The Business of Pharmacy Podcast™
Sept. 12, 2022

Primary Care Clinics in Pharmacies | Adam Wheeler, MD and Steven Stewart, PharmD, Big Tree Medical

Primary Care Clinics in Pharmacies | Adam Wheeler, MD and Steven Stewart, PharmD, Big Tree Medical

Adam Wheeler, MD and Steven Stewart, PharmD, Big Tree Medical discuss putting medical offices in pharmacies.

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(Speech to Text)

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

Steven: I'm Steven Stewart and I am with big tree consulting, which is a partnership company between big tree medical and the Waypoint company. And I am the director of clinic growth and marketing. 

Adam Wheeler, MD: I'm Adam Wheeler, I'm a pediatrician and I'm the CEO of big tree medical. And what we're talking about today is, uh, a newer idea for us, um, which is to. To marry a direct primary care clinic and a membership to a pharmacy as kind of a way to help the independent pharmacist survive onslaught of the pharmacy benefit managers and to kind of get in on the front end of the, the direct primary care wave that's uh, getting ready to start sweeping the country.

Mike Koelzer, Host: So guys, big tree medical. What is that? I know that it has a few different names. Should I say so there's a big medical and big tree, maybe consulting or whatever. Spread that out a little bit for me.

Adam Wheeler, MD: Yeah. So history is usually the easiest way to understand how things evolve. And so I'm a doctor and we started at a direct primary care clinic in Columbia, Missouri about almost six years ago.

Mike Koelzer, Host: What does that mean? Direct primary care.

Adam Wheeler, MD: yeah, good question. That's some lingo. So direct primary care is to serve patients, not insurance companies. So I have a direct relationship with my patients and that they're directly paying me.

Sometimes I work directly with an employer, so they're paying me directly. And then typically with direct primary care relationships, there's a monthly. For us, it's $59 a month. And then the patients get unlimited care at our primary care clinic.

Mike Koelzer, Host: How many of those then do you have? You have more than one?

Adam Wheeler, MD: Yeah. So we have about five in the state, um, mostly centered in mid-Missouri and we serve about 6,000 patients

then when COVID hit. Um, and we, you know, virtual stuff became reality. We said, well, what if we opened up our platform to allow, um, other providers throughout the country to use our platform?

So we have about 30 providers in about 42 states who are practicing on our platform right now.

Mike Koelzer, Host: How do they define themselves those 30? If it is, do they say we're part of a big tree or we buy big tree software or we did a big tree franchise.

How do they describe themself?

Adam Wheeler, MD: A lot of 'em are in corporate practices of medicine states, which kind of defines how they run. So they're not actually a franchise legally, but there's a bit of that feel to it. So we take a percentage of revenue, um, as you know, to run the software advertising website and then their job is to, um, take care of patients.

So they all have virtual only clinics. And for a lot of them, it's a side hustle. So they have 20 or 200 patients, um, that may be part or all of their job. They have a few people that are semi-retired and then they're just on call for their patients all the time.

Mike Koelzer, Host: Are there certain rules where they maybe can't, practice across state lines and so on?

Adam Wheeler, MD: yeah. So it all depends on where you have a state medical license and. you know, so some providers may have patients in 15 states, um, or they may have one, some of them are doing it as a part of the physical clinic that they own. And some of them, this is the only thing they're doing. So it's virtual only.

So we can't do everything, but we can do a lot. And we do a lot of, uh, mental health. We do a lot of medical weight loss. Um, the main restrictions are on controlled meds, of course. And then, um, you can't really bill Medicare, uh, but we're PA doing it for cash. So we don't, we don't care about Medicare.

Mike Koelzer, Host: When I picture online, I'm picturing, there's no way to hit the front of their knee. Right.

Adam Wheeler, MD: There's no way to hit the front of the knee.

Mike Koelzer, Host: So that precludes some of that stuff that I imagine.

Adam Wheeler, MD: Yeah. So usually in our hands, about 80% of, um, conditions that are cared for primary care can be taken care of on video. And, you know, if, if I don't know how your community is, but in our community, it's a few weeks to a few months waiting for a primary care visit. 

All of my people see patients on the same day. 

So, you know, there are times that our patients need to go to urgent care because I can't examine a belly to see if they have appendicitis, unless, you know, I touch them.

But you know, when I, in a traditional primary care practice, they send [00:05:00] patients to urgent care every day because they can't get them in.

So we end up using urgent care as a helper, less often than traditional primary care.

Mike Koelzer, Host: Steven. your pharmacy. Where do you fall into this? 

