049 - A Local Pharmacist's Journey In Medical Practice- A Conversation with Gautam Thakkar, PharmD

Coach JPMD begins season 2 with a conversation about pharmacies. Gautam Thakkar, PharmD is the founder of Pinebrook Pharmacy in Spring Hill, Florida. He joins me at our studio to discuss his journey from India to the United States and how he is successfully running multiple pharmacy locations in a tough market. You will learn the ins and outs of how pharmacies make money in addition to learning some personal things about Gautam in our rapid fire round.
Practice: Impossible
Show Notes

 Discover how medical graduates, junior doctors, and young physicians can navigate residency training programs, surgical residency, and locum tenens to increase income, enjoy independent practice, decrease stress, achieve financial freedom, and retire early, while maintaining patient satisfaction and exploring physician side gigs to tackle medical school loans. 

Transcript

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Coach JPMD  0:24  
Oh, welcome. Welcome to the practice and possible Podcast with your hosts, Coach JPMD. And we have a special guest today. Gautam Thakur from Pinebrook. Pharmacy, correct? 

Gautam Thakur, Pharmacist  0:36  
Yes, sir. 

Coach JPMD  0:36  
And so good to have you. You know, this is beginning of the second season.

Gautam Thakur, Pharmacist  0:42  
Yeah. Thanks for having me. And we will have some nice talk.

Coach JPMD  0:44  
Yeah, for sure. So pharmacy, pharmacies pharmacies have been something that's been really difficult for me to understand. Although we prescribe prescriptions every day. I can honestly say I still don't understand the pharmacy network, how you guys get paid how medicines actually get to your shelves? So I thought it was a great conversation to have with you. As a local pharmacist in Spring Hill, and I think only in spring hill or do you have other locations as well?

Ah no, we have three locations that two in Spring Hill one in Brooksville.

okay. So tell me about yourself. Tell me about you and 

Gautam Thakur, Pharmacist  1:22  
So you know, my name is Gautham Thakur pharmacist. Born and raised in India came when I was 26. Any foreign student, they come in any medical professionals, they have to go to so many exams and residency hours or internship hours. So went through all this process took me three years to get license work for Walgreens for about 10-11 years as a pharmacist. And then one day they were saying, Oh, the store I worked at, it was 24 hour store and I work night shift. So I had seven days on schedule to seven days off. And my supervisor said, Oh, we cannot turn this store to non 24 hours. So I said, Okay, no problem. But then what my options are, what do I do once you turn it on 24 hours where I would go? there say that you can go to Orlando, we have a mail order facility, I lived in Tampa, going on I4 every day it wasn't possible, then he's gonna move to Orlando, and we loved our neighborhood. Our kids loved the school. So I don't want to move to Orlando, then we ended up just decided you can take the severance package, shell company gave me a severance package took the money and then I invested in my own business. Any business is very hard. Sure. If you look at the SBA Small Business Administration's in a statistic, out of every 10 new business openings out of 10 Eight closes down within a year. And then the two now out of those two 60% were closed down in next three years. So they have very integration is very slim, and the business will survive. But I would say if you just put everything into it, you know, I had saved up so much money to start my own business. I had worked so much overtime at one chain store. And I thought if I don't succeed in this business, then I'm financially 10 years behind all my work, you know, being up all night long, it's all gone. So I had to put everything in and then you know, open up with one store and then we grew from 1..2..3 and four.

Coach JPMD  3:24  
That's wonderful. No, so you were a pharmacist in India?

Speaker 2  3:27  
I was pharmacist in India, you know, but any medical professionals who come to us, you know, they don't valid your degree, you have to take so many exams, clinical exams, internship hours. So I finished and got licensed

Coach JPMD  3:39  
And you were married at the time or did you get married here? 

Gautam Thakur, Pharmacist  3:41  
I no I was married at that's how I came here. My wife was here. So because we got married and then I came here. 

Coach JPMD  3:47  
Okay. And so how is it different in India versus here? Your pharmacist in India? I know that, you know, there a lot of you know, they probably don't prescribe as many medications as they do in India as they do here or am I wrong in that? 

Gautam Thakur, Pharmacist  4:02  
No, you are 100% right. People usually do the home remedies as much as possible. Even not just the medicine but even that seeing the dentist I don't remember if I ever been to dentists unless I had a toothache or something or dare to remove the tooth. But beside I never been to the dentist. So they usually don't see unless you have a problem. And it's changing a little bit. Now. As far as the drug, they're all same. You know, we don't have as many brand names, because now they're changing. So you know, you don't have a patron so everything is generic now. 

Coach JPMD  4:02  
Okay. So so what were the what would be the most common drugs that were prescribed in India compared to the US?

Gautam Thakur, Pharmacist  4:44  
for any particular indications?

Coach JPMD  4:46  
Well, in general, I'm sure antibiotic classes medication would be

Gautam Thakur, Pharmacist  4:50  
Those are very popular because of not as hygiene in general you know that people get rid of infections, so antibiotic hours, that would be the number one prescription drug that ever or prescribe. 

Coach JPMD  5:00  
Okay

Gautam Thakur, Pharmacist  5:01  
yeah. And then everything is same, you know, like beta blockers and calcium channel or and statin drugs. And

Coach JPMD  5:09  
so I used to love the show called How It's Made under the fear of watch that show. 

