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The Crisis in Rural Pharmacy Practice
The Crisis in Rural Pharmacy Practice Attracting pharmacists to rural areas requires capitalizing on benefits to offset perceived deficiencies. by .Joye Ann Billow, PhD, Gary C. Van Riper, MS, Linda L. Baer, PhD, and Ronald G. Stover, PhD
Introduction There is a growing concern over the status of health care delivery in rural areas. Although many medical models follow an urban profile, 25% (approximately 63 million people) of the current United States population reside in rural areas. This fact is critical when we view the special health care needs of the disproportionately high populations of elderly, minorities, and poor in these areas. The medical crisis in small towns, caused by rising health care costs and increasing insurance rates combined with a decline in population and the number of potential patients, is well-documented. The pharmacist is crucial in the health delivery model. As the number of clinics and hospitals decline in rural areas and as patients seek medical care in large population centers, the number of pharmacy practices decline as well. 1-5 The U.S. Department of Commerce defines rural areas as having a population of fewer than 2,500 people. With 51 % of the population living in rural areas, South Dakota ranks as the third most rural state. 6,7 Thus, South Dakota provides a good case study for rural pharmacy.
Influences on Choice of Practice Setting To better understand the perceptions of pharmacists, an interdisciplinary team of researchers conducted a survey of practitioners and pharmacy students in South Dakota. The factors that influenced whether or not pharmacists established their practices in rural areas were examined. The results (shown in Tables 1 and 2) directly paralleled Vol. NS31~ No. 12 December 1991/891
Pioneer Drug, Elk Point, S. Dak. (population 1,4(0). The pharmacy has been in continuous operation in the same location since 1904. Owner Kevin Wurtz adtkd Edgar's 0/' Fashioned Soda Fountain in 1987.
student responses indicating where they intend to practice following graduation. Income is the compelling factor for most pharmacists and pharmacy students choosing a practice location. However, most rural areas cannot compete with urban salaries, and attention must focus on factors that may cOlnpensate for lower salaries. Prospective employers must use these factors to vigorously promote the benefits of living and working in rural areas as part of an overall recruitment plan. AMERICAN PHARMACY
.4l1li
One factor is job satisTable 1. faction. When asked Willingness of Pharmacists to Own/Operate a about satisfaction derived Pharmacy in a Rural Area, from the challenge of their by Assured Income and Residence work, both rural and urban If Assured Good Income pharmacists clearly defined Participants' If Assured Adequate Income Urban· Rural· Rural· Urban· Responses their work as challenging, 25.9% 48.7% Willing to own and operate 32.4% 10.9% with rural pharmacists 13.1% Willing to operate notown 17.6% 8.9% 15.9% finding their work slightly 4.9% 3.3% 1.8% 1.0% Willing to own not op~rate more challenging than 23.0% 10.6% 25:0% 22.6% Reluctant to own or operate urban pharmacists. 28.8% 13.3% 50.5% 19.4% Not interested Another indicator of job 4.3% 9.7% 4.6% 3.9% Other satisfaction is the worker's ,- N 556 113 108 541 willingness to choose the field again, even after sev* Current Residence eral years of practice. Note: All differencespetween,rural and urban ,Vlfere found to be significant at the 5% level. More rural pharmacists (75%) than urban pharmacists (590/0) indicated that, Table 2 . given the choice, they would still go into pharmacy. Five Overall Most IRlportant Another factor is quality of life, which was defined by Factors in Determining friendliness, clean environment, good place to raise chilResidential Preference dren, reiatively low cost of living, and outdoor recreation. Although quality of life was not sufficient in itself Rank Rank (Urban Residence) (Rural Residence) Factors to offset the perceived value of the higher urban income, it appealed to many respondents. The results of this survey indicate that the traditional, Income 1 1 urban model of pharmacy practice is not feasible in Housing 2 2 retaining pharmacists in rural settings. The survey identiSafety 3 3 fied factors that might be acceptable as trade-offs against Quality of Schools 4 4 income to make a rural practice setting more desirable. 5 Work Schedule For example, students identified a safe environment, type Type of Practice 5 of practice, suitable hOUSing, and job opportunities for spouse as factors influencing their decisions. The profession must be creative in finding and applying innovative ways to capitalize on these compensating factors and in • Develop programs with financial groups, both public developing a new model for rural pharmacy practice. and private, to establish loan packages to assist in the
Recommendations Based on the results of our survey, we formulated the following recommendations, which may contribute to the understanding of pharmacy services in rural areas and may prove useful in averting the anticipated shortfall of these services. • Promote the quality of life, both personal and professional, as a bonus for those selecting rural practice. • Provide assistance in finding an appropriate position for both the pharmacist and the spouse. Colleges and schools of pharmacy may play a role as liaison in such a placement service activity for students. However, the major effort must come from within the profession by prospective employers. AMERICAN PHARMACY
purchase of rural pharmacies. • Develop tuition waiver or loan forgiveness programs for students as an incentive to enter rural practice. • Develop group practices where ·the pharmacist would be closely involved with other members of the health care team, either locally in a clinic setting or as an extension of an urban unit. • Balance the lower rural income with good benefit packages, attractive work schedules, guaranteed relief help for vacations, financial assistance for care and home, a partnership option, and bonus incentives. • Lobby for the banning of mail order pharmacy . • Develop or allow the incoming pharmacist to develop more diverse services, focusing on the pharmacy as a health care facility rather than a business; e.g., provide testing and monitoring with appropriate time for consultation, combine with veterinary drug supply dealers , December 1991/892
Vol. NS31, No. 12
expand services to nursing homes, or develop home health care supplies and services . • Develop a satellite pharmacy system with a pharmacist rotation system to serve several rural communities at locations in each . • Develop a mobile pharmacy that can physically travel on a rotation schedule among seve ral rural communities . Establishing mobile pharmacies may be difficult, since pharmacy licenses usually specify a permanent, physical location . Le gisla tive action would b e necessary to implement this model.
