Welcome. Hey, this is Eric here with dead
cow. We've got Tom and Katie.
We have our friend, Rolf Winkler here from The Wall Street
Journal. Hey guys, he's been writing
about how everybody is going online to get ADHD medication.
I was excited. Read your Your ear off because
one you really like to dig into these kind of shady med tech
companies. I remember a couple years back,
you busted, the chicago-based med tech company for basically
lying about their finances. I think right a Miry clay they
were yeah there was trials. Next year they were basically
misleading their clients in a pretty big way.
And what's that company called wrote it there and it was called
out? Come out come else doesn't exist
anymore. That outcome Health.
Yeah, it didn't work yet but yeah, that that they were
misleading, a bunch of people and then a month later,
investors sued him for fraud and three diamonds, 33 guilty pleas
and then 3 3, felony guilty pleas and then three of diamonds
and that's next year that trou, right?
And so and so now you moved over into easy prescription online,
tech companies and look like like I do before I read most
Wall Street Journal articles, I snorted a line of Adderall
before reading this thing, and I heard that Politics.
Huh, right? Exactly turns out.
It's really easy to get this shit now.
So I wasn't I shouldn't have tried as hard to like, dip.
All of my PC PS2, give it to me, but why don't you, why don't you
break down the world of online prescription?
And how we people who legitimately have ADHD are being
lumped in with the, the infect Amina.
Tom, do you take it easy? Right?
I used to, when I was a kid when I was younger.
Yeah. It's the ideas.
I was on Ritalin, I would say, by the way, up top of
discussing, his whole story we're not writing about how
Adderall Bad for metal, a DD HD. We mentioned, I make sure to
mention every story that psychiatrist will tell you for
somebody's properly diagnosed with ADHD.
These meds are good. These meds have great outcomes
for people helps to study. I don't IE.
I think they are great great, if you need to stay at a party all
night long. Yeah, wild.
See that's the other element is like, there's a reason that
Adderall and other stimulants are schedule to Controlled
Substances because of their in all the risk of abuse other
schedule. Two substances.
Has OxyContin and cocaine fentanyl lot of things are in
that category. So so how did you get onto this
story? Oh, you know I was talking to
some investors and one of them was saying man there.
These companies they're doing controlled substances and
they're kind of using this regulatory loophole.
That's been going on since the epidemic and I wouldn't touch it
with a ten-foot pole, it just it it really gives me the willies
basically and I thought, oh that sounds interesting which Loop
all well that? Yeah, this is the key thing.
So backing up the Public Health, Emergency for covid, created
because of that, they created an exception to something, called
the Ryan hate act. Ryan hate was a guy who got
Vicodin online back in 2000 or 2001.
And he died. And so they passed a federal
law, a years later 2008-2009, saying, you can't get schedule
to controlled mad without at least one in person visit.
Hmm, which makes Telehealth prescribing for ADHD, not A
thing at Tom would know this like if you've got ADHD it can
be it has long been a pain in the ass to get your beds, you
gotta show up at the doctor, sometimes they make you come in
every month even now that still think so.
And for folks, that that is tricky, right?
There's there's Hoops, people jump through, I think largely
because these are controlled substances, and doctors are
just, you know, worried about prescribing them during the
pandemic. The relax, the right heat act.
So now you can do Controlled Substances, online, most
Telehealth companies don't do this.
So I went back and checked for recent story.
We I can get into why I had to do this, but none of the big
General telemedicine companies, none of the big online mental
health companies, do Controlled Substances via Telehealth.
They just, they just don't want to touch it, right?
And they say on their websites, typically, you're not going to
get controlled substances from us.
You're gonna have to go see Or dr.
See somebody, a person, if that's what you want but a
couple startups. What are their names?
We haven't said their names up. Sure.
I there's there's a bunch of them that that are focused on
ADHD, but the biggest one here is cerebral which started off as
general mental health, depression, anxiety insomnia,
and then in 2021, the added ADHD treatment and they'll do
Controlled Substances for all the above.
They'll do benzodiazepines for frames ID, for instance which is
also again not common, tell a dock side, note out Just cite
stock, get hammered 40 percent this week and on their
conference call. One of the things they said is
they blamed the fact that they can't compete for users because
other companies, you know, hint hint nudge nudge cerebral are
offering a fuller menu of like people.
If people want Controlled Substances they're not going to
get it from us and and our mental health are better help.
It can get it for cerebral and so they'll go that direction.
So that's one reason we're it. We are struggling to compete for
clients sort of an interesting side of.
So there's just some of these companies cerebral is one done,
their website is done, first.com Dundee already done is another
their, their ADHD focused pretty much exclusively.
That's the one backed by David Sachs has cracker a sure David
Sachs. Joe Montana, Dave, morons in it.
Then there's a handful of smaller ones or something called
Clarity ADHD. There was one called ahead,
which was a unit of true pill, which just got shut down two
weeks ago, they put it out on the Saying we're no longer to
kind of do this ADHD treatment outline and then there are some
other smaller ones. Can I ask a business question of
front? Yeah, please, how much money is
there really to be made in prescribing Adderall?
I mean, they're basically doing the prescription, right?
They're not getting a cut of every time you get the drug.
Well, the business model for cerebral is and for done.
And for these companies is they charge you a subscription fee
for what they call medication management, Adderall something.
It has to get renewed monthly. So there is a so you show up you
pay them a hundred or maybe a hundred eighty dollars for an
initial evaluation which is 30 minutes.
It's a key fact, we should come back to it.
Initial valuation 30 minutes. And then every month thereafter,
if you've been prescribed a medication, you pay them a t-box
to quote manage that medication which can mean answer questions.
Some companies notably cerebro, often do follow-ups, video.
Follow-ups done. Does not require video follows.
But they'll charge you the 80 bucks per month going forward.
So, that's a great business because you're taking the drug,
you're in a subscription business.
So the goal is retention, keep them coming around.
And, you know, again side note, the accusation.
There was a former executive who sued the company yesterday,
labor law suit. And in that lawsuit, he said the
company did a study of patient retention found that people on
Adderall, were more likely to be retained for people.
