Estrogen Patch Shortage: Who Profits From Your Prescriptions with Mark Cuban

In this episode of unPAUSED, Dr. Mary Claire Haver sits down with entrepreneur Mark Cuban, cofounder of the Mark Cuban Cost Plus Drug Company, to unpack the estrogen patch shortage and why so many women in perimenopause and menopause struggle to find and afford hormone therapy. Holding up her own patch, Dr. Haver asks the question her patients keep asking: why is this so hard to get? Mark explains why the shortage hit so hard — patches require specialized manufacturing that pills don't, demand surged after the black box warning was removed, and supply couldn't keep up — plus how Cost Plus Drugs has worked to buy every patch manufacturers can produce, and who gets served first when a generic drug runs short. Then they take apart how drug prices are really set: how pharmacy benefit managers (PBMs) decide what your insurance covers, how rebates drive list prices higher, and why a handful of conglomerates now own the insurer, the pharmacy, the PBM, and the physician practice all at once. They compare what a generic estradiol patch costs to make against what many women pay at retail, cover Dr. Haver's case for vaginal estrogen as one of the most affordable treatments in menopause care, why there's still no FDA-approved testosterone for women, how untreated symptoms push women out of the workforce, and the playbook for lowering your prescription costs — from 90-day supplies to comparing cash prices with your copay. Guest links: Mark Cuban Companies https://markcubancompanies.com/ Cost Plus Drug Company https://www.costplusdrugs.com/ Mark Cuban (Instagram) https://www.instagram.com/mcuban/ Mark Cuban (X) https://x.com/mcuban Books: "The New Perimenopause," by Dr. Mary Claire Haver https://thepauselife.com/pages/the-new-perimenopause-book "The New Menopause," by Dr. Mary Claire Haver https://www.amazon.com/dp/B0CKBZ4K1Z Articles: Menopausal Hormone Therapy Use Among Postmenopausal Women (JAMA) https://jamanetwork.com/journals/jama-health-forum/fullarticle/2823976

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Speaker 00

  It's a scam from top to bottom. Nobody looks at the economics of healthcare and says, "It's working well."

• 0:05Dr. Mary Claire Haver?

  So in the past two years, estrogen patch prescriptions have nearly tripled.

• 0:10Speaker 00

  Oh my God, at least 10x.

• 0:11Dr. Mary Claire Haver?

  It was hundreds of dollars.

• 0:13Speaker 00

  Yep.

• 0:13Dr. Mary Claire Haver?

  For a simple tube, and you were selling it for 1345 or something.

• 0:18Speaker 00

  Shows you our markup's only 15%.

• 0:20Dr. Mary Claire Haver?

  It's on short supply because money?

• 0:22Speaker 00

  Yes. If it's harder to get, you can price it more.

• 0:24Dr. Mary Claire Haver?

  This can't be legal.

• 0:25Speaker 00

  These middlemen, too big to care. Don't give a shit. My next dollar's not going to change my life, but my next dollar might save somebody's life.

• 0:32Dr. Mary Claire Haver?

  Less than 9% of NIH grant money went to women's health over the last decade. Why do you think that is?

• 0:37Speaker 00

  It's run by men. What was truly missing wasn't his trust. And I'll give you the craziest example, and that's how I found out about the Everlymas.

• 0:55Dr. Mary Claire Haver?

  The views and opinions expressed on UnPaused are those of the talent and guests alone, and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. Every time I post about what medication costs on social media, my comment section explodes. One woman pays $14 for her estrogen patch, the next one pays 90. Same drug, same dose, same country. And underneath almost all of it, the same question, asked 100 different ways. Why isn't the cost consistent? Two women can be handed the same prescription on the same day and pay wildly different prices, and neither of them can understand

• 1:40Dr. Mary Claire Haver?

  why. That is not an accident. It's how the system was built. And lately, a lot of you can't get your estrogen patch at all, at any price. Here's why it's so confusing. Between your doctor and your pharmacy sit a handful of middlemen between drug companies and your health insurance. They're the ones negotiating medicine prices and deciding which drugs your insurance will cover. My guest, Mark Cuban, is an entrepreneur and investor many of you may know as one of the Sharks from Shark Tank. He has built and run many different types of companies, including the Mark Cuban Cost Plus Drug Company. He co-founded the company in January of 2022 and spent four years inside the machinery of how drugs get

• 2:21Dr. Mary Claire Haver?

  priced, bought, and distributed in this country. With the Mark Cuban Cost Plus Drug Company, he did the thing this industry treats as radical. He published the price of each medication with transparent pricing and a limited markup. It's all right there on his website. And today, we're going to talk about how this has fundamentally changed the pricing of medications in the United States. I'm Dr. Mary Claire Haver, a board certified obstetrician and gynecologist, and certified menopause practitioner, and adjunct professor at the University of Texas Medical Branch. Welcome to UnPaused, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life.

• 3:06Dr. Mary Claire Haver?

  This podcast is sponsored by Midi Health, the first virtual clinic created for women by women for the treatment of menopause. Don't let anyone tell you menopause is something you have to suffer through alone. Midi can help. Visit joinmidi.com to learn more. This episode of UnPaused with me, Dr. Mary Claire Haver, is brought to you by Alloy Health. One of the things no one really prepares you for in your 40s and 50s is how much your skin can change. And it's not simply aging. When estrogen declines during perimenopause and menopause, skin can become thinner, drier, and lose elasticity. For years, I thought the answer was just finding a better cream or stronger retinol. But when hormones are

• 3:50Dr. Mary Claire Haver?

  part of the equation, skincare alone may not be enough. That's why I was so interested in the M4 skincare from Alloy, specifically designed for perimenopause and beyond. In a clinical study, 88% of women reported improved elasticity with M4 face cream. And their line goes beyond your face, with products for your neck, chest, hands, and knees. And because these are prescription strength products, Alloy connects you virtually with a menopause specified doctor who reviews your profile and determines what's right for you. Try M4 skincare from Alloy and see results in as little as eight weeks. Head to myalloy.com

• 4:30Dr. Mary Claire Haver?

  and use the code MCH20 to get 20% off your first order. Your menopause specialized doctor will help you build a skincare plan for your needs. Plus, you get $0 unlimited messaging with your doctor. Head to myalloy.com and use code MCH20 to get 20% off your first order. This code is valid on products only. These are compounded products not subject to FDA approval. Buy smart, drive for less, and trade for more. That's Toyota affordability, and it all starts with a great deal from your local Toyota dealer. Make a smart buy on an all-wheel

• 5:11Dr. Mary Claire Haver?

  drive Camry, Corolla Cross, or get a Corolla sedan, packed with the latest features, advanced tech, and head-turning style. Take a test drive in two of Toyota's most popular SUVs, the spacious, family-friendly Grand Highlander and adventure-ready RAV4. And with so many hybrid and plug-in hybrid models available across the lineup, plus efficient all-electrics like the BZ, BZ Woodland, and all-wheel drive CHR, you can drive your way and skip the pump. And long after you leave the lot, your Toyota keeps delivering with legendary resale value built on a reputation for quality and reliability. So when it's time for your next Toyota,

• 5:53Dr. Mary Claire Haver?

  you could trade in for more. From a great deal today to a great value tomorrow. A Toyota is right for you. Shop toyota.com for deals and details, or stop by your local Toyota dealer today. Toyota, let's go places.

• 6:13Dr. Mary Claire Haver?

  Mark Cuban, welcome to UnPaused.

• 6:15Speaker 00

  Thanks for having me.

• 6:16Dr. Mary Claire Haver?

  So I'm excited to have you on the show, mostly because you are a problem solver. And we have big problems in women's health and supply chain for our estrogen patch, which I

• 6:27Speaker 00

  Yes.

• 6:28Dr. Mary Claire Haver?

  brought mine in today. What are you doing differently with the Cost Plus Drugs versus me going to CVS or Walgreens?

• 6:37Speaker 00

  So it's costplusdrugs.com is our site where what makes us different initially is when you go, we show you our actual costs. When you put in a straddle, whatever it may be, and it comes up, we'll show you what our cost is, what our markup is. And that typically means we're going to sell it for less than everybody else. So that's our initial goal, to make sure it's affordable, because it doesn't matter if it's available if you can't afford it.

• 7:00Dr. Mary Claire Haver?

  Right.

