A rural Ohio pharmacy school embraces pharmacists' expanded 'provider status' by deploying a mobile care unit

Mobile Health Clinics staffed by student pharmacists and 
supervising faculty provided health care in rural Ohio.

Dozens of states across the U.S. allow pharmacists to have expanded care status similar to the role a primary care medical professional would fill. In 2019, the Ohio legislature granted pharmacists "provider status," which means they are "recognized healthcare providers in the state insurance code and allowed to be reimbursed for services like chronic disease management and immunizations."

Using their change to "provider status" as a launching pad, leadership at Ohio Northern University's Raabe College of Pharmacy in rural Hardin County, Ohio, challenged themselves to reenvisioned how they could use their existing "HealthWise" service, which was originally intended for ONU employees, to address health care deficiencies throughout rural Hardin County and its rural county neighbors, reports Kay Miller Temple for Rural Health Information Hub.

During a Hardin County health needs planning meeting, Michael Rush, PharmD, who teaches residents and is the director of operations at ONU HealthWise, was inspired by a food truck he saw outside; he thought a mobile HealthWise might be the answer.

Location of ONU in Ohio

Once shared, Rush's idea gained traction, and numerous funding awards and grants led to Raabe College hiring a pharmacist and purchasing a bus, which "built out ONU HealthWise into the ONU HealthWise Mobile Health Clinic," Temple writes.

Today, ONU student pharmacists and their supervising faculty aboard the HealthWise Mobile unit provide a broad spectrum of health care, including "preventive health education, medication reconciliation, medication therapy management, and chronic disease state management," Temple reports. Health screenings, immunizations and specialty care are also addressed on-site.

The Healthwise Mobile unit services have continued to expand to meet their community's needs. When two rural pharmacies closed in 2024, the traveling care team filled the gaps. 

Michelle Musser, director of ONU's Rural and Underserved Health Scholars Program, told Temple, "The students need those experiences of working in a pharmacy, different from the mobile outreach experiences. This closure allowed them to experience firsthand what a rural pharmacy closure actually does to rural communities."

Building on the first Healthwise Mobile Clinic's success, Raabe College is investing in a second van. Temple adds, "HealthWise will eventually be present in Hardin, Allen, Auglaize, Hancock, and Wyandot Counties."

Study: How independent pharmacy challenges and closures impact rural pharmacists

Harris Pharmacy serves Rocky Ford, Colorado.
(University of Colorado photo)

Many studies on the closure of independent pharmacies focus on what happens to patients when a pharmacy closes. A new study by Michael J. DiStefano, PhD, at the University of Colorado, examines how those closures impact pharmacists. The study also explores how independent pharmacists navigate the current reimbursement model and what some states are doing to help them stay solvent. 

In interviews with pharmacists, DiStefano and his colleagues "heard palpable frustration, stories of mental health impacts and examples of how pharmacy closures touch entire communities," reports Matthew Hastings for the University of Colorado. 

DiStefano told Hastings, “It’s a series of ripple effects. When a pharmacy closes, not only do you see the impacts to medication access and job losses in that community; surrounding pharmacies will experience a series of stressors. All those patients impacted by the closure need to be added to your system, with new patient histories and records.” 

Study interviewees stressed that independent rural pharmacists should always have a succession plan that ideally includes a younger pharmacist who could take over the business, rather than a rural community having to recruit a new pharmacist who may not have the experience to navigate the financial demands of running a rural pharmacy. 

At Harris Pharmacy in Rocky Ford, Colorado, which serves a rural southeastern part of the state, owner Ky Davis believes running his pharmacy is all about problem-solving because there isn't another nearby pharmacy to refer patients to if his pharmacy runs out of a particular medication.

The current insurance reimbursement model for medications also means rural pharmacists can lose money caring for their patients. Davis told Hastings, "You're losing $80 to fill a prescription, and there's definitely a temptation to be like. We're not going to do that. We're not going to stock this drug."

At least in Colorado, lawmakers have eased some burdens on rural pharmacists, allowing them to approve prescriptions remotely. Davis told Hastings, "The bill passed this year has helped a lot. I’m able to leave the pharmacy open and remotely verify or have another one of our pharmacists remotely verify a prescription if I step away.” 

Report: Chain drugstores get $23.55 to fill a blood pressure prescription, but a small drugstore gets only $1.51

Adams Family Pharmacy often loses money filling
prescriptions. (Photo by A. Miller, KFF Health News)

Even as independent pharmacists face low or no profits from medication sales, pharmacy middlemen reimbursements favor large drugstore chains. The Federal Trade Commission and several lawmakers are starting to take aim at prescription benefit managers' power and repayment practices.

"On Sept. 20, the FTC sued three of the largest PBMs. . .The lawsuit followed a scathing FTC report that said the 'dominant PBMs can often exercise significant control over which drugs are available, at what price, and which pharmacies patients can use to access their prescribed medications,'" reports Andy Miller of KFF Health News.