I medications were more likely to be retained when that for
When they had ADHD. So that the Direction came down
from the CEO by Roberson, get the prescription rates according
to the suit, according this is alleged in the suit.
Correct? The executives of former VP of
product, right? Pretty.
Big role product and Engineering.
Yeah, and it dovetails with some of some of we can obviously not
it. I can't say anything.
That's what he's alleging, right, are reporting.
What did things like a new policy?
They have for auditing prescriptions which the nurse
practitioners we spoke to you know, Them uncomfortable and I
could go into that. And that's sort of how I ended
up really going down this path. Yeah, what just talk about that,
right? I mean this scale is the
operation is basically have nurse practitioners meat, over
video chat with a bunch of people and then sort of have a
doctor approval bunch of it or it seemed like in classic Tech
fashion. There's a sort of their skilled
at scaling the amount of prescriptions they can.
This is right. It's a pretty simple.
Yeah, the business model is pretty simple.
It's It's charging 80, 80 bucks to manage the medication, pay
the nurses anywhere from depending on the company, ten to
twenty five dollars per month to manage the patient and renew the
prescription and reinvest in tick-tocking, Instagram ads to
generate new clients. So that's the business model and
really how I got into it. The investor said yeah I
wouldn't touch this and I thought, huh?
That's funny and I went on glass door and glass door had this
Anonymous review. It was titled Adderall for all
and it was a quick paragraph. That said, basically, you have
to be comfortable writing stimulant prescriptions because
you will be expected to write a lot of them.
And especially if a patient scores a certain number on one
of these kind of very standard surveys that you get in as an
intake and if you don't prescribe the medication, if
they score a certain number on this on this test 6 questions,
if they get at least four or five Then the quality team
quote-unquote, will get in touch with you and ask you, why you
didn't. And I thought that's
interesting. I wonder if that's true.
What's this quality? Team went Woods is person
talking about and we went back in.
This was our first real story on this topic was cerebral.
Arendt kind of around the end of last year.
Started, auditing the nurses, right?
And sinners practitioners. And saying like look, only 52%
of our ADHD patients are on Adderall Which is the first-line
treatment. And so here are your patients
that aren't on Adderall either. Put them on a different
medication or change their diagnosis code.
The nurse practitioners are like, hold on a minute.
This is I don't want people at the top of the company which by
the way, the CEOs of these of done, its rib.
Roll have no medical background. I don't want that.
The company telling me what I'm going to prescribe.
It's my job. That's my license.
I'm the one that is supposed to determine how I'm going to be
prescribing. So, And by the way, you're only
given me 30 minutes to diagnose. A patient company says that they
don't have to diagnose in the first meeting.
The nurse practitioners. Say, they don't know what that
means that they've actually had a do diagnosed within the first
30 minute for ADHD. Tom, I don't know what your and
your kind of initial diagnosis was like, but I've seen these
poor Tom is not our test case, I'm happy to explain three four
hours, right? These are feces can be really
long. Diagnostic evaluations because
you have to do things like rule out anxiety and depression or
things that would be treated differently.
And Tom was your, he had tell me.
What was your? Oh I have all those things so
it's you know, you don't throw anything out.
No I mean look this was this was decades ago so it's a very
different time. I mean you have to remember this
was the mid 90s where ADD and ADHD were very fashionable
diagnosis to give to, you know, upper-middle-class white
Suburban kids, especially boys. So my mom is also a
psychologist. Not a Diet wrist and did not
prescribe it to me but sort of my access to that world of
diagnosis and the kind of conversations that people have
around it was extremely close to me.
So it wasn't that difficult at all.
Look from my perspective not having covered, you know, the
medical world and you know, can stay Controlled Substances.
You know, Adderall is a relatively new drug relative to
riddle, and right. I mean it only really kind of
came on the scene as a largely diagnosed medicine and the last
Last two decades, or something. I remember first hearing about
it. When I was in undergrad, I took
over from it, took over or the riddle in Market.
You don't hear about Ritalin anyway, right?
I mean it's probably because it's not as you know, it's not a
strong doesn't that's a give you the kick.
And, you know, for people who have severe ADHD, I'm sure it
does have a positive impact on on, you know, their ability to
function. But I mean, we all went to
college like undergrad. Oh no, maybe kitty, little bit
older. So may be slightly different.
But like I knew lots of people that were taken out at all with
him, okay? Somebody who loves Controlled
Substances. I'm going to say that they're
not always very hard to get. Yeah.
Also the idea that Adderall was a drug that was being abused.
I think predates these companies, but puts these
companies into a really interesting social context.
So Ralph told me about these stories.
A little while ago, I'd read them, we talked about them and
like in the educational realm, right there was a lot of
controversy over how many students were being prescribed,
Adderall particularly We in Elite settings where there was
all sorts of pressure to do well get really good SAT scores get
very high grades and then get into a really good college and
there were so the prescription for Adderall kind of came as a
package because you would get the Adderall prescription and
then say, you had a disability and then you would be given for
example, more time, on the SAT. And so, there are all these ways
in which upper middle class people were using both medical
diagnosis, and prescriptions to kind of game and Occasional
system that had become more competitive.
So, I are talking my SATs in the time limit couldn't have, we
went, we were Public School Tony's.
We didn't want my parents failed me, like, it's just not fair.
Yeah, I mean my parents were also an upper middle class.
White people right here is gonna known but everything.
But like, but like this is something that had already like
the The, the abuse of Adderall was already something that was
like, kind of like, culturally acceptable, particularly amongst
the market that DC's like to market products to people, with
Expendable, Cassius cetera. And so then when Ralph and I
were talking about this, I remembered that I'd been getting
all of these ads for these startups on Tick-Tock and I am
not, I don't think I'm in the demographic.
Oh my God Tick-Tock is always trying to convince me over Haiti
HD. Exactly.
I mean the longer you spend on The algorithm in knows, at
least, it figures out, the you wonder whether you have ADHD and
all of a sudden, you're getting a bunch of, that's the thing.
