The Adequacy of Pharmacist Supply: 2004 to 2030

III.  Pharmacist Requirements

The term “requirements” is a broad definition of the number of pharmacists necessary to provide an adequate supply, and health workforce researchers have used various approaches to estimate future requirement.  Needs-based requirements estimates are based on what someone thinks is needed or is ideal—e.g., based on epidemiological considerations and desired pharmacist work patterns.  Demand-based requirements estimates are based on future projections of the number of prescriptions that consumers will want filled and the anticipated role of pharmacists to meet this demand for pharmaceuticals.  For this study a demand-based definition and approach was used to estimate requirements.

National requirements for pharmacists continue to rise to meet the demands of a population that is growing and aging, increased per capita utilization of pharmacy services that accompanies technological advances in number and complexity of new pharmaceuticals, increased need for education and monitoring as patients consume more pharmaceuticals, and expanded pharmacy benefits afforded by Medicare Part D and other programs.  This growth in demand is tempered somewhat by advances in dispensing technology and improved communication systems that increase pharmacist productivity, as well as increased use of pharmacy technicians.  This section summarizes current demand for pharmacists and trends in demand determinants, and presents projections of pharmacist requirements under alternate scenarios.

A. Current Demand

Demand for pharmacists is derived from the demand for pharmaceuticals and the role of pharmacists in providing the dispensing, counseling, monitoring, and other services that patients require.  Demand-based health workforce studies typically use recent, historical health care utilization and delivery patterns to estimate demand for services.  The evidence suggests that the Nation currently has a moderate shortfall of pharmacists, and the implications of this shortfall are reflected in determining base year (2004) pharmacist requirements.  These implications include that pharmacists might be working longer hours or spending less time per patient than is socially desirable, or that pharmacies have had to reduce services because of unfilled pharmacy positions.

Because rates of growth over time in demand for pharmacy services and changes in pharmacist productivity can vary across settings that employ pharmacists, the PhSRM models demand for pharmacists in six settings: hospitals, other patient care (e.g., clinics, nursing homes), chain pharmacies and food stores, independent pharmacies, mail order, and non-patient care.

In 2004, there were an estimated 191,200 FTE pharmacist positions filled and an estimated 10,400 unfilled positions (Exhibit 23).  Estimates of the number of FTE positions filled in each dispensing setting were calculated by multiplying total FTE pharmacist supply by each setting’s proportion of FTE pharmacists (with the setting distribution determined by analysis of the 2004 NPWS). 

There were an estimated 10,400 unfilled FTE positions in 2004, or a vacancy rate of approximately 5 percent.  A 2004 study by the American Society of Health-System Pharmacists (ASHP) reports that 5 percent of hospitals’ budgeted pharmacist positions were vacant.^[20] While the number of vacancies continued to decline from a recent high of 8.9 percent in 2000, a 5 percent vacancy rate suggests that approximately 2,500 budgeted positions in hospitals were unfilled.  ASHP’s 2005 and 2006 surveys find that vacancy rates rose to 6.2 percent in 2005 and 7 percent in 2006.  A July 2004 survey by the National Association of Chain Drug Stores (NACDS) Foundation found that chain store pharmacies reported approximately 4,000 vacancies.^[21] Vacancy estimates are unavailable for “other patient care” settings (e.g., clinics), independent pharmacies, mail-order pharmacies, and non-patient care. It is assumed that the vacancy rate for other patient care settings is similar to that of hospitals; that the vacancy rate for independent pharmacies is similar to that of chain pharmacies, and that the vacancy rates for mail order and non-patient care are similar to the overall vacancy rate of 5 percent from the NACDS and ASHP combined results.

Exhibit 23.  Estimated FTE Demand for Pharmacists: 2004

Sources:  (a) Analysis of 2004 NPWS and 2004 Bureau of Labor Statistics Occupational Employment Statistics.   (b) American Society of Health-System Pharmacists (ASHP) 2004 Survey.  (c) Assumes same vacancy rate as for hospitals.   (d) National Association of Chain Drug Stores (NACDS) Foundation July 2004 Chain Pharmacy Employment Survey.   (e) Assumes same vacancy rate as for chain pharmacies.  (f) Assumes 5 percent vacancy rate based on average of ASHP and NACDS surveys.

