EDITORIAL:
PBM Reform: An Important Victory, But the War Continues!
On February 3 Congress passed legislation that is intended to provide long-sought reform in the operations of PBMs, including increased transparency and accountability, and the establishment of fair ("reasonable and relevant") contract terms with pharmacies. The NCPA, APhA, and NACDS (National Association of Chain Drug Stores) are to be congratulated for their strong and persistent efforts that resulted in bipartisan support for and approval of the legislation. Pharmacist Earl "Buddy" Carter, Representative from Georgia, has been a leader among the bipartisan group of legislators that have been advocates for PBM reform. In a press release on February 3 from his office, he notes:
"I came to Congress with the goal of building a health care system that puts patients before profits. Today, I can proudly say that we have enacted the first major PBM reform in decades, a meaningful step toward achieving that goal. PBMs have been stealing hope and health from the American public for decades, inflating prescription drug costs, forcing pharmacy closures, and blocking access to medications. To that I say: Not on my watch. The PBM mafia has officially been put on notice."
The Pharmaceutical Care Management Association (PCMA), the association that represents PBMs, also issued a press release on February3 titled: "PBM Reform is Done – Now What?" that includes the following statements:
"While drugmakers are quietly celebrating this achievement (they do in fact stand to make a lot more money from this law), they should also know that new oversight of their own actions is now coming. It is long past time for lawmakers to look into the ways the pharmaceutical industry games the system to block competition and artificially keep drug prices high. Patent abuse, shadow pricing, direct to consumer advertisements, pay for delay, switching – the tactics are many. All of them in service of keeping prices high."
The PBMs and pharmaceutical companies fault each other for the high cost of drugs but they each continue to increase their own profits and wealth. In the meantime, pharmacies can't financially survive and they close, and millions of patients can't afford their medications and experience greater inconvenience and risk of harm because of increased difficulties in obtaining their medications.
The approval of the new legislation is an important forward step for the public and pharmacists. However, it is but one victory in a continuing WAR. Close monitoring and enforcement are essential as we can expect that the PBMs will circumvent the law and exploit its loopholes. In addition, there are egregious policies of the PBMs that are not addressed in the new law.
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EDITORIAL:
Pharmacy Degree and Licensure Requirements Continued: Part 2
Editor's note: I appreciate the many responses I received to my editorial, "It is Time to Reconsider Pharmacy Degree and Licensure Requirements," (The Pharmacist Activist, January 2026). The most comprehensive response is from Jim Doluisio, Dean Emeritus of the University of Texas at Austin. Jim provided leadership in the development and implementation of the first post-baccalaureate Pharm.D. degree programs at the Philadelphia College of Pharmacy, University of Kentucky, and University of Texas, and he is in a unique position to provide observations and opinions regarding the changes that have occurred in our profession. His response is provided below. Following his response, I have summarized other responses/questions I have received.
Response from James T. Doluisio, Ph.D., Dean Emeritus and Hoechst-Roussel Centennial Professor Emeritus of Pharmacy, University of Texas at Austin
I write to support your opinion that a two-degree formal education structure should be considered as the foundation for professional practices in our profession.
It has always been my belief that our college had the responsibility to prepare our students for the current practices of pharmacy as well as to prepare them to adapt to future practice opportunities. I thought that the easy role was preparing them for the current practice opportunities, but I am concerned that this is the role that we did not get quite right with our current one-degree (Pharm. D.) requirement. It appears to me that our current structure is appropriate for a few but contains unnecessary education for some and inadequate education for others.
I support a 4-or 5-year post-high school B.S. program and a 7-year post-high school Pharm.D. program, 4+3 or 5+2. I also support the development of ‘external' Pharm.D. degree programs that could be pursued part-time by pharmacists with B.S. degrees.
Like you, I graduated with a 4-year pharmacy degree that was basically 1 year of pre-pharmacy instruction and 3 years of pharmacy instruction. However, we entered pharmacy school directly from high school and pharmacy schools (and pharmacists) were actively engaged with the pharmacy career orientation of high school students.
