Equitable access and reimbursement for pharmacy-based services: A case study of adult vaccinations

Abstract

Community pharmacies are vital access points for healthcare in the United States. The COVID-19 pandemic highlighted the indispensable role of community pharmacists for patients and the healthcare system. However, not every neighborhood has good access to pharmacies, and pharmacies are facing increased financial and operational pressures which threaten their widespread availability. Despite the importance of community pharmacies, robust evidence at a national level is lacking on 1) the populations and locations which have low access to pharmacies, 2) whether this lack of access affects utilization of pharmacist-provided health services, and 3) whether any of the proposed policy solutions, such as provider status recognition for pharmacists at the federal level, provide a plausible path forward to bolster access to pharmacist-provided health services. This investigation is structured as three aims. First, I defined, mapped, and characterized the locations of all “pharmacy deserts” in the U.S. at the census tract level. Pharmacy deserts are defined as areas that are both low-income (>20% of people living below the federal poverty line or median income <80% of the nearest metro area) and have low access to a pharmacy (>1/3 of people living outside a 1, 5, or 10-mile radius of any pharmacy, depending on urbanicity). I found that 15.8 million (or 4.7% of) people in the U.S. live in neighborhoods classified as pharmacy deserts. Further, the populations living in these neighborhoods were associated with a higher proportion of many known social determinants of health such as lower educational attainment, racial/ethnic minority status, and lower health insurance coverage. These patterns were generally consistent across urban and rural areas and across all 50 states in the country. Second, I evaluated whether these pharmacy desert neighborhoods were associated with lower utilization of a key pharmacy-based health service: shingles vaccination. I acquired census-tract-level vaccination data from seven different state Departments of Health and used propensity score matching to efficiently account for a variety of known confounding factors in the evaluation. The results from our primary analysis showed that pharmacy desert status was not associated with lower vaccination completion rates (0.4 fewer shingles vaccinations per 1000 population, p = 0.83). However, the results of our secondary analysis found that census tracts with low pharmacy access (as opposed to the two-part pharmacy desert definition that includes low-income levels) were associated with reduced shingles vaccination completion rates (2.4 fewer vaccinations per 1000 population, p = 0.004). This pattern indicates that lack of community pharmacy access may have direct health consequences for people living in these neighborhoods. Lastly, I used a national claims database to explore the effects of state-level provider status legislation on reimbursements for shingles and seasonal influenza vaccination visits at pharmacies. We found that despite having the legal authority to do so, there are very few pharmacy claims being submitted to health insurance plans for vaccination services. Our dataset contained 2.3 million vaccination visits between 2021-2022, of which only 0.4% had any outpatient services claims billed during the visit, even in provider status states. This inhibits more robust evaluation of these policies' effects and may indicate important implementation barriers to address alongside these new authorities for pharmacists. In sum, this body of work provides evidence on the current state of access to pharmacies in the U.S., the negative effect of poor pharmacy access on shingles vaccination, and the potential utility of state-level provider status legislation in improving the financial profitability of vaccination services in community pharmacies.