Life in the Desert

Let’s talk about the communities struggling to access healthcare due to distance and availability. Our experts share their experiences and insights in providing medical services and care in rural healthcare deserts. 

Transcript

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Hello everyone, and welcome to. That's understandable. I'm your host, Brendan McEvoy, US head of external communications at AstraZeneca. If this podcast has been enjoyable and informative for you, take a moment to like and follow on your favorite streaming service. And if you know anyone else interested in today's topic, be sure to share because our goal is to help everyone to better understand what science can do. When we all work together, I'd like to start today's episode off with a story that was shared by a listener. They said, I grew up in a small, rural mid-west community. At the age of seven. I was diagnosed with type one diabetes in a hospital that was a 30 minute drive from my parents home. After that, my pediatrician advised us to see a pediatric endocrinologist. The nearest one was 100 miles away. For the next ten years, my parents packed my younger sister and me up every three months and drove those 100 miles to the nearest children's hospital for my appointments. As kids, my sister and I loved it. We got to stay in a hotel with a pool and eat at neat restaurants in the big city. Never realizing the immense stress these Tripps put on my parents, my mom and dad were farmers and, like many other farm families at this time, were self-insured. For each appointment, my dad had to arrange for help to feed and care for our livestock. One time while we were gone, there was a large storm that scared the cattle and they ran through the fence. My dad had to rent a car and drive home while my mom, sister and I stayed at my appointment to help wrangle the animals that had run off. The animals that were our livelihood. Now that I'm a parent myself, I'm grateful to live in a large urban area with easy access to world class medical care. But I still have friends back home who make the same Tripp my parents made all those years ago to take their children to get the specialized treatment they need. I can't help but wonder, what are we doing to help rural families have better access to health care? I'd like to take a moment to thank the listener who shared their story with us and it really, as they say, speaks to the lived experience of so many people throughout the country. With that, we're going to start to try and answer this listener's questions during today's conversation, as we talk about health care deserts, sometimes called medical deserts, the World Health Organization defines a health care desert as a geographical area with limited access to qualified health care providers and quality health care services, or areas where people lack adequate access to six key health care services pharmacies, primary care providers, hospitals, hospital beds, trauma centers, and low cost health centers. According to a study done by Goodyear in 2021, 80% of the country lacks adequate access to health care. It also found that 30 million Americans live in health care deserts. That's more than the entire populations of New York, L.A., Chicago, Houston, Philadelphia, Phenix, Dallas, San Diego, San Antonio and Washington, DC combined. But luckily, there are people working on solutions to address distance related access barriers. And two of them are joining us today to discuss this topic. First is Doctor Cindy Juntunen, an associate provost and dean at California State University, Monterey Bay. Doctor Juntunen grew up on a North Dakota farm located in the health care desert and lived most of her life in the state. She has nearly 30 years of higher education experience, and is the chair of APA's Task Force on Developing Guidelines for Psychological Practices with Low Income and economically marginalized clients. Welcome, Doctor Juntunen. Oh, thanks so much, Brendan, and happy to be here. And please feel free to call me Cindy. We'll do. Cindy, thank you. And joining Doctor Denton in awe Cindy is Doctor Tripp Logan, community pharmacist and vice president of CMO, Pharmacies and Care Coordination in Charleston, Missouri. He is also the chief operating officer of Choose My Pharmacy. Doctor Logan has been nationally recognized for his work on patient care, health equity care coordination on social determinants of health, and positive health outcomes. Thanks for joining us, Doctor Logan. Thanks, Brendan. Trip here, also. All right, Cindy, with your background in education research. I'd like to start by asking you, how did we get to this point where so many Americans live with limited access to adequate health care, notably access that depends on where they are physically located? Yeah. I mean, it's a pretty complicated, picture, really, because there's a lot of factors that contribute to it. You know, when we think about health care over time, you know, in past centuries, people, even in small towns, you know, there would be a health care provider that would sort of come from the population of that town. Right? And then they would they would stay there. That's where everyone lived. People weren't as mobile and as, as health care fields became more specialized, as more and more people had to get more extensive training and move away to hubs where there would be, you know, schools that could provide them with advanced training, whether it be in, you know, physical health care or mental health care or any of those kinds of things, more people had to leave the communities that they were living in go away for training. And then once they had this, sometimes a very expensive, very time consuming training, they were, not surprisingly, looking for ways to specialize and become more, more, professionally mobile. And they had more options in larger urban areas. So that's one of the big factors is our our training demands increased over time. we needed more complicated, service providers, more complex and more sophisticated service providers as as our scientific knowledge supported our medical advances. And then people didn't return to sometimes usually small towns. It's not just small towns that are deserts, of course, but but often we can think about that. Rural communities really fit the picture that you that you're a listener described. Right? and they gravitated toward larger areas where they had more opportunity. So that's one of the main things that contributed. Yeah. Thank you. And and from your perspective, sort of in the same vein, has this sort of always been an underlying issue that maybe is just becoming more prominent now or or is there, you know, is it more of an emerging problem