Counterpunching the PBMs | Benjamin Jolley, PharmD

This transcript was generated automatically. Its accuracy may vary.

[00:00:15] Mike Koelzer, Host: Well, hello, Benjamin. Hey, 

[00:00:16] Benjamin Jolley, PharmD: how's it 

[00:00:16] Mike Koelzer, Host: going? Mike going well, great to have you back on the 

[00:00:19] Benjamin Jolley, PharmD: show. I'm excited to be back. It's been fun. Seeing the other folks you've had on. Since the last time we talked 

[00:00:24] Mike Koelzer, Host: Out of all the podcasts I've done, yours has so far been the highest listeners. 

[00:00:30] Benjamin Jolley, PharmD: Wow, that's pretty cool. 

[00:00:32] Mike Koelzer, Host: I think it's a combination.

Well, besides your good looks of having your picture on there and besides all the knowledge you have, I think it speaks to the mystery and the disgust of the PBMs and DIR and stuff of having that in the headline. Benjamin, your name has grown synonymous. Oh, I, I feel terrible saying that you're, , your name has grown synonymous with about the worst terms in pharmacy.

And it's kind of like saying Jesus' name is synonymous with the worst sin or something, but, so I , I wanna make sure that I, I wanna make sure that the listeners know that you're on the correct side. 

[00:01:24] Benjamin Jolley, PharmD: yeah, my, my, my name is Benjamin Jolly/DIR fees. You know, same thing one or the other same thing. Same thing.

You, you, your bit about Jesus is just, is very funny 

[00:01:36] Mike Koelzer, Host: Benjamin for those that haven't come across you for some reason, tell the listeners. What's going on? Why are we talking today? 

[00:01:45] Benjamin Jolley, PharmD: Why are we talking today? So we talked a few weeks ago about DIR fees, generic, effective rates, and all the games the PBMs play.

We came in contact through social media. Um, you and I, and I've built a little consultancy for folks to just understand what their contracts basically say in the world of pharmacy. Um, because most pharmacists take the approach to contracting by just flipping to the last page where it says the rate sheet and saying, okay, AWP, minus whatever percentage, fine, whatever I'll sign.

I need those patients. Um, most folks have taken that approach to contracting and I've found that that, um, is not wise and, um, Understanding what is in your contract, what it allows the PBM to do, what kind of fees are in there? What kind of, uh, true up are gonna be there, understanding that is really important for folks that try to run a pharmacy to maintain their business into the future.

Um, I mean, I, I don't think that, like, first of all, I think that to run a profitable business, you need to understand the business that you're running and reading the contract between you and the PBM to me is step one of understanding what business you're in. Like, because otherwise, um, you might as well be selling roses on the street, trying.

Succeed as a flower girl in the mid 18 hundreds. If you don't understand that business, that's a really weird thing to say, whatever. I dunno where that came 

[00:03:31] Mike Koelzer, Host: from here. I am thinking that I don't know, but maybe they did pretty well. I'm guessing they did. 

[00:03:37] Benjamin Jolley, PharmD: I have no idea. I'm just thinking of it like a movie. I don't know.

Um, what's that movie about a girl who has to figure out how to talk like a lady? Uh, like a do little, I think her name is 

[00:03:53] Mike Koelzer, Host: Maybe you'll have to sit down and watch those movies with your wife, but I've found a way out of it. So, 

[00:04:00] Benjamin Jolley, PharmD: um, My, my fair lady. That's the name of the movie? Oh yes. Yes. My fair lady.

She started out as a flower girl. 

[00:04:07] Mike Koelzer, Host: The other night, I'm in the other room and I hear this, just this monster sound, you know, just this clanking. I went to the other room because I was on the piano and I flipped to somewhere in time, the movie with Christopher Reeves and mm-hmm between, uh, I forgot her name, Jane Seymour.

So I'm playing and this awful sound comes from the other room and I go in there and my wife's just got the TV just cranked. So I realize she's got on somewhere in time. She said, you're playing, made me realize that I should be watching this. So she says, come on, sit down. So I sit down and she cuddles up next to me and kind of grabs my arm and holds on, you know, like we're dating or something.

And I realized that it had nothing to do with trying to cuddle with me. She was holding me there. She wasn't letting me get up.

I was stuck there for the whole. Hour and a half and I enjoyed it. 

[00:05:03] Benjamin Jolley, PharmD: but it's a fun movie. It's my, it's my, my mom's favorite movie, actually. It's 

[00:05:07] Mike Koelzer, Host: a very good movie. Yeah, it's a very good movie. So if you don't read the contracts, you're going into it blind and more than likely there's enough dirty players out there to take advantage of the people when they're, when they're blindly into a contract.

[00:05:22] Benjamin Jolley, PharmD: For sure that, so that, that, that's how we started talking, but we, we had talked after, off, off the air here and we, we thought, you know, we should really talk about, um, some of the good things that are happening in the world. Cuz like you said, my name is now synonymous with all of the worst things happening in pharmacy.

Uh 

[00:05:44] Mike Koelzer, Host: the reason why I think your message is so powerful is because a lot of us in the, in the pharmacy business, we take the PBMs, we take the D we take all that stuff and we say, that's, that's just a. Dirty necessity. And you try to actually block it out of your head and you find something kind of so far in the opposite direction that you're able to continue to stop thinking about it, but just like in the great movie somewhere in time, spoiler alert, I did that with Schindler's list when I was talking to, uh, Dr.

Maria a couple weeks ago, and I, I gave a spoiler alert of like a 35 year old movie. So I don't know if I have to give spoiler alerts for some more in time. I hope not. All right, but just in case, someone's intrigued by your mom's favorite movie and my wife's way to force me to sit on the couch for an hour and a half spoiler alert, but Christopher Re's character goes back in the past and he finds a penny in his pocket from like 1979.

It brings his thoughts back to the future. So. What most of us do in pharmacy is we try to forget about the PBM, forget about the D and try to do something else like MTMs or something that's pretty far distance from that, but then you can't get away from that penny in the pocket of realizing that you're still dealing with PBMs.

And you just get brought into this total opposite feeling again, of just this butterfly hate in your stomach about these characters. What I really like about you, Benjamin, what I love seeing in line online about you is. You hate them as much as the rest of us, but you haven't run from them in terms of doing something totally different.

You've sort of stayed in the same playground with them and it's like, all right, you might have bigger gloves than I do. You might have a longer reach, but I'm gonna jump around you and do things without necessarily going to a new playground. And so you've done things like your consulting business, and you've taken some information from the PBMs and are using it to your benefit.

And you are talking to people about ideas of maybe going to this local doctor or the local business and telling them some things about the PBM, where maybe you can niche out something to get a. Cash business on things that might be below the copay, blah, blah, blah. And so I loved that, how you were able to not just jump, but, but mold, you know, state, you, you stayed in the fight and it's not like I have to wake you up every once in a while and say, Benjamin, come back to reality.

You're doing all this cool stuff over here, but the reality is PBMs are doing this. And you're like, no, Mike I'm in that reality still, I'm seeing it all the time. And I'm trying to find my way around it because they are still part of this fight. And so we didn't have time on the first show, but I was really eager to get you back in to say, all right, what are some counter punches, right.

That maybe we can do. 

[00:09:13] Benjamin Jolley, PharmD: Right. I guess I'll just address what kind of counter counter punches we have. Right. So number one is just taking on PBMs in terms of their client base. Right? So. PBMs exist and have the market share. They do, because they're really good at selling their product, their formulary list, their rebate structures, their contracts with you to a planned sponsor.

And there's nothing like out there really stopping you from just going directly to that planned sponsor and saying, Hey, I think I can get you a better deal just by working with me directly. Um, particularly if it's someone who's really close in your, in your neighborhood or maybe it's you, um, that there was just this last week, um, someone shared an EOB of their own pharmacy's plan with their carrier.