B.  Trends in Demand for Pharmaceuticals

Future requirements for pharmacists are dependent, in part, on the future demand for pharmaceuticals.  Major trends in demand for pharmaceuticals include population growth and aging, changes in per capita utilization of pharmaceuticals due to technological advances and other factors, and the impact of Medicare’s new prescription drug program.

1.  Population Growth and Aging

The U.S. population is growing and aging.  Between 2005 and 2030, the population will grow by an estimated 68 million (23 percent).  In percentage terms, the population age 65 and older is growing significantly faster than the non-elderly population and will nearly double over the next 25 years (Exhibit 24). 

Exhibit 24.  Percent Growth in the U.S. Population: 2005 to 2030

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Source: U.S. Census Bureau population projections.

The elderly consume a disproportionate share of pharmacy services because of their much higher use of prescription medications and greater risk of complications and drug interactions (Exhibits 25 and 26).  Analysis of the 2004 National Ambulatory Care Survey (NAMCS) and the 2004 National Hospital Ambulatory Care Survey (NHAMCS) provides estimates of the average, annual number of patient visits with a physician in ambulatory settings (i.e., physician office visits, and hospital outpatient and emergency visits), and the average number of prescriptions written per visit.  Dividing total, annual prescriptions written for people in each age and gender group by the number of people in that population group produces estimates of average annual prescriptions per capita (excluding refills), although some prescriptions written go unfilled.

The population with the highest average, annual prescriptions per capita written in ambulatory settings is men age 75 to 84 (with 18.8 prescriptions), while the population with the lowest is men age 18 to 24 (with 1.4 prescriptions).  The population under age 65, which is projected to grow by less than 20 percent between 2005 and 2030, averages 4.3 new prescriptions per person per year.  The population age 65 and older, which is projected to grow by close to 90 percent between 2005 and 2030, averages 15.2 new prescriptions per person per year.  Changing demographics alone is projected to increase the number of new prescriptions generated through physician office and hospital visits by approximately 44 percent between 2005 and 2030.

About half of all prescriptions filled in retail settings are refills.^[22] Comparison of prescriptions written during outpatient visits (and primarily filled in a retail pharmacy) with total prescriptions dispensed in a retail setting (using IMS Health data) suggests that new prescriptions written equal approximately 54 percent of total prescriptions filled in retail settings.

Exhibit 25.  Annual Per Capita Prescriptions Written During Ambulatory Visits: Males

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Source: Analysis of the 2004 National Ambulatory Care Survey and 2004 National Hospital Ambulatory Care Survey.

Exhibit 26.  Annual Per Capita Prescriptions Written During Ambulatory Visits: Females

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Source: Analysis of the 2004 National Ambulatory Care Survey and 2004 National Hospital Ambulatory Care Survey.

2.  Trends in per Capita Use of Pharmaceuticals

Accounting for demographic changes alone would likely under predict future demand for pharmaceuticals.  From 1994 to 2005, the number of prescriptions dispensed increased 71 percent (from 2.1 billion to 3.6 billion), compared to population growth of 9 percent.^[23] The average number of retail prescriptions per capita increased from 7.9 to 12.3 during this period.  This trend of rising per capita use of pharmaceuticals will likely continue for the following reasons:

• New and More Complex Pharmaceuticals.  Scientific advancements continue to provide health professionals with the means to treat a growing range of health problems that previously were not treated with drugs.  This includes new drugs to treat rare diseases, as well as new medications such as cholesterol lowering drugs to provide preventive care.  Medco reports that utilization of specialty drugs—used to treat complex diseases such as rheumatoid arthritis, hemophilia, cancer, hepatitis C, anemia, cystic fibrosis, and growth hormone deficiency—grew by 19 percent in 2003, 16 percent in 2004, and 10 percent in 2005.^[24] Medco also reports that the world’s top 50 pharmaceutical companies are currently awaiting Food and Drug Administration (FDA) approval for about 125 new and supplemental drug applications, with an estimated 100 new drugs in the pipeline that could win FDA approval by 2008.  In addition, new uses are sometimes found for existing drugs.
• Evolving societal attitudes.  Societal attitudes towards the use of pharmaceuticals have kept pace with scientific advances.  Defensive medicine, direct-to-consumer advertising by drug companies, and a general acceptance to treat every ache and pain has contributed to a culture to use whatever drugs are available to alleviate health problems.  Prescription drug coverage has expanded over time, and this trend will likely continue. 
• Increased affordability and availability of generic drugs.  The drop in drug prices that accompany the increase in availability of generic drugs makes many drugs more affordable, increasing both the likelihood that physicians will prescribe a medication and that patients will fill their prescription.

