Case and Commentary
Jan 2005

Financial Incentives: The 50-Milligram Difference

Jennifer Rennan, MD
Virtual Mentor. 2005;7(1):101-105. doi: 10.1001/virtualmentor.2005.7.1.ccas17-0501.


Dr. Dan Troy has been practicing internal medicine for more than 20 years in a multispecialty group practice and enjoys his work.

He was put in charge of monitoring the group's expenditures for prescription drugs. After some research, he discovered that in the case of many formularies, it was actually more cost-effective to prescribe a higher dose of the medication and have the patient split each pill rather than prescribing the actual dose the patient needed. For example, the cost of a single 50-mg tablet of Zoloft was $2.40 while the cost of a 100-mg tablet of Zoloft was $2.43.

Dr. Troy noted that his group has consistently exceeded the financial limit that many insurance companies place on expenditures for prescription medication. Adopting a policy to prescribe more cost-effective medication when possible would improve the group practice's insurance profile and, at the same time, reduce the insurer's overall spending on prescription drugs.

Two weeks later, one of Dr. Troy's well-established patients, Ajaz Ria, came in for a routine check-up and a refill on his medication. Mr. Ria is a middle-aged man who comes in regularly and usually gets a prescription for Zoloft for treatment of his depression. Dr. Troy prescribes 50-mg tablets, with instructions to take one tablet a day.

Dr. Troy examines Mr. Ria and is about to write out his prescription, when he realizes that if he writes the prescription for 100-mg tablets, it would represent a savings of more than $400 over the course of a year. Dr. Troy suggests this to Mr. Ria. He explains that it is more cost-effective to purchase the medication in that dosage and split the tablets than to fill twice as many prescriptions for the 50-mg pills. Mr. Ria thanks Dr. Troy for his concern but explains that he would rather have the prescription for the 50-mg pills because he is used to taking the whole pill each day and he's afraid he'd forget to split it in half. "Besides," he remarks, "I pay the same co-pay in either case, so why does it matter?"

What should Dr. Troy do about Mr. Ria's prescription? (select an option)

A. Inform Mr. Ria that he will write the prescription for 100-mg.

B. Respect Mr. Ria's preference by writing the prescription for 50-mg.

C. Inform Mr. Ria of Dr. Troy's incentive to write the larger prescription and ask if he would be willing to get the 100-mg prescription.


Virtual Mentor. 2005;7(1):101-105.



The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.