Narrator - Dr. Abel  00:00
Welcome to HelixTalk, an educational podcast for healthcare students and providers, covering real life clinical pearls, professional pharmacy topics and drug therapy discussions. This podcast is

Narrator - ?  00:12
provided by pharmacists and faculty members at Rosalind Franklin University, College of Pharmacy.

Narrator - Dr. Abel  00:17
This podcast contains general information for educational purposes only. This is not professional advice, and should not be used in lieu of obtaining advice from a qualified health care provider.

Narrator - ?  00:27
And now on to the show.

Dr. Sean Kane  00:31
Welcome to HelixTalk. 148 I'm your co host, Dr. Kane, and I'm Dr. Patel, and the title of today's episode is grit, determination and entrepreneurship a pharmacist career path to starting an independent pharmacy,

Dr. Khyati Patel  00:46
we're going to ask for drum rolls, because we're really excited in this episode to interview Dr. Hetal Patel, our very own cop alumnus, regarding her career path that eventually led her to Open an independent pharmacy named Lebanon family pharmacy in Tennessee, and back in 2021 we're going to discuss the challenges and the opportunities of starting this independent pharmacy business, and what's the future of independent pharmacy looks like. Thank you so much for taking the time, Dr. Patel, to join us today.

Speaker 1  01:18
Thank you, Dr. Kathy Patel and Doctor Sean Cain for inviting me for this episode, I am really excited to talk to you guys about my experience today. Just a little bit of background on myself. I graduated from University of Tennessee, Knoxville in 2009 with a bachelor's in biochemistry and cellular molecular biology. And then after that, I worked for Cigna HealthSpring in Nashville for a few years as a prior authorization specialist, as a pharmacy technician. And then I also worked for a long term care pharmacy in California for a year in a closed-door LTC pharmacy as a inventory specialist. And then after that, in 2014 I started RFUMS College of Pharmacy, and graduated in 2018 So Doctor

Dr. Sean Kane  02:08
Patel, it sounds like you had some pharmacy experience before you came to pharmacy school, which I'm sure served you well in pharmacy school. And then at some point, as we mentioned, you ended up running your own new pharmacy. Was that the plan all along, or was it something that kind of happened during or after pharmacy school? Where did the the idea of making your own pharmacy come from?

Speaker 1  02:29
So I never thought that I would be a business like a pharmacy owner. I always wanted to be a business owner, because it's, you know, obviously, in our blood, my parents own businesses. So I always wanted to own something, but I never knew that it was going to be a pharmacy. So it's exciting.

Dr. Khyati Patel  02:46
Dr. Hetal Patel, you know, after pharmacy school, you said you joined a larger retail chain back in your home state, Nashville, Tennessee, and worked for about three years. Can you tell us a little bit about what that experience was like, because I bet before you started this own business, you probably captured some knowledge and experience on running the pharmacy. So very eager to hear that, too, absolutely.

Speaker 1  03:11
So I actually worked as an intern there as well when I was in pharmacy school, and then transitioned to continue my position as a pharmacist. Basically, was, like a segue plan. I really wanted to get into managed care, like PBM and insurance side of it, because that was one of the great jobs that I had as a technician. I really enjoyed doing, you know, prior authorizations and understanding the details behind how that side of the business works. And so, you know, I was waiting for my dream job to come, and that's the reason why I was like, Well, I still need to pay my bills. So I sat at the position at this major chain, and the experience was, I would say, not, like, 100% that what I wanted. So customer service was something that I was very, like, adamant on since day one, I always wanted to make sure that my, you know, patients had the care that they needed besides just, you know, getting their prescriptions filled. So that was one thing that I felt like I was missing while was working at the chains. And it was more like becoming pushy about, like, metrics and numbers and, you know, all of the pressures that come from making sure that the volume was met at the end of the day and not enough staffing, and so a lot of pressures on pharmacies that everybody faces. And then I felt like my patients, like safety was being compromised. And it was like, okay, experience, I would say no.

Dr. Sean Kane  04:40
Dr. Hetal Patel, I know that from a timeline perspective, you were at this chain from 2018 until 2021 so that would mean that the covid 19 pandemic included some of your work experience at this larger chain. How did that kind of impact both your experience at your chain pharmacy, and also your decision to kind of move forward with your own pharmacy.

Speaker 1  05:04
So at that, like, time covid was brand new, like, we didn't know a lot about it. We didn't get a lot of guidance, I would say, from upper management, regarding how to handle situations. There was a lot of things that as a pharmacist, you know, you're clinically trained to do a lot of stuff on your own, like you don't need someone to just babysit you at every single step. And there's a lot of things like personal hygiene, especially like sanitizing the workspaces and all of that. As you know, a healthcare personnel, you already knew how to do those, but we had to wait for guidance. We had to wait for like, you know, somebody to send the supplies. We couldn't go buy our own supplies and just clean the space. So lots of like, No, you can't do this. No, you can't do that. But, you know, as a healthcare provider, there was not a lot of trust placed in us as pharmacists, and then we transitioned to opening our own pharmacy, and that kind of gave me more free reign on doing whatever I wanted to do.