Gautam Thakur, Pharmacist  5:14  
No, I haven't 

Coach JPMD  5:15  
It's a Science Channel show how it's made or how it works. I think there are two different series. And so we go I went through medical school and obviously we know how to prescribe drugs, but I have no idea how pharmacies work. So part of this episode is somewhat selfish. I'm trying to figure out how pharmacies work I, I had a money tree series that I ran for managed care, and season one that kind of detailed every aspect of the managed care cycle. But pharmacy was one that I struggle with try to understand so. Can you explain before we delve into the how it pharmacies work, right, you're a small chain pharmacy? 

Gautam Thakur, Pharmacist  5:54  
Correct

Coach JPMD  5:55  
How does a small chain differ from a big chain? What are three things that make small chains better?

Gautam Thakur, Pharmacist  6:03  
There are a few things, customized service personnel services. So if you come to our pharmacy, we would probably would know with your name, what medications you take, we go above and beyond to take care of you give an example. Before I came here, I had a patient who called for one of the psychotic drug and copay was after deductible, it was $900, 

Coach JPMD  6:25  
Their copay. 

Gautam Thakur, Pharmacist  6:26  
Copay was $900. It's a brand medic brand new medications and patient couldn't afford it. So I select me see what I can do. I have a rep number and the medical rep for the brand. She told me what to do. I registered the patient's first three months will be paid by the manufacturer. 

Coach JPMD  6:46  
Okay

Gautam Thakur, Pharmacist  6:46  
So they will save that $900. So this is what we would do as a independent pharmacy that you will receive this kind of service at the chain store. We do free home deliveries. Now many of the chain store has started at smaller scale that they will deliver to the patient's home. At my pharmacy, I'm 24/7 pharmacist for my patients. So any of my locations of any patients has any questions during the morning, and can't wait till the next day we open they dial the pharmacy number, and they will give them option number five to leave the on call pharmacist a message, they leave the message and my phone rings. And I always say my phone is always with me. My wife may not be next to me some days. But my phone is always there. And I pick up and listen to message and if there is a need then I call them back. I also provide the home vaccinations for our patients. 

Coach JPMD  7:37  
Okay

Gautam Thakur, Pharmacist  7:37  
So then they're homebound. They cant go to the pharmacy, a doctor's office or any kind of vaccine COVID, flu and pneumonia shingles, I go to their home at no extra cost if their our patients.

Coach JPMD  7:48  
So I have so many questions around that. So you when when did pharmacists become eligible or able to to give injections? Because I don't remember that being something that they could do? Let's say 20 years ago, is that true?

Speaker 2  8:03  
I would guess about 15 to 17 years ago, they implemented that a pharmacist can do three day course. And they will learn to the CPR course. 

Coach JPMD  8:12  
Okay. 

Gautam Thakur, Pharmacist  8:12  
And I guess they go by the statistic that most of the people were unable to get vaccinated because there wasn't enough doctors who will do the vaccine. So this will tell us how another healthcare provider helped with this. 

Coach JPMD  8:23  
Okay.

Gautam Thakur, Pharmacist  8:23  
Same thing with the, the, you know, the COVID, when the vaccine came out for COVID, there wasn't enough pharmacists to take care of all the populations. So they allowed a pharmacy technicians to do the vaccine. So now they can do it as well. 

Coach JPMD  8:39  
Okay, so that changed, but that changes to the board of pharmacy or through your education. Is it now that pharmacists have to go through training when they go to school in this country to be able to give us the vaccines or give shots or give therapeutics.

Gautam Thakur, Pharmacist  8:53  
So when I was a pharmacist, you know, it wasn't taught in the pharmacy school at that time. So it was something new that introduced the bill that a pharmacist can do the vaccination. So they had approved course for three days. And it includes the CPR, training and everything. So once you finish that course, then you're certified even nicer. But now that teach them into school.

Coach JPMD  9:14  
And so you do the services, and you provide the services to your patients, big chains can't do that or don't do it. I can't see how they have the manpower to do it. How do you get reimbursed for this stuff?

Gautam Thakur, Pharmacist  9:27  
For the vaccine part

Coach JPMD  9:29  
for being able to deliver medications to the patients and being on call? Because you're going to you're going to have to pay a pharmacist to take call I'm sure. So how is reimbursement model different in your business model versus bigger chain.

Gautam Thakur, Pharmacist  9:42  
So it works against us we provide better more services and we get reimbursed less. And this has proven like some of the time a person goes to a bigger chain store and the PBM because they own the PBM excuse me, they own the PBM to They will pay them their own pharmacy $3,000. And if the same patient come next month to my pharmacy, they will pay us $120. And this has proven in many scenarios that because they you know, taking money from this pot, they're putting in that pocket because they own the PBM. They own the pharmacists. So if you go to their own pharmacy, they will reimburse them more, which is not a fair practice. But this is the industry that you have to live in.

Coach JPMD  10:25  
So you mentioned PBM, and I don't want to lose your train of thought, can you define what pre PBM is for, for our listeners,

Gautam Thakur, Pharmacist  10:32  
our pharmacy benefit managers

Coach JPMD  10:33  
Okay

Gautam Thakur, Pharmacist  10:34  
Right. 

Coach JPMD  10:34  
So you're saying the pharmacies also owned the PBM, because I thought that was different entities that have 

Gautam Thakur, Pharmacist  10:41  
they're different entities, but you know, like I own pharmacy, I also own the infusion center, things like that. So there are pharmacy chain stores. They own their PBM, too. Not all of them, but some of them,

Coach JPMD  10:53  
so that pharmacy benefit managers work with the insurance companies to provide the prescription drug benefits.

Gautam Thakur, Pharmacist  11:01  
Correct. So you know, health plan were contact one of the PBM in and then negotiate what the management fee would be to provide this benefit to their members. And then they choose one of those PBM available in the market. And then they provide the pharmacy benefits. But in many cases, that pharmacy benefit manager has their own pharmacists just like CVS. An example CVS Caremark is a PBM. But they have a CVS, you know, the retail pharmacy as well.