• 7:00Speaker 00

  And so affordability is a key for us. Transparency is a key for us. But like everybody else, we're very aware that there's a shortage of a lot of HRT therapies. And so what we've done is rather than having one vendor, or sometimes we'll have two, but typically one vendor, we've gone out and sourced every source that we possibly can find. We've gone to the two major manufacturers and said, "Look, we will take every unit of inventory that you're able to give us." And it's crazy because we still can't keep up. We thought, okay, we have enough inventory. Are we going to be able to sell it all? And it just flipped completely around. And because of that, we, the two primary vendors that we use have completely different pricing. And so we made the conscious decision to

• 7:45Speaker 00

  say, even if we run out of inventory of the less expensive one, we're going to explain to people that, look, we want to make sure that there's inventory available. Our most expensive version is still less expensive than most retail pharmacies, so we'll make that available to you. And you'll have the choice of ordering, you know, the more expensive one, or waiting for the less expensive one. And because we wanted the availability, because both prices are better than typical. And that's worked for us so far. We still run out every now and then, but literally, we are trying to buy up everything we can. If we were able to manufacture it, we would. But because it's the patches, it's a lot more difficult. We're not geared to do that. And we've gone to some of the manufacturers,

• 8:29Speaker 00

  and we've literally asked if we can buy out their entire volumes.

• 8:32Dr. Mary Claire Haver?

  All right. Hormonal medication.

• 8:34Speaker 00

  Mm-hmm.

• 8:34Dr. Mary Claire Haver?

  So in the past two years, estrogen patch prescriptions have nearly tripled. So this whole menopause gold rush.

• 8:42Speaker 00

  And our volumes are far more than just

• 8:44Dr. Mary Claire Haver?

  What have you seen?

• 8:45Speaker 00

  Oh my God, at least 10x.

• 8:46Dr. Mary Claire Haver?

  Okay.

• 8:47Speaker 00

  Yeah. I mean, it went, I don't know when the trigger point was, when the rules changed, but all of a sudden, I was like, oh my God, we're out of stock.

• 8:53Dr. Mary Claire Haver?

  Black box warning was one watershed moment.

• 8:57Speaker 00

  Yeah.

• 8:57Dr. Mary Claire Haver?

  You know, that people were less scared to go get their prescription filled, and doctors are getting more comfortable.

• 9:02Speaker 00

  Prescribing it, yeah.

• 9:03Dr. Mary Claire Haver?

  Prescribing it.

• 9:05Dr. Mary Claire Haver?

  But I think it's forty-four percent of all estrogen scripts are now the patch specifically. Why do we have specifically a patch shortage versus oral estrogen shortage?

• 9:20Speaker 00

  Oral is really easy to make. The patches require specialty manufacturing. If I could just gen up a manufacturing plant that could do the patches. Yeah, because it would take five years. Now, I don't know, five years, but it's going to take a period of time.

• 9:32Dr. Mary Claire Haver?

  So, demand for the patches at least tripled in two years, but the supply didn't.

• 9:37Speaker 00

  Right.

• 9:38Dr. Mary Claire Haver?

  Didn't no one see this coming or?

• 9:39Speaker 00

  No.

• 9:41Dr. Mary Claire Haver?

  If they didn't care?

• 9:42Speaker 00

  Yeah, it's not that they didn't care, right? I don't think people really, you know, once a drug goes generic, just the, the way it's dealt with.

• 9:50Dr. Mary Claire Haver?

  Economics.

• 9:51Speaker 00

  Yeah, the economics are completely different. And the manufacturers who had been making it, you know, if the numbers are the same for years, you don't anticipate that all of a sudden it's going to change. Um, and then it did. And now they're responding and they're adding capacity.

• 10:06Dr. Mary Claire Haver?

  But they were forced to, I think.

• 10:08Speaker 00

  Um, well, they could have raised the prices, but they chose to add capacity and we, we really tried to push them to that.

• 10:13Dr. Mary Claire Haver?

  Um, there was a letter writing campaign to the FDA when women couldn't find their patches. So at first on the website, on the FDA website, I would say, there's no patch shortage. Everything's fine, everything's fine. But like millions of women are on social media screaming that they can't get their patches. And, um, then finally, just in the last week, the FDA wording changed on the website that they're working with six manufacturers to try to, you know, encourage them to. What happens when we run out of stuff? Like, how does the FDA get involved?

• 10:44Speaker 00

  I think they can approve manufacturing plants or expansions more quickly.

• 10:48Dr. Mary Claire Haver?

  Okay.

• 10:48Speaker 00

  And that's a help. But it really just is how quick is the acceleration of demand?

• 10:53Dr. Mary Claire Haver?

  Okay.

• 10:54Speaker 00

  Because it's one thing to say, we're going to make more. But if you make, you know, more for twice the demand, thinking you're capturing everything. But, you know, the number, the acceleration rate, because women are getting more comfortable and doctors are, is five times that.

• 11:07Dr. Mary Claire Haver?

  Yeah.

• 11:08Speaker 00

  You're going to be behind no matter what. And I think that's what we really ran into. It wasn't a lack of interest. It was more, oh, my God. At least that's what it was for us. It was, okay, Stradiol, okay, it's going up the sales charts, right? Now it's a big hit and what can we get? What do you mean that's all we can get? You know, and, and, okay, we'll add manufacturers and we'll keep on just adding manufacturers wherever we can. But it was just, the demand just outstripped the supply far more than they could add supply.

• 11:41Dr. Mary Claire Haver?

  The demand isn't going to go down for menopause hormone therapy. I only predict it getting, increasing.

• 11:48Speaker 00

  As population age.

• 11:50Dr. Mary Claire Haver?

  We had about forty percent of women who were eligible on hormone therapy. We're still less than ten percent right now.

• 11:56Speaker 00

  Yeah.

• 11:56Dr. Mary Claire Haver?

  So.

• 11:57Speaker 00

  But literally, we've tried to buy manufacturers. I've tried to buy manufacturers. I, I get it, right?

• 12:02Dr. Mary Claire Haver?

  Yeah.

• 12:02Speaker 00

  I see it in my family, trust me.

• 12:04Dr. Mary Claire Haver?

  My husband jokes, we should buy an estrogen patch factory. And it's a, we're kidding. We have no, you know, no real plans to do that.

• 12:11Speaker 00

  No, but I, I would if I could.

• 12:13Dr. Mary Claire Haver?

  Yeah.

• 12:13Speaker 00

  And to build one is just not a simple task.

• 12:16Dr. Mary Claire Haver?

  Yeah.

• 12:16Speaker 00

  Um, but we discussed it. And, you know, it wasn't something we could do, but we're looking to try to pre-buy as much of people's inventories as we can.

• 12:30Dr. Mary Claire Haver?

  Would it be easier to make the gels or the sprays?

• 12:33Speaker 00

  Yes.

• 12:34Dr. Mary Claire Haver?

  I think it would be, but they're still under patent? Like, why, why don't we have a generic for those yet?

• 12:38Speaker 00

  Because of the patent.

• 12:39Dr. Mary Claire Haver?

  Okay. Okay.

• 12:41Speaker 00

  I don't know the exact dates they come out of patent, but you can look those up really.

• 12:44Dr. Mary Claire Haver?

  Yeah. All right. So I want to walk our listeners through this. I'm on your website right now.

• 12:48Speaker 00

  Okay.

• 12:49Dr. Mary Claire Haver?

  And, uh, this is the Dottie Estradiol Twice Weekly. That's basically this.

• 12:53Speaker 00

  Uh huh.

• 12:53Dr. Mary Claire Haver?

  Generic, you know, this is the generic patch I have in my hand. And on video, we're going to fly in the actual images from the website. So your drug price with us, thirty-nine eighteen. That's just slightly higher than, I think that's the more expensive price, but it's not really that much more. I think it was like twenty-five before.

• 13:11Speaker 00

  Okay, yeah, then.

• 13:12Dr. Mary Claire Haver?

  So, and you have in stock, the point oh five and the point one, which are the two most commonly prescribed.

• 13:17Speaker 00

  Okay, good.

• 13:18Dr. Mary Claire Haver?

  One, so yay. Um, so you save a hundred and forty-six dollars and sixty-nine cents on your medication. And here's why. I love how you say this. So retail price at other pharmacies. Now, is this the retail price for the brand name?

• 13:33Speaker 00

  No.

• 13:33Dr. Mary Claire Haver?

  This is the generic.

• 13:34Speaker 00

  It's the generic, but there's a standardized price called NADAC, and that's what we use to determine. Because if you just walk into a pharmacy as a cash pay, um, in most retail pharmacies, that's what they'll charge you.

• 13:46Dr. Mary Claire Haver?

  Without like a GoodRx coupon or something?

• 13:48Speaker 00

  Even, even with sometimes.

• 13:49Dr. Mary Claire Haver?

