key: cord-0772996-ft6zo1vy
authors: Schommer, Jon C.; Olson, Anthony W.; Lee, SuHak; Gaither, Caroline A.; Schondelmeyer, Stephen W.
title: A 15-Year Ecological Comparison for the Hiring Dynamics of Minnesota Pharmacies between 2006 and 2020
date: 2021-05-06
journal: Pharmacy (Basel)
DOI: 10.3390/pharmacy9020100
sha: 81b5345d14697fc64fee89d9661509a3eef6b674
doc_id: 772996
cord_uid: ft6zo1vy

Labor market forces in pharmacy are affected by frictional unemployment (job turnover), structural employment forces that require new skill sets for employees, and hiring practices that integrate technology or less costly labor such as pharmacy technicians. The objectives of this study were to describe hiring trends for both the pharmacist and technician workforces in licensed pharmacies on a biennial basis from 2006 through 2020 using data collected in Minnesota. Ecological comparisons were made between the survey years using descriptive statistics. For open-ended questions added to the 2020 survey, content analysis was applied. Demand for technicians increased which might be due to the expansion of their roles into activities that had been reserved for the pharmacist. Pharmacies reportedly would like to hire pharmacists to meet the demand for new services that pharmacists can provide. However, respondents articulated that this is not feasible under current economic pressures. This represents a lost opportunity for transformation in pharmacy that would establish pharmacists’ roles in the rapidly transforming health care value chain. We conclude that hiring dynamics in pharmacies are being driven more by economic and organizational shifts than meeting the demand for services that pharmacists can provide.

From 2000 to 2019, National Pharmacist Workforce Surveys monitored the size, demography, and activities of the pharmacist workforce in the United States [1] [2] [3] [4] [5] . Figure 1 represents the supply side of this appraisal by summarizing the number of pharmacy degrees conferred in the United States as the first professional degree from 1965 through 2019 and is useful for interpreting the findings from the national surveys. The "Capitation Years" in the 1970s resulted in growth in the number of pharmacy degrees conferred, during which time pharmacy schools and colleges received "capitation grants" on the basis of enrollment size and numbers of graduates through the Comprehensive Manpower Training Act of 1971 [6] and the Health Professions Education Assistance Act of 1976 [7] . These grants expired in fiscal year 1980, corresponding with a reduction in numbers of graduates per year, which were followed by another reduction in the late 1990s and early 2000s when degrees conferred transitioned to the "All PharmD" (see Figure 1 ). Between 2006 and 2010, "Pharmacy School Expansion" [8] took place to address pharmacist shortages produced from a combination of increased retirements by pharmacists trained during the "Capitation Years" and a shortage of substitutes produced during what scholars call "Retrenchment Years" (1980 through 2005) [1- 5, 8, 9] . Such periods of expansion and retrenchment were commonplace during the 20th century from influences such as the Great Depression, World War II, the GI Bill, changes in accreditation requirements, and education assistance acts [8] . However, the steepest slope in the accumulation of new pharmacy schools (since 1900) The most recent expansion reduced the shortage of pharmacists experienced in the early 2000s [1] [2] [3] [4] [5] 9, 10] . For example, the Aggregate Demand Index (ADI) for pharmacists from 2002 to 2008 had been in the 4 to 5 range (i.e., high demand for pharmacists nationally) [9] . From 2009 to 2015, the ADI dropped to the 3 to 4 range (i.e., moderate demand), and then to the level of 3 (i.e., demand in balance with supply) from 2016 to 2018 [10] . Figure 2 shows that pharmacist unemployment in the United States was less than 3% for the years 2000, 2004, and 2009 [1-3] . These national unemployment levels for pharmacists were less than both the national unemployment rate overall [11] and "natural unemployment" estimates from the United States Congressional Budget Office [12] , which is the lowest level that a healthy labor market can sustain without creating inflation [12] [13] [14] [15] . By 2014, pharmacist unemployment was 3.9% [4] , which was closer to, but still below, the natural unemployment rate estimate [12] [13] [14] [15] . Pharmacist unemployment in 2019 reached 4.4% [5] , which was equal to the natural unemployment rate estimate of 4.4%. The most recent expansion reduced the shortage of pharmacists experienced in the early 2000s [1] [2] [3] [4] [5] 9, 10] . For example, the Aggregate Demand Index (ADI) for pharmacists from 2002 to 2008 had been in the 4 to 5 range (i.e., high demand for pharmacists nationally) [9] . From 2009 to 2015, the ADI dropped to the 3 to 4 range (i.e., moderate demand), and then to the level of 3 (i.e., demand in balance with supply) from 2016 to 2018 [10] . Figure 2 shows that pharmacist unemployment in the United States was less than 3% for the years 2000, 2004, and 2009 [1-3] . These national unemployment levels for pharmacists were less than both the national unemployment rate overall [11] and "natural unemployment" estimates from the United States Congressional Budget Office [12] , which is the lowest level that a healthy labor market can sustain without creating inflation [12] [13] [14] [15] . By 2014, pharmacist unemployment was 3.9% [4] , which was closer to, but still below, the natural unemployment rate estimate [12] [13] [14] [15] . Pharmacist unemployment in 2019 reached 4.4% [5] , which was equal to the natural unemployment rate estimate of 4.4%. [11] . Natural unemployment estimated from U.S. Congressional Budget Office, Natural Rate of Unemployment (Long-Term) (NROU), retrieved from FRED, Federal Reserve Bank of St. Louis; https://fred.stlouisfed.org/series/NROU, accessed 17 February 2021 [12] [13] [14] .

