Cognitive Services Reimbursement | Amina Abubakar, PharmD, Avant Institute

Transcript Disclaimer: This transcript is generated using speech-to-text technology and may contain errors or inaccuracies.

Mike Koelzer, Host: [00:00:00] So Amina for those who haven't come across you online, introduce yourself and tell our listeners what we're talking about today. 

Amina Abubakar, PharmD: Sure. My name is Amina Abubakar and I'm a pharmacist and a pharmacy owner of three independent pharmacists here in the Charlotte area. And I also am the president of Avant Institute, which is a platform where we teach clinical services as an independent pharmacy owner.

About five or six years ago, my business transitioned from a product to services. So our revenue is about 70% clinical services and 30% product services. 

Mike Koelzer, Host: I didn't know you own three pharmacies. How far are they apart? 

Amina Abubakar, PharmD: So two of them are embedded in the medical practice and that's why people don't see it visibly.

Hmm. And then one is, uh, standalone in the community that serves a variety of medical practices. So over time, as I was forming these partnerships with medical providers, they saw a stronger, um, like strength in our pharmacy being specifically in their practice. So those two are really kind of like an ambulatory care service extension of our medical.

Mike Koelzer, Host: How far are those three apart are the two in the building that they're not in the same 

Amina Abubakar, PharmD: building I take. Yeah. So between our main location and one of the clinics, it's about five miles. And then the other one is about maybe 15 miles or so 

Mike Koelzer, Host: My dad had a few pharmacies and I, we never did. By the time I was in the business, we were down to one and I always wanted to have more than one pharmacy so I could hide cause then nobody would know where I was.

Yes. . Amina. I love some hard numbers you gave to us right there. One of 'em is that you own three pharmacies and that's cool because this isn't coming from a theoretical position, right? You own these three pharmacies. The bigger number though is 70% of your revenue. Yes. Is coming from clinical.

Yes. Wow. All right. So you're the person to listen to. I'm gonna pull my chair up and just listen here. I'm not gonna talk at all today. No, that's impossible. 70%. 

Amina Abubakar, PharmD: What's the ultimate goal? You know, when I first started, my goal was a hundred percent because I was struggling understanding the business of pharmacy when it came to the product.

And, uh, when I came out of pharmacy school, I was highly clinical, you know, but. Took the opportunity or it was only my, my only option was to go into retail, you know, because of just circumstances. But if I had it my way, I would have done a residency and I would have gone down the clinical route. So just because I started in, um, the retail of the community side, my brain never stopped looking for means that I knew I could bring value to patients.

what I didn't know was opening an independent pharmacy. Was a whole different ball game. And I remember telling myself Amina, you did really well in calculus and pharmaceutics and all this math, but you can't figure out a wholesaler's math to see if you can make money or not. Yeah. So I had the desire to just use my clinical knowledge in, uh, in my business.

So my goal was really to do a hundred percent. uh, 70% is still good because these patients that we offer clinical services, the doctors want them to stay with us and feel product as well. 

Mike Koelzer, Host: We have to be very easy on ourselves when we're dealing with pharmacy wholesalers, because on purpose, they've got these smoke and mirrors setup, and my listeners have heard me complain before, but we've been in business for 75 years at our pharmacy.

And when my wholesaler used to come in, I would plop down a bottle of, you know, let's say a big bottle of ibuprofen and I'd make a big, heavy one on purpose. So I could, you know, thump it down on the desk. And I would say, I'm doing, you know, X million dollars a year from you guys. And I'm not some guy walking in off the street to a used car lot.

I mean, you guys know me. I do a ton of business. I do all my business with you and you can't tell me. How much is this bottle of ibuprofen? And they're like, well, we can't tell you because you know, we've gotta look at the rebate and this month, this, and wait till this comes in and all that. And I'm like, that's baloney.

I said, you guys, oh, you know, maybe he didn't know it as a rep, but to not be able to get an answer when you're doing millions of dollars with somebody that smokes and mirrors. So. You don't need an excuse, why you weren't able to figure out the business part of this, because on purpose, it'd be like having a calculus test or something and [00:05:00] they're hiding part of the information you need to come up with an answer.

It's impossible. 

Amina Abubakar, PharmD: Yes. And I was missing the button to push . There was no button there, you know? And so you can see where my drive came from. Was this other way? Is. You know, and what can I do about that? I know I control a hundred percent and it's my labor. It's my time. So that became my focus to do things that at most I can predict what my cost is.

Right. And this is fixed. And so by taking on that journey, I wanna share with you that it went from just me being the pharmacist. And I remember hiring the first clinical pharmacist, cuz I wanted to get off the bench and be able to focus on this. And this was about in 20 15, 20 14 or 2015 when I hired the first clinical pharmacist.

And I said to her, I said, we have to figure this out. Okay. So the reason why I'm bringing you on, I can't even afford you yet, but I also know I don't have alternatives so by you coming on board, we are going together to, to do this. So going back in a timeline, now we, in 2021, we have 18 pharmacists. Wow.

And only I would say five FTEs are in the product side. 

Mike Koelzer, Host: Back up a little bit. When you said to your first employee, your first pharmacist, when you said we've got to figure this out, was that more of a call of bravery to take on this challenge? Or was there actually a reason why you knew you couldn't make it on the product side?

How did you know so much that you didn't want to? I know you were more clinical, but how did you not fall into this? Temptation to make it product. How were you able to tell her we have to go clinical and how can you tell me now that you had to go clinical? It seems like the temptation would've been there.

