Cutting Corners 

Critics of Kaiser's cost-cutting efforts warn of the dangers of an HMO policy in which sick patients with shaky hands must split their own pills.

After practicing emergency medicine for thirty years, Chuck Phillips wasn't surprised by much. Blood, guts, trauma, maimings -- whatever wandered into his Fresno emergency room, he was ready. The doctor teaches courses on treating trauma victims and has written the book, literally, on paramedic skills. But in early 1999, as dozens of senior citizens streamed into the ER of the Kaiser Permanente hospital where he worked, Phillips found himself shocked by what was happening.

Some patients complained of problems related to their high blood pressure, others of dizziness and chest pains; still others had suffered strokes, heart attacks, or kidney trouble. What didn't make sense to Phillips was that many of them were already taking pills for high blood pressure. It seemed to him that their medications should have kept many of these disorders in check. He was perplexed.

A hands-on, old-school doctor, Phillips began asking questions, and, in response to his probing, the patients showed him their medications. Something was very wrong. In the bags and boxes they displayed, Phillips found pills broken into fragments or even reduced to dust. Studying the labels, he noticed that the prescribed dosages were abnormally high. In cases where, for instance, ten milligrams was the appropriate dosage, the pills were prescribed in twenty-milligram doses with labels that read "Take one half daily." Patient after patient explained that Kaiser pharmacists had told them to cut their tablets in half. Some had been given small devices for cutting their pills, but others just did it by hand.

"The pills were just ruined," Phillips explains. "In thirty years of practicing medicine, I'd never seen anything like this."

Phillips concluded that his patients were taking wildly variable doses of medication for their high blood pressure because pills usually split unevenly, with portions often crumbling or even breaking apart into powder. This, he believed, was the cause of their health problems.

To see if he could figure out what was going on, the doctor wrote himself a prescription for twenty milligrams of lisinopril, a drug he takes for his own high blood pressure, and took it to the Kaiser pharmacy in his own neighborhood. Sure enough, when he picked his pills up, the dosage had been doubled. The pharmacist handed the medication to Phillips along with a pill-splitter -- a small plastic box containing a razor blade and a soft piece of plastic designed to hold the medication in place while it was cut in half.

"I said to the pharmacist, 'I didn't write it this way,' and he said, 'Well, this is the way it is.' Then I asked where was his authority to do this, and he copied me a page of protocols from the Kaiser main office."

The protocols spelled out six medications for high blood pressure, elevated cholesterol, and migraine that were to be prescribed in double doses and split in half by Kaiser patients. Lisinopril was on the list. But the policy also stated that the practice was voluntary for both the patients and doctors, and Phillips soon found that this wasn't the case. Despite his protests, he couldn't get the pharmacist to give him the twenty-milligram dosage he'd prescribed for himself. The doctor was steamed.

"This was bad medicine and had to stop," he says. "Kaiser says this is to keep the cost of medicine down, but if it's bad medicine, what's the point of keeping costs down?"

Some doctors might have written off the matter as just another maddening rule from the world of managed health care. But acquiescence wasn't Phillips' style. He was a rabble-rouser with a big mouth, the son of a crusading dentist who had treated the poor in Africa and tended to Mahatma Gandhi's teeth. Phillips was someone who wouldn't hesitate to call the state medical board to complain about something if he felt strongly enough about it -- which, in fact, he had done recently when one of his Hmong patients was left untreated at another Fresno emergency room.

The contract doctor certainly had motivation to take on Kaiser. Phillips also had a complaint pending with the federal Equal Employment Opportunity Commission over Kaiser's practice of paying young physician recruits 10 percent more than those with more experience. After he filed that complaint in 1999, Kaiser changed its policy, although a company spokeswoman told The Wall Street Journal that the doctor's complaint was not the reason for the revision. When Phillips' contract lapsed in mid-1999, Kaiser did not hire him again. He says he took on pill-splitting, like the age discrimination issue, because he thought it was wrong.

Phillips began campaigning to end Kaiser's scheme. His efforts ultimately stoked a growing, nationwide controversy over the practice -- one that pits leaders of the managed-care industry against the National Association of Boards of Pharmacy and the American Medical Association. Opponents of pill-splitting contend the issue is whether there are limits on how far health-care companies can go in their quest to save money. Meanwhile, health-maintenance organizations across the country are watching the dispute closely as they consider whether to implement their own pill-splitting programs.

Pill-splitting probably would have no advocates at all if not for the seemingly odd way in which the pharmaceutical industry prices its products. Pill makers typically charge roughly the same amount of money for any size dosage of a medication. There are two primary reasons, according to Dr. Randall Stafford, a researcher at Stanford's Center for Research in Disease Prevention. Larger doses don't cost much more to produce (and research and development expenses are actually far more relevant to the final price of a drug than the cost of its raw ingredients). And perhaps more importantly, image-conscious pharmaceutical companies don't want to be seen as profiting most from those unfortunate patients who happen to need stronger doses of their drugs.

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