Community Pharmacy Closures – A Trend That Effects Hospice

 

The Trend that no one is talking about but threatens Hospices access to medications: Community Pharmacy Closures

 

As the year begins, we are inundated with trends that are expected to impact hospices.  While there are the usual culprits, decreased funding and increased oversight, I noticed one alarming trend that was not mentioned –community pharmacy closures.  As community pharmacies disappear from neighborhoods across America, a hidden crisis emerges that threatens hospice patients at their most critical time.  As a social worker, former hospice executive and now president of HospiceChoice Rx, I think is important that we understand the profound impact of pharmacy closures on hospice care delivery and explore the urgent need for solutions. (1,15)

 

Community pharmacies represent far more than convenient places to fill prescriptions—they serve as lifelines for hospice patients requiring immediate access to comfort medications.  The relationship between hospice providers and community pharmacies forms a delicate ecosystem built on trust, proximity, and responsiveness.  When a hospice patient experiences breakthrough pain or respiratory distress, local pharmacists become partners in compassion, ensuring medications reach patients quickly to maintain dignity and comfort during their final days. (2,13)  These local establishments provide the rapid turnaround and personalized service essential to end-of-life care, often delivering critical medications within hours when symptoms demand urgent relief.

 

The American pharmacy landscape has undergone dramatic transformation over the past fifteen years, with closures accelerating at an alarming rate.  Major retail chains including CVS, Walgreens, and Rite Aid have announced plans to shutter thousands of locations through 2026, fundamentally reshaping medication access across the nation. (14-15) These closures represent not just business decisions but healthcare infrastructure losses with profound consequences for hospice operations and the patients they serve. (10)

 

If these giants in the pharmacy arena are struggling to keep their doors open, you can imagine the headwinds community pharmacies are up against.  Independent community pharmacies face a higher risk of closure than chain stores, with roughly 38.9% of independent pharmacies closing between 2010 and 2021. (8)  Community pharmacy closures are fueled by exclusion from preferred networks, low reimbursement rates, often below medication costs, and high-cost, punitive audits.  These “pharmacy deserts” leave residents, including hospice patients—with few alternatives for obtaining essential medications. (8) When you take into consideration hospice’s regulatory requirement that hospices ensure 24-hour access to medications for symptom management and pain relief, the expanse of these pharmacy deserts becomes much larger.

 

Furthermore, when it comes to medication urgency, Hospice patients exist in a category unto themselves.  Unlike chronic disease management or routine prescriptions, hospice care demands immediate response.  A patient experiencing respiratory distress cannot wait three days for mail-order delivery. (2)  Medications like morphine for pain, Levsin for secretions, and lorazepam for anxiety, must often reach patients within hours to prevent suffering. (13) These same-day or STAT fulfillment requirements make proximity to pharmacies essential. (6)

 

Additionally, some hospice pharmacy-PBM hybrids have shifted toward slower mail-order systems that cannot accommodate the urgent, unpredictable nature of end-of-life symptom management.  This leaves the community pharmacy filling only urgent or after-hour fills which have much higher operational expenses.  Without routine medications, the community pharmacy has less opportunities to negate these increased expenses.  Community pharmacies also struggle against inadequate reimbursements that fail to cover actual medication costs, and escalating audits and fees that retroactively claw back payments months after transactions. (4)  These financial threats create a cascading effect: pharmacies cut staff, reduce hours, eliminate specialized services, and ultimately close. Independent pharmacies serving the hospice populations lack the financial cushion of corporate chains, making them especially vulnerable to market forces prioritizing profit over patient access.

 

As pharmacies close, many hospices are left with limited choices and must adapt their medication ordering practices.  Hospices within a pharmacy desert may have no choice but to switch to a mail-order pharmacy which we know does not meet urgent medication needs. Hospices may also consider stockpiling medications for unpredictable symptoms or increasing the days’ supply ordered to greater than 30 days. (9)  However, these adaptations come with costs that are difficult for hospices to absorb due to low reimbursement rates.  Ordering a higher days’ supply increases medication waste as patient’s conditions can change rapidly, resulting in hospices paying for medications that are not used.  Hospices also find themselves spending valuable staff time coordinating medication logistics rather than providing patient care. (13)  Because nurses often assist in picking up medications after hours or in urgent situations, the extended travel time decreases time spent providing patient care.  Another often overlooked consequence is the impact on the remaining pharmacies who absorb overflow from closures, which leads to longer wait times, increased errors, and staff burnout that degrades service quality across the board.

 

Behind these statistics and the financial implications, there are real people experiencing profound consequences.  Consider Maria, whose father needed emergency morphine for breakthrough cancer pain on a Saturday evening.  Their community pharmacy had closed two months prior; the nearest alternative was 45 minutes away and closed for the weekend.  The family spent the night managing his pain inadequately with over-the-counter medications, watching him suffer needlessly until Monday morning.  Delayed pain relief and symptom management leads to patients suffering and diminished dignity during their final days.  Caregivers face increased stress witnessing unnecessary suffering which complicates their grieving process for years to come.  Meanwhile, hospice staff experience increased challenges to honor their commitment to their patients and their families to keep them comfortable.  When infrastructure failures prevent quality care delivery, hospice staff begin to feel powerless.  These added pressures and helplessness contribute to compassion fatigue or burnout, increasing staff turnover and perpetuating existing staffing shortages.