Was it, what was the actual reason you couldn't go 

Amina Abubakar, PharmD: product? Well, Mike, you're gonna have to invite me again so we can just talk about how my mind works and how I visualize things. And once I visualize them. Then. I have to make it work. So it comes from a personality that I have. I'll tell you. At the age of 14 years old, I told my family I would live in Africa.

I don't wanna live here anymore. And I'm going to go to a country that has dishwashers. So I don't have to wash my hands. They will have washing machines and I had never seen those. But I knew there had to be a better way. Yeah. And so every time I would come home from school and I would had to do those chores, I would think there has to be a better way of doing this.

So I would bring it to life and I would speak to it. And I remember when I ran, when I landed in the US and I saw these things, I had never seen them in. No one had had them in my family. We never had a dishwasher or, but I knew there has to be an easier way to do things. So I always have that feeling that why not?

You know, so that's my drive. , you know, when I saw that this was difficult, but I knew all the stuff that I had been taught and I've watched the vertical integration of clinical pharmacists hired in the system. So I know it exists, but it may not exist in an independent pharmacy world and I'm willing to make it 

Mike Koelzer, Host: work.

Ah, so that explains it then Amina. So your vision was so focused. The product wasn't an option. You were able to say, we have to go clinical. 

Amina Abubakar, PharmD: Yes. And because at the same time in our area mail order had started increasing. They were pharmacies. Uh, we're serving a lot of patients from the city of Charlotte mm-hmm and then CVS Caremark took over and those patients had to use CVS.

So I knew it wasn't a winning battle because I couldn't really control it. It doesn't matter that the patients want to choose us. So there's one way you're not making money on the product, but the other way that patients that you could make money on, they cannot come to. Yeah, exactly. So I just knew that was just hard, so I started looking at what else I could do as a pharmacist.

Mike Koelzer, Host: All right. So how does this work out then? We're all drooling here, Amina, and I know this is years and years of research and practice mixed into my simple little question there, but everybody listening says, well, how so? [00:10:00] How. 

Amina Abubakar, PharmD: What I found out is medical providers, especially independent doctors have a similarity with independent pharmacy owners.

Mm. But we have never. dialogue. Okay. The only relationship we have is like, hi, I'm so, and so I have a pharmacy, here's my flier. We deliver, you know, uh, please send your patients and that's the only relationship. Or then you get closer to where they like you, they rely on you, they call your pharmacy to ask all these complex patients.

They send you complex patients to help them because they trust you. They like it. And so that's where farm independent pharmacy owners and independent doctors have just kept their relationship. No one has really crossed the path and said, Hey, let me tell you the truth about my business. And I would like to hear the truth about your business.

Do you feel how I feel that I went to pharmacy school and I now work at a pharmacy, but there are forces outside of me. That could actually hurt me, you know? So I went out and that was the first dialogue I had. I was curious, you know, I was curious to see and hear from independent doctors, how they felt about their business.

Mike Koelzer, Host: How do you know a doctor's independence? I think I know the answer, but how do you know when you're looking up a doctor's name? Is it just because they don't have them? I don't know the group logo on their business. Yeah. 

Amina Abubakar, PharmD: They, yes. A lot of, you know, you'll hear the name of it. Isn't part of the health system around us, uh, though that's changing because some of them have sold their practices to the health systems and they still have.

uh, their name, but then you'll see a sign here in Charlotte. You'll see a big N which means they're part of the Novant health, you know, or you'll see the atrium, but you see and that's changing. And if you look at it's very similar to our independent pharmacies in that we feel like we can't survive. So our option is to sell back to the chains and the independent docs are the same way.

So, because I started this. Quite a long time ago. I knew those that were independent because they filled prescriptions at all pharmacies or their family, you know? So you, you know that, but our relationship was just 

Mike Koelzer, Host: That and they're facing the same struggles. It sounds like you 

Amina Abubakar, PharmD: said. And that's when I learned because at first, I didn't know, but I was just curious.

And so when my first dialogue was, they. This one doctor told me, let me tell you, I quit every day. Amina, it's hard. We don't get the same contracts as the health systems. And I was like, oh, here goes a similarity. And um, he said, and every day they knock on my door telling me that I can't survive, that I need to sell to them.

I was like, oh, let me show you my letters that come from this. And I, we, we started talking about how similar we were. and yet we are fighting these battles by ourselves. Right. And so I was like, okay. And then we got into more. Business related things. And they had the same issues I had learning how to take care of your books.

You know, they have as limited resources as we do, because I was the visionary. I was the owner, I was the pharmacist and I would take my work at home and try to finish the office related things. And yeah, they had the same thing because, you know, either it was their spouse, that was the bookkeeper or the front desk.

So it was a. Right. 

Mike Koelzer, Host: So you're relating to them and no better way to relate than, I mean, not forever, but then to commiserate with your eyes. Problems, 

Amina Abubakar, PharmD: right? Yes, exactly. And, but I was really curious. Yeah. You were just curious. I was curious to see if you know, their life was better than mine before I met them, and so through that, I was like, this is it.

We are partners. We are partners that don't have to be vertically integr. Wow. We can look at these systems that have already been built. Okay. Pharmacists, I did rotations in pharmacy school where pharmacists were instrumental to these medical providers, but they were part of this system. So I said, I'm going to go and research if there is anything that we can do together, that's legal.

You know, and that we can both survive and help each other. And that's just how it started. And he's like, sure, I'm open to, and at the same time, as I followed this method or understanding of their [00:15:00] world, it was the very beginning of our also learning about you have star ratings are coming in pharmacy and they said, oh yes, we are now going to have.

Quality measures and outcomes, you know, and we are going to move towards value based. And the provider was like, you know what hurts the most about it? Unless I take a patient home with me and I feed them the appeals every day, I'm never gonna win. And I was like, let me tell you about us. If you don't put the patient on a statin, I get dinged.

