Consumer health advocates continue work on health coverage at the Families USA Conference – National Consumers League

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With only 60 days left for consumers to enroll in the Health Care Marketplace, I joined health care advocates from across the country to hear from healthcare experts at the annual Families USA conference.  Keynote speaker, Vice President Joe Biden, opened the conference with rousing words stating, “Now for the first time, health care coverage for all, is the law of the land.”

The law is a testament to the power of advocates and others, who worked tirelessly to secure this basic right for Americans.

Vice President Biden kicked off the conference with a challenge to remember what life was like before the passage of the Affordable Care Act (ACA) – when pregnancy was a pre-existing condition, young adults were kicked off their parents’ health plan, lifetime dollar limits were in effect, and patients could be denied coverage because of a pre-existing condition.  Americans no longer go to sleep at night worrying that if a family member gets sick, they might lose their house, their savings, and go bankrupt due to high medical bills and inadequate health insurance. “It is not just about physical health coverage anymore, but about peace of mind,” said Biden.

Many speakers, including Biden, noted that the conversation about health care has changed.  Instead of talking about health care as a privilege, it’s now agreed that health care is a right everyone deserves access to.  People who previously had no access to preventive care are going to the doctor and getting much needed care as a result of the ACA.

However, the conversation needs to shift to making sure this law works.  The current challenge, as we all know, is getting people enrolled.  As Ezra Klein of The Washington Post noted, “The problem will not be if the website is working properly, the problem will be that some people don’t even have a computer to access a website.” We will need to make sure those populations on the fringe are able to enroll and benefit from the health law.

Kentucky was held up as an example of what can happen when a state opens up its own exchange and recognizes the value of ensuring all its citizens have health insurance. Ranked at the bottom of most national health statistics, Kentucky decided that this was an opportune time to improve its citizens’ health by putting the people before politics. Kentucky is the only southern state to expand Medicaid and open a state-based exchange.  This decision meant providing coverage to nearly 640,000 uninsured people in the state. Expanding Medicaid allows those people who earn too much to qualify for Medicaid and too little to enter into the Marketplace access to coverage under the law. Kentucky Governor Steve Beshear stated that an independent analysis proved that expanding Medicaid will inject over $16 billion into Kentucky’s economy over the next 8 years and create at least 17,000 new jobs. It is clearly a win-win situation.

“The time for politics is over,” proclaimed Klein.  Over 3 million have signed up for private plans through federal and state exchanges as of January 24.  It is expected that a million more will be signing up in January.   As Biden noted, the “ACA is the most consequential piece of legislation” in decades.  Let’s make it work.

Cancelled policies, mandatory insurance, oh my! What consumers need to know about health care insurance – National Consumers League

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92_ayannaHealth care Marketplace exchanges went into effect on January 1. Since open enrollment began in October, 6 million+ people have enrolled for new coverage under the law. Enrollment is still ongoing, and if you sign up by January 15, coverage will be effective on February 1. Despite the good news, media attention to “Obamacare” has been mostly negative because of roll-out glitches with the site and health plan “cancellation letters.”

It is estimated that 4.7 million people have received cancellation notices, stating that their 2013 health insurance policies have been cancelled effective January 2014 because of Affordable Care Act (ACA) guidelines, according to a House Energy and Commerce Committee report. About half of those who received cancellation letters are now able to renew their prior coverage. As for the other half, the government estimates that roughly 10,000 will not have access to affordable coverage under ACA and will have to buy unsubsidized insurance on their own. The remainder, however, will be insured through expanded Medicaid, state or federal health exchanges, expanded age limits on parents’ plans for young adults under 26, or in purchasing a catastrophic coverage plan.

What hasn’t been covered in the media is the reason behind cancelling health insurance policies. These policies were cancelled because they do not meet minimum standards set up by the ACA for health insurance coverage. For example, prior to the ACA, it was legal for health insurance companies to exclude certain individuals from purchasing health insurance policies based on their preexisting conditions. Under the ACA, practices such as this are no longer legal. Additionally, all insurance policies must include certain “essential health benefits,” as defined by the Secretary of Health and Human Services. An example of an essential health benefit that is mandatory under the ACA is the complete coverage of all childhood and adult vaccinations. If an insurance policy does not meet the ACA’s minimum requirements, it must be modified so that it complies with the ACA or it must be cancelled.

