WEBSTER GROVES — Steve Zielinski’s father was a pharmacist. More than just dispensing drugs, he solved problems: helping regular customers manage chronic illness, low-income patients afford medicine and older folks maintain their independence.
Zielinski wanted to do the same. He earned a degree, gained some experience and, last year, he opened Webster Pharmacy in Webster Groves. But it felt like everything had changed.
“Medications are treated as a commodity instead of health care,” said Zielinski. “I didn’t know it was going to be this tough to be an owner.”
Independent pharmacies have long been community cornerstones. They sponsor baseball teams and participate in bowling leagues. They establish personal relationships with customers, advocate for them, and offer advice. That accessibility generates trust and improves health outcomes, pharmacists say. And as the region tries to emerge from the pandemic, it could help the effort to reach more patients who need to be vaccinated.
But in the past couple of decades, the industry has become tortuous for small drugstores. The influence of pharmacy benefit managers, established in the 1960s as intermediaries for drug manufacturers, insurers and pharmacies, has expanded. Chain pharmacies have gobbled up more real estate, accounting for seven of every 10 prescriptions filled.
The boundaries between industry players have blurred. The parent company of CVS, the largest pharmacy in the United States, also owns Caremark, a pharmacy benefit manager, and Aetna, an insurer. Those entanglements lead to convoluted pricing structures, exclusive preferred-drug lists and below-cost prescription reimbursements, said the Missouri Pharmacy Association, an advocacy group.
Ron Fitzwater, the association’s CEO, calls reimbursement issues dictated by pharmacy benefit managers the “key culprits” in forcing pharmacies to sell or close. Twenty years ago, there were about 720 independent pharmacies in Missouri. Now there are about 500.
Zielinski called drug reimbursements “garbage.”
“The whole system is based on ‘let’s screw over the pharmacy,’” he said.
His frustration has led him to focus less on filling prescriptions and more on a functional approach — managing disease and reducing side effects with nutritional counseling, supplements and hormone replacement.
“You have to do something that makes you different,” Zielinski said.
And pharmacy owners have. Legacy Drugstores in Warrenton and Wright City have updated last century’s staple, soda fountains, to a liquid-nitrogen ice cream café. Ladue Pharmacy takes orders for custom-made Easter baskets. Kismet Pharmacy in University City sells gourmet coffee, CBD gummies and all-natural cleaning products.
In recent years, many independents have attracted customers by underscoring their place along the health care continuum, offering diabetes and asthma counseling and smoking cessation tools. Some are connected to telehealth platforms. Others employ bilingual technicians to communicate with non-English speakers. Free delivery of medications is an almost universal offering, but many pharmacists have also started making house calls to administer vaccines to homebound clients.
Lemonaid Community Pharmacy in Shrewsbury just opened in November, a stone’s throw away from a Walmart, Dierbergs and Schnucks, where CVS took over the pharmacies in July. Lemonaid manager Clayton Maxfield predicts customers will cross Watson Road for the individualized attention he can provide in the small storefront’s dedicated consultation space.
“People just want to talk to people,” said Maxfield. “They come in with questions, and we have the time to help them.”
Unlike some of the larger pharmacies at which he’s worked, Lemonaid does not require him to hit sales quotas or performance metrics, he said. A real person answers the phone.
Early on in Missouri’s COVID vaccine rollout, most shots were administered at large, assembly-line style events. Then a federal partnership with retailers like Walgreens and CVS was announced. Finally, last month, vaccine allotments began flowing to small pharmacies.
Winkelmann Sons Drug Co., on Meramec Street in south St. Louis, has been pushing to get the shot since it became available, but even before that, Dan Winkelmann was prepping his customers.
“It’s been a big emphasis the last six months, trying to make them comfortable with the shot,” said Winkelmann, a fourth-generation pharmacist.
It’s been a tough year. He lost about 50 regulars to COVID; they are neighbors, people he’s known for years. The Winkelmann name has had a presence in Dutchtown since 1913. His grandfather was one of seven siblings who followed their father into the trade. At one time, there were 20 Winkelmann locations around the city.
Winkelmann has been working at a pharmacy since he was a high school student, four decades ago. Now he mentors young pharmacists. He’s grateful he’s not starting out today.
“I’m fortunate I don’t have to build a business,” he said.
Rebecca Mawuenyega took over Dellwood Pharmacy a little over a year ago. She had left pharmacy work, shifting to consulting at a doctor’s office. But when the opportunity came up to purchase Dellwood, she decided to jump back in.
“It’s been quite a journey,” she said.
Most of her clients are lower income. Many use public transportation and don’t have internet access at home. Scheduling a COVID vaccine would be no easy feat. Mawuenyega started a list at the store, telling customers about it when they called her or while they were shopping.
Starting in March, Dellwood has received 200 doses a week. Mawuenyega brings in up to 10 temporary workers to help dispense the shots.
“We had a huge vaccination hesitancy in our community,” she said. “I think our presence here really, really helped. People get it and go back and tell others.”
Even with all the paperwork, the manpower required and the repayment complexities, it’s been rewarding.
That’s why she came back to the field in the first place.
“What keeps independent pharmacies going are the services and the relationships,” Mawuenyega said. “But there are a whole lot more leaving than staying in. It’s kind of a dance to stay in business.”