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How Much Can I Make? — Real Jobs. Real Stories. Career Insights
Pharmacist Career Insights - Surviving A Rigged Game
00:25:41
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- [00:04]
Dr. Nils Moller
The top 10 medications hasn't really changed much, except for a lot of the opioids are no longer in that list because the opioids were a big part of the top 10 lists for a while. So it's mostly cholesterol and blood pressure medication. There has been a really great trend with these, like, miracle drugs, these GLP1s, the weight loss drugs, but they're very expensive and difficult to get for people.
- [00:28]
Miravo Zeri
Welcome back to How Much Can I Make? The podcast about jobs and earnings. I'm your host, Miravo Zeri. Today we are joined by Dr. Nils Moller, holistic pharmacist, supplement strategist, and the owner of Village Apothecary in the iconic town of Woodstock, New York. With 20 years of experience, Neil knows the pharmacy world inside and out. His passion has always been to deliver great care to patients and the community. But as you'll hear, there are plenty of challenges that come with running an independent pharmac. Dive right in and uncover the realities of being a pharmacist and a business owner. First of all, thank you very much for doing it. I really appreciate it. Let's start with. Did you always know that you want to be a pharmacist?
- [01:19]
Dr. Nils Moller
Yeah, luckily I did. I was 14. I took a little stupid home economic assessment, like what kinds of careers would fit you based on your personality and health came up. My mother was a nurse, and so I sat in the guidance office and I scrolled through all the different, like A to Z, literally all the different types of things you can do in healthcare. And I got to pharmacists and I actually thought of my pharmacist and it was Pete Gage. And I just thought, like, how awesome he always was to everybody and how people looked up to him. And he was super smart. Was like, oh, yeah, let me try that. Let me go get a job over there. So I got a job working for Beatles Pharmacy and almost immediately was like, yep, this is what I'm going to do a little bit. But it was pretty much like that was. That was it for me. I applied to one college and I got in and it's pretty much been since age 14, a straight line to pharmacy. Wow.
- [02:10]
Miravo Zeri
How many years did you have to study?
- [02:12]
Dr. Nils Moller
It's six years and you get a doctorate degree.
- [02:14]
Miravo Zeri
Now, what inspired you to open your own pharmacy? Which is actually very good one. I use it.
- [02:20]
Dr. Nils Moller
Thank you. Well, the joke I always say is that I have a friend who opened a pharmacy and I'm like, if that idiot can do it, I can do it. So I was like, that's the joke that I always say around him. I was very entrepreneurial at a young age, and it was very attractive to me. And I had a number of mentors that kind of like, fan that Lane. And I always wanted to open up my own place. And I really, like. It was kind of interesting cause I had just taken a job at the VA in Albany, and I was like a clinical pharmacist. And it was like this really cool role, but I wasn't satisfied and I wasn't going to be satisfied. So like, literally at my honeymoon, I was like, aaron, I got it. I got to do something. Like, I need to open up my own place. And so that was really just me expressing my entrepreneurial desires. I don't need to go work for somebody and just like, be stuck. I need to be able to kind of like dream big and then like, have good people do good work.
- [03:10]
Miravo Zeri
But how do you compete with the big pockets of the corporate like Walgreens and cvs?