The Confusion— On multiple occasions, President Obama asserted that, under the ACA, all Americans would be allowed to keep their insurance policies, if they were happy with them. However, the ACA states that if you are signing up for or renewing an insurance policy that does not meet minimum standards, it either must be modified to meet these standards or must be cancelled. Unfortunately, President Obama’s statement was not broad enough, and did not take these minimum standards into account.

The Fix— Health insurance companies may now continue to provide plans that do not meet ACA guidelines for an additional year. This is left up to the discretion of the state and if a policy remains valid, insurance companies have the right to keep or discontinue these policies. If a health insurance company renews a policy that does not meet ACA minimum standards, it is required to specifically inform customers about how these plans do not meet ACA requirements and of alternative ways of getting health insurance, such as through the Health Insurance Marketplace where customers might be eligible for lower cost plans.

There are still a number of options for consumers to get coverage, in the event of a cancelled or modified policy. It is strongly recommended that if your policy has been cancelled you shop around for other health insurance policy options before choosing any particular policy. There have been reports of cancellation letters that urge customers to sign up for “comparable” policies at the same health insurance company that are often significantly more expensive. The smart thing to do is to look at your options before signing up for any policy.

If your insurance company cancels your plan, your options include:

  • Buy one of the plans that the company offers in its place. It must allow you to buy any of its other plans available to you.
  • Buy a new plan in the Marketplace. You may qualify for lower costs on monthly premiums and out of pocket costs based on your income. Visit the Health Insurance Marketplace. Use this online resource to find out if you qualify for lower cost private health insurance plans or inclusion within Medicaid or the Children’s Health Insurance Program (CHIP).  If you are not qualified for these, the Health Insurance Marketplace is still a place to get insurance at a standard price.
  • Shop around for health insurance policies outside of the Health Insurance Marketplace.  This can be a good option if you don’t qualify for lower costs based on your income.
  • Buy a catastrophic plan. If your plan has been cancelled and you can’t afford a Marketplace plan to replace it, you can apply for a hardship exemption. This will allow you to buy a catastrophic plan. A catastrophic plan has lower premiums than a comprehensive plan but only provides coverage if you need a lot of care. This plan typically requires paying all your medical costs up to a certain point, which is usually several thousand dollars.

Big changes in health care this fall – National Consumers League

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This fall, there will be a new way to buy health insurance. NCL takes a look at what it means for you. October 1 marks the beginning of a new way to buy health insurance, put into place by the Affordable Care Act, or “Obamacare.” The ACA increases health care coverage for many Americans, even those who were previously underinsured or living without insurance.

Consumers can now buy health insurance on the Health Insurance Marketplace. Here, you can sign up for health care coverage and see apples-to-apples comparisons of costs and coverage between plans that fit your needs. Plans on the Marketplace will offer core set of essential health benefits like doctor visits, preventive care, maternity care, hospitalization, prescription drugs, and more

What: The Health Insurance Marketplace allows consumers to sign up for health care coverage and see apples-to-apples comparisons of costs and coverage to find the plan that is best for you. You can see what your premium, deductibles, and out-of-pocket costs will be before you make a decision to enroll. The Marketplace gives consumers control over their health insurance options.

Who: Some states run their own Marketplace. In other states the federal government runs the Marketplace.

When: Enrollment opens on October 1, 2103 and ends on March 31, 2014. Coverage begins as soon as January 1, 2014.

Where: Go to HealthCare.gov to get started. With the ACA, it is easier than ever to see if you qualify for insurance or other assistance programs, like CHIP or Medicaid. Just one application will let you know whether you can get lower costs based on your income.

