Are we creating “vaccination deserts”?

We’ve all heard plenty about vaccine hesitancy… but, what if the professionals giving the shots start getting their own form of vaccine hesitancy, as in, “Do I really want to be in the vax business?”

Or maybe it’s just a new form of vaccine fatigue, as in, “Do I really want to keep promoting vaccines so hard?”

Those thoughts came to mind as we talked with Laura Cranston (photo below), the founder and former CEO of PQA (Pharmacy Quality Alliance) where she devoted much of her work to increasing the role of pharmacists in healthcare. She told us, “There is a great deal of burnout and stress on the frontlines of care, and pharmacies are no exception. Independent pharmacies, faced with challenges like reimbursements that have gone sideways, are going out of business and chains are closing stores. We are seeing an increase in pharmacy deserts.”

Why now? we wondered. “There are different issues converging,” Laura told us, adding, “there’s vaccine hesitancy, vaccine fatigue, new immunizations being introduced, a relatively milder flu season this past year, and pharmacists who are maxed out. You add to all these issues the complexity and pressures on third-party reimbursement and the impact of DIR fees, and pharmacies have to ask, Can I keep doing this?”

At Laura’s suggestion, we put that question to one of the pioneers of the pharmacy vaccination movement, John Beckner.  (That’s John on the right in the photo below, being introduced at the 125th Anniversary event at the VCU School of Pharmacy by the school’s Dean, K.C. Ogbonna.) In the late 1990s , John led successful efforts at Ukrop’s as it became what may have been the first pharmacy chain in the country to offer immunizations. He’s now with the National Community Pharmacists Association (NCPA), representing 19,000 independent pharmacies, and  whose goals include “making immunizations a core competency of community pharmacies.”

We started by asking John about the specter of “pharmacy deserts” and he replied, “There are deserts right now.” He mentioned two pharmacy chains cutting the number of locations, adding, “Chains are closing stores and nobody is going into that space.” As for the independents John works with, he says,

“It’s certainly a challenging time. We frequently survey our members, and we’ve seen that a majority of owners are worried about staying in business. In 2023, there was an average of one closure per day.”

The upshot is, “There’s a pharmacy desert, but that creates a vaccination desert, as well.”

What or who is to blame?

Money is, of course, an issue. There’s the problem of reimbursements for vaccinations, a topic we will have to save for another article, but for now, let’s just leave it with John saying, “We have been advocating for years for PBM reform,” and “We would love to see fair and equitable reimbursement.”

There’s also the issue of the vax pendulum swinging – it’s a response to the time when pharmacies were among the heroes of the pandemic response, with John noting, “No doubt there’s vaccination fatigue – on the part of the patient but also on the part of the pharmacy. We were pedal-to-the-metal for so long that pharmacies are a little weary, especially if there are staffing issues.” 

We asked, Does this mean that pharmacies will be backing off from giving vaccinations?

John’s answer was clear: “No. I have not heard of anybody deciding not to offer vaccinations anymore. Maybe it’s happened somewhere, but I have not heard of it. After all, if you label your pharmacy as a ‘health and wellness destination’ it’s very hard to backtrack.”

WHAT’S NEXT?

We have to hope the vax pendulum will start to reverse. We sought out someone who’s actively helping that happen: Bianca Daisy-Bell, Director of Clinical Pharmacy Services with SEMO Rx, with locations in Southeast Missouri (that’s the SE and the MO).  She reminded us that patients’ vax attitudes are seasonal, saying, “The interest in vaccinations comes in a cycle. In the Fall, you got plenty of early adopters, eager to get vaccinations, but then it’s seasonal and this time of year people aren’t thinking about vaccines — when you mention them, you hear things like, ‘I’ve got plans with my grandkids and I don’t have time.’”

Further, while some vaccinators might be fatigued, the pharmacies Bianca works with are busy expanding their immunization efforts. They have two pharmacies adjoining primary care offices and come to understand that much of burden will fall on them to assure that patients stay up-to-date on their vaccinations. Bianca told us,

“Primary care is overwhelmed. Do they have time to do a comprehensive vaccination screening? Probably not. The vaccinations guidelines have changed so much that it’s hard to keep up with them, and now patients have opinions about vaccines – do you want to open that can of worms? Trying to triage all that can take a lot of time.”

