Flip the Pharmacy | Pharmacists Tim Mitchell & Paula Boettler

This transcript was generated automatically. Its accuracy may vary.

[00:00:12] Mike Koelzer, Host: Well, hello, Tim and Paula. Welcome to the business of pharmacy podcast. Great to have you guys here. 

[00:00:17] Tim Mitchell, Pharmacist: Well, thank you very much. We appreciate the opportunity to talk to you, Tim. Let's start 

[00:00:20] Mike Koelzer, Host: with you. Introduce yourself and what's hot. What brings us together today? Would you say mainly, 

[00:00:27] Tim Mitchell, Pharmacist: well, my name's Tim Mitchell.

I'm a community independent pharmacy owner in Southwest, Missouri. You know, being a community pharmacy owner. For the last, I guess, 20, 25 years, uh, seen our profession change and trying to stay on top of, on the cutting edge of what we need to be doing as pharmacy owners and, and pharmacists in our profession.

Uh, we've recently had the opportunity to, to be involved in a flip the pharmacy grant. And, um, that's one of the real exciting things that why we connected. I guess Paula is the person that's. It's uh, taking the lead on the grant and, uh, we are very excited for the opportunity to talk about it today.

So, Paula, 

[00:01:07] Mike Koelzer, Host: how long have you 

[00:01:08] Tim Mitchell, Pharmacist: been at the pharmacy? 

[00:01:10] Paula Boettler, Pharmacist: Um, it's actually been almost 10 years and in May, it will be 10 years. So now. 

[00:01:16] Tim Mitchell, Pharmacist: So now this 

[00:01:16] Mike Koelzer, Host: The most important project ever comes in and Tim says, all right, Paula, you, you take it and make this work? No, but what, what's your role leading up to this? What's your role in the last 10 years before?

You're the official flip? The pharmacy, um, liaison. 

[00:01:31] Paula Boettler, Pharmacist: Well, I've actually had almost. Every role here. I started out as a student. Um, I came to this pharmacy on rotation. Um, it was one of the last rotations I had and actually Tim convinced me, uh, to go into community pharmacy, cuz that wasn't something that had actually entered my radar until I was on rotation here.

Yeah. Wow. Yeah. Um, I had, I had started out working at chain stores and I was kind of, I was thinking I wanted to go into a hospital. Because my mom's a nurse at a hospital. Yeah. And that was, that seemed natural to me. Um, and then I, uh, had the rotation at, um, the Mitchell's pharmacy and it completely changed my outlook on pharmacy.

And I saw Tim firsthand taking care of patients, which is, you know, different from just dispensing medication to them. Yeah. And that inspired me. And so Tim offered me a job here. I was like, yes, absolutely. I'm. Become a community pharmacist. And, uh, 

[00:02:33] Mike Koelzer, Host: and how long 

[00:02:34] Paula Boettler, Pharmacist: have you been a pharmacist then? Almost 10 years.

So I was on rotation in March of 2010. And then may I started working here all 

[00:02:41] Tim Mitchell, Pharmacist: in all we've had an opportunity to, to do a lot of different things. Um, this has really always been my passion. I can tell you back in the late nineties, early two thousands, our buying. Um, I decided to roll out a plan called D diabetes care.

And so they're like, this is what we're gonna do. You guys are gonna get paid to do diabetes care for patients. And I'm like, death is so cool. That's what I want to do. You know, when Paula came up, there were a few other pharmacists in between, uh, You know, me doing the diabetes care program and Paula coming on board, we, you know, kind of took it step by step.

And in the mid two thousands, we thought we would have a consulting, pharmacy consulting, only pharmacy as part of our business. Unfortunately, the business plan wasn't quite there because there was no payment , um, right. Uh, part of that. And so we tried to. To make it work, but, uh, it was just as the Medicare part D plans were rolling out and we knew right there was gonna be a, a part of, you know, MTMs and various things yeah.

That was gonna be, but there was no set way of getting paid and, and it just wouldn't, we couldn't, you know, fund it, the, the, the business plan changed. Of course, as Paula was coming on board, MTMs became more and more of a practice. And we knew that eventually, if we didn't get involved in these things, With both feeds in the bucket.

The way I look at it, these part D plans would be really relying on us to do this. And we felt like it was an important part of our business. I told all of our pharmacists and, and I said, Paula, I really need you to lead this because she's the clinical mind behind everything. Yeah. I, I'm kind of the idea guy and she.

Is the one that puts everything together. But, um, no, that goes, yeah. Soon as she came on, board started working on things, you know, smaller projects, this really being involved with CPS N and flipped the pharmacy, I feel like it is kind of our, our granddaddy project to be able to move forward. There were 20 different sites that were awarded to flip the pharmacy grants in the nation.

So, and we're one of 'em. So we're very proud of that. It's a small project. But Paula has worked diligently and is continuing working diligently. She's making this a successful venture for the professional pharmacy, not just our stores. It's not just about our stores, but it's about yeah. Profession pharmacy.

So let's see if I've 

[00:04:56] Mike Koelzer, Host: got this straight. So C P E SN. That is pharmacists from all. Across the nation that have banded together to try to encourage and promote services. Paid services that are not, not as tied to dispensing. Would that be fair? 

[00:05:21] Paula Boettler, Pharmacist: Yes. Yeah. So the, the, the whole point is that we, um, integrate these enhanced services into, um, the general community pharmacy practice.

And then, um, and then there's some part of CPS N that makes it a. Possibility to, um, look at payers and maybe try to work out some contracts on behalf of those pharmacies so that we can get paid, you know, in a, a program sense from, uh, insurance companies or, um, maybe state plans, things like that. And so that we can get reimbursed for these enhanced services that we're providing.

[00:05:58] Tim Mitchell, Pharmacist: Now, Paula, would 

[00:05:59] Mike Koelzer, Host: You say that what you just said there is more focused on a partnership with players mm-hmm . I know that's one of the focuses of flip the pharmacy because there's kind of a grant and they actually have a liaison from the, maybe the home office that's kind of working with the pharmacies and so on.

Yeah. Is that one of the major pushes of flip the pharmacy of banding with these payers? Or is that a goal in itself of CPS? N without even the flip. 

[00:06:33] Tim Mitchell, Pharmacist: Pharmacy. 

[00:06:33] Paula Boettler, Pharmacist: Well, I believe it's a goal of CPS in, even without the flip, the pharmacy, um, and flip and, and the kind of the idea behind flip the pharmacy is that we know pharmacies can do these things.

