"Having a Pharmacist in Rural America Is Too Expensive." Seriously?

‘We Are Experimenting With Removing a Pharmacist From the Community’

I was having a conversation with a colleague and friend recently, and he mentioned that his group was planning on experimenting with remote order entry and medication verification so that pharmacies in rural areas could use a technician instead of a pharmacist to dispense medications. His rationale was that “rural areas cannot afford a pharmacy” unless they can reduce costs through eliminating the pharmacist. I sat there, dumbfounded that a leader in the profession would have such a narrow view.

This Line of Thinking Ticks Me Off

Why do we continue to put up with being typecast as mindless robots who are unnecessary in the community? I grew up in a small town in Iowa where the health care system is 2 physicians who make rounds throughout the rural area, a few advanced practice staff members, and 2 pharmacies, still staffed by pharmacists, thank goodness. It is a disservice to that community to think that it does not need to keep degreed professionals living and working there.

Rural America Needs Pharmacists More Than Urban America Does

I agree that paying somebody more than $100,000 a year to be a glorified Parata machine does not make sense anywhere, let alone in rural America. But let’s review some facts about the health of our population in rural America.¹

Those who live in rural areas have higher rates of chronic disease than those in other areas; nearly twice as high rates of limitations for cognitive, major, physical, and social daily activities (describing about one-third of the population); and worse mental health status with less access to services. Those who live in rural areas also have lower rates of testing for chronic disease and fewer providers per capita. This all leads to higher rates of hospitalization.

A Community in Need

For the sake of highlighting the problem and opportunity for pharmacies, let’s create a mock rural community using the Rand Corporation’s latest rates for chronic disease.² Imagine a community in Appalachia, the Great Plains, Rocky Mountain cowboy country, or the Southwest with about 4000 adults in its 30-to-60-mile catchment area. Fully 1200 would have hypertension, 1000 would have a lipid disorder, more than 500 would have diabetes or a mood disorder, about 460 would have an anxiety disorder, fully 360 would have an inflammatory joint or nonasthma upper respiratory disorder, 275 would have asthma, and 230 would have coronary artery disease. That is more than 4000 person-condition combinations in that typical rural community. And oh, by the way, that community spends an average of $21.5 million a year on health care services, most of it on completely preventable conditions with well-positioned health care professionals focused on saving life, limb, and livelihood. Even a 5% reinvestment in effective local care delivery would provide for plenty of pharmacists and primary care dedicated to reducing chronic disease and likely pay for itself and more in preventing hospitalizations and disease progression.

Rural America Deserves Better

The solution to health care reform in rural America is not to remove or replace health care professionals with nonprofessionals or FaceTime with a call center pharmacotherapist. The solution is to empower the health care professionals who are already there, those who know the community, speak the language, and share coaches and teachers in the local school district.

Problems Are Opportunities

The same challenges that rural health care delivery faces also create the greatest opportunities. Close-knit communities are well positioned for collaboration. Working with law enforcement, the local chamber of commerce and social services, recreation centers, and schools can be much easier in a small-town community where everyone knows and ideally trusts one another a little bit more. Some of the greatest opportunities for health reform and meaningful system improvement are not in big cities. They are in small communities uncontaminated with overhead costs, pretense, and siloed and often excessive infrastructure.

Rural Pharmacists Deserve Better but Must Practice Differently

Pharmacists are important to their communities. This means they need to stand up for themselves, stepping up to the challenge and building their practices beyond putting pills in a bottle. Start a de-prescribing or polypharmacy service, a diabetes prevention program, a home delivery service that checks in on patients and connects them with social services when needed, a lipid clinic, a pain management program, and a urine drug screening program. Pharmacists should solidify that bridge with their primary care communities and let them help expand pharmacy practices. Pharmacists should tell the dean of the state’s schools of pharmacy, local legislators, the mayor, and the town council that they are up to the challenge and that they are more than a dispensary to be dismissed as dispensable.

Speaking of Rural America, Have You Heard About RAGBRAI?

The Register’s Annual Great Bike Ride Across Iowa (RAGBRAI) started in 1973, when 2 writers for the state’s newspaper of record, the Des Moines Register, sought to bike across Iowa from the Missouri to the Mississippi rivers and stop in small towns in rural Iowa along the way to tell their stories.

Now the largest gathering of bike riders in the world, RAGBRAI has been host to nearly 350,000 riders over the years, passing through 780 different communities and covering more than 80% of unincorporated towns in Iowa. This year, upward of 40,000 riders are expected on some days. Lance Armstrong, who rides annually and often with Jimmie Johnson, another avid biker, refers to the ride as Woodstock on wheels.

The Iowa Pharmacists Association (IPA) began sponsoring a group to ride in RAGBRAI 4 years ago, with the purpose of engendering goodwill with the association and the profession by pulling buggies behind the IPA riders’ bikes, with essentials for the ride, such as Band-Aids, butt cream, ibuprofen, and sunscreen.

The IPA makes it a focus of the ride to stop to visit with small-town pharmacies and local hospital pharmacists to highlight their presence and importance in their communities. I remember growing up in Iowa and RAGBRAI passing through my beloved hometown, Forest City, and now I have grown to appreciate the role that the event plays in promoting the consciousness of rural America to us city dwellers.

Pharmacy Times^® has partnered with the IPA this year to help sponsor the ride and support the IPA Foundation. Pharmacy Times^® is contributing $10,000 and is working with other sponsors to help support student scholarships. You can help by following the ride at #PTRidesRAGBRAI.

Troy Trygstad, PharmD, PhD, MBA, is vice president of pharmacy programs for Community Care of North Carolina, which works collaboratively with more than 1800 medical practices to serve more than 1.6 million Medicaid, Medicare, commercially insured, and uninsured patients. He received his PharmD and MBA degrees from Drake University in Des Moines, Iowa, and a PhD in pharmaceutical outcomes and policy from the University of North Carolina at Chapel Hill. He also serves on the board of directors for the American Pharmacists Association Foundation and the Pharmacy Quality Alliance.

References

• Georgetown University Health Policy Institute. Rural and urban health. hpi.georgetown.edu/agingsociety/pubhtml/rural/rural.html. Published January 2003. Accessed May 29, 2018.
• Buttorff C, Ruder T, Bauman M; Rand Corporation. Multiple chronic conditions in the United States. fightchronicdisease.org/sites/default/files/TL221_final.pdf. Published 2017. Accessed May 29, 2018.