The jointly managed state and federal Medicaid program has always been an important part of the American patchwork healthcare system. The Medicaid expansion of the Affordable Care Act and other changes to eligibility have not only increased the number and diversity of Medicaid beneficiaries, but also Medicaid’s potential financial and clinical ability to shape other healthcare segments in the same way that the Medicare program has done. However, not all of Medicaid’s structural practices may be worth promulgating. I suggest that the way Medicaid has chosen to select eligible drugs for its formularies nor the way its has paid for them are worthy of emulating. To start a new thread in these pages, I begin with a survey of drugs prescribed to Kentucky Medicaid beneficiaries in 2014. I freely admit that I will be learning along with my readers who I hope will participate in the process of exploration and understanding.
I will demonstrate an overlap in the use of drugs by both federal programs but also illustrate major differences. It will be obvious that many beneficiaries who are excluded from employment-based or ineligible for Medicare coverage are dependent on Medicaid for their health care. You might even become more concerned about recent promises to reverse Medicaid expansion and cut its roles. I will highlight the extraordinary cost of some new drugs such as those for the curative treatment of hepatitis-C. I will show that the cost to the system of every-day commonly used drugs overshadows that of the high-flying cancer drugs that are frequently featured in our news reports. You may be surprised to see how frequently opioid narcotics are prescribed. You should be concerned about the exploding costs of necessary and successful medically assisted drug treatment for opioid addiction. You will be as surprised as I at the personal and financial burden of depression and other mental disorders. Finally, you will probably be disappointed and maybe even a little angry about how little our public policy seems to be guided by the prevalence of the illnesses that most frequently affect us. Continue reading “Prescription Drug Utilization and Costs for Kentucky Medicaid in 2014.”
In my last article, I profiled the outpatient drugs prescribed to elderly and disabled Medicare beneficiaries of Kentucky in 2013. While I still had the analytical templates still in hand, I extended that analysis to all 50 states. Initial inspection suggests that the relative pattern of drug prescription (and dispensing) is not greatly different than that of Kentucky. It may not be a surprise that we of the Bluegrass state consume relatively more hydrocodone, oxycodone, and gabapentin relative to other drugs, but less oral anticoagulant. A more granular comparison of Kentucky to the the the nation will require a different approach. This Medicare data allows us to separate out the proportion of a given drug product that is dispensed and billed as a generic drug; a brand name drug; or as alternate preparations such as long-acting, tamper-resistant, or solid vs. liquid. The big take-away for me is that despite the supervision of Medicare’s prescription drug programs by pharmacy benefit managers and others, much money is being spent in less than a medically defensible manner– or is frankly wasted. We as a nation are leaving billions of dollars on the table for pharmaceutical companies and those who market and distribute their products. I will summarize below national utilization and cost figures and make available an Excel file supporting the graphics.
Background. I have been exploring the inaugural release of Medicare prescription drug utilization since its publication last spring. (We should get the numbers from calendar year 2014 in the next few months, but I have Medicaid 2014 in-hand and up-next!). The database does not include all Medicare beneficiaries, only those in Medicare Managed Care or in Medicare Part-D Drug plans, but that makes up a majority of bebefuicuarues. The proportions vary from state to state, but the Medicare programs covers eligible individuals over the age of 65, and some individuals who have been certified as disabled. There is a sizable proportion of individuals who are eligible for both Medicare and Medicaid for other reasons. I frankly do not at present have a good handle on the numbers of beneficiaries in these and other categories that may be included within the present data. Continue reading “Prescription of Medicare Part-D Drugs Nationally: $Billions Left On The Table.”
Visualizing prescription patterns for Medicare patients with an eye to safety and cost.
In the name of quality, accountability, and paying for results, what began as a trickle of information previously unavailable the public about utilization, cost, and outcomes of medical services became a torrent. The challenge for professionals and patients alike is how to evaluate and act upon all this data. I include myself among the learners. My readers may have guessed correctly that I like to look at spreadsheets, pivot tables, and maps. Exciting new ways of looking at such “big data” are also becoming available. “Data visualization” is a current buzzword and I am experimenting with it. In this article I use a new way to summarize the number of prescriptions and associated cost for all drugs prescribed for Kentucky Part-D and Medicare managed care beneficiaries in 2013. This segment of Medicare patients received over 25 million prescriptions and refills that year with a total cost of $1.6 billion. I will show that a few dozen drugs comprised half the volume and cost of all prescriptions, attempt to shock you again with the volume of opioids and other controlled narcotics prescribed to the elderly and disabled, introduce you to Kentucky’s most rapidly growing drug of abuse, and illustrate in one fell swoop how America can save $Billions nationally without any decrease in safety or quality of care. Does this sound like a late-night TV come-on? Read on. Continue reading “A Different Look At Drug Prescribing in Kentucky.”
This appears to be the case in Ohio.
