She called me her flashlight.

My first thought? The one in the junk drawer. The one with the half-dead batteries that quits three seconds after you need it.

It took me years to understand what she actually saw. Then a couple of weeks ago, a pharmacist told me what she’d done for a patient was “just doing my job,” and I realized I’d been hearing the same thing from the other side.

This one’s for every pharmacist who has caught something that mattered and called it nothing special.

🔦 LinkedIn Live tomorrow: From “Just My Job” to Your Money Map
Tuesday, November 3, 1 PM ET
https://www.linkedin.com/events/7523037456321921025
Can’t make it live? The replay will stay on my LinkedIn profile.

📍 Not sure which path fits you? Take the assessment: http://tmrx.care/start

If this landed, send it to the friend who’s been your flashlight. 🔦

Most of them said some version of the same thing. The cleanest one came from a pharmacist who’s been at the counter for eleven years:

“Fine, Thea. I believe you. But how do I actually get paid for it?”

Fair. Monday I told you that you’ve already done the work.

That the calls, the lab explanations, the “can you look at my mom’s list” conversations all have a name and a structure and a billing code.

And then I kind of left you standing there holding that, didn’t I?

So today is the map. Where pharmacist services actually get paid, who each path fits, and the first move on each one.

[Subscribe button: “Get the map every Thursday”]

It was never a mystery. It was a map nobody handed you.

I used to think getting paid for clinical work was some secret the consultants were keeping from the rest of us. Like there was a password.

There isn’t. There’s a map. Most of us have just never seen it, because we’ve spent our whole careers staring at the counter.

And the counter is built to hide this work. It pays per fill. It counts scripts, not judgment. Every catch you make, every phone call to an office, every patient you talk off a ledge about a new med goes into the same bucket as “just being a pharmacist.” Nothing in that system was ever going to show you where else the work gets paid. Nobody at corporate is losing sleep over that.

Once you name the work and claim it (which is what the last two weeks were about), something shifts. The question stops being “can I get paid for this?” and becomes “which door?”

That’s a much better question to be stuck on, quite frankly.

Three places, one paycheck

Let me tell you about a pharmacist I’ve been working with. I’m changing enough details that she won’t mind me sharing.

She works full time at a chain counter in a small town. That’s her paycheck.

On Tuesdays, a nurse from the family practice down the road calls her. Not the pharmacy line, her cell. “Can you look at this one? His blood pressure’s all over the place and I think it’s the timing on his meds.” She looks. She’s usually right. The office adjusts. The patient does better.

On weekends she visits her grandmother at an assisted living place across town. The aides figured out a while ago that she’s a pharmacist. So now she gets the binder. Who’s on what, who’s been falling, who seems foggier this month. She reads through it at the little table in the common room and leaves notes on sticky pads.

So here’s the tally. She’s doing medication management for a physician practice. She’s doing medication regimen review for a facility. And she’s doing patient counseling all day at the counter.

Three places. She gets paid in one. And even there, they’re paying her to fill, not for any of the thinking.

When I laid it out for her like that, she went quiet on the call for a second. Then she said, “I’ve been doing a consulting job for free for two years.”

Yeah. You have.

And here’s the part that got me. Every single one of those places has a payment path attached to it. That practice can bill for exactly the kind of between-visit work she’s doing on Tuesdays. That facility is supposed to be paying someone to review those binders. She just never knew the doors were there.

So let’s open the doors. All four of them, what each one pays, and the first thing I’d do on Monday morning.

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Every day at the counter, you support, educate, and hold patients accountable to better outcomes between their office visits. You answer the 8 p.m. phone call. You explain the lab result nobody else took time to explain. That’s not “just being a pharmacist.” That’s care coordination, and it has a name, a structure, and a billing code.

In this episode of The Dose, Dr. Thea Blystone makes the case that you don’t need more clinical knowledge to build a care management practice. More knowledge does not equal a business. You need the structure and the frameworks to name what you already do, claim it as your work, and finally get paid for it.

Here’s the math that should keep you up at night: there are over 311,000 pharmacists in this country. If each of us took 200 patients, we could cover every Medicare life in America — without even working full-time. The industry of pharmacy is shrinking. The value of a pharmacist is not.

If this one resonates, tell me which part you want more help with. And if someone in your network needs to hear it, send it their way.

I was in the hospital setting of my career at the time. Job number 8 out of the 8 different kinds of pharmacy I’ve worked in. It was early 2019, and I was getting my care management business off the ground.