Coach JPMD  11:28  
So they basically control the flow of all the money's

Gautam Thakur, Pharmacist  11:32  
correct many instances, like I had a store in the Oak Hill Hospital in Hernando County, and we closed down about 8-10 months ago. And the reason being because we are a bedside delivery contract. So we would go to the patient's bed before they go home, to see if they will like to get their prescriptions filled before they head home, that will know if all the drugs are covered, or not how much the copay would be. So they will liked it in that service. And we will take it to their bed before they go. Instead of stopping at the pharmacy and waiting three hours to get their prescriptions from picks up COVID changed things. And they say you couldn't go to the patients because it put them at higher risk for infection. So we lost that business, we had to close that store down. But the employees of the hospital, their PBM was CVS, I don't know remember what I think it was CVS or, but demanded them to go to the CVS Pharmacy. So even though I'm right there, the patient comes over here to work, the employee of hospital, still, they couldn't use us as a pharmacy provider, they had to use the one of the chain store.

Coach JPMD  12:37  
Yeah, that doesn't surprise me, especially with these big chains. So it kind of leads into the the sheet I sent you. And we can go over that real quick and real quick, because, you know, I found this report online. It's from the drug trial Institute. And they they do research, I guess, on pharmacy benefit managers throughout the throughout the country. And so I'll put some links in the in the show notes about this or for this, but as you look through here, you talked about the pharmacy benefit management that sits on the right side of the diagram

Gautam Thakur, Pharmacist  13:12  
Correct 

Coach JPMD  13:14  
How is that related to the manufacturer, like doesn't manufacture negotiate rates at the pharmacy benefit or because there's so many arrows in this

Gautam Thakur, Pharmacist  13:27  
right going in and out. So what pharmacy benefit manager would do, though, as a health plan, or if your a big employer held in 1000s of employees, you would need to manage this pharmacy benefit you would outsource to PBMs pharmacy benefit managers. If you're big enough, you can tell them what formula you would like to have, because he has such a big inner life that you're managing, if you are a smaller group than they will tell you okay, this these are the different formularies and then those drugs will be covered. And you know, the copay might be different tier A B C or 123. So PBM will decide which drug would go on which tier whether they were covered or not. In many instances it is because how much did they get from the manufacturer? Some example drug A you know says the manufacturer comes to the PBM so would you put our drug on our formulary and this Okay how much rebate would you give us that's okay every prescription

Coach JPMD  14:25  
I'm sorry to interrupt and you said the manufacturer so you're talking let's say ... those manufacturers will go to the PBM or PPO will go to them to see

Gautam Thakur, Pharmacist  14:36  
manufacturer would go to the PBM 

Coach JPMD  14:38  
manufacturer go to the PBM to try to get their drug on the formulary 

Gautam Thakur, Pharmacist  14:42  
correct for different than for statin or it's an example cholesterol there might be 10 different drugs, how they can get that drug on to the formulary, so they will increase their sell. So PBM would say okay, we can have your drug in our formulary but you have to pay us $100 every prescription gets filled.

Coach JPMD  15:03  
Even after the negotiated price, in addition to,

Gautam Thakur, Pharmacist  15:06  
Correct, in addition to some examples of drugs 

Coach JPMD  15:08  
Why is that not a kickback

Gautam Thakur, Pharmacist  15:10  
it is all legal in how they have big lawyers and they work it out and it's not kickback. 

Coach JPMD  15:15  
Okay. 

Gautam Thakur, Pharmacist  15:17  
So then it cost the increase the costs of the health care

Coach JPMD  15:23  
of course. 

Gautam Thakur, Pharmacist  15:23  
So, you know, if manufacturer has to pay $100 an example, you know, it could have been more or less, to the PBM, for everyone to have the drug on the formulary, then manufacturer has to increase the price. 

Coach JPMD  15:37  
Yes. 

Gautam Thakur, Pharmacist  15:39  
So that that counts for the cost of the drug. So many times people ask me is drug cost that much money? Like an example some of the drug for hep C and that one month's supply is $30,000. Thirty Tablets is $30,000 of one pill is $1,000. And how could you justify that, but there is lot of small thing like that that comes in play, like, you know, giving back to the PBM and things like that, that increase the cost to make the drug is not as much money. But you know, the manufacturer says oh, we have to put billions of dollar in research. And then we have to record this money. And that's why they get the pattern for certain number of years. That's one of the reason that the price goes up.

Coach JPMD  16:23  
Sure. And it seems like prices are going up every year. So 

Gautam Thakur, Pharmacist  16:26  
it does an average about 10% price would go up on brand new medications every year. So some of the pharmacy who can afford to buy more three months supply or you know, their orders use this they will buy because in January, an average 10% will go up.

Coach JPMD  16:41  
And so that cost is passed on to not only the consumer but also to the payer as well, right? 

Gautam Thakur, Pharmacist  16:48  
True

Coach JPMD  16:48  
because a payer now has to spend more money for that same drug. 

Gautam Thakur, Pharmacist  16:53  
Correct.

Coach JPMD  16:54  
 And then that goes back to the people who are paying the insurance premiums.