Um, they had been reimbursed, but like, they. Their own insurance for their birth control pills and their pharmacy had been reimbursed $4 and the plan had paid out $107 to the PBM. And so the PBM had taken a hundred, $2 for the, for the pharmacist owner to take a birth control pack off of her shelf and use it for herself, 

[00:10:37] Mike Koelzer, Host: just for our listeners.

The pharmacist got paid. Like how much on that $4, $4 and 1 cent and the PBM, which is in some other city that didn't touch it, didn't do a thing, charged the plan, like a hundred dollars or whatever, whatever 

the 

[00:10:56] Benjamin Jolley, PharmD: difference was. Exactly. Yeah. So, she went and built, built her plan, built her own insurance plan.

She has her card. She buys insurance from whatever, one of the big five plans. And they give her a drug card and she goes and builds. Her drug card gets paid $4, but then the plan sends her an explanation of benefits that says we paid a hundred, $4 for this. And so like, if that's happening to your own pharmacy, do you think it's not happening to the factory across the street or to the car shop across, uh, uh, two blocks down the road?

Like of course it is. Yeah. And so if you can, if you can somehow afford to move that product out your door for four bucks, then. You can surely do it for $24, right. And go save the plan, sponsor 70 bucks. 

[00:11:46] Mike Koelzer, Host: Tell us what you mean by plan sponsor. Give me an example of who that is. 

[00:11:51] Benjamin Jolley, PharmD: Whoever is paying the premiums for a plan.

So your pharmacy probably employs a number of people. Yeah. And you provide insurance benefits for some of them, I would guess, right? Yeah. Maybe not all of them. You're part-timers probably not. Right. Right. The way that the insurance industry works is basically you're paying premiums. And then the health plan that you're buying your product from is just using your premiums to pay for whatever services your staff buys.

And this is why health insurance is so, um, expensive for small businesses is because you. You have to pay the end person, the pharmacy, the doctor, the hospital, but then you also have to pay for the person in the middle to administer the claim and you have to pay the pharmacy benefit manager. And there's just all these mouths to feed at the end of the day, your insurance plan isn't paying anything.

It's you that's paying for it via your premiums. It's just, you, you, you don't see that tie directly, right? Yeah. Right. Gotcha. When you go and go to your doctor's office and they bill your plan, you don't ever see the money, leave your bank account for that specific claim. You see a premium go outta your bank account, but in terms of dollars, pretty much averages out, especially over a long timeframe.

Yeah. 

[00:13:09] Mike Koelzer, Host: Because if they don't get you that year, they're gonna come back the next year. Exactly. And raise your premium because now they know that you've got this certain disease. And so. 

[00:13:17] Benjamin Jolley, PharmD: Right. In essence, your insurance plan is not the one paying for it. Is it you? At the end of 

[00:13:21] Mike Koelzer, Host: The insurance carrier is not taking on a lot of risk.

It's really, they're really a bank account. Mm-hmm yeah. For your funds. 

[00:13:31] Benjamin Jolley, PharmD: I mean, the, the, they're a, the, the basic business model of insurance is just calculating what level of risk you think a given, um, plan sponsor's gonna have? Yeah, I think you're gonna spend a hundred thousand dollars, so I'll make sure that I bring in a hundred, $10,000 in premiums from you and I'm good.

Yeah. Right. Um, it it's, and that's like the whole point of insurance is that you have to be able to calculate the risk or it's not an insurable risk. Yeah. Um, you can't ensure something that you can't guess how often it's gonna 

[00:14:03] Mike Koelzer, Host: happen. What's the example of something that you, that an insurance cannot calculate.

[00:14:10] Benjamin Jolley, PharmD: Um, 

[00:14:11] Mike Koelzer, Host: like a whole COVID like wiping out all the businesses, 

[00:14:14] Benjamin Jolley, PharmD: a black Swan type event like that. Yeah. 

[00:14:17] Mike Koelzer, Host: You can't get pandemic insurance or something like that. 

[00:14:21] Benjamin Jolley, PharmD: You probably could, but it'd be either very expensive or they'd probably go bankrupt before you would actually get paid out. Right.

Mm-hmm things that aren't insurable you can't, it's either gonna be super expensive because they're gonna have to say, well, we have no idea how much this is gonna cost. And so we'll just charge you a billion dollars. So that 

[00:14:39] Mike Koelzer, Host: truly is an example. It's like, you really, they really don't know what that would come out to, so they don't take that risk.

[00:14:46] Benjamin Jolley, PharmD: Right. Um, but the prevalence of diabetes in a population is a well known number, right? Mm-hmm the CDC publishes diabetes prevalence all the time. The odds that someone who has diabetes is gonna go to the hospital and have a heart attack. You can know that number. It's. It's gonna be within a certain range, the odds, the cost of that heart attack, like going, having someone have a heart attack, go to the hospital, it's probably gonna be somewhere between 50 and $150,000.

Mm-hmm so if you just play those numbers out, just hire an actuary that knows what they're doing. You can play those numbers out and say, okay, we're gonna calculate how much the premium should be to cover the average risk that we estimate in this, uh, in this pharmacy or in this factory or in this, I don't know, tech company or whatever.

Yeah. Um, and so long as the insurance company can accurately guess that and set the premiums above that number. Gotcha. They make money 

[00:15:51] Mike Koelzer, Host: every time. And, and there's some things that they can't guess or predict that I'm going to get cancer, but they know out of a thousand lives that so many are going to get.

Cancer kind of thing. That 

[00:16:06] Benjamin Jolley, PharmD: that's exactly why you get insurance. Right. Gotcha. Right. Because like, that's the whole definition of insurance, right? It's that you don't know how many people are going, which, which people are going to this, which one, you know, how many, but you know that something like this is going to happen.

Mm-hmm if you have enough people. Yes. Right, right, right. Car accidents. If, if people are driving a hundred thousand miles between them, maybe one of those miles, there's gonna be a crash of some kind. Yes. Right, right. And you try and bring the number of crashes down so that you can keep more of your premiums, but there's gonna be this number so long as you can have a premium that's higher than the amount of crashes and the dollar value of those crashes.

You're good. Sure. Um, but understanding that that's that really, the insurance is not the one paying it's you, the, you, the employer, you the. As I used to say, the plan sponsor is the one that's paying for it. Then you realize that, you know, you could, rather than buying it from this middleman here, who then buys it from the pharmacy.

If I just went straight to the pharmacy and bought all of the drug, um, benefits for my employees directly from the pharmacy, we could cut out a mouth to feed, right? Yeah. Like we can't blame a PBM for, for wanting to make money. They, they, they employ people who have wives and children and need to feed their children and pay their mortgages.

You can't blame 'em for wanting to make money, but by cutting them out, you could have a more efficient, um, a more cost efficient system. Yeah. Um, like you don't need to pay an admin fee of however many dollars and you don't need to pay a spread between what you pay the pharmacy and what you pay the PBM that doesn't need to be there.

And so. Um, when you realize that that's a possibility, um, and to be clear, I haven't done this at all, but it's something that I have, like once I realized how this whole system worked and that that's even a possibility, I'm like, you know, this, I I've become obsessed with this idea over the last several weeks.

yeah, or just, can I cut a deal directly with the gas station across the street and the college up the way. And the, um, and my friend is a lawyer and is a partner in that firm. Can I provide benefits to all of the paralegals and all the lawyers in that firm directly, rather than them going to say, buy benefits from express scripts out in St.

Louis, they pay money out to St. Louis. It comes back to. why not just shorten the length of that transaction from going all the way to St. Louis back to just that's right. To me. Yeah. And I'll just send you an invoice at the end of each month and you just pay me and if you save money great. Um, that, that to me is what people call this design intermediation, um, which is a fancy word that means taking out the middleman.

