DANVILLE — Maintaining access to the kinds of care that keep people out of the emergency room is becoming more difficult in the sparsely populated corners of the Buckeye State. Some say the big corporations that work with the Ohio Medicaid program are partly to blame.

Here in the rolling farm country in central Ohio's Knox County, people boast of their deep small-town roots. The traditions of their Amish neighbors run even deeper. But public officials and an independent pharmacist find themselves struggling together to maintain basic health care for people who might find it difficult — if not impossible — to drive 20 minutes or more to find it.

They're hardly alone.

In an era of low reimbursements for drugs they dispense — especially under the Ohio Medicaid program — hundreds of Ohio pharmacies have closed, creating more than a dozen areas with no easy access to medicine and a pharmacist's care. Scores of other places across the state are one closure away from joining them, according to a Dispatch analysis of state pharmacy data.

>> Read 'Side Effects': Dispatch investigation into rising cost of prescription drugs

Some pharmacists fear that the problem will metastasize as more pharmacies shut their doors.

"When Medicaid managed-care reimbursements drive a pharmacy out of business, the problem doesn't end there," Denise Conway, who owns a pharmacy in Mount Vernon and is opening another in Danville, told an Ohio Senate panel in June. "The patients move to another pharmacy where the low payment rates suffocate another pharmacy."

The Dispatch's ongoing series "Side Effects" has been reporting on the role that pharmacy benefit managers have played in drug prices, in the decline of community pharmacies and in what some state officials say are practices that overcharge taxpayers.

These middlemen in the drug supply chain, such as CVS Caremark, OptumRX and Express Scripts, work on behalf of private insurers and government payers and determine how much pharmacies are paid. CVS Caremark decides community pharmacy reimbursements even though, as the nation's largest pharmacy retailer, CVS stores are in direct competition with them.

Ohio pharmacists have complained that the corporate giant has engaged in anti-competitive practices that have driven some of them to close. Such closures come at the cost of plenty of Ohio communities whose residents often have the greatest health needs.

A spokesman for CVS said that his company has not played a role in creating pharmacy deserts.

"These claims are simply untrue, and the paper’s desperation to paint CVS Health in a negative light — while we continue to reduce Medicaid costs for Ohio taxpayers — borders on obsessive," company spokesman T.J. Crawford said in an email.

The paper's analysis of Ohio Board of Pharmacy license data found that of more than 400 pharmacies that have closed since 2013, 14 left no other pharmacy within 2.5 miles. If you're healthy and own a car, that might not seem far to go for a prescription. But advocates for pharmacy access say that's the distance at which those who are too old, too poor or too ill have difficulty getting medications and meeting with a pharmacist for advice on how to take them.

Blake's Manchester Pharmacy closed in Adams County last year. Its owner blamed anti-competitive practices by CVS for marooning residents of the depressed southern Ohio river town 10 miles from the nearest pharmacy. In northeast Ohio, Seville and the east side of nearby Medina were left with pharmacy deserts when CVS bought the 20-store Ritzman chain earlier this year and closed 17 of them.

Of the 14 new pharmacy deserts, the towns surrounding eight of them have higher rates than the state average of people who use Medicaid or another health-care program centered on low-income clients, according to census estimates.

"Those are the most complex patients," Conway said, explaining that because they tend to be sicker and often older, they take more drugs and need more instruction on how and when to administer them.

Many more areas with high concentrations of such residents are poised to lose care if state officials don't deliver on promises to reform Medicaid. Pharmacy benefit managers such as CVS in 2017 billed the taxpayer-funded program $244 million more for drugs than they paid the pharmacists who supplied them. After a year of such promises, Ohio community pharmacists say they still are not being paid enough by the program to cover their costs.

The Dispatch analysis of pharmacy data showed 86 independent or small-chain pharmacies that are farther than 2.5 miles from another pharmacy, meaning if they close, they would have the potential to leave a pharmacy desert in their town. They're in places such as Plain City and West Jefferson, Mount Sterling and Ashville.

