The Shifting Pharmacy Market | Susan Lang, CEO, XIL Health

Speech to text: 

Mike Koelzer, Host: [00:00:25] Susan for those that haven't come across you online, introduce yourself and tell our listeners what we're talking 

Susan Lang, MA, MBA: about today. So my name is Susan Lang. I'm the CEO of X I L Health. We are a consulting firm that does very complex analytics and technology in the drug pharmacy space. And what we wanna talk about today is the shifts in the market that are materially disrupting.

The current way, drugs are delivered and consumers access drugs. And so we're gonna talk. What those shifts look like and how it would impact both the pharmacy and the consumer, your company, X I L the company's name was actually long consulting. She long is a nod to the years. I worked in China, um, trying to get their hospitals accredited, working with JCO.

So my background is I also spent 20 years running hospitals and, uh, and then in the last 10 years, China's not become so popular. So we thought of having a name that sounds a little bit Asian. Isn't good. So we actually cut the name short and, uh, we came up with X I L health, which has been much easier. And also people can't seem to pronounce her long.

Which means myth of the dragonfly. That's what it actually means. Mandarin. We, 

Mike Koelzer, Host: for the longest time, our pharmacy name was well, K that's our last name, but K drugstore. And it was that way from 1945, until Nancy Reagan came along in the, you know, in the eighties and it was say no to drugs. So then the drugs had a bad connotation.

So we changed it to pharmacy in the word, but now drugs are kind of cool again, you know, like you see like, you know, the coffee shops and stuff, kind of that real singular, that real singular name, right. 

Susan Lang, MA, MBA: Everyone with a single syllable, easy to downs, easy to type. Word. Right. So everybody is going for these one word sort of things.

So drug drugs work in that regard. Do you get much into the naming of stuff? I do, uh, quite a lot. We just launched a new national brand, um, with an affiliated company called advisory health. And it's a consumer discount cash card at the pharmacy. And when you're picking a name because, uh, domains has become a business and every domain is taken, particularly in healthcare, if you don't make something up, you actually can't find anything.

So, um, we came up with advisory as in advisor and, uh, that's gone pretty well. We. Just launched that brand just a couple months ago. Um, but we do, we do spend quite a lot of time on that and also talking with our clients who have multiple brands. So a lot of pharmacies , as you know, grow through acquisition, and then they have multiple brands.

And what do you do with multiple brands? And do you rename them or do you keep them, or, you know, even if you think about Facebook, just rename themselves, you know, it's just amazing to see sort of how people think about branding today, as opposed to what it was yesterday. I remember walking in Memphis on the federal express, right?

Which is now FedEx. Everything is short once a Wolf short. 

Mike Koelzer, Host: It is, I know a big deal for the dot coms. I think that it looks good in your print advertising to have this.com I think in reality, you know, with Google, it's like you could, your name could be about anything. And if you go on Google, then you see the company and then you click on that.

We don't go to the dot coms quite as much, but it's still. Still important and pretty cool to have it there. 

Susan Lang, MA, MBA: Sure. You know, um, if you think Yahoo didn't mean anything, you know, most of these names didn't mean anything. So then it becomes your brand story. Obviously, that kind of sets that tone and tells, tells what your brand is all about and what you're promising the consumer or your client.

So we do spend a lot of time on marketing. Um, it wasn't something we started out with, even though my background was marketing. I did marketing for 10 years, the first 10 years of my healthcare career. But we find now it's, there's so much noise in healthcare. So if you think about, you know, we've got a $4.2 trillion industry, there's so much noise in healthcare.

There's millions of sites that now marketing and branding has become so incredibly important to cut through all that noise. The 

Mike Koelzer, Host: names that people think would be good names. One of 'em kind of, it doesn't really bug me. I just don't think it's effective. But how many, like national, the name national or American or United or anything like around the flag?

It sounds good at first, but then they all kind of mush together like a patriotic thing. So I like the made up ones 

Susan Lang, MA, MBA: better. Well, this is, if you think about Mark Cuban's new initiative, it's called drug cost plus, so generic it's totally generic. Nobody's ever gonna remember that. So everybody looks up to Mark Cuban, right.

But nobody's gonna ever remember the name of that company. Um, it's interesting for a guy who obviously, uh, is worth billions and clearly has to understand marketing, but it seems like a weirdly generic unattractive name. Yeah. And then you 

Mike Koelzer, Host: gotta be careful about there's the old story of the, uh, what was that?

It was a car company. Nova or something [00:05:25] like that. I forgot. But anyways, in a different language, it was no go, you know, they named a car, something that was no go. So you probably have to be careful. Well, like your company, you know, you gotta be careful what country it came from and then check all the boxes off against the hundred most popular languages or something like that.

Exactly. Yeah. So Susan, what do you do all day? Walk me through the day. Your company touches on a lot of different things. We just talked about new companies and some of your clients are big chains, you know, but walk me through you get into work and are you then working with a team that you have there and then they're branching out to all these different things or what would be a typical day for you, which will give us a taste of the business.

Susan Lang, MA, MBA: Sure. So a typical day for me would be today. So today I started off, we had an all hands meeting at 9:00 AM. That means our staff from all over the country. So, uh, we are headquartered here in St. Louis, but we set up the company 10 years ago so that you could work from anywhere. Um, which turns out was way before the trend of working from home.

Right? We did it because personally I travel and I wanted to be able to be anywhere and still conduct business. So if I'm traveling, it doesn't matter which country I would be in. So that's why we set it up that way. So we've got, uh, employees in about nine states now. And so we do an all hands meeting once a month, which is quick 30 minutes.

Hey, here's how our quarter is going. Here's all the successes we've had. Here's the things we're working on. Um, and here's the culture every day, every time we meet, we take one value of our culture. We talked about it. So today was resiliency. So that's what we were talking about. And what does resiliency really mean in a company like ours?

Um, Because we did a fairly significant pivot during COVID. Most of what we do, uh, has been consulting. So we will go in and we will work with a retail pharmacy on managed care strategy, how to do procurement, better, how to buy their drugs better, or how to reduce their costs. So all of these different economic levers that make them more profitable, that's really what we do.

But then during COVID, if you think about it, especially larger companies sat on their cash, they weren't hiring as many consultants. So we had had some very long term, very stable, uh, relationships that of course stayed with us. But in terms of growing, we decided to pivot more toward technology and really start to build out, uh, technology platforms, analytical platforms for our clients, things that.

Though there were gaps in the market, really trying to close the gap between what a retail pharmacy can see and what a PBM actually does, the pharmacy benefit manager or the payer or the health plan. Right? There's no transparency here. So our tools are trying to bridge that gap and just level the playing field a little bit and give retail pharmacies a little bit of a leg.

On, um, understanding the economics of the rest of the market. So after my all hands meeting, then I start my series of meetings. During the day with my staff, I have an analytics and pricing meeting. Then I go from that to a technology meeting with our group, which is, um, we have a group in town and we have a group in Bangalore, India.