Yeah. Right. Um, but I, I think there's a lot of potential for small pharmacies like ours to do that because, um, we have personal relationships with the people who go and work in these businesses and own these businesses. Right? Yeah. The way that PBMs get their business is they pay off brokers.

Um, and then the broker tells the person, this is how you should buy your pharmacy benefits. The 

[00:19:46] Mike Koelzer, Host: insurance is there's no re there's no real reason why there's only. Three or four that come to your mind. That's the same as, let's say, chain pharmacies. These chain pharmacies might come to mind, but the things that you're talking about, these plans and stuff, they break down to independent brokers and so on.

Just like pharmacy does, is that yeah, right. 

[00:20:11] Benjamin Jolley, PharmD: Yeah. I mean, the blue cross does not. Um, blue cross blue shield does not have like some massive, uh, call center in each state. That is how they sell all of their policies. They hire someone like me and someone like you. Who can build a relationship with Joe who owns the sports factory down the way.

Right. And convince Joe that he should buy a plan from Blue Cross rather than from Humana, rather than from Aetna, rather than just having his own plan in house. Right. That he just has a bank account. Right. Um, and they pay them a commission for each time. They sell a policy. I've been reading a lot of stuff by guys that call themselves health Rosetta, uh, benefit consultants rather than brokers mm-hmm , um, health Rosetta being a, uh, like certification that a, a broker or, or a benefit consultant can get to say that they understand how to.

Do this kind of thing of like brokering a deal directly between a factory and a pharmacy rather, or a factory and a doctor's office or a factory and a hospital rather than using these big, huge carrier 

[00:21:28] Mike Koelzer, Host: networks. Okay. Benjamin, here's the problem. Blue cross doesn't allow that cutout though, right? They're gonna say no, I'm sorry.

We're blue cross. We don't have room for the Benjamins and the mics who are gonna strike separate deals. You are going to deal with these three or four PBMs at most. You can pick one of those. Is that a big issue or a big hurdle? 

[00:21:56] Benjamin Jolley, PharmD: That's definitely an issue that people have run into, especially over the last couple of years, as Cigna about express scripts mm-hmm and Caremark bought Aetna and Optum.

Became a division of United health, right? These vertical mergers between the insurance and the PBM definitely makes this harder, but it, it, it, it certainly can be done. How, 

[00:22:23] Mike Koelzer, Host: how, how would you break? How do you go to a place that has a blue cross? And you say, Hey, talk to blue cross, tell him you're dropping this PBM.

You're gonna go with Benjamins or mikes. And they say, no, we can't do it. How do you take that on 

[00:22:40] Benjamin Jolley, PharmD: here's what I'd say? Go read. There's a book by a guy named Dave Chase who started the health Zeta thing. Go read his book. It's called the CEO's guide to restoring the American dream. It's available online. He puts it out there for free, but like with the caveat that please donate basically.

Yeah. Right. You can also buy it on Amazon or, or your local bookstore. I'm sure. Please go to your local bookstore. Amazon is a giant monopoly. Just like these PBMs. Yeah. Right. And they do not have a friendly view of small business pharmacies. No. Um, unfortunately go, go read that book though. He lays it all out.

How do you do this? What, like, what do you look at? How do you do it in essence, long story short. How 

[00:23:28] Mike Koelzer, Host: do you break into a national market? If you're not a national player type thing, 

[00:23:32] Benjamin Jolley, PharmD: right. It's mostly directed at the employer who is buying the health benefits for their employee. 

[00:23:38] Mike Koelzer, Host: Yeah. A lot of times, if you convince them and they're the ones paying it, the local.

R rapper. Brokers are not gonna get any of their money. If they don't bend a little bit, there's tricks in this book to say, if you want my business, you gotta let me be in control of 10% of that. And then the 10% is the amount that's gonna go to the local pharmacy 

[00:24:01] Benjamin Jolley, PharmD: precisely. So like he, he, he just walks you through the whole concept from, from nuts to soup of like, how do you, um, build out a self-funded as they call it health plan where you're in control, which, which really as Howard Dansik puts, it self-funded is a misnomer.

You're still self-funding even if you're a fully insured plan. Yeah. Right. It's really just who controls them. Is it you that controls the money or is it the carrier? 

[00:24:31] Mike Koelzer, Host: Yeah. And that's quoting Howard. Howard's like, look at the blue cross. They do not walk around with stethoscopes. They're they're a bank, basically.

[00:24:39] Benjamin Jolley, PharmD: They're trying to become the company that walks around with stethoscopes though, particularly the United health group with their own employees. Oh yeah. Do you know how many doctors United health group employees are? No 

[00:24:52] Mike Koelzer, Host: 50,000. Well, that's a lot.

that's a lot, that's a thousand in every state and some of them don't have 'em so 

[00:25:02] Benjamin Jolley, PharmD: yeah, tho those are direct employees of United health 

[00:25:05] Mike Koelzer, Host: group. Not even like part of a PPO or something like that. 

[00:25:11] Benjamin Jolley, PharmD: No, their practice is owned by 

[00:25:13] Mike Koelzer, Host: United health group. It's like CVS being owned by who? Caremark. 

[00:25:16] Benjamin Jolley, PharmD: Exactly. Same, same thing, same exact concept.

United health group owns a bazillion physician practices. They usually run under names that aren't like United health group clinics or whatever. It's usually some, some other brand, but, um, if you look into it, they're Optum unit runs all of their offices, all their physician offices across the country, and they're.

The largest employer of physicians in the country. 

[00:25:43] Mike Koelzer, Host: And they benefit from that because there's not another company, there's not a doctor company making a profit off of them. They're making the profit from their own employees, right. They 

[00:25:54] Benjamin Jolley, PharmD: move, they move the money from one bank account to another, to another, to another, and they're able to make some good money, which it's a great business model for them.

It's phenomenal. It makes total sense for them to do that. It totally fits into the way that they see the world mm-hmm . Um, so I can't, I can't criticize them for wanting to own physician practices. I can think that it's, uh, anti-competitive and I don't think it's a good thing for society at large, but so far as their business model's concerned, it makes perfect sense.

Sure. It's just like CVS owning CVS specialty, pharmacy, and Caremark saying you have to go to our specialty pharmacy, same exact thing, perfect fit for their business model. I don't think that it's fair. and I don't think that it should be legal under our, you know, antitrust laws, but the government sees it differently than me.

So here we are. 

[00:26:47] Mike Koelzer, Host: I can understand why the patient could suffer because of not being able to maybe work with smaller business owners who arguably care more for this, you know, more for the patient and so on. I never quite understood the anti-competitive stuff. Is that for pricing monopolies, because eventually they raise the price or is it just like the government supposed to let little guys try to hit the American dream of the pursuit of happiness?

Antitrust 

[00:27:19] Benjamin Jolley, PharmD: law to me is a topic near and dear to my heart, but also, um, unfortunately, like I said, the government doesn't see it the way I do traditionally for the last like hundred years until about Reagan's administration. Um, Basically you were not allowed to have more than a certain percentage of any given business.

So like if you were a supermarket in a given market, you were not allowed to grow past a certain point, just because, um, we assumed that if like the government assumed that if you hit a certain point, you would start to use tactics that would suppress the ability of your competitors to 

[00:28:00] Mike Koelzer, Host: compete with you, which in the end hurts the consumer because of price raises or they care about people reaching for the American 

[00:28:06] Benjamin Jolley, PharmD: dream.

Your question gets it exactly what happened with the Reagan administration with antitrust law in the Reagan administration. And since then, the definition of antitrust has been like the, the reason for antitrust existing has been to prevent consumers from being harmed. okay. But antitrust law before that was not about consumer benefit.

Oh, it was about having a fair end level marketplace for everyone, producers and consumers. 

