ABSTRACT. Medicare Part D has improved access to prescription drugs for Medicare beneficiaries. However, the program has raised certain issues that threaten the viability of pharmacies. After a decade of Part D, we assess these issues as they concern rural pharmacies using survey responses. Independent rural pharmacies, the only retail pharmacy outlets in their communities, were surveyed. Email-based surveys were returned by 118 respondents. Rural pharmacies ranked two issues – direct and indirect remuneration (DIR) fees and delayed maximum allowable cost (MAC) adjustment – highest on scales of magnitude and immediacy of the challenge they posed to sustainability. 80% of respondents reported DIR fees as a challenge of very large magnitude and 83% reported it as a very immediate challenge. 78% of respondents reported MACs not being updated quickly enough as a very large magnitude challenge, with 80% indicating it is a very immediate challenge. Exclusion from the preferred networks of Part D plans was reported as a challenge of very large magnitude and immediacy by about 60% of pharmacies. Pharmacy staffing, competition from pharmacy chains, and contracts for services rendered to Medicaid patients were less likely to be reported as significant or immediate challenges. Policies that address the issues of delayed MAC adjustment and DIR fees could go a long way in ensuring the viability of these critical sources of pharmaceutical services.

Keywords: Medicare Part D; independent pharmacy; payment policy; pharmacy sustainability; access to care; rural

How to cite: Salako, Abiodun, Fred Ullrich, and Keith Mueller (2017). “Financial Issues Challenging Sustainability of Rural Pharmacies,” American Journal of Medical Research 4(2): 147–161.

Received 17 April 2017 • Received in revised form 4 August 2017
Accepted 5 August 2017 • Available online 28 August 2017


College of Public Health, University of Iowa
College of Public Health, University of Iowa
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College of Public Health, University of Iowa
(corresponding author)

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