Why: Before the ACA, more than 40 million Americans were uninsured. No one plans to get sick or hurt, but most people need medical care at some point.

How: The ACA gives everyone new protections, no matter what insurance they have. Now most plans can’t refuse coverage or charge more for pre-existing conditions like asthma or diabetes. Your plan can’t set a dollar limit on what they spend on your care during the entire time you are enrolled in the plan. Young adults can stay on their parents’ insurance up to the age of 26, and all plans must give a Summary of Benefits and Coverage, easy-to-read info about a plan’s coverage and costs. 

Beware of Fraud! Know the warning signs and how to protect yourself

With any new program, there is a lot of confusion around how it works or where to go for information. Sometimes consumers can become vulnerable to scams and fraud. With fraudulent websites or phone calls offering to help you sign up for “Obamacare,” it is hard to know who to trust. Here are some tips to protect yourself and personal health information from fraud.

  • Visit Healthcare.gov, the official site for the Marketplace, to sign up for coverage and learn more about the health care law.
  • Look for official government seals, logos or web addresses (.gov extension)
  • Compare insurance plans before making a decision or paying for insurance. There can be many that fit your particular needs!
  • No one should be asking for your personal health information. Don’t give it to anyone.
  • Keep personal and account numbers private. Don’t give your Social Security number or credit card or banking information to companies you didn’t contact or in response to unsolicited advertisements.
  • Never give your personal health or financial information to someone who calls or comes to your home uninvited, even if they say they are from the Marketplace.
  • Consumers should only get help to sign up for the Marketplace for certified application counselors and Navigators—check online for those organizations in your area approved by the government to help enroll individuals. These are free services provided to anyone who needs help. Beware of anyone who charges a fee in connection with enrollment.
  • Write down and keep a record of a salesperson’s name or anyone who may assist you, who he or she works for, phone number, street address, mailing address, email address, and website.

Learn more!

Online: HealthCare.gov | Call center: (800) 318-2596 | 24 hours a day, 7 days a week

TTY: (855) 889-4325

Information is available in dozens of other languages as well, including Spanish, Chinese, Vietnamese, and Korean. 

What health care reform means for young adults – National Consumers League

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The historic health reform battle ended in March, with the signing of the Affordable Care Act of 2010. While many of the law’s programs and benefits will be rolled out over the next 5-10 years, there will be several, more immediate, benefits that we will begin to see in the coming months.

You can actually see – state-by-state – which benefits have already been made available. It is now easier than ever to get access to health insurance.   Everyone will begin to see the benefits of the expanded access to affordable care – whether young adults, Medicare recipients, small business owners, or those just seeking additional preventive services.

What reform means for young adults

The new health care law enacted in March of 2010 has numerous provisions that will impact young adults. This demographic, though sometimes referred to as the ‘invincibles’, faces numerous health issues. The Department of Health and Human Services reports one in six young adults has a chronic illness and 30% are uninsured; young adults also have the lowest rate of access to employer-sponsored health insurance. The new law contains numerous provisions to cover young adults, whether through insurance provided through their employer, their parents’ health insurance, Medicaid changes, or the new Health Insurance Exchanges. Although many of its parts will not take effect until 2014, some major changes will occur in 2010.

Coverage

Before the law was passed, insurers could drop young adults from their parents’ health care plan when they turned 19, or upon graduation from college. The new law eliminates these practices. Starting in September 2010, dependent children up to the age of 26 will be eligible to remain on their parents’ plan, whether they are in college or not, living at home or residing in another state, or are single or married. The remaining exception, however, is that young adults offered coverage through their own job or if their parents’ existing plan does not qualify.

By 2014, all American citizens, including young adults, will be required to purchase insurance, with the threat of a fee for those who do not. There are various provisions in the new law, which make it easier to obtain coverage. Unemployed young adults with income up to approximately $15,000/year can look forward to an expansion of Medicaid for their health coverage. Individuals who make less than about $43,000 and who work at a place that does not provide affordable coverage can receive tax credits to help pay for insurance through new Health Insurance Exchanges. These exchanges will give consumers choice among plans and in a standardized format to help them find which is best for their needs. According to the Kaiser Family Foundation, prices each year will be capped at $5950 for individuals and $11,900 for families, excluding premiums.

