When telepharmacy is permitted in a state it is because pharmacy professionals, healthcare professionals, lawmakers, and regulators recognize the benefits of telepharmacy to public health. Providing convenient pharmacy access to rural and urban underserved communities across the state is always the main goal of telepharmacy.
While NABP has model rules for the practice of telepharmacy, each state creates rules and regulations for the practice of telepharmacy in their state. Some states have implemented a mileage restriction, and this blog dives into some of the impacts a mileage restriction, as it pertains to telepharmacy, has on the practice and access to care.
A mileage restriction is the minimum distance required between the location of a telepharmacy (or remote dispensing site) and the nearest existing pharmacy location. This effectively places a “bubble” around each existing pharmacy where no telepharmacy may be implemented for a set number of miles. The amounts vary among states; nine states have a 10 mile restriction, and eight have a restriction of greater than 10 miles. There are currently a handful of states with no mileage restrictions, such as Arizona, Illinois, Idaho, and Washington, which allow telepharmacies to operate where it makes most sense for the pharmacy owner.
Let's take a quick look at a list of the most common arguments in favor of mileage restrictions for telepharmacies:
1. “Telepharmacies cause unfair competition for existing pharmacies.”
Some are concerned an influx of telepharmacy locations will increase competition for traditional pharmacies, potentially costing them patients and business. The goal of a mileage restriction is to essentially keep telepharmacies from competing too closely with existing pharmacies.
2. “Telepharmacy poses a threat to pharmacist jobs, so we need to keep them from taking over.”
Proponents for restrictions fear that because telepharmacies don’t require a pharmacist on-site, they are a threat to pharmacist jobs. They worry that, if unchecked, pharmacy chains may replace all traditional pharmacy locations with telepharmacies and essentially reduce their pharmacist workforce.
3. “Telepharmacy isn’t as safe as traditional pharmacy, so we need to limit the scope of it.”
Pro-mileage restriction advocates feel telepharmacy is an unsafe alternative to traditional pharmacy, primarily because a pharmacist is not on-site (though the evidence proves safety is not an issue). However they do acknowledge patients in the most rural parts of their state don’t have convenient pharmacy options, and accept telepharmacy may be beneficial, but only in these rare circumstances.
Now that you have a grasp on what mileage restrictions are and why some have supported them, it’s time to dive into the four main components of why telepharmacy mileage restrictions may actually limit pharmacy access:
Need should be the main criteria for telepharmacy location, not mileage.
Telepharmacy exists to meet a need. It allows pharmacies to serve underserved patients and provides an opportunity for pharmacy businesses to expand their footprint in a cost-effective manner. When mileage restrictions are put in place, they present an unnecessary barrier in accomplishing these goals.
For instance, recently in Michigan, where they have a 10 mile restriction, a pharmacy wanted to place a new telepharmacy 9.8 miles away from an existing traditional pharmacy. The pharmacy sought an exception from the board of pharmacy, which was fortunately approved because the proposed telepharmacy was going to meet a need in a community that lacked convenient pharmacy access.
This same scenario has happened in other states as well, where the board of pharmacy waived the restriction because ample need was demonstrated. In fact, most states with mileage restrictions have the option for a waiver written in their regulations, stating that if a pharmacy can demonstrate the need for telepharmacy, they may be able to receive approval from the board.
The question we need to ask is - what is the difference between 10 miles and 9.8 miles, or between 9.8 and five, or five and three? It shouldn’t matter how far away the telepharmacy is from another pharmacy if it’s meeting a need. This is something regulators recognize, as evidenced by the waiver option. It begs the question - if need trumps distance, why have the restriction in the first place?
Need should be the ultimate determining factor for whether a telepharmacy can be implemented, not the distance to another pharmacy.
Mileage requirements keep underserved patients from being served.
Perhaps the patients negatively impacted the most by mileage restrictions are those who live in urban settings. It’s a common misconception that these patients do not have issues with accessing pharmacy services because they live in a more populated environment which often have more resources. Even in highly populated cities people struggle to get access to basic pharmacy services. There may be a pharmacy on every corner in some parts of the city, but there are many communities and neighborhoods that don’t have as many convenient options.