So we're working with our Indian, uh, technology group. And then we ended up having a special lunch because, um, one of our key leaders is having their first baby. So we had lunch for him. And then, uh, I'm on this call with you. And then this afternoon, I'll be on a couple calls with clients.

Really explaining. They're seeing things in the market frequently, our clients will call us and say, Hey, Amazon just made an announcement. Mark Cuban just made an announcement. We've just heard about this new PBM from this Microsoft group that split off from Microsoft. Susan, what do you think about that?

What's the risk there? D fees. There's just been new legislation. How are you interpreting that? So those are the, you know, we spend quite a bit of time again, um, trying to interpret this for executive teams that we work with. So that's, that's a typical day for me and I'm done about five 30 or six. 

Mike Koelzer, Host: Your consulting customers.

Is there a final deliverable? Just like you can say, look, you can point to something. Is it a final report or anything, or is it just people conversing and that's your final deliverable? 

Susan Lang, MA, MBA: Oh, no, we have all kinds of deliverables. So we have, um, standard reporting packages that we do. We have an analytic platform, X I impact, which actually gives you all the dashboard for all of the pharmacy, your pharmacy information, your financial information, your payer information, your claims information.

Um, we do all kinds of analytic reports that we send custom reports. And then we also do, uh, insights. We send monthly insights, which interpret what's going on in the market. So. It's not just the communication, although I, the verbal communication, although I will say we send out a lot of these reports, uh, but unless you've been with us for a long time, we will spend a lot of time with you in meetings, on the phone, on a zoom meeting, making sure that you understand what the report says, what the data is actually telling you and you [00:10:25] don't misinterpret anything.

So we do spend quite a bit of time on that again, which is this really knowledge transfer since my whole team came from a pharmacy benefit manager and they've done the analytics, they've done the pricing, they understand how it works on the payer side. Uh, we wanna make sure that you understand that the variables we're using are very specifically defined on how a pair would think about it, not necessarily how you would always think about it.

Right. That's what we're trying to get to. So we spend, you know, quite a bit of time. I have teams of people that actually account managers that manage our clients that spend a lot of time at different levels in the organizations. I tend to deal with the C Suite and executive level, and then I've got layers of people under me that will deal with other levels of their organization.

Mike Koelzer, Host: If I was a C Suite executive of a big pharmacy company. And let's say, I know I wouldn't, but let's say I knew, I knew just as much as you did. Let's say I had the same exact background you did. I'd like to hire you anyway, just to make you a scapegoat. You know, if things go bad, do people ever get you in just so they can blame Susan and X I, and then fire you and then move on, but protect their own job.

Susan Lang, MA, MBA: No, it's a great question. So I, when you work at a big company, again, I was a C-suite executive at a fortune 30 company myself for years. So when you work at a big company frequently, they will bring in these large consulting groups, the typical, the McKinseys, the Boston consulting group, whomever, um, because they have a very specific political slant of what they're trying to get done.

And then they will use those groups, escape, quotes. It's extremely rare. That happens with us. First of all, to get to us. We're very selective about who we take as clients. You have to know somebody on my team. We don't take cold calls cuz we don't know you. And I would say that the drug industry in general is hand to hand combat.

We don't trust everybody, uh, for good reason, we've been around a long time. So we don't take everybody as a client. We probably turn away 50% of the people that call. And the other reason is if I think you're jerky, I don't have to make you more successful. I'm over that. I had to do that in my corporate life.

I don't have to do that now. Right? So I don't actually want you to be more successful if you're not a good leader in your jerky. So we're, we are, we're the contrarian consulting group. We don't take all comers. We don't even care about all comers. We try to take quality, really quality companies with really quality leadership that if we can play a small part in helping them become more successful, that's fabulous.

Um, but that's really our goal. Our goal is to work with these groups and these individuals long term, um, mentor them, try to really help them strategically find some success. In an industry that 's just harder and harder. If you're a big company and you have earnings, it's harder and harder to find success.

So that's what we're doing. We're, we're in there trying to figure out what is the next big thing? Where do we think you might have leveraged in a couple years? How do we help you make a little bit more money? So you can fulfill your mission, right? No margin, no mission. Um, and we will always err, on the side of providers, whether that's hospital systems, physicians, pharmacies, as opposed to payers, because we think the providers actually add quite a bit of value.

Mike Koelzer, Host: All right. Well now you got me all interested about the jerky. Now you gotta gimme some examples of that. 

Susan Lang, MA, MBA: there's a lot of those. Let's hear it. Look, there are two ways to move up in a company. In my opinion, one is you're just super smart and really good at what you do. And those are companies that are high growth and you're really good at executing.

But then there are slow growth companies that now it's all political. Now executing is not the main thing you survive because you have really good political skills. Well, that creates lots of, you know, disproportionate power plays and jerkiness is what I, you know, not great. Right. So, and we, you know, we can all point out probably CEOs that we know or C-suite executives that we know that are like that, you know, and that's not that they're not successful within their organizations.

It's just that their philosophy of how they treat their staff and their values would be misaligned with my company. 

Mike Koelzer, Host: And some are actually jerks on a personal business level. Like they're a jerk to the person sitting next to them at the board meeting kind of thing. 

Susan Lang, MA, MBA: People's behavior, in my opinion.

And I've managed thousands of people. Over the years, people's behavior is very consistent. So you rarely find somebody that's jerky to me that then is very nice to everybody else cuz they just don't like me and they don't even know me. Right. So that's not really a thing. I mean, usually people are just consistent.

Um, and again, that doesn't mean they can't be successful. That just means I don't wanna work with you. And I'm to the point in my career where I'm very fortunate that I get to pick and choose. So if I can find folks that I think have similar values, but are missing some skill sets or some strategy work that maybe they haven't quite gotten their arms around, then that's a perfect match for us.

There's definitely other people with my skill set. The issue is they're still at big [00:15:25] corporations with non-compete, so you can't get access to that knowledge. There's very few people that have been in my level that are out doing consulting and have been doing consulting this long that are still relevant and sort of still in the game.

I get asked all the time, why am I still doing this? People say to me, I know you've made money. Why are you still doing this? Well, because I love it. And if there's other people I can find that are younger than me, that are still sort of in their midcareer and I can help them, then that's just really fun.

I mean, that's just a great sort of added bonus for us. 

Mike Koelzer, Host: I 

had this guy that was close to me, that was trying to get me into legal trouble and he was not a good person. And I kept looking at their marriage, you know? And I'm like, how can he be so nasty to me yet? Have a decent marriage. And it ended up, he couldn't, they divorced like five years later for probably some of the same personality traits he brought into being nasty to me.

Susan Lang, MA, MBA: Well, and, and eventually not always, but eventually you see a lot of these people's careers blow up because some of that catches up with you. All of us create enemies. Look, if you're out trying to really get something done, there are people that won't like it. I mean, obviously, right. And you're gonna create enemies regardless, but creating superficially, creating enemies for no reason.

So I can remember, I walked into a meeting for the first time. This is years ago, and I won't say large fortune 100 companies. So I dealt with all the retailers. I also dealt with all the drug manufacturers, all these. Anyway, I was very excited to go into the meeting. I love this company. I love their brand.

