Jay Pee working on Pharmacy software (Roche Business Ssystems) in 1973
Let’s make this discussion reasoned and based
on more than fear or hope.
There has been a lot of talk right here and other places that we are doomed. That pharmacists are going to be phased out at worst or marginalized at best by the big Drug Store companies.
I do not believe this, but I will listen. There was screaming in the 1970s that the new laws allowing pharmacy technicians would take pharmacists out of the loop. You know what happened there.
Now, again, thirty years later, the same gloom and doom fear-mongers are back.
I want to get this started. I don’t have time today to present my argument completely, but let’s start here. In 1970, the population of the United States of America was 203,000,000 people. Today, it is 310,000,000. Drugs are at the end of the funnel for almost every office visit. A paradigm of our culture is that THERE IS A DRUG FOR EVERYTHING. With a 35% increase in patients, there is probably going to be an increase of more than 35% in the number of prescriptions. My experienced tells me that. The average patient with a chronic condition takes more prescription medicines than 35% more than their counterpart in 1970.
IN 1970, THERE WEREN’T THAT MANY DRUGS TO CHOSE FROM.
That’s a start. I’ll discuss the enormous pressure that the baby boomers will put on the Prescription Mill this weekend.
C’mon you gloom and doomers, give me your best.
The Ace in the hand, the trump card is going to be the pharmacist doing what she/he has been trained to do. Using her knowledge and experience to assist in better outcomes.
I know that you think that you do not have frikkin’ time, so don’t whine to me. If you gloom and doomers want your down-in-the-dumps forecasts to come true, just keep doing what you have been doing. Just keep running the “Prescription Mill”, disregard your legal and ethical responsibilities for counseling.
I see nothing wrong with good technicians doing all of the filling. I see a lot wrong with pharmacists not even looking over to the patient. There is a lot wrong when the patient is looking at her pill bottle, then at you, then saying, “Excuse me” five times and you still ignore her.
The best way to be sure that you continue to have a professional’s job with a professional’s wage is TO BE AND ACT LIKE A PROFESSIONAL.
In 1970, a hypertensive 50 something male with hypercholesteremia and high trigklyerides would be given HCTZ, possibly reserpine and may hydralazine. Ciba made the combo. Ser-Ap-Es. There were a lot of strokes in those years. Resperine was terrific, but it depressed the heck out of the patients. For the lipds, doctors were recommending margarine (like Parkay) instead of butter.
Today, that patient will likely get HCTZ, atenolol, amlodipine, pravastatin, gemfibrozil. Maybe more. Five prescriptions instead of one. Plus his Cialis, bupropion, Flomax, Celebrex and allopurinol. That’s ten drugs a month for one guy and everyone of you knows plenty of men just like him. He complained about the quality of his orgasms. They were flat. You recommended the pravastatin instead of Lipitor and now he has wowees.
Let’s use age 62, the year one can start drawing Social Security for these purposes.
An American turns 62 every 7 seconds.
In 2020, 4,245,000 Americans will turn 62.
Between 1940 and 1994 (the boomer years) 202,000,000 Americans were born. 77% of all Americans now living were born after 1939.
I have a file of statistics, but I want to go and have a swim.
These people will not grow old gracefully. They will spend a lot of money to be vital, youthful, full-of-it and sexy for entire ride.
There will be money to be made and those among you with a little personality, some vision and just a little daring can take advantage of this opportunity. Talk to me at: jpgakis@hotmail.com
In the meantime, those among you who just want to be an employee can keep on going. Just make sure that you are the ones who mold the profession of pharmacy, not Wal-Mart or Rite-Aid. HEAVEN FORBID.
