Since the introduction of the Auvi-Q in early 2013, there has been a price war going on between Sanofi, the maker of the device, and Mylan, maker of the EpiPen. Both devices are epinephrine auto-injectors: single-use devices that contain a single dose of epinephrine and can easily be administered to oneself or to another person with minimal medical training. These devices are used to halt the serious, multisystem allergic reaction known as “anaphylaxis” which can occur when people with food allergies eat a food they are sensitive to.
By early 2014, my research on food allergies was well under way and I was starting to understand some of the priorities and events that shape the food allergy world. The price battle between Sanofi and Mylan was just heating up at around the same time. Both companies released “$0-copay coupons” within weeks of each other. These coupons allow people with health insurance in the United States to get their medication effectively for free. You hand the coupon to the pharmacy cashier and the company reimburses the store for what the patient would typically pay up front as a copay for their medication. It makes these devices free from the point of view of the patient – though the insurance company and drug manufacturers ultimately end up splitting the cost.
I remember how these coupons were received by food allergy bloggers, many of whom I’ve had the good fortune to meet in the year since they were first released. It seemed that the Auvi-Q’s design was winning over many people with food allergies and parents of food allergic kids. First of all, the device was much more convenient for sticking in a pocket or purse – roughly the size and shape of an iPhone 4. Second, the voice seemed to please mothers of allergic kids in particular, since it could guide untrained caretakers of their children through the process of administering the medication in an emergency.
A Changing Economic Picture
But now the price of the Auvi-Q is going up. Insurance companies are choosing not to cover the device, presumably because it’s so similar to other devices that are already covered (like the EpiPen). Coupons are harder to come by and no longer reduce patient’s cost to $0. For people without insurance, the $569.99 sticker price is prohibitively expensive.
There’s an excellent analysis of this series of events from a legal and parental perspective over at the food allergy blog Oh Mah Deehness! Homa points out that the “contract” implicit in purchasing goods from a store only extends to a particular transaction. The implication of this is, as I understand it, that there is no implied guarantee that the future price of the goods will remain the same. This is, she argues, a problem when it comes to epinephrine auto-injectors because there’s an ongoing need for a person with food allergies to have the recommended 2 unexpired, unused devices on their person at all times. It seems as though auto-injector manufacturers have violated the trust that they were building with the food allergy community last year – but what they are doing when they adjust their prices is, in fact totally legal.
A Social Science Perspective
I’m turning to Joseph Dumit’s Drugs for Life argument to parse this as a social scientist. I’ve mentioned Dumit’s work before, but I don’t think I’m mentioned this particular book. In this book, Dumit’s research reveals that the costs to develop new drugs combined with the profit motivations of shareholder-owned pharmaceutical companies means that these companies focus their efforts on producing “drugs for life.” Dumit means two things with this phrase: first, drugs that must be taken for life; and second, drugs that help sustain and extend life. Epinephrine fulfills both those criteria for “drugs for life,” though in a little bit different way that Dumit originally intended.
The benefit of developing “drugs for life” for pharma companies is that patients need to continue purchasing them on a regular basis for the rest of their lives. Today this is true for epinephrine auto-injectors for people with food allergies, since there is no other widely accepted rescue medication and no way to prevent or “cure” food allergies.
The Auvi-Q episode emphasizes one part of this story that Dumit hints at but doesn’t exactly make the focus of his argument. As people – both patients and doctors who prescribe medications – get locked in to expecting and relying on a product or product category, pharmaceutical companies have more and more leverage to raise prices to whatever level they wish. Now that epinephrine is widely accepted by both doctors and patients as the one best and vitally necessary rescue medication for treating food allergies, pharma companies have essentially unlimited power to demand whatever prices they want.
What the pharmaceutical industry ends up with is a market in which it has a lot of power to set prices – but not infinite power. Pharma companies have to play a delicate game, trying to maximize profits without alienating consumers.
In the case of epinephrine auto-injectors, there are in fact several options on the market, with different patterns of insurance coverage. Patients can find out which products, if any, are covered and potentially switch to them. This is the kind of argument we hear about a lot in debates about the price of health care in the US today: the market will fix it.
But there’s another angle to consider, too, separate from abstract appeals to “the market.” Patients have power as well, not only to switch to competitors but also to articulate their concerns publicly. This is especially the case in our age of social media, when local illness support communities have banded together into a network with national and international reach. The food allergy community is a well-read, well-spoken group, and some writers have even been featured before on major news outlets. $0 copays anticipated patient anxiety about price in a crowded market; perhaps they, or something like them, will come back if concern about rising auto-injector prices is articulated widely and loudly enough. Those women I’ve begun to call “mother activists” in my academic writing – many of whom will likely read this – might be able to slow the rising tide of high auto-injector prices.
My final verdict on this issue? Stay tuned – I think there is more to come…