Jason and Brandon discuss the differences between a compounding pharmacy versus a retail pharmacy.
Brandon Knott is a pharmacist and owner of Cascade Specialty Pharmacy, a pharmacy that specializes in providing medications that are not commercially available. Brandon has been a pharmacist for more than 15 years and has extensive experience in many aspects of the pharmacy business including Pharmacy Operations management at the University of Florida Health System, home IV therapy, traditional retail pharmacy and for the last several years as an owner operator of a compounding pharmacy.
To learn more visit: www.cascaderx.com
Below is the full transcript:
Announcer: Welcome back, America, to Sound Retirement Radio, where we bring you concepts, ideas, and strategies designed to help you achieve clarity, confidence, and freedom as you prepare for and transition through retirement. Now here is your host, Jason Parker.
Jason: America, welcome back to another round of Sound Retirement Radio. So glad to have you tuning in this morning. As you know, we’re always looking to bring experts onto this program who we believe can add significant, meaningful value to your life as you’re preparing for and transitioning through retirement. You’re listening to Episode 142, and I’ve got Brandon Knott on the program. We’re going to be bringing him on in just a minute to talk about pharmacy, compounding pharmacy specifically, and what that means and what you should be thinking about.
Before we bring him on, as you know, we like to get the morning started right by renewing our mind, so I have a verse here for us. This comes to us from Galatians 5:13. “You, my brothers and sisters, were called to be free, but do not use your freedom to indulge the flesh. Rather, serve one another humbly in love.” Then, of course, I have a joke for you. I know that if you’re going to be going to visit the kids and the grandkids, I know how much you enjoy sharing these jokes with them and the way they roll their eyes like my kids do when I share these jokes. What do you give a sick lemon? Lemon-aid, of course. You wouldn’t give it first aid; give it lemon-aid.
All right. With that, you’re listening to Episode 142. Brandon Knott is a pharmacist and the owner of Cascade Specialty Pharmacy, a pharmacy that specializes in providing medications that are not commercially available. Brandon has been a pharmacist for more than 15 years and has extensive experience in many aspects of pharmacy business, including pharmacy operations management at the University of Florida Health system, home IV therapy, traditional retail pharmacy, and for the last several years, as an owner-operator of a compounding pharmacy. Brandon Knott, welcome to Sound Retirement Radio.
Brandon: Hey, Jason. Thanks so much. Pleasure to be here with you. Appreciate the opportunity to talk with you.
Jason: Oh man, I’ve been wanting to get you on here for some time, so I appreciate you being a guest. I specifically chose that joke this morning, Brandon, because we’re going to be talking about medication. What do you give a sick lemon? What’d you think of that one?
Brandon: I’m glad you thought it was funny.
Jason: I’ve got more where that comes from.
Brandon: I’ll try to use that. I’m sure you do. I’ll be using that one the rest of the day, for sure.
Jason: For our listeners out there, Brandon is a good friend of mine. He’s somebody that I’ve known for a long time. We coached Little League baseball together. We spent several mornings over the last several years jogging together. We go the gym together. I’ve been wanting to bring him on as a guest because I think he’s really going to be able to add value to people’s lives. I read this interesting statistic recently, Brandon, from I think it was Newsweek that had this article, but they said nearly 40% of adults 65 and older reported use of five or more medications, which, to me, that seemed like a pretty high number.
Brandon: Oh, I’m surprised it’s not higher than that. Medication use is certainly on the rise. It’s kind of indicative of our healthcare system. We just want to treat problems.
Jason: Well, one of the other things this article-
Brandon: As we get older-
Jason: Yeah, people don’t tend to get healthier as they get older. One of the other things that this article said was that the drugs that are most commonly prescribed right now are used for medical conditions that tend to afflict people who are overweight or obese. The study found that 8 out of 10 of the most commonly used drugs are used to manage heart disease, high blood pressure, diabetes, and high cholesterol. Before we start digging into the difference between a compounding pharmacy and a regular pharmacy, any thoughts for our listeners about maybe some alternatives to taking prescriptions?
Brandon: Well, I mean, it really depends on what your problem is and how serious it is. There’s lots of complexities with certain diseases. There are certainly alternative treatments that people can seek after, but they’re not always appropriate, depending on how advanced your disease is. For instance, I personally have a mild form of high cholesterol, but I’m able to treat that naturally, and it’s very effective. If I had a severe case of cholesterol, that may not be the best choice for me.