[00:28:40] Mike Koelzer, Host: I gotcha. Okay. 

[00:28:42] Benjamin Jolley, PharmD: And, but in the, in the late seventies, early eighties and going forward, antitrust law was made out to be the only thing that matters is if prices go up for the consumer, if you, if we can't prove that prices are gonna go up, then we have to let the merger go through.

But that's a total revamp of the way that antitrust law read before that, that, that is one way that you can view antitrust law. Like the point of this is so that prices don't go up for people, but like just. um, Walmart can source widgets cheaper than I can. And, and the reason they can do that is because they've gotten so big that they can dictate prices to their 

[00:29:24] Mike Koelzer, Host: suppliers.

It's almost like the consumers can't complain because their prices have been fixed higher, but almost everybody else can sort of complain because their remuneration for their stuff is lower. Right? 

[00:29:37] Benjamin Jolley, PharmD: And so this whole concept that like, you've gotta push down the price, push down. The price means that companies that produce a higher quality product are pushed outta the marketplace.

Right? If, if the only person that you can sell widgets to is Walmart or Amazon or whoever, and they dictate you need to hit this price, right then widgets are going to go to the lowest common denominator. You're going to be sourcing all of your drugs from. where we are today, right? Yeah. PBMs have said you have to hit lower and lower and lower and lower prices to stay profitable.

And so now here we are, 90% of generic APIs are produced in China. Yeah. That's the natural consequence of not letting people become these PI power buyers, which doesn't raise prices for consumers, but it does decrease the choice in the marketplace. 

[00:30:29] Mike Koelzer, Host: It might be a little bit longer run, but in the end it crushes, maybe the American dreamer 

[00:30:35] Benjamin Jolley, PharmD: to me, to me, it does, right.

Like if, if I want to go and produce, um, if I wanna go start a generics company today to produce generic drugs, to sell to the American public, I'm gonna have to source my active ingredients from some. Or I'm gonna have to build a warehouse here, or I'm gonna have to build some kind of manufacturing facility here in the states to produce those drugs.

But when 90% of all of the generics are purchased by four companies who then sell them to all the independent pharmacies, red Oak sourcing, econ disc, let's see. Anyway, red Oak sourcing sells to Cardinal, or they, they are owned by Cardinal and CVS and they control something like 30% of all the generics purchased for the entire US marketplace.

Econ disc sources for Amerisource, um, Walmart IMM. I'm not sure what all of the company affiliations are, but basically you have four companies that buy like 90% of all of the generics for the entire US marketplace and then move them to their wholesaler division. And then those wholesalers sell them to the pharmacies.

It's gonna be really hard for me as a small startup. Trying to produce Losartan or whatever, right. To hit the price that one of those four companies is willing to accept. 

[00:31:57] Mike Koelzer, Host: The pharmacy still sees the manufacturer names that we're kind of used to, but the four you mentioned are like the wholesalers to the wholesalers 

[00:32:07] Benjamin Jolley, PharmD: precisely.

Gotcha. Right. So, so, and they're usually just divisions of the wholesalers that we work with physically, even red Oak sourcing is a 50, 50 venture of CVS health and oh, gotcha. And gotcha. It's 50% owned by Cardinal. I bought it from Cardinal. So really I'm buying from Red Oak sourcing who's then buying from techs or Teva or whoever. Frankly, our entire economy is just built around all of these monopolies and power buyers or monopolies that just buy everything.

It's really frustrating, but yeah. Um, but I think that's the way that. We as pharmacists, get the world, particularly independent pharmacy owners, get the world away from this. You have to just buy from these four companies in this industry or these four companies in this one, or these four companies in that industry is you, you, you go and just talk to people directly and you broker a deal between you and them rather than relying on, um, relying on a PBM to issue a card to you than you bill you, you, you go and cut out these middle men wherever they are in the wherever they are that you're working with.

Someone, the owner 

[00:33:20] Mike Koelzer, Host: of the company would have to either be big enough or have enough determination to. Say to the blue cross broker that comes if you want it, I'll give you it. But I need this cut out. Are there other ways, 

[00:33:36] Benjamin Jolley, PharmD: L like, well, let's just put it this way. The status quo for health benefits for employers is totally unsustainable and insane.

Mm mm. Right. Like your premiums go up by how much, every year. Right. Um, and it's just completely unsustainable to keep on having your premium go up at this rate. Like if you're spending say a hundred thousand dollars on your health benefits, you're just a fairly small company. Yeah. And your gross margin on what you're selling is 10%.

Yeah. That means just to support your health benefits, you need a million dollars in sales. Yeah. Right, right. Just for your health benefits, what these guys with the health Rosetta and this CEO's guide to restoring the American dream, what they found is that. A lot of that, a hundred thousand dollars is waste and is margin for the insurer, not, um, product and service being bought for your employees.

And so if you cut them out, you can reliably cut your cut that spend from a hundred thousand to 70,000, 

[00:34:46] Mike Koelzer, Host: probably double the service or triple or Dr. Right. 

[00:34:50] Benjamin Jolley, PharmD: And, and improve the service level for your employees, help them get better health, but spend less money because you're just spending it on the actual people, providing the services, rather than on layers upon layers of middle men.

I, I think that an employer who gets that concept and like, I, I talk about this all the time because people need to know this, like pharmacy owners need to know that they can. Build out a health plan. That's just in house rather than hiring a blue cross or a, or a United or a Cigna, an Aetna or whoever they can, they can have no PBM for their pharmacy employees.

And just say, you just get your drugs for free from my store. Or every time you fill a script, it's 10 bucks. I don't care, but it's cheaper for me to just move the inventory and hand it to you than it is for me to pay express scripts a hundred dollars and then pay me $4. 

[00:35:52] Mike Koelzer, Host: There comes a point where I start to eye some of these people and knowing that they're in this plan, that's just screwing me and you don't have a way to really screw them back, but they're not screwing you enough to drop everything.

Pretty soon, the patients start to take a little bit of that brunt of that, of, of not getting maybe your top service or maybe if you. Could decide between two customers, even if it's subliminally, you know, you're not trying to give them less service, but sometimes that anger has to go somewhere. Yeah. 

[00:36:27] Benjamin Jolley, PharmD: If you're losing money on someone, it's not, it's not a pleasant experience to give service to someone who you're paying money to do it.

It's not a pleasant experience. And I don't wanna do that. And the worst part is that they're probably not saving money by doing it. Like that's the whole point, that, that, the big idea of what I'm trying to get out there is that just because that employee plans like their employer is using a crappy PBM that pays you crap does not mean that they're saving money by paying you crap.

It's probably being marked up. , 

[00:37:06] Mike Koelzer, Host: You know, the complaints about Amazon and the complaints about this and the complaints about bigger companies. It's like, yeah. Some people could argue, well, yeah, I'm getting it cheaper. I can see I'm getting it cheaper because I paid, I paid this much, look at how much I paid on my credit card for this, at these two different stores.

And you could say that between a hardware store and you know, Walmart, or, or buying a burger at Joe's down the street for $10 or a 99 cent burger. But in pharmacy, it's backwards, you're paying the $10 for the, for the crappy burger and a, do you know it's backwards? Cause no one sees it. 

[00:37:41] Benjamin Jolley, PharmD: Exactly. Because it's not a free market.

It's a controlled market by the PBMs and hidden. And it's behind the scenes of your premium. It, it, it, you're not seeing the prices at all, unless you are a really savvy business owner. Who's really looking at how your premium dollars are being spent. If you even have access to that information, some of the insurers claim that that's proprietary information, they're not gonna tell you how much they paid out for you going to the hospital.

[00:38:10] Mike Koelzer, Host: It would seem like a very small goal to see a contract that you're in. And for those in the PS SAOs they can't even see the contract. And then sometimes people don't wanna see the contract. I think you're right. I'm gonna, I'm gonna have to start drinking here. If I keep talking about this now let's talk about something else now.