Gautam Thakur, Pharmacist  16:57  
True. The other costs, why so expensive, one of the reason is, as I share with you about the manufacturer has to pay them when the PBM for having the drug on formulary. Also, there's a very common term called spread I don't know if you ever heard that term called spread. So an example if you are an employer with 1000s of employee, you give out to PBM A in order to manage the benefit. And then your employee comes to my pharmacy for their prescription filled according to a negotiated pricing, the contract we have with a PBM they will reimburse us that day reimburse $10 But that PBM gonna invoice you for 20 dollar. Because that's called the spread so they pay us $10 And they charge you $20 I had one of the friend, he had a pharmacy, small pharmacy like mine in Tampa. So he was filling the prescriptions and he was losing money. So he his cost was $100 and he was cutting the numbers only $80. So to continue service, he told his customers I want to fill this prescription this time, but I can't afford to lose every month to full prescription was $20 This is an example I always give you visit Dr. Pierre, you know, you were asked me Gautam would you give me right to my home, I say OK come on Dr. Pierre I'll give you a ride. Then I give you ride drop you off at your home, and then he said Gautam give me $25 I say for what Dr. Pierre, because I let you know give me the ride. So same thing you know, with a PBM you fill prescriptions console, the patient's, you know, do all they need to do and then you buying it for $100 and you're getting reimbursed 80 dollars every single day. In my pharmacy we have about 8-10 claim that we are reimbursed less than our cost.

Coach JPMD  18:46  
And so is it is it that they know that this is happening and they they don't care because they can go to a big chain pharmacy and they'll absorb those costs because they're selling other things in their pharmacy is that

Gautam Thakur, Pharmacist  18:59  
no so if the same patient goes to the bigger one, they will get more money drastically more money because they have a better better negotiating power. Sometime because they own the both companies 

Coach JPMD  19:11  
yeah

Gautam Thakur, Pharmacist  19:11  
sometimes they would go and say oh I have 7000 store nationwide. I have drive throughs we have 2200 stores 24 hours so we need more money because we have more and more overhead so then they will pay them more but small pharmacy like us. They just give us a contract. We don't have any option but to sign off on it 

Coach JPMD  19:29  
Gotcha

Gautam Thakur, Pharmacist  19:30  
Right.

Coach JPMD  19:30  
So do you do other things in the pharmacy and as far as over the counter medications and other things to help cover those costs? 

Gautam Thakur, Pharmacist  19:39  
Yeah, we have some over the counter some DME supply in a wheelchair walk or anything.

Coach JPMD  19:44  
Okay, and what is the markup on that typically without 

Gautam Thakur, Pharmacist  19:47  
over the counter I would say about 50% markup 

Coach JPMD  19:49  
Okay 

Gautam Thakur, Pharmacist  19:49  
On over the counters and that one we can decide the price. I can tell my supplier put the sticker off $2 and syrup you know dollar 50 Okay, we'll put the sticker water I was And I can program in my POS, but prescription drugs, even though I say I want $100 PBM would say you will get only $75. You want to take it?

Coach JPMD  20:10  
Yeah. So it's so it's almost like gas stations or gas stations, you know, they don't make money on gas to pick up on the convenient stuff inside. And so that's how they're able to stay in business. That's, that's insane. So what about good RX? Because I went to a pharmacy one time and I know the drug know the cost of the drugs I had filled it before I gave my card and they charged me $150 I'm like, What do you mean $150? I have a good RX? Oh, yeah, we'll use a good RX. And we'll give it to you for 50 How can it be that it's that much different?

Gautam Thakur, Pharmacist  20:47  
So you said $150 wasn't with your insurance or cash? 

Coach JPMD  20:51  
It was with insurance. 

Gautam Thakur, Pharmacist  20:52  
Okay. So whatever insurance you have, they have a contract with the pharmacy that we will pay you for that drug, A drug goes by the AWP average wholesale price. 

Coach JPMD  21:04  
Okay. 

Gautam Thakur, Pharmacist  21:05  
So it's an example drug as their average wholesale price of $100. So, the pharmacy you went to has a contract with PBM that we will charge AWP plus certain percentage plus dispensing fee.

Coach JPMD  21:19  
And that's what those those things are up there the dispensing fee the

Gautam Thakur, Pharmacist  21:23  
correct, so pharmacies will get a small fraction of grant dispensing fee ranging from 20 cents to $1.50. That's a normal day give us that money to cover the cost of double labeling the vials and ink and things like that. But the good RX has a better negotiating power. And they have AWP minus 20 person plus 50 cents dispensing fee. So when you use your regular insurance, you know, the contract they have with PBM was not as good as the good RX has it. But the good RX is not a pharmacy, a sort of pharmacy is not of what you call the PBM. But they just have negotiate a contract that saying we're gonna send you so many people and give you more business direct towards your business. But we need this pricing.

Coach JPMD  22:13  
So so when you dispense as a pharmacist, you dispense medication, using good RX card, how does good RX make money

Gautam Thakur, Pharmacist  22:19  
Jude, before when they came out brand new, they weren't charging the pharmacy any money for your anything and they were just doing it, because you're new, you want to give everything for free. Now they charge pharmacy fee. So when you come to me, and you say good RX, and I build a good RX, all the drug goes by the AWP contract. And say, you build us according to AWP with this much, but over price, negotiate prices this much. They're gonna charge you $5 You know, whatever fee, you can say, by sending referring patients to you or what they can, and then Pfizer will pay $12. So they charge us now in a small fraction of fee, ranging from $5 to $25 per prescriptions,

Coach JPMD  23:02  
and that that claim is processed electronically to good RX. 

Gautam Thakur, Pharmacist  23:06  
Correct. 

Coach JPMD  23:07  
So the so it's a sweet, it's like a debit card. So 

Gautam Thakur, Pharmacist  23:11  
No so, you know, in our pharmacy software, the claim goes through, unlike your medical practice you have to bill and then you know, we will know right away how much we billing how much the PBM would or good RX will reimburse us and how much the copay would be. It's all live, it goes and then comes back within seconds. And then we print the label count the pill.

