US Pharm. 2024;49(4):32-36.
ABSTRACT: Over the years, pharmacies have grown in the number of services they offer and have become critical healthcare resources in the community. Despite this, pharmacy deserts exist due to a number of factors such as pharmacy closures, limited profit and reimbursement, and limited pharmacy networks. Coupled with pharmacy access issues is the revelation that healthcare inequities are still present. Investigating the characteristics and patterns of pharmacy deserts, understanding why they occur, and realizing the consequences of pharmacy deserts can provide insight into where the areas for improvement with pharmacy access are and perhaps insight into the ways to mitigate these issues and decrease healthcare disparities.
Medications are widely used and important in preventing morbidity and mortality for a variety of medical conditions.1,2 The advancement of medical care has also increased life expectancy, which increases the prevalence of chronic diseases and the number of individuals requiring medications to manage or prevent those conditions. Local pharmacies have played an integral role in providing access to these medications and consultation services. Pharmacy services also go beyond medications for chronic conditions and urgent care services and include diagnostic supplies and preventive care, such as immunizations.1,3-10 These diverse services, coupled with the presence of the pharmacies in the communities, make pharmacists some of the most visited healthcare professionals in a healthcare team—and some of the most widely dispersed.6,9 A study showed that a group of patients who received medication management interventions at a community pharmacy had 3% higher medication adherence, 1.8% fewer hospital admissions, 2.7% fewer emergency visits, and 0.53 fewer mean outpatient visits when compared with patients who did not.8 Pharmacists also improve medication safety, promote health, prevent disease, improve medication adherence, and reduce healthcare costs.8 Despite the extent of pharmacy services, barriers to accessing these services still remain a concern.1,3,8,9,11
What Is a Pharmacy Desert?
Unfortunately, in recent years in the United States, there has been an increased frequency of community pharmacy closures, which worsens pharmacy deserts.7 One analysis demonstrated that in 2020 in the U.S., 48.1% of the population lived within 1 mile of a pharmacy, 73.1% within 2 miles, 88.9% within 5 miles, and 96.5% within 10 miles, and these numbers varied based on urbanicity.12 The term “pharmacy desert” is modeled after the term “food desert.” It is described as a low-access community where the residents have to travel farther to get to the nearest pharmacy to fill their prescriptions.1,13,14 Cardinal Health mapped out rural pharmacy deserts and found that 2,177 rural towns with populations between 500 and 5,000 did not have access to a pharmacy within 10 miles.14
Pharmacy accessibility can be influenced by a multitude of factors, such as pharmacy closures, transportation, disability, economic challenges, and cultural or language barriers.11 There seem to be certain characteristics in pharmacy desert areas and the communities that live in them that may provide insight on how to address this issue. One study revealed that pharmacy deserts tended to have denser populations, more renters, more non-native English speakers, less vehicle ownership, more people living under the federal poverty level, and higher crime rates against property and people, and fewer healthcare professionals were more likely black or Hispanic.6
In general, pharmacy deserts can also be further delineated by geographic location (i.e., rural, urban, or suburban), level of income, and race and ethnicity.6 More densely populated areas, such as the urban areas, have more pharmacies compared with lower-density populated areas such as rural areas. However, pharmacy deserts can also be located in urban areas. A study completed in New York City showed that the boroughs of Bronx, Brooklyn, Queens, and Staten Island had only approximately 0.06 (±0.13) chain pharmacies per 1,000 residents compared with Manhattan, which had approximately 0.43 (±0.3) chain pharmacies per 1,000 residents. Another study looking at types of pharmacies across the U.S. showed that chain pharmacies made up 62.8% and 66.8% of pharmacies in large and small metropolitan areas, respectively, compared with 50.32% in nonmetropolitan urban areas and 21.3% in rural areas.12 In rural areas, 76.5% of the pharmacies were independent and franchise pharmacies. From a level of income standpoint, lower-income neighborhoods have fewer pharmacies compared with those with higher income.6 Those pharmacies also tend to be independent pharmacies as opposed to chain pharmacies. This difference can be problematic because larger chain pharmacies likely have more resources, services, and hours that support medication adherence.5,6 In lower-income populations, transportation also seemed to be a barrier.1 On top of that, medications were more likely to be out of stock in lower-income communities.3
