Modernizing Pharmacy Practices: Insights from Latin America | Mike Rizo, Pharm.D, MBA, Pharmcare Svcs.

This transcript was generated automatically. Its accuracy may vary.

[00:00:15] Mike Koelzer, Host: MIke, for those that haven't come across you online, introduce yourself and tell our listeners what we're talking about today,

[00:00:23] Mike Rizo: I'm Mike Rizzo. I'm the CEO of PharmaCare Services, and today we're gonna talk about the differences between the way we do pharmacy or we practice pharmacy in the US versus pharmacy or specialty pharmacy in Latin America. And the many different opportunities and the many different ways of seeing the same thing, the different definitions of, what dispensing is, what a patient is,

et cetera.

[00:00:49] Mike Koelzer, Host: Mike, what interests me talking to somebody who has this specialty in the difference . Regions are not just a different way potentially that the practice is done, but what are the employers down there willing to pay for? What's important to them versus what's important in the states.

[00:01:10] Mike Rizo: Mike, it's a very good question because we don't offer our services, per se, to the employers. 'cause the,  the system is so different in

Latin America that, as opposed to here in the states where A PBM will

go to HR and through a broker and try to get, the business of managing the prescriptions for a company is different.

So we

actually work with the payers. We actually work directly with the payers, whoever that payer might be. Most of the time it is an insurance company. But it could be the government, sometimes

it could be a group that is self-pay. So we actually manage that for them. We actually have the patient and then we have the payer. And  we are what puts all that together. And as opposed to the states where, we actually try to save money for the employer or we try to manage the claims, it's a little different.

[00:01:59] Mike Koelzer, Host: So in the US a pharmacy benefit manager, their customer, I guess, are bigger corporations who are saying how much and what care can you give to our employers? And in Latin America it's different because the employers are not part of that. how do the employers get out of that picture like it is in the us

[00:02:29] Mike Rizo: Let me start by explaining that Latin America it's pretty large, so

We have over 30 countries in Latin America, and everybody's pretty much doing their own thing, right? it's a big difference between, for example, Argentina and Bolivia, for example, when it

comes to healthcare there's a big difference between Columbia and Venezuela and they're next to each other.

There's a big difference between, for example, Venezuela and Colombia or

Mexico and Honduras. So it's totally different. So in some places you have the government that pays for most of healthcare, however,

[00:03:09] Mike Rizo: not for medications.  

in other places you have like your wife, for example, which is pretty comprehensive. They do pay for most medications. And then there is a process, a legal process for a patient to be able to get a specialty drug. It's a complicated process. They have to go through a judge, when the access to the drug and 

then 

the judge gives an order, then they could access the specialty medications.

[00:03:35] Mike Rizo: We have about 600 million people on the continent, in Latin America. That's from Mexico all the way down to Brazil, Mexico being like 120, Brazil being like 200. So both of them combined are about, the size of the US and then

the rest, 27, 27, 20, some countries make up the other 300 million people. So there is a percentage of the population that either because they can't afford it or either, because of their nature of what they do they travel a lot or they work with embassies or their expats, whatnot, they need to move around the continent. All the time. And I'm

not saying traveling, but I'm saying for, a position, somebody got a position

with the multinational in Honduras because there's a factory there and they need

to move there with their family, so these people buy a policy, an insurance policy, that allows them to have access to healthcare no matter where they're at.

[00:04:30] Mike Rizo: Including the US, including Europe.

So that's a big portion of our patients. So the patients at the beginning when we started, they usually, we would just manage when they come to the states. So let's use the example of someone from Honduras, for example. Let's say

someone it's in Honduras and gets diagnosed with some sort of cancer and they decide to come to MD Anderson or somewhere in the US to, get a second opinion 

and whatnot.

And they come and they see a specialist and they say, okay, yep, you this malignancy and we're gonna, we're gonna treat it this way and this is gonna be the regimen and you're gonna go through, nine, 10 cycles and

Here's the prescription. And I see you in three months, six months. So now you have a patient in Texas who doesn't understand the healthcare system here, if it is already difficult for people from here to understand it.

Imagine, someone from Honduras coming over here.

Usually they come with a family, you know, it's a new

diagnosis. What do we do now? And at the beginning what we do is we'll manage how that patient works, because most of these patients end up in Miami or someone in South Florida because it's the closest culturally speaking to Latin America.

. So let's say this patient's going to require chemotherapy every 21 days.

So now we handle that for that payer. They come to us and we become their their representative here for that

patient, 

that international payer. So do we. Deal with an infusion, an infusion suite in the area. We bring the patient there and the patient stays here. But what ends up happening is let's say after one or two sessions, the patient's like, how long am I gonna be here? They already process the new diagnosis. The family is getting inside. Like, I wanna go back to Honduras.

The

kids need to go back to school. What should I do?

And that's when it becomes complicated, and that's when the patient needs to go back home. Now you have a specialist in Texas who prescribed, who doesn't communicate with a specialist in, in Honduras.

And now. We are that link, we are that linkage between this physician, the other physician, and the patient in the middle for the treatment part of it, so then we need to subcontract, let's say the oncologist in the country and say, okay, we're gonna be able to provide this medication for you. 'cause is the important thing. So let's say in Honduras they have a formulary of drugs, whatever the government pays for.