Coach JPMD  23:31  
So when you're, I guess I'm still a little confused. So when you're you're when you're collecting that, that money for the patient so I can I pay you 50 bucks with my good RX card, right? I then you then take part of that $50 to pay the good RX.

Gautam Thakur, Pharmacist  23:45  
So I will have to pay good rx $5 $10 fees. Yep, they will send me the invoice and then I repay them that know fee, correct. Also, that's the way the fraction of money that you make them. How they make most money is the data. So they sell the data. 

Coach JPMD  24:02  
Okay

Gautam Thakur, Pharmacist  24:02  
so they probably wouldn't sell the HIPAA data, like your name or anything. But there are many companies in the industry. They would pull it all day by the data. And they paid a millions of dollars to get this data set. And Dr. Pierre, what his prescribing habit Oh, he prescribed this this this this this drug. So an example if you have Pfizer an example like Viagra, right, so you if you prescribe too many male Viagra then the company would get this data. Dr. Pierre has prescribed this many and then they will sell to Lilly for the Cialis. So now Lily's rep will come to you that appear you know our drug it lasts for 36 hours this last modified so they're our company will pay for this data all the manufacturing company to know what doctor prescribes.

Coach JPMD  24:49  
And we're in we have no idea physicians have no clue as to what's going on. I mean, even the consumer doesn't. That's insane. You know, I had no idea because a couple of years ago, actually about 10-15 years ago, I don't know if I told you this, but I, I had a dispensary in my office, Florida was one of the few states that actually allowed us to have a dispensary be a dispensing physician, where we dispense medications to our patients. And I just did it just to understand the industry. And so what we would do is we would purchase prepackaged drugs from this company named physician choice services. I think they went out of business, some company, they sent us a bulk, a box of all these medications. I was buying furosemide for 80 cents for a 90 day supply dollar. But then the co pays to the patients were $15. That is insane. I mean, it is, is that how much the markups are. Because if I'm buying it for 80 cents, right CVS, is buying it for 20 cents.

Gautam Thakur, Pharmacist  25:49  
Correct. So you're putting an example for furosemide buy 500 Count bottle, probably would cost me about $25 for 500 tablets. But even though you fight sell it $400 I wouldn't sell 500 to one patients. But then what the the expense adds to the cost is you know, the the overheads for the pharmacy, the pharmacy is insurance, you know, every time we send the claim, some time insurance company will charges 25 cents fee. When you send the electronic prescription to us, the company charges 25 cents fee to go receiving the prescription. So there are so many costs involved in it. And that you know, so I can if you want if I buy drug for 50 cents, even if I make 100% profit and sell it for $1. I can be in business because the minimum expense to fill the prescription. And average this a industry standard is $10 cost to the pharmacy to fill the prescription not counting the drug or anything,

Coach JPMD  26:48  
just because remember the administrative costs, correct? Correct per prescription

Gautam Thakur, Pharmacist  26:52  
that instead of a $10. That includes you know, the overheads and label wild

Coach JPMD  26:56  
Yeah, and so our overhead was lower because we actually use our own staff. Because you didn't we didn't need a pharmacy teller, right?

Gautam Thakur, Pharmacist  27:03  
We were in less than or the pharmacies, you don't need to find myself either in debt only expenses.

Coach JPMD  27:07  
So the expenses were lower, so we can actually transmit that costs to 

Gautam Thakur, Pharmacist  27:07  
other disadvantage to what then it opens up for the because you have a pharmacy license, probably the board inspector came in?

Coach JPMD  27:18  
Well, they they didn't because we decided not to prescribe narcotics. So we didn't prescribe narcotics or controlled substances. Okay, so it was, and I think that I think we did get inspected after

Gautam Thakur, Pharmacist  27:30  
they will normally do because now we have a pharmacy even though you're not doing control, to make sure that you are comply with you don't have any expired drugs in the minimum requirement of labeling and things like that. So some damage may not be worth it.

Coach JPMD  27:45  
No, it became not worth it. Because what happened, we did hire someone a medical assistant, that was actually a pharmacy tech to do it, but then they left. So then now we're in the business of trying to find a pharmacy tech to fill the position for something that we weren't necessarily making any money. All right, it was more of a service to patients because the patient patient comes in with bronchitis and we wanted amoxicillin or it was an easy fill. And so that's why we did it. So it was very interesting back in the days. So alternative medicine, do you have any experience in your pharmacy with alternative medicine or, or prescribing things that are not necessarily pharmaceuticals, or natural natural medicines?

Gautam Thakur, Pharmacist  28:27  
we don't do as much of a you know, like allopathic mainly we do it personally, me, I don't like to take any medications. And sometimes I always joke with the family, the medications are for sale, not for consumption. It's for other people, not for you. But if somebody comes I usually advise them. If someone is or borderline blood pressure or sugar or you know, I always still lose some weight, do some light exercise, that will definitely help you. There are some doctors in each doctor has different habits. So I have seen one doctor, when he prescribes prescriptions, I would say at least five to seven drugs on same prescription because this just habit of prescription. Yeah, some doctor would just say no, try this try this date, you won't want prescribe antibiotic. It doesn't look like it's just a why else. Oh, so we don't need it would go away. But patient doesn't like that answer. The same man Oh, my doctor is not good. So now some doctor would prescribe the medication because otherwise the patient wouldn't think he didn't give him anything.

