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Dr. Raffaele received his B.A. in philosophy from Princeton University and his M.D. from Drexel University Medical School in 1989. He trained at The New York Hospital/Cornell University Medical Center and was formerly a clinical assistant professor of medicine at Dartmouth Medical School. Dr. Raffaele is board certified in internal... Read More
As chief executive officer of MedQuest Pharmacy in North Salt Lake City, Utah, Bray actively works to protect patient and prescriber access to compounded medication. He regularly collaborates with PCCA’s Public Affairs team on legislative outreach and served on PCCA’s Advisory Council from 2018 to 2019. An active member of... Read More
A brief history of pharmacy compounding in the US Changes in regulatory status in the past few years.
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Money MattersJoseph M. Raffaele, M.D.
Welcome to another episode of the Telomere Summit. I’m your host, Dr. Joseph Raphael, and I’m very happy to have Jeffery Bray on today, the CEO of MedQuest Compounding Pharmacy to talk about some issues that he’s been very actively engaged in on Capitol Hill, to try to help the compounding industry with some difficulties that’s been having. I’m gonna let Jeff get into an explanation of that shortly. Welcome, Jeff.
Jeffery R. Bray, MBA, MAED, SHRM-SCP
Thank you. Appreciate the opportunity to be here. You’ve developed a great program here, and amazed at the amount of talent that you’ve been interviewing, and thank you for the opportunity to talk with you.
Joseph M. Raffaele, M.D.
Well, thank you very much. Jeff and I go way back. I’ve been using MedQuest Compounding Pharmacy since 2003, and fantastic service, and I consider Jeff a friend. And I just really wanted to have him on to talk about an issue that I wasn’t aware of until he started telling me about his activities in it, which is that there’s a movement, or there has been a movement to try to limit the amount of compounds that a pharmacy sends out of state. And that could severely impact a practice like mine, where my quest is in Utah, and I’m in New York state, and many of your practices, I’m sure as well. I know I’ve talked to colleagues that use some of the larger compounding pharmacies to, you know, get high quality compounds. And so, I think it’s important to have Jeff on to tell us about some of the history of this, and then also to tell us his activity, and what ultimately you all can do to help keep compounding safe, effective, and therefore our patients to better health outcomes.
Jeffery R. Bray, MBA, MAED, SHRM-SCP
Yeah, so Joe, you mentioned some of the issues that’s going on in compounding and one of the biggest ones that has really taken up an interest for myself, for the team at MedQuest and many other pharmacies throughout the US is this memorandum of understanding between the states and the FDA, Food and Drug Administration And this goes back to 1997, actually, with the Food and Drug Modernization Act. And in that, they had a section called a memorandum of understanding or MOU between states and the FDA, about interstate distribution of inordinate amounts of compounding drugs. And so that sat for 20 years, more or less. In the early 2000s, there was a court challenge, went to the Supreme Court.
The Supreme Court ruled in favor of compounders against the FDA. And it sat around for a long time, until approximately 2012, when we had a bad actor in the industry, that really did a lot of damage to the reputation of compounding pharmacies, unfortunately did a lot of damage to patients and really changed the industry forever. And the Drug Quality and Security Act came from that in an effort to better regulate and have oversight over compounding pharmacies. So here at MedQuest, we are, as you know, we are quality and compliance first. Those are two items that are non-negotiable for me and our team.
Everyone is on the compliance team. Everyone is on the quality team. And so we worked very closely with our regulators to try and provide a framework or an example of what compounding could look like. But what we found is that the agency and the State Boards of Pharmacies really wanted to kind of overregulate the industry. And so, we got involved, heavily involved actually, back with our elected officials in DC. And so part of that was just building awareness about compounding itself. I think you go back five, six, seven years when I first started getting involved in advocacy, and a lot of people didn’t know what compounding was, at least in DC and Capitol Hill.
We’ve worked very hard to change that, but it started out just one, educating them on what we do, the services we provide, why someone may need a compounded medication over a manufactured medication. And then as they got more involved in their knowledge of the industry, then we really tried to educate them on some of the issues such as the MOU, and what we provide for patients. So just a deeper dive into the MOU, it’s an outdated regulation. One, FDA sat on it for 20 years without doing much with it. Two, it talks about distribution, and distribution is a well-defined pharmacy term that talks about sending larger amounts of medication, in this case compounded medications, that are not patient specific. And so, that is what the MOU is really focusing on. Well, based on the Drug Quality and Security Act, it’s no longer illegal to send non-patient specific medications out. Everything a compounding pharmacy has to send out is patient-specific. So really, there is no longer any distribution in a traditional compounding pharmacy. They did create a 503B outsourcing facility, kind of a new type of compounding pharmacy. And that is where you can send out a non-patient specific medication.