The ideal rate of unemployment (natural unemployment) means the labor market and economy are strong and jobs are available [12] [13] [14] [15] . When a labor market is healthy, natural unemployment results from normal turnover (frictional unemployment). People who are frictionally unemployed might include new graduates seeking their first job, employees who decide to leave a position to move to a new town before finding a new job, or others who leave the workforce for personal reasons. Natural unemployment is also associated with structural unemployment in which people have skill sets that become outdated, or their jobs are being replaced by technology or less costly labor. Structural unemployment remains until workers receive new training. When "overall unemployment" is below "natural unemployment", inflationary forces create an overheated labor market linked to precipitous increases in wage rates and student debt loads, as well as a decreased incentive for workers to keep their job skills from becoming outdated.

Pharmacy scholars correctly predicted that retrenchment in the number of pharmacy graduates was needed before the end of the 2010s [1- 5, 8, 9] . Further, they described the need for continual transformation in pharmacy practice and education that would update job skills for pharmacist contributions to health care and patient wellbeing [8, 9, [16] [17] [18] [19] . There are signals that the number of pharmacy degrees conferred per year is decreasing (2019 Profile of Pharmacy Students-AACP). Furthermore, the majority of pharmacists in the United States (52% in 2019) now contribute a significant portion of their time to providing patient care services that are distinct from the medication dispensing process (up from 40% in 2014) [20] . However, Lebovitz The ideal rate of unemployment (natural unemployment) means the labor market and economy are strong and jobs are available [12] [13] [14] [15] . When a labor market is healthy, natural unemployment results from normal turnover (frictional unemployment). People who are frictionally unemployed might include new graduates seeking their first job, employees who decide to leave a position to move to a new town before finding a new job, or others who leave the workforce for personal reasons. Natural unemployment is also associated with structural unemployment in which people have skill sets that become outdated, or their jobs are being replaced by technology or less costly labor. Structural unemployment remains until workers receive new training. When "overall unemployment" is below "natural unemployment", inflationary forces create an overheated labor market linked to precipitous increases in wage rates and student debt loads, as well as a decreased incentive for workers to keep their job skills from becoming outdated.

Pharmacy scholars correctly predicted that retrenchment in the number of pharmacy graduates was needed before the end of the 2010s [1-5, 8, 9] . Further, they described the need for continual transformation in pharmacy practice and education that would update job skills for pharmacist contributions to health care and patient wellbeing [8, 9, [16] [17] [18] [19] . There are signals that the number of pharmacy degrees conferred per year is decreasing (2019 Profile of Pharmacy Students-AACP). Furthermore, the majority of pharmacists in the United States (52% in 2019) now contribute a significant portion of their time to providing patient care services that are distinct from the medication dispensing process (up from 40% in 2014) [20] . However, Lebovitz and Rudolph adroitly pointed out that "large-scale practice transformation will not happen overnight; consequently, schools and colleges of pharmacy must immediately change their perspective . . . to producing graduates who are prepared with expertise and professional skills to excel in many types of well-paying positions" [17] . Van Antwerp [21] proposed that the health care value chain, and pharmacy's role in it, will experience a rapid disruption into areas such as: gene therapy, microbiomics, digital therapeutics, central-fill delivery hubs, ingestible robotics, home health diagnostics, automated artificial intelligence algorithms, smart home technology, and social determinants of health. Thus, transformations in pharmacy practice and education will likely be both dynamic and disruptive.