I took the home study. Then a weekend training on how to run a program like this, so I could help patients in America learn how to be healthy and lose 7% of their body weight.

I thought it would be a nice side program for the care management I was already delivering. Patients going both directions. Some going into DPP, others going into continued support through care management. A feeder program for both sides, right?

And at the end of it, I was not able to be a trainer. I wasn’t working inside a pharmacy, and the program billed and got its grant money through a pharmacy’s NCPDP number.

So they let me sit through an entire weekend and a lot of home study to get into the room to do the thing, and then not be able to actually do the thing. Talk about being pissed off. Oh boy.

Now, the hospital had a community retail pharmacy. But I wasn’t a staffing pharmacist there. I was an inpatient pharmacist, second in charge, assistant manager. Retail and inpatient were two very separate entities under the same health umbrella.

I’m sure I could have asked. But it wasn’t the game plan I wanted after I realized they were only getting $750 at the time for someone to complete the entire 12-month program. Compared to care management services, it just wasn’t enough to pursue. I realized quickly, when I got home, it really wasn’t worth it.

I never taught a single group class. I use it every month.

I didn’t actually ever do a group training program. The opportunity never came out that way.

But where I use it all the time:

I use it training other pharmacists, as a game plan for monthly talking points about preventive measures patients can do in their homes.

I use it with patients in weight management and prediabetes programs with me. If you do this, we can help you lose weight. And patients love it.

My team at Tendco Health uses the Diabetes Prevention Program toolkit to educate patients on more than just a disease state. On actually being healthy in America.

And I used it last week at the Aging and Wellness Symposium to talk about how to make seniors healthy. It’s not by running a marathon. It’s by being able to sit to stand. Being able to move your muscles. Being able to know and understand what the things you’re putting in your mouth are doing to your health.

So yeah, I use the Diabetes Prevention Program almost every month with my patients. If not more than that, quite frankly.

More knowledge does not equal a business

Oh gosh, I get this question all the time. Did the Diabetes Prevention Program actually make a difference?

In my clinical experience, it did. But it also made a difference for my business.

I didn’t just take the certification and stop at the answer I got, that I could only do it inside a pharmacy. I turned it and said, okay, I might not have a pharmacy to use it in, but where can I use it?

I can use it in education to my community, at the free live talks I do to make the rural community healthier. I can use it to make my business stronger, by helping patients get better results with the education I took to be certified as a trainer.

I didn’t allow it to take a back seat. I moved it to the forefront. If this is a 12-month program, and it’s still valuable for how patients are actually going to be able to be healthy, why not use it when I’m doing monthly outreach to these patients?

Here’s the math. Today, Medicare’s most a group program can bill for one patient is about $822. That’s for the entire 12 months, and only if the patient makes every session and hits every weight-loss milestone.

I get to do this 12 months out of the year and bill insurance every month to do it...Up to $80 a month. And then you have remote patient monitoring on top of that. There’s so much more value from a billable standpoint, billing Medicare Part B, and I still get to use this education to help patients get healthy.

So I took a year-long, one-time payment opportunity and a certificate, and turned it into ways I can talk to my patients monthly. Recurring revenue from the monthly care we bill to insurance. And a way to support, educate, and hold my patients to a better standard.

And I definitely didn’t wait for permission. When I asked, I was not allowed to deliver this education as the Diabetes Prevention Program Group Lifestyle Balance. I can’t use that title. Okay, I’m not using that title. But I’m going to use the information I learned inside that program to help my patients in rural America.

That’s when you know a certificate program got good use.

What I’d tell 2019 me: use it sooner

If I go back to 2019, when I took this certificate program, I would say to myself: use this sooner.

I didn’t use what I learned inside this program until after I started teaching other pharmacists about it, so that they could use it too. I didn’t share it with my team until last year.

I wish I’d seen its value back then. Patients value this kind of information. I will always include it now in any care management program I do.

That’s why I give the outline of the entire program to my clients in the PIVOT Program today. It becomes an easy button to deliver the outcomes patients want and need. And it gives the pharmacist the data behind them, so they can move forward confidently.

Here’s what one of those monthly touchpoints actually looks like.

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Paid subscribers get the full kit: my story, the monthly touchpoint scripts, and the certificate worksheet.

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When I found out, I called them. It’s real money, and I wanted to make sure they were okay with it.

They were more than okay. “You’re the only person that calls us,” they said. “You’re the only one that called when my mom passed away.”