And the guy running the meeting who was at a senior VP level just was absolutely horrible to me. Brought out a long list of issues he had with the company I had just joined. Was it horrible? The whole meeting just devolved into a completely unproductive meeting. So that's just a strategic mistake to me.

So you've just created an enemy with me where you never had to, you don't know if I'm on your side or not. I'm brand new. It gives you a fresh start. Right? New leadership always gives you a chance to tell your story again. So that was just, you know, that was just an error and on his part. And it took us a long time to recover from that.

But it's just a waste of time. So a lot of that's just skills lacking some skills, lacking, some understanding. Um, and I understand also that if you've been in the industry, the industry is tough. When I say it's hand in hand combat, it is, this is a tough industry. Everybody is out, you know, scraping for whatever margin they can find and executives come and go based on those results.

So it's not that your results are inconsequential. Um, so you always feel the pressure to perform and to figure out what's going on. So it's a tough industry. 

Mike Koelzer, Host: What skill would somebody not have that would make them be eaten up and spit out quickly as they're trying to move up? It's like, sorry, you just didn't have this skill to move up higher.

Susan Lang, MA, MBA: Yeah, I think, um, it's a, it's a related skill, two things. One is the ability to let a colleague recover. If you've had a really passionate debate. and I'll explain what that means in a minute. And then I think that the second part of that is positive confrontation. So positive confrontation is being able to really stand in your, sort of in your circle and be able to talk and not be intimidated when you know that it is on behalf of the company.

So if you think about politics, a lot of people shy away from politics in companies because they think of the terrible side of politics, which is a self-serving side of politics. But the other side of politics is it's an informal way to end debates to run strategy, which is you have to build consensus.

And that means you have to influence people. And that takes political skills, right? So building coalitions of people that support your vision, being able to articulate that vision is really important. And then when somebody else has a different vision from you being able to positively confront them, not humiliate them, but confront them, ask a lot of the right questions and still kind of hold your own ground.

Mike Koelzer, Host: The opposite of that is when there's a confrontation, the relationship breaks down. So the pro part of that is keeping a good relationship yet standing your ground and trying to figure out a compromise of some 

Susan Lang, MA, MBA: sort and not making the confrontation personal. Yeah. So I've had a lot of people that come right at you.

So I, when I was at express scripts, I did about 160 billion in negotiations. And so if, if you, you can make it as personal as you want. It does not help you in making it personal. That just tells me that you don't actually have another strategy. That's fine. I'll ignore it. Cuz I can ignore almost anything if I'm focused on what I need to achieve.

Um, but then once you have that confrontation or once you disagree at the end of the day, if, once you are debating a strategy between you and your colleague, if you are on opposite sides of the fence on how to move forward, somebody will [00:20:25] break that tie either the person over you, which could be the CEO or the CFO will weigh in or something, but somebody's gonna have to make a decision, so win or lose.

You really have to let your colleague that relationship recover. So here's what I mean by that. And you'll see this in boardrooms a lot. You'll see this robust debate. The guys will get up from the table. They'll go behind the guys who just debated, they'll slap 'em on the shoulder and say, Hey buddy, you wanna go grab a coffee?

that's allowing him to recover women. Don't do that. Women pull away now we're uncomfortable now we're embarrassed. Now we don't know what to do. So we tend to pull away. Which means that it doesn't recover. It just festers. Let's just grab a cup of coffee. Let's go, you know, whatever. I mean, I do it myself.

So you have to do it to let that person know to signal that. Hey, it's okay. It's okay. That we didn't agree. And it's okay. Even if I lose, I'll do it. If I lost right. That's okay. Right. There'll be an, we will lift a fight another day. Um, and that's different from making it personal and holding a grudge. Now I've also seen people do that who I'm sure have held a grudge.

But they understand they have to let the relationship recover, cuz they may need that person in the future. They haven't forgotten. They're not gonna forget that you didn't back them. So there are people that will hold onto that, but they'll, in the short term, let you recover because they don't know when they will need you next to get what they need done.

So that's a really critical skill set, understanding how to navigate that. And I think it's very difficult. So in my world, in the corporate world, so politics start about the director level and then senior director, a little bit more VP is when they really heat up and that's pre C Suite. Right? And then once you go in the C-suite 80% politics typically, um right.

Cuz everybody's vying for resources and strategy and, and you know, want to get the good assignments and all this kind of stuff. Um, so I, you know, I've seen people hold onto that for a long time. I've seen people build coalitions around it, but you've gotta get comfortable with using politics because it's the right thing for the company.

Not because it's the right thing for you. People are not. I mean, I see a lot of people at the VP level that don't get up to that C-suite and they're just not comfortable with that. They're also not comfortable with how aggressive it is when you're in the C suite. It's super hyper aggressive.

Right. You're competing now. So, you know, there's this narrow. Right pyramid of very few people that get promoted at express scripts. There were 10 of us out of the whole company of thousands of people. And so everybody wants that spot. And when you're there, everybody wants to bump you off to take part of your portfolio.

So it's just a really, you just gotta, you just have to get comfortable with that kind of level of aggression, which means you also kind of have to ignore a whole lot of behavior and don't take the bait focus on your own, you know, what you can do to succeed, to move the company forward. That's what you have to focus on.

Mike Koelzer, Host: That's one of my complaints now with social media, is that the old politics, when you had 'me thinking Jerry Ford and Tip O'Neal, you know, and all these guys, they were on opposite sides, but it was almost cliche. They'd be going out to the bar together, you know, and I know that Scalia and, um, who's RBG.

What is her name again? Oh, Ruth Bader Ginsburg. Yeah. Ruth Bader. I know they were like best of buddies, you know? And they fought like all day now. I think part of the problem with social media is you have these fights, whether they're neighborhood fights or politics or whatever, and. You don't need to see these people at the potluck.

You go to your sides, you go to your social media and you know, Zuckerberg is smart enough to show you 90% of the people that are in agreement with you. Maybe a few, just to keep your blood boiling, but you get to go back to your sides. And there's none of that going on. You know, that this was an argument, but this is real life.

And in real life, we're still respectful if not cozy with each other. 

Susan Lang, MA, MBA: No, I think that's true, but it's, and, but it's not what happens in companies, right? So that superficial world that you can create in social media, outside of your workplace, in the workplace, at some point you have to interact with people.

You gotta go back at it. You gotta go back. And if you're in a, if you're in a leadership position, you're probably going to be co-located. At least part of the year with your colleagues, right? Whether you fly in for a week, two weeks a month or what, whatever you're doing. So, the problem is because it's what you're saying, though, my people are growing up now with this weird anonymity around social media, they don't have to learn those skill sets, but actually to manage your career, you still need them.

In my opinion, I think they're still really valuable to have. And I will tell you, my entire consulting practice is built on long-term relationships I've had. And most of the relationships I have folks were sitting across the table for renegotiating with me, not on my side of the table. And those are the people when I left express scripts immediately reached out and said, Hey, we wanna work with you.

