How the Cost of Epipen affects Your Patient Care

 

Epipen cost affects your care
The high cost of Epipen negatively affects your care!

How does the outrageous cost of Epipen affect patient care?

 

First, do you know why Epipen costs so much?

Short answer:  because they could!

 

Note:  This topic is actually divided into 2 posts:

  1. How the Cost of Epipen affects Your Patient Care
  2. 7 Epipen Cost-Saving Hacks (post on Thursday)

Note:  there are some political implications about Epipen according to the recent news that, most likely, are partly true, partly sensationalized, partly media skew, and 100% not what I care about.  I’ve tried to make this just a straight forward distilling of what I think and know from an allergist’s perspective!

Epipen politics
No Politics Today!

Background

If you haven’t seen the news recently, Epipen has been in the crosshairs of the public and the media.  And for good reason:

  • Over the past 7 years, the cost of Epipen has risen 461% from $56.64 to $317.82
  • Recently, from 2013 to 2016, Mylan raised EpiPen prices 15 percent every other quarter.
Epipen cost effects your care
Epipen costs have risen 461% – from $56.64 to $317.82

I’ve linked a lot of articles explaining more about this at the end, but my perspective is that once Auvi-Q, their main competitor, was unable to produce a consistent auto-injector and was forced to stop production then Epipen was able to get away with increasing the rates.

I am appalled by this, as are most of you.  And in my next post, I tell “7 Epipen Hacks that will Save You Money.

But until then, let me fill you in on more of the gossip.

 

Isn’t a Monopoly Illegal?

Ah.  One of the first questions I get a lot.

From my understanding, other companies are able to produce epinephrine auto-injectors (like Auvi-Q) and there is another major brand of epipen (Adrenaclick) so epipen doesn’t have a monopoly (then again, I got my law degree from an intense game of “Cards Against Humanity” so I might be wrong).

TL;DR – They don’t have a monopoly.

So why not just use the cheaper alternative?

I certainly agree… if you can find it.

Around Denver, it is very difficult to find a pharmacy that carries Adrenaclick.  I’m not entirely sure why, but it is about as rare as a blue unicorn (which, incidentally, are rarer than pink ones.  Common knowledge)!

Additionally, many pharmacies will auto-substitute Epipen instead of Adrenaclick if they have both on hand and the provider doesn’t specifically state “no substitutions.”

TL;DR – So the great, cheap alternative is hard to find and tricky to get.

 

What about the $0 copay coupon?

Another great questions… and a consistently frustrating one!

Epipen pairs their outrageously expensive medication with a proudly displayed $0 copay coupon.  Problem solved, right?!

Wrong.

The copay card is $0 only if you’ve already met your deductible AND the medication is in a tier where it would cost less than $100 at that point.  What does that mean?

Essentially, it is a $100 off coupon.

But depending on the pharmacy you go to and your insurance plan’s coverage, the $550 medication (price in one pharmacy in Denver after pharmacy adds their cost) drops down to $450.

Note:  I recently asked about the ineffectiveness of the card to our Epipen rep, who very robotically told me “People are picking high deductible plans without reading the coverage and THAT is causing most of the problems with the Epipen coverage.

So… it’s all your fault.  Apparently.

TL;DR – If you have 2 kids with food allergies, that’s almost $1000!  For a medication that you hopefully will never need/use.

Epipen cost negatively effects your care
How has this affected your allergy care?

How has Epipen’s increasing cost affected patient care?

This is the question that the media has not touched on yet, although they should.

For someone like me, who tries hard to find the most cost effective solution for my patients, this has been terrible.

There are 3 major ways your care is compromised by Epipen’s cost:

  1. Fill Rates / Access to Medication
  2. Patient guided treatment changes
  3. Provider guided treatment changes

 

1.  Fill Rates / Access to Medication

The first way you are negatively affected is simple:  if the medication costs too much, you won’t get it filled!

If I were to guess how many of my patients have returned for a follow up without getting their prescription filled, I’d guess it was about 20-25%.