- [03:16]
Dr. Nils Moller
So I believe that the evidence has kind of shown that there is no competition. The level of care and patient preference always has been predominantly with an independent pharmacy. People love that relationship. I don't think that there's enough of an advantage outside of maybe being able to buy your Benadryl really cheap like a CVS or a chain pharmacy. So we've always won. The reason that it's difficult for us to compete in a financial sense is because the chain pharmacies have rigged the system. The chain pharmacies have purchased the go between the intermediaries, between an insurance company and a patient called a pharmacy benefits manager pbm. And the PBM is the. The organization that sets the rules for who gets paid what and what pharmacy you can go to. So CVS owns Caremark, and by owning them, they can then tell patients where they can go, and then they can pay themselves more than they. They pay me for that same customer if they choose to not go to a cvs. And that's just kind of like very, very, very tip of the iceberg. But essentially the reason that independent pharmacies have died off dramatically is because this vertical integration, this monopolistic practices that have been allowed to happen in this country around the financial side of prescription business, when it comes to care, there is no competition. If we blow them out of the water totally. I have people that are. When you have to force someone to use you as part of the rules of the game, that really indicates to me that you can't compete otherwise. I mean, it's absolutely insane, right? Imagine if, like, we, you know, you wanted to buy a hammer from a hardware store. You would just go to, like, whatever hardware store you had a relationship with and. Or like, whatever one was, like, nearest to you. Now imagine if somebody dictated what hardware store you could be buying your stuff from. That's literally what happens in health care, where the job you get will dictate what insurance you have, which then dictates which major health care system you can use. You can't just go see a doctor. You're part of these major systems, which then tells you which hospitals you can use, which labs you can use, which pharmacies you can use, all based on that one decision, instead of having any choice or freedom here. It's really, really perplexing. If you put into ChatGPT, does the business of pharmacy make sense? ChatGPT will say wholeheartedly, no. And we know this because the community pharmacy organization just did it and sent out an email with the response. You know, if you have an organization like a PBM that is shrinking how much you get paid while your costs are going up, it doesn't work. I'll tell you something about owning a pharmacy. During the pandemic, a lot of people wanted to support us. They wanted to come and give us their business. And I would have to say no.
- [06:06]
Miravo Zeri
Wow.
- [06:07]
Dr. Nils Moller
Because it was like the worst thing that somebody could say is that I want to give you my prescription business, which is the opposite of any other. Like, if the restaurant starts doing good and gets a good reputation, you want more people in the door.
- [06:17]
Miravo Zeri
Right.
- [06:17]
Dr. Nils Moller
The problem is, is that I don't know if your prescription plan is going to have predatory reimbursement practices, meaning I could lose money filling the prescription.
- [06:26]
Miravo Zeri
Whoa. Explain that to me. How is that possible?
- [06:28]
Dr. Nils Moller
The pb, that middleman, is who sets what pharmacy will get paid to dispense a drug. They know what all the numbers are. They know how much the drugs cost us. They know how much everybody's getting paid for the system. So they use all of that data and they say, well, we're going to only pay you the cost of the drug, and that's it. So they're just going to reimburse us. So let's say Your drug is $100. They're going to pay me a hundred dollars. So that means that I have $0 to then pay my staff to give you the prescription 17% of the time, which is up from about a half percent or like a quarter of a percent when I first started 20 years ago. It's now 17% of the time we're getting reimbursed less than the cost of the drug. So when we fill a brand name prescription, like insulin or heart attack medication, Right. Blood thinners, stuff like that, we will lose about 6% on every claim. And if the drug costs $500, you're talking about anywhere, you know, like you're talking about losing 30 bucks every time, but it's really anywhere between 20 and $100 that we'll. Those weight loss drugs that were going around, Those are about 1,000 bucks a piece. So pharmacies were filling them for their patients and losing about 80 to $100 every time they were doing it. So there's no other business that exists that does that, that sells stuff at a loss because they kind of have to. And so these PBMs kind of create these rules in which pharmacies are disincentivized to exist. And if they do exist, they're disincentivized to take the prescription. So that way that the prescription either comes back to them through their mail order pharmacy or go the pharmacy that they own themselves in the community. And so it's another way to kind of rig the system.
- [08:07]
Miravo Zeri
So how do you make money? How do you make money?
- [08:09]
Dr. Nils Moller
How do you make money? So you really don't. So the pharmacy business, if it's managed correctly in today's terms, you can kind of break even. And then you have to hope that you're making money on other things. And so, so, yeah, it is a, it's. And this is why, again, independent pharmacies basically peaked around 2016. That was probably the, the. They were at their highest value and probably at the highest number that they'd ever been. And now they've been on the downward swing. We sold our SoRooGarty store in 2016, and we didn't know, but that was the height of it. That's the most that we would ever get for the value of our store. And it's been downhill ever since that because the reimbursement schemes are getting worse and worse and our pay is getting worse and worse. And, and it's, it's horrible. So, so to, to be a pharmacy is, is often a losing battle in a lot of markets, especially in, like, New York.