The new law also intends to make obtaining insurance easier for young adults who work for small businesses. Many young adults work for small businesses. According to Kaiser Family Foundation, 36 percent of working uninsured young adults were employed in a small business with fewer than 25 workers. Incrementally over the next four years, small businesses with less than 25 employees will be eligible to receive tax credits to help make health insurance more affordable for their employees. If the small business has fewer than 100 employees, they also will be able to purchase insurance through the new Health Insurance Exchanges.

Preexisting conditions

Starting in September 2010, insurers can no longer deny coverage to children up to 19 with preexisting conditions such as asthma and high blood pressure. However, young adults over the age of 19 will not have this protection until 2014. In the meantime, adults with preexisting conditions who have not had insurance for a six–month period will have the option to either enter a temporary national pool for high-risk individuals or join pools set up by their state. You can find more information about whether your state is covered by this national plan here.

Preventive care

Under the new law, young adults can also take advantage of the many expansions to preventive care.  New health plans must cover certain preventive services without having the consumer share the costs.  Consumers will not need to pay a deductible, co-pay, or coinsurance when receiving preventive care. The preventive services covered include blood tests, many cancer screenings, and counseling for a wide array of issues.

Patient safety starts with you – National Consumers League

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Health care is not always as safe as we would like it to be. More than 10 years ago, the Institute of Medicine came out with a groundbreaking report that found that as many as 44,000 to 98,000 people die in American hospitals each year as a result of medical errors. What can consumers do to make sure they have a safe experience when they get health care?

Medical errors happen when what was planned as part of medical care does not work out, or when the wrong plan was used in the first place.) While there have been many efforts to improve safety over the last decade, progress is slow. Medical errors can happen anywhere you get your health services: in hospitals, clinics, a doctor’s office, nursing homes, pharmacies, and even in the patient’s home.

The best way you can help prevent errors is to be an active member of your health care team. That means taking part in decisions being made about your health care. Research shows that patients who are involved with their care tend to get better results. You can get better and safer care by asking questions about your diagnosis, treatment options, how you’re being cared for, and any medications prescribed for you.

Become an informed consumer.

Before seeking care, gather information about the illness or condition that affects you. Use reliable sources (like government Web sites such as the National Guideline Clearinghouse, Centers for Disease Control and the National Institutes of Health). Research options and possible treatment plans.

Choose a doctor, clinic, or hospital experienced in the type of care you require. For example, see the website developed by the Centers for Medicare and Medicaid Services, Hospital Compare, for information on comparing hospitals.

Keep track of your own medical history and your medications.

Write down your medical history, including medical conditions you have, illnesses, and hospitalizations. Keep track of all your medications (both prescription and over the counter) and dietary supplements (vitamins and herbs). This is called a personal medication record (PMR). There are several formats for keeping a PMR, and you should pick what works best for you.  Share all this when you visit the doctor, or go to the hospital or clinic.

Be a part of the team.

It’s your job to work with your doctor or other health care providers. Clear communication between patients and those that are taking care of them is critical to improving safety and reducing the risk of medical errors.

Make sure you share your health history and medication use with your team. The PMR is a good way of doing that.

Make sure you understand the care and treatment you are going to receive. Ask questions! The Ask Me Three program from the National Patient Safety Foundation encourages patients to ask their team these three important questions:

  1. What is my main problem?
  2. What do I need to do?
  3. Why is it important for me to do this?

Follow the treatment plan agreed upon by you and your doctor. Make sure you receive the instructions verbally AND they are written down for you.

Get a partner.

Involve a family member or friend in your care. Ask a family member or friend to be with you in the hospital or come along to appointments to speak up for you if you can’t. They can help you understand care instructions and be your advocate when it’s time to make decisions. It helps to have a second set of ears, especially if you are nervous or distracted about your condition.