So really, the industry as we’ve grown, has already solved this problem, partly because of the 503B outsourcing facilities that send out larger quantities of compound medications, directly to hospitals, directly to physicians, to take care of any needs that may be emergency or otherwise, where the traditional 503A pharmacy like a MedQuest Pharmacy and many others, they are working with patient specific individuals, sending out prescriptions based on their unique needs. So that’s kind of the background of it, but FDA has taken the stance that interstate distribution is the same thing as patient specific dispensing. And that’s really where we disagree. Full disclosure, I have a great relationship with the FDA.
We partner with them. We work with them. We’re always striving to be better, and have sat down with the highest leadership in FDA to really explain what we do at MedQuest, what other great compounding pharmacies do throughout the US, and how we can partner with them rather than get into kind of a contentious situation where we disagree on some key issues. Unfortunately, those efforts were moderately successful, but it ended up in litigation. So, MedQuest Pharmacy as well as five other pharmacies took it upon ourselves to sue FDA on this policy. And after over a year in court, we got a nice win in terms of FDA violating the Small Business Flexibility Act, which required them to do a study on how this would impact small businesses such as compounding pharmacies. They failed to do that.
And so the judge has sent it back to them to either conduct that study or prove why they don’t need to conduct that study. So I believe they have until February 22nd. It was extended a few months, but to come back and either do the study, or have some reason to why they shouldn’t. Other aspects associated with that, and the main aspects would be the difference between distribution and dispensing. You know, we don’t distribute. So really the MOU should not apply. We only do patient-specific dispensing, and therefore it’s really not designed to fall under the purview of FDA there. So, some of the implications of this though, is states have a choice today of whether or not to sign the MOU with the state or with the FDA. If the state signs the agreement, and today there are only three states that have done so, New Hampshire, Kentucky, and Colorado, well, additional reporting requirements come into play.
Any pharmacy that ships over 50% of their medications across state lines will have to report, you know, where they’re licensed, what they’re shipping, the percentage of their medications out of state. And that in itself is not necessarily a huge burden. It will increase costs. You will need additional personnel to do that. It puts a burden on the State Boards of Pharmacy.
The real issue though, is if a state does not sign it, and 47 states have not signed yet, many have indicated they will not sign it, and many have legal hurdles on whether or not they can sign it. And so if a state does not sign it unfortunately, a pharmacy would be limited to only shipping 5% of their medications across state lines. And so that would be devastating for any pharmacy that is near a border, you know, that are servicing people outside their region, outside of their state, any of the larger compounding pharmacies that may ship across the state, across all the US, in terms of providing patient specific medications. So it’s really devastating to the industry. And I think just one thing I wanna point out is this regulation goes back to 1997. And as you know, the industry has changed significantly since that time.
Reporting wasn’t in place at that point. Licensing wasn’t in place at that point. Fast forward to where we are today, just in MedQuest alone, we have 64 different pharmacy specific licenses. We’re licensed in all the states. We can ship throughout the US. Certain states have multiple licenses. So 64 different licenses just for the pharmacy. I was counting how many pharmacists licenses we have, because there’s 20 states that require an individual pharmacist to be licensed as well, and we have over a hundred pharmacist licenses within the building. So from a licensing point of view, is completely different from 1997. We’re here in Utah. We have to follow all Utah laws. If we’re shipping to a patient in New York, we have to follow all New York laws as well. And so, that’s a totally different landscape than what it was when this ruling was put in place. The other component as well is reporting.
So we report to all 50 states on a daily basis, what we may be shipping into their state. Primarily, that’s geared towards controlled substances, but a state like Nebraska, anything you ship into that state whether it’s a manufactured medication, a compounded medication, a supply, an OTC, you have to report what you’re shipping into that state. And there are two states where you have to report real time. So as one of my talented pharmacists will kind of sign off on that final prescription, we have five minutes to report what that prescription is and where it’s going.
Joseph M. Raffaele, M.D.
What?