Counter to these trends is that some drugs previously sold only by prescription are now available over the counter.  Also, as prescription drugs consume a larger proportion of health care expenditures this segment of care is coming under increasing scrutiny by insurers and employers trying to contain rising health care costs.

A Medco (2006) Drug Trend Report shows that as a trend driver of retail pharmaceutical sales, annual increases in prescriptions dispensed have been trending down in recent years.  Prescriptions dispensed increased 4.6 percent 2002, 3.8 percent in 2003; 5.4 percent in 2004, and 2.7 percent in 2005 (Exhibit 27).  Express Script (2004 and 2006) Drug Trend Reports show similar findings—a downward trend in the annual increase in volume of prescriptions dispensed.^[25] Although the annual increases in prescriptions dispensed are shrinking, these annual increases are larger than can be explained by changing demographics alone.

Analysis of the average number of prescriptions written per visit to a physician show that prescriptions written per visit have been increasing over time for office visits (Exhibit 28), hospital/clinic outpatient visits (Exhibit 29), and emergency visits (Exhibit 30).^[26] For example, for people age 65 and older the average number of prescriptions written per physician office visit grew from 1.3 to 1.7 (27 percent) between 1995 and 2004.

Projected pharmacist requirements are sensitive to assumptions of future prescriptions dispensed per capita.  Demand is modeled under three scenarios: 1) a low prescription per capita growth scenario assumes that prescriptions written per physician visit remains at their 2004 levels, so increases in per capita consumption of pharmaceuticals is driven purely by changing demographics; 2) a high prescription per capita growth scenario where prescriptions written per physician visit increase annually at the historical (1995 to 2004) rate of increase for each age group modeled and for each outpatient setting modeled; and 3) a moderate-growth scenario which assumes that prescriptions written per physician visit increase annually at half the historical rate of increase. In support of this third scenario, Medco and Express Scripts data show that the rate of growth in prescriptions dispensed in retail settings has diminished in recent years.  Also, anecdotal evidence suggests that insurers have begun to more aggressively manage pharmaceuticals in order to control rapidly rising health care costs.

Exhibits 28 through 30 show the range in projected prescriptions written per visit. The trends in prescriptions dispensed assume a one-time 6 percent permanent increase in prescriptions per visit starting in 2006 to account for the impact of Medicare Part D (discussed in more detail later).

Exhibit 27. 

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Exhibit 28.  Prescriptions Written per Physician Office Visit

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Source: Analysis of the NAMCS 1995 to 2004; trend extrapolated 2005 to 2030. 

Exhibit 29.  Prescriptions Written per Hospital/Clinic Outpatient Visit

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Source: Analysis of the NHAMCS 1995 to 2004; trend extrapolated 2005 to 2030. 

Exhibit 30.  Prescriptions Written per Emergency Visit

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Source: Analysis of the NHAMCS 1995 to 2004; trend extrapolated 2005 to 2030. 

3.  Medicare Part D

Medicare Part D, the Medicare prescription drug benefit, was implemented in January 2006, with an initial enrollment period through May 2006.  According to HHS figures, as of June 2006 a total of 22.5 million people were enrolled in some type of Part D plan.^[27]  Another 15.8 million Medicare beneficiaries were reported to have creditable coverage from other sources.  An estimated 4 to 5 million people, or about 10 percent of Medicare beneficiaries, have chosen not to enroll, and do not appear to have creditable prescription drug coverage.

Of the roughly 38 million Medicare beneficiaries who now have coverage through either Part D or some other creditable source, most had drug coverage in 2005, either through Medicaid, Medicare Advantage plans, or employer plans.  Those most likely to have been uncovered are those who enrolled in a stand-alone Part D plan (10.4 million) or who are newly enrolled in a Medicare Advantage prescription drug plan (1.2 million).  While the exact number who previously had no drug coverage is unknown, it is likely that some if not most of these 11.6 million people had no coverage prior to enrolling in a Part D plan.  Numerous studies and surveys have shown that prescription drug use is higher for those with health insurance than for the uninsured.