Lastly, race and ethnicity appear to have some correlation since pharmacy deserts were found mostly in black and Hispanic neighborhoods as opposed to white or diverse neighborhoods.1,13 It has long been known that there are racial and ethnic disparities in access to healthcare services, and access to pharmacies is no exception.1 It was previously believed that the contributors to the racial and ethnic disparities in use of prescription drugs were due to affordability alone. Furthermore, studies are revealing that medication insurance benefits and socioeconomic status alone do not fully explain those disparities. Rather, residential segregation by race and ethnicity and geographic accessibility may also play a large role in the differences in healthcare access, and pharmacy deserts affect minority neighborhoods and low-income populations more. For example, in 2012 in Chicago, the mean number of pharmacies in segregated white communities, integrated communities, segregated black communities, and segregated Hispanic communities per census tract were 0.67, 0.83, 0.55, and 0.56, respectively, which were statistically significant differences.1
The number of available pharmacies also statistically significantly differed between the groups, as there was a 30% increase in the number of pharmacies in segregated white communities compared with a 17% and 11% decrease in the number of pharmacies in segregated Hispanic and black communities, respectively, despite the adjustment for population density. Chain pharmacies made up 58.6% of available pharmacies in segregated white communities as opposed to 38% of available pharmacies in segregated black communities—yet another statistically significant result. Looking at travel time, people living in segregated black communities had to travel farther than those living in segregated white communities. When looking at the breakdown of the different communities living in pharmacy deserts, 5% of segregated white communities were pharmacy deserts compared with 29% of the integrated communities, 34% of the segregated Hispanic communities, and 54% of the segregated black communities.
It was also found that low-income black communities had a higher proportion of pharmacy deserts compared with low-income white communities. It is important to note that a high number of segregated black communities live in both medically underserved areas (MUAs) and pharmacy deserts. Similar patterns arose when looking at 30 of the most populated cities nationwide.4 In 2015, the mean numbers of pharmacies in white and diverse neighborhoods were 1.15 and 1.23 per census tract, respectively, and 0.85 and 0.97 per census tract in black and Hispanic neighborhoods, respectively. More black and Hispanic neighborhoods were in pharmacy deserts at 38.5% and 39.5%, respectively, compared with 26.7% of white neighborhoods and 28.2% of diverse neighborhoods. Pharmacy deserts were also more likely in low-income black neighborhoods (47.7%) compared with low-income white neighborhoods (40.3%). Of the pharmacies that opened between 2010 and 2015, they were more likely to open in white neighborhoods (29.7%) compared with black neighborhoods (25.7%) or Hispanic neighborhoods (21.2%). Independent pharmacies were more often located in black and Hispanic neighborhoods. Pharmacy closure rates were lower in white and diverse communities at 11% and 11.7%, respectively, compared with black and Hispanic communities at 14.1% and 15.9%, respectively.
One other population for which accessibility needs to be considered includes the elderly, since they not only use approximately 25% to 30% of the prescription medications in the U.S. but also tend to have more comorbidities and limitations, leading to increased risk for adverse reactions, drug-drug interactions, and medication errors.8 One study demonstrated that the number of pharmacies per 10,000 elderly patients was lower in rural areas compared with urban areas and the travel distance to a pharmacy was also farther in rural areas. The findings in this study were mostly consistent with those of other studies regarding race and ethnicity except for the fact that the pharmacy deserts had fewer black and Hispanic populations compared with white populations and that there were fewer independent pharmacies. The explanation for these different results could be due to the fact that this study focused on patients enrolled in a State Pharmaceutical Assistance Contract for the Elderly and excluded out-of-network pharmacies. There were more minority populations receiving support from the State Pharmaceutical Assistance Program that lived in urban areas. Regarding the discrepancy with independent pharmacies, one of the explanations was that the independent pharmacies could have closed from the inability to compete with chain retail pharmacies and low population density.