Jeffery R. Bray, MBA, MAED, SHRM-SCP
So the landscape has completely changed in terms of where we’re at. Unfortunately, it ended up in litigation. We are confident that we’ll, you know, have a positive ruling, or at least we’ll have an opportunity to go back to the agency and kind of work through these issues so that, you know, the MOU does not become something devastating, not only for pharmacies, but I think more importantly, for patients, and limiting the access for prescribers and providers like yourself in terms of being able to take care of your patients. So that was a long answer to a short question, but hopefully, I covered some of the high points there.
Joseph M. Raffaele, M.D.
No, it’s really an excellent summary of it. I was reading about it earlier. I guess the original rationale for it was something that really has become, you know, kind of an anachronism really, which is there is going to be more difficult to get reporting to a State Pharmacy Board, of an adverse event when it goes to another state, but now with what you’re telling me, and of course with things being so much more digitized as they are now, that really doesn’t make any sense.
So, what’s the real rationale behind it? Why would… And yet my other question just on the top of my head is, assuming, and you’re the one that knows best, whether that the reporting is not as onerous or burdensome as one might think to, you know, report, if you’re gonna ship something out of state, why are some states also setting aside potential legal issues, but why are some states sort of reluctant to sign the MOU, which would make things a lot easier? And as a CEO of a large compounding pharmacy that services many, all states probably, do you want states to sign the MOU, or do you not? Or, you know, where are we with that? These are just the things that pop into my head here that might be popping into our new circumstances.
Jeffery R. Bray, MBA, MAED, SHRM-SCP
Yeah, and it’s a tricky situation because I truly believe it’s a bad policy. It does not help patients. It does not address the concerns that maybe an FDA or a State Board of Pharmacy has. As you mentioned, reporting is, I mean, it’s a burden, not as part of the industry. And we do a great job of reporting, as do a lot of other pharmacies. And so the need specifically for adverse events for example, which is the root issue here, that is something that is very easily done. I think we do a better job than some of the, you know, major chains, and some of the pharmacies out there that really don’t know once it leaves the pharmacy.
You know, we know exactly what we sent to all of our patients. So, adverse events is the root cause here in terms of how does FDA or State Board of Pharmacy track that across state lines. I believe that has been solved by just the industry itself. With the states, it’s a complicated issue. Philosophically, this is a state regulated industry. That’s primarily regulated by State Boards of Pharmacy.
But as I mentioned, 64 different licenses on a state level, FDA has oversight, DEA has oversight. We had the EPA in here last week for an inspection. You know, a great conversation. And at the end of it, the inspector, you know, said, thank you, I learned a lot today. Can I meet with one of your pharmacists? And full disclosure, we gained a new patient out of it. So, every day we’re expecting someone to walk in and inspect the pharmacy.
We view that as a positive. If they come in and find something we can do better, great, that’s a win, we improve, and everyone wins. If they come in and say, hey, you’re doing a great job, keep it up. We’re always asking, are there any tips or tricks or anything that we can do to become better? So, kind of the philosophy of regulators are partners, they’re friends. You know, sometimes we disagree, but taking that philosophy has really helped the industry overall. But so philosophically, it’s a state issue. And so, State Board the Pharmacies are not fond of the FDA kind of regulating something that they should be regulating that they are regulating. So, that’s at the core of it. I also think of the-
Joseph M. Raffaele, M.D.
So, it’s the state boards that are saying, no, they’re saying please don’t sign that because this is our territory, we don’t want the FDA coming in here.
Jeffery R. Bray, MBA, MAED, SHRM-SCP
Yeah, on some level. It’s interesting because the MOU does not define who signs in the state. Is it the state attorney general, is it State Board of Pharmacy? Here in Utah, it’d actually be the Division of Occupational and Professional Licensing, not the State Board of Pharmacy. So there’s confusion on who may be able to sign it. Like in Texas for example, it’s illegal for them to sign it. Florida, it violates privacy laws. So Florida will not be able to sign it. And so the states are trying to work through these issues, but there’s a cost to it as well. And any agency is unfortunately underfunded. And so to divert resources away from some of the more important issues to this reporting requirement that really doesn’t accomplish anything, is a little bit problematic.
So part of our discussions with our elected officials have been, hey, this is a bad policy, it violates federal statute, FDA violated their own rules. It doesn’t really accomplish what they hope it will accomplish. And, you know, key pharmacy terms are being disregarded. So I do believe that legally, we are on the right side here, but because of the negative impact it could have for patients, if the state does not sign, our message has had to change slightly to say it’s a bad policy, but between the difference of, you know, not signing of that policy or signing a bad policy, is better to sign it so that patients aren’t negatively impacted.