Conclusion It is not enough to determine the Casey's Qinic Pharmacy, Kennebec, S. Dak. (population' 3(0). Owner Terry residential preferences of future pharCasey leases space behind the medical clinic. ·The pharmacy has been in macist . Researchers and policy-mak- operation since 1981. ers alike need to determine the most important fac tors used by pharmacy f oye Ann Billow, PhD, is professor, Department ofPharmaceutistudents to determine their prefe rred residential area . cal Sciences, South Dakota State University, Brookings. Gary C. Van The factors influencing migration can be used in policy Riper, MS, is assistant prof essor, Department of Pharmaceutical Scidecisions designed to attract pharmacists into rural areas. In our survey, most pharmacists and pharmacy stuences, South Dakota State University. Linda L. Baer, PhD, is vice preSident f or academic affairs, Bemidj i State University, Bemidji, dents clearly indicated that income is the compelling facMinn. Ronald G. Stover, PhD, is associate professor, Department of tor in selection of their precise setting. Combined with the fact that the recent National Pharmacists' CompensaRural Sociology, South Dakota State University. tion Survey found that the lowest pharmacist incomes The work reported was supported by a grant from the National were in rural areas,8 it is not surprising that there is a Council of State Pharmaceutical Association Executives and The shortage of pharmacists to serve these areas. Upj ohn Company to the South Dakota Pharmaceutical Association. The recommendations derived from this study consist primarily of straightforward responses that capitalize on the benefits of rural life and pharmacy practice to offset References the perceived deficiencies. Many of these recommenda1. Subcommittee on Intergovernmental Relations, Committee on Governtions, such as financial aid for education , have been used mental Affairs. Governing the heartland: can rural communities survive by other professions and their successful experie nces the farm crisis? Washington, DC: US Senate, 1986. may serve as models for pharmacy. 2. Bauer JC, Weis EM . Rural America and the revolution in health care. Rural Development Perspectives. June 1989;2-6. The concept of the mobile pharmacy is perhaps the 3. Wright JS, Lick DW. Health in rural America: problems and recommen most innovative idea proposed , although innovation is in dations. New Dimensions in Rural Policy: Building upon Our Heritage. Washington, DC: US Government Printing Office, June 5, 1986;461-9. the eye of the beholder since a model in the form of the 4. Hosokawa MC. Issues in rural health care. New Dimensions in Rural bookmobile was developed decades ago. The problems Policy: Building upon Our Heritage. Washington, DC: US Government associated with this model emphasize that the problems Printing Office, June 5, 1986;470-6. 5. Zwaska MA. Issues facing small/rural hospital pharmacies. Pharm faced by rural pharmacy practice w ill not be solved by Times. April 1989(hospital edition);9HPT-12HPT. magic, but must be actively and thoughtfully addressed 6. Statistical Abstracts of the United States, 109th ed. Washington, DC: US by the members of the profession. Department of Commerce. January 1989;xvi. 7. South Dakota State University Census Data Center Newsletter, Graphic Clearly the people in rural areas desire and deserve a Summary of South Dakota 1990. "quality of life" comparable to the urban areas. Innova8. Schondelmeyer SW, Mason HL, Schafermeyer KW, et al. National Phartive models that capitalize on the technological and commacists' Compensation Survey. Washington, DC: American Pharmaceutical Association, 1990;149. munication advances will allow continued quality health services to these areas.
