Expert Perspectives on the Clinical Impact of Non-Medical Therapeutic Switching - Episode 1

Why and How Non-Medical Therapeutic Switching Occurs

March 19, 2021
Adam Friedman, MD, FAAD, The George Washington School of Medicine & Health Sciences

Adam Friedman, MD, FAAD defines non-medical therapeutic switching and discusses common tactics payors use to pressure practitioners and patients to switch.

Adam Friedman, MD, FAAD: When I think about nonmedical switching, I think of a very common, classic nightmare: You are on stage doing your thing, jamming, doing great in front of a massive audience. Suddenly, you are naked, and the audience starts laughing. They start pointing; you lose your confidence, and everything spirals down from there. Why on earth would I reference that? Well, nonmedical switching of medication is when a treatment regimen is changed for reasons other than efficacy, adverse effects, or adherence and is more often related to drug formulary changes aimed at reducing drug cost. How does that relate to this horrible nightmare? Well, when this happens you are caught off-guard as the practitioner, and your patients lose confidence in your ability because they are thrown this sudden change out of nowhere, 1 that you as the practitioner are often unaware is occurring.  

That can really put a strain on the physician-patient relationship. Keeping in line with the dream, there is really no sensical explanation for nonmedical switching other than cost saving. I have to agree, cost cutting is certainly very important—especially these days—but there is growing evidence that nonmedical switching, particularly when you apply this to a medication that is meant to manage a chronic illness like psoriasis, atopic dermatitis, or hidradenitis suppurativa, will actually result in a higher cost in the long run. It may affect patient outcomes, medication-taking behaviors, and even the use of health care services. Although this approach may cut costs early on, in the long-term, we already know that nonmedical switching can increase costs down the road. 

For example, in 1 national study, researchers found that 1 of 10 patients who had underdone this medical switching were being hospitalized. Sixty percent of these patients experienced adverse effects from the new medication they were put on against the wishes of or without even the knowledge of their physician; 28% of patients had breakthrough disease. When it comes down to the patient experience, 83% reported that they were frustrated with this move by their insurance, and 40% just gave up. They stopped taking the medication altogether, which as we all know—whether we are a patient, a physician, or a practitioner—is going to unfortunately lead to very poor outcomes, especially when it comes to chronic inflammatory diseases. While nonmedical switching acts as an immediate patch on the growing problem of health care’s economic burden, in the long term, it has a tremendous negative impact on many facets of health care overall.

Insurance companies have developed some interesting ways to ensure a patient is moved from 1 medication to another. Let’s also be clear: In these situations, you often have a patient with a chronic medical condition. Let’s say that we are outside dermatology; patients with diabetes would be subject to nonmedical switching. Or in dermatology, it would be patients with psoriasis. For psoriasis, patients may be on a biologic or a small molecule inhibitor; they are doing wonderfully, they are clear, and they are loving life. Even with that, even though they’re doing well—for example, with psoriasis, we know that controlling this disease can actually limit very expensive comorbidities—the insurance will say, “You know what? You’re doing well. We can switch you to something similar, like a biologic biosimilar or a generic of 1 of those other medications.” 

For the insurance to ensure this happens, they can do a couple of things. First, they can just tell the patient it is happening, and the physician does not even know about it. If there is not a structure in place to ensure good communication between the physician and the patient, this is just going to happen, and no one will be the wiser. Other, sneakier ways the insurance companies can do this is by removing the current medication that is working so well from the patient’s formulary. They can also increase the patient’s out-of-pocket cost. For example, the medication may be covered, but the co-pay could be thousands of dollars, so it would clearly be a nonstarter. They could also block the use of coupons—co-pay coupons have become very popular, especially from the side of the specialty pharmacies. The insurance company can offer a financial incentive to pharmacists or even to health care practitioners to switch a patient’s medication. I would argue that this is more common on the pharmacy side. There are some relatively easy ways for these payers to get the patient on the medication of their choice—not of the physician’s choice—and they really cut us out of the choice and also wall in the patient to force them to follow their approach.

Transcript Edited for Clarity