Pulse
Rx for Rural Pharmacies
Small towns are finding creative ways to preserve access to pharmacy services.
By Kim Kiser
Diane Stusynski was working as a technician at the only pharmacy in Karlstad, Minnesota, in 2004 when she learned that her boss, the pharmacist, wanted to retire. The town’s 850 residents, many of whom were elderly, depended on the store, and its closing would mean they would have to drive to Thief River Falls 35 miles away to have prescriptions filled—a trip that would be especially difficult during northwestern Minnesota’s winters. “We needed to keep a pharmacy in town,” she says. “The elderly population often can’t get places. Sometimes they’re lucky if they can get out of their homes or find people to pick things up for them.”
At the time, other small towns were experimenting with telepharmacy, an approach in which a pharmacy technician such as Stusynski works under the supervision of a pharmacist in another community to fill prescriptions. In 2002, after the pharmacy closed in Sebeka, Minnesota, the town’s clinic converted a room into a pharmacy and established computer, audio, and video connections with the outpatient pharmacy at the hospital in Wadena. (The Sebeka telepharmacy closed in 2010.)
Telepharmacy had also proved to be a way of maintaining pharmacy services in rural North Dakota. In 2001, that state became the first to allow the practice. Today, North Dakota has 73 telepharmacy sites, 51 of which are in retail stores.
After hearing about the success in North Dakota, the pharmacist in Karlstad approached officials at Thrifty White Pharmacy, a regional chain based in Maple Grove, Minnesota, that had several remote telepharmacy sites in North Dakota, about setting up a similar arrangement. Several months later, after receiving a variance from the Minnesota Board of Pharmacy’s licensing rules, Thrifty White established a remote site in a grocery store in Karlstad.
The day after the old drug store closed, Stusynski reported to the new pharmacy, located in a corner of Supermarket Foods, where she has been filling prescriptions ever since.
The Way it Works
Now when a patient brings in a prescription, Stusynski scans it and sends an electronic copy to a pharmacist at Thrifty White’s central facility in Fargo (the facility is licensed as a nonresidential pharmacy by the Minnesota Board of Pharmacy).
Stusynski then enters into Thrifty White’s computer system the patient’s name; the doctor’s name; the name, strength, and quantity of the drug prescribed; directions for taking it; and information about whether it can be refilled. A claim is then sent to the patient’s insurance company. After the pharmacist verifies the information entered by the tech, and if the claim is accepted, a label is printed out at the pharmacy in Karlstad. Stusynski then pulls the stock bottle of medication off the shelf, counts out the number of pills ordered, places them in a container, and attaches a portion of the label to the container.
The Hospital Connection
Since 2004, Minnesota hospitals that don’t have pharmacist coverage 24/7 have begun connecting to pharmacies in larger hospitals for after-hours support. In most cases, a nurse at the rural facility faxes or electronically transmits the medication order to the hospital that does have full-time pharmacy coverage for review before the drugs are administered.
Cody Wiberg, Pharm.D., executive director of the Minnesota Board of Pharmacy, says one of the reasons for doing this is a Joint Commission best practice standard requiring a pharmacist to review an order before a drug is administered to a patient. “Some hospitals might be denied reimbursement if they were to lose Joint Commission accreditation,” he says. “So they have a financial reason for doing this.”
Wiberg says a number of large Minnesota-based systems including Allina, Mayo, and Fairview are providing after-hours pharmacy support to small hospitals. In addition, Catholic Health Initiatives in Fargo serves several hospitals in northwestern Minnesota through its ePharmacist Direct program, and Cardinal Health, an Ohio company, provides support to Virginia Regional Medical Center. Avera, based in Sioux Falls, South Dakota, is the most recent system to approach the Board about providing remote support.—K.K.
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Next, she sets the stock bottle and pill container in front of one of three cameras in the store and establishes a two-way audio/video connection with the pharmacist in Fargo. Under the eye of the camera, she shows the pharmacist the stock bottle and the pill container, removes the contents of the pill container, counts out the pills, then shows the pharmacist the label. The pharmacist compares what he or she sees with what’s on the prescription and an image of the pill, and checks the National Drug Code directory to verify the product and manufacturer. Once the pharmacist determines that the prescription has been filled correctly and there are no potential drug interactions, Stusynski adheres the rest of the label to the container, seals it, and gives it to the patient.
The patient then goes to a corner of the store that has another two-way audio/video system to receive counseling from the pharmacist on how to use the medication, possible side effects, and what to do if he or she misses a dose. All the while, a security camera is monitoring the pharmacy area and sending images back to Fargo.
