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Friday, June 10, 2005
Beldar predicts strange bedfellows will gang-rape insurance company
I'm a cynic. But when I read this story — about giant United Healthcare urging its insureds to "save money" by literally cutting their prescription pills in half, and handing out "pill-splitter" devices to help them do so — I instantly imagined the strange bedfellows that will surely be combining in the near future to eat up all those "savings" and probably more:
Drug companies and plaintiffs' personal injury lawyers, soon-to-be partners who are asking themselves "Could we really be this lucky?" and "Are they really that stupid?"
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UPDATE (Fri Jun 10 @ 10:25pm): Plindrome's and Xrlq's comments below alert me that I needed to be more clear as to my reasoning and, unusually for me, less terse. (Also I failed to mention a couple of additional bedfellows who will join in the gang-bang.) Plindrom writes, "Actually it can be more economical to buy a stronger dose and split it down to what you need." This is basically United Healthcare's purported justification.
But the determination as to exactly "what you need" — and the determination of who should determine that — are what will spawn litigation.
The conventional wisdom — which drug companies, pharmacists, doctors, and plaintiffs' personal injury attorneys will point out in unison and in four-part harmony — is that "what you need" is something to be determined only by a combination of professionals with appropriate medical and pharmacological training, judgment, and expertise. And those determinations must be made selectively and individually, those professionals will all tell you, based on each individual patient's individual diagnosis and condition.
This is scientific and medical gospel. And it may even be true. Regardless, I think that it will be accepted by 98 out of 100 juries as being true, in general.
Under that gospel, you, I, your friend, and all other laymen lack the necessary training, expertise, and judgment. And United Healthcare, despite its employment of folks wearing both green eyeshades and white coats, most emphatically lacks both those qualifications and the required opportunity to assess individual patients' situations.
Moreover, United Healthcare has a financial incentive that may not, and often likely does not, correspond with its insureds' needs. United Healthcare's across-the-board uninformed and inappropriate medical advice to its insureds will inevitably be interpreted as having been intended to line its own corporate purse at the direct risk of its insureds' health. (The "we were going to pass the savings along to our insureds and their employers" defense, even if sincere, will play poorly.)
People who take medications presumably suffer from diseases and conditions that prompt them to do so. A very large number of people who are close to dying (or experiencing further morbidity or disability) are taking medications of one sort or another. These people and their families comprise the pool of potential future plaintiffs.
The doctors and pharmacists and drug company scientists will mount the witness stands to tell juries that yonder widow's poor dead husband needed precisely X amount of drug Y each 12 hours — not roughly 4X divided roughly by 4, more or less at random. They will explain that coated pills cut into pieces and stored in steamy medicine cabinets lose their potency or have other unintended and unpredictable reactions. They will explain that the handy-dandy pill-cutters handed out by United Healthcare aren't adequate substitutes for their FDA-mandated and -inspected manufacturing, measuring, and packaging processes. They will explain that they had good, indeed compelling, scientific reasons to formulate the dosages and schedules they did. They will explain how it was entirely foreseeable that some patients won't have secured their physicians' and pharmacists' cooperation in prescribing and dispensing jumbo-sized dosages before the patients started cutting pills into pieces, so that instead of getting even roughly the intended dosages they only ended up getting a fraction of the intended dosage. They will explain how it was likewise foreseeable that many patients wouldn't just cut up the specific pills suggested by United Healthcare, but would instead expand the practice to ultra-sensitive medications.
And these witnesses will patiently and persuasively tell those juries that United Healthcare's encouragement that these witnesses' patients (United Healthcares' insureds) become their own doctor-pharmacists instead caused them to become the proximate cause of their own deaths and/or disabilities — including yon widow's poor late husband, whose risk of heart attack (or stroke or whatever-he-just-died-of) absolutely skyrocketed when the decedent started cutting up his own pills over his kitchen table or bathroom sink.
In some number of cases, these accusations may indeed be justified.
And even in those instances where the witnesses are guessing, or even guessing wrongly, there will doubtless still be lawsuits brought. Ultimately, in a substantial percentage of those, United Healthcare will end up paying substantial amounts of money by way of judgments and settlements.
