Will Your Access To Compounded Medications Become Limited: The “Memorandum Of Understanding” And Its Status On Capitol Hill​

Introduction and Jeffrey Breyu2019s Background 0:00

As chief executive officer of Med Pharmacy in North Salt Lake City, Utah, Jeffrey Brey actively works to protect patient and prescriber access to compounded medication. He regularly collaborates with public affairs teams on legislative outreach and has served on Pca's Advisory Council. He earned his Master of Business Administration degree from the University of Utah in 2012, a master of Arts and Education degree from the University of Phoenix in 2003, and his undergraduate degrees from the University of Arizona in 2001.

As a lifelong learner, he is also a pharmacy regulatory specialist, certified in Health care Compliance, and is a board Governance and Board Leadership Fellow with the National Association of Corporate Directors. In 2020, he was awarded the APC Advocacy Champion Award in recognition of his extraordinary advocacy on behalf of America's pharmacy Compounders and the patients they serve. In 2021, he was honored as the first recipient of the El David Sparks Advocacy Award that celebrates passionate, committed, and tenacious advocates for compounding pharmacy.

He is honored to serve as CEO of Midwest Pharmacy and lead its talented team in their mission to provide patients and prescribers with digitally enabled pharmacy and health care services in the quest to live a better life. Welcome to another episode of the Telomere Summit. I'm your host, Doctor Joseph Rafael, and I'm very happy to have Geoffrey Bray on today, the CEO of Med Quest, Compounding Pharmacy to talk about some issues that have been. He's been very actively engaged in, on Capitol Hill to try to help the compounding industry with, some difficulties it's been having.

I'm going to let Jeff get into an explanation of that shortly. Welcome, Jeff. Thank you.

The MOU and Compounding Pharmacy Regulation 2:00

Appreciate the opportunity to be here. You've, developed, a great program here. And I'm amazed at the amount of talent that you've been interviewing. And, thank you for the opportunity to talk with you. Well, thank you very much. Jeff and I go way back. We've been I've been using Med Quest Compounding Pharmacy since 2003. And, and, you know, fantastic service. And I consider Jeff 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 at use some of the larger compounding pharmacies to, you know, get high quality compounds. And, 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, there for our patients to better health outcomes.

Yeah. So so, Joe, you mentioned, the issues going on and compounding and, and one of the biggest ones that has really, taken up, an interest, for myself, for the team Med Quest and many other pharmacies throughout the US is this memorandum of understanding, between the the states and the FDA food, drug and administration that are, Food and Drug Administration. And, this goes back to 1997, actually, with the food, drug, 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 2000, 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, 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 to better regulate and have oversight over compounding pharmacies.

So here at Med Quest, we are as you know, we are quality in compliance. First, those are two items that are non-negotiable for me and our team. Everyone's 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 a good 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 over overregulate the industry. And 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 5 or 6, seven years when when I first started getting involved in advocacy and a lot of people didn't know what compounding was, at least in capital, 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 compound medication over a manufactured medication. Right. 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 and what we provide for patients.

So just a deeper dive into the MOU. It's really, 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 legal 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 right. They did create A503B outsourcing facility, kind of a new new type of compounding pharmacy. And that is where you can send out 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 quantity quantities of compounded medications directly to hospitals, directly to physicians to take care of any needs that may, you know, emergency or otherwise. Right.

Where the traditional 503A pharmacy, like a midwest pharmacy and many others, they are working with patients, specific individuals, sending out prescriptions based on their unique needs. So that's that's kind of the background of it. But FDA is taking 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.

What next? What other great compounding pharmacies do throughout the U.S., and how we can partner with them rather than get into kind of a, a contentious situation where we disagree on some key issues. Unfortunately, those efforts were, moderately successful, but it ended up, in litigation. So Med Quest Pharmacy, as well as five other pharmacies, I 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 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.

FDA Litigation and Interstate Shipping Limits 9:00

And so the judge has, sent it back to them to conduct 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 of 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, 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 right or with it with FDA. If the if the state signs the agreement. And to date, 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 their license, what they're shipping, the percentage of of their medications out of state.