Steven: So I'm a new grad and basically I met with Ben through a group called Medis and kind of explained this idea that I had,

Mike Koelzer, Host: And let me jump in a second. Ben is with Ben Coakley. He's waypoint, and they've got a few different industries that are helping out. One of them is pharmacy. How did you meet up with Ben?

Steven: So I met up with Ben through the Medi connections. So from my university. I reached out to her, I was talking to our Dean about an idea that I had, uh, Dr. Tracy Haman, and she was friends with the mediport, Dr. Frisk, Michelle frisk. And I talked with her and she said, you have to meet Ben.

And so I talked to Ben and that led me here. And so Ben and Adam got together and Ben pitched having me join the team. And my whole thing is really helping this expand. So mine is going to talk to the pharmacist, be their first contact and then get them started. And since I do have a pharmacy background, I'm pretty familiar with it.

I am young. I am new out in the world, but you know, when you're, when you're there, it's, it's pretty easy to see when you're in a pharmacy, that's just getting swamped. And the quality of life isn't there. Nobody wants to be there. And when you don't, when you're not your best in healthcare, you can't provide the best care.

So by increasing the quality of life in our pharmacies and our primary care doctors, because they need help too, with this, they're getting swamped. It's a numbers game. It's not a quality game. If you increase their quality of life, you increase their joy in working and you can also increase patient care and outcomes.

Mike Koelzer, Host: So let me get this straight, Steven. Are we still talking virtual or is this something physical? Getting a big tree into the physical pharmacy?

Steven: It is,

it is.

Yes. So they'll like to put the NP in there and like Adam was talking about with the corporate practice of medicine laws. That's where it gets a little tricky on how we have to go about doing that. We work on that every day, or I work on it definitely every day, too. Adam puts a ton of work into

Mike Koelzer, Host: The corporate practice of medicine law. What is that?

Adam Wheeler, MD: so corporate practice of medicine laws are of call 'em CPM is present in just over half of states. And it basically states that a for-profit company cannot own a clinic. So it has to be owned and operated by a physician. 

Mike Koelzer, Host: Are they saying physicians don't make a profit or are they saying they make it, but they're also physicians.

Adam Wheeler, MD: They're saying they make it, but they're also doctors. And so that theoretically, um, keeps people from being, um, selfish,

But you know how that works. 

Mike Koelzer, Host: Selfish you mean. If you're not a doctor, it might be all business without that medical intervention. So this at least marries the two of them in theory.

Adam Wheeler, MD: theory,


Mike Koelzer, Host: Gotcha. 

Adam Wheeler, MD: So, you know, what we've seen, what I've seen personally is all of these independent pharmacists who are getting destroyed. And I'm like, what if we put a clinic inside their pharmacy, um, and have a, you know, a nurse practitioner or physician assistant. Um, based clinics do direct primary care and then sell a combined membership between the pharmacy and the direct primary care clinic so that the pharmacists have a better revenue stream.

And then we can leverage the relationships that the pharmacists have to help build the medical practice. And my goal is to have it owned by the pharmacy. Um, and that's available in some states, uh, Florida and Missouri, for example, we can do that. Other states like North Carolina, um, we can't do that. And so we have to come up with some, you know, solutions that satisfy the lawyers.

Um, but we're, you know, that's, that's been done. So it allows us to have kind of this joint operation between a clinic and the pharmacy,

Mike Koelzer, Host: I'm just guessing that's something with a few more layers in it. Like 

The physician is leasing space and then the pharmacy is getting something from that. And so on just a few more layers that make it legal.

Adam Wheeler, MD: Yeah, there's a few more layers. Um, certainly part of it is this is a facility owned by the pharmacist. So they're leasing space from the [00:10:00] pharmacist and then there's the element of the joint membership. So, you know, the pharmacists are getting a cash flow stream that has about a 25% net profit.

Mike Koelzer, Host: This works for all states, even the ones that have that law.

Adam Wheeler, MD: So every state is different. So that concept, um, according to our lawyers should work in all states, but we're kind of going, uh, we're in the beta tester phase now. So we've got a test side in North Carolina. Um, and they seem to have one of the more restrictive laws. And so we're finishing off that contract and then we'll move on to, uh, a few others.

Mike Koelzer, Host: You might as well start with the one that's toughest, as long as you don't lose your steam. You know, it's a good 

Adam Wheeler, MD: right.

Mike Koelzer, Host: In general, will work out the details with the states, but in general, what's the process then

Adam Wheeler, MD: We have a pharmacy as the host and they use either some of their excess space. Um, we really just need two 10 by 10 rooms. One of which has a sync. 

 One is an exam room and one is an office for the.

And then, um, a little area to create a waiting room for which can be in the pharmacy, in the retail space, the pharmacy, and then that's all we need.

