
EpiPen Price Rise Sparks Concern for Allergy Sufferers - helloworld
http://well.blogs.nytimes.com/2016/08/22/epipen-price-rise-sparks-concern-for-allergy-sufferers/
======
gmisra
One of the early on-line responses was "maybe we can figure out how to 3D
print these cases". It turns out that an Epi-pen is just a plastic safety
housing around a normal syringe.

Some discussions:

[https://www.reddit.com/r/news/comments/4y5481/cost_of_epipen...](https://www.reddit.com/r/news/comments/4y5481/cost_of_epipen_continues_to_rise_putting_burden/d6lao38)

[https://www.reddit.com/r/3Dprinting/comments/4y7f26/epipen_f...](https://www.reddit.com/r/3Dprinting/comments/4y7f26/epipen_fork_of_the_enable_project/d6lmoaf)

~~~
Cyph0n
That second discussion got heated quite fast. I agree with the downvoters
though. 3D printing a medical device is not something to take lightly.

 _Edit:_

Here's why I agree.

You download this design from the internet, and 3D print the parts. You then
assemble it. Awesome!

Some time later, you get an allergic reaction. You use the pen, but it fails
to work correctly. Who's responsible? The designer? You (if you're alive)? The
printer manufacturer? Your friend who emailed you the design? etc.

There's a reason why even getting such a simple design considered for FDA
approval and certified for use on live humans is such a long and complex
process. It's easy to make something that works some of the time, but it's
_extremely_ hard to make it work essentially every time, especially in life-
or-death scenarios.

Of course, the price hike is terrible and the company behind it deserves
punishment, but that doesn't make it OK to endanger the lives of people.

~~~
toomuchtodo
Scarcity demands innovation. I don't think its being taken lightly; more like,
"a private company is gouging medical users and the government won't step in".
Not left with many options when your life depends on it.

EDIT: Alternatively, a "better" temporary solution would be to arrange for the
import of these from Canada, where the price is fixed by the government.

~~~
infinite8s
Well the cheaper and more effective solution would be to carry around a
syringe and a small bottle of epinephrine.

~~~
icantdrive55
That makes too much sence for the FDA, AMA lobby, big pharma, and very
entity/persons that makes a killing off health care.

As to the simplicity the EpiPen, I once used it, and under stress didn't do it
right.

When I was younger I was very interested in medicine. In college finished all
pre-med courses. Interned at a Coroner's office, etc. Even spent some time in
med school. Very familiar with giving a subdermal injection.

Now my father had a bad asthma attack years ago. I knew he was in poor health,
so my stress level was high. He blurted out where the EpiPen was kept. I got
the device, didn't have time to read the instructions, and just stuck it in
his thigh. I apparently pulled it out too quick--just wasn't thinking, and
nervous. I pulled it out so quick, because I was scared, felt the device was
foolproof, and felt weird hurting my father. We luckey had enother one around,
and injected him longer this time. If I was forced to use a syringe, their
would be no assuming. "I need to get the drug into the syring. I then need to
empty the syring into his thigh. Done?"

Well it didn't work, and he ended up in the emergency room. He survived.

I drove home feeling guilty, and still do today.

I always felt a kit with a single dosed bottles of epinephrine, and a syringe
would make intuitive sence to a lot of people? I know I would have felt more
comfortable that night.

I honestly think the powers at be underestimate the abilities of the average
person, especially a person who's had an previous asthma attack. If a
doctor/nurse spent a minute showing a patient how to injection themselfs with
epinephrine; I don't think most would ever forget. Plus--we have all watched
injections given on the boob tube? "But the average person would probally jab
the syringe in the Carotid artery, or pull a Pulp fiction." They could jam it
into a carotid, even with a EpiPen--with enough effort/stupidity?

I hope in the future we have over the counter life saving medications over the
counter, including naloxone.

Demand passing a basic test if worried about consumers hurting themselfs?
Something like a CPR certification? If the patient can pass, they can buy
cheap medications over the counter? They don't need fancy propriatiatry drug
delivery gadgets in so many cases.

I really think the only way to bring down medicine costs will be to make many
drugs OTC, and demand basic competency exams if worried about ineptitude?
There will always be people out there that will find a way to
abuse/overdose/screw up dosesages on medication. Let's just try it for a year?
Especially with certain life saving drugs. How many diabetics die each year
because they don't have a prescription for insulin, and couldn't get to a
hospital?