There will be no savings in the long run because United Healthcare is painting a bulls-eye target on its own chest, virtually inviting blame for everything that can, could, or does possibly go wrong with its insureds' medications and health. It has money, making it a juicy target. And it's just gored the respective oxen of doctors, pharmacists, and drug companies — all of whom make rather more sympathetic and persuasive witnesses that United Healthcare's own personnel, whether they're wearing green eyeshades or white coats.
Add lawyers into the mix. "Heck," the lawyers will say during their closing statements, "United Healthcare might just as well have shipped bulk chemicals and mixing vats to their insureds so they could compound their own medications. That would be about as safe, and would have saved even bigger bundles of money."
I repeat: Can United Healthcare really be this stupid?
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UPDATE (Sat Jun 11 @ 6:10pm): A reader emailed me with this link to a post in March by my blogospheric friend Ted Frank at Overlawyered, which reports that at least one California lawsuit challenging something similar being done by Kaiser was summarily thrown out of court. It's altogether possible that this emboldened UHC. I'll do some more digging into that case and update again with my conclusions, if any.
Posted by Beldar at 08:19 PM in Law (2006 & earlier) | Permalink
TrackBacks
Other weblog posts, if any, whose authors have linked to Beldar predicts strange bedfellows will gang-rape insurance company and sent a trackback ping are listed here:
» Insurer UnitedHealthcare Pushes Pill-Splitting Savings from Outside The Beltway
Tracked on Jun 11, 2005 6:45:43 AM
» Catching my eye: morning A through Z from The Glittering Eye
Tracked on Jun 11, 2005 3:07:30 PM
» Catching my eye: morning A through Z from The Glittering Eye
Tracked on Jun 11, 2005 3:37:14 PM
» Pill-Splitting from damnum absque injuria
Tracked on Jun 14, 2005 5:49:05 PM
Comments
(1) Plindrome made the following comment | Jun 10, 2005 9:39:49 PM | Permalink
Actually it can be more economical to buy a stronger dose and split it down to what you need. Had a friend describe cutting down a 5mg to four 1.25 mg pieces the other night. Don't know if this is on point; simply taking a lower dose could be a bummer.
(2) Xrlq made the following comment | Jun 10, 2005 10:16:26 PM | Permalink
OK, maybe I've been in the insurance industry too long, but what exactly is wrong with this idea?
(3) Xrlq made the following comment | Jun 10, 2005 11:39:33 PM | Permalink
Sorry, I must be dense, but even after your update, I still can't envision any situation in which a remotely compent doctor would tell his patient "you need to take 50 mg. of Derkaderkatin every morning, and dammit, it'd better be one full 50 mg. pill, and not one-half of a 100 mg. pill." And I'm saying that as someone whose job it is to warn insurance companies (albeit not health insurers) about every goofy plaintiff action they may face if they engage in X rather than Y.
Then again, I may be biased. As a soon-to-be UHC customer, I want my free pill splitter, and if this program were discontinued anytime between now and July 1 it would really harsh my mellow.
(4) SemiPundit made the following comment | Jun 10, 2005 11:59:21 PM | Permalink
Why is a higher dose pill cheaper than a lower dose pill?
(5) Beldar made the following comment | Jun 11, 2005 12:09:51 AM | Permalink
Semi: The cynics would answer that it's because of drug company greed.
The drug companies would say that it's because they have big investments and higher continuing costs in measurement and packaging. Selling an ounce of drug X in 100 doses (with 100 blisters spread out among 10 blister packs) costs them considerably less than selling that same ounce in 200 doses (with 200 blisters spread out among 20 blister packs), so they have to charge more on a per-ounce basis for the smaller-dosed pills. The docs, pharmacists, and drug companies will all agree that the higher price is justified, though, because it's necessary to give consumers the exact dosages they've been prescribed in a controlled fashion, rather than encouraging consumers to get out their pill-cutters (or their mortar-and-pestel sets and tiny scales). They'll argue that the additional costs associated with the smaller doses are cost-justified, and that the risks associated with consumers doing their own measuring of (and physical messing with) the medications don't justify the marginal cost savings.
