High-dosage pill splitting saves money, irks patients

By Kyung M. Song
Seattle Times staff reporter

	MARK HARRISON / THE SEATTLE TIMES Don Williams, executive director of the state pharmacy board and a Group Health member, was unhappy when told to use double-strength cholesterol pills and split them, a tricky task.
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The idea is simple: Use a pill cutter to split double-strength prescription medications and halve your drug costs.

Health insurers — exploiting peculiarities of drug pricing that make some large doses just as cheap as smaller ones — are increasingly urging patients to buy higher-strength tablets and taking half at a time.

Last month, Regence BlueShield sent notices to 45,000 customers in Washington offering free pill splitters to anyone who accepts a higher-strength prescription. The deal applies to Zoloft, Vioxx and four other Regence-approved drugs. Seattle's Group Health Cooperative has had a similar program for a decade and was one of the nation's first health plans to do so.

But some patients contend that pill splitting isn't as easy — or voluntary — as insurers claim. Cutting drugs in even doses can be tricky, particularly for those who are very old. And promoting half tablets could tempt penny-pinching patients to split other drugs that should always be taken whole.

Also, pharmacists worry that insurers might eventually make splitting some tablets mandatory, inconveniencing them and their patients. The American Medical Association and the American Pharmaceutical Association formally oppose mandatory tablet splitting.

Pill-splitting hazards Done correctly, splitting prescription tablets can save you money. Done incorrectly, it can endanger your health. Many prescription drugs that aren't specifically recommended for splitting can be split. But some never should be cut. They include: • Drugs that have coating for controlled release or to protect against moisture, such as long-acting painkillers. • Drugs that require finely calibrated dosages, including anti-seizure medications and blood thinners. • Very small pills that are difficult to split evenly. • Drugs that come in non-tablet forms, such as capsules. • Drugs that cost more for higher strengths, which would reduce potential savings.

Making double-strength pills last twice as long can save patients with insurance $20 or more in regular prescription co-pays. Uninsured patients or those with no prescription coverage, including many seniors on Medicare, can save even more.

"Sometimes, splitting the tablet makes the difference between being able to afford the medication or not," said Marc Mora, an internist and chair of Group Health's pharmacy and therapeutics committee.

Ironically, one reason why pharmaceutical companies charge equal prices for drugs of different strengths is so people needing larger doses won't try to scrimp by splitting or skipping pills, said Dr. Randall Stafford, assistant professor of medicine at Stanford University, who last year published a study showing that tablet splitting can be safe and economic for certain drugs.

Stafford said the compound ingredients in drugs cost relatively little compared to development, marketing and distribution costs. A 20-milligram pill costs nominally more to manufacture than a 10-milligram pill, he said.

Don Williams, a Group Health patient who has taken cholesterol-lowering medication for six years, argues that the co-op erred in approving at least one particular drug for splitting.

Williams's doctor put him on 10 milligrams of Zocor for his cholesterol but wrote the prescription for 20-milligram tablets. When Williams asked his Group Health pharmacist about the discrepancy, he was handed a pill cutter and told to split the tablets.

"There was nothing voluntary about it," recalled Williams, who happens to be a non-practicing pharmacist and executive director of Washington's Board of Pharmacy.

Williams had trouble splitting the shield-shaped Zocor pills. Zocor is coated and does not have a scored line in the middle, both of which hindered cutting. Williams estimates the pill broke in unequal doses four of 10 times. Group Health has since changed Williams' cholesterol medication twice. He now takes full-size lovastatin, a cheaper drug Group Health now favors for all its high-cholesterol patients.

Jim Carlson, Group Health's director of clinical pharmacy services, said Williams had the right to ultimately reject a half-tablet drug. But Carlson conceded that Williams' pharmacist could have failed to give him that option explicitly.

"If a patient expressed concern, the pharmacist would engage in more conversation" about the benefits of splitting tablets, Carlson said. "But there is not specific scripting on how patients are counseled."

Group Health's Mora said he is aware of long-standing concerns about cutting pills in even doses, especially for children.

But Mora said Group Health promotes cutting tablets only when it can be done safely. The co-op has eight prescription drugs — all non-scored — approved for splitting and allows half tablets for any medication when it is deemed safe by a physician or a pharmacist.

Premera Blue Cross, Washington's largest health insurer, does not endorse half tablets. "We believe that's something that strictly should be left to the doctor and the patient," said Premera spokesman Chris Jarvis.

Pill splitting can reap big savings for insurers. Prescription drugs are the fastest-rising category of health-care expenditures in the United States, outpacing increases in spending on doctors, hospitals and nursing homes. In 2001, Americans spent $1.42 trillion on health care, $140 billion of that on prescription drugs.

Splitting tablets means insurers have to pay for refills half as often. Cholesterol-lowering drug Lipitor, which is the No. 1 prescribed medication for Regence customers, costs the same for a 40-milligram pill as a 20-milligram pill. Each Lipitor pill on average costs $3.64 wholesale, which is the price before negotiated discounts.

SuAnn Bond, Regence's assistant vice president of pharmacy services, said it's too soon to gauge the popularity of its half-tablet program. Bond said Regence could shave as much as $5 million annually off its prescription-drug claims if every eligible patient split pills.

That would be a small but still significant savings for Regence, which pays out more than $200 million a year for prescription drugs. Patients have split pills privately for years to stretch their money. But insurers were slower to embrace the practice even as they were aggressively pushing generic medications as cheaper alternatives to name-brand drugs.

"There is no one thing that's going to reverse" rising prescription costs, Bond said. "But we can do a number of different things together."

John Oftebro, owner of Kelley-Ross Pharmacy in downtown Seattle, estimates that just about every other patient who lacks prescription coverage inquires about tablet splitting. Oftebro said many drugs, such as the anti-anxiety pill Valium or painkiller Vicodin, are meant to be split when patients don't need the full dose.

But Oftebro, a pharmacist for 38 years, warned that a host of drugs should never be split. They include medication with controlled-release coating, such as painkiller OxyContin, because breaching the coating could result in overdose. Other drugs, such as blood thinner Coumadin and anti-seizure medicine Depakote, can become dangerous if the dosage is off by even a milligram.

Oftebro worries especially about older patients who lack the dexterity to properly split very small or irregularly shaped pills.

Williams, the pharmacist who had to split his cholesterol medication, does not believe his treatment was compromised. Nonetheless, he remains unhappy that his Group Health pharmacist never gave him the option to take a whole pill.

"My feeling was that I didn't have any choice, and I was having to do this just to save them money," Williams said.

Kyung Song: 206-464-2423 or ksong@seattletimes.com

Copyright © 2003 The Seattle Times Company