‘They need us because of their trust in us’: The fight to stay alive in N.C.’s pharmacy deserts

Story by Korie Dean

Graphics by Hailey Haymond

Photos by Gabrielle Strickland

YANCEYVILLE, N.C. — Vernon Massengill steps out from behind the counter at North Village Pharmacy.

“Hey, George!” he yells to a customer at the check-out counter, then dives into a minutes-long session of “talking junk” with the man who he has likely seen at least once a month for the past 40 years.

Another customer gets in line and Massengill, 73, welcomes her into the conversation.

Massengill isn’t putting on a show.

He has steered this pharmacy with a careful yet commanding touch since the day he opened it in January 1976. He knows his customers by name. He has seen them grow up, get married, have families.

He raised his own family here, too. Melissa Jones, his daughter who grew up saying she’d never go into the family business, is busy filling prescriptions alongside four other pharmacists, all of whom were born and raised here in Caswell County.

For many people in Caswell County, a rural county of about 23,000 north of Burlington, North Village is one of the most valuable medical resources they have.

That’s because it’s the only pharmacy in the county.

Data from the Rural Policy Research Institute shows that Caswell County and Tyrrell County are the only counties in North Carolina with just a single pharmacy. One county, Hyde, has no pharmacy at all.

At a time when corporate and chain pharmacies seem to be on almost every corner in suburban or urban areas, North Carolinians in these rural counties have limited access to pharmacies, leaving them to travel far distances to pick up their medications, seek medical care or, more recently, receive a COVID-19 vaccine.

These are the state’s pharmacy deserts.

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It’s not uncommon for Massengill to drive to the pharmacy in the middle of the night at least once a week to fill prescriptions for hospice patients.

“I’ve always said that I would never let any patient that needs medication do without just so I could sleep another two or three hours,” Massengill said. “I said when I opened up the store way back when, no old person or no baby would ever go without medicine, whether they had money or not.”

Yanceyville, Caswell County’s seat, sits about 30 miles, or about a 45-minute drive, from the closest hospital, Alamance Regional Medical Center in Burlington. Aside from the county health department, county residents’ only options for primary care are two federally funded health centers. Data from the North Carolina State Professions Data System shows that there are only seven physicians in the county, compared to the state’s median of 65 per county.

“I don’t think that we’re unlike any other rural county in the state,” said Jennifer Eastwood, Caswell County’s health director. “We have limited resources.”

That lack of medical resources, along with a general lack of job opportunities within the county, causes many residents to seek medical care outside of the county. In the county’s 2019 Community Health Assessment, which surveyed 543 county residents, about 60% of responders said they travel outside of the county for their routine medical needs.

“We have a very transient population,” Eastwood said. “The people that live here don’t work here. They work in surrounding counties, and I think that’s where they generally get care and even get their prescriptions, because it’s more convenient for them.”

But many Caswell County residents — about 50%, Massengill estimates — do fill their prescriptions at North Village.

Considering many prescriptions are filled at least on a monthly basis, that means customers likely come in to the pharmacy 12 times a year, or closer to 30 times for high-risk patients, such as those with chronic conditions.

And when medical concerns arise, North Village is often their first stop for advice.

In addition to dispensing and filling prescriptions, pharmacists are trained in clinical patient care. While that training isn’t as extensive as what physicians receive in medical school, it’s generally enough for pharmacists to identify which over-the-counter medicines to recommend, or to provide interim medical advice until a customer can see a doctor.

“Think about having that resource right there in your community where you can walk in the door and you know that there’s a clinically trained person in that building who will talk to you if you ask to speak to them,” said Stephanie Kiser, a career pharmacist who now oversees the Rural Pharmacy Health Certificate Program at the UNC Eshelman School of Pharmacy Asheville campus. “Pharmacists are very busy, but most pharmacists went into pharmacy because they really love the relationship aspect of working with patients and customers.”

That relationship with customers requires an immense amount of trust, which Massengill and his staff work day-in and day-out to establish with each patient who walks through their doors.

Most days, you’ll find Massengill behind the pharmacy counter wearing khaki pants and a polo shirt — not a white pharmacy lab coat. He served on the county’s board of health until he reached the term limit. When he’s not at the pharmacy, he’s ensuring buildings are safe by serving as the county’s fire marshal.

“In small towns, we see patients at dance recitals. We see them at ball games. We see them at festivals,” Massengill said. “We want to be part of their life.”

And customers know exactly what to call him.

“I’m not Mr. Massengill. I’m not Dr. Massengill,” he said. “I’m Vernon. And that’s what I want the patients to call me.”