How PBMs dominate reimbursement in Georgia is a drastic example of smaller pharmacies being shorted. The American Pharmacy Cooperative, which represents independent pharmacies, "reviewed the price differential paid to a north Georgia pharmacy and nearby chain stores," Miller explains. "The analysis showed chains were paid well beyond the family business. For example, the chains received an average of nearly $54 for the antidepressant bupropion, while Bell’s Family Pharmacy in Tate, Georgia, got $5.54. . . . For a drug used to treat blood pressure, amlodipine, chain pharmacies received an average of $23.55, while Bell’s got $1.51. . . Bell’s Family Pharmacy closed earlier this year."

Nikki Bryant is a pharmacist and co-owner of Adams Family Pharmacy in rural Cuthbert, Georgia, who has worked to find creative ways to bolster the business' income because the pharmacy loses money. "Bryant and other independent pharmacists say they lose money filling certain prescriptions while reimbursements favor chain pharmacies like CVS that have corporate ties to pharmacy benefit managers," Miller adds. "Bryant said she can make more profit on cake and coffee than with many medications."

Some lawmakers are scrutinizing PBMs. "Members of both parties in Congress have tackled PBM reform," Miller reports. "House members recently introduced another proposal, known as the Pharmacists Fight Back Act, which supporters say would add transparency, limit costs for patients, ensure they get the benefit of drugmaker discounts, and protect their pharmacy choices."

Years of underpayments by PBMs to smaller pharmacies have disproportionately harmed rural communities by "accelerating closures of mom-and-pop pharmacies across the country, said the National Community Pharmacists Association," Miller reports. "The U.S. loses almost one such pharmacy a day, said Anne Cassity, a senior vice president of the association."

Rural pharmacies are medical 'cornerstones' in their communities; despite financial stresses, some are growing

Photo by Tbel Abuseridze, Unspash

Rural pharmacies have long served their communities as multi-service medical clinics, and many have faced financial stresses lately, but the future may be brighter. "Pharmacies are often cornerstones of rural communities providing access to medication and medical equipment as well as providing medication counseling, monitoring of blood pressure and glucose, and other services," reports Dr. Whitney Zahnd for The Rural Monitor. "Over the past several years, studies from the Rural Research Alliance of Community Pharmacies have demonstrated notable decreases in pharmacies in rural communities. The now 20-year financial impact of Medicare Part D, coupled with the increasing influence of pharmacy benefit managers, has negatively impacted the financial viability of rural pharmacies. This has led to a 9.8% decline in pharmacies in non-core rural areas and a 4.4% decline in micropolitan rural areas between 2003 and 2021."

Not all the news is bad. Zahnd writes, "Recent findings from Rural Policy Research Institute have identified that, since 2020, the tide may be turning. The rate of closures has slowed since 2020, and new rural pharmacies have opened throughout the country." NuCara Pharmacy, which began as a rural pharmacy in Conrad, Iowa, pop. 1,000 is an example of a smaller pharmacy chain that has managed to innovate and stay open. "CEO Brian Wegmann noted additional changes that have broadened both the modalities of pharmacy services, such as the inclusion of telepharmacy, and the expansion of services provided by NuCara, such as infusion, home health, and respiratory services. Additionally, NuCara has moved into areas where chain pharmacies like ShopKo moved out of rural communities, such as Greenfield, a rural town of just over 2,000 people in southwestern Iowa."

Beyond additional "modalities" of support, some area researchers made rural pharmacies their object study to "understand the unique challenges and strengths they possess, especially as many interventions and initiatives are developed in urban or suburban settings that may not be translatable to rural settings," Zahnd reports. In the Southeast, researchers from several universities formed Rural-CP, which "reviewed how other pharmacy practice-based research networks were structured and started making in-person and virtual site visits to rural pharmacies. . . . They are now engaged with 125 rural community pharmacies across seven states in the Southeast, most of which are independent or small chain pharmacies. . . . Any projects that engage these pharmacies also must provide a financial incentive, which has ensured that pharmacies are supported for their time."

Rural pharmacies are also finding ways to face their recruitment challenges. The University of Illinois-Chicago rural pharmacy education program "is one of a handful of programs at schools of pharmacy that provide a concentration or certificate in rural pharmacy," Zahnd explains. "The Rpharm program, established in 2010, is an interprofessional program that educates students about unique elements of rural pharmacy practice and prepares them for working in an interprofessional environment alongside medical and nursing students who are participating in the University's rural medicine and rural nursing programs. . . . . Wegmann of NuCara Pharmacy noted the mutual benefit of having pharmacy students do rotations in rural NuCara Pharmacy locations. He told Zahnd: "We're an attractive spot for student rotations because of the dynamic and diverse practice settings that we can offer because of our compounding and home infusion services as well as our community sites."

Abortion roundup: Biden administration says hospitals must provide abortions if woman's life is at risk, despite state laws

Here's a roundup of news about abortion:

This week the Department of Health and Human Services "told hospitals that they 'must' provide abortion services if the life of the mother is at risk, saying federal law on emergency treatment guidelines preempts state laws in jurisdictions that now ban the procedure without any exceptions following the Supreme Court’s decision to end a constitutional right to abortion," Zeke Miller reports for The Associated Press. The directive could provide clarity for doctors who say they're afraid to provide routine care to women suffering miscarriages.