Coach JPMD  29:25  
I hear that I see that a lot. And it's a mindset. I think more physicians who have time to sit down with your patients to educate them and and teach them that they don't have to necessarily take medications they can their bodies can usually heal themselves. And so that's that's what I'm doing with Season Two and helping physicians who to practice medicine the way they want to practice medicine, and some physicians are moving towards alternative ways of practicing concierge practices. Doing things like weight loss and and And what I'm finding is that it's bringing patients, it's bringing the physicians to a happier state. And because when they are free of the corporate medicine, and they're free of having to be forced to prescribe certain things, to prescribe certain things like statin drugs for patients who may have a normal classroom, so yes, one of our HEDIS measures is you have to prescribe a cholesterol medication for diabetic who may have control diabetes, and have a normal cholesterol. I'm not sure if the studies show that that actually increases longevity. But, you know, that's what he just tells us. Right. So how do you how would you support a physician, that independent physician who's looking to help their patients.

Gautam Thakur, Pharmacist  30:44  
and when you brought up the HEDIS measure, and we always marked it over pharmacy, how we can help a doctor to make their HEDIS measures? One of them is through compliance. So you know, patients have not complained, you get dinged, we get dinged as well as a pharmacy. They charged us the fees, if our ... 

Coach JPMD  31:01  
Fees, what do you mean? 

Gautam Thakur, Pharmacist  31:02  
Some an example of patients taking statin drugs, blood pressure or diabetes medications, if they get filled 30 day supply on first of the month, and they don't come back for refill flipped up the next month, we get penalized. They charge us, huge amount of fees. And it could have been 1000s of dollar end of the year.

Coach JPMD  31:22  
So that's, that's it's so you're saying all the managed care side on managed care? 

Gautam Thakur, Pharmacist  31:26  
Managed Care.

Coach JPMD  31:27  
Okay. So you're, you're basically on the hook...

Gautam Thakur, Pharmacist  31:29  
Many managed care patients

Coach JPMD  31:30  
Yeah, yeah. On the on the ACO patients or the Medicare patients

Gautam Thakur, Pharmacist  31:33  
So should be able to charge us the fee. So it is in our interest to make sure that we fill all the prescription on timely fashion, if patient is not able to come and pick it out. We offer them the delivery. So we do everything possible. So taking the prescription filled on time.

Coach JPMD  31:47  
Yeah. So how do you feel about patients who actually don't want to take a bit drugs, and you're still getting dinged on that. 

Gautam Thakur, Pharmacist  31:52  
So we will try as an example you brought up about a statin drug. That's our measure, too. So if I don't fill even though I cannot prescribe it, if I could prescribe, it also cannot prescribe your statin drug because your diabetic. But we cannot prescribe it to be able to send the fax to the doctor according to American diabetic Association, you should prescribe statin drug doctors might say yes or no, it doesn't know we can prescribe it, we can fill it. We still get dinged

Coach JPMD  32:20  
which I think is crazy. 

Gautam Thakur, Pharmacist  32:23  
and it's not right as you mentioned, patient should not be on it if you know is  under control and everything....why just put on  extra drug if they don't need it?

Coach JPMD  32:31  
I also tried to figure that one out. But I think I know. Maybe we'll we'll talk about it this time. But we'll save it for another episode.

Gautam Thakur, Pharmacist  32:38  
so I have heard that you're coming back to the concierge service. Yeah, I love that idea. And that's where the future is going. 

Coach JPMD  32:43  
I think so 

Gautam Thakur, Pharmacist  32:44  
I see so many doctor, I know personally, they're going towards that route. They have 24/7 access to their physician, they have kind of a family relationship, they know them well. And then just unlike you have to prescribe your patient statin, even though it's ignored their interest, you don't agree with it, but he's still otherwise you will get dinged. So you can get out of all those scenarios, you feel passion for your that you're helping somebody get healthier. So I think this is the future I would probably you know have Doctor into service you know I will  pay for it even though I may have insurance, but I will have access to somebody that I can call and ask opinion that doctor would give me an opinion not because the insurance company or CMS or somebody wants them to prescribe this when they will Okay. Same thing when somebody asked me Oh, Gautam, what would you recommend as a you only as a patient or as a friend. So if a friend I were said this, if he has a professional thats the same thing with you know, when you ask a doctor, no, you have to have a statin drug otherwise you will get dinged and all that thing. It will save them money. Same thing I'm working with some of the bigger employers, some doctor provide them service to the big employer, they have their site in the their manufacturing unit. So I went to them and I looked at us and see there the bill for how much they pay for the prescriptions. And I'm not to buy information but just the drug and the quantity and and I saw so much opportunity I see you paying you know $1,200 For this drug I can give you for $800 this drug I can give you for that much. And it was 1000s of dollar of savings because now there is no middlemen. No no spread we know because then there's so many factor was done out of the scenario. And employers say yes we will be interested working directly with you with CMS or managed care or Medicare patient become challenging because they're gonna see this prescription getting prescription filled every month and want the report back then you had to go to that PBM circle

Coach JPMD  34:55  
I look at it as a circle of control 

Gautam Thakur, Pharmacist  34:57  
Correct 

Coach JPMD  34:58  
I mean its controlling All aspects of medicine. And what I've realized and what I've done the research on is that we do all these things to control medicine control pharmacies, control PBMs. But yet, we're not getting the outcomes. When you look at life expectancy in the US, we ranked 46 of the world, 2022 46 in the world,

Gautam Thakur, Pharmacist  35:20  
even though we had the best technology, healthcare, and so

Coach JPMD  35:24  
we are we're not doing things as good as let's say Japan

Gautam Thakur, Pharmacist  35:28  
Right

Coach JPMD  35:29  
Or Sweden, and France. They ranked where they said they could do the research. I did a whole podcast on on that, and I'll link that in the show notes. But I think we're just spending too much money in that control aspect. And, you know, money corrupts, and that's what it boils down to. So how can I know I opened the dispensary. But then when I tried to look at how we can open up the pharmacy to help patients. One of the things that I found out was that we physicians can't open pharmacies open to the public. Is that still true?