- [09:06]
Miravo Zeri
Wow.
- [09:07]
Dr. Nils Moller
And so it doesn't make sense. And again, this isn't an independent pharmacy. If you notice, Rite Aid has gone bankrupt for the second time, has closed all their stores. That's not because Rite Aid doesn't know what they're doing. It's because Rite Aid is subject to this as well.
- [09:19]
Miravo Zeri
Wow.
- [09:20]
Dr. Nils Moller
They don't own the pbm, so they're losing money on all of their stores. Walgreens just sold to private equity because they weren't surviving. And they're owned by the Boots Company, like a European retail brand, which is like a very successful brand. And they still had to kind of get out. So chain pharmacies, hospital pharmacies, independent pharmacies are all suffering. And the other thing about purchasing, so like when it comes to purchasing, that, because that's the first thing that people will say is like, well, you're small so you can't buy like cvs. And that's not true. I belong to a buying group, one of the biggest in the country. There's something like 7,000 pharmacies in my buying group, which is more than what cvs. And we do billions of dollars in business and we have one of the best like buying deals in the country. And so like if I buy a Lipitor prescription, a generic Lipitor, that might cost me $0.40 to fill your prescription, about a penny a pill. But if I'm getting paid 45 cents by the insurance company, it doesn't matter if I buy it at 20 cents or if I buy it at 10 cents because I'm still only making 40 cents. And that's not enough to cover our costs. And that's the important point is like there are two costs here. There's the cost of the drugs and then there's the cost of the service. So we are buying as best as we really can when it comes to those pills. We. But we're still not getting paid for our services. If you can change where pharmacies are getting paid a flat fee for their service, like, because I'm just putting pills in a bottle for people and providing consultative services, that's pretty much the same thing all day. No matter the different drugs you get. If I can get a flat fee for that, and I know it's dependable money that will improve pharmacy care, there will be less of the chain related crappy service, there'll be more independent pharmacies, People will be healthier because of that change.
- [11:00]
Miravo Zeri
I'm surprised because years ago I remember hearing that being a pharmacist is one of the lucrative jobs in the healthcare industry. And they make a lot of money.
- [11:10]
Dr. Nils Moller
Pharmacist is, I mean, like a pharmacist today can get anywhere between 60 and probably $80 an hour in the New York market, which is a really great career. And I Think that that's great. I also think that the education bubble hasn't really helped pharmacists. So what? That 50, because when I graduate was like 50 to 70 bucks an hour. Okay, that 50 to $70 an hour. What that gave us was mobility. It gave us the ability to, like, work really hard and then like go from middle. And some of my friends were lower middle to upper middle. You know, if you work really hard, you married another pharmacist, then you have that mobility, you pay off your debts, and there you are. And so now if you get out of school, you're getting the 60, 70 bucks an hour, but you have $240,000 in student loan debt. So now you're locked in for 10. Like, how do you save for weddings? How do you say. Which are insanely expensive. How do you save for any of the life things that used to be a part of American life, like these big celebrations, buying a house, starting a family. How do you do that if you have a mortgage essentially hanging over your head the minute you get out of school? I would say that. Should I go to pharmacy school? Well, you should go to pharmacy school. If you're passionate about the practice of pharmacy, you're not going to be one of these shits. Essentially, you can beat and bleep me if you like. That is ruining our practice by pushing profit over people or, you know, a vomit that works at cvs. If you're not going to be those people and you're going to actually be passionate about changing the way that we practice in this country and being that example of what could be, then yes, you should do that. But otherwise, I would say there's better uses of your skill set that will be far more lucrative.
- [12:49]
Miravo Zeri
So you have to do some extra things outside the prescription drugs. Is that why you started the vitamins?
- [12:57]
Dr. Nils Moller
That's exactly.
- [12:57]
Miravo Zeri
Which are actually very good, by the way.
- [12:59]
Dr. Nils Moller
Yeah. Thank you. And it's actually also why, when it came down to, like, which store should I sell? Because the industry was changing, we got kicked in the face a bunch. And I had these four stores and I had to make a business decision about which one should stay in, which one should go. So the pharmacy in Saugerties was doing three to four times the volume of our Woodstock store.