And he was like, what? That's illegal. You don't prescribe. I was like, so you understand that? Wow. We're, you know, we are being measured and penalized on things we don't control, but I'll tell you something. those patients, instead of you taking them to your house and feeding them and giving them pills. I make phone calls, we have delivery drivers, we bubble pack.

We do all these things, but we don't get paid extra for it. But now I'm starting to see that all the work that I do is very valuable to me. But how can he pay me? So my research started going further and we found a way that I could do all these services for them. They could bill for these services and pay me 

Mike Koelzer, Host: interesting.

Backing up a second here. People listen to, this is gonna say, well, am. Well, that's fine. You're out in the country, in the, in the Hicks and, and everybody's a family doctor there, but I know where you're from. I mean, down in North Carolina, there's, you're a couple hours from, I guess, what do they call it?

The triangle mm-hmm . If any place has these huge vertical integration, it's gotta be around where you are, right with all. Schools and hospitals and all that. So it's not like you're in a, necessarily a special part of the country able to do this. You're pretty much in the thick of it. Aren't you? 

Amina Abubakar, PharmD: I'm in the thick of it.

Yes. What do you have there? We have Novant and atrium. This is, these are the big, uh, biggest and largest health systems that we have and they're actually fewer docs. So what pharmacists have to understand, you don't need many doctors to be successful. You see. That's important to notice. You could just have one medical provider and as you start having those partnerships, you start with a few services and you expand, uh, we've had relationships where at 200 patient bases that we manage is sufficient for us to have one FTE.

because of everything that we can do with those patients, because we realize on the medical side, they have a book of codes and services that the doctors don't even touch them. They don't even have time to do that work for those patients, but they're allowed. To contract out or hire a clinical staff that can work on those.

So the opportunity is there, but a lot of these providers, once we go in, they're used to only offering the services that they've always offered, which is okay. Here's Mike coming in, here's sick. Here's an office visit. And they leave it at that, but as we've entered value based medicine, there are tons and tons of codes that are allowing these medical providers to engage with this patient for preventative care, to engage with these patients on a wellness side.

Mike Koelzer, Host: how long was it when you started this? I mean, you must have been thinking where's my next meal coming from to then think about this and then be able to get this going. Were there some pretty barren times, or did this come together quickly? Once you knew that this was it, you had to make it or break it. 

Amina Abubakar, PharmD: So at a small scale, it was quick because as soon as we found those codes, you know, and I thank God in Google because I had to try to piecemeal it.

Right. And I found some information from articles that said, pharmacists are paying their way using annual wellness visits. They were published by UNC Chapel Hill, but it was a vertical integration. So I took that information test piloted with one of our providers and bam, we got paid. So right at that moment, that was good, but the scalability is what we've suffered through to get it right.

Mike Koelzer, Host: I take it then that they're able to bill for these other companies. You're not their employees. You're still your own pharmacy doing 

Amina Abubakar, PharmD: this. Yes. So [00:20:00] what it is is that, um, historically medical providers, as long as they're in charge of the overall patient, they're allowed to hire lease. Or contract out parts of their service sets.

For example, they could bring a nutritionist in who could take care and see their patients manage nutrition, and then they could bill for that. So it's a, it's a model that already exists. And so, or they could bring a specialist I've seen primary care that would bring a pain specialist, uh, or a psychiatrist.

Or a social worker to take care of patients with a substance use disorder. So those methods already exist where you don't have to hire everyone. Right. But you could. So I started using that model in designing our pharmacist as that specialist who can come in. Why 

Mike Koelzer, Host: do they allow that? Just. They probably know it's gonna be hard to have eight different people billing for this.

And they say, well, just have the doctor do it. And you can work through the doctor and the doctor will bill it. Is that why they do it for ease? Why do they allow that 

Amina Abubakar, PharmD: they allow that because sometimes you only need that specialist a few times a month, so they don't have to be your employee, you know? And it allows this specialist to go to several different places.

I understand 

Mike Koelzer, Host: the employee, but why wouldn't the government say, okay, if they're not your employee, well, then let's have that people bill us directly. Why doesn't the government demand that you bill them directly? Why do they allow that through the 

Amina Abubakar, PharmD: doctor? Sure. They don't demand it. I think options are better.

Gotcha. And having options. So it doesn't mean you couldn't do it the other way you could send out, you know, to a psychiatrist and a psychiatrist who will bill for it. But a lot of these value based models that are existing if you wanna contain cost. So billing through primary care is a lot less expensive than billing through a specialist.

So you. You could pay the specialist a day or an hourly rate or however, but your billing as a primary care, which attracts more people. To, to go for those services. Because specialist copays are higher. Oh, that's interesting. Right? Yeah. So I saw this example: in one of the clinics, we have an HIV specialist and he told us let's not make this an HIV specialist.

Let's make this a primary care. So the patient's copays are lower. Oh. And they can come more frequently than for us to build as a specialist. But I'm part of this team and it's okay if we build under primary. With HIV specialty. Wow. So that's kind of how I've learned a lot in my education. Hanging out with these docs has just expanded my knowledge base.

And all I do is I take that and I apply it to our world. 

Mike Koelzer, Host: There will be payment if this is done right. Because the doctor's already doing it. It's part of their system they've been doing for decades and decades. 

Amina Abubakar, PharmD: Mike, this is my business. You know, that means we are getting paid and we are growing. Yeah.

Mike Koelzer, Host: Well with 18 full-time 

Amina Abubakar, PharmD: pharmacists. Yes. You can expect that payroll is not easy, but they grow these services. We get paid and we love it. And so, yes, but what people don't understand is those intricacies, right? Mm-hmm how to apply it because I've been to S and I listened to it for an hour, and I looked at one of our pharmacists and, and I asked.