And now this patient got prescribed a specialty drug that they don't even know what it's,

so now we need to work with that government to bring in this medication for this

patient. So there is a process oftentimes we need, an order from a judge or whatever's needed to be able to import this medication for this one patient for the treatment. And there comes the clinical aspect of it. Okay, now we gotta manage this therapy. You We have a team and the team will call the physician, we'll call the patient, Hey, how's the therapy going?

Do you have any questions for our pharmacists here? But even all of this is new to them 

They don't, they're not used to seeing a pharmacist even dispensing, let alone the, the consultation part of it.

Dispensing in itself is a new thing. I mean, you walk into a pharmacy in Latin America, and with the exception of Costa Rica and Argentina, you don't even see a pharmacist.

So you just buy whatever you want, 

[00:07:48] Mike Koelzer, Host: Is there anybody putting any kind of a roadblock up from that or do you just go buy it like you would in over the counter medicine in the states?

[00:07:56] Mike Rizo: For most drugs, you just buy it over the counter. Okay. So

 That's a big, big interesting point that you just brought up because.

[00:08:05] Mike Rizo: When we first started, we didn't know any of this, we

would just take care of the patients here. And then Covid came and a lot of these patients couldn't move. So our clients started coming to us and saying, Hey, we need you guys to help us. The patient's stuck in over there and they need to get therapy. So we had to get out. I mean, I personally had to go out like 27 times during covid to different parts to start setting up, change the business model on the go

[00:08:32] Mike Koelzer, Host: Different parts of Latin 

America. 

[00:08:34] Mike Rizo: of Latin America. And you fast forward that and now we have to have our own specialty pharmacists in parts

all the way to Brazil to be able to dispense. Because when I say dispense, that in itself is a new terminology for most of the pharmacists over there.

So even that was like something new to me, 

you 

I started hiring pharmacists, and I would tell 'em, Hey, I need you to dispense the medications and counsel. They're like I don't know what you mean by that, that's not my job, 

I said what exactly is your job? Oh, my job is to work in a manufacturing plant, and

[00:09:10] Mike Rizo: I know how to manufacture medications. That job belongs to the physician. I'm like, oh

wait. But you don't even have a manufacturing plant here in this country, so what do you do? How do you make your salary? Oh, we go, we are allowed to sign for controlled substances in Five independent pharmacies, one,

one per day. But are you physically there? No, I don't have to be there.

I just have to be responsible for whatever goes on there. So they're

not really, they're not really practicing pharmacy the way

We are trained. So I was like, wait, wait, this is not adding up here. So

How am I gonna be able to do this? How am I gonna be able to monitor therapies and dispense and do this the way that we do it in the states? And that is what made us redo the whole business model and say, all right, so we need to go back to the drawing board and say, Hey, listen we, this is not gonna work. We cannot subcontract pharmacies like A PBM would do. The whole PBM thing is new. I mean, I use the term PBM because that's what we know in the states.

 But basically we become the managers of the medications, but not just the medications of the treatment. 'cause a lot of the clinical aspect, 'cause these patients are pretty much on their own, they don't come back to see the specialist if they come back three, six

months and then the oncologist over there, or they're specialists.

I'm using an oncologist as an example, but it could be anything. The specialist in the country now is like, yeah, I know about this drug, but I really don't have any experience. 'cause here we don't have it, we don't have access

to it. So we become that, that NTT that helps them with learning about the new medication.

 No, I call it,  the name of the business is PharmaCare.

I actually call it pharmaceutical care. This is,

We do pharmaceutical care. We do a lot of clinical work here

'cause we, there's no way around it.

BuT even the payer. Just now, we've been doing this for about five years,

and even the player now is starting to understand the value of what we do because their players are from over there. at the beginning they were like, why would you wanna talk to my member? They don't even call a patient. Why would you want to talk to my member? They were

afraid that we were trying to sell them something.  Well, tHe patient is gonna start a new therapy. Does he even know how to take it?

Does he know that he could not take it with food or that he must take it with food?

Can we know what else he's taken to so we don't waste his medication? They were like, what? hOw is that your responsibility? I'm like,

it is. So there was this big barrier at the beginning. We were talking Chinese to them, we were talking in a totally

different language, and then I had the pharmacist who I was trying to train, and they were like, that's not my job. I don't feel comfortable. That's outside my scope.

The physician might feel like I'm invading the territory.

 So we started hiring physicians as well. So now we have as many physicians in the team as we have pharmacists in the, in, in these countries.

And they work in collaboration with the pharmacists and a lot of good things are happening and this physician, 'cause the reality is, when I was saying in this countries that I was a pharmacist, they wouldn't understand what I was saying or why I was getting into all these areas

that, 

that this does not pertain to me.

I'm like, so now I don't even call myself a pharmacist in this country. I said, I'm a pharmacologist.

[00:12:33] Mike Rizo: Then that makes com makes them ask me the next

question. So are you a physician 

now? Are you a pharmacist in the States? Yeah. And then I go on

to explain what the pharm D program is and

how it came about in 2001 and why it's so important to monitor all these therapies and et cetera, et cetera. So basically, I used this analogy the other day. I was talking to someone, I came to the office and he was cracking up. I'm saying, I'm gonna use this going forward. We are the guys with the machetes like cutting all the bushes, you know, trying trying to get there and trying to

make people understand what we do. There,

There are no roads. And then one very important point, Mike, and this is all that has been discovered for us, is, we have about 33 countries in Latin America. You have. Three or four that are like the leaders in the region, 

 Brazil, Argentina, Colombia and Mexico. And the rest kind of like follows the the,

let's say what regulation wise, what these

other countries do. Right? For example, the Dominican Republic looks up to Colombia a lot, and then Argentina and Euro y they look at Europe a lot.

