Here’s what healthcare professionals would like to say to Mylan’s CEO

Pharmaceutical executive Heather Bresch will appear before Congress today to explain her company’s EpiPen pricing

Why has the cost of an EpiPen increased by more than 450% since 2004?

That question and many more will be asked of Heather Bresch, the CEO of medical-device manufacturer Mylan, when she appears before the U.S. House Committee on Oversight and Government Reform today. Bresch’s testimony before the bipartisan panel will be her first public appearance since August.

“There is justified outrage from families and schools across the country struggling to afford the high cost of EpiPens. We look forward to receiving answers … from Mylan about its dramatic price hike for this life-saving medication,” the committee co-chairs said in a joint statement.

We asked the medical professionals of Figure 1, the central nervous system of healthcare, what they would ask Heather Bresch. There are more than a million doctors, nurses, paramedics, pharmacists and medical students using Figure 1 around the world. Here are the major points of the discussion, which continues here in our free mobile app.

1. How can you weigh profits against people’s lives?

Healthcare professionals echoed the general anger that has been directed at Mylan since this news broke last month.

“I’d ask them to give me one good reason why profits can be placed over people?”
Neurology resident

“I am required to carry two pens with me at all times. What I would like to know is how Mylan can justify the cost of $600 when an ampoule of epinephrine that contains three doses costs approximately $4? My life is worth more than your profit!”
Nurse practitioner

“Have you ever seen a real anaphylactic reaction in a child? I pray that you never have to and that you can use your ridiculous amount of revenue to prop your pillow at night as people die because they can no longer afford medication.”
Registered nurse

“I have given my 11-month-old his EpiPen on more than one occasion. It is awful that, to save his life, I have to pay hundreds of dollars.”
Registered nurse

“I would ask how she would feel being the mother of a child with a life-threatening allergy and having to choose between paying bills or purchasing an EpiPen. For me, $600 takes away from money for housing, food, and general care of my family. How dare someone that makes millions of dollars tell me that a $100 coupon will ‘offset’ the cost of the EpiPen.”
Advanced practice nurse

“Given that there are a limited number of autoinjector devices on the market, and the fact that this is a life-saving device/drug, why hasn’t an antitrust investigation been initiated?”
Physician assistant

Note that on Sept. 6, 2016, New York Attorney General Eric T. Schneiderman opened an antitrust investigation into Mylan. “If Mylan engaged in anti-competitive business practices, or violated antitrust laws with the intent and effect of limiting lower cost competition, we will hold them accountable,” he said.

2. Generic options are not a viable alternative.

While some healthcare professionals suggested off-patent formulations…

“There’s been a generic auto-injector on the market since 2014, made by Mylan’s competitor. Regardless of your personal brand preferences, I would hope you’ve been prescribing the generic auto-injector to your patients these past two years. It’s just a best-practice thing since there’s far better insurance coverage for it and the cash pay price is usually less than 1/3 of the cost of EpiPen. … You just write for “Epinephrine USP Auto-injector 0.3 mg 2-pak” (or 0.15) and the pharmacy fills it with the generic pens. Funny how we’re all on here sending the CEO of Mylan to hell for suddenly and single-handedly killing children, while practicing providers have been writing for the competitor’s generic product since 2014.”
Nurse practitioner

“I would ask Mylan why they care what people think? There is a generic on the market and as a shareholder I only care about money. People have a choice. Nobody is forced to buy Mylan. That is why generics exist!”
Vascular surgeon

“Over a month ago, they lowered pricing for their generic to $300. Don’t get me wrong, it’s still a ridiculous amount, but they HAVE done something.”
Registered nurse

…others argued that the prices for the generic EpiPen are often just as high …

“I just bought the generic for my son — two twin packs were $1,000. I don’t qualify that as something.”
Nurse practitioner

“You are aware that this generic is just as equally expensive, yes? $600 yesterday at the drug store for a 2-Pak for my daughter. GENERIC!”
Registered nurse

“The generic is barely cheaper. There is no real play on this market.”
Registered nurse

… and that there were other issues with generics.