How many people do you think are gonna leave this CE and be able to execute? That's what it is. Yes. And we laugh because there are so many things that the person did not share. So in order for people to be successful, it's not the shiny, it's not that, oh, this is cool. I'm doing this clinical service. If you aren't getting paid, it's not helping us.

And now you'll see why Avant Institute was built. It wasn't built because we had a lot of time and that we wanna go out there and just teach or have courses online. It was really to find people that say, I want to make this a business. 

Mike Koelzer, Host: You're not out there to say I'm Amina and I don't have any employees.

And I've got like 40% of my day empty. And so I'm gonna start up a consulting business so I can make some more money. This is like, we've got 18 FTEs and we're gonna show you how it's done. Yes. 

Amina Abubakar, PharmD: And I'm gonna show you where you're gonna fail. And if you don't listen, you are going to fail. So I'm gonna tell you how you don't lose X number of [00:25:00] dollars that we lost, because we didn't know this one thing, or we didn't know how this relationship could really unlock it.

Just like the whole specialty, how this whole thing works. It's really taking the medical world, digesting it and reverse. engineer it into this new relationship that we have. And it 

Mike Koelzer, Host: works. If I ask this of a lot of people, why do you do this at the Avant Institute? Somebody's gonna say, well, we wanna give back.

We wanna do this for the world. We're good people and so on. But this avant Institute, why do you do it? I know it's a business, but are you gonna make a lot of money by teaching other people this? Because there's so much want and desire now, Amina, I'm not gonna let you sit here and tell me you're doing it just outta the goodness of your 

Amina Abubakar, PharmD: heart.

No, I'm doing it. We saw many people failing after investing tons and tons of money. Okay. And then coming to me and say, Amina, do you have 15 minutes? Or I have a quick question. Yeah. I tried to do this service and it failed. And I told myself, even if I give them an hour of my time, they're not going to be able to be successful.

Gotcha. Because of the question they just asked me, they don't know what's underneath. Right. They don't know all the failings. Yes. It's an iceberg. All they saw was the top and they got the codes we do for free. Their Medicare learning network. You can have the codes, it's Medicare, it's public, but how to make it work and how to make it work as a business and how to help scale and all that.

It's a whole diff underneath it. So the reason why, so people would then. Can I come and shadow you? Can I come? So we weren't available to be there for everyone. So I sat down with our pharmacists and said, listen, when I go out there, this is what I see. And these are hardworking people with relationships with these doctors.

They don't know how to make it work. So what I'm going to do is we are gonna buy time. I'm gonna stop you from being in the clinic and I'm gonna put you to be a trainer. Okay. Which again, it's a trade off, because they would say Amina, if we do this, I wanna be in the clinic. That's how my productivity works.

And I said, no, we are going to do a swap. So if we book you to be a trainer, or if I find a pharmacist or a pharmacy similar to your clinic, then I'm gonna match you and you're gonna coach them. And that's how we started. So it's really the functionality of us being available, cuz otherwise we have to work on our.

Mike Koelzer, Host: Yeah, you're doing a disservice too. If you talk to someone just for an hour, you're doing them a disservice. You're giving them almost like enough rope to hang themselves. If you don't give 'em more than an hour. And 

Amina Abubakar, PharmD: you'll you'll. If you talk to people we've trained, I've asked them two questions. Do you wanna do this as a business?

Or you wanna be inspired? Because those are two different pathways. Okay. Right. If you wanna be inspired, then I can talk to you for 15, 20 minutes. And I can tell you all the stuff that we do, but if you wanna do it as a business, right, then you have to be fully immersed and fully engaged in how we start from the why to the what, to the how.

And that's a different training. I'm trying 

Mike Koelzer, Host: to put myself in your shoes and I'm trying to think like, if I started Avan Institute, I can see doing it well, it's like this podcast has a couple different things to it. I enjoy doing it. That's number one. And I, maybe I'm helping some, maybe helping some people or the future someday.

I might monetize it. There's probably a few different reasons. If I was doing an Institute, I might have similar reasons. I might be doing it for the future of pharmacy. I might be doing it for my own business, but the other thing I might say is. I'm not gonna give my secrets away. I'm just gonna grow RX clinic pharmacy to like a hundred of these and screw everybody else on the east coast.

You could do that too, 

Amina Abubakar, PharmD: right? Yes. I could do that, but you know why I don't do that? Why not? I don't do that because these services are relationship based if you want them to work. Mm, okay. Healthcare, I'm a fundamental believer. Healthcare is delivered best locally. Gotcha. Okay. And so I want it to be that ecosystem, right.

That ecosystem is for every community. Has these hubs, right? That you understand the patient's dialects, you understand the resources in your community. So it really is more sustainable rather than me becoming the male order of clinical services. I'm not going to do a good job. 

Mike Koelzer, Host: That's what I think I was trying to get at, because if I look at a different business, because I can see, we already talked about someone doing it, who maybe just had time on their hands and said, Hey, I'm gonna be a consultant.

I'll make enough money. That way you don't need that. You're doing fine with the RX [00:30:00] clinic. Correct. And then the opposite of that would be taking this and saying, well, I'm not gonna give away. Secrets, I'm gonna make this into a huge business of RX clinic pharmacies across the country. So that was the answer where this is almost like, I know you're not going down this road.

It's almost like. Franchise in a way only in the sense that you can't do it well by owning a hundred of these pharmacies across the country, let's say you, you needed to pull money out of this idea to pay you for your research on this. The best way to do it is Avant Institute, because this is only gonna be successful for.

