I recently participated in a panel discussion on medication safety issues with a colleague who serves as a patient advocate. We’ve been on panels together and make a great team—a doctor and a lawyer who are actually on the same side! This time, though, she said something that I hadn’t heard her say before and that I had some trouble with. She criticized a pharmacist who suggested to a patient that a therapeutically equivalent drug could be substituted for the medication her insurance company no longer had on its formulary. She emphasized to our audience that what the pharmacist was suggesting was not the same chemical compound as the drug she had been taking. She thought this was wrong.

My colleague is a staunch consumer advocate who has courageously fought for health justice. We have been allies in numerous campaigns on behalf of the public’s health against entrenched vested interests. I have nothing but the highest regard and admiration for her. Yet her criticism of the pharmacist who, following an insurer’s pharmacy benefits management plan, suggested a clinically reasonable therapeutic substitution is emblematic of a dilemma facing patient advocates. The horns of this dilemma pit the rights of individual patients to the health care they want versus the greater good of the community.

The enormous resources poured into health care in this country—about $3 trillion dollars a year—make this conflict unavoidable. The struggle to achieve universal, affordable, high-quality health care is far from over despite the enactment of the Affordable Care Act. Tens of millions of Americans remain uninsured. Those with insurance face higher and higher out-of-pocket spending through the imposition of high deductibles. Premiums continue to rise faster than wages, especially for lower wage-earning families.

High costs for health care also impede our ability to fund key social services such as food security, adequate housing, affordable daycare, safe neighborhoods and recreation that are vital to good health. It also undermines our ability address vital global challenges as well, such as global warming and the alleviation of suffering in the developing world that can lead to international terrorism.  

If we don’t rein in health care spending, it is almost certain that our efforts to advance a competing, life-saving agenda will be significantly undermined. 

Bringing this lofty conversation down to more pragmatic issues, let me return to the topic of therapeutic substitution. During the summer months, my eyes itch from pollen allergy. I buy a 10-ml bottle of ketotifen eye drops over the counter for about $12. I could also get the same relief with a prescription for Patanol (olopatadine) that costs $169 for a 5-ml bottle. I’ve used both and find they work equally well. What’s wrong with at least starting out with the less expensive alternative rather than the one that costs more than 28 times as much?

While it is illegal for a pharmacist to substitute one drug for a chemically different drug that does the same thing, public and private insurance plans achieve the same result by changing their formulary. For instance, I’m frequently confronted by a change in what Medicaid will cover for stomach-acid problems—one year it’s Nexium and the next year it’s Protonix, whichever the state is able to get a better deal on. In almost all cases, the drugs work equally well even though they are different chemical compounds. Rarely, a patient will find that one works better than the other, and I can obtain an exception from Medicaid to allow the patient to continue on the drug that is no longer on the preferred drug list.

Commercial health insurers are doing the same thing by using different copayments for drugs on different tiers Going back to Patanol eye-drops, for instance, my insurance company lists that drug as a tier-3 drug that requires a $45 copayment. The problem is that not all patients know that a lower-cost alternative is available. There is no generic Patanol that the pharmacist can substitute, but there is a therapeutic equivalent, ketotifen, that will probably do just as well.  Using Patanol costs the patient more ($45 versus $12) and the health plan more ($154 versus 0), which can eventually increase premium costs too.

Patient advocates are justifiably wary about policies and practices that limit patients’ ability to get the health care they want. Our sad national legacy is one that all too often denied patients, especially poor patients, the care they needed. Patient advocates should continue to be champions for low-income and chronically ill people and to fight for the right to health care that is needed. But they should also recognize the need to limit wasteful health care spending, because these at-risk  patients are also the first to suffer when high costs lead to cuts in programs and benefits. Policies like therapeutic substitution, campaigns like Choosing Wisely , and initiatives like Community Catalyst’s Voices for Better Health can stem unnecessary spending while safeguarding and improving the health of the patient.

The role of patient advocates should not be one of fighting any perceived infringement of patients to any health care service or product available, but rather one of partnering with patients to secure safe, cost-effective and better organized health care. In the long run, there really is no dilemma—this is the best strategy for individual patients as well as the broader community.

Stephen R. Smith, M.D., M.P.H., Community Catalyst Physician Consultant