Workforce
Finding the Right PrescriptionAs demand for pharmacists grows and competition from retail outlets heats up, hospital executives are looking for new ways to fill their vacancies
The 2,400 residents of Wheatland County, Mont., were left in the lurch two years ago when the area's only pharmacist packed up shop and moved away. The nearest retail pharmacy was 45 miles away in Big Timber. A 90-mile drive south to Billings would take even longer. Residents could rely on mail order services, but those can take up to a week to fill orders.
Life wasn't any easier for Scot Mitchell, CEO of 57-bed Wheatland Memorial Hospital in Harlowton, who was having his own difficulties finding an able and, more importantly, willing body to staff the hospital pharmacy.
"There's no way we can recruit a pharmacist to this area. This is the frontier," he says of the small city in the center of the state.
Mitchell isn't alone in his frustration. Executives at hospitals big and small not only face a shortage of licensed pharmacists, but heady competition from such retail titans as CVS, Target, Walgreens and Wal-Mart. While there have been some gains in the number of students entering pharmacy doctoral programs--a 5.3 percent increase from 2003 to 2004--and the number of graduates with Pharm.D. degrees--8,158 in 2004, an 8.9 percent increase over 2003--demand still outpaces supply. Hospital pharmacy vacancy rates currently stand at about 6 percent, according to the American Society of Health-System Pharmacists, Bethesda, Md. Meanwhile, the National Association of Chain Drug Stores in Alexandria, Va., reported more than 4,000 open slots in July 2004, the latest data available. And with the new Medicare drug benefit kicking in, the group expects demand to increase dramatically during the next several years.
Filling those vacancies remains a difficult task. The Pharmacy Manpower Project, an industry research group, has been tracking pharmacist supply for several years. According to the group's Aggregate Demand Index, hiring difficulties for all locations reached 3.97 on a 5-point scale in February.
To try to keep pace with demand--or at least provide adequate pharmacy coverage--hospital executives are being forced to come up with a host of aggressive and innovative practices. They are looking at everything from better pay and benefits to harnessing the power of the Internet and outsourcing arrangements.
Filling the Void
Despite his hospital's size, Wheatland's Mitchell has found a way to not only provide full inpatient coverage, but also fill the town's need for a retail option. On the inpatient side, Wheatland turned to St. Vincent Healthcare, a 314-bed hospital in Billings to supply prepacked medications, which are replenished daily. Nurses and physicians can consult with St. Vincent pharmacists 24-hours a day and pharmacists visit Wheatland Memorial once a month to conduct chart reviews. The procedure built off of an existing contract for outpatient prescriptions in which Wheatland nurses could fax orders to St. Vincent for review by a pharmacist. This, however, was limited to a few drugs. Town residents still lacked a convenient way to get their medications.
In 2004, the two hospitals found a way to improve pharmacy services. They launched the state's first telepharmacy program. With $210,000 in grant money from the Charles M. Blair Memorial Trust and $40,000 from an anonymous donor, Wheatland bought two dispensing machines. Now, patients drop off prescriptions at the pharmacy, located in the hospital, which are then scanned by a pharmacy technician and faxed to St. Vincent for review. At St. Vincent, the pharmacist enters the prescription into a computer and back at Wheatland, the drugs are dispensed from secure medicine cabinets. The pharmacy technician labels the package and hands it to the patient, who can go into a private room for consultation with the pharmacist via videoconference.
"It's really helped the community," Mitchell says. "It's improved patient care and provided residents a service they weren't getting before."
Level Playing Field?
The struggle doesn't end with recruiting to rural areas or coping with a general health care worker shortage. Hospitals also face strong competition from retail pharmacies, with those companies generally offering more flexible schedules, higher salaries and better benefits.
The federal government is playing hardball as well to recruit needed pharmacists for its various agencies.
The Indian Health Service, part of the U.S. Public Health Service Commissioned Corps, offers a $30,000 signing bonus for pharmacists who commit to four years of service and student loan repayment for two-years of service.
