the state of pills
DESCRIPTION
The State of Pills SlideshowTRANSCRIPT
Overview: Tennessee: The State of Pills
Bill Cecil
Agenda
• The Problem• Health Production• Health Status• Cultural/Historical• Economic• Policy
– TennCare– Grier– Substance Abuse
• Demographics
The Problem: Prescriptions Per Resident 2007
19.318 18 17.3
12.7
10.3 10 9.2 9.1
0
5
10
15
20
25
Pre
sc
rip
tio
ns
Pe
r R
es
ide
nt
Source: Novartis 2008/2009 Pharmacy Benefit Report
The Problem: Prescriptions Per Resident
11.912.6
14 14.5
17.8 17.9 17.7 18.117.3 16.9
18
8.5 99.8 9.9
11.7 11.5 11.3 11.3 11.3 11.812.7
0
2
4
6
8
10
12
14
16
18
20
Year
Pre
sc
rip
tio
ns
Pe
r R
es
ide
nt
Tennessee
U.S.
Source: Novartis 1998 thru 2008/2009 Pharmacy Benefit Reports
The Problem: Retail Prescription Spending Per Resident 2007
$1,597$1,519
$1,439$1,363
$1,148
$780$885
$837 $811
$-
$200
$400
$600
$800
$1,000
$1,200
$1,400
$1,600
$1,800
Re
tail
Pre
sc
rip
tio
n S
pe
nd
ing
Pe
r R
es
ide
nt
Source: Novartis 2008/2009 Pharmacy Benefit Report
The Problem: Retail Prescription Spending Per Resident
$405$498
$579
$879
$1,010$1,084
$1,188 $1,193$1,273
$1,519
$345.99$412.48
$460.50
$632.59$707.59$737.78
$798.87$835.08
$948.72
$1,148.06
$-
$200
$400
$600
$800
$1,000
$1,200
$1,400
$1,600
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
Year
Re
tail
Pre
sc
rip
tio
n S
pe
nd
ing
Pe
r R
es
ide
nt
Tennessee
U.S.
Source: Novartis 1998 thru 2008/2009 Pharmacy Benefit Reports
The Problem: Poisoning Deaths and Rates per 100,000 All Races, Both Sexes, All Ages
ICD-10 Codes: X40-X49,X60-X69,X85-X90,Y10-Y19,Y35.2, *U01(.6,.7)
7.08 7.19 7.789.16
9.85 10.2810.95
7.117.98 8.35
9.61
12.1913.54
15.37
0
2
4
6
8
10
12
14
16
18
1999 2000 2001 2002 2003 2004 2005
Year
Ag
e-A
dju
ste
d D
ea
ths
pe
r 1
00
,00
0
U.S.
Tennessee
Data Source: WISQARS. NCHS Vital Statistics System for numbers of deaths. Bureau of Censusfor population estimates.
Tennessee’s death rate is 40.8% above the national average
The Problem: Geographic Variation in the Prescription of Schedule II Opioid Analgesics among Outpatients in the United States
Lesley H. Curtis, Jennifer Stoddard, Jasmina I. Radeva, Steve Hutchison, Peter E. Dans, Alan Wright, Raymond L. Woosley, and Kevin A. Schulman
HSR: Health Services Research 41:3, Part I ( June 2006)
Health Production: Health Returns on Investment in Health Care
0
10
20
30
40
50
60
70
80
$0 $1,000 $2,000 $3,000 $4,000
Per Capita Health Care Expenditures
Dis
abil
ity
Ad
just
ed L
ife
Exp
ecta
ncy
(yr
s)
Source: World Health Organization World Health Report 2000
USA
Health Production: Life Expectancy At Birth - 2002
74.3
77.3
81.8
80
74.6
70
72
74
76
78
80
82
84
Tennessee USA Japan Australia Mexico
Yea
rs
Sources: HIT Mortality Tables, NVSR53-05 Deaths Final Data 2002, CMS-NHE, OECD Health Data 2004, WHO World Health Statistics 2006
$372$2,519$2,662$4,383$5,282
Per Capita Health Care
Expenditures
Health Production: Mortality Due to Malignant Neoplasm - 2002
Political Division
Age-Adjusted Mortality (per
100,000)
Per Capita Health Expenditures 2003
Tennessee 217 $5,282
USA 134 $4,883
France 142 $2,981*
Russia 152 $167*
China 148 $61*
*Reported by the WHO in US$ at the average exchange rateSources: WHO, CDC, TN DOH, CMS
Health Production: Health Care UseCABGs 2004
State Population CABGs DeathsPopulation
Death Rate*