I used to have so much respect for any sector of the health care; now I look
at most of them with utter discontent.

~~~
maxerickson
It's recommended to seek medical attention immediately after using any
epinephrine injection.

There's a pretty fair chance that you driving your living father home from the
emergency room is evidence of the injection working.

------
ascorbic
Meanwhile, in single-payer Britain the NHS pays £26 ($35).

[https://www.evidence.nhs.uk/formulary/bnfc/current/3-respira...](https://www.evidence.nhs.uk/formulary/bnfc/current/3-respiratory-
system/34-antihistamines-immunotherapy-and-allergic-emergencies/343-allergic-
emergencies/anaphylaxis/adrenalineepinephrine/intramuscular-injection-for-
self-administration)

~~~
norea-armozel
You know what's weird about this situation is that often I've been told by
people here in the US that the price NHS and other single payer systems pay is
only possible because we here in the US supposedly pay for it at the free
market price. I don't believe that myself since it wouldn't make much sense to
say that the prices would plummet to such a degree as to be unprofitable. But
I do wonder how much of the price would be affected if every country in the
world were under single payer systems. Would it be even marginally higher?
Would it be possibly lower for all? I'm not sure. But I would love to see
someone analyze this to see if this is statement I keep hearing is 100% bunk.

~~~
clarkmoody
> we here in the US supposedly pay for it at the free market price

The free market price system does not work in American healthcare because we
do not have a free market. Healthcare is one of the most heavily regulated
industries and the third-party payment system means that consumers are
divorced from the price mechanism.

~~~
tcbawo
As a consumer of epipens, I can assure you that we are not divorced from the
price mechanism. We are talking about $300+ a unit for a dispenser (the drug
itself costs pennies). The time needed for competition to manifest in the
market will cause much suffering.

------
grandalf
Someone might reasonably wonder why a federal task force is required to
investigate "price gouging" for an item that contains under $10 of materials
and is not mechanically complex.

Why wouldn't an entrepreneur simply introduce a competing epi-pen design and
bring it to market for $300 (for example) and undercut the price being charged
by Mylan?

We're told to hate the Martin Shkrelis of the world, and to resend the Mylans,
but the truth is that our system prevents price competition _because_ it is
designed to protect established firms. This is why many established firms and
"industry leaders" strongly supported the affordable care act.

~~~
clavalle
The government has created a moat for the current pen through regulation,
particularly the extensive testing needed to bring it to market as a medical
device whom people's lives depend on it delivering the right dosage with a low
failure rate.

This creates something of a small granted monopoly.

It makes sense for the government to step in when something goes wrong.

There are lots of theoretical arguments for a freer market that may drain that
moat and allow competitors to quickly react to gouging but the reality is that
consumers don't have a great way to test things like epipens and a market
trial and error approach seems a little barbaric.

~~~
dleslie
Seems to me that less testing is necessary for an established product.

Are there patents involved?

~~~
maxerickson
Sure, any company wishing to enter the market can use the expired patent as a
reference.

~~~
dleslie
It looks like there's a minefield of patents granted post-1995[0]; and so
which enjoy a 20-year term of protection.

I can't see why any protection is necessary.

0:
[https://news.ycombinator.com/item?id=12344059](https://news.ycombinator.com/item?id=12344059)

------
kabdib
If your kid is allergic and needs an EpiPen (or something like it), most
school districts will not allow the child to attend class unless they have one
at the school. Maybe two.

And of course you have to carry them. There's another two.

So that's $2400. Out of pocket if you don't have insurance, or if your
insurance doesn't pay.

The EpiPen manufacturers are abusing their monopoly.

~~~
Mandatum
Given the proper age, teaching kids to use syringe/vials or having a school
nurse that can administer epinephrine would be a much cheaper alternative.

EpiPens are purely about the delivery mechanism. Stabbing a syringe into your
thigh and injecting a predetermined amount of epinephrine into your leg isn't
majorly complicated.

Maybe having a single pen on the kid and vials/syringes at the school would be
a cheaper option.

~~~
Johnny555
I don't think you've ever seen a child in Anaphylactic Shock if you think all
you need to do is train the child to use a vial and needle. Even training
school personnel is not a great idea - While an ER nurse or paramedic can
handle it because they give injections every day, a teacher or even a school
nurse may go for years without ever needing to do an epinephrine injection and
the stress and inexperience may make them unable to perform under pressure of
having a child dying in front of them.

