A Stanford University Medical Center researcher said pill-splitting saves money and is likely to be safe and effective with appropriate screening … even though he didn’t specifically study the safety of the procedure.
“When properly implemented, pill-splitting can be a safe, viable cost-saving strategy,” noted Dr. Randall Stafford, a researcher at the Stanford Center for Research in Disease Prevention and lead author of an article published in the August 2002 issue of the American Journal of Managed Care.
However, the doctor also noted: “In no sense did we look at the specific outcomes of pill-splitting.” Stafford said follow-up with patients on the safety of pill-splitting was outside the scope of his study.
The study has drawn much attention, driven largely by its potential impact on a pill-splitting lawsuit filed against HMO giant Kaiser Permanente. The suit charges the company endangers some patients’ health, solely to enhance profits, by forcing patients who are prescribed smaller-dose pills to accept and cut in half the larger-dose pills.
Kaiser says the lawsuit is without merit. Pill-splitting is purely voluntary, Kaiser representatives say, and encouraged only for a handful of drugs–and even then only for those patients who would not be adversely affected by an imprecise dose. Plaintiffs disagree, contending some patients “are simply provided the double-dose medications and a pill-splitter, often without direction or instruction.”
What the Study Finds
Using pharmacy claims data from a Massachusetts HMO with 19,000 members, Stafford and his colleagues examined how often pill-splitting was used. They found the HMO used the practice infrequently and saved only about $6,200 annually.
The researchers then used a screening process to determine which medications were appropriate for pill-splitting, excluding those medications that had time-release formulas or were not in tablet form. Starting with the 256 medications most commonly prescribed both nationwide and within the HMO, the researchers eventually narrowed the list to 11 medications they deemed could be split “safely and effectively with significant cost savings.”
Those medications include Lipitor, Paxil, Seerzone, Viagra, Zoloft, and Celexa. They projected the annual savings from splitting these pills could be as high as $259,576 annually for the 19,000-member HMO.
HMOs save money by recommending pill-splitting because the wholesale costs of some medications are exactly the same (or nearly the same) for a larger-dose tablet as a smaller-dose tablet.
For example, 50-milligram tablets of Zoloft, an antidepressant, cost approximately $227 per 100, so it would ordinarily cost an HMO $454 to prescribe 50 milligrams per day with 200 daily doses. But 100-milligram tablets cost about $233 per 100, so the insurer can save $221 in a single prescription by forcing the patient to accept and split the 100-milligram tablets to obtain 50 milligrams per day.
The Safety Issue
The study has caused such a stir because both consumers and insurers are demanding relief from skyrocketing health care costs, particularly those related to prescription drugs. Kaiser spokesperson Beverly Hayon said she believes the public’s frustration over the high cost of prescription drugs is fueling litigation against insurers. “Pill-splitting is one of the few ways, where warranted, that insurers–and therefore their members–can save money on prescription medicine,” she said.
Patients can directly save money on pill-splitting because they are paying only one co-payment for a prescription that lasts, say, two months, rather than paying two co-payments during the same period.
However, mandatory pill-splitting has been condemned by the American Medical Association (AMA), American Society of Consultant Pharmacists, and American Pharmaceutical Association due to the health risks involved. These include the chance patients will divide the pills unevenly and wind up taking incorrect doses. Because some patients suffer from cognitive impairments, they may forget which pills they must split.
Said Audrey Timmis, an elderly woman who suffers from emphysema who is lead plaintiff in the suit against Kaiser Permanente: “When I tried to split the pills–which were slightly smaller than an aspirin–I usually ended up launching them across the room like tiddly-winks or crushing them into powder between my fingers.”
Plaintiff Dr. Charles Phillips, formerly under contract with Kaiser, said the Stanford study is suspect from a safety viewpoint. “The issue is really simple–the split pieces are not equal,” he said. “Dosing may range 40 percent between a small and large fragment. This is not modern medicine but rather an experiment in testing the inaction of regulatory agencies. It is bad pharmacy practice.”
Stafford said he does not support mandatory pill-splitting. However, he noted that the practice, if done correctly, could help those who pay for prescription drugs out-of-pocket, including the uninsured and some Medicare beneficiaries who do not have prescription drug coverage. For them, pill-splitting “may make newer, more expensive medications available to people who might not otherwise afford them.”
“Physicians should consider using pill-splitting with selected medications and patients,” said Stafford, a pharma-economist who studies how physicians use medications. “And,” he adds, “patients may want to bring it up with their doctors.”
Vicki Lankarge is a health care reporter for insure.com, The Consumer Insurance Guide.