But the pharmacy industry’s current model of payment and insurance reimbursement is making it hard for locally owned, independent pharmacies to stay afloat.

From 2003 to 2018, more than 1,200 independently owned, rural pharmacies closed in the United States. In North Carolina during that period, 26 ZIP codes lost all of their pharmacies, while 10 ZIP codes lost all but one.

Many pharmacists attribute those losses to pharmacy benefit managers, or PBMs: third-party administrators of commercial health plans that negotiate with insurance companies how much patients pay at the check-out counter, and how much pharmacists make per prescription filled.

Massengill said that it’s not uncommon for North Village to make just five cents for filling a patient’s prescription. On many prescriptions, the pharmacy loses between $2 and $3 just by dispensing the pills — and that doesn’t include the manpower or the cost of supplies that the pharmacy incurs in the process.

Generally, chain and corporate pharmacies, with their large, multi-store models, have better buying power and receive better reimbursements from PBMs.

“Big box chains and PBMs are sort of intertwined,” said Penny Shelton, the executive director of the North Carolina Association of Pharmacists. “They oftentimes are steering patients towards their preferred pharmacies. They’re not allowing small, local group pharmacies to be a part of the network, or they’re making the reimbursement so poor that pharmacies are losing money on the prescriptions that they fill for the patients that are under that particular PBM-contracted health plan.”

In North Carolina, PBMs are not currently required to be licensed to operate within the state, and there are no oversight measures from the Department of Insurance.

Senate Bill 257, “Medication Cost Transparency Act,” which is being considered in the General Assembly, would implement some oversight measures and allow the Department of Insurance to audit PBMs that operate in North Carolina.

Other pharmacy bills being considered by the General Assembly this session include House Bill 512/Senate Bill 575, which would allow pharmacists to have limited prescriptive authority for certain classes of medications, and House Bill 96, which would allow pharmacists to administer injectable drugs, such as insulin. North Carolina is one of three states in the country that does not currently allow pharmacists to administer such medications.

Allowing pharmacists to offer those services would streamline patient care and potentially bring in additional revenue.

But for some pharmacies, it’s already too late.

Massengill watched three of his friends close or sell their pharmacies in neighboring Alamance County just in the past year.

“Y’all better not let this place close,” he tells the other pharmacists regularly.

North Village tries to make up the money they lose to PBMs by offering other services that give the store a competitive advantage, such as partnering with local long-term care facilities to provide medication adherence counseling, performing point-of-care testing for strep throat and the flu, and providing multi-dose pill packaging, a specialized way of packaging pills by the time of day a patient should take them.

“You have to do other things in pharmacy because you can’t survive off filling prescriptions,” Melissa Jones, Massengill’s daughter, said.

This year, Massengill hopes to establish a collaborative practice agreement with Caswell Family Medical Center, one of the county’s two federally funded health care centers. Similar to such agreements between physicians and nurse practitioners, a collaborative practice agreement would allow Massengill and his pharmacists to monitor chronic health conditions, continue testing for minor illnesses and, with approval from the physician, actually prescribe certain medications to patients.

That agreement will allow Massengill and his pharmacists to “practice at the top of their license,” or use all of the training that they receive in pharmacy school, and make up some of the income they are losing to PBMs.

“We have way more training in those types of things. Give us the ability to use it,” Massengill said. “We don’t want to get millions and millions, but just give us a fair value for what we’re doing with your patient.”

Massengill has no plans of letting his store close. He couldn’t even keep it closed for two weeks at the beginning of the pandemic.

“I just couldn’t do it because my patients needed us,” Massengill said. “They need us because of their trust in us.”

These days, he and his team are on the frontlines of the COVID-19 vaccination efforts in the county, both administering vaccines and fighting misinformation about them.

Pharmacists are eligible to administer COVID-19 vaccines under the state’s standing order for vaccine administration, which was issued by the state’s health director, Dr. Elizabeth Cuervo Tilson, in late December.

Many local, independent pharmacies weren’t able to get vaccines as early as chain pharmacies, such as Walgreens. But because of an early partnership with the county health department, North Village has been administering vaccines since the standing order was updated in December. To date, Massengill and the other pharmacists estimate that they have administered about 5,000 vaccines.

In some ways, he’s spent his whole career preparing for this moment — and he doesn’t have plans to slow down anytime soon.

When he leaves the pharmacy at the end of the day, he’s headed an hour away to a long-term care facility in a neighboring county to administer more vaccines.

In the time it takes for the patients to roll up their sleeve and receive their shot, Massengill will earn their trust and maybe even “talk junk” with them.

And tomorrow, he’ll be right back behind the counter at North Village, where he has spent every day since 1976, ready to do it all again.