Dr. Sean Kane  06:04
So would you say that the pandemic, in some ways, a silver lining is that it prompted you kind of kick yourself in the butt a little bit to get moving on your own pharmacy, or was that kind of in the cards already, and it didn't really impact your decision process.

Speaker 1  06:17
It was part of the decision process. Another major thing was that when you're working for a major chain, you're not the only star person there. Obviously, there's a lot of pharmacists and a lot of people competing for physicians and trying to, you know, get permanent at a store, because when you're a floater, you're traveling like, you know, sometimes two hours away from, you know, your family. And I was a new mom, like, I just had my baby, I was offered, like, a really good position before I went on my maternity leave, and then when I came back, they said that they had to offer it to someone else, which, you know, when the explanations that I got from upper management weren't that clear why they didn't need that make that decision. So it's like, you know, a lot of things going on where they just don't give you any explanation why they're making certain decisions. And here you're thinking that I gave my 150% I, like, you know, offered them to come back from my maternity leave early. And I've never called out. I've, you know, I'm there, like, every single time, like they, you know, scheduled me to be there. I even covered other people's shifts. So I was like, What am I lacking here? And how come I got passed on for like, a position that was, you know, a store that was, like, two miles from my house, and I was back to traveling, like, two hours a day, so that kind of played into it as well. And I'm like, if I'm giving, you know, my efficiency, like, what am I getting in return? Like? So that was another thing that I kind of played into opening my own pharmacy as well.

Dr. Khyati Patel  07:47
You know, couple of things I want to highlight that you were really looking out for your patient's interest, and you were looking out for your own interest, and as a new graduate, a new practitioner, to realize and take this huge step, it's a big thing, and I commend you for doing that. I want to get in the dirtiness of how this independent pharmacy came about. You know, you you left that job, and then next day you opened the pharmacy. Right? It was that easy?

Speaker 1  08:17
No, it was not easy at all. It took a lot of time and planning before you even open your doors. I feel like there's about eight to 12 months research that you want to do before you set like an opening date for yourself. So lots of planning. First thing I would say is just look for a location that you feel like is going to work out for you. If you're planning to have a drive through, make sure that you know, either you're going to build, get some land and build from, you know, ground up, or you're going to rent a space. So those are the things that the first thing that you want to look at. The other thing I did was I also went around in the community, you know, went to the Chamber of Commerce, talked to a few people that I knew that were my previous patients. What kind of unique value can we provide to the community as a new pharmacy? What are the services that are lacking in this community based on the prescription volume that the area is handling, how many pharmacies are there in the area, also like what kind of reviews people are leaving on the social media pages. That's something that you can look at as well. Also, there's few companies like McKesson, which is a drug supplier company, that has these programs where you can contact them, and they'll provide you with an Excel spreadsheet that tells you if that location that you're thinking about is a good location for you to open a pharmacy or not. So there's, you know, they'll tell you how many providers are in the area, how many times prescriptions they're writing. What kind of prescriptions are they're writing? What's the patient demographics like? How many people are there that are over 65 how many younger population lives in that area? How many pediatric formulations you're getting? So stuff like that. It's like. That's where you start out. And I think that's one of the major points that you want to start off, like thinking about and planning out.

Dr. Sean Kane  10:08
So Dr. Hetal Patel, I wanted to go back to that planning phase a little bit because I think this is kind of a fascinating area. So you're doing this months before you even know where your pharmacy is going to be. And I mean, this data driven approach is to help you understand where you want it to be, right? You know, Lebanon, Tennessee, has a population of about 40,000 people, so this is not a very, very, very small town. But I love that you talk to the community. I love that you use data to figure out where would it make sense to place your pharmacy? Obviously, you're going to put a pharmacy where the most prescriptions are tried to right? But what other factors played a role in terms of what kind of pharmacy you wanted to build more the mission and vision of the pharmacy, if you will, what was it that you wanted to value add that the community didn't already have?

Speaker 1  10:54
So for us, like, you know, after talking to people, we realized is that customer service was one of the big things that were missing. Now, our pharmacy is located right in turn off Walgreens and CVS, and we're the third corner, and then we have an independent pharmacy right behind us. So when I proposed this location, people were like, are you crazy? Why do you want to compete with these, you know, big chains and also independent pharmacy right behind you, and I was like, Well, you know, there is a reason why I'm okay with competing with them. Is because customer service, like when you go to these places, what do you expect? You expect, like a person smiling at you, you expect you know them, knowing you sometimes by your name, or understanding what medical conditions you have, making sure that sometimes you may just remember, like, one of the major conditions that you have, and then make sure that your over the counter recommendations also include that knowledge. And you can't do that when you're doing 1000 scripts a day and just, you know, working as a floater, like, if you are not at the same store every day, you still don't know your patients, and I think a lot of patients, or a lot of people in this community, were tired of just seeing, you know, these new faces all the time, and their pharmacist not knowing them and knowing their condition. And they were just getting tired of like, the rude customer service they were receiving, and a lot of drug interactions, you know, that the patients actually caught themselves and they're like, well, I could have, you know, had a major issue, if I would have taken this so lots of, you know, things like that. And then when covid hit, obviously everybody got overwhelmed, and it just made the problem even more worse than what it was before, with short staffing and everything like that. So we thought that customer service was the biggest thing that was lacking in the community, and so we were okay with competing everybody else, just based on this one thing that we take the time to listen and hear. So if a person wants to come in and just talk to us about anything that they have, some people even come and talk to us about their cats and dogs. We're okay with that.