Newsrooms should reframe abortion coverage to capture the complexity of American viewpoints on the topic. They should also reconsider internal rules about avoiding political speech, which often stifle conversation on the topic and leave journalists poorly prepared to capture the nuances of the issue, writes Kelly McBride, the Senior Vice President and Chair of the Poynter Institute's Craig Newmark Center for Ethics and Leadership.

A pharmaceutical company has submitted an application to the Food and Drug Administration for an over-the-counter birth control pill. If approved, it would be the first such medication available nationwide without a prescription. Read more here.

More babies will be born now that Roe v. Wade has been overturned, but rural areas in many states are so-called "maternity deserts" with little or no access to childbirth services. Some who oppose abortion say the government should expand services that make it easier for people to bear and raise children, but it's a subject of fierce debate among those who favor smaller government. Pregnancy and childbirth costs an average of $2,854 out-of-pocket for people enrolled in large group health-insurance plans, according to a new data analysis.

Even in states where abortion is legal, many women with autoimmune diseases are being denied access to methotrexate, a critical and commonly prescribed medication that can cause miscarriages (and is uncommonly used off-label to induce abortion). One Texas pharmacist refused to dispense it to an 8-year-old girl. Some doctors say they've been ordered to deny prescriptions because of fears that they could be sued. Without medication, many patients risk irreversible organ damage or death. Read more here.

Abortion providers are trying to open new clinics as close as possible to states with abortion bans. Meanwhile, most abortion clinics in Montana have barred out-of-state patients from receiving abortion pills for fear that they could be sued.

Women in the sparsely-populated rural West may face outsized difficulties in accessing abortion. Read more here.

Quick hits: Apply by March 31 for business journalism fellowship; Americans cut back on pricey meat analogues

Here's a roundup of stories with rural resonance; if you do or see similar work that should be shared on The Rural Blog, email us at heather.chapman@uky.edu.

An anonymous donor has given Washington State University its largest gift ever for an initiative aimed at bringing more pharmacists to rural Washington. Read more here.

A journalism professor has a list of 21 types of political spin journalists should know about, and how to spot them. Notable entries include the "dead cat bounce." Read more here.

One columnist shares how her sons' experiences in growing up on the farm will serve them well as adults. Read more here.

Got an idea for an investigative or enterprise journalism project involving business, finance or economics. Apply by March 31 for a fellowship of up to $15,000 from The Harold W. McGraw, Jr. Center for Business Journalism at the City University of New York. Past fellows have produced rural-centric stories, including a recent one from the Center for Public Integrity on Black farmer debt. Read more here.

The National Press Foundation and the Society of Professional Journalists are seeking journalists to fill out a short survey to help the nonprofits design journalism training that serves newsrooms best. Take the quiz here.

The Agriculture Department has named new Farm Service Agency and Rural Development state directors for North Dakota and South Dakota. Read more here.

As inflation rises, consumers are cutting back on purchases of expensive plant-based meat alternatives, and 54% said in a recent survey that such products are too expensive. Read more here.

Amid a severe truck driver shortage, a new study says 90% of long-haul trucking could be done by self-driving trucks. There are some logistical hang-ups and the trucks would have to get better at bad-weather driving, though. Read more here.

Independent rural pharmacies are shuttering, killed off by chains; millions of Americans are left in 'drugstore deserts'

Number of healthcare deserts by county, defined as counties where most people lack adequate access to pharmacies, primary care providers, hospitals, hospital beds, trauma centers, and/or low-cost health centers. (GoodRx report; click here for more information.)

"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," Markian Hawryluk reports for The Washington Post. "An analysis by GoodRx, an online drug-price-comparison tool, found that 12 percent 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 percent of counties."

Independent pharmacies are struggling to compete with chains whose relationships with insurers and pharmaceutical benefit managers give them a competitive edge. "Insurers also have ratcheted down what they will pay for prescription drugs, squeezing margins to levels that pharmacists call unsustainable," Hawryluk reports. "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 middlemen, who claw back pharmacy revenue through retroactive fees and aggressive audits, leaving local pharmacists unsure if they’ll end the year in the black."

Those pressures have whittled away at the number of independent pharmacies. "From 2003 to 2018, 1,231 of the nation’s 7,624 independent rural pharmacies closed, according to the University of Iowa’s Rural Policy Research Institute, leaving 630 communities with no independent or chain retail drugstore," Hawryluk reports.

UPDATE, Nov. 18: A study for the PBMs' trade group, by two Penn State professors, found that the number of independent pharmacies in the U.S. increased 12.9% from 2010 to 2019, while the number of chain pharmacies decreased 0.2%. Also, "CVS Health announced Thursday morning that the company plans to close 900 stores nationwide over the next three years because of what executives described as changes in consumer shopping behavior, population, and the future of health care needs," The Boston Globe reports.

Quick hits: pharmacists could administer kids' vaccinations; what post-pandemic food supply chains could look like

Here's a roundup of stories with rural resonance; if you do or see similar work that should be shared on The Rural Blog, email us at heather.chapman@uky.edu.