that, or, you know, that has maybe sort of become more, more relevant or prevalent in recent years? I think it's probably closer to the latter of an emerging. But like the emergence has been, you know, we've got a long runway on the emergent. You know, this has been happening. I, I took my first steps in one of my dad's drugstores. I've been in this, small community in the Mississippi Delta area of Missouri, living in one of the poorest counties in, in the state, which is also one of the poorest counties in the country, grew up here, went to pharmacy school. I've been out for 20 something years. I've been watching this happen my whole career. There were five pharmacies in this little town. When my dad got out of pharmacy school. second generation. He got out in 1975, I think, and as of January 1st, now there's one pharmacy in the town, no federally qualified health center. There's, we still have multiple physicians in town now. You know, we have a family nurse practitioner, possibly a few days a week. So, you know, we're seeing, you know, what caused it? like Cindy was saying, a lot of different reasons. One of the things that we've seen is just the provider squeeze from a reimbursement in a regulatory standpoint, pharmacy providers, our, you know, the the revenue is not there as it was 15 years ago for pharmacy providers. And, the burden of regulatory but liability, I mean, there's just there's a lot to it. You don't just show up and practice like you used to do. Same thing with primary care. And so it's just been a gradual. And I think the Covid pandemic, threw gasoline on this fire also because then you had a high level of burnout and, workforce is more expensive now than it was pre-pandemic. So, yeah, it's all these things happening at the same time that's creating a problem. And I know in the pharmacy industry, my colleagues are struggling and pharmacies are closing regularly. And we could talk about, you know, we if there are more pharmacies or less pharmacies where they are zip codes and so on. But I think it's just so multifaceted. The reality is it's here. I mean, that's where our yeah, that's interesting Tripp. So you're actually, you know, you have the perspective of sort of being in the same community for a long period of time and kind of seeing the transition, right, of, of less and less, whether it's pharmacies or, you know, this physician. So, it is the does the, the example I shared, the, the, the listener story, does that sort of then resonate with you in terms of, of how you've seen in the community that you live over the years? It does. So our service area is, six, seven counties right now. I'm also a, it very involved in a national network of independent pharmacies, over 3500 of them, all in similar situations as this. So the organizations called the Community Pharmacy and Health Services Network, or CPS. And so I'm seeing it across, you know, it's not just here locally, but the story is very similar in most places where we are. you know, I give me in my community, if you need an answer for an allergist, you have to go at least one county over, maybe three counties away. that's really challenging if you've got issues, if, you know, if you've got some transportation struggles, transit isn't real dependable around here. You know, their their access, the access points to care are hard to get to, including, you know, mail delivery, U.P.S., Fedex, like, those are all challenges in in areas like this, things that all of us take for granted, particularly those in urban areas. You know, it's just hard to get to a post office, right? It's hard to get to in your chronologies. It's tough. So there are a lot of a lot of solutions that are being, experimented, that are being deployed right now. But I don't know that anybody's got it, like completely figured out. So, you know, in, in, in introducing both of both of you and the work that you do, it's clear that you've, you, you know, both have dedicated a lot of your efforts to helping to address some of the issues that we're talking about here. and, and essence trying to improve access to health care in, in communities where there's, where it's not readily available or accessible. So maybe starting with you, Cindy, what progress have you seen, throughout your career as you sort of, you know, focused your efforts and time in this area? yeah. Well, there's a couple of big things that I think have really changed over time. so I, you know, most of my career has been spent training psychologists and counselors, right, to work on mental health issues and behavioral health and substance use, those kinds of things. And, so one of the huge transitions, of course, in that area is, increased access to services through psychology or telemedicine. you know, the idea, you know, even a 15 years ago, 20 years ago, talking about doing therapy online felt like a really abnormal response to a situation. And now it's, you know, it's really, it's almost commonplace. Right. we started training. We started training students in 2010 to provide services via video. And that was at the time one of only 2 or 3 places that were doing that. But we did it because we knew how hard it was for our rural clients to get into the hubs where their psychologists and counselors are located. So that's, you know, that's certainly one, one big, big shift. The other thing that I think doesn't get as much attention but but should and, and is that, helping providers see the benefits of working in isolated and rural areas. And I tend to focus on rural. But there again, as I mentioned, you know, that's not the only thing, but but helping people see that, you know, this is a social justice issue, right? Like a lot of young, young professionals or young providers really care about that. They care about, you know, the idea of making sure that they're working with marginalized communities. And and if we really help people understand that. Yeah. When you're talking about geographic isolation, you're talking about engaging in social justice work. Right. And so, you know, we we developed a program at the University of North Dakota that focused on rural psychology with the idea of helping people understand that rural culture is different. And you have to understand those differences in order to be an effective provider. And that really helped change the conversation in a really positive way as well. So that's, I think another important change that that in now in the in the mental health field, there's a lot more attention being paid to the fact that rural communities have unique needs. It's not just that they're located somewhere, it's that there's a whole society that goes along with rural life that's important for providers to understand. So I think that's a