So, that’s kind of where we’re at. I think there are some big hurdles. States are getting more and more comfortable with it, the litigation, most states are waiting. They have until October of 2022 to decide whether or not they will sign or not sign. And so we’ll continue working on the Hill. We’ll continue working with the boards of pharmacies to educate them. I would love another opportunity to sit down with FDA, just to talk through this, and try and work this out ’cause I do believe litigation, everyone loses, but that’s kind of where we’re at in terms of the states have some challenges of being able to sign, but we’re trying to make sure` that patients are not negatively impacted.
Joseph M. Raffaele, M.D.
So it sounds like you’re saying that there’s still gonna be the oversight, it’s been going on for a long time, anyhow, the reporting looking for adverse events, and that sort of stuff. So really not much is being accomplished by this, other than to put a burden onto compounding pharmacies and State Boards of Pharmacy to comply with a policy, really is outdated. So, you would prefer to see them just scrap the memorandum of understanding altogether, or to make some significant amendments to it that make more sense and less burdensome, and allow, I guess some states decide, although if a state like Florida can’t sign it because of privacy issues, then I mean, how do they ever get around that really?
I mean, I guess the wording has to be changed or something has to be changed. And I guess what I’m trying to get to is what should a doctor or patient, anybody that hears about this that’s interested in keeping their right to access compounding pharmacies around the country, whichever one they want. That’s a sort of a choice that most of us take for granted and other industries now with the advent of online ordering and Amazon, et cetera, et cetera, what should they do to help you and your cause to keeping compounding safe, but as available as it needs to be?
Jeffery R. Bray, MBA, MAED, SHRM-SCP
Yeah, and you mentioned a key point there, patients always have a choice what pharmacy they go to. Providers have a choice of where they may send a prescription. And that’s a key issue where, you know, the MOU could restrict you as a patient or you as a provider, your ability to choose your own pharmacy. And I think that’s a significant issue. And so what can we do? Well, the MOU in itself, I’m actually pro-regulation, as you know. We spend a considerable amount of time, effort and money in terms of just staying above and beyond any compliance. You know, in 2020, we’ve spent $3.8 million on a building expansion, geared towards us staying ahead of regulations. And I think that’s we’re proud, we’re excited we’re able to do that.
I think the unfortunate aspect is some of those great community compounding pharmacies are not going to be able to keep up. I think that’s another factor that comes into play. You know, ideally, people can go to their local compounding pharmacy and get the medication that they need, but as more and more pharmacies, not only compounding pharmacies, but community pharmacies are shutting down and going out of business, you’re gonna rely more and more on specialty pharmacies out there. So, it definitely is a complicated issue.
So, I’m pro-regulation, I think my opinion is we sat down with FDA. We can figure something out that would make sense. I would personally voluntarily provide that information directly to FDA, let them know what we’re shipping, where we’re shipping it, and partner with them. So that’s kinda my philosophy on that. As far as what to do as a patient, as a provider, one of the biggest , another compounding pharmacy, one of the big things is engaging with your elected officials. I tried to count before the interview here, but we have had close to 40 different members of Congress, house representatives, US senators come to MedQuest Pharmacy to see what we do. And that has been really life-changing experiences for them.
It’s great for my team, you know, when people come in, they get to meet some impressive people who, you know, are good people, regardless of your politics or what some of your beliefs may be. These are good people. They care. You may not agree with everything they say or do, but you know, they’re here to learn. And so when they come in and see it up close, it’s just eye-opening for them to see the amount of time and effort that goes into making a compounding medication, but also, the various checks in place, the quality in place, that goes back to the supplier, until it reaches the patient, and just the overall compliance involved. So, engaging with your lawmakers is something that’s going to be important.
As physicians, as medical providers, you carry a very powerful voice. And elected officials enjoy hearing from medical providers in terms of what you may need in terms of better taking care of your patients. So, I would encourage engagement with your elected officials, know your representatives, know your senators, write letters, depending on who your pharmacy of choice may be, encourage your pharmacy to invite their lawmaker to the pharmacy to see it up close and personally. I can tell you that’s the biggest impact that someone can make, is getting them into a compounding pharmacy to see it up close. Other things that we do as an industry, we’re involved in all the major pharmacy associations. We believe it’s our honor and privilege to give back to the community as well.