Xrlq, let me try it this way: The whole point of the existing prescription and marketing regime is to try to make the process idiot-proof and resistant to meddling. UHC is encouraging consumers to meddle, and some of them will be idiots (which UHC should be able to foresee and therefore will be held liable for when it happens). If you tell your doc you intend to cut your 100-mg pill in half, he'll tell you that sometimes you'll cut it into two pieces that are actually 55/45, and sometimes 60/40, and sometimes 65/35. (Or actually, if it's crumbly, maybe your two pieces are 45/35, with 20 mg in dust on the bottom of your bathroom floor, and you are only getting 80-mg every two days instead of the intended 100-mg per two days.) If Derkaderkatin is an antidepressant that works by building up a particular level in your bloodstream over a period of weeks, then it may not matter if you get 35 mg on Monday and 65 mg on Tuesday. But if it's something like nitroglycerin for your angina, it might be the difference between living and dying. Once UHC starts handing out those pill-cutters and telling its insureds that the key to their financial health is cutting up their pills, someone's going to croak because he got 20-mg instead of 50-mg of some med in which that makes a mortal difference. Or because the second half of that 100-mg pill, even though it weighs precisely 50-mg, has degraded over the three weeks it's been in the bottom of the bottle in your steamy medicine cabinet because the coating was broken and moisture got in, so it only has the same effectiveness as a 20-mg pill would have.
Besides the docs and the pharmacists and the drug company research scientists who'll be called to trial, there will also be the "human factors" and packaging experts. They'll explain that there's a good reason why Rapapraxatalazone comes in 100-count bottles, and the caplets are pre-scored so you can easily snap them in half, whereas Praxatrapazolene comes in heretically-sealed blister-packs of no more than 10 doses, with instructions to the phamacy not to sell you more than two packs at a time. And they'll all say that UHC screwed up their careful plans that were laid for the protection of you, the consumer just to save a few pennies.
(6) ed made the following comment | Jun 11, 2005 12:49:59 AM | Permalink
Hmmmm.
"Sorry, I must be dense, but even after your update, I still can't envision any situation in which a remotely compent doctor would tell his patient "you need to take 50 mg. of Derkaderkatin every morning, and dammit, it'd better be one full 50 mg. pill, and not one-half of a 100 mg. pill.""
A lot of doctors would not allow this, and I should know since I'm on kidney dialysis.
1. A lot of pills are engineered with timed release. If you take one half of a coated pill, that is engineered with timed release, then you're getting the full dose immediately. This is why there are labels that read "DO NOT Crush or Chew!" You swallow them and the stomach acids will slowly let the drugs flow into your system.
Too much and just about anything can happen. Up to and including **bleeding stomach uclers**. Many drugs can be toxic in too high a dose and many more can seriously damage the stomach lining.
People like to think pills are nothing more than aspirin, but modern pills are an engineering marvel. They are precisely designed to do a specific job. If you cut them, then they cannot do the job for which they were designed.
And yes, there are drugs that you must take exactly as prescribed. If you are a recipient of a transplant then you must take the prescribed anti-rejection drugs. In the exact dosages prescribed. At the EXACT TIME prescribed. And in the EXACT ORDER prescribed.
When I asked what the leeway was I was told 5-10 minutes, maximum. And even 10 minutes was possibly too much.
(7) antimedia made the following comment | Jun 11, 2005 12:54:53 AM | Permalink
No offense meant, Beldar, but your prediction of what will happend is precisely why I hate lawyers. We poor dummies out here in red-neck-land just aren't competent enough to split our own pills and save money?
A pox on the trail lawyer mentaility.
(8) Beldar made the following comment | Jun 11, 2005 1:16:52 AM | Permalink
No offense taken, antimedia. But this isn't a situation where trial lawyer mentality is creating a problem.
The docs, pharmacists, drug company scientists, etc. will all tell you that consumers ought not be splitting their own pills, because the money they're saving isn't worth the risks they're creating. And I'm not talking about "bought-and-paid" experts-for-hire, I'm talking about bona fide experts in those fields, and that's their real opinion rather than something they're saying just because they're being paid to say it.
