Posted: November 29, 2018
Patient and physician advocacy organizations have long derided the utilization management tactic known as non-medical switching used by payers. Non-medical switching occurs when insurers and pharmacy benefit managers effectively force patients to from their recommended treatment by increasing out-of-pocket costs through benefit design changes. Patients with complex chronic conditions are prescribed some of the most expensive drugs available, and payers are desperate to move these patients to lower cost alternatives. Unfortunately, many of these alternatives are not equally efficacious for particular patients, and they can suffer adverse medical consequences. With an increasing number of biosimilar products becoming available in the United States, this trend has accelerated.
Now this practice is beginning to spill over from payers to hospital systems. CSRO has been fielding reports from physicians around the states who have found that their patients are no longer able to access their prescribed treatment. Some hospital systems are no longer carrying biologic originator products, meaning that patients must find an alternative site of care. Other hospitals are removing the drugs from their formulary and instructing physicians to move their patients to biosimilar products. Even more troubling is that the hospitals have deemed the biosimilar products to be interchangeable with their reference product, a status that can only be conferred by the FDA. While studies have demonstrated that many patients are able to tolerate such a switch, a one size fits all policy puts patients who cannot at risk.
CSRO is documenting instances of non-medical switching being driven by hospital systems, and you may submit occurrences to info@csro.info.