And so we go back to DC quite often, in terms of being able to advocate for the profession. One of the benefits we have at MedQuest, because we have patients in every single district in the US, I can go into any representative’s office. And obviously I’m gonna introduce myself. I’m gonna introduce, usually I have a talented pharmacist with me, you know, Dr. Hali, O’Malley, who’s our vice president of pharmacy and compliance joins me quite often in DC. She’s the clinical expert, graded advocacy. We introduce our story, but if we’re meeting with a representative from New York, we may tell our story, but I think it’s more important to emphasize, here’s how many patients we work with in the state, here’s how many providers we work with in the state, and then here’s how many community pharmacies you have, and here’s how many of them do compounding.
And so we really try, it’s not about Jeff and MedQuest and Utah, it’s about the community pharmacy or the compounding pharmacy in New York, servicing patients in their district. And that’s where it becomes very powerful. And that’s kind of our way of trying to give back to the industry, where there is enough opportunity for all of us out there. And we just want to make sure we’re taking care of those patients. One really good aspect that has come from this is that, you know, we’re no longer competitors, in my opinion, we’re colleagues.
So it’s been a couple of years pre COVID, but we had 25 of the largest compounding pharmacies spend three days with us here at MedQuest, open doors, full transparency, you know, sharing best practices, you know, if they could go home and get something that would help their pharmacy get better, we gladly shared that, if there’s something that they could share with us that helped us get better, we were very appreciative of that. So the industry is really joined together, has made significant improvements over the past 25 years, and really worked together very nicely in terms of how do we protect patient access to compounding medications, and how do we make sure that patients always have a choice of where they want to go?
Joseph M. Raffaele, M.D.
Yeah, I mean, you as always understate how much you’ve given back to this cause in terms of hours of time in the air flying between Utah and DC and the amount of time you spent, which has really been fantastic. And then also that’s great to hear about the, I think you probably mentioned to me before, but to hear about all the 25 compounding pharmacies coming together and sort of, you know, being a more collegial rather than a competitive atmosphere. And I think that serves everybody really well. Let me think. Oh yeah. So are there any medical societies that have taken a position on the MOU, such as the AMA or the ACP or American College of Surgeons or anything like that, or are they just not aware enough of that to sort of take a position on it?
Jeffery R. Bray, MBA, MAED, SHRM-SCP
Yeah, we have a nice coalition. There was a coalition of 30 different organizations really focused on this. Compounding affects so many different industries, you know. Compounding medications really only about two to 3% of the population may need a compounding medication. Now at MedQuest, we’re a full service retail pharmacy. We dispense manufacturer medications. We dispense compounded medications. We’re really agnostic in terms of what we do.
As you know, it’s based on you as a physician, your patient, the pharmacist involved in terms of what they may need. So as a compounded medication, we can’t make anything that’s commercially available. That comes into play with allergies, different strengths, different dosages, different delivery forms. And so we’re really meeting a unique patient need that cannot be met anywhere else. And I think the different associations that in the coalition, they realized the importance of that, where, you know, the majority of your needs may be met by a manufactured medication. But for those cases that need something specific, that’s where the compounder is vitally important. In some cases, it’s a matter of life and death, now we tend to specialize in a bio-identical hormone therapy, so it may not be life and death, but it’s an important aspect of what drives us.
Joseph M. Raffaele, M.D.
Those too at sometimes…
Jeffery R. Bray, MBA, MAED, SHRM-SCP
But as you know, I mean, some of the work that you’ve done, diagnostics are getting better and better. And so as diagnostics improve, if you know exactly what you may need to optimize your health, or if you know that a medication or a filler, or some sort of delivery form may be better or worse for you, why shouldn’t you have the opportunity to really customize it to you as an individual? And so, again, kudos to the work that you’re doing in terms of just advancing the entire industry, and looking at the diagnostics and looking at just your patient base alone, in terms of the diversity, and how optimizing health can really make a difference.
Joseph M. Raffaele, M.D.