Um, there's been a demonstration of it. Like what they ask. The Asheville project. The problem is that it's not getting, um, widely documented and it's also not getting necessarily widely adopted by all the pharmacies. Yeah. And so the idea was this is a push forward. So the flip the pharmacy, um, is a push on those, um, pharmacies.

To kind of step up the game a little bit and start documenting so that we get credit for it. And then the payers will start to take notice and we can, you know, get that benefit. And in fact, there's six domains to flip the pharmacy. The sixth domain is, um, is, uh, developing a. A business model and expressing value.

So that's a whole, um, domain in the flip, the pharmacy is to get, uh, get the return of investment for these pharmacies, um, that have committed to performing these enhanced services. In 

[00:07:37] Mike Koelzer, Host: the past. Our pharmacy has done that, where. The best I can describe. It probably is one of, one of, my bad diets. That's gone Orry, you know, where you're, you're doing it and you're, and you're putting forth the effort.

And then all of a sudden you're not seeing the return or you're not seeing the payment come in and that's okay to do while you have the energy and maybe for a month or two or, or three, but pretty soon that energy you run out of steam yourself. And then also you just don't have the financial. Means to pay someone.

Once somebody runs outta steam, you don't have the financial means to, to, to pay for that steam instead of just using it from, we wanna do this, but now you have to start paying for it because you have to make it happen. So in, in flip the pharmacy, do they have anybody lined up yet? Or do they have people that are looking already?

Or is that something that's part of this 

[00:08:35] Tim Mitchell, Pharmacist: to, I don't wanna just 

[00:08:38] Mike Koelzer, Host: Say the word hope, but. I know that's part of the push. That seems to me like the biggest part. Do you know where things are with that at 

[00:08:47] Tim Mitchell, Pharmacist: this 

[00:08:47] Paula Boettler, Pharmacist: point? So with flip the pharmacy it's nationwide, but each team is kind of based on their own local CPS and network.

Okay. So, the state network, some of the local CPS N networks already have a payer association set up, like with a, a state based payer, probably. I don't know of anything like nationwide as of yet, but I think it'll, it'll kind of stay with that. I think it'll be up to the state to kind of develop those. One thing that I see happening is for the CPS N networks to go to the payer and say, look what our pharmacists are doing.

they have to have the eCare plan, um, documentation to show that that's what they're doing. And that's been, I think, a little bit of a stumbling block. I know that originally, when we signed up with CPS N and then they, we got the platform to do the eCare plans, and then they said like, um, you had to do at least one by a certain date.

And then they wanted us to do like 10 quarterly. And that's about what we were 

[00:09:46] Mike Koelzer, Host: doing. And for the listeners, the eCare, the eCare is documenting your success basically of the patient 

[00:09:51] Paula Boettler, Pharmacist: interaction. Yes. Yeah. So we're making some kind of intervention and we're submitting it electronically. Um, and this can, this could eventually lead to us submitting electronically to, um, an insurance company or another physician, something like that.

But right now we're submitting these to CPS N so they can collect that data. And so before we flipped the pharmacy, we were just doing like 10 quarterly. And so when they first started training us, um, for the first month, Was October, they said, you know, every pharmacy in your group, we want them to have at least 25 eCare plans by the end of the month, hopefully 50.

And honestly, I was like, oh, that's gonna be really hard. I mean, we haven't been doing that many, but it's amazing how once you commit, you know, like, well, I don't wanna be the only pharmacy that's not meeting the goal. And so you start working on and then you. Seen the other plans come in from other pharmacies and you're like, well, if they can do 50 sh I can do 50.

I mean, we're similar pharmacies. Yeah. And then it kind of builds on itself. And so they saw, um, really good results just from that first month. Um, I think they had like 9,000 eCare plans over 500 pharmacies. Um, with the first month of, flip the pharmacy. And that was almost 60% of the total eCare plan submitted for all of CPS N so, wow.

That's great. Um, already one month in they've they've, they've had good 

[00:11:15] Mike Koelzer, Host: results in the pharmacy were so naturally helpful and have unfortunately, or whatever, you know, it's been tied into the product. So we've given the information away. And I think even the information people can find now, but people don't know what to do with the information.

You can look up online what something is, but they don't know the best way to take that information and put it into practice. We all are pharmacists, we're doing things. That all of a sudden you're like, I didn't even realize I just helped someone there. They just asked me if I could give my little two year old, uh, you know, who has this type of fever?

Can I give them both ibuprofen and Tylenol? You know, and for us, it's maybe a simple, quick answer, but it's like, that's a big one. Deal for a mother. Who's got a sick baby. And I imagine a lot of those things you were doing, and you're like, of course that's a documentable thing, but you just didn't think about it in the 

[00:12:09] Paula Boettler, Pharmacist: past, right?

Yeah, exactly. Um, in fact, the only thing that we've really had to change to implement is just the documentation part. The things we're documenting are things that we were already doing. You know, there's an emphasis right now. Month on blood pressure monitoring. So the idea is they want us to be checking people's blood pressure when they come in to get their medications.

And hopefully these are our patients that we have on synchronization, and then we can keep checking them every month and then we'll have longitudinal data that will be able to show that a pharmacist can monitor these patients because we have so many visits with them in a year compared to the doctor's.

[00:12:49] Tim Mitchell, Pharmacist: It 

[00:12:49] Mike Koelzer, Host: Sounds like flip the pharmacy, it sounds like this is a good TV show and you're gonna have to have a camera crew around . Are they doing any, are they doing any of that? Are they, are they, are they sending someone around with video equipment and making a documentary? Cause I wanna watch this late at night on, 

[00:13:06] Tim Mitchell, Pharmacist: uh, TLC or TLC or Amazon prime 

[00:13:08] Mike Koelzer, Host: or something like that.

you guys have been like, I have. Through the years. I'm sure. And Tim, you mentioned this where we've known about the kind of the MTM model or the documenting and things like that. And I know that the change has to happen and this is how it has to happen. But what fears do you have? And this is no bang on CPS N or flip the pharmacy or whatever, but it's more on, I guess, some of the PBMs or the insurance companies, if anything, what fears do you have going into the program as far as you know, what, what doubts do you have going 

[00:13:46] Tim Mitchell, Pharmacist: into this?

