medicine, drop size, and vampire blood

[cellio]

A recent mailing from my employer's department of reducing health-insurance costs (that's probably not their real name) offered some advice that seemed questionable to me. They suggested splitting pills -- not, they hastened to point out, that we should take half the dosage we need, but rather, we should get pills that are twice as strong as they need to be and then split them. They suggested that a stronger drug doesn't necessarily cost any (or much) more to fill, so you can fill your prescription half as often, saving you half the copay and them a lot on the balance. (Aside: what bright person decided that your cost, if insured, should be per month rather than per some volume? If I take a medicine twice as often as you do, why shouldn't I pay twice as much for it?)

I wonder how the pill-splitting scheme could actually be implemented legally and what doctor or pharmacist would go along with it. I find it hard to believe that a large company would advise its employees to commit insurance fraud (in a manner that's traceable), so there must be a way to do it, but I'm puzzled. (The company self-insures; maybe that's why it's ok?)

I was telling this to Dani last night, and commented that even if it's kosher I can't benefit from it for my prescriptions -- the medicine I take for glaucoma is in the form of eyedrops, and I don't know how to get double-sized drops. (Nor am I going to ask my ophthamologist to write a bogus prescription.) This, combined with some recent TV viewing, led us to wonder how big a drop is, anyway. We didn't have an internet connection to hand; Dani tried to work it out theoretically while I tried to work it out empirically. (Things often fall out that way with us.) A medicine that I take once a day (two drops) comes in a 2.5ml bottle and lasts about a month (maybe a little more). Viscosity matters, of course; this stuff is closer to water than to syrup. So I posited about 25 drops/ml for my medicine. (Google later suggested 20 drops/ml of water as an approximation.)

And that's when we turned our attention to the amount by which a character in the True Blood episode we'd just watched overdosed. The character had a quarter-ounce vial of an illegal substance (vampire blood) that he was supposed to take one drop of at a time. Wikipedia tells me that the viscosity of normal blood is about three times that of water. It has no data on vampire blood. Assuming (and I don't know if that's valid) that drop size is directly correlated with viscosity, this suggests that the character overdosed by a factor of approximately 46. Ouch. :-) (Yes, it did hurt.)

Ok, fine -- what have you done with your science education lately? :-)

Comments

[mortuus.livejournal.com]

I love your use of science :-)

[ichur72.livejournal.com]

There's another reason why it might be a bad idea. If I understand correctly, some pills are formulated in such a way that you really ought to take them whole -- e.g., the drug is not released on the desired schedule if you circumvent the process of letting the coating dissolve and then moving on to the innards of the pill.

[sue-n-julia.livejournal.com]

I was going to mention this myself. I take pain meds that splitting them actually could cause overdoses as too much hits at one time. And if someone is using a pain patch, that's even worse.

I think a message to the Pennsylvania Insurance Commission might actually be in order. Insurance companies should not be suggesting dangerous strategies to reduce their costs.

S

[cellio]

Oh, good point. Even though I actually had that knowledge available (discussions with my vet about mixing Erik's meds into his food), I hadn't thought of that.

[ichur72.livejournal.com]

It was one of the first things that came to mind as I'm on an extended-release medication that doesn't work as intended if it doesn't dissolve from the outside in.

All in all, it seems safe to say that your employer's department of reducing health-insurance costs could stand to develop some better ideas. I know that saving money almost always involves making hard choices, but the strategy they suggested just sounds hinky.

[miz-hatbox.livejournal.com]

Plus, even for things that are not time-released, not all formulations are created equal. I know someone who is on Prednisone, and the insurance company told her doc (or maybe the pharmacy, I forget which) to change her prescription to do the pill-splitting thing, and the new, half-of-twice-as-big prescrip did not help at all. She had to convince the doc who had to call the insurance and get them to okay the old take-all-of-one prescription.

[dagonell.livejournal.com]

"Ok, fine -- what have you done with your science education lately? :-)"

Wrote a short story about a werewolf who became an astronaut. I had in wolf-form in a specially made suit running across the surface. The editorial board apparently spent three days trying to figure out if my calculations for his speed were valid. :D
-- Dagonell

[cellio]

Were they? :-)

[jerusha.livejournal.com]

Well, one reason why "take twice as much <> pay twice as much" is that, whatever pricing you're looking at [wholesale, retail, co-pay], a 100 mg pill is not going to cost twice as much as a 50 mg pill.

However, one should definitely check with one's pharmacist, because as ichur72 points out, some pills must not be divided or crushed, because of formulation issues (controlled release construction, coatings, etc). Your pharmacist could also tell you if the pill is scored or otherwise constructed with the idea of being divided.