positive change. Yeah, definitely. And I definitely wanna come back to the the telehealth or telemedicine piece too, because I think we can dig into that. But before I do. So, Tripp, from your perspective, what what progress have you seen. Pre pandemic and post pandemic or kind of like it's almost like to me we've got there was a pivot during this time at least in in my industry. And you see it throughout the health care I, I would imagine Cindy would concur that the availability and acceptability of a tell a visit pre pandemic and post pandemic are totally different. At least they are in my in my area. from from the payment from the reimbursement abilities to just the patients accepting that as a viable option. So I've also seen that what you know what I'm excited about, also is very concerning. But, you know, maybe the excitement is coming out of a lot of concern is that that, a lot of people in what I would consider like underserved, underrepresented areas, whether that's urban, rural, wherever it is, we're calling them a desert here, in, in a lot of different and looking at research and depending on how you want to spend, what a pharmacy, desert or health care desert is, you know, there's a lot of different definitions, and I don't know that anybody's really landed on. But if if a patient needs care and they can't get access to the care in their community, that's to me what what the health care desert. So when you when you have that what's the solution? how does this person find the care that they need even if it's health related social needs, if it's social determinants of health, those are all things that positively or negatively impact health. And so it could be clinical, it could be social. It could be, you know, a number of things. So what we've been focusing on and this is where year five of a national initiative to cross-train community, pharmacy technicians is community health workers. And so like I said, like in my community, we don't have a physician that's here every day. We don't have an FCS, we don't have a hospital, very little transit. We've got nine community health workers on site in pharmacies that are open every day during business hours. Right. So I can walk in and find access to care if they're a community health worker who's an expert in all the resources available in the community. So if you need transit, they know who it is. There's not anybody in the country that knows more about Mississippi County, Missouri, and the services offered than the community health workers. In my practice. So that allows us to help people navigate the health care system better. we currently have, are in the last, let's see, 16 months have created a network of pharmacies that are doing the exact same thing in 30 states right now that have community health workers embedded in pharmacies used for care coordination, longitudinal care coordination, you know, may be transportation tomorrow, may be medications to our the next month. It may be food insecurity the following month that may be back to transportation the next or some combination of that. That's what these community health workers are doing. And their jobs are really to to take community members by the hand and help them get the care that they need, the support that they need to, to best take care of that, you know, their personal health and their family's health. And funding for that has come through a lot of different avenues. I could go down, you know, to talk through that as much. But the, the acceptance of this type of service and the, rate at which, it's not only spread but being utilized right now in the country is, to me, one of the most exciting things because they're their community pharmacies and primary care clinics and these the these really, local public health departments that often offer I mean, they offer services, but they're a lot of times are not working together. They need somebody to to help everybody work together. And that's how these community health workers and pharmacies are leading an effort. And it's it's been a really exciting to watch. We've got tons of data and, publications that are not only out, but coming out about how this work helps. Not that this solves all the problems, but if there's a community, if there's a pharmacy and a community, they are oftentimes the front door to health care because it's easier to get in there than it is to get into primary care or the hospital or wherever. And so, we're we're really excited about that. That's a positive change. What's not super positive is pharmacies are closing at a rapid rate. So our primary care clinics, you know, this is we've got a what I would say almost like, tragic situation with, the closure of independent primary care clinics, the closure and acquisition and closure of independent community pharmacies or small chain pharmacies. there's all kinds of, publications coming out right now or change or closing drugstores. Independents are closing drugstores. So that's that ruins our model because that access point is in there. And so that it's been a lot of concern about what what we're going to do in the future. Tripp and Cindy's description of the situation facing rural communities when it comes to access to care was eye opening. As I listened, I wondered how much pressure the shortage of health care providers was placing on these communities. Both you and Cindy, I've already talked about Covid 19 and a sort of before Covid and after Covid. So maybe, Cindy, starting with you, because up front we talked about you know, you talked about sort of some of the the obstacles or challenges which are, contributing to why there is a, you know, lack of, you know, physicians and other health care services within communities around, you know, going to larger cities for more education and opportunity and potentially not coming back. So I would imagine and, you know, correct. Am I wrong or help me, or maybe there's even other components to it that that I won't highlight here, but I would assume Covid 19 then made the situation worse because we were hurting, you know, nationally or internationally really, that there was a lot of people that were just leaving the health care field because of burnout and other things. So is, I guess it's fair to say that it exacerbated the issue. Is that is that fair? Oh, yeah. I think it definitely exacerbated the issue in in a number of really important ways. I think, I think I think the burnout by itself, I mean, and I know that there's, you know, still research being done on this, but but I think what we actually can see, the trends, you know, if we get, you know, ten years down the road and we can actually see Mike, I can't imagine that the data won't show that there's some kind of trend that