To better understand labor market forces in pharmacy, we propose that it would be helpful to describe frictional unemployment (job turnover) and structural employment forces that require new skill sets for employees and hiring practices that are affected by technology or less costly labor such as pharmacy technicians [16] [17] [18] . This will help inform decision making by policy-makers, employers, and educators about skills development, novel career pathway planning, innovative training options, scope of practice updates, alignment of payment policies, tiered degree systems, and post-graduate training and credentialing [9, [16] [17] [18] [19] .

In order help fill this gap in understanding, the objectives of this study were to describe hiring trends for both the pharmacist and technician workforces in licensed pharmacies on a biennial basis from 2006 through 2020 using data collected in Minnesota [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] . Minnesota was selected based on the availability of longitudinal data over the span of 15 years. For 2006 through 2020, hiring trends were described in terms of (1) degree of difficulty to hire pharmacists and technicians, (2) the wage rates the pharmacy market is willing to offer pharmacists and pharmacy technicians, (3) ideal and realistic demand for pharmacists and technicians, and (4) job turnover for pharmacists and technicians.

In light of the dynamic pharmacy labor market and the COVID- 19 pandemic, five openended questions were added to the 2020 survey. They were as follows:

What are the most impactful services available at your pharmacy? What are the ideal characteristics of your next pharmacist hire? What things do your pharmacy staff members need the most right now? What things does your community/the people you serve need the most right now? How has the COVID-19 pandemic affected your pharmacy? Findings from the answers to these questions can provide insights for how pharmacies are conducting their hiring practices for adding new skill sets, within the rising prominence of the roles filled by technology and technicians. 

Data were collected through biennial surveys of pharmacies located in Minnesota (Table 1) [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] . Each pharmacy location in Minnesota (as recorded by the Minnesota State Board of Pharmacy) was used as the unit of analysis. Outpatient pharmacies included pharmacies that were determined as being reasonably accessible by any ambulatory patient/client for receiving prescription medications and associated services. Inpatient pharmacies included hospital, institutional, and restricted-access specialty practices. In Minnesota, there were approximately 1200 pharmacies within the state. Of these, about 200 are categorized as inpatient and 1000 are categorized as outpatient. The number of pharmacies varies from year to year due to openings, closures, mergers, and record keeping adjustments made by the State Board of Pharmacy. According to a 15-year ecological comparison of Minnesota outpatient pharmacies [33] , with subsequent analysis using State Board of Pharmacy records for the year 2020, the composition of outpatient pharmacies in Minnesota changed between 2006 and 2020 and is noteworthy for this study. First, the ratio of independently owned pharmacies to chain corporationowned pharmacies changed from 1:2 in 2007 to 1:3 in 2020. Second, the traditional retail model associated with convenient location based on population density and metropolitan designation that was utilized in 2007 changed by 2017. The ecological comparison showed that by 2017, community pharmacies shifted from the traditional retail model to health care access models based on population health needs. That is, community pharmacies were transitioning to become better organized to operate as health care access points (often associated with clinics, medical centers, or specialty centers) that provide and are reimbursed for patient care and public health services such as medication optimization, immunizations, specialized services, and more [33] .

Since data were collected from key informants (owners, directors, or managers) at each pharmacy during even numbered years from 2006 through 2020, an ecological study design [34] was possible and adapted. For the years 2006 through 2018, each key informant was mailed a cover letter, a postage paid return envelope, and a questionnaire. Approximately four weeks after the initial mailing, another survey form and postage paid return envelope were mailed to non-responders. For 2020, the same process was used, but email was the delivery channel and an online response option was provided using the Qualtrics XM survey platform.