Pharmacies smaller companies and you wouldn't do well going into a hundred pharmacies across the country as the 

Amina Abubakar, PharmD: owner. Exactly. And that's just my philosophy. Someone else could look at this and be able to do that. But I have found the more I've worked with our local providers, the deeper the relationships are, we are part of this community.

We are now partnering in more ways than I ever dreamed of. So within one practice, we are finding deeper meaning. Actually, I'm helping them grow their practices. Right. Right. So one partner we had, they went from 20 15 1 provider. Okay. Maybe three FTEs to 35 and three locations. Why? Because now I'm part of that business.

I'm part of that board and I'm part of that less drive this, the more patients you bring in, the more work we get to do. So in partnerships, don't be afraid to scale. So I help my partner scale. rather than me trying to spread myself thin. So through Avan Institute, as I said, Mike, let me teach you to do it in your community.

You already have low hanging fruit. You probably have low. You said, you know, you guys have been in business, uh, all these years, you have doctors in your area do it right. And I'll help you. But also through Avan Institute, I'll tell you how my expansion has improved. I've had people call when they've come to the training and they call me back and say, Amina, I'm not gonna be where you are anytime soon, because my attention, my pharmacy is still my number one attention, and I cannot leave it.

What I want from you is that I have a relationship. You have the expertise, okay. I'm gonna bring you to the table and we partner. So I've done a few of them. Where they're like, so for me managing several more pharmacists in the same way, doesn't add any more to headache, cuz I'm, it is the scalability there. Now I know how to do that.

Right. And you know what, they're bringing me to the table in their community. As a partner. So we now go in half and half on the pharmacist cost. They have the relationship and the patients, and I bring the expertise and we've done phenomenal. So I've just done that in our neighboring state, South Carolina.

And, uh, yes, we've now just hired our third pharmacist there and we just started this year. I mean, 2020 during the pandemic. . Wow. 

Mike Koelzer, Host: All right. Cuz that's where my mind was going. It's. the whole thing. I didn't mean to make it sound like you weren't just a nice person, but I thought money evens out the score.

It's a score card, right? You know, with all this crap you got going on in your, um, crap. Good crap. All this excitement is going on. Yes. The busyness with all this busyness. I was looking for the reason for spreading this information and, and that's really cool. That's who brought you to the dance meeting a local right doctor and saying I'm local and small too, you know, so that's where you start, but then that's really interesting too, that secondary of partnering with people, how far is that 

Amina Abubakar, PharmD: gonna go?

Yeah, and I never even thought about it until he was a graduate of our class and he said, listen, I went back with this material and my docs are in. But I don't think I can be where you are as fast as I want to. So this is mine also, but I had to think through and, you know, and, and cuz I like to be hands on.

So South Carolina was close enough for me. I drive there, I meet with the providers. We have meetings, we are growing strategically. So I'm really hands. with this. And remember when I started this, Mike, I just wanted to save my little pharmacy. That's all I wanted was like, I have to save myself. 

Mike Koelzer, Host: it seems like the next step would be somebody that you have instead of you going to South Carolina.

Now you're sending one of your employees. Somewhere else. Would that be the next step where Amina doesn't go, but one of your employees goes. So instead of them spending a few hours training in Avan. They're actually then going and becoming these partners through you. Yes. 

Amina Abubakar, PharmD: And, uh, we are [00:35:00] open to that. You know, we are open to that and I know I have been criticized in the industry that I've kept every resident, but they don't wanna leave.

So it's not me. right. It's not you, they don't wanna leave. Right. So, I'll tell you what that has led us to. This is a, I'm glad you asked this question. So we were a part of a residency program, fellowship program. We've kept every resident and every fellow. Wow. Because they're able to come in, we get a clinic, they open it, they love it.

It's their business. They're generating enough money and they have a salary out of it. They stay. so now people started telling me Amina, this isn't helping us. You need to cross pollinate that knowledge so we could hire these folks. Yeah. So what we've just done and it's starting this year, Avan Institute has our own fellowship now.

Mm. With the intention of us bringing the folks in, they work with us for a year and we send them to everyone else. Wow. 

Mike Koelzer, Host: That's really cool. So 

Amina Abubakar, PharmD: we've started the fellowship. 

Mike Koelzer, Host: Just so everybody's understanding this, give me an example of just a patient going to the doctor who needs this. How does your pharmacist then enter the picture?

Where do they do it? Are they doing it on your property or the doctor's property? And then finally, how does that communication get to the doctor and the billing and so on? 

Amina Abubakar, PharmD: Okay. So depending on the services that we are offering, there's a supervision role. So we have services that require general super.

That means we can do it outside of medical practice. So we do it in our pharmacy. We have our pharmacists that are working from home. It can be done remotely. And these are those monthly touchpoints. If you wanna call it coaching of behavior that you are working with this patient every single month, 20 minutes.

At a minimum with a patient. Okay. So we do that and we don't have a physical location that we have to, but because some of those patients are patients. We feel prescriptions for, we have entered it into our workflow. Okay. So our workflow is now designed to send patients, um, Re for our remote patient monitoring.

For example, our drivers deliver the devices of scale, blood pressure, and blood sugar to the patient's home data that comes into our pharmacies and pharmacy technicians. They monitor, we have intervention. We document in our, um, Clinical platform that we have. And then we send the urgent messages to the providers if they need to act on.

And if not, then at the end of the month, they get a summary that goes to the patient's chart. So when a patient comes in for a visit, the provider can skim through it and say, oh, I see you've been working with RX clinic on, on these initiatives. So that's one. And we do those for our behavioral health integration, our remote patient monitoring and our chronic care management.