The required 5-year (2+3) B.S. program that started in the 1960's was instituted to enhance general education. In the 1990's some justified a required 6-year (2+4) Pharm.D. program on the 'too crowded' nature of the 3 pharmacy education years in the 5-year B.S. program while others suggested that the ‘too crowded' nature should be addressed through better curriculum management.
I strongly agree with your comment that the 7–8-year post-baccalaureate Pharm.D. programs were "a pharmacy success story." Unfortunately, these programs were discontinued when our profession universally established and defined the Pharm.D. as a 6-year program and discontinued the 5-year baccalaureate program. Additionally, it appears to me that the current universal 6-year Pharm.D. program, in terms of professional competencies, is more closely related to the former 5-year B.S. program rather than the former 7-8-year Pharm.D. programs.
It should be noted that almost all pharmacy students completed the 4-year program or 5-year program in 4 or 5 years. Currently, many students in 6-year Pharm.D. programs are taking 8 years post-high school to become a pharmacist. Although a time of 8 years post-high school was not the intent of the current requirement, it is the reality for many. Thus, the intended 1-year increase required in the 1990's has resulted in an increase of 3 years for many. Would this 2-year inflation in the non-pharmacy years also have occurred if the 5-year B.S. programs had continued? Have pharmacy schools decreased their interest in high school and pre-pharmacy activities? Are current pharmacy students making their career decisions later and on different criteria? It would be good to have definite answers to these questions. But there is no doubt that the actual cost of becoming a pharmacist today has become very expensive...a great deal more expensive, in real terms, than it cost me. And that increased cost has not been offset by increased income...nor does it appear that the professional practice activities/opportunities of many pharmacists with a 6-year+ Pharm.D. degree program differ much, if at all, from pharmacists with a 5-year B.S. degree program.
As you have stated, we now have over 25 years of experience with the program/degree changes made in the 1990's. It seems to be time, perhaps past time, for the current stewards of our profession to evaluate whether our current formal educational structure is optimally serving societal health needs.
Our profession has a great and long history. And we have much to cherish and much to be proud of. But from my vantage point I am proud of some things that others might not notice. Proudly, we have a great history of attracting students, like me, who are the first in their family to earn a college degree. Proudly, we have a great history of giving opportunity to minority students and women students. Proudly, some pharmacy graduates have outstanding careers in professions such as scientists, professors, physicians, lawyers, dentists, veterinarians, teachers. Proudly, pharmacists have served their communities as mayors, school board members, youth sports coaches, volunteers. And, proudly, pharmacists have served the health needs of their patients with skill, dedication and distinction.
We have a proud history and heritage. We have much that we need to preserve and much that we need to change. We will continue as a great profession only if we make certain that our best days of providing needed societal services are in our future. That begins with the quality of the students we recruit....and the quality, versatility and vision of our education...and the quality, skills and innovativeness of our practitioners.
All professions, including our profession, need periodic points of renewal to continue and enhance their services. The status quo is not an option.
Summary of other responses
Most of the pharmacists who responded supported the re-establishment of a baccalaureate degree (i.e., B.S. in Pharmacy) as the entry-level degree for licensure, although many felt that pharmacy leaders would not support such a change or even be interested in discussing it. Some voiced a preference for a 5-year baccalaureate degree, rather than a 4-year program, because of a concern that 4 years would not be sufficient to provide a foundational education in pharmacy. Many respondents identified the cost of a pharmacy education and the burden of college debt as deterrents to pursue a career in pharmacy. A pharmacy Dean, while courteous in not rejecting my thoughts, noted that my recommendations "would not be embraced by the academy."
Several respondents expressed concern that the proposed changes could result in or accentuate a "class system" within pharmacy (i.e., those in dispensing/distribution roles and those in "clinical" roles) that could be divisive rather than unifying within the profession. A few questioned the ethics of the organizations and colleges of pharmacy with respect to their strategies to recruit students for professionally-fulfilling responsibilities that would not be provided by the largest employers (chains) of pharmacy graduates.
Some respondents viewed changes in the degree and licensure requirements for pharmacists in the context of creating healthcare practice models in which physicians diagnose, pharmacists prescribe, and pharmacy technicians dispense medications. A pharmacist/physician described how he uses student pharmacists on rotation in innovative ways that extend the value of his medical practice. He is also an advocate for the integration of a pharmacy education with a physician assistant studies education that would provide prescribing authority for pharmacists.