The trial lawyers are just going to be asking them the same thing in a courtroom setting.
Moreover, we're talking about a consumer population that includes a lot of people who may not be quite as sharp and capable as you are, my friend, because of natural population variation in part, but also because of age and infirmity. The whole field of "human factors" is based on the notion that manufacturers and distributors of products ought to anticipate at least the most obvious and likely human errors, and guard against them when it's comparitively cheap and easy to do so. I'd agree that oftentimes this concept is overplayed, to the detriment of personal responsibility. But again, I think there are usually sound medical and scientific reasons for the way drugs are prescribed and marketed, and at least some economic justification for the price differential this scheme is trying to exploit.
Understand my perspective here: I've defended health insurance companies before. They're particularly vulnerable and in my view, appropriately vulnerable when they start stepping over the line of being insurers and put themselves into the position of dictating and directing decisions traditionally made by doctors and other healthcare professionals. Here, UHC is encouraging its insureds to ignore the joint recommendations of their doctors, pharmacists, and drug company manufacturers. They're playing with fire; if they were my client, I'd tell them they're going to get burned.
(9) ThomasD made the following comment | Jun 11, 2005 1:35:57 AM | Permalink
Just a pharmacist talking here.
1. In the world of prescription insurance/medication use this is old, old news. Many insurors/pharmacy benefits managers (PBMs) have been mandating this for years.
2. Many, many, many tablet formulations are scored for easy splitting. I would be hard pressed to argue that these products should not be broken. If I were a manufacturer this would seem doubly difficult to pull off with a straight face.
3. Even some meds that are not scored can be safely broken, as long as the portions are consumed consecutively. This gets technical, but has alot to do with how drugs are absorbed and eliminated from the body, and how the proper pharmacologic effect is related to drug concentration in the body. Obviously this is very product specific and does require a little bit of advanced knowledge, training and experience. But don't presume that the insuror/PBM doesn't employ such individuals to advise them on these issues.
4. Compared to other things that insurors/PBMs do such as restrictive formularies, prior authorization processes, and mandatory substitutions in order to cut costs tablet splitting seems like small potatoes. After all you are still getting the same dose of the same drug as recommended by your practitioner.
5. I will sometimes recommend tablet splitting to cash customers if I believe the specific medication can be safely and reliably used in this manner. Again, it would be the height of hypocrisy to say otherwise when an insuror mandates the exact same approach for the exact same medication.
(10) Norman Rogers made the following comment | Jun 11, 2005 8:31:56 AM | Permalink
Case in point: Viagra (a drug I suspect you're familiar with) is specifically designed (diamond shaped) to be difficult to split.
Why? Because pill splitting is rampant.
Why? Because many, perhaps most, drug pricing and perscription plans don't charge differently for different strength dosages.
Hence, it's cost effective to get your physician to prescribe the highest strength formulation and to divide the pills/capsules into the dosages that work for you.
And you can split Viagra. Trust me. And the result is you get 12 doses instead of the measly six your insurance company will let you purchase per month.
The real problem you envision is the opportunity this formal advice creates to institute frivolous lawsuits. And, you're thinking like a lawyer (not an unreasonable train of thought for you) who would protect his client.
Of course, the real solution to the problem you address is a "Loser Pays" tort system. Are you in favor of that?
(11) Evan made the following comment | Jun 11, 2005 9:05:52 AM | Permalink
Beldar: Even if UHC is engaging in a stupid practice, what's your legal theory? Most of contracts between UHC and its insureds would be governed by ERISA, and under ERISA, there are very limited rights. State court theories are preempted. In Texas, for example, there was once a Texas Health Care Liability Act that required health plans to "exercise ordinary care when making health care treatment decisions." The US Supreme Court held that this act was preempted by ERISA in Aetna Health Inc. v. Davila.
I am not an ERISA expert, have not read the Davila case in a long time, and don't know whether it or other ERISA precedent might be distinguished on some basis. I do think, however, that your post raises ERISA issues.
I certainly agree, however, with one of your basic premises, that UHC is "playing with fire." UHC's behavior is definitely the sort that gets the attention of the Dickie Scruggses of the plaintiffs' bar.