An IM injection is easy to do when you're calm, but just filling the syringe
can be difficult when you're under intense pressure.

~~~
Adirael
I wonder why glucagon isn't done in the same format as EpiPens are. I'm a T1
diabetic and I have one glucagon vial at work and one at home. In the case I
go low (barely responsive low) someone has to go grab it from the fridge (it
needs to be there) load the syringe and use it on me.

When people sleep over I teach them how to use it and I do something like a
show and tell at job from time to time so new people know about it.

~~~
diabeetusman
It's not just 'load' the syringe. There's a liquid and a powder that has to be
mixed. First, the liquid is injected into the powder. Remember to remove the
protective cap from the vial and the two protective caps from the needle
(apparently, people frequently forget the one on the vial and break the
syringe). Then, mix by rolling, not shaking, for 30 seconds. Then, withdraw
the mixture into the syringe and inject it.

Not only does it need to be kept refrigerated, the shelf-life isn't that long
to begin with (about a year).

I'm also a T1D and there's a reason that, despite the various seizures I've
had in my lifetime, I've never received Glucagon.

Cake icing squirted between your gum and cheek also works (although everything
ends up sticky and blue by the end of it).

Edit: I didn't mean to sound like you didn't know what you were talking about,
I just wanted to expand on what you were saying about 'show and tell'

------
invaliddata
The adrenaclick generic is much cheaper than the epipen, with or without
insurance. Although technically different epinephrine auto injectors cannot be
substituted (you can only be prescribed the one written by your doctor, or its
generic equivalent), practically speaking the only difference between the
epipen and the adrenaclick design is the instructions for use. I would hope
there isn't a case of doctors being unaware of the alternatives.

~~~
alexhornbake
Thank you for mentioning adrenaclick. Generics have been completely missing
from the public debate. While epipen price gouging is very real, and a
problem, there is one short term solution for allergy sufferers: demand an Rx
for the generic. They are under $200 (source: checkyourmeds.com). Vote with
your wallet!!

Looks like the differences are: extra safety cap and Epipen brand has an auto-
retracting needle.

[https://m.youtube.com/watch?v=LRgqwgCh4Fs](https://m.youtube.com/watch?v=LRgqwgCh4Fs)

~~~
ultramancool
Great business to be in, attach an auto injection mechanism to maybe $5 worth
of syringe and epinephrine.

Then undercut your competition by over 60%. I hope they do well. If more
generic manufacturers get in on this or the patent expires we might see this
go down to a more reasonable <$50 price, but this is definitely a step in the
right direction.

------
sevenless
How many people will this price hike kill? I'm sure that's estimable.

What would be morally justified, to stop it?

~~~
rdtsc
Nah because it would upset the free market.

I mentioned in another comment when someone from Europe or Canada asked
something to the effect of "how come everything has to be free market in US
even healthcare and such".

And I think the answer is we treat free market as a religion. We don't
evaluate what is better, healthier, more rational answer for a problem. Like
say, "How do we keep people from dying from anaphylaxis?" We don't answer
that. We always answer first, what would free market want? Will it want us to
do this? If not, we don't proceed.

We treat it as if it is deity of sorts and if we disobey we'll be punished.

Someone replied and said this idea isn't so outrageous because a similar
concept has been defined already in politics:

American Civil Religion
([https://en.wikipedia.org/wiki/American_civil_religion](https://en.wikipedia.org/wiki/American_civil_religion))

I am just proposing there is a similar religion in respect to free market.

It is often sold in propaganda terms of course -- we are not communists here,
we just want efficiency, we want progress, don't worry stuff will trickle down
eventually and so on. So we make it palatable but the main incentive is
worshiping the deity.

It sounds crazy but evaluating a lot of things we do as a society through that
perspective can be interesting.

~~~
jdpedrie
That's silly. How do you propose to "evaluate what is better, healthier, more
rational"? I suppose some panel of experts could give you their best
approximation, but it will always be sub-optimal. Markets exist in order to
answer these questions, and they answer them by delegating the decision to
every person involved in the decision, not by hoping a designated person can
make a guess that's close enough.

It appears that the problem in this case is that there is a single producer
who is able to engage in monopolistic pricing, which is certainly not
something a market-oriented person would condone.