One pharmacist questioned whether the huge amount of debate, resources, and time that would be necessary to address and implement changes in degree and licensure requirements was appropriate at a time when the profession had urgent challenges like PBM reform.
These and the other responses I received can't be considered a representative sampling of views and opinions across the profession. Indeed, none of them have been provided by individuals who are currently in pharmacy leadership positions. However, they provide thought-provoking views from individuals who love and value our profession, but are greatly concerned about its future. The responses are of value for me in assessing the validity of my opinions and the priority they should be given.
Extending the discussion and taking action
I consider the review and revision of the pharmacy degree and licensure requirements to be a starting point that must be addressed in the context of the current and anticipated increased roles and responsibilities of pharmacists, and the extent to which our profession can exercise influence over the continuation and expansion of these roles. The most important lesson from the profession's decision to go all Pharm.D. is that the profession did not provide a corresponding commitment to increase the standards of practice and employment opportunities that would enable most graduates to utilize their advanced expertise and skills.
To extend the discussion initiated in my January editorial, I recommend the following:
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A model B.S. in Pharmacy curriculum should be constructed. The curriculum should be designed to provide the foundational knowledge and skills that every pharmacist should have to qualify for licensure. A primary goal should be that the curriculum can be completed in 4 academic years. The curriculum should prepare graduates to fulfill dispensing responsibilities and clinical responsibilities such as prevention of errors and other drug-related problems, drug utilization review, and medication management.
The drug therapy component of the curriculum should primarily include the medications that are available generically and account for more than 80% of the prescriptions/medication orders dispensed in community and hospital pharmacies, plus the most widely used single-source medications for the most common medical issues.
Priority consideration should be given to establishing a curricular "track" that will encourage entrepreneurism and pharmacist ownership that will restore and increase the number of independent pharmacies that provide professional and personalized services to patients residing in pharmacy deserts and to other underserved populations.
The opportunity to earn a B.S. in Pharmacy and to become a licensed pharmacist in at least 2 fewer years than is required at the present time will significantly increase the number of applicants to colleges of pharmacy. It will also facilitate a career pathway in which an increased number of pharmacy technicians will pursue earning a degree in pharmacy.
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In my January editorial I recommended that an optional 3-year post-baccalaureate Pharm.D. degree program that includes a one-year pharmacy residency be provided for pharmacists holding the B.S. in Pharmacy degree who wish to pursue advanced professional/specialized responsibilities. Upon further consideration, I am revising this recommendation to a 2-year post-baccalaureate Pharm.D. program with a residency as a subsequent and separate option. There would be a separate admissions process for the Pharm.D. programs.
The completion of the 2-year Pharm.D. program following the 4-year B.S. in Pharmacy program in a total of 6 years is consistent with the minimum period of time now required to earn the Pharm.D. degree. However, there would also be greater flexibility in the Pharm.D. degree program to include didactic coursework and experiences in curricular "tracks" that would facilitate pursuit of credentials beyond the Pharm.D. degree in specialized areas of practice.
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Residency opportunities and certification in specialties could be pursued following completion of the Pharm.D. degree program OR the B.S. in Pharmacy degree program, although it would be anticipated that those who hold the Pharm.D. degree would be more competitive in being accepted into residency positions.
Residency programs have been traditionally provided in hospital pharmacies. Attention should be given to increasing the number of residencies in community pharmacies, long-term care pharmacies, and selected other areas of pharmacy practice. Many pharmacists who have pursued certification in a specialty have done so following completion of one or more years of residency experience. Notwithstanding the value of any of these experiences, there can also be redundancy. For example, for pharmacy graduates who have a strong interest in a particular specialty, is it important that they participate in a residency, rather than obtaining employment in the specialty area of interest and earning specialty certification at an earlier time?
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The criteria for eligibility to take the examination for certification in a specialty should be as flexible as possible in recognizing the knowledge acquired in employment experiences, self-learning, and other initiatives.
I have more ideas but want to hear more of yours.
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