 

While the challenges are complex, proven approaches and emerging proposals offer pathways forward.  Solutions require cooperation among pharmacists, hospice providers, pharmacy benefit managers, insurers, pharmaceutical manufacturers, and policymakers.  Legislative solutions, regulatory reforms, and care model innovations must work together to preserve hospice patients’ access to essential medications. (5)  Many state legislatures are sponsoring bills for PBM reform to increase transparency in pricing and stabilizing pharmacy reimbursement.  HospiceChoice Rx supports these reforms.  As a hospice-only fiduciary PBM, legally and ethically bound to prioritize its customers’ interests above our own, we already operate according to many of the proposed standards such as transparent pricing, fair pharmacy reimbursement, and increased choice within our pharmacy networks.

 

It is also important to preserve the local nature of hospice care and believe that a hospice’s success comes from its relationships with the communities it serves.  HospiceChoice Rx operates as a cooperative alliance with hospices, local pharmacies, and other end-of-life-focused organizations.  We believe that collaboration and system-level innovation provide the best results.

 

Community pharmacy closures represent more than business trends or market corrections—they threaten the fundamental promise of hospice care to provide comfort and dignity at life’s end.  When pharmacies disappear from neighborhoods, hospice patients lose access to timely palliative medications that make the difference between suffering and peace during their final days.  The convergence of financial pressures and policy failures has created a perfect storm endangering medication access for America’s most vulnerable patients.  Yet this crisis also presents an opportunity for transformative change.  Healthcare professionals, policymakers, and community members must act now to prevent further pharmacy closures.

 

Support local pharmacies, advocate for reimbursement reform, and demand policy solutions that prioritize patient access over profit margins.  By recognizing pharmacy infrastructure as essential healthcare access, strengthening financial sustainability for community pharmacies, we can build a more resilient hospice ecosystem. (10,2,15,7)

 

References

1. National Community Pharmacists Association (NCPA). (2023). NCPA Digest: The State of Community Pharmacy in the U.S. 2023. Retrieved from ncpa.org.
2. American Academy of Hospice and Palliative Medicine (AAHPM). (2022). Position Statement: Ensuring Access to Palliative and Hospice Medications. Retrieved from aahpm.org.
3. Centers for Medicare & Medicaid Services (CMS). (2021). Medicare Part D Program Reforms and Their Impact on Pharmacy Reimbursement. Washington, D.C.: U.S. Government Printing Office.
4. Smith, J., & Chen, L. (2023). “The Desertification of Pharmacies: Rural Closures and Health Disparities.” Journal of Healthcare Policy and Practice, 15(2), 112-128.
5. Congressional Research Service. (2023). Community Pharmacy Access and Federal Policy Responses. Washington, D.C.: Library of Congress.
6. Palliative Care Today. (2024, January 15). “Supply Chain Disruptions and Essential Palliative Medication Shortages: A Growing Concern.” Retrieved from pallcaretoday.org.
7. Healthcare Leadership Council. (2023). White Paper: Strategies for Sustaining Community Pharmacy Services. Retrieved from hlcl.org.
8. Guadamuz, J. S., et al. (2023). “Fewer Pharmacies in Black and Hispanic/Latino Neighborhoods Compared With White or Diverse Neighborhoods, 2007-20.” Health Affairs, 42(2), 265-274.
9. Qato, D. M., et al. (2017). “Changes in Prescription and Over-the-Counter Medication and Dietary Supplement Use Among Older Adults in the United States, 2005 vs 2011.” JAMA Internal Medicine, 176(4), 473-482.
10. National Community Pharmacists Association. (2023). “2023 NCPA Digest: Sponsored by Cardinal Health.”
11. Pharmacy Workforce Center. (2023). “Aggregate Demand Index Report: National Pharmacist Workforce Trends.”
12. American Society of Health-System Pharmacists. (2023). “Drug Shortages Statistics.”
13. National Hospice and Palliative Care Organization. (2023). “NHPCO Facts and Figures: Hospice Care in America.”
14. Hernandez, I., et al. (2022). “Trends in Retail Pharmacy Closures in the United States, 2009-2015.” Health Affairs, 41(11), 1611-1619.
15. S. Government Accountability Office. (2022). “Retail Pharmacies: Closures, Locations, and Access in Underserved Areas.” GAO-22-105396.
16. Medicare Payment Advisory Commission. (2023). “Report to the Congress: Medicare Payment Policy.”
17. Pharmacy Benefit Management Institute. (2023). “Prescription Drug Benefit Cost and Plan Design Report.”
18. Guadamuz, J., et al. (2024). “More US Pharmacies Closed Than Opened in 2018-21; Independent Pharmacies, Those in Black, Latinx Communities Most at Risk.” Health Affairs, 43(12)