Non-medical switching is a discussion that happens every day for some physicians. Insurance companies and P&T committees change formularies resulting in therapy changes. Patients have to endure these changes or pay the difference.
We are approaching that time of year when we begin to see more of these formulary changes. Patients purchased their insurance plans before the start of the year and can now use it. Decisions about health plans are not made lightly. Patients consider the monthly premium, out of pocket costs, drug copays, current drug therapy, and more.
Despite doing due diligence in picking a health plan with coverage considerations for necessary therapy, patients do not have stable coverage. Health plans can still change formularies, drug tiers, and coverage options. In most states, there is only a notification of change requirement (for example, 45 or 60 days).
Non-medical switching is a frequent practice that deprioritizes patient outcomes in lieu of profitability.
What is Non-Medical Switching?
Non-medical switching is the practice of switching a medication to a more cost-saving option without increased evidence for efficacy or safety. The insurance company or prescription benefit managers (PBMs) can reduce or completely eliminate coverage for the original prescription.
These changes in coverage are cost-driven by the insurance company or PBMs. They aim to drive down costs without any data supporting better patient outcomes.
This non-medical switch could also occur based on reducing coverage or blocking manufacturer copay coupon assistance programs. Because these are necessary for affordability, the prescription would become unaffordable. The patient would then have to switch therapy. This poses risk for side effects, decreased quality of life, more doctor visits, and worse outcomes.
By deprioritizing patient outcomes, non-medical switching has negative consequences for the patient experience.
The patient journey to better health outcomes is long. The patient first starts to experience symptoms. In some cases, it isn’t a quick progression or decline in daily function. But over time, it gets worse and their quality of life decreases.
Once the patient goes to a healthcare facility, it takes approximately 4.8 years for patients with rare diseases to get diagnosed. Despite being referred to specialists, going to multiple facilities, and enduring multiple investigations, there are still delays for diagnosis.
Then there’s payer policy and step therapy. The barriers set in place to try low cost alternatives to see subtherapeutic outcomes. Some policies require a trial of multiple therapies before moving on to an effective treatment. And these fail-first trials often take months.
Now, we’re at least 5 or 6 years into the patient journey, probably more, and we aren’t seeing a change. The patient is losing faith in the health system. The patient has finally gone through enough trials and tribulations to qualify for a specialized therapy that has more promising data. There are still administrative hurdles to go through, but we’ve seen it before. Prior authorizations, high copays, delays, but the patient finally gets on therapy.
Alas, the patient sees a change in status, an improvement of outcomes. An improvement of quality of life.
Non-medical switching takes away the relief of better outcomes and quality of life. The patient has to go back to trying different therapies, knowing that the drug they need is not covered or unaffordable.
After years of trying to get a diagnosis and get on treatment, it isn’t a surprise that many patients don’t want or are afraid to switch therapy. Non-medical switching brings the fear of losing remission status for many patients.
Impact on Patients
Patients are often overwhelmed by the practice of non-medical switching. Changes in therapy without any financial benefit results in a lot of risk for the patient.
For a patient, it means:
- having to relearn complicated medication names
- figuring out what the medication does
- readjusting to therapy and possible pill burden
- out of sync medications
- possible decreased efficacy
- potential side effects
- return of symptoms
- medical complications
- abandonment of therapy
A simple switch isn’t so simple.