And Ecuador for example, they look at us here in the States.

So when you talk to someone from Ecuador, it is so much different the way they do things than someone from Argentina, for example.

But then I discovered, I say. yOu look at the European Union, it's 27 countries, but they do have the the EMA, which is the equivalent to the FDA,

So here is a 300 million people, 50 states, but you have the FDA and we kind have to follow

what they say.

So that, in my opinion, is the biggest problem in the region. They don't have one entity that regulates or at least, gives the guidelines to follow, and so everybody's doing their own thing. 

It is very, very, Very difficult. So we deal with things very primitively. For example, something like, is the medication legit? Is the medication legitimate? It's a big deal in Latin America. 

I found out that 10%, and this is data from the World Health Organization, The WHO, we found out that 10% of all the medications in the world are fake, and this medications end up in this regions, 

they end up in the developing nations, like pretty much Latin America. And because of this lack of harmony among the regulatory entities, it's pretty much open season for these criminals.

That's one thing that we found out when we started entering this market, is trying to help the payer.

 When we started saying, okay, so how do you validate

[00:15:24] Mike Rizo: Is your member or your patient actually getting medication? That is supposed to be where, where they were prescribed

and pretty much they were like we ordered it through a pharmacy. I'm like, yeah, but that's a medication that is not available in that country.

So do you go a step further? So all that, now it's part of what we do.

So

When this player's contract is with us, we take charge of all of this for them.

[00:15:56] Mike Koelzer, Host: It sounds like you're doing a lot of stuff that the PBM in the US could do, but. You are actually doing a service where they're just peeling money off of it. you're actually doing something, being, quote the middle person.

[00:16:14] Mike Rizo: tHat's why sometimes when people ask me, what do you guys do? I, I feel like, okay, should I say I'm a PBM

because you know that carries such a bad name. Now, it's a

bad reputation with that. But in reality, this is pharmacy benefit management. What we do, you know, so we are actually managing

this for your patients.

So first of all, we have to ascertain that the medication came from the manufacturer through the

distribution channel. This is called good distribution practices. So

it came through that, and then that the medication was prescribed correctly. That's clinical pharmacy. And then that the patient knows how to take it. And, we have a whole counseling and a whole team behind that, and we accompany the patient throughout the process. That's more clinical pharmacy now, but I. I mean, I guess that's originally what PBNs were supposed to be doing.

[00:17:06] Mike Koelzer, Host: Like you said, you're in trouble. If you say you're a pharmacist and you're involved with a PBMs, you know everybody's gonna throw you out.

[00:17:15] Mike Rizo: Yeah. You'll be surprised. Recently in a couple of meetings I have started to explain it, like using, like translating it and someone out of the blue comes and says, oh, so you are A PBM.

I'm like this happened the other day. We were in the Dominican Republic, and someone said, so you are A PBM.

I said, oh, do you know what A PBM is? And they kind of knew what A PBM was. I'm like, oh,

wow. I mean, sometimes, like for example, in Euro y We work with a big group they're like, the closest to it here will be a hospital system, because the way they have the healthcare there it's everybody in the country puts x amount of money for, to have access to the health systems.

And then they go through something called It's basically, it's like a unionized type of thing,

but it's private, 

so it's a private entity that handles the benefits.

There's like three or four big ones in the country, and the market is divided by all three or four. And then they have their own hospital soap. They contracted with us because it's capitalized, so they give them a certain amount of money per member per month. And they recently started to realize that with all the new specialty medications, medication costs are growing and growing probably faster than anything else.

So they hired us to start, 

 Working with formularies, and this, all these things that we do here, you know, like step

therapy, let's try and regulate this.

Let's talk to the physicians, let's talk to your specialist. It's a very interesting project. 'cause it's something perhaps closer to what a PBN 

Should be doing. In the us. But

no, we don't deal with any of that. Rebatable things or, or DRR fees from our subcontracted pharmacists or, or none of that.

[00:18:59] Mike Koelzer, Host: Mike, out of the countries, let's say the 30 some countries. , are there any that stick out to you as being whatever, hard to work with Untrusting for various reasons? Are there some that are more difficult than others that attempt tempt?

[00:19:20] Mike Rizo: deFinitely probably one of the most challenging is Venezuela because of the situation there, it's very hard. It's very difficult to obtain anything. When we get an order for chemotherapy, we have to provide, sometimes even the supplies. And

I'm talking about even the needles, 

 They patient shows up for the infusion and they have to bring with them everything.

They don't, the center doesn't provide anything that has happened. And it's very challenging. And also, since we have to deliver to different parts of the country, I remember one time we had the medication sitting in the capitol.

It needed to go outside of the capitol and they didn't have gas. That's ironic. Venezuela, right. 

they didn't have gas to move from. And so we were stuck there for two days and the patient was almost late for the therapy.

And we were, we already had everything there and inside the country it was harder to move than bringing that specific medication needed for this patient from Europe. So

we got from Europe to Venezuela faster than from Venezuela to Venezuela,

you know, to deal with a lot of these things. A lot of coordination, logistics is a big part of it.

