Therapeutic Substitution
Therapeutic substitution is a policy designed to reduce costs to drug plans by limiting coverage to the cheapest product. A policy of therapeutic substitution affects patients starting new medications, as well as patients already on medications. Under therapeutic substitution policies, if a patient is starting a medication for the first time, they are forced to begin with the reference medication, even if this was not the one prescribed by their doctor. Or, if patients are already taking a medication, a policy of therapeutic substitution forces them to make a medically unnecessary switch from the medication prescribed by their doctor to another medication that is chemically different, but within the same therapeutic class of medications1.
Therapeutic Substitution is based on the assumption that drugs within the same therapeutic class are medically interchangeable because their mechanisms of action do not differ significantly, even though they are not chemically the same.
Therapeutic substitution takes place when a pharmacist dispenses a different, usually cheaper drug than the one originally prescribed by a patient's doctor. It is a form of reference-based pricing that puts cost before patient health and negates a physician's knowledge and experience of their patients' history and disease.
The Better Pharmacare Coalition has serious concerns about the impact of therapeutic substitution and other cost containment measures on patients and the health system:
- Patient access or choice to a wide range of effective medicines and health products is limited.
- Experts are not able to prescribe the medications they feel are most effective to their patients. Instead pharmacists, who do not see patients and do not have any clinical expertise in treating patients, are able to over ride the knowledge and expertise of that patient's own doctor. This has a negative effect on the doctor/patient relationship and threatens quality health care.
- Therapeutic substitution is a short-term solution that simply pushes costs to other parts of the healthcare system and generates negative health outcomes for patients.
The Better Pharmacare Coalition feels that the health of BC patients comes first. Increasing choice enhances patient care; limiting choice to innovative medications flies in the face of patient individuality.
Ensuring patients get the right medicine at the right time should be the priority of the health care system. Therapeutic substitution undermines this principle.
Government must discontinue the practice of trying to pick "winners and losers" in determining which drugs in which category should be covered and by how much. Those are choices to be made together by doctors and patients, the people who know the medical and experiential circumstances, the experts who have the education, training and experience to make such judgments.
For additional information on Therapeutic Substitution, you can download a BPC Fact Sheet here.
- Gainor et al. (2003): 654.