When King’s assassination sparked riots in Chicago in 1968, the white-owned pharmacies in the area were ransacked. Muldrow’s father went to check on the pharmacy only to be told by the Vice Lords he had nothing to worry about.

“‘Go home,’” Muldrow said they told his father. “‘We’re not gonna let anybody touch you.’”

For nearly 60 years, the small drugstore has survived by building deep roots in the community, selling medicine, food and electronics in a neighborhood largely ignored by the large drugstore chains. Del-Kar is bucking a trend that has undermined numerous other pharmacies in Chicago and other U.S. cities. Although chain pharmacies are pulling out of many urban areas, sometimes , Muldrow isn’t quitting.

“Once you respect the community, the neighborhood looks out for you,” said Muldrow, 51, who started working as a pharmacist at Del-Kar in 1992. “They know that you’re here and you’re doing something positive.”

Like other community pharmacists nationwide, Muldrow has seen private insurers steer his customers toward their own allied chain, mail-order and specialty pharmacies. Urban independent pharmacies, particularly those in low-income Black and Latino communities, have been than chain drugstores.

And pharmacies of all kinds in these communities, chain and independent, face a tough economic situation: They often have a disproportionately high share of customers enrolled in Medicaid or Medicare, which pay lower rates than private insurance.

“There’s really no financial incentive for pharmacies to open and stay open in minority neighborhoods,” said , a University of Southern California pharmacy professor.

According to a she worked on, Black and Latino neighborhoods accounted for a third of pharmacy openings in Chicago from 2015 to 2020 but more than half of closures. As a result, the prevalence of pharmacy deserts increased from 33% of majority-Black census tracts to 45% and from 9% of majority-Latino tracts to 14%.

“Pharmacies are choosing to open in areas that already have pharmacies, in part because those are also the areas that have higher incomes and insurances that provide higher pharmacy reimbursement rates,” said , a University of Southern California health disparities researcher who led the study.

Muldrow said insurance often pays less for a medication than it costs him to acquire it. For example, he might be reimbursed $400 for an Advair inhaler that costs him $600.

“The profession is not what it used to be,” he said. “The profitability has been snatched.”

Average dispensing fees, set by insurance plans and intended to cover Muldrow’s overhead and salary, have plummeted from about $3 per prescription 30 years ago to as little as 10 cents, he said. He once sold medical supplies like lift chairs and oxygen tanks. But since Medicare implemented new fraud safeguards requiring accreditation, he said, he would have to pay $1,500 to $2,000 a year to continue receiving Medicare reimbursement.

“Now you have elderly people in the neighborhood that can’t come and get stuff,” Muldrow said. “They have to go to the hospital. They got to go through the mail.”

Muldrow keeps his store open by supplementing the meager payments he gets for filling prescriptions with other income. “The secret to our success here is that we own the property,” Muldrow said. “If I was paying $3,000, $4,000 or more a month rent, I would have been wiped out.”

Muldrow had job offers from multiple chain drugstores when he graduated from pharmacy school but chose to work for his father. “‘The only way I can repay you for giving me the opportunity to go to school is to come down here and work and continue what you started,’” he recalled telling him.

Chicago has encouraged pharmacies to locate in underserved areas — with little success. Qato pointed to a CVS branch that in 2010 received to open in East Garfield Park. A nearby independent drugstore quickly closed, and the CVS shut its doors several years later, creating a pharmacy desert.

Illinois launched in 2019 to subsidize pharmacies in underserved urban and rural areas. But, Qato said, the program doesn’t adequately target neighborhoods at risk of becoming pharmacy deserts and excludes large chain pharmacies, which may be the only drugstores remaining in a neighborhood.

A year into the program, she said, only three of 80 eligible pharmacies in Chicago have received funds. Muldrow said he hadn’t heard of the program.

Some business strategies create de facto deserts. Late last year, the health insurer Aetna, owned by CVS Health, began preventing its Medicaid patients in Illinois from filling prescriptions at Walgreens pharmacies. As a result, some patients could no longer use the closest drugstore.

Dr. Thomas Huggett, a family physician at the Lawndale Christian Health Center on the West Side of Chicago, said some of his patients had trouble getting their medications in the first month of the new policy. One patient, who was homeless and had been diagnosed with severe mental illness, couldn’t get his prescription filled. Another had to take two buses to get his injectable antipsychotic medication. A third patient couldn’t get Suboxone, a treatment for opioid addiction.

“In the middle of one of the hotter spots in the country for opioid overdoses on the West Side of Chicago, it’s hard to imagine how anybody could justify it,” Huggett said.

In urban areas, Illinois regulations require prescription insurance plans to have at least one in-network pharmacy within a 15-mile radius or a 15-minute drive of their enrollees. But that can be too far to be practical for many customers, Huggett said.

“The majority of patients who have Medicaid have Medicaid because they are poor, and they generally don’t have cars,” Huggett said. “Looking at the maps, it is just so stark to see. The CVSs are intentionally avoiding black areas of Chicago.”

CVS spokesperson Mike DeAngelis said that about half of CVS stores nationwide are in areas that rank high on the Centers for Disease Control and Prevention’s , which tracks poverty, lack of vehicle access and crowded housing, among other factors.

“Maintaining access to pharmacy services in underserved communities is an important factor we consider when making store closure decisions,” DeAngelis said in an email. “Other factors include local market dynamics, population shifts, a community’s store density, and ensuring there are other geographic access points to meet the needs of the community.”

James Spidle, a 66-year-old veteran with serious heart problems, walks a mile using a cane to catch a bus in the Washington Heights neighborhood, about 13 miles south of Del-Kar, to pick up his prescriptions from a Walmart.

“I do the walk back and forth as a stress test,” he said. “If I don’t have any chest pains, I keep going.”

A closer option, a Walgreens, closed in 2016. A sign on the door directed customers to another branch that was a mile away in a more affluent neighborhood and had a grocery store pharmacy across the street.

, the community development arm of Trinity United Church of Christ, has tried to fill the gap, using church vans to drive people to the nearest pharmacies. Melvin Thompson, its executive director, listed four other chain pharmacies that had closed within a three-mile radius of the Walgreens that shuttered in Washington Heights.

“Here we are in the midst of a pandemic, and we’re losing even more of these vital services in communities that can’t afford to lose,” he said. “It’s citywide, but it just seems to be relegated to Black and brown communities.”

Walgreens officials did not answer questions about how the company decides to close stores, but said that in metro Chicago about 99% of Chicagoans live within 2 miles of one of their stores. Walgreens spokesperson Kris Lathan said the company allocated $35 million to reopen 80 stores in Chicago damaged during the civil unrest after the murder of George Floyd in 2020.

“All but two of those locations have reopened,” she said. “The remaining two will open in the first half of 2022.”

Democratic state Rep. said pharmacy closures represent a loss of health care access for the community. “The pharmacy is not just a place to pick up medicine, it’s a surrounding of health care,” he said. “Who’s going to talk to that person when they get their medicine mail-delivered?”

It can also be a lifeline in other ways. During the pandemic, when indoor dining was shut down, Muldrow set up an outdoor grill and served burgers, tacos and other food. That showed him how much the neighborhood needed him — and for a lot more than medications. He is planning an expansion, to include a bodega with a juice bar and restaurant.

Muldrow was also reminded that the community is there for him in return. Last year, during the civil unrest, several businesses near Del-Kar were destroyed. But, in an echo of 1968, his shop emerged unscathed.

“I didn’t have any worries. I slept real good,” Muldrow said. “The brothers over here on Lawndale, they watched over me. If you know the people, the people look out for you.”

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So when pharmacy chains and big-box stores began expanding into rural markets, he sold his drugstore in 2007 to Pamida, a grocery chain owned by the Shopko department store company, hoping that would keep his practice alive. Then, in 2019, when Shopko declared bankruptcy, shuttering more than 360 stores, he and another Shopko pharmacist helped open a new drugstore for the city of about 2,000 people.

Across the country, pharmacists like Mather are filling the voids left when large drugstore chains and big-box stores with pharmacies pull out of small communities. In some areas, pharmacists who were let go when big chains closed are now opening new drugstores, often in the same locations. In other areas, pharmacy owners from neighboring towns are opening new branches. Without them, numerous communities would have been left with no pharmacy.

It didn’t used to be this way. Big-box stores like Shopko started to move aggressively into the pharmacy market 30 years ago, hoping customers would fill their carts while the store filled their prescriptions. Large chains established beachheads in small towns by acquiring independent pharmacies or driving them out of business.

