Pharmacies Switching Patients’ Drugs to Save Money, Some Charge

Consider this scenario: A patient walks into a pharmacy, drops off a prescription and ends up with an entirely different drug than the one prescribed by his or her doctor. Not a generic drug, but a nonchemically equivalent alternative drug within the same class.

In many states, including California, the practice is perfectly legal. It’s known as therapeutic substitution, and many times doctors aren’t aware the switch is happening.

Cholesterol-lowering drugs, antidepressants, epilepsy drugs and medicines that reduce stomach acid are switched the most, according to the National Consumers League, a nonprofit advocacy group representing consumers on marketplace and workplace issues. While the medicines are in the same family of drugs, doctors say varying levels of effectiveness can have grave consequences.

Switching a patient from one epilepsy drug to another, for instance, could trigger seizures for some patients. Changing antidepressants may produce less effective results.

“The problem with doing wholesale therapeutic substitution is that patients are individuals, and sometimes what works well for a group wouldn’t be particularly good for one patient,” said Dr. Ori Ben-Yehuda, a cardiologist at UC San Diego Medical Center.

Anti-arrhythmic drugs, for example, can take years to get right and have varying effects on people, he says.

Some medical associations say they’re worried that health plans are pressuring pharmacies to switch patients’ drugs to save costs.

Legal Switches

Pharmacy groups deny the charges, saying that prearrangements made between pharmacists and prescribers allow them to switch a drug if the prescribed one is unavailable or isn’t covered by a patient’s health insurance plan.

“This is not done outside the context of good evidence,” said Cynthia Reilly, director of the Practice Development Division at the American Society of Health-System Pharmacists, a 35,000-member organization that represents hospital pharmacists.

The ASHP says it supports the concept of therapeutic substitution, so long as pharmacists seek approval from an “authorized prescriber.” Reilly says an authorized prescriber may be a doctor, nurse practitioner or pharmacist who has set up what’s known as a collaborative drug agreement with a physician in advance.

Either way, patients say most of the time they aren’t notified of the change. A 2008 survey conducted by the National Consumers League showed that 10 percent of prescription drug users experienced a substitution in the past two years, and two-thirds said neither they nor their families were consulted before a switch occurred

Dr. Ted Mazer, an ear, nose and throat specialist and past president of the nonprofit San Diego County Medical Society, says pharmacists are required to notify him of any potential switches. But, he says, patients have come to him seeking treatment for problems related to ineffective medicines, or old medications contraindicated for their illness.

He says doctors should have a say when medications are being switched.

“A pharmacist is not licensed to practice medicine, and changing a drug is practicing medicine,” he said.

Contributing to the problem, Ben-Yehuda says, is that doctors often prescribe a drug without knowledge of whether it’s covered under a patient’s formulary.

A Guessing Game

“We don’t have good systems yet at the point-of-care that the computer might be linked at the physician level to the formulary,” he said. “Now, it’s a guessing game.”

With insurance agencies mandating the use of generic drugs whenever they’re available, doctors say it’s all too common for patients to get confused and end up doubling up on doses of brand-name drugs and generics. The same, they say, could happen if patients end up on two different generic drugs.

Kristen Binaso, a practicing pharmacist and spokeswoman for the American Pharmacists Association, says patients should take the time to ask questions and check to make sure the medicine they’re receiving is the one their doctor intended.

“They need to realize this is not McDonald’s,” she said. “This is not a drive-by to get their fries; this is a medicine and you need to know what you’re taking.”