Yeah, I mean, I think it really does dovetail into the whole moving towards more personalized what we call N of 1 medicine where, you know, it may not be economically efficient or viable for a large pharmaceutical company to have enough different strengths or doses, but there’s an exact right dose that we can figure out based on all the evaluation that we’re doing now. And we’re not trying to make the patient fit the dose, but make the dose fit the patient. And that’s where compounding, you know, that’s why I use it in almost all of my patients because it is important to practice personalized, you know, N of 1 one medicine and get the results as optimal as possible. So I think, you know, when I first heard about this, I was like, oh, I’m really worried about not being able to continue to get the access to your products, which I’ve had access to for over 17 years now, but with all the work you’ve been doing, it sounds like the whole issue is in pretty good hands, and hopefully, we’ll have the outcome that we’re looking for and we’ll be able to continue. Are there any parting words you have to say about compounding or the future or next steps?
Jeffery R. Bray, MBA, MAED, SHRM-SCP
Yeah. Well, I think there’s another issue out there that everyone should be focused on is just bioidentical hormone therapy in general, compounded hormone therapy. It’s another aspect that FDA is focusing on, and there’s some threats to access to hormones moving forward. Nothing has taken place yet, but there was a recommendation to place all hormones on the demonstrably difficult to compound list, which would basically make them illegal to compound. And so, unfortunately, that’s was not a great recommendation and FDA did violate a couple of statutes involved in that. We have politely let them know that there are some concerns with that. Again, we’d love to partner with them, but that’s another issue that we’ll continue working on, continue educating on. Just in January, I have an opportunity to meet with six US senators here in Utah, another six or seven members of the house.
We have a tour set up in February where a handful of house representatives will be touring MedQuest just to see it up close. So, I think I cannot emphasize enough the importance of patients sharing their stories with their elected officials, writing letters, sending emails, for physicians, for medical providers, medical professionals, to share their stories with their elected officials, letting them know how this is really life-changing for many patients, and that you’re providing a need that they cannot get anywhere else. And whatever pharmacy you may be working with, if you’re working with MedQuest Pharmacy, thank you, we appreciate your support. If you’re working with other pharmacies, please let them know the importance of being involved as a pharmacy, and, you know, getting back to DC if they can, joining the various associations to show their support, and writing their own letters and making their own phone calls to their elected officials.
All that to say is I’m extremely optimistic of the future for compounding. Again, some of the work you’re doing, Joe, is incredible, and seeing firsthand, some of the data of your patient population and what it can do for, in my opinion, the entire US population, in terms of really looking at what they may need to optimize their health, you know, whether that’s lifestyle, diet, exercise, all the things that we all should be doing. But if there is a situation where they need a medication, whether that’s compounded or manufactured, a nutritional supplement, other types of products that will help them, you know, live a better life. It’s an honor to work with you. It’s an honor to work with other providers who are really leading this industry. And I think compounding will continue to be such an important aspect of taking care of patients. So again, thank you for the opportunity to talk with you.
You know, thank you for what you’re doing, not only as a thought leader of the industry, but what you’re doing for your patients, for your colleagues, and really, it’s just an honor to work with you and an honor to be able to talk with you about the importance of advocacy and the importance of compounding.
Joseph M. Raffaele, M.D.
Well, thank you very much. And again, I would say, you know, you’re always understating how much work you do in support of the compounding industry. And, you know, it is an honor to work with you and work with MedQuest for all these years. And I think that, you know, with the new diagnostics that are out, and hormones are continuing to be very, very important, they’re being shown to affect these diagnostic markers in ways that kind of make HRT for both men and women, what originally was before the women’s health initiative, which is really anti-aging or longevity medicine that’s really important to have, but having in exactly, the kind of right dose, right formulation, and, you know, if you can get it from a commercial pharmacy, that’s great. If not, then we need to have compounding available, and it looks like you’re ready to take on whatever fight that is needed to keep the industry going and helping our patients, and we all thank you for that too.
Jeffery R. Bray, MBA, MAED, SHRM-SCP
Well, it’s definitely a team effort. We’ve got a great quality team here at MedQuest. We have great partners in the industry, a lot of really good pharmacies out there. Our trade associations do a great job, and obviously we couldn’t do it without the support of physicians, of prescribers, of medical professionals out there. So just thank you for all the support out there, and for the ability to work with talented people such as yourself, the audience here and, you know, the ability to take care of patients and their unique needs.
Joseph M. Raffaele, M.D.
Well, again, thank you for coming on, and I will look forward to seeing you very soon out in Salt Lake or here in New York, or perhaps in DC, more likely, who knows for sure? But happy new year, and I’ll talk to you soon, Jeff.
Jeffery R. Bray, MBA, MAED, SHRM-SCP
All right. Thank you, I appreciate it.
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