And the market for healthcare is not a free market. Not anything resembling a
free market.

~~~
rdtsc
> Markets exist in order to answer these questions,

Well in this case it answered that the price should be $600. This means
people, kids, astamatics are going to die at some point in higher numbers
because of that.

I say the market is drunk or evil and should not be allowed to make medical
decisions.

But because it has a religious following, we don't want to make it angry so we
can't say "we mandate EpiPen cost to be $25". Instead we dance around it and
say "oh we'll create this health insurance thing, and then that will pay for
it". But only if you work. Or ... if you don't you have to buy it anyway, or
you have to pay a penalty. But unless you are old, then we kind a let you off
the hook a bit and you sign up for this other thing. All of that is done in
paper and in how it is presented to the public because we don't want to upset
the free market gods.

~~~
gwright
Setting prices via administrative fiat doesn't eliminate problems. If the
price is set to low, there will be shortages or no product at all. If the
price is set to high, then the blame for the high price is shifted to the
legislature rather than the supplier.

In any case, it is the government that is creating the conditions that allow
the price to be set so high in this case. Blaming the 'market' for adjusting
to the conditions created by government is confusing cause and effect.

------
xnor
If people don't want to buy two epipen there's always that neat trick for
multiple doses in precarious locations far from hospitals.

It is a well known hack taught in wilderness medicine training.

[https://www.youtube.com/watch?v=luultUD0eK0](https://www.youtube.com/watch?v=luultUD0eK0)

~~~
Terr_
So a "used" epi-pen's internal syringe might contain 4-5x more epinephrine
than actually goes into a standard dose? I assume this means most of the
expense of making it comes from the housing/mechanics. (And recouping whatever
cost of QA/approvals.)

~~~
smu3l
The drug itself is very cheap. With an Rx you can purchase an ampule with
about 3 doses for < $10.[1] You can administer it with an insulin syringe,
which I don't think requires an Rx. Of course administration is a lot more
tedious and requires some training.

I worked at a summer camp where we would carry 1 or 2 pens plus a bunch of
ampules if we were in a wilderness situation where we couldn't get to
emergency care and needed more than one dose.

[1] [http://www.buyemp.com/product/epinephrine-
ampule](http://www.buyemp.com/product/epinephrine-ampule)

~~~
yoohoocthulhu
The drug is cheap...because it's unpatentable (as a molecule anyway) and is
old enough that any patents would be expired anyway.

The marketing of autoinjectors has some legitimate public health value, but
it's also a clear business strategy to get new drug prices for an ancient drug

------
eliben
If the product is decades-old, why haven't generic variants appeared?

Something seems to be missing from this article.

~~~
sriram_sun
There are generics. What is patented is the delivery mechanism. I've had to
administer it twice. You take the cap off and just push it into the thigh. The
top part moves back and the needle pushes through.

~~~
eliben
Thanks, so this is the missing information. The article misleadingly says the
medication is decades-old, where actually the pen itself is patented.

~~~
toomuchtodo
The patent is expired:
[https://www.google.com/patents/US4031893](https://www.google.com/patents/US4031893)

Courtesy ceejayoz below:
[https://news.ycombinator.com/item?id=12340464](https://news.ycombinator.com/item?id=12340464)

~~~
shanacarp
so why aren't there more case manufactures

~~~
tw04
For the same reason there were no competitors to daraprim before Martin
Shkreli decided to be a complete ja. When the price is low enough that there's
little profit to be had, nobody bothers competing because it's not worth the
time, money, and effort to get FDA approval. When the price gets jacked up
like that, you will find generics pop up quickly. The problem is the window
between the price hike and when generics pop up can sometimes be years due to
needing to get FDA approval.

In this case there was a competitor, but they recently had their product
pulled from the market in an FDA recall. So Mylan decided: why not raise the
price 600% (and rising) when it's a drug people HAVE to have.

Capitalism in action baby. Let's deregulate EVERYTHING!

~~~
refurb
Hmmm... from your description, it sounds like the market is working, just not
fast enough for everyone.

It's not worth it for a company to develop their own Epi-pen since profits are
so low. Eventually enough drop out that one manufacturer raises the price.
Significant profits result which attracts other competitors. Prices drop.

Would you just prefer the gov't to step in and set the price? What happens if
companies decide it's not worth the effort? Have the gov't force them to
produce the product?

~~~
toomuchtodo
> Would you just prefer the gov't to step in and set the price? What happens
> if companies decide it's not worth the effort? Have the gov't force them to
> produce the product?

Cut out the private market and have the government manufacture it directly.

~~~
refurb
Can you give me some examples where the gov't has come in as a manufacturer
and it's actually gone well?