  Okay. So manufacturing price, this is your price that you paid the manufacturer was twenty-nine dollars and seventy-two cents. Your fifteen percent markup, which is you markup across the board, was four dollars and forty-six cents. Pharmacy labor, so to go get that filled and, you know, five dollars. And then the standard shipping, five twenty-five. That's where we get our thirty-nine eighteen from. So this person, me, saved a hundred and forty-six dollars and sixty-nine cents had I not just gone to whatever pharmacy, walked in and paid the price without my insurance. Where is that a hundred and forty-six dollars going?

• 14:25Speaker 00

  It's not going to us. I mean, it's, that's when, when I mentioned earlier.

• 14:28Dr. Mary Claire Haver?

  When I throw my credit card down, where's that delta going? Who's, who's profiting?

• 14:33Speaker 00

  Okay, so it's like some pharmacies, so you're saying if I bought it for a hundred forty-six, where'd that money? Oh, into the pocket of the pharmacy.

• 14:41Dr. Mary Claire Haver?

  So take me back to twenty twenty-two when you started the company. Why? Why did you do this?

• 14:45Speaker 00

  Because nobody looks at the economics of healthcare and says, it's working well. And specifically for pharmacy, um, we've all heard the stories of somebody walking into a pharmacy, waiting in line, getting to the counter and realizing they don't have enough money or it costs more than they expect. And it's horrific, it's tragic. And that was the motivation, that there are drugs that nobody knew the price to. That to this day, unless you're going to cost plus drugs, or maybe, you know, GoodRx in some cases, you have no idea what a medication costs. And if you don't have insurance or if you're high deductible, that can create all, all kinds of economic problems for you and obviously health problems if you can't afford it.

• 15:27Speaker 00

  So we wanted to be completely transparent because what was truly missing was, is, wasn't his trust.

• 15:33Dr. Mary Claire Haver?

  Yeah.

• 15:34Speaker 00

  And I look at our primary product at costplusdrugs.com as being trust. And really, to me, it's a formula where trust equals transparency divided by self-interest. And we're the only pharmacy that, anywhere in, in the world where you can go to our site and it shows you what our actual cost is. That's about as transparent as you can get. And it shows you our markup's only fifteen percent, which is about as little self-interest as somebody can afford to do and still stay in business. And so because of that, we, we really focused on trust. We started, we launched January nineteenth of twenty twenty-two with a hundred and ten drugs. Now we're to thousands of them.

• 16:11Dr. Mary Claire Haver?

  So let's start with the basics for our listeners. Um, how does the current prescription drug price model work? Like, take what you're doing out of it. Take me back to twenty twenty-one.

• 16:24Speaker 00

  Right, typically.

• 16:24Dr. Mary Claire Haver?

  Yeah.

• 16:25Speaker 00

  So typically, people have insurance of one form or another. You may have Medicaid, you may have Medicare Advantage, you may have Medicare.

• 16:32Dr. Mary Claire Haver?

  Cross, whatever.

• 16:32Speaker 00

  You know, with Part D, then you may have it from your employer. And so typically, you have a, a plan that you're a part of and you know for the given medications that you take, what your cost out of pocket is going to be typically, not always. So if it's, you know, an inexpensive generic, it might be five or ten dollars, whatever. Um, if it's what they call a specialty generic, which is still just a pill, right? But they use it as an excuse to increase the price. You might have a co-insurance, which might cost you twenty-five fifty. Or if it's a cancer drug or, you know, Everolimus or something, might be more than a hundred dollars that you're paying out of pocket. And then either the taxpayers or your employer covers whatever the balance may be.

• 17:15Speaker 00

  That's typically how it works for most people then and today.

• 17:19Dr. Mary Claire Haver?

  Talk to me about tears, you know, as, as a healthcare consumer myself, besides being the person writing the prescriptions. I can remember like trying to help, patients would bring in paperwork and like sitting there with them, trying to figure out what their out of pocket would be. And like, I have fifteen minutes maybe with a patient, ten, you know, if it's not a, a well-woman exam. And you, you know, for me to sit there and help them go through the paperwork, to figure out the pricing, to help them, and then source the pharmacy where they're going to get the best deal was, we just don't have time.

• 17:54Speaker 00

  Yeah, I mean, it's not cost effective for anybody and it's, it's maddening because you want to spend more time with patients, but what, what good was your time if they can't get access to the?

• 18:05Dr. Mary Claire Haver?

  They can't get it, right.

• 18:06Speaker 00

  And so typically, that's all part of the plan that they, that, that they chose, right? Because, you know, there's open enrollment and your employer, whoever, and you go through that whole process. And, you know, to their credit, for the most part, there's apps where you can go and look and look up the medication and it'll tell you at the, at the patient's side, not on the doctor's side. Right? Real-time pharmacy benefits offered through and, you know, through Epic or whoever are, is hard to come by right now. And they're actually trying to improve that so that doctors can have more say in what's going on. But really, it comes down to people just thinking it's going to be done the way it's always been done. You know, I chose this plan, this is what I thought would happen.

• 18:50Speaker 00

  And unfortunately, sometimes they change the plans and the rules of the plans, you know, mid-stream. But that's typically the way it works.

• 18:56Dr. Mary Claire Haver?

  How do you, how did you spread the word about this? I found about it on social media. I saw a clip of you talking about something and then I got curious, went to the website. And I couldn't believe, and I think you had just gotten it on formulary, how cheap vaginal estrogen was.

• 19:12Speaker 00

  Yeah.

• 19:13Dr. Mary Claire Haver?

  And this was right when the GSM guideline, the General Urinary Centromenopause Guidelines were coming out and we were preaching from the rooftops, but patients couldn't afford it. It was hundreds of dollars.

• 19:24Speaker 00

  Yep.

• 19:24Dr. Mary Claire Haver?

  For a simple tube and you were selling it for thirteen forty-five or something. And I just couldn't believe it.

• 19:31Speaker 00

  Yeah, and that's because we're cost plus. Literally, we go out there and we find quality manufacturers. Um, and there's some things we manufacture ourselves, but they're more injectables, um, than tubes, um, creams or, or pills. But we go out there and find a quality manufacturer and then we negotiate. And whatever price we're able to get. We show it and market up just 15%, but the better news is as our volumes go up and our volumes have really skyrocketed lately, um, our, our cost goes down and, and that means the cost to the patient goes down as well. And in terms of spreading the word, right? Initially, it was just my big mouth, right? I have a platform and I get out there and I talk about it, social media, TV shows, whatever it may be. Um, but we don't spend

• 20:14Speaker 00

  any money on marketing. We made the conscious choice that we'd rather be able to sell the medications for less because you never know when that ledge, that, that threshold is, right? Where above this amount, they can't afford it. So rather than spending money on marketing and advertising, like a lot of the people in the company wanted to do, it's like, no, you don't understand. When somebody, you know, a, a cancer drug like, um, a Matnip, right? If somebody was paying $900 or for, looking at paying $900 and our price was $34, they're going to be happy, A. They're going to tell their doctor, right? And they're going to tell their friends. They're going to go on the Facebook groups or social media groups and everybody else who has a similar condition, they're going to say, hey, go

• 20:55Speaker 00

  check out cost plus drugs. So we went from launching in January 22 to now having millions of people we've helped.

• 21:02Dr. Mary Claire Haver?

  So I found a quote where you said, the prescription drug industry is the easiest industry you've ever disrupted. Why is that?

• 21:10Speaker 00

  Because it's really, really simple, right? What's the price? How much does it cost? You know, what's the price? Who pays for it? And if that person can't pay for it, who helps them?

• 21:21Dr. Mary Claire Haver?

  Okay.

• 21:22Speaker 00

  That's it. And we made it clear what the price is and we deal with cash. We deal with some insurance companies, um, through some PBMs, but mostly we just try to make it so it's as simple as possible. You just go to costplusdrugs.com, you sign up, you find the med, you put in your credit card, you tell your doctor where to send it and that's it.

• 21:41Dr. Mary Claire Haver?

  I've done it online and showed people how to do it.

• 21:43Speaker 00

  I appreciate that. Thank you.

• 21:44Dr. Mary Claire Haver?

  And so especially for the vaginal estrogen. So let's go back talking a little bit more about disparities in drug pricing. Um, I'm on social media a lot. I do a lot of education around menopause. And a few months ago, I, we were talking about how long did it take you to get your prescription for hormone therapy? And then what did, what was prescribed to you and what did you pay? And there were thousands of comments and women really shocked by the differences in what they were paying. So one woman was paying, you know, $25 for her box. Um, hers happened to be covered by, that was her copay.

• 22:19Speaker 00

  Right.

• 22:20Dr. Mary Claire Haver?

