Congratulations, Graduates! You Are Entering the Profession at the Peak of Simultaneous Opportunity and Peril
Never have there been so many opportunities for non–dispensing pharmacist roles. At the same time, there has never been such a need to save the dispensing environment.
New Graduates Should Prepare for a 40-Year Career Horizon
Approximately 15,000 pharmacy students have graduated from nearly 150 schools and colleges of pharmacy in the past few weeks,1 and each of them likely has dual feelings of excitement and anxiety. How much can change over 40 years? A lot. And these changes are accelerating.
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The health care sector is not on a linear change trajectory, and we cannot know at this moment if there will even be pharmacists by the time these new graduates retire (or even if 40 years gets one to retirement now). Will gene therapy negate the need for most medications? Will physician practice yield to artificial intelligence? Will the dominant health care provider group be health coaches and wellness experts? Will we gain interventions but continue to fail to use them effectively? Will health care send our national debt to $100 trillion, and will taxpayers come to terms with rationed care? Only time will tell.
Most New Graduates Seek Postgraduate Programs to Build Their Resume
Just over half of pharmacy graduates now apply for residencies, with likely more than 40% of them getting matched with one through the 2 phases of the match process.2 The number of single-year residency slots and students who seek them continues to grow, alongside second-year residencies, which are also seeing large growth in sites and slots. Will we reach a point where most pharmacists entering the workforce spend 10 years studying post high school in order to move into independent practice? Many of these students are honing their skills in specific settings of care with specific knowledge and experience that the majority of pharmacists do not experience. Should we consider the new pharmacists “specialists” or “generalists”?
Most Pharmacy Positions See Residencies and Fellowships As Nice, Not Necessary
Most of the pharmacist workforce still practice largely as generalists, or what some specialists might call “dispensers.” Some community pharmacists consider the term a slight, particularly toward community pharmacy practice sites. However, 57% of the entire pharmacist workforce are dispensers who work in community pharmacy settings.3 Probably a substantial portion of the 26% of those working in health care facilities are also dispensers, pushing generalist pharmacists, many of whom did not have residency training, past two-thirds of the entire profession of more than 300,000.
Most of those 200,000 pharmacists practicing in community pharmacies played an outsized role during the COVID-19 pandemic, both saving and improving lives with health care services delivery while demonstrating an economically sustainable model for the future. It turns out that pharmacists who are generalists and happen to engage in or supervise dispensing make a great access point for cost-effective health care services, with greater throughput, margin, and provision of services to the socially vulnerable.
2024 Could be a Breakout Point for Community Pharmacy as it Embraces New Models of Economic Sustainability
Will we make the turn quick enough for those hundreds of thousands of pharmacists, as well as their teammates and workforce partners who are becoming patient engagement experts, community health workers, dietitians, patient navigators, and medical-at-home helpers? Most community pharmacies are now in the throes of contracting with pharmacy benefit managers for the 2024 calendar year, and word on the street is that many contracts are completely unsustainable and put pharmacies underwater.
Meanwhile, chain pharmacies and independents alike are preparing for a substantial increase in the diversity and volume of services. One chain is preparing to put thousands of collaborative practice agreements in place, whereas others are implementing colocated direct primary care. Nearly all “combo” pharmacies who serve both ambulatory and longterm care patients will soon be exploring medical-at-home partnerships and services provisioning.
At the same time, pharmacies are becoming the predominant provider of adult immunizations, providing 90% of all COVID-19, influenza, pneumococcal, shingles, human papillomavirus, and Tdap vaccinations.4 Pharmacies as the primary site of care for testing services, screenings, and even prescribing for some categories of medications are likely only a few years away. But will pharmacies still be around to realize this public health and professional opportunity if they are losing money with each prescription they fill? Will they be around, but not staffed by pharmacists?
WIll Riding the Pandemic's Coattails Save Community Pharmacy Practice, the Schools of Pharmacy, and Legions of Graduates With Massive Student Debt?
COVID-19 accelerated what has been a long and slow slog toward a change in practice and business modeling for community pharmacies. Pharmacists were hard pressed to find an open position in 2019, and now they are offered sign-on bonuses in some areas of the country (against falling dispensing margins). This best of times, worst of times scenario is burning pharmacists out. They cannot fill enough prescriptions to stop losing money, while the margin-producing health care services need the dispensing to produce the necessary patient engagement and access. Importantly, this engagement and access are what makes community pharmacy a ripe site for public health-oriented care as well as the delivery of chronic services.
The Future is Bright – But for How Many?
Many pharmacy staff in the health system space feel safe and secure, often with lots of letters behind their names, excellent residency training, and employers plum full of cash flow and 340b “savings.” What is unknown is the effect of continued below-cost dispensing rates on pharmacy closures, along with narrowed or eventually eliminated 340b access for community pharmacy. What if there is a collapse of community pharmacy? Will that balloon in labor supply squeeze and transcend geography and setting of care?
We Must Save Community Pharmacy or All of Us – Including Patients – May Be Hurt
Why tempt fate? We are all better off (as patients ourselves as well as pharmacists) if all of pharmacy supports all of pharmacy. Our health care system is notoriously ineffective for the dollars we invest in it, but shockingly little of eachhealth care dollar is spent on community pharmacy operations (after removing what the pharmacies paid for the medications they dispense). It is a tiny investment to keep 60,000 accessible locations open to communities across the country. Surely we can all get behind saving this tried-and-true setting of care.
About The Author
Troy Trygstad, PharmD, PhD, MBA, is the executive director of CPESN USA, a clinically integrated network of more than 3,500 participating pharmacies. He received his doctor of pharmacy PharmD and master in business administration MBA degrees from Drake University and a doctorate PhD in pharmaceutical outcomes and policy from the University of North Carolina.
References
1. Academic Pharmacy’s Vital Statistics. American Association of Colleges of Pharmacy. Accessed May 24, 2023. https://www.aacp.org/article/academic-pharmacys-vital-statistics#:~:text=In%202019%E2%80%9320%2C%2014%2C320%20first,degrees%20were%20awarded
2. Lagasse J. Almost 5K matches made for pharmacy residency programs. Healthcare Finance. March 17, 2023. Accessed May 24, 2023. https://www.healthcarefinancenews.com/news/almost-5k-matches-made-pharmacy-residency-programs
3. Oster NV, Pollack SW, Skillman SM, Stubbs BA, Dahal A, Guenther G, et al. The Pharmacist Workforce in the US: Supply, Distribution, Education Pathways, and State Responses to Emergency Surges in Demand. Center for Health Workforce Studies. September 2020. Accessed May 24, 2023. https://familymedicine.uw.edu/chws/wp-content/uploads/sites/5/2020/09/Pharmacist_PB_Sep_25_2020.pdf
4. IQVIA. Trends in Vaccine Administration in the United States. January 13, 2023. Accessed May 24, 2023. https://www.iqvia.com/insights/the-iqvia-institute/reports/trends-in-vaccine-administration-in-the-united-states
