Rural counties are more likely than the rest of the nation to lack a pharmacy, putting already vulnerable populations at greater risk of not receiving essential healthcare services, a new study says.

According to a new brief from the RUPRI Center for Rural Health Policy Analysis (RUPRI) at the University of Iowa, 138 counties across the country do not have a pharmacy of any kind. Of those, the analysis found, more than 70% are in rural counties. The research indicated that nearly 8% of all noncore counties (counties that are not part of a metropolitan or micropolitan statistical area) have no pharmacy in them.

Keith Mueller, one of the brief’s authors, said pharmacies are critical in maintaining the health of rural residents, who are more likely to be older, uninsured, or on Medicare or Medicaid.

“It’s the whole array of pharmacy services that you receive from the pharmacist that’s critical,” he said. “People can get medications by mail order, but if it’s a short-term need, and you need to fill that prescription quickly, mail-order isn’t necessarily going to do that for you… And you’re still not going to get the services of a pharmacy-trained individual.”

Pharmacists do more than just fill prescriptions, he said. Pharmacists also do vaccinations and health screenings, as well as handle patient education and counseling.

“There are multiple communities in which there is still a retail pharmacy, but there’s no hospital,” Mueller said. “One of the reasons that we focus on pharmacies is sometimes they’re the last essential provider standing because there’s still people in the community who need that service.”

When hospitals close down, he said, the community pharmacists become the last line of defense when it comes to rural residents’ local health care. A study published in the American Journal of Pharmaceutical Education backed that up, finding that pharmacists are the “most accessible and frequently visited members of the healthcare team,” and may help to address healthcare needs in areas with dwindling primary care providers.

RUPRI’s study identified rural counties as “noncore” counties. These counties have no urban area of 10,000 or more people and are not economically tied to counties with cities of 10,000 or more residents.



RUPRI’s analysis showed the availability of pharmacies of any type was lower in noncore counties than in other counties. More than 7% of noncore counties have no retail pharmacy of any kind compared to 2.3% in micropolitan counties and 1.9% of metropolitan counties. (Micropolitan counties have a market area with a city of 10,000 to under 50,000 at their core. Metropolitan counties have a market area with a city of at least 50,000 residents at their core.)

RUPRI’s analysis showed the availability of pharmacies of any type was lower in noncore counties than in micropolitan or metropolitan counties. More than 7% of noncore counties have no retail pharmacy of any kind compared to 2.3% of micropolitan counties and 1.9% of metropolitan counties.

Nearly 96% of noncore counties had no franchise pharmacies, compared to 89% of micropolitan counties and 80% of metropolitan counties. (Franchise pharmacies are independently owned but have a franchise agreement with an entity that provides services such as marketing in exchange for a fee.)

Only 10% of metropolitan counties had no chain pharmacies, compared to 44% of noncore counties. (Chain pharmacies are a group of four or more pharmacies under common ownership. Chains include pharmacies such as CVS, Walgreens, and Walmart.)

A little over 18% of the population in noncore counties without a pharmacy were over 65, and nearly 40% were non-white.

“Noncore counties with no retail pharmacies had the highest percentage of uninsured and unemployed people and people with incomes below the federal poverty level,” the report found.

Another RUPRI study in 2018 found that between 2003 and 2018, an estimated 1,230 independent rural pharmacies closed across America, leaving fewer than 6,400 in business. In the same study, researchers found that changes in Medicare Part D had a negative effect on rural pharmacies. While the changes led to higher prescription drug use by rural residents, they changed the way pharmacies were reimbursed for the drugs, resulting in a loss in revenue. 

“For many rural independently owned pharmacies, Medicare Part D [the prescriptioin drug benefit] replaced direct payments from cash-paying customers with low and late reimbursements from Part D plans, leaving many of these pharmacies unable to generate positive revenue from prescription sales,” the study said. 

One solution for this, Mueller said, was an expansion of telepharmacies that would allow rural residents in counties without pharmacies to access pharmacists via internet connection or by phone. But federal and state policies would need to be changed to increase access to telepharmacy, he said.

Currently, Mueller said, 23 states fully permit the utilization of telepharmacy services, and 11 more have laws or regulations that allow waivers, or have telepharmacy pilot programs.

Changes in reimbursement of pharmacies, he said, could keep stores open in underserved areas.

“I also think that we need a policy approach, in terms of essential providers which we do with hospitals,” he said. “We think about a model like that for Rural Health Clinics, maybe we need to think of a similar model, which affects payment policy… If there’s a status for the pharmacy like there is for hospitals and clinics.”

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