When calibrating droppers, the USP standard dropper delivers 20 drops of water per milliliter. However, because, as you point out, the viscosity of different liquids differs from water, droppers intended for use with a particular liquid will be calibrated specifically to that liquid. With eyedrops, there is the additional consideration that, in the eye, medication is better absorbed in smaller drop volumes. (That is to say, if you have two formulations, one with 1 mg of drug in a 0.05 mL drop (USP standard drop), and the other with 1 mg of drug in an 0.03 mL drop, the 1 mg from the smaller drop will be better absorbed.) Basically, this is because the volume of the eye is limited; the excess volume of a larger drop drains away through the lacrimal system without ever coming into contact with the cornea. (Part of my day job involves helping to teach pharmaceutics, which is the science of getting drugs into dosage forms.)

[cellio]

Thanks for the information. Semi-coincidentally (it was a side effect of the eyedrop question), we found a useful discussion of glaucoma meds that mentions in passing what you said about the eye absorbing drops. I always worried a little that not all of the drop actually makes it into my eye; my doctor has told me not to worry about it but we never discussed why not. (My doctor is very good about answering questions and explaining things; it's just that this was farther down in the queue and we have limited time.)

[hlinspjalda.livejournal.com]

The insurer seems to make the call based on the frequency per month that one takes the medication; that is, a maximum of X dosages per month is covered. We have direct experience of this situation with two of the classes of medication Mr. Fixer takes. In both cases it's the prescribers initiating the change of prescription. They know from experience (and we have learned too) that the insurance company will throw a big hissy fit and not cover it if the prescribers write the prescriptions the way that is most correct for Mr. Fixer the individual.

There have not been any delivery issues with these particular medications, i.e., no harm is done by splitting the larger pills and taking them by halves, and the dosage he takes winds up being the correct one. Obviously, for some medications and delivery systems this would not be the case.

So I guess if you want to look at it that way, the prescribers are conspiring with the patients against the insurance companies in order to get the patients the health care the prescribers say they need. Or is it simply gaming the system? From our perspective here on the inside of that situation, it's pretty damned frustrating and ugly that the insurance company takes 12.5% of Mr. Fixer's gross annual income every year and then counts beans with his medications.

*shakes self* Sorry. Button.

[cellio]

No need to apologize. The health-insurance games have been degenerating. :-(

[eub.livejournal.com]

Hm, I don't see this as insurance fraud, or collusion in fraud by the prescriber. If the medication is one where half of a 2X mg pill is pharmacologically equivalent (which, yeah, not all are), then I see it as more like prescribing a generic.

I believe the price structure is like this all the way through. For the pharmaceutical company, the marginal cost of most chemical synthesis is small compared to what people (and their insurers) are willing to pay for a pill. For the insurance company, the cost is the wholesale cost plus the cost of handling a prescription, whatever's in it. Then from the milligram-of-drug perspective, you can look at this as undercharging high-dose pill buyers, or overcharging low-dose pill buyers, and I think it's really arbitrary which, but in any case it does invite arbitrage.

BTW, one big factor affecting drop size in liquids of the same viscosity is surface tension, I think. Or at least I know alcohol comes out of an eyedropper in smaller drops that water, and think surface tension makes sense as an explanation. :)

[cellio]

My fraud alarm went off at the suggestion that we get the prescription for the same number of pills but double-strength and fill it half as often. Since part of the "copay contract", so to speak, is that I'm paying $X for my share of a one-month supply, but under this scheme I'm getting a two-month supply, it seemed like either the doctor would have to write a fraudulent prescription ("yes, your honor, this is what I prescribed; I have no idea why the patient only took half the dosage") or the pharmacist would have to dispense something other than what was written. That the suggestion might be coming from the insurance company hadn't occurred to me. (I had read it as coming from the folks in our company who pay the insurance company...)

Should I ask what circumstances led you to push alcohol through an eyedropper? :-)

[http://users.livejournal.com/merle_/]

That's true, but the insurance companies care little about the teensy fragment of copay. I got a printout from a pharmacy once and the total amount claimed was over ten times the copay, and the amount they got was at least five times -- and they do get more the more pills you get, whether you personally pay more or not.

Which is a form of fraud, in the sense that you should be paying a fair share. I justify doing it precisely because the copay scheme is so completely stupid. If I can get two months' meds for the cost of one just because they have a poor pricing scheme, more power to me.

Very few doctors go for it, though. Most feel that if they prescribe a double dosage you might take it. Which is a perfectly reasonable conclusion for some drugs and many people.

Splitting pills, though, is something I do not do, unless they are chewable things like Tylenol. I don't want sharp edges going down my throat, and I don't trust that they are not time-delayed things.

[baron-steffan.livejournal.com]

Hi, it's your friendly cyber-neighborhood pharmacist here. Some points on this thread....

Splitting pills is often recommended, is legal, and is often quite a good idea. And understand, I'm no friend of Blue Cross bean-counters here. But here's how it works. Quite often, the (wholesale) price of a bottle of pills bears no relation to the strength, i.e. a bottle of 100 pills of 1 mg Mickeymycin will cost $100, and a bottle of a hundred 5 mg pills will cost me $100, and a bottle of a hundred 10 mg pills will cost me $100. The insurance companies are well aware of this. So if the insurance company is going to pay me the cost of the pills plus, say, a $2 dispensing fee, 30 pills of 5 mg will cost them $32, but if you get 15 pills of 10 mg and split them in half, it will cost them $17. But part of those figures is your copay. So say they give you a break on the copay for splitting: you pay $5 instead of $10. That means they pay me $12 instead of $22, you pay me $5 instead of $10, and everyone goes home happy.