The average student loan debt for pharmacy school is about $60,000; the Indian Health Service pays $20,000 per year for each year of service until the loan is repaid and an additional $4,000 per year to cover the federal taxes. Pharmacists also receive a yearly retention bonus between $3,000 and $12,000 that is based on level of service.
"We compete against hospital pharmacies. Everybody is competing against the retail pharmacies," says Capt. Robert Pittman, the Indian Health Services' chief pharmacist. "Our pay scale has not kept up with the private sector, so we've developed ways to keep it more in line."
Fighting Back
If hospitals are to become employers of first choice, they'll have to match efforts by their retail and federal rivals. Some hospitals are already doing just that, says Doug Scheckelhoff, director, section of pharmacy practice for the ASHP.
Thomas Jefferson University Hospital, Philadelphia, for instance, redesigned its pharmacy practice model and significantly improved its vacancy rate. Currently, the hospital has one opening and that's a newly created position.
At the height of the pharmacist shortage in the early 2000s, the hospital's vacancy rate was 20 percent. The 600-bed hospital has about 50 full-time pharmacists handling inpatient orders. Among other things, the hospital created a five-step career ladder to provide opportunities for advancement and brought salaries more in line with the retail market.
More importantly, pharmacists now spend about 70 percent of their time directly involved in patient care, a move enabled by expanding the role of pharmacy technicians to enhance their dispensing responsibilities.
Technology has also helped by improving efficiencies. The hospital has had a robotic filling and dispensing system in place for 12 years but recently invested in a new patient care system and computerized physician order entry.
"These changes have allowed pharmacists to move out of the four walls of the pharmacy, which was a literal prison," says Howard Cohen, the hospital pharmacy director. "Our pharmacists can now practice patient care as part of an integrated team."
Getting Help
Easing the existing staff's workload is another worker-friendly strategy being tested. But not every hospital can afford hire a new slew of pharmacists. For them, outsourcing some shifts can provide a cost-effective solution.
Union Hospital in Elkton, Md., took that route, turning to Cardinal Health based in Dublin, Ohio. Cardinal Health provides the hospital with overnight pharmacy coverage and is paid based on the volume of the orders reviewed.
The 108-bed hospital couldn't afford or attract pharmacists to work the night shift. Day-shift pharmacists had to be on call at night to answer questions should they arise. Pharmacists were unhappy because they were getting two to three calls a night.
"We really worried about retention and the workload of our pharmacists," says Kathleen Tierno, director of pharmacy. Through the arrangement, orders are faxed to Cardinal for review and dispensed through secure cabinets. "The after-hours service has improved employee satisfaction and reduced our potential for errors," she says.
Cardinal fills about 5,000 orders per month--orders that normally would have been filled by day-shift pharmacists. State law requires that the hospital maintain on-call pharmacists, but calls have been reduced to about two to three per month.
A Look Ahead
Exactly how much more aggressive and creative hospitals will have to get to keep up with the demand for pharmacy services depends in large part on whether the workforce shortage grows or stabilizes. Two key factors will influence that question, says Katherine Knapp, dean of the College of Pharmacy, Touro University-California, Vallejo. The first is the rate of growth in the number of prescriptions that are written each year. Historically, the growth rate has been about 4 percent a year; but from 2000 to 2003 the rate was 7 percent to 9 percent. If it stays in that range, the shortage will worsen, she says.
The second factor is gender. Women, who make up 53 percent of the pharmacist workforce, tend to keep part-time schedules, according to Knapp. If the number of women in the profession grows--and current data suggests that it will--there won't be enough pharmacists to keep pace with demand.
The American Association of Colleges of Pharmacy reports that 62 percent of pharmacy school applicants for the 2003-2004 school year were female.
"Women's preference for working part-time will continue to cut into the potential supply of pharmacists," Knapp says.
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This article 1st appeared in the May 2005 issue of HHN Magazine.
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