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The State of Pills

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The State of Pills Slideshow


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    • 1. Overview: Tennessee: The State of Pills Bill Cecil
    • 2. Agenda
      • The Problem
      • Health Production
      • Health Status
      • Cultural/Historical
      • Economic
      • Policy
        • TennCare
        • Grier
        • Substance Abuse
      • Demographics
    • 3. The Problem: Prescriptions Per Resident 2007 Source: Novartis 2008/2009 Pharmacy Benefit Report
    • 4. The Problem: Prescriptions Per Resident Source: Novartis 1998 thru 2008/2009 Pharmacy Benefit Reports
    • 5. The Problem: Retail Prescription Spending Per Resident 2007 Source: Novartis 2008/2009 Pharmacy Benefit Report
    • 6. The Problem: Retail Prescription Spending Per Resident Source: Novartis 1998 thru 2008/2009 Pharmacy Benefit Reports
    • 7. 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) Data Source: WISQARS. NCHS Vital Statistics System for numbers of deaths. Bureau of Census for population estimates. Tennessee’s death rate is 40.8% above the national average
    • 8. 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)
    • 9. Health Production: Health Returns on Investment in Health Care Source: World Health Organization World Health Report 2000 USA
    • 10. Health Production: Life Expectancy At Birth - 2002 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 $5,282 Per Capita Health Care Expenditures
    • 11. Health Production: Mortality Due to Malignant Neoplasm - 2002 *Reported by the WHO in US$ at the average exchange rate Sources: WHO, CDC, TN DOH, CMS $61* $167* $2,981* $4,883 $5,282 Per Capita Health Expenditures 2003 148 China 152 Russia 142 France 134 USA 217 Tennessee Age-Adjusted Mortality (per 100,000) Political Division
    • 12. Health Production: Health Care Use CABGs 2004 * 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 12,321,592 5,885,597 6,435,995 Population 2.1 259 13,590 Total 2.82 166 ‡ 9,262 ‡ Tennessee 1.45 93 † 4,328 † Massachusetts Population Death Rate* Deaths CABGs State
    • 13. Health Status: Tennessee State Health Rankings Source: United Health Foundation and Public Health Association Only South Carolina, Mississippi and Louisiana ranked lower
    • 14. 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.
    • 15. Cultural/Historical: United States Map in 1791 Wikimedia Commons
    • 16. 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
    • 17. 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   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.                                                                                                                                                                                                                                                   Smoky Mountain Moonshine Still
    • 18. 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
    • 19. Cultural/Historical: THE BALLAD OF THUNDER ROAD Let me tell the story, I can tell it all About the mountain boy who ran illegal alcohol His daddy made the whiskey, son, he drove the load When his engine roared, they called the highway Thunder Road. Sometimes into Ashville, sometimes Memphis town The revenoors chased him but they couldn’t run him down Each time they thought they had him, his engine would explode He'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
    • 20. Cultural/Historical: Moonshine to Drugs?
      • On May 9 th 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.
    • 21. Cultural/Historical: Schedule II Drugs Days Supply per 1,000 Members Moore 395 Henderson 588 Haywood 672 Warren 905 Hardeman 954 Williamson 957 Gibson 987 Obion 1000 Dyer 1003 Wayne 1020 Rutherford 1039 Lawrence 1050 Stewart 1071 Bedford 1084 Lake 1093 Meigs 1118 Crockett 1159 Weakley 1160 Houston 1209 Lauderdale 1218 Chester 1225 Lincoln 1238 Hardin 1247 Giles 1249 Madison 1259 Humphreys 1277 Maury 1311 Dickson 1329 Pickett 1381 Macon 1398 Cannon 1402 Sumner 1418 Bradley 1419 Marshall 1429 Benton 1466 White 1483 Fayette 1505 Shelby 1509 De Kalb 1510 Blount 1517 Tipton 1530 Davidson 1539 Hickman 1637 Wilson 1662 Montgomery 1676 Robertson 1709 Unicoi 1711 Lewis 1759 Cumberland 1763 Carroll 1770 Grundy 1778 Monroe 1796 Putnam 1805 Rhea 1816 Sullivan 1892 Hamilton 1903 Franklin 1930 Henry 1938 Greene 1944 Scott 1957 Trousdale 1974 Decatur 1982 McNairy 2053 Claiborne 2063 Washington 2118 Bledsoe 2151 Perry 2230 Polk 2239 Sequatchie 2306 Knox 2310 Coffee 2350 Overton 2357 Johnson 2376 McMinn 2406 Marion 2427 Cheatham 2471 Van Buren 2480 Anderson 2510 Smith 2529 Sevier 2586 Hancock 2652 Hawkins 2733 Carter 2741 Loudon 2751 Cocke 2793 Hamblen 2972 Union 2999 Grainger 3066 Clay 3143 Jefferson 3361 Jackson 3362 Campbell 3396 Roane 3409 Fentress 4475 Morgan 4854 0 to 1259 1259 to 1763 1763 to 2376 2376 to 4855
