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Mapping a New Future

AACP Article

What do pharmacy closures mean for public health, and how can schools help the profession build back?

By Athena Ponushis 

It was over a routine, focus group phone call, when three researchers—Sophia Herbert, Nicole Pezzino and Jennifer Bacci—decided to bring visibility to the drastic rate of pharmacy closures. Familiar with the community pharmacy landscape and working with independent pharmacy owners through the Academia-Community Transformation (ACT) Pharmacy Collaborative, they knew that pharmacies had been closing for years, but they also knew the rate of closures was going to continue to climb. Acknowledging this reality compelled them to action. “We need to do something,” Dr. Sophia Herbert, assistant professor at the University of Pittsburgh School of Pharmacy, remembers the three researchers affirming. “We need to put this message out there so people other than pharmacists realize what’s going on, and maybe will do something about it.”

The more they talked, the more their plan took root. They each had P4 students who would be joining them on rotation soon. They came up with a project: Their students would comb the media for pharmacy closures in every state, compile what they found into a map of locations, add a series of links to news stories reporting on closures and upload it all on the ACT Pharmacy Collaborative website.

The pharmacy closures map gained traction rather quickly, but the picture was not complete. Many pharmacies were closing that were not receiving attention from local media, so the team opened up a “report a closure” feature, inviting the public to submit news of more closures. Now the density and color of the pins on the map are hard to deny: Pharmacy closures are not an isolated problem, they are a nationwide occurrence. “Making that visual impact was really our goal with the map,” Herbert said, “to convey that message and point people toward action, whether it be spreading the message, participating in some legislative action, or supporting a local community pharmacy in any way. Times are certainly challenging right now and many pharmacies are struggling to keep their doors open.”

The Why Behind a Worrisome Wave

There have been many shifts in the community pharmacy marketplace, but the main driver impacting closures would be the decrease in reimbursement for drug products. That decrease varies from place to place, but as Herbert explained, “Nationally, the overall trend is reimbursement for drugs is tanking. And in some cases, pharmacies are even losing money dispensing a drug product. They are getting reimbursed less than what they paid to obtain that medication.”

Such losses do not make for a viable business model. There are different reasons for the diminishing returns, but the main culprits right now are pharmacy benefit managers (PBMs). Originally, the purpose of PBMs was to help pharmacies and health plans work together. Every pharmacy must have a contract with every health plan that it is billing and dispensing medications through, so the PBM was designed to serve as the middleman between the pharmacy and the health plan to orchestrate the contract. PBMs may have come out of a genuine need, but they have not been heavily regulated and the end result has been PBMs profiting while pharmacies are closing, ultimately leaving patients suffering. “This is not a situation of pharmacies wanting to make more money,” Herbert said. “They want transparency, they want to know they are going to be able to turn a modest profit, or at least break even, on the medications they are dispensing.” An unfair drug reimbursement system means that pharmacies cannot keep their doors open if they are relying on repayment.

Dr. Jennifer Bacci, associate professor at the University of Washington School of Pharmacy, said it’s no secret that pharmacies are closing. It’s happening in urban centers like Seattle and in rural communities. From independent to corporate community pharmacies, no pharmacy is immune from the effects of the marketplace.

“It’s an important time for us as a profession to own what happens next, because if we don’t step up to create the future for ourselves, then other people will,” Bacci said. She sees pharmacy closures as both a problem and an opportunity. “That’s the message I try to communicate to my students. There is an opportunity to come into community pharmacy and help create the future. It will not look the way it looks now, and that’s O.K. But we need to take ownership of what we want, we need to step up and make it be what we want it to be. That’s our opportunity.”

Map Gains Traction in Political Discussions

Map Gains Traction in Political Discussions

In April, Pennsylvania State Senator Judy Ward issued a statement urging reforms in order to lower prescription drug costs. In noting several pharmacy closures across the Pittsburgh region, Ward said, “We’re seeing this issue repeated across the commonwealth and the nation. The University of Pittsburgh has created a website (ActForPharmacy.com) that tracks community pharmacy closures and provides a sobering view of the challenges Pennsylvania community pharmacies face in staying open—and of Pennsylvanians who desperately need their prescriptions.” Read the full statement here: https://senatorjudyward.com/2024/04/26/reforms-needed-to-lower-prescription-costs-for-pennsylvania-pharmacies-families/

Impacts on Public Health and the Pharmacy Workforce

The public health impact cannot be understated. People need face-to-face interaction with pharmacists for their medications and medication-related services. When people lose the ability to go into a healthcare space embedded in their community and talk with a trusted healthcare provider, they lose a lot.

Dr. Nicole Pezzino, associate professor at Wilkes University Nesbitt School of Pharmacy, started working in a community pharmacy when she was 16 years old. The issue of pharmacy closures is personal to her. One pharmacy where she did a rotation has closed. Her mentor ran a diabetes clinic in a community pharmacy. His clinic had a collaborative practice agreement with 50 providers in the greater Pittsburgh area. There was a waitlist for new patients but he would find a way to squeeze them in. She would follow up with them every week until they reached their goal. “I remember telling him when I was a student, ‘I’m going to take over for you. We’re going to be partners first, and when you’re ready to retire, I got you,’” Pezzino said. Her mentor passed away a few years back. Catching up with the pharmacy owner recently, she learned that the pharmacy had closed. Pezzino said it’s “saddening and frightening” to think of more pharmacies closing and patients losing out on those services.