I hung up and sat there.

What I’d been giving them every month didn’t feel like anything special to me. It was a phone call. A check on how things were going. The stuff I just know how to do.

To them, it was the one part of their health care that showed up.

We’re trained to discount ourselves

Then look at the normal day.

You caught a dose that would have sent someone to the ER.

You untangled an insurance mess the office couldn’t.

You talked a scared patient through a new diagnosis at the counter while the line backed up.

You noticed the refill that came in too late and knew what it meant.

You kept your techs steady when everyone was short.

We call all of that “just being a pharmacist.” The patient on the other side of it doesn’t.

The reason we discount it is simple. Nobody counts it. There’s no line on the receipt for the judgment. So we learn to treat it like it’s free.

What happens when you start counting

When I moved into between-visit care, partnering with physician practices to follow their patients by phone and with remote monitoring, I expected to learn a new skill set.

Mostly, I didn’t. I used the same skills I’d been using for years. The difference was that, for the first time, the work had a name, a structure and a place in the patient’s care plan. It wasn’t squeezed into a five-minute gap at the counter. It was the job.

That’s when I understood what the couple meant. The skills weren’t new. I had just never seen them counted.

Your turn: the “normal day” inventory

Before you decide what’s next, take stock of what you already carry. This is the exercise I wish someone had handed me:

1. Write down a normal day. Not the highlights. The whole thing.

2. Circle every moment where your judgment changed what happened for a patient.

3. Next to each circle, write who would have caught it if you weren’t there.

If the answer is “nobody” more than once, you’re looking at the work that matters most. It’s also the work most likely to be missing for patients between their appointments.

That list is where every pharmacist I’ve worked with starts. Not with a certification. Not with a website. With proof of what they already do.

If you’re still saying “I want pharmacy to fit my life, I just don’t know where to start,” start there. You have more than you think. You’ve just never counted it.

If this landed, hit reply or leave a comment and tell me one thing you circled. And share it with a pharmacist who keeps calling their work “nothing much.”

- Thea

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Tomorrow night, Tue Oct 13 at 7 pm ET: The Possibility Finder.

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I told her the truth. I’m not hiring. What I do is help pharmacists build this kind of work themselves, in their own state, with physicians of their own.

Her answer came back a few hours later:

“I feel that I will not be able to build something of my own.” 😔

I asked her which part felt out of reach.

Finding physicians to start.

That’s the one I hear most. I said it myself, sitting in my car after a 12-hour shift, two hours from home.

But here’s what I’ve learned since. It’s almost never about finding a name. She already knows prescribers. Every office she’s called about a script. Every doctor whose patients come through her line month after month. They know her. They trust her. She just hasn’t been counting those relationships as something she owns.

The real question underneath is harder: can I actually make this work? Which of those relationships is worth starting with? What am I bringing them? What do I say in that first conversation so it doesn’t sound like a sales pitch?

Nobody hands you that. And without it, “I’ll never be able to build something of my own” feels like the truth.

Maybe yours isn’t physicians. Maybe it’s expertise you’ve stopped noticing because it comes easy to you. A patient population you understand better than most. Cash-pay work, long-term care, something inside pharmacy, or you honestly have no clue yet.

That’s the point. You may not need more before you start. You may need to see what you’re already starting with differently.

That’s what we’re doing Tuesday night.

The Possibility Finder is the live founding intensive inside The Full Prescription, my founding membership. In one working session, you’ll look at what you already have, where your expertise could get paid, which possibilities actually fit you and the life you want, and which direction to explore first.

Tuesday, Oct 13, 7pm ET, on Zoom.
Founding membership: $297/year. The intensive is included, along with the year of founding access that follows it.

Join as a Founding Member

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If her sentence sounds like yours, come Tuesday.

Thea

I don’t know exactly why. Maybe nobody has to make eye contact. Maybe the ride has an end, so it feels safe to start something. But I’ve heard about friendships, heartbreaks, teachers, and a few things I was not prepared to hear that early in the morning, all from the passenger seat.

In a few weeks my daughter starts driving, and the Drop Off Club loses a member. I’m not sad about it. I love watching them grow into whatever’s next. But I’m very aware of how close I came to missing all of it.

For about 15 years, I floated. Twelve-hour shifts, sometimes two hours from home, sometimes in opposite directions on back-to-back days. I kept changing jobs, sure the next one would feel better. It never did, because I kept fixing the wrong thing.