~~~
John23832
They've done pretty well in the power sector. One could argue that most power
(electric) companies are really just state run shells.

[https://en.wikipedia.org/wiki/Hoover_Dam](https://en.wikipedia.org/wiki/Hoover_Dam)

------
hoodoof
Mylan refers the press to their local politicians "go talk to them about it,
we pay our lobbying fees to get whoever we want elected specifically so we can
charge any price we want, you can't do a damn thing - it's a free country".

------
helloworld
Why haven't competitors entered the market with cheaper products?

~~~
ccleve
There are really two villains here, Mylan, of course, but more importantly,
the FDA. FDA regulations make the cost of bringing a new medical device to the
market absurd. There are no competitors because the time and effort to bring a
competing device is so ridiculously high that it doesn't pay to do so.

I have a child with a peanut allergy. I am worried every damn day of my life.
I see articles about people who die every year because they didn't have an
Epipen handy. The numbers of people who die will increase. I want to see FDA
bureaucrats hauled to those funerals so they can see what they've done.

~~~
dfsegoat
So, The FDA, because they require drug and device makers to demonstrate
efficacy and safety by going through a rigorous clinical trial process, are
evil? Really?

I also find your comment pretty uninformed considering that the FDA just paved
the way for generic drug makers to basically "knock-off" super expensive
biologic drugs like Humira and Enbrel which were previously covered by similar
patents.

The FDA has it's problems - but to say that it is an agency staffed by people
who don't care ("bureaucrats") who typically have both Ph.D _and_ M.D.s and
have dedicated their careers to ensure patients have safe and effective
medicine is unfair.

edit: grammar.

~~~
ccleve
> So, The FDA, because they require drug and device makers to demonstrate
> efficacy and safety by going through a rigorous clinical trial process, are
> evil? Really?

Yes, if the process is so rigorous and expensive that it drives the cost of
drugs beyond the reach of people who need them, and it hampers the effective
functioning of the free market. And I think it's widely accepted that's far
more expensive to bring a drug to market here than it is elsewhere in the
world.

The FDA believes its mission should be to ensure that drugs are safe and
effective. That is wrongheaded. Instead, it should undertake a rational
risk/benefit approach. Rather than saying that no drug gets through the filter
unless it's safe (as demonstrated through reams of evidence), it should ask,
how much risk should we tolerate in exchange for how much benefit?

In the case of Epipens, there's little risk, because epinephrine is an old,
widely-used drug. There is some risk that it will be mis-administered by a
less-than-perfect device, but the fact is that a $10 bottle of epinephrine and
a $1 syringe can save a life. It is offensive that the FDA thinks it should
get in the way of the distribution of such things.

I was in Colorado last summer and took my son horseback riding. Our tour guide
was allergic to bee stings, but she was just scraping by financially, and
couldn't afford an Epipen. She'd been stung before, and her throat had
tightened, but fortunately she happened to have an old, expired pen from
before the price went up and so she survived. But now she was going out bare.
We gave her one my son's pens. It won't last long. It's possible that she
won't last long either.

You want evidence this is an evil system? There it is.

~~~
DSMan195276
I don't really think you know all the history here. There _are_ other
companies who have/are attempting to create competitors to EpiPen. A few of
them weren't able to get passed by the FDA, and one of them passed the FDA in
2012 but was recalled because of the product misfiring. The EpiPen problem
seems to be much less an FDA problem then it is a problem with manufacturing,
other companies don't seem to be able to make products that work nearly as
well as EpiPen. If the FDA wasn't in the picture, you would still have the
problem that there aren't any other reliable replacements for EpiPen even
though companies have tried.

IMO, I also don't see how your solution would solve any real problems. People
shouldn't have to ask themselves "Do I buy the one that is 600$ with a 100%
success rate, or the one that's 100$ with a 95% success rate?". That sounds
like a pretty bleak state of affairs, and could easily encourage cutting
corners to cut costs. "How much does a death cost us?"

~~~
derekp7
What about buying 5 of them that are $20 bucks a piece? Maybe they can be made
in a stackable format, so it would be easy to carry 5 of them. If one
misfires, snap it off and use the next one in the stack.

