© 2003 pharmacy manpower project, inc pharmacy manpower 2020: meeting needs of patients...

© 2003 Pharmacy Manpower Project, Inc

Pharmacy Manpower 2020: Meeting Needs of Patients

Implications for Educators, Practitioners and

Regulators

Slide Library2003


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


Section One

Is There a Pharmacist Shortage?, How Are They

Currently Deployed?


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


US Population and ADIJuly 2001

0

10

20

30

40

50

60

70

80

90

100

Pe

rce

nta

ge

States withdemand levels

>4.5

States withdemand levels

between 3.5 and4.5

States in whichsupply and

demand are inbalance

States in whichdemand forpharmacists

exceeds supply

US Population


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


So we have a shortage of pharmacists…

A shortage of pharmacists to do

what??


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


Hospital Pharmacy, 2001:

1,898,000,000 drug orders 50,000 hospital

pharmacists 37,960

orders/pharmacist/year

One drug order every 3 minutes


What About Tomorrow?


Section Two

Common Vision for Pharmacists:

Helping People Make the Best Use of Their Medicines


Common vision of pharmacy practice:

helping patients make the best use of their

medicines.

Pharmacists Roles in Patient Care

• Pharmacists as drug therapy managers• Assessing, counseling and monitoring drug

therapy• Dealing with medication misadventures: $177

billion drug morbidity/mortality Ernst F, Grizzle A JAPhA 2001;

192-200. • Overseeing medication management systems• Delivering pharmaceutical care: could save over

$105 billion annually if universally available Johnson JA, Bootman JL AJHP 1997 54: 554-558.


These new roles are not just assuring safe and accurate

medication distribution….what about

tomorrow?


2020 Rx and Order Projections

Outpatient prescriptions: 7,500,000,000 (+5%/yr)

Hospital drug orders: 3,000,000,000 (+2.5%/yr)


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


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


If Nothing Changes…..

Hospital Pharmacy, 2020:

3,000,000,000 orders 65,000 hospital pharmacists 46,154 Rx/pharmacist/year

One order every 2 minutes


These figures reflect a

supply/demand model that only focuses on order

fulfillment. Something must

change.


How Does Need Fit Into Workforce Projections?

• Wants• Demands• Supply• Professionally-determined needs


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

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


Their drug use has not yet been factored into the workforce

equation…


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


Section Three

Manpower Conference: Why, What, How


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


Conference Goals

• Identify the future need for 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


Participants and Process

• Two dozen experts:– All segments of pharmacy– Medicine– Economics– Workforce specialists

• Three days of deliberations – all discussions; no speakers


Forecasting Need: Criteria for Best Practices

IOM’s Quality Chasm Report aims are that practices must be:– Safe– Effective– Patient-centered– Timely– Efficient– Equitable


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


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


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


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


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


Section Four

Conference Outcomes, Projections and Assumptions


Current and Projected Need for Pharmacists

2001 Estimated Deployment

2020 Forecast Need

Order fulfillment(Dispensing)

136,400 100,000

Patient Care 48,000 295,000

Other 12,300 22,000

Total Need 196,700 417,000

Total Supply 260,000

Projected Shortfall

157,000


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


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.


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

Productivity Study, November 1999, www.nacds.org/publications/research&studies


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


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


Pharmacists’ Time:Actual and Preferred

9%16%

19%

56%

Medication dispensing

Consultation

Business management

Drug-use managementresponsibilities

9%19%

34%

38%

Medication dispensing

Consultation

Business management

Drug-use managementresponsibilities

Source: Schommer JC et al. Community Pharmacists’ Work Activities in the United States During 2000

Percent of Time Pharmacists Devote to Specific Tasks—Actual

Percent of Time Pharmacists Devote to Specific Tasks—Preferred


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


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


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


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


Patient Care Functions Will Require Nearly 300,000 FTE

PharmacistsExpanded 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


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


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


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


Hospital-Based Drug Therapy Management

• About 5,000 hospitals in the U.S.• About one pharmacist per hospital

performs population-based patient care: safety, policy, etc.

• Best practice estimate doubles this number


Hospital-Based Drug Therapy Management

• 10,000 FTE pharmacists currently provide this service

• ASHP surveys find that only about 10% of best practice services are now routinely provided

• Conference estimates that 100,000 FTE pharmacists needed for this function


Drug Therapy Management in LTC and

Related Settings• 3,000 FTE pharmacists currently

provide this service• Although over-65 population will

be much larger in 2020, it will also be healthier

• Best practice estimate is 18,750 FTE pharmacists in 2020

Drug Therapy Management Needs Forecast: Summary• Conference forecasts a need for almost

300,000 pharmacists to meet drug therapy management needs of patients in 2020.– Ambulatory patient care: 165,000– Hospital-based patient safety, policy:

10,000– Hospital-based patient care: 100,000– Long term patient care settings: 18,750