And, and that in itself is not necessarily a huge, burden. It will increase costs. It will increase, 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 it, many have indicated they will not sign it, and many have legal or legal hurdles on whether or not they can sign it. Oh, interesting. 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 know is near a border. Sure. 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 want to 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. To fast forward to where we are today. Just in Med Quest alone, we have 64 different pharmacy specific licenses. We're licensed in all all the states. We should, we can ship throughout the U.S. certain states have multiple licenses. So 64 different licenses just for the pharmacy. I was counting how many pharmacist licenses we have, because there's 20 states that require an individual pharmacist to be licensed as well.

And we have over 100 pharmacists 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 the 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. Right. 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 in that state, whether it's a manufactured medication, a compound, a 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. So the landscape has completely changed.

And in terms of where we're at, unfortunately, it ended up in litigation. We are confident that will, 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, 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 a long, answer to a short question, but hopefully, I covered some of the high points there.

Nos. And, and a 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 when, 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?

I mean, why would any of my other question just off 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 as one might think, to, you know, report if you're going to ship stuff out of state, why are some states, also setting aside potential, you know, legal issues? But why are some states sort of, reluctant to sign the MOU, which would make things a lot easier. And, as the CEO of a large compounding pharmacy that services many, all states probably.

Do you want people to sign the states to sign the MOU, or do you not, I mean, or, you know, where are we with them? These are just the things are popping up here that might be popping into our. And it's a 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 may be in the FDA or the state board of Pharmacy has reporting has increased, as you mentioned, reporting is, I mean, it's a burden, but it's part of the industry.

And we do a great job of reporting, as do a lot of other pharmacies. And and so the need specifically for adverse events, for example, which is the root issue here. Sure. That is something that is very easily, 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 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, 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, regained 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. You know, 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, their 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 boards of pharmacies, are not fond of FDA kind of regulating, something that they should be regulating and that they are regulating. So that's at the core of it. So is the state forward thinking better saying no. Yeah. They're saying please don't sign that because this is our territory. We don't want the FDA coming in here. 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 the state board of pharmacy here in Utah. It actually be the Division of Occupational and Professional Licensing, not the State Board of Pharmacy.

State Reporting, Licensing, and Compliance Burdens 18:00

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 state, you know, 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 is a little bit problematic.

So part of our discussions have 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 their they hope it will accomplish. And it, 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 a bad policy or signing a bad policy is better to sign it so that patients aren't negatively impacted. Right. So, that's 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, because I do believe litigation, everyone loses. But that's that's kind of 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. So it sounds like you're saying that, there's still going to 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, to, comply with a policy that 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 it make more sense and less burdensome and allow, like 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 it has to 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 in other industries. Now, with, you know, the advent of online ordering and Amazon, etc., etc.. What should they do to help you and your cause to to keeping compounding safe?

But, as available as it needs to be? Yeah. And you mentioned a key point there. Patients always have a choice. What pharmacy they go to. Right. Providers have a choice of what? 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 for your ability to choose your own pharmacy. That's right. And I think that's that's a significant issue. And so what can we do? Well, the mou it in itself, I'm actually pro regulation, as you know.

We spent a considerable amount of time, effort and money in terms of just staying above and beyond any compliance, you know, in 2020. We spent $3.8 million on a building expansion geared towards just staying ahead of regulations. And I think that's it's, you know, 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 going to rely more and more on on specialty pharmacies out there. So it's a 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 that's kind of my philosophy on that. As far as what to do, as a patient, as a provider. One of the, the biggest for another compounding pharmacy. One of the big things is engaging with your elected officials, right. We have had I tried to count before the interview here, but, we have had close to 40 different, members of Congress, House of Representatives, US senators come to med 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 the people come in, they get to meet some impressive people who, you know, are good people. Regard regardless of your politics or or what your 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 it's just eye opening for them to see the amount of time and effort, that goes into making it a compounded medication. But also the various checks in place, the quality in place that goes back to the supplier, the, 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 our elected officials enjoy

Advocacy, Patient Access, and Industry Outreach 25:00

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 that, to the pharmacy to see up close and personally, I can tell you that's that's 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 we believe it's our, honor and privilege to give back to the community as well. And so we we go back to DC quite often in terms of being able to advocate for the profession. One of the benefits we have med quest, because we have patients in every single district in the US. I can go into any representatives office and obviously I'm going to introduce myself. I'm going to introduce usually I have a talented pharmacist with me.