 Farm Care services have gone through a lot of changes.

Like any business person, that's trying to solve problems

And more problems come up and you're trying to solve more problems. 

When we went all in into the international world and we decided to do what we do right now, we didn't plan it the way that worked out like most

business people, you You start with one idea and you have to have the flexibility to adapt to

what you know, know, what the market really needs from you, not what

you think, the market needs from you.

And 

when we started it was business partner and I doing this, and then we brought in the technology guy Now in about less than five years, we're about 40 people, 

10 of us are here in, in, the US and the other 30 outside, now we have pharmacies in Mexico, in Ecuador, a pharmacy in Brazil, a dispensary in Colombia. And now we also have an infusion suite in the Dominican Republic. now we've gotten a step further with these payers, they're like, okay, you know what if, I could also guarantee the infusion of all these medications for you. So that way everything is more centralized. All these patients come and they're like, okay, so

, that's another step into our development of our model, you that is now turning into something more, I would say more structure.

[00:22:03] Mike Koelzer, Host: Mike, would you say that your company is the leader, one of the leaders, are you in competition with people? How would you rate that in this business climate?

[00:22:17] Mike Rizo: That's a very good question because when we first started and we started going to the payers, they would be like, okay, talk to the providers department.

You have to become a provider for us. And then we were categorized as a provider and I'm like, okay, what do you mean the provider?

Who else is your provider?

And then we started seeing anything from a logistic company that they would contact to see if they could get medications from them, from X market into

where the patient was,

To local pharmacists that they just have access to the local medications,

but not the specialty medications,

to all the people that do a little bit of everything.

So we saw an opportunity to say, Hey, listen. Okay, you cannot treat medication the same way you treat a cane. Or crutches.

It's not the same. Let me explain to you why.

And at the beginning, it was difficult because they were like, you know how people are afraid of changes or new things?

And they're like, okay, we've been doing this for 10, 15 years this way.

We have a list of providers,

we put an email out and they tell us whether they could get it for us, how much? And we decide. I say, okay, wait,

you decide based on what you

know. We are trying to contain costs and this and that. Wait a minute. Contain cost. In what sense? So

you're telling me you just buy the cheapest thing

that you could find,

Where does that come from? And you go. Beyond that oftentimes the person that was dealing with this had no medical training. And if they have medical training, they did not have pharmacy training for sure.

So

a lot, most of what we've been doing for the last four years is educating the market. It's It's listen,

all right, so let's just from basic, this is how medication gets manufactured. This is how it -gets distributed, this is how it ends up in the patient's hands, and this is what happened after The patient has it, there is all of this stages that we can help you with, and if we do this the right way, the patient gets the outcomes for which the treatment was prescribed.

Perhaps as you count all that, you will be saving more money or containing more costs than just buying something that you don't know where it came from or

what the patient is getting. And they, little by little, started understanding, and they're like, okay, I see kind of what you're saying, but I was assuming that if I order it through a provider that has a license in that country or whatever it's all good. I'm like, yeah, I thought so too until I

started going out and realizing look, yeah, you do have good providers, but sometimes it's just the way the countries, they don't have access to the medication and they don't even do it, purposely trying to do something wrong.

They're just trying to procure something for, if it's a

logistics company all of a sudden got a request to bring something in, they don't,

they just gonna call out and see, hey, just the same way they would do to bring in a phone or a computer.

But But we're not, we're not dealing with phones and computers here,

[00:25:20] Mike Koelzer, Host: Mike,

There anybody , is there any oversight in terms of, because oversight does two things. It's supposed to help the situation to teach people and so on, but it also, there's a lot of people that maybe try to get around things if nobody was watching them. Is there any oversight? I know you mentioned there's not like the European Union kind of FDA kind of thing.

Is it just not there?

[00:25:29] Mike Rizo: Every country has their own version of it. It's usually their ministry of health.

And like I said, Columbia has a big one. It's called vima. Brazil has a visa. Argentina has um, AFMA and Mexico has Kafa Priest and everyone has their own agency. And they kind of copy what you know, the other is doing. And then also you have the. There's this organization, the Pan-American Health, whatever organization, they write guidelines, but they don't enforce anything. So there is oversight at the local level, but oftentimes they don't even know what they're looking for. So

If you're a patient and you have your local insurance and the medication that you're prescribed is not covered, and then you have this other insurance and it's covered, you're gonna go get it somewhere and bring it in. Or you're gonna tell your insurance, Hey, how do I get this? And your insurance is probably gonna go to their providers and somebody might say, Hey, I have access to that.

But nobody's really following the process the way that we have brought up the standards in the industry to say, Hey, listen,

We can do all this for you. We can even work. So when you ask me about whether we have competition, yeah, we had competitors at the provider level, but we have positioned ourselves in a way like we could, we can help you handle all this, but

not just the fact that the patient gets the medication, but

Happens when they get it?

Who's going to

Infuse it? How, in the case of an infusion medication, how are they gonna administer? Do you have a place to administer? Is it the nurse, is it the physician? And all this is new to them. Even when we started calling at the beginning, the patients were like, why are you calling me

[00:27:07] Mike Rizo: now? They look, they look forward to that phone call monthly, to see How did you do in the prior cycle? Do you have any questions for us? Anything you need to know about therapy? Things that we take for granted here, we brought in the president of a PHA per se of Ecuador, we brought him to the college, local College of Pharmacy here where I'm in their counseling board.

