Take the Handcuffs Off to Serve Rural America

Rural areas have just 39.8 physicians per 100,000 people compared with 53.3 physicians per 100,000 in urban areas, according to the Rural Health Association of America.¹

Although family physicians make up 15% of our nation’s physician workforce, they provide more than 40% of care delivery in rural areas, and their ranks are shrinking every year, and medical students are rejecting family medicine residencies.¹ In 2019, more rural hospitals closed than in any other moment in history, and the results of a study last year showed that 100 rural hospital closures over the earlier part of the century led to a 6% increase in mortality, while another study’s results identified 430 additional rural hospitals that are at risk for closure.^2,3

WORSE ECONOMY, WORSE ACCESS, WORSE OUTCOMES

Rural communities have about 20% less income, and fully one-quarter of children live in poverty. Rural communities have higher rates of tobacco use and also rely on supplemental programs to access food at a rate about 50% greater than in suburban and urban areas.¹ And those hospital closures? In the 1990s, they led to a greater than $700 loss of income per capita in those communities and a 1.6% increase in unemployment. Those figures are likely much worse now, as health care employment has grown as a proportion of total economic output.⁴

The results of a study by Health Affairs published in December showed 3 principal reasons for the widely acknowledged deficit in health outcomes between rural and urban residents: percentage of uninsured, socioeconomic depravation, and the short supply of primary care physicians.

FALSE PROPHETS: TELE-SOLUTIONS ARE NOT A SUBSTITUTE FOR COMMUNITY PRESENCE

Of course, private equity has been invested into a proposed solution for this problem. Accessible and available telecare management, telemedicine, telepharmacy, telepsychiatry, and tele-everything are proposed to fill the gaps, so that we can literally “call it in.” Yet, do we really believe that fewer human interaction and touch, fewer local health care businesses, and fewer local health care professional providers are helpful to that community?

A SOLUTION STARING US IN THE FACE, HIDDEN TO EVERYONE ELSE

Many pharmacy advances arise from a lack of accessible and affordable care in rural communities. New Mexico and North Carolina both cited the need to fill gaps in rural health care delivery when they became the first to states to allow pharmacist prescribing under collaborative practice agreements. Emergency medical services, family physicians, and pharmacies have been the cornerstone of community-based rural health care delivery since the inception of modern medicine, and they need to be protected where they remain and brought back where they have been lost.

PHARMACIST OVERSUPPLY, MEET PROVIDER UNDERSUPPLY

Yet pharmacists have an even more compelling case as the only health care profession with an oversupply—in fact, a glut—of professionals ready, willing, and able to step in with much-needed general practitioner services. In addition to addressing the disproportionate prevalence of chronic disease and poor outcomes related to them in rural areas, pharmacies are excellent community-based locations for durable medical equipment, hearing aids, laboratory monitoring, patient-centered disease management services, and point-of-care testing. Additionally, pharmacies can provide an additional tax base, new investments, and even fresh food markets in areas that do not have outlets for fruits and vegetables.

UNHANDCUFF US, NOW

There are numerous ways to support community-based, rural pharmacy practices. Protection from predatory reimbursement is primary. Much like critical access hospitals, federally qualified health centers, and rural health association practices, rural pharmacies should have a cost-plus-based system of reimbursement. This would look like a national average drug acquisition cost-plus dispensing fee or 340B-like model of reimbursement for products. We should allow and pay for basic services, such as disease management and point-of-care testing, as well as coordination efforts with local primary care providers or specialists in urban areas. We should consider supporting more community pharmacy residencies and ownership succession support in rural pharmacies.

WHAT IS "RURAL," EXACTLY?

The Office of Management and Budget (OMB) defines rural as anything not “urban,” which is more than 50,000 individuals in an “area,” and OMB likes to use counties to draw borders. Micropolitan is any area with more than 10,000 people but that is still considered rural.

The US Census Bureau takes a more precise approach to “areas” with the 50,000-person threshold but uses 2500 as the threshold for “urban clusters.” Regardless, under the US Census Bureau definitions, just under than one-fifth (19%) of the US population lives in a rural area that covers 95% of our nation’s land mass. That is a lot of places and spaces to build desperately needed pharmacies that can be hubs for primary care, wellness programs, as well as a solution for food insecurity.

ENGAGING OUR ASSOCIATIONS AND STAKEHOLDERS

Community-based pharmacies can address many of the concerns of both policy-makers and residents of rural America. Your state pharmacist and pharmacy associations can be excellent vehicles for rural care advocacy and promotion of rural pharmacies and pharmacists as a solution to an ever-thinning provider workforce. But do not stop there. Rural areas have many constituencies and stakeholders, from agencies on aging to local chambers of commerce, rural economic development entities, rural health associations, and rural poverty think tanks. It is about community, not just health care or pharmacy. Let’s go get some allies to unleash the benefits of community-based pharmacy investment.

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 and a PhD in pharmaceutical outcomes and policy from the University of North Carolina. He also serves on the board of directors for the American Pharmacists Association Foundation and the Pharmacy Quality Alliance.

REFERENCES

• About NRHA. National Rural Health Association. ruralhealthweb.org/about-nrha/about-rural-health-care. Accessed February 25, 2020.
• Ellison A. Rural hospital closures hit record high in 2019 — here’s why. Becker’s Hospital CFO Report. December 5, 2019. beckershospitalreview.com/finance/rural-hospital-closures-hit-record-highin-2019-here-s-why.html. Accessed February 25, 2020.
• Gujral K, Basu A. Impact of rural and urban hospital closures on inpatient mortality. NBER Working Paper No. 26182. nber.org/papers/w26182. Published August 2019. Accessed February 25, 2020.
• Holmes GM, Slifkin RT, Randolph RK, Poley S. The effect of rural hospital closures on community economic health. Health Serv Res. 2006;41(2):467-485.