NCPA Survey: Majority of Independents Concerned About, Prepping for “DIR Hangover”

Survey also reveals ongoing drug shortages, staffing challenges

NCPA June 2, 2023

ALEXANDRIA, Va. (June 2, 2023) – A new survey released by the National Community Pharmacists Association indicates that a strong majority of independent community pharmacy owners/managers are concerned about upcoming cash flow challenges resulting from changes to federal policy effective Jan. 1, 2024. Many respondents say they are working now to prepare, but there remains palpable fear that pharmacy closures are a real possibility. These questions were included in a survey NCPA regularly sends to its members for use in providing context on supply chain issues, staffing concerns, or other economic pressures they are facing.

“With PBM pressures and other economic issues at play, it continues to be a challenging environment in which to operate an independent pharmacy,” said Anne Cassity, senior vice president of government affairs at NCPA. “Under pressure from regulators and policymakers to straighten up, PBM-insurers are in overdrive trying to make people believe they don’t need oversight or reforms while seemingly carrying on with tactics that make it difficult for patients to access care and independent pharmacies to remain healthy. Without hard results, their promises are empty. Work must continue to advance changes that demonstrably support pharmacy teams, the patients they serve, and the supply chain we all rely on.”

For the first time in this survey, NCPA asked independent pharmacy owners/managers for insight relating to the “DIR hangover.” This is what NCPA has dubbed the period starting Jan. 1, 2024, when bills for pharmacy direct and indirect remuneration for the end of 2023 will come due to pharmacy benefit managers just as those DIR fees for the beginning of 2024 will be moved to the point of sale. The DIR hangover is a result of provisions taking effect from the Centers for Medicare & Medicaid Services Medicare Part D final rule for contract year 2023.

Ninety-eight percent of survey respondents say they are concerned about the upcoming DIR hangover and how it will affect their pharmacy; a strong majority (70 percent overall) say they’re very concerned. Eighty-five percent are taking steps now to prepare. When asked to select ways they are preparing, respondents most commonly report putting aside cash for estimated DIR (64 percent), exploring loan opportunities to get through the hangover period (42 percent), updating technology and leveraging pharmacy software systems to help predict reimbursements (28 percent), and working with consultants (23 percent). Write-in responses include that they’re investigating additional clinical services and cash-based streams of income, considering layoffs or pay cuts, and reevaluating third-party contracts. Several respond that they’re praying for intervention or even looking to sell or close their pharmacy.

Drug shortage issues also are a concern among independent pharmacy owners/managers. Ninety-seven percent report shortages of Adderall or generics, consistent with our most recent survey on this subject. Nearly 80 percent say they are having a hard time getting diabetes drugs, 71 percent say the same for ophthalmic antibiotics, 68 percent for amoxicillin, and 63 percent regarding children’s pain- and fever-reducing medications. Regarding staffing, 66 percent say they’re having a difficult time filling open staff positions, which is about the same as the results of our most recent survey. Pharmacy technicians continue to be in the highest demand (77 percent), followed by clerks/front-end staff (45 percent), pharmacists (31 percent), and delivery drivers (19 percent).

Note: This NCPA survey was conducted from May 19-30, 2023. It was sent to approximately 8,000 independent pharmacy owners and managers, with approximately 430 responding.


Founded in 1898, the National Community Pharmacists Association is the voice for the community pharmacist, representing over 19,400 pharmacies that employ nearly 240,000 individuals nationwide. Community pharmacies are rooted in the communities where they are located and are among America’s most accessible health care providers. To learn more, visit