was sort of triggering Covid related to rates of burnout and departures from from health care fields. yep. There are also a lot of new students coming in because they were inspired by, you know, the heroic kind of and that's important. But that still means that there's going to be this shift for communities that I think we're really barely at the beginning of understanding yet. And I also think, we really saw it in terms of like things like substance abuse treatment. You know, one of the things that Covid, correlated with was, an increase in, the opioid, crisis and an increase in overdose death, overdose deaths. Right. And, and and we also saw that being, accompanied by a decrease in providers, a decrease in the real ability of providers. We have a large number of substance use cancers in the United States that are approaching retirement age, and nowhere near enough students in the pipeline to replace that cadre of providers. And that, you know, whether it's a coincidence that that happened at the same time as Covid or whether Covid exacerbated some of the retirement rates, you know, but those things were all happening at once. We I mean, that is an area that I think is is an area of really extreme crisis that's become more known and more discussed since Covid. So, and frankly, the rates of anxiety and depression went up during Covid as well, which has resulted in more need. And interestingly, Covid had the unexpected, I think, potentially positive impact of people feeling more comfortable talking about their concerns. Right. Like a lot of people said, hey, we're going through a crisis. It's okay to feel like you're in a crisis, you know? And so it normalized the discussion. But normalizing the discussion about mental health things usually results in an increase in services. And there were an increase of service providers available to meet those needs. So, you know, so so yeah, I mean that all comes together in a pretty wicked little mix. Yeah. That was yeah. Yeah. And Tripp and like other you know any builds from you in terms of, you know the how Covid 19 exacerbated or, you know, or, you know, positive or negative impacts in terms of I think, you know, Cindy, you had shared potentially some positive being people maybe being more comfortable and seeking, mental health services. So Tripp any any thoughts from you? Yeah, I agree with Cindy on just generally how how we've seen pre and post in pharmacy specifically pharmacy prescription drug product reimbursement has been on the decline for a really long time. And during the pandemic it kind of masked that because there was a lot of vaccination opportunity for pharmacies. Like, I'm proud of my colleagues across the country that, pharmacists and pharmacies did a great job vaccinating the public during the pandemic. And so that was a lifeline that a lot of my colleagues needed at the time. And it also, opened the eyes of a lot of other segments of the healthcare industry and the public on, access and services in a pharmacy, whether it's point of care testing, you know, Covid testing, flu testing, strep testing, RSV testing, vaccinations, Covid and beyond. So those are those are definitely positives that have happened. But, you know, afterwards, you know, once the the pandemic started, going away and moving into more like, you know, normal life, like we were seeing before, that's, you know, a lot of the financial challenges in, in community pharmacy practice have, you know, resurrected and reared their ugly head again. And so a lot of my colleagues are in a lot of trouble. And so, you know, if if we're at risk of losing, say, 20, 30% of pharmacies over the next five years in communities that were that removes another access point. And Covid, I would say is not directly related to that, but it is there is some correlation because, you know, after during the pandemic, labor costs went up and there were a lot of things that, you know, if you're already, if you're if you're margin is already pretty tight and then labor costs are going up and reimbursements going down, it just, you know, expedites a problem that that that's already occurring. Chip one thing as as we're talking and I'm going to sort of state the obvious for for both of you. But it may not be the obvious. It may not be as obvious to our listeners that while we're talking about pharmacies, I think depending on where you the where you live, if you live or, you know, you might be thinking of pharmacies only as sort of these large chains. Right. But I think it's important here. And I think the perspective that that you're talking about is we're also talking about independent pharmacies, right, that are I would assume, have so much more, you know, overhead and burden than those that are supported by sort of, you know, national networks or large corporation. So I again, I'm stating the obvious, but I think just to help put it in perspective, as we are seeing you know, large national chains closed down, I mean, I can only imagine it's even more difficult for independent pharmacies in some of these communities where they don't have some of the lifeline of a larger corporation that maybe is is helping helping them flow during during rough times. Yeah. And then thank you for for saying that because that's at so you look at like my little pharmacy owns pharmacy in this town. It's just across the wall over here. You know, my purchasing power for drug product is a lot different than, say, a Walgreens, a CVS or Rite Aid Walmart. Right? I mean, you can only imagine the difference in the purchase price. But the really tragedy is that it, you know, I went to 14 semesters of college to get my pharm.d, you know, we we pharmacists are very highly educated, very clinical minded experts in medication optimization. it's a health care professional that's located in a community that's very accessible. But, the way that pharmacists have been historically paid is basically on a bar sale model. You buy prescription drug and you sell the prescription drug. And that margin is what pays a pharmacist. And there's a disincentive a lot of times. And so we're starting to see this across all pharmacy. So when I say community pharmacy I'm saying a pharmacy with the front door there's chain, there's independent. I've got a lot of great colleagues that are pharmacists working in chains doing the best they can. A lot of times the, the, the mission is a little bit different. And so is, you know, how they structure their budget. We're a lot more service oriented, a lot of pharmacies are essentially dispensaries. You know, they're just dispensing drug product all day long. And that's that's their business model. Most of my colleagues in my network, you know, their service first, which means d