  Another woman, it was well over a hundred dollars. And so why is that?

• 22:24Speaker 00

  So the copay is obvious, right? She's paying her insurance premiums and, and even then you, your cobate might still be more expensive than a cash out of pocket price. But at the same time, if you walk into a retail pharmacy, they're trying to make as much money as possible. You know, especially if it's part of a big conglomerate, you know, a lot of these big, huge healthcare conglomerates are too big to care.

• 22:46Dr. Mary Claire Haver?

  Welcome back to another Midi Pause. I'm Dr. Mary Claire Haver, host of UnPaused. Let's talk about a menopause symptom that affects millions of women, but still doesn't get nearly enough attention. Genital urinary syndrome of menopause, also known as GSM. Now, that may sound like a complicated medical term, but GSM refers to a group of symptoms that can affect the vaginal and urinary systems during and after menopause. And the reality is, it's incredibly common. Symptoms can include vaginal dryness, irritation, burning, painful sex, urinary urgency, frequent urinary tract infections, or feeling like you constantly

• 23:31Dr. Mary Claire Haver?

  need to use the bathroom. And unlike hot flashes, which often improve over time, GSM symptoms can actually worsen if left untreated. One of the reasons you may not have heard about GSM is because not enough women, and sadly, some doctors, know about it. This lack of awareness can be due to women feeling embarrassed or just not reporting their symptoms. It is important to remember that vaginal dryness is not a little annoyance or something to dismiss. GSM can significantly affect physical comfort, intimate relationships, self-confidence,

• 24:10Dr. Mary Claire Haver?

  and overall quality of life. You do not have to suffer in silence. The reason GSM occurs is simple. Estrogen plays a critical role in maintaining the health of vaginal and urinary tissues. As estrogen declines during menopause, these tissues can become thinner, drier, and less elastic, leading to symptoms that affect both intimacy and everyday comfort. Unfortunately, many women assume these changes are just a normal part of aging that they must accept. That isn't true. Effective treatments are available and the first step is talking to

• 24:50Dr. Mary Claire Haver?

  a healthcare provider who understands menopause care. That's where Midi Health can help. Midi specializes in caring for women during midlife and menopause, including conditions like GSM that are often overlooked or undertreated. Their clinicians help women understand what's happening in their bodies, discuss treatment options, and develop personalized care plans. Depending on a woman's symptoms and medical history, they may include vaginal estrogen therapy, non-hormonal treatments, moisturizers, lubricants, or other evidence-based approaches designed to improve comfort and quality of life. Just as importantly, Midi provides

• 25:33Dr. Mary Claire Haver?

  a supportive environment where conversations about your symptoms are taken seriously, not dismissed or minimized. The good news is that relief is possible and women don't have to just tolerate these symptoms. Go to joinmidi.com, join M-I-D-I.com and connect with one of their clinicians today. This podcast is sponsored by Midi Health. You've heard me talk about my menopause toolkit. It consists of nutrition, exercise, hormone therapy, and other medications, stress reduction, sleep quality, and community connection. When you put those pieces together, they don't just ease symptoms, they support your long-term

• 26:16Dr. Mary Claire Haver?

  health. That's why I recommend Midi Health. They put your toolkit to work for you. Midi is a virtual clinic built by leaders in women's health with clinicians who understand the science of female aging and who take the time to understand you. Through one-on-one visits, they listen to your symptoms, your goals, and your concerns, then create a personalized care plan tailored specifically to you. And best of all, Midi is covered by most major insurance plans, making expert, high-quality care accessible and affordable for every woman. All of which is why Midi should be part of every woman's menopause toolkit. Book your

• 26:57Dr. Mary Claire Haver?

  virtual visit today at joinmidi.com. That's join M-I-D-I.com. Insurance coverage varies. Check with your plan for coverage. One of the biggest things I see, most women are not getting enough fiber, especially the right kinds of fiber, and they don't even realize it. That's why I like using Chronometer. It makes it incredibly easy to actually see what you're eating and understand your nutrition on a deeper level. I especially appreciate that it tracks both soluble and insoluble fiber because they each play different roles in overall wellness, digestion, and

• 27:36Dr. Mary Claire Haver?

  metabolic health. What sets Chronometer apart for me is the accuracy and detail. A lot of tracking apps only focus on calories, but Chronometer gives you meaningful micronutrient data I can actually use. The platform is easy to use, reliable, and helps you make more informed nutrition choices without guesswork. If you want better insight into your nutrition during midlife and beyond, download Chronometer for free today at chronometer.com and start learning what your body may really need.

• 28:12Dr. Mary Claire Haver?

  Let's talk about the conglomerate because I saw someone testifying in Congress and they had a, you know, a board popped up and it was, I didn't realize, walk me through a CVS, you know, and, and all the touchpoints they have in the healthcare system.

• 28:33Speaker 00

  The largest of them has more than 3,000 subsidiaries. They do more than $160 billion a year of intercompany transfers, meaning they work with their, those 3,000 subsidiaries in every way they can.

• 28:47Dr. Mary Claire Haver?

  What's in the subsidiaries?

• 28:49Speaker 00

  Um, it might be like for CVS, they own Aetna, the insurance company. You know, it might be the CVS pharmacies. It might be Caremark, which is their pharmacy benefit manager that works with your employer. It might be, I forget the name of their third-party administrator who works on the medical side and makes the drugs that are infused at a hospital or a clinic more expensive. And so they always default to paying their own subsidiaries more, particularly in a world of the ACA where there's this thing called medical loss ratio, where they have to spend at least 85% of their premiums on healthcare. Well, if you pay a subsidiary doctor, clinic, pharmacy more,

• 29:34Speaker 00

  you reach that threshold, the 85% threshold, much more quickly. And on the alternate side, you get to keep that margin in your subsidiary company. So it's left pocket, right pocket. And then at the pharmacy level, they charge to market whatever they can get away with. I mean, that's normal business. I mean, I'm not, I'm not mad at them, but you know, again, that's the difference with costplusdrugs.com because it's the same price for everybody, no matter what city, what state, what time of day, it doesn't matter, it's the same price.

• 30:05Dr. Mary Claire Haver?

  You mentioned the pharmacist, PBM, pharmacy benefit manager. What is that? And that was not a term I'd heard of until probably about a year ago. You start popping up on my feeds, talking about this.

• 30:17Speaker 00

  Raising hell.

• 30:18Dr. Mary Claire Haver?

  Explain to our listeners.

• 30:19Speaker 00

  If I can, right?

• 30:20Dr. Mary Claire Haver?

  Who these people are and who they work for.

• 30:22Speaker 00

  What's a pharmacy benefit manager? It's just what it implies. When your employer, if you get your insurance through your employment or if you get your insurance through the ACA or if you get Medicare and standard, traditional Medicare and you buy Part D supplemental insurance. The company that manages the pharmacy benefit is called a pharmacy benefit manager. And their job originally was to just process claims. You know, hey, you know, I need my Stradial, I'm going to, you know, I've got a prescription. When I show up at the drugstore, they have my prescription and somebody needs to process that to make sure everybody gets paid. Okay, that's what it was originally meant to do.

• 31:06Dr. Mary Claire Haver?

  Okay.

• 31:06Speaker 00

  Then, because in doing that, they were able to build up a formulary, you know, the list of drugs that's available to you in your insurance plan. Because they were able to build up tens of millions of lives each, they were put in a dominant position where they basically controlled how much volume any manufacturer would get. You know, so if you're on the formulary to the exclusion of your competition, you're in a great position. Well, the pharmacy benefit managers realized that they could charge the manufacturers for access to that formulary. And that's where you hear these discussions of rebates and everything going on. Now, they would tell you, they offer all these other clinical services and everything. I'm not a big fan of that.

• 31:50Speaker 00

  I'd rather get my clinical services from doctors rather than insurance conglomerates. But that's what they do. They process claims, they go out and negotiate pricing, and they make determinations of how much you're going to pay as a plan holder.

• 32:08Dr. Mary Claire Haver?

  Wow. Does the way that PBMs pay for generic, does that lead to shortages?

• 32:15Speaker 00

  It's not so much that how they pay for shortage, how they pay for generics. It's more how affiliated companies of theirs structure their purchasing. So CVS is a partner with a company called Red Oak. And they, they go out and together they purchase a lot of generics. Probably purchase about lower cost than we do at Cost Plus Drugs. But they retain a lot of that margin. And then because they have to set up a network of pharmacies who want access to all the lives they cover, the plan holders they cover, they tell the pharmacies, we're only going to reimburse you X amount of money for your generic prescriptions that you fill.

• 32:59Speaker 00

  And by definition, that's going to make them more expensive in certain circumstances.