And they showed him the school, they showed him the farm, the program.

And this gentleman was fascinated. I took him to visit a couple of specialty pharmacists in our network here. And I say, see, all of this is done by pharmacists. This is what I was trying to tell you, that

I wanna help you guys

have your pharmacist in headquarters do all of this, so then the authorities actually want this too. They're like, okay, so you're bringing this standard, so what do we need to, where do we need to start? And I'm you need to start by having a pharmacist in the pharmacy.

[00:28:00] Mike Koelzer, Host: Yeah. Yeah.  

[00:28:01] Mike Rizo: That's a,

That's step one. I mean, how could you run a pharmacy without a pharmacist,

And then you need to start dispensing,

not just selling stuff like vitamins, 

[00:28:11] Mike Koelzer, Host: Mike, out of the 30 countries, I know it's all Spanish, are there any language barriers some countries use? it. Different types of measurement or different slang and things like that, or is that not an issue at all?

[00:28:24] Mike Rizo: Brazil, because of Portuguese. I speak Spanish, but I thought that because I speak Spanish, it was very similar. Now, every

when I go over there, it's like I struggle. But you would find in all of these countries, especially in the big ones, they're very advanced in certain areas.

For example, Brazil

in compounding, they're like, wow. I was like, oh my God. So 12% of all the 12% of all the prescriptions are compounded.

[00:28:49] Mike Rizo: You see a compounding pharmacy literally in every corner.

You And so there's a culture of compounded medications

there.

So we actually have a specialty pharmacy there, and at least half of everything we do is compounded.

I'm like, oh

my God. So you find that type of thing, same in Mexico, I've been to like the city. I went one time to see a visit, equivalent to a 5 0 3 A or 5 0 3 B here.

And I was like, oh my God, look at this. They did all of this and everything was good. So you do find these things, 

And in certain areas. So they know the same in Columbia for example their system is very advanced and if we, if I could compare it to something here, I would compare it to managed care.

So everything is managed care there. anD it works. But another thing that happens in Latin America is sometimes things work, but the new politician wants to change everything because

it's 

Just, Hey, look, that idea came from the opposite. And we have to undo all this. That's what's happening in

Columbia right now. They have a system that actually works when it comes to cell healthcare. I don't know if they know that because they don't know what else is going on

around them, and they're going to do a reform and change everything right now, and their

system actually works, you know?

[00:30:06] Mike Koelzer, Host: how about the technology through all the countries? I have no idea on this stuff, but as far as all the interoperability and the wifi and the internet and all that, is that all as well connected in Latin America as it is in the states or better?

[00:30:21] Mike Rizo: Again, you'll be surprised. For example, in Uruguay we helped a group, a technology company. they were trying to get the when the bidding for the electronic prescription.

And so we did quite a little bit of work with that company, and I was fascinated by how advanced they are in technology in a euro y everything. It's the id, like the driver's license. They have a number. And instead of us having a social security number and a tax ID or this, that they have one number for everything, whether you're a

business, whether you're, whether you're, and that number is connected through like a central

database.

When you go to the pharmacy, your prescription is ready. There. There. I was like, oh, wow. This This is

good. Oh, and so they were trying to make the electronic prescription mandatory for the whole country. I was like, wow. And when I went, you know, well, we have a global entry in the airport here. They have a global entry for everybody in Euro y. You don't even see a person when you get there. There's a machine there that takes a picture and goes right in. I'm like, wow, I wasn't expecting that. And then I see

 So you do find this thing the same in Argentina. I was there during Covid and they had this program where um, basically was like an AI power thing it makes appointments for the testing, for the vaccination.

All this time I wasn't, you're not chatting with a person and it

worked. I'm like, wow, look at this. My brother is a physician over there, and he was explaining to me the program. I'm like, wow, that we don't have something like that yet. So you do find these things over there, 

 . 

[00:31:43] Mike Koelzer, Host: Mike, what's something that, uS citizens maybe take for granted, I don't mean necessarily in a real bad way, but it's like we don't even think about doing this with pharmacy, whatever it is. Maybe having enough pharmacies or pharmacies being open long enough or the distance to them or the amount of care and so on.

What's something that we take for granted here in the states that we maybe shouldn't take for granted? Because you see it in Latin America that it's not happening?

[00:32:16] Mike Rizo: I Will start with the access to medications,  man, with and the medications that are legitimate medications here. That was eye opening to me when I started going out there and saw we don't have any of these medications here. Recently

 were working with a group we learned about, how we are trying to get biosimilars approved here and how we started to get the the insurance and the PBM to approve the biosimilars where I, about a year and a half ago, I learned that there are a lot of bio copies or bio mimics to biosimilar.

Okay? This is somebody in some country that decided to manufacture. A medication and they just call it biosimilars.

So now it gets even more dangerous, so in a lot of these countries you get what you get. And remember the doctor, an oncologist in Ecuador bringing me to his office, and he's showing me, and he goes, look at this. this. is from Korea. This is not supposed to look like this.