The number of prescriptions to be filled will continue to increase dramatically. But, I don’t believe you can extrapolate more prescriptions being filled with jobs for more pharmacists, better working conditions, increased professionalism, and increased opportunities for pharmacists to own a business. Just look at how the status of pharmacists have changed over the past 40 years. Some changes have been good, and some not so good. Pharmacists have moved from the role of business owner and employer to that of a peasant being controlled by his overlords. This has happened because of the rise of third party payors. The current trend is toward more people getting rx’s filled and them being payed by third parties. This does not bode well for us pharmacists. All those baby boomers that you mention are going to put a strain on Medicare, Medicare Part D, Social Security, and Medicaid. I think we all recognize that the current course in which healthcare is traveling is economically unsustainable. Can you for see government cutting payment to providers? When that happens, how will it effect us pharmacists? I think you know the answer. It will mean a pay cut for pharmacists. We have undergone one of the largest financial disasters since the great depression. Our economy is on life support. The baby boomers are retiring and are about to strain the system to the breaking point. More money being siphoned off by government to pay for healthcare for the baby boomers is going to keep the economy in a stagnate state.
I believe your model, based on more prescriptions to be filled as a help to pharmacists, is too simplistic. When the economy of Greece, just one small country, can effect the whole of Europe, then you have to realize that the world has grown very complex. There are a lot of factors outside pharmacy that can influence pharmacy, and I expect those factors to determine the direction and future of pharmacy.
Consider the airline pilot job as a cautionary tale. Once a highly regarded, highly compensated and well trained profession; it has fairly quickly turned into a low paying borderline unsafe nightmare of a job for all but a few senior pilots. Airline management is not interested in anything but good PR and lowest possible costs which fortunately requires at least a nominally safe operation. Pharmacy..at least the chain drugstore variety is a high paying borderline unsafe nightmare of a job with the same management outlook. How long before the LOW paying starts to apply? One possible saving condition? The absolutely mind boggling automated Rx screw ups coming from the doctor places. Inject 10 ml’s of insulin?? Methotrexate 1 tab tid #90 w/refills….That stuff might keep the R.PH around.
Great minds think alike Rex, keep an eye on Drug Topics and remember your airline analogy, and that i turned in the story you’ll see in a month or two story a couple weeks ago….
Jim, you saw the change that was to come in the 70′s, you were just a little off time frame wise. I was once asked to come in and manage an incredibly busy pharmacy where the techs had taken over. The company had put in a series of new, inexperienced pharmacists in a place with well-oiled, experienced techs. Predictably, the new RPh’s looked like idiots and were actually a hindrance to getting Rx’s out the door. Thing is…although I could never admit this, the techs that had mutinied weren’t doing that bad a job. It is only a matter of time until one pharmacist sitting in a cubicle somewhere, is doing quality-control & DUR work, and made available via video link for any counselling needs for a dozen pharmacies while the store is staffed with only certified pharmacy technicians. Walgreens has already made moves in this direction with its POWER program. In a nutshell, it is very easy to imagine a world where many more prescriptions are being “filled” with fewer pharmacists.
I agree that presiption volume is not an indicator for the future of pharmacists. If we were really doing our jobs, there would be far fewer presciptions filled and that aint’t in the Big Box business plan. The fact is that repackaging drugs is not viewed as a valuable service and that all many pharmacists do, for many reasons.
It’s a good question and I’m going to outline my answer as logically as I can.
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All of the revenue generating work that retail pharmacists do (entering a prescription, filling it, checking it, running register) does not require six years of doctoral college level education. At best, it requires at least one person to have an associates degree, an eye for detail, and some sort of accountability (such as a license).
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Patient counseling is pretty much a joke. No one sits down for 5-10 minutes and describes every single little thing like we practice in those counseling competitions. The best we can do during most patient’s limited attention span is blurting out “don’t take this with alcohol” and hope for the best. Blurting out bullet points does not require six years of doctoral level education either.
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In the military, if they don’t have enough pharmacists to cover the dispensing, they make due with techs. They can do this because they are not beholden to state laws written back when the dinosaurs roamed.
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So, the only reason retail pharmacists are still at their jobs is due to state laws that say a pharmacist must be present.
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So are we doomed?
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I don’t know, but I am very pessimistic. It really depends on how things play out. The major driving factor of whether we are doomed or not will be financial.