So it cost about $17,000 to start a clinic. And then, um, we then provide, um, the, the game plan. So doing that through a company called big tree consulting, which is who employs Steven. And they basically run the game plan that we have worked out. And that includes the software that includes the web integration.

Uh, we have a business coach that works with the pharmacist and then we find a clinical team to work with them and. It's a nice deal for everybody. The pharmacy likes it because they've gotta. A steady stream of patients who have a monthly fee, they have really low, predictable medical costs. So their generic meds are, um, we usually sell their generic meds at wholesale. Like not AWP, like true. Here's what I paid for it. And so they get most of their revenue then from that membership.

And so they like it because now they have a super steady revenue stream. And then there's a synergy between the clinic and the pharmacy. You know, some people are coming to the pharmacy and then to the clinic and some people are coming to the clinic and join the pharmacy. So it's, uh, it's kind of a match made in heaven.

It also benefits employers. So we have quite a few employers who are interested in partnering with us as a way to lower medical costs. So there's some pretty good data out there that this model, uh, lowers the total cost of healthcare considerably. And you know, the only people that it hurts are the, uh, PPMS and the insurance companies.

And I don't see any of us losing sleep over it.

Mike Koelzer, Host: What do you think are some of the hurdles, the biggest hurdles that you guys have solved with this process versus a pharmacist?

Just doing it on their own 

Adam Wheeler, MD: yeah. I mean, that's the conversation I had last night with a doctor pharmacist team and they're, you know, we charge a fee, um, to. To make this work.

The costs that come out before we get to net profit, about 20% of the gross revenue goes to big tree consulting.

and then we provide the electoral property, which is the game plan that we've figured out that allows somebody who's, you know, anybody can do this on their own.

Um, but I've had all these hurdles that I've been jumping over the last five years and I can I've, that's what we're, we're giving them. And then we do some business coaching and then we set up the web environment that allows everything to work together.

And that was one of our big hurdles, to be honest, is just setting up a system.

So a patient can go from, I wanna join a DPC practice to I'm enrolled in a DPC practice 

and putting all those pieces together was, you know, has taken a lot of, um, trials and failures and consultants that I've had to pay.

Mike Koelzer, Host: It seems to me that one of the biggest hurdles for pharmacies who have ideas of doing stuff like. Let's get into oxygen or let's get into this. It's difficult because you can't dabble in some stuff, you can't dabble in oxygen. You need the certification, this and that. You almost have to be like a full-time person before you have any business.

When I think of hiring a PA or a NP for the pharmacy, it seems to me that we'd have to start way too small and then it's. [00:15:00] Hey, this, uh, NP is only here for 30 minutes a week kind of thing.

Adam Wheeler, MD: What we've found is you kind of have to have two pieces. You have to have the clinical team, and then you've gotta have the behind the scenes team. And so the behind the scenes team is actually a big part of the cost. So what we do is scale that on a per patient basis and patients who are enrolled.

So if you have one patient, then you end up paying me like 10 bucks. Okay. So this is not a deal where I charge you 200 grand up front. And then, it scales with the pharmacy because the big expense is that upfront stuff.

Mike Koelzer, Host: But how does the pharmacy grow this? I mean, I'm picturing, starting off with, you know, the subscriptions increase, but you can't have, I. I'm assuming the NP and PA are just not sitting around twiddling their thumbs for, you know, 90% of the week. Right. You have a way to, to grow that.

Adam Wheeler, MD: Yeah. I mean, there is certainly some thumb twiddling, um, in that that's, this is the problem in healthcare is how do you start something? And so we've got a proforma worked out. To kind of show them, okay, if we do this growth rate, which is what we've seen, then your maximum that you need to, to lay out is gonna be X.

And so we almost treat it like some of the franchises who will say, Hey, you need to have this much liquid capital. You need to have, you know, this kind of flow.

And then, you know, we have found that it's successful in, um, in the early phase, which is where we're at, um, in those contexts. And so usually that we want, you know, if you grow at a pretty typical growth rate that we've seen, you know, you're never out more than about $40,000.

Mike Koelzer, Host: So the pharmacy is paying the wage of the PA or the NP.

Adam Wheeler, MD: Depends on the state. So in corporate practice of medicine states, it has to be the physician.

Um, and so a lot of times, I mean, pharmacists doctors work together and run the same social circles. People have a friend and they're like, Hey, can you be my medical director? They don't actually have to be a primary care physician in that we can hire a collaborating physician through an organization that we worked with, but we just need a doctor.

Who's going to be the medical director of the clinic.

Mike Koelzer, Host: as it's growing symbolically, if the person's twiddling their thumbs, and I just mean that they're not being used at that point, that's a wage that ultimately the pharmacist is paying. That's a paid employee. Who's not pulling in revenue quite yet.