Gautam Thakur, Pharmacist  36:08  
That's true. But there are some like if the recently i think this year. Some of the ACO, because they have the risk in our ACO is all the risk management. And they asked the CMS to give them an alternate to open the pharmacy. So I think this year, if you have ACOs, ACO can open their own pharmacy. And then the exception I think is this year,

Coach JPMD  36:30  
so when but are they able to serve as a community or only 

Gautam Thakur, Pharmacist  36:34  
Only their own patients

Coach JPMD  36:35  
Yeah. So it becomes like a dispensary 

Gautam Thakur, Pharmacist  36:36  
right 

Coach JPMD  36:42  
one of the things that happened to around COVID. And I'm not going to tell too deep into this, but might be able to do that another episode. But I was told by a pharmacy pharmacists big chain pharmacist that they were not allowed to prescribe certain drugs, because the pharmacy board told them not to prescribe it. Does the pharmacy board tell you guys that they can or can't prescribe drugs?

Gautam Thakur, Pharmacist  37:06  
So I don't think so the pharmacy board came to us and then they would say no, you can't have unless there's a control and something unethical and inappropriate. The board has given a pharmacist the authority to deny any prescriptions. 

Coach JPMD  37:20  
So it does do that 

Gautam Thakur, Pharmacist  37:22  
So if you prescribe something that I don't think this is ethical, or is in interest of the patients for whatever reason, so I feel uncomfortable filling it so I can deny it and nobody can question me. But my colleague, he or she says, Oh, I don't have any problem putting this prescription so other pharmist can fill under that versus in their own name and check and everything.

Coach JPMD  37:44  
So So could that pharmacists be at jeopardy of losing the job if they could never have things not true? Because it's up to their judgement personal 

Gautam Thakur, Pharmacist  37:51  
doing that. I don't see anything wrong in it. At that time and ivermectin prescription during the COVID, it was helping many people. There was some pharmacies I know online pharmacy, they were filling 1000s of prescription for ivermectin and people were you know, doctor were ordering it. They were filling it, people were paying for it. 

Coach JPMD  38:11  
Yeah. 

Gautam Thakur, Pharmacist  38:12  
And somebody believed it would work. But it is not officially FDA approved indication for it 

Coach JPMD  38:18  
sure. 

Gautam Thakur, Pharmacist  38:19  
So then the pharmacist might say, Oh, something happens. Sometimes they will put very high dosage. And it says it's for the horse its for the animal.

Coach JPMD  38:28  
But that was so that was horse do-do because a lot of a lot of that was untrue, because I prescribed it to many of my patients and it worked. It worked.

Gautam Thakur, Pharmacist  38:38  
So what happens when you prescribe it? If I fail? If something goes wrong with the patient? Then, you know, somebody might question me, so why didn't you question that this is not right dosage, it is not approved for this indications, or somebody do the lawsuit. You know, pharmacists filled that, you know, this high dosage. So to protect himself, you know,

Coach JPMD  38:57  
yeah but I think, I think they were they were also looking at other media outlets to to discredit it because they weren't that much different from the dosages given to patients with parasitic diseases in Africa, and in Africa is prescribed almost like water to prevent river blindness,

Gautam Thakur, Pharmacist  39:15  
when there aren't as many lawsuits in Africa. 

Coach JPMD  39:18  
Yes, that's true. But it did when win the Nobel Peace Nobel Prize in Medicine for that. So that's a whole other topic. probably save that for another podcast episode. So what's the one thing you could tell a physician that they should do in their practice in order to succeed, so I try to try to help physicians understand what they can do. And from your perspective, as a as a pharmacist, you see and hear talks about doctors offices. So what's the one thing you could tell the doctor, as young physician that they could do in their practice to succeed.

Gautam Thakur, Pharmacist  39:52  
So I'm a pharmacist. I'm a entrapreneur and opened up my own pharmacy in group one to four they sent the open up the infusion center now where we do all the biologics IV antibiotics in Brooksville, we opened up about three weeks ago. 

Coach JPMD  40:07  
Congratulations 

Gautam Thakur, Pharmacist  40:07  
Alright, thank you. And after I left Walgreen pharmacy, many of my friends, they came to me because they were tired of in a chain, you know, environment, a lot of stress. This I opened up my own pharmacy to and I was already in the business, they asked for my advice. And they were they would come to my pharmacy, and I would tell them what license you would need, where to go, where to apply distributor or where to get cheaper drugs, how blue marketing, that more business, where every single person that I give advice, and I will probably do the same advice to any physicians or any intrapreneur I will say in that matter. I always, I said before, I'm a businessman, I'm a human. I had a lady when I open the store, she lived 15 miles away from my store, and she was getting Lasix or Furosemide. And literally, I was making 20 cents on her prescription not counting my overt acts. And I still deliver to her. Because that's the right thing to do. A 90 year old lady can't get to the pharmacy to pick up the script is my moral and a response to take care of her. I kept that moral and I told all of my friends who came to me for advice, I said, do it but always, at least for first year, do it that you're doing for charity, you are not doing this business for making money. I have this motto after 15 years and I'll continue because that's my passion, you have to have a passion for what you do, then you can do it longer durations. If you do it, because you have to, then you wouldn't burn out within a year or two or three. So just have a passion for what you do and taking care of your patients. Whatever way you could, you know, that's why we're setting that that's the success.