Dr. Khyati Patel  13:00
And so, you know, your story sounds like the story of a lot of the pharmacy, especially the big chain operations that we have heard and nationwide actually during this pandemic. So it's, it's good to see that something good came out of this, which is a patient care and customer service for the patrons of your community. So after performing the needs assessment, you know, establishing your vision and mission for the operation, what were some of the other steps you had to take? I bet that wasn't the only thing. Sounds much easier, but there were a lot more planning that went behind it. And we're, we're eager to learn about those two

Speaker 1  13:38
absolutely so one of the things that I also did was I also approached the independent pharmacies that were close to me and the proposed location, and we kind of approached them as not just competition, but as a family that how can we make a space for ourselves as independent pharmacies and help the community together, instead of just individually helping or make it or competing with each other. So that was one thing that I did, and then the next thing we had to do was conduct a financial analysis. So we had to kind of think about, well, how much capital is going to take for me to open a pharmacy? Am I going to need a loan for that? Or am I going to be self financed, or somebody else can help me? In our case, like my sister is my co owner of the pharmacy, so she helped me fund half 49% so that worked out. I didn't have to take a loan. But that's one thing that you have to consider. Another thing is that you need a business plan. And if you're going to go apply for a loan in a big bank, it is required for you to have a business plan and a financial analysis. They wouldn't even give an appointment to you to talk to you if you don't have those two things first, and if you're not applying for a loan, that's fine. It's still a good idea to have that business plan ready, just so you know what you're going to be facing down the road. And then after you have those you have to think about what kind of. You want to be? Are you want to be like totally independent, 100% independent, or are you wanting to be part of like an independently owned franchise, like health mark or Good Neighbor Pharmacy? And then after that, you have to think about leasing the building that you, you know did all the research on for getting your construction plans ready, if you're thinking about building it, I would ideally pick something that's very, very low cost, like especially when it comes to the rent, because the rent is one of your biggest bills every month. So that's something that you would want to keep in mind. Also, the electricity cost adds up, the sewer bills add up. So you want to make sure that your location, square feet wise, makes a sense to how much revenue you're thinking about bringing with that financial analysis that you're doing. So that's something that we looked at. You really have to focus on the rent is. Reason is because your building is basically just going to be sitting not doing like. You're not going to be running the business out of it for about six months while you're planning and doing all the paperwork. The building is just sitting there for six months and you're paying rent on it, actually, because you need an address. You need a physical address in order to apply for all of the paperwork that's needed for the pharmacy. So the lease is the first thing that you'll do. After that, you will consult a designer. And if you're doing the construction, then obviously you'll have to do that first. You have to consult a designer to make sure that you're following the state requirements regarding what kind of building construction has to be inside for the pharmacy. So you need to have a consultation area, you need to have a drop off area, you need to have a pickup area and stuff like that. So that's one thing that you have to do right after the rent and lease is done. And then after that, you have to have an electrical inspection done to make sure that the city, you know, approves the you have to get a city inspection done, building safety inspection done. After that, you have to make sure that your security system is all set up before the state board comes in. You have to make sure your c2 space is bought and placed out of public view. Make sure that you have your insurance and liability insurance all ready to go. All these needs to happen before you even apply for your tenant, like state board of pharmacy license for your pharmacy, because they will not pass your application unless you have all of this in place. So all of my all of this is happening your your building is just sitting like you're not doing anything. So you have to really focus on that.

Dr. Khyati Patel  17:43
So Dr. Hida Patel, you know, it's an intricate process, and it seems like it needs patience, it needs money. And I was particularly blown away by the fact that, you know, you need to have a place rented for six months and have a postal address for the place to be able to fill out these forms and stuff while not making any money. So I don't think that this opportunity or this plan is for the faint at heart. You have to have a right planning, and you have to have the right funds ready to, you know, at your disposal, and ready to make zero penny on it. Absolutely.

Speaker 1  18:23
Another thing to keep in mind is not just you know your pharmacy, like building, is sitting for six months, but even after you open and you get your prescriptions and your payments, like start rolling in, that's another three months. So you're not going to see anything in your bank deposit, like a plus sign until, like, you know about, you know, eight to nine months, you know, into the whole process. So you also have to keep that in mind. And the next step, after doing all of that and getting your state inspection, is basically applying for all of your paperwork. Or before even you do the state inspection, you have to make sure that you register your business. So there's an article of organization that you have to file. You apply for your tax ID, you apply for your NPI number, you apply for the NCPDP number, which is what you need in order to get paid from all these insurance companies. You have to apply for your DEA number, your CSOS ID. You have to make sure you choose, like a ERX software for your prescriptions to come in and your fax line and your phone number, make sure you open business bank account. Make sure you get your CPA, which is the collaborative practice agreement done with local providers if you're going to do your immunizations. Also if you are deciding to choose a PSAO, which is a pharmacy services administrative organization to do your contract. Choose that wisely, because not every PSO will fight for you. Either you can do your direct contracts with insurances, or you can choose one of those PSAs that are available. Also make sure you're choosing the. Right buying group and the right vendor for your pharmacy. It all comes down to the nitty gritty details of how much percentage that they're going to charge you, how much percentage they're going to take away from you.