- [13:19]
Miravo Zeri
Wow.
- [13:19]
Dr. Nils Moller
I chose Woodstock because. Because it was way more diversified. Almost every single person was buying a substantial amount of supplements and the supplement business was very strong. So that meant that I was not single threaded, I was not subject. Like, if I stayed in Sardis, I feel I would probably be bankrupt at this point because of, like, the nature of the business. It's not only why I started doing supplements, but it's why I chose Woodstock over Sardis or even the Lake Katrine building is because it was a stronger niche.
- [13:48]
Miravo Zeri
Do you. Do you also distribute your vitamins through other distributors to other places?
- [13:55]
Dr. Nils Moller
We that is coming now. Yeah, that's something that we're going to be beginning now. It was actually something that I had started in 2020, but something in 2020 got in the way and so we've been pretty distracted. So now that everything's kind of settled down, we're going to be doing that pretty aggressively in the upcoming days. And again, if you think about it though, like, I'm a pharmacist, I own a pharmacy, I should be practicing pharmacy, and that should be enough. The bigger kind of picture to understand here is the tension that I have between how I was kind of raised in pharmacy by those initial, like, people I thought of my mentor and the people that hired me at Beatles and like, the culture of what I thought pharmacy was and like, what it has to be today. Whereas, like I was told, you treat everybody the same and never think about money. Yes. If some patients are more profitable, some are less profitable, it doesn't matter. You serve the community, serve the people when they come to you. Right. And you just do a great job. Now we have to think about money where it's like, I have to say to somebody, I can't take your insurance, I can't fill your prescription, I can't stop your. Stop your medication.
- [14:53]
Miravo Zeri
The most popular drugs today are the weight loss and the Lipitor.
- [14:57]
Dr. Nils Moller
So, you know, the top 10 medications hasn't really changed much except for a lot of the opioids are no longer in that list because the opioids were a big part of the top 10 lists for a while. So it's mostly cholesterol and blood pressure medication. There has been a really great trend with these, like, miracle drugs, these GLP1s, the weight loss drugs. But they're very expensive and difficult to get for people. It's not as successful as one would think. It's a pretty big business.
- [15:23]
Miravo Zeri
When you order a drug, you order after you get the prescription or you have to stock them.
- [15:29]
Dr. Nils Moller
Inventory management is a very important part of our business because if you think about it, you have lots of skus, lots of items to manage, and then each item has different manufacturers. So like a Lipitor prescription could have 10 different manufacturers and there's different costs. And now there's even different reimbursements. So you'll get paid differently by the different ones that you use. So we have to kind of identify, like, what's the ideal product to use? Right. To get paid the best. Because that's a stupid thing. Right. It should just be, like, what's the best option for the people? So we have to manage all the different items and then all the different, like, variations of the items. And then you have drugs that are super expensive and some that are very, very cheap. So you have to make sure that you don't have too much inventory because that could be financially problematic. And then all of them are ticking time bombs because they all can expire. You see, in my store, there's stuff on the shelf.
- [16:21]
Miravo Zeri
Yes.
- [16:22]
Dr. Nils Moller
And we have mechanisms to make sure that people can get the crucial things that they need at least get started. And then the next day, we can get in the rest of their medicine.
- [16:31]
Miravo Zeri
During COVID I saw you administrating vaccine to hundreds of people. And you could even go into the pharmacy, and there's a nurse, there's a receptionist that gets you. Who pays you for all of this. It was all free.
- [16:44]
Dr. Nils Moller
The COVID was very interesting, and Covid is a remarkable time for me in two different pieces. One, all the stuff that I'd been like felt like a washing machine vibrating in place when I was like, I'm sitting on a train track, but I'm a washing machine vibrating because there was an opportunity to be a train. And so I felt like Covid was the first time I could be a train. Right. Like, I could literally say, here's the problem. I'm energetic. I can hire great people and manage a big system, and we can deliver for a big group of people. And it was like, the fruition of everything I wanted to be when I was 14, which was to be significant for the community. That's what I really wanted from pharmacy. It wasn't because I was good at science. It wasn't because I liked the white coat. It was because I wanted to be significant for my community, like my mentors. Right. So Covid was great from that perspective. And then the other side of it, it was really great because it was the first time in my career that we got paid the same for everybody, no matter what, from the government, from insurance companies. And then the government made sure that there was no games. Everybody had a minimum that they had to pay us. And if they didn't pay us the minimum, the government would top us up.
