Is drug switching fraudulent?

If you hand a pharmacist a prescription from your doctor for X drug, but the pharmacist gives you Y drug instead, is that fraudulent?

The Merriam-Webster dictionary defines fraud as “intentional perversion of truth in order to induce another to part with something of value”. In the example above, the pharmacist has knowingly given you Y, which is clearly not X, and got paid in return. That seems to fit the definition of fraud – and yet this is what seems to be occurring. Do you agree?

According to the news article, “MAOPS Physician Survey Supports Need for Missouri Senator Kurt Schaefer’s Bill”, Missouri Association of Osteopathic Physicians and Surgeons (MAOPS) is supporting a bill by Missouri Senator Kurt Schaefer:

This act establishes procedures for governing switch communications. A switch communication is defined as a communication from a health insurance carrier or PBM to a patient or the patient’s physician that recommends a patient’s medication be switched by the original prescribing practitioner to a different medication than the medication originally prescribed.

The bill would provide a process before the health insurer or PBM is allowed to “switch” drug Y for drug X (in the example above) by communicating with the patient or the patient’s physician.

Three observations:

  • By providing a process before drug switching can occur, this means that drug switching has been occurring, and the bill is setting forth a process before it can happen. Sounds crazy, right? Because if you went into a restaurant, ordered a hamburger, and were served (without you knowing it) chopped vegetables that tasted like hamburger, what would you call it?
  • Asking the patient whether the drug switch is ok is not enough. In the restaurant example above, asking diners whether they want the veggie burger instead of the hamburger is ok. To get prescriptions, you need a doctor – you can’t just decide what you want by yourself. So, if the insurer or PBM asks patients whether they want to take the generic because it’s cheaper or another branded drug instead, that’s not ok. When was the last time people (who are not physicians) could write a prescription for themselves? Only doctors can write prescriptions.
  • Asking the physician’s office whether the drug switch is ok is not enough. The receptionist and staff can’t write prescriptions either.
  • The only one who can change the prescription is the doctor who wrote it.

In short, it seems ludicrous that this bill would have to be introduced at all to stop something which shouldn’t be happening in the first place — non-doctors (i.e. health insurers and PBMs) from playing doctor (i.e. writing or rewriting prescriptions).

4 Responses to “Is drug switching fraudulent?”
  1. Interesting issues raised. I’m not sure that I think it’s fraudulent, but it is somewhat deceptive. I have had pharmacies call me directly to discuss the change. For example, I recently spoke directly to a Medco pharmacist about switching a patient’s pancrease formulation from one to another. This precipitated my calling the patient to see how she felt about the change. The call took about 10 minutes. Frequently drug selection and prescribing requires significant negotiation with patients–not something that can be done without another office visit to discuss. I agree that it is inappropriate to expect that drug substitution should occur just by way of a physician signing off on a form faxed over from a pharmacy requesting the change.

    • Ben Garrett says:

      This is a tricky issue because some drugs are fairly equivalent and some are not. I really think physicians should have more authority to insure the prescriptions they write are the one the pharmacy fills, but the problem obviously involves cost and what’s on a given formulary, depending on the patient’s insurance. While some money is saved, there’s a lot of time wasted by the pharmacist and the patient and the physician when calls go back and forth about what is truly equivalent. The insurance companies are probably saving but ultimately I bet if you factor in the labor and time involved, this is a process that generally does NOT save money (except for the insurance provider). Somehow, some way there’s a better way to do this and unfortunately healthcare reform is likely to make this more complicated instead of less so…

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