This is the only, I forgot the name of the medication. I wanna say it was Doxorubicin. This is the only sin that we find here now. This is supposed to be liposomal. This is not supposed to look like this. And I have no idea what I'm infusing to my patients right now. And I was like,

wow. Yeah. And here we take all that for granted. I personally, oftentimes complain about the over regulations and how many people regulate pharmacies. And I say, with

We are the most regulated profession. Everybody, local state feds, da, it's too much. But

now that I've seen the flip side of that, I'm like,

Whoa, wait. Maybe I should change my message a little bit. 

And 

We do need all this, all these safety things in place. 'cause we take all this for granted. Every so often we'd read in the magazines or the journals Hey, look, there was counterfeit medications that made it into us. But that's something rare. Imagine that being The norm. 

you know, you know where you're at regardless of whether you have the money, regardless of whether you have the insurance, you really, don't know what you're getting. So

That's something we take for granted.

[00:34:21] Mike Koelzer, Host: So, Mike, your day I know you bounce back and forth a little bit. How often are you going across the border? And how many employees and team members and so on in your business are you seeing on a daily basis?

[00:34:38] Mike Rizo: Oh yes. Here in Miami we are actually Miramar, which is like 20 minutes north of Miami, but

Miami's like the point of reference.

It's 10 of us here

in the headquarters. And of them are MDs, two are pharmacists. Then we had the head of IT here. Then we have a couple people from case management.

We have a pharmacy intern too. And basically from here we handle the whole operation. And we have about 30 people in different countries. So we have a couple more physicians in the Dominican Republic. We have physicians in Argentina, we have pharmacists in Ecuador, pharmacists and two pharmacists in Brazil with their technicians. have another team in Columbia as well. And we keep on growing. So basically it's 10 of us here trying to manage the whole region.

 I go out at least once a month. In fact, I'm back out again in a couple of days. So I am trying but I go out at least once or twice every month.

[00:35:35] Mike Koelzer, Host: Are you, so your home base is around Miami?

[00:35:39] Mike Rizo: Yeah, I live here with my family. My wife and my kids are here in Broward County,

a little small city called Cooper City, which

is a beautiful city. And we are here. And I try to make all my trips, three, four days, which really gets tiring because, you imagine going to Argentina or Brazil, it's like a nine hour flight.

It's like you're going

to Europe and try to get there on Monday and work really hard all the way through Thursday to try and be back home by Friday.

You do that twice a month or every month and it can  add up. when you're in Miami, does it feel nice compared to some of the American countries?

It

depends 

like for 

I'm originally from Cuba, so I'm supposed to like the tropical weather,

but I really don't, I

don't like

the heat that much.

So when I go to Argentina and or Uruguay or Quito and Ecuador it's 50, 60 degrees. It's oh my God, I wish we could have at least three months of this in Miami. 

[00:36:39] Mike Koelzer, Host: Oh. Because it's cooler in a lot of those because you're going down fairly far south.

[00:36:44] Mike Rizo: Yeah. Sometimes it could be really cold, if you go during winter which

would've been summer for us here as a winter for them, and you go there during winter, it gets pretty, pretty cold. 

[00:36:55] Mike Koelzer, Host: How is traveling between all the countries? Is that fairly loose, or is that difficult at all? far as, I guess, I guess driving or flying.

[00:37:05] Mike Rizo: For the most part.  For the most part it's pretty

loose, rarely a country would start asking me a whole bunch of questions like, what are you doing here?

Why do you come here so often? Or whatever. But then I think that's probably the person that had a bad

day or something, I don't think had to do with the country.

It's pretty, the connections are pretty good. We

have so many airlines and so many

hubs,

that. 

[00:37:25] Mike Koelzer, Host: like going through the states up here.

[00:37:26] Mike Rizo: Yeah. Yeah. Pretty much. Pretty much. 

[00:37:28] Mike Koelzer, Host: Mike, if you weren't able to do this any longer, let's say there's no more work you get to do in Latin America, do you see any holes in the US system that you would try to form a business around if you were cut off from Latin America?

In other words, do you see skills and talents that you have and ideas in business that you could only do in the US in a fictional world where you could not do anything. In Latin America.

[00:38:02] Mike Rizo: Definitely. You There is a large population of I would say Hispanic population in South Florida

that they come here let's just put it this way, every time there is a political party or something that the people in certain countries in Latin America feel that there's going to be going to become unstable,

or they think that things are not gonna go the way they expected it. it. A lot of them come to they relocate to Miami

and they open businesses here. So when they come over here they don't understand the healthcare system.

I don't know where to go. They don't know how to go, they don't know where to get their medication. And we do a lot of that here.

1. Right now. So

When a patient comes here, we do use the services of A PBM that have access to every pharmacy, and we handle the dispensing, the prior auth or anything that is needed while that patient is here. Because,

That's a patient that just got here. He doesn't live here, he doesn't have a social security number, but he has an insurance company that covers it here. So we become that bridge, now, that patient goes and fills a prescription somewhere in Utah. And we handle that from here, from Miami. So even

if we didn't have the business in Latin America, we would continue to do what we do here. For

example, these patients that require, let's say, that same patient all of a sudden requires

home infusion, 

that patient's required Pancam iv, I don't know, daily for 21 days. He wouldn't know what to do. He wouldn't know what. We handle all that from here. We'll subcontract the nursing agency in Utah, the home infusion company, and we speak that language. I mean, we're PharmDs from here. We have an

MD in the team from here. So we do all that here. I mean,

a big part of what we do is when they are here. So the way we like to explain what we do is like we don't care where the patient is, whether he is in the States or whether he is back home.