Accessibility of other pharmacy services also differed between communities. Immunizations, 24-hour services, and drive-through services were less likely to be available in minority neighborhoods compared with white neighborhoods.5 A study involving recently diagnosed breast cancer patients enrolled in Medicare showed that those with very low pharmacy access, where there was no pharmacy within the recommended driving distances, were less likely to receive the influenza vaccine.10 Black and Hispanic women and those with Medicaid, who were low income, who were diagnosed during September and November, and who had a higher cancer stage were also less likely to get vaccinated. It is important to note that in those with very low access, these patients were more likely to be white and less likely to be low income. There were no other differences found between race, ethnicity, Medicaid enrollment, or census tract level based on pharmacy access, but these results could be due to the cohort selected for investigation.
Pharmacy access can impact public health issues as well. A study in Baltimore demonstrated that limited geographical pharmacy access may prevent expedited partner therapy (EPT) in treating Chlamydia trachomatis.15 One-third of Baltimore residents were not within walking distance of a pharmacy. Twenty-five of 200 (12.5%) census tracts were considered pharmacy deserts. Census tracts with high C trachomatis rates had lower median pharmacy density compared with others. A higher percentage of minorities lived in pharmacy deserts (93.1%) compared with non-Hispanic white individuals (6.9%). Another notable fact in this study was that pharmacists were largely unaware of an EPT program, demonstrating that extra education should be provided to inform pharmacies and pharmacists of the types of services that can be offered.
Why Do We Have Pharmacy Deserts?
There are several postulations as to why pharmacy deserts are happening. One in eight pharmacies in the U.S. shut down between 2009 and 2015, generating pharmacy deserts, with a majority of these pharmacies being independent pharmacies in low-income urban areas containing many underserved populations.7 Pharmacy benefit managers (PBMs) were introduced with the aim of negotiating prescription drug prices between insurance plans, drug manufacturers, and pharmacies, but the rate of reimbursement to pharmacies has actually decreased.4,7 Additionally, some of the PBMs’ preferred pharmacies may be mail-order or specialty pharmacies instead of community pharmacies.14 This highlights the issue of the limited pharmacy networks that forces many patients, including those with Medicaid and Medicare, to go to pharmacies farther away.4,5 Limited pharmacy network access may also lead to decreased pharmacy revenue and patient volume, which results in more pharmacy closures.5 Similarly, health insurance companies also tend to partner with chain pharmacies to provide lower prescription costs. Independent pharmacies are often excluded from those partnerships and cannot compete with chain community pharmacies.7 Smaller pharmacies have also had to compete with larger pharmacies, but with the availability of online prescription services, the battle to remain in business becomes more difficult. The lack of transportation also influences patients’ pharmacy access and decreases not only revenue but also patient medication adherence.16
Consequences of the Pharmacy Desert
Pharmacy deserts have a significant impact on a patient’s medication adherence.2,3,8,11 The more chronic conditions a patient has, the more medications he or she has to take. Difficult access such as longer travel time or distance may contribute to a patient’s nonadherence, leading to poor health outcomes and increased medical care costs from increased hospitalizations or emergency department visits.2 Although there are programs to enhance affordability and accessibility, they are only available at certain pharmacies, threatening medication adherence. Nonadherence is one of the main sources of healthcare system waste in the U.S., with about $100 billion spent per year on avoidable hospitalizations and $290 billion per year in avoidable expenses overall.
It appears that those who live in underserved areas may not receive the same in-depth explanation of their medications, which can also lead to medication nonadherence.3,17 There is also a higher cost-related underuse of medications, demonstrating that the affordability of medications for patients living in these areas affects medication adherence.18 Lower access to pharmacies has also impacted preventive care services such as vaccinations. During the COVID-19 pandemic, huge efforts were placed into vaccination campaigns, but these vaccinations were less likely to be available in pharmacy deserts.5 Patients also cite stigma surrounding carrying certain insurances, having lower income levels, or living in MUAs or underserved population areas, which can also deter them from going to their pharmacies.6
Are There Solutions?