In some survey years, all of the pharmacies were included in the sample and, for some years, a portion of the pharmacies were sampled for the survey. Sample sizes and response rates for each survey year are summarized below (Table 2 ) [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] :

To measure the degree of difficulty to hire pharmacists and technicians, a five point scale was used from 1 = not difficult at all to 5 = extremely difficult. Key informants were also asked to report both the ideal and realistic number of pharmacists and technicians their pharmacy would like to hire in the next year. To monitor job turnover, respondents were asked to report the number of staff members who left in the past year and the number of current open positions (for pharmacists and technicians). Finally, respondents were asked to report the hourly wage (in dollars) they would offer a newly hired pharmacist and pharmacy technician. More detailed information about the wording of these questions is available from the corresponding author (schom010@umn.edu). Ecological comparisons [34] were made between the survey years using descriptive statistics. Since the number of pharmacies changed from year to year, the findings reported in Tables 3 and 4 are reported as averages or as a number per 100 pharmacies. Additionally, hourly wages are summarized both as reported and as inflation-adjusted dollars. That way, year-to-year comparisons can be more clearly interpreted by readers. For ecological studies, it should be noted that the unit of observation is the group, not separate individuals (or pharmacies). 

For responses to the first question (impactful pharmacy services), categories developed by Goode and colleagues [35] were used for coding responses. For the other four openended questions, one of the authors (JS) developed an initial list of coding categories for content analysis of the written comments. This list was reviewed, modified, and operationalized by three researchers (S.L., A.O., J.C.S.) who met in person for this purpose. Agreement was negotiated as a valid interpretation of the text and this discussion was driven by the study objectives and consistency of emergent themes. When the final set of analyses was compared, all investigators agreed upon major themes. Triangulation, conducted by using multiple analysts, also provided a quality check on selective perception and blind interpretive bias that could occur through a single person performing all of the analysis [36] . The final categories and operational definitions for (1) impactful pharmacy services, (2) ideal characteristics of next pharmacist hire, (3) pharmacy staff member needs, (4) needs of people served, and (5) To help assure rigor, random comments were selected and coded by three judges to make sure that consistent application of coding rules was being followed. Comparisons in the patterns of responses between outpatient and inpatient pharmacy types were made using descriptive statistics (chi-square analysis). Table 3 summarizes findings for outpatient pharmacies. The degree of difficulty (1 = not difficult at all to 5 = extremely difficult) to hire pharmacists has been below 3 (indicating relatively low difficulty) since 2010 in Minnesota-with the lowest score (2.1) reported in 2020. This is in contrast to the degree of difficulty to hire technicians in Minnesota being above 3 (indicating moderate difficulty) since 2014. Consistent with labor economics theory, the hourly wage for a newly hired pharmacist peaked in 2010 and then declined (using inflation adjustment to 2020 dollars). In contrast, the hourly wage for a newly hired technician increased between 2006 and 2020. Without adjusting for inflation, starting salaries for full-time pharmacists from 2006 to 2020 increased 18% and starting salaries for full-time technicians increased 44%. For reference, the Consumer Price Index (CPI) between 2006 and 2020 rose 29% [38] .

Regarding hiring plans for pharmacists and the number who left in the past year, Table 3 shows year-to-year variation without strong, discernable trends over time. Regarding hiring plans for technicians and the number who left in the past year, Table 3 shows year-to-year variation without strong, discernable trends over time. Table 4 summarizes findings for inpatient pharmacies. The degree of difficulty (1 = not difficult at all to 5 = extremely difficult) to hire pharmacists has been below 3 (indicating relatively low difficulty) since 2010 in Minnesota-with the lowest score (2.0) reported in 2020. This is in contrast to the degree of difficulty to hire technicians in Minnesota being at or above 3 (indicating moderate difficulty) since 2014. Consistent with labor economics theory, the hourly wage for a newly hired pharmacist peaked in 2010 and then declined (using inflation adjustment to 2020 dollars). In contrast, the hourly wage for a newly hired technician increased between 2006 and 2020. Without adjusting for inflation, starting salaries for full-time pharmacists from 2006 to 2020 increased 27% and starting salaries for full-time technicians increased 40%. For reference, the Consumer Price Index (CPI) between 2006 and 2020 rose 29% [38] .