Dr. Sean Kane  20:13
Dr. Hetal Patel, you just outlined probably 20 things, and I'm sure the actual list is like 50 things of all the things you have to apply for, and the inspections and the numbers that you need and stuff like that. I know that you did not learn all that in pharmacy school. Where did you learn this crazy list of all of the things that you need to do? Is there a cheat sheet somewhere? Is there some hidden resource for aspiring entrepreneurs and pharmacies? How did you know what to do and when to do it.

Speaker 1  20:42
Unfortunately, there's not like one resource that you can use. I joined ncpa, and then once I became a member, I read through articles, and then I contacted other independent pharmacies that were not in my area. They were far away from me, so they wouldn't think that I'm competition, ask them the questions that I needed to ask, and also, like, you know, making sure that I read the articles that are published by McKesson and AmerisourceBergen. So all these distributors, they actually help you with a lot of paperwork and kind of preparing you. But all these like license and inspection and all of that. Basically, you just learn as you go along, like there's nobody that you know told me that I needed this, this, this, I wish that there, there's a class that teaches all this, but unfortunately, I just had to learn as I went

Dr. Khyati Patel  21:34
along, a class or perhaps a book or a set, you know, I don't know, three months or the CE seminar that teaches you and walks you through everything, but this is, this is therefore that much more amazing that you piecemeal these things on your own, and you know, you made it into a process, and you made it into, you know, an operation. And it seems like, you know, you established the pharmacy in January 2021 and your grand opening was in June 2021 but you were sitting in a community, right? You're not just operating in this abstract space. What kind of things that needed to happen prior to opening, weeks prior to opening, you know, maybe it's connecting with the community or other preparations for the pharmacy.

Speaker 1  22:24
So basically, a week ahead of your opening date. Well actually, I would say a couple of months ahead of your opening date. Contact your local chamber of commerce. You know, if you're a member of there, they will actually help you set an opening a ribbon cutting day, and then they will market that for you and send it out to all the members in the community, saying that, hey, you know, let's welcome our new member, which is a small business, and they're setting and opening a ribbon cutting day on so and so day. Make sure you invite your friends and family. So it's like a community event that they will actually plan or set a date for you, and then what I did was I went ahead and made sure that my inventory was ordered like a week before, because you don't want your inventory to sit too long on your shelf. Reason why is because not everybody has those 0% interest credit line contract for a year anymore, the only contracts that you can negotiate was the six months from the date that you received your inventory. So it's not from the date that you opened your pharmacy, but the date that you placed your order and received it. So you have six months from that day where you will never receive an invoice for that inventory, but it'll be just sitting on your shelf, so you don't have to pay for it upfront. But you know, after six months, you're still going to end up paying for everything. And then at six months, a week before, or a couple of weeks before, putting an alarm in your phone to make sure you return the unused inventory, because if not, then that's just all the dollars that you lost with, you know, sitting inventory. And then make sure your vials are ordered, your bags are ordered, your labels, your staples and everything that needs to go, like the supplies in the pharmacy are all ready to go a week before the opening and then on opening day, we made sure that a week before that, we contacted the caterer for like, light snacks and refreshments, if you want to DJ, have that have some fun goodies, you know, for people that are going to come. So, yeah, it's a lot of planning to just, you know, do like the opening event as well.

Dr. Sean Kane  24:32
And, you know, Dr. Hetal Patel, one thing that we talked about before this podcast interview was really your commitment to customer service. And I think we've heard it today as well, and I'm also hearing a lot about community engagement. So you mentioned the Chamber of Commerce. I've heard of that term. I've never met my Chamber of Commerce in any city I've ever lived in. I don't know what they do, but it's great that not only are you aware of it, but they literally helped you with your grand opening. They helped you market it. Can you tell us more about. Both the like customer service aspect, but maybe even more the community aspect of you're not just another business sitting in the city of Lebanon, Tennessee, you are integrating yourself into the community, right? And I think that philosophy is so different, and something that is worthy of talking about a little bit more, yeah.

Speaker 1  25:20
So absolutely. So we always keep telling people that we're not just here to make money. So at our pharmacy, you don't pay more, but we just care more. And that's, you know, something that I always tell my patients, Chamber of Commerce has been a blessing to us. In one way, what Chamber of Commerce does is basically connects. It's a big networking opportunity. It connects all the small businesses. And, you know, members directory is published every year. There have a magazine that's published every year that you can publish your business in. They have, you know, all these events, like every month, they will have, like this business card exchange event that you go to, all the small businesses that are in the area will attend, will exchange business cards, will network and communicate with each other about what their business brings to the community, and not just like money wise. What else are we doing to help? You know, the people in our community also, I've got, actually, a couple of corporate contracts because of the industrial side of the networking that the Chamber of Commerce provides. So we did some flu clinics, we did some covid vaccine clinics at these corporate sites because of the people that we met through all this networking. So it's a great asset to have. So if you want to be part of it, that's really great way to market your pharmacy

Dr. Khyati Patel  26:39
and Dr. Hida Patel, you wanted to provide good customer service to your patrons in the community. Can you tell us a little bit about how your pharmacy services differ from maybe your competitors in the area, and what are some of the highlights of the services that you offer?