Adam Wheeler, MD: Somebody's paying for it.


Mike Koelzer, Host: I imagine that you can sell this program, and get this subscription base before you actually have someone in the office.

Adam Wheeler, MD: Yeah. To some degree. I mean, you know, we typically like to have about a thousand to 1200 patients on each, uh, provider's panel. So, um, that's a lot higher than some DBC practices. Um, but we do it and we have some tricks to allow us to do it. Um, which is part of the secret sauce, but we've got the ability to see that volume of patients.

And so, you know, it takes you, let's say it takes you a year to get to that. And let's say break even as close to 500, before that you're paid, somebody's paying a salary. Um, now you certainly wanna start, start it going before the clinic opens. And so we make a big deal of it on Facebook. And this is part of what we provide is we've got a whole marketing package that you use your pharmacy Facebook page to, to implement. And then, um, there's just starting to be a buzz about direct primary care. So we utilize that and say, Hey, we're coming to this community. And you know, the thing that's sweeping the country is now here. The other thing that we found is patients often go to see the clinic because they have a condition that's not being adequately treated by their current healthcare team. And so we specifically target mental health and, uh, medical weight loss because those areas, um, are very. Uh, let's just say my primary care colleagues are challenged to deal with those areas. And so we've invested quite a bit in creating programs that allow people who aren't even comfortable in those areas to become comfortable.

And then, you know, advertising medical, [00:20:00] weight loss in every community in anywhere I've ever been strikes a nerve and people are like, that's, that's what I'm looking for. And then they join as a member.

Mike Koelzer, Host: It strikes a nerve in a good way. It combines medical and weight loss and people like that when it's available

Adam Wheeler, MD: Well, it strikes a nerve both ways. So, um, people who are struggling with obesity, um, you know, they, they struggle with it. They want to fight that fight and there are great tools out there now. 

Um, so, and then there's always a few people in the community that get angry because they think we're SI trying to.

You know, start an anorexia bulimia epidemic, but, um, that, that fuels the fire too.

Mike Koelzer, Host: That's cool that you're both filling a hole from a negative side, like the primaries done at the time and they're overworked in that kind of stuff, but you're also proactively doing stuff that they don't even want to think about because they're so busy, you know, the weight loss and smoking or whatever.

 All right. So Steven, you come in and Adam gives you this little pitch and he says, all right, now, go get us a lot of customers.

Steven: Uh, kind of, um, no. So because of how good Ben is. With his networking and things like that. He, in the Waypoint company, they've been catering to the independent pharmacies for years now. I mean that those are that's, their bread and butter is helping pharmacies. So we're just adding on another solution to further help them to help them stay in their communities, you know, increase the quality of life for everyone, the patients, you know, giving them access to what they didn't know they ever needed.

So that's, that's honestly, one of the best things is giving the solution people never knew. They.

Mike Koelzer, Host: I imagine that Ben. Through his network and let's say current Waypoint customers and those that at least know of him that maybe haven't taken the leap yet. Whatever. I imagine that warms people up quite a bit. You don't have a, probably a huge need, especially early here to, to jump in with cold calls and things, because these people have been warmed up they're, uh, ready for stuff like this.

Steven: Yeah. In, in a, we had a waiting list when Ben first started talking about it. So we host webinars monthly. We just had our first one this past month and we go and explain this solution. So, and depending on the state, it also depends on the plan, of course. So if you are in the corporate practice of medicine states that does decrease it a little bit in like the revenue and numbers and things like that. From what we've seen in Florida, where your growth profit rate is looking really nice. So when people see that growth rate, I mean, it's, it's phenomenal. They're like, there's no way, there's no way.

And so by showing them like, this is really how we get it done and things like that. It's, um, it is kind of hard for them to initially trust cuz they're a little skeptical, cuz they're so used to getting essentially screwed one way or the other that when they see this, they're like, there's absolutely no way, but even how we set it up, we take the lesser of the percent.

We're still letting them maintain everything. We're just making it smooth and easy for them. By taking out everything that they would have to do on their own because Adam and Ben have already done it. They've already got it. We're just helping them do it now.

Mike Koelzer, Host: As you guys look for slash see growth in this, will it be on a, expanding from an epicenter or is it easier to pick and choose states that seem to be more friendly and so on? How do you see the growth happening?

Adam Wheeler, MD: So what we're trying to do is target, um, pharmacy owners and some degree physicians who have the right mindset,

um, you know, they're entrepreneurial. They see a need in their community that they want to attack. And so we're willing to go wherever we find those kinds of pharmacy owners.

