Prescription of Narcotic Analgesics in Kentucky and Indiana– A Comparison.

Summary
There are 37% fewer providers in Kentucky than in Indiana who prescribed opioid narcotics to Medicare patients in 2013, but they wrote 43% more total opioid prescriptions  per prescriber than in Indiana (254 vs. 178). Indiana spent more on opioids overall than Kentucky ($80.1 million vs. $53.6 million) at a cost that averaged 34% higher per prescription. Of the specialties with the largest number of prescribers or the highest rates of individual narcotic prescribing, only Nurse Practitioners and Rheumatologists prescribed a higher rate in Indiana than their Kentucky counterparts.  In both states, Nurse Practitioners prescribed opioids at rates substantially below those of Internists or Family Practitioners.  The almost across-the-board higher rates in Kentucky were substantial, but were particularly striking for the three major pain-management specialties. Cancer and end-of-life providers in either state did not prescribe opioids at greater than average rates per prescriber– well below those of physicians in general practice and only at a small fraction of the rates of pain-management providers.  High-prescribing outliers skewed the averages upwards in several specialties, if not most. The data pose the question: are there structural reasons for the differences in narcotic use between the states, or do the substantial differences result from simple practice preferences or amount of endemic prescription drug abuse? Continue reading

Article Temporarily Withdrawn.

Yesterday I posted an article comparing opioid prescriptions in Indiana and Kentucky by specialty based on the 2013 Medicare Part-D database. Among other things, I concluded that Kentucky providers prescribe more opioids in general than Indiana providers.  On further review I discovered that the Kentucky data, but not the Indiana data, included the drug tramadol (brand name Ultram).  This would increase the apparent number of prescriptions in Kentucky and their attendant costs. Thus, while I believe most of the intra-state conclusions and my general opinions remain valid, I need to recalculate the Kentucky numbers without tramadol to make a fair comparison.  Accordingly, I will redo the Kentucky numbers and tables without tramadol and repost.

I apologize for this embarrassing oversight.

Peter Hasselbacher

[Addendum Aug 30, 2015. The original article and its supporting tables have been updated with tramadol removed from the Kentucky dataset. None of the original conclusions or opinions are materially changed.]

Epidemic Opioid Abuse in Southern Indiana– Continued.

Plenty of drugs to go around!

Louisville Magazine’s August issue included an excellent extended piece profiling the impact of narcotic addiction in Austin (Scott County) Indiana. The sensitive and insightful article by senior writer, Anne Marshall with the collaboration of photographer William DeShazer, is titled, “The Craving.”  The article deserves a wide readership and I recommend it to you.  [Not all browsers may open on-line version of the story available here.]  The title would be appropriate for a late-night horror show, but in real-life, the story is even more scary. This tiny town is ground-zero nationally for epidemics of opioid addiction, HIV and hepatitis, and the other medical and social side-effects of this class of drugs.

Based on visits and extensive interviews, the article makes clear the enormous cost of opioid addiction on entire communities. It is not just the users that pay the price.  Legal or otherwise, the presence of opioid narcotics in communities exacerbates the poverty and social isolation that provide an important foothold for drug addiction and accelerates its grasp on communities large and small. By no means, however, is opioid addiction limited to the poor. To believe otherwise is to to hide out heads in the sand and allow this horror to grow. Some accounts of the epidemics in Scott County worry that the problem might spread to Louisville. Bad news folks! I am reliably told it is already abundantly here. This story could have been written about hundreds of towns and cities, large and small all over the nation, including Louisville.

Admittedly hard to fix– Why tie our hands?
In addition to accounts of human heartbreak, the article highlights longstanding political and institutional barriers to most effectively confront a problem that has always been with us. Detox and treatment options are subject to limitations of both effectiveness and availability. Relapse rates are high. The cost of medical treatment is also high and treatment itself is subject to both provider and patient abuse. Hard to swallow is the ideologically driven political foolishness that ties the hands of those offering effective support like needle exchanges, or playing games with the funding of Planned Parenthood which was providing HIV screening to citizens of Scott County. Perhaps when it is acknowledged that opioid abuse is not limited to the poor, to minorities, or other socially marginalized people, we will hear both the public and their elected representatives singing a different song and making resources other than more prisons available. Sad to think that is what it might take! [Read today’s story in the Lexington Herald Leader about a new federal prison in Eastern-Kentucky promoted as an economic development issue and weep!] Continue reading

Nomination and Board Appointment Process At UofL Is Broken.

Summary.
The process of nominating and appointing members of the University of Louisville Board of Trustees has broken down, and– as seems to be the case for some other Kentucky universities– has been out of compliance with Kentucky law for some time. A system designed to prevent politicization of our Board and to foster gender and minority diversity has produced nothing of the kind. A major reassessment of the entire process is in order but it cannot be done behind closed doors in either Frankfort or Louisville.