Studies (like this one on Los Angeles and this one on Chicago) show that even when patients live less than one mile from the nearest pharmacy, they may still experience obstacles to pharmacy care. This is certainly the case in some urban settings where patients may experience disabilities, or economic, cultural, and even linguistic disparities to care. Not to mention the additional difficulties associated with transportation, such as relying on public transit, taxis, or walking several city blocks in inclement weather.
This same concept can be applied to other areas as well, not just urban cities. Having patients make the round-trip to the pharmacy several miles away on rural highways with sometimes icy roads or other inclement conditions is unnecessary when they could have pharmacy access conveniently located in their own community with telepharmacy.
Traditional retail pharmacies often can’t survive in the lower-income areas of the city, so telepharmacy provides a great opportunity for a pharmacy to open a standalone location or inside of a clinic. These locations are suddenly more financially viable, and simultaneously provide drastic benefits for patients.
The free market already accomplishes the main goal of mileage restrictions.
As stated earlier, one of the reasons cited for implementing mileage restrictions is to protect existing pharmacies. Some people fear the increase in competition posed by an influx of telepharmacy locations will be bad for the existing pharmacies and may run them out of business.
It’s worth mentioning there are no regulations restricting where a traditional pharmacy can be located, so there is theoretically always a risk of increased competition for an existing pharmacy. There is nothing about telepharmacy that makes it inherently more threatening to a traditional pharmacy - in fact, it shouldn’t be a threat at all.
We’ve stated this many times, but it bears repeating - telepharmacy is not a intended to directly compete against traditional pharmacies. In fact, in Idaho (a state with no mileage restrictions), a telepharmacy was opened near a traditional pharmacy and the telepharmacy struggled to attract business. Before long it became clear that patients preferred the traditional pharmacy and the telepharmacy was forced to close its doors.
Telepharmacy exists to meet a need for underserved patients. If a patient population’s needs are already met by an existing nearby pharmacy then there is no need for a telepharmacy. Plus, it’s important to note that the scope of practice for pharmacists and pharmacy technicians is not changed with telepharmacy, and since it is a retail brick and mortar location, all the same costs and expenses associated with a traditional pharmacy still apply. Telepharmacies aren’t able to undercut the competition with lower prices, as they face all the same reimbursement challenges of a traditional pharmacy, and they have to pay their staff and keep the lights on just like everyone else.
A mileage restriction is not necessary to protect existing pharmacies because there is no reason to put a telepharmacy right next to a traditional location, and many times it would be an unwise business decision to do so.
Mileage restrictions hurt struggling independent pharmacies.
Above, we discussed the pro-restriction argument that telepharmacy takes pharmacist jobs and provides a way for chains to crowd out the market. However, the truth is telepharmacy is a great tool used by many independent pharmacies to expand their businesses and keep them strong.
Small, independent pharmacy businesses struggle to make ends meet. Between declining reimbursement rates and low net operating margins, they are constantly looking for ways to keep their business financially solvent. Telepharmacy is a way for pharmacies to expand their footprint in a cost-effective manner, most commonly to underserved areas where a traditional pharmacy would not be feasible.
At TelePharm, we’ve worked with hundreds of pharmacists who have utilized telepharmacy to expand their businesses and have even seen telepharmacy serve as a lifeline for their struggling pharmacy locations that might otherwise have had to close for good.
By restricting where telepharmacies can be located, it simply places an additional barrier in front of struggling independent pharmacies that are looking for a way to keep their businesses afloat and continue to serve their patients.
Hopefully now you have a full picture of the nature of mileage restrictions and the impact they have on telepharmacy. It comes down to this: telepharmacy exists to help patients who need it, and mileage restrictions often interfere with patient access.
Please feel free to utilize this article as you have discussions with peers, regulators, or pharmacy boards. If telepharmacy is legal in your state, you can work to lower or eliminate the existing mileage restrictions. If it’s not yet legal in your state, you can help shape the regulations to be as beneficial as possible to pharmacies and patients alike.