is the best option for providing access to clinical services such as point-of-care testing and vaccine administration. It would be the most expensive option, however, and continued access to the pharmacy would be highly dependent upon the availability of subsidies.

Telehealth allows pharmacy staff to provide information and dispensing services and is less costly than moving the pharmacies back into a community. However, separation between the pharmacy  staff and the patient limits the availability of clinical services.

Mail-order would be the cheapest option to bring medications back into a community, but lacks the interaction with pharmacy staff. The patients  would be missing out on education opportunities and regular follow-up that may be needed to promote adherence and catch medication use errors. Long term resolution of the pharmacy desert problem will take a multi-modal approach. The needs of the patients should come first in assessing the pharmacy services to bring back to a pharmacy desert. 

References 

1. Gebhart F. The Growing Problem of Pharmacy Deserts. Drug Topics Web site.  https://cdn.sanity.io/files/0vv8moc6/drugtopics/2bd5b1e618d8edf31172d1161e98dd20aac8edef.pdf. Published 2019. Accessed 09/01/2020. 

2. Abell A, Balick R. Behind closed doors: What happens when pharmacies close? Pharmacy Today  Web site. https://www.pharmacytoday.org/article/S1042-0991(20)30208-5/fulltext. Published  2020. Accessed 09/01/2020. 

3. Hoffman-Eubanks B. The Role of Pharmacy Benefit Managers in American Health Care:  Pharmacy Concerns and Perspectives: Part 1. Pharmacy Times Web site.  https://www.pharmacytimes.com/news/the-role-of-pharmacy-benefit-mangers-in-american-healthcare-pharmacy-concerns-and-perspectives-part-1. Published 2017. Accessed 09/01/2020.

4. Hoffman-Eubanks B. The Role of Pharmacy Benefit Mangers in American Health Care:  Pharmacy Concerns and Perspectives – Part 2. Pharmacy Times Web site.  https://www.pharmacytimes.com/news/the-role-of-pharmacy-benefit-mangers-in-american-healthcare-pharmacy-concerns-and-perspectives–part-2. Published 2017. Accessed 09/01/2020.

5. Dima M. Qato MLD, Jocelyn Wilder, Todd Lee, Danya Qato, and Bruce Lambert. ‘Pharmacy  Deserts’ Are Prevalent In Chicago’s Predominantly Minority Communities, Raising Medication  Access Concerns. Health Affairs. 2014;33(11). 

6. Peterson PPaA. Mapping pharmacy deserts and determining accessibility to community  pharmacy services for elderly enrolled in a State Pharmaceutical Assistance Program. PLoS One.  2018;13(6). 

7. TelePharm. State Pharmacy Desert Maps. TelePharm Web site. https://blog.telepharm.com/whatis-a-pharmacy-desert. Published 2018. Accessed 09/01/2020.