WALDEN, Colo .– The building that once housed the last pharmacy in this town of less than 600 is now a barbecue restaurant, where pit chef Larry Holtman prepares smoked brisket and pulled pork on the same counter where the pharmacists distributed life-saving drugs over 30 years ago.
It’s an hour’s drive over treacherous mountain passes in Laramie, Wyoming, or Granby or Steamboat Springs, Colorado – and the nearest drugstores. The exit roads from the valley in which Walden is located are regularly closed by heavy winter snows, preventing residents and drugs from entering.
Walden suffered the fate of many small towns across the United States as the pharmacy economy made it difficult for community pharmacies to survive. With large drugstore chains buying out independent drugstores and increasingly controlling the supply chain, cities like Walden have too few inhabitants to attract a drugstore chain and little appeal for pharmacists ready to go. alone.
Without local access to prescription drugs, the city of mostly cattle ranchers and hay farmers has outsourced a delivery system, taking advantage of anyone’s trip to these big cities to collect drugs for the rest of the city.
âReally, it’s a network of community and people who strive to know that others have needs,â said Tina Maddux, who runs a nonprofit that provides food and other things. aid to Walden. âWe are a community that is mobilized for the well-being of all. “
The system is just one of the creative ways rural communities cope with the lack of health care. In Walden, the senior center runs a regular shuttle to larger facilities so older residents don’t have to drive to shop, see a doctor, or renew their medication. In October, a pharmacy in Steamboat Springs began delivering medicine to Walden once a week. Mail order pharmacies can help with medications for chronic illnesses, but not for acute needs.
Yet these solutions cannot replace a physical pharmacy, as pharmacists do so much more than count pills. They can administer flu or covid shots and, in some states, like Colorado, even prescribe contraceptives. Some run diabetes management or smoking cessation programs. Medications can be complicated, and without a live person to talk to, patients can struggle to take them correctly.
In Walden, residents are a blizzard, an accident, to be cut off from their medications.
This uncertainty leaves Whitney Milek with constant anxiety. Her youngest son, Wade, 8, takes medication to control his seizures. She usually collects her medications from Laramie, where the family does their major grocery shopping. But when she needs to refuel between trips, she turns to her neighbors for help.
The informal system mainly goes through a Facebook group created in 2013 as a sort of online garage sale. For years, people have posted asking if anyone walks up to a pharmacy and can bring back a prescription. Neighbors deliver to neighbors, even during the pandemic, and no money is exchanged.
âThere are times when no one goes there and you end up having to mail them, which is a whole different thing, especially with seizure medication,â Milek said. “Some are controlled substances and they can’t post them.”
Two winters ago, Milek called one of his son’s prescriptions at a Steamboat Springs pharmacy. But when she arrived, the drug was out of stock. As road conditions deteriorated rapidly, she asked if the pharmacy would be mailing the drugs, but was told that she lived too close for mail delivery. She turned to a pharmacy in Laramie, who eventually agreed to mail it to her, but didn’t have it in stock either.
âSo he ended up going five days off,â Milek said. âIt doesn’t matter if you miss a dose here or there. But when you miss that much over a period of time, your tolerance level decreases. “
This medicine should be carefully managed to gradually build up in Wade’s blood to avoid a serious allergic reaction. It took three weeks to increase his daily dose when he started taking the drug two years ago.
âWhen he went five days without, he had to start all over again. It was Christmas vacation, so he wasn’t in school. I brought him to work with me because I didn’t feel comfortable leaving him with someone else, âsaid Milek, an accountant. âI didn’t know what was going to happen.
Wade was fortunate enough to avoid complications this time around. But having a local pharmacy by mail comes at an additional cost – $ 26, in their case, for a prescription last month – an additional fee for those who can’t make it to a pharmacy. Mail order pharmacies usually do not charge shipping costs, but can have issues as well. Last year, some of Wade’s mailed drugs were stuck in a Denver processing plant for three weeks. The Mileks had to fork out $ 1,600 out of pocket to get replacements.
Walden does not have a hospital, only a small clinic where Dr. Lynnette Telck and a nurse practitioner take care of the residents. The clinic stocks basic medications to meet routine acute needs – antibiotics for strep throat, asthma inhalers – and they can mix liquid suspensions for those who can’t swallow pills.
âIt’s a small town, so we all wear several hats,â Telck said.
Studies show that without a pharmacy nearby, patients are less likely to keep up with their medications and their chronic health problems can worsen. Without readily available medication, Telck said, patients may end up taking an ambulance to the emergency room.
âIt’s so expensive for the system,â she said.
Walden bills itself as the moose-watching capital of Colorado and is a recreational mecca for hunting, fishing and snowmobiling. But Telck said it might be difficult to attract a pharmacist because the city lacks amenities such as cinemas and shopping malls.
âIt’s pristine and wonderful in its original way and we love it,â she said. âBut not many people want to come to rural areas. Salaries are not as high as in the big cities.
Middle Park Health, the Granby hospital system that operates the Walden Clinic, had considered installing a more complete pharmacy in the clinic, but could not find a technician to staff it.
âThe days when this was a profitable and desirable business? It’s much more difficult than it was a decade or two ago, âsaid Gina Moore, associate dean of the University of Colorado School of Pharmacy. âYou come out of eight years of college – four years of undergraduate education and four years of pharmacy school – with some pretty significant student loan debt. It’s very difficult to go to a rural community where you don’t earn money.
In cities without an emergency room or late clinic, pharmacists often become the health care provider of last resort. They tell patients whether they need to make the long drive to the hospital late at night or whether they can wait until morning.
âA patient will often come to the pharmacy as the first point of access to health care,â Moore said. âOur pharmacists learn to understand and be able to counsel people on what can be self-treated with over-the-counter medications versus when to see a higher-level provider or emergency care service. . “
Researchers at the University of Iowa’s Rural Policy Research Institute have documented how the game is increasingly stacked against community pharmacies.
“It’s just not a really attractive business model anymore,” said Keith Mueller, director of the institute.
In 2013, they discovered that the new Medicare Part D drug plans resulted in low and late reimbursements, replacing direct customer payments. This has left many pharmacies unable to generate a profit. In 2018, surveys showed that pharmacies were having more difficulty with the narrowing of the margin between what they paid for drugs and what they were reimbursed by health plans.
Cities with more than 10,000 residents are often served by at least one Walmart or supermarket pharmacy, Mueller said.
âBut you go out into smaller communities, the predominant modality was the local pharmacy,â he said. “We don’t see this replacement of independents being shut down by a CVS, Rite Aid or Walgreens.”
The Mileks wondered if they should move close to his family in Wyoming to be closer to a hospital and a pharmacy.
âWhen you can’t go to a drugstore it’s scary because things can happen so fast,â Milek said. “People have no idea what it is here.”
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