To forecast the impact of Medicare Part D on prescription drug utilization, analysts at the Centers for Medicare and Medicaid Services (CMS) were consulted.  CMS predicted that total  retail prescription drug spending would increase by 7.7 percent between 2005 and 2006.^[28] This estimate included the impact of Part D implementation.  Without Part D, CMS analysts predicted that there would have been an 8.1 percent growth in spending.  While Medicare will fund a larger share of drug expenditures under part D, the overall rate of spending growth would be reduced due to price discounts and rebates under the program on the order of 27 percent, which would more than offset the increase in utilization.

While the focus of the CMS models and analyses was on predicting changes in drug spending, not utilization, CMS analysts provided a breakdown of the components underlying the projected increases (Exhibit 31):^[29]

Exhibit 31.  Estimated Impact of Medicare Part D

After accounting for population changes and increases in drug prices, the residual is an approximation of the assumed increase in prescription drug utilization.  Comparing the 5.2 percent residual growth in spending with Part D to the 3.2 percent residual without Part D suggests a 2 percent increase in overall retail drug utilization attributed to Part D. 

Given that the majority of Medicare beneficiaries are age 65 and older and that the elderly consume approximately 35 percent of retail prescription drugs^[30], an increase in retail prescriptions of 6 percent for the over 65 population was found to be consistent with the 2 percent overall increase.^[31] IMS Health reports that during January 2006, prescription volume for the age 65+ population was up 4 to 5 percent over the same period last year.^[32] For modeling, a permanent upward shift of 6 percent in prescriptions per physician office and per hospital outpatient visit for the age 65 and older population starting in 2006 was assumed.^[33]

C.  Trends in Dispensing Setting, Practices, and Efficiency

The efficiency with which prescriptions are dispensed and the amount of time pharmacists spend per patient determines the number of pharmacists required given the demand for pharmaceuticals.  Efficiency and time spent per patient varies by dispensing setting and practice, and the proportion of total prescriptions dispensed by setting will likely change over time.  Consequently, in addition to modeling demand for pharmacists in non-patient care settings,  demand for pharmacists in five dispensing settings: hospitals, independent pharmacies, chain drug stores (which is grouped with supermarkets and mass merchandisers), mail order, and other patient care (clinic pharmacies, home health, and nursing homes) were also modeled.

This section describes current practice patterns and trends in dispensing setting.  Issues detailing with the role of pharmacists are discussed in a subsequent section. 

1.  Trends in Dispensing Location

Of the estimated 201,600 budgeted FTE pharmacist positions in 2004, the settings with the largest number of positions are chain pharmacies (77,300), hospitals (49,200), and independent pharmacies (36,200) (Exhibit 32).

Exhibit 32.  FTE Pharmacist Demand by Dispensing Location: 2004

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While demand for pharmaceuticals is projected to grow in each setting, this growth likely will be uneven for the following reasons:

• Increase in pharmaceuticals for chronic conditions.  The elderly have higher prevalence of chronic conditions that require the continued use of pharmaceuticals.  Mail order pharmacies will likely gain slightly in market share as a result of the increasing demand for medications to treat chronic conditions.
• Efficiencies and cost competitiveness.  Hospitals and mail order pharmacies, as compared to retail pharmacies, are better able to take advantage of new technology that reduces the cost of filling prescriptions.  The efficiency of mail order pharmacies allows them to fill prescriptions at lower cost than retail pharmacies.  Insurers often require or set lower copays for prescriptions filled by mail order to help direct patients to use mail order when possible.
• Market forces.  Mergers and acquisitions could result in some reallocation of market share between chain and independent pharmacies.  Discount drug prices by stores such as Walmart could increase the proportion of prescriptions dispensed by mass merchandizers. 

An analysis of IMS Health National Prescription AuditTMPlus data on retail (non-hospital) total dispensed prescriptions finds that each year between 2001 and 2005 market share (Exhibit 33):

• declined approximately 0.3 percentage points for chain pharmacies and food stores,
• declined approximately 0.4 percentage points for independent pharmacies,
• increased approximately 0.3 percentage points for nursing homes, and
• increased approximately 0.4 percentage points for mail order pharmacies.

A linear trend using 2001 through 2005 data extrapolated to 2010 was modeled;  it was assumed that market shares remain at their 2010 levels through 2030.