- [17:49]
Miravo Zeri
Oh, okay.
- [17:50]
Dr. Nils Moller
So, like, it was $40 per vaccine. So if we gave a vaccine, we got $40 and if we got paid $20 from insurance, we would tell the government, they would give us $20. That allowed me to do math. And that's why I was everywhere, because I would have a community, let's say like Dover Plains out in Dutchess county, where nobody thinks about they had a group of people that needed the vaccine, but nobody was providing it in an efficient way. So then we would know if we drive me and a nurse basically two hours away and did 10 shots, that would still be financially beneficial. So then we can start to be very generous with our time and serve communities that are outside of our normal reach. And so, and then we would were able to speak up for specific groups of people that were being marginalized because we knew, listen, we can go to this church and we can give three shots, but at least the three elders are cared for. Where they, where they would have a hard time getting to some place and getting in line and getting these vaccines. We're going to come to them, get them their vaccines and then they don't have to think about it. Right. And so it allowed us to kind of do that. So it's the first time in my career where we got paid for everything. And you saw what happened, right? Like I gave 70,000 vaccines and I have a 1400 square foot store.
- [19:01]
Miravo Zeri
I didn't know it was that big of a number. Wow.
- [19:04]
Dr. Nils Moller
We're one of the biggest in the country. And certainly if you go by square foot, I think we were the biggest.
- [19:08]
Miravo Zeri
Wow.
- [19:09]
Dr. Nils Moller
Yeah. So. So in the situation of COVID the government paid the drug companies a flat fee for each dose and then they paid the providers a flat fee for their service. And that's the way it should be structured, right? Cover the drug, pay for the service.
- [19:22]
Miravo Zeri
Exactly.
- [19:23]
Dr. Nils Moller
And yeah, so now it's. Everything's private, it's no longer funded by the government. So I pay Moderna for. Let's like I ordered 5,000 vaccines. Those vaccines now cost instead of $15 that they were paying the government, they cost about $100. So when I order like 5,000, I have a half million dollars of inventory. Right. And I have to make sure that I use them up. So you better believe I'm very sweaty during vaccine season.
- [19:50]
Miravo Zeri
Right. Do you think there's going to be any kind of problem now with RFK in charge and he killed the RMA.
- [19:56]
Dr. Nils Moller
And all of that chaos and incompetence are definitely the theme here. I actually just during this interview I got a text message that The Moderna vaccine has been approved by the fda. And so that means that we now have. The CDC has to say who can get it. Basically, Kennedy is now in charge of the FDA and the CDC in his role. So he's fired everybody from the CDC that was responsible for vaccine stuff. And those. This is some of the most credentialed, experienced, and like unbiased people, like, well vetted people in all of government. And he fired them so that way he can put in a sycophant. And so it's, it's a problem on a lot of different levels. And yeah, if you're listening to what I'm saying, I'm telling you that basically the only reason that we even survive is because of our vaccine business. If that goes away, it's not that I would be poor. What it means is, like, it doesn't make sense for me. The effort and reward doesn't make sense.
- [20:55]
Miravo Zeri
Of course. What's the biggest reward in your business?
- [20:58]
Dr. Nils Moller
It's literally the patience. There's nothing that makes any of it worth it except for what we could do for people. One of my longtime patients, he's one of the geezer corps in Woodstock. You know, those guys that eat breakfast every day. Like they do community services and stuff, the old guys. He came to me and said that he was just told by his doctor that he had bowel ischemia, meaning his bowel is dying. It's almost like a heart attack in the gut and like it's slowly dying and he's going to die. He's got about four days to live to maybe seven. And he said, so I just want to be comfortable. I want to like, I eat and I feel sick. And so I designed a diet for him that was like sort of something that I would use if somebody's going through like radiation or chemotherapy. Something very gentle to gut, but still gets proper calories and proper nutrients. And so use a couple of our supplements, but not the supplements aren't the magic part. He took the advice, so he started that diet and it's been like six months.
