Pharmacist Workforce Challenges:
Exploring Today’s Manpower Shortage
Katherine K. Knapp, PhD, Professor and Director of the Center for Pharmacy
Practice Research and Development College of Pharmacy, Western University of Health
Sciences, Pomona, CA
Published by Cardinal Health 12.01
Background. The recent, intense interest in the pharmacist workforce stems
from the perception that there are not enough pharmacists to fill open positions.
A similar shortfall occurred over a decade ago and gradually resolved. Therefore,
the initial reports of a new shortage in 1998 were not met with alarm. It was
not until more than a year passed during which vacancies continued to mount across
a variety of pharmacist employment settings that the possibility of a long-term
workforce problem was considered. A Congressional report in 2000 characterized
the pharmacist shortage as an acute event most strongly related to increased use
of prescription medications and new healthcare roles for pharmacists. Both these
factors increased the demand for pharmacists and pharmaceutical care services.
A New Model Describing the Pharmacist Workforce. Data characterizing the
pharmacist workforce has improved over the last decade. In 2000, the Bureau of
Health Professions published information about a new model that projects pharmacist
numbers by gender and age through 2020. The model estimates there were 196,011
active pharmacists in 2000 and that pharmacist numbers will increase by about
1.4% per year through 2010. This rate of growth slightly exceeds the projected
U.S. population growth of approximately 1% per year. The model also portrays an
increasingly female pharmacist workforce with 46% women pharmacists in 2000 rising
to 58% by 2010. Through 2010, pharmacists leaving the workforce by reason of death
or retirement will be predominantly men. The model also estimates that about 314
pharmacists trained outside the U.S. will enter the pharmacist workforce each
year.
The principal shortcoming of the new model is that the estimated headcount it
provides does not factor in work patterns of pharmacists. Historically, women
pharmacists have preferred to work part-time during child-bearing and child-rearing
years and men pharmacists have tended to work more than a 40-hour week. If these
patterns were to persist, the increasingly female pharmacist workforce would coincide
with a continually decreasing work contribution for each pharmacist. Another work
pattern observed in women pharmacists has been a preference for work in institutional
settings such as hospitals. If the shortage persists, this preference could be
problematic for pharmacist employers in non-institutional settings.
Recent Information about the Pharmacist Shortage. In 2000, the American Society
of Health-System Pharmacists (ASHP) called attention to growing pharmacist vacancies
using survey data from directors of pharmacy. Their report noted that more pharmacy
directors (70%) were having difficulty filling positions requiring experienced
practitioners than filling entry-level positions (40%). These findings were mirrored
by survey results from The Lazarus Report, also from directors of institutional
pharmacies. The Lazarus Report also documented rapidly rising pharmacist salaries
in 2000. The National Association of Chain Drug Stores (NACDS), through surveys
at six-month intervals, has reported continually growing vacancies in community
pharmacies since 1998. Drug Topics, a trade journal, has tracked the rise in pharmacist
salaries across both the institutional and community settings, an indicator of
increased demand. The Aggregate Demand Index, a monthly report of the difficulty
in filling open positions across the U.S., found that, since 1999, the highest
unmet demand for pharmacists was occurring in Minnesota, California, Wisconsin,
Kentucky, Iowa and Texas. The same survey found that only in Hawaii and Rhode
Island were supply and demand for pharmacists in balance.
Sorting Out Causes of the Shortage. The 2000 Congressional report concluded
that the principal reason for the shortage of pharmacists was the recent growth
in the use of prescription medications. Prescription growth rates in the latter
1990s outpaced growth rates earlier in the decade and greatly outpaced the growth
of pharmacists. Several factors contributed. As the 1990s progressed, the Baby
Boomers, a large population segment, entered age groups where medication use is
known to accelerate. At the same time, third party coverage increased from 44%
of prescriptions in 1992 to 78% in 1999 and covered prescriptions are known to
be more often filled and refilled. Direct-to consumer advertising was also growing
in the late 1990s further increasing the demand for prescription medications.
Prescription medication use was also rising in the institutional setting although
this phenomenon is more difficult to quantify. Overall, all these factors, occurring
concurrently, increased the demand for pharmacists and their services beyond the
available supply.
Further exacerbating the emerging problem has been the expansion of pharmacist
roles in healthcare. ASHP surveys of the responsibilities of ambulatory care pharmacists
in 1997 and 1999 showed pharmacists in integrated health systems were increasing
their routine participation in nontraditional activities involving both patient
care and management. At the same time, community pharmacies began offering immunization
programs and programs that address common, chronic diseases treated primarily
with medications (for example, asthma and diabetes mellitus). Screening programs
coupled with patient education targeting, for example, osteoporosis and hypertension
have also become more widespread. These new activities further increased the demand
for pharmacists.
Looking Forward … What Can Help? The supply of pharmacists can be
increased but probably not enough to serve as a sole solution to the shortage
problem. Since 1996, six new pharmacy schools have opened. Other schools have
completed the transition to the Doctor of Pharmacy degree, a step that often reduces
graduate numbers, at least temporarily. Support for increasing the supply of pharmacists
must include steps to increase applications to pharmacy schools that have been
falling since 1997.
Pharmacists already in the workforce can also contribute to solving the shortage.With
the proper incentives, women pharmacists may change from traditional work patterns
and work more. Incentives may also induce pharmacists to postpone retirement and
remain in the workforce.
Broader use of pharmacy technicians is another avenue for coping with the shortage.
It is estimated that there are about 200,000 pharmacy technicians in the U.S.,
about one technician for every pharmacist. Other data characterizing pharmacy
technicians are sparse. By passing the Pharmacy Technician Certification Board
examination, almost 90,000 pharmacy technicians have demonstrated competencies
that give pharmacists and employers confidence in delegating responsibilities
to them. With the recognition of medication errors as an unsolved, national problem,
however, other steps such as additional training may also be necessary.
Legislation also impacts on the shortage situation. Legislation, generally at
the state level, is required to change the allowable activities of pharmacy technicians
and other aspects of delivering healthcare. California and Florida could increase
the flow of pharmacists into their states by adopting the reciprocity practices
of other states. State-based changes could also accelerate the rate at which students
move into practice after graduation.
Automation and technology offer the strongest possibilities for moving the quality
of the medication use process forward even if pharmacists are in short supply.
Many advances in automation have, to date, been applicable mostly to large systems
such as the Veterans Affairs system or the Kaiser Permanente system. In institutions,
automated medication dispensing cabinets and bar coding can enhance safety as
well as productivity. Physician use of electronic prescribing software could make
the process of dispensing prescriptions safer and more efficient. The adoption
of automation and technology solutions can be held back by cost, restrictive legislation
and the fact that many advances are still applicable primarily to large systems
while many pharmacy operations are relatively small. However, as recently pointed
out in an Institute of Medicine report, the very limited application of technology
to healthcare has been an obstacle to achieving quality. The pharmacist shortage
may be a spur to the wider and better use of automation and technology in the
medication use process.
Summary. It is widely accepted that the pharmacist shortage is a reality.
Nevertheless, quality gains in the medication use process must move forward; and,
therefore, multiple, partial solutions should be considered and implemented judiciously.
These solutions should be built on the expectation that the demand for pharmacists
and their services will continue to grow in the foreseeable future.
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