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Rural Oregon patients can have issues with Access

Getting medications in rural areas of Oregon can prove difficult for some patients


Murray’s Drug is a throwback to a simpler time.

Opened in 1959, long before national drugstore chains and mail-order pharmacies dominated the prescription world, the family-owned business is still the only place in town for the 1,200 residents of Heppner to fill a prescription. In fact, between their Heppner and Condon stores, pharmacists John and Ann Murray and their daughter, Laurie Murray-Wood, run the only brick-and-mortar pharmacies in all of Morrow, Gilliam, Sherman and Wheeler counties.

“It’s hard to keep these pharmacies open six or seven days a week,” he said. “When we were raising our kids and Ann and I were the only pharmacists, we had two stores to cover, so five days kind of became the norm.”

As a result, Heppner is one of many towns across Oregon with limited access to prescription drugs. A recent analysis from Oregon State University suggests that the lack of pharmacy services may be boosting the rates of hospital readmissions among seniors, coming at great cost to both patients and the health care system.

The study tallied the cumulative number of hours pharmacies were open in each primary care service area across Oregon, then compared those to readmission rates at local hospitals. In urban areas with plentiful access to pharmacies, hospital readmission rates among patients over the age of 65 were lower, at about 14.7 percent of discharges. In rural areas where pharmacies were open fewer hours per day, hospital readmission rates were a half percentage point higher at 15.3 percent.

“That’s pretty significant considering the number of patients that are admitted into hospitals in Oregon each year, and when you translate that to the amount of money that’s being saved in reducing readmissions,” said Sarah Bissonnette, an OSU post-doctoral fellow and lead author of the study.

Rural hospitals do what they can to help patients but are often limited in how much medication they can provide at discharge. Pioneer Memorial Hospital in Heppner has a drug room that supplies medications for inpatient or emergency room patients, said Pioneer CEO Bob Houser. “They can get most of their pharmacy fills here if they are sent home on a weekend when Murray’s Drug is closed.”

“The drug room in the hospital is not a retail pharmacy, but we are allowed to send home up to a three-day supply of drugs with the patient to use until the pharmacy is open.”

But if patients need medications not stocked by the hospital, they may need to drive an hour to Hermiston to get the prescription filled.

The Murrays have taken multiple steps to limit the impact on their community residents. They publish an emergency number that local residents can call if they cannot wait until morning or through the weekend to fill a script.

“I fear that it does affect admissions,” he said. “We try to provide services and get it to them when they need it. But say that person is timid, or feels it’s an imposition, even though it’s endangering their health. The wait to get medicine or going without medicine is always a bad thing.”

Patients treated for pneumonia might be started on antibiotics and then sent home with a prescription for more. But if they can’t get to a pharmacy to fill that prescription for a day or two, that infection could return. Or heart failure patients who can’t fill a prescription for a diuretic could see fluid build up in their lungs and have difficulty breathing.

The researchers found that while pharmacies in Portland were open more than 3,800 hours each week, some rural areas had only a single pharmacy, open 54 hours per week.

“There are only two 24-hour pharmacies in the state of Oregon, and both are in the Portland area,” said David Lee, an OSU assistant professor of pharmacy and senior author of the study. “So if you need medication at kind of an odd hour, the only place you can do it is Portland.”

Because pharmacy access was lower in rural areas, the analysis could not tease out the different impact of pharmacy hours versus other limitations of rural areas — such as the lack of doctors or support services — that could also play a role in higher readmission rate s.

“There’s been research showing that rural communities have less access to physicians and other health care entities,” Bissonnette said. “We think it’s important to consider pharmacies as well.”

But hospitals now have a vested interest in ensuring patients can get their medications after discharge. Since 2010, Medicare has levied increasing financial penalties on hospitals if too many patients need to be readmitted within 30 days. Some hospitals across the country are now opening dispensaries to ensure their patients aren’t going without.

Bissonnette said while some states have regulations that prevent hospitals from sending patients home with more than a day’s supply of medications, it’s largely a resource issue.

“Hospital pharmacies aren’t set up to do the outpatient billing of insurance, so that’s a huge barrier,” she said. “It might mean an extra pharmacist when you only have one, so that’s a significant amount of staff increase and money.”

The correlation was clearly visible in the data for Central Oregon. Bend has 14 pharmacies and St. Charles Bend had a readmission rate of 13.5 percent. Redmond with six pharmacies has a slightly higher readmission rate at 14.6 percent, while Madras and Prineville, with three pharmacies each, had rates of 15.4 and 15.7 percent, respectively.

Michael Powell, pharmacy director at St. Charles Bend, said he believed that lack of pharmacy access did contribute to readmission rates, although the hospital had not yet quantified the impact. The hospital is running a pilot program on one nursing unit, having pharmacists deliver prescriptions and counsel patients at their bedside prior to discharge. That also helps to identify when patients are unable to afford their medications so they can be referred to the hospital’s assistance programs.

“I do believe that we will have significant positive impact on readmission rates through these programs,” Powell said. “But we do not have data to show this yet.”

The OSU researchers also found that pharmacies and hospitals tended to be located close together. So patients who lived farther from a hospital had more difficulty filling their prescriptions.

Some Murray’s Drug customers must travel three hours round trip to pick up their medications. If someone forgets or has trouble making the trip, the Murrays are often there to close the gap. Two months ago, a patient in Fossil had run out of medications, so the Murrays sent an employee from their Condon store on a two-hour delivery trip.

“That’s the kind of stuff we do in rural areas,” he said. “It doesn’t pay not to help people.”

Lee said mail-order services could help improve medication access for patients in rural areas, but recommended that hospitals follow up with a phone call to ensure that patients understand how to take their medication and what the potential side effects could be.

The Murrays, however, counter that mail-order pharmacies are hurting access. As more insurance companies require patients to use mail-order pharmacies, they’re putting independent drug stores out of business. And that might leave a discharged patient nowhere to fill prescriptions on a same-day basis. The Murrays and other independent pharmacists in Oregon are pushing for legislation that would prevent pharmacy benefit managers from excluding community pharmacies.

“They want us to be there for their antibiotics. That’s unfair,” Ann said. “We just want a level playing field.”