Uncle Sam, MD?

(April 10) — Now that health care reform is the law of the land, state governments will have to start looking for serious ways to control health costs. And one tempting target will be prescription drugs, which account for an increasing share of the nation’s health tab.

But one cost-cutting idea bandied about would put patients’ care at risk and could easily end up costing more money than it saves. It’s called “therapeutic substitution,” and several states already use it in an attempt to cut costs in their Medicaid programs.

Therapeutic substitution is a practice in which a pharmacist swaps out a drug prescribed to a Medicaid patient for a cheaper alternative. This new drug isn’t a generic — it’s simply in the same “therapeutic class” as the original. That means it’s approved to treat the same ailment but likely has a fundamentally different chemical makeup.

Many states already allow therapeutic substitution — some don’t even require a patient’s consent to make the swap. Others, including Washington, D.C., have recently considered legislation that permits this practice.

But the idea carries important health risks.

Substitute medications, even if they are meant to treat the same ailment, can affect patients in dramatically different ways. That is why many different factors go into a doctor’s decision about which pill to prescribe. For drug classes that require an especially fine-tuned interaction with the patient, like epilepsy medication, switching pills can even be fatal.

A 2002 Harris Interactive survey suggested that about 13 percent of all patients who took substitute medicines — about 1.1 million people — reported that the new drug was ineffective in treating their conditions. And 22 percent experienced new side effects.

Drug substitution can also make it difficult for patients to follow their regimens. New medicines often require a different dose frequency or a shift in diet. And the pills themselves can have a different color, shape or packaging. These changes cause confusion, especially among the elderly.

Such behavior compromises patient care. And less healthy patients require more medical services, like office visits, lab tests and operations. Those services require additional dollars.

So, ironically, this move that’s meant to cut down on health care expenses actually raises them.

This has already happened in Canada. Back in 2003, the government of British Columbia, Canada’s most westerly province, instituted a drug-substitution policy for acid-related diseases. Qualified patients would be switched to the cheapest available “proton pump inhibitor” medication. Between 2003 and 2005, 87,000 people had their drugs changed.

The result? Avoidable health care costs climbed by $43.5 million over that three-year period, according to a study by the Fraser Institute, a Vancouver-based free-market think tank. The drug switching undermined patient health, leading to bad medical outcomes and higher health care spending.

Which is no doubt why doctors overwhelmingly oppose therapeutic substitution. Indeed, a 2008 survey from the Medical Society of the State of New York found that 93 percent of doctors complained about pressure from the government to switch prescription medications.

Patients are wary as well. Seven in 10 say they would be very concerned if a drug they were taking was switched out for another drug in the same class without their doctor’s knowledge or consent, according to 2008 Harris Interactive survey. Fully 78 percent support a requirement that physicians be consulted before any substitution takes place. And 85 percent want to be notified if their prescriptions are changed.

Drug treatment is a highly complex process. And doctors are best positioned to make the difficult determination of what medications will work for a specific patient.

In their race to cut down on costs, proponents of therapeutic substitution are encouraging bad medicine.

Sally C. Pipes is president and CEO of the Pacific Research Institute. Her latest book is “The Top Ten Myths of American Health Care.” Follow her on Twitter @sallypipes.

Nothing contained in this blog is to be construed as necessarily reflecting the views of the Pacific Research Institute or as an attempt to thwart or aid the passage of any legislation.

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