Community Pharmacies in Crisis: Navigating the Challenges and Closures

Pharmacies, most agree, are no longer simply just a place to pick up a filled prescription. Even before the COVID-19 pandemic, pharmacy services had begun to expand. The public health crisis, however, would thrust community pharmacies in the US into the spotlight, and they responded. Their offerings—and the reliance on them—exploded.

Seemingly overnight, retail and community/independent pharmacies introduced virus testing clinics for COVID, then vaccination distributions at a large scale. Community pharmacies in particular have always been in the background, though, supporting doctors, patients, and communities. From prescription fulfillment, to test-and-treat services, to counseling, these entities play a vital role in the patient care ecosystem.

“The pharmacy itself has greatly changed—we're not just the destination you come to after you go to the doctor's office,” says Kathy Collier, DPh, regional vice president of operations, Express Rx Pharmacy. "We've had to shift in the pharmacy to be more of a destination healthcare place. We have had to pivot and become a place where we are part of that healthcare system.”

Pharmacists, of course, play a crucial role in public health. In addition to the COVID immunizations, community pharmacies administer vaccines for ongoing flu seasons, for global travelers, new parents, elderly citizens, and those immunocompromised—dealing with such afflictions as chicken pox to hepatitis A and B virus to yellow fever and respiratory syncytial virus.

Today’s pharmacist focuses on enhancing overall community health through an increasing educational role—offering directives on medication use, preventive care, healthy lifestyle advice, and aiding in chronic disease management for conditions such as diabetes and hypertension by offering personalized care and monitoring.

“In pharmacies at large, not everybody who walks in is sick. A lot of people are there because they're caregivers, so they need counsel just as much,” says Ian Stone, senior vice president of Mesmerize. “They need those five minutes with the pharmacist on how to administer the pill, the liquid, or whatever the drug is. Independent pharmacists do a really good job coaching.”

While many are experiencing unprecedented market and business challenges, such as the emergence of online pharmacies, industry director-to-consumer drug delivery models, and other alternative point-of care entrants, community pharmacies believe they still offer a unique and significant position in the mix. They don’t just serve local communities, they’re often part of them, too. Whether that’s, for example, sponsoring local sports team, building relationships, or being a go-to or trusted source for advice and support. While the dynamic may not be the same as in decades past, their presence and value still resonates in the community and with longtime customers.

“…We've got some pharmacies that have customers that come in every day, literally because they have nothing else to do,” says Laura Edmundson, PharmD, MBA, vice president of pharmacy at Brookshire Brothers, Inc., a Texas-based employee-owned grocery store. “They'll just come and they'll sit down and check their blood pressure on our blood pressure kiosk and say hello. That's part of their routine, visiting the pharmacies.”

A SHIFTING ACCESS TERRAIN

Pharmacy deserts has become a popular term in 2024. These are geographic areas—a neighborhood, town, or county—where some or even all of the pharmacies have closed. So what happens when a community pharmacy has to close? In rural towns, the local pharmacy is often the closest healthcare provider for miles. At these locations, people can check their blood pressure, access healthy foods, get advice on over-the-counter (OTC) aids, or better understand their prescription drug interactions and side effects. For patients with unreliable access to transport, local pharmacy delivery and walkability matter most.

“We have a lot of rural locations at Express Rx (based in Little Rock, AR), so it is very important for us to be able to offer some of these services that maybe people in our communities can't get because they don't have a local doctor's office,” says Collier. “It's huge now that we can offer immunizations and some testing that they would have had to drive to another town to get or just not get it at all.”

Adequate access to healthcare is an ever-present challenge. Telehealth boomed during the pandemic —telemedicine use among physicians grew from 15.4% in 2019 to 86.5% in 2021, according to the National Center for Health Statistics.¹ But not every patient has reliable internet or the computer literacy necessary for telehealth visits, however. It’s important that pharmacies are there when patients have questions.

“We're the most accessible healthcare provider,” says Edmundson. “You don't need an appointment to ask your pharmacist a question or to get counseling from them.”

As mentioned, nationwide, pharmacies are closing. Across the US, more than 7,000 pharmacies have shuttered since 2019, according to data from Lucas Berenbrok, PharmD, associate professor of pharmacy and therapeutics at the University of Pittsburgh School of Pharmacy. He considers that estimate conservative. Of those pharmacies, 54% were independent drugstores, an AP analysis of Berenbrok’s data found.² It’s not just the “little guys,” however. In June, CNN reported that Walgreens planned to close a “significant number” of its 8,000+ stores. CVS, reportedly, already closed 244 stores between 2018-2020, and had plans to close about 900 more starting in 2021.³

“The biggest thing lagging behind now is that we don't have provider status. We can't bill, in many cases, for clinical services. We can put pills in a bottle, but we can't bill for every sort of point-of-care test,” says Michael Halliwell, director of pharmacy and whole health, Balls Food Stores, a longtime retail grocery chain serving Kansas City, KS. “The hard part is that pharmacies have been crying about reimbursement for a long time, and it's gotten worse and worse. Over the last five years, there has been a dramatic reduction in what we get reimbursed.”

Halliwell adds that a big issue has been the increasing levels of direct and indirect remuneration (DIR) fees. “We're paying 2020-freeze clawbacks,” he notes. “We’ve been getting hit with DIR fees since January 1—twice the DIR fees, in fact, which literally levels so many independent pharmacies who don't have cash. It’s bad out there.”

The margins, therefore, have gotten smaller and smaller, with more tasks falling on pharmacists’ plates and fewer resources to go around. Every time someone shops online or elsewhere for cheaper prescription or OTC products, the pharmacy loses ground. With rising prices for prescription drugs in recent years and new complexities emerging in payer coverage, pharmacies, much like patients, have felt the squeeze.

There is some help from new advances in technology and automation. Inbound call centers, as well, assist in managing the volume of pharmacy calls and utilize central-fill pharmacies to fulfill recurring prescriptions. This allows pharmacists more room to operate at the top of their license, offering in-person consultations and counseling, testing, and immunizations.

“Community pharmacies are stressed at the moment. We've got a lot on our shoulders,” says Edmundson. “All those patients have to go somewhere, which just puts more workload on the pharmacies that are still here. There have to be workflow adjustments to make offering these types of services viable.”

Without a significant shift, the current trend of pharmacy closures will likely continue. To turn back the tide, experts believe policies need to change, and community pharmacies need stronger support and advocacy to bridge the healthcare gaps that are steadily widening.

About the Authors

Marina Crouse is a copywriter with MJH Life Sciences®, parent company of Pharmaceutical Commerce. She works closely with such MJH media brands as Mesmerize, which specializes in patient education at the point of care.

Michael Christel is Group Managing Editor of Pharmaceutical Commerce, Pharmaceutical Executive, and Applied Clinical Trials.

References

1. Telemedicine Use Among Physicians by Physician Specialty: United States, 2021. National Center for Health Statistics. February 2024. https://www.cdc.gov/nchs/products/databriefs/db493.htm

2. As Pharmacies Shutter, Some Western States, Black and Latino Communities are Left Behind. AP. June 3, 2024. https://apnews.com/article/pharmacy-closure-drugstore-cvs-walgreens-rite-aid-91967f18c0c059415b98fcf67ad0f84e

3. Meyersohn, N. Why Walgreens, CVS, and Rite Aid are Closing Thousands of Drug Stores Across America. CNN. June 28, 2024. https://www.cnn.com/2024/06/28/business/walgreens-cvs-closing/index.html