(12) 10ksnooker made the following comment | Jun 11, 2005 10:22:15 AM | Permalink
Pill splitters work great. Anybody that can think knows how to do this. Doctors will go along. Cuts a $5 pill down to a $1.25 in no time.
Works with liquid medicines as well, you just need some accurate measuring devices and distilled water.
The whole drug cost charade is a cruel hoax, played mostly on Americans.
(13) Beldar made the following comment | Jun 11, 2005 11:08:05 AM | Permalink
Evan, thanks for the comment. (For my other readers: I solicited Evan's comment specifically because he's another lawyer-blogger who has experience from both sides of the PI docket and who's presently involved in some drug class action cases.) [Edit: I may have made some overbroad assumptions about the nature of Evan's current practice here. Beldar.]
I'm far from an ERISA expert, even though in 1984 I defended a health insurer in a federal court jury trial of a punitive damages claim purportedly brought under ERISA for denial of benefits on a quack cancer remedy. (That's how long ago it was -- ERISA had barely begun to be interpreted by court decisions, and the plaintiff wanted to be in federal court, and everyone thought he could get a jury and punitives. Things have changed quite a bit since then, huh?)
But as I understood Davila, and still understand it after a quick re-reading, it basically says that contract claims for denial of coverage are preempted by ERISA, even when the plaintiff attempts to recast them as tort or statutory claims:
Thus, interpretation of the terms of respondents' benefit plans forms an essential part of their THCLA claim, and THCLA liability would exist here only because of petitioners' administration of ERISA-regulated benefit plans. Petitioners' potential liability under the THCLA in these cases, then, derives entirely from the particular rights and obligations established by the benefit plans.
And at bottom, the plaintiffs there were suing based on Aetna's refusal to pay for specified benefits based on Aetna's interpretation of its health insurance plan. Nothing Aetna was doing interfered with the ability of the insured plaintiffs to get the precise treatments and meds their doctors had prescribed if they did so at their own expense, outside the plan coverage.
Here, though, it sounds at least from the press report that UHC is going beyond saying, "This we'll pay for, that we won't." Instead they're saying, "Here's a plastic doohickey. We suggest that you use it to contravene the instructions given by your physician to your pharmacist, and we'll both save money as a result." UHC has stepped completely outside the traditional role of an insurer, and it's having well more than the indirect financial effect on patients' medical choices. Davila says that lawsuits premised on that indirect financial effect are preempted under ERISA, but I think it could be distinguished. In which event, the cause of action I'd plead is one for state common-law negligence (failure to use ordinary care in the discharge of a duty volunteered for by UHC, that of medical care advisor and patient noncompliance facilitator).
ThomasD, thanks very much for your comments too. I'm glad to have a pharmacist weigh in (and hope we might hear from some docs out there too). When you recommend to a patient that he deviate from the prescribed meds, you're using your training and expertise as to both the medication and that particular patient, and the patient is making a well-informed decision to deviate from the rules. What UHC is proposing, it sounds like to me, is that patients make their own uninformed decisions to deviate from the rules. And they're not just indirectly trying to encourage that by saying "This we'll pay for, that we won't."
Norman, I'm trying to decide whether I should take offense at your suggestion about my personal familiarity with Viagra. But, seriously, that particular drug is another good example of the class of meds in which the risk of underdosing may threaten a Friday evening's plans but not the patient's life. As ThomasD said in his comment, "Obviously this is very product specific and does require a little bit of advanced knowledge, training and experience." My concern is that even if "the insuror/PBM ... employ[s] such individuals to advise them on these issues," that advice is not, across-the-board, an adequate substitute for the patient's own physician's and pharmacist's advice, and injecting them into this loop is likely to create more confusion and more patient-noncompliance (deliberate or unintentional). And when UHC hands out pill-splitters, it's pretty likely (and pretty obvious in advance that it's likely) that they're going to be misused by patients who have no "advanced knowledge, training, and experience." It's not the family of the guy whose Friday night got ruined who will be bringing these lawsuits. It's the family of the guy who took UHC's pill-splitter (that might have be used relatively safely to split his Viagra tabs) and instead used it on his life-critical meds -- and then died.