Massachusetts 6,435,995 4,328† 93† 1.45
Tennessee 5,885,597 9,262‡ 166‡ 2.82
Total 12,321,592 13,590 259 2.1
* Per 100,000 residents
† Annual volume and mortality estimated from: Surgeon Specific Mortality Rates following Isolated CABG Surgery. January 1, 2002-December 31, 2004. Available at: www.hcp.med.harvard.edu/massdac/reports/SurgeonSpecificRates2002to2004.pdf
‡ Tennessee Hospital Association
Health Status: Tennessee State Health Rankings
30
34
38
42
46
50
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Sta
te R
ank
Source: United Health Foundation and Public Health Association
Only South Carolina, Mississippi and Louisiana ranked lower
Cultural/Historical: The Whiskey Rebellion 1794-?
1791 - Alexander Hamilton proposed a tax on liquor to pay the
states debts from the Revolutionary War, igniting the Whiskey
Rebellion of 1794. The suppression of the Whiskey Rebellion had
the unintended consequences of encouraging small whiskey
producers in Kentucky and Tennessee, which remained outside
the sphere of Federal control for years. In these frontier areas,
they also found good corn-growing country as well as limestone-
filtered water and therefore began making whiskey from corn.
Cultural/Historical: United States Map in 1791
Wikimedia Commons
Cultural/Historical: Effect of the Tax
The important effect was Appalachian mountain people accepted markets offered by popular culture but rejected its legal and political institutions.
By the 1950s, some 25,000 gallons of white lightning reached the market each week from the counties of eastern Tennessee alone.
Sanders. University of Texas. Folk Geography Pt II at:http://www.utexas.edu/depts/grg/sanders/GRG305/folk_geography.htm
Smoky Mountain Moonshine Still
Revenue officers with a captured still on Rich Mountain in the Great Smoky Mountains, November 18, 1931. National Park Service Historic Photograph by George A. Grant.
Revenue officers with a captured still on Rich Mountain in the Great Smoky Mountains, November 18, 1931. National Park Service Historic Photograph by George A. Grant.
Cultural/Historical: Smoky Mountain Moonshine Still
Sanders. University of Texas. Folk Geography Pt Ii at:http://www.utexas.edu/depts/grg/sanders/GRG305/folk_geography.htm
Cultural/Historical: Moonshine Stills Captured
Cultural/Historical: THE BALLAD OF THUNDER ROAD
Let me tell the story, I can tell it allAbout the mountain boy who ran illegal alcoholHis daddy made the whiskey, son, he drove the loadWhen his engine roared, they called the highway Thunder Road.
Sometimes into Ashville, sometimes Memphis townThe revenoors chased him but they couldn’t run him downEach time they thought they had him, his engine would explodeHe'd go by like they were standin’ still on Thunder Road.
Blazing right through Knoxville, out on Kingston Pike,Then right outside of Bearden, they made the fatal strike.He left the road at 90; that’s all there is to say.The devil got the moonshine and the mountain boy that day.
-Robert Mitchum
Cultural/Historical: Moonshine to Drugs?
On May 9th 1923, during prohibition, District Judge
John C. Knox of the Manhattan Southern District
ruled that as long as liquor was legal for medicinal
purposes congress could not restrict doctor’s
judgment in prescribing it. It is estimated that 10
million prescriptions were issued each year during
Prohibition.
