Rural Pharmacy and Prescription Drugs
Prescription drugs are a key component in the healthcare rural Americans receive. Pharmacies and pharmacists, in particular, play a critical role in dispensing these medications, educating patients, and ensuring patient safety. However, rural community pharmacies face many challenges to stay open, including low-volume purchasing, slim profit margins, unfavorable insurance practices, and a limited pharmacy workforce.
When a pharmacy is not available nearby, timely access to pharmaceutical services can be compromised due to lack of transportation options, extreme weather conditions, or the patient being too sick to travel the long distance to the nearest pharmacy.
While the development of telepharmacy and online mail order pharmacies might suggest that geographical limits to access are no longer a concern, many rural residents do not have the equipment, technical skills, and/or telecommunications accessibility that these services require. In addition, telepharmacy is not currently allowed by regulation or statute in some states. Rural pharmacies and pharmacists will continue to fill an important and much-needed role in the health of rural people.
- Looks at the financial viability of rural pharmacies
- Discusses the challenges to providing accessible prescription drugs
- Examines the 340B Drug Pricing Program
- Explores technological advances and new business models in providing pharmacy services
- Addresses the rural pharmacy workforce shortage
Frequently Asked Questions
- Why is it important for rural people to have access to pharmacy services?
- What challenges exist to maintain rural pharmacy services?
- Is there sufficient access to pharmacies and pharmacists in rural America?
- What is the role of a pharmacist in a rural hospital?
- What resources are available to help individuals pay for prescription drugs?
- What is the 340B Drug Pricing Program and who benefits from this program?
- How are telepharmacy and other new business models maintaining pharmacy services and pharmaceutical access in rural communities?
- Who can I contact for assistance with rules and regulations on pharmaceutical services within rural healthcare facilities?
Why is it important for rural people to have access to pharmacy services?
Pharmaceutical care is an important aspect of the spectrum of healthcare. Pharmacists are part of the healthcare team and provide counseling to patients and advice to medical staff and case managers. They have an essential role in helping prevent medication errors and in identifying drug interactions. Pharmacy services include more than just supplying prescription drugs, a role that online mail order pharmacies can, and increasingly do, fill. Pharmacists also provide immunizations and advice on over-the-counter medications and support other healthcare facilities such as skilled nursing facilities, hospitals, and hospice care. Furthermore, the rural population tends to be older and have more chronic health conditions than the urban population, which makes access to pharmacy services important to the health of rural residents. Older rural adults, who may have multiple prescriptions, can particularly benefit from a relationship with a pharmacist who, along with their physician, can help them manage their medications. However, regardless of patient age, pharmacy services are essential components to meet the healthcare needs of all rural residents.
What challenges exist to maintain rural pharmacy services?
A 2017 analysis by the RUPRI Center for Rural Health Policy Analysis indicated the closure of rural pharmacies has slowed down. However, there continue to be several issues of concern by rural pharmacists that challenge their provision of pharmacy services including:
- Outdated maximum allowable cost (MAC) pricing for wholesale costs to pharmacies
- Direct and indirect remuneration (DIR) fees charged to rural pharmacies by pharmacy benefit managers (PBMs)
- Pharmacy benefit manager (PBM) practices restricting their preferred networks to mail order and chain store pharmacies
- Competition from mail order companies and chain store pharmacies who often are able to purchase prescription drugs in large volume at a reduced cost
- Being a non-preferred pharmacy for Medicare Part D plans
- Difficulty in finding replacement pharmacists due to retirement or the sale of the pharmacy
Many of these issues put financial pressures on rural pharmacies that can lead to closure, limiting access to pharmacies and pharmacy services for residents. For more discussion about these challenges, see Issues Confronting Rural Pharmacies after a Decade of Medicare Part D.
Is there sufficient access to pharmacies and pharmacists in rural America?
Independent, rural pharmacies are struggling to survive due to declining rural populations, increased competition from internet and chain store pharmacies, higher cost of prescription drugs for low-volume pharmacies, and difficulty in finding replacement pharmacists for those who retire.