According to the Bureau of Labor Statistics, the number of pharmacists employed at big-box stores peaked at more than 31,800 in 2012. But as online sales and mail delivery of consumer goods and prescription drugs grew, the big-box stores had no reason to stay. By 2019, the number of big-box pharmacists had dropped to fewer than 18,000. (The bureau no longer reports the number.)

“The big-box stores came into smaller and smaller communities, and they, in essence, outcompeted all the other pharmacies in the area,” said , a pharmacy professor at Northeastern University in Boston. “Now they’re completely gone and with them the pharmacy services and everything else they provided. They left a vacuum in a lot of these places.”

With CVS Health’s recent that it will close 300 stores a year over the next three years, more towns could lose another tier of pharmacies: the big drugstore chains. CVS has not yet said which stores will close.

“We’re considering a number of factors when making these decisions, including local market dynamics, population shifts, store density, and the needs of underserved communities,” said Mike DeAngelis, a CVS Health spokesperson. “In fact, reaching underserved populations has been a priority for us all through the pandemic, such as the access to testing and vaccines we’ve provided.”

Kathleen Bashur, a spokesperson for the , said chain pharmacies of all types and sizes play a significant role in meeting the health and wellness needs of communities throughout the nation. “The decision to close a store is a difficult one,” she said.

Zgarrick attributes much of the decline in big-box pharmacies to Amazon and other online merchants that undercut the profitability of their non-pharmacy sales. In the past, big-box stores could treat pharmacies as loss leaders and make up that revenue with sales of other goods. Now, Zgarrick said, big-box stores have to ask tough questions about how to allocate their space: “‘At the end of the day, how are we going to make the most money per square foot? Is it by having a pharmacy or by selling tires?’”

, a University of California-Santa Barbara history professor who has the rise of Walmart, said big-box stores are constantly reevaluating their store locations, closing less profitable stores and opening new ones in places where they think they can make money.

“They just keep a kind of slow churn,” he said.

The cost of building a big-box store is about $10 million, Lichtenstein said, and such stores can net $200 million in annual revenue. Pulling out of a location is therefore not a huge loss for a big company if revenues falter.

“So they will shut down the stores and leave a devastated town because the Walmart put the other guys out of business,” he said.

Walmart did not answer questions about its closures.

The growth in online options for all kinds of items, spurred by people shopping from home during the covid-19 pandemic, has put further pressure on big-box stores.

“Now they’re less likely to do that roaming shopping than they were five years ago,” said Adam Hartung, a business strategy consultant with . “They’re not going to say, ‘Oh, let’s pick up a prescription and, while we’re at it, let’s walk through the store and look at vacuum cleaners.’ That doesn’t happen anymore.”

Hartung said that the U.S. retail market has an excess of shops, by as much as 40% compared with other countries, and that more big-box stores are likely to close in the coming years.

But closures provide opportunities for regional chains or pharmacists willing to strike out on their own.

In Orofino, Idaho, the mayor, the chamber of commerce and many residents appealed to pharmacist Rod Arnzen after Shopko pulled out. So Arnzen began delivering to Orofino from his store 23 miles away in Kamiah. He then opened a branch in Orofino in the building left behind by the pharmacy that had previously sold its business to Shopko.

Andy Pottenger, who owns a pharmacy 45 miles away in Lewiston, Idaho, added a second pharmacy in Orofino, population about 3,000, after receiving hundreds of responses to an ad he had placed in the local paper to gauge interest.

“It was overwhelming,” he said. “That kind of cemented the idea that we should do it.”

In Montana, Mike Matovich, a third-generation pharmacist, opened stores in Roundup and Hardin after Shopko closures there.

“It’s a pretty good-sized community and has a hospital and clinic in town,” Matovich said of Roundup, “and all of a sudden people are driving 50 miles one way to fill an antibiotic for a sick child.”

Matovich has seen what can happen when a rural community loses its only pharmacy.

“If there’s a hospital clinic and a pharmacy there, they’re going to do fairly well,” Matovich said. “Once you lose one or the other, the communities start to struggle because people start leaving to be closer to health care.”

For the residents of Greenfield, Iowa, Shopko’s decision meant they had to scramble. Shopko had sold the pharmacy records to a Walgreens 50 miles away. Some people turned to the Hy-Vee grocery stores in the nearby Iowa cities of Atlantic or Winterset, or to the Walmart in Creston — each at least a half-hour drive away. Others switched to mail order.

“It was sheer chaos,” former Shopko pharmacist Rachel Hall said. “People were trying to figure out what to do, where they should send their prescriptions.”

Mather, Hall and the rest of the Greenfield staff were given just one week’s notice after being told they had nothing to worry about. Their pharmacy had been among the chain’s fastest-growing locations.

“We literally had trophies from Shopko that we threw away when we left,” Hall said.

Former Shopko executives contacted by KHN declined interview requests. Shopko Optical, which operates in 11 states, said it is no longer affiliated in any way with Shopko Stores and declined to comment.

Mather and Hall didn’t want to give up on Greenfield. They reached out to NuCara, a chain with 30 retail pharmacies across five states, and it agreed to help them open a drugstore in their city.

NuCara opened pharmacies in two other communities that Shopko vacated. In the Minnesota cities of Cokato and North Branch, NuCara partnered with pharmacists who had previously sold their pharmacies to Shopko, said Brett Barker, vice president of pharmacies for NuCara.

In Greenfield, Hall and Mather were forbidden from telling customers about the new NuCara drugstore until Shopko officially closed its doors. Hall said Shopko management wanted to maintain the value of the customer files it was selling to Walgreens. So Hall and Mather asked the local chamber of commerce to get the word out.

They found temporary space at the local hospital, which relocated its billing office to accommodate them. A year later, they moved back into their former location in the old Shopko building, leasing the space from new owners, who were running a household goods store there.

After serving three generations of Greenfield customers, Mather was relieved the town still had a pharmacy. But he couldn’t get past how Shopko had ended things.

“The way they slammed the door, I was really unhappy about that,” Mather said. “It wasn’t fair to all the people at the Greenfield pharmacy and the people of Greenfield. Shopko couldn’t have cared less.”

Yet the move brought Mather full circle. Greenfield still has a pharmacy, just as when he started at Murdy Drug in 1968. It’s just a different storefront, with a new name on the sign.

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When Billinger died of a heart attack in 2019 at age 71, he was still running Teddy B’s, the pharmacy his father had started more than 65 years earlier in Cheyenne Wells, Colorado. With no other pharmacist to work at the store, prescriptions already counted out and sealed in bottles were suddenly locked away in a pharmacy that no one could enter. And Cheyenne Wells’ fewer than 800 residents were abruptly left without a drugstore.

Pharmacies were once routinely bequeathed from one generation to the next, but, in interviews with more than a dozen pharmacists, many said the pressure of running an independent drugstore have them pushing their offspring toward other careers. And when they search for a buyer, they often find that attracting new pharmacists, especially to rural settings, is difficult. With a large group of pharmacists nearing retirement age, more communities may lose their only drugstore.

“It’s going to be harder to attract people and to pay them,” said , a professor emeritus at the University of Wisconsin-Madison School of Pharmacy. “If there’s not a generational thing where someone can sit down with their son or daughter and say that they could take the store over, there’s a good chance that pharmacy will evaporate.”

Tom Davis, Billinger’s friend and co-owner of Kiowa Drug in Eads, Colorado, stepped in to sort out the mess in Cheyenne Wells. With permission from the State Board of Pharmacy, the county sheriff let Davis into Teddy B’s in the eastern Colorado town to take an inventory of the remaining drugs. Customers who had dropped off their prescriptions before Billinger died were able to pick up their medications.

Davis then bought the pharmacy from Billinger’s estate. He runs it as a convenience store and six days a week delivers prescriptions to it from Eads, 44 miles away.

“By the time you paid a pharmacist, the location there was borderline unprofitable,” Davis said.

He has received numerous requests to open pharmacies in other eastern Colorado towns, but making that work financially would be difficult. Reimbursements from insurance plans have dwindled, and customer bases have eroded as health insurers push patients toward mail-order deliveries.

“I fill prescriptions every day where my reimbursement is less than the cost of the drug,” Davis said. “In other settings, you might tell a patient, ‘We don’t have that in stock,’ or ‘Why don’t you go down the street to the chain?’ But down here, we just take care of our patients, and we just eat it.”

He can survive, he said, because, after 48 years, he no longer has any business debt.

“I look at my bottom line,” Davis said. “With the amount of profit that I had at the end of the year, that would not have been enough if I was having to pay a mortgage.”

have found the number of pharmacists nationally to be sufficient, even more than enough, to meet current needs, although supply and demand don’t always line up. Finding pharmacists is more difficult in rural areas.