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Will reimbursement for prescriptions continue to drop? Or will it rise? Will pharmacist salaries start dropping or will they keep going up? Basically, if expenses go up and revenues go down companies will be under more pressure to cut costs in order to stay in business.
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Health care reform will affect this, but I have no idea how. We’ll just have to see what comes to pass as the regulations are finally written and legislation is further amended and modified over the next few years. A case can be made for reimbursement to go either way. Drug stores could successfully lobby for more money. The government could just as easily cut reimbursement to save more money.
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The industry has been responding to pressures to cut costs for a long time. No tech hours and 12 hour shifts with no overlap were just the first wave. The industry is now further adapting with it’s move towards centralized filling and mail order.
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Once these improvements max out, getting rid of the pharmacist may be the next option. Consider taking a pharmacist who makes 100K/year (with benefits) and replacing them with someone who makes 50K/year (with benefits). If most stores have two pharmacists, that’s a 100K per store per year savings.
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So what stands in the way of getting rid of the pharmacist? Two things. First, state laws saying that a pharmacist must be on duty. Second, the absence of low-level pharmacist-tech hybrid who could easily take over and do the work for cheap.
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Colleges have already begun to offer degrees and certifications for pharmacy techs. It’s almost a given that these programs will improve and that their graduates will eventually push for more responsibility. Every health care profession (except pharmacists) have successfully increased their scope of practice and responsibility.
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No law (except perhaps laws of physics) is rock solid. If and when lower cost replacements become available expect the industry to push for states to change their laws. It’s also possible that the industry could circumvent the states entirely by working legislation into some future federal health bill.
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And no, this will not come as a “get rid of the pharmacist” campaign. It will probably first emerge as an answer to those areas that are perpetually underserved such as the ghetto or rural areas. If techs work fine in these situations we can expect them to become increasingly mainstream.
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As techs-as-pharmacists become more mainstream we can expect that their salary will increase and pharmacist salaries will decrease until they reach an equilibrium point. The question for future pharmacists then becomes: At a salary of $XXK/year is retail pharmacy (or pharmacy school in general) still worth pursuing? Especially since working conditions will probably not improve.
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If the answer is yes, then we will have a mix of PharmDs and associates degree holders doing the job of a retail pharmacist. If the answer is no (as I suspect it will be), then pharmacy school enrollment will drop and retail pharmacists (especially the younger ones) will opt for career changes. As these pharmacists exit the work force more techs will fill their positions.
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Back to the present day. Pharmacists have done nothing to advance their profession. If anything, we’ve gone backwards. We used to compound medicines, now we count by fives. We’ve basically become assembly line workers. We don’t generate a single dollar of profit outside of the action of dispensing medication.
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We don’t charge for counseling. We don’t get paid for MTM. We can’t do therapeutic interchange. At least half of us are terrified of having the ability to switch out Nexium for Prilosec without a doctor’s approval. We don’t get a bounty for saving money, recommending more efficacious treatment, or catching doctor’s errors. We don’t get paid for sending someone to the ER because they are about to have a heart attack.
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If a CEO, policy maker, economist or any other person of power looks over what a pharmacist is being paid to do, they won’t see any of the above. There is nothing except anecdotes to prove that that pharmacists actually perform these activities or that these kinds of interventions have any real value. Thus we should not expect them to be included into the calculations.
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So in conclusion, the pharmacist as a retail dispensing machine is probably doomed.
Yes, JP simplifying the equation to simply look at increased script counts is being a little short sighted. Automation and technology alone could more than make up for increases in prescription counts over the next ten years. Those filling machines will become more and more cost effective for retail chains and they will implement them as soon as it is financially viable for them to do so.
Retail pharmacists get paid to do one thing: fill prescriptions. And if we are lucky we can administer flu shots. That is another revenue generating task. That is why most retail chain locations offer flu shots. They make the company money and the pharmacists will be required to do them with no additional compensation. And because the pharmacist sees none of that extra profit it all goes to the chain.