Karlstad is one of 13 communities in rural Minnesota where this type of telepharmacy is in use, according to Cody Wiberg, Pharm.D., executive director of the Minnesota Board of Pharmacy. “These are towns that can’t support a traditional pharmacy,” he says.
A Familiar Story
The fact that the average age of pharmacists in rural Minnesota is over 50 and that many, like Stusynski’s former boss, are looking to retire is only part of the reason why telepharmacy is catching on. “It’s really a combination of factors,” Wiberg says.
For one thing, finding pharmacists to practice in or buy stores in rural communities has become as challenging as finding physicians to work in rural clinics. During the mid 2000s, Minnesota saw a significant shortage of pharmacists—a situation that is starting to change, according to Wiberg. “Salaries tripled between 1999 and 2009,” he says. (According to the Minnesota Department of Employment and Economic Development, the mean salary for pharmacists in the state is more than $114,000.) To compete, pharmacies often had to offer signing bonuses. The ones that could do that were usually the larger chains with stores in metropolitan areas. “With the sort of salaries pharmacists coming out of school could make working for a chain and with the debt they’re in—my oldest daughter graduated five years ago with $110,000 in school loans—there are a lot fewer young pharmacists who are willing to take a risk and buy a pharmacy in a town with 1,500 people,” Wiberg says.
The other issue that discourages pharmacists from going into rural practice is reimbursement. “Gross margins have gone from 20 percent to 10 percent for prescriptions,” he explains. Wiberg served as the state’s Medicaid pharmacy program administrator from 1999 to 2005. He recalls reimbursement for pharmaceuticals being cut as part of a 2003 budget-balancing deal. Reimbursement had been based on the average wholesale price (AWP) of a drug minus 9 percent plus a $3.65 dispensing fee. (Private insurers were paying AWP minus 13.5 percent plus a $2.50 dispensing fee at the time.) The state now pays AWP minus 15 percent plus the same dispensing fee. This year, however, lawmakers did vote to increase the dispensing fee by $1 for rural independent pharmacies—the first increase in reimbursement in more than a decade.
Consequently, “there’s a real squeeze between expenses and reimbursements,” Wiberg says. “The cost of drugs is going up and reimbursement is going down. In 1985, when I graduated from pharmacy school, you had to fill 70 to 75 prescriptions a day to make a profit. Now you have to fill a couple hundred to make a profit.”
Adding Up the Cost
- One in three Americans never fill their prescriptions.
- Three out of four do not always take their meds as directed.
- More than one-third of medication-related hospital admissions are related to poor adherence.
- The costs associated with not taking medications as prescribed is $300 billion in the United States.
Souce: National Consumers League © Theo Malings - Fotolia.com October
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And that’s where telepharmacy can make a difference, as the cost of running a remote site is lower than the cost of running a traditional pharmacy. According to Tim Weippert, executive vice president of pharmacy for Thrifty White, telepharmacy equipment costs between $15,000 and $20,000.
Researchers have found that concern about whether care delivered via telepharmacy is as good as that provided by traditional community pharmacies is unfounded. A 45-month study by researchers at North Dakota State University found that the error rate in remote telepharmacies is slightly more than 1 percent, which is about the same as the rate in practices with a pharmacist on site. “It shows telepharmacy is as safe as traditional pharmacy,” says Ann Rathke, telepharmacy coordinator for North Dakota State’s College of Pharmacy, Nursing, and Allied Sciences and one of the authors of the study.
Since Stusynski began working at the telepharmacy in Karlstad, she has seen instances where errors have been prevented. “The checks and balances are stringent in Minnesota, and the quality assurance system we have in Fargo is so good that they’re more likely to catch problems before prescriptions go out the door,” she says.
This has proved to be an added bonus for the residents of Karlstad, who were concerned about losing their pharmacy not that long ago. “It’s hard to find pharmacists to come to real rural areas unless there’s a lake for them to fish on, and we don’t have one,” Stusynski says. “So this has been awesome for us.”
America’s Other Drug Problem
A new campaign launched by the National Consumers League aims to get patients with chronic health problems to do what doctors often can’t: take their medications. Called Script Your Future, the three-year U.S. Agency for Healthcare Research and Quality-funded effort is raising awareness about the importance of taking prescribed medicines, particularly for patients with diabetes, respiratory disease, and cardiovascular disease. It’s also providing tools for patients. One is a service that will send a text message reminding patients to take their medicine.
Information about the campaign is online at www.scriptyourfuture.org.