You know, Doctor Harley O'Malley, who is our vice president of pharmacy and compliance, joins me quite often in DC. She's the clinical expert. Great. At 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 Med Quest in Utah. It's about the community pharmacy or the compounding pharmacy in New York servicing patients in their district. And that's where 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 have has come from this is that, you know, we're no longer compared, in my opinion.

We're colleagues. So it goes it's a it's been a couple of years pre-COVID. But we had 25 of the largest, compounding pharmacies spend three days with us here in that quest. 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 that. So the industry is really, really joined together, has made significant improvements over the past 25 years.

And, and really work together very nicely in terms of how do we protect patient access to compounded medications and how do we make sure that, patients always have a choice of where they want to go? Yeah. I mean, you, you, as always, understate how much you've given back to this, to this cause in terms of, hours of time in the air flying between Utah and DC and, and the amount of time you spent, which is really been fantastic. And then, also that, that's great to hear about the, I think you mentioned to me before, but, to hear about the all the, the 25 compounding pharmacies coming together and sort of, you know, being a more collegial rather than competitive atmosphere, I think that serves everybody, everybody really well.

Let me think of just. Oh, yeah. So are there other, are there any medical societies have taken a position on the MOU, such as the AMA or the, you know, the, ACP or, American College of Surgeons or anything like that, or are they just not aware enough of that, to, to sort of take a position on it? Yeah. We have a nice coalition. There was, a coalition of 30 different organizations really focused on this, compounding effect. So many different industries, you know, compounded medications. Really, only about 2 to 3% of the population may need a compounded medication.

Now, well, we're a full service retail pharmacy. We dispense manufactured medications, we dispense compounded medications. We're really agnostic in terms of what, you know, what we do. As you know, it's based on you as a 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 the 30 some odd in the coalition. They realize the importance of that where you know the majority your needs may be met by a manufactured medication. But for those cases that need something specific, that's where that compounder is vitally important in some cases as a matter of life and death. Now, we tend to specialize in, bioidentical hormone therapy. So it may not be life and death. But it's not to. It's sometimes, regardless, but as you know, I mean, some of the work that you've done, the 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 and how optimizing health can, can really make a difference.

Yeah, I mean, I that really does dovetail into the whole moving towards more personalized what we call and of one medicine where, you know, it may not be economically, you know, 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.

And, you know, almost all of my patients, because it's it is important to, to practice personalized, you know, and of one medicine and get the results as optimal as possible. So I think, you know, I when I first heard about this, I was like, oh, I'm really worried about not being able to continue to to get the access to the, 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 whole issue is in pretty good hands. And, 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? Well, I think there's, another issue out there that everyone should be note, focused on is just bioidentical hormone therapy in general, compound and hormone therapy. It's another aspect that FDA is focusing on. And there's some threats to, to, access to hormones moving forward. Nothing, has taken place yet, but there was a recommendation to place all hormone on the demonstrably difficult to compound list.

Hormone Therapy and the Future of Compounding 33:00

What? Which would basically make them illegal to compound. And so, unfortunately, that's, was not a great recommendation and FDA did violate, a couple 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'll have I have an opportunity to meet with, six U.S. senators here in Utah. Another 6 or 7 members of, of the House.

We have a tour set up in February where a handful of House representatives will be touring Midwest 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 Midwest 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 seen firsthand some of the data of of your patient population and what it can do for, in my opinion, the entire U.S. 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 needed 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 just 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 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 in the industry, but what you're doing for your patients, for your colleagues. And really, it's just a, 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.

Well, thank you very much. And I, again, I would say, you know, you're always understating how much, work you do in, in support of the compounding industry. And, you know, is an honor to, to work with the work with you and work with us for all these years. And, you know, 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 be, affected, affect these diagnostic markers in ways that kind of make for both men and women.

What originally was before the Women's Health Initiative, which is really anti-aging or, longevity medicine. That is, that's really important to have, but haven't been 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, is needed to keep the industry going. And helping our patients. And and we all thank you for that, too.

Well, it's definitely a team effort. We got a great quality team here. Here at Med Quest. 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 of physicians, of drivers, of medical professionals out there. So, just thank you for 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.

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 D.C., more likely, who knows for sure. But, Happy New Year, and I'll talk to you soon, Jeff. All right. Thank you. Appreciate it.