“Once they get a taste of the big city,” Kreling said, “it’s hard to get them back to the farm.”

Workforce data also shows worrisome trends. Concerns about a shortage of pharmacists led the federal government to pour money into pharmacy schools in the 1970s, creating a temporary bump in the number of graduates. The people in that bulge in the pharmacist pipeline have hit retirement age.

“Many of them owned independent pharmacies, and they were working in rural communities,” said University of Minnesota pharmacy professor , who studies workforce issues.

Now, as the demand for pharmacists to provide testing and vaccinations during the covid-19 pandemic increases, drugstore chains are offering incentives — such as large salaries, signing bonuses and help paying off school loans — that are often more enticing than anything a rural pharmacy could muster.

How pharmacy graduates envision their careers has also shifted. Many no longer want to own a pharmacy and are content to work at pharmacy chains or other health care organizations, according to several pharmacy school professors. As of 2018, only about worked in traditional retail drugstores.

That makes rural recruitment more difficult.

Denise Robins had worked at R&R Family Pharmacy in Springfield, Colorado, for 18 years when the owner retired. She and three family members bought the drugstore in a last-ditch effort to keep it open.

“None of us are pharmacists, so that made it a little tougher,” Robins said. “We just knew it was really going to make it hard for people here if they had to travel an hour to get to a pharmacy.”

But finding a pharmacist to work in the southeastern Colorado town of fewer than 1,400 people was a challenge. The first pharmacist Robins found commuted 48 miles one way from Lamar. But after a year and a half, the trip became too much.

She then hired someone who wanted to work for only a year, to make enough money to travel. Then Robins interviewed two University of Colorado pharmacy school graduates. She hired one, but that didn’t work out. So she called back the second candidate, who still had not found a permanent job. He had two young kids, and he and his wife were working opposite schedules. He took the job two years ago and has remained there since.

I fill prescriptions every day where my reimbursement is less than the cost of the drug.

Tom Davis

In Berryville, Virginia, pharmacist Patricia White opened Battletown Pharmacy in 2011 because she wanted to carry on the family business. Her father had owned a local pharmacy and had recently died. But when turning a profit with Battletown proved a struggle, White decided to retire.

She lined up two potential buyers, but neither went through with the sale. She then hoped to transfer the pharmacy to a recent graduate but didn’t want to saddle him with a failing business.

“I told him he couldn’t make any money, and he said, ‘Thanks for being honest,’” White recalled.

Closing seemed like the only palatable option. Battletown shut down at the end of August. “I did not want to sell out to a chain,” she said. “That’s always been my mentality.”

When a chain buys a pharmacy, it doesn’t always decide to run it. Instead, it might close the pharmacy and transfer the pharmacy’s prescription files to one of its outlets. Retiring pharmacists who spent decades serving a community generally don’t want to see that happen, said , a Northeastern University pharmacy professor.

“They’d like to sell their pharmacy to another pharmacist who would continue to run it very much in the same manner,” he said.

Some plan ahead, hiring another pharmacist and offering that person an equity stake in the business. Over time, the new pharmacist can buy out the owner. Many independent pharmacist-owners plan to live off the profits from selling their pharmacy, its inventory and its prescription records.

“Their pharmacy is their retirement savings,” Zgarrick said.

But, Zgarrick said, the added pressure from the pandemic may be pushing more pharmacists into retirement. And a long-running bull stock market may mean some pharmacists have enough in their retirement portfolios to call it quits without a sale.

In Eads, Davis, 70, still loves being a pharmacist. He and his brother co-own seven pharmacies and have started to plan for retirement by hiring five young pharmacists and allowing them to buy ownership stakes in those pharmacies over time.

He had wondered how long he could keep the Kiowa pharmacy running, though. With fewer than 700 residents, Eads may be the smallest town in Colorado with a pharmacy. Combining Davis’ customer base with Cheyenne Wells’ may have saved pharmacy access for both communities.

“So maybe where we could have lost two pharmacies in the area, we’ve been able to exist. We’re stronger now than we had ever been,” Davis said. “That wasn’t the original plan. We cared about those people and just wanted to take care of them.”

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Julie Perkins, farmacéutica y propietaria de Batson’s, fue a la escuela secundaria local y regresó después de graduarse para comprar la farmacia hace más de dos décadas. Perkins y su esposo también compraron la tienda aledaña en 2006 para ayudar a diversificar los ingresos y poner a la farmacia sobre una plataforma más firme.

Pero con la pandemia aumentando la presión de las grandes cadenas, que pueden operar a precios más bajos, y de los intermediarios farmacéuticos, que pueden imponer tarifas elevadas de forma retroactiva, Perkins se pregunta cuánto tiempo su negocio puede seguir siendo viable.

Le preocupa lo que les ocurrirá a sus clientes si no puede mantener la farmacia funcionando. El condado de Elk, con una población de 2,500 habitantes, no tiene hospital y cuenta con solo un par de médicos, por lo que los residentes deben viajar más de una hora, a Wichita, para cualquier cosa que no sea atención primaria.

“Por eso resisto”, dijo Perkins. “Estas personas han confiado en la tienda desde mucho antes que yo estuviera aquí”.

Las farmacias de las esquinas, que alguna vez estuvieron tanto en las grandes ciudades como en los pueblos rurales, están desapareciendo de muchas áreas del país, dejando a unos 41 millones de estadounidenses en lo que se conoce como “desiertos de farmacias”, sin fácil acceso a las farmacias.

Un , una herramienta en internet para comparar precios de medicamentos, encontró que el 12% de los estadounidenses tienen que conducir más de 15 minutos para llegar a la farmacia más cercana, o no tienen suficientes farmacias cerca para satisfacer la demanda. Eso incluye a la mayoría de personas en más del 40% de los condados.

De 2003 a 2018, , según el Rural Policy Research Institute de la Universidad de Iowa, lo que dejó a 630 comunidades sin farmacias minoristas independientes o de cadena.

Las farmacias independientes están luchando debido a la integración vertical entre las cadenas de farmacias, las compañías de seguros y los administradores de beneficios farmacéuticos, lo que les da a esas empresas un poder de mercado que las farmacias comunitarias no pueden igualar.

Las aseguradoras también han reducido lo que pagan por los medicamentos recetados, reduciendo los márgenes a niveles que los farmacéuticos consideran insostenibles.

A medida que los planes de medicamentos de las aseguradoras llevaban a los pacientes a sus farmacias afiliadas, las tiendas independientes fueron testigos de cómo sus clientes los abandonaban. Se encuentran a merced de los intermediarios farmacéuticos, que recuperan los ingresos de las farmacias a través de tarifas retroactivas y auditorías agresivas, lo que deja a los farmacéuticos locales inseguros de si terminarán el año con sus números en rojo.

Eso tiene un impacto directo en los clientes, en particular los mayores, que enfrentan copagos más altos por medicamentos recetados si tienen un plan de medicamentos y precios de lista más altos si no lo tienen. Si sus farmacias locales no pueden sobrevivir, pueden verse obligados a viajar largas distancias y enfrentar esperas para obtener sus recetas en farmacias con poco personal que atienden a más y más pacientes.

“Vivir en un área con baja densidad de farmacias podría aumentar los tiempos de espera, disminuir el suministro y dificultar la compra de medicamentos recetados”, dijo , investigadora principal de GoodRx en el estudio sobre el “desierto de farmacias”.

Las presiones financieras sobre las farmacias independientes comenzaron a aumentar hace dos décadas cuando Medicare instituyó su programa de la Parte D utilizando planes de seguro privados: los clientes más frecuentes de las farmacias pasaron de pagar en efectivo los precios de lista a utilizar coberturas de seguro que pagaban tarifas negociadas más bajas.

“Se produjo una liquidación del mercado, una gran ola de cierres de farmacias”, dijo , director del Rural Policy Research Institute.

Las farmacias independientes vieron reducirse sus márgenes. En promedio, el costo para una farmacia por dispensar una sola receta, teniendo en cuenta la mano de obra, el alquiler, los servicios públicos y otros gastos generales, oscila entre . Pero el reembolso suele ser mucho menor.

Varios farmacéuticos dijeron que aproximadamente la mitad de los reembolsos de los planes de medicamentos no cubren los costos de los medicamentos y sus gastos generales.

“Lo que te queda es el 50% de los reclamos de los que puedes ganar algo de dinero y, en realidad, un pequeño porcentaje de reclamos de los que puedes tener una suma de dinero extremadamente alta”, dijo Nate Hux, propietario de una farmacia independiente en Pickerington, Ohio.