Those three services are general supervision. Then we have services that require direct supervision, and that means we have to perform these services within the premise of the medical provider. and this is our annual wellness visit. And now we've grown into our pharmacists seeing patients for substance use disorders.

They're seeing patients for HIV, prep and P so the services just became more and more, but they're doing those within the medical provider and we call. Co visit models that within that one hour, this practice is generating a lot more money because we are letting the provider work at the top of their license with seeing patients and diagnosing.

But at the same time, the pharmacists are bringing in patients for these services under direct supervision. So per hour, we are generating a lot more money than the provider by the. 

Mike Koelzer, Host: And those have to be like, there's some billing stuff that says once a year, this has to be done in person, that kind of 

Amina Abubakar, PharmD: stuff.

Correct. So the annual wellness visit is once a year for the patient, but also for our Medicare patients that we see for weight loss is called I B T intensive behavioral therapy for, uh, weight loss intensive. Behe 

Mike Koelzer, Host: Is there that weight loss again? Aina I said it last show too. You guys always bring up weight loss.

I know all my, uh, guests have gotten together for an intervention for me. 

Amina Abubakar, PharmD: yeah. So we are bringing for the services that require face to face and they require to be done within the practitioner's premises, but with COVID a lot has changed. So during the, uh, the pandemic we've been able to do a lot of those visits virtually though, 

Mike Koelzer, Host: I told a customer this morning, patient customer, this morning, I said that COVID has.

Speed up technology in healthcare by 10 years. [00:40:00] I just threw that figure out. Yes. Because you know, doctors, the medical profession, you know, they're quick, in some ways pharmacy was quick, but other, other areas of healthcare is pretty slow. I think it sped stuff up though with telemedicine and. Online visits and all that stuff.

Would you say that? 

Amina Abubakar, PharmD: Yes. And we saw how quickly a lot of our practices had to adapt. 

Mike Koelzer, Host: Yeah. And if they didn't, they'd be in trouble and the patients would be in 

Amina Abubakar, PharmD: trouble. Yes. But I'm really glad where technology is going. We've had more touchpoints, uh, less, less nohow. Because patients are at home convenient, but I'm still watching it.

We are having some patients have a burnout of, um, virtual visits because they're also virtually working and they're asking to come in because of social isolation. Oh, is that right? So while it's exploded, I'm also seeing some of the patients saying I need a human connection. because I do zoom school with my kids and I do zoom office visits.

Now I'm doing the provider. Can I come in 

Mike Koelzer, Host: now? Well, I mean, if you think about a doctor's visit a lot of these people, if they're lonely, I mean, you think about going in there and the doctor, you know, puts their hand on your back or whatever the doctor does, you know, but there's. There's a physicalness there that, uh, you take that away from people.

It's an odd thing. 

Amina Abubakar, PharmD: So those are the services. And by doing these services now, which is even more cool is that the payers are asking our clinics, how are you guys achieving these goals? You know, because they're comparing similar practices and they're seeing that. Practices are outperforming. So now I'm in the, um, meeting rooms with payers that are giving us the dashboards to say, Hey, these are the patients that are costing us hospitalizations.

Could you guys work on it? So I love the growth of this organically and that's why I can't be everywhere because in each practice, remember, I. One practice could be sufficient. A subset of patients could be sufficient, right? Cause you are going, it's like Pandora's box. You are going to find so much more.

That can be done. That was never being done. Are you gonna get burned out? No, because I get to do the fun stuff. Now talk, teach, mentor our team and you 

Mike Koelzer, Host: force the other stuff away 

Amina Abubakar, PharmD: from you. Yeah. So I'm more now in our company. I'm more of a chief of vision and happiness. Right, right. Then we have a business strategist and we have.

Directors of different programs. So the team is growing and they're taking on leadership. So we have a good team. 

Mike Koelzer, Host: At what point did you say I need these. Other leaders. 

Amina Abubakar, PharmD: Yes, I was drowning. I was exhausted and I didn't know that that's what I needed. Mm. And, uh, I'm a believer of a, I've always invested in getting a business coach to look at my business.

And so we invested and got what is called a business x-ray right. And through the business x-ray I was told that our business was stage. and in stage three, I now have a leadership to staff gap that everybody's coming to me. Mm. And then I needed to work on delegation and that's why I was, uh, what they call a flood zone.

Okay. So I was going through a flood zone. That is a lot for me. but I know I have to do it. So that was, uh, good to step away and look at my business as an x-ray and get my diagnosis if you wanna call it. And that's when I, uh, I knew that delegation became the next stage for our business. How long 

Mike Koelzer, Host: Did the x-ray team look at you?

How long of a process was that to talk to you and to help 

Amina Abubakar, PharmD: you? It was a three day weekend. It was a three day weekend. They sent a survey. To all of our team, they asked several questions and then they, uh, got all the results and then they met with me and just presented the good, the bad, the ugly that I needed to hear how they were feeling.

Yeah. how things were happening and it was good. And so I'm, I'm a, I like doing stuff like 

Mike Koelzer, Host: that. How did you then implement it? Their suggestions, the consultants that you hired, did they help you implement that? Or did you just, I mean, cuz then you had to hire people, right? You had to get this in place and so on.

How did that come about? Yeah. 

Amina Abubakar, PharmD: So once I knew that I needed, uh, I'm a visionary. Yeah. And based on their x-ray, I had a hyper amount of time and vision. But I actually needed to spend time in management, so I needed to reverse. So they call it like a crystal ball. So I can't continue to envision mode. I'm gonna burn out my staff because every day I have a new idea.