(By the way, I am in favor of "loser pays," with perhaps some modifications; but it ain't gonna happen.)
10ksnooker, with due respect, your comment "[a]nybody that can think knows how to do this" precisely illustrates my point. The same could be said, I guess, for appendectomies hand Granny the knife, point to yer belly, and lie down on the table. People who are already inclined to be their own doctor-pharmacists, when affirmatively encouraged to do so by someone like UHC, are going to get into areas where layman's guesses are going to lead to medical disasters. Perhaps that will only be in one percent of patients; but the legal costs from that one percent will quickly swamp all the "savings" from the practice.
(14) Patterico made the following comment | Jun 11, 2005 12:37:35 PM | Permalink
OK, maybe I've been in the insurance industry too long, but what exactly is wrong with this idea?
Anyone in the insurance industry has been there too long.
(15) antimedia made the following comment | Jun 11, 2005 4:56:32 PM | Permalink
Beldar, thanks for your response. I can certainly understand the points you've articulated, but ISTM if the healthcare insurer is at risk for pill splitting, then certainly the drug manufacturer would be as well?
After all, they're manufacturing the higher strength pills that make splitting possible. Right?
(16) Beldar made the following comment | Jun 11, 2005 5:22:16 PM | Permalink
Antimedia, my understanding is that the pills that are being split are manufactured in the higher dosages because some physicians are prescribing those higher dosages for some patients not because the drug companies are trying to encourage splitting by making pills in dosages too high for anyone to properly use un-split.
If a drug company were doing that, however, it's not inconceivable to me that it might subject itself to liability. I just doubt that that is the case, factually.
What UHC is doing here is encouraging its insured to exploit the system. It's trying to take advantage of the fact that drug companies sell higher-dose versions of some meds at lower prices. If the drug companies are being honest with their pricing (a big "if," I'll grant), and if the lower costs for the higher dose meds really only reflect their cost savings and the higher costs they charge for the lower dose meds really only reflect their cost increases for measuring, handling, packaging, etc., then the exploit that UHC is encouraging wouldn't, in theory, cost the drug companies anything. Their net should end up the same, even if their gross drops. So it's not that UHC is "ripping off" or defrauding the drug companies that I object to.
And neither am I in favor of "high drug prices" in general, nor am I necessarily defending the drug companies for the surcharges they impose on the US market. (Those are complicated subjects beyond the scope of what I'm arguing in this post.)
No, what concerns me is that this exploit while it might be okay if it could be successfully limited to selected medications for selected patients can't be effectively so limited. If this tampering with the system could be limited to "safe" occasions, it would require involvement and cooperation, at a minimum, from docs and pharmacists or so it seems to me. UHC isn't in a position to make this scheme of deliberate circumvention of the "rules" work safely and reliably by itself, and in fact suffers from a huge conflict of interest anyway, even if it could.
Let me try another metaphor. This is sort of like a cop going to assembly at your kid's elementary school and saying, "You know, you'll really save some time if you selectively ignore that red light in the cross-walk and cross anyway when you've looked both ways." Well, yeah, you will save time, and nobody will be hurt, if there really are no cars coming. But can all the elementary kids be expected to do that, consistently? Aren't you inviting risks that are likely to get out of hand? And do you want cops encouraging this?
(17) James B. Shearer made the following comment | Jun 11, 2005 6:11:27 PM | Permalink
I thought prescriptions were dosage specific. If I have a prescription for 90 50 mg pills is the pharmacist allowed to fill it with 45 100 mg pills without checking with the doctor. I would have thought not.
And suppose I go to my doctor and ask the prescription to be changed from 90 50 mg pills to 45 100 mg pills so I can split them and save money. Is the doctor liable as an accomplice in defrauding the drug company?
Alternatively suppose I ask the prescription to be changed from 90 50 mg pills (to be taken one a day) to 180 50 mg pills (to be taken twice a day) with the doctor aware I will actually be taking one a day for 180 days. Under my medical plan this may save me money (because there is a cap on my copay for a 90 day prescription). Now is my doctor liable as an accomplice in defrauding my insurance company?
