Hannah Mamuszka and Lena Chaihorsky take on the drug pricing debate from the patient’s side, where the question is not what a drug costs but whether it works for the person taking it. Chaihorsky frames it with a metaphor that runs through the episode: we argue endlessly over the price of milk while ignoring that the whole family is lactose intolerant. Mamuszka tells a story that shaped her career. As a young scientist at a small pharma company, she spent years developing a biomarker for a drug at the FDA’s suggestion, only for the agency to drop the requirement and for her CEO, at the launch party, to explain that they would treat every patient the label allowed because there were investors to repay. The drug worked in roughly 38% of patients and caused serious side effects in about 40%, and the biomarker could tell those groups apart. They trace how that logic became structural, including the FDA’s early-2000s move toward companion diagnostics for all targeted therapies, which collapsed under industry pushback. Chaihorsky then walks through the economics that decide which drugs patients can get when no biomarker stands in the way: PBM formularies rank-ordered by rebate rather than by mechanism of action, step therapy, and a pharmacy-versus-medical budget split that leaves no one owning the cost of being wrong. Their closing asks are simple. Patients should ask how their doctor knows a drug will work for them. Employers heading into benefits season should ask who their PBM is and what its contract rewards.
July 9, 2026
Episode 5: The Price of Drugs Is Only Half the Problem