Speaker 1  26:56
Absolutely so one of the biggest programs that we have here is called VFC, which is Vaccines for Children program. We are actually the first pharmacy that got approved for this program in Tennessee, and we're very proud of it, because a lot of people struggle when it comes to pediatrician appointments, especially like when that covid time was going on, kids couldn't get appointments at, you know, pediatricians office and then health department was very overwhelmed that they didn't have time to do, you know, back to school vaccinations. People couldn't, like, you know, get the required, like, pediatric vaccinations, but they were missing doses and stuff like that. So I looked on the CDC website and saw like, Okay, what other programs that we can have in this community? And VFC caught my eye, and I was like, okay, so this is something that we can do. And recently, know, the CDC and the FDA allowed pharmacies to become part of that program. Earlier, it was only open to like, pediatricians offices and the health department, but now pharmacies are allowed to do that as well. So we became a part of that and got approved, had to spend a lot of money like getting the right fridge, getting the right freezer, getting the right Ultra freezer, getting the right digital data loggers for the temperature monitoring, so getting the right portable refrigerator for it. So lots of stuff, lots of requirements, but it was worth every single penny, because when I see patients coming in and they say, Well, you just saved us, because my kid could have missed, you know, getting in school this year because their vaccines weren't up to date. So that's, you know, big thing coming from the community, and no other pharmacies did that here. So all the urgent care clinics and everybody started recommending us because they're like, well, they're the only ones, besides pediatricians and the health department that have marketed the service. So it was, it was a big, big thing for us to do that, and I

Dr. Sean Kane  28:51
just want to highlight that. And you, you said it, but so nonchalantly, I think we have to highlight it again. You were the first pharmacy in the state of Tennessee to have this Vaccines for Children program, right? That? Yeah, that is an incredible statement on its own, let alone that even after doing that in your community, you have other healthcare providers referring patients to your pharmacy, saying that you are one of these VFC providers, and that's giving you more business, and you're serving the community. You're taking advantage of this program in a good way. You're expanding vaccinations to kids. I mean, what amazing service that you're providing to the community.

Speaker 1  29:30
Absolutely, and we were so proud of it. And one thing to tag along with that service that we added was free multivitamins for all kids in Wilson County. So I have a two and a half year old girl, and I know how hard it is to feed kids sometimes. So we were like, Okay, what is something that new parents are struggling and nutrition was something that came up with school board meetings that I had, so part of the Chamber of Commerce. I'm also part of the education committee here. I'm also part of. I'm the ambassador committee here. So when we went to the education committee meetings, one of the things that the teachers complained about was nutrition for kids. And so I was like, well, as a pharmacy, what can we do to help that? So what we did was we came up with this program, which is free multivitamins for all kids in Wilson County. It all comes out of our pocket. We don't receive any grants or any funding for it, but it just feels good to do something, you know, for the community, and you know, provide like great service to everybody, and that, not only, you know, helps people, but it also brings in business. So when these parents come in for their vaccines and when they, you know, get these free multivitamins, well, guess what? Next time they're getting a prescription, they will remember us. And so that's just, you know, making sure that our name, like stays out there, and people don't forget about us.

Dr. Sean Kane  30:50
And I mean, we've covered One of the notable things that your pharmacy offers, the VFC program, but can you just briefly tell us some of the other services that are either unique or or common with the independent pharmacies that maybe people wouldn't expect a pharmacy like yours to offer.

Speaker 1  31:07
So we also do basic compounding at the pharmacy. We do free prescription delivery within 15 miles, and a lot of pharmacies in this area used to charge for the service, but you know, after we started marketing, free delivery, now everything is free. And then we do free notary services. We have free flavoring for prescription medicine, but also over the counter. So if you buy like an over the counter Advil or Tylenol you don't like the flavor, we'll change that for free. And then we have free covid testing at our location. We do travel testing. We do travel vaccines at our location, we do adherence packaging for our patients, not like the long term care patients, but people that come and see us all the time. We do free packaging for them, and just, you know, everything that our patients ask us for, we'll try to accommodate within our services that we offer.

Dr. Khyati Patel  31:59
Well, that is amazing. And I can tell you, not knowing other competitions you have, you truly your services truly stand out as far as the offerings you know, for your community and what they need, especially the kids. I mean, the VFC thing sounds amazing. So much planning that went behind it. You definitely are serving the community in a meaningful way. So that's, that's great. I want to go back to the conversation about prepping and, you know, stepping up and kind of doing some of the research and franchising and organizing for the pharmacy. I heard the word health Mart. We want to know more about that. All I know is it's a network of 5000 pharmacies that operate under this independent pharmacy banner. What does it mean for you to be a part of this network? And how does the health Mart pharmacy help independent pharmacy starter businesses?

