Pharmacy Manpower 2020: Meeting Needs of Patients

Today’s Objective • Provide insight into the pharmacist shortage and projected growth in prescription use by US population • Describe factors leading to expanded patient care roles as drug therapy managers by pharmacists • Present findings of Conference convened to forecast professionally determined need for pharmacists in 2020 • Discuss implications of the projected, significant shortfall of pharmacists in 2020 to pharmacy education, practice and regulation © 2003 Pharmacy Manpower Project, Inc

Are We Experiencing a Pharmacist Shortage? • Employer perspective: • Staffing problems • Job vacancies in community and institutional practice, industry, academia and government • Escalating salaries • Customer/patient perspective: • Inconvenience • Decreased access • Published ADI analysis: 92% US population lived in areas where pharmacist demand exceeded supply 1999-2001 © 2003 Pharmacy Manpower Project, Inc

Are We Experiencing a Pharmacist Shortage? • Pharmacist perspective: • Increased workload/stress • Longer working hours • Education Perspective: • Formation of new pharmacy schools • 12 since 1987 • Government Perspective: • HRSA Report • Federal legislation on loan forgiveness • Bush initiatives to expand 340B eligible clinics and add pharmacy services to address growing number of uninsured © 2003 Pharmacy Manpower Project, Inc

Assure Safe & Accurate Medication Distribution Community Pharmacy, 2001: 3,000,000,000 prescriptions 132,000 community pharmacists 22,727 Rx/pharmacist/year One prescription every 5 ½ minutes © 2003 Pharmacy Manpower Project, Inc

Pharmacists as drug therapy managers Assessing, counseling and monitoring drug therapy Dealing with medication misadventures: $177 billion drug morbidity/mortality ErnstF, Grizzle A JAPhA 2001; 192-200. Overseeing medication management systems Delivering pharmaceutical care: could save over $105 billion annually if universally available JohnsonJA, Bootman JL AJHP 1997 54: 554-558. Pharmacists Roles in Patient Care

Pharmacist Supply 2001: 200,000 active pharmacists 2020 projection: 260,000 active pharmacists • Based on new graduates, adjusted for those leaving; assumes 20% enrollment growth existing schools and 3 new ones in addition to those slated to open © 2003 Pharmacy Manpower Project, Inc

If Nothing Changes….. Community Pharmacy, 2020: 7,500,000,000 prescriptions 172,000 community pharmacists 43,604 Rx/pharmacist/year One prescription every 2 ¾ minutes © 2003 Pharmacy Manpower Project, Inc

What We Are Unsure About... • Role of drugs in future health care • Role of genomics and biotech as an adjunct, replacement, or addition to current drug therapy • Organization and financing of drugs and pharmacy services • Extent of adoption of new pharmacist roles © 2003 Pharmacy Manpower Project, Inc

What Hasn’t Sunk in Yet... • The baby boomers are not yet 60!--But they will be soon! • A boomer will turn 65 every 10 seconds beginning in 2011 • Everyday in the US, 6000 people reach the age of 65 • The over-65 population will DOUBLE by 2030—they use 3 times the number of medicines • Other special need populations, such as pedicatric patients or chronic disease sufferers, may influence demand

One could already argue we need 150,000 more pharmacists now to help patients with their medication and tackle the $177 billion in annual drug related morbidity and mortality. Barbara Wells2002-2003 AACP President © 2003 Pharmacy Manpower Project, Inc

Led to: Conference on Professionally Determined Need for Pharmacy Services Convened by the Pharmacy Manpower Project, Inc. Held in Baltimore, MD October 29-31, 2001 Carried out by the University of Maryland School of Pharmacy © 2003 Pharmacy Manpower Project, Inc

Conference Goals • Identify the future needfor pharmacy services from a health professional viewpoint • Describe “best practice” characteristics for providing these services • Suggest the number of pharmacists to meet projected needs in 2020 © 2003 Pharmacy Manpower Project, Inc

Participants and Process • Two dozen experts: • All segments of pharmacy • Medicine • Economics • Workforce specialists • Three days of deliberations – all discussions; no speakers © 2003 Pharmacy Manpower Project, Inc

Forecasting Need: Criteria for Best Practices IOM’s Quality Chasm Report aims are that practices must be: • Safe • Effective • Patient-centered • Timely • Efficient • Equitable © 2003 Pharmacy Manpower Project, Inc

External Trends Examined • Population • 325 million by 2020 • Older • More diverse • People • Healthier • More Internet savvy • Therapy • More targeted (biotech) • More expensive • Health care organization • Managed care • Community pharmacy • Institutional pharmacy • Reimbursement methods • Drug product related • Other • Technology © 2003 Pharmacy Manpower Project, Inc

Technology Changes Influencing Pharmacy • Electronic data processing and information transfer: • Electronic order entry • Expert systems to evaluate drug orders • Improved electronic communication systems • Improvements in automated order fulfillment systems for both outpatient and institutional use © 2003 Pharmacy Manpower Project, Inc

Summary • A 3-day conference of 25 selected participants evaluated the need for pharmacists in 2020 • Best practice criteria were developed and applied to order fulfillment, drug therapy management (patient care), and other functions • Estimates of professionally determined need were made and compared with the estimated supply of pharmacists • A shortage of pharmacists with significant magnitude was forecast: 157,000 conservatively • Next steps were suggested © 2003 Pharmacy Manpower Project, Inc