Actually, Paula and I have had a number of conversations about moving forward with this and how it's a bright light. There's so much doomsday in the profession of pharmacy right now. And there's a lot of people crying. The sky is falling, the sky is falling and you know, there may be some individuals sticking their head in the sand saying, we don't believe anything's gonna change.

We're gonna just keep doing what we're doing. My fear is that we lose sight of it. Future of what this profession is going to, or my fear is that, well, I don't have a fear as long as we can stay focused. So I guess my fear is, yeah, we're gonna lose sight. Your fear is not doing anything, not doing it. And we both agree.

And I'm not saying that everybody that I come in contact with there, there are many that feel like I'm just gonna give up, and quit. A friend of mine had a pharmacy just south of here that just closed last. You know, it's a sad deal to see this community with no pharmacy. Yeah. My hope is that this is going to continue to be the bright light of what we have to offer.

My son is a second year pharmacy student at U MKC and ah, um, you know, my wife and I had a discussion about whether or not. We would encourage him to go into pharmacy because he wanted to do that. And, you know, I, I see it as a huge opportunity for someone like him to, to do something out of the box.

And I actually just told Paula the other day, I said, I see you as someday being the mentor for my son. Um, yeah, right. Moving forward because he's the next generation of pharmacy. Um, and you know, CPS N gives us that hope. Um, it's a clinically integrated network. Which, um, gives us the opportunity to work together with other like-minded stores.

Yeah. Stores that are out looking for things. You know, I have a friend that he and I were talking about CPS and he sat on the advisory council with me and we were actually talking about. How people, some pharmacies feel like CPS N is supposed to bring those payer opportunities to them. And it's not just that.

I think it gives, I, we, we see CPS N as, as kind of like, um, a counselor, a pharmacy counselor for us. Yeah. Right. Give us ideas. And we're the ones that need to take the responsibility to go out and try to find these opportunities and make 'em happen. And yeah, there are states that are doing. Um, you know, and we're, we're working on that.

It's not like we're behind everybody, but they're like Iowa is a very forward thinking. Always has been a very Randy McDonough and, and the group up there they're, they're like the brains behind a lot of this. Uh, Oklahoma does a lot of cool things. Arkansas's doing some things and, and I know there're other states that are really doing some cool things, Missouri.

Um, is, is also one of the things that Missouri's doing is the community health workers, community health workers is really pretty much what technicians and pharmacists do in our pharmacy on a daily basis, but we're training them in a different way. And we have five individuals including myself, going through community health worker training right now through a community college.

And it's, it's looking at. Taking care of patients in a little different fashion, but still using our pharmacy sense. Community health workers have been used in hospitals and, uh, you know, social worker settings for many years. But the important thing is we are looking at implementing community health workers in the pharmacy side.

And what Paula was saying is. You know, utilizing blood pressure checks and, and blood glucose checks, just simple things that we've done for years, but also utilizing our technicians as community health workers in the community. I've got a couple of patients right now that I'm caring for that need, you know, a specific kind of, uh, adherence packaging because they're having some trouble, um, they're gonna need their blood glucose and we're not providing home healthcare.

This is just, yeah. You know, checks and making sure that their medicines are where they need to be. We do a quick blood glucose blood pressure check, and we will come back to the pharmacy. We'll produce that in an eCare plan. We can send that information to the physician, like what she said, but it'll be one of the eCare plans that we do on our flip the pharmacy project.

So there's a lot. Newer things that are kind of outside the box, but it's still the same things we've been doing, but we're documenting it now. And we're doing these types of things so that we can bring these to payers and say, Hey, look what we're doing. We are able to. Touch these many lives and we can do these kinds of services for these people.

And oh, by the way, we can take care of the, the, the people in your business or, you know, wherever it may be for the state. I know the state of Missouri has raised some ears, uh, to what we're doing, uh, in Southwest, Missouri. Yeah, because they heard a lot of our employees were in the community health worker class.

They're like, Hey, this is an idea. That's something that we hadn't thought about. Um, I wouldn't say I'd like to take credit for it. It wasn't my idea, a friend of mine in Southeast, Missouri, his name's trip, Logan trip, and Richard Logan, who actually started this idea and, uh, have been running with it and they talked to me about it and it's, it's something that we're implementing and we think it's a really, really neat idea.

And we're hoping it'll take hold, and move forward. So 

[00:19:20] Mike Koelzer, Host: I've always told my team at my pharmacy. It's like, I don't know how exactly we'll do this, but look at a guy like Steve Jobs, who knew his technology, but he died of cancer. And arguably, because of medication, I guess his own medication management, his own decisions.

But I mean, the number one killer of people now is, you know, what, heart disease and cancer we can't do as much on right now, but heart disease, then you look. How many family fights has there been, or people that one of the siblings overdrawn with their energy, because they're helping out, they gotta help out their mom and do their medicines, you know, while the other sibling is out in some other state or something like that, there's all kinds of stuff where it's like, if people can take that place of somebody who is overseeing stuff, there's not.

People overseeing the whole drug regimen, I guess, you know, that's where it seems that maybe we have to change our name, you know, just like, just like always like the janitors have to change their name to custodian and , you know, steward, this is now our, you know, in flight, whatever, you know, I mean, it's like maybe it just means a name change, you 

[00:20:34] Paula Boettler, Pharmacist: know?

Big healthcare problem is the expense of it. And, a lot of the expense is people being in the hospital. And so keeping people out of the hospital is something that pharmacists can do for, and I think for sure think that's the, the, the key to it all. And maybe, um, we just need to keep advocating for ourselves in that way, because, um, and it's not just us too.

It's the pharmacy technicians taking on these extra roles. Yeah. And that is one of the, um, that's one of the domains that flip the pharmacy is increasing, um, increasing the use of non pharmacist staff, um, in the pharmacy or, yeah, domain three is, um, Bringing them into the, the process other than just counting pills and, you know, and troubleshooting insurance.

Um, and so far, uh, our technicians here have been, have really embraced it. In fact, I think it actually increases their job satisfaction. Mm-hmm of being able to take on these extra roles. Um, this month, uh, the challenge on the flip the pharmacy was to, uh, pick one of our technicians out, which I think we actually have a few of.

Are gonna do it. And there's a, uh, training on the American heart association. Put some of it free for them. And they go through this training and they learn how to take a BR blood pressure properly. And then we can have the technicians assisting us in taking these blood pressures and keeping a monitor on the patients.

