As Drugstores Close, Older People Are Left in ‘Pharmacy Deserts’
https://www.nytimes.com/2024/12/21/health/drugstore-closures-seniors.html
Shuttered drugstores pose a particular threat to older adults, who take more medications than younger people and often rely on pharmacies for advice.
In July, a notice appeared on the front door of The Drug Store, the only pharmacy in rural Kernville, Calif. After 45 years, the proprietor wrote regretfully, it would be closing in four days and transferring customers’ prescriptions to a Rite Aid about 12 miles away.
As the news spread, “there was a real sense of loss, a sense of mourning,” said Roberta Piazza Gordon, who owns Piazza’s Pine Cone Inn in Kernville. The pharmacy had served as a community crossroads where people chatted with neighbors and with the friendly staff.
Its closing also created practical concerns. “We are an aging population,” Ms. Gordon, 69, said of the townspeople.
She relied on The Drug Store for her blood pressure and cholesterol medications and for anti-inflammatories after injuring her shoulder. Her husband, who is 70, also regularly filled prescriptions there.
At The Drug Store, “you got your flu shot, your Covid shot, your pneumonia shot,” she said.
Now those services require a 20- to 30-minute drive to the Rite Aid, which is in Lake Isabella and which Ms. Gordon described as understaffed for its growing number of customers.
“On any given day, there’s a line of 10 to 15 people waiting at the pickup window,” she said. Unlike The Drug Store, the Rite Aid doesn’t deliver.
That leaves Kernville residents in what researchers call a pharmacy desert, defined as living more than 10 miles from the nearest pharmacy in rural areas, two miles away in suburban communities, or a mile away in urban neighborhoods.
Nearly 30 percent of pharmacies in the United States closed between 2010 and 2021, according to a new study in the journal Health Affairs. After initial years of growth, the number of closures outpaced that of openings from 2018 to 2021.
“It’s an unprecedented decline,” said Dima Qato, the director of the medicines and public health program at the University of Southern California and the senior author of the study.
Like many health disparities, reduced access to pharmacies affects some communities more than others. Closings “happen more in low-income Black and Latinx neighborhoods than any other, and in neighborhoods that are more heavily dependent on Medicare and Medicaid,” Dr. Qato said.
In Miami-Dade County, Fla., for example, more than half of pharmacies closed over the decade, and while many others opened, the county experienced a 5 percent net loss. Forty-one states, and about a third of U.S. counties, had fewer pharmacies in 2021 than in 2010.
“It’s going to get worse,” Dr. Qato said.
Several big chains have more recently announced further closures. When Rite Aid declared bankruptcy last year, the company said it would close 154 locations.
In 2010, it owned about 4,800 pharmacies. When it emerged from bankruptcy in September, it had 1,300.
CVS, the nation’s largest pharmacy chain, opened 100 stores between 2022 and 2024; in that period, it closed 900. Walgreens announced in October that it would shutter 1,200 of its roughly 8,500 stores over three years. Independent pharmacies, the Health Affairs study noted, face more than twice the risk of closure compared with chain stores.
Declines in the numbers of pharmacies pose a particular threat to older adults, who take more medications than younger people do. Nearly 90 percent of seniors reported taking a prescription drug last year, and almost 60 percent took four or more, according to an analysis by KFF, a health research organization.
Moreover, “pharmacies don’t just dispense medications,” said Dr. G. Caleb Alexander, an internist and epidemiologist at Johns Hopkins University and a co-author of the Health Affairs study. “They deliver other services.”
Eighty percent of shingles vaccinations were administered at pharmacies last year. So, too, are 60 to 70 percent of flu shots and 40 to 50 percent of pneumococcal vaccinations during cold and flu season, according to the IQVIA Institute for Human Data Science.
Some pharmacies include walk-in clinics that offer other medical services. At Walmart stores in 21 states, for instance, pharmacists can test customers for strep throat, flu and Covid-19, and provide prescriptions for those who test positive.
When pharmacies close, some customers simply stop taking vital medications. In a 2019 study of older adults taking cardiac drugs — such as statins, beta blockers and blood thinners — adherence to prescribed regimens dropped immediately among those whose pharmacies had closed, compared with that of the control group. The decline persisted after a year.
“These are commonly used medicines that treat important cardiac conditions that people take daily for years,” said Dr. Alexander, a co-author of the study, which appeared in JAMA Network Open.