That may not seem bad.  But consider this:  Epipen is given for LIFE THREATENING reactions!  It has no other use! So that means that about 1 in 5 of my patients with a life threatening condition don’t get the life saving medication!

Fill rates are never 100%, even with access to free medications, and some studies have suggested that 33% of patients fail to fill at least one first time prescription.  That is, unfortunately, normal.

But Epipen is the ONLY medication to treat potentially life threatening anaphylaxis!  So a relatively high percentage of patients with a known life-threatening condition are unable to get their life-saving medication!

Thanks, Epipen!

2.  Patient Guided Treatment Changes

The second way Epipen’s cost negatively affects your care comes with patient-guided treatment changes.

Increasingly, patients have been asking whether or not their symptoms NEED them to have an epipen.  Patients have been minimizing their (or their child’s) potentially life-threatening symptoms to get me, the allergist, to say that they don’t need the expensive medication.

I’ve also had an increasing number of patients tell me that diphenhydramine (Benadryl) is all they need to treat their allergy.

This is WRONG!

Medically, this is a very simple answer:

  • Epinephrine is THE ONLY medication that treats anaphylaxis.
  • Diphenhydramine (Benadryl) helps the skin look better, BUT DOES NOT STOP AN ANAPHYLACTIC REACTION!

Still, the number of school forms that have been deliberately checked otherwise shows the extent of patient-driven changes in medical treatment.

I am 100% in favor of my patients being fully invested in their treatment and encourage them to google anything and everything and let me know their thoughts.  But in the case of anaphylaxis, there is no amount of reading that changes what happens in the body during an allergic reaction.

Patients with food allergy/insect allergy/anaphylaxis NEED epinephrine to stop a reaction.  But due to the high cost, your care is getting compromised.

3.  Provider Guided Treatment Changes

The cost of Epipen doesn’t just change how you present your symptoms.  I have seen many primary care providers sending patients to me having told them that their symptoms were “not severe enough to need an Epipen.”  Much of the time, this just isn’t true.  But this doesn’t just change the habits of primary care providers, but even allergists.

Let me tell you how I have even been affected by Epipen’s cost:

Currently, as a direct result of the Epipen’s cost, I find myself doing as many risk/benefit calculations I can to try and find a way NOT to give them an Epipen.

It’s a slight variation in thinking, but I think it’s significant.  Previously I would think whether or not it was safer to have an Epipen for any set of symptoms, particularly when a diagnosis wasn’t 100% clear yet.  Now, I approach each situation as to whether or not the NEED an epipen.  It’s a small change that went from prioritizing safety to prioritizing NEED.

Luckily, I am a trained allergist so I know all the variations and presentations that NEED an Epipen (and if I’m ever unsure, I still default to giving an epipen).  What about all the providers who don’t have a 2 year fellowship specifically about allergies?

Still, just knowing that my care has changed as a result of a medication’s cost is unsettling and makes me uncomfortable.

 

TL;DR – The easy and medically correct decision to give anyone with a potentially life-threatening allergy an epipen has now become a type of barter triaging arbitrary health risk against perceived monetary benefit and is a dangerous game.

 

 

What is there to do?

Right now, it seems limited.

I am almost finished with my “7 Epipen Hacks that will Save You Money” post, which pulls together every sneaky loophole workaround idea I could manage.

Also, maybe, the political and social pressure will lead to a cheaper Epipen in the future.

 


Until that time, you could read through some of these recent news articles and familiarize yourself with the extent of the problem:

  1. http://www.consumerreports.org/drugs/can-you-get-a-cheaper-epipen/
  2. http://www.nbcnews.com/business/consumer/mylan-execs-gave-themselves-raises-they-hiked-epipen-prices-n636591
  3. http://blogs.wsj.com/washwire/2016/08/24/hillary-clinton-calls-for-mylan-to-lower-epipen-price-amid-outcry/
  4. http://www.npr.org/sections/health-shots/2016/08/24/491232665/latest-target-in-the-drug-price-wars-the-ubiquitous-epipen
  5. http://www.forbes.com/sites/emilywillingham/2016/08/21/why-did-mylan-hike-epipen-prices-400-because-they-could/

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