Rural Health News (the former name of the Rural Monitor) looked at the topic of rural pharmacies in its Fall 2002 issue. At that time, the possibility of Medicare drug benefit changes was discussed, as well as the need for pharmacists to receive reimbursement for services beyond filling prescriptions. Additionally, telepharmacy and remote pharmacy were mentioned as new trends.
Since then, there have been several changes including Medicare prescription drug discount cards and the Medicare Part D prescription drug benefit legislation. The need for telepharmacy and remote pharmacy services is expanding. And some state programs are trying to find new ways to pay pharmacists for professional services.
For more information on rural pharmacy and prescription drug issues in rural areas, see the following Rural Assistance Center resources:
RAC Information Guides
•
Pharmacy and Prescription Drugs Information Guide
Information, resources and frequently asked questions related to providing pharmacy services and access to prescription medications in rural communities.
•
Health Care Workforce Information Guide
Information and frequently asked questions on physicians, midlevel practitioners, pharmacy and dental health care providers for rural communities.
In addition, the Health Workforce Information Center web site offers resources, including a list of related organizations and funding sources, on its Topics and Professions > Pharmacy Occupations page.
Independent, rural pharmacies are fighting to survive. Declining rural populations, along with increased competition from Internet and chain store pharmacies, have contributed to pharmacy closures throughout the United States.
Since May 2006, 503 independently owned rural pharmacies have been lost, leaving 213 rural areas with no retail pharmacies, according to Keith Mueller, director of the Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis at the University of Nebraska Medical Center.
Yet, the picture isn’t entirely bleak. Rural pharmacies are finding new business models and rural pharmacists are embracing new technologies, like telepharmacy and remote pharmacy, to reach their patients.
In this issue, we look at innovative programs that support rural pharmacy and rural prescription drug services, new business and technology models for rural pharmacists, and patient safety programs.
Rural Pharmacies
Rural Pharmacies Struggle to Survive
by Candi Helseth
Pharmacist Kathy Nelson, of Casselton, N.D., helps customers both in-house and through telepharmacy.
While many rural pharmacies in the United States are struggling to survive, some independent pharmacists are opening new businesses and using technology to meet needs in rural areas.
In North Dakota, pharmacist Kathy Nelson, who has owned Casselton Drug for five years, is widening the reach of her services. Nelson opened a second pharmacy site three years ago in the Arthur grocery store 16 miles from Casselton. Six months after opening, Nelson said Arthur’s nursing home asked her to handle all their patients because they appreciated the individualized service.
Nelson employs telepharmacy technician Jennifer Joyce to work full-time at Arthur. Joyce fills and dispenses prescriptions under Nelson’s watchful eye. Using video conferencing equipment, Nelson checks and approves all of Joyce’s work. When patients arrive to pick up their medication, Joyce directs them to a private consultation room for a face-to-face, real-time consultation with Nelson.
For Joyce, it’s the job of her dreams. “I absolutely love my job, I wouldn’t trade it for anything. People here are so appreciative after not having had a pharmacy in Arthur for the last 15 years. I get to know patients personally and help them. If I need assistance, Kathy is right there for me.”
North Dakota was the first state to approve legislation, in 2001, allowing retail pharmacies to operate in remote areas without requiring a pharmacist’s presence; since then, 16 additional states have approved telepharmacy legislation. In the decade prior to the creation of the North Dakota Telepharmacy Project, the state had lost 26 pharmacies. Now 40,000 North Dakota rural residents have had pharmacy services restored, retained or established, according to Ann Rathke, Telepharmacy Coordinator.
North Dakota’s telepharmacy sites are full-service pharmacies with complete drug inventories, drug utilization review, verification and patient counseling, Rathke said. Telepharmacy technicians like Joyce must complete more college educational requirements than those required for a pharmacy technician.
“Our research has shown that telepharmacy hasn’t compromised patient safety and access has definitely improved,” Rathke said. “When the pharmacist is left out, as is the case with Internet and mail-order pharmacies, safety is more likely to be compromised.”
Seventy-two pharmacies now provide coverage for 34 North Dakota counties and two Minnesota counties, resulting in approximately $12 million in rural economic development, Rathke said.
Medicare and chain stores create new challenges
The net loss of more than 500 independent pharmacies nationwide coincided with the implementation of two major policies related to prescription medication payments: Medicare prescription drug discount cards and the Medicare Part D prescription drug benefit. Passed to make drugs more accessible and affordable for senior citizens, the plans also created competition among providers, which independent pharmacists say has been unfair to them.