Like, I don't even think it's that targeted.
I really think they're just spending because I am the last
person on this planet, who needs an upper one is speed art.
Maybe at the beginning content, like just the discussion on ADHD
on Tick-Tock the room. Like, I don't, I don't even get,
I'm not even in those. If you saw my Tick Tock feed,
I'm not even I'm not exposed to any of that.
It's like my Talk feet is very clearly, like middle-aged lady
cooking stuff, like really random Japanese things and then
like, first round, eight HD sounds like targeted ads for
benzos. That's the wrong stuff.
Yeah, well I mean Ralph, I mean to get back to your story, what
I find so interesting about, you know, Katie's sort of
explanation here and your Origins and getting to this
story is that it really seems like a Kind of Perfect Storm
cast. Dating series of events all
related to the pandemic because in one sense, we have this
particular loophole that gets opened up at the beginning of
the pandemic. There's also the rise of
Telehealth as kind of, the dominant form of medical care,
or arising from a medical care. And then there's the advertising
through Tick-Tock, which is huge.
Pandemic winner, as people spend all their time at home, trying
to find some ways to occupy themselves.
And it's like it almost seems inevitable that there are going
to be companies out there that Recognize the what some wood,
some would say opportunity and efficiency others would say,
exploit you know, the weaknesses in the system to basically find
a way to build a big business off of it, right?
I mean, it's always the word, tell the doc used on their
earnings call today's exploit. Yeah, it just seems, you know
it, you know, it reminds me of to I remember a couple of years
ago. Remember, he's the weed app that
everyone is using in Sam? Yeah, doc.
Oh yeah, this was back before. We'd was legalized in California
and you would meet with a doctor.
Who it if you didn't have a prescription in like I would
say, 45 seconds. Prescribe you marijuana and it
was such a joke to me, but of course it was weed.
So it was all for a good cause, but like he was just very clear
to me that like the ability to prescribe someone over, you
know, through Telehealth was going to create, you know,
Grease the wheels a lot and to correct a connect-the-dots even
more. I think we're off my realizes
David Sachs was a A seed investor and he's as well.
So clearly has had his Insight that Telehealth on stuff.
People really want is a smart strategy.
Know the timing I still have to figure out the timing by the
way, because done and cerebral were both founded in 2019.
Lee 2019 cerebral launched in 2020, I think done lunch early
20s. This is before depend emic
cerebral dislodged. They were doing controlled
substances when they when they started.
And I actually don't know, the started kind of late in 2020, I
don't know what done which was focused on it, which is focused
on ADHD, like what was their planned right at the beginning.
I haven't yet figured that out like, what was without the
public health emergency was out. Is there a sense that the law
will get changed back? Or like you know what sort of is
there a, you know, what's the procedure?
And I would be at? Yeah, it's my understanding and
this is not sophisticated enough it is that when the A public
health emergency ends this all goes away.
Now I think there may be ways for this particular thing to be
extended and their reasons. Why both Democrats and
Republicans now kind of don't want the public health emergency
to end because there are policies that come with it that
they like and it's a good excuse for those to continue.
So you know it just kind of keeps getting extended for.
I use it six-week increments. Hmm so you're right it said
really is dead. Really is Part of it.
But but you know what, by the way, we should say this kind of
near the top. One thing these companies say is
that look, we're expanding access to mental health
treatment and important medications that people don't
have access to, that's not wrong.
I talked a lot of people and they say, look, there's a lot of
people particularly in rural areas who have no access to
mental health care and the can suffer from ADHD to, right?
Are they? But they can't, they may not
have a psychiatrist nearby whose and Owen eaten by the the way
nor the money to spend on a three hour for our evaluation
that's and you know that's the other thing that's one thing
these companies say and then the question comes down to is is the
is the but the expert the experts we talked to basically
say well, You know, there needs to be more access.
That's true and really where they focus on is the 30-minute
evaluations. They just say, you know, that's
not that's too fast to a proper diagnosis but there is a truth
that with mental health diagnosis.
A lot of the direction is being taken by the patient.
And if the patient really wants Adderall, I mean, you can just
Google what the symptoms are and you could just say you have
which Citing sources. I talked to say they drink and
they're certainly for any Provider.
By the way, you could do that for any provider, not just an
online and if you're an elite, you can just find sort of the
psychiatrist who prescribed, your friends Adderall and they
clear and they did that psychiatrist can sleep easy at
night saying that patients know what they want.
Well I mean it's it's mental health drugs are very
complicated to prescribe and do largely sort of in my view fall
to the patients and hiding like what's appropriate for them
because they're describing their own mental state.
There's no, there's very little data.
You know, the DSM-5 says that check me on this but, you know,
the latest Psychiatry handbook says that ADHD doesn't exist
unless you had it before each 12.
The prior version of that of that textbook said it had to be
seen prior to age 5. Hmm?
Right. So, you know, I'm not a
psychiatrist. I'm not an expert.
Sure. Okay, but it's just, it's a
testament to your point. That we're working on subjective
stuff here, not necessarily part deal.
There's no for mental health care.
There's no blood test. You can take the tells you
you've got Russian and there are the there are very complex, like
exams. You can take.
I don't really know the details but like you, you know, there
are groups that have like psychological batteries that you
can take to see. But are we really?
You know, we would never really require that before a
psychiatrist prescribes mental health drugs.
So that you can always say, oh there's more you can Do I mean
obviously to me I can give my opinion.
I mean 30 minutes seems really fast Controlled Substances like
it's naturally something where you just try to create friction
and just sort of see like to somebody seem to want this like
do we have human beings? We're really spending time with
them and thinking about them or we truly monitor, you know,
there are even though you could be sort of cynical that at the
end of the day, if somebody really wants Adderall, you don't
have to be a genius to figure out how to get it.
There's still a value in friction and oversight.
In human contact and connection. Yeah, well, it seems to me one
of the biggest accelerants to this problem.
If you want to call it a problem is the business model, right?
The fact that these are Venture Capital funded companies, who
are trying to thwaite find a way to scale it.