When I finally figured out the right thing, it fit in one sentence.

I want to be done by 3:00.

I didn’t care what time I started. But at 3:00 I wanted to be in that car. I was a single parent when I started building, and I wanted to be the go-to parent. Every practice, every hockey game, every softball game, every recital.

A WISH VERSUS A RULE

Here’s what I didn’t understand back then. For years I had a wish: I’d like more time with my kids. Everyone has that wish. It’s a good one. And it gets traded away the first time someone offers more money, a better title, or a schedule that’s “only for a few months.”

A rule doesn’t negotiate.

Once “done by 3:00” became a rule, it started making decisions for me. It’s the reason everything I built had to be location independent. It ruled out [ADD: one real opportunity your 3:00 rule made you say no to, and how that felt]. It ruled in [ADD: one thing it said yes to].

I stopped asking, “Is this a good opportunity?” and started asking, “Does this keep the rule?” Those are very different questions. Plenty of good opportunities break the rule.

YOUR RULE WON’T LOOK LIKE MINE

Mine happened to be about time. Yours might be about something else entirely. When pharmacists tell me what they’d change, the answers usually take one of a few shapes.

A time rule. “I’m done by 3:00.” “I don’t work weekends.” “I’m home for dinner.”

A money rule. “Nothing that pays less than I make now.” Or, “It has to replace one shift a week first, and then it can grow.”

A place rule. “Nothing more than 30 minutes from home.” “I want to be able to work from anywhere.”

A work rule. “I use my clinical brain every single day, or it’s not the job.”

None of these is better than the others. A money rule is not less noble than a time rule. The only bad rule is the one you never write down, because that’s the one that gets broken without you noticing.

HOW TO FIND YOURS

Start with the question I asked on this week’s episode of The Dose: if you could change ONE thing about the way pharmacy fits into your life, what would it be?

Then rewrite your answer so it can’t be negotiated. “More flexibility” isn’t a rule. “Off by 3:00 four days a week” is. “Better pay” isn’t a rule. “Not less than a specific number by next fall” is.

Then hold up whatever you’re considering (the consulting idea, the new job, the side project, even staying put) and ask one question. Does it keep the rule?

If the answer is no, that doesn’t mean the idea is bad. It means it isn’t yours.

When you’ve written your rule, reply and tell me what it is. I’m collecting these, and I’ll share what I’m hearing.

If this landed, send it to one pharmacist who needs it. Not ten. One.

For paid subscribers, I made a one-page worksheet that walks you through all of it: naming your one thing, turning it into a rule, and holding up the options you’re weighing right now. Print it, fill it in, and stick it somewhere you’ll see it the next time a “good opportunity” shows up. It’s just below.

Thea

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She had a list of providers she wanted to talk to, and she’d worked with two of them before. She hadn’t contacted any of them, because she wanted her business set up first. Then the proposed Medicare rule on RPM came out, and she started asking herself why she’d start anything in the middle of something that might change.

So the list sat there.

I hear this all the time. The paperwork feels like progress. The business name, the LLC, the EIN, the bank account, the liability policy... all of it feels productive, and none of it requires you to talk to anybody. None of it tells you whether a provider wants what you’re building, either.

The conversation is the scary part, so we save it for last.

I asked her for four messages that day. Two texts to providers she already knew, and two LinkedIn messages to the ones she didn’t have numbers for. No pitch, no brochure. Just “I’m trying something new in pharmacy and I’d love your thoughts on it.”

By that afternoon she’d sent three. One booked a meeting. One said they’re moving buildings and want to talk once things settle. One she’s still waiting on.

Her business still isn’t finished. She has a meeting anyway.

I push the conversation first for a simple reason. The conversation tells you what to build. Which patients the practice worries about most. Whether they want help with blood pressure, diabetes, or the patients who keep bouncing back after a hospital stay. How their day runs and where you’d fit into it. Whether the work is even a fit for them. A state filing can’t tell you any of that. A provider can.

I watched it happen again with another pharmacist this month. She spent a morning shadowing in a physician’s office. Before she left, he told her he was happy to work together, asked her for the billing codes, and asked if she could send him a sample contract. She texted me afterward: “Obviously I still need to do the business part on my side.”

Neither of them waited for the paperwork to be finished. The conversation came first, and the yes told them when it was time to finish it.