You have to have somebody in your court that’s going to advise you. There’s herbs and things, for instance, that people can treat for depression. Well, if you have a serious form of clinical depression, that’s probably not the right thing. Now, if you just get a little depressed every now and then, or just have a little anxiety, yeah, you might be able to treat that with some herbal products. You have to be careful, and that’s why you need to seek advice and get good counsel on some of these products and make sure that it’s appropriate.
Jason: You bring up a good question there. People that are taking these alternative paths to medications, herbal remedies instead of prescription medications, as a pharmacist, do you need to know about those herbal supplements that they might be taking? Can they interact with a prescription medication?
Brandon: Yeah, there certainly are some interactions that you need to be aware of. It depends on medication classes, classes meaning blood pressure medicines, cholesterol medicines. There are certain classes of drugs that may be more sensitive to those types of interactions. Whoever’s managing those medications for you, you should always just be open with them and just let them know like, “Hey, I’m also taking blah blah blah blah blah.” A multivitamin, that’s not really a concern, but certain other herbals that you’re using actually to treat something, that you might want to mention. It might tip off a professional, like your doctor or your normal pharmacist. Just might spark something that they say, “Oh, you should be careful about that or looking out for yourself.”
Jason: Well, Brandon, one of the reasons I wanted to have you on the show is because Sound Retirement Radio is all about people who are getting ready for retirement and people transitioning into and through retirement. Healthcare is one of their biggest expenses as they’re making this transition into retirement. With as many people using prescription medications, I don’t think that a lot of people … I know I really didn’t … understand the difference between a compounding pharmacy, a retail pharmacy, and something like a hospital pharmacy. Will you take a quick minute and help our listeners understand the difference there?
Brandon: Yeah, sure. Be happy to. I’ll just go back in time. Before the 1970s, before the FDA really came on to be, there were very few commercial drugs. Your average pharmacy made most of the medications there at the pharmacy, whether that’s an ointment or a salve or an elixir. A lot of those were made at the pharmacy level. In the 1970s, the commercial drug manufacturers, for reasons of safety and effectiveness for marketing practices, created a process where medications that were going to be marketed to physicians and the public had to meet certain criteria.
Since then, that’s where we have big pharma. The pharmaceutical companies, they’re bringing out products. Fast forward, 99% of the medications that are consumed now are manufactured under the FDA guidelines. That’s really changed the landscape of our healthcare system, especially as it comes to the pharmacy side, but that inherent ability of a pharmacy to create things still exists today; it just looks differently than it did a few decades ago.
Hospital pharmacies, they’re taking care of somebody’s acute needs. If you’ve got pneumonia or you’ve had a heart attack or something, they’re basically there to support you during that period of time where you’re at the hospital so that your body can recover and then go back home. Their mission and focus is quite different than a community pharmacy. Your community pharmacy is your typical retail chain, your Walgreens, your CVS, your Rite Aid. They’re there really to handle minor acute needs like if you have a cough or cold, so you might need an antibiotic, or if you have a chronic condition that you need to be maintained on medications, like you mentioned before, if you have high blood pressure or cholesterol, conditions such as that. They’re there really to supply those needs.
Nowadays, everybody who’s in any profession, you tend to specialize in one aspect of that profession. Your retail chains, they’re really not going to make medicines like the old days, because they don’t have the time to, nor do they have the expertise. That kind of broke out. Really, there was a resurgence in the ’90s of these pharmacies that are termed compounding pharmacies, and basically they make medicines. We formulate medicines now.
When you say “make a medicine,” that doesn’t necessarily mean that they are creating the new active ingredient. That’s not the case. The active ingredients they’re using are already FDA approved, and they’re approved for human use. We’ve already approved that they’re safe to use in humans, but we’re just taking that and reformulating it, maybe in a different dosage form. Now, dosage forms are like capsules, liquids, creams, white mints, things like that. That’s a dosage form.
They’re creating things that aren’t necessarily commercially available, and there’s a wide … reasons why that’s needed. People have allergies. Man, anyone knows that people are becoming more and more intolerant towards things in their diet, whether they’re gluten-sensitive or dairy-sensitive. All these fillers and inactive ingredients in products create a lot of problems for people. Some people have allergies or sensitivities to products. Maybe the dosage that’s available doesn’t work for them, or maybe they need it in a different dosage form. Maybe they can’t take something orally and they need it reformulated, but there isn’t something that’s available.