More tips for: hospital stays

  • Don’t be afraid to remind doctors and nurses about washing their hands before working with you. You are part of the health care team and it is okay for you to remind them. Hand washing is one of the best ways to stop hospital infections, including the MRSA infection, which can be very serious.
  • If you are having surgery, make sure that you, your doctor and surgeon all agree and are clear on what exactly needs to be done. Some surgeons sign their initials directly on the site to be operated on before surgery.
  • If you have an intravenous catheter, to prevent infection tell you doctor or nurse if the bandage comes off or there is soreness around the catheter.
  • If you have a urinary catheter, make sure it is removed as soon as possible to prevent an infection. Ask your health care team every day if it can be removed.
  • Quit smoking. Patients who smoke get more infections.
  • When you are being discharged, ask your doctor to explain the plan to you, and write it down so that you understand what you need to do. Research shows that at discharge, doctors think their patients understand more than what they really do about what they should do when they are at home.

More tips for: medications

  • Make sure ALL your health care providers know ALL the medications, both prescription and OTC, as well as dietary supplements such as vitamins and herbs, that your are taking. Keep a Personal Medication Record (PMR), make sure it is up to date, and share it with your health care provider.
  • Tell your health care providers about any allergies and adverse reactions you have to medications.
  • When your health care provider write you a prescription, make sure you can read it and know what medicines you are being prescribed.
  • Ask about your medicines when you are prescribed them and when you receive them. Ask:
    • What is it for?
    • How long do I need to take it?
    • What side effects are likely, and what should I do if I have them?
    • Can I take it with other medicines and dietary supplements?
    • Is there any food or alcohol that I need to avoid while taking?
  • When you pick up your medicine at the pharmacy, ask if this is the medicine that was prescribed. Most medication errors involve the wrong drug or wrong dose.
  • If you have questions about the directions on the medicine label – ask!  Medicine labels can be hard to understand.  For example, does “three doses daily” mean take a dose every eight hours around the clock, or just during waking hours?

For more on this subject

National Patient Safety Foundation

Agency for Healthcare Research and Quality (AHRQ)

AHRQ’s Questions are the Answer

Fact sheets on Health Care Associated Infections (English, Spanish, and Large Print)

Health care reform: good for consumers and America – National Consumers League

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The lack of comprehensive health care coverage is America’s albatross – it makes our businesses less competitive and our workers less healthy. We need to put partisan concerns aside and work NOW to ensure that the system is reformed. The cost of doing nothing is unthinkable.

American families are paying about $15,000 a year for health care, twice as much as we did twenty years ago, and we pay $6,500 more for health care than any other industrialized country in the world. Yet despite these high costs we have poorer health outcomes.

We need to address why we are overpaying for care that is not making us healthier. Health reform, as proposed in several current bills in Congress, will move us towards greater accountability, efficiency, accessibility, transparency, and quality. It is essential that everyone have access to affordable health care or the system will remain broken.

For consumers, health reform will translate into choice – with a greater number of options available, including keeping and supplementing your own insurance, at more affordable and competitive prices. Reform will also make it easier to compare and understand the true costs and benefits of plans. As consumers and employees, we can make choices what will help push for health insurance and benefits that are competitive, innovative, and cost-contained.

With unemployment nearing 10 percent, many Americans have lost their employer-based coverage. Further, of the nearly 50 million uninsured, close to 80 percent are working Americans. It is imperative that we not leave our most vulnerable citizens out in the cold, which is why health reform will only be effective if everyone is covered.

Experts project that families will pay $10,000 more annually on medical costs by 2016 if we DON’T fix the system Health care coverage for all Americans is a moral imperative that must not be allowed to fall victim to partisan politics.

Dental care key to health reform – National Consumers League

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Providing preventative health care is one of the most important strategies for lowering our nation’s health costs. We hear a lot about the 46 million Americans without health insurance, but rarely do we hear that more than twice that lack dental insurance.