Vol. NS31, No. 12 December 19911893
AMERICAN PHARMACY
Introduction There is a growing concern over the status of health care delivery in rural areas. Although many medical models follow an urban profile, 25% (approximately 63 million people) of the current United States population reside in rural areas. This fact is critical when we view the special health care needs of the disproportionately high populations of elderly, minorities, and poor in these areas. The medical crisis in small towns, caused by rising health care costs and increasing insurance rates combined with a decline in population and the number of potential patients, is well-documented. The pharmacist is crucial in the health delivery model. As the number of clinics and hospitals decline in rural areas and as patients seek medical care in large population centers, the number of pharmacy practices decline as well. 1-5 The U.S. Department of Commerce defines rural areas as having a population of fewer than 2,500 people. With 51 % of the population living in rural areas, South Dakota ranks as the third most rural state. 6,7 Thus, South Dakota provides a good case study for rural pharmacy.
Influences on Choice of Practice Setting To better understand the perceptions of pharmacists, an interdisciplinary team of researchers conducted a survey of practitioners and pharmacy students in South Dakota. The factors that influenced whether or not pharmacists established their practices in rural areas were examined. The results (shown in Tables 1 and 2) directly paralleled Vol. NS31~ No. 12 December 1991/891
Pioneer Drug, Elk Point, S. Dak. (population 1,4(0). The pharmacy has been in continuous operation in the same location since 1904. Owner Kevin Wurtz adtkd Edgar's 0/' Fashioned Soda Fountain in 1987.
student responses indicating where they intend to practice following graduation. Income is the compelling factor for most pharmacists and pharmacy students choosing a practice location. However, most rural areas cannot compete with urban salaries, and attention must focus on factors that may cOlnpensate for lower salaries. Prospective employers must use these factors to vigorously promote the benefits of living and working in rural areas as part of an overall recruitment plan. AMERICAN PHARMACY
.4l1li
One factor is job satisTable 1. faction. When asked Willingness of Pharmacists to Own/Operate a about satisfaction derived Pharmacy in a Rural Area, from the challenge of their by Assured Income and Residence work, both rural and urban If Assured Good Income pharmacists clearly defined Participants' If Assured Adequate Income Urban· Rural· Rural· Urban· Responses their work as challenging, 25.9% 48.7% Willing to own and operate 32.4% 10.9% with rural pharmacists 13.1% Willing to operate notown 17.6% 8.9% 15.9% finding their work slightly 4.9% 3.3% 1.8% 1.0% Willing to own not op~rate more challenging than 23.0% 10.6% 25:0% 22.6% Reluctant to own or operate urban pharmacists. 28.8% 13.3% 50.5% 19.4% Not interested Another indicator of job 4.3% 9.7% 4.6% 3.9% Other satisfaction is the worker's ,- N 556 113 108 541 willingness to choose the field again, even after sev* Current Residence eral years of practice. Note: All differencespetween,rural and urban ,Vlfere found to be significant at the 5% level. More rural pharmacists (75%) than urban pharmacists (590/0) indicated that, Table 2 . given the choice, they would still go into pharmacy. Five Overall Most IRlportant Another factor is quality of life, which was defined by Factors in Determining friendliness, clean environment, good place to raise chilResidential Preference dren, reiatively low cost of living, and outdoor recreation. Although quality of life was not sufficient in itself Rank Rank (Urban Residence) (Rural Residence) Factors to offset the perceived value of the higher urban income, it appealed to many respondents. The results of this survey indicate that the traditional, Income 1 1 urban model of pharmacy practice is not feasible in Housing 2 2 retaining pharmacists in rural settings. The survey identiSafety 3 3 fied factors that might be acceptable as trade-offs against Quality of Schools 4 4 income to make a rural practice setting more desirable. 5 Work Schedule For example, students identified a safe environment, type Type of Practice 5 of practice, suitable hOUSing, and job opportunities for spouse as factors influencing their decisions. The profession must be creative in finding and applying innovative ways to capitalize on these compensating factors and in • Develop programs with financial groups, both public developing a new model for rural pharmacy practice. and private, to establish loan packages to assist in the
Recommendations Based on the results of our survey, we formulated the following recommendations, which may contribute to the understanding of pharmacy services in rural areas and may prove useful in averting the anticipated shortfall of these services. • Promote the quality of life, both personal and professional, as a bonus for those selecting rural practice. • Provide assistance in finding an appropriate position for both the pharmacist and the spouse. Colleges and schools of pharmacy may play a role as liaison in such a placement service activity for students. However, the major effort must come from within the profession by prospective employers. AMERICAN PHARMACY
purchase of rural pharmacies. • Develop tuition waiver or loan forgiveness programs for students as an incentive to enter rural practice. • Develop group practices where ·the pharmacist would be closely involved with other members of the health care team, either locally in a clinic setting or as an extension of an urban unit. • Balance the lower rural income with good benefit packages, attractive work schedules, guaranteed relief help for vacations, financial assistance for care and home, a partnership option, and bonus incentives. • Lobby for the banning of mail order pharmacy . • Develop or allow the incoming pharmacist to develop more diverse services, focusing on the pharmacy as a health care facility rather than a business; e.g., provide testing and monitoring with appropriate time for consultation, combine with veterinary drug supply dealers , December 1991/892
Vol. NS31, No. 12
expand services to nursing homes, or develop home health care supplies and services . • Develop a satellite pharmacy system with a pharmacist rotation system to serve several rural communities at locations in each . • Develop a mobile pharmacy that can physically travel on a rotation schedule among seve ral rural communities . Establishing mobile pharmacies may be difficult, since pharmacy licenses usually specify a permanent, physical location . Le gisla tive action would b e necessary to implement this model.