prescribing to some, like somebody comes into our place, they've got 12 drugs. My clinical teams like, you know, I really do. We need all 12 of these. Or can we possibly get you off of a couple when the bar sell model that you know, that doesn't make sense, right. So so as we're shifting to pharmacists as providers and open up scope, the pharmacies scope of practice in states and, and federally, you know, that we're seeing more and more just not moving quickly enough and that that's that's one of the unfortunate realities, medication mismanagement, medication misuse, like, that's a major driver of hospitalization. And so if we can help minimize that in the community, then that's what we really should be doing, not contributing to the problem by having to sell more drugs. You know, that's not what any of us went to school for. And so, you know, we're in this in the middle of this transition period with pharmacies. And, you know, I've seen, press releases from major change that they're shifting to more service oriented post pandemic because they saw the value of Covid testing and vaccines and so on. And so they're independents have been doing that for a long time. But it's my hope that that really we shift from this, you know, buy sell product driver of of how the business model works for pharmacy to really where our job is for medication optimization and do the best by the patient. And it's based on, you know, service based delivery, not necessarily product delivery. Yeah. Thank you. It's it's helpful that, to sort of get it more of an inside scoop on on the, the impact and the model that currently, is in place. And I do it resonates with me having to live in a more, an area where there's access to more services that, you know, a viewpoint. I think that would be common in a pharmacy in the, in the town that I live. Is that you that you would you would essentially go there to drop off or, or fill a prescription. It would probably be less likely to ask the pharmacist there for sort of advice or, you know, questions about about your health care conditions or, or whatnot. So it's an interesting perspective. And I like early on where I was thinking in my head, your through the work that you're doing in the pharmacy there, you're actually kind of like rebranding in the sense like what the role of a, of a pharmacist is, which is which is great. I do have one more question. specifically that, related to something you said in that I'd love to shift gears a bit to talk about some of the ways from a policy or, you know, broader industry perspective of how, you know, how companies can can help to, to help, you know, sort remediate the issue. So one of the things that you mentioned up front, I think you you talked briefly mentioned sort of, you know, mail order pharmacies, online pharmacies and, and you you put a point up front that, you know, that you said something around sort of even that, you know, mail services might be sort of limited depending on town. So is it is mail order pharmacies. Is are is that sort of addressing some of the gaps in communities where we are seeing less, you know, pharmacies either disappear. or is that and maybe creating a in like an inaccurate sense of comfort that pharmacies, you know, mail order pharmacies are kind of plugging the hole, if you will. I like I'll thank you for this question. I like this question a lot. So, I like to always frame this in what what does the patient need? Do they need a pharmacy or a pharmacist? Okay. And so 98 if, if I'm getting my oral contraceptive or I'm getting my allergy medicine, you can get that from the mail or your pharmacy from a kiosk. Right. You don't really need a pharmacist. You need a prescription. You need a pharmacy. Right. But a lot of people need a pharmacist. And it is really challenging in underserved, underrepresented areas. When there's a need for a pharmacy, you've got a major drug interaction. You got out of pocket cost issues, you got an access barrier, you don't know how to use your inhaler or administer insulin. you got a question? My insulin was out of the fridge for a while, and I don't have minutes on my cell phone. Right. That's what we deal with. So these people need a pharmacist is typically the most complex, most at risk, with the worst outcomes in the highest cost of health care system. Those are the ones that need a pharmacist. So when you remove the pharmacist from that region and all that's left is, is service for somebody, it needs a pharmacy or just a prescription. We created a health care vacuum. And so that's what I'm afraid of. And that's what we're seeing now. So you're not going to see a lot of colleagues of mine saying mail order pharmacy is the enemy. What what we're saying is removing the pharmacist from the community where there is not an access point to health care, that's the enemy. And so we need to make sure that we stabilize those. And that's what we're working every day trying to ensure that we're doing. And that's great. Thank you. So Cindy, I'll up point this one to you first as we get into, yes. Certain considerations that could help, expand access to services or sort of, eliminate the barriers. So the first is, are there sort of policy considerations that we should consider that might help support, expanded access and rural or areas where there, where health care is healthcare services are limited. Well, certainly there's still policy considerations related to like telehealth, telemedicine and that's that haven't been resolved consistently across jurisdictions. Right. You know, in terms of reimbursement rates, as Tripp kind of mentioned, that those kinds of things that that needs some additional work. The other thing that, sometimes gets overlooked in all of this, too, is, the way in which we do licensing is usually jurisdiction, you know, in most of the health care professions is by state. It's really hard. Portable licensing is a policy thing that could really help. You know, you've got somebody who lives at the border of North and South Dakota. And you know, they can't see the rural neighborhood next door because of the, you know, as one example, right? Like, of course, some states have worked, have worked out those things. But there's but the inconsistency across the country is, is substantial. And so from a policy perspective, looking at the way licenses can be more mobile and information could be shared more easily across state lines would really help providers and, and the patients that they work with across many of the health disciplines. It definitely would be a really huge factor for a lot of mental health areas that I'm more familiar with. So I think those are important things. The other, you know, there is a pretty successful set of