Non-Patient Care Needs Forecast

• Estimated at 22,000 in 2020

• Relatively small but critical area

• Specialty and leadership positions in– Profession– Industry– Academia– Government


Variables and Assumptions: Order

Fulfillment• Outpatient Order

Fulfillment– 2001 prescription

number: confident– Growth rate (5%):

conservative– Mail order growth

(10%): conservative, given low base

– Dispensing productivity increases: liberal

• Hospital, LTC Order Fulfillment– 2001 drug order

numbers: unknown (extrapolated from orders/patient/day)

– Hospital growth rate: liberal (5%)

– LTC orders: conservative


Variables and Assumptions: Drug

Therapy Management• Ambulatory:

– Highly-managed setting (HMO)(one pharmacists/1000 patients): confident/liberal

– Community setting (1/1000): unknown/liberal

• Institutional:– Hospital patient

safety/policy: confident

– Hospital patient care: survey-based/confident

– LTC patient care: conservative


Variables and Assumptions:Other Needs; Pharmacist

Supply

• Other Needs:– Category by

category assessment: conservative

• Pharmacist Supply– Enrollment growth

in existing schools (10% total): conservative

– New schools (class size 100; 3 new 2010-2020): moderate


Assumptions Underlying Conference Projections

• Improved and compatible IT systems will be implemented throughout health care

• Patient data and reference information will be available to practitioners at the point of service in real time

• Health care teams will really work• Quality and safety systems will be in place• Financial incentives will be appropriate


Manpower 2020: Conclusions

• A large shortage of pharmacists is forecasted in 2020

• The supply of pharmacists needs to increase substantially

• Productivity of pharmacists needs to increase even more than projected

• Or services will remain unmet or be provided by others


Additional Conclusions• Conference forecasts demonstrate

that professionally determined needs for order fulfillment services and for drug therapy management services are inextricably intertwined

• Unless an even more dramatic solution is adopted to meet the forecasted demand for dispensing, the expansion of direct patient drug therapy management by pharmacists will fall far short of need


Section Five:

Actions Needed by Profession

Actions Required By The Profession• Embrace responsibility for drug therapy management

• Commit to obtaining and maintaining the knowledge, skills and abilities required by patient care

• Achieve provider status for pharmacists under Medicare

• Obtain a supporting payment mechanism• Expand the size of the profession in order to meet

unmet societal needs• Fully utilize technology & technicians for order

fulfillment


Even If You Disagree with the Details…

• Each person will filter the forecasted numbers through their unique perspective and experience

• Where you find you might reduce the needed number of pharmacists in one area, you will find you raise it in others


…You Will Agree at a High-Level

• Your revised forecasts compared against pharmacist supply estimates will show a significant shortfall of practitioners

• Findings should be used and challenged within the profession’s practices, educational and regulatory arenas and other stakeholder groups to assist in their long-term planning efforts


What Does 2020 Look Like…

• If we don’t move ahead?• Open discussion• Top 10 Issues Summary


Section Six

Implications for Various Stakeholder Groups: Educators, Practitioners,

Regulators, All


Implications for Educators: How to Expand the

Profession?• Good news: today’s graduates are

being educated at level consistent with profession’s long-term patient care vision

• Many new opportunities for pharmacists, especially with doctoral level training


Implications for EducatorsProducing more graduates:

– Enrollments rising; impact of PharmD transition closing

– 12 new schools since 1987– Decade trend numbers show sizable

increase– Role of foreign graduates?

Foreign Pharmacy Graduate Equivalency Examination™ (FPGEE®).


Entry-Level Pharmacy Graduates

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Year

Number of First Professional Degrees Conferred 1985-2002

PharmD

BS Pharmacy


Projected Entry-Level Graduates

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

2000 2001 2002 2003 2004 2005 2006

Year*

Enrollments by Expected Graduation Year

PharmD

BS Pharmacy

*Data for expected graduation for years 2003-06 from Profile of Pharmacy Students Fall 2002. For years 2000-02 from Profile of Pharmacy Students Fall 1999.


Implications for Educators

Expansion of programs that support current practitioner’s transition to new roles:– Accessible – Affordable– Flexible– Partnerships with practice organizations


Challenges for Educators

• Faculty needs: new models & partnerships with practice; more residency trained faculty needed

• Training sites: new models, residencies• Curriculum to address distributive/patient care roles• Technology application to both: e.g. distance education• Sharing resources across institutions: curricular resources,

faculty?• Financing for expansion in era of state budget issues• Research enterprise: where will growing funding be

secured?


Challenges for Educators/Practice

Determining how many practitioners will need to make the transition?– Decrease of 25,000 for order fulfillment

(dispensing) over 20 years vs. need for 295,000 in drug therapy management services

– Create tools to identify best practitioners to target?


