Beyond EpiPen: Spiking costs of basic drugs burden patients, emergency services

Aug. 26--Basic lifesaving medicines that emergency workers use every day are getting so costly, officials are scrambling to figure out how to pay for them. And as patients struggle with drug costs, EMS workers and emergency room doctors are seeing the impact.

The price paid by Philadelphia Emergency Medical Services for naloxone, which reverses opioid overdoses, has risen 150 percent since 2013. Calcium chloride, administered to heart attack patients, has soared nearly 290 percent. Lasix, used to treat heart failure and kidney disease, has spiked nearly 820 percent.

Even epsom salts -- used for asthmatics who don't respond to steroids or epinephrine -- have risen nearly 6-fold.

"We've had to ask for budget increases to keep up with the cost of medications," said the head of Philadelphia's Emergency Medical Services, Dep. Commissioner Jeremiah Laster. "The prices have gone up astronomically."

The recent national outrage over the skyrocketing cost of EpiPens, the lifesaving allergic-reaction product, has brought renewed scrutiny to the rising prices of other pharmaceuticals. But it's an old story for Laster and other emergency services officials -- who not only are seeing prices go up, they're also seeing the consequences of patients unable to afford their medicines.

EpiPen's manufacturer, the formerly Pennsylvania-based Mylan, hiked the price of its epinephrine delivery device by over 600 percent in less than 10 years.

Philadelphia EMS doesn't use EpiPens. Instead, emergency workers use a less expensive nasal spray epinephrine, and paramedics can administer the drug through a syringe. But even the price of generic epinephrine has risen more than 200 percent since 2013.

With the retail price of EpiPens topping $600 for a 2-pack, some people with life-threatening allergies opt not to buy it at all.

"They just rely on calling 911 and take their chances," Laster said.

As the opioid epidemic rages and record numbers of people die of overdoses, the cost of generic naloxone has more than doubled. In 2013, Philadelphia EMS spent about $15 per dose and administered it to 2,600 patients. Total cost: $40,000.

Last year, naloxone spiked to $38 as the department responded to nearly 15,000 overdoses and administered more than 3,000 doses of the opioid antidote. Total cost: $113,000.

Smaller EMS companies pay even more per dose because they don't receive the volume discounts afforded large cities.

The Second Alarmers Rescue Squad of Montgomery County, which covers Willow Grove, Jenkintown and Abington, pays nearly $50 a dose for naloxone. The non-profit volunteer company pays for each dose it administers out of its own budget.

"We don't itemize the medicines we give," said Ken Davidson, assistant chief of the Second Alarmers. "With our ambulance services, there one lump sum bill. There's nothing we can do to recover their cost. It's frustrating."

Even price increases for drugs that aren't designed as emergency remedies are having an impact on emergency services. Philadelphia EMS workers don't even carry insulin, another familiar drug that has seen astonishing price hikes. But Jonathan R. Anolik, an endocrinologist at the Lewis Katz School of Medicine at Temple University, says he's seeing patients at with diabetes that should be manageable turn into emergencies because they can't afford their insulin.

"They get a $20,000 to $50,000 hospital stay because they lack the funds to pay for a $250 bottle of insulin," Anolik said. "It's hard to know if 100 percent of them are admitted because they couldn't afford it, but for most, it's because of costs."

At Thomas Jefferson University Hospital, emergency medicine pharmacist Glenn Oettinger said he sees "quite a few patients" coming into the ER because their medicines cost too much.

"A barrier has been created for them that prevents them from effectively treating their illness, whether it's diabetes, high blood pressure or seizures," Oettinger said. "A visit to the ER is very expensive. Not only to the individual, but also for the hospital. It's all completely preventable."

Guy David, associate professor of health care management at the Wharton School, said that in large part, prices for basic medicines have risen because the pharmaceutical companies can charge whatever the market will bear.

"It's like the price of french fries at Disney World," David said.

Unlike in Canada and Europe, the U.S. government does not impose limits on drug prices.

"The prices aren't regulated," David said. "That's part of the issue."

Some makers of generics say they raise prices due to higher costs of raw materials, or in order to keep up with competitors who have raised their prices, though overt price collusion is illegal.

Another factor is that when manufacturers merge and consolidate, or when a company stops production of a drug, competition that otherwise could keep prices in check decreases. Drug wholesalers also come in for some of the blame, as does government regulation on how drugs are produced.

The pharmaceutical industry frequently has said that drug costs aren't the biggest driver of overall health care costs. But for consumers who don't have lavish health insurance, and for local governments, drug prices can be a considerable burden.

Philadelphia has already paid out $267,000 this year for EMS medications.

"Obviously any price increase is a strain," said Dep. Commissioner Laster, "And of course, that cost is passed on to taxpayers.

"That means everybody pays for it."

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