Nearly half a million Washingtonians live in pharmacy deserts
Stretching above its foothills, the glacial crown of Mt. Rainier stands guard over Packwood, one of Washington’s dwindling lumber towns.
Today, Packwood — population 319 — may be best known for its biannual flea market. Every spring and fall, thousands of visitors descend on the town. For travelers, it’s the last stop west of the Cascades for 60 miles.
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But the end of the line for medical services lies 15 miles west of Packwood, at a clinic in Randle. Reaching a pharmacy and hospital from Packwood demands a 40 minute drive to Morton.
It’s a pilgrimage that Maree Lerchen, a longtime Packwood resident and owner of Mountain Valley Real Estate, said has caused residents to leave town.
“We’ve lost a lot of our elder community,” Lerchen said. “There used to be 30 to 40 people at the senior center every day, then they closed for COVID reasons, and now they’re back and there’s like four or five.”
The decline could be due to deaths, Lerchen said, and residents deciding it was time to move in with family closer to medical services.
With limited daily transit options in Packwood, seeking medical care is a journey. And if a health emergency strikes, the town is served by a volunteer ambulance crew.
Because of her insurance, Lerchen drives 100 miles to Olympia to access her clinic. Lerchen counts herself as fortunate for not needing many prescriptions. She has them shipped to her from her clinic as needed, describing the nearest pharmacy in Morton as “absolutely overwhelmed.”
Packwood used to have its own physician and pharmacy — both of which shut down after the mill closed in 1998, taking 360 well-paying jobs with it. As families moved away, Lerchen said short-term rentals took their place, further reducing the ability of future medical facilities to keep their doors open. At the same time, the local economy moved from timber to tourism.
“Which provides, unfortunately, not year-round, full-time family-wage jobs,” Lerchen said. “It’s just not there.”
And Packwood isn’t unique in its lack of access to pharmacies in Washington State.
University of Washington researchers recently completed an analysis of pharmacy deserts. While the publication is in the review process, Rachel Wittenauer, a Ph.D. student with the university’s CHOICE Institute, said roughly 450,000 adults statewide in both urban and rural areas are living in pharmacy deserts.
Pharmacy desert communities are defined as being both low-income and one in which two-thirds of the population lives more than one mile away from a pharmacy in an urban area, or at least 10 miles away in a rural area.
“They’re underleveraged in terms of their distribution, and it’s important to consider which types of populations have access to them,” Wittenauer said.
The analysis found that roughly 30% of census tracts in Washington were designated as higher-risk for COVID infection and complications. Of census tracts that were pharmacy deserts, two-thirds were at high-risk. Many of these are in areas that are already disadvantaged, or are bearing the impacts of structural inequity and racism.
While the UW analysis did not specifically look at race, Wittenauer said most other studies on the subject find pharmacy deserts occur heavily in non-white communities.
“The structural components of that are obviously an underlying issue here,” Wittenauer said.
Pharmacies are the most widely-distributed health care access point, and when they close, it can impact people’s ability to receive care. Recent studies have found that proximity to pharmacies impacts the rate at which people receive vaccines and other medications.
To help visualize pharmacy deserts, a map compiled by TelePharm pinpoints more than 80 towns in Washington located further than 10 miles away from a pharmacy. However, the map appears only to consider physical distance, and not other equity metrics, and includes some areas like Sultan which recently received pharmacies. The TelePharm map can be seen below:
In a recent report, Kaiser Health News found rural pharmacies nationwide are in crisis. Pharmacy owners nearing retirement are struggling to find someone to take the helm. In a profession once regularly passed down by generation, the children of pharmacists are opting for less stressful careers than afforded by running a small town pharmacy.
The high cost of running a pharmacy also impacts their ability to remain in underserved communities.
A 2020 report found that among the 443 pharmacies that responded to the study — roughly one-in-three statewide — the mean cost of dispensing a prescription in 2018 was $12.20, about $.20 lower than the national mean cost. The cost for dispensing Medicaid drugs was slightly lower, at $11.43 per prescription. Kaiser Health News noted that drug plan reimbursements are often far less than the dispensing cost and overhead expenses.
A prior study from 2014 found the mean cost of dispensing was $10.55, and Medicaid cost of dispensing was $10.30. The difference between 2014 and 2018 could be partially accounted for by a 6% cost increase from inflation. The study found that pharmacy labor costs could also influence the increase. Bacci said many pharmacies in Washington are at a point where they’re not being reimbursed enough to cover the cost of acquiring drugs from insurance companies.
The state allows pharmacies to operate without a pharmacist on hand at all times, as long as there are strategies that allow them to communicate with the employee dispensing medications.
Washington also allows pharmacists to contract for patient care services with commercial state plans, making it one of only seven states to do so. These could be helping to bring the average dispensation cost down in the state, but it leaves out those served by Medicare, which is dictated by federal law.
“Federal policy change would be major,” said Jennifer Bacci, professor of pharmacy at the University of Washington.
In its analysis, the University of Washington made three policy recommendations to address pharmacy deserts. The first is urging Congress to approve the Pharmacy and Medically Underserved Areas Enhancement Act, which would allow pharmacists to be reimbursed for some health care services under Medicare Part B in underserved areas.
The second recommendation is to consider different financing mechanisms for pharmacies beyond medication reimbursement, and to find ways to encourage pharmacies to stay open in underserved and rural areas. In addition to dispensing, other costs include rent and labor which can be addressed outside of reimbursements.
Third, the analysis recommends using technology—specifically telehealth —to let pharmacists consult with patients.
While Washington’s legislature has studied prescription drug costs, it should also focus on attracting pharmacies to rural areas of the state, said Rep. Peter Abbarno (R – Centralia). Abbarno represents the 20th legislative district, which includes Packwood.
After State of Reform reached out to Abbarno, he said it prompted discussion with staff about how to incentivize health care professionals to come to communities that are traditionally lower income and rural. Abbarno said:
It’s hard to attract people to rural communities and then pay them the wage to keep them there.”
The legislature could try to attract pharmacies to set up in rural parts of the state by creating B&O tax or relocation incentives, he said. Or they could create ways to forgive portions of pharmacists’ student loans for working in underserved areas for a certain period of time, similar to programs created for teachers.
Several pharmacy bills have been introduced for the 2022 legislative session, or were carried over from last year. Many deal with mail-in prescriptions and pharmacy access.
Despite the challenges in operating rural pharmacies, there are notes of hope.
Sultan, a town of roughly 5,100, lying some 23 miles east of Everett along Highway 2, was without a pharmacy until Invara opened in 2019. The brick-and-mortar pharmacy serves Sultan and the surrounding areas, and provides delivery services.
In Lewis County, Arbor Health — a public hospital district that runs several clinics and the Morton hospital — has plans to open a primary care clinic in Packwood this year. A portion of the building would be reserved for a pharmacy run by an outside organization, said Diane Markham, public information officer for Arbor Health.
The hospital district is looking for a good location for the clinic. However, a lack of housing and transportation may make it hard to recruit people to the area for a job.
“I’m positive that it’s a real hindrance for them to not have health care located in their own town,” Markham said.
Still, the benefits to Packwood residents and those in the surrounding areas of having a pharmacy in town is evident, she said.