• 33:06Dr. Mary Claire Haver?

  Women in menopause are, you know, experiencing, besides the shortage, and we'll go back to that in a second. But it's, you know, that's mostly our listeners are women in menopause. But I think it happens across the board. Where suddenly you're, everything's covered, you're doing great, you've got your meds, and then boom, it's a new year.

• 33:29Speaker 00

  Oh, yeah, yeah. And things change.

• 33:31Dr. Mary Claire Haver?

  And things change. You can't get it, you can't find it. I know my kid's ADHD meds was a

• 33:36Speaker 00

  Yeah, they went up.

• 33:37Dr. Mary Claire Haver?

  Calf scramble, you know, to try to find their medications. Because things are coming off and on formularies. Is that even legal?

• 33:45Speaker 00

  It's legal, unfortunately, because what happens is the insurance company that designs the plan and works with or is owned by the pharmacy benefit manager says, wow, things changed in HRT. We're getting a lot more patients that are expecting us to use the premium money that they paid us or that their employer paid us. Well, we're spending a lot more and it's so popular, we can charge them more. And again, they're too big to care. Their mission is to make money. When you, you know, they're public companies. And when you listen to them talking to Wall Street, you don't ever hear them say, well, our volumes are going up, so our price is going to go down to patients. You hear them say, business is great.

• 34:30Speaker 00

  We have the opportunity to raise prices, so we're going to do that because we, we're going to make more money. That's our fiduciary responsibility to their shareholders. But at the same time, the laws are changing so that the PBMs that they own are now being defined as fiduciaries to the employer that they're hired by. And the employer has a fiduciary responsibility to the health and wellness of their employees or their members, employees and their families. And so while these prices have gone up, there's an opportunity for employers, in particular self-insured employers, to respond to this and take their fiduciary responsibility and say no to the PBMs. And that's where I spend a big part of my time

• 35:14Speaker 00

  is trying to educate CEOs that it's your money. You did hire this conglomerate to manage all the claims and set the pricing, but at the end of the day, you want the women in your company or the wives or the daughters or the mothers to be as healthy as possible. I mean, that's why you have insurance in the first place. And so a lot of these rules are evolving now and changing right now, and the employers lag behind. Cost Plus Drugs pricing, where Canadians have to buy out of pocket. Most drugs, if it's made available in a hospital in Canada, you don't have to pay out of pocket. If it's not prescribed out of a hospital and the rules are changing, you do have to pay out of pocket. And so we're cheaper than Canadian drugs. In Germany, there's some of the same things, other countries.

• 35:57Speaker 00

  So Cost Plus Drugs, we have people from all around the world trying to buy from us. We can't sell to them. So on the generic side, which is 92% of the prescriptions, the US is cheaper. And, you know, I'm proud to say that Cost Plus has played a big role in that. On the brand side, we're a lot more expensive. On the specialty drugs, on the cell and gene therapy, we're a lot more expensive. Part of that, I would say, and I'm guessing 70 to 80% of that is middlemen increasing the price. If you took out the middlemen of that, the pricing structures would change and prices would go down.

• 36:32Dr. Mary Claire Haver?

  Why? Walk me through that.

• 36:33Speaker 00

  So if you want the inside baseball?

• 36:35Dr. Mary Claire Haver?

  Yeah.

• 36:35Speaker 00

  Okay, so when a brand medication.

• 36:38Dr. Mary Claire Haver?

  So say we get a female testosterone approved. Pretend.

• 36:42Speaker 00

  And it's a brand, right?

• 36:43Dr. Mary Claire Haver?

  It's going to be a brand to start.

• 36:44Speaker 00

  So let's just say it's a $600 testosterone. I don't know what a good price is, I don't know. I'm trying to use

• 36:50Dr. Mary Claire Haver?

  Just pretend it's $600.

• 36:52Speaker 00

  This is meant to use easy math.

• 36:53Dr. Mary Claire Haver?

  Yeah.

• 36:54Speaker 00

  And so it's $600 list price. The manufacturer probably has to pay rebates to the pharmacy benefit managers.

• 37:02Dr. Mary Claire Haver?

  Why?

• 37:03Speaker 00

  In order to be on their formulary. Otherwise, they're going to say

• 37:06Dr. Mary Claire Haver?

  For the privilege of like having it on the formulary.

• 37:08Speaker 00

  Right.

• 37:08Dr. Mary Claire Haver?

  So they can sell it.

• 37:09Speaker 00

  Literally, I had a conversation yesterday with a company that sells combojesic, which is a non-opioid pain medication. Yeah. And, you know, they told me that the PBMs that they talked to and all of them, basically, all the big ones, the big three, told them that unless they raised the price, and I forget what their exact price is, but it's under $200. But unless they raised it to $700, with most of that being rebate, not only would they not put them on the formulary, but they will block them otherwise. That's the way this industry works. And so if you have a testosterone that's supposed to be $600, again, pulling numbers out of the air. What ends up happening now is the manufacturer, there's three big wholesalers too.

• 37:53Speaker 00

  There's three big pharmacy benefit managers and three big distributors that, in case of the wholesalers, control 95% of the transactions in pharmacy. You would think they'd be big enough as multi-hundred-billion-dollar companies each to go and negotiate a great price. But what ends up happening for brand medications is they'll say, the brand will say to them, okay, we'll give you 5% off. Okay, that's kind of weird. But okay, so now it's $570 to the distributor.

• 38:25Speaker 00

  How can they sell to pharmacies? They can't sell for less than $570, right? Otherwise, they'd be losing money. So now, anybody who walks into a pharmacy for that testosterone is going to pay at least $570. And if you don't have insurance, or you have a high deductible, or you're in your deductible phase, you're probably paying $570 to $600. Now, here comes the crazy part. The manufacturer of that brand testosterone isn't making $570. They are only making $300 to use easy money, or easy numbers. Why is there a discrepancy between the $570 and the $300? Because they have to take that delta and pay it to the pharmacy benefit managers in order to get placed on those formularies and not exclude it.

• 39:10Dr. Mary Claire Haver?

  So that's the middleman you're talking about.

• 39:12Speaker 00

  That's the middleman, right? So if we were in a good system, what would end up happening is that brand manufacturer, the testosterone, would say, look, in the old system, I would make $300. I'm going to sell it to this distributor for $310. And the distributor was previously making $30, so they're going to sell it to the pharmacies for $340. They're going to make more. But now, the pharmacies are only paying $340 instead of $570, so they can sell to every patient for $230 less. And that is the delta you see between what happens here in the United States versus what happens in the rest of the world. And it's another reason why the prices of brand medications are so high.

• 39:57Speaker 00

  And the crazier part is, when I talk to the CEOs of these brand companies, and I say, why do you do this? You have all these patients who can't afford it, for the reasons we mentioned, can't adhere to it if they were able to afford it once, right?

• 40:11Dr. Mary Claire Haver?

  Right.

• 40:12Speaker 00

  Why are you not doing it this other way that is the more efficient and better for everybody way? And they say to me, they're like, Mark, we literally get threatened by the pharmacy benefit managers who are part of these big conglomerates, that if we don't play by these rules, they will remove not just this drug from that formulary, but all of our portfolio.

• 40:34Dr. Mary Claire Haver?

  All right, when a generic goes short, who gets served first? So whoever's hustling on the back end? Like if CVS, or Walgreens, or Mark Cuban, or...

• 40:45Speaker 00

  When a generic goes on short supply, it really depends who the manufacturer is and who they have relationships with.

• 40:51Dr. Mary Claire Haver?

  Okay.

• 40:51Speaker 00

  And...

• 40:52Dr. Mary Claire Haver?

  How did you, how were you, you have patches in supply?

• 40:55Speaker 00

  Because we're telling our manufacturers, more, more, more, more, more, we need as much as you can make, and we'll pay you a little bit more. And so that's why you saw, we had one really low price, and then we basically sold all they could make. So we went to a manufacturer who charged us more, but we, I just felt, I made a decision, I just felt though, you know, when we got the low-cost patches in, then people, they would be available to people. But I wanted to have a supply, even if it was more expensive.

• 41:25Dr. Mary Claire Haver?

  Okay.

• 41:26Speaker 00

  Yeah.

• 41:26Dr. Mary Claire Haver?

  Okay.

• 41:29Dr. Mary Claire Haver?

  So I want to talk to you about estrogen vaginal cream.

• 41:31Speaker 00

  Okay.

• 41:32Dr. Mary Claire Haver?

  This was the cheapest I'd ever seen it. I didn't, I had patients, we were prescribing it left and right in my clinic. And they were coming back, and it was hundreds of dollars. You know, and these poor women were having to choose between...