So it does matter that even in a tough negotiation, you treat people with respect, that you let people recover, that you leave a little bit on the table for people to make sure that, you know, we all know, Hey, everybody works for somebody. You gotta [00:25:25] answer to someone. right. So you don't have to maximize every single time you have to optimize for the long term.

So I think those are just, it's a different way of thinking about sort of how you deal with people. Um, and I think what is happening is less and less of those less and less folks have these skills because of what you say, because they're living in this sort of meta alternative universe. Right. Um, but at the end of the day, deals get done because people wanna deal.

They wanna get the deal done with you. That's how all the deals get done. Um, so not that they're not tense and you don't have to like everybody, but you have to wanna get a deal done, which means you have to wanna deal with me to some extent, otherwise you'll go on to the next deal. Right? So it does matter that you can actually manage your relationships effectively.

You don't have to like people. What I tell people I mentor is if you're dealing with somebody that you particularly can't stand, find one thing about him or her that you like. I don't care if they have a dog, find that one thing you can talk about. that you actually both like so that you can at least build a little bit of rapport with that person.

Mike Koelzer, Host: When my wife and I are in a big fight, I say, say one thing you like about me, she says, well, your in-laws are better than my in-laws. 

Susan Lang, MA, MBA: There you go. But see, it helps. It helps you recover. 

Mike Koelzer, Host: So Susan, these C Suite executives, what are their biggest external concerns now? You know, we've got things. BBMs we've got Amazon, we've got Mark Cuban out there.

What arrows are they trying to 

Susan Lang, MA, MBA: fend off? So, I mean, I'm just talking, I'll talk at a very high level and then we can get to some specifics. So there's a couple of things that have happened in the market in the last 10 years that have dramatically shifted the market. The first is high deductible health plans. So having that's a structural shift in the market due to changes in insurance.

Right. And what that means is that all of a sudden, if you're a family of four, you have to put aside $7,500 to pay for your healthcare. And once you spend that $7,500 or $5,000, whatever that deductible might be, then your insurance really kicks in. So then the first dollar kicks in, people don't have that money by the way, set aside.

And because people don't have that money set aside, everything as healthcare is now moving toward, not everything, but everything outpatient is moving toward cash pay. So, what we have learned through high deductible plans is, and what people are learning in the pharmacy space is that if somebody has a high deductible plan, it might be cheaper if they use a discount cash card and just pay cash than using their insurance.

That's a ginormous shift in the market, right? That used to never be that way that doesn't 

Mike Koelzer, Host: go to their deductible, but they don't care because it's so high that they might 

Susan Lang, MA, MBA: not hit it. They don't care because 78% of people will never hit the end of the deductible in a year. So they don't care unless you're having a surgery, you end up in an ER or something like that.

You're not gonna hit the end of your deductible. So that's sort of the first big thing that's happening. The second thing is it's an industry that is enormously complex with no transparency and a very complex supply chain that moves in multiple ways. At one time, if you think about a normal supply chain, you go from A, B, C, D all the way down in a linear way.

That is not the drug supply chain. You've got. Dollars moving back and forth and in circular ways, because of all kinds of complexity in the market, which also makes this an industry that is ripe for people who are looking for profit pools. So it used to be, we would look for revenue pools, but now you're looking for profit pools and start pulling off threads of profitability because of the massive consolidation that has happened.

So if you think about, um, really healthcare is now dominated by about 45 fortune 100 companies, right? Walmart is the largest, and you've got CVS United, just go all the way down the line, Pfizer, everybody. Um, so when you get to be that large, it's very difficult to manage at the local market level.

So that gives entrepreneurs an opportunity to jump in because they're just looking like me. I'm looking for a niche. I don't have to be all things. All people, I don't have to be a, you know, $160 billion Cardinal healthcare. I don't have to do any of that. I'm just looking for that niche. So what we have is we have a lot of nontraditional entrance into the drug space.

You're actually caring a lot about the customer. And what you're trying to do is disenfranchise the middle man. And you do what I call distributive economics. You take what the middle man was making. And you redistribute that you take a little bit, you give the rest to the customer or the consumer, and then everybody wins.

And you realign that part of the market, big companies are doing it. Disruptive companies are doing it. Small companies are doing it in niches, right? A lot of startup money. So we have billions of dollars flowing into healthcare startups trying to figure out where these threads or profitability are.

And because we can manage it more effectively and efficiently, and we can redistribute that those economics and realign with the client 

Mike Koelzer, Host: and they'll do it better because they just like anything. They haven't spread it out and they're able to [00:30:25] focus on their niche and things like that. 

Susan Lang, MA, MBA: Exactly. Right. It's a much more focused niche as opposed to managing if you're United healthcare, which is a fabulous company.

So I'm not cooking them, but my God, they're so big. So you can't manage everything at the minutia level, down in the community. Right. Which leaves room for entrepreneurs to come in and make small disruptions here and there, if you're large companies and you have nowhere else to grow and you're in technology and you say, oh my gosh, okay.

Well, here is this $4 trillion industry. How do I get into that? Right. 17% of our economy, I'm not playing in that space. That's a great growth space. So how do I enter that space? Where do I find a niche for myself? So that's what we're seeing now in healthcare. That's whether that's the mark Cubans, whether that's the Amazons, whether that, you know, there's a group of guys that left Microsoft who have jumped in there's, you know, there's just groups of these folks that are coming in from other big companies that are trying to disrupt.

And then you've got a lot of executives that have left the big companies, such as myself who are also trying to disrupt this inside knowledge. Right? So, um, if you think about what is happening in the market between the, the structural shift in insurance to high deductible plans between the massive consolidation, which leaves room now to devolve some of these organizations and create niches and then the movement to cash pay, you know, and then you've got the gig economy with less people insured.

Right. That just needs access to medical services and pharmacy services, but don't necessarily get healthcare anywhere, cuz they're in the gig economy. All of these structural things are shifting the way we think about the drug industry and what I think the drug industry will look like, you know, in the next 10 years.

So that's been actually really exciting for us because as a disruptor, as an entrepreneur, when everything is stable, it's not helpful to me. I want things slightly unstable so I can figure out, you know, throw the pieces back up and let's see if we can reconfigure them in a different way. That's what I'm trying to do.

Stability just locks me out. Right? There's gotta be a big problem or some instability for me to be able to jump in and fix that. So this is a great time. If you love healthcare, it's a great time to take a look at healthcare. There's innumerable issues we could work on. You know, healthcare is messy and, and problematic, so there's lots of things we can work on.

Um, so, so it's exciting. 

Mike Koelzer, Host: You know, what's interesting about Amazon is that I was listening to, uh, L Reese and Jack trout, the authors of 22 immutable marketing laws. I was listening to that book a month ago or so, and. They've got it right. But they all talk about, you know, niching down and you know, if you're not the first man on the moon, then give up on being known, unless you're the first woman on the moon, that kind of thing.