Listen. All right. So listen, here's why you're here. Okay. All right. That is possible. I did an episode with Howard Danzi and he talked about this, about forming a smaller insurance in the book that you mentioned too, and so on. All right. That would be a very cool step to beat the PBMs. Let's say, in the meantime, though, we read the book and you give Howard a call and you do this and do that is our interview over right now, or do you have a little bit more life that we can talk 

[00:39:06] Benjamin Jolley, PharmD: about?

I have a little more, if you want, come on, bring it on, 

[00:39:09] Mike Koelzer, Host: bring it up. 

[00:39:10] Benjamin Jolley, PharmD: This makes me a lot happier and a lot less angry. Okay. So I've mentioned this to you before, um, off the air, but yeah, one of the things that I think is a real positive of pharmacy right now is, um, you know, we, we basically get all our prescriptions from Surescripts via e-prescribing right?

Yeah. But something, something beneficial that I've noticed recently is that starting in the middle of last year, a lot of the large EHR companies that the physicians use EHR with are electronic health records, the physician computer system, right? Yep. Um, a lot of their, a lot of the larger companies there that epic Cerner, um, MD toolbox, couple others.

Anyway, they've started to, anytime the physician sends a prescription to me, they attach some clinical information to it as well. Mm-hmm so I get a diagnosis code, you know, how, how, like just essential to practice, knowing what someone is using a drug for is it 

[00:40:22] Mike Koelzer, Host: helps a lot to know if they're trying to quit smoking or they're suicidal or they're depressed or something.

Right, 

[00:40:28] Benjamin Jolley, PharmD: right. Like the same drug that matters. So. They put it, they put the diagnosis code with the drug, but then also, and, and most people see that part. But the thing that I saw that most folks, most pharmacists don't realize is that they're also sending a height and they're also sending a weight and they're also sending the most recent blood pressure recorded in the physician system.

And that's exciting to me, um, because like I have seen people on LinkedIn and elsewhere complain, man, physicians just assume that I like them, they send me an e-prescription that says weight based dosing for this drug. Like that's all that's in the SIG is just weight based dosing for this diagnosis. And it's like, and then they call the physician and say, Hey, what's their weight.

I don't know . Yeah. Right. But it turns out that and like the physician responds, well, I just assumed it's in the chart. It would go to you. But it turns out that in the last year, It's actually going to you now, um, as part of the new standard for sending Eres prescriptions, there's, um, a requirement for any pediatric prescription that, and they haven't fully implemented this on all of the different EHRs, but, um, there's a requirement that they send you a height and a weight like that.

That is a required field. It will not. The standard requires that before you can even send a prescription, you have to attach a heightened weight, which interestingly upsets some PE, some specific specialties in pediatrics, because they don't usually take people's heightened weight, cuz they're like, I don't know a nose doctor.

Right? What do they care about? What is the person's height? They're treats. Some kind of weird nasal infection 

[00:42:19] Mike Koelzer, Host: Benjamin here. Here's why I think it's a stupid idea. Take the weight because every time I go to my doctors, their scale's always broken of course, and it always reads high. 

[00:42:31] Benjamin Jolley, PharmD: I 

[00:42:31] Mike Koelzer, Host: now. Wouldn't you think it'd be 50, 50, like down 20 or up 

[00:42:36] Benjamin Jolley, PharmD: 20?

You would? Sure think so. So once we have that fixed, once you have that taken care of, at least you're getting a weight, even if you have to adjust it downward a couple pounds, 

[00:42:47] Mike Koelzer, Host: it's like taking the, uh, thermometer under the mouth or the, or the under arm you have to adjust. All 

[00:42:53] Benjamin Jolley, PharmD: right. So anyways, anyway, so, so you're getting these Heights and weights and blood pressure.

So you actually can do the kinds of things that a physician typically expects if they're practicing in a hospital setting, right? Like, yeah. In, in most hospitals that I've ever. Stepping foot in, um, into their pharmacy department, physicians don't do the vancomycin, they say vancomycin by pharmacy protocol.

And then the pharmacy takes over dosing of that vancomycin. And that's their job is to make sure that this person's vancomycin is not gonna kill their kidneys, but it's gonna kill the bacteria. Right. Yeah. Um, and so that, that's like their entire it's entirely in their court. They don't have to ask the physician for PO permission anymore.

It's just, that's what you do. You just say pharmacy does the dosing. You can't do that if you don't have weight though. Um, right. So it, it, it opens up that realm of possibility or for me personally, Um, blood pressure has been a big focus of the flip, the pharmacy program over the last six months. Right.

I don't know how familiar your listenership is with, uh, flip the pharmacy. 

[00:44:05] Mike Koelzer, Host: N CPA has a part in that and also C PSN, C P E SN. Yep. 

[00:44:11] Benjamin Jolley, PharmD: And, and also community pharmacy foundation. Yep. Gotcha. Okay. So flip the pharmacy is a practice transformation initiative to help pharmacies move from a, a practice model of, I must check this prescription as fast as possible and get it out the door as fast as possible to a model of, I need to make sure that this patient is taken care of in a holistic manner.

Mm-hmm right. Um, I need to make sure that the drug that I'm dispensing to them is appropriate for the condition that we're trying to treat and is working for that patient, right? Yeah. Um, like, it is the, um, for, for example, with blood pressure, um, it, it should be in my mind, a, just part of our practice model in pharmacy that anytime we dispense a antihypertensive medicine, we just double check that the patient's blood pressure under control.

Yeah. And if it's not, then we intervene in some way. Yeah. We either ask the doctor, Hey, can we increase the dose of the lisinopril? It's five milligrams. It's been five milligrams for five years. Can we make it 10 milligrams? Yeah. His blood pressure's one 50 over 80. It needs to be below one 40 over 80. Can we, can we push this dose up a little bit?

Yeah. Like that, that should be just part of what we do. Right. It's not hard. Every pharmacist has that in their capacity. Yeah. Saying, is this blood pressure above one 40 over 90 or not? you can do that saying, is this dose titrated to the maximal dose or not? You can totally do that. Yeah. But that should just be part of what we do.

And if you're getting a blood pressure reading from the physician office on every single prescription transaction you get for that patient. Yeah. It becomes much easier. Cuz then you don't have to go and take the person's blood pressure. Right. You don't have to ask them what their blood pressure was.

You just say, you know what, on your last clinic visit, it looks like your blood pressure was, you know, a little high, right? Um, how's your diet? Are you taking a lot of salt? And if we're willing to do that, we should be compensated for that because blood pressure control is so very simple and not, and like every pharmacist in the country, I guarantee they know enough about it.

Antihypertensives and enough about blood pressure. That for a vanilla patient, who's just taking lisinopril. They can do all of this, right? Yeah. And so, anyway, we, but we, we should take that leap of just saying, you know what, we're gonna do this, and we're gonna write down what we did. This is the concept with flip the pharmacies that you get pharmacies to actually write down what they did in a structured way.

Yeah. Right. In traditional pharmacy practice, we don't usually write down a soap note every time we dispense lisinopril. Right. Right. And you don't need to ; that's not what we're asking anyone to do with the flip of the pharmacy concept. But instead you think about it as you're dispensing and you write a brief note about what you're doing.

You say, you know what? Mrs. Jones's blood pressure's a little high. Next time I talk to her in a month, we're gonna talk to her about it again. we're gonna check her blood pressure the next time she's in the pharmacy a month from now. Yeah. And we're gonna make sure that it is under control. And if it's not, we're gonna call the doctor and we're gonna write down what we did.