Jason: Yeah. Boy.
Brandon: What’s becoming more and more popular is “Hey, my insurance covers this item, but, boy, my deductible is really high and I can’t afford a few hundred dollars to pay for that medication.” We get asked, “Hey, can you guys make something that’s similar?” A lot of these products are old drugs, things that have been around for a very long time. People have seen it, as generic companies are being bought up, that the price is going up astronomically on these old drugs. We get asked, “Hey, can you come up with something that’s cost-effective that might have the same end result for the patient?” That’s kind of a new area that we’re really expanding into that we’ll talk a little bit more about.
Jason: All right. My mom, I know she has some allergies, so she has to be really careful with certain ingredients in her medications. For her to know that there’s somebody like you out there that can say, “Hey, call, let us know what your allergy is,” and then be able to work around that to be able to maybe still provide the medication, that’s pretty cool.
The other thing is, Brandon, I know there was somebody here locally who was having a lot of pain in their ankle and didn’t want to take pain medication orally, just because it upset his stomach and made him feel kind of loopy. You were able to come up with a solution there to help treat that pain without the side effects that came along with it.
I want to ask you specifically, though, because you’re in this field every day, what are the areas that you find where you guys are helping people the most when it comes to prescriptions? We talked a little bit about people with allergy sensitivities, but what are some of the areas that you’re helping people?
Brandon: Yeah. I kind of break it out into a handful of categories. One of them that’s … is people’s pets, dogs and cats. We do a lot of reformulations of medicines and flavors to enable people to treat their animals in a manner that’s not traumatizing to the animal or to the owner. We do a lot of reformulations for those companion animals, we do dose customization, customized hormone replacement therapy for women and for men, and then pain management. As you just mentioned, we make topical creams that have high-powered ingredients. The great thing is is you don’t get the same side effects if you’re not taking them systemically, so that’s an advantage for some people.
For other more specialized illnesses that we kind of work into where the patient base isn’t large enough for a manufacturer to bring a product to market because it’s just too expensive for them to do that and recover their expense, we focus on some of those. For instance, we work with a lot of patients that have chronic sinusitis, working with ear, nose, and throat doctors for those products. In men’s health most recently, kind of an interesting one, is I had a urologist friend of mine say, “Hey, what can you do for Cialis? I have a lot of patients who need Cialis, but, gosh, it’s hardly ever covered and it’s super expensive for them. I have a lot of patients who just can’t afford the treatment. Is there anything you can do?”
On that case, I said, “Oh, that’s interesting. Let me take a look,” and we were able to acquire the active ingredient in Cialis. It’s FDA-approved supplier, so there’s some vetting you have to do to make sure that the chemical that you’re purchasing is a good quality. We vetted out that supplier, and it was good. Then we were able to reformulate that product and provide that to patients for a fraction of the cost. Just for a frame of reference, $2 a dose versus $15 to $30 a dose.
Brandon: My urologist friend was thrilled to be able to offer something like that to his patients.
Jason: And in customized, specialized doses so that it’s really designed for them. I think it’s important that our listeners understand people can’t call you directly, right? I mean, there has to be a doctor prescription before they reach out to a pharmacist. You can’t just pick up the phone and call you. Is that a true statement?
Brandon: Yeah, exactly. We call it the triad. There’s a relationship between … We’re customizing medications for people, so as a pharmacist, I need to understand the needs of the patient and then I also have to work with the doctor to say, “Okay, is this customization appropriate for this patient?” There’s a three-way relationship that needs to occur because if I’m making a medicine for you, your doctor is the one who needs to say yeah, that seems appropriate, and needs the pharmacist to say, “Okay, this is how we can formulate that. This is what we can do and can’t do. Let’s see if we can come up with a solution that works.”
That’s not to say that all that discussion has to be that lengthy. Some things are fairly straightforward, but in the end, yes, you do need a prescription because these are powerful medications. They’re not over-the-counter-type products. We’re using prescription-only medications typically. You do need a doctor, but pharmacy is a great place to start because we can discuss it first, make sure that it’s an appropriate thing for you, and then include your doctor.
Jason: Are these specialty types of pharmacies, like the compounding pharmacy that you have, is that an area that’s growing, or is everything just kind of getting consolidated and we’re starting to see more of the specialty side of pharmacy go away? What’s happening there?