~~~
DSMan195276
That only works if you can actually tell if it misfired or not - if you're
administering it to someone else, you may simply not be able to. With that,
part of the problem was that the misfires would deliver some of the drug but
not all, and only sometimes would completely fail to deliver any of the drug.
Telling if you got 50% vs. 100% would probably be tough - and even if you
could, if you took two because the first gave you 50%, you might end-up
getting a big overdose or still get an underdose. So having multiple of those
pens really just doesn't solve the problem if the pens themselves are
unreliable.

------
ohitsdom
The petition to Congress mentioned in the article:

[http://www.petition2congress.com/20720/stop-epipen-price-
gou...](http://www.petition2congress.com/20720/stop-epipen-price-gouging/)

------
Mandatum
They don't produce EpiPen's as a generic in India because the Indian medical
community does not recommend self-administration of epinephrine.

If you're that much in need though, you can buy pre-filled epinephrine
syringes for intramuscular injection - just keep in mind the ease-of-use of an
EpiPen won't be available. You have to take the time to take off the cap,
insert and inject the medicine.

~~~
shanacarp
what happens if someone goes into anaphylaxis?

~~~
Mandatum
I assume they intramuscularly inject epinephrine just as you would with an
EpiPen. I doubt it'd be hard for patients to get hold of an epinephrine kit.

You'll also find developing countries have far less allergic population. It's
said this is partly due to urban environments having more vitamin D deficiency
as well as people being more exposed to more pathogens/etc during childhood
outside of developed countries.

------
BryanBigs
Since Sanofi previously had an equivalent product on the market for at least 3
years (called Auvi-Q), I'm really curious - why were people paying up for an
Epi-pen? Was it the brand name? Do schools mandate it's an Epi-pen? I know
Sanofi pulled the product in October of last year, but it seems like Mylan has
been raising prices during that time.

~~~
nix0n
They seem to have some manufacturing trouble, leading to a recall[0] and
pulling the product from the market. They mention Epi-Pen and Adrenaclick[1]
as alternatives.

[0][https://www.auvi-q.com/recall-faqs](https://www.auvi-q.com/recall-faqs)
[1][http://www.goodrx.com/adrenaclick](http://www.goodrx.com/adrenaclick)

------
gkanai
This is a simple example of how health care systems should be nationalized. Or
that the profit motive in health care is corrosive to health.

~~~
ucaetano
No it doesn't. Switzerland has one of the best healthcare systems in the
world, which is completely private (although there are some public hospitals),
but heavily regulated.

~~~
robryk
Alas, there are significant differences between the Swiss and US one. Most
importantly, law in Switzerland specifies exact coverage criteria for basic
health insurance and prohibits excluding pre-existing conditions from it. I'm
not sure how financing of hospitals works exactly (I was under the impression
that they are at least partially publicly owned). Minor things: there are
phone-a-doctor public services that are free of charge for residents in some
areas.

Edit: also, every company that provides basic insurance can vary the price
based on a limited set of factors and must accept any person.

~~~
maxerickson
The ACA standardized basic health insurance and prohibited excluding pre-
existing conditions.

------
kuon
Is this only in the US?

I'm in Switzerland, and I bought some for my kid, I paid around 80$ per piece.

[http://compendium.ch/mpro/mnr/22294/html/fr](http://compendium.ch/mpro/mnr/22294/html/fr)

You have the price at the far bottom of the page, around 76CHF.

I'm a bit concerned if the price is going to be x10.

~~~
Thlom
I'm not familiar with the swiss health care system, but in Norway the
government foots most of the bill for prescription drugs. The government is
negotiating price with the manufacturer and as a big buyer they can get a fair
price.

~~~
mrweasel
I have an EpiPen, just in case, because I keep bees. It is a prescription
drug, but government co-pay doesn't kick in because the price is to low. I
paid USD120, around DKK800, for one EpiPen.

My guess is that the US prices are higher, because insurance will pick up the
bill for most people, allowing the manufacturer rise the prices with little
consequence... for most people. Generally speaking Americans tend to pay a
high cost for their lack of a national healthcare system, with very little
benefit.

------
shanacarp
This is one of those devices that also should be low cost because businesses,
locations, ect should have them as well as individuals (many people can have
first time deadly allergic reactions, including as adults)

That the price for the case is expensive just rose as random is serious
business. There really is no need for it to be so expensive

~~~
slowmovintarget
I have no evidence, but this headline coupled with the insulin price hike...
it really feels like this is an attempt to manufacture a crisis.

I fill a prescription for epi-pens once a year (nut allergies), but insurance
bears the brunt of the cost.