Yeah. I called the doctor and my blood pressure, um, lisinopril dose increased. Yeah. Right. And then we're gonna take credit for that. And we're gonna go and talk to, uh, Joe's sport factory down the road. And we're gonna say, Hey Joe, here's the deal? Heart attacks cost you a lot of money. Yeah. You know what prevents heart attacks, having blood pressure under control.

You know what I do every time I check a prescription for someone, for any of your employees, I look at their blood pressure. And if it's not under control, I do something about it. How about we work out a model where you pay me just a little bit, like, I, I don't need the hundred thousand dollars that you spend every time you, every time one of your employees goes to the hospital for a heart attack.

I just want to. I don't know, a thousand bucks to take care of all of your employees. Like this is not a hard thing to do. Just gimme like a thousand bucks. I'll monitor all of your 20 employees every time they come in the store, we'll just make sure this happens. You just pay me a thousand bucks a year for all of your employees to do this.

And I will happily make sure that your employee's blood pressure is under control on the assumption that your employees will then have fewer heart attacks in the future. And you'll save a hundred thousand dollars. Right. Right. Or, or you do the same thing and you take that same concept to your state Medicaid plan, right?

Yeah. Your state covers hundreds of thousands of people. Right. And they have heart attacks all the time. They have blindness, they have kidney disease, you know what prevents all of those things, having controlled blood pressure. and so, Hey, how about pay me just a small amount for each, each enrollee as just a, a monitoring fee.

And we will, we, my, my pharmacy and all of the other pharmacies that, uh, work with us, we will do this. And so the flip, the pharmacy program is a grant funded by the community pharmacy foundation to help, um, pharmacies get used to this concept of taking care of people over time like that it's not a hard intervention, but by, by actually going and documenting it and taking credit for it, pharmacists do do awesome stuff all the time.

They go and save people, Medi money on their drugs by switching 'em from brand to generic or, or doing some formulary research and saying, Hey, you know what? This drug would actually be cheaper for you and would work better, but we don't take credit for it. That's 

[00:50:33] Mike Koelzer, Host: right. It's been said the. Quick oil changes.

We have a lot to learn from them. They spend 10 minutes and they come up and they bring up this, you know, paper and they've checked 30 things and they circle this and do that and do that. And we certainly do that. We just, we just don't don't report it. Right. 

[00:50:51] Benjamin Jolley, PharmD: We, we don't take credit for it. And that's, that's what the point of this is, is to write down what you're doing.

And then, because you're writing down what you're doing and someone's holding you accountable for it, you're gonna do it more. 

[00:51:06] Mike Koelzer, Host: Yeah. Right. 

[00:51:08] Benjamin Jolley, PharmD: And so you get people used to the concept of writing down what they're doing in a structured way, which is called the pharmacist e-care plan. And that, frankly, just, just watching people's blood pressure, that's a phenomenal intervention that pharmacies should be paid for.

Yeah. Pharmacists can do all of the work necessary for most patients with high blood pressure to make sure that their blood pressure is under control. Like. find me a pharmacist who does not know that the max dose of Losartan is XYZ. Yeah. Like a hundred milligrams a day. Right. And if you find a patient who's on 25 milligrams, a day of Losartan and their blood, pressure's not under control.

You call the doctor and you change the dose. I mean, it doesn't have to be, it doesn't have to be going and figuring out what the ideal cancer regimen is. Like the ideal group of drugs to treat cancer is right. It can be this very simple stuff, but there is enormous value there. And because we don't take credit for it, that value isn't paid for.

Yeah. And so our value as pharmacists is based on the way the PBMs pay us. Pills in a bottle, the NDC is what you get paid for. 

[00:52:26] Mike Koelzer, Host: So Benjamin, I, I used to do these, um, well, they call 'em. I guess sprint triathlons or Olympic distance triathlons, uh, three or four years ago, I did a handful in the summer when I was doing 'em.

They looked at me and they said, yeah, we need a different word on this than sprint. Let's just call 'em short ones. There was always somebody in the crowd saying, excuse me, when we get to this part of the race, do we turn this way or that way? And I always thought, now I'm looking at you and. I don't know everything, but I don't think you're gonna be in the lead just by the looks of it.

you just follow the other people, but, and if you're that far behind, if like the pen, the ultimate contestant is like a mile in front of you and you can't see them, then you've got problems bigger than this. All right. So here's why I ask it this way. I don't wanna be that person that's looking for a problem, but let me ask in the example that you just gave about, you throw a number out there, a thousand dollars to the local company.

And so on in that picture that you painted, if you went out tomorrow and did this, let's say you had a hundred of these figures and this and that, do you think that would happen? Does anything give you pause in terms of, well, I'm not quite the salesman type Mike, or I don't really think this could happen because of this company, I don't know if I could do this and blah, blah, blah.

Do you have confidence that it could happen? And I guess specifically, I mean, insurance, do you think a company and I think they would, do you think a company would say, all right, we're paying a hundred thousand dollars. There's no law that says I can't give a thousand dollars to somebody else for a different service.

So do you picture that as reality? 

[00:54:27] Benjamin Jolley, PharmD: Absolutely. There are employers and their health plans in this country right now that are paying for 

it 

[00:54:33] Mike Koelzer, Host: outside of their big insurance 

[00:54:35] Benjamin Jolley, PharmD: purchase. Right. It's just a additional benefit to their employees outside of 

their 

[00:54:39] Mike Koelzer, Host: health plan. Gotcha. Well, frankly, it's not insurance.

I mean, you're doing it for everybody and there's no risk, there's no risk. You're not saying I'm gonna take care of them. If they have a heart attack, you're just looking at the blood 

[00:54:48] Benjamin Jolley, PharmD: pressure. Right? Like, frankly, that, that, that actually brings up a separate issue, which is why do we use insurance to buy drugs at all?

it's a known expense, right? Yeah. You're, you're not gonna not get your blood pressure medicine that like, you know, that it's going to be this amount every month for the next forever. Right. Using insurance to pay for that is dumb. just like this kind of service using insurance to pay for. It is dumb. It should just be paid for, with cash with 

[00:55:23] Mike Koelzer, Host: all the specialty drugs that we can't fill.

Anyways, that has been taken from us. Our drugs only get so expensive. 

[00:55:31] Benjamin Jolley, PharmD: Right. I mean, you, you're looking at, like, you're looking at maybe a couple hundred bucks a month, right. For any given drug that you have in an independent pharmacy, the specialty stuff. Yeah. You need insurance for, if someone's gonna get on some crazy hemophilia drug.

Right, right. You need insurance for. But for the lisinopril, the Losartan, the atorvastatin, these drugs are dirt cheap, right? This is like going and filing a claim with your insurance when your glass breaks. Yeah. Or when you need an oil change or when you need to put gas in your car. Yeah. Right.

Like what kind in what world would you think that it's a good idea to file a claim with a Geico to get gas put in your car, right? Like, they're just gonna make your premiums go up next year. 

[00:56:20] Mike Koelzer, Host: Yeah. Uh, but it's like getting a haircut 15, 20 times a year. And instead of me paying 15 bucks, I'd pay $30 to this national firm to give me a card to say, I can go in and get half of that in haircuts every 

[00:56:36] Benjamin Jolley, PharmD: year.

Right. It it's, it's not an insurable risk . That's the big point is pharmacy as a general rule is not. Really insurable risk because it's a known expense, like, you know, precisely who is going to spend the money. It's not like the whole, we know someone's going to have this problem. It's Mike is going to be taking that same drug

Yeah, 

[00:57:02] Mike Koelzer, Host: exactly, exactly. Because of the people who've got it. If, if you've got a certain thing, unless you have a big surgery, you're probably gonna have that forever. And, and the pharmacies, we're just not carrying that, breaking the bank product anymore. That's specialty stuff. 

[00:57:21] Benjamin Jolley, PharmD: And they've channeled that entirely to mail order.