Note that you're not getting a double supply. You're still getting a month's supply of medicine. Now, in most jurisdictions your pharmacist would have to call your doctor, but in RI it actually isn't necessary. There's a state regulation that says we can change strength like this or even dosage form (say, pills to liquid for a pediatric antibiotic) if in our professional opinion there's no difference. So in a simple pill-splitting case, there's no problem. No illegality, no fraud, and most importantly, no difference whatsoever in your therapy. Win/win.

This would not be done in the case of extended-release formulations, or enteric coatings or suchlike, where the characteristics of release, distribution, elimination, etc. would be altered.

As for the drops-per-mL question, the insurance industry standard is 18 drops per mL. A 5 ml bottle of eye drops used as 1 drop in each eye twice a day is billed as a 22 day or 23 day supply. United Health of RI is particularly hard-assed about this one: no slack for the arthritic granny with glaucoma who spills a half-dozen drops with each dose. The older "Apothecary" system of weights and measures had a unit, the minim, which was approximately a "drop": IIRC there are 16.32 minims in a mL (or older "cc").

[cellio]

Thanks for all the information.

The scheme you described -- half as many double-strength pills, and half the copay as patient incentive -- seems perfectly reasonable to me where medically appropriate. The scheme that was proposed in the email we received was different: get the same number of double-strength pills and fill it half as often (for the usual copay). Since insurance companies pay for a one-month supply and you're getting a two-month supply, this seems questionable. If the insurance company is suggesting it then that's cool; I understood the email as being a suggestion from my employer, and I wasn't sure how I felt about that.

[baron-steffan.livejournal.com]

But the insurance company works for and with your employer, under a negotiated contract. So nobody is being snowballed. They're doing this, probably, because it benefits both of them. The insurance company pays less, so they can keep the company's costs down. And as a side effect (not that they really care), you win as well. The only one who can potentially lose under the scheme you report is (drum roll) the pharmacist, who gets his fixed dispensing fee every 2 months instead of every month. What else is new?

[paquerette.livejournal.com]

Is it sort of like with soda pop? You pay just about the same for a 20 oz soda as you do for a 2L. The cost of teh actual ingredients is negligible; it's the cost of creating the product and bottling it (or turning it into tablets) that you're paying for.

I'm glad to hear from a pro on this, as I had always thought that the "getting larger pills and splitting them" was inherently illegal, something about meds only being able to be used as labeled or something like that. I don't know why.

[baron-steffan.livejournal.com]

I'm not privy to the arcane mysteries behind how Big Pharma determines their ultimate wholesale prices, but clearly it isn't directly proportional to how much actual active drug is in the bottle. This is a classic case of political spin-doctoring: to me, it looks like they're sticking it to me because they're not giving me a discount for buying a tenth as much drug: they're charging me the same price for 100 mg (100 x 1 mg) as they are for 1,000 mg (100 x 10mg). But they will say, no, no, what they're doing is that they're *not* charging me $1,000 for 1,000 mg...aren't they just wonderfully generous and kind-hearted and altruistic? So how do you interpret it? Clearly there's a lot going on in this calculation, and it involves research and regulatory costs, advertising, projected life of their market share before Barr Labs comes out with the generic and all their efforts go "poof" overnight in a puff of mist...IOW, way more than the bare cost of manufacturing 1,000 mg of mickeymycin.

As for the splitting issue, what would be fraudulent is if I gave you two months of drug and billed it as one month, or claimed you were taking two a day when the Rx is for 1 a day. But I'm not doing that. It's all on the up and up.

[nsingman.livejournal.com]

Good question! My undergraduate majors were chemistry and mathematics, and just today, I was discussing the negative heat of solution of CO2 in water with some colleagues as I was denigrating anthropogenic global warming hysteria. We also talked about pursuit curves and following wildlife.
:-)

[cellio]

Excellent! Keep up the good work. :-)

[http://users.livejournal.com/merle_/]

Ah, first season True Blood. I would say "the books are better" but that would sound pedantic.

[cellio]

"the books are better"

Yeah, probably, but I'm enjoying the show (and it's something Dani and I can do together), and I probably wouldn't get around to reading the books. Dani has read the books, so I'm getting his running comparison.

(I was wondering if anyone reading this had seen that show.)

[http://users.livejournal.com/merle_/]

True, reading the same book at the same time isn't much of a "together" activity. It's even worse if the two people have dramatically different reading speeds...

The show seems closer to the books than, say, Dresden Files, except of course it's been HBO-ified, so tons and tons more sex and swearing. The second season felt slower than the first to me, but that might be because I got the first all at once and the second slowly dribbled in.