The federal government will allow pharmacists to administer routine immunizations to children as young as three. Read more here.

Residents of Alabama's Lowndes County lack adequate wastewater systems and must regularly deal with sewage backing up into their yards and homes. Environmental activist Catherine Coleman Flowers, who has spent the past 20 years bringing attention to the issue, says it's only one of many such rural areas. Read more here.

A California lawsuit alleges that kids are falling behind because of distance learning, and that the state hasn't done enough to provide students with technology like computers or hotspots so they can learn. Read more here.

A policy expert discussed what post-pandemic food supply chains could look like. Read more here.

In rural areas, Covid-19 is an obstacle to healthy development for children of color. Read more here.

The Department of Health and Human Services has published new hospital-capacity data that it says is more accurate than previous estimates. Read more here. A scientific probe in November found that HHS data varied wildly from state-aggregated data. Read more here.

Nearly one in four North Dakotans know someone who has died from Covid-19. Read more here.

The U.S. Department of Agriculture's Rural Development is seeking applications for Rural Energy for America program. Read more here.

An editorial in the Las Vegas Sun cites rural issues the Biden administration and other Democrats must address, including reducing the power of large agri-businesses. Read more here.

Mail delays expose pitfalls of prescription home delivery

The recent delays with the U.S. Postal Service have exposed a pitfall with mail-order prescription drug plans: some people aren't getting their meds on time, Shelby Livingston reports for Modern Healthcare.

Some health-insurance plans require patients to fill long-term medications by mail, and some rural residents may prefer that since they live far from pharmacies or lack transportation, Livingston reports. Some evidence suggests that receiving meds by mail increases the likelihood that patients with chronic diseases will take their meds. But that can only happen when medications show up on time and undamaged.

"AllianceRx Walgreens Prime, a home delivery venture between Walgreens and PBM Prime Therapeutics, said prescriptions have taken longer to be delivered by the USPS since March, and the company is monitoring how those delays affect patients. In some cases, delivery has been significantly delayed by three or more days," Livingston reports. "AllianceRx attributed the delays to the covid-19 pandemic, aircraft availability, significant network volume and the USPS elimination of overtime. It said it is evaluating soon-to-be-implemented postal rate increases and is looking at other mail delivery options if delays worsen. Alliance sends most prescriptions through the USPS, but also uses DHL E-Commerce to sort and enter shipments to the USPS, which helps speed up the process, it said."

The House Energy and Commerce committee said it will investigate how Postmaster General Louis DeJoy's changes have affected prescription-drug delivery. But pharmacist trade groups say the issues aren't new, and that mail-order prescriptions are prone to delays or other problems that can make it hard for patients to stay medicated.

"Even before the slowdown there was some unpredictability in the shipment of medications," B. Douglas Hoey, CEO of the National Community Pharmacists Association, told Livingston. He said that auto-shipments sometimes get lost in the mail, and that during slow-downs, medications are sometimes exposed to unsafe temperatures. "When patients experience mail order issues, the burden falls on local pharmacies that end up filling emergency supplies of medication," Livingston reports. "But those local pharmacies likely won't be reimbursed for that work, he said."

Local, independent pharmacies may lose out in another way over mail-order prescriptions, said Scott Knoer, CEO of the American Pharmacists Association. He told Livingston that he worries that, when pharmacy benefit managers require members to deliver prescriptions by mail, it can hurt the bottom lines of local pharmacies and help drive them out of business.

Quick hits: Rural neighborliness a lifeline; rural pharmacies struggle; webinar on farmers' aid short of information

Here's a roundup of stories with rural resonance; if you do or see similar work that should be shared on The Rural Blog, email us at heather.chapman@uky.edu.

Rural neighborliness, which one writer dubs "the front porch network," is a lifeline in Appalachia during the pandemic. Read more here.

Pharmacies in rural Colorado struggle to compete with big chains to remain in business—and remain cornerstones of their communities. Read more here.

"More than half of the political comments posted publicly on social media in rural parts of six swing states last week criticized President Donald Trump for his handling of the Covid-19 pandemic," The Daily Yonder reports. That's an increase since the last such analysis a few weeks ago.

A USDA webinar on Thursday promised to give more details on how the agency will distribute $16 billion in aid to farmers, but it lasted only 15 minutes and gave few answers, Politico reports.

Death in Mud Lick digs into the opioid crisis in rural West Virginia, underlines the value of local journalists

A new book from former Charleston Gazette-Mail reporter Eric Eyre takes a deep dive into the opioid epidemic through the lens of Kermit, W.Va., a town of 382 people whose pharmacy distributed 12 million pain pills in three years. Death in Mud Lick details one woman's fight to seek accountability from major pharmaceutical companies after her brother's overdose death.

"The story is also a reporter’s firsthand account about what it’s like to mine for the truth while working for a newspaper fighting for survival on multiple fronts, as greedy corporate owners make serious budget cuts to maintain the paper’s profit margins and as combative politicians stonewall," Ralph Berrier Jr. reports for The Roanoke Times. "Death in Mud Lick is for readers who root for the underdog, who want justice served and who love newspapers."

