The Texas State Board of Pharmacy today is holding a hearing on a proposal to eliminate the pharmacist-to-technician ratio requirement for retail pharmacies.

The measure is opposed by the National Community Pharmacists Association and Texas Pharmacy Association, who say patient safety would be at risk if pharmacist supervision was expanded to include more pharmacy personnel.

Yet proponents of dropping the ratio requirement — including the National Association of Chain Drug Stores and Texas Federation of Drug Stores — say being able to have more technicians on hand to dispense prescriptions frees up pharmacists to spend more time consulting with patients, providing a higher level of care. They also note that pharmacies should be able to determine their own staffing needs.

ALEXANDRIA, Va. — The Texas State Board of Pharmacy today is holding a hearing on a proposal to eliminate the pharmacist-to-technician ratio requirement for retail/community pharmacies in the state.

The measure is opposed by the National Community Pharmacists Association and the Texas Pharmacy Association, among others, who say patient safety would be at risk if pharmacist supervision was expanded to include a greater number of pharmacy technicians.

However, proponents of dropping the ratio requirement — including the National Association of Chain Drug Stores and the Texas Federation of Drug Stores — say that being able to have more technicians on hand to dispense prescriptions frees up pharmacists to spend more time consulting with patients, providing higher levels of care and service. Furthermore, they note, pharmacies should be given the latitude to determine their own staffing needs.

Currently, for retail pharmacies (defined as Class A pharmacies), the Texas pharmacy board requires that the ratio of on-site pharmacists to pharmacy technicians and pharmacy technician trainees not exceed 1:3, and the ratio of pharmacists to pharmacy tech trainees cannot be more than 1:2. The proposal to be discussed at the Nov. 4 board hearing aims to end these requirements.

No change, though, would be made to the current requirement that retail pharmacies not exceed a 1:5 ratio of on-site pharmacists to pharmacy techs and pharmacy tech trainees, as long as the pharmacy dispenses no more than 20 different prescription drugs and doesn’t produce sterile preparations including intravenous or intramuscular drugs on-site.

That requirement also mandates that a pharmacy have written policies and procedures on the supervision of pharmacy techs and tech trainees, including that they can be involved in only one process at a time. For instance, a tech trainee who is compounding nonsterile preparations or is involved in preparing prescription drug orders can’t also call doctors for the authorization of refills.

In a letter to the Texas State Board of Pharmacy, NCPA said it has "serious concerns" about the prospect of completely eliminating pharmacy technician ratios.

"NCPA believes the proper training and supervision of technicians by pharmacists is critical to the health and safety of patients," the association stated. "It is our thought that proper supervision is a key factor in successful utilization of technicians maximizing their roles. Once a pharmacy’s workload increases, there should not be a unilateral allowance of increased technician utilization."

NCPA cited a study indicating that pharmacy staffing plays a role in the risk of potential drug-drug interactions, with the findings showing that automation and additional pharmacy personnel are insufficient in compensating for increased pharmacist workload.

"We contend that elimination of ratios is not in the best interest of pharmacists or the patients they serve," NCPA explained in the letter. "NCPA does not agree that state boards of pharmacy should allow individual pharmacies to set their own ratios. There should be clear delineation of the roles of pharmacists and technicians. NCPA does support the enhanced utilization of technicians so that pharmacists have more time to provide patient care services. However, we think the elimination of pharmacist-to-technician ratios could prove counter to the goal of improving patient outcomes and lowering overall health care spending."

The association added that although it doesn’t have a formal position on a specific ratio, it’s opposed to leaving open the number of technicians that a pharmacist may supervise.

"We believe this is particularly important, as many pharmacists work in environments in which they have no ability to control the number of technicians they are compelled to safely oversee," NCPA pointed out.

The Texas Pharmacy Association (TPA), in a letter to the state pharmacy board, said it conducted an informal, statewide survey of pharmacists and pharmacy technicians, drawing more then 1,400 respondents. Over 89% of pharmacists and 75% of technicians supported limiting the supervision ratio to 1:5 or less.

"TPA has a long-time position in support of regulations that cap the technician supervision ratio at 1:3. Legally, this supervision ratio pertains to pharmacy technicians; however, nearly all pharmacists in Texas also supervise many other pharmacy staff," the association explained in the letter. "At any one time, these additional individuals and employees could include other pharmacists and student pharmacists, along with a very wide range of staff that is not directly involved in the dispensing process, such as cash register staff, clerical staff, staff in the front part of the store, etc.

"The association’s position always has been based on the likelihood that high supervision requirements will impact patient safety unless appropriate education and workflow issues are addressed," TPA noted.

In a letter last week to the Texas pharmacy board, NACDS called for the elimination of the pharmacist-technician ratio requirement, explaining that pharmacists in Texas and elsewhere are facing a growing demand to provide more health services, such as medication therapy management and disease management. Earlier last month, via its RxImpact advocacy website, the association also urged pharmacy professionals to send messages to the Texas pharmacy board to express their support for the elimination of the ratio mandate.

"The extent to which pharmacists can engage in these types of direct patient care activities depends heavily on pharmacists ability to delegate to pharmacy technicians the administrative and nondiscretionary work that must also be performed in a pharmacy," NACDS explained in the Oct. 30 letter. "The existing pharmacist-to-pharmacy technician ratios that arbitrarily limit the number of pharmacy technicians in certain classes of pharmacies impede pharmacists’ ability to optimize use of pharmacy technicians to perform nondiscretionary tasks. Eliminating these ratios will allow pharmacists to determine the appropriate number of technicians for their pharmacy."

NACDS pointed out in the letter that 16 states and Washington, D.C., don’t mandate ratios, while required ratios in Montana and New Jersey can be exceeded if the state pharmacy board grants a waiver.

The association also suggested that the proposal in Texas to eliminate the required ratio could address safety concerns with the addition of language such as, "Consistent with patient safety, no pharmacist shall supervise more technicians than he or she can safely supervise."

"We believe that pharmacists are fully capable of determing the appropriate number of technicians that they can safely utilize to assist them with duties in the pharmacy," NACDS stated in the letter.

Pharmacists spend 44% of their time performing technician tasks instead of pharmacist activities, NACDS said in an Aug. 2 letter to the Texas pharmacy board, citing a recent internal study by a national pharmacy chain. The elimination of ratios would enable pharmacists to devote more time to such activities as patient counseling, quality assurance and immunizations, the association noted.

"Due to the limitations of the 3-1 technician-to-pharmacist ratio," NACDS stated in the letter, "pharmacists practicing in retail pharmacies today are having to carve out time from their other important work to complete tasks that could otherwise be done by a technician, in accordance with TSBP [Texas State Board of Pharmacy] rules."