GREENFIELD, Ia. — Bill Mather felt like he let the whole town down.

Mather, 74, has spent all 51 years of his pharmacy career in Greenfield. After graduating from Drake University, he joined an existing business, bought into it and eventually bought out the proprietor.

But as Iowa pharmacies began consolidating into a smaller number of larger players, he sold Mather Pharmacy to the Pamida chain of department stores — with the understanding that the company would maintain a pharmacy in Greenfield.

Mather worked for the company inside the Greenfield store's pharmacy, which in 2013 merged with Shopko, a Wisconsin-based retail chain.

"The trend in pharmacy has been the same as everything: The big get bigger and the independent numbers keep shrinking," said the soft-spoken Mather.

But Shopko — like Sears, Toys "R" Us, and Younkers — has struggled in the era of online shopping. After shuttering dozens of stores, Shopko declared bankruptcy in January. With subsequent waves of announcements, Shopko targeted 70 percent of its stores for closures.

The Shopko chain put its entire pharmacy business on the auction block, threatening local access even in communities that managed to retain their retail stores.

In Greenfield, the news was swift and sharp: The pharmacy's demise would come months ahead of the store's closure, leaving the town with no pharmacy. The community — and the local pharmacy's staff — were given two weeks' notice.

"It made me sick," Mather said. "I owed this community."

More:Shopko closing nine Iowa stores as retail chain declares bankruptcy

In Greenfield, 'there was nothing else'

Greenfield, about 50 miles southwest of Des Moines, is no stranger to the long-term trends that continue to redraw the rural American landscape. After all, the southwest Iowa community's population peaked nearly four decades ago.

But it seems to punch above its weight. The county seat of 1,800 people is home to a hospital, a factory and schools. Shops, professional offices and a single-screen theater orbit the 126-year-old courthouse on the town square.

Yet it almost became a town without a pharmacy.

"It was a pretty big surprise," said Rachel Hall, the pharmacist who managed the Shopko pharmacy. "I don't think a lot of people saw it coming."

Hall, from nearby Fontanelle, was in the dawn of her career when Shopko made its announcement. But she was already committed to Greenfield and her patients. She and Mather immediately started searching for a Plan B, any way to keep a pharmacy in town.

The loss of Greenfield's only pharmacy would have tracked with decades of changes in Iowa's pharmacy industry. While the number of Iowa pharmacists has grown in recent decades — from 2,344 in 1996 to 2,991 in 2017 — they have increasingly consolidated in larger communities, according to the Iowa Pharmacist Tracking System.

Over those 21 years, the number of Iowa communities with at least one pharmacist dropped from 251 to 223 — a decrease of 11 percent.

In 2017, every Iowa city with a population of at least 5,000 was home to at least one pharmacist. But of 867 communities with populations below 5,000, only 143 had a pharmacist.

Now, more than two-thirds of all Iowa pharmacists work in communities with 15,000 or more residents.

When Shopko put its pharmacy business up for sale, the staff in Greenfield thought an independent buyer might emerge. But the retailer sold the store's pharmacy records to Walgreens, whose closest store is more than 50 miles away in the Des Moines metro area.

"As long as there's something in town, that's good," said Hall, 28. "That's what concerned me most about Greenfield: There was nothing else in this town."

'It's the quickest we’ve ever pulled something off'

Hall and Mather connected with NuCara, a Conrad, Iowa-based chain of pharmacies. They believed there was an ongoing need in Greenfield — and NuCara officials agreed.

Hall, seven months pregnant with her second child, simultaneously worked to close down Shopko's pharmacy and open NuCara's newest location in Greenfield. She owns a 20 percent stake in the store.

After the federal Drug Enforcement Agency expedited its approval and the Iowa Board of Pharmacy issued a license, NuCara opened its doors on Feb. 12 — a day after Shopko's pharmacy closed. It temporarily located in the former business office of the Adair County Memorial Hospital.

"It actually was very quick," said Brett Barker, vice president of pharmacies for NuCara. "It's the quickest we’ve ever pulled something off."

While some customers have already migrated to options in other nearby towns, Hall said many are relieved to have a local option. The entire staff has migrated from Shopko to the NuCara location less than a mile down Kent Street.

"We already know a lot of the people," she said. "And we already know their needs and wants."

'The pharmacy business model is changing'

Rural Iowa is facing two simultaneous challenges: the retail apocalypse has left smaller towns with fewer shopping options. And at the same time, widespread consolidation has reshaped the pharmacy industry.

In Iowa, 75 percent of independent pharmacists work in communities of fewer than 15,000 people.

Yet the ranks of independents have shrunk by more than half over the past two decades: In 1997, the Iowa Pharmacist Tracking System counted 693 independent pharmacists. But by 2017, only 310 were working in the state.

And Shopko's closures could put even more distance between rural residents and the prescriptions they need.

"Shopkos are located primarily in rural counties," said Kate Gainer, executive vice president and CEO of the Iowa Pharmacy Association. "A lot of those pharmacies were the only pharmacies in their town."

She said changing reimbursement levels and increased pressure from pharmacy benefit managers makes it tougher to survive without the backing of a larger chain.

