A Vision of Pharmacy's Future Roles, Responsibilities, and Manpower Needs in the United States

This paper was prepared by the 1997-1999 ACCP Clinical Practice Affairs Subcommittee A: Michael S. Maddux, PharmD, FCCP, Chair; Betty J. Dong, PharmD; William A. Miller, PharmD, FCCP; Kent M. Nelson, PharmD, BCPS; Marsha A. Raebel, PharmD, FCCP, BCPS; Cynthia L. Raehl, PharmD; and William E. Smith, PharmD, PhD

Pharmacotherapy. 2000;20(8) 

In This Article

Forecasting Manpower Needs

Manpower demand studies have a long history of inaccuracy, especially at times when the workforce and nature of the work are undergoing rapid change.
Wells, 1999 [81]

No one understands why we have these swings in demand and supply. Since 1990, we've gone through a shortage, a slight surplus, and now it appears we're back in an era of shortage.
Knapp, 1999 [82]

Future demand for pharmacists remains an unresolved issue for the profession. Both future surpluses

[83]

and shortages

[6]

of pharmacists have been predicted. The most controversial of these predictions was rendered in a 1995 report of the Pew Health Commissions that projected a surplus of 40,000 pharmacists by the year 2005.

[83]

This report generated widespread dialogue concerning manpower throughout the profession and among pharmacy academicians.

Recent pharmacy workforce statistics[49] indicate that pharmacists held approximately 185,000 jobs in 1998. About 60% worked in community pharmacies that were either independently owned or part of a drug store chain, a grocery store, department store, or mass merchandiser. Most community pharmacists were salaried employees, but some were self-employed owners. About 25% worked in hospitals, and the remaining 15% worked in clinics, managed care organizations (MCOs), mail-order pharmacies, long-term care, pharmaceutical wholesalers and manufacturers, home health care agencies, academic institutions, the federal government, or other pharmacy-related environments. About 20% of the pharmacy workforce is engaged in part-time employment.

Future manpower needs will undoubtedly be influenced by a variety of developments, several of which are likely to increase the demand for pharmacists. The continued rise in America's prescription drug use is projected to result in the dispensing of 3.5-4 billion prescriptions annually by the year 2005, an increase of as much as 44% from the estimated 2.8 billion prescriptions that were dispensed in 1999.[14,82] If Medicare offers an outpatient prescription drug benefit, this would improve access to prescription drugs for the one-third of beneficiaries who currently lack coverage, further fueling the increase in future prescriptions.[84] To accommodate rising prescription demand and to enhance market share, chain pharmacies are increasing the number of chain outlets and expanding store operating hours.[85] As we enter a new millennium, women will outnumber men among the pharmacist workforce, primarily as a consequence of the increased number of female pharmacy graduates and the retirement or death of the relatively large cohort of post-World War II male pharmacists. The U.S. Bureau of Health Professions projects that by the year 2003 the majority of pharmacists will be women.[82] As women traditionally have been more likely to engage in part-time employment during their professional careers, it is anticipated that this gender shift will contribute further to an increase in pharmacist demand. Although there are data indicating that the impact of the increased part-time force has been counterbalanced by a sizable cadre of moonlighting pharmacists,[86,87] it seems unlikely that the number of moonlighters will keep pace with the expected growth of the part-time female pharmacy workforce. In addition, relative job dissatisfaction and decreased employee retention may contribute to a shortage of pharmacists in selected areas of practice, particularly in the chain pharmacy sector.[85] Other factors likely to drive an increased demand for pharmacists during the next 5 years include evolving roles for pharmacists in MCOs, where pharmacists are participating in management of drug utilization among "high utilizer" populations and analyzing data that address specific MCO performance outcomes[31,88]; increasing employment of pharmacists by the pharmaceutical industry to pursue research involving drug development, disease management, outcomes measurement, and pharmacoeconomics[49]; increasing job opportunities in long-term, ambulatory, and home care settings, as pharmacy services continue to shift toward these sectors[89,90]; and creation of new roles for pharmacists in the online telehealth environment, including Internet-based drug purchasing and online patient counseling, a heretofore uncharted landscape for pharmacy practice.[91]

Factors that may contribute to future decreases in pharmacist demand include an anticipated increase in number of pharmacy school graduates; expanded use of automated dispensing systems, mail-order prescription services and pharmacy technicians; and an eventual downsizing of the dispensing pharmacy workforce due to increased managed care penetration.[5,49] However, recent data suggest that the short-term effect of managed care on the institutional pharmacy workforce has been negligible.[31] Whereas the influence of expanded managed care penetration on the pharmacy workforce as a whole is controversial, it appears that the number of pharmacists required to manage the drug distribution process will decrease in the long term.[5]