Coach JPMD  41:46  
sage advice sage advice I thank you for that. I think I think someone out there needed to hear that. Because we've got some a lot of crazy things we want out of this this world and and if you're passionate about taking care of patients do it do it because you're passionate.  Last episode, or one of the episodes before this one. I gave Dr. Singh actually 10 rapid fire questions. I don't know if you saw that. Well one liners or one one word answers 10 questions and we didn't rehearse this so so are you ready for my rapid fire? 

Gautam Thakur, Pharmacist  42:25  
We will try

Coach JPMD  42:27  
What's your favorite sports team?

Gautam Thakur, Pharmacist  42:29  
While you know I was born in India, so like or follow my sports here. So I play cricket. Of course, India, cricket dimia 

Coach JPMD  42:38  
Favorite food? 

Gautam Thakur, Pharmacist  42:39  
Indian food

Coach JPMD  42:41  
Which Indian food? 

Gautam Thakur, Pharmacist  42:42  
Oh which Indian food? Um, you know, we have so many steaks. And then each is different the food from every state is different. So I would say I Punjabi food  that you normally find in Indian  restaurants that's my favorite paneer I would say paneer?

Coach JPMD  43:01  
What do you what to do when you retire?

Gautam Thakur, Pharmacist  43:04  
I don't think so I will retire because I enjoy so much everything I do. So my son he is going to go in a pharmacy become a pharmacy graduate in the next few years. And he will probably take over business. But I don't think so because I enjoy so much. So I don't know what I will do when I retire. I love people. I need people to talk to and help people. If you ask me one thing what makes me happy. Helping people makes me happy. So I will probably continued because that's my retirement. I'm retired right now. 

Coach JPMD  43:34  
That's cool. What would your mother want you? What did your mother want you to do when you grew up?

Gautam Thakur, Pharmacist  43:41  
Just happy person 

Coach JPMD  43:42  
Didn't want you to be a doctor or lawyer?

Gautam Thakur, Pharmacist  43:44  
No, I wanted to become a forest officer when you take care of or protect the animal in the forest because in a table a lot of poaching. They kill all this animal. But then it's just under became a pharmacist though.

Coach JPMD  43:57  
It's gonna get a little harder. Maybe the one thing that your wife wishes that you can change in you

Gautam Thakur, Pharmacist  44:06  
spend more time at home.

Coach JPMD  44:08  
Okay. Maybe one thing that you have one thing that your lead pharmacist did not know about you or does not know about you.

Gautam Thakur, Pharmacist  44:30  
If I say now then she would know. 

Coach JPMD  44:31  
I know 

Gautam Thakur, Pharmacist  44:38  
I dodn't know Dr. Pierre, what was that? Because I usually share all my story personal sites and there's anything that my staff doesn't know or if they don't know, but can it's not that important that they don't know. Yeah.

Coach JPMD  44:50  
Okay. You wiggle your way out of that question. No, that's okay. Last book that you read.

Gautam Thakur, Pharmacist  44:57  
I don't like to read. I only do the audiobooks. 

Coach JPMD  45:00  
Ok so last audio book 

Gautam Thakur, Pharmacist  45:02  
I have an app is 12 minute app. So they will give you the essence of that book in 12 minutes. So I have listened to every single day, you know, going back and from what 

Coach JPMD  45:15  
What was it called?

Gautam Thakur, Pharmacist  45:17  
Let me see which one was the last one because I do like four or five books every day. So everything which one was the last one? 

Coach JPMD  45:24  
Is there like a series? 

Gautam Thakur, Pharmacist  45:25  
So they give me a series of like seven day challenge. So one day they would say how to become a good leader. The next book would be about the time punctuality or managing the time. Okay, managing the family, you know, how do we the good habits have? I forgot the author good habits of successful people.

Coach JPMD  45:44  
So we have those? 

Gautam Thakur, Pharmacist  45:45  
Yes. So it's all right. 

Coach JPMD  45:46  
Stephen Covey. 

Gautam Thakur, Pharmacist  45:47  
Yes. 

Coach JPMD  45:47  
Yeah. All right. So favorite vacation spot?

Gautam Thakur, Pharmacist  45:52  
Belize.

Coach JPMD  45:56  
Favorite physician in Spring Hill.

Gautam Thakur, Pharmacist  45:59  
Oh, man, I don't want to make hundreds of physicians upset. Let me see. I would say you know, the most I hear, favorite to me would be favorite to my patients. 

Coach JPMD  46:12  
Yes. 

Gautam Thakur, Pharmacist  46:13  
So, the most people have said good things about the physicians. What was it was about Dr. Korupolu

Coach JPMD  46:21  
Kudos to Dr. Korupolu, he made on that podcast practice impossible podcast. Thank you Guathum Thakur for being on the Practice Impossible Podcast. We really enjoyed you and I've enjoyed the knowledge you've given me about pharmacy and just in general, your your knowledge on the

Gautam Thakur, Pharmacist  46:33  
And if you get any of the questions on your postcard,  please forward to me and you know,

Coach JPMD  46:47  
sure. So how can we find you?

Gautam Thakur, Pharmacist  46:49  
You can email me on my email is my first name spelled GautaM@Pinebrookpharmacy.com. And I'll gladly reply, any questions you may have, and any stories or more tips about how to be a successful entrepreneur, and agender all doctors medicine and I'll give you what I have done in my practice.

Coach JPMD  47:13  
That's awesome. Thank you so much for your time. Appreciate it.