When it rains on our parade, it pours.
On the same day I wrote about the statutorily impermissible imbalance of membership on the University of Louisville Board of Trustees with regard to sex and race, James McNair of the Kentucky Center for Investigative Journalism published an extensively researched article documenting the major tilt towards registered Democrats on the Boards of UofL, the University of Kentucky, and the Kentucky Community & Technical College System (KCTCS).  In a state with 53% registered Democrats, 39% Republicans, and 8% independents or other, the breakdown of appointees at the state’s three largest institutions of higher education are currently as follows:

               Dem        Rep      Other
UofL        12            3             2
UK           12            4             ?
KCTCS       7            1             –

Continue reading

UofL Board of Trustees Under The Microscope.

Kentucky Gov. Steven Beshear is taking some heat for not including an African-American among his latest round of appointments to the University of Louisville Board of Trustees. Criticism from the community included claims that by passing over three available African-American nominees for the positions, that the Board was without an African-American member for the first time in many years and in fact violated state law.  This is incorrect.  The Board currently has as its student representative a female African-American trustee who, if she follows precedent, will not be a potted plant.  Nonetheless, attention to the makeup of the Board is a matter that should be of considerable concern to the public.  The UofL Board itself has been regularly in the news for some time, and is likely to remain there a good bit longer given rising community concern over University governance (or frequent apparent lack of governance), executive compensation, tuition increases, political contributions by Board members, probation of academic units, lawsuits against major former partners, scandals and outright criminal activities involving a few employees and faculty, high-profile separations or dismissals– including some with golden parachutes and non-disclosure agreements, a troubled partnership with a religious organization that is tearing the downtown medical center apart, or whatever other story-of-the-week keeps the pot of concern bubbling.  I confess to helping keep the heat on.  Fueled by secrecy and non-stop controversial revelations, our University’s reputation is being damaged.  Demands for accountability have past the point that they can be ignored.  It is therefore useful to examine how it is that board members of the various state universities and the community and technical colleges are selected.  The process is defined in detail by state law but it is obvious to me that existing statutory requirements are being be followed loosely if at all.  Let me explain. Continue reading

Is HB-1 Working To Decrease Prescription Drug Abuse And Diversion?

Summary.
House Bill-1 passed in 2012 was a landmark legialstive effort to deal with Kentucky’s exploding epidemic of substance abuse. It clearly was effective in acheiving some of its goals, but it seems to have had less effect in some parts of the state and may have done as much as it can. We have improved our ability to collect data about prescription of controlled substances, but we have lagged in taking advaitage of what we have learned. We need to keep trying to do other things. Not all will work as well as hoped for either, but doing nothing is a non-starter.

Press conference(s).
In July, Governor Steve Beshear, Attorney General Jack Conway, Senate President Robert Stivers and House Speaker Greg Stumbo presided over a press conference to provide an update on House Bill 1, the comprehensive prescription drug abuse legislation passed in 2012.  Details presented included that the number of overdose deaths were down, the numbers of prescriptions for commonly abused drugs had dropped, and that 20 pain clinics had been shut down since HB-1 took effect.  Recall that prescriptions for controlled drugs dispensed in Kentucky must be reported to the Kentucky All Schedule Prescription Electronic Reporting (KASPER) database. The number of prescribers enrolled in the KASPER program increased from 75,45 to more than 24,000 with a tripling of queries to the KASPER database for reports on their patients from 811,000 to 2.7 million.  Over a ten-month period, the number of doses of hydrocodone dispensed dropped 9.5% from 198 million to 179 million doses. The number of doses of oxycodone dropped 10.5% from 72 million to 64 million does. Some of the other improvements were not so impressive.  Overdose fatalities over the previous year dropped, but only from 1023 to 1004. The number of physicians disciplined for prescribing violations by the the Kentucky Board of Medical Licensure rose from 53 to only 64.  Some bad news was that the number of overdose deaths attributed to heroin rose from 22 to 143, a forerunner of worse to come.

There is no doubt that HB-1, enacted in July 2012, has had an impact in the right directions, but some of the observed effects were relatively modest and some of the major impacts were probably one-time benefits.  Most of the immediate impact of the bill was either predictable or the result of picking the low-hanging fruit.  The 20 or so “pain clinics” that were shut down were obvious pseudo-medical pill-mills in disguise.  Enrollment in KASPER by prescribers became mandatory with the new law which also required prescribers to make at least some inquiries about their patients before prescribing selected high-risk drugs.  A stunning number of out-of-state licensed prescribers all of a sudden discovered it was too risky to use Kentucky as the drugstore of choice for their prescriptions to abusing co-conspirators.  These changes to the prescriber population alone would be expected to decrease the overall volume of controlled substances entering the system.  The distressing observation remained that use and diversion of controlled prescription drugs remains huge and pervasive.