Um,

We are going to treat that patient the same, with the same standards and the same quality.

So if it was, if we decided not to have more business out there, there's plenty for us to do here

with the insurance and through the self-pay as well. Because like I said, a lot of these patients come here and they don't know where to start. They don't know how to,

you so If there wasn't a

[00:40:05] Mike Koelzer, Host: language barrier, do you think there's other parts of the world that could replicate what you are doing there? Just that, there other places in the world that have the same balances of things going on where they need a company like yours 

[00:40:25] Mike Rizo: Yes, I recently had a visit here from a friend of mine. I had lost track of him. Ended up being that he was in Singapore working

for five years. He came to the office and we were catching up and then when I explained everything that we are doing here, he goes, man, this is something that they were probably going to go crazy about.

Like If you go to Singapore and you start offering this service to different parts of Asia. So I would say anywhere in the developing world, there is a need for what we do because again, I go back to the training of the pharm d and

part of what I do, and I just do this because I like doing it,

is just talking about what we do here.

 I'm a big believer that the more we talk about what we do as PharmDs and

the more we get out from behind that counter and checking

prescriptions, the better.

And it's. The more I talk about it and the more global it becomes the function of somebody who is an expert on medication management, the more of a need, the more of a demand for that service. 'cause, and the realization that the physicians that now work with me that they have about. Our knowledge. They're like, oh my God, I didn't know. I mean, you're telling me that every pharmacist that I see in Walgreens CVS knows this? I say, listen, they know way more than me. I'm not even,

I'm not even top of my class.

These guys have all this knowledge. So anywhere that we could go out there and make this the standard practice, the need is there. Whether they know it or not, that's a different thing. But once you educate 'em on, listen, this is what needs

to be done. The therapies are more complicated every day.

 I remember when I was practicing in oncology, a clinical pharmacist, 20 some years ago, or 15 years ago, monoclonal antibodies were the second line. They were basically immunotherapy. For just cancer.

Now we have 80 autoimmune diseases and all of them are treated with monoclonal antibodies.

And we have in the pipeline,

mRNA car T-cell, this and that. The therapies are gonna get more and more complicated, and

We are the experts on managing how that is administered, handled, and monitored. But we need, it's only 300,000 of us in the US and yes, you do have in Europe hospital pharmacists who are very good. For example, Costa Rica, the same you have I've been surprised by the knowledge of the PharmDs in Costa Rica,

but those are the exception, not the rule. See what I'm saying? So we've had the PharmD program for over 20 years now,

and it needs to be a global thing. So

I definitely think, yes, that in every developing economy, our services will be appreciated.

[00:43:09] Mike Koelzer, Host: What's the status of, I know we talked about how pharmacists are quite different, or at least they have been up to this point. What's the status of pharmacy schools and being able to train people in Latin America, the universities and so on? Are they putting out pharmacists like US pharmacists or are they not?

Or will they ever get there?

[00:43:29] Mike Rizo: I hope so. It's at least one of my dreams, or is my vision. I do tell you this, when I go and I talk to them, they're very receptive. They're like,

Okay, we want to do this.

We know and we know that it's being done in the states and they do have pockets of it, they like,  in the hospital they might have some, somebody doing some pharmacokinetics, somebody help 'em with anticoagulation.

But not to the extent that we do it here.

So 

the, 

they do want to change,

But like anything, you know, it starts here. It starts in Europe. 'cause it's also a reality. You The manufacturers, the market is the US and Europe.

So a lot of these medications get there five, 10 years later.

So the

The same goes for education.

know, You're not gonna educate somebody on

how to monitor, monoclonal antibodies when they don't have 'em available, so it makes no

sense, 

[00:44:15] Mike Koelzer, Host: I have a I live in a decent sized city in Michigan and I have a cottage, which is about 30 miles north, and I was talking to a physician friend of mine and he was saying, Mike, the people that are 30 miles north of here, more out in the rural country, he said they wanna be out there.

They don't want the medical attention, which people in the city want. They don't trust the doctors as much. And want people to mind their own business and all that kind of stuff. Would that be the same in Latin America where maybe some people are more accepting of current medicine and some would rather not?

[00:44:56] Mike Rizo: Imagine, you have countries where the population uh, Guatemala for example, is over 80% is indigenous, and they do not believe in western

medicine. So that you have a lot, high incidents of diabetes, for example.

And it's the same here.

I remember when I was a student, we used to have a rotation in the Indians reservation. And it was the same thing here. They did not want the medications, even if we brought them to them and then we

wanted to they didn't trust what we were doing 'because it's in

their belief. So you do see that throughout the region and unfortunately it's the contrast are very uneven when, you get out, mostly I'm, I visit the capitals or the big cities, but when I have to travel outside 

I went to Peru for the first time on a medical mission last year, and I will continue to go every year.

I went with this group of surgeons from here, from Miami, And I saw. they really didn't have any access to, to 

healthcare. 

And even if they had it, like in this clinic, it's hard to get them to come and to even trust the physician. So that

is a fact, that is a reality in Latin America, for sure.

[00:46:03] Mike Koelzer, Host: Tell me about Guatemala. So you said 80% of the people don't believe in modern medicine, does that mean? They're not. Taking certain drugs, how does that 80% get by if they're not accepting that?