And once you realize that there's money, frankly in
prescribing this particular drug.
And that there's an audience that wants it.
For one reason or another. I understand.
Even if you want to be responsible, you're still
incentivised. Do more and that gets to, you
know, The NPS complaining about the fact that they were being
reprimanded by their bosses for not prescribing, it often
enough, right? It's like who's really in
control here? Is it the need?
Is it like the public need for this for altruistic and socially
beneficial reasons? Or is it the business model that
says, hey, let's double down on this, you know, we're a SAS
product. We found like a great Market,
let's figure out a way to maximize the people and the
most, you know, profitable user base within addiction is a very
Good business model, like asphalt cigarette.
Come the best. A dictionary.
Investor will tell you that I think speaking of Texas, right?
I deleted it was too much. I couldn't like I looked at my
staff, there was a day when I had been on Tick-Tock.
Nine hours. I was like, first of all, I work
tonight our day. I'm deleting it right now but
changes from week to week, these companies also really were
Remind me of some of the early crypto businesses and Bitcoin
businesses and a, what am I an early like the current
cryptocurrency businesses? Because they're working in a
gray area around regulation. And so, you're seeing right now
as the federal government wants to expand the definition of what
an exchange has its expanding it so much.
That would inevitably sweep up all of these crypto currency
exchanges that had not been regulated and they're fighting
it. Because once that happens, the
cost of doing business will go up.
They will have Put in all these regulatory pieces will have to
hire General, counsel's blah, blah and then they will not be
as profitable. Well, they'll probably still
make money, but they won't make the kind of money that made
them. Good, VC, Investments.
And so, you're seeing this, like, big lobbying push around
it. And similarly, with these
companies, I wonder One our Pharma companies work, you know,
how did the Pharma companies feel about these startups?
Because if they like them, these startups will have an enormous
lobbying operation at their fingertips.
And then to, you know, have we seen any sort of work by these
companies to keep this area unregulated or lightly
regulated? Yeah, I don't know.
And the other question for you Ralph is he were talking to, you
know, former maybe some current employees.
These companies, especially the, the medical professionals are
these side jobs for them, are they full time employees for it?
Or is this kind of that particular typically contractors
their contractors? Yeah, I know work for more than
one they often they're often doing this for more than one
platform. And there are lights.
It's often they have a day job. Yeah, it's kind of a side gig.
They're doing tell they're picking up Telehealth
appointments in the side. Yeah, I've noticed a rising
trend of that and that seems to also be ripe for these kinds of
problems. Because if this is basically a
pitch to them saying, hey, do you want to make more money?
Why don't you spend a couple hours during the week quickly
press, you know, meeting with people and prescribing stuff to
them and of course doctors will say and rightfully so that, you
know, there they care about the seriousness of their profession
and the The Integrity of their license.
But you know, there's just certain Financial incentives
working extra on anecdotes that was on the financial incentives
that I think. I know that for reader reactions
that got some of the biggest reactions.
We spoke to one done nurse practitioner and she shared how
it works and she said, you know, she's got 2,300 patients, all
ADHD all getting at are all substantially all I'm sure
there's a handful that aren't but she said substantially all.
And Sheeran is them every month. And she doesn't see all of them
every month. Basically, they send in a form
that says and sometimes they leave it blank.
She says, if it's Blake, that means you're good to go.
You're stable, that's great, and she renews them.
And she said, she returns the prescription sometimes as fast
as two-minute, and it works out because the way done pays its
nurse practitioners, you don't have to see them for the
follow-up. You can just you just get paid a
percentage of your hourly rate to manage them on a monthly
basis that and that works out to depending on your earlier.
Rate somewhere between seven and ten dollars, I did the math with
her. And I said, okay, 2,300
patients, 89 bucks per month to clear and 20K.
She said, yeah, yeah. Twenty twenty thousand dollars a
month. It's great and make better by
make more than a lot of doctors. So, you know, yeah, that
Financial incentive for nurses on that Partners practitioners
on that platform is kind of what you said it.
It's it's it's just to renew quickly now, right?
I will be. Let's that I want to, you know,
Say that sheep certainly said she feels she's doing great
stuff. She gets a lot of really caring
emails from people who say this is changing and wife is helping
them to better at work. This is helping them in their
relationship. So, you know, I can't, I can't
just beat that, you know, there are probably a lot of people
that say, this is great and she's helping them so, you know,
it's up to readers to judge, right?
I mean, first of all, the traditional medical system is
not great or always attentive and you can talk about the this
speed Need of, which Telehealth can be delivered here?
She can seem troubling but the sort of slowness and lack of
access. The traditional, you know, if
you need this drug and you can't even get sort of the medical
systems attention, you know? That that it's it's own problem
but also just it speaks to me. Like and maybe this is just the
mindset of what I cover. But like the Giga fication of
the Healthcare System, right? That this this model which has
proved so popular to venture capitalists is going to be
attempted in almost every single industry.
That Allow for and we've clearly seen it come in into, you know,
the the medical world. And you know it's not the
dominant form by any means. You know, this is still kind of
like a burgeoning startup kind of industry but we've seen what
happens with Giga fication. That's actually really important
Point Tom. Because one of the things the
nurse practitioners told me, they said, look, I get, I have a
readout an employee kind of feedback read out to tell me how
well I'm doing and I get reviews from my Patients, write from 1
to 5 and then comments to tell me how I'm doing and she said,
you know what, I'm not an Uber driver.
I'm supposed to be able to say no to people.
If I don't think they're, if I think there are here, seeking
medication that is inappropriate.
And of course, those are the people that give me a 1, right,
right. Yeah, works, right.
He's supposed to be able to say, no.
I know it's, you know, with with other customer service
businesses, the customer is always right to what the
customer wants. You know, it makes sense here.
In medicine. We asked prescribers nurse
practitioners a doctor's. We give them a special
responsibility to be able to say, in my professional
judgment. This is what you got.
You don't have this. You think you have it?