In general, ignoring health issues, what are the fraud implications of gaming the system by not taking prescriptions as prescribed?
(18) ed made the following comment | Jun 11, 2005 9:57:52 PM | Permalink
Hmmmm.
I don't think there are any issues of fraud. If a doctor gives a specific prescription, then the drug company isn't damaged by that prescription. Actually the drug company is helped by that prescription since it has now made a sale where it otherwise might not.
But I do think it's a clear case of liability. I know that I would never, under any circumstances, advise or allow anyone, to whom I owe any legal responsibilities, even the option of splitting pills.
I'm sure that there are plenty of pills that you can split safely. I am also equally certain that there are many pills that it would be taking a potentially life-threatening chance to split.
I for one wouldn't like having the legal liability because a customer or client split a pill and ended up on a respirator.
(19) James B. Shearer made the following comment | Jun 11, 2005 10:23:36 PM | Permalink
ed, the drug company is being damaged because the patient is obtaining the drug at half price (assume the 50 mg pills and the 100 mg pills cost the same per pill which is common). Suppose for example the drug company offered a preferential price to patients suffering from a particular disease which required many pills a day and a doctor falsely certified that his patients had this disease so they could obtain the cheap price. This would be fraud would it not? Here the doctor is falsely certifying (by giving a prescription he knows will not be taken as directed) that his patients require 100 mg pills once a day when in fact they do not. It seems at least arguable to me that the doctor and patient are conspiring to obtain a price to which the patient is not entitled thereby defrauding the drug company.
(20) e m butler made the following comment | Jun 11, 2005 11:25:25 PM | Permalink
I split one medicine metropolol(sp?) for other reasons than economy ...One pill lasts only 20 hrs out of a 24 hour day ,while the same pill split 1/2 taken twice a day lasts the whole 24 hours...
(21) ed made the following comment | Jun 12, 2005 10:38:34 AM | Permalink
Hmmmm.
"ed, the drug company is being damaged because the patient is obtaining the drug at half price"
Except that the doctor doesn't owe any sort of duty to the drug company. We're not talking about a licensed agent, we're talking about a doctor.
(22) James B. Shearer made the following comment | Jun 12, 2005 2:26:05 PM | Permalink
ed, I don't think you need a duty towards the victim to be liable for fraud. Suppose for example, a wife needs an expensive medication which is covered by her husband's medical insurance but not by her medical insurance. Suppose their doctor helps them out by writing a prescription for the husband knowing it will be taken by the wife. Are you saying the doctor is not liable for fraud?
(23) william h. heino sr. made the following comment | Jun 13, 2005 12:06:12 PM | Permalink
6/10/05 by Ryan Nakashima.AP “Splitting pills chops costs, insurers discovering”
Isn’t it interesting how the article mentions, seniors are able to cut their prescription costs by splitting their pill medication. Everybody, recognizing the value in this. The nations second largest health insurer-UnitedHealthCare, Regence Group, seniors. Everybody benefits. Even the U.s. department of Veterans Affairs,.. who saved $46.5 million.
Tim Heady CEO of Pharmaceutical Solutions mentions, “For every patient that chooses to reduce their cost by 50%, it would reduce ours…” But, while the VA mentions 1.1 million patients having split pill prescriptions, the VA had not mentioned that, veterans who split pills, the cost is increased by 50%,.. in violation of law, 38 USC 1722a.
If a veterans prescription calls for one(1), 80Mg pill each 30-day period, the veterans’ co-pay cost is $7. However, if this same exact 30 pill prescription supply is used for splitting, it would be 15, 40Mg pills each 30-day period. A 2 month supply. Co-pay increases to $14. Doubles in cost for the same exact $7.00, 30-day supply. An excess of the cost exists. Paragraph 2. “The Secretary may not require a veteran to pay an amount in excess of the cost to the Secretary for medication as described in paragraph 1.”
In earlier figuring, I estimated 150,00 split pill prescriptions. Was I wrong! The VA claims 1.1 million. Now, of this $46.5 million in savings by the VA, how much of these split pill charges were taken illegally from the veteran in violation of 38 USC 1722a? Let’s use the conservative figure, 1 million, times $3.50 in over-charges. $3 million, 500 thousand dollars (3,500,000), in excess of the cost.