To be clear, you still need the business in place before you sign anything or see a single patient. Entity, EIN, bank account, professional liability. Talk to an attorney about which entity your state requires. I’m not telling you to skip any of it. I’m telling you not to wait on it to plant seeds.

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The part nobody warns you about comes next.

The first conversation goes well. The provider says “let’s talk more.” Then you hear nothing for weeks, and most pharmacists read that silence as a no and quietly let it go.

My first yes took months, even though that office had known me for years. The pharmacist I started this story with got a meeting in an afternoon. Same kind of relationship, a different clock.

In my case, the physician left the country for a month right in the middle of it. What I kept sending that office while I waited is a big reason they said yes.

This week in the paid library, I laid out the touches I’d use between a first conversation and a signature, with every message written out so you can fill in your details and send it.

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If you have a list sitting there right now, send one message today. Just one.

That was weeks ago.

You’ve checked your phone more times than you’d admit. You’ve written a follow-up text four times and deleted it. You’re starting to wonder if you misread the whole thing.

This is the stretch where most pharmacists quietly give up. Most of them never got a no. They got a silence, and they filled it with their worst guess.

If you already have a warm contact and you’re stuck somewhere between “let’s talk more” and a signature, this one is for you.

Mine took months. My first physician partner already knew me from years of calls about prior auths and prescriptions that needed cleaning up. He still didn’t say yes on the first ask. He left the country for a month in the middle of it, and everything stopped. There were weeks I could not stand that nothing was moving.

That contract lasted more than three years.

What kept it alive was showing up with things that helped their office. Articles, updates, small things that made their day a little easier.

That’s the one idea you can use today. Every touch between the first conversation and the signature gives the office something and asks for nothing, until the day you ask. No chasing, and no messages that are really about your anxiety.

The harder part is knowing what to send, when to send it, and when to stop. Behind the paywall this week:

- A 90-day touch map, six touches, and the job each one does

- All six messages, written out with blanks for your details

- Three signals that a slow yes is still a yes, and three that it has turned into a no

- What to do when the physician disappears for a month

- The one-line re-ask I’d use when it’s time

To get the full touch map and all six messages, upgrade to paid.

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I hear that question all the time from pharmacists. It’s a fair question. So in this bonus episode, I answer it two ways.

First, with what care management actually is: the same conversations you’ve been having at the pharmacy counter for years. Support, education, and accountability between office visits, with one extra step that gets you paid for it.

Second, with a 2 a.m. phone call from pharmacy school, when I told my mom I wanted to quit. She didn’t give me a pep talk. She gave me one sentence, told me to go to bed, and hung up.

Turns out she answered this question 25 years before anyone asked it.

🎙️ 6 minutes. Listen, then tell me: what’s the reason YOU haven’t started?

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Years later, when I decided to build my own practice and needed a physician to talk to, that's the office I called. They already knew me. They still didn't say yes right away. It took months of showing up, a physician who left the country for a month, and weeks where nothing moved at all.

In this episode, I share what happened next, the trust bucket I didn't know I'd been filling for years, and what a pharmacist I'm coaching found when she looked at her own "ordinary" work a little differently.

Ten Names and a Conversation is the exact sequence I gave a pharmacist who told me she could not approach physicians. Two conversations later, a cardiologist offered to collaborate, offered to make introductions, and offered to let her shadow …

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That’s the moment a lot of pharmacists freeze. We thought getting the conversation was the hard part. Then the physician is interested, and the one question we can’t answer is the one about money.

It’s the question I hear more than any other. In comments, in DMs, on discovery calls. Some version of this:

“If pharmacists aren’t recognized Medicare providers, how does anyone get paid?”

It’s a fair question. We were trained to be right. We were never trained to be paid.

So here’s the flow I’ve used for 8 years, with 21 physician partners and hundreds of patients.

THE MONEY FOLLOWS THE WORK

1. I do the work. Monthly check-ins with patients between office visits, reviewing their readings, education, medication problems, and following up when something looks off.

2. I document it in the provider’s EHR. Everything lives in their chart, because these are their patients and it’s their billing.

3. With my physician partners, the provider bills. The services are billed through the physician’s practice, the same way the practice bills for other work its clinical team does.

4. Insurance pays the provider.

5. And the structure that I have used, the provider pays me by invoice every month.

No pharmacist provider number. No new law. No check coming out of the physician’s own pocket.

WHY THE PHYSICIAN SAYS YES

Sit on their side of the desk for a minute. They have patients with high blood pressure, heart failure and diabetes who need someone watching between visits. The physician doesn’t have time for that, and neither does the staff. The codes that pay for that work exist, and most practices leave them sitting there.

