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

[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.