Speaker 1  32:57
So healthmart pharmacies is basically a franchise like model, but it's not 100% focused on metrics and volumes like they don't control you. There is a standard of procedures that you have to sign an agreement with them for. But if you are a first time pharmacy owner, have never owned a pharmacy ever, I would 100% recommend to become a part of health mart or any other independently owned franchise that's available. So AmerisourceBergen is another drug distributor that has Good Neighbor Pharmacy as their franchise model, and then McKesson has healthmart as their franchise model. What that does is that you pay a monthly fee. But then if you decide that you want the PSAO, to do the contract on your behalf with the insurances, that PSO fee is included in that monthly franchise fee that you're paying, you haven't access to a lot of you know, products for, like marketing and lots of like, you know, insight on what other programs that you can add to your pharmacy. A new program that we added recently was nutrition depletion assessment, which is a free-of-cost program to our patients. After looking through the website, it has a dashboard that you can log in, and then it kind of lets you have access to a lots of policies and procedures and immunization documentation, standing order protocols like so. And if you need like these forms for like covid testing, it has all these ready made forms that you just download, and it just puts your Pharmacy's name on it. So it streamlines a lot of policies and procedures for like your DEA license and your see sauce license, you have to show them the c2 policy. What's your policy of purchasing see twos and how you're going to return it? How are you going to do the inventory on that? So all of that has to be on paper. So becoming a part of health mark, you get access to. To Bula intelligence, which is a law firm that does all the, you know, legal paperwork for you when it comes to the policies and procedures. So it's, you know, really great. And it also has like health smart University, which is a built in, like program that is free of cost, where you can take all these trainings. So fraud was an abuse training, Sudafed training, so all of that that needs to be on file, you can always, you know, assign those trainings to yourself or your employees, and then just go from there. So easy to keep documentation. It also does background checks monthly, like Sam inclusion checks that you have to do every month. So for pharmacies, like a SAM inclusion check is required every month. Background Check is required. So all of that gets done through this, you know, unique platform that they have. And I think it's a great, great service. And I think everybody that's a one new pharmacy can, you know, utilize their services really well.

Dr. Sean Kane  35:59
Dr. Heath Patel, one thing that kind of strikes me about the health martyr similar franchise model is it almost like levels the playing field. From the independent pharmacy that doesn't have a huge staff of lawyers and people working on documentation for you and policies. That's something that I'm sure the larger retail chain pharmacies have available to them, but for the independent guy or girl, that's that's not something that is really that feasible without spending hundreds of hours of your time to do all of these tasks. So it does feel like that makes it more accessible for you to be able to do all the stuff that you're supposed to do without taking your time to do all of the stuff that you're supposed to do. And then you can focus on things like the VFC program, or focus your time on that customer service and things like that.

Unknown Speaker  36:45
Absolutely, absolutely.

Dr. Sean Kane  36:48
Well, I've heard a number of challenges already in this episode, in terms of just starting your pharmacy, all of the challenges associated with the licensing and leasing and the finances and things like that. What stands out to you in terms of since opening your doors? So after June 2021 what are some things that stand out to you in terms of bigger challenges that you've had to overcome as a new pharmacy owner?

Speaker 1  37:12
I think the biggest challenge is two. Biggest challenge, actually, one of them is the pricing of medications. So as a new pharmacy owner, you really don't know what other pharmacies are getting. So you don't know how much distributor is giving them minus the wholesale price. So there's always a percentage, like, for example, they're going to get, you know, 10% minus the wholesale price. And for brand, you get, like, 4% minus the wholesale price. And that 4% or 10% is supposed to be basically your profit. And so a lot of people that are starting out don't know about these percentages. So when you're contracting, you're like, Okay, fine, I just need to open this pharmacy. I'm just going to contract, and I'm going to sign all these papers and just be done with it. Don't do that. Read. Read every single line in those contracts. Make sure that you negotiate on those percentages, because there's a lot of times where you will find other distributors that are selling a medication bottle for like, $2 while your primary vendor is selling it for $20 I mean, that's a huge difference. So what I had to do is, you know, just negotiate with my local sales person and be like, hey, you know, this person is selling it for this much, and it's the same brand, same count. How come you're charging me this much? So just you know, make sure that you negotiate your percentage as well. The other challenge I'm facing right now is the DIR fees from the PBM so like I mentioned earlier, PSOs are like the new middlemen, basically. So PBMs are the pharmacy benefit managers. They're supposed to be the middleman between the insurance companies and the pharmacies. Now the psalos are the middlemen between the PBMs and the pharmacy, so they're the ones that kind of help you do these contracts, and, you know, make sure that you get a good deal. Sometimes they don't fight for you, and they don't fight for the deals that you're getting. And when you ask them, they're like, Yeah, we went back and forth, and our underwriters went back and forth. And I was like, Can I see proof of that? They will never send you them. So you have to make sure that, you know, you stay adamant about asking for proof, asking for, you know, a lower rate when it comes to those Dil fees. And then just if you can, I think the first year is always hard when you don't know anything about these contracts, you let a PSA will handle that. Once you get a handle on how everything runs on the back end, once your workflow smooths out, I would always recommend that you direct contracts with insurances, because with direct contracts, it's a huge difference like so right now, a PBM is charging you 23% Dr. fee on a brand name drug. Well, you're only getting it 4% less at your wholesale price, so you're losing, you know, about 18% of the profit. Well, not even profit. You're actually paying out of pocket to dispense it to a patient. So that's a lot of money to lose. Of so with direct contracts, that same, that same TBM, if you do a direct contract with them, they say that, well, if you're only dispensing like 5% of your total, you know, prescription volume as by name, we won't charge you a dir fee. But if you go over 5% your dir will be like 30% which is okay, so there's different contracts that you can negotiate on. And I think that's the biggest challenge, like in this independent pharmacies and everybody is facing right now is basically just trying to make sure that you get out more than you put in.