When I walk in, I’m not asking a physician to spend money on me. I’m offering to do the work their team can’t get to, document it in their system, and get paid from what that work brings in.

That’s why the conversation goes so differently than pharmacists expect. The physician hears revenue they’re already missing, and patients who finally have someone picking up the phone between visits.

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WHAT THIS MEANS FOR YOU

If the money question is what’s kept you out of the physician’s office, you’re in good company. A pharmacist told me recently that she felt confident talking to physicians, but not knowing how she’d get paid made the whole thing feel too overwhelming to set up on her own.

That uncertainty is the most solvable part of this model. The structure already exists. You don’t have to invent it.

What you do have to get right is the setup. Which services fit the practice, how the agreement is written, how your documentation supports the billing, and how the invoice works. That’s where pharmacists get tripped up, and it’s the part worth learning from someone who’s already built it.

ONE HONEST NOTE ABOUT 2027

CMS has proposed changes for 2027 that include a provision about how the clinical staff doing this work are employed by the practice. I filed a comment on it, and the final rule is expected later this fall. When it lands, I’ll tell you what it says and what it means for this model. Patients will still need someone between visits either way.

IF YOU WANT TO SEE THE WHOLE MODEL STOOD UP

On October 29, I’m teaching Monetize Your Expertise live at the ASCP Annual Meeting in National Harbor, just outside DC. Anyone can join ASCP and register, and it walks through the whole model start to finish: the services, the agreements, the documentation, and how the money moves. Registration closes October 22.

REGISTER HERE

The physician is going to ask how it gets paid. Now you know the answer.

Monetize Your Expertise | ASCP Annual Meeting, National Harbor | Halloween Weekend Register Here

Learn the billing codes. Understand the RPM platforms well enough to pick one. Get clear on the supervision rules. Figure out the contract. Probably another certification, because this one is clinical and that feels like the responsible thing to do. Then the LLC, the name, the website.

Nobody assigned that curriculum. She wrote it herself, which is why it has no end.

I did it that way too. I sat for twenty-four months asking myself whether I was good enough to do this, whether I actually knew how, what I was supposed to do first. Twenty-four months. Nobody was withholding permission. I simply couldn’t find anyone who had done the work, only people who could describe the services.

Why the curriculum can’t be finished

Work down the list and you’ll notice how much of it you can’t settle in advance.

Which platform should you use? Depends on what the practice already runs and what the physician is willing to look at.

Which patients? Depends on the panel. A cardiology clinic and a rural primary care office aren’t the same problem.

What goes in the agreement? Depends on what the office actually needs from you, which you don’t know yet.

How much of the model do you need to command? Depends on what the physician in front of you asks.

Every answer is downstream of a conversation that hasn’t happened. So you study in a vacuum, which feels like progress and produces nothing, because you’re preparing for a meeting with a person who doesn’t exist yet.

The curriculum isn’t preparation. It’s an extremely organized way to avoid the only conversation that would tell you what to study.

The pharmacist who proved it in two weeks

A pharmacist started with me this month. Over ten years in a hospital. Not burned out, not bitter. Stagnant, which is harder to act on, because nothing is wrong enough to justify a change.

She’d been circling a niche for years without landing on one, and when I asked what was in her way she didn’t say clinical knowledge. She said she couldn’t approach physicians. Not that she hadn’t. That she couldn’t.

So I gave her the only assignment that works at that stage. Ten physicians you already know, from ten years of people calling you about a dose or a prior auth or a prescription that didn’t look right. Pick one. Go be curious about their practice.

She had two conversations.

A cardiologist she knew from in-house offered to collaborate, offered to introduce her to other physicians, and told her she could come shadow his clinic whenever she wanted. A nurse practitioner told her she knew physicians who would want this.

No website. No entity. No technology. No billing knowledge, and she said so out loud.

She called them two basic conversations.

Then the physician asked the only question that mattered

He didn’t ask where she trained. He didn’t ask about board certification or how many years she had in. None of the things on the curriculum.

He asked about feasibility. What could actually be billed, and how this would work inside his practice.

She told him honestly that she didn’t know much about the insurance side.

Now look at what that conversation did to her workload.

Before it, she had an infinite list of hypothetical things to learn, none of which she could finish, all of which she was failing at simultaneously. After it, she had one question, asked by a real cardiologist, about a real clinic, that she needed to be able to answer before she walked back in there.