Eric Eyre

Readers should appreciate the scale of Eyre's battle and what it accomplished, ProPublica reporter Ken Armstrong, a former colleague of Eyre's, writes for The New Yorker. Eyre researched and wrote the book while he was still cranking out near-daily stories for the paper, facing off against the powerful drug industry with little funding, decrepit equipment, and an increasingly difficult battle with Parkinson's disease. He persevered, and "his reporting led to restrictions on prescriptions, greater tracking, more transparency. He shamed an industry and saved lives. Working at a small newspaper, Eyre made a big difference," Armstrong writes.

For Eyre, who won a Pulitzer Prize in 2017 for his coverage of the opioid epidemic in rural West Virginia, the book perhaps serves as his final bow in journalism: With his Parkinson's getting worse, he submitted his resignation letter last week; Armstrong reports:. "The same day his book came out, Eyre left the paper."

Trump administration shielded Walmart from criminal prosecution over opioid prescriptions, investigation finds

A ProPublica investigation has found that top Department of Justice officials shielded Walmart from criminal prosecution in 2018 for allowing suspicious opioid prescriptions to be filled over the objections of thousands of Walmart pharmacists. This happened as the Trump administration told the public it would crack down on those responsible for the opioid epidemic, Jesse Eisinger and James Bandler report. Their blockbuster report is based on Walmart internal emails and documents, legal correspondence, and interviews with nine people familiar with the investigation.

Joe Brown, U.S. attorney for the Eastern District of Texas, and a team of employees including Heather Rattan, who has spent most of her career prosecuting drug cartels, began investigating Walmart in 2016. According to the evidence they gathered, Walmart pharmacists in Texas and other states reported hundreds of thousands of suspicious or inappropriate opioid prescriptions to their supervisors. They knew these opioids were being prescribed by "pill mill" doctors, and begged the corporate office to allow them to refuse to honor such prescriptions. Some of the doctors had been banned from sending prescriptions to all of Walmart's major competitors.

Walmart corporate officials didn't take broad action in response to these claims at the time, even though some customers who got those prescriptions died from overdose. The company said it could not cut off a doctor entirely, and that each prescription must be evaluated individually, the Texas prosecutors found. Some doctors were only banned after prosecutors began investigating Walmart, Eisinger and Bandler report. But pharmacists in some states had limited power to block individual doctors because of protective measures by state boards of pharmacy and medical boards.

The company appeared primarily concerned with the profitability of such opioid prescriptions: "An opioid compliance manager told an executive in an email, gathered during the inquiry and viewed by ProPublica, that Walmart’s focus should be on 'driving sales'," Eisinger and Bandler report.

It wasn't the first time Walmart had gotten in trouble for failing to vet opioid prescriptions; in 2011 the company entered into a secret settlement with the Drug Enforcement Administration in a similar case and promised to make greater efforts to curb improper filling of opioid prescriptions, admitting no wrongdoing. That settlement has not been previously reported. "Walmart had repeatedly run afoul of the Controlled Substances Act," Eisinger and Bandler report. " The company had received more than 50 'Letters of Admonition' from the DEA for its prescribing practices from 2000 to 2018, according to records obtained by ProPublica."

In 2018, Rattan, the federal prosecutor in East Texas, told Walmart she was going to indict it for violating the act, an unheard-of step against a Fortune 500 company, for failing to properly track and report suspicious opioid prescriptions.   Walmart had admitted to mistakes and appeared open to a civil settlement, but stopped cooperating with prosecutors in mid-2018. Through law firm Jones Day, which has deep ties throughout the government, Walmart "added a Trumpian tactic: At a moment when the president had established a habit of attacking the investigators in his own government, the company followed a similarly aggressive approach," Eisinger and Bandler report. "Walmart lawyers complained to Washington about the Texas prosecutors, accusing them of seeking to 'embarrass' the company while using the threat of criminal charges to extort a larger civil fine. Criminal and civil investigations can run in parallel, but it’s an ethical violation for prosecutors to use the threat of criminal penalties to generate a higher civil settlement."

A Walmart lawyer also said in a letter to a Justice Department official that criminally convicting Walmart could harm millions of senior citizens and low-income people who rely on federal programs for food and medicine, since a convicted corporation might be barred from participating in such programs. As prosecutors continued their chase, "Walmart exercised its PR and political muscle," Eisinger and Bandler report: In May 2018, the company announced it would limit first-time opioid prescriptions to no more than a seven-day supply.

Walmart got high-ranking Justice employees to intervene, and the department informed Walmart that it would decline to prosecute. The prosecutors didn't give up, and in October 2018 got a sympathetic ear from acting DEA Director Uttam Dhillon. They all headed to Main Justice to meet with Deputy Attorney General Rod Rosenstein. He refused to revive the criminal case, and suggested prosecution of individual employees. But Justice blocked that too, and Trump appointees in the department consistently sided with Walmart when the team filed a civil case, Eisinger and Bandler report. One of the Texas prosecutors resigned in protest in October 2019.