Mail-order pharmacies come up in this discussion. “Mail order can certainly help some patients and I’m glad that it exists as an option, but we cannot rely on mail order to take care of everyone’s mediation-related needs,” Herbert said. “It’s not realistic.” Medication management, immunizations and other services that can be provided by an embedded pharmacist in a community is huge, and when that pharmacy closes, it all goes away.

Herbert believes that the profession will continue to feel the effects of closures and changes in the marketplace for some time, but there is still a great need for pharmacists in this country. “I think with this kind of crashing of a system, there’s going to be a rebirth of what community pharmacy looks like,” she said. She does not know a pharmacist working in a direct patient care setting who is not feeling the changes in the healthcare landscape in some way, but she does hold hope that these changes will bring a new era of pharmacy practice and a way that works better for the profession and the patients. The ones who will usher in this era will be students.

“It’s an important time for us as a profession to own what happens next, because if we don’t step up to create the future for ourselves, then other people will. That’s the message I try to communicate to my students. There is an opportunity to come into community pharmacy and help create the future.”

—Dr. Jennifer Bacci

Empowering Students to Act

Faced with this reality, educators are having hard conversations—trying not to be dreary, finding ways to be encouraging—but they must involve students and show them the landscape they are entering while assuring them that they can impact the profession’s future. “We need to empower them to be part of the change,” Herbert said.

Pittsburgh’s School of Pharmacy takes its entire class of second-year students to legislative day, an event the Pennsylvania Pharmacists Association puts on every year at the capitol in Harrisburg. Faculty weave it into the course for students who are spending time at community pharmacies, seeing the impacts of drug reimbursement and hearing preceptors talk about it at their sites. This past year, they advocated for a bill that would regulate PBMs and support pharmacists, making cash flow transparent and giving means to fight back any acts of unfairness.

“Demonstrating that students can be involved in the advocacy for change, whether that be in a legislative way or a local way, at their own pharmacy, whatever it might be for them, I think is important.”

—Dr. Sophia Herbert

“Demonstrating that students can be involved in the advocacy for change, whether that be in a legislative way or a local way, at their own pharmacy, whatever it might be for them, I think is important,” Herbert noted.

It can be hard to conceptualize what pharmacy closures really mean, but the impact continues to spread. Herbert has family members and friends who rely on pharmacies for healthcare. “If they have a question about something related to their healthcare, they are not making an appointment with their primary care physician. They are going to the pharmacy to talk with a trusted professional,” she said. At legislative day, some of the legislators talked about closures in their districts that had affected them or someone they know personally. Legislators who had been touched by pharmacy closures were much more inclined to enact change to prevent further closures.

At Wilkes, Pezzino sees her students as inherent advocates. She teaches them to amplify their voices in their profession by sharing their personal stories. She asks her students, many of whom work in community pharmacy, to think about times when things went really well, or times when things didn’t go so well. They talk about the issues together, as a class, digging for root causes. Students naturally progress from sharing their stories in class to writing letters to legislators to posting stories on social media, strengthening their voices.

When Pezzino broaches the subject of PBMs, she uses a colleague’s method and puts unfair reimbursement in the context of grades: “Let’s say I tell you today that you are going to get an A on your transcript because you did everything you were supposed to do, you turned everything in, you did everything right,” she tells students. “In your mind, you are getting an A, but six months later, when you get your transcript, it says C.” She then explains, “That’s what it’s like. Some of our best performing pharmacies are hitting all the metrics but still losing money.”

Pezzino sees a difference in how students react to pharmacy closures depending on their academic year. Her younger students seem more excited about the opportunities. “But my newer grads are saying, ‘I signed with a store that just closed. What’s going to happen to my job?’” she said. “There might be a little bit of fear there, but when you have that, you are forced to innovate.”

As the pharmacy profession invests energy into remedying the drug reimbursement problem, they must also invest in ensuring that pharmacists are paid fairly for provision of services. “While we navigate this difficult time and extraordinary change in the marketplace, remember there are other ways for pharmacies to earn revenue besides dispensing,” Herbert said. “While we fight against poor reimbursement and fight for regulating PBMs, we must also try to expand access to pharmacist-provided services, point-of-care testing, hormonal contraceptive prescribing, immunizations, diabetes education…there are so many services pharmacies can offer beyond dispensing of drug products.”

As far as the ACT Pharmacy Collaborative pharmacy closures map goes, Herbert, Pezzino and Bacci will keep updating it as long as it’s useful. There are other resources in the pipeline, including a recently released map of closures specifically linked to pharmacy claims that may show the effect on communities to a greater extent: https://storymaps.arcgis.com/stories/21620f1e0 7c14d7f81adc4503faaf51e

“I truly believe there is great possibility for what we will be able to do in the community pharmacy space in the future,” Herbert said. “We’re just at this turning point, and unfortunately, I think it’s going to take this crashing and closing of many pharmacies for people to wake up to what’s going on. But we will be able to rebuild what the future looks like together.” A future where community pharmacies are seen as a hub of community health and community pharmacists are treated as healthcare providers.

Athena Ponushis is a freelance writer based in Ft. Lauderdale, Florida.

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