“The user directions [on generics] could be clearer. The instructions on the EpiPen guide someone who has no experience (like a goodSam, teacher, parent, etc) to successfully administer. Even someone who needed to self- administer might forget under duress.”
Registered nurse

“Also, this product is not interchangeable with EpiPens, so a different prescription is required to fill this product. Insurance coverage is also an issue with generic epinephrine auto-injectors, making the entire situation very difficult to navigate from the pharmacy, provider, and patient end.”
Pharmacy student

3. “Not everyone can use a syringe and a vial.”

Epinephrine does not have to be administered via an autoinjector— it can be administered via a syringe and vial…

“Are MDs able to prescribe epinephrine in a vial with syringes to circumvent this piracy?”
Registered nurse

“You can — I asked my MD to do it for me. It brought the cost down to a cool $85.”
Registered nurse

…but this solution is neither realistic nor practical.

“They are. The problem is teaching people to administer it. What about a child? If a child has an allergic reaction at school, who will give the epinephrine? The school might have an on-site nurse, but in areas that are stretched thin, one nurse rotates through several schools.”
Advanced practice nurse

“The whole ‘breaking the ampoule, drawing it up, and delivering it’ process is not an easy task to perform when someone is dying in front of your eyes.”
Registered nurse

“Do you really feel it is feasible for unlicensed, inadequately-trained personnel, or laypersons to adequately measure and administer epinephrine using a needle and syringe in an emergency situation?”
Advanced practice nurse

“Yes. But not everyone can use a syringe and vial.”
Registered nurse

4. How much does it actually cost to produce?

Some healthcare professionals wanted to know if the profits were being used for research and development, but others cautioned against this line of thinking.

“Does [it] matter much? Can you make people with anaphylaxis pay $300 more for their product so you can help develop, say, a new proton-pump inhibitor? And why did the CEOs salary shoot to $18 million per year?”
Other healthcare professional

“Don’t include the price of developing the product because Mylan didn’t pay for that.”
Other healthcare professional

Others questioned the overall lack of transparency regarding the markup.

“It’s not a matter of supply and demand for this product. There is no shortage at all of epinephrine. It costs less than $2 for a whole vial of it for a hospital. It gets packaged into this little convenient push button injector and all of a sudden it costs $600? No.”
Registered nurse

“I wonder if the motivation behind the ridiculous price increase is that, since everyone in the U.S. is ‘required’ to be insured, they assume that the insurance companies will pay the difference. My opinion is that gouging people or insurance companies like this is downright criminal. Other manufacturers get fined for price gouging.”
Registered nurse

“Please explain the economic mechanisms you believe are at work to cause this cost increase. Then please provide at least two reasonable and actionable resolutions to the perceived problematic mechanisms.”
Registered nurse

5. How can you justify the price of EpiPens when you compare prices around the world?

U.S. healthcare professionals were curious about the markup of EpiPen in other countries, so Figure 1’s global community weighed in.

“I’m a pharmacy technician in Canada, and we also use Mylan-brand EpiPens. The cost runs about $114 before markup/dispensing fees, and that price has been consistent for several years now.”
Pharmacy technician

“The same product costs €38 in France.”
Emergency medicine physician

“Under €20 in Montenegro.”
Emergency medical technician

“This is what infuriates me. Most countries that have single payer healthcare have worked out similar lower prices for pharmaceuticals.”
Dental assistant

“My biggest question is not why, but why now? Of all the drugs — from the HIV/AIDS drug mentioned earlier, to even my birth control pills ($100 a pack), why did the public choose this drug to start an uproar? There are thousands of other lifesaving drugs that people can’t afford. How can we, as healthcare professionals, use this drug to open up dialogue about creating better access for our patients?”
Registered Nurse

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