Brandon: It’s an interesting time in the business. On one hand, there’s a growing population saying, “Hey, I don’t want to be treated like a number. I want to be treated like an individual, and I want things to be customized for me.” There’s a larger demand for that as I think people are starting to realize that “You know what, I go to the doctor and I get treated, but I’m not feeling great. I’m feeling okay. I really want to take it to the next level. I want to feel great.” Medicine where people are paying for additional services to go to specific doctors that will give them that extra level of care, and those doctors typically work with pharmacies that want to deliver a higher level of care as well. In that case, there is a greater demand.
On the other side of that, our industry, the compounding pharmacy industry, is becoming more and more regulated, which is not a bad thing. What that means, there are less and less people are operating in that space because now they have to have more specialized equipment, more training, so there’s consolidation in that area. A lot of independent pharmacies, for instance, they might do a little compounding on the side with a handful of prescriptions now and then. Well, the operating costs are going to dramatically increase for that, so a lot of people are starting to get out of that business for that reason. The runaround answer to your question is our business is growing. We’re seeing more and more people, more doctors, saying, “Yes, I have a need for this,” for a variety of different reasons, why they need to have a partner in the business.
Jason: That’s good to hear, from your standpoint, that more and more people are seeking out these customized solutions rather than just kind of taking the off-the-shelf whatever’s recommended. I have to tell you, Brandon, I’m glad that these solutions exist because a friend of mine, Dean, he told me that his dad suffered from high blood pressure. The medications have gotten so much better, but when his dad was suffering from high blood pressure, he had to take 20 or 30 medications, and he was taking them all the time. He had shared with me that, had his dad lived in this day and age, he’d be able to take one medication a day and have that problem resolved.
At the same time, this is a big expense for people. Do you have any tips? Compounding, this more specialized pharmacy solution, is it covered by insurance or is this something people typically have to pay out of pocket for?
Brandon: It’s highly variable. If you want specialized care, you’re typically going to have to pay for it yourself. That’s really true for the healthcare industry in general, that when you seek out something that’s customized for you, you are going outside the box, because our healthcare system wants to keep us in a tight lane. Once you start going out of that lane, everyone knows that’s when you get the prior authorization; you get a lot of resistance from the insurance carriers. We see that on our end, as well. We do work with insurance companies, and we try to get things covered, but I think you have to be prepared to pay out of pocket for it.
Jason: Okay. Do you have any tips-
Brandon: That’s kind of-
Jason: Well, you shared a minute ago, though, how sometimes, by having a custom formulary and a custom dosage, that it can actually reduce the cost compared to an off-the-shelf brand. I guess people just have to kind of break the spreadsheet out and sit down and crunch the numbers to see if the quality and the experience is justified if the insurance isn’t going to cover that.
Brandon, we’re almost out of time. If people are interested in learning more about the work that you’re doing, how can they find you? What are some resources you have available?
Brandon: Yeah, I would say go to our website. It’s not all-encompassing of everything we do, but it’s a good start, and our phone number is there. That’s www.cascaderx.com. They can certainly call me at the pharmacy, and I’ll be more than happy to answer any questions they have and give them more information if they need it.
I did want to just touch on real quick, Jason, if we could, how people can reduce cost. I think that what it comes down to is people need to take control of their own healthcare. If they’re on a lot of medications, they should be very confident on why they’re on every single medication that a doctor has prescribed for them. They need to be asking those questions. I know I have seen time and time again where people have a long list of medications and they’re not really sure why they’re on some of them. That could be an opportunity to reduce cost because maybe you don’t need to be on it. Maybe it was started at a point in time and it’s just been carried over over time, so asking those questions to make sure that they understand why all these medications are prescribed for them and then weigh out those costs.
Jason: Boy, and just getting back to that initial quote that I shared from that Newsweek article, that people aged 65 and older, 40% of them are taking more than five medications. That’s a lot. I mean, to me, it seems like a lot.
Well, I appreciate you being a guest on Sound Retirement Radio. Any final thoughts before we finish up today?
Brandon: I just appreciate the opportunity. I just want to remind people that sometimes the healthcare system can be a lonely place, but there are pharmacists out there that care about your health, and I encourage you to seek those people out.
Jason: Awesome. With that, Brandon, we’re out of time, but thank you for being a guest.
Brandon: All right. Thank you, Jason. Take care.
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