The case for dental coverage is the same as for health care. People without health care coverage often get sick with illnesses that could be treated at far less cost if caught early. When it comes to dental care, kids with minor tooth problems may end up with dental disease for the rest of their lives. This can hurt their ability to stay in school or get a job. Adults with missing teeth find it hard to get jobs as well.

But poor dental health can also kill you. The Washington Post ran a story about Deamonte Driver, a 12-year old who died of complications stemming from a toothache that could have been cured by an $80 tooth extraction. Deamonte’s family had lost its Medicaid coverage, and few dentists would even take Medicaid patients anyway. Bacteria from the tooth spread to Demonte’s brain, leading to hospitalization and two operations. The total cost of the hospital care was about $250,000, and the hospital was still unable to keep him alive.

The National Consumers League, with our long history of work on health care, has joined with several other groups including the American Dental Education Association, the Dental Health Foundation, and Oral Health America, in a campaign to underscore the importance of including dental care in health care reform. The groups have sent an open letter to Congress asking for recognition of these facts:

  • Dental conditions become more serious and are more costly to treat without intervention.
  • Untreated dental disease can have fatal and costly consequences.
  • Access to dental insurance is extremely difficult for the nation’s poorest. Half of all states’ Medicaid plans provide no or extremely limited dental coverage.
  • 130 million Americans, including 16 million children and 80 percent of seniors, lack dental insurance coverage. This is more than twice the total number lacking basic health insurance.
  • Poor oral health can complicate diabetes; heart disease; pneumonia; and further study is needed to determine the documented link between gum disease and preterm low birth weight babies.

Having dental insurance can be the difference between simple tooth decay and losing your teeth, or the difference between a toothache and a serious operation. Dental care is preventive care; it saves our hospitals and taxpayers the high cost of treating life-threatening complications and helps poor and middle class people get and keep jobs.

 

Considering a visit to a retail health clinic? – National Consumers League

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Retail health clinics have been popping up all over the United States in recent years. Many consumers find them appealing for their conveniences, but critics question the quality of care and are concerned about their impact on the traditional doctor-patient relationship.

As the United States is facing an increasing shortage of primary care physicians, Americans are turning to other sources of primary care. One delivery model that has attracted growing attention is the retail clinic, which focuses on providing convenient and accessible services at lower, easy-to-understand costs. These clinics are expanding rapidly across the country, from fewer than 100 in 2005 to thousands today.

These clinics are typically located in large retail settings, such as drug stores or big box stores. They are staffed largely by physician assistants or nurse practitioners, who can write prescriptions and have phone access to physicians. The growth of retail health clinics has been limited to parts of the country with legal frameworks that enable such clinics to deliver care and prescribe medication. The care offered through these clinics is restricted to a limited number of generally minor and easily treatable illnesses such as strep throat or urinary tract infections. Retail clinics often provide school and camp physicals, flu shots, and cholesterol checks.

The growth of retail clinics in America has generated debate on how they deliver health care to the consumer. The retail clinic provides convenience to the consumer by with extended weekend hours, central locattions, and fast service with an average wait time of less than 15 minutes – with no appointment necessary. Also many of the clinics post the cost of their services clearly for patients. However, critics argue that there are problems with quality of care due to staffing issues, continuity of care, and there is concern about how the clinics might impact the traditional doctor-patient relationship.

As retail clinics expand, state legislatures have taken a variety of approaches to regulating them. Some states are expanding the scope of practice for nurse practitioners, while others are moving for greater involvement by physicians. A handful of states require that physicians be on-site to support the nurse practitioners. Still other states such as Pennsylvania and California have called for expanding the scope of practice of nurse practitioners, including increased autonomy at retail clinics. Many states have seen bills aimed at additional regulation of clinics. Specifically, a few states have proposed laws restricting clinics by prohibiting the provision of medical services where tobacco is sold.