Right. They've taken all that. And so like, if you're gonna work with an independent pharmacy, just say, okay, fine. We'll use our PBM card for those crazy expensive drugs and we'll just pay the pharmacy directly for the 

[00:57:37] Mike Koelzer, Host: others. And I wonder if you were to do that, if it would, like we talked about the insurances being bank accounts, if it would make your.

Costs go down and then the insurance costs go down. 

[00:57:50] Benjamin Jolley, PharmD: I mean, it's got to be right. It seems so Y you'd think like the, I mean, we, we talked about the last time we talked that, um, the concept of a medical loss ratio, right. They have to spend a certain amount on claims. Yeah. And if you don't file those claims and the PBM, can't mark up those claims and can't therefore make your medical loss ratio be here.

Then the medical loss ratio is gonna be here and they can only mark up an additional 20% of that for the total premium cost. Right. Yeah. And, and so if those claims aren't hitting the insurance, then theoretically your premium should go down. That's on the assumption that, you know, you work in a, in a world where the actual cost of things is tied to the price that you're paying for your premium.

[00:58:41] Mike Koelzer, Host: What I love about what you've said. I've heard it on a couple shows of yours. It's like, guys, you can do this. If you can't do this, you know, you've never said it, but if you can't, you can do this. You can take blood pressure. You can do, you can do this, right. 

[00:58:54] Benjamin Jolley, PharmD: You, you, you can interpret blood pressure.

You can say that is high. Yeah. That is low. 

[00:58:59] Mike Koelzer, Host: You're just, you're just naming it. You're just naming it. That 

[00:59:02] Benjamin Jolley, PharmD: drug is, is to do is to the target dose. I can do this. Like, this is not hard. 

[00:59:08] Mike Koelzer, Host: I think that sounds great. And I think pharmacists are easy people. If you gave, if you gave a pharmacy a thousand dollars and said, this is for doing this, and it's not a lot of money, but you know, if I do need you to write down what you did both.

Yeah. You have to write it down, but you'll feel good about it. You actually get a thousand dollars. We're not gonna try to make you do this. Eight years before you see any money it's tied. PE people love to be tied to money, even if it's not. Well, look at the look at the billionaires. It doesn't matter how much these guys have in billions after, after the first, uh, hundred million, 20th of, yeah, the first 20th of a, of a billion or, or hundredth of a billion, you're doing fine.

You're just, you're just keeping score. And so that thousand dollars is like, just show me something, you know, show me, show me, I'm keeping score. In fact, sometimes when I pay my team members at the pharmacy, I almost forget I'm paying them sometimes. And I, and I start being too nice to them. I'm like, Hey yeah, bill, could you please do this for this customer, do this or that.

And I think what I wanna start doing is paying my team members in their twenties. Just 

[01:00:28] Benjamin Jolley, PharmD: don't want, instead of cutting them a check instead of 

[01:00:32] Mike Koelzer, Host: them twenties. No, I wouldn't hand it to 'em on payday. They come up. So let's say somebody comes up to a pharmacist and let's say, that's, you know, let's say they get $2,000 that week.

Okay. And this pharmacist I've been kind of like, you know, treating well, cause I don't want them upset if I do this or whatever. And they come up and I wouldn't hand it to 'em I'd take, what is it? A hundred, a hundred twenties. And I'd go 20, 40, 60, 80, a hundred. And I would do that, uh, a hundred counts of that.

And I'll say now I ain't asking you any more damn favors next time when I just, when I'm thinking something and I just say, Hey, do this, they'll do it. 

[01:01:13] Benjamin Jolley, PharmD: yeah, you follow? I do. I do. Yeah. I mean, you're giving them money, 

[01:01:18] Mike Koelzer, Host: right? You're giving them money. You're giving them a bunch of money. Yeah. Sometimes you don't see that and you just think they're working for you look out of the goodness of their heart, 

[01:01:28] Benjamin Jolley, PharmD: But no, the people work for money.

It's true. I mean, generally money is what people say, like in HR stuff. They say this all the time that usually money is not the reason why someone goes to one company versus another though. Right? Yeah. And a raise does not necessarily mean that they're going, that you're going to get that much money of extra value from the person, right?

Yes. Yes. But you are paying people in money and getting paid in money, motivates people, um, and particularly motivates business owners. Right? yeah. If you see a thousand bucks hit your, uh, your bank account, that is for, I took care of Joe's crab shacks or Joe. Or factories, blood pressure. You're gonna keep doing that.

You'll keep doing it right. And you're gonna go find another company. That'll pay you another thousand 

[01:02:23] Mike Koelzer, Host: bucks. Here's what I don't like about my theory though, at the pharmacy of paying in twenties, I'm afraid I'll come home sometime to Margaret and she'll say underwear, underwear, socks, , you know, things that she washed for me, you know?

Or she'll like, if we have, you know, macaroni and cheese, she'll say macaroni, macaroni, and just like put each one down. Cause there's a lot of love behind that. A single 

[01:02:45] Benjamin Jolley, PharmD: one each. Yeah, 

[01:02:46] Mike Koelzer, Host: Benjamin, we took it this big thing. And then we say no, but this is really cool. Anything else? And, and I think this could go, and I think if we did that, that'd be really, really tremendous.

I'm not saying you have to have something else, but you have some more good news to share with me. 

[01:03:03] Benjamin Jolley, PharmD: Well, um, I mean, J just take that same concept of blood pressure, apply it to other common disease states, diabetes. Yeah. Right. And just expand that concept. Yeah. Right. yeah, that's that, that to me is where I want pharmacy practice to be.

I want to get paid fairly for the drug. Yeah. I get paid at least the cost of the drug, plus a reasonable markup to, uh, to pay for the drug. And then I wanna get paid just a fee to take care of people's health overall. Right. Uh, like per person per month fee to just make sure that I'm practicing here and like that money can be contingent on me actually doing stuff for 'em right.

Yeah. It isn't like on, uh, on social media the other day, someone was like, and now there's, there's these DIR fees and now there's this contingent performance fee. But honestly, if it's not tied to the product, but it's tied to my actual performance. Which that, that's the thing that I really don't like about DIR fees is cuz they're saying we're gonna make your payment for the product, be contingent on your performance.

I wanna just get paid for my performance and have that be contingent on my performance on making sure people's blood pressure is under control and stuff. Yeah. Right. Um, but like expand that out to other disease states, diabetes, uh, I don't know, lipid control, like there's, there's a lot of things that pharmacists can do, um, to improve the overall health of people at a very low price to the, to the end payer.

Right? Yeah. Like paying for a pharmacist to recommend that a dose be increased is super cheap, um, relative to, or paying for a pharmacist to call someone and say, Hey, um, Mrs. Jones, let's talk about why you're not taking your drugs on time. Yeah. Like getting people to actually take their drugs on time that, um, That saves the end payer, a lot of money at the end of day, for sure.

And the, the crazy thing to me is that, um, health plans that these big companies, United health group, and, you know, CNA and so forth, pay gobs of money to companies that have ionized solutions to some of these, some of these big problems. And like the solution that they come up with is mailing a letter to someone saying high blood pressure is this yeah, right.

That then just goes immediately into the trash, but they get paid like a buck piece for every letter. They send out that they are already spending this money on things that do not work, but if they pay us to do this stuff, we can actually deliver. I know we can. Yeah, we can actually deliver. and probably for cheaper, 

[01:05:56] Mike Koelzer, Host: right?

We have medical equipment at our store and we don't bill any insurance for it. And we kind of use the theory. I've always had a theory. It's like, all right, people don't use their insurance very much for medical equipment a lot. Of'em don't even know they have it. And when they do get it, they gotta ask about deductibles and have a prescription and blah, blah, blah.