The decline, though small (5 to 6 percent for each drug category), was “clinically significant,” he continued. “With the number of older adults on these medications and the incredible churn of pharmacies, we’re talking about hundreds of thousands of individuals a year at risk” of discontinuing prescribed drugs.
Experts cite a number of reasons for the wave of shutdowns. Dr. Qato pointed to “a lot of mergers and vertical integration in the pharmacy industry,” as well as low reimbursement rates through Medicare Part D, which covers prescription drugs, and state Medicaid programs.
Others note the huge sums that chains like CVS and Walgreens paid to settle lawsuits related to the opioid crisis.
The role of pharmacy benefit managers has come under particular scrutiny, including from an investigation by the Federal Trade Commission. Its interim report in July was pointedly subtitled “The Powerful Middlemen Inflating Drug Costs and Squeezing Main Street Pharmacies.”
These intermediary companies, many affiliated with insurers or pharmacy chains, design drug formularies and negotiate prices. They also determine which pharmacies are in network for insurance plans, and which of those are “preferred,” offering patients lower co-pays.
“That’s why they’re so powerful,” said Ge Bai, a health policy and management researcher at Johns Hopkins. “They control the money.”
Nearly all stand-alone Medicare Part D drug plans, and more than half of Part D plans included in Medicare Advantage, designate preferred pharmacies, the trade publication Drug Channels has calculated.
“Patients don’t go to you if you’re not preferred,” Dr. Bai said. That puts independent pharmacies, less likely to be “preferred,” at risk of lower reimbursement and closure.
Congress, Medicare or the F.T.C. could take steps to address this. Dr. Bai compares financially imperiled pharmacies to rural hospitals kept open with federal support.
“You either let them die, or you subsidize them with taxpayer money,” she said. “It will be expensive to do” but might prevent pharmacy deserts.
Dr. Qato argues that Part D plans should not select preferred pharmacies at all.
“Allow patients to choose which pharmacy to go to, with the co-pay the same, regardless,” she said. “So the pharmacy is reimbursed fairly, whether it’s preferred or not.”
The odds that an incoming Republican administration or Congress would take any such action seems remote, however. Dr. Bai predicted less scrutiny from the F.T.C. in coming years as well.
So older consumers may be navigating the fallout on their own, turning to online and mail-order sources as local pharmacies fold.
In Oxford, Mich., “going out of business” signs suddenly appeared in the windows of the Rite Aid pharmacy last summer.
That was where Jon Katz, 75, a retired ad executive, filled three cardiac prescriptions, and where his wife, Cathy Katz, 68, a retired medical assistant, got antibiotics when needed.
When they picked up anti-seizure medications for their disabled adult son, Joey, the pharmacists greeted him by name. The family was vaccinated for Covid there, too.
Now the nearest pharmacy is a Walgreens in Rochester Hills, 10 miles away. “It’s understaffed and overwhelmed due to the influx of new customers,” Mr. Katz said. “The service is lacking and the technical glitches are too many.” And nobody knows Joey’s name.
But it’s their best option for now — as long as one of them can drive. When older people can’t, Ms. Katz said, “you just hope you have a big, healthy family.”
Filed under: General Problems
An immediate solution—in part—would be for Congress and regulators to carve out Medicare Part D reimbursements by eliminating “preferred pharmacy” plans. That would take the cooperation of Pharmacy Benefit Managers and insurers. Is that a bridge too far? Considering how some insurers are vertically integrated by owning the medical provider, the clinic, the pharmacy (I.e. United Health Group Optum) and the BPM (I.e. United Health Group OptumRX), chances are slim that any sort of fairness will occur.
The pharmacy I just lost was a mom and pop. In this area there are no more mom and pop pharmacies left that will even take on anyone as patient at all who uses controlled substances. I refuse to even try to deal with CVS or Walgreen’s which turned out to be wise because look what’s happening to Walgreens. I ended up at a Kroger pharmacy that at least appears to be OK. I will be keeping a close eye on things and it will be a while before I develop any sense of trust.
I’m being forced to switch pharmacies starting in January 2025 because I was compelled to switch Medicare Advantage providers. With Humana, I was able to go to an independent pharmacy but under BC/BS, I have to go to the enemy’s camp, CVS.