Every day I have a new idea and I was told that I needed to spend 70% of my time managing, but I was like, no, they were like, if [00:45:00] not, then you have to hire a manager. So that was a trade off, like Amina either. You can now follow the x-ray and be 70% manager, 10% vision. You've you know, you've spent, you got here because you always spent a hundred percent in vision, right.

That's why you got here really fast. Yeah. But this is not sustainable at different stages. You have to change. So when I say that I'm not gonna change, cuz I'm not gonna stop dreaming. Right. Then they told me, then you need to bring an integrator, someone who could manage the team and you work with them.

And so they can grow the team. So that's when we hired our first. Which we call the chief of business and strategy. So I dream about it. I go to him and he says, okay, I see where, what, what you want to do. Let me work with the team. See who's available. What, so that has worked out really well. And from him, we now have grown our directors of different 

Mike Koelzer, Host: programs.

He helps set that up. . 

Amina Abubakar, PharmD: Yeah. So I just have to deal with him. 

Mike Koelzer, Host: no, he just has to deal with 

you. 

Amina Abubakar, PharmD: yes, I know. He always leaves the meetings, like, oh my God. you need to interview him and he'll tell you all the secrets of how crazy it is behind the 

Mike Koelzer, Host: scenes. How did you actually hire him? Did you hire him or did, did your x-ray 

Amina Abubakar, PharmD: team help?

No, I hired him because, uh, the first clinical pharmacist that I had hired. Uh, I knew him. And he was, uh, one of, uh, leaders in the, uh, for pharmacy fraternity. And he had seen him and he was like, you know, he's a blend of you and me. So I had a vision. Uh, the first clinical pharmacist was very integrated and that's why we were very good together and successful.

And she said, he's a hybrid of me and you. And I think he'll be able to, to help us. And so I met with him. And I liked, uh, his experience. He came from Walmart. So I knew we needed some level of corporate structure, but not necessarily to be corporate, but they were things that key things that we needed to have in place.

So we brought him on board after several discussions and, uh, he's done fantastic. And we couldn't be happier. That's great. 

Mike Koelzer, Host: If I was in that. And somebody was that good for me, cuz he really cleared your day up a lot and your life up a lot, right? Yes. I'd always be afraid of losing someone like that.

Could you replace him? He's not supposed to listen to this, but if he's good, I'm always like, oh, 

Amina Abubakar, PharmD: Here's the difference? Just because someone is good. I've always been a believer from 10 years ago or maybe eight years. I still have to build systems. So the systems aren't built around the person. Right, right.

Exactly. So it's whatever he does, we are systematizing it because I see him growing into a different role and someone has to go into his role. So if God forbid and not just losing him because he's going somewhere else, but yeah. He could lose on the upside. Right. You. I could need him to grow and move into a different territory for us or different, uh, products, projects that we are doing.

And that has been happening. So he's been grooming one of our P CS. We told her not to be a P IIC. Now she moved from director of op to director of operation and compliance. So I see that. But. Everything we do in our pharmacy. There's a system. That's 

Mike Koelzer, Host: great advice. And there's a book out years ago. I read it.

It's called the ETH manager. Emo revisit Michael Gerber. 

Amina Abubakar, PharmD: Oh yes. Emo. The reason why small businesses fail. That was my first eye opening experience. And 

Mike Koelzer, Host: In there they say that even if you're in a role, let's say your business is growing and you know, you've got yourself and two others in the business, but you can picture within.

You know, a year they're like eight people in the business. Well, start thinking, okay, for this hour, I'm doing this task and yes, I'm doing it, but this is really a task that should be done by, you know, the CMO or the CFO or the COO, whatever. Well, pretend you're in that position. Start writing some stuff out and start saying, this is a position.

Well, you're still doing it, but you're creating these positions along the way. And that's what you're doing with your guy. It's like, yeah, he's a good guy. But he's also a position that you're then making, you know, whether it's job descriptions, diagrams, all this kind of stuff, because who knows what's gonna happen to someone like God forbid it's an accident or something that takes somebody away from us when you're doing stuff like you're doing it's positions and processes, not just people, it's good people and great systems.

Amina Abubakar, PharmD: Correct. And so now we've even. Outgrown Google sheets and uh and those things. So we have, we've just done an internal internet. So you could create that position, it will give you the position description, who you can go [00:50:00] to for these things. So, yes, we have been working on systems this whole last year, not just systems to write them up, but we are now housing them in an internet with the 

Mike Koelzer, Host: access.

I always think like I'm gonna get an organ, I'm fairly organized, but I always think I'm gonna get organized and like, Three years goes by and I'm like, I thought I had a great system. Why the hell did I not have that PDF of something? Like, where did that go? You know, I can't believe I don't have that. Yes. So Amina don't give any of your secrets away, but let's hear some of that vision.

What are we going to do? What do we get cooking up? What we 

Amina Abubakar, PharmD: are cooking up right now is, uh, we are moving to our forever home for our medical, um, For our pharmacy, we just bought, I can't say we just bought, like last year we bought an old Rite aid that we are renovating it into having what we call our pharmacy of tomorrow, how it's going to look like.

Uh, so they're really neat and clinical. Services coming that don't require a medical provider, but it will create this medical hub for us. So we are super excited about this project right now. 

Mike Koelzer, Host: Is it gonna be a, a show globe where it's like, you'll bring in some of these avant Institute people to see this. 

Amina Abubakar, PharmD: Yes, because you know, when Avan Institute, people were coming for our what's known as advanced learning immersion experience, we always did it in a clinic, right?

Yeah. So we had that immersion part that they were in a clinic. We have medical bills. We have this, now that half of our building is a medical practice and half is the pharmacy side. Oh. And we have a classroom. So when people come in to learn, they should feel like, okay, I've, I've been here done. , it's not just a webinar and it's not just theory.