Dr. Sean Kane  40:36
And it's so ironic that that I mean in other businesses, that's almost like a given, right? Like you're going to charge more money than what it costs you to buy the thing that you're selling. But because of the complexity of, as you said, PSOs and PBMs and dir fees and contracts and things like that, sometimes you don't even know that you're losing money until after the fact, which is absolutely insane. And I just want to highlight, you know, we talked about this with Dr. Benjamin jolly back in he looks talk number 137, we didn't even really touch on psaos. And I think you put it very well that it's like a middle man to the middle man. So they're something that can be really helpful when you're starting your pharmacy. If you don't know the landscape of PBM negotiations, but it is another person taking a little bit more profit away from that pharmacy that 20, 3040, years ago that wasn't even a thing and wasn't something that was necessary. Again, I think it highlights the unnecessary complexity that we have and some of the pitfalls of the current pricing structure and reimbursement model that we have in pharmacy in general, and it's really hurting independent pharmacies too.

Speaker 1  41:43
Yes, absolutely. And there's another thing that also plays in effect, and that we are kind of being challenged on, is Mac appeals. So every time you have a claim that or reimburses you below the cost of acquisition for commercial plans, you can file an appeal saying that, hey, I'm getting paid this much, but this is my acquisition cost. Can you readjust? You know what your maximum allowable cost is, and they will review that you send them a copy of your invoice. What we're struggling with right now is every single direct contract that we have. They come back and say, Well, you can find it cheaper at another wholesaler, and that's why we're going to stick to the Mac price that we have. So there's not a single Mac appeal that we have won or gotten paid for or gotten an adjustment on. Another thing is that with these PSOs, you have to be very careful, because they say that they will automatically file for these MAC appeals for claims that qualify as soon as we get a below cost, you know, reimbursement Well, when you ask for a report, they will say, well, contact your switch company. And when you call the switch company, they said that, well, you know, you have to make sure that your PSAO have contacted us to get access, to give you the access for it. So it's basically going round and round and round. And you i It's been eight months. I still haven't gotten an answer on that, so I'm still trying to find out where is my Mac of you report.

Dr. Sean Kane  43:16
So I just want to highlight the craziness of the situation for just one second. And we did talk about this back in 137 but the Mac price is the maximum allowable cost that the PBM is going to reimburse you for. So we'll use atorvastatin. Their Mac price might be $10 for a atorvastatin of 30 day supply. Your cost in terms of Hetal Patel buying it is going to be, let's say, $20 so you pay 20 bucks for it, they're going to give you $10 and then you appeal and say, Hey, I can't get it for cheaper than 20. This isn't the best I can do. And when you say that, and you're appealing their Mac price, ideally, they say, oh, yeah, we made a mistake. You know, it really needs to be higher. But what you're saying is they are just rejecting and rejecting and rejecting, and they're just going to pay you 10 bucks regardless of what you're appealing, which is what we kind of heard from Dr. jolly as well.

Speaker 1  44:09
They they have a software built in so like, for example, I'm a PBM, and I you filed an appeal with me. Well, I'm going to write in atorvastatin in my software, what it will do is look up atorvastatins cost and every single distributor that's available in the United States. And it will pull up a distributor's name that has that medication for the lowest cost. It doesn't matter if they're, you know, contracted with you, or it doesn't matter like if they're primary, secondary, tertiary. It doesn't matter if they follow pedigree or not, and pedigree is a whole different situation and discussions that we can have. But they don't care. They'll just pull up this random number and just say, well, this other person has it at this price, so we're not going to adjust it for you. In Tennessee, actually, Thursday, we had a budget with discussion. Then there's the House bill that's, you know, in Senate right now, where they're asking, or pharmacists and pharmacies are asking, where we change that duration from three days to four days, where a Mac appeal can be readjusted so that four days, that extra one day time, is what pharmacies are asking to make sure that they have enough time to gather all the documentation and make that adjustment needed. So, you know, there's some legislation going on about about that issue as well.

Dr. Khyati Patel  45:31
Well, Dr. Gita Patel, I just have a newfound respect for what you do, because it sounds like you're wearing I stopped counting after 25 how many different hats you're wearing. Kudos to you for undertaking this huge venture and trying to make it successful, you know, for your community, for your patrons, and for your own self and your career path. This is, this is very commendable. I want to go back to the roots. And you kind of alluded that you know you didn't, kind of know that you were going for entrepreneurship after graduation, but just to help our student audience who might be thinking to follow your footstep. Were there any classes or topics that you learn in pharmacy curriculum that you think helped you prepped for this path.