That’s the trade. An imaginary curriculum with no end, swapped for a finite problem with a deadline attached to an actual opportunity.

It’s the single most useful thing a first conversation does, and you can’t get it any other way. No course, no certification, no amount of reading will tell you which two questions your physician is going to ask. Only your physician can do that.

She didn’t get a contract

I want to be careful here, because the punchy version of this story isn’t the true one.

She didn’t walk out with a signed practice. She walked out with interest, an offer of introductions, and an open invitation to shadow. The shadowing isn’t even on the calendar yet. Her cardiologist isn’t around her hospital consistently, she texted him about dates, and she’s waiting.

It might come together. It might not. Too early to know.

What she definitely got was the next conversation, and a reason to prepare for it. That’s the correct expectation to have for a first conversation, and setting it any higher is how pharmacists talk themselves out of having one. You’re not walking in to close. You’re walking in to open a door and find out what’s on the other side of it.

The part nobody puts in the success story

A week later, offer in hand, she told me it was still hard for her to picture what she’d be doing exactly, because she didn’t really know.

She did the thing and the feeling didn’t catch up.

That belongs in the story. The version where fear evaporates the moment you act is a lie, and it makes everybody who acts and still feels scared assume they did it wrong. You didn’t do it wrong. The feeling lags. Go anyway.

Then she said the thing that changed how I explain all of this.

That it would probably be good to have a better idea formulated in her mind of what she was bringing to the table, and that it would help her confidence.

Two weeks earlier, confidence was a personality trait. Now it was a preparation problem.

That’s the sequence, and it only runs in one direction. You don’t need confidence for the first conversation, you need curiosity, and curiosity costs nothing because there’s no wrong answer to a question about someone else’s practice. Preparation is what you build afterward, for the conversation where it starts to matter.

Your ten

Open a note on your phone right now. Ten physicians you already know.

Not the ones you should know. Not a list you buy. The ones who have called you over the last decade, the resident who is an attending now, the hospitalist who always asked you first.

You didn’t build that network on purpose, which is exactly why you don’t count it. Ten years of small trust is sitting there unused.

Pick one name. Ask to grab coffee. Tell them you’re looking at doing something different, supporting patients between office visits, and you’d like their thoughts.

Then ask about their practice and let them talk. What’s hard. Which patients worry them between visits. Where the quality metrics are hurting. In the rural practices I’ve worked with across northwestern Pennsylvania, I keep finding the same thing: long stretches between visits, and nobody consistently managing what happens in between. That gap is the opportunity, and I find it widest in the places that have the fewest people to cover it.

And then it gets to billing

Not always in the first conversation. Her cardiologist made his offer before it ever came up, which tells you something worth holding onto: billing isn’t the gate to a physician’s interest. It’s the gate to that interest turning into something real. Once he’s picturing this inside his own practice, what he needs to know is whether it can survive contact with his schedule and his staff.

You don’t need that answer to start. She’s proof.

You do need it before the second conversation, and that’s the difference between studying and preparing. Studying is what you do to postpone the conversation. Preparing is what you do because a cardiologist asked you something specific and you intend to walk back in there with an answer.

That’s what Monetize Your Expertise is for. Live at the ASCP Annual Meeting, Thursday, October 29, at the Gaylord National in National Harbor, Maryland. Four hours in the room with me, the full home study program, and 10 hours of CE. You leave knowing what’s billable, how the physician arrangement is structured, and what to say when the feasibility question lands.

Code THEA500OFF takes $500 off. You’ll need to be registered for the annual meeting to attend.

Register for Monetize Your Expertise → ASCP.com/CareMgmtCert

Register by October 22. That gives you the week you need for the home study before we’re in the room together, and it runs with a minimum headcount, so registering early helps.

Go have the first conversation this week. Come to National Harbor ready for the second one.

I repeated it back on the recording and then stopped talking. Eight years into building this, I didn't know that was the thing I'd been chasing the whole time.

She also had two conversations she called basic. One ended with a cardiologist offering her an open door and asking a question she couldn't answer.

What she said that I didn't see coming, and why the part that scares you isn't the part that's actually hard.

She couldn't answer the billing question. You don't have to be her.

I'm teaching Monetize Your Expertise live at the ASCP Annual Meeting — Thursday, October 29, at the Gaylord National in National Harbor, MD. Four hours in the room with me, plus the full home-study program and 10 hours of CE.