programs, mostly funded by the federal government, but some by state governments are doing student loan repayments to encourage people to relocate to areas that are food deserts or, sorry, some food deserts, so sorry, medical deserts. and, and that those have been pretty successful. But they are cumbersome. A lot of people don't apply for them because of the hassle connected to them. So there could be some streamlining there. And I think it's also probably worth considering whether upfront scholarships that are then contingent on service might actually help more people get into, the training required for health care professions. So if you reduce the financial barrier at the front end and give people tuition waivers or scholarships contingent on them then working in underserved areas for some period of time, I think that's a policy, work that could really, make a difference and actually encourage more people from the beginning of their training to be considering working in these desert areas, and then that would allow them to get the training experience they need in underserved settings to be more successful and to hopefully minimize and increase retention and minimize some of the burnout that we see with people who who go to more isolated areas. So those are three things that come to mind that I think could have a real powerful impact. And I just a follow up question from as, so I understand and correct me if I'm wrong. So from a physical standpoint, if you're, you know, licensed, professional in one state, you might not be able to, you know, or you can, I guess, policy sort of restrictions in to your example, like if you're on the border of North and South Dakota being able to you sort of help the next community over, does there's the same apply for from a telehealth perspective? Are there different you know, if you're if you are licensed in North Dakota, does that mean you could only sort of provide services to tell our services to, patients in the same state, or do they have sort of workarounds from a telehealth perspective? So there are emerging workarounds, but again, they're really inconsistent across jurisdictions. Okay. So generally the issue is that you have to be licensed wherever the patient lives. and so you will see people who are, you know, like so I live in California, I have a license still in North Dakota. If I got a license in California, I could see patients in both North Dakota and California. That would be fine. But, I couldn't see patients other places in the country based on most and I. And that even that's not 100%. That's based on the jurisdiction of the that's based on the rules of the state or province where the patient lives. So yeah. So so it also is really confusing. Yeah. It's confusing for the provider as well as the as well as the potential patient. Yeah. Right. Because you know, you'll have people who say, well, you know I'm moving over here. Oh I can still see you. And I like seeing you and you're, you can do it online. Well, I can't see you anymore. Unfortunately, because, I mean, it's very baffling for everyone. So consistency is the kind of issue here, right? Is there a way for, for for these, these, licensure laws to be a little bit more transparent and a little bit more malleable, given the reality of how mobile we've become? Like we have become way more mobile than our that our licensing boards sort of recognize, right? Yeah. Yeah yeah yeah. It's it, it's it's quite, quite complex there. Yes. Chip, from your standpoint, any other considerations from a policy lens that could help support a lot of times when, when I'm thinking through this or we're working through this, whether that's in, in, you know, with a state or with this federal, I like to look at like what's going on in other sectors of health care. So if you look in so we're we're in the middle of the what what would or soon become, you know, the worst financial crisis in the history of community pharmacy, right. Where pharmacies are like, we're seeing this and there's a there's a pushback in some sectors of the industry say, well, that may or may not be true. it's absolutely true. So, what like what has happened in other places? There are a lot of other programs like, critical access hospitals. The reason that those exist is, you know, they're subsidized in order to be there in that community because that community has a high default rate down payment. Right. And so if they close, then there's a health care vacuum that cost the system more money, that cost the state government, the federal government more money. So there's a critical access hospital there. So that could be applied in pharmacy. But very little are talking about solutions such as that. there are other subsidy program farm subsidies. I'm in an agriculture area. There are farm some subsidies. And typically those subsidies come about because there is some market access change that is implemented by the by the government or out of the control of the farmer. So there's another mechanism there where, an area could be subsidized because market pressures in the area that are out of the control of the providers. But again, you know, that that's going to require some rethinking of how we view, health care regions, health care ecosystems and how how these health care system, how they're all interoperable. Because, you know, if I'm just a one pharmacy sitting out here and I don't talk to anybody else, nobody's thinking about me. But if the health system, the health plan, the public health department, the State Department, health, if they see me as valuable to the community, and all of a sudden this this changes. So that's what we're trying to really speed up is the value expression of the pharmacies. And hey, patients outcomes are better if they go to this pharmacy versus this pharmacy or this pharmacy versus no pharmacy. so those are the things that we're currently studying and research and, and publishing as fast as possible to in an effort to not only show the value to these pharmacies in the in the communities, but ensure that they're sustainable and they're there for for another, you know, 20, 30, 40 years. As Cindy and Tripp discuss possible solutions and steps that could be taken to help alleviate some of the burden placed on rural communities and remove some of the barriers to access. I had a thought. How could other players in the health care system collaborate with providers to help increase access? You know, I think we we touched on in addition from from a policy standpoint, some other potential ways in which to alleviate the, you know, the issue, or, you know, lack of access to health care services. I actually had, did an episode recently where we're talking about sort of the importance of collaboration