“Under Medicare D, beneficiaries are covered by private plans that negotiate and contract their fee schedules with pharmacies, basically a take it or leave it approach,” explained Keith Mueller, director of the Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis. “Independent pharmacists operate on a much smaller profit margin and can’t get the same discounted rates as large retailers who buy in volume. So rural pharmacies saw a sharp drop in prescription drug revenues for Medicare patients whose plans switched them to another source of payment.”
Medicare plans require a lot of administrative time too, which is tough for minimally staffed independent operations. In most circumstances, pharmacists receive payment only for prescriptions they fill, and not for other patient services, said Rebecca Slifkin, director of the North Carolina Rural Health Research and Policy Analysis Center.
“Medicare D improved access for senior citizens, but there’s so much hoopla to go through with authorizations, and they need help with the paperwork,” Nelson said. “Then I have some patients whose plans require them to get their prescriptions by mail order. These pharmacies don't take care of the problems they create. Medications don't arrive on time or the patients have side effects, and there is no one to answer their questions. The patients come to me. I've always helped them, but it is frustrating to see how those mail order pharmacy health care providers ‘treat’ their patients.”
Large chain drug stores, which already have the advantage of higher volumes and lower economies of scale, are “in cahoots” with insurance companies to pressure patients into using chain stores to fill prescriptions, said Paul Moore, 2008 president of the National Rural Health Association and owner of an independent pharmacy in Wilburton, Okla. “The big guys like Walgreens and Walmart are already buying their drugs at much lower prices than we can. Anti-trust laws prevent us independent pharmacists from doing what they’re doing.”
Big providers offer incentives or rebates to direct patients away from local providers. Moore said his parents, whose local pharmacy is in Denison, Texas, can only get a 30-day supply of their medications at Denison. If they go through their insurer’s mail order source, they get a 90-day supply with only one co-pay.
“We’ve done a whole series of studies on rural pharmacies, and even before Medicare Part D passed, we were looking at shifts to mail order and other providers,” Slifkin said. “We could see it was going to be tough on rural pharmacies.”
Rural communities need pharmacists
Independent pharmacists are important contributors to rural communities and their loss is deeply felt, Mueller and Slifkin said.
Moore, for instance, has served as the hospital administrator in Atoka, Okla., and as Atoka County Health Authority CEO, where he was responsible for emergency medical services, a home health agency, a rural physician clinic and the first critical access hospital in a six-state region. He also provides remote pharmacy services to small, rural hospitals (see Remote Pharmacy Services Offer Quality Assurance). Most importantly, he says, he knows his patients and their medical needs personally.
“If someone is having problems with a med, they come up to me at church, a ball game, wherever I am in the community,” Moore said. “I help them regardless of where they’re buying their meds.”
In Casselton, Nelson said she’s the only health care provider in town “a good share of the time.” She and Joyce spend a lot of uncompensated time conferring with social workers and community agencies to help patients with medication needs. Community members also appreciate being able to shop locally at Casselton Drug for options such as health and beauty items, giftware and Hallmark cards. Nelson recently hired two florists and added a floral department.
While diversification is working for Nelson, it’s not a viable option in many rural settings, Mueller said. Their research indicates rural pharmacies will continue to close unless health care reform changes the current picture, Slifkin added.
“As health reform continues to be debated, the issue of local pharmacy services needs to be part of the ongoing discussion,” Mueller asserted. “We need to have pharmacy services in that reform and redesign health care mix. The local, independent pharmacist in remote areas is a model that’s likely no longer sustainable.”
Pharmacist Dwayne Ragan provides remote pharmacy services from his home in Clyo, Georgia, to three critical access hospitals and one PPS (Prospective Payment System) hospital in Georgia.
When Ann Fagan Cook took over as administrator of Parkview Hospital in Wheeler, Texas, seven years ago, patient medication errors at the 16-bed critical access hospital (CAH) averaged about 4 percent.
Nurses at the CAH dispensed medications to patients, and a traveling pharmacist was on-site only eight hours a week.
“I’m a nurse by training and I found the medication errors very distressing,” Cook said. “When we had two near-misses where we came very close to using serious medications in the wrong amount, it was obvious we needed to do something different. But we also needed to find something we could afford."
