Take action against drug switching that hurts patients

• Dr. Lynn Rankin is board certified in neurology and headache medicine in practice in Des Moines and is a member of the Alliance for Patient Access.

Chronic migraine is a challenging — often debilitating — condition. It causes not only severe headache attacks, sensitivity to environmental stimuli, and fatigue, but also a host of other issues, from anxiety and depression to social isolation. Far too often, though, just when patients get their migraines under control, they’re forced off their treatments to something less effective and less tolerable.

This decision is made not by patients and their clinician, but by bureaucrats at insurance companies. And this practice, known as non-medical switching, has little to do with medicine or what’s best for patients.

In fact, non-medical switching is quite the opposite. It’s about dollars and cents, driven by insurers’ bottom lines. Clinicians widely view it as having a negative impact on quality of care as well as downstream adverse health or employment outcomes. But still, non-medical switching continues, with each insurance company making their own willy-nilly rules.

I see the negative impact of these switches far too often. Just a few weeks ago, a non-medical switch happened to a patient of mine. She and I had worked together to find an effective treatment for her migraines, a medication known as a monoclonal antibody. And this treatment worked spectacularly for her — until her insurance company unceremoniously forced her off.

My patient had finally found the way to control her migraine attacks, restoring her ability to be present at her job and as a mother. Then she was abruptly thrust back into debilitating migraines, missing work and time with family. She had to endure her misery for two months while we underwent a lengthy appeals process to get her back on the treatment that worked for her.

You see, much like migraines themselves, a patient’s journey to disease control is arduous. It entails a lengthy trial-and-error process whereby the patient and clinician work together to find the right treatment regimen, a very individualized regimen. And that’s why non-medical switching baffles me so much. Why are such hard-won victories, which are so critical to a patient’s care, nullified by decision makers who are so distant from the patient-physician relationship?

Plans often try to justify non-medical switching as an important tool for managing health care. They claim the practice is necessary to control the costs of medications and keep premiums from rising. And they argue that the non-medical switch to a lower-cost medication should be equally effective for patients. The argument is deeply flawed.

Firstly, it’s inconclusive that non-medical switching actually produces cost savings. In fact, it’s likely the opposite. Non-medical switching has been shown to raise rates of treatment abandonment, hospitalization and emergency room visits — all of which actually raise costs. Then there are the broader social costs, like missed work or school, and reduced productivity.

Secondly, just because medications are grouped into the same class doesn’t mean they are equally suitable for every patient. There are so many differences between individual patients, and those differences can have substantial influence on their medication response. Getting patients’ care right is a delicate process of art and science, and one-size-fits-all approaches like non-medical switches are simply incompatible with that. I like to say that all eight CGRP targeting medications and all seven triptans for migraine have their own fan club.

Legislators have become aware of the dangers of non-medical switching. I’m pleased to say that a bill currently being debated by Iowa lawmakers could curb the practice, at least for the plan year. If passed, House File 626 would eliminate mid-year coverage interruptions to medications that have already been prescribed and approved, preserving patients’ access to critical treatments. The legislation would also better respect clinicians’ medical judgment and alleviate our offices of excessive administrative burden.  Limits on out-of-control prior authorization requirements could help too, but that is another battle for another day.

House File 626 is an important step in the right direction. By supporting the bill to limit non-medical switching, our lawmakers can end unnecessary patient suffering and return health care decisions to those best suited to make them — patients and their doctors.

Dr. Lynn Rankin is board certified in neurology and headache medicine in practice in Des Moines and is a member of the Alliance for Patient Access.