And so, you know what, we're working on one outside of Charlotte, North Carolina, it's a community. I would've never chosen cause I've never heard of it. But the pharmacy owner there, Billy, really wants the service community to have a passion for independent pharmacy, uh, staying viable in the air we live in and, you know, I'll fight with that guy all day long.

[00:25:00] So we're really looking for those kinds of folks. And when we find them, we can, we can plug it in.

Mike Koelzer, Host: Are you able to do a lot of this communicating? online, video chat and so on. 

Adam Wheeler, MD: I, you know, I'm still a face to face guy. Um, and I really thought, I really like to be there and see it and get to know people, um, so that when we run into things that we can, you know, fight together as opposed to time, some random guy on video. So, um, you know, Steven or myself, you know, we want to be there.

Experience the pharmacy, see the community help, you know, give my take on where they're at. Um, so yeah, I like to travel. So, you know, Billy and I, North Carolina have hung out a couple times and he's walked me through his construction. And, uh, we did some training for some of his staff in, you know, at family vacation in Orlando.

I stopped by our, uh, upcoming Orlando clinic. So we could, you know, spend some time with the local pharmacist. So, you know, we want this to be a family that they're a part of and that we're just adding our expertise to, the community that they've developed around their, their, um, Pharmac.

Mike Koelzer, Host: You don't necessarily have to be there at the beginning of X or at 0.5 X. You might combine something at 0.3 X because you're traveling in that part of the country or, or something like that.

Adam Wheeler, MD: Yeah, exactly. And then what we want to do is as we're bringing new staff on, so we want that nurse practitioner spends their first week at our model clinic, um, and sits in what we call our team room, where we've got, you know, half a dozen nurses, half a dozen NPS and PAs doing their thing, because we want them to absorb this culture.

Um, unfortunately, so much of healthcare right now is a, we serve the insurance company culture. and we want to be, we serve the patients and so break new people of their bad habits. I mean, frankly sometimes it is impossible. Um, they're so married to the volume world, but, uh, we want them to come in and say, no, no, we're nice to our patients.

Uh, we, we serve them cuz you know, it's not a long term membership. We allow patients to quit at any time. And so if we're not doing a good job taking care of them, they will leave. And so we, we really wanna push that, uh, that culture. And so even as we go into North Carolina and Florida, we still want that culture to be paramount.

Mike Koelzer, Host: You guys have Karen's down there. Don't you in the south, 

Adam Wheeler, MD: only in 

Tennessee. Yeah.

Steven: I do. 

Mike Koelzer, Host: All right. So I am your subscriber. I wanna say that you might have less Karen's than if you were dealing with insurances and stuff, because it feels like people that do this are more on your team, it seems versus versus against you.

Do you feel that, or am I missing something?

Adam Wheeler, MD: you're exactly right. And that's what, you know, I was in a regular fee for service, um, large pediatric practice for 10 years. I played the game, you know, I could do all my checkups in six minutes with the best of them. This is completely different. And part of it is it's new. And so it takes somebody with a little bit of whatever it is to dive into it. But people just so appreciate the difference in a patient-centric practice versus an insurance -centric practice that, you know, we have people that yell and quit. Um, and we have people that, you know, refuse to pay their bills, just like everybody else. But we have so many, we have way more than those who come in and say, Hey, I wanna get the new, big, big tree.


cause I wanna wear it around. 

Mike Koelzer, Host: What are the emotions that are the hardest for each of you 

What's the worst feeling that you've experienced as you walked down this road? 

Steven: so, I guess for me everyone's got such good contact with Ben or Adam, especially Ben with these pharmacies. And then they don't know who I am 

and I go in there and I have to, you know, they size me up immediately and I just have to make sure that it's always a good impression and try my best. You know, you can't always get everybody And you know, that, that can be a bit of a struggle, but I haven't been, I wouldn't say fearful of 

because I know it works. Like I saw it. I saw, I went to Missouri before, um, I was officially hired June 1st and I spent time there and I saw it. 

Mike Koelzer, Host: How are you, Adam?[00:30:00] 

Adam Wheeler, MD: Uh, I'd say it's probably pissed off.

When I talked to the pharmacist , I realized, I mean, to be honest, I'm just a doctor. So I thought the pharmacists were the problem. Okay. And then I'd never heard of the PBMs until I started playing this game. And so now all of a sudden I appreciate the pharmacist and I'm like, oh, it's these, it's these PBMs.

And, and then you got the insurance companies who refuse to play ball. Right. Um, and they've got so in our community, they've got the employers in their back pocket. So we had a big meeting with the brokers in our community to say, Hey, you can insert this into your self-funded health plans. Your cost will go down.

