The Scheme to Change Your Doctor's Prescription--A Glimpse of Obamacare or Just Unethical Profiteering?

Documents from the pharmacy industry reveal perverse incentives to change patient prescriptions to therapeutically similar, but altogether different, medicines. Who is really really benefiting (and profiting) from this arrangement? Photo: Wikimedia Commons (Ragesoss)

SAN DIEGO, February 14, 2012 – Is legislation needed to protect patient safety from pharmacy-promoted drug switching? Commonly called ‘therapeutic substitutions’, prescription drugs in pharmacies all across America are often subject to financial schemes that switch prescribed drugs to ‘similar’ (but molecularly different) medications under the same therapeutic class.

These machinations aim to save insurers billions of dollars while providing pharmacists with dubious bonuses to play along.

Such behavior begs the central question that observers of healthcare reform may ask: are registered pharmacists (designated ‘RPh’) betraying their sworn oath by carrying out undisclosed and unethical ploys to exploit incentives by insurers that reward pharmacies and pharmacists at the expense of the doctor-patient relationship?

Pharmacist Code of Ethics & Oath – Pharmacy Pledge & Sworn Statement

The following are the first four edicts of pharmacy’s equivalent to a physician’s Hippocratic Oath.

  1. 1. A pharmacist respects the covenantal relationship between the patient and pharmacist.
  2. 2. A pharmacist promotes the good of every patient in a caring, compassionate, and confidential manner.
  3. 3. A pharmacist respects the autonomy and dignity of each patient.
  4. 4. A pharmacist acts with honesty and integrity inprofessional relationships.

Here is the ‘Pharmacist’s Oath’:

At this time, I vow to devote my professional life to the service of all humankind through the professionof pharmacy.

I will consider the welfare of humanityand relief of human suffering my primary concerns.

I will apply my knowledge, experience, and skills to the best of my ability to assure optimal drug therapy outcomes for the patients I serve.

I will keep abreast of developments and maintain professional competency in my profession of pharmacy. I will maintain the highest principles of moral, ethical and legal conduct.

I will embrace and advocate change in the profession of pharmacy that improves patient care.

I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public.

The Reality of ‘Drug-Switching’ Schemes

The following was obtained from the CVS/pharmacy “Pharmacy Team Training Guide” (February 2010), in the packet entitled “CustomeRx Savings Initiative:” the cover page reads as follows: “This training guide is to be read by all Pharmacy Team members prior to taking the Web-based Training in LEARNet.” The guide’s introduction continues “this new program will proactively identify lower cost products (typically generics) in the same therapeutic class for patients who are on brands that do not have a generic available.”

The manual goes on: “…the [technician]…informs the RPh that Mrs. Jones has a cost savings opportunity.” Using the example of the drug Aciphex, it goes on: “He explains to her that there are other medications that are in the same therapeutic class as Aciphex that are lower cost under her script plan…he explains that…he would be happy to contact her MD to present the cost savings information and obtain a new script if the MD deems it appropriate.”

What is not disclosed to the patient is the reality of how the above scenario plays out in the vast majority of cases. Most physicians do not answer the phone when the pharmacy calls to ask to switch a patient’s prescription. In most cases physicians or their nursing staff who authorize such changes do so under hurried conditions. Many doctors believe that the request to change the drug initiated with the patient themselves, with the primary goal of saving money.

It is highly likely that the patient is not informed by the pharmacy or pharmacist of the financial arrangement that exists behind the scenes between pharmacy, insurance company, and pharmacist. Furthermore, most doctors’ offices are extremely busy, if not frankly harried, and there is little opportunity for the patient’s healthcare provider to carefully reflect on the circumstances under which the original prescription was first written.

According to the Outcomes Pharmaceutical Health Care online website, ‘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 bonuses can reward pharmacists with thousands of dollars of extra income annually.

It is crucial to understand 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 may occur by making such a switch.

Because therapeutic substitutions result in changes to medicines with different active ingredients, patients with high cholesterol, high blood pressure, infections, depressions, etc. can effectively be pressured to make changes that may short-change their own treatment plans.

The behind-the-scenes economic arrangements from switching out prescriptions medications is not disclosed to patients, nor are there laws to mandate disclosure. This activity can undermine the doctor-patient relationship; it ignores differences between medications, putting pharmacy/pharmacist profits over patient health.

Considering that approximately 100 million Americans are on prescription medications for the common diseases of high blood pressure and high cholesterol alone, cost-driven ‘drug switching’ can have a profound and unpredictably deleterious effect on a huge percentage of the population.

It would behoove state and federal legislators to devise legislation to effect a ‘Prescription Drug-Patient Bill of Rights’, which would be posted by each pharmacy counter and require pharmacists engaging in such medicine-switching behavior to address the following questions on behalf of patients:

  1. Is this the same drug as my physician originally prescribed?
  2. Did my doctor personally approve of this switch, and can I consult with him/her first?
  3. What are the health implications of such a switch?
  4. Is this the same dosage as my original prescription?
  5. Are you (the pharmacist) receiving a financial incentive to make this switch for me?

The public knows little about the secret, financially-driven schemes between health insurers and pharmacy outlets; these arrangements allow for what would (in the medical profession) be considered kickbacks. There are federal anti-kickback laws to prevent such behavior by medical doctors. Why are there no such laws to regulate this behavior in the pharmacy industry? Currently, no such laws exist.

The pressures created by the ‘Affordable Care Act’ (Obamacare), and by local Accountable Care Organizations (ACOs) which are mandated by the new health care law, may exacerbate these hidden arrangements between insurers and pharmacies. There appears to be a loophole in necessary oversight in the area of therapeutic drug substitution. For the sake of our health, we must address and remedy this growing and dangerous practice.

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.

AMS and many other medical groups in the United States are convening in San Diego this May 5th and 6th, 2012 for a ‘Coalition of Doctors Conference’ to address issues of concern related to patient safety and the recent healthcare reform legislation.



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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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