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.

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Whatever the reasons behind these pricing strategies, the result is that the cost savings from pill-splitting can be phenomenal for organizations that purchase and then resell medication in large volumes. For instance, officials at Kaiser appear to have realized in the '90s that they could save millions of dollars a year on drug costs simply by buying double dosages of a handful of drugs and then having patients split their tablets in half. Kaiser's California director of drug-use management, Matt Nye, told USA Today in 1999 that splitting the cholesterol-lowering drug lisinopril saves the firm $4 million to $5 million a year in California alone. Nationwide, he estimated, pill-splitting saved Kaiser $40 million to $50 million per year.

At a time when skyrocketing pharmaceutical bills are driving health-care bills upward by an estimated 15 percent a year, some academics endorse this practice as an effective way to help rein in such costs. "When properly implemented, pill-splitting can be a safe, viable, and cost-saving strategy," says Stafford, author of a study on pill-splitting published recently in the American Journal of Managed Care. "Physicians should consider using pill-splitting with selected medications and patients, and patients may want to bring it up with their doctors." Stafford's study suggests that health-care providers accrue the bulk of the savings, however; patients typically save only about $1 a month.

Kaiser officials insist that their approach to the practice is completely safe and entirely voluntary. As Phillips discovered that day at his local pharmacy, the HMO's literature theoretically limits the practice to six approved drugs and says that splitting pills is a choice, not a mandate, for both doctors and patients. "Kaiser Permanente implements tablet-splitting programs in a safe and beneficial manner, maintaining or improving the quality of care our patients receive while helping to mitigate rapidly escalating drug costs," a company statement says.

However, Phillips insists that his own research into Kaiser's operating procedures uncovered another 31 types of pills that were being broken in half -- often by patients with epilepsy, emphysema, heart ailments, or other disorders.

Phillips is an unlikely hell-raiser. He's a sixty-year-old father of seven who occasionally donates his services to low-income Laotians in his community. But the blue-eyed doctor definitely has the crusader in him.

Once Phillips thought he had figured out Kaiser's pill-splitting scheme, which appeared to be mandatory for doctors, pharmacists, and patients, he started what could only be called a crusade. He decided the best way to make noise was to go over the head of Kaiser, so he got in touch with the American Medical Association, the California Medical Board, and the California Consumer Health Care Council. He also contacted the federal Food and Drug Administration and Department of Health and Human Services.

Phillips found an ally in John Metz, chairman of the California Consumer Health Care Council in San Francisco. "At first I was like, 'What's the big deal?'" Metz recalls. "Then I listened some more and it became clear to me that there was something very rotten going on." After hearing Phillips out and learning more about the issue, Metz signed up to help the doctor take on Kaiser. Together, the two men started collecting stories and evidence about pill-splitting directly from patients.

All across California, they found Kaiser members who were breaking pills in two. Most shocking were the cases of very ill elderly people who were breaking their medications in half. For instance, Pittsburg's Winston Yarborough told them he was forced to split his lisinopril pills despite suffering from essential tremor disorder, a disease that makes his hands and body shake.

"I went to the Kaiser pharmacy and they gave me my pills and said I had to cut them in half," says the 67-year-old Yarborough, who also suffers from diabetes and asthma. "I really didn't want to do it, but the pharmacist said I had to. ... I was shaking when I had to split the pills and it was really hard and there wasn't anybody around to help."

The retired warehouseman says that since his pills crumbled into small particles when he split them, he would eat a bunch of broken pieces in an effort to get the proper dosage. It didn't always work. "I got sick from not taking the right doses," he says, although he cannot recall exactly how the broken medications affected his health.

Metz and Phillips also heard the story of Mary Cargile, a 74-year-old Aptos resident who suffers from high blood pressure and essential tremor disease. She was given a prescription for Diamox, a medication she takes to help control her tremors and, ironically, told to split the pill that was supposed to stop her shaking.

At first, she thought nothing of the pharmacist's instructions. She says she was thrilled to get a new drug that just might help. "I was desperate to have something to control the shaking so I didn't complain," says Cargile, whose tremor disorder makes it impossible for her to drive and a struggle to even hold utensils. "When I got to the pharmacy, they gave me a splitter and didn't talk to me about it, and I was too stupid to ask any questions. I had to have friends help me split the pills because I live alone."

Metz and Phillips were shocked by what they were hearing. "Asking somebody with essential tremor disease to split pills is like the theater of the absurd," Metz says.

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