Patient satisfaction goes up and United healthcare invited them all the same night to a 

baseball game. 

It's like, all right. Come on guys, like we have, we've gotta solve this problem. Patients are suffering, patients can't get in to get care and you're gonna, you know, play that game and just, it makes me mad.

Steven: Well, then you also in the pharmacy side now, and everybody knows that because of how that model is. Sometimes they lose money. give people their medications. So if you're in the pharmacy world, it's like, oh yeah, we already know that already. But a lot of people they'd be like, what do you mean you're losing money off helping me?

And you'd be like, no, like you're $10,000 specialty med, you know, we're actually gonna lose money off of you. But that, you know, that's kind of becoming a norm, almost accepted in some of the pharmacies, kinda like we don't know, you know, it just is what it is, 

but it doesn't have to.

Mike Koelzer, Host: Adam is kind of a side bonus for our listeners. Let's forget about the big tree for a second. What advice would you have for, and this is just a side bonus. What advice would you have for a pharmacist dealing with a doctor's office? Cuz if you thought of that all this time, is there anything they can do to help that or some other issue like that?

Adam Wheeler, MD: Uh, that's a great question. So I, I mean, it's, it's shocking how little of the pharmacy world that we doctors understand. Okay. And our big tree owns a pharmacy now and I employ pharmacists. So I get a little bit of it. Um, and you know, I remember when I was, so we used to dispense our own meds using the physician dispensing model and my staff hated it.

I hated it. And I'm like, I wish I could find somebody who just liked to keep this inventory and count to 30 repetitively and help these patients understand their meds. I'm like, wait a second. That's called the pharmacist where there's a whole industry out there for this. And so when we moved to the pharmacy model, it was a giant breath of fresh air because we were on the same team.

And so I think to be honest, probably the simplest thing Mike is to is to foster relationships between, um, the pharmacist and the physicians,



buy 'em lunch. And because they're all open for lunch, even say like, Hey doc Smith, can I take you out for lunch? um, and then just chat and talk about your struggles.

Um, hopefully not all with Dr. Smith, you know, but you know how this is hard and you know, any way we can serve you guys better, we want to do that because we're all here to serve the patients. Right. And

so, you know, as opposed to the only communication I usually get from pharmacies is, Hey, I've got another prior off for you to do,

Mike Koelzer, Host: Especially with. Independent doctor's offices. There's a lot in common with independent pharmacies, a lot in common, a lot of the same struggles. And if you can maybe reach out and make that emotional connection with the doctor's office that they're going through the same things that gets you on the same side.

Adam Wheeler, MD: I mean, I would even say on a day to day basis, the independent pharmacist and the independent doctor probably have more in common than the academic doctor and the academic pharmacist because, you know, you're worried about making payroll. I'm worried about making payroll.

You're trying to hire good people. I'm trying to hire good people.

you're trying to figure out how to keep your employees happy without breaking the bank. So am I, so those kinds of things, um, you know, should allow for a nice bridge to create a relationship that can really be for the patient's benefit.

Cuz there's a lot of times I'm [00:35:00] like I need a solution for X 

and a pharmacist knows the solution, but I don't know any pharmacists.

So I don't know who to ask, you know, or the pharmacist says, I wonder why nobody in our community prescribes Monro for weight loss? Well, you could go ask your doctor friend.

It may be a good reason. It may just be that nobody's heard of it.

And so, you know, the team dynamic should be far superior for the patient.

Mike Koelzer, Host: Steven, you mentioned that it might be hard to go in and say, well, now you're helping Ben and stuff out.

I think what I would do is I would say, listen, Ben signs my paycheck because there's a lot of times where people say they're. W with somebody and they're not like we had some people come in the store and say, they're with Amazon.

And it's like, I know you're not with Amazon. You're probably linked up somehow with one of those percentage things or something like that. But I think if you went right in there and said, Ben signs my paycheck, then they know you're really connected. And maybe you already do that.

Steven: So some of our reach out it has been, uh, that's made the connection or they've reached out to Ben and he forwards me the email and says, Hey, Steven's got you. Um, talk with him. He's our main guy here. And then I go on and, you know, try and see what I can do now. One thing that's pretty interesting. It teaches pharmacists and pharmacists in different states, they, I mean, they honestly have different personalities too.

Mike Koelzer, Host: I had a, um, salesperson on for a company of half dozen shows ago and I told him, I said, people must like you because I think he was a Tian. I said, you probably do well with your Southern friendly charm. And he said, Mike, you might be thinking that cuz you're from the Midwest, but he says, you go out to New York and those guys, like, if you say a couple words too many, they're like, hurry up. What do you want? You know, that's just a different pace.