Use THEA500OFF for $500 off. You'll also need to be registered for the annual meeting.
Register here: ASCP.com/CareMgmtCert

Registration closes well before October 29. Get your seat today!

Hundreds of refills. New scripts stacked behind them. Providers still sending more through lunch, because their Tuesday was backed up too. I had a protein shake in the car on the way in and figured I’d eat around two, maybe three, once the afternoon rush broke.

That’s the Tuesday after a long weekend, and if you have worked retail you already knew every line of that paragraph before you read it.

The part nobody names is this.

The holiday didn’t remove the work. It deferred it and charged interest.

That is not bad scheduling. Nobody built that queue wrong. It’s what happens when the work has no ceiling and nobody is measuring whether you’re okay. Four days of work turns into five days’ worth of hours, and the only thing that flexes is you.

The part that actually stings

I spent years thinking the problem was volume. More tech hours, more pharmacist hours, some overlap, and it would be fine.

It wasn’t volume.

If your labor feels like it doesn’t count, it’s because nobody is counting it. Including you.

Think about what actually filled your day. Prior auths, insurance claims, billing calls, forty minutes fighting a plan over a drug the patient has been on for six years. None of that shows up anywhere. There is no line item, no quality metric, and nobody at the end of the month says she spent forty hours on that. It evaporates.

Then think about why you went to pharmacy school. I got taught for four years that I was going to care for people, and then I came out into a labor force where the labor keeps getting heavier and the caring keeps getting squeezed into whatever margin is left.

That gap is what discouragement actually is. It isn’t weakness, and it isn’t the burnout everybody throws around so easily. It’s an accurate read on doing high-value work inside a structure that can’t see it.

What changes when it gets measured

I want to be careful here, because the answer is not quit your job. I am not telling anybody to blow up their life on a Tuesday.

The point is that pharmacist labor can be structured so it is visible, billable, and bounded.

Same skills, same license, different container.

One of my RPM patients came to us after a CHF exacerbation discharge. Three months in, I found out he was legally blind. It was in the chart, one line deep, and nobody had said it out loud. We got the vendor to text his daily readings so his phone could read them to him.

He has been enrolled four and a half years. Over 1,500 readings, 97% adherence, more than 300 interactions. He lost 22 pounds in nine months and he has not been readmitted for heart failure since the day he enrolled.

We did nothing exceptional clinically. We supported him, educated him, and held him accountable between office visits. That’s the whole thing.

The difference is not that the care was better than what you’re doing at your counter. The difference is that somebody counted it.

The rule on the table right now

This is why I’m writing it this week instead of saving it for a slower one.

CMS has proposed that remote monitoring be paid only when the clinical staff furnishing it are direct employees of the billing practice. Contracted clinical staff would not qualify.

That is not a judgment about whether the care is good. It’s a judgment about whose payroll you’re on.

The offices that lose the most are rural. A two-provider practice in a county without a hospital cannot add a pharmacist to the payroll. The math has never worked. What they can do is contract with a pharmacist-led team they trust. Take that away and they don’t build an internal program, they just stop offering the service.

The patient with the 1,500 readings was served by a contracted pharmacist-led model. Under this proposal, the practice that enrolled him could not have billed for it.

The comment period closes September 14, 2026.

What to actually say in a comment

This is the part I skipped when I talked about it on the podcast, and it’s the part that stops most people from doing it.

You don’t have to write like a lawyer. CMS is not grading your grammar. A comment that gets read does three things.

Say who you are. Name, credential, where you practice, what you do. Two sentences is plenty.

Describe one patient, de-identified. What was happening, what your team did between appointments, what happened as a result. This is the part almost nobody submits. CMS gets plenty of policy argument and almost no patients.

Say what the proposal would do to that patient. Not to your business. To the person.

Fifteen minutes, start to finish.

Go to regulations.gov and search CMS-1848-P.

The reason it matters more than it sounds: the people CMS reliably hears from about remote monitoring are the bad actors and the entities under investigation. They don’t hear from the good ones. If we stay quiet, the record gets written by the fraud reports.

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One more thing

If reading this made you tired in a specific way, that’s information, not a character flaw.

I built a short assessment that tells you how ready you actually are for care management work. It takes a few minutes and it’s honest with you about where you’re standing right now.

tmrx.care/tbo-assessment

And if you know a pharmacist who walked into that queue this week, send them this. That’s the ask.