Cultural/Historical: Schedule II Drugs
Moore395
Henderson588
Haywood672
Warren905
Hardeman954
Williamson957
Gibson987
Obion1000
Dyer1003
Wayne1020
Rutherford1039
Lawrence1050
Stewart1071
Bedford1084
Lake1093
Meigs1118
Crockett1159
Weakley1160
Houston1209
Lauderdale1218
Chester1225
Lincoln1238
Hardin1247
Giles1249
Madison1259
Humphreys1277
Maury1311
Dickson1329
Pickett1381
Macon1398
Cannon1402
Sumner1418
Bradley1419
Marshall1429
Benton1466
White1483
Fayette1505
Shelby1509
De Kalb1510
Blount1517
Tipton1530
Davidson1539
Hickman1637
Wilson1662
Montgomery1676
Robertson1709
Unicoi1711
Lewis1759
Cumberland1763
Carroll1770
Grundy1778
Monroe1796
Putnam1805
Rhea1816
Sullivan1892
Hamilton1903Franklin
1930
Henry1938
Greene1944
Scott1957
Trousdale1974
Decatur1982
McNairy2053
Claiborne2063
Washington2118
Bledsoe2151
Perry2230
Polk2239
Sequatchie2306
Knox2310
Coffee2350
Overton2357
Johnson2376
McMinn2406
Marion2427
Cheatham2471
Van Buren2480
Anderson2510
Smith2529
Sevier2586
Hancock2652 Hawkins
2733Carter2741
Loudon2751
Cocke2793
Hamblen2972
Union2999 Grainger
3066
Clay3143
Jefferson3361
Jackson3362
Campbell3396
Roane3409
Fentress4475
Morgan4854
0 to 12591259 to 17631763 to 23762376 to 4855
Days Supply per 1,000 Members
Cultural/Historical: Clandestine Methamphetamine Laboratory Seizures
Calendar Year 2008 As of December 31 Total Seizures: 815
599108108
22Source: Tennessee Meth Task Force / Meth Intelligence System
Economic: Pharma Advertising Oxycodone and NASCAR
Economic: Prescription Drug Price/Quantity
0
5
10
15
20
25
0 10 20 30 40 50
Copay ($)
Rx
PM
PY
Generic
BrandedBranded Drugs: -0.024 Rx for every dollar increase in copay ($41)
Generic Drugs: -0.21 Rx for every dollar increase in copay ($4.76)
71.4%56.1%
86.1%
60.2%
69.7%
69.1%
79.8%
71.8%
65.5%
72.1%
69.8%68.3%
67.9%
Economic: Third-Party Rx Retail Share by State2005
Source: Novartis
U.S. Average 74.1%
Policy: Impact of Grier on Generic and Brand Rx %
30%
35%
40%
45%
50%
55%
60%
65%
70%
Feb-99
Apr-99
Jun-99
Aug-99
Oct-99
Dec-99
Feb-00
Apr-00
Jun-00
Aug-00
Oct-00
Dec-00
Feb-01
Apr-01
Jun-01
Aug-01
Oct-01
Dec-01
Feb-02
Apr-02
Jun-02
% Generic % Brand
Post-GrierPre-Grier
Source: BCBST Data Warehouse
East Grand Region BCBST TennCare Non-Duals
Policy: Tennessee Prescription Drug Spending Per Capita
$1,519
$879
$488
$272$178
$105$63
$1,010
$1,188
y = 49.452e0.1187x
R2 = 0.9803
$0$200$400$600$800
$1,000$1,200$1,400$1,600
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
Per Capita Rx Expenditures Expon. (Per Capita Rx Expenditures)
From 2000 to 2001 Rx Spending Rose $300 per capita
Sources: CMS, Novartis
Spending above trend = $4.9 Bn over the 5 years, 2001 - 2005
Policy: States with Prescription Monitoring Programs
1939C-II
1943C-II, III, IV
1967C-II, III, IV
1961C-II
1987C-II, III,
IV, V
1988C-II
1998
C-II, III,IV, V
1995C-II, III, IV
1994C-II
1994 C-II & Benzodiazepines
1990C-II
1978C-II, III
1981C-II
1995C-II, III,
IV, V
1984C-II, III,
IV, V
1995C-II
1992C-II
The Alliance of States with Prescription Monitoring Programs http://nascsa.org/monitoring.htm
2007 C-II,III,IV
Unintentional Poisoning Deaths --- United States, 1999—2004 MMWR February 9, 2007 / 56(05);93-96
Policy: U.S. Deaths by Unintentional Poisoning
Substance __1999__ __2004__Drugs 11,155 19,838
Nonopioid analgesics 168 212Psychotherapeutic drugs 671 1,300Narcotics and hallucinogens 6,009 9,798Other drugs acting on the central nervous system 21 22Other and unspecified drugs 4,286 8,506
Other substances 1,031 1,112Alcohol 320 358Organic solvents & Halogenated hydrocarbons 63 67Carbon monoxide and other gases 534 562Pesticides 12 3Other and unspecified chemicals 102 122
Reports for All Ages include those of unknown age. * Rates based on 20 or fewer deaths may be unstable. Use with caution. ** Standard Population is 2000, all races, both sexes. *** Population estimates are aggregated for multi-year reports to produce rates. Produced by: Office of Statistics and Programming, National Center for Injury Prevention and Control, CDC Data Source: NCHS Vital Statistics System for numbers of deaths. Bureau of Census for population estimates.