Parkview is among the 63 percent of CAHs nationwide that do not have full-time pharmacists on-site. Paul Moore, an Oklahoma pharmacist whose primary platform as the 2008 president of the National Rural Health Association was pharmacy issues, says, “About one-half of CAHs use a retail pharmacist either in their community or a neighboring community. As the number of independent pharmacies continues to decline throughout rural America, it’s one more example of how losing these small town services negatively impacts the community as a whole. Retail pharmacists often fill needs for the local hospital, EMS and other rural health care networks.”
Seeing the need for finding new ways to bring pharmacy services to rural providers, Moore created Remote Pharmacist Services (RPS), a private business, three years ago. Moore and other pharmacists review pharmacy inventories, check all orders, and provide therapeutic interventions before a medication is dispensed to patients in the hospitals RPS serves in Oklahoma, Georgia and Texas.
Within a few short months of implementing RPS’s services, Parkview’s error rate was down to less than one-half of 1 percent. “We’ve had the system in place about four years now and it has really made a great deal of difference in the quality of care we give to patients,” Cook said. “We have a lot of oil field injuries and vehicle accidents. We couldn’t afford to be making mistakes because when we transfer patients, they have to go a long ways from here.”
Susan Huckert, a pharmacy technician at Parkview Hospital in Wheeler, Texas, uses a bar coder to identify Katie Gallardo. If the bar code doesn't match the patient's identify, the card holding the patient's medications will not open.
At a time when small facilities are already grappling with workforce issues related to the lack of pharmacists on staff or in the community, Moore said that several health care quality oversight groups, including the Joint Commission on Accreditation of Hospital Organizations (JCAHO), are demanding greater oversight of the medication distribution process by pharmacists to reduce medication errors.
“It’s pretty obvious that these rural providers aren’t going to be able to find full-time pharmacists even if they can afford them,” Moore said. ”With remote pharmacy, where you can leverage a pharmacist taking care of three to five hospitals, it becomes cost effective for these small hospitals. I hope it’s an idea that takes off in more states because it offers answers for small areas where the retail pharmacist is no longer available as a back-up.”
Nationwide Collaborative Aims to Improve Patient Safety
by Candi Helseth
Throughout the nation, 110 teams are working to improve patient safety and health outcomes by charting a course that will lead to clinical pharmacy services being included in the mix of interdisciplinary services geared toward patients. The teams are voluntarily participating in the HRSA Patient Safety and Clinical Pharmacy Services Collaborative (PSPC), now in its second year. HRSA initiated PSPC in response to growing concerns about medication misuse and its impact on patient safety, according to Jimmy Mitchell, HRSA Director of the Office of Pharmacy affairs.
The Collaborative integrates evidence-based clinical pharmacy services into the care and management of high-risk, high-cost, complex patients with chronic diseases, Mitchell said. Collaborative goals also include improving patient health outcomes and patient safety, and sharing evidence-based practices with other community-based health care providers. Sixty-eight teams participated in the first year of the collaborative, which was formed in 2008. A second year is underway, and includes 110 teams representing more than 350 organizations including community health centers, poison control centers, hospitals, colleges and schools of pharmacy, Ryan White HIV/AIDS program grantees, primary care associations, state health departments and rural health clinics.
Clinical pharmacist Glenda Carr provides a patient consultation at the Nampa (Idaho) Clinic. The clinic is one of the teams participating in the HRSA Patient Safety and Clinical Pharmacy Services Collaborative, which is designed to decrease medication errors and improve patient safety.
“These teams represent a broad spectrum and we have some fantastic rural programs that include critical access hospitals and other rural safety net providers that are creating systems changes,” Mitchell said. “Rural America has fewer resources and more chronic disease, which in turn means more drug use, which means greater opportunity for medical misadventures. With the system changes being implemented, the potential impact in positive change for rural America is huge.”
The Idaho State Office of Rural Health used Medicare Rural Hospital Flexibility and State Office of Rural Health grants to help fund their teams’ expenses. Director Mary Sheridan said the teams have developed practices that are valuable for all rural providers.
“What our teams really focused on were our points of transition of care, those hand-off times where errors most often occur,” Sheridan said. “Team members participated in learning sessions offered by HRSA and then came back to share what they learned and the changes being made. One of the benefits I see was engaging clinical and non-clinical staff, educating everyone in an organization about their role in patient safety.”
Sheridan said, in her experience, non-clinicians are often inadvertently omitted from planning processes. Yet, the patient who arrives with a bag of medications at a clinic will have a non-clinician like a receptionist as the first point of contact.