Es esa pequeña porción de medicamentos por los que se paga demasiado, especialmente los genéricos, lo que determina si una farmacia puede sobrevivir. Un plan de medicamentos puede reembolsar por una droga genérica que cuesta $4… unos $4,000.

“Surtir una receta genérica, desde un punto de vista financiero, es como tirar de las máquinas tragamonedas en un casino”, dijo Ben Jolley, farmacéutico independiente en Salt Lake City, Utah. “A veces pierdes una moneda de 25 centavos, a veces pierdes un dólar y, a veces, ganas $500. Pero debes tener esas recetas con las que ganas $500 para compensar las pérdidas que generan el resto de tus medicamentos”.

Algunas farmacias aumentan sus precios de lista para asegurarse de obtener los reembolsos más altos que los planes de medicamentos están dispuestos a pagar. Pero eso eleva los precios para los pacientes que pagan en efectivo.

Jolley, quien también trabaja como consultor para farmacias a lo largo del país, dijo que algunos farmacéuticos juegan con el sistema facturando cargos excesivos por los medicamentos que mezclan en el lugar o llamando a los médicos para que receten a sus pacientes medicamentos más rentables.

“Las farmacias que juegan a este juego se vuelven excepcionalmente ricas”, dijo. “La mayoría de las farmacias no se sienten cómodas con este juego o no son conscientes de que así es como funciona el sistema, por lo que se quedan rezagadas. Por eso ves que cierran todas estas farmacias”.

Los administradores de beneficios de farmacia, corredores conocidos como PBM, también alejan a los clientes de las farmacias independientes hacia las cadenas afiliadas, las farmacias de pedidos por correo o especializadas, con gastos de bolsillo más bajos. Algunos PBM impiden que las farmacias locales ofrezcan los medicamentos más costosos.

Los administradores de beneficios responden que hay más farmacias independientes hoy que hace 10 años. Un análisis realizado en nombre de la , un grupo comercial que representa a estos administradores, mostró un aumento del 13% en el número de farmacias independientes de 2010 a 2019. Sin embargo, muchas abrieron en comunidades que ya tenían farmacias.

“Los PBM no buscan sacar del negocio a las farmacias independientes”, dijo Greg Lopes, vocero del grupo comercial. “Los PBM están intentando y a menudo tienen éxito en reducir los costos de los medicamentos”.

El grupo comercial de las aseguradoras, , anteriormente America’s Health Insurance Plans, declinó hacer comentarios.

Katie Koziara, vocera de , un grupo industrial que representa a las farmacéuticas, dijo que el gran poder de mercado de los PBM puede dejar a los pacientes con menos opciones.

“El sistema podría funcionar bien para los planes de salud y estos intermediarios, pero crea barreras de acceso para los pacientes vulnerables”, dijo Koziara. “Nos preocupa el problema emergente de los ‘desiertos de farmacias’ donde los pacientes, particularmente entre las comunidades de color, no pueden acceder fácilmente a una farmacia comunitaria para obtener sus medicamentos”.

Los farmacéuticos independientes identifican habitualmente a las empresas de nivel medio como la principal causa de sus problemas. En la farmacia de Batson, en la zona rural de Kansas, Perkins tuvo recientemente un cliente que había estado tomando Emgality, un tratamiento de anticuerpos monoclonales inyectables para las migrañas fabricado por Eli Lilly and Co., que cuesta hasta $760 al mes. Pero el plan de medicamentos de la clienta no le pagó a Batson para surtirlo, lo que la obligó a esperar hasta que pudo enviarlo por correo desde una farmacia especializada.

Perkins dijo que es frustrante, pero muchos de sus clientes que reciben medicamentos por correo se los llevan a ella para que les expliquen cómo tomarlos.

Incluso cuando las farmacias ganan dinero con una receta, no hay garantía de que puedan quedarse con gran parte de las ganancias. Los planes de medicamentos cobran tarifas a las farmacias cada vez que necesitan interactuar con la base de datos de reclamos de PBM. Si bien esas tarifas son de solo 10 a 15 centavos por transacción, una farmacia ocupada puede necesitar verificar la base de datos cientos de veces al día.

Los PBM también han implementado tarifas retroactivas basadas en las métricas de desempeño que establecieron. Las farmacias pueden terminar perdiendo dinero con una receta surtida meses antes. Los PBM los describen como medidas de calidad, pero los farmacéuticos se quejan de que tienen más que ver con el volumen de ventas. Muchas de las métricas rastrean cómo los pacientes toman sus medicamentos, lo que las farmacias difícilmente pueden controlar.

Un contrato de PBM, , mostró que solo el 1% de las farmacias pueden evitar tarifas retroactivas.

Jeff Olson, propietario de en Iowa, dijo que pagó $52,000 en tarifas retroactivas sobre ingresos de $6 millones en 2015. Si bien sus ingresos anuales se mantuvieron estables hasta 2020, esas tarifas retroactivas el año pasado totalizaron $225,000.

“Ese es dinero que no se puede usar para la nómina, que no se puede usar para agregar esos otros servicios que su comunidad necesita”, agregó Olson.

Además, dijo Olson, no sabe qué métricas usan los planes de seguro para evaluar su desempeño y calcular las tarifas.

“Ellos mismos definen la calidad”, dijo , vicepresidenta de asuntos farmacéuticos de la Asociación Nacional de Farmacéuticos de la Comunidad. “Si tienes contratos con 20 planes de la Parte D, son 20 programas de calidad diferentes que se supone que debes conocer y seguir”.

Según los Centros de Servicios de Medicare y Medicaid (CMS), estas tarifas retroactivas fueron . Los precios más altos resultantes significan que los beneficiarios de Medicare agotan su período de cobertura inicial más rápido y entran en una brecha de cobertura antes.

En la farmacia de Olson, en St. Charles, Iowa, una ciudad de menos de 1,000 habitantes, las tarifas y otras presiones financieras obligaron a Olson a reducir la escala y operar la tienda como una telefarmacia. Los técnicos surten recetas bajo la supervisión de un farmacéutico externo y los clientes ven a un farmacéutico solo un día a la semana.

Para una ciudad sin otro proveedor de atención médica, eso significa seis días en los que nadie puede proporcionar vacunas o realizar pruebas, por ejemplo, para la faringitis estreptocócica.

De vuelta en Howard, a Debbie Lane, de 70 años, le gusta el servicio personal que Perkins ofrece en Batson’s.

“Es mucho más fácil ir a una tienda local, y si llegamos después del horario de atención o por una emergencia, ella nos abrirá”, dijo Lane.

Perkins le dirá a Lane si puede ahorrar dinero conduciendo hasta una cadena de farmacias en Wichita. Y, recientemente, Perkins la ayudó a decidir qué plan de Medicare sería el menos costoso por los medicamentos que toma. Lane sabe que es difícil mantener abierta una farmacia de un pueblo pequeño y le preocupa lo que podría pasar si Batson cerrara.

“Sería devastador”, dijo Lane. “Hay muchos como yo, que a veces pagamos un poco más para asegurarnos de que Julie se mantenga en el negocio”.

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Julie Perkins, pharmacist and owner of Batson’s, graduated from the local high school and returned after pharmacy school to buy the drugstore more than two decades ago. She and her husband bought the grocery store next door in 2006 to help diversify revenue and put the pharmacy on firmer footing.

But with the pandemic exacerbating the competitive pressures from large retail chains, which can operate at lower prices, and from pharmaceutical intermediaries, which can impose high fees retroactively, Perkins wonders how long her business can remain viable.

She worries about what will happen to her customers if she can’t keep the pharmacy running. Elk County, with a population of 2,500, has no hospital and only a couple of doctors, so residents must travel more than an hour to Wichita for anything beyond primary care.

“That’s why I hang on,” Perkins said. “These people have relied on the store from way before I was even here.”

Corner pharmacies, once widespread in large cities and rural hamlets alike, are disappearing from many areas of the country, leaving an estimated 41 million Americans in what are known as drugstore deserts, without easy access to pharmacies. An by GoodRx, an online drug price comparison tool, found that 12% of Americans have to drive more than 15 minutes to reach the closest pharmacy or don’t have enough pharmacies nearby to meet demand. That includes majorities of people in more than 40% of counties.

From 2003 to 2018, , according to the University of Iowa’s , leaving 630 communities with no independent or chain retail drugstore.

