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

[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.