Steven: Yeah. So it's those people skills that you have to learn on the fly and use them to kind of get your point across. So some people face you. I think face to face is the most important conversation you can have.

You can't beat it. You it's more personable. You can actually be there. You can feel the person's aura and things like that versus over a screen. It's hard. You can't just, you can look people in the eye, but it's not the same, you know, you can shake that hand. but I mean, how do you virtually shake a hand?

Mike Koelzer, Host: Adam, if I ask you what your goal is, you're gonna say it's helping patients and pharmacy and that kind of stuff.

Take that off the table. We know what would be cool for you in like five years? 

Adam Wheeler, MD: So I'm a doctor. So I do like seeing patients and, um, I, you know, I have a pre full practice right now and I wanna keep that going. but you know, a lot of, a lot of me is, is driven by this pissed off at healthcare, um, idea. And 

that sounds whatever, but it's, it's really broken

and, you know, certain parts of the country, you know, Missouri, for example, um, 111 of the 114 counties or primary care shortage areas.

And that has big implications. Like the death rate of Missouri is going up. So I'm, I mean, I'm really passionate about this. I'm not a very good manager though, Mike. Um, and so I tend to have big ideas and then lean on somebody like Steven to, to get them into play.

So I'm not very good at managing the beach. It's kind of boring. Um, I like to have a fight on my hands

and that's, that's what we're doing.

Mike Koelzer, Host: There's a book out it's called, how not to give a F you know, the, the cuss word F and, this guy's premise is he said, love to solve problems. It's nicer maybe to solve problems that maybe don't have as much weight on them, but you always wanna solve problems.

So, now, someday I want my problems to be less of an employee and maybe like, do I wanna make apple pie or blueberry pie today and then go to the store and, you know, push the apples and check out the blueberries and things like that. I want that kind of problem. But as humans, we all wanna solve problems still.[00:40:00] 

Adam Wheeler, MD: And it's true. And I have this addiction to tackling big problems.

Um, and so, you know, my wife would tell you I'm one big idea after another kind of guy, but you know, it really, um, charges me to see people who have been suffering and then getting care again. And, you know, that's, that makes up for a lot of hours of travel and a lot of, um, soccer games that you can miss or what have you.

Um, my wife and I work for a big tree as well. So she's our operations person and she's really, uh, passionate about just helping people and. Um, maybe too passionate about it. I wish she'd be more passionate about hanging out with me maybe. Uh, but she is just all in. And so it's, it's really, this culture where we're tackling big problems and that probably means I'll die of a heart attack quicker than the guy who doesn't give enough.


That's right.

Mike Koelzer, Host: The structure of the business. So the big tree is the medical side and then the big tree consulting. I imagine that's off more with this growth side. Are there any other business divisions that you guys have or picture having, or do those two divisions? Pretty much take care of where you need to go.

Adam Wheeler, MD: Yeah, no. So, um, big tree medical is kind of the mothership, um, and that owns and operates clinics. Um, then we have a big tree medical group, which is the legal entity. Uh, when we do work with insurance companies, which we try to avoid, but we have some memberships that allow people to do that. So they hold the insurance contracts, um, which is necessary legally. Then we actually own an insurance agency, um, that helps employers design, um, lower cost, higher quality, higher per higher touch, um, health insurance, and health insurance, like, um, solutions for businesses. And then we have a, um, big tree consulting, which is, uh, the entity that, uh, Ben and I own 50 50, um, to try and, um, push this concept into the, uh, independent pharmacy world.

Mike Koelzer, Host: Let's say you just had a physician's office and you said, Hey, I wanna start doing more direct care. Is there a benefit of splitting that between the direct care business or LLC and the one that works with insurance companies?

Like they can't demand, you do something on the direct care. You're like, Hey, that's a different company.

Adam Wheeler, MD: Yeah, no, it's worse than that. Of course. Cause it's insurance companies. So they actually write their contracts that you cannot be providing direct primary care. Cuz they don't want this model catching on because it's better for patients and worse for them. So we have to hold those contracts in a,

um, separate um, to kind of get a route that.

Mike Koelzer, Host: It seems like a lot of pharmacies could do that. There was a pharmacy I talked to and they separated their delivery. Into a separate LLC. It was all their drivers and cars, but they split it into an LLC for, uh, liability reasons and so on.

And it kind of makes me wonder why more pharmacies don't split their businesses for, like, let's say the cash side of things. It seems like we pharmacies could split more of an LLC for that and then have another pharmacy for the insurance side. I'm sure the I'm sure the PBMs have something in their contract to 

Adam Wheeler, MD: I'm I'm a 

hundred percent sure that 

Mike Koelzer, Host: yeah, like you can't be on the same property and do this or that or something like that.