“What is that non-clinician’s role in ensuring proper documentation—or what about the employee that opens the mail and receives the lab reports?” Sheridan said. “What is that individual’s role in communicating and documenting information to improve patient safety? When our teams examined processes, they discovered potential gaps that could lead to the communication of incomplete or inadequate information.”
HRSA presented an award to one of the Idaho teams for demonstrated improvement in clinical pharmacy services. Team member Rhiannon Avery, Healthcare for Homeless Services manager at Boise, said the homeless clinic had no clinical pharmacy services when their team formed.
“Because our patients are homeless, there are a lot of different health complexities that we face with their care,” Avery said. “One of our biggest accomplishments was bringing a clinical pharmacist into the picture once a week to work with clinicians and patients. That helped us achieve accurate medication lists. The pharmacist also spends time with patients educating them, which is especially valuable when you have a large number of patients with chronic diseases as we do.”
The teams in Idaho are expanding to three clinics in rural communities: Melba, Homedale and Caldwell. Avery said these teams are piloting tools to reduce cultural and language barriers because most of their patients speak Spanish as their primary language.
HRSA provides leadership, sharing practices from successful organizations and helping teams test, refine and implement changes within their organizations, Mitchell said. Teams share their results, recording steps they’ve taken, outcomes, demonstrated patient safety improvement and clinical pharmacy services measures.
“We also bring all the teams together four times a year for learning sessions where teams share what’s working and how their results have improved,” Mitchell said. “We’re documenting what these teams are doing successfully and how these successes can be replicated in other provider situations.”
Mitchell is confident that the Collaborative’s work will help to reverse adverse drug events, which are currently a leading cause of death and injury in the United States.
340B Program Offers Reduced Rate Prescription Drugs to Rural Communities
The 340B Drug Pricing Program was created to ensure that health care providers for vulnerable patient populations can access prescription drugs at a reduced rate. This program is open to certain federally funded grantees and other safety net providers, such as disproportionate share hospitals (DSHs). DSHs can be urban or rural and provide service to patients regardless of the patient’s ability to pay for those services. Rural DSH hospitals are typically smaller sites located in remote areas. Participation in the 340B Program can allow these hospitals to achieve great savings on outpatient drugs to assist the vulnerable patient population in the community.
Requirements
In order to be eligible for 340B, rural DSH hospitals must meet the following requirements as outlined in the program statute:
The hospital must have a Medicare DSH adjustment percentage greater than 11.75 percent. Check your DSH percentage at http://www.hrsa.gov/opa/dsh.htm.
The hospital must fit one of the following descriptions:
Be owned or operated by a unit of state or local government
Be a public or private nonprofit corporation that is formally granted governmental powers by a unit of state or local government
Be a private nonprofit hospital that has a contract with a state or local government to provide health care services to low-income individuals who are not entitled to benefits under Title XVIII of the Social Security Act or eligible for assistance under the state plan of this title (Medicare or Medicaid).
The hospital must opt out of its group purchasing organization (GPO) for all outpatient drug purchases; while hospitals may not use their outpatient GPO, they can participate in the 340B Prime Vendor Program to access even greater savings on 340B covered drugs and other value-added services. See http://www.340bpvp.com for more information.
Additional sources of information:
340B Journey - A knowledge management tool with a folder dedicated to rural hospitals.
Education modules - PowerPoint presentations on 340B basics, available from HRSA’s Pharmacy Services Support Center (PSSC).
OPA website - This site contains helpful information about 340B and registration forms.
(Written by Danielle Mathers. This is an excerpt of an article that appears in the November issue of Pharmacy Today; full text of the article will be available on the PSSC Articles page.)
For more information on rural pharmacy and prescription drug issues in rural areas, see the following Rural Assistance Center resources:
RAC Information Guides
Pharmacy and Prescription Drugs Information Guide
Information, resources and frequently asked questions related to providing pharmacy services and access to prescription medications in rural communities.
Health Care Workforce Information Guide
Information and frequently asked questions on physicians, midlevel practitioners, pharmacy and dental health care providers for rural communities.
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In addition, the Health Workforce Information Center web site offers resources, including a list of related organizations and funding sources, on its Topics and Professions > Pharmacy Occupations page.
The Rural Monitor is published by the Rural Assistance Center.
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Reprint Policy: Articles, photos, and charts appearing in the Rural Monitor may be reprinted with the permission of the Rural Assistance Center and proper citation. For permission, please contact ksande@raconline.org.
