Early on in the pandemic, access was an issue in these Type 1 pharmacy deserts, which led to lower vaccination rates in those communities. The pandemic impacted closures as well, Qato pointed out. “There were more temporary closures but also many pharmacies that closed permanently,” she said. “At the same time, pharmacies are playing a more important role in providing and responding to the covid pandemic with testing and vaccines. The importance of pharmacies was underscored during covid—they have always been important in addressing public health emergencies.”
Even prior to the pandemic, Qato continued, pharmacies offered key services such as immunizations, point-of-care testing and access to things like contraceptives and naloxone. “Anything you can get at a pharmacy is less accessible if you don’t have a pharmacy nearby. It’s a real problem with real health impacts. It was reinforced during the pandemic. The communities that really need vaccines don’t have a pharmacy to go get them. That’s important because 80 percent of covid vaccines are administered at retail pharmacies. Minorites are most affected and disproportionately die from covid but have the hardest time getting the vaccine.”
Wisseh’s study found that a pharmacy shortage often equates to fewer clinical pharmacy services, such as health screenings and medication management. “In regards to medication adherence, access becomes an issue,” she said. “It can lead to primary medication nonadherence where people don’t fill the prescription at all. If you are not filling prescriptions for chronic conditions such as high blood pressure, diabetes, asthma and COPD, you run the risk of them being uncontrolled. That’s one of the key things I would think would be an issue for not being able to get medication. Another one is not having insurance—are you going to spend your money on medication when you have to pay rent or buy food?” As Qato noted, getting prescriptions filled on time is often not related to personal choice but rather a function of living in minority neighborhoods, which can make it more difficult to get to the pharmacy.
“We need more data and evidence on the impact of pharmacy access on health outcomes and on medication use outcomes,” Qato said. “From what we know so far, we should at least ensure equitable access to pharmacies. There shouldn’t be fewer pharmacies in neighborhoods that need them more. Policies that encourage pharmacies to stay open should be a priority.”
Training Students to Examine Root Causes
One concrete step that can reduce barriers to access is increasing pharmacy reimbursement rates, according to Qato. But she cautioned that any policies aimed at increasing access must address equity. An Illinois program that began two years ago intended to ensure that the state would increase pay to pharmacies for Medicaid prescriptions. However, some pharmacies in urban areas did not meet eligibility criteria, so while rural communities benefitted, many minority neighborhoods with pharmacy shortages did not.
“You need to develop policies that have equity at their core,” she noted. “The distribution of pharmacies is totally inequitable. We have to address the problem focusing on policy changes to prevent closures, to encourage new pharmacies to open. Pharmacy networks and plan requirements don’t allow people to use any pharmacy they want to. Most of the time the ones in networks that are preferred are pharmacies that are chains, and we know that if there’s a pharmacy nearby [in minority communities] the closest one is usually an independent. And they are excluded from these networks. Insurance doesn’t cover the medications if they fill them at that pharmacy.”
To prepare future pharmacists to address access issues, Wisseh said schools must examine social determinants of health and any social identities that have consistently faced systemic discrimination. “We should be training students to understand structural competency. Health is not just biology,” she said. “We need to do more to integrate some of those social and structural aspects that shape different communities’ health.”
Exploring why medication access is the way it is regarding who gets insurance coverage and why certain groups are marginalized is also necessary, she added. “It’s also making sure faculty are prepared to teach on such topics. From what we’ve found in our recent review article on the incorporation of social determinants of health with regards to structural racism, sometimes faculty don’t know how to teach it. Being able to educate students on these issues and partnering with community organizations to work with the underserved would definitely help.”
Qato agreed that while pharmacy school programs that focus on outreach in underserved neighborhoods are a good start, she said it is crucial to expose student pharmacists to community-level barriers in accessing medications. “Getting into those communities and talking to pharmacies that had to close and why they closed. Meeting with community organizations and patients affected by closures. Getting students to understand what’s happening on the ground,” she explained. “Students are trained to focus on clinical care and ensuring that patients get the right medications. What’s missing is before we get there—before we get patients to control their diabetes or hypertension—we need to know why it’s not controlled. Getting at the root causes of medication safety and adherence is important, and we do that by looking at people not just by race but also where they live and how that may impact medication use. We don’t see a lot of that training.”
She acknowledged that this has only recently become a research priority, but it presents an opportunity for student pharmacists to learn how to interact with patients and understand the why behind their situations. “We want students to understand the policy issues that impact these problems that their patients may be reporting,” Qato continued. “What tools do pharmacists and students have to address those problems? For pharmacy schools to equip students with whatever solutions are available and make sure pharmacists and trainees use them would go a long way. If a non-adherent patient comes in or has uncontrolled blood pressure, it’s important to investigate why. Do they experience barriers in getting prescriptions filled? Did their pharmacy close? There should be options for them so they can take the medications they need without that getting disrupted. Maybe it’s making them aware of a mail-order option, but students aren’t trained to ask or respond to those barriers.”
Wisseh said pharmacy schools across the country are at various stages of addressing these issues, but many are working toward building community partnerships and integrating diversity, equity, inclusion and antiracism in the curriculum. “At UCI, I am currently developing a series with an interprofessional education course that looks at deeper understanding of culture and group-based trauma for minority communities so students can have understanding of cultural and structural competencies,” she said. “We’re trying to be more aware and move toward cultural humility.” She echoed Qato’s sentiment that a major step toward greater understanding involves working with populations that lack access. “On a population level it has to do with working within the community and having programs that would help. We need more data to understand how this is affecting communities.”
Jane E. Rooney is managing editor of Academic Pharmacy Now.