Independent pharmacies are struggling due to the vertical integration among drugstore chains, insurance companies and pharmaceutical benefit managers, which gives those companies market power that community drugstores can’t match.

Insurers also have ratcheted down what they will pay for prescription drugs, squeezing margins to levels that pharmacists call unsustainable. As the insurers’ drug plans steered patients to their affiliated drugstores, independent shops watched their customers drift away. They find themselves at the mercy of pharmaceutical intermediaries, which claw back pharmacy revenue through retroactive fees and aggressive audits, leaving local pharmacists unsure if they’ll end the year in the black.

That has a direct impact on customers, particularly older ones, who face higher copays for prescription medications if they have a drug plan, and higher list prices if they don’t. If their local pharmacy can’t survive, they may be forced to travel long distances to the nearest drugstore or endure waits to get their prescriptions from understaffed pharmacies serving more and more patients.

“Living in an area with low pharmacy density could increase wait times, decrease supply, and make it harder to shop around for prescription medications,” said , GoodRx’s lead researcher on the drugstore desert study.

The financial pressures on independent drugstores began mounting two decades ago when Medicare instituted its Part D program using private insurance plans: Pharmacies’ most frequent customers went from paying cash for list prices to using insurance coverage that paid lower negotiated rates.

“A market clearance occurred, a big bolus of pharmacy closures,” said , director of the Rural Policy Research Institute.

Independent pharmacies saw their margins shrink. On average, a pharmacy’s cost of dispensing a single prescription, factoring in labor, rent, utilities and other overhead, ranges from . But the reimbursement is often far less.

Multiple pharmacists said that about half of drug plan reimbursements fail to cover the costs of drugs and their overhead.

“What you’re left with is that 50% of claims that you can make some money on, and really, the tiny percentage of claims where you make an extremely high amount of money,” said Nate Hux, who owns an independent pharmacy in Pickerington, Ohio.

It’s that tiny sliver of wildly overpaid drugs, especially generics, that determines whether a pharmacy can survive. A generic drug that costs $4 might get reimbursed by a drug plan at $4,000.

“Filling a generic prescription, from a financial standpoint, is like pulling the slots at a casino,” said Ben Jolley, an independent pharmacist in Salt Lake City. “Sometimes you lose a quarter, sometimes you lose a buck, and sometimes you make $500. But you have to have those prescriptions that you make $500 on to make up for the losses on the rest of your meds.”

Some pharmacies increase their list prices to ensure they capture the highest reimbursements that drug plans are willing to pay. But that raises prices for patients paying cash.

Jolley, who also works as a consultant for pharmacies across the country, said some pharmacists game the system by billing excessive charges for drugs they mix on-site or calling physicians to switch patients to more profitable drugs.

“Pharmacies that play this game get exceptionally wealthy,” he said. “Most pharmacies either don’t feel comfortable playing this game or aren’t aware that that’s how the system works, so they get left behind. That’s why you see all these pharmacies closing.”

Pharmacy benefit managers, brokers known as PBMs, also steer customers away from independent pharmacies to affiliated chain, mail-order or specialty pharmacies with lower out-of-pockets costs. Some PBMs prevent local pharmacies from offering the most expensive drugs at all.

The benefit managers counter that there are more independent pharmacies today than there were 10 years ago. An analysis conducted on behalf of the , a trade group that represents pharmacy benefit managers, showed a 13% increase in the number of independently owned pharmacies from 2010 to 2019. However, many of those new stores opened in communities that already had pharmacies.

“PBMs are not seeking to put independent pharmacies out of business,” said Greg Lopes, a spokesperson for the trade group. “PBMs are trying and often succeeding in lowering drug costs.”

The insurers’ trade group, , formerly America’s Health Insurance Plans, declined to comment.

Katie Koziara, a spokesperson for the , an industry group representing drugmakers, said the large market power of PBMs can leave patients with fewer choices.

“The system might work well for health plans and these middlemen, but it creates difficult access barriers for vulnerable patients,” Koziara said. “We’re concerned about the emerging issue of ‘pharmacy deserts’ where patients, particularly among communities of color, cannot readily access a community pharmacy for their medications.”

Independent pharmacists routinely identify those middle-manager companies as the leading cause of their troubles. At Batson’s drugstore in rural Kansas, Perkins recently had a customer who had been taking Emgality, an injectable monoclonal antibody treatment for migraines made by Eli Lilly and Co., that typically retails for up to $760 a month. But the customer’s drug plan wouldn’t pay Batson’s to fill it, forcing her to wait until it could be mailed from a specialty pharmacy.

Frustratingly, Perkins said, patients who get pushed to order drugs by mail often bring them to her when they need help deciphering how to use them.

Even when pharmacies make money on a prescription, there’s no guarantee they can keep much of the profit. Drug plans charge pharmacies fees every time they need to interact with the PBM’s claims database. While those fees average only 10 to 15 cents per transaction, a busy pharmacy might need to check the database hundreds of times a day.

PBMs also have implemented retroactive fees based on performance metrics they set. Pharmacies can wind up losing money on a prescription filled months earlier. PBMs describe these as quality measures, but pharmacists complain they are more about sales volume. Many of the metrics track how diligently patients take their medication, which pharmacies can hardly control.

One PBM’s contract, , showed only 1% of pharmacies are able to avoid retroactive fees.

Jeff Olson, who owns in Iowa, said he paid $52,000 in retroactive fees on revenue of $6 million in 2015. While his annual revenue remained flat through 2020, those retroactive fees last year totaled $225,000.

“That’s money that can’t be used for payroll, that can’t be used to add those other services that your community needs,” Olson said.

Moreover, Olson said, he doesn’t know what metrics insurance plans use to evaluate his performance and calculate the fees.

“They define quality themselves,” said , vice president of pharmacy affairs for the National Community Pharmacists Association. “If you have 20 Part D plans you contract with, that’s 20 different quality programs that you’re supposed to be aware of and keep up with.”

According to the Centers for Medicare and Medicaid Services, such retroactive fees were as in 2010. The resulting higher prices mean Medicare beneficiaries burn through their initial coverage period faster and enter a coverage gap, or “doughnut hole,” sooner.

At Olson’s pharmacy in St. Charles, Iowa, a town of fewer than 1,000 people, fees and other financial pressures forced Olson to scale back and operate the store as a telepharmacy. Technicians fill prescriptions under the eye of an off-site pharmacist, and customers see a pharmacist only one day a week.

For a town with no other health care provider, that means six days when no one can provide vaccinations or test for strep throat.

Back in Howard, Debbie Lane, 70, likes the personal service Perkins offers at Batson’s.

“It’s a lot easier to go down to a local store, and if it happens to be after hours or an emergency, she’ll open up for us,” Lane said.

Perkins will tell her if Lane can save money by driving to a chain drugstore in Wichita instead. And, recently, Perkins ran the numbers to help Lane decide which Medicare plan would be the least expensive given the medications she takes. Lane knows it’s a struggle to keep a small-town pharmacy open and fears what might happen if Batson’s closed.

“It’d be devastating,” Lane said. “There are a lot of us like me, who will sometimes pay a little extra to make sure that Julie stays in business.”

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The clock was about to strike midnight, and Scott Newman was desperately feeding pages into a scanner, trying to prevent thousands of dollars in prescription payments from turning into a pumpkin.

As the owner of Newman Family Pharmacy, an independent drugstore in Chesapeake, Virginia, he was responding to an audit ordered by a pharmacy benefit manager, an intermediary company that handles pharmacy payments for health insurance companies. The audit notice had come in January as he was scrambling to become certified to provide covid-19 vaccines, and it had slipped his mind. Then, a month later, a final notice reminded him he needed to get 120 pages of documents supporting some 30 prescription claims scanned and uploaded by the end of the day.

“I was sure I’d be missing pages,” he recalled. “So I was rescanning stuff for the damn file.”

Every page mattered. Pharmacy benefit managers, or PBMs, suspended in-person audits because of covid last year, shifting to virtual audits, much as in-person doctor visits shifted to telehealth. Amid added pandemic pressure, that means pharmacists such as Newman are bearing significantly more workload for the audits. It also has allowed benefit managers to review — and potentially deny — more pharmacy claims than ever before.

According to data from , a pharmacy audit assistance service, while the number of pharmacy audits in 2020 declined nearly 14% from the year before, the overall number of prescriptions reviewed went up 40%. That meant pharmacies had to provide more documentation and stood to lose much more money if auditors could find any reason — even minor clerical errors — to deny payments.

The average audit in 2020 cost pharmacies $23,978, 35% more than the annual average over the previous five years, the PAAS data shows. And the number of prescriptions reviewed in September and October was fourfold over what PAAS members had seen in previous years.