right within, you know, within the health care ecosystem, but with outside as well. So with that in mind, you know, do either of you feel that there are actions that, you know, other players in the health care ecosystem, including, you know, large corporations, you know, pharma, biotech, other, providers, or even outside the health care ecosystem. Are there actions that, that those players could, could take to help, you know, remediate these shortages? Well, just one quick thought that I have is I think, I think and, and kind of tags a little bit on to what Tripp was saying earlier about the community health worker. I think one of the things that that, I think it's really critically informed that we have an informed public, a public that has enough health literacy, that they understand that there are services that they can ask for and that they can advocate for themselves to access. You know, I think about one of the things about being in a in a medical desert area is things sometimes don't get diagnosed until so late into their expression that you end up with more severe cases. You know, I'm thinking about a situation I worked with with a student one time where we had somebody who came in for treatment thinking that their issue was substance use, and they actually had a bipolar disorder that had been undiagnosed until, I mean, for years. Right. And, and, and when you in the the complications of the lack of information and and the lack of of of of of health literacy complicates these issues. And I think lots of agencies could be of all could be involved in helping to ensure that we have an educated population that understands some of these things and understands how to advocate for themselves and how to get access to them. And then I also think a key piece of that working more effectively is, you know, integrated care models whenever possible, where you've got professionals from different aspects, you know, if you have a a pharmacist and a psychologist and a, physician working together as a team, then even the kind of really hardest to serve folks with the most complicated set of things are getting better wraparound care. Right. and if a team is working together, even though at first the, you know, making the team work takes some initial upfront investment and time, you know, you have to think and you have to learn about other professions. But in the long run, it ends up being a workload. Most people suggest that once they get into those kinds of systems, their work, they have more support. So even in isolated areas, they have colleagues they can turn to and trust. Right. those are things that I think a lots of entities, including employers, and companies could be involved in supporting. That's great. Tripp, any any additional thoughts from you on on that question? Yeah, I love Cindy's answer. And, if I could like if this was a text message, I would hit that double exclamation mark and then because, so I'll tell you a quick story. we in in in Missouri, CPS and Missouri's our network. We had three pilots with the National Kidney Foundation and the pilot last year was to see if community health workers within community pharmacies can identify chronic kidney disease before it becomes, you know, progressed like, you know, like progression, right? Prevent dialysis prevent and stage renal disease. That and what we have discovered is that community pharmacists who recognize people with blood pressure and diabetes and their community health workers who have relationships, can actually get these people screened. We used a local public health department in my community collaboration, and we detailed the, the, the local providers in the in three county region. And then we referred in to them. And guess what? Now we've got great working relationships. and we've got data to show that we're effective in preventing chronic kidney disease, which is related to end stage renal disease, which lead to dialysis, terrible outcomes, transportation issues, dialysis, I mean, just terrible things to poor people. So that's why I'm doing this podcast, because messaging, we have to get the message out there that collaboration is important, that these communities have complex patients, that tell it doesn't work for some people, like my people don't have broadband and they don't have cell phone minutes. We do tell it deserts, right? And we do phone based visits and we facilitate them. But that's not good for everybody. And so in a technology age where an app or a cell phone is the the, it's the answer. A lot of times for those with low health literacy, low technology literacy, it's not the answer. And so at I feel like sometimes we as, as Americans get too far into digital, digital, digital and forget health care is local, health care is very personal. And sometimes you don't want to do it over, you know, over a device. And the more we can get this message out there, that local collaboration is still needed to to drive positive outcomes in health care, that some can be done digitally. And we we do all the time. And I'm a proponent of Mayo if that's the best. If that gets you your medicine best, that's great. But the people that we take care of, they need a whole lot more. And we got to be here. And what I love about what you just said, Tripp two, I think is so focusing on prevention and early intervention sometimes, sometimes that, you know, medical different, different health care fields have been worried about that because like that it will somehow interrupt their own, workflow that we're always going to have plenty of people who have full blown disease structures, whatever they might be, right? That being able to get policy makers to pay attention to the value of prevention and early intervention would have benefits for the entire population because, you can prevent a lot of costs and a lot of heartache and a lot of personal loss and pain through those kinds of programs. I think that's a fantastic example. That's great. And and one of the things that that you said, which, I'm glad you said it because and we've had other, I've had other conversations around, you know, digital and whether or not that is something that is, you know, obviously we talk about it sort of revolutionizing the world in so many ways. But the point that the previous guest made that I think you made as well, which is important, one is that there is still an equity component there as well. Right? Because there's not equal access to digital. so it's as a as great of a resource telemedicine or telehealth is it's still there's still barriers even with that. So it's not you know, there's not one quick solve, to a lot of the issues that we're talking about. So we're, we're, you know, coming up on, on our time here. So I