You gotta be first in your market. And I agree with all that, but to listen to them and then see what Amazon has done. It's a strange thing. They're huge. And they've got the market and they sometimes are doing a lot better than anybody that is trying to niche them down. They're going in, in the opposite direction.

They're saying, no, we're not gonna niche down, and specialize and give real great service. We're gonna give great service to everybody. It's an odd switch that this book didn't pick up on. It's just an odd thing to think of something that big, that does so well. 

Susan Lang, MA, MBA: So that's a supply chain company that's scale, right?

That's leveraging scale. So what they're saying is nicheing, doesn't help us. It makes our costs go up. We have the technology we need, we're gonna leverage our scale and implement more technology, which I get. Right. Um, but if you think about Amazon, even, so they had a bad quarter, they, they, there are problems.

They haven't been able to solve it. So unfortunately for them teaching the marketplace, that when you're sitting at home at 10 30 at night, you have nothing to do. So order your toothpaste online and then 20 minutes later order something else. But we don't put them in the same box. They haven't been able to figure that out.

Same problem we have with mail order pharmacies. They don't have a way to put those orders together. But then we went through a shortage of cardboard, which made their costs go through the roof because everybody's ordering one off. They're not taking a list of things and ordering. So Amazon hasn't figured that out yet.

It's the same thing. Mail outta pharmacies. So problem mail or pharmacies have. What happens is your scripts. Don't come at the same time, your prescriptions. So we're sending you multiple packages to the same house, but it would be so much more cost effective. If we could just send you one a month, it just doesn't work that way.

So they've sort of created this monster and they're gonna have to figure out how to solve it, because there is a question around the sustainability of how much cardboard you can use. It 

Mike Koelzer, Host: might be like me setting up my pharmacy and saying, uh, we have delivery. And every delivery person that comes out is also gonna clean your garage for you and scrub your toilets, you know, and it's great service, but that's not [00:35:25] sustainable.

And they've gotten people into that habit, but now they 

Susan Lang, MA, MBA: can't do it. And your labor costs have gone up. Right. So, all of these, all of these issues, you know, so, so everybody's got their own issues, but they definitely have the scale, but also financially they've had a bad quarter. So it's not as if everybody's making a ton of money either.

Right? Lots of companies are still laying off. Lot of companies can't figure it out. There's a lot of startups in healthcare that have, uh, announced massive layoffs. Also, it's just that managing a global economy with a global supply chain is really complex for everybody. Even the drug supply chain, which is global, has been really complex, right?

Our active ingredient for the drug, the chemical ingredient comes from China, goes to India. We pull it in India, we ship it. You know, we ship it to Europe, we repackage it in the Caribbean, whatever. It's just, it's just a, really, these are really, um, complex supply chains and margins have shrunk. And so I think it's, um, it's been really hard for some of the larger companies to turn the ship.

On the other hand, they have unlimited access to capital, which small companies don't. Right. So they can make, they can afford to make some mistakes, take some risks and make mistakes, which Amazon's probably the king of. Right. They've had as many failures as successes. Um, they don't talk about 'em.

We just, everybody just moves on. Um, but they also have the capital to be able to fail safely and, and be, you know, be okay. Whereas a small company, you really don't have that. You've gotta actually be right. A lot of the time or you just won't, you know, you won't survive 

Mike Koelzer, Host: Amazon, you see it in the pharmacy on a small scale.

It's right. It's one thing if Mrs. Smith is going to order a book, it's okay for that to show up in Eight days. No, one's going to die if you don't get it right away. It's another thing when you answer the phone and you're talking to Mrs. Smith and she's punching in on the push button on the phone, thinking she's talking to a computer and you're trying to get her to talk to you and they need their medicine today.

And they messed up on, you know, I mean, it's like, it's a 

complicated 

thing. 

Susan Lang, MA, MBA: It's complicated. And if you think about, uh, who fills prescriptions in the United States, I mean, everybody does, but disproportionately seniors do. Seniors, take more seniors also want to call your customer service and talk longer.

Seniors also are very nervous. Like you just said, when the drug doesn't come on time, they get really nervous because then they probably need the doctor to write another script and get that filled at a retail pharmacy. There's a lot of, Psychological issues with having that prescription. If you have a chronic illness and you need that medicine to keep functioning, right?

We're gonna go back to this current theme, this constant theme of you have to be functional. You want that script in your hand, you wanna know that you have it and you're okay. You don't wanna worry that because a COVID in the supply chain, it's not coming on time. And what if you don't get it next month?

That makes people really anxious. So they have a lot of, you know, they bought PillPack. So Amazon bought PillPack. Then they moved into, uh, clinics for their own employees. Right? Which is sort of an expanded primary care clinic that also has physical therapy. So they're trying a bunch of things. We had that coalition between, you know, Berkshire Hathaway and Jamie diamond and right.

So we've tried other coalitions, they thought they were gonna change healthcare for their own employees and it did not work. Um, so you've had people come in and out of this sort of market where it's not worked. Google has come in and out several times, Microsoft has come in and out several times. So. Lot of people come into healthcare.

And what happens is they'll call us as consultants. And what I hear from their CEOs is, oh my gosh, this is so much more complicated than we ever thought. Yes. Right. This is enormously regulated, cuz you're dealing with people's lives. This is life and death stuff. Right? So it's not like anything else.

If you think about the legacy of Silicon valley, just build it, fix your problems later, build all the technology. Don't worry about the bugs, fix it later. Hard to do in healthcare. 

Mike Koelzer, Host: It's hard to do when someone needs their next dose in two hours kind of 

Susan Lang, MA, MBA: thing. Exactly. Really hard to do in healthcare. It's easier to do if you know, it's easy to do with social media because if you get bumped off the platform because they went down for a day who cares?

I mean, it might aggravate you. It's not gonna kill you, but your medicine not coming actually could kill you in, in some circumstances. Right. So it's just, it's just a totally different level of commitment. To a minimally viable product. The first time has to be right. You've got a 

Mike Koelzer, Host: 83 year old lady who sleeps for five hours a day.

So the other 19 hours a day, she's waiting for her bottle of drugs 

Susan Lang, MA, MBA: to show up. Right. If she doesn't get her meds, it's not just affecting her. She's if she has anybody in her family, she's calling like me. That would be me taking that call from my mom saying, oh my gosh, my, my medic, since didn't come, what do I do now?

Okay. We gotta call your primary care doctor. We'll get you another script. We'll go to the pharmacy. You know? So it affects other people. It affects a lot of people, a lot of caregivers. And or if you have nobody around you, then the worst case scenario is you don't take your meds, you have an adverse event and you end up in [00:40:25] urgent care center or, you know, somewhere else.

Right. So, um, yeah, just definitely a, a D. Um, mindset. So when you see people jumping in like the mark Cubans, who just jumped in also, he's decided that we have a drug cost issue. Well, here's what I think about the economics of drugs. So if you think about there's, let's just say 6 billion prescriptions in retail filled a year around that 6.2 billion outta there.