• 41:48Speaker 00

  That's tough, yeah, yeah.

• 41:49Dr. Mary Claire Haver?

  X and Y, but they had to have this medication, or they were having recurrent UTIs, dryness, all the pain, everything. And so, I don't know if you know Rachel Rubin, or, okay.

• 42:01Speaker 00

  Yeah, Dr. Rubin, like, was one of the very first people that reached out to us about this.

• 42:05Dr. Mary Claire Haver?

  Yeah, so...

• 42:05Speaker 00

  That's why I found out, yeah.

• 42:06Dr. Mary Claire Haver?

  She said, you have saved millions of women by being really the first person to have affordable vaginal estrogen.

• 42:14Speaker 00

  And I owe it to her, because she's the one who educated me on it.

• 42:16Dr. Mary Claire Haver?

  So she wanted me to make sure I told you this.

• 42:20Speaker 00

  I appreciate it.

• 42:20Dr. Mary Claire Haver?

  So your drug price, so the drug price is $13.21. If every single post-menopausal patient, like over 65, used vaginal estrogen regularly, we could save Medicare billions in urosepsis and hospitalizations and recurrent UTIs. It is the number one preventative treatment for recurrent UTIs, which then can lead to sepsis and death. And so, so much of this could be prevented with this, and you were the first person to make this affordable...

• 42:54Speaker 00

  Well, I appreciate that.

• 42:55Dr. Mary Claire Haver?

  For patients.

• 42:55Speaker 00

  What I would recommend, there is a woman by the name of Dr. Allison Galvani, who's out of Yale. She does a lot of research work for Medicare for All. Like, when you see the Medicare for All savings reports, she did those. And I can connect you. You should have her do some research on the impact on the cost to Medicare versus the availability here.

• 43:19Dr. Mary Claire Haver?

  Yeah.

• 43:21Speaker 00

  And/or, and some people, you know, I don't want to get into politics, but, you know, on TrumpRx, I don't know if it's listed there, but that's one more source as a portal where people can find out that it's available to them. And so those are the two steps I would take. Because to your point, you just want more people to know it's available.

• 43:40Dr. Mary Claire Haver?

  Know it's available and be able to afford it.

• 43:42Speaker 00

  Yeah, and that's our mission.

• 43:43Dr. Mary Claire Haver?

  The only drug you're gonna, that's gonna work is the one you're using.

• 43:46Speaker 00

  And those, and that's not something we typically run into shortages on either.

• 43:50Dr. Mary Claire Haver?

  Okay.

• 43:50Speaker 00

  At least not so far. So it's literally going generic in Canada next year.

• 43:55Dr. Mary Claire Haver?

  Wow.

• 43:55Speaker 00

  Yeah.

• 43:56Dr. Mary Claire Haver?

  I think people will be going across the border.

• 43:58Speaker 00

  Yeah, they'll be taking the trip, right? But that's always the thing, right? If you're responsible enough to buy multiple months and store it properly, always buy as much as you can afford.

• 44:10Dr. Mary Claire Haver?

  There's something I love about the change of seasons. Rediscovering the pieces in my wardrobe that I know I'll reach for again and again. As we head into fall, I'm especially looking forward to pulling out my Quince Mongolian Cashmere sweaters. They're the kind of wardrobe staple that makes getting dressed feel effortless, comfortable, timeless, and incredibly versatile. That's one of the things I appreciate most about Quince. They focus on the everyday essentials that we actually wear, using elevated materials like Mongolian cashmere, organic cotton, and quality denim, while keeping the prices remarkably accessible. Their Mongolian cashmere sweaters start at just $50.

• 44:54Dr. Mary Claire Haver?

  Quince works directly with ethical manufacturers and cuts out the traditional middleman, which allows them to pass those savings on to you. Their pieces can be 50 to 80% less than comparable luxury brands. Find the fall pieces you'll reach for most at Quince. Download the Quince app for app-exclusive offers, or go to quince.com. Get free shipping on your order and 365-day returns. Now available in Canada and the UK, too. And when Quince asks where you heard about them, let them know it was unpause. It's the best way to support the show. As a physician, I constantly tell women navigating perimenopause and menopause

• 45:38Dr. Mary Claire Haver?

  that the traditional scale simply doesn't tell the whole story. Midlife hormonal shifts change how our bodies distribute weight, making total body composition a much more clinically meaningful metric than just a single number after age 40. That's why I recommend looking into the Withings BodyScan 2. It goes far beyond the basic scale by providing medical-grade, six-zone, segmental body composition insights, including muscle mass, visceral fat, bone mass, and vascular age. Tracking bone mass is especially vital as bone density loss accelerates during menopause, raising the risk for osteoporosis and giving you concrete data to discuss with your doctor.

• 46:22Dr. Mary Claire Haver?

  What truly sets the BodyScan 2 apart from standard options is its advanced cardiovascular screening, including a six-lead ECG with AFib detection to give you a complete preventative health picture right at home. It brings the same grounded, data-driven clarity to your health that I strive to bring to my practice every day. Head to withings.com to learn more, and use promo code UNPAUSED for 10% off. Consult your physician before starting any new health or fitness regimen. This episode is brought to you by Whoop, the wearable health and fitness coach that gives you personalized insights into your sleep, recovery, strain, and overall health, so you can empower your day.

• 47:05Dr. Mary Claire Haver?

  Whoop keeps things intentional by staying screen-free. It won't buzz to you to hit a step count, but rather works alongside a companion app to deliver clear, actionable physiological data. With membership tiers like Whoop 1 for everyday performance, Whoop Peak for long-term wellness, and Whoop Life for medical-grade insights, there's a fit for every goal. Lately, I've been spending a lot of time in Colorado, hiking and getting outside whenever I can. And with how much I travel for work and how busy my schedule can get, I'm always looking for ways to better understand how my body is responding to everything I'm asking of it. That's where I think something like Whoop 5.0 wearable could be really helpful. It could give me insights into my sleep, recovery, and strain,

• 47:50Dr. Mary Claire Haver?

  whether I'm hiking in Colorado, traveling for work, or simply trying to keep up with a busy week. It can help me recognize when I have the energy to push myself and when my body might be telling me it's time to slow down and prioritize recovery. To learn more, head to whoop.com.

• 48:11Dr. Mary Claire Haver?

  All right, you had mentioned something earlier that caught my attention. You talked about specialty drugs. We have generic and then we have. What is a specialty drug? And why does it seem like so many women's health drugs are specialty drugs?

• 48:22Speaker 00

  A specialty drug is whatever a PBM decides is a specialty drug.

• 48:28Speaker 00

  That's it. Like literally, when you look at a PBM contract for an employer or city, state, whatever, it says, we are not going to pass through rebates. We're not going to pay this or this or this for specialty drugs. And then separate 500 pages away, it says, we get to decide what's a specialty drug. I mean, like, omatinib is considered a specialty drug. If we're ever.

• 48:49Dr. Mary Claire Haver?

  I don't know what those are.

• 48:50Speaker 00

  Omatinib is for CML.

• 48:52Dr. Mary Claire Haver?

  Okay.

• 48:52Speaker 00

  For cancer.

• 48:53Dr. Mary Claire Haver?

  Chronic myologic leukemia for our listeners.

• 48:55Speaker 00

  And then, um, everolimus is for, um, heart rejection medication. Right? And literally, they're pills.

• 49:04Dr. Mary Claire Haver?

  And pills are easy to make.

• 49:06Speaker 00

  They're not hard to make, you know? And so, you know, that's what happens. Now, there's also more complicated ones that are injectables, like a GLP-1 would be, but hospital-administered drugs, right? They're not necessarily hard. And what you're seeing is you're seeing infusion centers and places that will charge less than a hospital for that medication. But it's really structured just to maximize earnings for providers and the middlemen, and to a certain extent, the manufacturers as well.

• 49:37Dr. Mary Claire Haver?

  So we're going to do a deeper dive into women's health. But before that, how would you fix all this? Like, you know, you're.

• 49:47Speaker 00

  I'm working on it every day, right? Yeah, I'm working on it every day.

• 49:50Dr. Mary Claire Haver?

  But like, if you could blow it all up and start over.

• 49:53Speaker 00

  This is the shark tank hat I put on, right? Because that's what I do. That's what I've done my whole career. This part of this business, this part of this business, this part of this business. Here's where I can compete with it. Here's where I can invest in it. Here's where I won't touch it. And that's what's happened here. And by not working inside the system, all those middlemen we talked about, we don't work with them. Because I don't want to be, there's no way we're ever going to be aligned, because they're not ever putting patients first. And, you know, people are like, well, you're a rich guy. You're just trying to make money. No. Like, my next dollar is not going to change my life, but my next dollar might save somebody's life. And that's the way we look at it at Cost Plus.