do have one more question that's I'm going to ask you, but first, I wanted to give you both an opportunity. If there's anything sort of burning on your mind that is, you want to make sure that you share with your listeners on today's topic before. Before I get to that last question, I've got something several health care deserts is the theme. And, there is like a hearing on Capitol Hill, this, this, this, this comes up a lot, particularly around pharmacy. And what I'm seeing in practice right now with pharmacies, patients be able to access pharmacies is and I hope, I hope your listeners understand this because I think it's foundational to, to knowing if we're having if we if we have an emerging pharmacy health care desert problem or not, is there are a lot of pharmacies closing and there are other pharmacies opening. And so when you look at numbers, sometimes it looks like, well, we had a thousand close and we had 999 open. And so really that's a loss of decline. But if you look at the zip code of where the pharmacies are closing. So if you have five pharmacies in five counties, two of them close, but two of them open combo shops like they do long term care. And those are two additional licenses, but they're still two communities without pharmacies. we're also seeing hospitals open up outpatient pharmacies that didn't have them before. And if you can access the hospital, you can access health care. Chances are the pharmacy that closed, you know, on the other end of the county, that community is without a pharmacy. And so there are these market dynamics that are happening right now in pharmacy. So it may be a net net loss of small. But the loss to the community and to the patients is huge. And we'll see this in research coming out soon. But this is in the last 18 months. The trends that we're seeing. I just wanted to share with the audience that, be aware that this is a true an emerging problem, and the numbers may not always tell the right story. That's great. No, I appreciate you sharing that. Something we'll definitely have to keep an eye on. So we're at our last question. but before, you know, and I want to make sure that, and it's kind of a tall ask here because you've covered a lot of ground during this conversation, but and thinking about everything that you said today to each of you, what is the single most pressing thing that needs to be done to help address barriers in accessing health care for patients living in these health care deserts? Cindy, can I can I start with you first? Yeah, I think, I think so this it so it's a big ask and this is going to be a, a broad answer, to a big ask. I think, that, it is critically important that we figure out ways to make what are now deserts. both, equitably reimbursed and supported for professionals and, enticing and important enough ways that people will choose to live there so that we get professionals to those areas and don't continually ask the people who live in desert areas to make massive compensations in order to get to services. Right? Like, I mean, I, I agree with what was just said that, you know, Tello devices help. They are not a panacea. They've never and they won't I don't see any way that they'll become a panacea. so how do we, change this equation so that we don't put all the work for equitable distribution of health care services on the consumer? Because that's what we're doing right now, asking people to give up a day of work, get to the services, and instead systematically shift providers into a more equitable distribution across communities. I don't think we can do that by mandating that people live in certain areas, but I think we can figure out ways to systematically build in incentives so that that work is viewed as equally prestigious, equally important, and equally rewarding as work in more clustered areas. Thanks, Cindy and Tripp. Same question to you. So Bernard, I had no idea what I was going to answer this and tell Cindy then. So I love what she said. So I'm going to take this right down the pharmacy line. Two. So in order for that to happen in pharmacy, pharmacies have to be viewed as not the same. So right now when you go get a prescription, it's like which pharmacy do you want? They're all the same. Well they're not all health systems are different. They're all graded and rated. Every nursing home Long-Term care facility is rated every. Health plans rated. Pharmacies do not have standardized ratings, which means that the value expression of one pharmacy and the other is equal. It's can you fill a prescription. So until we measure that. And so that's where I choose my pharmacy and how we've spent in my network, we spent a lot of time segmenting out value like value expression from one pharmacy to another based on standardized measures. How does one pharmacy stand up to the other. Because once you can show that, well, all of a sudden using one pharmacy is less expensive because when you get insurance, underwriting is lower in the premium because you're using a safer pharmacy, or when when payers and employers are building their pharmacy networks, they know that pharmacies have better outcomes. So my employees need to go to that pharmacy that's preferred pharmacy. But in today's world, that's not how networks are built and pharmacies are viewed the same. So I totally agree with Cindy. Until we differentiate and really try to focus on how we get the resources in the right areas, in pharmacy, we have to define the right area, and that could be based on social vulnerability index. That can be based on zip code, but it probably needs to be based also on the providers that are providing care in the area and include pharmacy in the equation, which pharmacies typically been excluded from that equation. Right. Well, you've definitely given us a lot to think about. So I just want to thank you both again for for joining me today on on today's for today's discussion. But more importantly, thank you so much for the work that you're both doing to both bring awareness to the realities of patients living with within these health care deserts, as well as the work you're doing to help bridge those gaps for those patients. So thank you so much for joining now. Thank you. Great meeting you, Brandon. You too. Cindy. Great. Yeah. You too. Yeah. With all the amazing advances we've made in health care over the years, sometimes it's important to step back and take a hard, realistic look at the issues that are still in front of us. Access to quality health care is critical and ensuring both people and society stay healthy. Thanks again for joining us on that's understandable. For more information about today's episode, be sure to check the show notes. Until next time, be well. Be healthy. Be understanding.