Ky. touts bill to rein in Medicaid pharmacy managers, whom rural, independent pharmacies blame for trouble and closure

Pharmacist Gregg Henry updates customers of his closed store. (Photo by Greg Eans, Owensboro Messenger-Inquirer)

The Kentucky Senate has passed a bill aimed at reining in the middlemen who decide who gets paid how much for drugs in Medicaid, a problem that advocates say is threatening independent rural pharmacies all over the country.

"We're going to be the first state in the country that is going to do something like this," the bill's sponsor, Sen. Max Wise, R-Campbellsville, told Melissa Patrick of Kentucky Health News. "There are going to be a lot of eyes on Kentucky." The bill is now in the state House.

Rosemary Smith of the Kentucky Independent Pharmacist Alliance, which represents 500 independent pharmacists, told Patrick, "This bill will allow us to stay open." Smith said she and her husband have been forced to close two of their drug stores because of low reimbursement rates from pharmacy benefit managers, who act as middlemen between insurance and drug companies; they determine what drugs are offered, how much is paid for the drug, and payments to pharmacists.

In Kentucky, each of the state's five Medicaid managed-care firms contracts with a PBM to manage the state's $1.7 billion-a-year prescription drug business. Wise's bill would require the state to hire a single PBM. CVS Health, an affiliate of the drugstore chain, which holds most of the state's current PBM business in contracts with manged-care firms, criticized the bill, Deborah Yetter reports for the Louisville Courier-Journal.

Gregg Henry told Renee Beasley Jones of the Owensboro Messenger-Inquirer that he was closing his pharmacy in Sacramento, Ky., after seven years because of the low reimbursements paid by the PBMs, which started in 2017. He said he lost $5,000 in January alone because of recent cuts.

"This little bitty pharmacy in this little bitty community stood up," Henry told Jones, in reference to at least two years of fighting against the PBMs. "I hope our martyrdom creates a wake-up call about the absolute necessity for the passage of this legislation."

Rural Minn. woman sues after two pharmacists refuse to fill morning-after pill prescription because of religious beliefs

McGregor in Aitkin County (Wikipedia)

A rural Minnesota woman has filed suit after two pharmacists refused to sell her emergency contraception because of their religious beliefs. She says the issue highlights how religious-objection rules hurt rural women, Katie Shepherd reports for The Washington Post.

Andrew Anderson, 39, lives in McGregor, a town of about 400 people. She and her longtime partner have one biological child and four adopted or foster children. When their condom broke in January 2019, Anderson called her gynecologist the next morning and received a prescription for Ella, an emergency contraceptive. The prescription was sent to Thrifty White Pharmacy, the only one in McGregor.

The pharmacist at Thrifty White, George Badeaux, refused to fill Anderson's prescription because he said it would be against his religious beliefs. Badeaux, who is also a pastor at a nearby church, advised her not to go to a nearby pharmacy because the employees there would also probably refuse to fill the prescription, Shepherd reports.

"Anderson did not give up. She drove about 20 miles to a CVS pharmacy in a neighboring town, where another pharmacist declined to fill her prescription," Shepherd writes. "Anderson said that pharmacist, who is not named in the suit, told her the pharmacy did not have Ella in stock and could not get it from a wholesale provider in time for her to take the pill, which must be taken within five days of unprotected sex.

Anderson said the CVS pharmacist called a Walgreens in Brainerd, more than 50 miles from her home, and told her that it didn't have the pill. However, when Anderson called the Walgreens herself, the pharmacist there confirmed that the CVS pharmacist had just called, and said the store did have Ella in stock and would be happy to fill her prescription the next day, Shepherd reports. She and her young son made a three-hour round trip in a blizzard to fill the prescription, he writes.

Anderson sued Badeaux, Thrifty White, and the unnamed CVS pharmacist who refused to fill her prescription and misinformed her about its availability at the Brainerd Walgreens. She notes in her lawsuit that, though Minnesota allows pharmacists to refuse to fill emergency contraception prescriptions because of personal beliefs, the law requires the objecting pharmacist to help the patient find another way to fill the prescription, and neither pharmacist did that, Shepherd reports.

"The lawsuit argues that refusing to provide women access to the morning-after pill is a form of sex discrimination and violates people’s civil rights," Shepherd reports. "Anderson said she believes rural women are particularly at risk to have their medical needs overshadowed by a pharmacist’s personal beliefs because there are so few places to buy medication."

Community pharmacies could be a key to getting more rural teens vaccinated for virus that causes sex-related cancers

Alabama Department of Public Health

There's a vaccine for a virus that causes sex-related cancer, but rural teens are less likely to get it or know about it. Rural pharmacies could help improve vaccination rates, writes Casey Daniel, a Ph.D. pharmacist who teaches in the family medicine department at the University of South Alabama.

"Human papillomavirus (HPV) is the most common sexually transmitted infection, with 80 million Americans currently infected and 14 million new cases of infection each year," Daniel notes, but only about two-thirds of 13-to-17-year-olds start the HPV vaccine series, and fewer than half have up-to-date vaccinations. Rural HPV vaccination rates are 11 percent lower than urban rates, partly because rural areas have fewer health-care providers, Daniel writes in the Journal of Rural Health.