[00:46:18] Mike Rizo: It's complicated because what I said, like I said, when you go to these countries, In the city or in the capital. And it totally, like one time you asked me about Guatemala, but I use the example of Mexico being, being, being bigger.

One time someone asked me, so how is Mexico? And I answered, which Mexico, because it's like a thousand Mexicos within Mexico, 

There are places in in, in all those countries where they don't have a doctor there, they don't have

a pharmacy, they go

to their local, to the local spiritual guide

or whatever, and they do what they call green medicine.

You know, So

basically national medicine, alternative therapies. And they swear by this, when I was in Peru, I. Ended up with appendicitis over there, and all these people came with all these herbal products. And I'm like,

no I don't know what I'm taking. I'm a pharmacist. I don't know this thing, but they truly believe that

they were gonna cure my appendicitis with a lot of herbal

tea. You know, Of course

they did have a hospital. They have, operating room. But

 All these things coexist, and you have to respect their culture too. So it gets complicated, 

you know, when you, when they feel that you're imposing your beliefs on them, 

very complicated. 

[00:47:20] Mike Koelzer, Host: Does the life expectancy, is that reflected in those. Kind of beliefs or I'm guessing it might be the same as the us

[00:47:31] Mike Rizo: Mike, that's a very good question. And oftentimes when I'm there and I, it's a very fine line when I'm talking to practitioners from all these countries,

there's a fine line that I might sound arrogant

I was trained in the States. So

I'm very, very cautious, you know, about what I

say, the way I say things. And one time someone just got up and said, look, you come from the states with all these fancy MTMs and this and that, but you guys don't live any longer than we do. And our quality of life is actually better because, you know, after like you're like 60, you can barely walk and over here we're walking like 10 miles just to go get the bread every day

and come back home and I'm like, I had to say, you know what?

I don't know the statistics very well, but yeah, I gotta get around the court. But you know, he did have a point, he did have a point, we spent like, what. Of the GD on healthcare and 10% of that is on medications and the reality is we're not doing much better in terms of life expect in a lot of s It's a very

question. 

[00:48:36] Mike Koelzer, Host: some of the people in various walks of life. They're skeptical of AI, chat, GPT and all that. And I say, look, let the kids use chat GPT on their term papers but let's set the bar higher. We have the same life except, I mean, it's inching up, but it's a lot worse in a ton of places in the world.

And so let AI do that stuff. And let's then move on to higher level goals.

[00:49:05] Mike Rizo: That's right. That's right. And that's what, and when I said earlier that I'm very passionate about the functional medicine aspect of her

For integrative medicine, I like the term integrative medicine, as something that I've been obsessed with, even since I was in pharmacist school, because I've always said that, look, it's not like we're doing Everything perfect, just look up our numbers. Just look up all the money we're putting into healthcare and the

results that we are getting in terms of life expectancy. So perhaps we should be more open-minded towards a lot of other things that we maybe are not trained

or don't understand. So we have physicians in the group here that we work with that are, that's all they do, functional medicine. And, and I go to, sometimes we do this symposium where we, gather a bunch of physicians

And we do it on just this topic, like sometimes functional medicine or integrated medicine.

And I'm fascinated when they, the way they see medicine, and I said, wow, being a pharm d we're trained more like. There's a condition and you treat it, and there's a receptor.

And this, eh, perhaps we need to take a step back 

and I'm seeing a movement towards that in pharmacy as well. I see Scott here from Miami, who's a friend, you know what he's doing with sports medicine. And I see a couple of guys doing a sports medicine magazine. Now I see a movement towards integrated pharmacists, functional pharmacists.

That's great. It's, in my opinion that's where it should all go, a more

comprehensive approach. 

[00:50:26] Mike Koelzer, Host: Mike, I gotta believe that the US companies, the dirty PBMs and the corporate behemoths and so on, if they could . enter an area and know they could make money at it. I'm sure they would. Do you think the PBMs and those types are too big of a nut to crack for them? Or how come they don't have their hands in everything like they do in the us?

[00:50:57] Mike Rizo: Mike, I think it's a matter of time to be honest with you because

At the end of the day a lot of countries, they copy what they

perceive. It's working in the US

It doesn't necessarily have to work,

thEy perceive that, look, if they're doing this, we should be doing this.

[00:51:17] Mike Rizo: In Latin

 America, like it, changes so much.

You know, every time there, there's a turn and a political party

takes over. They they undo everything and

redo it. 

But I do think it's a matter of time

because let's be honest, you know, if the PBMs were really doing what they were supposed to do, like what we are

doing, like what other guys I think like Capital

RX is doing and a

few other things like prescriptive,

Some PBMs that are doing what we were supposed to be doing are a good thing. The problem is,

What they evolved or what they became,

[00:51:44] Mike Rizo: So there is a, definitely, there's a need for what we do everywhere 

you. 

[00:51:47] Mike Koelzer, Host:   gOlly, Mike, thanks for joining us. It's interesting to see all this stuff going on in other parts of the world.

We get it. I get so sick sometimes of complaining about all this stuff in the US and it's fun to hear it from other countries to realize if I were there, I'd probably complain about stuff there too, , but thanks for opening that up for us, Mike. That's really fascinating. 

[00:52:12] Mike Rizo: Thank you, Mike. It's been a pleasure to be here with you today.