**4. Discussion**

While pharmacy technicians in the United States who began their work between 1997 and 2006 have likely experienced modest positive wage premiums over time, pharmacy technicians who begun their work after 2007 have likely not experienced any positive wage premiums, with some earning less than what would have been expected had their wages kept up with the CPI. It should be noted that pharmacy technicians who have been working in this role since the late 1990s and early 2000s likely account for a very small portion of the pharmacy technician workforce in the United States. According to data from Desselle and colleagues, the median length of employment as a pharmacy technician in the US is approximately 9–10 years [27] compared to a median length of employment of approximately 22 years for pharmacists [28]. The majority of pharmacy technicians in the US have entered the workforce since 2006, and as such have not experienced much in the way of positive wage premiums, and may have even experienced negative wage premiums. Pharmacy technicians who have entered the work force since 2006 may have benefitted indirectly from hourly wage levels that were higher in CPI-adjusted dollars than if had they started in the field earlier. Since 2006 wage premiums for pharmacy technicians in the US have fluctuated in a manner and to a degree similar to those experienced by the median of "all occupations" in the US economy. Yet, what has been asked of pharmacy technicians in terms of expanded job roles [4–12] and regulatory requirements [21–23] has increased over this time. While one would expect to see positive wage premiums as a result of these increases in job roles and requirements, this was not observed in our analysis, and is consistent with the findings of other researchers [21,22]. Pharmacy technicians in the United States also have not experienced wage changes in the manner of those experienced by pharmacists, who experienced relatively large positive wage premiums in the late 1990s through the late 2000s [29].

Pharmacy technicians employed in community pharmacy settings in the United States (grocery stores, chain and independent pharmacies, mass merchandise stores) have generally experienced lower hourly wages and have been more likely to experience negative wage premiums than pharmacy technicians in hospitals and governmen<sup>t</sup> settings. Community pharmacy technicians have been described as "the face of the community pharmacy", which translates into them being a critical source of patient loyalty, satisfaction and engagement. Their expanded job scope has resulted in higher levels of job stress [30]. As pharmacy technicians are essential to community pharmacy in the midst of their practice becoming more patient-centric model, community pharmacies must compensate their technicians at levels in line with the responsibilities they are increasingly being asked to take on, or risk losing them to other practice settings (such as hospitals and government, which has consistently paid pharmacy technicians higher hourly wages) or to other jobs outside of pharmacy entirely. Mattingly and Boyle have found that pharmacy technicians were the lowest compensated of 14 health technologist occupations in the U.S. state of Maryland, despite having education, training, and regulatory requirements similar to those other occupations [31]. Chui and colleagues stated that community pharmacies must redesign technician jobs, deploy them more effectively, and provide the training and compensation commensurate with these jobs so as to re-engineer practice with greater patient safety in mind [32]. In a 2005 study, Desselle found that as little as a \$0.75/hour difference in hourly wages (approximately \$1.00/hour when converted to 2018 levels) explained a significant portion of a pharmacy technician's intention to remain with their current employer or seek other employment [33].

This study has limitations that are important to recognize. The US Bureau of Labor Statistics Occupational Employment Statistics are exclusively collected in the United States and its territories. The results described here are limited to pharmacy technicians in the United States. The manner in which the US BLS provides its data (it is over one year old at the time it first becomes available), and the subsequent use of this data to calculate the presence of positive or negative wage premiums means that the findings reported here are a trailing indicator of the state of the labor market in the past. This study of US BLS data precludes any ability to discern from pharmacy hiring managers and other stakeholders the realities of the hiring market at the present time. While this analysis enables identification of past incongruities in the labor market (e.g., groups who have experienced either positive or negative wage premiums), the analysis does not allow us to separate to the extent to which wage premiums (or lack thereof) can be explained by changes in the supply of labor willing to work at these wage levels, or changes in the demand for services provided by pharmacy technicians. There is ample evidence that the demand for the services of pharmacy technicians in the United States has been high during this time period. The fact that significant positive wage premiums have not been observed, particularly since 2006, may be due a variety of factors. These include increases in the supply of pharmacy technician labor that kept up with the changes in demand. The lack of wage premiums may also be explained by other factors, including the role that technology has played in automating various dispensing and administrative roles that had previously been performed by pharmacy technicians, as well as negative pressures on pharmacy revenues generated by dispensing, which are needed to pay employee wages and other expenses.