Policy: 2004 & 2005, United States
Unintentional Poisoning Deaths and Rates per 100,000 All Races, Both Sexes, All Ages
ICD-10 Codes: X40-X49
Rank State Number of Deaths
Age-Adjusted Rate**
1 West Virginia 287 15.99
2 New Mexico 282 15.16
3 Nevada 313 13.47
4 District of Columbia 73 13.42
5 Oklahoma 427 12.38
6 Kentucky 471 11.34
7 Pennsylvania 1,348 11.04
8 Florida 1,851 11.02
9 Alaska 70 10.8
10 Arizona 565 10.36
11 Washington 636 9.86
12 Tennessee 576 9.6
U.S. Average 19,838 6.7
Rank State Number of Deaths
Age-Adjusted Rate**
1 New Mexico 334 18.1
2 Nevada 348 14.3
3 Kentucky 558 13.4
4 Louisiana 556 12.6
5 Pennsylvania 1,438 11.8
6 Oklahoma 400 11.6
7 Florida 1,999 11.6
8 Tennessee 676 11.2
9 Arizona 603 10.5
10 Maine 136 10.5
11 Washington 684 10.4
12 North Carolina 877 10
U.S. Average 23,618 8
2004 2005
Demographics: Increase in Poisonings by Rural Status of State
% of Population w/Rural Status
% Increase in Fatal Poisonings
0-19.9 44.2
20.0-34.4 91.9
34.5-61.8 177
Analysis of Unintentional Poisoning Deaths --- United States, 1999—2004 MMWR February 9, 2007 / 56(05);93-96
Division % of Population with Rural Status
United States 21
Tennessee 36.4
Demographics: Tennessee Gender and Poisoning Deaths*
Gender 1999 2004 Absolute Change
% Change
Females 2.5 7.82 5.32 213%
Males 5.96 11.35 5.39 90%
Total 4.15 9.6 5.45 131%
Office of Statistics and Programming, National Center for Injury Prevention and Control, CDCData Source: NCHS Vital Statistics System for numbers of deaths. Bureau of Census for population estimates
*Age-Adjusted to 2000 standard
Demographics: Change in Poisoning Deaths by Age Group
1999 - 2004
0%
54%
150%
67%
133%
37%49%
100%
0%
20%
40%
60%
80%
100%
120%
140%
160%
United States Tennessee
0 to 21
21 to 40
40 to 60
60 UP
CDC WISQARS
Age Bands
Summary
Context: At Aggregate levels the U.S. is the least efficient producer of health as measured by life expectancy of those countries measured by the WHO.
– At Aggregate levels Tennessee is less efficient than than the U.S. at producing health.
– However, the Tennessee prescription drug problem is very unlikely to be a consequence of provider practices.
• Likely causes include: 1. cultural/historical2. economic-lowest OOP for Rx3. rural nature of the state4. questionable policy – Grier, zero Rx OOP in TennCare and
no funded controlled substance policy until recently5. gender and age-
the rate of poisonings for females tripled from 1999 to 2004. The increase in poisonings, in Tennessee, by age group is significantly different than national figures and doesn’t reveal a change in mortality for children (<20 y.o.).