Oops— Start over!
Even though I had heard last week’s press conference live, I was a few paragraphs into the document summarized above before I realized I was erroneously reading a press release from July 25, 2013 that I had just downloaded from the Internet!   The players from last week’s press conference were the same, but the occasion was the release of a study commissioned by the Cabinet for Health and Family Services and prepared by a unit of the University of Kentucky’s College of Pharmacy.  The report compared two year’s prescribing of controlled substances before HB-1 to that of the following full year ending July 2013.  The July 27, 2015 press conference therefore had a longer follow-up to draw upon but the results were not all that different and not always better than those of two years before. Continue reading

Executive Compensation at UofL— A Tipping Point?

Over the past few years there has been a plethora of events, reports, investigations, prosecutions and miscellaneous scandals involving the University of Louisville that should have made the Louisville and Frankfort communities sit up and take notice that all may not be well or even legal within the Cardinal Citadel.  However, a recent series of investigative and other reports about the amount and mechanisms of executive compensation have proven to be the tipping point for public outrage. The income disparity between a select few in leadership and the not-keeping-up-with-inflation salaries of faculty and staff– supported as they are by soaring student tuitions– became too great for University of Louisville spin-meisters to stonewall, to facilely explain away, or to blame on the Commonwealth’s lack of funding.  Prominent among the recent reports are those of Chris Otts of WDRB, Andrew Wolfson  of the Courier Journal, and Stephen George of Insider Louisville. The faculty and staff of the University are also understandably outraged.  I put my two cents in also.

I don’t have the patience or space to detail how the story unfolded. The journalists above have published detailed analyses of “how much, how come, and who knew?”  The story has gone nationwide.  Troubling is the observation that numbers and other details from different sources do not always agree.   Official UofL and UofL Foundation documentation is shockingly sparse, inconsistent, and embarrassingly incomplete. The recollections of present and former Trustees of what actually transpired vary, in my opinion, proportionally to obvious personal loyalty to President Ramsey and to the detriment of University credibility.

In its typical effort to deflect the widespread criticism, the University hired an outside consultant to prepare a comparison, or more correctly a justification for the Board of Trustees of how President Ramsey’s compensation compares to that of presidents of other selected universities.  However, at the very session at which the consultant presented its report to a formal meeting of the Trustees, it was revealed that the necessary supporting information given to the consultant by the University was incomplete and grossly understated Ramsey’s compensation!  [Incomplete disclosure? Has that ever happened before?] Additionally and following subsequent full disclosure, the consultant expressed concern about some elements of Ramsey’s compensation that were atypical at other universities.  Despite this revelatory debacle, a majority of the full Board voted to give Ramsey a (reduced) raise and a bonus! It is apparent to me that UofL Board members, both old and new, have no idea how much money Ramsey has been getting nor how he came to receive it!  Shame on them! Ramsey recently forcefully complained that his credibility was being challenged by those asking for accurate information.  It is clear that somebody’s credibility is in tatters.  It is now the responsibility of President Ramsey to tell us whose. Continue reading

Potpourri of Health Policy Issues in June.

My cup runneth over with potential issues to explore.

June has been a busy month both locally and nationally insofar as things I like to write about. The shame-on-me is that I have not carved out enough time to do so!  In part I am still picking up the pieces after my early spring travels. Exploring how to unpack and deal with the new Medicare prescription drug data base also took a lot of time.  The truth is that I am a slow writer handicapped by a default and probably over-wordy professorial style.  I haven’t even been able to update the Institute’s Facebook and Twitter pages!  What follows is a list of things that occured during the month that I wanted to write about and hope to do so in more detail later.  These are not necessarily in chronological order or of importance.

The Supremes Rock & Rule!
We were presented with two back-to-back major decisions by the U.S. Supreme Court. The first, King v. Burwell, allows federal subsidies of health insurance premiums for low income individuals and their families to continue even if their insurance was purchased in states that chose to allow the federal government to operate their health insurance exchanges.  The lawsuit brought by Obama/Obamacare-haters to limit premium support to insured individuals in states like Kentucky that chose to operate their own exchanges would have essentially gutted the Affordable Care Act (ACA) and tossed millions back into the uninsured category. For the time being, Obamacare stands intact for at least the next year and a half, despite promises by opponents to throw up additional challenges. All our legislators should be working together to deal with a major remaining deficiency of the ACA.  The Act has been very successful in decreasing the number of uninsured people, but it makes little headway against the exploding costs of unnecessary, marginally effective, or for that matter even necessary medical care.  Continuing to forbid the federal government to negotiate over the prices of drugs is a case in point. Subsidies were deemed necessary for a reason! Continue reading