And maybe we'll even have some that go out to people's homes and are able to take it. Um, those are the people that are probably at the highest risk of ending up back in the hospital. So if we. If we can have these touch points with the patient and show that we're making the interaction or we're, um, making a positive intervention with them.

Um, then I think players will understand, Hey, if we, uh, you know, if we join forces with these pharmacists, then we can save ourselves money, right? By keeping people out of the 

[00:22:36] Tim Mitchell, Pharmacist: hospital 

[00:22:37] Mike Koelzer, Host: that. Really farsighted to flip the pharmacy and, um, CPS N because the summit seems, my quick thing would be like, all right, well, free the pharmacist up, but it's almost like, no, we're gonna free up the whole profession.

And even with the technicians, along with the rest of the profession, having that whole new angle, because obviously it seems that you. Need to have a pharmacist around doing that. You could have one pharmacist per location or in charge of so many technicians and so on. So that seems like a really great plan to 

[00:23:11] Tim Mitchell, Pharmacist: meet.

What, what we're trying to do is work as a team. Yeah. Um, including the technicians or in this case, community health workers as kind of like the eyes and the ears for the pharmacist, and then we'll do those eCare plans. And then when we. You know, if everything's moving smoothly and there's no issues, then it'll be a very simple process.

If there's, if there's something that pops up and you know, Joe's blood pressure is 200 over. Yeah. Right. You know, 105, then we need to figure out what's going on. We need to call the doctor. We need to figure out if he's taking his medicine or, you know, he's gonna stroke out on this here. So. Um, that's, there are eyes and ears with what's going on.

And I think the most of those opportunities is for us to, to touch patients by utilizing our community health works. And it's, you know, to be Frank it's as a business owner, utilizing a community health worker technician position is. In the business side. I mean, this is the business of pharmacy podcasts, right?

Yeah. Um, we have to look at what's feasible, affordable wise for our pharmacy to be able to provide and for sure. And, you know, um, and I'm not saying not having enough pharmacists. I try not to, you know, work as our pharmacist, just one that's in charge of 20 people. But yeah, I think it's important that we understand that they.

A vital part of what we're doing. Um, and there, there, you know, it's, it, it keeps our overhead, uh, under control as well. So yeah, 

[00:24:44] Mike Koelzer, Host: well, and the pharmacist truly to be valuable has to focus on what only a pharmacist can do and that's on very serious and complicated drug problems and the technicians. Would serve a great role in the not insignificant role by any means, but of the checks and the, the community workers and so on, but then funnel those more problem things down to a pharmacist who not, not everything that comes up is that important.

And so that's certainly where they are, and you don't have to pretend they are. That's where the technicians can really do their part and, and save the pharmacist, uh, discretion for the. More important, you know, problems that come along. 

[00:25:30] Paula Boettler, Pharmacist: So, um, flip the pharmacy has six domains that are emphasized, um, monthly. So the first six months will be, um, the six domains.

And then they'll start over again. So like month seven through 12 will be those same six domains, but just like a step, a step further. Okay. Gotcha. So the first domain is leveraging the appointment based model. And the idea behind this is getting, um, patients synced their medications synchronized so that they're making one visit to the pharmacy and on that visit, hopefully touching base with the pharmacist.

And so we can have, you know, check, check up on them. How's their blood pressure doing? Um, you know, maybe, uh, look at their glucose ratings, things like that. Sure. Um, 

[00:26:19] Tim Mitchell, Pharmacist: and do, do you guys, 

[00:26:20] Mike Koelzer, Host: do you guys sync meds right now? 

[00:26:22] Paula Boettler, Pharmacist: We are getting better at it. okay. 

[00:26:26] Mike Koelzer, Host: We tried it, we tried it like three times. I was in charge of it.

Maybe they have to wait till I'm fired, but we did terribly at it. Yeah. We did terribly at it. Every time we started it almost seemed like the, the, the patients were, I had one of my . One of my guys came back and said, it's almost like they're, the patients are sabotaging us. You know, we set up this whole thing the day before and they, and they'll call back the next day.

Like, they've never, like, they've never heard. Before, and I know that's a combination of a lot of different reasons, you know, both our communication and forgetfulness and all that kind of stuff. But yeah, it's been a real bear for us. 

[00:26:59] Tim Mitchell, Pharmacist: Well, and, 

[00:26:59] Paula Boettler, Pharmacist: and I think convincing the patients. I think that's probably a hard part.

And, um, you know, in some of the, the flip, the pharmacy materials, they encourage you to not use necessarily the term med synchronization and yeah. Right, exactly. Okay. Would you like me to make it so that you only have to come to the pharmacy once a month and then they're okay with it, but if there's yeah.

Words like convenience and yes, if you start, you know, throwing around words, Synchronization or enrollment that turns them away. And so we tried to avoid that. Exactly. Um, we've also kind of tossed around, you know, like, you know, maybe signing people up for like, a drawing if they get, you know, signed up for the med sync, things like that.

Yeah. Um, I will say, though, there is an emphasis, and I think this is a kind of a confusing point for a lot of pharmacies that already, you know, think, oh my PA my patients are synced up. We, you know, fill them every month. Well, the idea is it's not an autofill program, so. One really important part of the med synchronization is that, that call about a week before, because that call is when we can start making interventions.

So, yeah. Right. And the technicians can make that call and say, you know, like we have a little bit of a checklist for the technicians and they call and say, you know, have, have any of your medications changed? Have you added any medication? Um, that way we can, you know, kind of start looking ahead in case there's a therapy duplication, for sure.

Um, have, uh, have you been in the hospital because that can throw their adherence off sometimes, but it's good for us to know if they've been in the hospital and they don't necessarily come forth with that information you have to ask. Yeah. Um, and so. If, if they're, if the technicians are talking to someone and they're saying, okay, so this person might have some issues.

That's when they flag the pharmacist over and then we can talk to them. Um, and then, and then, you know, we may be able to resolve some issues by talking to their doctor and then sending an eCare plan. And we've, you know, made a positive intervention, probably saved ourselves time, you know, because going back and fixing a problem always takes more time than, you know, fixing it ahead of time and likely.

[00:29:08] Mike Koelzer, Host: You save someone from a hospital visit a week later, but yeah, which is great. The challenge is saying it's like calling the insurance and saying, all right, listen, they would've been in the hospital. If it wasn't for us, you know, it's 

[00:29:21] Tim Mitchell, Pharmacist: like, you really can't. 