I don't think so, right? Yeah, and I mean we can get his
political I guess as we want here but like obviously this is
the inevitability of a for-profit Health Care Systems
like this is, you know, people who are making money that didn't
you know of the in the dr. Sam when they realize they could
make more money by doing extra work on the side and this is A
system that is allowing for a huge amount of people that are
unattended for that are unserved finding an outlet in which they
can be served. Now, again, like you're saying,
most people are using it legitimately and most people do
really need these drugs. But again, the system allows for
all kinds, not just II. Really, there's a view of this
where I mean, it exposes regulatory distortions, right?
Obviously, if Adderall wasn't regulated, there wouldn't be
this workaround to get people to To get people access to the
approvers who they need, right? I mean, the reason these nurse
practitioners are able to make so much money is because they've
basically been given a special power to dispense something that
people want. So there is do not follow this
or I mean not really called a argument because like you could
make the same argument with the pill Mill doctors and opioids,
right? Like right, it made a lot of
money, certainly, they had this special power, right?
But that doesn't mean that the power should be exploited or,
and to be clear that the And I mentioned, the one nurse has
2,300 patients. That's an outlier most.
Most of the people we spoke to current and former, you know,
did I heard patient counts between 200 and 400?
To 500 was was really tired. The higher bar, there are some
definitely we've heard of and reported out that have more than
that. But I only say that because I
did the thing that bad a lot of his nurse practitioner, they
aren't actually cleaning up. They aren't actually making a
ton of money. So Fritz is the cerebral ones,
they get frustrated because they have a half hour appointment.
To diagnose people to get paid for half hour appointment.
They don't get paid to do documentation and administrative
stuff outside of that time. So a lot of times they can't
necessarily hey I'm gonna Zoom with you but I'm typing because
I get to take notes. I got because that's the time
I'm going to pay for and by the way we've got patients back back
back back use it to. They don't actually make a ton
of money and a lot of them, they cycle through very, very
quickly. There's a lot of, there's a lot
of turnover, with a lot of the nurses, some other like some
others, like the gig. I don't really want to stick
around and been doing it for a long time.
Have built Big patient panels others.
You know they cycle through pretty quickly because they're
they're not make enough money or they just cut it.
Don't like the arrangement. I mean that sounds like uber
yeah it's another gig you know dynamic current through a lot of
people, it's a way for people to make money on the side.
It shouldn't be your full-time job.
The companies don't optimize for it to be your full-time job.
There are some jobs where I do want it to be the person's full
time job. Like I really do want my health
provider who seeing me who Give me a powerful drug for it to be
their full-time job. Or at least they think they can
at least give their full-time attention.
Interesting. Of course you know if I'm
playing devil's advocate here if you want to increase access and
I'm the companies and I believe in that mission, you say to
yourself. You know what guys you're right.
We'd love to give everybody two hours, three hours, give
everybody. We can't the people who don't
have access to this and typically can afford it, they're
not going to pay us what it would take what what, what it
would cost us to pay a nurse practitioner to give you three
hours of their time and then To see you every month.
This is what you could afford. So this is what you're going to
get. This is the mental health care,
you can afford and we'll get kind of thing which, which is
not. I'm not saying that in a way
that that, I mean pejoratively. I mean, this is the economics
to, to I forget which one you said this is the economics of a
for-profit health care. So, exactly, exactly, exactly.
It's like everybody gets what they can.
All raise our hands and shake her head and say, oh my God,
they're not getting the best care.
They should have more care. I think about this when I report
this and you say, well sure, I'd love to give him more curious.
But who's going to pay for that? I mean, this is a friend of mine
when she had a baby in New York City which if you want to see
the for-profit Health Care system at work, that's the best
place on the planet. You know, she gave birth.
I think it was NYU so she's an upper middle-class person.
So she gave birth in a room that had lots of other women but they
all have like a curtain and some sense of privacy.
And if you have more money, you get your own Suite with like,
really nice amenities and places to sleep for guests.
And if you don't have any money, you're in a cure and a
basically, a Corral. Yeah.
Can I propose something? And I'm kind of amazed that no
VC is thought about this, but to me, it seems like the solution
to all of this, which is. Why isn't it that my Uber driver
can prescribe me medication? I did, was he like look?
Yeah, look if I'm in the car for 15, 20, 30 minutes, an
absolutely aggravated. Yeah.
As your driver, you draw, I'll be at your most unfocused, your
most mentally unwell when you're, you know, in a in one of
these cars, you know, rushing off to the airport or something
like that. No one better than your Uber
driver to. Describe these things.
I've certainly heard of Uber drivers selling people
marijuana. So, yeah, there's certainly a
question, like the benzo, right? Why is Uber failing to extract?
Its cut here. You know, know you're building
the super. I thought about just delivering
the drugs about prescribing them.
I'm just want to know what's done that.
So what kind of other turn to this in a story you wrote Ralph
is that it sounds like some of the big pharmacies are pushing
back on some of these prescriptions, right?
Right. Like CVS and was it maybe Rite
Aid or Walgreens have declined to fill some of the
prescriptions from Walmart startups, Walmart?
Yeah, this is, this is kind of an interesting wrinkle.
We had heard from sources that they would have problems with
pharmacies often individual locations.
Done had a particular problem with Walmart specifically, seem
to be blocking a number of their prescribers from filling
prescriptions. So, at one point, they just
stopped any prescriptions to Walmart and Walmart confirmed on
the record that they block some shame prescribers for done.
And Don has a basically appeal, that and no decision has been
made to to unblock the vertices are well, big corporates just
wielding, but it makes sense because they just got think
about how much money they just had to pay in all these opioids
settlements because they were no screaming pharmacies and they
got they were sued, they have lost a lot of money.
If I were, if I were a pharmacy, I'd be like extremely cautious
right now. Because right.
They went into the opioid crisis thinking.
It's just some open, it's just, it's just rice.
Craptions. It's just breakthrough pain.
It's just it's just the early 90s and we're just making people
feel better, but it isn't. It is interesting that we have
these huge companies that can act as sort of many governments,
you know, saying, no, you're not allowed to do this, right?
Exactly. Like leave it to all done, well
to know what do you know what though?