Regarding hiring plans for pharmacists and the number who left in the past year, Table 4 shows year-to-year variation without strong, discernable trends over time. The composition of full-time pharmacists increased from 68% in 2006 to 81% in 2020. Open positions for full-time pharmacists dropped from 18 per 100 pharmacies in 2006 to 9 per 100 in 2020. Open positions for part-time pharmacists dropped from 20 per 100 pharmacies in 2006 to just 2 per 100 in 2020.

Regarding hiring plans for technicians and the number who left in the past year, Table 4 shows year-to-year variation without strong, discernable trends over time. Table 5 summarizes findings from the content analysis for the five open-ended questions (refer to the Appendix A for categories and operational definitions) . For outpatient pharmacies, the most impactful services were Medication Optimization and Wellness/Prevention services. For inpatient pharmacies, the most impactful services were Medication Optimization and Public Health. Table 5 . Content Analysis Summary for Open-Ended Questions Contained in the 2020 Survey (n = 322 since these questions only were included for the 2020 survey).

What are the most impactful services available at your pharmacy? (sums total more than 100% due to multiple responses) The distribution of "ideal characteristics of your next pharmacist hire" was statistically different for outpatient and inpatient pharmacies. For outpatient (community-based) pharmacies, the ideal characteristics were Specialized Experience/Training (43%) followed by Work Ethic (35%) and Interpersonal Skills (21%). For inpatient pharmacies, the percentages (proportions) were significantly different: Specialized Experience/Training (75%) followed by Work Ethic (22%) and Interpersonal Skills (3%).

Two (2) representative written comments for this question included:

Can effectively communicate, embraces treatment modalities such as: Rx, OTC, dietary supplements, dietary components to health, chiropractic and kinesio therapies, acupuncture, and other non-drug therapies. Hunger for learning. Innovative in thought and process. Collaborative in nature.

Residency trained, hospital experience, willingness to work weekends, evenings, holidays. Comfortable with face to face patient interactions. Additional certifications preferred (BCPS, ACLS, PALS; ASHP certificates).

Regarding pharmacy staff member needs, both types of pharmacies (inpatient and outpatient) reported the same things: Staff Support (64%), Staff Training (29%), and Health System Reforms (7%). Two (2) representative written comments for this question included:

Budgets are tight. We need to ensure items are properly billed to avoid audits and are utilizing the systems in place to ensure insurance companies are giving us preferred status. Additional training could be helpful. Additional staff would be helpful, but not currently possible due to budget constraints.

More help/support from corporate. The expectations are hard to accomplish with the limited resources provided from corporate with the most important resource being more budget hours for staffing. More management training. Most new pharmacists have minimal training and therefore desire to manage people.

Regarding what the people they serve need right now, both types of pharmacies reported the same things: Access to Care (43%), Quality Care (27%), Affordable Care (21%), and Social Justice (9%). Two (2) representative written comments for this question included:

A pharmacy that they can come to and not worry about the cost of their medications-if they are preferred or not. They need someone who listens to them and can help them with their needs and how to navigate the health care system-they need an advocate in the health system. Home delivery so that they can get their medications during this pandemic.

Healthcare reform. Medicare is a mess with preferred contracts and DIR being unsustainable. Costs are running out of control forcing increased price sensitivity and patients falling in to polypharmacy traps that decrease safety. Pharmacies need to be incentivized to provide high quality services that improve patient care; NOT filling as many Rx's as possible for the lowest price possible. PBM's need to provide value and the current model does not; too many dollars are leeched out of healthcare and while not the only problem, they are a big one.

We would be remiss if we did not provide examples of comments related to Social Justice. Examples for this category included:

Providers/systems that care enough to take the time necessary to achieve positive/life changing outcomes. Someone who will address all aspects of health from a mind, body, spirit perspective. Dynamic providers that can fill in deficiencies that are unique to each patient and situation. Suitable living arrangements. Education. Jobs. Financial assistance. Safe environment. Trustworthiness. Understanding. A focus on population health strategies-focusing on community change-adding more walking trails, community gardens, exercise facilities, youth facilities. Activities to keep kids from going the route of drug addiction (more youth focused activities & outlets).