Comparing us to airline pilots is reasonable. We are going down the pharmacist equivalent of what has happened to those professionals. Even though lives are at stake companies are just looking at the bottom line.
Pharmacy techs that can check prescriptions could become as common as physician assistants are now. Cost savings is what is needed with a government heart set on providing healthcare to the masses. This desperate need to save money will drive ideas like tech check tech even if state boards of pharamcy don’t like the idea.
We are at a crossroads right now in pharmacy but all those with a position of power don’t look out for the best interest of pharmacists. I am afraid that we will become marginalized going forward even more than we are have been. Look at how the public and our employers treat us currently. Is that how professionals are treated normally? That business model where one pharamcist is available via video conference for a dozen stores and techs are checking is a definate possibility. We will be responsible for more and more with less and less in the meantime. And I am too young to retire and say “good luck” to all the younger pharmacists. I still have many years to go. What will pharmacy look like in ten or twenty years? I don’t know but personally I’m afraid at what the possibilities could look like for us all.
So yeah JP call me a doom and gloomer. I’ve been called a lot worse. I work retail. But realize this: what I am saying just might become true and the profesion of pharamcy will be destroyed forever. We are already treated like fast food workers. Is it really thatunlikely that things will become worse? And with all of the new pharmacy schools opening there will be even more pharmacists searching for those jobs going forward. Bottom line is this: for the first time in my entire career the outlook for pharmacists is not rosey going forward (in my opinion). And that scares me a little. Actually, it scares me a lot more than just a little. And I’d like to think of myself as someone who wouldn’t get worried very easily. So call me whatever you like but realize that I am trying to objectively evaluate the outlook for the profession I chose to dedicate my career to and I’m not liking what I see.
Everyone has certainly raised some good points. I’ve been practicing for over 20 years now and have seen many changes in the field. When I first started, mail order was going to do away with us, then PBMs , and now central fill. I am confident that there will always be a need for a pharmacist to be present in any high volume setting. Why? Because it is in the public’s best interest that at least one person actually know why this patient is taking this med, how it works, which others they need each month, which ones get billed to which third party,how to manage inventory, how to deal with difficult customers, how to implement and enforce company policy policy in the department and do them well each day. I have never worked with a single tech or group of techs that could do all of the above well. (Emphasis on All) Not to mention that in spite of our salaries, we are still cheap insurance against multimillion dollar settlements that result from someone doing a job that they are in no way legally qualified to perform. Change is inevitable. Join your state associations, network with other pharmacists, hone your skills, and be aware of trends in the field. I’ve made it this far and I have every intention of making it to the finish line knowing that I did the best I could for myself, my company, and the patients I serve.
Fantastic points! One might think vga has thought about this for a while.
Our one and only (let me repeat: ONE AND ONLY) potential savior in this industry is our state boards. That committee will ultimately save us or destroy us. Guys, I only know one of my state’s board members. He’s a good guy but guess what his regular job is. He’s in management at a PBM.
Some of you who care more than me, write these wonderful blogs and can really put your thoughts into words need to focus on these people. Not congress or your state representative or any bullshit like that. Those people would nod and tell you how your right but wouldn’t understand a goddamn thing you were talking about. Write to your boards. Apply to sit on your boards. That is where salvation lies. Or at least where “doom” is kept at bay.
Uh =- lipitor decreasing orgasm quality and that being helped by a change to pravastatin?
Got a reference for that one? Sounds like a great way to miss an LDL target and put a patient at higher risk for vascular events.
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I read it on a geriatric care website somewhere, but have never had the opportunity to counsel such a move, but.. I would, I think, at least bring it to the complaining patient as an option. I mean if he is so upset at the poor quality of his orgasms that he would spontaneously talk to me about it, he must have having really bad orgasms.
As long as the pharmacy schools only except the top GPA’s and ignore the spirit and personality of the student you will continue to have lemur-like professionals as new graduates.
Also, decreasing cholesterol in a male or female that does not eat a high fat diet will depress Testosterone, leading to more than sexual problems. Endocrine issues are more than one pill fixes.