It's simpler than that. It's not necessarily the
company's, it's the pharmacist, the pharmacist themselves at the
local level. This isn't what makes this story
interesting to report the companies will see the companies
that ADHD prescribers the sources will say, yeah, Issues
with pharmacies and you call the pharmacies and they sometimes
say, yeah, we believe it but we may not see it because the
pharmacist at the local level, it's their corresponding
responsibility to vet the prescription and decide is this
somebody we want to prescribe to because for instance, they could
check the prescription drug monitoring database to see if
the patient got this prescription for a controlled
substance elsewhere and now they're coming to you for the
same thing, they be drunk shopping this all these
databases, you know. So, That's one thing as the
pharmacist at the at the local level sometimes and and there's
sometimes stop this and so the ADHD company will see that light
were not getting filled over here.
Let's figure out how to fill this.
And by the way, there's obviously a lot of other
administrative reasons, things don't get filled for sure like
insurance doesn't cover it or they're out of stock that that
that also happens. But there's this other thing but
she's gets to Katie's point about in the week of the opioid
crisis. They created these basically
Central compliance groups. The pharmacies did To monitor
their own networks. Of pharmacies to see what
prescriptions are coming in to see.
Are there prescribers, who have a suspiciously high volume of
something that we need to be careful about Controlled
Substances, specifically, right. And Walmart, that controlled
that. So we did get to the central
group to Walmart. It wasn't just individual
subscribers. The central group is the one
that is blocking some done prescribers because they, they
saw stuff come in that they were clearly uncomfortable with and
They made they made that choice. So that is that is an
interesting kind of other piece of this is yeah that the
pharmacies are, you know, they just want to get a handle on.
Controlled substances are all is one and so, they're treading
carefully there. There's, they're mine.
Why don't you deny they had legal liability?
That the opioid issue is because they had people who worked in
their networks, who flagged prescribed, who flagged
prescriptions and pharmacists, who were ignored.
So that is one of the reasons why These big pharmacies even
had like legal exposure in the first place.
So it's not that this is new that now their flagging and
noticing with Adderall what it is.
They were also flagging and noticing with opioids and just
not paying attention to it. So they're just paying attention
to and one other interesting wrinkle is that the companies,
the pharmacies can't see, typically that a prescription is
coming from cerebral or done, they see a prescriber
information. Yes, they see the patient's
information with cerebral, we reviewed Dude, you know, we were
viewed. We reviewed one prescription
that was sent over and they confirm this.
That basically, you know, there's support phone number
that is common that if they called that number it would be a
cerebral could customer service representative.
So if the pharmacist had a question about the prescription,
they could call the number, then they'd see that it's coming from
cerebral Telehealth provider, but that's not something that's
readily. Apparent will in the
prescription comes in through the system.
So you know, the dump people were wondering, how does?
How does Walmart know it's coming from us?
That was something a sorceress and their guess was the support
phone. Number was common to a few
different people. Mmm, so maybe they were drawing
drawing a connection there. But yeah, that's so that, that
also complicates things for the pharmacies anyway, side note to
those databases that they have to monitor prescribers.
They don't share information but a mean between home.
So CVS only sees what's happening soon as well.
Only sees what's happening in Walmart's Network.
So, whereas with the prescription drug monitoring
databases for patients that if you get Adderall, if you get an
arrow prescription or been so that goes onto your readouts,
every pharmacist in its Fritz there by state.
So everything you got in a state is there when you got to
Walgreens CVS, a local Farm, some other Independent Pharmacy.
All of them can see that data, but as he stated their mind you
so much apart a goes, how like they were able to how the bank's
because they didn't share information on.
They're only sharing centralized information on loans and
collateral that created this huge blind spot.
Like that's so crazy. Yeah, I mean there's also
assuming that there is an incentive on the part of the
individual pharmacies to try to root this out, right, like even
the decision to call up these support numbers to find out what
the fuck is going on here. That's coming from the
individual, impulse on the pharmacist to be like, this is a
little weird to me. I should find out, which, if you
are overworked, maybe you are working as a pharmacist as a
part-time job, as Another thing, you again, may not be
incentivized to look into it. Like the system is not pushing
for this. It's Tommy visual of socialist,
I'm just saying, it's the system we live in.
Do you hate capitalism? Well, I mean, again, it got me,
my Ritalin. When I was a see, you know, 11,
so it's worked for me. I made friends through that, you
know, it's like you go to the bathroom and you give out your
extra riddle in the people. If you're not readily making
friends, like you gotta find something be in Dylan kid is a
way to do it as one of the more capitalists Among Us.
I mean, I do think maintaining Norms in the healthcare system
is essential for what it does, and sort of the telemedicine
system goes against that in certain ways because it
abstracts, I mean, the whole gig economy system abstract, sort of
Labor from the person getting the good.
So I certainly agree. That's troubling here.
I'm also always the one defending sort of the Venture
Capital model and sort of rolling my eyes at like Who
cares? If they you know, blow up like
if it's some random software company or whatever I do
certainly agree that here. It's just a case where like is
that much lost for Humanity if this grew slowly.
You know, it's just sort of like it's an interesting idea, but
there's something real is why not?
Just grow it slowly and like see if it if it's better or not.
But like the idea that it's Blitz, scaling, it seems like
wholly unnecessary from a society perspective, the pot,
the Show positives of delivering Adderall to people who would not
be able to get it just don't in any way seemed to overwhelm the
potential negatives. And so it just seems like an
obvious business where slow growth seems far more
appropriate, tell that to David Sachs are but they're certainly
money to be made in moving into areas where other people's sin
Clauses might block them and where there's regulatory
Arbitrage, and points of inflection and writing.
It's just going to affect all the All the dick pill companies
that came on the scene, the last couple of years.
I guess, I guess they predate, they predict these may not stop
the march of the deck pillow. You think it sound?
Do you think the US Congress would make her the DEA would
make those pills control size? Means I think the rise.