When asked about how the COVID-19 pandemic affected their pharmacy, most responses related to Service Access and Coordination (33%), followed by Staff Workloads and Stress (26%), Revenues and Expenses (23%), and Regulations and Precautions (17%). Two (2) representative written comments for this question included:

Changing to a curbside/delivery/shipping model to keep staff and business safe has increased the workload for all of us. Expenses are up at the same time reimbursements are at an all time low. Not enough resources to continue to safely and effectively carry on much longer. Trying to figure out our next move to offset additional reimbursement cuts coming with the 2021 PBM contracts. We are all exhausted trying to keep up with the ever increasing workload caused by pharmacy closings due to economic and civil unrest issues.

Leveraging more remote capabilities than planned at this point, escalated our strategic plan. Has us reimagining physical structure needs of the future. The pandemic will no doubt speed up tools and investigations already ongoing into more autonomous and augmented workflows. Virtual care team structures and the tools/applications that go along with supporting that continue to advance.

We limited the number of examples for each open-ended question but received many insightful comments. For readers who are interested in seeing more written comments to the open-ended questions, please contact the corresponding author at schom010@umn.edu.

Before the findings are discussed, study limitations should be acknowledged. First, workforce data were collected from licensed Minnesota pharmacies and do not include other work settings in which pharmacists are employed. Since we only collected data from licensed pharmacies, our findings do not represent job characteristics in other settings. Second, we received responses from only a portion of the pharmacies in Minnesota. Our estimates are based on the assumption that respondents to our survey were representative of Minnesota pharmacies. Third, the number and mix of various types of pharmacies coded as inpatient or as outpatient could have changed from year to year and could affect comparisons over time. Fourth, ecological comparisons were made with group level information. To avoid errors of ecological fallacy, inferences should not be made about individual pharmacies from the results of aggregate data [34] . Finally, Minnesota has unique characteristics such as: (1) relatively highly integrated health care systems that include pharmacists in collaborative care, (2) community pharmacy practice transformation into centers for health and personal care, (3) specialty services development in pharmacies, and (4) challenging economic pressures placed upon pharmacies by other organizations in the health care value chain. Not all of these characteristics may apply to other regions to the same extent.

Between 2006 and 2020, the findings showed that the market for jobs in licensed pharmacies in Minnesota transitioned from a slight undersupply to an oversupply of pharmacists. During that same period, the technician labor market transitioned from a slight oversupply to a moderate undersupply of technicians. Trends in salaries are consistent with labor economic principles that showed pharmacist salaries grew at a lower rate and technician salaries grew at a higher rate than the Consumer Price Index (CPI).

The higher demand for technicians might be due to their expanding roles that have enabled them to conduct work activities traditionally reserved for the pharmacist, but at less cost, in order to meet economic challenges in current pharmacy practice [39] . Furthermore, responses to our open-ended questions suggest that pharmacies are transforming their work systems and processes of care for the next generation of pharmacy practice [40] and (1) seek pharmacists with specialized experience and training, (2) acknowledge the need for expanded staff support, and (3) are focusing on creating better patient access to their service offerings. Thus, in addition to typical frictional forces (job turnover), the hiring dynamics of Minnesota pharmacists have been affected by structural unemployment forces that require new skills for pharmacists and transitions to technologies and technicians for fulfilling traditional pharmacist work activities [13] [14] [15] .

While the findings show that Minnesota pharmacies would like to hire more pharmacists into roles that require new skills, survey respondents articulated that this is not feasible under current economic pressures. In addition, respondents described how economic pressures not only limit expansion of pharmacist roles but also are creating understaffing and job stress. Thus, an oversupply of pharmacists may exist due to economic pressure and organizational responses to that pressure rather than a lack of demand for the expanded services that pharmacists can provide. This may represent a lost opportunity, resulting in understaffing at pharmacies that not only adversely affects pharmacy staff wellbeing/resilience but also patient safety [41] .

We expect this labor market to remain dynamic in light of uncertainty surrounding: (1) the U.S. political economy, (2) effects of health care reform, (3) social justice and health equity transformation, (4) new job opportunities in organizations that are not licensed as pharmacies, (5) the use of technicians as less expensive substitutes for some pharmacist work activities, and (6) abrupt adjustments in business models and practices for existing pharmacies. In addition to typical functional unemployment forces (job turnover), we expect structural unemployment to also be a force that drives the need for new skills training.