Conclusion It is not enough to determine the Casey's Qinic Pharmacy, Kennebec, S. Dak. (population' 3(0). Owner Terry residential preferences of future pharCasey leases space behind the medical clinic. ·The pharmacy has been in macist . Researchers and policy-mak- operation since 1981. ers alike need to determine the most important fac tors used by pharmacy f oye Ann Billow, PhD, is professor, Department ofPharmaceutistudents to determine their prefe rred residential area . cal Sciences, South Dakota State University, Brookings. Gary C. Van The factors influencing migration can be used in policy Riper, MS, is assistant prof essor, Department of Pharmaceutical Scidecisions designed to attract pharmacists into rural areas. In our survey, most pharmacists and pharmacy stuences, South Dakota State University. Linda L. Baer, PhD, is vice preSident f or academic affairs, Bemidj i State University, Bemidji, dents clearly indicated that income is the compelling facMinn. Ronald G. Stover, PhD, is associate professor, Department of tor in selection of their precise setting. Combined with the fact that the recent National Pharmacists' CompensaRural Sociology, South Dakota State University. tion Survey found that the lowest pharmacist incomes The work reported was supported by a grant from the National were in rural areas,8 it is not surprising that there is a Council of State Pharmaceutical Association Executives and The shortage of pharmacists to serve these areas. Upj ohn Company to the South Dakota Pharmaceutical Association. The recommendations derived from this study consist primarily of straightforward responses that capitalize on the benefits of rural life and pharmacy practice to offset References the perceived deficiencies. Many of these recommenda1. Subcommittee on Intergovernmental Relations, Committee on Governtions, such as financial aid for education , have been used mental Affairs. Governing the heartland: can rural communities survive by other professions and their successful experie nces the farm crisis? Washington, DC: US Senate, 1986. may serve as models for pharmacy. 2. Bauer JC, Weis EM . Rural America and the revolution in health care. Rural Development Perspectives. June 1989;2-6. The concept of the mobile pharmacy is perhaps the 3. Wright JS, Lick DW. Health in rural America: problems and recommen most innovative idea proposed , although innovation is in dations. New Dimensions in Rural Policy: Building upon Our Heritage. Washington, DC: US Government Printing Office, June 5, 1986;461-9. the eye of the beholder since a model in the form of the 4. Hosokawa MC. Issues in rural health care. New Dimensions in Rural bookmobile was developed decades ago. The problems Policy: Building upon Our Heritage. Washington, DC: US Government associated with this model emphasize that the problems Printing Office, June 5, 1986;470-6. 5. Zwaska MA. Issues facing small/rural hospital pharmacies. Pharm faced by rural pharmacy practice w ill not be solved by Times. April 1989(hospital edition);9HPT-12HPT. magic, but must be actively and thoughtfully addressed 6. Statistical Abstracts of the United States, 109th ed. Washington, DC: US by the members of the profession. Department of Commerce. January 1989;xvi. 7. South Dakota State University Census Data Center Newsletter, Graphic Clearly the people in rural areas desire and deserve a Summary of South Dakota 1990. "quality of life" comparable to the urban areas. Innova8. Schondelmeyer SW, Mason HL, Schafermeyer KW, et al. National Phartive models that capitalize on the technological and commacists' Compensation Survey. Washington, DC: American Pharmaceutical Association, 1990;149. munication advances will allow continued quality health services to these areas.
Vol. NS31, No. 12 December 19911893
AMERICAN PHARMACY