Given the complexities of the issue, we believe stakeholders will benefit from the opportunity to engage in an open and balanced discussion. NCL has found that multi-stakeholder forums help both consumers and policy makers navigate complex issues. Along with a final report on the forum, NCL will develop consumer education, including factors to consider when visiting a retail clinic. NCL will also summarize the issues state and federal policy makers and regulators should be considering as clinics expand. The report and consumer education pieces will be posted to the NCL website, and NCL will distribute the report to appropriate policy makers.

Thinking about visiting a retail health clinic? Start here with these FAQs

When should I use a retail health clinic?

Retail clinics are designed for providing basic services – cold, flu shot, strep test, etc. Retail clinics are intended for non-emergency and non-urgent use. Often a nurse practitioner or physician assistant provides the care.

Will my health insurance cover my visit to a retail health clinic?

Contact your insurance company to determine if the services are covered BEFORE you go. Ask the retail clinic if there are any other fees. Oftentimes, the fees-for-services are listed as they will be charged, while other times additional procedures might result in additional fees.

How will I know whether a clinic is legitimate?

The Convenient Care Association certifies its member clinics based on a variety of conditions, but not all retail clinics are members of the Association. You have the right to know whether or not a clinic and its practitioners are legitimate. Check to see if the clinic – or at least its practicing providers – are accredited or certified and don’t use their services if the clinic is not certified. Don’t be afraid to inquire about the practitioners’ licensing and certification to ensure that the clinic is legitimate.

What should I tell the retail clinic?

Be sure that you provide whoever cares for you with a detailed medical history – any conditions you may have, medications you may be taking, reactions to medications, past surgeries, history of treatment for disease, allergies, etc.

What should I tell my primary care provider?

Be sure to communicate back to your doctor anything that was prescribed or diagnosed while at the clinic. Get a report form the clinic and take it back to your doctor. And if you take a child, always report back to your pediatrician.

What if I don’t have a primary care provider?

Many of those who visit a retail clinic report that they do not have a primary care provider.

While a retail clinic can provide some basic services when you are in a pinch, it is best to have a primary care provider who knows and understands your entire health history and not just a single condition or ailment.

What consumers need to know about Rx drug substitution – National Consumers League

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If you take prescription medication, there’s a good chance that someday you’ll be asked to switch from your current drug to a new one. There are many reasons, including costs to you or your insurer, changes in your insurance coverage, or new drugs coming on the market. Therapeutic substitution can offer benefits, but it can also pose risks. The key to ensuring your safety when making a switch is full transparency.

What do we mean by therapeutic substitution?

Here’s an example. Say you have acid reflux and have been taking omeprazole, a proton pump inhibitor to treat it, for several years. Because the cost of another proton pump inhibitor, lansoprazole, is less for your health insurer, your doctor is contacted by your health insurer and asked to switch you to another proton pump inhibitor, lansoprazole, in an effort to save costs.

The availabilty of another drug at a lower cost to your insurance program is one of the top reasons for therapeutic substitution. Among others:

  • Another drug is available to your insurance program at a lower cost.
  • A medication is no longer covered by your insurance program.
  • A cheaper medication is available.
  • You may be offered discount coupons on a different drug, or your doctor may be offered financial incentives for prescribing a particular drug instead of others. This is a practice that concerns some advocates, because it is important that when a switch is considered, your health is always the top priority.
  • Your doctor wants to switch you to a drug that may be more effective or a better fit for your needs.

How does therapeutic substitution happen? There are several ways:

  • Your health insurance company may contact your doctor and urge her to switch from the prescribed drug to another drug in the same therapeutic class.
  • Your health insurance company may contact you, the patient, directly to say you can save money by switching your current prescription drug (a brand name) to a generic version of a different brand name drug. The new recommended drug is in the same class as the one you’re taking, but it’s chemically different. Learn more about drug classes here.
  • Your health insurance company may call or write you to say that your current drug is no longer covered, and you should talk to your doctor about switching you to another drug in the same class that is covered. Otherwise, you’d have to pay out-of-pocket to stick with your current medicine.
  • In some health insurance plans, your doctor and pharmacist all follow the same coverage rules, which include a pre-approved list of drugs. If your doctor prescribes a certain drug that isn’t covered, your pharmacist could substitute it with one that’s on the pre-approved list. In this case, you might not find out that you’ve been switched until you go to the pharmacy.

