Community Pharmacy Can Win and Still Lose

Forward Momentum on PBM Reform

Pharmacy benefit manager (PBM) reform is just getting started, but recent developments have been substantive. From laws barring PBMs from owning their own pharmacies (Arkansas) to growing carve-outs that require PBMs to operate as independent Medicaid contractors (New York and elsewhere) to commercial-plan approaches using cost-to-dispense or minimum-reimbursement floors (Iowa), reform is accelerating—both in the variety of tactics being tried and in the number of “me too” states adopting them. Even at the federal level, which usually lags behind states in pharmacy reform, bills like the Pharmacists Fight Back Act (HR 6609) are actually making it out of committee instead of being sent to endless “studies” and “deliberation.”

Standard-of-Care and Scope-of-Practice Expansion Is Accelerating

North Carolina followed suit with Idaho, Alaska, and Iowa in allowing a standard-of-care framework to define pharmacists’ scope of practice, rather than relying on piecemeal, incremental gains through explicit statutory language. This shift indicates a sea change in legislative perception of pharmacists’ capabilities and value, enabling them to “practice at the top of their license.”

Pharmacist Billing Is Reaching a Critical Mass in Some Geographies

There are now 17 states where pharmacists can bill for practitioner services (“provider status and payment”)—opportunities that have moved beyond piloting and toe-in-the-water billing to a scale that allows for clinical and economic sustainability for pharmacist-provided services.

But What If There Is a Lack of Workforce to Take Advantage of These Wins?

So…winning. Not there yet, but getting there. The future is bright, yes? Well, yes and no. We could win these policy and professional battles—securing fair rules and removing the handcuffs on billable patient care—and still lose if we don’t have pharmacists and associated workforce members in sufficient numbers to deliver on the main value proposition: access to cost-effective care in the community. Our main selling point could become our Achilles’ heel.

Schools and Colleges of Pharmacy Are Nearing (or in) Crisis Mode

Although pharmacy applications rose in the last measured cycle (fall 2025) by 6%, applications have been down a whopping 36% since their peak in 2012 (approximately 17,000 applicants) and stand roughly equivalent to when I started pharmacy school 30 years ago this month.¹ This is despite a roughly 5-fold increase in the number of prescriptions dispensed in the US over the same time period.

The Big Tell: Diversification of Degrees and Programs Beyond Pharmacy

Many nonpublic schools and colleges that don’t have diversification of funding through their state(s) or research endeavors are most at risk. Many of them have responded to the applicant-enrollment-dropout crisis by diversifying their academic offerings to include everything from more allied health degrees—occupational therapy, physical therapy, nursing—to more generic “health sciences” degrees, along with greater investment in undergraduate tuition revenue. They are not abandoning pharmacy per se, but they clearly are sending a signal that being a 1-trick admissions department invested only in pharmacy is too risky—an overall tell of their outlook on the profession.

Why Do We Have This Problem?

A commentary by Daniel Brown, published in the American Journal of Pharmaceutical Education, makes the following salient points:

“Pharmacy education used to be an excellent value among health profession options. That is no longer the case. In 2004, the combined annual tuition and fees for in-state public and private pharmacy schools averaged $10,297 and $21,374, respectively. By 2019, those mean costs had risen to $25,012 and $41,602. Increased tuition costs have translated into ballooning student debt. According to the 2019 AACP [American Association of Colleges of Pharmacy] Graduating Pharmacy Student Survey, mean student loan debt at graduation was $144,083 and $198,560 for public and private school graduates, respectively. These debt totals represent an increase of almost 70% over the last 10 years…. Gone are the days of guaranteed full-time, high-paying positions for graduates straight out of pharmacy school. Many pharmacy graduates are faced with accepting part-time or per diem positions, reduced salaries, difficult working conditions, undesirable locations, and/or unemployment.”²

It should be noted that this was written in 2020; there is now pharmacist demand in selective geographies and settings, with bonus offerings that look like those of the 2000s (again).

How Are the Dynamics Different From at the Turn of the Century?

Despite fewer graduates, there remains a healthy number of licensed pharmacists. Yet community pharmacy jobs (in particular) are getting ever harder to fill, especially in rural areas and locations with a history of stressful and potentially unsafe working conditions. A wholesale, across-the-board shortage is not evident; however, what is evident is that large portions of the licensed workforce are not willing or able to take up positions in what they perceive to be undesirable, even if that means unemployment or underemployment.

What Possible Solutions Exist?

As Brown put it, “The best long-term solution to the enrollment crisis addresses the demand side of the equation.”² Yes, but those jobs need to be desirable and in demand as well. There needs to be a profession-wide effort to “make pharmacy fun again” and cultivate hands-on experiences rooted in patient care delivery at the high school and undergraduate levels, within care and business models that entice applicants, enrollees, and practitioners. Yes, we need PBM reform, scope-of-practice expansion, and pharmacist billing to continue—because the parents whose children become college students and then professionals need a different experience with pharmacies and pharmacists: asking for more, receiving more, and expecting more from pharmacists’ involvement in their care. Public perception matters, and it affects workforce entrants—from pharmacists to pharmacy technicians and the entire pharmacy workforce.

About the Author

Troy Trygstad, PharmD, PhD, MBA, is the Executive Director of CPESN USA, a clinically integrated network of more than 3500 participating pharmacies. He has recently served on the board of directors for the Pharmacy Quality Alliance and the American Pharmacists Association Foundation and currently serves on the board of directors for Pharmacists Mutual Insurance Group. He received his PharmD and MBA degrees from Drake University and a PhD in pharmaceutical outcomes and policy from the University of North Carolina and proudly practiced in community pharmacies across the state of North Carolina for 17 years.

REFERENCES

1. American Association of Colleges of Pharmacy. Pharmacy school interest rises as applications jump 6%. AACP. December 2, 2025. Accessed August 27, 2026. https://www.aacp.org/article/pharmacy-school-interest-rises-applications-jump-6

2. Brown D. Years of Rampant Expansion Have Imposed Darwinian Survival-of-the-Fittest Conditions on US Pharmacy Schools. American Journal of Pharmaceutical Education, 84.