He says that gap could be filled by pharmacies, which are more widespread than doctors' offices and open longer hours. "In the 2018 President's Cancer Panel report on HPV vaccination for cancer prevention, pharmacies were specifically recommended as a way to increase vaccine accessibility," he writes. "Most pharmacies are also ideally suited for immunizations because of their inherent infrastructure and storage capacity for various medications. Many pharmacies offer vaccines such as flu, pneumonia, and shingles, and therefore, they have established immunization protocols that can be easily adapted to HPV."

Convenience is important for HPV immunization "because this vaccination is a multi-dose series requiring subsequent visits," Daniel writes. "While large chain pharmacies have a broad, mass market appeal, there is a considerable case to be made for collaborating with 'community pharmacies' as alternative settings for HPV vaccination, particularly in rural and small-town settings. In these areas, independent community pharmacies are often an established part of the community. Community pharmacists frequently have personal relationships with their patients, knowing them both within and outside the bounds of the pharmacy, and have a unique, established trust. They are trusted providers within the community, acting as the first line of health care and consultation for many patients."

That's also important for HPV immunization because research has shown that rural parents are less likely to be aware of HPV and the vaccine. Community pharmacists "frequently have personal relationships with many local individuals," Daniel writes. "Therefore, they can function in both education and reinforcement regarding the importance of HPV vaccination. . . . In the exploration of alternative settings to increase HPV vaccination, community pharmacies have been significantly overlooked. Particularly in rural settings, these pharmacies have vast potential to reach under-served, disparate populations and serve crucial roles in addressing community health care needs and filling resource gaps."

Secret reports on opioid sales to be released; last day to sign up for Fri. workshop on covering epidemic, recovery

"A special master in a landmark national opioid trial has ordered the release of previously secret reports that detail “suspicious” orders of powerful painkillers placed by pharmacies and purchased from giant drug suppliers," Eric Eyre reports for the Charleston Gazette-Mail and The Herald-Dispatch in Huntington, W.Va. Special Master David Cohen, who is assisting with more than 2,000 lawsuits against drug companies in Cleveland's federal court, also ordered the Drug Enforcement Administration to unseal two additional years of data tracking all prescription opioid shipments to U.S. pharmacies. He also unsealed the transcripts from hundreds of depositions, including testimony from DEA agents and executives of pharmaceutical manufacturers and distributors.

"The unsealing of the records follows a yearlong legal battle by the Charleston Gazette-Mail, The Herald-Dispatch and The Washington Post to make the information public," Eyre reports. "The nation’s largest drug distributors and manufacturers fought for months to keep the pharmacy order reports and data under wraps. The reports and data single-out pharmacies that ordered unusually large numbers of prescription-opioid pain pills."

Prescription drug distributors are required under federal law to report to the DEA suspiciously large orders of opioids and then block such orders, but a congressional report last year said the drug makers routinely did not do this.

Though the DEA no longer opposed making the reports public, the companies wanted a judge to block their release, saying the reports were "confidential business data" that contained "trade secrets," Eyre reports.  They also said releasing the reports would violate privacy rights for pharmacies and customers, and said that unscrupulous pharmacies could learn from past reports how to "game the system" in order to avoid being flagged for suspicious orders in the future.

Cohen said some details in the suspicious orders might remain private if the pharmaceutical companies could show how the specific information in question would help rogue pharmacies divert drugs to the black market, Eyre reports.

Eyre will speak Friday morning at Covering Substance Abuse and Recovery: A Workshop for Journalists, in Ashland, Ky., just 10 miles down the Ohio River from Huntington. Registration is $60 and is still available, but will close for certain today.

Quick hits: Cricket burgers; fewer children have health insurance; EPA shunts blame for FOIA policy

Here's a roundup of stories with rural resonance; if you do or see similar work that should be shared on The Rural Blog, email us at heather.chapman@uky.edu.

The next wave of plant-based "meat" could have an unexpected ingredient: crickets. Read more here.

The Environmental Protection Agency is blaming an advisory board's recommendations for part of its controversial new Freedom of Information Act policy. Read more here.

The number of children with no health insurance continued climbing in 2018, especially among the lower-middle class in states that didn't expand Medicaid. Read more here.

A rural hospital CEO is tapping into people's desire to "buy local" in order to help his hospital stay afloat. Read more here.

As rural pharmacies close, Western states seek a solution. Read more here.

Rural doctor's weight-loss clinic sees big results with old-fashioned methods: eat better food, less of it, and exercise

Dr. Carol Peddicord holds a model representing five
pounds of body fat. (Clinton County News photo)

A doctor and a pharmacist in rural Albany, Kentucky are seeing big results in the fight against obesity after opening a weight-loss clinic. Since The Doctor's Health and Weight Loss Clinic opened in January, its 433 patients have lost a collective 4,079 pounds, and most have maintained their weight loss, Brett Gibson of the Clinton County News reports.

Dr. Carol Peddicord and pharmacist Arica Collins of Dyer Drug Co. came up with the idea for the clinic after seeing how many patients came in looking for a quick fix to lose weight. But the best way to do that is to live a healthier lifestyle, not through a pill or a crash diet, the News notes.