Pharmacists have long complained that audits seem to have little to do with rooting out fraud, waste and abuse, but have become a way for these intermediary companies to enrich themselves. According to business analysts at IbisWorld, the pharmacy benefit manager market in the U.S. has grown to nearly this year, up from less than $300 billion eight years ago.

Even before the pandemic, independent pharmacies were struggling financially with reimbursement rates they say are too low, the loss of customers to mail-order services or chain pharmacies, and a variety of measures by the benefit managers, including charging pharmacies fees and keeping manufacturer rebates for themselves.

Adding insult to injury: Many independent pharmacies report having received buyout offers from the large drugstore chains that own the PBMs, which pharmacists see as the primary reason for their financial struggles.

At a minimum, pharmacists say, virtual audits increase wait times and drive up costs for customers. At worst, the audits cost pharmacies thousands of dollars in payments for drugs already dispensed to customers, and may ultimately drive them out of business.

“It’s definitely pulling pharmacy staff away from their duties, and it’s become an administrative burden, which does have a direct impact on patient safety,” said Garth Reynolds, executive director of the . “They have to be the de facto audit team for the pharmacy benefit managers.”

Trent Thiede, president of PAAS National, said many of the more than 5,000 pharmacies he works with stepped up to offer covid testing and shots and to become an even bigger resource for customers during this health crisis. “With vaccinations in full swing, priorities should be focused on serving patients and our communities, not responding to audit requests,” Thiede said.

When auditors come in person, they primarily do the review themselves, occasionally asking pharmacists to pull additional documentation.

“In these virtual audits, you have to pull the prescription, put it through a copier of some kind, get everything aggregated, get all the signature logs. They want your license off the wall. They want all the employee licenses faxed,” Thiede said. “It’s a lot more laborious for these pharmacies.”

Express Scripts, one of the nation’s largest benefit managers, moved to virtual audits as a safety measure, said spokesperson Justine Sessions. “The virtual experience is very similar to the in-person audits in both scope and scale, and are conducted with the same frequency,” she wrote in an email. “When it is safe to do so, we intend to resume on-site audits.”

Phil Blando, a spokesperson with CVS Caremark, a benefit manager affiliated with the CVS pharmacy chain, said in an email that the company has heard positive feedback from its pharmacy network since going virtual.

“We were one of the first PBMs to simplify processes for our network pharmacies — such as relaxing previous requirements for paper patient signature logs,” he wrote, “when we knew many pharmacies and members were social distancing during the pick-up or delivery process.”

Dave Falk, who owns 15 Illinois pharmacies, said the largest audit he had ever seen before the pandemic was for 60 to 70 prescriptions, valued at $30,000 to $40,000. Then, last fall, his pharmacy in Robinson had to defend $200,000 in prescriptions in a virtual audit.

“None of these prescriptions were below $450,” he said. “These audits are not random. It’s a money grab by PBMs.”

He was appalled when the auditor asked his pharmacist to report the temperature of the refrigerator for perishable medications. The information has no bearing on whether prescriptions filled months earlier were appropriate.

“They’re looking for any reason to recoup funds,” Falk said.

After Falk and his pharmacist spent hours providing the documentation, the auditor initially denied $36,000 in drug payments, mostly because of missing patient signatures. Like most pharmacies during the pandemic, Falk’s had stopped collecting patient signatures last year for safety reasons. Major trade associations representing the PBM companies and pharmacies had come to last year that patients wouldn’t need to sign for medications provided through mail order, delivery or curbside pickup.

Nonetheless, Falk’s staff had to track down dozens of patients to have them sign affidavits that they had received the prescriptions, reducing the auditor’s denial to $12,000.

“That’s $12,000 for ridiculous reasons,” Falk said.

In Newman’s eight years as a pharmacist, he said, he has undergone six audits, all but the most recent done in person. In the virtual one, conducted on behalf of the health insurer Humana, Newman uploaded his documentation before the deadline. But he, too, was flagged for missing signatures.

Dan Strause, president and CEO of Hometown Pharmacy in Madison, Wisconsin, said his pharmacies received more than 1,000 pages of audit requests last year, covering more than $3 million in prescription claims. That represented 1.5% of his company’s total annual revenue. He said pharmacists saw a surge last year of what they call predatory audits, which look for ways to deny legitimate payments for prescriptions.

“What they did in 2020 was reprehensible,” Strause said. “While we were taking care of patients, they’re sitting back in their comfy offices figuring out ‘How can we make money off this? Can we find a loophole? Can we find a missing document? Can we find a reason to take back stuff?’”

Lisa Dimond, a spokesperson for Humana, said the company is required by the government to perform audits to see if pharmacies are adhering to regulations, but conducted fewer audits and reviewed fewer prescriptions in 2020 than in 2019.

“We have worked to reduce as much administrative burden as possible on our network pharmacies, offering extensions, when needed, while still working to ensure pharmacies are filling prescriptions appropriately for the safety of our members,” she said in a statement.

Pharmacists bristle when large pharmacy chains that operate their own benefit managers offer to buy their stores, acknowledging that times are tough. Joe Craft owns the Happy Druggist chain of pharmacies in central Ohio. He said he regularly receives letters seeking to buy his business from the same companies that cause him to lose an average of $6,000 in payments with every audit, about a week’s worth of revenue for a single drugstore.

“When you read that letter, you’re thinking to yourself, ‘Hell, yeah, times are tough,’” he said. “Of all people, they should know.”

And oftentimes, when independents are sold to bigger chains, those drugstores are shut down, and the chain pharmacy directs customers to one of its locations miles away.

Thiede and many pharmacists believe that, while in-person audits may resume after the pandemic, virtual audits may be here to stay as well.

“They can do more because they don’t have to travel and fly across the country and sit in your pharmacy all day long,” Thiede said. “They can just do it from their home and accomplish more.”

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It’s an hourlong drive over treacherous mountain passes to Laramie, Wyoming, or Granby or Steamboat Springs, Colorado — and the nearest pharmacies. The routes out of the valley in which Walden lies are regularly closed by heavy winter snows, keeping residents in and medications out.

Walden has suffered the fate of many small towns across the United States, as the economics of the pharmacy business have made it difficult for community drugstores to survive. With large pharmacy chains buying up independent drugstores and increasingly controlling the supply chain, towns such as Walden have too few residents to attract a chain drugstore and no great appeal for pharmacists willing to strike out on their own.

With no local access to prescription drugs, the town of mainly cattle ranchers and hay farmers has crowdsourced a delivery system, taking advantage of anyone’s trip to those bigger cities to pick up medications for the rest of the town.

“Really, it’s a network of community and people reaching out and knowing that others have needs,” said Tina Maddux, who runs a nonprofit that provides food and other assistance in Walden. “We’re a community that pulls together for the wellness of everyone.”

The system is just one of the creative ways that rural communities deal with a lack of health care. In Walden, the senior center runs a regular shuttle to the bigger locales so older residents don’t have to drive to pick up groceries, visit doctors or refill their meds. In October, a pharmacy in Steamboat Springs began delivering medications to Walden once a week. Mail-order pharmacies can help with medications for chronic conditions, but not for acute needs.

Yet these solutions can’t replace a bricks-and-mortar pharmacy, as pharmacists do much more than count pills. They can give flu or covid shots and, in some states, such as Colorado, even prescribe contraceptives. Some run diabetes management or smoking cessation programs. Medications can be complicated, and without a live person to talk to, patients can struggle to take them correctly.

In Walden, locals are one snowstorm, one mishap, from being cut off from their meds.

That uncertainty leaves Whitney Milek with constant anxiety. Her younger son, 8-year-old Wade, relies on medications to control his seizures. She usually picks up his medicines in Laramie, where the family does its big grocery runs. But when she needs to refill in between trips, she turns to her neighbors for help.

The informal system runs primarily through a Facebook group created in 2013 as a sort of online garage sale. For years, people have been posting to ask if anybody is headed toward a pharmacy and can bring back a prescription. Neighbors deliver to neighbors, even during the pandemic, and no money is exchanged.

“There are times when nobody is going and you end up having to have them mailed, which is a whole other thing, especially with seizure meds,” Milek said. “Some are controlled substances and they can’t mail them.”

Two winters ago, Milek called in one of her son’s prescriptions to a Steamboat Springs pharmacy. But when she arrived, the medication was out of stock. With road conditions rapidly worsening, she asked if the pharmacy would mail the medication but was told she lived too close for mail delivery. She turned to a pharmacy in Laramie, which eventually agreed to mail it to her — but also didn’t have it in stock.