- [21:52]
Miravo Zeri
Wow.
- [21:52]
Dr. Nils Moller
Yeah. His doctors, his nutritionists, like, credit the advice and everything that we started him on as being solely responsible for that.
- [22:02]
Miravo Zeri
Wow. I didn't know you do things like his design diet. I thought that something that is that.
- [22:07]
Dr. Nils Moller
His doctor would do now around, like anything helping people achieve their wellness goals. I look at life very holistically. So prescriptions and conventional care is just one part of the whole thing. We have like our diet, sleep, mental well being, our environment, exercise all of that stuff is very crucial, and it's an important part of the medications and supplements that you use. So we always incorporate that advice. Whether or not it's taken. We incorporate that advice into everything that we do.
- [22:39]
Miravo Zeri
So what was the one thing you wish you had known before you started?
- [22:42]
Dr. Nils Moller
The only thing I would say is, like, I would have been even more aggressive about my continuing education because there does come a point where most of my focus is around the business.
- [22:52]
Miravo Zeri
Right.
- [22:53]
Dr. Nils Moller
And not around the clinical stuff. So now at this point, if I wanted to really be sharp again, it would take a lot of effort or it would just probably make more sense for me to get one of these, like, hotshots out of school that are super smart, that are passionate about that and, like, just know how to hire those people and have them do that work.
- [23:10]
Miravo Zeri
How do you choose your people, by the way?
- [23:12]
Dr. Nils Moller
Really out of desperation. I mean, like the pharmacist, like, it's a very difficult market to hire people in. And so I put up job postings. You know, we're looking for smart people, we're looking people for cultural fit. So, like, I'm actually going to be announcing today that we have a new pharmacist that's starting with us. Her name is Kayla, and she's everything that we would all want. You know, she's very smart, very efficient. And like, I was like, I need you to go above and beyond for these people. She's demonstrated just in a few times, in the few times that she's been there that she's like, as obsessed about it as I am. And so then this is going to be a very good thing. And so, like, it's really like you're. You're picking people based on the cultural fit. Are they going to fit with your organization? Are they going to fit with your current co workers? Are they going to be synergistic, drama free? Do they believe in the mission and are they going to, like, really fulfill it for you?
- [23:58]
Miravo Zeri
How many people do you need working for you in the pharmacy technically?
- [24:01]
Dr. Nils Moller
Well, and CVS really pushes this. You don't need very many. You need a pharmacist to check the prescriptions. And typically you have another staff person called a pharmacy technician and that that person is responsible for kind of like the adjudication of the claims, billing, the insurance and data entry of the prescriptions and then putting them into the pills, into the bottles, repackaging them. That. And then you would have like a cashier working for you in a lot of chain pharmacies. Because the nature of a chain pharmacy is to increase productivity. While I believe sacrificing care you often will see in a pharmacy like mine. So you've been into my pharmacy and you know lots of people working and that allows us to provide a higher level of care. In a similar size, like volume wise pharmacy, you would probably see one, maybe two people. It would be the pharmacist and that's it.
- [24:50]
Miravo Zeri
All right. I really appreciate it. I learned a lot about the business of pharmacy, I have to tell you. Yeah, you shattered some ideas I had.
- [24:58]
Dr. Nils Moller
Different and, and hopefully, like with our concerted efforts, like we can kind of change everything, people.
- [25:04]
Miravo Zeri
It's amazing how the whole healthcare and all aspects of health care in this country is totally screwed up, completely rigged.
- [25:11]
Dr. Nils Moller
Yeah.
- [25:11]
Miravo Zeri
Yeah. All right.
- [25:14]
Dr. Nils Moller
Thank you.
- [25:15]
Miravo Zeri
Thank you. Okay, that's a wrap for today. If you have a comment or question or would like us to cover a certain job, please let us know. Visit our website at howmuchcanimake info. We would love to hear from you. And on your way out, don't forget to subscribe and share this episode with anyone who is curious about their next job. See you next time.