Importation of prescription products from Canada and other countries, ordered mostly through mail and courier services, accounted for less than 1 percent of total pharmacy sales in the United States in 2003.^[34]  IMS Health reports that cross-border importation of medications from Canadian Internet pharmacies declined by 23 percent between 2004 and 2005 (as measured by total sales volume in U.S. dollars), and that “importation is no longer as significant a market issue as it was two years ago.”^[35]

Exhibit 33.  Trend in Share of Total Dispensed Retail Prescriptions

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Source: IMS Health National Prescription AuditTMPlus data for 2001 to 2005, shown with linear trend through 2010. 

2.  Role of the Pharmacist and Productivity Trends

Demand for pharmacists is derived largely from the demand for pharmaceuticals.  For each prescription generated, pharmacists spend time dispensing the medication and counseling and educating the patient.  Pharmacists also have administrative responsibilities, some of which are related to patient volume (e.g., ordering bulk medications).  Pharmacists in some settings might be involved in research and other activities not directly related to patient care.

While historically the role of pharmacists has focused on dispensing, pharmacists report a desire to have greater involvement in patient education, counseling, and disease management. ^{[36], [37]} According to the 2004 National Pharmacist Workforce Survey, pharmacists currently spend half their time dispensing medication and one-third in counseling and drug use management—but they would like these proportions to be reversed.^[38] Advances in pharmacology contribute to a need for pharmacists to interact more with patients.  Drug therapy is becoming more complex, and pharmacists are often more knowledgeable than the prescribing physician regarding the possible drug interactions and side effects associated with new pharmaceuticals.

For a given level of pharmaceuticals demanded, the demand for pharmacists is dependant on the number of prescriptions filled per pharmacist—taking into account the amount of time per prescription spent dispensing, providing counseling/education, and other activities.  The greater the average time spent per patient to fill a prescription, the larger the number of pharmacists required to serve a given population.

The use of automation and technology, pharmacy technicians, and other potentially productivity-enhancing activities varies by dispensing setting.  In addition, the degree to which pharmacists are engaged in non-dispensing activities (e.g., consultation, management, research, etc.) varies by dispensing setting.  Consequently, the average number of prescriptions dispensed per hour per pharmacist varies by dispensing setting with mail order pharmacies reporting the highest rate and independent pharmacists reporting the lowest rate (Exhibit 34). 

Exhibit 34.  Average Prescriptions Dispensed per Hour

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Source: 2004 NPWS analysis.

Part of the variation in average number of prescriptions dispensed per hour is explained by how pharmacists allocate their time (Exhibit 35).  Pharmacists in hospitals, for example, spend less time dispensing and more time in drug use management and other activities (e.g., research) compared to pharmacists in other settings.  Independent pharmacies report the lowest rate of prescription dispensing per hour, yet have the largest portion of pharmacist time allocated to dispensing activities.  This highlights the disparities across settings in ability to use labor-saving technologies, with automation more likely to occur in settings with high prescription volume.  Mail order pharmacies, on the other hand, have the highest allocation of time to consultation and yet have the highest average number of prescriptions dispensed per hour.

Exhibit 35.  Average Time Allocation Across Activities

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Source: 2004 NPWS analysis.

3.  Technological Advances

Technologies in use in pharmacies include automated systems for managing work flow, for receiving prescription orders, and for dispensing medications.  Workflow management systems often incorporate automated checks for errors or possible drug interactions.  Orders can be received using fax machines, interactive voice response systems, or over the Internet.  The process of filling prescriptions can be automated to varying degrees, from counter top pill counting devices through robotic systems that count pills, fill bottles, and apply labels. 

While the degree to which each type of technology is currently being used varies by setting, the vast majority of pharmacies currently use some type of automated order processing and some type of automated dispensing technology.  According to a recent survey of community pharmacies in 18 metropolitan statistical areas of the United States, over 85 percent possessed at least one type of automated prescription processing technology.^[39]  The most common technology was the counter top pill counting device (62 percent).  In a 2003 study, all four of the national retail chains surveyed, 85 percent of the regional chains, 73 percent of the independent pharmacies, and 92 percent of the hospitals surveyed had some kind of automated pill-counting system.^[40]

Many hospitals and high volume pharmacies employ costlier robotic dispensing systems.  In a 2005 national hospital survey, 15 percent of hospitals used a robotic distribution system, with 40 percent of larger hospitals (those with over 400 staffed beds) using robots.  The use of robots in hospitals has been steadily increasing, with only 4.5 percent of hospitals using robots in 1999, and 7.8 percent in 2002.^[41]

Nearly all community pharmacies employ some type of automated telecommunication system for processing orders, with 85 percent using more than one source.  Over 85 percent of community pharmacies have fax machines available, and 83 percent offered automated phone systems to process refills.  While electronic prescribing has been slow to reach critical mass among health care providers, 65 percent of community pharmacies report Internet availability to process refill orders (Skrepnek, 2006). 

