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FromDrug Benefit Trends®
Managed Care Matters Robert McCarthy, PhD [Drug Benefit Trends 11(12):19, 21, 1999. © 1999 Cliggott Publishing Co., Division of SCP/Cliggott Communications, Inc.]
One knows, of course, that pharmaceutical costs are managed care's No. 1 concern and that the trend of the drug spend is upward and accelerating. But one did not know -- or at least I didn't -- the precise degree of desperation some health plans are evidently experiencing as they calculate their Rx outlays. A window into that mind-set was recently thrown open by a story in the Las Vegas Sun (October 25, 1999) that reported a controversy surrounding the "pill-splitting" strategies of a couple of Nevada health insurers. These two plans, Health Plan of Nevada and the VA Southern Nevada Health Care System, have had patients on Lipitor or Zoloft or Celexa, to name just three drugs, getting half as many pills in double the dosage form. Then they've had the patients split the pills and have instructed them to take half a pill at a time, which would be the correct dosage. The plans have even supplied these patients with a pill splitter to facilitate the daily bifurcations of their medications. Why do this? Why risk patients' forgetting and taking double the dose in a single pill -- or improperly wielding the pill splitter and ending up not with two halved single doses but with a handful of shards and crumbs? Money, of course. Savings. Since many pharmaceutical companies price double-dose-sized pills exactly the same as the single-dose size, you can save half the cost of the therapy if you buy the bigger pill and split it. "Frankly, we're trying to preserve the pharmacy benefit -- especially for our elderly and Medicare eligible enrollees," says Health Plan of Nevada spokeswoman Jenny Des Vaux Oakes. "Pharmaceuticals are so expensive, the cost of the pharmacy is so high, that in order to keep the benefit viable without raising premiums, we've indicated that with regard to three drugs, patients accept them in double-dose sizes. And that's the case unless there is a sound medical reason, attested to by a physician, that the patient can't successfully utilize the prescription in a double-dose size." Cost savings are the upside. The downside could very well be improperly medicated patients either not getting better or even ending up in hospital with overdoses, which translates to outraged physicians, patients, and consumer groups. Representatives from all those constituencies, as well as from the health plans involved, met with the Nevada Board of Pharmacy on November 4. "It's not that pill-splitting is anything new," says Keith McDonald, executive secretary of the board. "Physicians and pharmacists have been doing it for years, on a patient-by-patient basis. You do it to titrate a dose not otherwise available in whole-pill form. But the plans have been requiring that pills be split when there is an appropriate-dose, whole-pill form. Or where the pills are coated, so that when you split them they have a tendency to shatter. Or when the pills are in odd shapes. Or are not scored. With regard to some of these pills, we asked the plans: did you contact the manufacturer when you decided to do this? Did the manufacturer authorize the split? The answer was: "No, and No." Disgruntled plan participants were able to show McDonald handfuls of crumbled tablets: the result of pill-splitting gone awry. One woman who had been given a pill splitter along with her medication turned out to have clubbed hands and to be mentally retarded. Build Your Own Not to pick on these Nevada MCOs -- there have been no reported misadventures, no patients harmed. But surely the risk is there, and it's evidently being run on the chance that some pharmaceutical dollars may be saved -- pharmaceutical dollars that are clearly in short supply. Yet surely the pill-splitting strategy is less a rational benefit redesign and more a Rube Goldberg machine: your pills... and here's your pill splitter. As McDonald asks: What's next? Will we be handing patients empty capsules and vials of time-released crystals and instructing them to "build your own"? Wondering what's next myself, I consulted the consultants. How widespread is this sort of pharmacy benefit jiggering and jury-rigging? "I'm aware of several examples across the country where plans are doing this; in fact I believe a Blue Cross plan in upstate New York is doing it with Zoloft," says Debi Reissman, PharmD, principal of the Irvine, Calif-based consulting firm Rxperts. "Plans are encouraging the docs to write for the 100-mL size, even though the dose is 50 mL, and then the patient is instructed to split the pill." Richard Zunker, PharmD, clinical product and marketing director, Prime Therapeutics, a Minnesota-based PBM, is aware of an HMO in the Minneapolis area that splits pills in selected categories with selected products. "I can't speak to the reasons why plans would implement pill-splitting therapies," Zunker says. "But if the justification is cost savings, then it may be the plan hasn't done a very good job looking at other areas where outlays can be reduced. There are other, better strategies, such as real formulary management. You know, Zoloft is often mentioned with regard to pill-splitting, because the pill does come in a double-dose size and the pill is scored. However, both Paxil and the new SSRI, Celexa, are less expensive than even the double-dose size of Zoloft. And since the SSRIs are basically the same, you can get the patient the same therapy, save even more costs, and not require the patient to perform open-pill surgery. In other words, if you do a little better job of managing up front, then you shouldn't need to have patients helping you save your pharmacy spend on the back end by doing such things as splitting their medications."
Dr McCarthy is a freelance journalist who writes extensively on managed care issues.
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