Finding the right medication for a heart condition can be tricky and time consuming. So what happens when the insurance company then compels patients to switch?
Known as “non-medical switching,” this is a cost-control tactic that insurers and other third-party payers use to protect their profits. Patients who are stable on an effective medication may be pressured to abandon that treatment for a less expensive, but also less effective, substitute.
Non-medical Switching is Increasingly Common — and Dangerous
This disruptive practice is widespread. But it causes particular concern in patients with cardiovascular disease.
For these patients, progress may be hard won. Finding the right combination of medications can take a prolonged period of trial and error.
Yet one study of cardiologists found that half had received “frequent” or “very frequent” requests from insurers to switch patients from one lipid-lowering agent or anti-clotting drug to another. Given the seriousness of heart health concerns, this practice introduces significant risk to patient wellbeing.
Specialists in all medical areas have raised concerns about non-medical intermediaries like health plans making care choices for patients. These switches save insurers some money but may expose patients to new side effects and substandard care.
Switches Introduce Consequences…and Higher Costs
Driving stable patients from a trusted treatment creates new issues. Some studies show non-medical switching can actually increase medical costs if patients experience:
- Symptoms that return or worsen
- Side effects, drug interactions or allergic reactions
- Confusion, fear, resistance or distrust of the new drug
- Lab testing or additional monitoring to assess the substituted treatment
- Emergency room visits related to unintended consequences of switching treatments
In addition to both practical and cost concerns, non-medical switching overrides the relationship of trust between the prescribing physician and the patient. For conditions that require careful ongoing monitoring and compliance with prescribed treatments, patient trust is crucial. When insurers interfere with patients’ confidence in the quality of their care, patients may become less adherent to their medication regimen or less committed to managing their disease.
Patient advocates and policymakers are watchful for non-medical switching especially in January, at the beginning of the benefit year. That’s when insurers release new formularies, lists of which drugs will be covered and for whom. This time of year can be nerve-wracking for patients and providers, as they look ahead and wonder: Will treatment progress soon be undermined by outside decisionmakers?
Policies to minimize this non-medical switching is underway in many states, but broader reforms are needed.