[00:29:22] Paula Boettler, Pharmacist: Well, and that's where the documentation, hopefully that 

[00:29:25] Tim Mitchell, Pharmacist: will, I guess, that's 

[00:29:25] Mike Koelzer, Host: where it comes.

If they look at it and someone's smart enough to say yes, They would've been in the hospital if they wouldn't have caught this and we know that's true. Yeah. 

[00:29:33] Paula Boettler, Pharmacist: Well, and if you, if you look at the num, you know, if you're a, a numbers person and you look at 'em and you're, and you have a big enough, um, pool of the numbers, so 500 pharmacies doing these eCare plan, and they may be able to see a difference.

So that's what the hope is. Yeah. They've 

[00:29:47] Mike Koelzer, Host: gotta see those big numbers. That's right. Mm-hmm, where you can start seeing those trends happen. That's a great, great 

[00:29:51] Paula Boettler, Pharmacist: reason. Yeah. And, and so that is, that's the, the first domain. Um, and I think that's just my take home point is that med sync is not autofill. Med sync is, is a yeah.

Right. Overthinking intervention. 

[00:30:03] Mike Koelzer, Host: It's that call a week ahead. That starts the ball rolling. And yeah. 

[00:30:07] Tim Mitchell, Pharmacist: Yeah. 

[00:30:07] Paula Boettler, Pharmacist: And then, um, the second domain is improving patient follow up and monitoring. Um, and then kind of like we've talked about previously is that we see patients a lot more than they, then they go to the doctor.

So these are all opportunities for monitoring. Every time we see them is an opportunity for monitoring. Um, yeah. Right. And so we may be able to see a, uh, a problem ha you know, if they, if they only go to the doctor once a year and their blood pressure starts going up at six months and they may not, uh, right.

Then we could, you know, step in and, and, and head something off before it gets to be a real problem. 

[00:30:42] Mike Koelzer, Host: Um, yeah. And, and I, I think there's sometimes, sometimes it seems that even catching something good that happens. Like, let's say that I. To the doctor and then three months later, whatever it is, your exercise has picked up or your weight has gone down or something.

And sometimes that positive feedback can extend that versus saying to the doctor, you know, I know I'm here a year later, but you should have seen me nine months ago. I was killing it and then, then I went downhill after that. But sometimes that positive reinforcement might be, is probably a good thing too.

No, 

[00:31:20] Paula Boettler, Pharmacist: actually, absolutely. That's kind of how it works with the pharmacies themselves too. They keep emphasizing to us that we take these, um, make these kinds of small manageable goals. And that we keep the timeframe reasonable, and then you get all this positive reinforcement, you know, like the 25 E care plans.

Well, once you've done 25 E care plans, you're like, oh, I can do that again and again. And, um, and so, yeah. Right. So with the patients, it's the same way if they're getting, um, if they make a goal to lose one to two pounds in a month, and then they hit that goal and then the pharmacist gives them a high five the next month.

And then they think, oh, I can lose another one to two pounds doing that same thing. And then they've, you know, They've created a, uh, yeah, a pattern. Um, so I, yeah. Right, exactly. Um, and, and so the, the third domain is the developing new roles for non pharmacist support staff, which we were kind of talking about with the community health workers.

And then there's, I'm actually doing some advanced training. That's Ava available for technicians as well that they can, you know, learn. That's great. Kind of developing their own technician role. And then, uh, the fourth domain is optimizing the utilization of technology and electronic care. Um, and I see this as making the eCare plans as a normal part of the dispensing process.

So we were kind of talking about last month, how. when immunization, when pharmacists first started doing flu shots and things like that, it was seen as possibly gonna be hard to work into the normal dispensing process. You know, mm-hmm well, I'm gonna have to do a bunch of things to step out of my role as pharmacist and step into the role of, uh, vaccine giver and, um, yeah, right.

I hope to eat well. Plan's kind of like that. And after a while we're like, oh yeah, that's just another step that I always do. Sure. Um, when I'm I'm right. Looking through a patient's. Um, and then the, uh, the fifth goal is, or the fifth domain is establishing working relationships with other care team members.

So other healthcare professionals. And I think this kind of, um, seems pretty self-explanatory if you, if you're communicating well with the patients, um, other physicians or other prescribers, then you're probably gonna get better care results from that. Um, And that, and then the last one that makes a lot of sense.

Yeah. And then the last one is developing the business model and expressing value so that we can, uh, show payers that we're providing this longitudinal care. We're taking care of people over, you know, a, a. A longer time and we're keeping up with them rather than just a point of sale, you know, a quick transactional type business, if they can start seeing pharmacists, you know, kind of like your, um, uh, you would see your general practitioner, you know, the, the person they go to.

Yeah. Right. Uh, on, on a, on a monthly basis, not a, you know, not just some place they visit once in a while. And they skip between pharmacies and things like. that makes 

[00:34:15] Tim Mitchell, Pharmacist: sense. 

[00:34:16] Mike Koelzer, Host: You know, it seems to me, and as, as we were talking about the, about the, um, intervention, the, the eCare intervention or documented by eCare, it seems that when you talk about timing that.

It probably could be argued that what you put in proactively in an intervention practically, if not more saves more time than not even the medical problem, not I'm not talking like the ER visit, but even like some customer being on the phone and just being totally confused, you know, or comes in with.

Two bottles that are labeled differently, but you know, the medicines, the same medicine in both bottles, you know, just stuff like that, that you're spending time on anyways. And if you could grab that ahead of time, you know, you're probably, you're probably saving time up front compared to the long 

term.

[00:35:13] Paula Boettler, Pharmacist: Yeah. Yeah. I think so. And it, that kind of goes to our, um, our adherence packaging that we. Yeah, we have PA it takes longer to fill, you know, to process the adherence packaging, but the patients that are getting it, it saves us time because we're not necessarily get a phone call every, you know, week or day or, or, you know, so I, I think that, um, you know, saving them confusion and, um, and actually making it easier for them to.

You know, saving them time as well. Um, it also saves us time. Yeah. 

[00:35:46] Tim Mitchell, Pharmacist: If you had to open 

[00:35:46] Mike Koelzer, Host: up a store to put your store out of business, 

[00:35:51] Tim Mitchell, Pharmacist: what would you do? That's a good question. I always ask that of myself. It's, it's actually a good question to think about or a good question. Things to think about as a store owner, because you're always on the edge to be, you know, what's coming down the pike and, and I've always wanted to be on the cutting edge.