Automation has the potential to both increase productivity and reduce errors.  A number of before-and-after observational studies have been conducted at retail pharmacies, showing reductions in time spent dispensing medications on the order of 10 to 15 percent.  Differences in pharmacist productivity across settings and the corresponding differences in use of technology would also point to productivity gains through technology.  However, some studies have shown that automation increases numbers of prescriptions dispensed per pharmacist, but does not increase counseling rates or patient satisfaction.^[42]

Electronic-prescribing (or “e-prescribing”) offers the potential for moderate improvements in pharmacist productivity.  A recent study measured the time to process new prescriptions (n=400) and renewed prescriptions (n=400) using four prescription submission methods: e-prescription, walk-in by the patient, phone-in by the health provider, and fax-in by the health provider.^[43]  This study found that the amount of pharmacist time needed to process a new prescription was lower for e-prescribing versus other prescription submission methods, but renewed prescriptions walk-in required less processing time than other forms of submission (Exhibit 36).  NACDS reports that less than 1 percent of prescriptions written by doctors in 2004 were delivered via e-prescription.  As of June 2005, 49 States allowed e-prescribing.^[44]

Exhibit 36.  Differences in Rx Processing Time by Prescription Submission Method

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Source: Rupp MT.  April 2005.  E-Prescribing: The value Proposition.  America’s Pharmacist. ^[45]

The technology exists, and is already in use in some settings, to automate the majority of the dispensing process, from the transfer of the prescription, through automated checking for errors or harmful interactions, through robotic pill counting, bottle filling, and labeling, to delivery to the patient.  Overseen by pharmacists and implemented by properly trained and certified pharmacy technicians, full implementation of technology would allow the pharmacist’s role to be primarily one of supervision, patient and provider counseling, and medication management.  Barriers to this practice model are technology investment and maintenance costs, reimbursement mechanisms for pharmacists’ time, and the need for greater integration of pharmacists into the patient care team. 

Robotic systems can cost upwards of $200,000 per installation, making them cost-effective only in high volume pharmacies.  Most insurance programs pay pharmacists only for drug dispensing services.  There is still a lack of widespread recognition on the part of physicians, other providers, and general public, on the use of pharmacists as the primary patient care resource for medication issues.     

There is some evidence that these barriers are beginning to erode, particularly with regard to reimbursement for non-dispensing activities.  The Medicare part D benefit plan requires medication therapy management services, which may be delivered by a pharmacist, for specific enrollees.  It remains to be seen whether medication management will become widespread as a benefit in private drug insurance plans, and whether the profession will be successful in marketing the benefits of its expertise.

D.  Future Pharmacist Requirements

Using the PhSRM, a range of future requirements for pharmacists under alternate assumptions based on numbers of prescriptions (RXs) per capita was projected:

A low Rx/capita growth scenario assumes that current patterns of pharmaceutical use and dispensing will continue into the future, incorporating the following trends:

• A growing and aging population will consume more pharmaceuticals,
• No growth in prescriptions written per physician visit (controlling for age and health care delivery setting),
• Improvements in the efficiency of dispensing pharmaceuticals due to technological innovations will be offset by increases in the proportion of pharmacist time spent counseling patients, and
• The proportion of retail pharmaceuticals dispensed from mail order and nursing-home based pharmacies will rise slightly.

A high Rx/capita growth scenario is based on the above scenario, but assumes that prescriptions written per physician visit will increase over time as new medications become available (in addition to increased Rx/capita due to an aging population). The assumed annual rate of growth is the average increase in prescriptions dispensed per physician visit over the period 1995 to 2004, with the increase in per capita use of pharmaceuticals varying by age group and outpatient setting (office visit, emergency visit, hospital outpatient visit). (Prescriptions dispensed per hospital admission is modeled the same for each demand scenario, using pharmacist-to-inpatient day ratios that remain over time for each age group).

