An open letter to Heather Bresch: What is legal is not always ethical


Dear Ms. Bresch,

I couldn’t help but notice the barrage of negative press you’ve received lately regarding the significant price increases in EpiPens. A 461 percent increase since 2007, to be exact. People who require this medication for themselves or their children are up in arms about spending over $600 for a twin pack of autoinjectors. Most of these people have life-threatening anaphylaxis if they are exposed to certain allergens. To them, whether or not they have an EpiPen could mean life or death.

Now, I don’t want to bore you with the medical stuff. You are not a clinician; you are a business woman. I know you have likely not broken any laws with your price increases on EpiPen (and, for that matter, metoclopramide, dicyclomine, tolterodine and ursodiol, just to name a few). They were purely business decisions, I’m sure. A CEO who manages to increase her compensation by almost 700 percent over an eight-year span clearly knows how to make good business decisions for herself and her company. And I realize that your company, Mylan, is not alone among pharmaceutical companies in this practice of inexplicable price hikes.

These hikes on prescription medications far exceed inflationary price increases, and are placed on old medications that have not improved a bit over the years. As Rodney Whitlock, a consultant with the Campaign for Sustainable Rx Pricing puts it, if other companies took the same approach, “… Ford would be selling the Pinto for $84,000.”

I’m sure you are aware that lawmakers are calling for government regulations to reign in these prescription drug price increases. Many argue that Medicare, forbidden by law to negotiate directly with pharmaceutical companies to obtain lower prices for its Medicare Part D recipients, should be free to do so. Medicaid requires inflation-based rebates; perhaps this policy could be applied to Medicare too?

However, for a patient who does not qualify for Medicare or Medicaid, these policies are of little use. And I’m sure, with your business sensibilities, any rebate or price reduction required by the government will just be met with more price hikes paid by the nonbeneficiaries in the loop.

You argue that Obamacare is to blame for these increases, since patients with higher deductibles are spending more out of pocket for prescriptions and are now faced with the true cost of their medications. Is the real problem the fact that these exorbitant prescription prices are now exposed to the general public, or is it the prices themselves? Now, Ms. Bresch, being a business woman, you know that even if insurance pays quietly for high-priced prescriptions, the cost is eventually passed on to patients through higher premiums. Is this not your own reasoning when asked about the EpiPen price increases during your recent CNBC interview? You admitted that the cost of EpiPens in the U.S. subsidizes the cost around the world, where they are sold in Europe for between $100 to $150. Are you not simply passing on the cost to patients in the U.S. to make up for lost revenue?

The fact is that you are leveraging a state of zero competition. Your competitor Auvi-Q was recalled last year, and Teva’s generic version of the EpiPen failed FDA approval. Perhaps, if you could spare an EpiPen for the FDA, the injection would provide this regulatory body the energy boost it needs to expedite approval of generic drugs, providing the only reliable way of truly fixing the prescription drug cost hike problem.

You stated in your CNBC interview that “Our health care is in crisis.” Yes, Ms. Bresch, I and my fellow physicians have noticed that something was awry for some time now. The rising cost of health care, for which I believe you and your counterparts in the pharmaceutical industry are partially to blame, is prompting Medicare to find innovative ways to stop the financial bleed, focusing of physicians’ utilization of services. The ballooning number of hoops required to jump through to receive payments for necessary treatments has put a tremendous strain on physician practices, increasing frustration and practice costs, reducing career satisfaction, and prompting practice closures. The number of primary care physicians in the U.S. has been plummeting to the point where less than 25 percent of new physicians choose to pursue primary care. The strenuous hours and ever reducing reimbursements are pushing medical students to more financially stable specialties. As a result, patients can’t find a primary doctor.

And contrary to what some believe, most physicians don’t choose medicine as a career to get rich. As you well know, there are better ways of doing that. What we are choosing is the treasured opportunity to help our fellow human beings. Being in the presence of their pain, their suffering, and their personal stories while making a difference in their lives provides the energy that keeps us going. Not the paycheck. Perhaps it’s this repeated reminder by our patients, that they are the root of our efforts, that physicians and all providers understand that compensation is not always measured by money. Again, your decisions to increase prices on prescriptions beyond inflation and reason likely did not break any laws. But what is legal is not always ethical.

As the old saying goes, “You can’t take it with you.” You may have had a more luxurious ride through life, but when life comes to a close, you will be at the very same place as everyone else, including those struggling to afford the very medications that have contributed to your 18 million dollar salary in 2015. At that point, what will be of more comfort to you: your designer heels, or the thought that you used your privileged position in life to help a substantial number of fellow human beings?

I can tell you the answer a patient struggling to breathe with anaphylaxis would give you.

A concerned physician

The author is an anonymous physician.

Image credit: Amy Kerkemeyer /


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