 

Common therapeutic drug substitutions – National Consumers League

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Therapeutic substitution, known also as drug switching and therapeutic interchange, is the practice of replacing a patient’s prescription drugs with chemically different drugs that are expected to have the same clinical effect. Many times patients switch to a different drug with no problems. However, for certain medications and conditions, therapeutic substitution could cause problems.

Consumers with a few specific conditions may be more likely than others to encounter a switch. Here are some of the conditions in which therapeutic substitutions may be more common, as well as the concerns about substitution expressed by some patient groups. As always, it is important to talk to your doctor about any potential therapeutic substitution.

In the lists of medicines, the Brand Name comes first, (and generic version is in parentheses).

Antidepressants 
Antidepressants stimulate chemical changes that increase the levels of neurotransmitters in the brain responsible for a person’s mood.

Some examples of antidepressants:
Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Luvox (fluvoxamine), Celexa (citalopram), and Lexapro (escitalopram). Antidepressants are associated with drug groups known as MAOIs, tricyclics, and SSRIs and are commonly prescribed by psychiatrists and other physicians to treat depression, bipolar disorder, and other mental illness.

Substitution concerns:
The American Psychiatric Association, Mental Health America, National Alliance on Mental Illness, and the National Council for Community Behavioral Healthcare oppose therapeutic substitution based on the substantial risk of serious adverse outcomes in people with mental illness. These groups support policies that provide patient access to the medications their doctors think they need, and they encourage shared patient-physician decisions based on the unique needs of individuals.

Cardiovascular Medications
There are several classes of drugs used to protect your heart, monitor your cholesterol level and blood pressure, and prevent other damage.

  • ACE inhibitors are used for controlling blood pressure, treating heart failure, preventing stroke, and preventing kidney damage in people with hypertension or diabetes. They also improve survival rates in patients who have had a heart attack.
  • Examples of ACE Inhibitors include: Capoten (captopril), Vasotec (enalapril), Prinivil (lisinopril), Accupril (quinapril) and Univasc (moesxipril)
  • Statins are used to lower cholesterol levels in people at risk of developing heart disease.
  • Examples of statins include: Lipitor, Zocor (simvastatin), Crestor, Pravachol (pravastatin), Mevacor (lovastin).

Substitution concerns:
The American Heart Association and the American College of Cardiology oppose therapeutic substitution and believe that only the prescribing doctor is equipped to determine the best drug or combination of drugs. These organizations believe that therapeutic substitution may result in the patient receiving a drug that doesn’t work well enough, produces life-threatening toxicity, or interacts dangerously with other drugs the patient is taking.

Epileptic medications
The drugs taken by patients with epilepsy are called antiepileptic drugs (AEDs) and are designed to change the electrical signaling in the brain to stop or prevent seizures. 

Examples of AEDs include:
Dilantin (phenytoin), Luminal (phenobarbital), Tegretol (carbamazepine), Neurontin (gabapentin), Lamictal (lamotrigine), Gabitril, Keppra, and Zonegran (zonisamide).

Substitution concerns:
The Epilepsy Foundation is concerned that there are enough differences among AEDs that any kind of medication substitution, (including switching from brand-name to generic), could be dangerous, and it could result in less control over seizures. The Epilepsy Foundation says that changing from one drug formulation to another can usually be done successfully if the patient’s blood levels, seizures, and toxicity are carefully monitored, but it says any medication change must require the permission of the treating doctor and the patient.

Proton-pump Inhibitors
Patients with dyspepsia, peptic ulcer disease, or acid-reflux may be prescribed a proton-pump inhibitor (PPI), drugs that result in long-lasting reduction of gastric acid production.

Examples of PPIs include:
Prilosec (omeprazole), Prevacid (lansoprazole), Nexium.

Substitution concerns:
As with any substitution, it is important to talk to your doctor, and be aware of the benefits and risks of substitution.