Tuesday, 18 November 2014

Therapeutic Substitution. Sounds Good, Is It?

Today at the 2014 Best Medicines Coalition Conference I heard about an interesting study outlining the effects of a healthcare policy change by the British Columbia government in 2003. The PharmaCare program implemented a drug reimbursement policy called Therapeutic Substitution, where all patients with acid-related diseases (mostly GERD) were required to make a medically unnecessary switch from their Proton Pump Inhibitor medication to the cheapest brand name PPI.

That brand was Pariet,which had negotiated a good price for their new drug with PharmaCare based on promised volume of users.

With therapeutic substitution patients are forced to switch from one brand of drug to a different chemical in the same class. Rob Oliphant who was in attendance called this "bureaucratic substitution". At the time he wrote an Op Ed piece for a newspaper stating, among other things, that a decision like this needs public input and that medical guidelines should be built through consensus and with expert input.

This is an interesting idea that looks very attractive to governments which are trying to save money. I hope we don't see it come back as a new light bulb idea idea.

And the results of this money-saving scheme? It took an FOI (freedom of information) request and two years waiting for the de-identified health record information before we saw this study in 2009 titled "Increased health costs from mandated Therapeutic Substitution of proton pump inhibitors in British Columbia"

Healthcare spending for drug expenses, extra physician services and additional hospital services was 43.51 million dollars Canadian. This does not include the pain, inconvenience and suffering of the patients who bore the brunt of this policy.

This is Gail Attara's slide from today's presentation. If you look at the study link earlier in the blog you will see she is a co-author. It took a huge amount of work and determination by her to obtain and analyze the data. This study is now used by Johns Hopkins and others to illustrate possible health consequences caused by arbitrary decisions intended to save money.


  1. I've already dealt with this when the dr ordered my PPI and medicaid wouldnt apprve it. I went on another med that made me nauseus, and then tried another. They still denied my med. Dr wrote and I was able to get one month of the drug he ordered. Then I wrent on Medicare the next month and it began all over again. The insurance company drug approval appeal dept and I are close.

  2. How frustrating to have to start over, and the story is too familiar. My friends in the US talk about this often. I had sympathy, and now I find it is often the same in Canada. Even with private insurance through an employer in Canada, if the company changes providers then you need to start over and go through this "step" process. Patients need to work together to have input into these practices that are so shortsighted.