Yeah, they're going to take their dick pills away from
congressional Reliance on dick. Pills is probably equal to those
of Controlled Substances. So I would say, you know, as
long as they Can keep the flow of spice going for both they're
probably they're probably okay individually but yeah I don't
suppose hymns is going to be wrapped up in any sort of
crusading Congress person's desire to to regulate these
companies but you never know. Can I ask you a very basic
question and Ralph? We can cut this if you don't
know you're not a doctor but like what is if somebody gets
Adderall and they're not like they don't have ADHD like what?
What is the crisis or like, they're addictive.
It's a difference. Doing blow and so that's just
going to deteriorate their health over time or like what
they have like heart problems or like, what, what is the problem?
Like, it's so there the Essex. So there are side effects that
can include the heart related issues, cardiovascular issues,
that's something we've reported. So, you know, you want to check,
this is another challenge with Telehealth is sometimes.
Certainly for older people who get diagnosed with ADHD which
happens you want, Get a blood pressure cuff on them.
You want to check their blood pressure because you don't want
to necessarily give them a stimulant.
If they've got a blood pressure issue, that's not something you
can do over Telehealth. So yeah.
There there are those side effects.
I think you're right. You should talk to a doctor for
more of it. Some of the readers that have
come to us. And after our stories of said,
you know, look, I got myself addicted to stimulants and it
became a problem for me. Others have said, you know,
sometimes, Stimulants lead them to other kinds of uppers other
kinds of drugs. But that's not, you know, how
many of the kids you went to college, who pop it out?
Are all this predates me to really are they all having
serious problems? No, probably know.
They're all, they're all investors.
They're all Wall Street. Weezer there is this interesting
question? I have you like, I mean, like, I
know a lot of people who did a lot of cocaine not and I'm we're
all in our 40s and 50s now and they're not all Rogue addicts,
but a lot of them I bring that up.
So we don't all accidentally become like drugs scolds it's
funny. I feel like we're all.
I won't speak for I'm Pro, you know, recreational drugs but
then you know you hear like oh the prescribed drugs and all of
a sudden it's like, oh, that that needs to be done the right
way. I also think we're why are we
why are we making this false like barrier between like like
recreational prescription, drugs, prescription drugs, are
recreational drugs, right. And we should also State out.
That's not what they're for, but they're off.
I'm just saying, prescription drugs, and prescription
Veterinary. Arie drugs are not uncommonly
used as Recreation, right, right.
And we don't want to come off as like you're saying on drug
scolds and deciding, which drugs, you know, are acceptable
socially and not, I do think it is dead, cats stated platform
that we are anti whippets that's program than anyone.
I'm just not comfortable inhaling things.
Like I, if I needed stream, whatever, guys.
Oh wow. Well, we'll have to take this up
in the next day at our next meeting because I know you were
either way. I didn't think we've never
discussed. So we're like, I think if this
show stands for anything, it should be inside a lot of
restaurants. So like, you know, I just like
Something's Happened. Well, what?
Well, I do I just really Adderall criticism.
There is this like the medical system still has this
assumption, they'll like the Baseline human psychology is
like preferable. Like, you know, we're not in
this like world, where people are like, oh yeah, like
Limitless is good, but it's not clear like long-term whether we
could. Decide that like every human
being is better like, with some like pharmacological adjustment,
whatever happened to bath salt, we want, do you want to live in
that world? Yeah, I mean, if it's better, if
I mean that's I stood out to be in your story, what a part of
one of responding to is it's like, oh, people can get high
off Adderall. It's like, oh man, they
experience like euphoria that they wouldn't have otherwise
like this is like terrible, you know.
I that that that's sort of the impulse that I don't quite get
like, Isn't it good that people get extraneous Euphoria, if
there weren't other negative consequences, just like, what is
the issue with people getting more Euphoria than they would
have? Otherwise?
I don't have a process of that. But that's just what it's like
the problem with all drugs, that's all that's like.
Sometimes they're very, very addictive, and people can't
become addicted to them. I'm sure there are people out
there who have like done heroin and didn't end up complete
addicts. Right, right, right.
I mean, it's, you know, there's there's the local dance reason
of Drugs. It's like the old Bill Hicks you
know routine about like you never see a news story about
someone who took acid and had expanded Consciousness and like
understood the world in a slightly more interesting way.
It's always some like dip Shady jumped off of a roof.
That becomes the story but then Michael Pollan, writes a great
book about it though. Yeah, it's good.
Yeah. I say that I even write it.
Is it good? I got to read it as a good but
it's like an ex. Did you like the New Yorker?
A say version. I have read that either that
reference trying to sound smart and absolutely Does that make me
even have those guys look like no?
But look at ya know. You've nailed her audience.
It's people who want to sound smart by claiming they've read
books. That's well, Tom has never
claimed that he won't even read the fucking time about.
So right. I've read the covers of a lot of
books and I feel like I got the vibe in our last few minutes
here. Do you want to talk briefly
about? You Lon, does anybody have a new
thought on a Lon? I've probably read 80,000 words
on Elon Musk, Scanned, the lab. He won't do it.
My thanks to her. Like this is all, this is all
not gonna happen. These actually gonna bail on it,
I don't think so, but it's possible.
I love those takes. I don't, he's already sold a lot
of Twitter stock in order to do that.
So I was like, yeah, we're not Scott Galloway who does not get
much mind sharing my brain but he had predicted incorrectly
that, you know, Elon would have, you know, the acquisition
wouldn't happen. You know, I that was my
inclination to, but now he's like doubling down saying that
this isn't going to happen. Vince like it's putting like,
you know, good money after bad. Yes.
Especially since that, you know, almost everyone was wrong about
this, right? And every step along the
process, the idea that like, okay, you did not happening, no
fucking private Equity, saviors, coming in the singing, companies
piece of dogshit, only Elon Musk going to take it and this is the
stronger than I heard. But you did, you did come down
on my knees. I did say that about private
equity and I did say that Twitter was a dog shit.
It is. Definitely You know, you said he
lied, you thought he was going to buy it so I you could stand
behind that. Pretty strongly.
Okay. Here's my here's my one take and
this is extremely Insider e, but I guess this is the red venue
for this venue for the yeah, the last 50 minutes or whatever.