    • 22. Cultural/Historical: Clandestine Methamphetamine Laboratory Seizures Calendar Year 2008 As of December 31 Total Seizures: 815 599 108 108 Source: Tennessee Meth Task Force / Meth Intelligence System
    • 23. Economic: Pharma Advertising Oxycodone and NASCAR
    • 24. Economic: Prescription Drug Price/Quantity Branded Drugs: -0.024 Rx for every dollar increase in copay ($41) Generic Drugs: -0.21 Rx for every dollar increase in copay ($4.76)
    • 25. Economic: Third-Party Rx Retail Share by State 2005 Source: Novartis U.S. Average 74.1% 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%
    • 26. Policy: Impact of Grier on Generic and Brand Rx % Source: BCBST Data Warehouse East Grand Region BCBST TennCare Non-Duals
    • 27. Policy: Tennessee Prescription Drug Spending Per Capita Sources: CMS, Novartis Spending above trend = $4.9 Bn over the 5 years, 2001 - 2005
    • 28. Policy: States with Prescription Monitoring Programs 1939 C-II 1943 C-II, III, IV 1967 C-II, III, IV 1961 C-II 1987 C-II, III, IV, V 1988 C-II 1998 C-II, III,IV, V 1995 C-II, III, IV 1994 C-II 1994 C-II & Benzodiazepines 1990 C-II 1978 C-II, III 1981 C-II 1995 C-II, III, IV, V 1984 C-II, III, IV, V 1995 C-II 1992 C-II The Alliance of States with Prescription Monitoring Programs http://nascsa.org/monitoring.htm 2007 C-II,III,IV
    • 29. Policy: U.S. Deaths by Unintentional Poisoning Unintentional Poisoning Deaths --- United States, 1999—2004 MMWR February 9, 2007 / 56(05);93-96
      • Substance __ 1999__ __ 2004__
      • Drugs 11,155 19,838
        • Nonopioid analgesics 168 212
        • Psychotherapeutic drugs 671 1,300
        • Narcotics and hallucinogens 6,009 9,798
        • Other drugs acting on the central nervous system 21 22
        • Other and unspecified drugs 4,286 8,506
      • Other substances 1,031 1,112
        • Alcohol 320 358
        • Organic solvents & Halogenated hydrocarbons 63 67
        • Carbon monoxide and other gases 534 562
        • Pesticides 12 3
        • Other and unspecified chemicals 102 122
    • 30. Policy: 2004 & 2005, United States Unintentional Poisoning Deaths and Rates per 100,000 All Races, Both Sexes, All Ages ICD-10 Codes: X40-X49 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. 2004 2005 6.7 19,838 U.S. Average 9.6 576 Tennessee 12 9.86 636 Washington 11 10.36 565 Arizona 10 10.8 70 Alaska 9 11.02 1,851 Florida 8 11.04 1,348 Pennsylvania 7 11.34 471 Kentucky 6 12.38 427 Oklahoma 5 13.42 73 District of Columbia 4 13.47 313 Nevada 3 15.16 282 New Mexico 2 15.99 287 West Virginia 1 Age-Adjusted Rate** Number of Deaths State Rank 8 23,618 U.S. Average 10 877 North Carolina 12 10.4 684 Washington 11 10.5 136 Maine 10 10.5 603 Arizona 9 11.2 676 Tennessee 8 11.6 1,999 Florida 7 11.6 400 Oklahoma 6 11.8 1,438 Pennsylvania 5 12.6 556 Louisiana 4 13.4 558 Kentucky 3 14.3 348 Nevada 2 18.1 334 New Mexico 1 Age-Adjusted Rate** Number of Deaths State Rank
    • 31. Demographics: Increase in Poisonings by Rural Status of State Analysis of Unintentional Poisoning Deaths --- United States, 1999—2004 MMWR February 9, 2007 / 56(05);93-96 177 34.5-61.8 91.9 20.0-34.4 44.2 0-19.9 % Increase in Fatal Poisonings % of Population w/Rural Status 36.4 Tennessee 21 United States % of Population with Rural Status Division
    • 32. Demographics: Tennessee Gender and Poisoning Deaths* 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 *Age-Adjusted to 2000 standard 5.45 5.39 5.32 Absolute Change 131% 90% 213% % Change 2004 1999 Gender 9.6 4.15 Total 11.35 5.96 Males 7.82 2.5 Females
    • 33. Demographics: Change in Poisoning Deaths by Age Group 1999 - 2004 CDC WISQARS Age Bands
    • 34. 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/historical
      • 2. economic-lowest OOP for Rx
      • 3. rural nature of the state
      • 4. questionable policy – Grier, zero Rx OOP in TennCare and no funded controlled substance policy until recently
      • 5. 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.).