Speaker 1  46:23
Absolutely So. Pharmaco economics is something that I would say, you know, focus on that class, not on the hospital sides of the calculations. But if you can, you know, find material that explains you more about the dirc calculations, the Mac calculations, the acquisition cost versus the wholesale cost calculations, all of that. If you have knowledge ahead of time, you don't get caught off guard, like, you know, getting $70 less on a prescription. And you're like, Man, I wish I knew how to do those calculations beforehand, before I signed the contract, you know. So that's, you know, one class of pharmacoeconomics. And then another class that I really, really enjoyed was when I took Advanced community practice elective with Dean winickie. And then there was a independent pharmacy owner that owns Hayat pharmacies there, Dr. hasheesh zaiba, that came through and gave us, you know, a little insight on what it takes to open, you know, a pharmacy. And that was really like in the back of my mind when I was, you know, thinking about opening and everything. And he said that, you know, one thing he said, it really stuck with me that it's not an easy road. There are nights that you're going to not sleep thinking about what I need to do next. And it's true, I rather have those kind of sleepless nights and think about, oh, I hope I didn't hurt that patient by giving them the wrong medication. So I rather have, like, business related stress than, you know, stress about me, like, you know, hurting a patient so well.

Dr. Sean Kane  47:55
Dr. anthel Patel, you know, you're approaching your one year opening, Grand Opening anniversary this summer, which is super exciting. First of all, at again, Lebanon family pharmacy, looking back, what are some of the biggest wins and benefits of deciding to go out on your own as opposed to sticking with that chain retail pharmacy that you had previously been with?

Speaker 1  48:16
Absolutely so the quality of life is very, very different, and I think that's the biggest win. You're working more hours, obviously, than you would be working, you know, at another chain. But you know, when you go home, at least you're at peace, like I just said, I rather, you know, stress about the business than actually hurting a patient. So there's that that has changed a lot. I have more time to spend with my daughter on the weekends, I have a set schedule. I have not like, you know, covering other people's shifts, because I know that I have to be there on the certain day and certain time. So it kind of helps me plan out my, you know, weekends very well. Another thing is that I grew more as a person and a business owner after opening this pharmacy. I never knew that how much, you know, courage I had to do this, or how much determination I had, but this has taught me a lot. I grew as a person, and then I've become more active with my communication skills and trying to be on like a local radio show, and, you know, promoting your pharmacy and talking about all these different topics on TV. And, you know, it's been interesting. It's been very interesting journey. And I feel like it just makes me very happy to know at the end of the day that we have made a difference, and people know that we have made a difference because they're talking about us. They're talking good things about us. They're leaving us good reviews. So it kind of, you know, makes you happy knowing that, yeah, people are liking what you're doing.

Dr. Khyati Patel  49:45
One step further. Dr. hita Patel, with that, you know, what is the future of independent pharmacy look like we've always heard there is, you know, always this overtaking by chain pharmacies, the the dire PBM and DIR issues make independent pharmacy businesses non sustainable. But we want to hear, based on your, you know, successes and challenges, what does that future look like for you?

Speaker 1  50:13
So the challenges are always going to be there. Another challenge that I see that's popping up in future is more like, you know, clinics, like small doctors offices, primary care providers opening dispensaries in their locations. What that does is that it takes away from the cash patients that we have at the pharmacy. So the insurance might not be paying us a lot of money, but at least with cash patients, we have the ability to recover what we have lost a little bit. And so when, you know, physicians like start opening these little dispensaries, that kind of takes away from, you know, a chunk out of our profit as well. But you know, those challenges like these are always going to be there. But I think the biggest win, and the biggest you know thing that I see in the future is that the momentum, you know, is picking up towards all these legislative changes when it comes to PBMs and when it comes to, you know, restrictions on these dispensaries and stuff like that. So that looks good, even though it's a challenge right now, and also, as long as you have, you know, the grid, you're determined and you're a strong entrepreneur, you can always make it. So that's good.

Dr. Khyati Patel  51:18
And I think that's a wonderful lasting message that you have to have the grit, the willpower and the love for what you do in order to sustain and, you know, start the business and face the challenges. So thank you so much. This was a great learning opportunity for me, and I'm sure Dr. Kane can attest the same, yeah.

Dr. Sean Kane  51:40
I mean, your story is absolutely amazing, which is why we had you on the podcast. And you know, even though we talked before the podcast, I still learned a lot more even during today's episode. So again, thank you so much for your time. For the listener. If you want to see show notes, those are available at HelixTalk.com Again, this is episode 148, we're on Twitter at HelixTalk, and we love the five star reviews in iTunes, so keep those coming. So again. Dr. Hatha Patel, thank you so much for your time. So with that, I'm Dr. Kane.

Dr. Khyati Patel  52:06
I'm Dr. Kathy Patel, and thank you again. Dr. hito Patel, for being here. Thank you so much for having me. And to our student audience, study heard and plan your future. Heard as well.

Narrator - Dr. Abel  52:20
If you enjoyed the show, please help us climb the iTunes rankings for medical podcasts by giving us a five star review in the iTunes Store. Search for HelixTalk and place your review there

Narrator - ?  52:31
to suggest an episode or contact us. We're online at HelixTalk.com thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science.