A moderate Rx/capita growth scenario takes the midpoint between the low and high Rx/capita growth scenarios, which is equivalent to an annual growth in prescriptions written per physician visit that is half the annual 1995 to 2004 average increase.

Under the low Rx/capita, moderate growth, and high growth scenarios, annual growth in demand for pharmacists between 2005 and 2020 is, respectively, 1.4 percent, 2.3 percent and 2.9 percent (Exhibit 37). Between 2005 and 2020, the growth and aging of the population will increase demand for pharmacists from 204,300 to 255,700 (a 51,400 increase). Moderate growth in Rx/capita will likely increase demand by an additional 33,100 pharmacists, bringing the total demand in 2020 to 288,800. High growth in Rx/capita could increase demand by an additional 33,100 pharmacists, bringing the total demand to 321,900.

Exhibit 37.  Components of Growth in Pharmacist Requirements

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Source: Projections from the PhSRM.

• In addition to the above three scenarios for Future Pharmacist Requirements, which assumed different rates of growth in prescriptions per capita, three additional scenarios were modeled  in order to test the sensitivity of the projections to alternate assumptions regarding hours worked by pharmacists and their productivity.  Results are presented in Exhibits 38 and 39.
• The current pharmacy system is stressed, with pharmacists working approximately 10 percent more hours per week than is desirable.  This scenario starts with the moderate growth scenario but assumes that base year demand is equal to vacancies plus 1.1 times base year FTE supply.  Under this scenario the shortfall of pharmacists in the base year is 29,500 (10,400 actual vacancies plus an additional 19,100 FTE pharmacist positions filled by pharmacists working more hours than is desirable).
• The amount of pharmacist time needed per prescription increases by 1 percent per year (compounding to a 28 percent increase by 2030) reflecting pharmacists spending more time counseling patients to reflect a greater role of pharmacists in patient care and the increasing complexity of new drugs. This scenario starts with the moderate growth scenario but incorporates this increase in pharmacist time spent per prescription.
• The amount of pharmacist time needed per prescription decreases by 1 percent per year (compounding to a 22 percent decrease by 2030) reflecting productivity gains from the adoption of new technologies and increased use of pharmacy technicians.

Note that a combination of the latter two scenarios is largely offsetting; productivity gains from improved technology and use of pharmacy technicians could allow pharmacists to spend more time providing counseling to patients without affecting overall pharmacist requirements.

Exhibit 38.  Projected Pharmacist Requirements Under Alternate Scenarios

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Source: Projections from the PhSRM.

Exhibit 39.  Projected FTE Pharmacist Requirements

Source: Projections from the PhSRM.

As illustrated using the moderate Rx/capita growth scenario projections, chain retailers will continue to employ the majority of pharmacists, followed by hospitals, independent pharmacies, other patient care setting employers, non-patient care employers, and mail order pharmacies (Exhibits 40).

Exhibit 40. Projected Requirements by Dispensing Location: Moderate Rx/Capita Growth Scenario

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Source: Projections from the PhSRM.

Few pharmacist requirements projections have been published, and the projections that have been published are not directly comparable (Exhibit 41).  BLS (2001) estimates there were 217,000 pharmacist jobs in 2000 and projected 270,000 jobs in 2010.  BLS (2006) estimates there were 230,000 pharmacist jobs in 2004 and projects 287,000 jobs in 2014.  FTE positions and number of jobs are not equivalent, with some pharmacists working part-time jobs. Knapp (2002) reports that a conference attended by approximately two dozen pharmacy workforce experts concluded that by 2020 there would be an estimated need for 417,000 FTE pharmacists.  This estimate assumes that in the future there will be a greatly increased need for pharmacists to provide primary services—a more than five-fold increase from the estimated 30,000 FTE pharmacists providing primary services in 2001 to 165,000 FTEs by 2020.  Similarly, there would be a more than seven-fold increase in the number of FTE pharmacists providing secondary/tertiary services (130,000 FTEs in 2020 compared to 18,000 FTEs in 2001).  The needs-based estimate reported by Kapp envisions a very different role for pharmacists in the future compared to the demand-based projections presented in this report.

Exhibit 41.  Comparison of Pharmacist Requirements Projections

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Source: Projections from the PhSRM.