Steven, relatively early in your career, you're off into an entrepreneurial setup Emotionally, how did you end up already in a business like this versus going a traditional pharmacy route?

Let's say.

Steven: Mine came actually from an injury. Um, I messed up both my wrists. I tore them. So I had surgery on my right wrist and the surgery went fine. Uh, but ended up when the pin removal happened, caught infection in my hand, and that pretty much sealed the deal and I'm right-handed so I have bad wrists. And if I were to sit there and twist bottles every day, which I would do for a month on rotations at different [00:45:00] places, you know, it hurts like I do. I'm 26 years old and have arthritis in my hands.

So it kind of led me to look for other options. So you kind of look into the research side of things, but mine was more out of. trying to find my own solutions 

and still follow this path that I was on. Cuz everything happens for a reason. Right. 

 But you know, we create our own luck,

You gotta go out there and talk and find things, 

which is how I ended up finding Ben.

Mike Koelzer, Host: I was watching TikTok. I saw somebody there yesterday and they said, one of the best ways to approach life is by saying, I don't know. I don't know what the best for me even is because I go through life sometimes with anxiety. And I think a lot of that is because I think I know the best road for me, like a year or two down the road, but what the hell do I know?

I mean, I don't know where the best spot for me is. 

Steven: Well, exactly. And, you know, I had the option to stop. And I chose not to. So I went through a good portion of our didactic courses having to write with my left hand, 

which is atrocious, by the way. Um, so I honestly, sometimes couldn't even reread my notes, but it's just one of those things, you know, you, I never didn't think I couldn't do it.

So I think having a good, strong belief that you can achieve will go a long way. 

Mike Koelzer, Host: What you guys are doing it's the whole thought that we, as pharmacists, have to get more broad in our thinking and.

Having a show like this is neat because I think it gets the listeners thinking along the lines of expanding and a new vision. So thank you. Keep doing what you're doing.

Adam Wheeler, MD: Yeah, we appreciate letting your audience hear what we're doing. Um, and I, again, as the token doctor. , I apologize for all the rude comments that we make to at least the independent pharmacists. and cuz now that I have an understanding of what you guys are going through, it's really rough.

It is considerably more rough than the independent doctor world. so it'd be nice to us. cuz we're just ignorant of the plight that you guys are in.

Mike Koelzer, Host: Well, that's a, nice gesture on your part, Adam. I think that we all have to realize that we're on the same side. Years ago, I had a customer that was just pissed off about something.

And my pharmacist who was no longer with us would sometimes get a little bit combative and the problem was they were facing each other. So I hearken back to some of my marketing books and stuff I read, and it said, physically go on the same. Side as the patient and look out symbolically in the same direction.

So I thought, okay, I'm gonna go out there and stand next to her. And so I was about a foot away from her and I said, Mrs. Smith, you know, boy, I'm, I'm sorry. And this and that. And she looked at me and she had smoke coming out of her ears. And she said, I'm going to give you five seconds to get away from me. so I appreciate Adam that we're on the same side, looking out as doctors, we truly are.

Adam Wheeler, MD: We are, and we've got, uh, a big, 

hairy thing to fight in the insurance, uh, PBM world. 

And there's no reason for us to, to fight amongst ourselves

 And so hopefully things like big trees and other entities, um, can really provide a solution for communities and for pharmacists, and for burned out clinicians too.

Steven: Ben, he talks about the pharmacy of tomorrow. So another thing on top of this with Adam. On top of this , we can build other solutions on top of that.

So we're constantly gonna be looking for other solutions. We just need to get this one going and then the next one will come. That's what Ben does. That's what he does best is coming up with his ideas and then having us, we just get together and figure it out and find that solution.

If pharmacy keeps going the way it goes, they're gonna get priced out and the independents aren't gonna be able to keep up. So coming up with these solutions is really [00:50:00] beneficial. So the Waypoint company and Adam constantly gonna still be looking for more


cuz we

I also kind of find it fun.

 It's exciting.

Mike Koelzer, Host: Steven and Adam, such a pleasure, thanks for joining us. And I look forward to keeping in touch with you guys.

Adam Wheeler, MD: Thanks bunch, Mike.

Steven: Yeah, always. Thank



Steven StewartProfile Photo

Steven Stewart

Director of Clinic Growth and Marketing

Doctor of Pharmacy: The University of Tennessee Health Science Center
Company: Big Tree Medical

Summary: Protect your pharmacy and community for generations to come. Our easily implemented Big Tree Direct Primary Care model allows for a clinic to seamlessly integrate into your pharmacy. We take care of the background work, so you can focus on patient care. Let us bring access and care back into the healthcare world together. Contact us to know more!