Taking the foregoing trends into account, short-term predictions for pharmacist demand have been published. The U.S. Bureau of Labor Statistics (BLS) estimates that employment of pharmacists will increase 0-9% between 1998 and 2008, a rate slower than the average for all occupations in the U.S.[49] The BLS predicts that during this period automated drug dispensing and increased use of technicians will help pharmacists fill prescriptions. It also notes that growth of pharmacist employment in hospitals is expected to be slow, reflecting continued reduction in hospital stays, downsizing, and consolidation of departments. On the other hand, the BLS suggests that the increased number of prescription drugs used by middle aged and elderly people could increase demand for pharmacists in all practice settings. The BLS also acknowledges that cost-conscious insurers and health systems will continue to explore the roles of pharmacists in primary and preventive health services. This is based on their realization that the expense of using drug therapy to treat diseases and conditions is often considerably less than the potential costs for patients whose conditions go untreated, and that pharmacists can play an important role in reducing the expenses resulting from unexpected complications due to adverse drug events or drug interactions.

Based on a study of the pharmacy manpower issue conducted by the Pharmacy Manpower Project, Knapp recently analyzed the impact of managed care on future demand for pharmacists and pharmacy services.[31] Unlike the BLS outlook, this analysis predicts that there will be a steadily increasing demand for pharmacists and their services. Although unable to validate the downsizing of the pharmacy workforce predicted by the 1995 Pew Health Professions Commission's report,[83] Knapp calls for pharmacists to continue documenting their value to the health care system and participating in activities that improve patient outcomes.[31]

From a manpower perspective, is pharmacy "short-handed" or just "short-sighted"? A federal study is under way to address this question. The Healthcare Research and Quality Act of 1999 requires the Health and Human Services Department to study the pharmacist workforce supply and report its findings to Congress in December 2000. Meanwhile, we believe that the projections of the BLS, the Pharmacy Manpower Project, and the Pew Commission are not necessarily at odds with one another. While we have long been disturbed by the relative lack of data to support the Pew Commission's manpower forecast, we recognize that pharmacy has been relatively slow to embrace new technologies in the areas of information, communications, and robotics that were anticipated by the Pew report.[91] The profession also continues to struggle with developing expanded roles for technicians in the drug distribution system.[14] However, once technology, new centralized dispensing systems, and technicians are widely utilized to increase drug distribution efficiencies, it is probable that the need for pharmacists engaged solely in distribution will decrease. The wisdom of Pew's suggested downsizing of pharmacy school classes by 2005 has been called into question by current manpower trends. Nonetheless, it is not impossible that Pew's predictions might yet coincide with the emergence of a new era of decreased pharmacist demand -- a trend that would be consistent with the slower-than-normal growth in pharmacist jobs through 2008 that recently was forecast by the BLS. Thereafter, future manpower needs no doubt would be affected by the profession's success in redefining and transforming itself into a discipline that provides care and impacts patient outcomes.

Recent demonstration projects, including the Mississippi Medicaid Disease State Management Program, may be instrumental in providing necessary documentation of the contributions that pharmacists can make toward more effective and cost-efficient care.[14,15] In addition, recently published data indicate that pharmacists in managed care and integrated health systems have broadly expanded their ambulatory care functions, including using pharmacoeconomic data to make formulary decisions, conducting medication management programs, tracking adverse drug reactions, providing written information with each new prescription, monitoring patient outcomes, and monitoring compliance with medication use.[92] Such continued expansion of pharmacist responsi-bilities could produce a demand for "nondispensing" pharmacists that would seriously challenge the profession's manpower resources for the foreseeable future[6,56] (though this possible increase in demand may be mitigated somewhat by enhanced clinical efficiencies enabled by new technologies such as artificial intelligence applications for streamlining and monitoring drug therapy). Regardless, if pharmacists' current professional roles remain unchanged, manpower requirements will be determined primarily by cost-driven changes in drug distribution management. Such changes eventually could produce an environment that requires fewer pharmacists to successfully support the future health care system. In view of these uncertainties, it seems to us that academia should carefully assess the nation's future pharmacy manpower needs before seeking to adjust pharmacy school enrollments. Clearly, these potential manpower trends should serve as a wake-up call for the entire profession.

Finally, academic pharmacy is facing its own manpower problem.[93] Expanding pharmacy workforce needs, increasing numbers of pharmacy schools, rising numbers of doctor of pharmacy students, and relatively static supply of faculty training programs (Ph.D. programs, residencies, and fellowships) are contributing to an inadequate supply of faculty to meet the current demand. The number of faculty departing academia to pursue careers in the pharmaceutical industry appears to be increasing, at least in the short term.[93] It has been recommended that the academy increase efforts to recruit new graduates and experienced practitioners into academic career tracks, support the growth of clinical residency programs to meet the rapidly increasing need for clinical practitioner faculty, promote expansion of fellowship programs to increase the supply of academic clinical scientists, and establish effective mentoring processes for new faculty.[64,93] In addition, we suggest that formal instruction in didactic and experiential teaching be incorporated into clinical residency and fellowship training, particularly in those programs that are affiliated with schools of pharmacy.

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