So what I do at my pharmacy is I carry medical equipment, like under a hundred bucks. And my theory is that people come in and see crutches for whatever, you know, 30 bucks. And they see a little wrist brace for this, then a commode for this. It's almost like if I need a commode, I'm not in the type of mood to be thinking about insurance too.

Just, just let me buy the commode, you know, catch mm-hmm . Do you see any parallel to that with either the employer, with things getting so confusing or with patients things getting so confusing that there's room for. Cash business in 

[01:06:55] Benjamin Jolley, PharmD: there. I think so. I think so. I think that the trick is just figuring out how to market that to somebody mm-hmm for them to pay you for it.

Right. Yeah. Um, 

[01:07:05] Mike Koelzer, Host: And I don't wanna say drugs so much. We know the $4, you know, the, the generic fees, I'm thinking more of these services may be tied in with the medicine somehow 

[01:07:12] Benjamin Jolley, PharmD: or right. Yeah. What, what, what I'm thinking is that, like, from my perspective, the person who's paying for the end, mm-hmm, the end of not doing this is the person who's easiest to sell it to.

Right. I think that they're already paying for what happens if they don't do something about this. So it's easier in my mind to sell to them where most patients don't see that they are paying for this end of day. Ultimately they're 

[01:07:43] Mike Koelzer, Host: paying for it because of they could get fired because the company doesn't have enough money and things 

[01:07:47] Benjamin Jolley, PharmD: like that.

Right. So, I mean, they're ultimately paying for it because like, okay, Let let's put it this way. People in, particularly on the left in this country have noted for years that wages have pretty much stayed more or less flat. They've increased very marginally over the last 40 years. Sure. But total compensation of employees has actually increased substantially over that time.

The gap between those two numbers is almost entirely the cost of health insurance. Mm. You're not paying for it directly. It's not money coming out of your pocket as an employee, but it's money that theoretically would have come to you. Yeah, except that it's going to the doctors and the PBMs and the insurance companies.

Yeah. Instead of to you 

[01:08:39] Mike Koelzer, Host: for us business owners, it's like, you look at someone and they don't see this, but throw health insurance in there. Their whole cost just went up 20% because of the health insurance. Right. I can't throw in five on top of that or whatever, that's a 

[01:08:51] Benjamin Jolley, PharmD: rate, right. I'm not paying you $40 an hour, but I'm paying out $40 an hour for the work you do.

Right. For sure. I'm paying you 25, but the cost of your health insurance is another $15 an hour, right? Yeah. And so, um, people don't see that, but I, I, I, I mean, I've seen all of these charts. That's like, here's the growth of wages. Yep. And here's the growth of total compensation. And the difference is health insurance.

And it's huge, but it means that your wages aren't going up because you're paying, you're just getting paid differently by going to the hospital instead. Yeah. Right. And so anyway, but the point of bringing that up is that it should matter to the right. Each individual person. And I think there are people who will pay cash for this.

I have to believe that, or else there's no reason to even pursue it. Right. If, if it's not gonna be valued by anybody, then there's no point in doing it. I think that the person who's paying for it right now is the employer. And so they're probably more likely to be willing to pay for 

[01:09:54] Mike Koelzer, Host: it. Knowing that insurance is really a bank account that they're gonna just pay more on next year.

All right. So Benjamin, we talk about pharmacists having a service and getting paid for it. And so on, you've done a really neat thing by consulting. How do you like it? How do you like the thought of you getting paid to talk to people and not doing the pharmacy? Let's say, I said, I'm gonna pay you X a year and you don't even know what X is, but you can spend your time.

However you want to, you can spend half in the pharmacy, half on the phone with people, or you can do a hundred percent on the phone and none in the pharmacy. I'm not gonna tell you you're gonna get paid the same either way. Would you like doing that or is it a pain in the S 

[01:10:38] Benjamin Jolley, PharmD: I actually really like talking to people about, you know, helping, like honestly, helping someone understand why their bank account just keeps going up.

And then every time they pay their wholesaler, it goes to zero. Like, yeah. I talked to a guy yesterday who literally was like for the last six months, it's just money comes in. I pay my wholesaler. It's. come in, pay me wholesale. It's gone. And we looked at his DIR fees and he'd been selling, uh, $80,000 worth of brands at a loss that he didn't know he was selling at a loss.

Um, and so of course, if you're selling stuff at a loss, your bank account is not going to go up. Yeah. Right. But like helping someone just take control of gain that sense of control of, okay. Why, why do the numbers not add up? Right. J just helping someone understand that is it's really satisfying personally.

Um, however, I think that most of the value that I bring to people is because I am on the bench because I am checking prescriptions. Right. I don't think that I would be nearly as effective in talking to people if I didn't do that one and two. I do actually enjoy being a pharmacist. 

[01:12:02] Mike Koelzer, Host: Would you be a pharmacist for like 50% and then maybe run the business for 20% and then do consulting for 30%?

[01:12:12] Benjamin Jolley, PharmD: Some, some mix close to that. Yeah. 

[01:12:15] Mike Koelzer, Host: Benjamin in closing, you've been outta school now two or three years, let's say on a scale of one to 10, with 10 being, you're really excited about the profession and one being it's affecting you through, you know, anxiety leading to depression, leading to burnout and those kind of things.

And let's say we all go through ups and downs 

[01:12:38] Benjamin Jolley, PharmD: through the week. When you see that lisinopril that pays 47 cents total, you say, you know, I think it's a one today. Yeah. 

[01:12:46] Mike Koelzer, Host: yeah. Let's say there's some ones and some tens. Were you at one in 10, two years ago and you're still at one in 10 or, or it used to be smaller or is it wider now?

How does the pharmacy affect you? And in which way does it affect you 

[01:13:03] Benjamin Jolley, PharmD: mentally? I'm excited about the future. I'm uh, I, I think that you are, I think that there's a lot of work ahead of me. They like the small business pharmacy, independent pharmacy profession. I think there's a lot of work ahead of us to get to where we need to be.

But I think that if we can pull that off, the future is very bright. 

[01:13:26] Mike Koelzer, Host: Would it be fair to say that you started a little higher? Once you learned all the crap that's out there, you took a dive. I went way down. Oh yeah. Once you're faced with the pits of hell, it doesn't get a whole lot worse than that. It's like, all right, there's a fire.

I can see it still, but then there's really nowhere to go. But up, 

[01:13:44] Benjamin Jolley, PharmD: uh, yeah. I, I, I think that, I think that our future is bright. If we can deliver on getting, you know, getting people to pay us for these services, I think that people will pay us and are paying us. And I think that the future's very bright for that kind of business model.

Like frankly, running a store where all you do is put pills in a bottle and. That's it. And you don't try to engage people in their healthcare beyond that. I, I don't think the future's right for those folks. Well, 

[01:14:21] Mike Koelzer, Host: Benjamin I'm a lot older than you are, but thanks for your mentorship online. And one thing I really appreciate, like I said, is that you're where I think the sky meets the ground.

There's a lot of, a lot of, and I'll put myself in that position, a lot of us complainers out there and then there's a lot of us people with big dreams, but until those kinds match up, you don't really get that gears, you know, together that traction. And that's what I really appreciate in seeing your stuff. And so thank you for that.

And I'll continue to be a fan 

[01:14:51] Benjamin Jolley, PharmD: that's flattering. Thank you. I do hope that I can, you know, try and actually marry those two, right? Yeah. Get, get the, get the blue sky initiatives of all of the people in the, in academia pharmacy. To actually come down and be a business model, right. That's right.

That's my dream. and I think, I think we're like this close. We're just, Ugh. Honestly, just gotta go sell it now. Right. 

[01:15:19] Mike Koelzer, Host: You're gonna be a regular fixture on the show. I'm afraid. So I signed you up. So until next time, thanks. Benjamin will 

[01:15:26] Benjamin Jolley, PharmD: be in touch. Okay. Talk to you later, Mike.