Lewis Drug pharmacists Graham Protexter and Sara Hahn prepare prescriptions on Jan. 12, 2023, at a store on South Minnesota Avenue in Sioux Falls. (John Hult/South Dakota Searchlight)
When Jessica Strobl’s 87-year-old grandmother needed to fill an antibiotic prescription last fall, her regular Black Hills area pharmacy was closed.
She returned the next day to fill the prescription, but it was closed again. During that time, her infection worsened — enough to send her to the emergency room.
While Strobl’s grandmother has since recovered, it’s a cautionary tale about the consequences of a short-staffed pharmacy and the importance of accessible health care in South Dakota.
It’s a concern statewide, as pharmacies are “randomly reducing hours and closing,” according to September state Board of Pharmacy meeting minutes. The concern surrounds a pharmacy technician shortage and an impending pharmacist shortage, both of which are ripple effects from the coronavirus pandemic’s stress on the health care industry.
An inspector with the Pharmacy Board even noted in a December meeting that several pharmacists are “still slaving away” over the lunch hour, when the pharmacy is closed to patients for a staff break, because the pharmacy was short staffed with too much work to do.
Strobl is the president-elect of the South Dakota Pharmacists Association and vice president of professional services at Lewis Drug Pharmacies.
“In underserved areas of the state, there may only be one pharmacy in the entire county. If that pharmacy can’t remain open, then the people who already have minimal health care access have important services that are unavailable,” Strobl said.
Pharmacy technicians are ‘invaluable’
While the regional Lewis Drug chain hasn’t seen a mass exodus of pharmacists like other parts of the country, Strobl acknowledges there has been turnover among pharmacy technicians.
“In the pharmacy world, technicians are literally invaluable,” Strobl said. “We can’t do our job without them.”
Technicians have taken on increased responsibilities, essentially doing the job a pharmacist did years ago including locating, dispensing, packing and labeling prescribed medications for patients — which are then reviewed for accuracy by a pharmacist — and helping pharmacists with administrative tasks.
The workload at the Monument Health compounding pharmacy increases about 5% each year, said Dana Darger, system director of in-patient pharmacy at Monument Health in Rapid City. But Darger hasn’t had a full staff in three years to handle that increase.
At least once a week, Darger has to pay a pharmacist to cover a technician shift.
Technician pay starts out around $15 to $18 an hour and increases to $18 to $22 an hour after a technician is certified. Pharmacists make an average of $125,214 a year in South Dakota.
And it’s not just paying pharmacists for technician work that ends up costing pharmacies more. Darger said he has to pay for expensive, pre-made medications instead of compounding them in-house because he doesn’t have the staff to do it.
“Technicians can legally do more today than I could as a licensed pharmacist in 1979, yet we don’t pay them like pharmacists,” Darger said. “We’ve got to get the wages up so we have more people interested in technicians.”
Pharmacist shortage follows national trends: ‘errors will happen’
The pharmacist shortage has already hit pharmacies across the country, and it’s looming over South Dakota.
“I think we’re headed into the mess nursing is in now,” Darger said.
South Dakota’s only pharmacy school at South Dakota State University missed its target enrollment goal for the first time ever this year, said Dan Hansen, dean of the College of Pharmacy and Allied Health Professions.
The target enrollment for the fall of 2022 was 65. Only 43 students are enrolled.
COVID-19 is the likely culprit for the drop in enrollment, Hansen said, since this class would have been high school seniors during the first wave of the pandemic.
The pandemic is a factor in the number of early retirements among pharmacists or pharmacists choosing new careers. They’re burned out from the stress, said Amanda Bacon, executive director of the state pharmacists association.
“Pharmacists were the frontline of the pandemic too,” Bacon said. “In a lot of cases, clinics were closed and hospitals had limited access. But your neighborhood pharmacist was still there and made sure you got your medications in a safe manner.”
When you’re under the gun to get so many prescriptions done and don’t have the support to do it, errors will happen. It’s just a matter of whether or not it will be caught.