According to the RUPRI Center for Rural Health Policy Analysis report Update: Independently Owned Pharmacy Closures in Rural America, 2003-2018, 1,231 independently owned rural pharmacies were lost from March 2003 to March 2018, including 630 that served as their rural community's only retail pharmacy. Another study, Rural Pharmacy Closures: Implications for Rural Communities, found 119 sole community pharmacies closed between May 2006 and October 2010; 31 of the communities affected had no other healthcare providers.
Previous studies have shown a common cause for closure has been pharmacists retiring and being difficult to replace. According to the Bureau of Labor Statistics, Occupational Employment Statistics for 2019, less than 12% of all pharmacists in the U.S. are employed in nonmetropolitan areas. Rural pharmacists tend to work longer hours than their urban counterparts, and relief coverage for vacation and illness is hard for rural pharmacists to find, making it difficult for rural areas to recruit and retain pharmacists.
Yet, the picture isn't entirely bleak. The pace of pharmacy closures has slowed according to Telepharmacy Rules and Statutes: A 50-State Survey. Rural pharmacies are finding new business models and rural pharmacists are embracing new technologies, like telepharmacy, remote pharmacy, and local delivery or mail to reach their patients. The Rural Virtual Infusion Program, for example, allows rural cancer patients across a 26-county region to receive chemotherapy treatments at tertiary infusion centers. More examples are included in the Models & Innovations section of this guide.
What is the role of a pharmacist in a rural hospital?
The role of the rural pharmacist varies across rural hospitals and Critical Access Hospitals. Types of roles that a hospital pharmacist fills may include:
- Dispensing and managing medications throughout the hospital and at remote sites
- Compounding medications
- Drug inventory management
- Medication regimen review and reconciliation upon admission and discharge
- Managing, adjusting, and monitoring of medication therapy
- Department management of budget and personnel
- Compliance with all state and federal pharmacy laws and regulations
- Development and maintenance of all pharmacy policies, procedures, and services
- Patient, staff, and health professions student education
- Training student pharmacists
- Leading or participating in quality control and improvement efforts, including reduction of adverse drug events and antibiotic stewardship
Identifying Adverse Drug Events in Rural Hospitals: An Eight-State Study found that Critical Access Hospitals in those states employed fewer full-time pharmacists than PPS (Prospective Payment System) hospitals in both rural and urban areas. Due to patient volume, many CAHs cannot employ a full-time pharmacist, relying instead on part-time, contract, or shared pharmacists. Oftentimes, the pharmacist from the local community pharmacy also acts as the hospital pharmacist. Alternatively, CAHs may rely on telepharmacy services to meet their needs. When the pharmacist is not a full-time employee of the hospital, their activities are likely to be limited in scope and may not include roles like patient education or participating on quality improvement committees.
Also, the role of a rural hospital pharmacist is frequently modified due to budgetary and staffing challenges that may distinguish their roles from a hospital pharmacist in an urban setting. These challenges include:
- The responsibility, along with the difficulty, of staffing the pharmacy, including hiring pharmacy technicians and full-time, part-time, and temporary or as-needed staff.
- Participation in multiple hospital committees and task forces that relate to medication.
- Limited time for pharmacist staffing on site, requiring remote order processing services after hours.
- A less than robust formulary due to budget constraints or availability of staff 24/7.
- The need to provide pharmaceutical services remotely to ensure continuity of care while not on site, which requires the capability to provide services by phone and/or via remote computer access.
What resources are available to help individuals pay for prescription drugs?
Several resources are available to identify programs that can help individuals pay for prescription drugs.
Medicine Assistance Tool offers a database of prescription drug assistance programs available from pharmaceutical companies. The website allows patients, caregivers, or healthcare providers to search for specific medications and find matching assistance programs.
