Why We Built Fillex: A Conversation with CEO Dain Rusk

Over the past two decades, pharmacy has undergone a quiet but significant transformation.

Margins have tightened. Prescription volume has grown. And pharmacists — once positioned as frontline healthcare providers — are increasingly constrained by operational demands.

To understand what’s driving these changes and why a different model is needed, we sat down with Fillex CEO Dain Rusk. With decades of experience leading pharmacy operations at companies like Publix and Albertsons, Dain has seen these shifts firsthand. 

In the following conversation, Dain shares his perspective on the economic pressures stifling the profession and how pharmacy can reclaim its role in patient care.

Life Behind the Pharmacy Counter

You’ve spent decades leading pharmacy operations. What changes have had the biggest impact on the industry over the course of your career?

Dain Rusk: I’ve seen good changes, and I’ve seen some really bad ones.

The biggest change is reimbursement — it’s become incredibly aggressive. Many pharmacies are operating at less than a 1% bottom line, and some are losing money outright.

That reality forced pharmacies to rethink their entire business model. It pushed people to start investing in technology, starting with in-store automation and counting machines. 

Meanwhile, the role of the pharmacist shifted. Twenty years ago, pharmacists weren’t even allowed to immunize. Now they’re some of the most accessible healthcare providers we have.

The question became: How do we free them up to actually do that frontline clinical work?

The role has expanded, but the economics haven’t kept pace. What kind of pressure does that create inside the pharmacy day-to-day?

Dain: You have to remember, medicines are an important aspect of treatment.

Medications can cure serious infections and treat long-term conditions. Medications also can help relieve pain and improve mental health.

Medications hold so much potential and promise – the last place a patient wants to be is standing in line.

If you call a pizza place and they tell you it’ll be ready in 15 minutes, you’re fine with it. Tell that same person it’s going to take 15 minutes for their prescription, and they become upset.

In their mind, it’s just putting a label on a bottle. They don’t see the 50 people ahead of them or the 2,500 prescriptions a week being filled by one pharmacist and a few technicians.

The pharmacist ends up in what I call “the firing line.” People are standing there, watching, frustrated — all while you’re trying to do complex, high-risk work.

"Pharmacists are paid for what goes into the bottle, not the knowledge behind it — creating a fundamental misalignment."

You can see how that leads to burnout, but it goes deeper than just workload, doesn’t it?

Dain: It does. It’s not just labor shortages; it’s how the work is structured.

Pharmacists went to school to be practitioners. They want to help patients, understand drug interactions, and improve outcomes. In reality, most of their day is spent filling prescriptions. 

Pharmacy is unique in that compensation is tied to dispensing products, not to clinical expertise like it is in many other healthcare systems. Pharmacists are paid for what goes into the bottle, not the knowledge behind it — creating a fundamental misalignment.

You ask someone when they graduate from pharmacy school how excited they are, and they’re full of energy. Six months later, they feel like they’ve been in a sweatshop all day. They’re dealing with demand and they never have time to actually help patients. That’s what drives burnout. 

The Fulfillment Infrastructure Gap

Some providers have tried to solve that with central fulfillment, but many haven’t. What makes central fill so difficult to build and operate at scale?

Dain: Running it isn’t the hard part. The hard part is getting it built.

Imagine going to leadership and saying, “We’re barely making money, and now we want to spend $25–$50 million.”

That’s a tough sell — especially in grocery organizations. If they’re going to spend that kind of money, they’d rather build a grocery warehouse than a pharmacy facility.

It’s a capital challenge, not an operational one.

Even when companies do invest, they usually can’t justify building out a network that covers 100% of their stores. The only way to justify that expansion is to bring in additional volume, and the only place to get that volume is from competitors. 

But no one is going to give their volume to a competitor.

So even when it works, it can’t truly scale?

Dain: Right. You end up with capacity that is limited by your own network. At the same time, other organizations need that capacity but can’t access it. So the system stays fragmented.