~~~
gwright
Insurance simply distributes the high cost to many people via higher premiums.
Without competition to reduce the cost or regulations that set the price by
law, the high cost remains.

~~~
ancap
>or regulations that set the price by law, the high cost remains

It is important to note that even such a law does not magically remove the
high cost. Certain products have a high price for a reason and setting the
price by fiat is guaranteed to cause shortages. That's when people really
start dying. See Venezuela for a prime current example.

~~~
JshWright
There is no supply side reason for the high price Mylan is charging for
EpiPens. It is a couple bucks worth of materials (plus QA, distribution, and
all that). The R&D costs have long since been amortized away to nothing.

~~~
ancap
How do you know? The medical industry regularly has shortages of dozens of
different products [1]. And that is to say nothing of the cost of navigating
through all the regulatory hurdles.

[1] [http://www.economicpolicyjournal.com/2015/10/drug-
shortages-...](http://www.economicpolicyjournal.com/2015/10/drug-shortages-
price-gouging-and-our.html)

~~~
JshWright
The price of epinephrine in other packaging (vials, ampules, etc) has remained
more or less unchanged (speaking from firsthand experience as someone who
orders supplies for an ambulance service). It is not an epinephrine shortage
driving this price increase.

Similarly, the EpiPen is already an FDA approved product, and has had no new
regulatory hurdles to jump through recently.

------
grandalf
A friend of mine has a child with an allergy and was visiting Turkey. A family
member of his (in Turkey) is a physician, and said that in Turkey nobody uses
epi pens and allergies are generally never the cause of visits to the ER.

Is this true? What's going on?

------
samgranieri
Oy. As someone who carries two of those damn things (grumble grumble Peanut
allergy grumble grumble) and is a very conservative eater, this is not good.

Luckily, I haven't had to use one of them in like 8 months.

------
nilved
This seems less damming to me considering the medicine naturally occurs inside
your body. What reason is there that nobody else can make a competing product
for cheaper?

~~~
infinite8s
Regulatory hurdles to get a new device approved.

~~~
nilved
Maybe regulation is not so good after all

~~~
rtkwe
There was a competitor but it wasn't able to reliably inject the correct
amount of medicine so it was recalled. [0]

[0] [http://www.fiercepharma.com/marketing/sanofi-s-auvi-q-
recall...](http://www.fiercepharma.com/marketing/sanofi-s-auvi-q-recall-puts-
mylan-s-rival-epipen-full-control-of-blockbuster-market)

------
grandalf
link to patent:

[https://www.google.com/patents/US20050273054](https://www.google.com/patents/US20050273054)

------
serge2k
Well you know, they need to recoup the R&D costs to develop the drug.

> Mylan, the pharmaceutical company, acquired the decades-old product in 2007,
> when pharmacies paid less than $100 for a two-pen set

Oh.

This is why US health care is broken people.

~~~
kasey_junk
This is one reason. Another reason is that a huge chunk of the population will
simply not see these costs.

For instance, I choose to be on a high deductible plan at my work (they offer
both a high deductible plan and a traditional PPO). My wife has the choice of
a reasonably priced HMO and a extremely expensive PPO.

On my high deductible plan if I need a refill for an epipen I pay the full
boat unless I'm past my deductible (or really my HSA does) on my wifes HMO
plan we pay $25 every time we need one. We both have prescriptions, what is
the rational decision for my family to make if we need a new epipen?

That cost differences is not "free money", it comes out of the pocket of my
wife's employer and peers rather than my employer and peers. There is a
dramatic agency problem in the US health system as well.

~~~
maxerickson
Apparently they'll cover your copay.

[https://www.epipen.com/en/copay-offer](https://www.epipen.com/en/copay-offer)

(I didn't read it closely, but the eligibility criteria seem to be 'private
insurance')

~~~
kasey_junk
I don't have a copay on epipens, but I do have a deductible. This actually can
help me but the max is $100 off of full price (a few years ago I got $75 off
with a similar card).

~~~
maxerickson
Oh, I didn't think you would be terribly concerned about the savings, I
thought the company helping patients use their insurance was a nice addendum
to your comment about the agency problem.

Edit: The way I read it, if you give the card to the pharmacy, the company
will pay the $25 on your wife's plan.

~~~
kasey_junk
Yeah, for sure. It is interesting. Also copays vs deductible etc all seem to
be ways to complicate coverage on purpose.

------
Ironchefpython
> selling service contracts, [...] The price is still $0 and there are still
> no regulations on it.