Uh, and I feel like we're moving. You are at Siemens moving in that direction. I still am. And I'm, and I don't mean this in any bad way, but I still keep pushing for more and more things. Um, and of course, some of my staff say, can we just do a few things really well instead of having to do 10 different things, if you had a crystal ball, you maybe could, well, you gotta find what works and then some things you just have to CU 'em out.

Yeah. And move on. But you know, if I had to have a store, actually, I, I just, I just saw a little video of a store down in Texas. Just, I loved, I, I mean, I don't know what kind of practice they have as far as their, if they're in CPS N or what, but, um, I, you know, I, I like their, their. Set up their store, but you know, the one thing I, I really feel like the store needs to, to be for the future is patient centered or client centered.

And, and, you know, as soon as they're walking in the door, they know the focus is on them and not on the products that are out on the shelves. Um, it's about their healthcare and, you know, I. I, I do feel like patients are in, in our community are starting to understand what we're doing. Not all of them, but many of them are mm-hmm I will tell you it has taken a while for patients to understand.

Well, even when we started doing flu shots and other immunizations, uh, and medication administrations, I mean, we, we, we administer lots of different injectables. Um, there were a lot of people. Didn't understand that we did that. And because no other pharmacies were doing it and today people expect it. I mean, they, they, they know they can go to the pharmacy to get a flu shot or a pneumonia shot.

And it's the same way with, with, um, well, and Paula, actually, we have discussions regularly, uh, about this. We feel like it's going to be the same way with this, you know, as, as she just mentioned. Yeah. I feel like patients will see me. Probably 20 or 30, you know, someone that's taking medicine on a regular basis probably sees me 20 or 30 times a year.

Right. They may see their physician. Yeah. Two or three, maybe four at the most, a year. Yeah. So, you know, we have an opportunity, which it's a huge opportunity to. Make a big difference and, and probably keep them out of the emergency room or, or keep them from being admitted to the hospital. For whatever reason, if we can catch something in one of those 20 to 30 times that we see 'em.

And so we've started most patients when they come in for blood pressure medication or local glucose medicine, we actually ask them if they'd like to have their blood pressure checked. Right. And we can use our great community health workers to do it, or the pharmacist can do it as well. It doesn't take just a few minutes and guess what?

We can also do an eCare plan when we do that. Um, so it's an intervention. And so Paula is happy because we can, we can reach our goal of reaching those, uh, eCare plans, but we also have documentation of what we did. For the patient's, um, physician or whoever else may be interested. Um, and you know, and it's not like we just share that, but that's information that we are documenting before we would do a blood pressure and not document it.

You might as well say you didn't do it if you didn't document it. So 

[00:39:34] Mike Koelzer, Host: What idea, if any, have you had that you say now that could really make an impact? It's either too costly or you don't have the trust in it to pull the trigger. And let me give you an example, you know, some pharmacies have had it where you walk in and you don't see any products, period.

You know, there's a desk, there's, there's no products. That's something that comes later. Things like that. Do, do you have anything that's like a, and I'm not saying you do because Tim and Paula, you guys are you're killing it. Implementing what you think should be implemented. Is there anything out there though that you're like, oh, that'd be cool, but it's a fearful thing to 

[00:40:20] Tim Mitchell, Pharmacist: jump into that I can say as a store owner, the cost and the resources and things are always on my mind.

And, you know, we have a team that we talk about these things regularly and sometimes I get pulled back, but. I'm one of the ones that sometimes jumps in before I start thinking about things. Um and, and so sometimes they have to pull me back. Um, and yeah, but, you know, I, I, I don't know. I, I, I don't think there's anything I'm really scared to implement.

Um, I mean, you know, buying big, expensive pieces of equipment to do dispensing. Is something I've done. Um, I'm and it's scary. Yeah. But you know, I, I, I don't have the fear of implementing these things, but I guess the biggest thing is, is just making sure it's done properly. And when you say you're gonna do something, you need to do it and not, not, yeah.

Just do it halfway. And 

[00:41:19] Mike Koelzer, Host: I've seen that where you can bring out things and kind of confuse them, you confuse the customer because you can't bring it out slowly enough or, or things like that. No, it sounds like you guys are, are doing it. You mentioned Oklahoma as like those guys being like someone that you look towards somewhat, what do they have, do they have the communication?

Do they happen to have a few pharmacists there that seem to be clicking together? What made them stand out in your mind? And it does have anything to do with their location in the US or anything. What, what do you point towards them that might. 

[00:41:58] Tim Mitchell, Pharmacist: Well, I'm pretty close with the individuals in Oklahoma. I talk to them regularly because we're, you know, regionally we're pretty close, but they're actually in Oklahoma city.

Sure. But they do have a team of individuals that run their CPS and network that are very, very integrated. The great thing about Oklahoma, CPS N. And it's part of RX select. They actually have their own transparent PBM, which actually helps move along. Some of these things are called max care.

And, um, there's, they're somewhat to an advantage because of some of the data that they can, uh, work with. Gotcha. Yeah. And, and in Missouri, we're, I'm not saying we're behind them. It's just that we don't have, we don't have our own transparent PBM that we can work with. And, and, you know, with that there's some funds and so forth that help grow that so that you can build a team.

Um, we are working on building a team in Missouri, um, and, um, we're doing some really good things. Um, but they also have some really good connections with their, um, State players. Uh, they just, I think that one of their projects is an opioid project, um, and very timely. Um, but you know, and, and again, in Missouri, uh, we are.

Making connections with our state payers making connections with Missouri Medicaid. Yeah. We already have a lot of really good things going to Missouri. The Pharmacy association has been facilitating a lot of that. Um, but again, funds are somewhat limited, so you have to be careful. Yeah. You know, you can't, you can't just hire a.

Team of six people to work on these projects when you don't have the funds to, to pay those people. Right. Unless they're all gonna be volunteers. Yeah. Right. So we've been primarily volunteer driven for a while. So the, uh, 

[00:43:44] Mike Koelzer, Host: PBM that probably saves some time right there. So that instead of bitching, about a hundred percent of 'em you maybe are only bitching about, you know, 80% of 'em or something like that, that saves time, you know?