6.2 billion. 91% are generics. Okay. About 2% are specialty drugs, which means biologic injectables infused drugs. And then there's about another 7% that are brand drugs. We really don't have an access or cost issue for the vast majority of generic. For the vast majority of generics, those are inexpensive drugs.

Whether you go to Walmart for the $4 list, or you can go and get free antibiotics at different places. What we have is we have a problem with brand drugs and we have a real problem with specialty drugs. So specialty drugs are only two and a half percent of the volume of drugs, but they account for upwards of 50, 55% of all the costs.

So when Cuban says he's gonna solve the problem, and he's trying to solve a problem that politicians haven't solved, he jumps in with a hundred generic drugs. That's not where I see the problem. I don't think the difference between paying $11 or $8 is the issue and accessing your drug. It's paying $3,500, $5,000 a month.

There are some drugs, as you know, that are $90,000 for three month treatment. That's the problem. And he has no solution to that. I don't have a solution to that either. So I don't see him as doing anything disruptive whatsoever. Um, it's no different than cash discount cards that are out there. So I don't know.

I mean, maybe his name will get him, you know, enough notoriety enough publicity that he'll get some volume coming through, but I don't, I don't see anything he's doing as disruptive at 

Mike Koelzer, Host: all. Yeah. That's a disruption to the tuna, maybe 40 bucks a year or something like that. But then it loses a definition of disruption basically.

Susan Lang, MA, MBA: Yeah. I looked up a couple of his drugs and he was charging. So I looked up one drug. His drug was gonna be $8 and 60 cents versus a cash card at 5 97. You know, it's this it's again, it's three or $4 difference. It's not where people are struggling every month. 

Mike Koelzer, Host: One thing I'm surprised about Susan is when I see these pharmacy-like delivery apps or something, and I'll see that they've raised like, you know, a billion dollars, some California firm.

And I look at their stuff and I'm like, well, that's an app. And sometimes I'm wondering if they're getting these investors in and painting too easy of a picture because I'm looking at stuff. So I'm like, that's not very advanced. I'd like to get a billion dollars for that. 

Susan Lang, MA, MBA: I've worked with a lot of different investors, institutional investors, some of the biggest companies helping raise money for clients.

Um, you know, I think everybody's looking for the next big thing. I think GoodRx was one of the companies that did disrupt the market, but they weren't the initial disruptor, the initial disruptor was Walmart with their $4 program. Right. And then a good sort of took that kind of philosophy. And, and, uh, and actually there was a company called U a, which started cash cards in the United States.

So they weren't the first in the market. Right, right. Uh, but they took it and they decided that they wouldn't negotiate or contract with pharmacies. They would go directly and just work with the PBMs cuz they couldn't figure out their business model. So even today they don't have a network, it's all owned by the PBMs and the PBMs will tell you, they're just sort of the marketing arm for them.

Um, having said that they have disrupted the market in that they have taught consumers. That they could potentially get a better price with a discount card than using their insurance. So that that's been a big shift and that's a, a good shift in the market, so that they've done something positive 

Mike Koelzer, Host: and their stock has taken a dive recently.

Right. Good RS. 

Susan Lang, MA, MBA: Oh, they're getting crushed. Right. But they, but again, they've raised a ton of money. They went public. Then we had a lot of healthcare companies, several go public using spec, right. These, uh, these special project initiatives where you sort of have a shell company that goes public, and then you put the company in, after it raises the capital.

And we've had a lot of those kinds of, uh, not do well this year. So there's been a lot of money pouring into healthcare. And I think that what the problem right now, Mike, is that there. More money than there is probably good really solid companies with a path to profitability. Right? A lot of these companies don't seem to have a path to profitability.

A lot of the ones that I look at, I spend quite a bit of time, uh, with private equity, you know? So they're placing money maybe where they're, you know, where they're betting, but they probably are looking for a little bit more quality. It's like the 

Mike Koelzer, Host: early.com days. Yeah. Money's waiting out there and you might have, let's say you have a hundred ideas and 98% of 'em aren't gonna make it, but they wanna invest in more than just 2%.

They want to go down to like the top 20, but it's like, it's not there still it's in the top 

Susan Lang, MA, MBA: two, maybe. Exactly. And they do have some time constraints and it is regulated private equity. When you take in. A fund how, uh, quickly you have to [00:45:25] actually put that money into an investment vehicle. So there are constraints for them.

So they're constantly looking for I'm sure. Investment vehicles, I'm not private equity, so I'm not speaking for them in any way, but, um, but I, I think there is quite a lot of, uh, capital available. So for folks that have good ideas that, uh, can think they can scale a company that has a path to profitability, there's probably a lot of money out there.

Right. Um, and then I think there's a lot of people that invest in healthcare that actually don't understand anything about healthcare whatsoever. And so then you see some of these folks get funded and you think, gosh, that doesn't make sense, but again, they're not necessarily working with funders that are adept healthcare as 

Mike Koelzer, Host: consumers.

We think we can name. All the successes, you know, look at Amazon, look at Google, look at Facebook, look at TikTok, look at Instagram. It's like, yeah, but you've named the top player in all of those. And there's hundreds and thousands of them that have failed. 

Susan Lang, MA, MBA: Oh, there's millions, millions of companies. 

Mike Koelzer, Host: Right?

You don't think that way cuz you think, oh, it's just easy to do an app startup. It's like, no, there's like one Amazon, you know, maybe Walmart is coming, you know, They're very 

Susan Lang, MA, MBA: few well, and these companies are really old, you know? So the other thing we don't remember is these are not new companies. I mean, Amazon's been around what now?

29 years, 30 years, these are old mature companies in a mature industry. These are not like sort of the new, so they talk about the new unicorns, right? Who are the new unicorns you wanna get to within a couple years, get to a billion dollar valuation. And then when you look at that, a lot of these companies get to the valuation, but they don't go on to become these really massive companies.

Like what we have seen with Cigna and the other companies in healthcare. Um, very hard to do in this day and time. Right. We're just in a different time. Most of those companies grew organically for the first, so many years. And then it's all acquisition, which means you have to have an enormous amount of capital.

Um, and that's even how to express scripts, right? Express screw. We did find the first 10 years probably organic growth, but then it's all acquisition after that. If you really wanna grow, you've gotta acquire. So move quickly. So, you know, lots of, uh, factors that will go into trying to build a company, a massive company, but it also takes decades.

It's not quick. These companies have been around for decades. And as you say, for every one company that makes it to a hundred billion dollars in market cap, there's millions of companies that are probably no longer in business. 

Mike Koelzer, Host: And what industries are out there now that haven't consolidated in the last 20 years that can get to those levels.

I mean, you've already hit computers and the. Distribution of Amazon and things like that. I mean, maybe there could be a leader in AI. I mean, there's 

Susan Lang, MA, MBA: probably still room and wearables. If you think about healthcare wearables still, I mean, I know Apple Google, but there's actually others that are still in that market.

There's still an entrance in the market. It's new enough technology. So health wearables, there's also in the provider space. There's things that haven't consolidated. So, uh, physical therapy, we also own a physical therapy clinic that is not consolidated. Home health is not consolidated, right? So there's still other, probably areas in healthcare that haven't consolidated yet that are just very human capital intensive, um, and are, and very local, right.