The ADAP (AIDS Drug Assistance Programs) Directory lists programs by state that help people living with HIV/AIDS who are uninsured and underinsured have access to medication.
State Pharmaceutical Assistance Programs (SPAPs) is a list of programs by state that, in partnership with Medicare, may help pay drug plan premiums and/or other drug costs. Not all states are listed.
What is the 340B Drug Pricing Program and who benefits from this program?
The 340B Drug Pricing Program allows certain facilities, such as Federally Qualified Health Centers, FQHC Look-Alikes, Critical Access Hospitals, Sole Community Hospitals, Rural Referral Centers, and Disproportionate Share Hospitals that meet certain requirements, to purchase prescription and non-prescription medications at reduced cost. Participating facilities can use these savings to reduce the price of medications for patients, increase the number of indigent patients served, expand the number of drugs offered, and expand other services offered to patients, as highlighted by 2020 340B Health Annual Survey: 340B Hospitals Use Benefits to Provide Services and Improve Outcomes for Low-Income and Rural Patients. The 340B program is based on Section 340B of Public Law 102-585, the Veterans Health Care Act of 1992.
The 340B Prime Vendor Program (PVP), is a free federal program open to all eligible entities. The PVP negotiates pricing below the 340B ceiling price, helping to establish distribution solutions and networks that improve access to affordable medications for participants of the 340B Drug Pricing Program. In addition, the PVP offers value-added products and services in an effort to decrease the cost of providing medication to patients of the participating facilities. The program is voluntary and open to facilities that are already registered with Health Resources and Services Administration (HRSA) for the 340B program. Registration for the program is done via the PVP's online enrollment system. Additional assistance is available at 888.340.2787.
For more information about the 340B Drug Pricing program, see the Health Resources and Services Administration's Introduction to 340B Drug Pricing Program. Should you need technical assistance, contact the Prime Vendor Program by phone at 888.340.2787 or email at ApexusAnswers@340bpvp.com.
How are telepharmacy and other new business models maintaining pharmacy services and pharmaceutical access in rural communities?
Telepharmacy, which employs technology to provide pharmacy services at a distance, is being used to provide additional access to pharmacist services in existing pharmacies such as in rural hospitals with limited hours of on-site pharmacist coverage. Telepharmacy also allows more timely review of medication orders. Telepharmacy Rules and Statutes: A 3-Year Update for all 50 States provides a review of state legislative and administrative activities regarding community-based telepharmacy. For more information about the telepharmacy model, and on how to set up a telepharmacy program, see the North Dakota Telepharmacy Project.
To read about additional examples of telepharmacy programs, see the Telehealth Models for Increasing Access to Pharmacy Services page of the Rural Telehealth Toolkit.
Several other business models and service enhancements are used by rural pharmacies to increase access to pharmaceuticals. One example is courier services, which bring prescription drugs to the patient or to an outlying location. Security can be an issue with the delivery of controlled substances using this approach. Other examples include mail order service for a minimal fee or at no cost and curbside pickup, with the convenience of picking up prescriptions without leaving your vehicle.
Although not a new model, a rural pharmacy may want to utilize a locum tenens pharmacist through their state pharmacy board, regional hospital or health system, college of pharmacy, state pharmacy association, or an independent staffing agency. Locum tenens programs help provide relief staffing by pharmacists willing to substitute for other pharmacists on a temporary basis.
Who can I contact for assistance with rules and regulations on pharmaceutical services within rural healthcare facilities?
Please contact your:
- CMS Regional Office Rural Health Coordinator for questions about CMS policies and regulations regarding pharmaceutical services located within RHCs, FQHCs, and CAHs
- State Pharmacy Board for state licensure and state laws regulating the practice of pharmacy
- Medicare Administrative Contractor (MAC), for questions about Medicare Part A or Part B drug coverage, billing, and reimbursement issues
For CAHs specifically:
Your State Rural Hospital Flexibility Program Contact can provide guidance regarding pharmacies located in CAHs.
Last Reviewed: 10/27/2020