• 50:33Dr. Mary Claire Haver?

  So you've talked about women's health. We found some good, good soundbites. Right now, less than 9% of NIH grant money, and I know a lot about this, went to women's health over the last decade, specifically to women's health. And you've talked about it as being overlooked and underfunded. Why do you think that is?

• 50:54Speaker 00

  It's run by men.

• 50:57Dr. Mary Claire Haver?

  I hate to keep saying patriarchy, but I, I, you know, grew up in the system. I was trained in the system. I, and it took me, what, 20 years of practice to really like be able to take a deep breath and realize how much bias was built into the system.

• 51:14Speaker 00

  Look, as an entrepreneur, I always look to see where things are screwed up, because that's what creates opportunity. But most people don't think that way. Most people just go to work, do their job, do the best they can, want to go home, play with their families, the dog, the cat, and that's it. You know, I used to tell, you know, as my early, in my early companies, people say, well, let's listen to our customers. And that's what you're supposed to do, listen. I was like, no. Our customers, it's not their job to figure out where we're supposed to go next or what coming, what's coming next. It's just like the straddle, right? We saw Dr. Rubin, you know, turn me on to it. I realized it was an issue. Let's get ahead of it. Most people, that's not their job. They don't think about that. They just want to, you know, spend time at home and live their lives and live as best

• 51:59Speaker 00

  of life as they possibly can.

• 52:01Dr. Mary Claire Haver?

  Right.

• 52:02Speaker 00

  And when it comes to NIH, NIH grants, the people making the decisions even are like that.

• 52:07Dr. Mary Claire Haver?

  Yeah.

• 52:07Speaker 00

  Right? They just want to go home, right? They're going to take the path of least resistance every single time. And that's what happens in medicine in general. That's what happens in government. That's what happens in most companies. As I said, I think, you know, the CEOs could change all of healthcare in this country, literally change it for the better, so we have a better system than overseas. But that's not their core competency.

• 52:32Dr. Mary Claire Haver?

  So there, I had mentioned it earlier, this menopause gold rush, right? And menopause seems to have become, and that's what the media is calling it. I'm just happy the conversation is happening.

• 52:43Speaker 00

  Right.

• 52:45Dr. Mary Claire Haver?

  But it, this does seem to be a category that investors are getting more curious about and maybe fighting over a little bit. What do you think is happening here? What do you see in your?

• 52:55Speaker 00

  People see opportunity, you know? Not so much in the manufacturing side of it, but, you know, using AI, trying to come up with new drugs, drug discovery, repurposing other drugs to see if they're applicable. And the FDA is open. I give them credit, you know? There's people there, you know, Chris Klaup at HHS really want to do the right thing. And I think some of those things have been accelerated to the benefit of women.

• 53:20Dr. Mary Claire Haver?

  So just yesterday, the day that we're filming this yesterday, there was an FDA open hearing on testosterone for women. And, I mean, it went on eight hours of testimony from clinicians, from patients, you know, who have been helped, but, you know, listeners may not realize, we don't have an FDA-approved testosterone product for women in this country.

• 53:43Speaker 00

  I had no idea.

• 53:45Dr. Mary Claire Haver?

  Yeah. And so when we do prescribe it, I borrow the men's version or some.

• 53:49Speaker 00

  Right, it's off-label, right?

• 53:50Dr. Mary Claire Haver?

  Some people compound it. We use it off-label, but, you know, men need 10 times the amount in general that women do. And so having to titrate the pump can be a little sketchy and having to check levels. I am excited by this meeting, because everyone at HHS and FDA who were there speaking, you kind of got the feel that this was positive and they were, you know, but it, it's more complicated than that. FDA doesn't make drugs. FDA approves drugs. What would it take to get a female, probably knowing what you know about manufacturing?

• 54:27Speaker 00

  I mean, somebody's got to make the time and investment to go get all the approvals. You know, we've looked into it and it's, the FDA typically isn't the inhibitor, unless you're trying to make hundreds or thousands of drugs like we do. Then they can get in the way, but not operationally, more on a cost perspective. But, um, I think as it comes to light, just what the gold rush is, people find ways. Like, I've invested in two companies that are trying to figure out ways to get through endometriosis, you know? I mean, I've had somebody in my family that we've had to deal with it, other people close to us. And, you know, it's crazy.

• 55:10Speaker 00

  It's like almost every woman is going to go through it at some point, and there's no way.

• 55:14Dr. Mary Claire Haver?

  Well, it takes seven to 10 years to get the diagnosis.

• 55:17Speaker 00

  Yeah.

• 55:17Dr. Mary Claire Haver?

  Like, she goes through years of, of, oh, you're just crampy, that you're this, you're that. And there are some biologics being explored on.

• 55:26Speaker 00

  Yeah. And I've invested, who knows, will they turn up? I'm like, I don't know. I don't understand this. Here's some money if it helps.

• 55:33Dr. Mary Claire Haver?

  Yeah.

• 55:33Speaker 00

  See what happens.

• 55:34Dr. Mary Claire Haver?

  Yeah. I do, one of the things I think is powerful about social media is all of this awareness and knowledge around.

• 55:41Speaker 00

  Oh, sure.

• 55:41Dr. Mary Claire Haver?

  Female health and.

• 55:43Speaker 00

  For sure.

• 55:43Dr. Mary Claire Haver?

  Where the discrepancies are when we look at female versus male health. When you got into this business and really started digging through, because you've been doing this for four years, and I think, did I read 2018 is when?

• 55:54Speaker 00

  When I really started getting into.

• 55:55Dr. Mary Claire Haver?

  You got the pitch? And so it took four year, or math, four years to like build the company and then you've been, so eight years in the game.

• 56:03Speaker 00

  Yep.

• 56:05Dr. Mary Claire Haver?

  When you look at male versus female, what do you see?

• 56:08Speaker 00

  See, I never looked at it that way. You know, for us at Cost Plus, it was every FDA drug that was approved that we were allowed to sell. We weren't getting access to brands like we wished, and we didn't do controlled substances just because it's too risky.

• 56:21Dr. Mary Claire Haver?

  It's too, yeah, it's a lot.

• 56:23Speaker 00

  So it was more about how can we offer every FDA-approved medication that, and do it at the least expensive price? We didn't really try to discern if it was for men or women, but just as out of common sense, watching our volumes go, talking to Dr. Rubin, talking to you, you see the obvious, right? We're not dumb. And so, you know, and then that educates us on the whys, you know? And it's good, you know, that women are getting more attention. I went and spoke at a women's health event at the New York Stock Exchange, learned a lot more there. You know, it's just, if I think of it, put aside gender or biology. If I think of it just as a taxpayer, healthy people are a lot less expensive.

• 57:08Dr. Mary Claire Haver?

  Yes.

• 57:09Speaker 00

  You know, and wellness is an issue, but wellness can't cure everything. You know, there are just certain things, men.

• 57:17Dr. Mary Claire Haver?

  We're going to get sick.

• 57:18Speaker 00

  No one dies healthy, you know? And so there, the more we can invest, knowing that it's an investment, not a cost, and the smarter we can be doing it. And probably the harder part is the smart side of it, because there's politics involved. But even then, the risk reward is off, off the charts.

• 57:38Dr. Mary Claire Haver?

  So when women are healthy, they tend to reinvest in their communities. They tend to, their families are healthier. You know, they're making 80% of the healthcare decisions in the US.

• 57:49Speaker 00

  Let's just look at the birth rate.

• 57:51Dr. Mary Claire Haver?

  Yeah.

• 57:52Speaker 00

  If we don't have enough babies and you know, now menopause is a woman a little bit different, but still just healthy women endometriosis, you know, if, if we can't deal with that.

• 58:02Dr. Mary Claire Haver?

  It's taking 10 years to get her diagnosed. She's losing.

• 58:05Speaker 00

  And if we can't deal with it, you're losing those years of fertility. And again, not to be political, but just having two daughters.

• 58:10Dr. Mary Claire Haver?

  Yeah.

• 58:12Speaker 00

  You know, and nieces and you know, and so there's, there's value in that. Again, if you put aside the empathy and the human value of it and just looked at it as a business, and I'm not saying do that, right? They're both important, but just as a business decision, it's good economics. It's better tax, saves taxpayers money, healthier, you know, less.

• 58:36Dr. Mary Claire Haver?

  Less burden on the medical system.