I assume at this point that you're being paid to shill some political
viewpoint on the internet, because you just explained that the price of
software isn't actually zero, because it's unusable (to the customers that buy
a service contract) without a service contract, and creating a company that
employs the developers that wrote the software to support that software has a
high barrier to entry. (because those developers are already employed)

To pick at company at random, HortonWorks. I pick on them because I recently
saw an invoice. $20,000 for 16 hours of training. So by your argument, there
must be some kind of regulation there, right?

~~~
WalterBright
You're making quite a vast assumption that service contracts mean the software
is unusable without them. Red Hat Linux is just one counterexample.

A further vast assumption is that your arguments are so compelling that anyone
not convinced must be a paid shill.

There are many software consultants who charge over $10,000/day for doing
training. Many companies find them worthwhile when amortized over a roomful of
engineers. Those consultants aren't suckering anyone in by giving them free
software, in fact, they don't provide any software whatsoever.

~~~
Ironchefpython
>> it's unusable (to the customers that buy a service contract) without a
service contract

> You're making quite a vast assumption that service contracts mean the
> software is unusable without them. Red Hat Linux is just one counterexample.

No. I'm not. I'm basing that on the tautology that consumers of "free"
software who purchase expensive service contracts spend their money purchasing
expensive service contracts.

Software is free in the same way that air conditioning at the mall is free,
the hugs handed out by the "free hugs" guy are free, the way that the
privilege of watching advertisements on TV are free. Somebody is spending time
and money making this software, because they think they are going to get more
out of it than they put into it (either tangibly or intangibly (except for
that TempleOS guy, who does it for the voices in his head))

And this still doesn't change anything about the EpiPen. There's a consumer
surplus, and the price is increased to maximize capture of consumer surplus
regardless of the cost in human lives. I don't care how free software is, the
price on EpiPens is going up to maximize profit.

To frame this as a simple dichotomy, would you rather live in a world where
people die to maximize profit, or a world where regulation is applied to
reduce human suffering and death?

~~~
WalterBright
> To frame this as a simple dichotomy

Except it's not so simple. Peltzman showed with statistics in "Regulation of
Pharmaceutical Innovation" that the 1962 FDA amendments resulted in an
increase in human suffering and death. (The 1962 amendments added "and
effective" to the FDA's mandate.)

While some ineffective drugs were prevented from reaching the market, this was
overshadowed by good drugs being delayed, and a sharp reduction in new drugs
being developed due to huge cost increases from the regulations.

Markets are very dynamic systems, and unintended side effects always happen
even with regulations that have the best of intentions.

------
tomohawk
The US is subsidizing the rest of the world. When Canada decrees that the
price of something will by X, then guess who pays?

~~~
mikeash
Do these things actually cost more than $100 to manufacture? The US isn't
subsidizing the rest of the world with this, we're subsidizing the
shareholders of a single company.

I've seen this argument made regarding American health care costs in general.
Everyone else pays much less because we're subsidizing them, the argument
goes. Except that American medical R&D spending is about $500/year per capita,
while the gap in health care costs is thousands. That's some combination of
waste and people getting rich off of other people's suffering.

This product could pretty clearly be sold at a profit at the old price. But
they can make more money if they charge more. People will die because they
can't afford it anymore? Fuck 'em, apparently.

~~~
tankenmate
Indeed, the UK NHS (National Health Service) pays £26.45 per pen. NICE (the
NHS purchasing and commissioning body) negotiates prices on most drugs,
devices and medical services used by the NHS, and they make sure that the
prices they get are not only evidence based but also sustainable (in both the
fiscal and health sense).

------
glusterfuck
These are $125 for two pens or thereabouts in the UK, same device. Presumably
import is regulated?

[https://onlinedoctor.lloydspharmacy.com/uk/allergy/epipen](https://onlinedoctor.lloydspharmacy.com/uk/allergy/epipen)

~~~
tankenmate
Actually the NHS pays £26.45 per pen.[0]

And yes it is regulated; it is considered both a drug and a medical device.

[0]
[https://www.evidence.nhs.uk/formulary/bnf/current/3-respirat...](https://www.evidence.nhs.uk/formulary/bnf/current/3-respiratory-
system/34-antihistamines-hyposensitisation-and-allergic-
emergencies/343-allergic-
emergencies/anaphylaxis/adrenalineepinephrine/intramuscular-injection-for-
self-administration/epipen)