Strengths of Approach • Knowledgeable participants • Balance of viewpoints • Rapid engagement with issues • Global perspective • Highly focused • Substantial pre-meeting preparation • Analysis based on “best practice” case examples © 2003 Pharmacy Manpower Project, Inc

Weaknesses of Approach • Short 3-day meeting • Small, selected group of participants • Broad-brush discussions • Quantitative estimates are rough • Many assumptions about external environment, health care organization and financing, uptake of technology in communications and dispensing, and regulatory issues © 2003 Pharmacy Manpower Project, Inc

Order Fulfillment Functions Will Require 100,000 FTE Pharmacists • Defined narrowly to include only order fulfillment functions (“bottling”) • Best practices focus solely on assuring that a prescription is completed and delivered precisely as ordered • Assumes that drug orders entering the dispensing system have been assessed, clarified and verified • Pharmacist need will be to design, implement and oversee order fulfillment systems • Pharmacists will not have to inspect every order personally • Assumes that post-dispensing pharmacy services such as counseling and monitoring will be accomplished as patient care functions © 2003 Pharmacy Manpower Project, Inc

Best Practices for Order Fulfillment • Concentration of fulfillment of maximum number of orders in sophisticated central fill facilities • Current examples include mail order pharmacy (Merck Medco) and the Veterans Health Administration • Increase the efficiency of community pharmacy based order fulfillment: • Increase use of qualified pharmacy technicians • Increase use of automation • Reduce administrative burden of third party programs • These are in addition to Quality Chasm criteria. © 2003 Pharmacy Manpower Project, Inc

Community Pharmacy Order Fulfillment • Conference estimates that 101,400 FTE pharmacists currently dispense about 30,000 prescriptions per pharmacist per year • Arthur Anderson report identified major inefficiencies in use of pharmacists in order fulfillment NACDS Education Foundation: Pharmacy Activity Cost and ProductivityStudy, November 1999, www.nacds.org/publications/research&studies © 2003 Pharmacy Manpower Project, Inc

Many Initiatives Will Affect The Shortage... • Automated dispensing/central fill/pre-packs/unit of use • Bar-coding and electronic control of products • e-prescribing, electronic record-keeping and drug use control • Improved use of qualified technicians and other supportive personnel © 2003 Pharmacy Manpower Project, Inc

Outpatient Order Fulfillment Forecast • 80% of time now spent by pharmacists in the order fulfillment function can be assumed by automation and/or technical personnel • Therefore, best practices could increase order fulfillment output/pharmacist five times • Conference projects outpatient prescriptions to grow at rate of 5% per year © 2003 Pharmacy Manpower Project, Inc

Pharmacists’ Time:Actual and Preferred Percent of Time Pharmacists Devote to Specific Tasks—Preferred Percent of Time Pharmacists Devote to Specific Tasks—Actual © 2003 Pharmacy Manpower Project, Inc Source: Schommer JC et al. Community Pharmacists’ Work Activities in the United States During 2000

Hospital Order Fulfillment Forecast • 35,000 FTE pharmacists currently fill about 1.9 million drug orders per year in hospitals • Inpatient drug orders to grow at 5% per year, assuming that patient population stays about the same size with increased acuity • Best practices could double order fulfillment output/pharmacist © 2003 Pharmacy Manpower Project, Inc

Long Term Care Order Fulfillment • Conference estimated at 196 million prescriptions in 2001 • Orders for assisted living, home care and hospice not estimated separately • Conference forecasts assume these orders included in outpatient and inpatient totals © 2003 Pharmacy Manpower Project, Inc

Order Fulfillment Needs Forecast: Summary • Assuming all conference projections hold, about 100,000 pharmacists will be needed in 2020 for the order fulfillment function. • This assumes that utilization rises 5% annually, mail order and hospital productivity double, and community practice productivity improves by a factor of five © 2003 Pharmacy Manpower Project, Inc

Order Fulfillment Projection Assumes: • Increased use of information technology and automation, with safety assurances • Changes in regulatory environment • Successful adaptation to HIPAA • Changes in pharmacist attitudes and culture © 2003 Pharmacy Manpower Project, Inc

Patient Care Functions Will Require Nearly 300,000 FTE Pharmacists Expanded need will be due to: • Population demographics & special need populations • More drugs, increased potency, higher cost • Emergence of personalized drug therapy through gene therapy and biotechnology • Requirements of specialized drug therapy management for high-risk treatments • Increased need for communication among patients and providers © 2003 Pharmacy Manpower Project, Inc

Patient Care: Drug Therapy Management • A core function of pharmacy: drug therapy management, and other aspects of pharmaceutical care • Patient care needs were assessed in all settings • Mechanisms for paying pharmacists for these services is prerequisite and assumed © 2003 Pharmacy Manpower Project, Inc

Ambulatory Drug Therapy Management Forecast • Two best practices models were discussed: a highly-organized HMO (Kaiser Permanente-Denver) and community pharmacy • Estimates of pharmacists needed based on two methods resulting in range of 165,000 to 358,000 pharmacists; used the more conservative number • Agreed not all patients require same level of primary care © 2003 Pharmacy Manpower Project, Inc

Ambulatory Drug Therapy Management Forecast • 2/3rds of population get at least 1 Rx/year while 40% receive 4 or more Rx/year • Latter group requires complex primary care at best practice estimate of 1 FTE pharmacist per 1000 patients; while remaining population receives services at a ratio of 1 FTE pharmacist per 5,500 patients © 2003 Pharmacy Manpower Project, Inc

Pharmacy Manpower 2020: Meeting Needs of Patients