Implications for Practice: How to Accelerate

Change?Continued, rapid

implementation of technology and qualified pharmacy technicians to improve order fulfillment efficiency, patient safety and patient services


Implications for Practice: How to Accelerate

Change?Increase residency trained

practitionersAs of May 2003 *

• 383 Accredited pharmacy practice programs

• 242 Accredited specialized residencies • 1,077 Residents/year

*Programs that have been accredited or have applied for accreditation


Stepping Stone Summit: Technology Recommendations

APhA/NCPA/NACDS in 2/2002:#1 – Bar code verification#2 – e-prescribing systems & interface#3 – In pharmacy dispensing automation

& central fill#4 – Broadband Internet connectivity#5 – Reduce regulatory barriers


From American Society of Automation in Pharmacy (ASAP)

2003 Hot Technologies: ASAP Survey 2-2003

• E-signatures, primarily HIPAA driven

• E-prescribing will grow• Continued system integration: IVR,

dispensing, POS• High-speed Internet connectivity


Adapted from July/August 2002 ComputerTalk

Chain Use of Technology: July 2002

90

50

45

40

40

20

45

40

65

90

85

0 10 20 30 40 50 60 70 80 90 100

Percentage

Chains using IVR

Stores in chain withIVR installed

Using IVR to route refills to doctors

Chains evaluatingrobotic solutions

Chains using scanners in the pharmacy

Stores in chain using scanners

Central fill on the agenda

Central processingon the agenda

Chains that applied for HIPAA extension

Will be applying forHIPAA extension

Want continuedsupport of 3.2


Hospital Use of Technology

• Computerized Prescriber Order Entry (CPOE)– 3.5% of hospitals use CPOE

• Use of Automated Storage and Distribution Devices (ASDDs)– 58% have some ASDDs

• Bar Code Point-of-Care Technology– 1.3% verify medication, patient id, and nurse at the

bedside

• Pharmacy Robots– 8% use robot filling devices

Source: 2002 ASHP National Survey of Pharmacy Practice in Hospitals


Adding Pharmacy Technicians to the Mix: 131,000++ (12-02)

And Ratios are Changing...

Greater than 2:1 2:11:1No Established RatiosNo Data

Alaska

Hawaii

Puerto Rico


Implications for Community Practice

Continued creation of opportunities for new service development in the community:– Residency programs in community

practice: 65 programs with 32 that are accredited or have applied for accreditation

– Participation in demonstration projects, e.g. Patient Self-Management: Diabetes

– Partnerships with education and practice organizations

Seeking payment mechanisms and provider status


Challenges for Practice

• Generating sufficient capital to support practice transition

• Maintaining practitioner knowledge and skills: Does CE enterprise need to be different?

• Addressing attitudes and culture among practitioners to embrace new technologies and roles


Challenges For Practice/Regulators

• Changing regulatory environment to embrace rapid practice change

• Securing collaborative practice authority

• Securing ability to immunize

Immunizations Bill Passes in House


Implications for Regulators:

“Technologically Facilitated Care”

• How to regulate “technologically facilitated care”

• Remove impediments to change that can improve dispensing efficiency and patient care: – Qualified pharmacy technicians– Automation– information sharing: HIPAA concerns and

security


Implications for Regulators

• Focus on outcomes vs. structure, process

• How to ensure continuing competence among a changing workforce


Implications for All

• How to implement services that people don’t know they need– Physicians, public not overly concerned

about medical errors NEJM 2002: 347:19330194

– Public not aware of health professional shortage AmerisourceBergen Poll 7/2002

• Continued learning from those successfully implementing among patients

• Publicizing outcomes from practices widely


Implications for All

• People outside the profession care about drugs and believe they are:– Expensive– Toxic– Complex


Implications for AllThey are not a no-risk proposition and must be actively managed


What if This Was Your Mom?

What Will You Do When You Leave?

• Elderly consume 34% of all Rx’s

• Many have issues related to medication access and coverage

• Adverse drug reactions (ADRs) are among the top 5 threats to senior’s health


What If This Was Your Child?

• Little known about ADR’s in children

• Pediatric ADR Reporting System--Pediatric Pharmacy Advocacy Group

• 2 to 17% of children admitted to hospitals were admitted due to ADRs Mitchell et al AmJEpid: 1979: 196-204.

• 65-75% of FDA-approved meds not approved for use in children Yaffe et.al Ped. Pharmacology 1992: 3-

9.

What Will You Do When You Leave?


How Are You Spending Your Time?

• I’ll get to that project tomorrow?

• My colleagues are tackling that issue

• That issue is the responsibility of X, Y and Z?

• What can I do?

Or…


How Are You Spending Your Time?

Are you moving ahead to:– Implement new programs?– Implement technology?– Use qualified support

personnel?– Collaborate with

colleagues?– Stay current with new

developments?

Or taking other steps to help patients?


Where To Go From Here?

• Open Discussion: what are top 5 issues for Educators, Practitioners, Regulators?

© 2003 pharmacy manpower project, inc pharmacy manpower 2020: meeting needs of patients...

Documents