“So, he ended up going five days without,” Milek said. “It’s not a big deal if you miss a dose here or there. But when you miss that many over a period of time, your tolerance level goes down.”

That medication must be carefully managed to build up gradually in Wade’s blood to avoid a severe allergic reaction. It took three weeks to scale up to his daily dose when he started taking the drug two years ago.

“When he went five days without it, he had to basically start all over again. It was over Christmas break, so he wasn’t in school. I brought him to work with me because I didn’t feel comfortable leaving him with anybody else,” said Milek, a bookkeeper. “I didn’t know what was going to happen.”

Wade was fortunate to avoid complications that time. But having a local pharmacy mail medications comes with added costs — $26, in their case, for a prescription last month — an extra tax on those who cannot get to a pharmacy. Mail-order pharmacies typically don’t charge for shipping yet can run into snags, too. Last year, some of Wade’s mailed medications got stuck in a Denver processing facility for three weeks. The Mileks had to pay $1,600 out-of-pocket to get replacements.

Walden has no hospital, only a small clinic where Dr. Lynnette Telck and a nurse practitioner care for residents. The clinic stocks some basic medications to handle routine acute needs — antibiotics for strep throat, inhalers for asthma — and they can mix up liquid suspensions for those who can’t swallow pills.

“It’s a small town, so we all wear many hats,” Telck said.

show that, without a drugstore nearby, patients aren’t as likely to keep up with their medications and their chronic conditions can worsen. Without readily available medications, Telck said, patients can end up taking an ambulance to an emergency room.

“It’s just so darn expensive to the system,” she said.

Walden touts itself as the moose-viewing capital of Colorado and is a recreation mecca for hunting, fishing and snowmobiling. But Telck said it could be hard to attract a pharmacist because the town lacks amenities like movie theaters and shopping malls.

“It’s pristine and wonderful in its own quirky way and we love it,” she said. “But not a lot of people want to come to rural areas. The wages aren’t as high as in the big cities.”

Middle Park Health, the Granby-based hospital system that operates the Walden clinic, had looked at putting a more complete pharmacy in the clinic but couldn’t find a technician to staff it.

“The days of that being a profitable, desirable business? It’s a lot tougher than it was a decade or two ago,” said , an associate dean at the University of Colorado’s School of Pharmacy. “You come out of eight years of college — four years of undergraduate and four years of pharmacy school — with pretty significant student loan debt. It’s very hard to go to a rural community where you don’t make any money.”

In towns without an ER or a clinic open late, pharmacists often become the health provider of last resort. They tell patients whether they need to make the long trek to a hospital late at night or can wait until morning.

“A patient will often come to the pharmacy as the first point of access for health care,” Moore said. “Our pharmacists are taught to understand and to be able to advise people on what can be self-treated with over-the-counter medications versus when you need to see a higher-level provider or an urgent care.”

Researchers from the Rural Policy Research Institute at the University of Iowa have documented how the deck is increasingly stacked against community pharmacies.

“It’s just not a really attractive business model anymore,” said Keith Mueller, the institute’s director.

In 2013, they found that new Medicare Part D drug plans resulted in low and late reimbursements, replacing direct out-of-pocket payments from customers. That left many pharmacies unable to turn a profit. By 2018, surveys showed pharmacies were struggling more with the narrowing margin between what they paid for the drugs and what they were being reimbursed by health plans.

Towns of more than 10,000 people are often served by at least a Walmart or a supermarket pharmacy, Mueller said.

“But you get out into smaller communities, the predominant modality had been the corner drugstore,” he said. “We’re not seeing that replacement of the closed independents by a CVS, Rite Aid or Walgreens.”

The Mileks have talked about whether they should move near her family in Wyoming to be closer to a hospital and pharmacy.

“When you can’t get to a pharmacy, it’s scary, because things can happen so fast,” Milek said. “People just have no concept of what it’s like out here.”

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“And then covid hit,” said Dave Schultz, who co-owned the store with his brother. “And that was the final straw.”

The covid-19 pandemic sank many businesses in 2020, particularly those relying on in-person sales to stay afloat. For pharmacies — especially independent pharmacies — the pandemic lockdowns exacerbated long-standing economic pressures. Many small owner-operated pharmacies adapted quickly, delivering their traditional amenities in safer ways or capitalizing on new services created by the pandemic, such as covid testing and vaccinations. But others, like Tobin’s, became casualties of the pandemic, closing their doors for good.

It’s too early to quantify just how many pharmacies succumbed to covid and assess how patients will be affected. The total number of pharmacies has declined over the past five years, as pharmacy chains get larger while independent community pharmacies — often the last place left to fill a prescription in some small towns — go under. The Rural Policy Research Institute rural pharmacies, about 16%, closed for good from 2003 to 2018, well before the pandemic pinch. And according to the , after five years of declines, the number of urban and rural independent pharmacies dipped below 20,000 for the first time in 2020.

from covid testing and vaccinations may help keep some independents afloat, but that comes with added costs and logistical challenges.

“Pharmacies are struggling,” said , president of PRS Pharmacy Services, a consulting firm in Latrobe, Pennsylvania. “We’re getting calls from a lot more pharmacy owners that want to sell their stores. They’ve had enough.”

Most pharmacies, he said, saw a decline in prescriptions last year as customers hesitated to visit their doctors for anything but emergencies. That drop in business also meant fewer sales of over-the-counter medicines and ancillary items sold by the stores. Meanwhile, pharmacies had to buy protective equipment to keep staffers and customers safe and beef up their technology to address the new reality.

Lattanzio said some independent pharmacies, which had always preferred the personal touch of having staff members answer the phones, have had to invest in new systems to handle thousands of calls a day from people seeking vaccines. Costs rose even as revenues dropped.

“For the most part, they lost money,” Lattanzio said. “If you didn’t lose money, you did something really right.”

When Lattanzio opened his first pharmacy 20 years ago, he saw gross profit margins of 36%. Now independent pharmacies are fortunate to see margins of 3% to 5%, if they survive the pandemic at all. Much of that decline comes from the impact of pharmacy benefit managers, which manage commercial and public health plans’ prescription drug reimbursements to pharmacies. Those PBMs, often aligned with large drugstore chains, systematically squeezed the profits out of independent pharmacies. That left many smaller chains or unaffiliated pharmacies unable to bear the added hit from the pandemic.

“I’m afraid to see the outcome,” said Joe Moose, co-owner of , a chain of seven drugstores on the outskirts of Charlotte, North Carolina. “The delay in payments, the increased cost to keep operating in the early days of this, combined with the fact that reimbursement is so poor already — covid may be the final nail in the coffin for some of us.”

Moose Pharmacy is trying to adapt. When it had to stop in-store purchases during the pandemic, the chain expanded curbside services and hired additional drivers. Home deliveries tripled. Workers ferried food, toilet paper, paper towels and shampoo to customers.

“We had to build out our website. We put in technology so that people could text us from the parking lot. It had to be HIPAA-compliant,” said Moose, who owns the chain with his brother. “And keep in mind that all of that is happening at no change in reimbursement.”

Covid also interrupted the medication supply chain. In normal times, the pharmacy’s supply of drugs is automated, so when it dispenses medicines, replacements show up in the next day’s delivery. But Moose and his staff had to resort to the old way of calling up five or six wholesalers to see who had the drugs in stock.

When covid testing was scarce, the pharmacies taught their employees to perform rapid tests. Once vaccines arrived, Moose sought out patients who couldn’t make an appointment on a smartphone, who couldn’t drive to mass vaccination clinics, or who were just afraid to leave their home.

Staffers delivered vaccines to one elderly man with cancer, whose wife had died a year earlier. He and his disabled adult son didn’t want to risk going out and contracting the virus.

“But he trusts us, and so we deliver medication to him probably every other week,” Moose said. “So it made sense that we bring the vaccine to him.”

, a pharmacist in Charleston, Missouri, said one of his three pharmacies is in rural Mississippi County, which has no hospital or chain pharmacy for the 14,000 residents. There, four independent pharmacies and the county health department formed a consortium to help distribute covid vaccines.

“It started with a group text, and the next thing you know, we’re vaccinating hundreds of people a week collectively,” Logan said.

Because pharmacies can make up to $70 per covid test and $40 for each vaccination,  many pharmacies are earning new revenue to offset some of the retail losses, said Owen BonDurant, president of in Centerville, Ohio.

