Splitting Up

Smart shoppers can't resist a two-for-one sale. But should you purchase prescription drugs the same way you buy canned corn or frozen pizza? For years, people who take daily medications have saved money by asking their doctors to prescribe pills with double the dose they need, which they then cut in half with a knife.

Although skeptics say the practice might be unsafe, a growing number of health insurers are encouraging patients to split pills as a way to combat the rising costs of prescription drugs. In June, UnitedHealthcare, one of the largest managed-care companies in the United States, advised members in Wisconsin to discuss pill-splitting with their physicians. The insurer plans to introduce the program nationwide before the end of the year.

"Consumers are asking what they can do to bring their costs down," said Tim Heady, chief executive officer of UnitedHealth's Pharmaceutical Solutions drug-benefit business. "This program provides better access to important drugs and can improve compliance with these medicines by helping them to be more affordable and accessible to more people." U.S. Veterans Administration hospitals and some state Medicaid programs ask patients who are prescribed certain medications to split pills, too. But although the practice can save money for insurers and patients alike, is tablet splitting a good idea? Representatives for the pharmaceutical industry and drug store owners say no. Other experts insist that, in some cases, medical consumers can divide and prosper.

Splitting pills saves cash because of a strategy employed by the pharmaceutical industry called "flat pricing." Although a gallon of milk costs considerably more than a half gallon, there is often little or no price difference between high and low dosages of medications. For instance, Drugstore.com recently offered 10 tablets of 100-milligram Viagra for $93.99, which is the same price it charged for an equal number of 50-milligram Viagra tablets.

Drug manufacturers use flat pricing to keep consumers from switching to cheaper brands if they need to increase dosage, said Dr. Michael P. Cecil, author of Drugs for Less (Hatherleigh Press, 2005). Cecil, a cardiologist in Covington, Georgia, lists in his book about 100 pills that can be safely cut in half as a way to battle the rising costs of prescription drugs.

According to the Henry J. Kaiser Foundation, spending on prescription drugs in the United States rises more than 10 percent a year. Patients who pay for their own medications can reduce their drug bills by up to 50 percent with pill-splitting. For example, someone who halves a double dose of the top-selling cholesterol-lowering drug, Lipitor, could save close to $600 a year.

But even people whose health insurance covers prescription drugs might be able to save a few dollars. For instance, UnitedHealthcare members who agree to split pills will only be required to pay half the usual out-of-pocket co-payment for their medications; a typical $25 co-payment will be reduced to $12.50.

The savings for providers can also be substantial. The Veterans Administration, for example, trimmed $46.5 million from its annual drug tab in 2003 simply by asking patients to split Zocor, a cholesterol drug. "We were able to treat two patients for the price of one," said pharmacist David Parra of the Veterans Affairs Medical Center in West Palm Beach, Florida.

Drug manufacturers and pharmacies oppose pill splitting, arguing that it's too difficult to divide a tablet into equal halves, especially for the elderly and people with poor vision or arthritis. The Pharmaceutical Research & Manufacturers of America, an industry organization, and the National Association of Chain Drug Stores discourage the practice. "It's a lot of responsibility to put on the patient and doctor," said Jeff Trewhitt, a spokesperson for the pharmaceutical group. "We strongly urge that pill-splitting not be pursued."

Neither Trewhitt nor Mary Ann Wagner, vice president of pharmacy regulatory affairs for the chain-drug-stores group, could provide estimates of how much money their respective industries would lose if pill-splitting became more widespread. But a 2000 study estimated that if all Americans who take just 12 of the most commonly prescribed psychotropic drugs - which includes antidepressants and antipsychotics - split pills, consumers would save nearly $1.5 billion.

Some physicians oppose tablet splitting, too. Emergency-room physician Charles Phillips said he has opposed the practice since some of his patients began telling him that they were required to chop double doses of certain medications. When he examined their drug bottles, he was alarmed to find pill fragments of all sizes. "They'd go from big, to little, down to dust," said Phillips, who was a plaintiff a 2002 lawsuit questioning the legality of managed-care provider Kaiser Permanente's pill-splitting program, which it began in the early 1990s. (The lawsuit was unsuccessful; Kaiser Permanente spokesperson Beverly Hayon said that the insurer's pill-splitting program has been voluntary since its inception.)

Critics such as Phillips charge that splitting a pill too often produces unequal fragments, leading to erratic dosing that could threaten a patient's health. A review in 2004 in The Medical Letter on Drugs & Therapeutics found that trained pharmacists are at best able to divide tablets into roughly equal halves about two-thirds of the time, even when using pill cutters available in drug stores. In one experiment, just 27 percent of tablets divided equally.

However, properly chosen pills can be split as a way to save money, said Dr. Gianna Zuccotti, deputy editor of the Medical Letter. Many drugs remain active in the body for a long time, so subtle variations in dosage won't make much difference, she said. In fact, Parra and colleagues recently published a study in the American Journal of Cardiology showing that patients at six V.A. hospitals who split Zocor had cholesterol levels similar to patients who took whole pills. Zuccotti suggests splitting pills one at a time and taking the second half as the next dose (rather than chopping up a month's worth and tossing the fragments back in the bottle) to be sure you don't take too much or too little medicine at once.

Don't split pills with a knife or razor, said Parra, because it's easy to slip and cut yourself. "Definitely use a pill splitter," he said. Most pharmacies carry a few varieties; Cecil recommends buying one with a clear cover and V-shaped tip, which allows for more precise placement of the pill. Certain pills should not be split, including capsules; enteric-coated tablets; extended-release pills; and pills that combine two drugs in which one dose increases with tablet size but the other does not. What's more, some drugs have a "narrow therapeutic index," meaning that tiny changes in the dosage can dramatically change their effects. To be safe, always talk to your doctor or pharmacist.

This article originally appeared in the Los Angeles Times.

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