The State of Pills

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.).