Welcome to ‘Therapeutic Substitution’

As if consumers needed an additional reason for disliking health-insurance companies, a report from the National Consumers League (NCL) suggests some are getting one in the form of “therapeutic substitution.” The term applies to a phenomenon in which a consumer is given “an alternative to a prescribed medication that is not chemically or generically equivalent but is in the same therapeutic class and is used to treat the same condition.”

The report says insurance companies initiate such substitution — with or without consulting the consumer or the consumer’s doctor beforehand — as a cost-saving measure. In a survey fielded over the summer for the NCL by Harris Interactive, 10 percent of prescription-drug users said they’ve been subjected to therapeutic substitution themselves at least once during the past two years; 9 percent said another family member has experienced this. Among those who believe they got a therapeutic substitution, just one-third said their doctor knew about it prior to the switch. Only one-fourth percent were consulted themselves before the substitution was made.

Overall, relatively few of the survey’s respondents were aware of the practice: Among respondents who’ve filled at least one prescription in the past year, 66 percent had never heard of it. Once the concept is explained, though, people are predictably hostile to it, particularly if their doctor isn’t involved in the decision. Seventy percent of respondents said they’d be very or extremely concerned if their prescription were switched without their doctor’s knowledge and consent.

If their doctor were consulted beforehand, many fewer (22 percent) would be so concerned. And if their doctor felt the two medications were interchangeable, 57 percent said they’d be likely to consider making the switch. Consumers are wary, though, of insurers meddling with the doctor’s judgment: 68 percent said they would “oppose insurance companies offering incentives to physicians for switching patients to lower-cost alternatives.” An even larger number (73 percent) would oppose insurance companies offering incentives to pharmacists to do the same.

It’s not that consumers are utterly averse to using cheaper medications. One question in the survey asked respondents how likely they’d be to consider changing their medication to one that is “much less expensive.” Nineteen percent said they’d be extremely likely to do so, and another 25 percent said they’d be very likely. If approached by their insurer “suggesting a new medication that would cost less,” 71 percent would be extremely or very likely to take the matter up with their doctor. But they’re fairly lukewarm to getting such hints from their insurers. Twenty percent said they’d “very much favor” insurance companies contacting patients “to inform them of lower-cost alternatives to their medications.” Another 31 percent said they’d “somewhat favor” this practice.