In a lot of ways, very local. So those haven't consolidated yet. But when you look at sort of just other industries, if you think about what Uber did, Uber took on a 20 billion industry. Not a $4 trillion industry. So if you think about it, they were trying to disrupt a $20 billion industry, that is not the same as disrupting healthcare at $4 trillion, right?

It was not consolidated. They were not fighting with the fortune one hundreds who already controlled the space who were not making room for anybody. Right. They have no intention of making room for you. So it's really different. It's just a very different dynamic of how you penetrate this market.

There's also some devices now, like, uh, if you think about diagnostic devices, like, uh, There's a device for cardiac, right? Where you can put two fingers on this little device and you can listen, look at your, uh, heart and make sure that it, you, you don't have a rhythm issue or anything. So there's a whole new area that will be coming up around personalized health devices where you're collecting your own health information.

Mike Koelzer, Host: I read last year, I think it was Tim cook from apple. And he said at the end of time, at the end of the day, at the end of whenever, people will look back on apple as a healthcare 

Susan Lang, MA, MBA: company. Yeah. And he said that would be his greatest achievement. And I have no idea. People have asked me that I have no idea what he's talking about.

so I don't know. I don't know what their plans are. Well, you know, like 

Mike Koelzer, Host: something with the watches and all that heartbeat stuff. Don't you think? Or do you think that's hogwash? 

Susan Lang, MA, MBA: Well, I don't know. I mean, look. When I think about healthcare, giving people a lot more health data, there's some amount of having more personal health data that is actionable.

That's good. [00:50:25] Beyond what's actionable. Just makes you anxious. Frankly. One of the cultural aspects of American healthcare is we're incredibly, incredibly focused on our health in a way that other countries are not. So day to day, we talk about health constantly. We go to the doctor all the time. For those of us who can access physicians, we use way too much care there.

Then there's places in the United States that don't have enough care. So we're very preoccupied. In lots of ways with our healthcare in the United States, but we kind of 

Mike Koelzer, Host: suck at it. We're down the list of a lot of countries, as far as our health is concerned. Right? We 

Susan Lang, MA, MBA: are, I mean, we have like sort of maternal child health is not great here.

So for all the technology and all the expense, it's not really great. Um, we're ranked like 40th internationally. So, um, there are places where we have so much room to improve. Um, so in terms of wearables, if it's something that's actionable, that's great. If it's not actionable, but you just wanna check your heart rate all the time.

Probably not good. That's probably a little bit too much focus on that. you know, so, but this is sort of, this is gonna be kind of the test, right? Which is. What is really helpful and healthy versus what is just more and more information. I mean, there's so much information out there today that you can't do anything with it.

There's so much data, right? We talk about big data. Everybody's got data. The question I have about wearables is who in the world is managing that data and where does it go? Who's got access to that data, cuz almost all of these companies that have wearables use a third party, who is that? 

Mike Koelzer, Host: I think that's gonna be blockchain.

Wouldn't you say that the blockchain's gonna come and store all that stuff. People don't want to trust the government. With their money, the big eye in the sky for the money. They certainly don't wanna do it for healthcare. I wonder if blockchain's gonna help with that. People feel like they own it more than even giving it somewhere, but then 

Susan Lang, MA, MBA: who do you want to have your data and what are they doing with it?

You're not saying, who do you want 

Mike Koelzer, Host: to store your data? You're saying, what kind of company would you trust to use the data? 

Susan Lang, MA, MBA: Exactly. And what can they do with it? And who can they sell it to? I mean, it's the same thing. If you think about ancestry.com, ancestry.com collects more genetic material than any company in the country by doing their genetic testing.

Well, they also sell that data to pharma. You know, I think there's gonna be some newer industries that are gonna pop up around controlling your data, controlling your health data, controlling your genetic information, all this kind of stuff. I think so. I think there's, uh, gonna be sort of these cottage industries that will spring up based on outcomes of things we're doing now, where people will want more control.

If people won't control privacy around how they're spending, you know, how they're shopping online, they're clearly gonna want some privacy around what their health information looks like. Um, HIPAA, but notwithstanding, which we already have HIPAA laws, but HIPAA, but notwithstanding. So, um, that's gonna be interesting.

So I think there will be, you know, there's gonna be more innovation. Uh, I think every time we shift in the industry, it hopefully creates some new pockets for innovation, which I think will be positive. I think there's a lot of runway out there still, when you think of 

Mike Koelzer, Host: big in quotes healthcare companies, and then let's throw out the PBMs because they don't really add value.

And now let's throw out hospital systems because that's when you're, you know, you're stuck there. What companies come to mind as the leader in personal healthcare. I'm trying to think in my head, who is this? Who has that niche on a large scale? Does 

Susan Lang, MA, MBA: anybody, I would tell you the company that I think is trying really hard to have that niche is CVS health.

So CVS has backed into, if you look at their, uh, public strategic plan that they put out for investors, you know, they're backing into several different areas of healthcare, whether that's, uh, what I call convenience clinics or urgent care centers or mental health, or, you know, combined with pharmacy. I mean, they're clearly trying to, for the.

Retail consumer who doesn't have to be hospitalized, who doesn't need some level of inpatient side of care, whether that's a step down unit nursing home. So that's all the inpatient side of care. So set that aside. They're trying to kind of really own this retail space. So I see them trying to own it.

Walmart has definitely, um, dipped its toe in the water. They were supposed to open 200 sort of urgent care primary care centers. I don't know what exactly they're calling. It was a blended model, but then I know they pulled back a little bit from that. So I'm not sure that they're making the same level of commitment.

What you see right now is this blending of medical clinical and pharmacy coming together in an outpatient setting that is away from hospitals, away from hospital outpatient, whether it's freestanding clinics, whether it's convenience care, whether it's in the home. I think the site of care, the further away you get from a hospital, the less expensive the care is, and that is really when people want, they want to age well in their home.

So I think there's several home health companies that are really looking to set up smart homes. Google has tried with the smart technology to set up smart homes. So I do think that's another [00:55:25] whole industry that's been around for about 10 years, but hasn't really caught on to scale yet. But over time could, when you 

Mike Koelzer, Host: talk about the CVS and the home companies and stuff, does third party come to mind or do you think more of cash for like these CVS things and the, you know, these high deductibles, so people are gonna be paying cash.

Susan Lang, MA, MBA: So third party parties come to mind, especially for Medicare. So I don't see seniors. I don't think people necessarily have savings to pay cash for everything. There are pockets of that that will pay cash. But I think generally I think there's gonna be a continuous, large shift to cash for both clinical. as well as pharmacy services and combinations of those services through membership programs, through subscription programs.

Um, the Ashner clinic, for instance, in Louisiana, has a model out there where they'll give you a couple of primary care visits and some low cost generics for a subscription price. So I do see that starting to take hold a little bit. And I think people are really looking at that and saying, Hey, does that make sense?