It is important to remember that healthcare disparities are preventable differences in health indicators and outcomes. That means that it is possible to find a solution, bearing in mind that health equity requires new and innovative policies and practices to replace the old ones that maintained inequitable healthcare.19 Several proposals or ideas suggest possible ways of addressing the disparities in pharmacy access. Federal, state, and local governments and private agencies could consider incentivizing pharmacies to open or relocate to pharmacy deserts.1,4,7,14,20,21 This could be in the form of grants or tax benefits. Increasing Medicaid reimbursement could potentially incentivize pharmacies to move to or open in pharmacy deserts and possibly prevent pharmacy closures.1,4 For example, Illinois implemented the Critical Access Pharmacy program, which provides extra Medicaid payments to independent pharmacies found in areas that are designated by the federal government as MUAs.4,5 Unfortunately, this effort yielded few results since it failed to improve pharmacy access in black and Latino neighborhoods. This is because only 41% of pharmacy deserts were located in MUAs, so many pharmacies did not meet the eligibility criteria. Therefore, it would be important that the term pharmacy desert also be incorporated into these policies to protect all pharmacies in underserved areas so that the benefits for critical access pharmacies are realized.
Medicare Part D reformation could potentially also improve pharmacy reimbursement to prevent pharmacy closures.1,4,5 It could implement convenient access standards, require higher reimbursement to pharmacies, and broaden preferred pharmacy networks to improve accessibility of the pharmacies. Widening preferred pharmacy networks could also help prevent pharmacy closures and improve patient access, particularly in pharmacy deserts.5 The 340B program could be implemented for pharmacies that are at higher risk for closure in these pharmacy deserts, such as independent pharmacies.4,14,18 It is suggested that publicly funded programs to support and encourage projects and innovative ideas to increase pharmacy accessibility would be another option to minimize the effects of pharmacy deserts.1
Other incentives can be offered to expand services that may improve pharmacy access, such as home delivery, drive-through services, and 24-hour services.4,5 Expanding these services could better accommodate patients who use public transportation, have limitations in mobility, or have limited flexibility in their schedules.5 Increasing other services such as preventive care services could further aid the minority communities and improve the population’s health.1 Involvement of primary care and specialty providers in encouraging patients to receive their vaccinations through the clinic or the community pharmacies, continuing vaccination campaigns and events, and having standardized nursing vaccination orders could improve preventive care services.10 Innovative methods of delivering pharmacy services would likely improve access to pharmacy services while minimizing the burden on the patient. Telepharmacy services would not only decrease staffing costs but also improve accessibility to a pharmacist for those who may not be able to travel to a pharmacy.9,11,14 The adoption of telepharmacy may actually decrease the geographical areas of pharmacy deserts and the percentage of patients living in them while still giving the opportunity for face-to-face interactions.11
Different organizations or students and volunteers from colleges and universities can help run nonprofit pharmacies, free clinics, or other outreach programs in pharmacy deserts.7 The students involved would hopefully not only prevent pharmacy closures but also benefit from hands-on experience. The creation of low-cost healthcare access programs that are equitable may also improve pharmacy access by having both a clinic and pharmacy at the same location.4 Opening or expanding community health centers to include pharmacies allows patients the option to not only have their medical issues addressed but also have their prescriptions filled all in one place.1,14 The burdens of physicians could be shared by granting pharmacists provider status at a federal level for certain patient care services while allowing pharmacists to be reimbursed for their services.9,19 Since patients visit their community pharmacies twice as often as their primary care providers, there is a potential opportunity to increase the availability of healthcare services to patients, especially with the physician shortage.12 Recruiting the next generation of pharmacists and helping them stay engaged in the effort to remove healthcare disparities could be of huge benefit to patients and perhaps generate the momentum to move policies forward.19
Conclusion
If the issues contributing to pharmacy deserts are not addressed, it is likely that pharmacy deserts will continue to expand, and the situation will worsen. It is crucial that continual efforts are made to expand pharmacy services and access to pharmacy desert areas to improve outcomes and decrease healthcare disparities, especially in the segregated minority and low-income communities. Knowing where the pharmacy deserts are and the risk factors and causes for them can provide insight into where pharmacy resources are needed so that those can be prioritized. Increasing awareness of pharmacy deserts and their impact on patient outcomes, in addition to the possible solutions and resources to combat them, could provide a pathway to improving healthcare equity.
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