My claim, violation of 38 USC 1722a, appeal has been forwarded to the Veterans’ Board of Appeals in the early May.
(24) David Nieporent made the following comment | Jun 13, 2005 9:25:13 PM | Permalink
James,
Nobody, least of all the doctor, is making any representations to the drug company? Where do you get fraud?
You need a relationship between the parties for fraud. The doctor has none with the drug company in the context we're discussing. The patient, not the doctor, is buying the drugs from the drug company.
(25) James B. Shearer made the following comment | Jun 14, 2005 3:45:36 PM | Permalink
David Nieporent, if a doctor charges me $100 cash for an office visit but gives me a receipt for $200 which I can send to my health insurance company, the doctor is helping me defraud the insurance company even without a direct relationship. Right?
(26) Joe made the following comment | Jun 14, 2005 4:28:02 PM | Permalink
Recently I received a prescription from my doctor with the instructions to split the pills. Dumb old me thought, "Splitting hard little pills is a pain, why didn't he just give me a lower dose?" I then go online to check prices and, low and behold, ALL doses for this drug, from 2.5 mg to 10 mg are exactly the same price! I can understand not pricing the 2.5 mg pill at 25% of the 10 mg pill, (though the price is so high, factoring in the manufacturing costs is tiny so it would be darn close), but the same price! Give me a break (pun intended.)
(27) BladeDoc made the following comment | Jun 15, 2005 12:36:32 PM | Permalink
Certain drugs can be split and are scored to make it easier to do so. Clearly the drug company could make the pill harder to split (not scoring or make the pill smaller and harder etc.) so it seems to me that they are giving de facto permission to do so (Coumadin is a good example). OTOH it is contraindicated to split certain medications becasue of needs for precise dosages, time release and the like. If the insurance co. is just telling the people to cut the pills without making this distinction, yes they're stupid and will likely be sued. If they are merely encouraging their clients to ask their physicians to prescibe medications in splittable doses there's nothing wrong with that.
(28) Rorschach made the following comment | Jun 16, 2005 10:25:51 AM | Permalink
I have a similar but different beef with UHC's prescription formualary rules. I happen to be allergic to a number of antibiotics. In fact, there are only two (unfortunately in the same drug family) that I can take more or less with impunity. They are Cipro and Levoquin. Back on '02 when everybody got scared of anthrax in the mail, UHC implemented a limitation of 3 days worth of Cipro without a doctor getting pre-approval and even with pre-approval, they'd only pay for 5 days worth. With the exception of urinary tract infections, 3 days of an antibotic, and even 5 days worth is a recipe for breeding drug resistance and will do more harm than good. If you call thier 800 number to complain, they will insist that those limitations do not exist and that Cipro is on thier formulary list. But when the pharmacy calls to get approval to fill more than 3 days worth, no such luck. Interestingly, Levoquin, which is very similar and is just as effective against anthrax (but was not hyped in the media) has no such restrictions. There is a generic of Cipro available, but there is not one of Levoquin which seems somewhat backwards if the idea is to save money. Isn't this behavior bordering on playing doctor?
(29) william h. heino sr. made the following comment | Jun 16, 2005 4:49:20 PM | Permalink
Just a thought..I think when pill splitting is mentioned, they don't mean every pill across the board. As someone suggested, there are those pills that can be, and there are those that shouldn't be split.
But, to give you an idea as to the Veterans Administration cost for pills. A veterans copay is $7 for a 30-day supply.This is from the Federal register 12/6/01..."VHA conducted a study of the pharmacy administrative costs relating to the dispensing of medication on an out-patient basis and found that VA incurred a cost of $7.28 to dispense an outpatient medication even without consideration of the actual cost of the medication. This covers the cost of consultation time, filling time dispensing time..direct and indirect personnel costs, physical overhead and materials, and supply costs. Under these circumstances, we believe that a $7 copayment would not exceed VA's cost."
Does this give you an idea of the overall picture of the real cost of medication? It does me!
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