Yeah, sure, sure. That saves some time. With any of these groups, how often, if at all, do you have camaraderie, like an annual thing, like either with your state group or with the federal thing, do you guys go to a, uh, the yearly convention 

[00:44:17] Tim Mitchell, Pharmacist: or whatever, or, yeah, I was actually just at NCPA in San Diego. NCPA. Is that where they also meet then?

Yeah. So, so NCPA. Actually help pushing the initiative of CPS N oh, is that right? Okay. Help fund it. Yeah. Gotcha. So, gotcha. I mean, it's a work group of a lot of individuals putting funds in to make this work. Uh, N CPA was one of the new organizations. Oh, interesting. So, yeah, there was a good portion of a day or two of CPSM activities.

Oh, that's great. Uh, at the NCPA meeting, uh, we also recently had. A regional meeting that had Oklahoma, Texas, Arkansas, Missouri, Iowa. Um, I think Illinois, it was a unified conference in Kansas city last, uh, July. Um, and we all got together and talked about, you know, How we're doing things and collaborating, uh, ways that we could maybe work together, looking for payer opportunities and a lot of different things.

And again, you know, it's, it's not like CPS N is gonna be bringing those players like what you were describing to us, but it's more of equipping us to go out and, and be our own advocates and find our prayers. I mean, I'm working. Our city here, our county, our local school district. We have a community college that I'm talking to.

We have, um, you know, a construction company, a couple construction companies, a trucking company. There's a bunch of different companies that are all looking for ways to try to save money in their healthcare. We feel like this could be an answer for some of not, maybe not all, but at least an answer for some of their, their, uh, woes and why their healthcare costs are going.

So, so. We're looking that way in our own business, I mean, we're not a huge business, but we're also looking for transparent ways that we can deal with our own employees. We have yeah. 35 employees between our three stores and right. We're looking at ways to, to try to think outside the box with our healthcare insurance and our, and our prescription insurance as well.

So for 

[00:46:20] Mike Koelzer, Host: sure. If I told both of you, if I said you have to take a month off from the pharmacy, you're not allowed to, you know, look at any data from your pharmacy, any patients, things like that, but you are able to progress with ideas to bring back. Would that be a good thing or would that be. A bad thing.

Oh, you'd have to check in with Tim once in a while. I just to keep tabs on you or 

[00:46:52] Tim Mitchell, Pharmacist: probably vice 

[00:46:52] Paula Boettler, Pharmacist: versa, you know, I, I can see it both ways. I think about stepping away from the pharmacy sometimes. And when we go to conferences, I feel this way, stepping out of the pharmacy and seeing new things and, you know, kind of stimulating creativity and things like that.

But I think for me personally, I don't think I could be out of the pharmacy for a month. And it would, I would just be somewhere thinking about what's going on at the pharmacy. I just don't know if I could step away 

[00:47:19] Tim Mitchell, Pharmacist: that much. 

[00:47:20] Mike Koelzer, Host: It almost seems like you have an idea and you almost kind of test it out. Like you have the idea and then a day later you test it and so on and, and you wouldn't have that ability.

Yeah. Yeah. How about 

[00:47:28] Tim Mitchell, Pharmacist: you? I love being a pharmacist and I love taking care of patients. I love patient care, patient contact that's keyed. Right. And, and, and, and if I spent too much time away from it, I'm afraid, like Paula said, I would miss it and I would want to get back into it very quickly. Um, that being said, I think it's important to, to like when I went to N I was gone for a few days.

I, um, and it, it re-energizes me and gets me focused on the things I need to focus on. Um, and I think it's important. That all store owners have that opportunity. I know it's not always easy because it costs money. Yeah. When you leave, you've gotta have somebody come in. You can't just close your store down, you know?

Yeah. 

[00:48:09] Mike Koelzer, Host: The key is that you like it, cuz I've, I've said that before, like if someone came in and said, Hey, we can turn your store into a hundred stores and you'll be in charge. And. But you have to focus on that. It's like, you'd have to be like in a high rise in some big city or something, running things now, some may like that.

Some may not, but at some point it's like, 

[00:48:28] Tim Mitchell, Pharmacist: no, I, I didn't do that for this. Yeah. Right. I think it's just built in community pharmacists to, to have that connection, to have that, you know, want to be down on the front lines and taking care of people and getting that. I mean, it's a job satisfaction thing. It really is.

When you see somebody. Get better. And, and, and you know, that they're taking the information. I mean, there's, there's some very frustrating things about the, the job as well, but, but I will tell you, uh, that level of satisfaction is always high when you can be directly right down there on the front lines and working on it instead of setting in a, an office, you know, just looking at numbers.

All day long. Yeah. Right. 

[00:49:07] Mike Koelzer, Host: What non-medical profession would each of you be in if you lost your license and, well, let's be more positive. let's say you never, let's say you never got a license. I don't want to go down that road because you guys will start ratting each other out. Um, let's say you never had the license and you, and you weren't able to go to healthcare.

What, what road would you have taken if it wasn't for, he. 

[00:49:34] Paula Boettler, Pharmacist: Well, the most likely thing would, for me, would've been, um, research because I was actually, I had a, a, my bachelor's degree is in biochemistry and I was headed down the, uh, pathway to going into research. I worked in a lab and things like that. So that's probably where I likely would have been, but I would hope that I would have some kind of job that, um, would allow for some creativity because I have found over the years that that is what, um, Keeps me going.

And that's part of the reason why I really like working here because I am allowed to be creative in my job. So 

[00:50:13] Tim Mitchell, Pharmacist: what field would that 

[00:50:14] Mike Koelzer, Host: be in that you could be 

[00:50:15] Tim Mitchell, Pharmacist: creative? 

[00:50:16] Paula Boettler, Pharmacist: I don't know. I mean, I do. Um, as far as hobbies go, I, um, I do a lot of photography and things like that. And um, that makes sense. Uh, Yeah.

So that kind of thing, I don't know. , it's hard to imagine 

[00:50:31] Tim Mitchell, Pharmacist: a lot of fields 

[00:50:32] Mike Koelzer, Host: don't allow for creativity. No. Even the ones you think they do, you know? Yeah. Yeah. 

[00:50:36] Tim Mitchell, Pharmacist: But 

[00:50:36] Paula Boettler, Pharmacist: photography would work. Yeah. And whenever I was in pharmacy school, I never really thought about pharmacy being, you know, being able to be creative in that until I got into community pharmacy.