When Joe Craft opened Plain City Druggist in 1999, the Madison County village of about 4,500 had been without a pharmacy for seven years. He opened another pharmacy in West Jefferson in 2016, replacing a pharmacy that had closed there eight years earlier. In both towns, his pharmacies are the only place to fill a prescription for miles around.

Then, he started seeing his Medicaid reimbursements drop in 2017 and again in 2018. He's considered dropping Medicaid, but hasn't done it.

"These are the people at the lowest socioeconomic level," Craft said. "I'm hoping to break even on my Medicaid business."

The calculus is more dire for Fruth Pharmacy in Wellston, about 80 miles southeast of Columbus. Its owners say that if Medicaid reimbursements don't improve, they will close that and their 10 other pharmacies in southeast Ohio within a year. Two of the closures would create pharmacy deserts.

"When PBMs like CVS Caremark slash rates to local providers through the Medicaid program, it ends up drying up patient access to health care in communities that typically have the greatest needs," said Antonio Ciaccia of the Ohio Pharmacists Association, which represents community pharmacists.

In Danville, the effort to revive the local pharmacy illustrates how closely its services can be tied to other basic forms of care. It also shows how the failure of a pharmacy in one area of high need can jeopardize others.

When CVS — whose nearest pharmacy is 12 miles away in Mount Vernon — bought and closed Lonsinger Pharmacy in 2017, people in Danville, a town of 1,200, were stunned.

"One man broke down crying," librarian Betty Carpenter said of an elderly resident. "He said, 'I can't walk to Mount Vernon.' He could walk to Lonsinger's."

A basic health clinic, which had also operated in the building, closed around the same time. Lane Belangia, who is CEO of the Knox County health center in Mount Vernon, wanted to reopen it as a full-service, low-cost clinic. But he knew that would be pointless if people still had to drive 20 minutes for their medicine.

"We asked, 'If we put in a clinic, where would people go to the pharmacy?'" he said. Also, though Knox County qualifies for more than $600,000 annually as a federally qualified health center and for drug discounts under a federal program, it couldn't afford the building — or to start and operate a pharmacy.

So Belangia approached pharmacist Conway, who, with her husband, Kevin Conway, an engineer, bought and gutted the pharmacy portion of the 1950s building and are in the process of rehabilitating it. As the three walked through the building recently, they described the importance of providing low-cost medical, dental and mental-health care in the same place as a pharmacy.

“People walk in the door and they don’t think much of their condition because it’s been so chronic for so long, but we look at (some of) them and it’s off to the hospital they go," Belangia said. "Then we can see them after they’re well and manage that disease successfully.”

That differs from many commercial walk-in clinics that merely treat the "easiest," most acute symptoms and send patients on their way, Belangia said. And it's especially important for the local Amish population, which can be reticent about obtaining medical care.

“They’re notorious for not seeking preventive care until it’s too late — especially if it’s oral care,” Belangia said.

Five years ago, Knox County was hit with what was then the largest measles outbreak in the United States in 20 years. Belangia said that motivated many young Amish parents to seek vaccines for themselves and their children. That in turn got them to seek other forms of preventive care. That virtuous cycle was threatened when Danville lost its pharmacy and the clinic that depended on it, he said.

Even as she starts a new pharmacy in Danville, Denise Conway said her operations are threatened another way.

Low Medicaid reimbursements are putting a strain on her operations in Mount Vernon and an additional threat looms from a potential pharmacy desert in Marengo, 18 miles to the west. Business owner Max Peoples recently told the Senate Finance Committee that he bought the Marengo pharmacy in 2015 in a high-Medicaid area at the behest of the mayor, who was trying to avoid creating a pharmacy desert in his community.

"To date, it has cost us more than $400,000 to get the pharmacy up and running, and in hindsight, it's one of the worst decisions I ever made," said Peoples, who also owns Uptown Pharmacy in Westerville.

He added that if the legislature doesn't force Medicaid pharmacy benefit managers to improve reimbursements, he'll close in October. That would force his patients to Sunbury, 12 miles to the south, or to Mount Gilead, 12 miles to the north — or west to Mount Vernon, where Denise Conway's pharmacy is on the town's east side.

"I'm the pharmacy down the road from him," she said. "The cycle will continue."

mschladen@dispatch.com

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