The emphasis is on healthier, Peddicord told the News: "We don’t want people to be skinnier, we want them to be healthy and live longer."

Obesity is a significantly bigger problem in rural areas than in suburban and urban areas, according to the Centers for Disease Control and Prevention. Among adults, 34.2% of rural residents are obese, compared with 28.7% in metropolitan counties.

Though the duo first conceived of the clinic because they were worried about children's health, most of their patients are women between 35 and 58. There are a few high schoolers, though, and they're starting to see more men coming in. That's good, Peddicord told the News, because men typically have heart disease earlier in life.

Albany, in Clinton County, Kentucky
(Wikipedia maps)

The clinic, which takes insurance, offers individually tailored wellness plans for patients, depending on whether they have high blood pressure, diabetes, and/or heart disease. They offer diet plans and will soon have plans for meal replacements such as shakes, the News reports.

Though Peddicord was glad to note that the clinic's patients had lost 680 pounds last month, she told the News that pounds aren't the only thing that matter. Patients have seen other "non-scale victories," such as being able to stop taking insulin for diabetes. "People are losing weight, feeling better and are able to exercise," Peddicord said.

Rural coroner made the tough call on local opioid epidemic

Coroner Steve Talbott, in his funeral home
(Photo by Michael S. Williamson, The Washington Post)

How many rural coroners, witnessing death after death from opioid overdoses, would call police in an effort to see how their county was being inundated by the misused prescription drugs? We don't know the answer to that question, but we do know what funeral director Steve Talbott, the elected coroner of Clinton County, Kentucky, for the last 25 years, did. He made the calls, and one result was the conviction of a local physician who shared a building with the pharmacy that dispensed more opioids per person per county in 2006-12 than any in the U.S.

Jenn Abelson, Andrew Ba Tran, Beth Reinhard and Aaron C. Davis of The Washington Post reported the story last week, following the Post's publication of other stories drawing on the Drug Enforcement Administration database for those years. Their story is a look at the opioid epidemic from the bottom up, in Albany, Paintsville and Booneville, Ky.; Kanab, Utah; and Carthage, Tenn., where pharmacies were funnels for large volumes of painkillers.

When Talbott responded as coroner to an overdose death, the Post reports, "Friends and relatives of the dead rarely had answers to Talbott’s questions: What kind of pills did they take and where did they come from? A toxicology report often answered the first question. It was the second one that typically eluded Talbott. As overdose deaths soared, Talbott repeatedly called the state police, hoping they could identify the source of opioids poisoning his community."

Clinton County (Wikipedia map)

Since 2006, 41 people have died of prescription opioid overdoses in the county of 10,000. Talbott told the Post that law enforcement took far too long to pay attention. "The federal investigation began in 2015 after Talbott noticed multiple overdose deaths involving patients of a local physician, Michael L. Cummings, and the Kentucky Board of Medical Licensure expert found Cummings’s treatment of several patients fell below minimum standards of care, court records show," the Post reports. "In 2017, Cummings was charged in federal court with the illegal distribution of controlled substances, which resulted in the deaths of three patients." He pleaded guilty in March to 13 counts of illegally prescribing controlled substances, and was sentenced July 24 to 30 months in prison and fined $400,000. Cummings had his medical practice in the same building as Shearer Drug.

The Post reports, "The 6.8 million opioid pills bought by Shearer Drug from 2006 through 2012 accounted for 66 percent of the total ordered by the county’s five pharmacies, according to The Post’s analysis." When Talbott heard those figures from the Post, he told the newspaper: “It’s a lot of pain medication for this little town.”

"Talbott, who said he grew up with [pharmacist Kent] Shearer and attended the same school, hasn’t talked to the pharmacist in a few months," the Post reports. "Talbott said the overdose deaths have waned since Cummings was indicted in 2017, but the epidemic is far from over." He told the paper, “There were just too many people dying from these drugs in such a small place. I hate these drugs. They are awful.”

Database, Post map show how many pain pills individual pharmacies dispensed in 2006-12; the top 10 were all rural

Map by The Washington Post; click on it for a larger version or click here to view the interactive version.

How many opioid pills did your local pharmacy dispense between 2006 and 2012? The Washington Post, expanding on its earlier reporting of databases from the Drug Enforcement Administration, has analyzed and mapped the data to provide a first-of-its-kind, granular look at how many prescription painkillers flowed through individual pharmacies and into communities during that time frame. "The Post’s analysis of the data found that a small percentage of pharmacies received nearly half of the pills distributed in the United States between 2006 and 2012," the Post reports.

"This analysis used two measures for comparison: the number of pills per person per year within a five- to 10-mile radius of each pharmacy and the cumulative number of pills per person based on the county population," The Post reports. All 10 of the pharmacies that dispensed the most pills per person were rural; Shearer Drug in Albany, Ky., led the pack with 96 pills per person per year, for a total of 6,778,550. Albany is the only town in Clinton County, which had 10,272 in the 2010 census.

UPDATE, Aug. 13: The Post "says local journalists in over 30 states have collectively published more than 90 articles based on the data. They’re listed here," Columbia Journalism Review reports.