We're out of dead cat. Yeah.
Anyway, yeah, I am really fucking tired of journalists who
are tweeting out, you know, they're like, oh, I'm on the
hell site beat for MTV News or something.
I can tell you what Twitter is going to look like under Elon
Musk, and let me do a whole thread about what this is going
to. You like is I spend my time, you
know, dming people who have groper I you know Abby's and I
understand the true hell of what the internet can be.
It's like you don't fucking know.
I'm sorry just because you spent a whole bunch of time on 8chan
and feel like you have a better read on like you know, the new
form of Nazis that are out there that you have like a read on
what's going to happen here. Nobody knows.
Nobody has any clue? And so I'm tired of you claim it
expertise here. We're all in this together.
Was that in cidery enough orders making predictions as As
actually long been Katie's stance, reporters making big
predictions is just like a dangerous strategy, don't do it.
We already come off as know-it-alls were bad at making
predictions. Like I mean that's I do think
with the Elan thing, you know reporters are used to
traditional fight MMA, right? And so if you looked at it by
traditional lemon, a standards, it looked like it was never
going to happen. But the whole thing about Elon
is that he doesn't even look like.
It wouldn't happen for normal investor rights are private
Equity investor along. Right, something pretty good,
right? It's right.
You on frame. You should have been Does Elon
tend to succeed on things that nobody believed in.
Yes. So maybe he's going to
come up with the money in my pockets in the Deep Pockets of
my two friends, right? Keep in mind, I never thought
the money was a barrier, right? That was the thing for a while.
So I think I deserve to be sold a bunch of Tesla shares and the
stocks up lap before we started recording.
The stock was up. So it's classic like you think
it's still way down? Since this Twitter thing was
announced it. Yes.
But it's but as of the actual cell, he's getting a Bargains
up, right? Getting a deal unless you think
the actual eventual price is going to be 0 but otherwise
Frame. We should have said he surely
should try to diversify away from Tesla and this is the best
excuse, anybody could ever come up with to sell some Tesla
shares its to use that money to invest in a financially ruinous
decision. Right?
Yeah. And I'm gonna come, I'm gonna
say that. I'm really happy that the like I
very rarely make predictions but the two that I've made that I
was right on one. Donald Trump becoming president
211 must like Twitter. When I mean, there's a certain
there's a certain Connected here that may seem to have tested
which is the dumbest possible outcome wasn't that elon's thing
the the funnest outcome will be the true one or whatever.
I don't know if that's related to eat lunch specifically but it
clearly I think what you want is tweeted, something like that.
Rob, give us a neon tape. Give it whatever her doll or
takes, but what do you want, take?
Oh god. Um, you know, it's it's funny to
me all of the people along the way who have been doubters a
deal on the short Sellers and Tesla for I think a lot of
people are still suing him over funding secured because, you
know, they lost money on that. And meanwhile, the stock is up
oh much. Since then I, you know,
everybody thought that compensation package, he got was
just nutty and crazy and it's never going to amount to
anything and it made him the richest person.
But all right, said, actually raises rates substantially could
all end. Yeah, the FED actually went to
like 5% or something. I want to see what high beta
stocks like Tesla, doing that world.
Where I feel like I went to the heart of heard on the street,
like I feel like Like we were just transferred of it like
until like the essence of heard on the street distilled.
It was very, it was very wonderful.
Hey Kurt on the street was very negative on Tesla for a long
time because no cash flow. This devaluation doesn't make
sense in. This is all crazy but, you know,
and the other thing I will say Zealand.
I mean he's been angry at me before I when I got minor league
scoop and you know he's threatened, I'm never gonna talk
to you again, Ralph. If you write this story even
ever talked to me, once he won, right?
Oh that's classic. That's yeah.
This Jared Burchell guy that was he was kind of get seeing his
name was helpful to Landing that scoop.
He's he falls. He's always said, I'm getting
written about but uh, you know, see what you peace, I know in a
lot of ways and unpleasant, dude.
But you know what people say? Oh, he's a fraud, he's this,
he's that. But you know what?
Look at the cars in the road. Look at the rockets that blame
themselves and think about strategically to speaking is
American for a minute. I like the is that there's an
American car company that is leading the EV with the lead in
the show in V's. I like that.
We are no longer a hostage to Aryan space and the soyuz rocket
to get to space. It's nice that we have an
American company that actually makes us competitive.
There it would be really great if we had a lot of other
American companies that built their own stuff, you know, I
don't know. For all the all the reasons that
it get somebody like trouble. I did right right org.
Or Draw the same reasons to draw a lot of support to somebody
like Bernie Farhad in the New York Times, just wrote a
positive. Eli, I didn't read for Hans take
but, you know, on the one hand, yeah, he's a super be in a lot
of ways is super unpleasant, dude.
But you know, he built rockets that that land themselves, he,
you know, has convinced everyone that Evie's were going to be
saying, guess what? If he's a real thing, it's not
it's good, that's it. These are good things.
I do think there's like an ant ice-cold mood.
Like, I mean, clearly I'm on board with being more positive.
It'll be Interesting to see if, I don't know that we get
positive on Ilan as the owner of Twitter.
I don't know the entire time, I don't know about that.
But, you know, to it together. I mean, it makes sense
tactically for Ilan to Cozy up to the far right.
You know, especially if you ever sells this fucking truck, you
know, that's like the customer base for his cyber truck and and
clearly, if you were like, oh and EV CEO like, who's their
natural families, who would be the libs?
There's a certain, like, go against type and keep everybody
in the fold, but I feel like he's is sort of going above and
beyond, it's starting to seem a little too sincere.
He keeps engaging with like terrible people.
I'm right wing Twitter and I keep sort of naively.
Hoping he's going to rein it back.
Trust the Plan, Eric plan, it's all we can do.
All right, thanks for joining Ralph.
This is great. Hey, thanks for having me.
Goodbye. Goodbye.
Goodbye, goodbye, goodbye. Goodbye.
Goodbye.
Goodbye, goodbye, goodbye. Goodbye.