The corporate pharmacy scheme that injures patients

In a corporately-motivated, system-wide practice called therapeutic substitution, pharmacists switch out prescription drugs for generic, related medicines in a scheme that is often subject to financial reward.

SAN DIEGO, August 13, 2012  - In a corporately-motivated, system-wide practice called therapeutic substitution, pharmacists switch out prescription drugs for generic, related medicines in a scheme that is often subject to financial reward. This switch changes the physician’s order to drugs that are ‘similar’ (but molecularly different) medications under the same therapeutic class. Although cursory efforts are often made to contact the physicians’ offices, many patients simply check a box that insures “cheaper alternatives” are allowed, and never receive a full consultation by their pharmacist that a change to their doctor’s order has been made.

Many patients are not aware that clinical studies may show a swing of 10% or more above or below the baseline of the intended drug’s effects on their body; many are not aware that their clinical conditions may not tolerate such deviations from the intended target state of the prescribed drug.

Physicians are not easily pigeon-holed into one political ideology or another.  Many are socially moderate, but fiscally conservative; some are extreme liberals, and some are stark libertarians. Almost all, however, are conservative in their desire to preserve the doctor-patient relationship. Their motivation is simple:  they want to maintain a sacred relationship between highly skilled professionals and their ailing clients. Doctors need more societal support to keep the government and dangerous corporate profiteering out of the examination room—not less. Despite the misleading perception that some medical groups speak for them, the vast majority of all practicing doctors in America remain strongly opposed to the new health care law because, amongst other things, it supports therapeutic substitutions of prescription drugs and threatens the physician-patient bond.

In this fight, physicians should be able to look to their pharmacist colleagues for corroboration and support. Physicians are trained to physically examine and historically assess patient maladies; pharmacists, experts in pharmaceuticals, are called upon to lend expert bio-chemical assistance in making sure that the physician’s diagnosis is translated into a safe prescription based on science, not profit-making.

All of this brings us to the frightening reality that the Patient Protection and Affordable Care Act (aka Obamacare) could, if not ultimately repealed, continue the dangerous slide from free-market medicine to government-run, ‘socialized’ health care in the United States over the next decade. Instead of tax incentives to promote more charity care to patients, for instance, the federal government is on track to make sure Uncle Sam tells each and every citizen just what tests they need and just what procedures they will be allowed to undergo. Under Obamacare, if you are found to be too old, too sick, too complex or too costly as a patient, predetermined national templates will decide whether you can get your hip replaced, your prescribed chemotherapeutic medication started in the hospital, or the drug your doctor prescribed actually filled by your local pharmacy retail outlet.

In a previous article under this column,  “The Scheme to Change Your Doctor’s Prescription – A Glimpse of Obamacare or Just Unethical Profiteering,” this author made the point that a patient deserves a ‘pharmacy bill of rights’. It was stated that “patients need to be able to consult with their physician when ‘therapeutic’ drug switches are made, and they need to know if such a switch rewards the pharmacy chain and pharmacists financially.”

The piece went on, “Patients deserve to know that some programs, such as United Healthcare’s Medco even threaten to take their business away from pharmacies that are not successful in effecting such patient drug switches…”

A United Healthcare memo to pharmacies states, “effective February 1, 2010, United Healthcare, processed by Medco, implemented a process to encourage members to switch…to lower cost alternatives…if you are not successful in encouraging the patient to switch to a lower cost alternative, you will lose the prescription to mail order.”

The Outcomes Pharmaceutical Health Care online website has stated that ‘targeted intervention programs’ (called ‘TIP’ under trademark designation) allow for incentives from $20 to $100 dollars or more to pharmacies for each drug switch that is made at the retail pharmacy counter; oftentimes, pharmacists themselves are then given periodic bonuses that are directly tied to the number of patient prescription switches that are made.

These financial incentives reward pharmacists with thousands of dollars of extra income annually.  We must recognize that the therapeutic switches in patient prescriptions are not between chemically identical medications, and that patients are not apprised of the potential differences in efficacy or drug interactions that do occur by making such a switch.

Therapeutic substitutions result in changes to medicines with different active ingredients; hence, patients with complex medical conditions will suffer a decrement to their medical care.

Today, several states, such as California, are considering legislation built upon the notion that the time has come to create a ‘patient-pharmacy bill of rights’; an idea originally and initially put forth in this column months ago. It is time for pharmacists themselves to stand up to their pharmacy chain corporate bosses, and to the weight of federal efforts to promote generic medications—inferior or not—over brand name prescription drugs. We should all be able to agree to support ‘transparency laws’, which would bring behind-the-scenes pay-backs to pharmacists into the light of day. Transparency laws—none of which exist today for the pharmacy industry—would make it illegal to apply monetary kickbacks to pharmacists, and mandate that patients are informed of the financial reward given to the pharmacist for switching out a patient’s prescription.

Doctor Dorin is the Founder and President of the non-profit group America’s Medical Society; he is a practicing, board-certified physician in Southern California.


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Adam Frederic Dorin, M.D., MBA

Doctor Dorin is a Hopkins-trained, board-certified anesthesiologist, practicing in a large group in San Diego. He is a small business owner, a Commander in the US Navy Reserves, and the Founder/President of America's Medical Society, Inc., (AMS) a non-profit corporation created to serve and educate physicians and the general public in matters of national health-care reform and medical politics

Contact Adam Frederic Dorin, M.D., MBA

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