These guys are doing it. I've been able to see it firsthand and look at the workflow, cuz everything is good until you know how to make it into your workflow 

Mike Koelzer, Host: out of that 70%. Mm-hmm I think it's a very small percentage of things that you're billing directly as a pharmacy, not through the doctor. What are your hopes and dreams?

If there are any. Pharmacists being providers. 

Amina Abubakar, PharmD: I have mixed feelings about it while it sounds great that we can be providers. I feel that we will be limited in the revenue on how these services are going to pay out. What I'm really interested to see is payment reform. Okay. Because of pharmacists being considered providers, Then we are limited to billing at a nurse level.

Pharmacy salaries are higher, so the economics is what I'm watching for. So they could say great Amina. You're now a provider. You can do this service at your pharmacy. And you're going to be able to only build level one level one is. $20, $17. So I'm worried about the economics, but I guess it's the first step.

That's why I say I have mixed feelings because right now through collaboration I'm not billing under me, but my provider is limitless. So economically wise, we are winning together, but once I have to build it under me, I'm worried. What do you mean limitless, limitless, meaning they can build level four.

They can build complexity and I could spend time with them during that office visit. And we could generate $300 versus me by myself 

Mike Koelzer, Host: because there physicians have higher rates 

Amina Abubakar, PharmD: So far what I've seen is a small scale where pharmacists are credentialed and are billing. we can only build certain levels. Levels are high complexity, medical complexity.

Mike Koelzer, Host: Oh, medical complexity. And along with that is higher pricing. It's not just higher pricing. It's also complex. Right? So you're 

Amina Abubakar, PharmD: allowed to touch patients with higher complexity, right? Because again, just because I'm a provider, a pharmacist provider, they might say I could adjust insulin and bill for it.

That's like a nurse visit. I could monitor patients on warfarin. That's a nurse visit. I'm not because I'm not making medical decisions. I'm wondering how the payment reform is going to happen. Gotcha. Because they are pharmacists today able to build under their NPI, but they cannot go above level two.

So economics wise, I'm not sure if we would be in a good position. So that's why I have mixed feelings. Like I want it, but I hope it goes with payment [00:55:00] reform. So they understand the pharmacist's cost. Yeah. Right. And be able to reimburse in a meaningful way. Yeah. And also, I feel like once we become providers, now we are going to have the same stress.

They have that we are outcomes based on our own NPIs and who's going to save me now. 

Mike Koelzer, Host: Yeah. Right, right. And then we're gonna have to help her 

Amina Abubakar, PharmD: and pay them and pay them to come in and help me. Yeah. Yes. So those are my mixed feelings, our listeners right 

Mike Koelzer, Host: Now, what do they do after listening to this? Are they gonna go online?

What are they gonna look up? Are they gonna go to Avan Institute online? Look things up. Sure. 

Amina Abubakar, PharmD: And you know, uh, many people who've taken all classes. We reject some folks from classes, because if you, I wanna know that you are going to use this knowledge to transform your business. Okay. So it's very important.

I'm addicted to success rates and we have people doing phenomenal things. So yes, you can explore. We have a lot of free information available if you're just getting started, you know, learning the language, what are these services? And. Once you get to the possibility of having a provider and you need a team behind you to make this work and that you have someone to come back to and coach you have that dialogue design that contract.

But if you're still exploring, we have. A lot of on demand courses that you can take at your leisure to learn and then go out there and find what I say, your first partner, and then call us, cuz I wanna make this happen. Um, more than you ever believe. We don't 

Mike Koelzer, Host: wanna focus on the negative here, but who would someone be that maybe it's like this isn't quite the fit 

Amina Abubakar, PharmD: for you?

Yes, no. We've had, uh, people approach us like that. , they are not willing to change number one, you know? And so I don't want you to take the class and then say I wasn't successful. Right. Right. And also some, they don't have the time to invest in doing the actual process. So if you are just exploring, right, just learn on your own.

You don't have to. Uh, do further investment and have us if you're still exploring. But what I'm looking for is someone to say, oh my goodness, one that I'll never forget. It was a father and a daughter. The father was a physician. The daughter was a pharmacist. They didn't know they could have worked together.

Really. That was a S slum dunk for us because they're like, so we help them design and they're super happy, super successful. Fantastic. So if you have a long hang. good relationships with providers, but you just don't know how you're going to make this happen. Then you need to come to us 

Mike Koelzer, Host: and your website's fantastic.

I was on it this morning and those who are not ready yet can go on. And there's a lot of reading. There's some videos on there that talk about this, about your different classes and things like that. So anybody, whether they're on the fence or not, should be checking out your website and seeing if this might be for you.

Amina Abubakar, PharmD: sure. And they need to stay tuned. We are having the new classes come out soon. It's called the masterclass. So we are not just lecturing, but you'll see the videos of behind the scenes. So if you can't travel, we wanna give you as much immersion from our experts. Cuz our pharmacists are truly experts.

They've all created their own jobs. Doing. well 

Mike Koelzer, Host: Amina. I can see why everybody kept talking about you. Thanks for taking the time to talk to me. 

Amina Abubakar, PharmD: No, this was fun. I didn't know what to expect, but, uh, this was great. 

Mike Koelzer, Host: yeah, it was a real pleasure talking to you and best wishes on things. It's cool to go on and really have some meat and potatoes.

Well, thank you. Yeah. All right. I mean, I keep up the good work. We'll be 

Amina Abubakar, PharmD: following. All right. My pleasure. Take care. Yeah. Thank you. Bye-bye.