Splitting Pills and Promoting Good Ethics

A recent article from Minnesota describes the pill-splitting program at HealthPartners, a 52 year old not-for-profit HMO serving 635,000 members. The point of the story is that only a quarter of the members who could make use of the program are actually doing so.

I was curious to understand why so few HealthPartners members did what I so regularly advised patients in my own practice to do, so I went to the HealthPartners website and found a description of the program. Because the program exemplifies admirable ethics I quote it in full:

Save money with our pill splitting program
Now you can cut your prescription bill in half with select medications when you use HealthPartners' new pill splitting program.

How it works
With this program, you save money when you split higher strength pills into your prescribed dose. Instead of 30 lower strength tablets, you receive 30 tablets with twice the strength to last for 60 doses -- all for one copay. We are able to reduce your drug costs because the cost per pill for higher strength is about the same as they are for lower strength pills.

How to get started
When you're ready for a refill, fill your prescription as you normally do. Just tell the pharmacist that you'd like to use the Half-Tablet Advantage Program.
Pharmacies can adjust the medication strength and directions, dispensing a higher-strength medication for splitting in half for your prescribed dose.
You receive 30 tablets (to last for two months) and pay a single copay.
Your pharmacy can give you a tablet splitter for a small cost.

Which medications are covered with the program?
Medications on the Half-Tablet Advantage Program Drug List have been carefully chosen based on their wide therapeutic margin (slight differences in the daily doses of these medications make very little therapeutic difference), tablet characteristics and ingredient costs. Some of these medications come as scored tablets, and others are not scored (and will need a pill-splitter).

Splitting other medications may also be clinically appropriate, but this program applies only to select medications.

HealthPartners Half-Tablet Advantage Program Drug List:
Cholesterol medications: atorvastatin (Lipitor) and simvastatin (Zocor).
Antidepressants: sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil, generic).

Pill splitting is not recommended for all patients
Splitting tablets may be more difficult and may not be appropriate for patients with poor eyesight, tremors, debilitating arthritis, poor memory or behavioral health issues. Providers, pharmacists and patients can at any time decide that pill splitting isn't appropriate in a particular case. The Half-Tablet Advantage Program is totally voluntary.

I'm perplexed as to why any patient would not make use of this program. It is restricted to medications that are clearly safe to split. (In my view the program could go further than it does!) It cuts a member's copayment in half. And, because HealthPartners is a community-minded, mission-driven, not-for-profit enterprise, the savings that accrue to the health plan go towards socially valuable uses, not, as is so commonly feared in U.S. health care, huge executive bonuses and swollen overhead budgets.

I hope HealthPartners surveys members who could use the pill-splitting program but aren't to learn their reasons. My guess is that the main reasons would be (a) lack of knowledge about the program and (b) erroneous fears about the safety of pill splitting. And for some, (c) physical limitations make pill splitting difficult.

But for some, doubt about whether the drug savings contribute to a socially valuable purpose may be be their reason for not using it. My belief comes in part from a discussion I had some years ago with a patient who had survived the holocaust and who was very grateful to the U.S. for taking him in after the war:

Me: So just to review, we've agreed that using a low dose of Zoloft (25 mgm) would be a good idea.

My patient: That's right.

Me: The drug company charges the same amount to our pharmacy [I practiced at a not-for-profit HMO, much like HealthPartners] for different size pills. When I prescribe 25 mgms of Zoloft I usually recommend splitting a 50 mgm pill in half. That will save some money for you and for the pharmacy. Does that seem fair to you?

My Patient: Yes.

Me: Because I teach and write about these things I want to ask you another question. Do you think it would be fair and reasonable for me to ask you to split a 100 mgm pill into quarters? This is very rarely done and it's fine for you to say "no."

My patient: It doesn't seem reasonable to me.

Me: That's fine. Here is a prescription for the 50 mgm size...

After the appointment, while I was finishing my note, my patient returned to the office:

My Patient: I thought more about your question. This country has done so much for me that I thought the least I could do is to give something back by splitting the larger pill into quarters.

We talked a bit more, and he clarified for me that what changed after he left the office was his reframing the pill splitting as something that served wider society as well as his own pocket book.

Splitting pills in accord with the exemplary program at HealthPartners serves a public good as well as a private one. If I were in charge of the program, in addition to publicizing it more to members and encouraging the doctors to make more use of it, I'd add a sentence about the benefits pill splitting confers on the HealthPartners community to the description I quoted above.