More than 16% of the nation's independently owned rural pharmacies shuttered between March 2003 and March 2018, according to a policy brief by the RUPRI Center for Rural Health Policy Analysis at the University of Iowa. Some pharmacists and experts blame PBMs for opaque practices that leave these smaller pharmacies struggling to cover their costs, but there is another part of the PBM practice that has attracted less public criticism: the reimbursement rates for drugs. Anthony Reznik, director of government affairs for the Independent Pharmacy Association, said independent pharmacies are often reimbursed less than what they paid for drugs, and they can be at a disadvantage when PBMs are the ones setting the pharmacy reimbursement rates. Michael Swanoski, a senior associate dean at the University of Minnesota College of Pharmacy, noted that prescription drug revenue is vital for small pharmacies. He said the decline reported in the brief is significant for those communities where closures are occurring. For example, 630 rural communities saw their only pharmacy shut down from 2003 to 2018, the RUPRI report found. PBMs are not the only source of financial concern for rural pharmacies, however. RUPRI Center Director Keith Mueller said the report revealed a sharp decline of rural pharmacies between 2007 and 2009 following the implementation of Medicare Part D. He said the shift in how pharmacies were compensated under the program that covers prescription drugs for older adults caused a "market disruption."