“So that has brought a significant increase in profit margins for the short term,” BonDurant said. “Covid has probably saved a lot of pharmacies. Because PBM pressure has been so hard, especially on some of these rural and inner-city pharmacies, a lot of them still are on the verge of going out of business.”

The cash infusion from the federal Paycheck Protection Program also kept many pharmacies afloat, and allowed some to make investments that better position them for the future.

“We would have had to shut down or sell because the PBMs were brutal last year, and they killed off a lot of our friends in Wisconsin,” said Dan Strause, president and chief executive officer of in Madison, Wisconsin. “Without the PPP, there would have been far more facing the same fate.”

Some of the changes born of necessity could stick. In a by the National Community Pharmacists Association, 3 in 5 community pharmacists said they expect more pharmacies to offer point-of-care testing after the pandemic, and more than half said additional pharmacies will give immunizations.

Hashim Zaibak, CEO of in Milwaukee, said his pharmacy is considering testing for the flu, strep and hemoglobin A1C levels for those with diabetes, and it will continue providing vaccinations.

“Those changes are here to stay,” Zaibak said.

Tobin’s owners considered selling their pharmacy, but finding no buyers, they shut down for good in September. Schultz said it’s unclear whether they could have survived had covid not happened — or if the vaccine revenue might have helped. He knows of two other independent pharmacies in Wisconsin that closed in the past 18 months.

“The real crux of the matter is you’re getting paid, in some cases, $60 under the cost that we end up paying for the medication,” he said. “How do you justify that portion of your business?”

Oconomowoc has one independent drugstore, two grocery store pharmacies and a Walgreens to serve its 17,000 residents. But Schultz worries about many of the older, sicker customers who relied on the personalized care his pharmacy provided. One of his former pharmacists now works at a drugstore outside of town but delivers medications to some of Tobin’s most vulnerable former customers on her way home.

“She just didn’t think they would survive going someplace else,” he said.

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A by the Rural Policy Research Institute found that 111 rural counties, mostly between the Mississippi River and the Rocky Mountains, have no pharmacy that can give the vaccines. That could leave thousands of vulnerable Americans struggling to find vaccines, which in turn threatens to prolong the pandemic in many hard-hit rural regions.

And in those areas without pharmacies, rural residents may have to drive long distances to get shots, and do so twice for two-dose vaccines. by the University of Pittsburgh School of Pharmacy and the West Health Policy Center found that 89% of Americans live within 5 miles of a pharmacy. But more than 1.6 million people must travel more than 20 miles to the nearest pharmacy, which can mean facing difficult weather and road conditions in remote areas.

“If pharmacies are closed, especially in places where there’s no other health care provider, then you’ve got essentially a health care desert,” said Michael Hogue, president of the . “You have to be dependent on either a mobile clinic coming in from another area to provide vaccines, or the citizens are going to have to drive farther to get a vaccine.”

So far, with a limited quantity of doses and strict limitations on who is eligible, that hasn’t been a problem. But as vaccination opens up to the general public and supplies of the vaccines increase, local health departments may be overwhelmed with demand and may need to offload the task of vaccinating local residents to other health care providers.

“It’s probably not playing out yet because we’re not getting enough supply,” said Keith Mueller, director of the Rural Policy Research Institute’s Center for Rural Health Policy Analysis. “That means we have some time for those local health departments to figure this out: Who in my radius, if you will, has the capacity to administer vaccines?”

From 2003 to 2018, 1,231 independent rural pharmacies closed, Mueller’s team found, leaving some 630 rural communities with no retail drugstore. The changing economics in the pharmacy industry did them in, a combination of national pharmacy chains expanding and consolidating, big-box stores and supermarkets opening their own competing pharmacies and pharmacy benefit managers eating into small-pharmacy profits. Mail-order options siphoned off business.

And you can’t get vaccines in the mail.

In many towns, those pharmacies represented the last bastion of health care in their communities. Now more than ever, residents are feeling the void.

“We have no medical infrastructure,” said DeAnne Gallegos, a spokesperson for the San Juan County health department in southwestern Colorado. “We don’t even have a doctor.”

With the closest pharmacy located in a neighboring county an hour away in Durango, vaccinations in San Juan County have been handled by the public health director and two nurses. They hold weekly vaccination clinics if they get any doses. As of Feb. 18, the health department had fully vaccinated 298 of its 700 residents.

Counties are allocated doses based on their year-round populations, but the health department hopes to vaccinate out-of-staters who visit as well. San Juan County deals with an influx of tourists and second-home owners coming from states such as Texas, Arizona and Florida, where the pandemic has hit harder and vaccination rates are lagging. So the health department could end up vaccinating more than 200% of San Juan County’s official population to keep covid out.

“Our attitude is, no matter what your driver’s license or your ZIP code says, if you are living within our tightknit community, that is someone we hope the state would allow us to bring into the fold,” Gallegos said.

But that stresses what she called the frail structure the department had in the first place.

“It’s our responsibility to make appointments, manage the data, make contact, receive phone calls,” Gallegos said. “When you don’t have the staff or the budget to hire additional staff, that also makes it very difficult.”

Farther east, Custer County hasn’t had a pharmacy for years. Only recently, a pharmacist who lives in the county but works in an adjacent county an hour away has started delivering prescriptions to Custer residents when she returns home after each shift.

But she can’t bring vaccines home from work.

Instead, a public health nurse who was due to retire at the end of 2020 decided to stay on to vaccinate residents with the help of another nurse and retired health care workers who maintained their licenses. According to Custer County Public Health Agency Director Dr. Clifford Brown, they have vaccinated more than 630 of the county’s 5,200 residents.

In an ideal world, they could have handed off the task to a pharmacy.

“We do feel the pinch,” Brown said. “I wake up about 3 o’clock in the morning thinking about, how in the world are we going to stretch things to cover for this day?”

Pharmacies offer distinct advantages as vaccine providers. Hospitals, which didn’t traditionally vaccinate the general public, have had to create programs to distribute their allocated doses.

In Colorado, pharmacies give over a million flu shots a year, said Emily Zadvorny, executive director of the , and, particularly in smaller towns, have a much closer relationship with their customers than larger health care providers do. She pointed to a pharmacist in Kiowa County, Colorado, who pulled a list of all his customers age 70 and up and called each of them to schedule their covid vaccinations.

“They have so much more capacity than they have supplies,” Zadvorny said. “It’s just a slow process of ramping up.”

Even where pharmacies exist, it’s been a challenge for independent drugstores to participate in the covid vaccine rollout. For influenza, pneumonia or shingles vaccines, stores typically order as many doses as they think they can sell, which get delivered alongside the pills they distribute.

The covid vaccines, on the other hand, are being distributed through a national program that comes with a significant learning curve for pharmacies. The federal Centers for Disease Control and Prevention partnered with 21 pharmacy chains, including four networks of independent community pharmacies that give smaller drugstores more purchasing power. According to the National Community Pharmacists Association, those four networks include about 8,000 of the 21,000 community pharmacies nationwide. Pharmacies that are not part of those networks can apply to be vaccine providers in their states.

“The biggest hurdle for most pharmacies is just getting approved,” said Kyle Lancaster, pharmacy director for Our Valley Pharmacy, a three-pharmacy chain in rural Lincoln County, Wyoming.

Our Valley applied to federal and state health agencies and had to upgrade its freezers with digital data loggers, which upload the pharmacies’ refrigerator and freezer temperatures and report them directly to the CDC.

Most small pharmacies like his, he said, had been limited to the Moderna vaccine, which has less stringent temperature requirements than Pfizer’s version. The Johnson & Johnson vaccine, , would be even easier for rural pharmacies to handle.

Lancaster said he’s unsure how many doses of the vaccine his chain will get or when.

Those uncertainties leave residents such as Nan Burton, 63, worried about how to get vaccinated. Last year, she and her husband decided to ride out the pandemic in their vacation home in Lincoln County, trading apartment living in Seattle for the wide-open, physically distanced spaces of Star Valley Ranch, about 8 miles from the nearest Our Valley branch. With plans to retire fully next year, now they’re staying for good.

So far, Lincoln County — more than three times the size of Rhode Island — has vaccinated about 2,500 of its nearly 20,000 residents, mainly through the local hospital. But with no major chain pharmacies in the region, the county must wait for independent community pharmacies, such as Our Valley, to get up to speed.

Burton said she and her husband have little choice but to wait and hope that the vaccine distribution logistics are sorted out. They’d be willing to drive hours to get a vaccine if they knew they weren’t taking it away from someone else in need.

“Until there’s some kind of a national push to do outreach to rural communities, I think we’re going to be in trouble,” Burton said.

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This story can be republished for free (details).