Cities and towns in Ohio in which medical professionals write opioid prescriptions to Medicare beneficiaries at the very highest rate per inhabitant are co-located in counties with the highest per-capita consumption of prescription opioids overall and those with problems of prescription drug abuse in general. In Ohio these areas are in southern Ohio and the I-77 corridor in eastern Ohio. These observations link by association the number of prescriptions by providers listed in the Medicare Part-D database, to opioid utilization and abuse in the general population.
The 25 providers who wrote the largest number of opioid prescriptions to Medicare beneficiaries in 2013 practice for the most part in the big cities, especially near Cincinnati. In contrast, Columbus has a surprisingly low opioid prescription rate for Medicare patients– a difference that begs to be understood. Continue reading “Is Prescribing Of Opioids To Medicare Patients Representative of Opioid Prescribing Generally?”
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 “Epidemic Opioid Abuse in Southern Indiana– Continued.”
What drugs and by which specialties?
When I first looked at the recent release of outpatient prescription drug utilization by Medicare patients, I was immediately struck by how many narcotics were being prescribed by physicians and other medical providers for so many patients. The vast majority of providers prescribed a handful of different and mostly inexpensive opioid drug products to a relatively few patients, On the other hand, a smaller number of providers wrote for many different opioid formulations, some fantastically expensive, for large numbers of patients. Is good medicine being practiced? Is it possible to tell? Should we even care? Of course we should. In this analysis I break down further the utilization of a subset of the most common opioid analgesics, show which medical specialties prescribe the most, and begin to highlight the vast discrepancy in narcotic use among individual providers. From the full CMS database, I extract and make available an Excel file enumerating prescriptions of selected narcotic analgesics by Kentucky medical providers . Continue reading “Narcotic Analgesic Drug Use By Medicare Patients: Continued”
Another Accountable Care Act initiative with website problems!
For many years now, many public policy concerns have been expressed about the huge amounts of money that pharmaceutical companies and medical device manufacturers give directly to physicians and academic medical centers. An old drug detail-man in Kentucky once told me his company gave Cadillacs to the highest prescribers of his drugs. I doubt that things are that blatant anymore, but so much money flows into individual and departmental pockets that it is difficult to assemble members for expert panels of the FDA, CDC, or other policymaking organizations who are not receiving money from drug and device makers. Full disclosure was supposed to solve the problem, but that does not work. The Open Payments initiative is part of a larger movement for greater transparency and accountability. I plan to write more about this, including my own experience over the years interacting with Pig Pharma and Big Devices.
Continue reading “Rocky Rollout of Sunshine Act— The Open Payments Program for Physicians.”
National news media of all sorts have been reporting about an “epidemic of meningitis” associated with contaminated steroid shots given for back pain. I might as well chime in too. There have been 47 cases identified so far with five deaths, including one Kentuckian. Because hundreds or even thousands of people have received such injections, these numbers will surely increase over the next few weeks. Meningitis is inflammation or infection of the tissues surrounding the spinal cord and brain. The epidural or peri-spinal steroid shots in these cases are injected deeply around the spine and close (if not adjacent) to the meninges. Once the infection breaks through into the spinal fluid or bloodstream, it spreads widely in short order including to the brain. Continue reading “New Epidemic of Meningitis: Predictable and Unnecessary.”
The medicine that we are too willing to swallow.
It has only been a lack of time, never of material, that limits the number of entries in this column. (Are any of you out there interested in writing about something?) One has only to open the local newspaper or watch any news program to stumble across things that should cause our ears to perk up, if not make our blood boil. Last Friday’s Courier-Journal provides a typical example. There were no fewer than five different news articles that were exactly on point for issues we have been writing about this past year. The articles highlighted the massive squandering of money and flesh by a broken healthcare system, a substantial risk of the most commonly touted screening procedure, an example of the unconscionable bills that hospitals are willing to present to their patients, a Kentucky hospital being sued for massive but lucrative overtreatment, and a report of still one more widely used treatment for Alzheimer’s syndrome that didn’t work. There seems to be no limit to the amount of abuse the American public is willing to take from the healthcare industry that is supposed to serve them. Fortunately for me, I don’t have much hair to pull out anymore. Continue reading “Cure and Outrage Coexist Comfortably in American Medicine”
I was unaware that the result from Lilly was not the only recent major failure of a clinical trial of antibodies to the amyloid plaques in the brains of Alzheimer’s patients. It seems that many other big and little-name drug companies have been trying the same approach with their dozen or so different antibodies. Each is trying to make it to market first where the biggest money lies. (Consumers should beware when the commercial pressures are this great.)
Last month, Pfizer and its partners announced a similar failure of several studies which showed no clinical improvement when their particular antibody, bapineuzumab, was administered to several thousand patients over 18 months. Continue reading “More Failed Studies of Antibody Treatment for Alzheimer’s Disease.”