The findings showed an increased demand for technicians in Minnesota pharmacies which might be due to their expanding roles that have enabled them to conduct work activities traditionally reserved for the pharmacist, but at less cost, in order to meet economic challenges in current pharmacy practice [39] . Minnesota pharmacies reportedly would like to hire pharmacists to meet the demand for new services that pharmacists can provide. However, respondents articulated that this is not feasible under current economic pressures. This represents a lost opportunity for transformation in pharmacy that would establish pharmacists' roles in the rapidly transforming health care value chain. Respondents also described how economic pressures are resulting in understaffing at pharmacies that adversely affects pharmacy staff wellbeing/resilience and patient safety. We conclude that hiring dynamics in pharmacies are being driven more by economic and organizational shifts than meeting the demand for services that pharmacists can provide.

Group Education, Exercise Classes/Yoga. Patient Support Services: Telehealth, Stay-in-Home Patient Care Services, Durable Medical Equipment, Care Transitions, Drive Thru/Curb Side Pickup Services, Medical Equipment, Oxygen/Continuous Positive Airway Pressure (CPAP) services, Home Care, Infusion Services. Public Health: Population Health, Emergency Preparedness, Practice-Based Research, 340B Drug Pricing Program, Collaborative Practice, Team-based/Collaborative Care. What are the ideal characteristics of your next pharmacist hire? Specialized Training/Experience: Training, experience, and abilities that are specifically suited to the needs of the organization. Work Ethic: Ability and motivation to be flexible, efficient, and focused to meet the changing needs of the organization. Interpersonal Skills: Ability and motivation to be aware (of self and others), caring, and collaborative. Strong communication and conflict management skills. What things do your pharmacy staff members need the most right now? Staff Support: Staffing, workload, technology, quality of work life. Staff Training: Opportunities for learning new skills and for applying abilities. Health System Reforms: Changes to burdensome insurance, benefit management, regulatory, and reimbursement schemes. What things do the people you serve need the most right now? Access to Care: Locational convenience and communication connectivity for obtaining medications, advice, and services. Quality Care: Tailored, accurate, responsive, reliable, stable, and consistent care with emotional support and continuity. Affordable Care: Financial assistance, affordability, and insurance payment reform. Social Justice: Education, housing, safety, jobs. How has the COVID-19 pandemic affected your pharmacy? Service Access/Coordination: Work System and Care Process changes to provide access and coordination

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Update on Pharmacist Workforce Data and Thoughts on How to Manage the Oversupply

Finding a Path Through Times of Change

Transforming community-based pharmacy practice through financially sustainable centers for health and personal care

Pharmacist Segments Identified from 2009, 2014, and 2019 National Pharmacist Workforce Surveys: Implications for Pharmacy Organizations and Personnel

The Future of Pharmacy

Changes in the Minnesota pharmacy workforce between

Changes in the Minnesota pharmacy workforce between

Changes in the Minnesota pharmacy workforce between

Changes in the Minnesota pharmacy workforce between

Changes in the pharmacist and technician workforce in licensed Minnesota pharmacies between

Changes in the pharmacist and technician workforce in licensed Minnesota pharmacies between

Changes in the pharmacist and technician workforce in licensed Minnesota pharmacies between

Changes in the pharmacist and technician workforce in licensed Minnesota pharmacies between

Changes in the pharmacist and technician workforce in licensed Minnesota pharmacies between

Changes in the pharmacist and technician workforce in licensed Minnesota pharmacies between

Available online: www.health.state.mn.us/divs/chs

A 15 Year Ecological Comparison for the Market Dynamics of Minnesota Community Pharmacies from

Study Design VI-Ecol

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Pharmacist and student pharmacist views of professional and personal well-being and resilience

Xiong regarding open-ended question development for the 2020 survey are greatly appreciated. We gratefully acknowledge the Minnesota pharmacists who received and responded to the survey. We value their time and effort in providing the requested information. Without their help, the report would not be possible.

The authors declare no conflict of interest.

What are the most impactful services available at your pharmacy [35] 

Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. "Your participation is voluntary and your response is confidential. Only aggregate responses will be reported. By completing the survey form, you are providing your consent to participate in the project." Data Availability Statement: Data files are stored in encrypted format at the University of Minnesota. Requests for access to the files may be sent to the corresponding author at schom010@umn.edu.