Can I replace my deductible plan or do I just really need catastrophic coverage? So if I am hospitalized, that's all I really need to pay for. And I think the more options that are out there for consumers, the more they will start to see this as a real possibility. But I do think that's also in the early stages, out of all 

Mike Koelzer, Host: the things I've said today, while we're talking here that have got me the most giddy was that, uh, good RX stock is going down.

Our listeners know why we hate good RX and those discount cards. Well, 

Susan Lang, MA, MBA: you know, GoodRx, um, they went public. They have a business model where they are really the marketing arm, the consumer marketing arm for PBMs, which is not what a PBM does, right? PBMs work with employers. They don't work well directly with consumers.

And there are some exceptions. Humana does a pretty nice job with individuals, for Medicare and things like that. But generally, you know, except for Medicare payers working with employers. So they needed somebody who knew the consumer market and good, or got really good at that. The problem is the economics are not aligned with the pharmacy.

They take the, as a middleman, they take so much money off the table for pharmacies. It's just, it's crazy where pharmacies are literally losing money by filling good scripts. 

Mike Koelzer, Host: GoodRX came in and piggybacked with the PBM. So the same mandate with the PBMs is you have to do this good RX came along for that ride, basically.

Susan Lang, MA, MBA: Yeah. But a PBM can't tell a consumer what to do. They don't control consumers at all. Right? 

Mike Koelzer, Host: So where's the in, away from 

Susan Lang, MA, MBA: GoodRx. So I think you really have to look at them, you need to work with a cash card. If you're a pharmacy, you need to work with a cash card strategy for cash cards that are unaffiliated with a PBM or health plan.

That's really what needs to happen. And there, there are just a couple out there. Um, advisory health is one. Um, single care is one blank. Health is one there's very few out there that are unaffiliated, but you really need to work with an unaffiliated plan to make sure that the consumer is still getting the best price, but you are not being underpaid and losing money.

I mean, filling a consumer script and losing money. What's the point of it? I mean, right. Obviously then the more volume you get, the worse your economics get. It makes no money. It's completely misaligned. So really thinking about that strategy, uh, we do quite a lot of work in that strategy. We have a tool that actually can take, um, a pharmacy's cash cards and we can rank them by economics and let them see how much they're making, um, on each individual cash card.

So I think that's gonna be really important in the future. Otherwise, as cash grows and becomes a bigger part of the pharmacy's book and they're losing more money on it, their economics will just continue to deteriorate. So this is a place they need to pay attention to. 

Mike Koelzer, Host: Where are you gonna be in 10 years, Susan?

Are you gonna be doing what you're doing 

Susan Lang, MA, MBA: now? No, I hope not. No. I wanna be doing something different in 10 years. I've been doing this a long time. You wanna change? Yeah, I think in 10 years, you know, I'm, uh, I'm working on a book right now in leadership, so that'll be exciting. I've done a lot of international work.

I sit on a board for a company called Develop Africa. We work in Sierra Leone, improving their healthcare. So there's just lots of others, I have lots of other interests. I have worked globally for a long time. I think in this space specifically, I have about eight more years. Where does eight come from?

Eight comes from my age, probably right. I'm 60 this year. 

Mike Koelzer, Host: I was gonna put you in eight years at 

Susan Lang, MA, MBA: 37. See, that's so kind of you, Mike, but you know, I'm an old dog. I've been doing this a long, long time. Oh, I've got a great team. I've got a great young, younger team that can sort of pick up where I left off.

Mike Koelzer, Host: Will you always be. In some business relationship with somebody you'll always be doing some consulting, maybe an hour a day somewhere. You don't wanna hang it all 

Susan Lang, MA, MBA: up. No, I won't hang it all up. No, there's no way I, I had a company last year, so I, I own, let's see, I started four companies in the last 10 years.[01:00:25] 

I still own three of them. I sold the first company I ever started, which was, who pays the last quarter of last year, which was a health advocacy company. We worked with employers to advocate on behalf of their employers so they could use their benefits correctly. Didn't have to overpay, you know, check their medical, uh, bills, make sure there were no errors, all that kind of stuff.

So we sold that company and started this new affiliate company this year with advisory health. We still own physical therapy companies. I own consulting companies. Um, I own a company that we do actually farming and we try to keep, uh, family farms intact. And, uh, so I, I mean, I'm an entrepreneur here, entrepreneur, so there's lots of other ideas I already have of things that I want to do.

So I won't be out. Um, And I also do a lot with private equity. I sit on boards, I do things like that, but, um, I really, really wanna turn my focus to making sure we get some of these younger folks, uh, that are really passionate about healthcare situated correctly. I'd like to spend, you know, 10 years doing that and setting up a formal mentorship program and making sure we get these kids, you know, positioned right for success and helping them navigate through.

So there's just, there's just a lot of things that I wanna do, so I won't be out. I'll just be, you know, you constantly in this industry have to reinvent yourself. Right. About every 10 years, uh, you have to reinvent yourself, and learn something new. Um, it's, it's constantly changing, you know, 10 years in healthcare.

Oh my God. Eight years in healthcare, Mike, that's a long time in healthcare. 

Mike Koelzer, Host: It's interesting that you say, Hey, I'm at seven. My youngest is 11. And so we're in a house that suited our family, but gradually became too big for us. And so here's my plan. I tell my wife because we have a cottage up north. And so here's the plan: every time we have one of these open houses, it's like a two year to- do list for me, you know, for my wife, cuz it gets a house in order.

So what I'm gonna do is come to Drew's. Graduation party. He's 11. Now, when he turns, let's say 18, he has his graduation party. I'm gonna have an open house from two to five for all the family and friends and classmates and things like that. And then come five o'clock I'm gonna have my realtor pound in a sign up front for me.

Open house to sell it. And, you know, people can come by and have the stale, Jimmy, John sandwiches and so on. And maybe I'll even trick some of 'em into putting a hundred dollars check into the graduation gift box or something like that. But then we're gonna sell and go. So I'm at seven years, I'm hopefully one year in front of 

Susan Lang, MA, MBA: you all right.

Seven years. But then do you wanna do something else or you want out, I have 

Mike Koelzer, Host: no idea, Susan. This has been on my mind for, you know, the store. I was there at one point when I was 13 years old. So for 42 years, this has always been on my mind. And so I might get done for a week and then have to go, you know, volunteer at the Red Cross or do I have no idea?

So I'm not pretending I have any idea. 

Susan Lang, MA, MBA: Well, the thing is right, you have all these skills, right? So, uh, you don't wanna just stop. You wanna be able to pass those skills onto someone else, right. And still make a difference. Eventually I want more control over my schedule. I travel quite a bit. I'd like to travel even more, but I still have skill sets that I think are relevant so long as I'm still relevant.

I can still pass some of that on. 

Mike Koelzer, Host: Susan pleasure talking to you. Great talking to you, Mike. We'll get you on here again. When your, um, book comes out, talking more about leadership. That'd be great, Susan. Nice 

Susan Lang, MA, MBA: talking to you. Okay. Thank you so much. Take care, Mike.