"It's very difficult," she said. "The pharmacy business model is changing."

In 2013 and 2014, 74 Iowa pharmacies closed, which the pharmacy association blamed on unfair tactics from pharmacy benefit managers, the third parties that administer prescription drugs for healthcare plans.

To remain competitive, many pharmacies have diversified by adding specialized on-site pharmaceutical mixing known as compounding, medical equipment sales or immunization services, Gainer said. But many independent operators get squeezed out because of declining reimbursements for prescription medication.

Pharmacies once operated on a pretty simple premise: the more prescriptions you fill, the more profitable the business. But not anymore.

"A good percentage of prescriptions (that) pharmacies fill today, they lose money on," Gainer said. "So, depending on the mix of prescriptions they fill, more prescriptions might actually mean they lose more money."

It's 'just not possible' to have a pharmacy in every town

The loss of pharmacies in rural Iowa has been somewhat alleviated by the advent of telepharmacies. Iowa's first telepharmacy opened in 2012 in Victor as a pilot project, but the concept didn't receive regulatory approval from the Iowa Board of Pharmacy until the spring of 2017.

Today, 12 telepharmacies operate in Iowa.

Andrew Funk, executive director of the Iowa Board of Pharmacy, said that effort has been an important tool in providing access in rural communities.

Likewise, he said many pharmacies offer delivery services to wider regions. And many are just a small jaunt away from other rural communities.

Even in Greenfield, it's not a huge distance to nearby providers. Fontanelle, about six miles away, is home to an independent pharmacy. And Creston, less than 30 miles to the South, is home to a Medicap pharmacy as well as big-box options like Hy-Vee and Walmart.

Collectively, Funk said, those variables help to meet patient needs, even without a brick-and-mortar presence.

"Ideally, you have a pharmacy in every small town in Iowa," Funk said. "But that's just not possible."

Some Shopko drug stores may live on.

In December, Hy-Vee acquired six Shopko pharmacies, including stores in Forest City, Mount Ayr and Emmetsburg. The grocery chain will operate standalone pharmacies in those Shopko stores — even if the primary retail stores close.

The West Des Moines-based grocer also purchased the records of patients at 22 pharmacies across the Midwest, sending the patient information to existing Hy-Vee pharmacies.

And NuCara helped yet another community keep its pharmacy after Shopko's exit. It partnered with a pharmacist in Cokato, Minnesota, reopening a pharmacy that sold out to Shopko in 2015.

"All over the Midwest there's definitely a big vacuum," said Barker, with NuCara. "A lot of communities are losing their only pharmacy. So people are scrambling."

In weighing where to invest, NuCara officials generally look at a community's population and demographics. They believe communities under 1,500, for instance, can struggle to maintain a full-line pharmacy business.

But there's also a more subjective eye test: Barker said he looks for communities that feel vibrant. Does the town have a strong base of other medical services? Is Main Street littered with abandoned storefronts? Does it look like people support their local businesses?

Driving around Greenfield for the first time, he had no concerns: "You can tell that folks here support their community," he said.

'We're not going to have a Target come into town'

A decade ago, chains like Shopko were pressuring mom-and-pop businesses across rural America. They gobbled up independent pharmacies and threatened Main Street businesses, said Brian Depew, executive director of the Center for Rural Affairs.

"There's this cycle of really preying on the communities by small-box stores," he said. "Shopko comes in and puts pressure on these little retailers, then 10 years later Shopko closes, and the ultimate impact is no pharmacy."

Depew wonders if retailers like Dollar General might ultimately mete a similar fate to small towns. Much to the chagrin of mom-and-pops, Dollar General has opened hundreds of new stores each year, primarily in rural markets.

And in Greenfield, the town's retail future is now a much more pressing concern. Despite a petition circulating around town, the Shopko proper is set to close by early May.

"The closure of the store has been a much bigger hit because there aren't any other options," said Heather Shaull, chief financial officer of the Adair County Health System. "We're not going to have a Target come into town and provide those same types of (retail) services."

The hospital's billing department has moved into a cramped, windowless room down the hall to make space for the pharmacy up front. NuCara has inked a six-month lease with the hospital as it looks for a permanent space somewhere in town.

On a recent weekday morning, pharmacists and techs were busy unpacking and stocking the store's first drug order. The familiar antiseptic smell loomed beyond the sliding glass windows that frame the pharmacy.

Mather, the 74-year-old pharmacist, continues to work part-time for NuCara. A few weeks ago, his brewing anxieties about succession planning boiled over. But those concerns have dissipated now that the new pharmacy has opened.

Customers are relieved, too.

"The general comment is, 'Thank you for being here,'" he said while sitting at one of the six tables in the hospital cafeteria. "I feel a lot better."

The historical trends eroding rural America continue to threaten the quality of life in towns like Greenfield. But Mather believes in both NuCara and Hall, the pharmacist leading the local upstart.

He's not interested in full-time retirement, but he can now envision a future in which Greenfield holds onto this important institution, long after he dispenses his last bottle of pills.

Kevin Hardy is a business news reporter for the Des Moines Register. He can be contacted at kmhardy@registermedia.com.

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