By contrast, Bianca’s team has been involved with research new ways to close vax gaps. They received a grant to have CHWs (that’s Community Health Workers) help with education and coaching. As Bianca puts it, “They provide a different kind of voice” versus “a person in a white coat.” They also have a grant to experiment with “transportation insecurity,” taking vaccinations to people who have difficulty getting out. (That’s Bianca in the photo below, doing a home vaccination.)

It’s good to be reminded that there are people like the folks at SEMO Rx who are actively pushing to expand immunization coverage, especially when we are reminded that primary care providers are probably not going to be able to pick up any slack left by pharmacy closings.

OTHER REASONS TO BE HOPEFUL

What else would help? Back to John Beckner of the NCPA, who’s in a good position to spot other possibilities:

1. John reports that he’s optimistic about legislation that will help with reimbursement, saying, “We’ve shined a bright light on the egregious practices of PBMs, and reform is now a bipartisan issue. The finish line is in sight – we just need Congress to act.”
2. Meanwhile, there’s help available on getting paid: the NPCA has published a Vaccine Billing Guide.
3. More states are allowing more vaccinations to be administered by pharmacy techs, thus making vaccine programs more profitable, especially when pharmacies are offering offsite vaccinations to employer groups.
4. Given the renewed interest in foreign travel, some pharmacies are offering “travel clinics” – a consulting service for not only vaccinations, but also advice on medications and supplies helpful when visiting variouscountries/regions.
5. Lastly, John is seeing an opportunity for pharmacies to increase their vax programs with adolescents and children, saying “rates are alarmingly low” and “if a pharmacy wanted to add a target group to close gaps, that would be the group.”

Is there vax fatigue among vaccinators? You bet. But while the vax heroes of the pandemic might be weary, it’s good to know they are regrouping, working to find new ways to close the immunization gaps, even as those gaps get so wide that some are becoming “deserts.” As football coaches like to say, “Games are won in the off-season.”

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STATS OF THE MONTH

Immunization Registration Data: Insufficiently Analytic?

By Bill Davenhall, Geospatial Advocate

Immunization registration data is critically important in counting and reporting operational statistics at the national, state, county, and sometimes at a more “local” level,  but immunization registration data has much more to offer analytically and there are ways to accelerate the understanding of household participation with greater geographical granularity.  Let’s talk a bit about the geography of immunizations.

Immunization registration data reminds me a great deal of the voter registration systems used in all US States. Here is why: The Voter Registration System includes every registered voter and reveals if they voted in any recent election. It also contains their political party affiliation  (if any declared), along with name and street address. It does not reveal how they actually voted. Discovering a registered voter who did not vote in the last election cycle is the goal of some campaigns, while discovering the household that never votes is equally attractive to another campaign. This data also allows you to discover the households that neither register to vote or have a have a registered voter at any address. The data “knows” where every household is located, geographically – thanks to the hard work of the United States Census Bureau and a geocoding system that appends a precise latitude and longitude to every street address in the United States.

Who might get an immunization is much like voting in an election – it  comes down to human behavior, and as many research reports claim those actions are largely “dependent” on many other “uncontrolled” factors. For example, a recent Census Bureau survey found that approximately 29% of college educated registered voters did not vote in the 2022 mid-term elections because they were “too busy” – surprised?

Geographic segmentation is a hybrid analytical process (when you also have specific knowledge of their actions). It’s one of the most productive ways to understand the unique variability of certain groups of people in various parts of the nation with different experience, attitudes, and ultimately discoverable health outcomes. Innovating your analysis using more granular geographies from the Census Bureau, such as Block Groups, can help you accelerate your understanding the trends in immunization behavior – like monitoring the changing attitudes about vaccine acceptance and dependency in much smaller geographic areas with much more local context.

A great deal of geographically granular data about each immunization administered over the last decade is available. There are millions and, in some cases, billions of street addresses that have been collected and now sit in state data warehouses awaiting to be analyzed by a new generation of public health data scientists. Being able to communicate the value of an immunization (i.e. lives saved, diseases prevented) in a very local geography or neighborhood will likely go a long way in building greater confidence in the value of vaccines as well as in getting citizens adopting a more desirable immunization behavior in their household.

As always, I appreciate 2^nd opinions,