And I thought, wow, 

[00:50:47] Tim Mitchell, Pharmacist: you'd think the opposite, 

[00:50:48] Mike Koelzer, Host: you know? Yeah. You really would. Yeah, but it's truly creative. There's truly a ton of creativity that can go into it. Mm-hmm , especially at the, you know, ownership level and so on. Yep. What about you, Tim? If you weren't on the medical side? 

[00:51:00] Tim Mitchell, Pharmacist: Uh, before I went to pharmacy school, I was actually a teacher.

Uh, I was a, uh, biology and chemistry teacher. Uh, you were, yeah. And, and, uh, this was back in the late eighties, early nineties and. Um, you know, I enjoyed teaching. I, I'm not certain, was the best teacher. I had a lot of kids tell me they learned a lot in my class, but, um, I, I spoke or I taught, uh, middle school and that is a challenging thing.

Yeah. But, you know, I would probably still be teaching, um, or maybe getting ready to retire from teaching and, and do something else because it would be close to 30 years now, I think. Um, yeah, with that being said, um, you know, I, I'm not. I don't know. I, I, I guess I was allowed to be somewhat creative, but you still had to kind of, you know, stay within the, the guidelines of the, the teaching, uh, or of the, the, the schools, um, rules and so forth.

As far as I like, I would love to take field trips. I took my kids on field trips, took 'em outside. We did solar energy stuff. I really enjoyed that kind of stuff. So, uh, that's probably what I'd still be doing. So 

[00:52:05] Mike Koelzer, Host: how long did you do that before you went 

[00:52:06] Tim Mitchell, Pharmacist: into. I actually worked in a pharmacy when I was working on my teaching degree.

I taught for about. Uh, three years. And then my wife, my wife and I were married, you know, during this time. And I told her, I said, you know, I, I really enjoyed working in a pharmacy and I just feel like I really want to do something else besides teaching. And she's like, mm-hmm . So what we, she was pregnant with our first child.

She's like, what are you wanting to do? We're getting ready to have a child then I wanna go back to school. And she's like, are you kidding me? wow. So we, we. Picked up our house and we moved to Kansas city and I, and I, you know, it was, uh, two and a half hours away and we lived up there. We found a place to live.

She found a teacher. She was a teacher as well. She found a teaching position in just south of Kansas city in the run more peculiar school, school district. And we were able to live there, uh, for four years while I finished my, uh, pharmacy degree. And then we moved back. So, um, wow. Kind of an interesting story in itself, but was that 

[00:53:07] Mike Koelzer, Host: financial at all or was it C or was it, it was 

part 

[00:53:10] Tim Mitchell, Pharmacist: of it dissatisfaction with teaching or, no, I wasn't dissatisfied with teaching.

I, you know, I was working on my master's degree, uh, while I was a teacher and I had a bachelor's degree. You gotta take school forever as a, and, um, and I, I will say, you know, Portion of the decision was because teachers unfortunately just don't make that much money. And, I 'm sure. And I, and I saw, you know, teachers that had been working there for 30 years, still struggling financially and thinking, wow, right.

This is, it is sad that these people are grooming the future of our society. Yeah. And, you know, they can't make ends meet. So, so right. That is part of it. Um, uh, you know, I, there were other things, but I just felt like. I could be. And, you know, I, I wasn't sure how creative, I really didn't know. I would even own my own stores at that time.

Um, I was just kind of up in the air about whether I'm just ready for a challenge and I want to do so. Yeah. Part of it was the challenge part of it. It's like, I think I can do this. Uh, I can, I can get through a school of pharmacy. It's a professional school. 

[00:54:17] Mike Koelzer, Host: Yeah. You had take a ton of teaching hours after that, like every few years or something, don't you to get your 

[00:54:22] Tim Mitchell, Pharmacist: master's in crap.

I wasn't far from the master's degree, my wife actually was about, I think she was about three or four hours away from her master's degree. When I decided to go, I still had a little bit more cause I was doing a different master's program, but yeah. Um, We both just stopped and we put all of our energy in getting through pharmacy school, so, wow.

Um, and we did it, we did it. So we're still together today. 32 years later. 

[00:54:48] Mike Koelzer, Host: That's a good sign. That's a good sign. Yeah. Well, that's 

[00:54:51] Tim Mitchell, Pharmacist: great. She's been a very big supporter of us in the pharmacy as well. That's great. 

[00:54:58] Mike Koelzer, Host: So five years from now, um, Tim are you going to have the same amount of physical buildings and so on or will it be more or less?

[00:55:11] Tim Mitchell, Pharmacist: You know, I don't know. I think the market will determine that again. We've talked about this as well, especially with my son, if he decides he wants to come back, which he tells me he wants to, to come back to work for us. Um, I do feel like that the type of business will be different. Mm-hmm will still be dispensing, but I do feel like we'll have a more clinical practice than what we even have today.

Mm-hmm. Um, and it will be connected with, uh, you know, ideally what I'm thinking is we'll be well connected with the, uh, medical, uh, organizations around the hospitals and the clinics in the area where they know that, that they can send patients here to get certain types of care. Yeah. But as I stated before, we do infusion therapies here through our specialty, uh, compounding pharmacy.

So we'll be able to provide a home. Uh, we're looking at the medical at home model, uh, utilizing com uh, community health workers, as well as, uh, some nurses that we employ to, to do some of these things and, and using our pharmacists in that role. Um, I, you know, it is gonna be a different world. I don't know if we'll have the same number of buildings.

Yeah. We may have to, we may have to do some consolidation, uh, based upon what the market demands are. Yeah. But we also may be reaching out into other communities. Maybe they don't have pharmacies anymore. Yeah. Um, or access to any medical care at all, so, right. Cause there's a lot of areas around here that are very rural as well.

[00:56:42] Mike Koelzer, Host: So yeah, I bet there are. Hey, great talking to you guys. 

[00:56:46] Tim Mitchell, Pharmacist: Well, it's nice talking to you too. We appreciate the opportunity and look forward to, uh, listening to more of your podcasts and, and, uh, hearing what everybody else is doing in the world. The way 

[00:56:56] Mike Koelzer, Host: that these are set up so we don't have to cover everything.

We don't have anything that we have to teach or whatever. We just really get to ask some of the interesting questions. So I appreciate you guys, you know, joining in with that. Yeah. 

[00:57:09] Tim Mitchell, Pharmacist: Thank you. Keep up the good fight. All right. All right, Tim and Paula, nice talking 

[00:57:13] Mike Koelzer, Host: to you. You too.