What Is PBM Non-Medical Switching?

Non-Medical Switching (NMS) is switching a patient’s medication for reasons other than the patient’s health and safety, typically at the request of a third party. Non-medical reasons for a patient to switch medications include:

  • To increase a private insurer’s earnings.
  • To lower a government agency’s or employer’s expenses.
  • A contract between the payer and a specific manufacturer to prefer that manufacturer’s product.

SpectrumPS believes patients and their physicians should retain control over their treatment decisions, as opposed to an insurer, the government, a pharmacy, or any other third party. However, this fundamental right is endangered for patients in several nations, including numerous Canadian provinces.

Non-medical switching is a method employed by health insurers to cut expenses and increase profits by compelling stable patients to transfer their current, effective medications to alternatives that may not be as beneficial. In other words, insurers compel patients to switch prescriptions for non-medical reasons, ignoring physician recommendations and individuals’ specific needs.

HOW DOES NON-MEDICAL SWITCHING OCCUR?

  • removing coverage for particular drugs
  • Boosting patients’ cost-sharing (e.g., copay or coinsurance)
  • Enhancing patients’ out-of-pocket expenses
  • Reducing the plan’s maximum coverage for prescription drugs

BUT AT WHAT COST IS MONEY SAVING?

Finding an effective treatment to manage a complex ailment can take years. This carefully constructed equilibrium can be disrupted if these stable plan members are forced to switch drugs to save money. Even the tiniest deviation in treatment protocol can result in hazardous side effects, bad health outcomes, and a decline in quality of life.

In addition, when a patient discontinues a medicine and then returns to it after failing other medications, the once-effective treatment may lose its efficacy due to tolerance development.

Patients with complicated chronic diseases, autoimmune diseases, and immunodeficiency disorders who were stable on a drug and were subsequently compelled to switch therapies by their insurance provider may have a disturbance in the management of their condition, resulting in deterioration:

  • Medical complications
  • a return of symptoms

Decreased life quality

Non-medical switching supplants doctors’ prescription authority and compels stable patients to switch medications to decrease costs and enhance profits, irrespective of the potential adverse effects on patient health outcomes.

PROTECTING PATIENTS

Patients must have access to various therapy options to select the most effective treatment strategy. This is especially true for medications covered by the medical benefit, such as intravenous immunoglobulin (IVIG), and biological therapies for patients with primary immunodeficiency diseases and immune-mediated inflammatory conditions, such as rheumatoid arthritis Crohn’s disease, ulcerative colitis, multiple sclerosis, psoriasis, and lupus.

We feel that influencing the course of treatment for these individuals involves the practice of medicine, which should be left to their physicians and not insurance professionals.

To prevent increased clinical risk and maintain the health of stable patients, state legislators must enact new legislation and strengthen existing protections that limit — and ultimately prevent — health plans from compelling patients to switch medications for non-medical reasons during the plan year or re-enrollment period.

Non-medical switching is a daily topic of conversation for some clinicians. Insurance companies alter formularies, resulting in modifications to treatment methods. Patients must accept these adjustments or pay the price differential.

We are approaching the time of year when formulary modifications become increasingly prevalent. Patients who acquired insurance plans before the beginning of the year can now utilize them. Health plan decisions are not made lightly. Patients evaluate the monthly premium, out-of-pocket expenses, drug copayments, and existing drug therapy, among other factors.

Patients do not have continuous coverage despite their diligence in selecting a health plan with coverage considerations for necessary therapy. Plans may still modify their formularies, drug tiers, and coverage alternatives. In the majority of states, simply a notification of change requirement exists (for example, 45 or 60 days).

Non-medical switching is a common practice that favors profitability over patient outcomes.

What does Non-Medical Switching entail?

Non-medical switching refers to switching a medicine to a less expensive alternative without additional evidence of its efficacy or safety. The insurance provider or pharmacy benefit managers (PBMs) might restrict or eliminate coverage for the initial prescription.

These changes in coverage are cost-driven by the insurance company or pharmacy benefit managers (PBMs). They intend to reduce expenditures without any evidence showing improved patient outcomes.

This non-medical change could also result from reduced coverage or elimination of manufacturer copay coupon assistance programs. The prescription would become costly due to the necessity of these components. The patient would subsequently be required to switch treatments. This increases the likelihood of adverse consequences, decreased quality of life, increased doctor visits, and poorer outcomes.

Non-medical switching has detrimental effects on the patient experience since it de-emphasizes patient outcomes.

Patient Journey

The patient’s path to improved health outcomes is arduous. The patient initially shows symptoms. In certain circumstances, the decrease or advancement of daily function is not rapid. However, as time passes, their quality of life declines.

Once a patient with a rare disease visits a healthcare facility, it takes around 4.8 years for a diagnosis to be made. Despite referrals to specialists, visits to several facilities, and multiple diagnostic procedures, there are still diagnostic delays.

Then there are payer policy and step treatment to consider. The obstacles are erected to prevent low-cost alternatives from producing subtherapeutic results. Some rules mandate the use of numerous ineffective medicines before moving on to a good one. Moreover, these failure-first trials can take months.

At this point, the patient’s trip has lasted at least five or six years, if not more, and there is no sign of improvement. The patient has lost confidence in the health care system. The patient has suffered enough to be eligible for specialist therapy with more encouraging data. There are still administrative obstacles to overcome, but we have been in this situation. Despite prior authorizations, exorbitant copays, and delays, the patient is eventually placed on therapy.

Unfortunately, the patient experiences an improved condition—an enhancement of life quality.

Non-medical switching eliminates the relief of improved outcomes and life quality. The patient must return to attempting alternative treatments, as the drug they require is either uninsured or pricey.

After years of attempting to obtain a diagnosis and begin treatment, it is not surprising that many patients are unwilling or fearful of switching therapies. For many patients, non-medical switching induces the dread of losing remission status.

Influence on Patients

Patients are frequently overwhelmed by the process of rotating between non-medical providers. Changes in therapy without a corresponding financial reward expose the patient to a significant danger.

It means for the patient:

  • requiring patients to relearn complex medication names
  • determining how a drug works
  • readjusting to treatment and potential pill burden
  • Discordant medications
  • potential diminished effectiveness
  • possible adverse effects
  • reoccurrence of symptoms
  • medical complications
  • renunciation of therapy
  • A simple swap is not so straightforward.

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