• 58:37Speaker 00

  Less burden on everybody, less emotional burden, less burden on families, less burden on schools, less burden on companies, because if that 10-year point hits and they realize it's endometriosis and you're 30 and working at your job, you're going to HR first.

• 58:52Dr. Mary Claire Haver?

  Yeah.

• 58:52Speaker 00

  Right? Because then you're wanting to find out, you know, what doctors are, am I eligible to go to? Are they any good? What are the circumstances? Can I afford my coinsurance? Or my co-pay? What's the availability? Can I go tomorrow? I'm in pain. Or can I go six months from now? All those things impact everything.

• 59:08Dr. Mary Claire Haver?

  So in menopause, in the UK, they measured it, they're measuring it better than here. It 20%, one in five women will leave their job due to untreated menopause. And that's just hot flashes. That's what we know how to measure. We're not talking about the brain fog and the, you know, in the US, it's at least 10%. So this is, you're at your peak, you know, you're supposed to be leaning in, you're supposed to be running the company and all of a sudden you're taking a backseat. Now, some people leave jobs for good reasons, but you know, we're losing workforce, well-trained employees to this stuff we're not even treating.

• 59:42Speaker 00

  Yep.

• 59:42Dr. Mary Claire Haver?

  So.

• 59:43Speaker 00

  And in an AI world, those people are more valuable. You know, you want people, AI doesn't understand the consequences of its actions. People with experience and domain knowledge do.

• 59:53Dr. Mary Claire Haver?

  So my parents' generation, so my, my dad's passed away, my mom's in 90s. So she's kind of, we're at the end now. But they grew up wanting insurance to cover everything. And you know, they had insurance, they'd worked for it, they were proud of it. But if insurance wouldn't cover something, then they didn't get it. They would go without because it's not worth having, this should be covered. I don't think, my children, when I talk to them about it, they look at insurance for catastrophe. The number one cause of bankruptcy in the US is medical. And so my kids look at it as, well, this is something that's going to keep us out of bankruptcy if the unthinkable happens. You know, we end up

• 1:00:38Dr. Mary Claire Haver?

  with these huge bills. And you know, I think I'm somewhere in the middle. And do you, you know, but what's happening is the older generation, me plus, so I'm 58, they won't go get their medication. What would you say to them?

• 1:00:54Speaker 00

  Um, so let's divide medical, uh, medical and medication pharmacy.

• 1:01:00Dr. Mary Claire Haver?

  Yeah. So just their prescriptions. They're like, well, insurance is going to cover it.

• 1:01:04Speaker 00

  Pharmacy is a bigger problem. Because with medical, if you go to a nonprofit hospital and you don't have the financial resources, and I'm not just talking the emergency room, right? I'm just saying, if you don't have the resources and there's something, endometriosis, whatever it may be, right? They have to offer you some type of payment plan.

• 1:01:25Dr. Mary Claire Haver?

  Most people don't know this.

• 1:01:26Speaker 00

  Exactly why I mentioned it, right? They have to do it, but it has to be nonprofit hospital, not, uh, federally qualified health centers. They have to see you if you don't have a nickel cheer name. And so they may not be able to solve or, um, support you or care for you and everything that you're facing, but they can refer you to somebody who can. Don't ever not get care. And you're better off not going to the emergency room. Because if you go to the emergency room, they just look at it, well, we have to treat.

• 1:01:55Dr. Mary Claire Haver?

  Are you going to die or not?

• 1:01:56Speaker 00

  Right. And, yeah, right. And then we're to stabilize you and kick you to the curb. Right? That's an overstatement, but still. But if you go to a nonprofit hospital and you say, hey, here's what I'm facing, I can't afford it. I'll work on your schedule, right? Now, if it's an emergency, go to the emergency room.

• 1:02:10Dr. Mary Claire Haver?

  Right.

• 1:02:11Speaker 00

  But, um, you have a chance where they're supposed to work out a payment plan and work with you. They're supposed to offer charity care as, in order to get the tax breaks that they get as a non-profitable. That's where that tax breaks.

• 1:02:26Dr. Mary Claire Haver?

  How would a regular person figure this out? Like, okay, I have this medical problem.

• 1:02:30Speaker 00

  Claude.

• 1:02:31Dr. Mary Claire Haver?

  Aha.

• 1:02:32Speaker 00

  Chat GPT. Go to whatever your favorite AI is and say, um, you know, I've got this, I really want to see a doctor. I don't have insurance. I don't have coverage. What's the best approach for me to take? Um, will any of them work with me on a plan and see me? And I don't want to go to the emergency room.

• 1:02:51Dr. Mary Claire Haver?

  Okay.

• 1:02:52Speaker 00

  You can, if you have it on there, you can type it in there and see what it comes up with.

• 1:02:56Dr. Mary Claire Haver?

  Um, so let's get practical for our audience as we're wrapping up. Um, give them some advice, like on prescription drugs. So.

• 1:03:06Speaker 00

  So first, know your health plan. You know, know what drugs are covered.

• 1:03:12Dr. Mary Claire Haver?

  And can AI be helpful here?

• 1:03:14Speaker 00

  AI is less helpful in this because each plan's different and it may not have access. But I would definitely recommend if, whatever you have online that's available to you, put that link into your AI and have it just say, hey, I want you to understand all of this so I can ask you questions about it. Because the AI will be able to look at all the details in the fine print where you're going to, your eyes are going to glaze over and you might not see it. And then you can then ask AI questions. Like, is my estradiol covered? Is, whatever it may be, right? Um, what's the price? What tier is it in? Where can I buy it? It'll answer those questions. I mean, I use it. Does cost plus drugs carry it? All those things I use it for. So that's first and foremost in, in understanding. Um,

• 1:03:59Speaker 00

  but from there, you know, you've just got to understand all your options. And I know it sounds.

• 1:04:10Dr. Mary Claire Haver?

  It seems like a lot of work.

• 1:04:11Speaker 00

  It's not intuitive, right, to do this, but please use AI. But just don't use one AI.

• 1:04:17Dr. Mary Claire Haver?

  Okay.

• 1:04:18Speaker 00

  Use the interface, the free interface, right, for Claude and, um, Chat GPT and Gemini, and ask the same question to each. It's like if you have three friends just sitting there. They're not, they're all going to be a little bit right. None of them are going to be a hundred percent right. And so you have to take, or if you do a search, right, you're going to get three different links. One might be misinformation and you may not know it, right? But having them, you know, ask the same question and challenge your AI. Are you sure that's right? Don't just presume that it's automatically accurate. So, you know, okay, Chat GPT, I'm not quite sure if this is right. Doesn't matter whether you know or not. Will you check this for me? I want you to be absolutely positive. Okay,

• 1:05:01Speaker 00

  Gemini, this is what, you know, my friend said. And they said A, B, and C. Will you check this for me and tell me if they're accurate, meaning the output from Chat GPT? And then go to Claude and do the same thing. They're not all going to be wrong. And they will, all might have a different perspective. They all might give you different.

• 1:05:18Dr. Mary Claire Haver?

  They can fact check each other.

• 1:05:19Speaker 00

  Yeah, they can fact check each other. And you can use your common sense to make a determination. But they will be able to go and look at the websites of hospitals and say, hey, I can't afford this. I need this. This is what my doctor said. I can't afford.

• 1:05:33Dr. Mary Claire Haver?

  This CAT scan, this medication, this surgery.

• 1:05:36Speaker 00

  And I looked at my insurance and the CAT scan was going to be $1,800 out of pocket. Is there somewhere else? And oh, by the way, I live in the state of Texas. Can I apply this to my deductible? In Texas, you can, but not for pharmaceuticals. And Indiana, you can for pretty much everything. Tennessee, I think you can too. So using AI as a tool. It's not the end all be all. It's not the final answer on anything. But we know how we are as humans. Our eyes glaze over when we look at these plans. I don't care who you are. You know, I consider myself marginally smart and I just like.

• 1:06:11Dr. Mary Claire Haver?

  Any last advice to our listeners?

• 1:06:14Speaker 00

  Yeah, go to costplusdrugs.com.

• 1:06:19Dr. Mary Claire Haver?

  You can find full episodes of UnPaused on YouTube at Dr. Mary Claire. You can also find me on Instagram at Dr. Mary Claire and get honest and accurate information on health, fitness, and navigating midlife at thepauselife.com. UnPaused is presented by Odyssey in conjunction with Good Roommate Media and Long Wave Digital.

• 1:06:44Dr. Mary Claire Haver?

  This episode was sponsored by Midi Health, the first virtual clinic created for women by women for the treatment of menopause. Don't let anyone tell you menopause is something you have to suffer through alone. Midi can help. Visit joinmidi.com to learn more.