Why hasn’t a more open model emerged before now?

Dain: Because of how the industry is structured. It’s competitive and vertically integrated. Everyone’s tied into their own ecosystem. So if you build something, it’s for you.

You’re not opening it up to someone down the street who’s competing with you. That’s what’s kept it from evolving.

Was there a specific moment when it became clear that the industry needed a different model?

Dain: The pandemic. No question.

Before COVID, central fill was considered a luxury. Afterward, it became a necessity.

When pharmacies were asked to deliver vaccines at scale, the only way to do that was to free up pharmacists. And the only way to do that was with fulfillment infrastructure.

At Publix, we had that infrastructure, so we were able to give the first COVID vaccine in the U.S. Other pharmacies didn’t have that. They were dealing with medication errors and pharmacists quitting in the middle of a shift.

It became obvious: the model doesn’t work without infrastructure.

"The idea has been validated, and honestly — it’s bigger than I expected."

A Utility Model for Pharmacy

How did those experiences lead you to build Fillex?

Dain: For me, it’s personal. I’m a pharmacist and I believe in this profession. But the only way pharmacists can provide value-based care is if we give them their time back.

That’s really what led to Fillex.

Interestingly, we thought we’d have to go out and “sell” this model, but we haven’t had to reach out to a single customer. Everyone — retail, health systems, PBMs, manufacturers — is coming to us.

The idea has been validated, and honestly — it’s bigger than I expected.

How does Fillex make this possible without that massive upfront investment?

Dain: We remove the capital barrier. We build it, we operate it, and we aggregate volume across partners. Instead of spending tens of millions, you’re paying for access.

I describe it like a utility. You don’t build your own power plant; you pay for electricity. We want to be that for fulfillment: predictable, scalable, and always there.

Because we’re independent, we can bring competitors together in a way no one else can.

And as those partners grow, their needs can change, too.

Dain: Exactly. Some just need shared capacity. Others may want something more dedicated over time. So we built flexibility into the model.

You’re not locked into a big upfront decision. You can grow into it.

What happens if the industry doesn’t change?

Dain: You’ll see more consolidation and more closures. The pressures we talked about earlier — volume growth, reimbursement, labor — aren’t going away. 

The system just gets tighter and tighter. You’d see fewer pharmacies handling more volume under the same constraints. 

At some point, something has to give.

" Healthcare is personal. The only way to keep it personal is to give pharmacists the time to actually engage with patients."

The Future of Clinical Care

What is the path forward for pharmacy?

Dain: Care. That’s where pharmacy wins. Relationships, conversations, and helping patients manage their health. But you can’t do that if you’re spending your day filling prescriptions.

If we take the fulfillment burden off the pharmacy, pharmacists can focus on what actually matters.

That is how pharmacy stays relevant.

And that’s ultimately what Fillex is trying to solve.

Dain: Exactly. This isn’t about replacing pharmacists; it’s about enabling them.

Healthcare is personal. The only way to keep it personal is to give pharmacists the time to actually engage with patients.

Fillex isn’t just another fulfillment option — it’s a different model entirely, designed to remove the structural barriers that have constrained the profession for decades.

It’s about giving pharmacists the time to practice at the level they were trained for.

Ready to Scale? If you’re looking to scale without taking on additional capital or operational burden, Fillex can help you explore a different path forward.

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About Fillex

Fillex is building the modern infrastructure layer for pharmacy fulfillment. As the nation’s first open-access central fulfillment network, Fillex provides pharmacies of all sizes with scalable, automated, and fully licensed facilities designed to handle high-volume prescription dispensing with industrial-grade precision.

Through a combination of advanced automation, integrated logistics, and operational expertise, Fillex enables pharmacies to offload repetitive fulfillment tasks and redirect their teams toward clinical services. Fillex offers both shared network environments and dedicated facility models, giving retail chains, grocers, health systems, and digital pharmacies flexible access to world-class fulfillment capabilities without the capital investment or operational complexity of building their own infrastructure.