– Dan Hansen, dean of the College of Pharmacy and Allied Health Professions, SDSU
Those pharmacists are warning students not to enter the profession, Hansen said. One of his first-year pharmacy students was told by seven pharmacists over summer job shadows to stay away. With those pharmacists leaving, employers are looking to hire people who aren’t applying.
“There was a larger chain pharmacy in grocery stores in the Midwest where three years ago it would have had a pharmacy opening and would have received 20 applications,” Hansen said. “Right now, they have 20 openings and haven’t had an application in three months.”
The demand is so high in some parts of the county that some stores offered $75,000 sign-on bonuses for pharmacists.
It scares Hansen to think not only about the number of pharmacists leaving the profession, but the gaps created if the positions aren’t filled.
“If a gap is filled with a pharmacist working 60 to 80 hours a week, they’re more prone to making an error,” Hansen said. “When you’re under the gun to get so many prescriptions done and don’t have the support to do it, errors will happen. It’s just a matter of whether or not it will be caught.”
Those errors include getting the wrong medication for the patient. Consequences range from no side effects to death.
Changing how pharmacies operate
But Hansen believes the shortage will be remedied in the next five or so years, as entities work on solutions, and said there’s “never been a better time” to enter pharmacy. He projects SDSU’s pharmacy class size will return to its target in the next few years.
Solutions already in the works include technology improvements, efforts to change the pharmacy model and more lucrative pay for technicians, Strobl said.
“Overall in South Dakota, we’ve been pretty lucky to avoid some of the issues that pharmacies are seeing nationwide,” Strobl said. “But there’s definitely still an issue that needs to be addressed and we need to look forward into the future to make sure community pharmacy is sustainable.”
One of the most immediate needs is paying technicians more and turning it into a career, Strobl said, by adding responsibilities and making them more involved in patient care.
“These technicians have customer service experience, they’re hard workers and they’re smart. They’re desirable candidates for all types of positions,” Strobl said. “We need to reinvent that role to utilize their talents to the fullest and pay them accordingly so they don’t search for a job just with higher pay.”
The state pharmacists association is working with an online training company to offer certification at “a very reasonable rate,” Bacon said. In the last five years, more than 150 people have gone through the program. Fourteen high school students are attending Pharmacy Technician University through a virtual school program in South Dakota.
Hansen believes so-called “central fill” locations will become more widespread as well. Pharmacies like Hy-Vee are using central fill locations, with one in a former north-central Sioux Falls grocery store, to fill prescriptions and send to retail pharmacies. Such centers relieve refill work for technicians and pharmacists.
As the health care industry as a whole changes after the pandemic, the role of the pharmacist is changing as well, Strobl said. Currently, pharmacies are only reimbursed for products sold. That doesn’t include other services pharmacists provide, such as counseling patients on drug use, chronic illness maintenance and health plans.
“We consider ourselves to be the drug experts — that’s what we’re trained on,” Strobl said. “Pharmacists could be reimbursed for our expertise that isn’t dependent on selling a product.”
Increasing transparency in payments for medications from pharmacy benefit managers, or companies that manage prescription drug benefits on behalf of health insurers, would address the costs to pharmacies as well, Strobl said. The association plans to support a bill tackling the issue at the state Legislature this session. A bill introduced last year failed in the Senate.
“We’re fighting for transparent reimbursement on our products,” Strobl said. “Pharmacies are only reimbursed on products but that payment is not transparent. We might be told we will get paid $5 on a product and then they claw back $3. And then really we’re only paid $2 at the end.”
There are 14 separate steps to verify a prescription, according to a presentation from CVS Health to the state Board of Pharmacy in December. The company’s solution is to implement technology to reduce workload.
The same is true for hospital pharmacies and regional chains as they search for solutions. However, Darger doesn’t want Monument Health to turn to robots, especially because they’re expensive.
But pharmacies will have to invest in technology if they can’t get enough people in the industry.
“There are a lot of industries in the U.S. that could be taken over by a robot or computer. The next decade or two in pharmacy is going to determine if pharmacists and technicians will continue to be human,” Strobl said. “My wish is we find a nice balance of the two, technology supplementing that human touch.”
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