What drugs and by which specialties?
\n<\/b>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.\u00a0 Is good medicine being practiced?\u00a0 Is it possible to tell? Should we even care?\u00a0 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.\u00a0From\u00a0the full CMS database, I extract and make available an Excel file enumerating\u00a0\u00a0prescriptions of selected narcotic analgesics\u00a0by\u00a0Kentucky medical providers .<\/p>\n
In an initial article<\/a>, I used aggregated summary files provided by Medicare that focused on what drugs had been prescribed and how often.\u00a0 In this article, I begin to explore the more extensive provider-specific files to focus on who is doing the prescribing. Before launching into the actual data, I need to emphasize a few caveats.\u00a0 The CMS data does not include patients in classic fee-for-service Medicare, or those in insurance plans without drug coverage (if there are any such plans). Recall also\u00a0that patients end up in the Medicare program because they are older than 65 and worked enough quarters in their life, or through the Medicare disability program.\u00a0 Beneficiaries in the latter category can be expected to have a different set of diagnoses and to be younger than the former.\u00a0 Furthermore, data from providers who prescribe a given drug to fewer than 11 patients is excluded from the database thereby underestimating total opioid consumption by Medicare beneficiaries.<\/p>\n Disabled vs Aged<\/b>. What drugs are being prescribed? Attached is a list of 24 different opioids<\/a> or opioid combination preparations from the CMS Part-D database by their generic chemical names, together with the 74 different brand-name and generic products available.\u00a0 For each product, the number of providers using, the total number of prescriptions written, the total drug cost, and a calculated field containing cost-per-claim are listed. For 7 of these, only a single brand or generic version was available in 2013.\u00a0 For example, no brand-name option for the basic drug codeine sulfate was present in the database.\u00a0 Conversely, other products containing the same active ingredients had from 2 to 14 different versions available!\u00a0 For example, generic hydrocodone\/acetaminophen came in\u00a013 different brand-names including the well-known Vicodin and Lorcet.\u00a0 This table allows comparison of brand-name vs. generic formulations.<\/p>\n The most commonly prescribed opioid drugs in this national population are: <\/b> Some drugs more expensive than others.<\/b> Cost of brand-name vs. generic preparation.<\/b> For oxycodone HCL, the opioid category containing the drug OxyContin,\u00a0 the difference between the generic and brand versions is 12 fold.\u00a0 I wonder in my own mind why this drug is so much more expensive or for that matter so often prescribed.\u00a0 Is it more effective for the relief of pain? Are its supposedly abuse-resistant forms worth the extra expense?\u00a0 Is it solely due to aggressive marketing over the years that has drawn penalties from regulators?\u00a0 Is it the ultimate value of these drugs on the street?\u00a0 Who can help educate me?<\/p>\n Money well spent?<\/strong> Who is writing prescriptions for all these drugs?<\/b> Interventional pain management and pain management are at numbers 9 and 11 respectively tending to use more expensive drugs. I suppose no one will be surprised by this.\u00a0 The four different oncology specialties listed\u2013 in which practices narcotic analgesics are said to have their most defendable value\u2013 are further down the list. \u00a0Hospice and Palliative Care is number 50 on the list.<\/p>\n Given my bias, I was disappointed to see orthopods and rheumatologists high on the list of opioid prescribers.\u00a0 Orthopods are of course surgeons, and much of their utilization is likely to be for post-operative reasons. However, the fact that rheumatologists and physical medicine specialists are heavy users of opioid analgesics suggests\u00a0that only a tiny proportion of Medicare beneficiaries are taking narcotic analgesics because they have cancer or other terminal diseases and for whom drug dependence is not much of an issue.\u00a0 We as a profession are using narcotics to treat moderate musculoskeletal pain or less objectively defined disease just like the drug companies told us to.\u00a0 We knew better.\u00a0 Shame on us.<\/p>\n Do dentists do it better?<\/b> How many drugs does one provider need?<\/b> A last thought.<\/b> I will continue to slice and dice the CMS files in an effort to determine what kind of useful information can be extracted.\u00a0 I urge any of you readers to do the same and I welcome your ideas and comments. I provide a manageable-sized subset Excel file (1 MB) of opioid prescription<\/a> by Kentucky providers for your use to this end. \u00a0I already provided a larger\u00a0Excel file (36 MB)<\/a> containing all drugs<\/span> prescribed by a Kentucky provider to these patients.<\/p>\n Peter Hasselbacher, MD I\u00a0extracted the opioid prescriptions for all U.S providers that serves as the basis for the discussion above,\u00a0but it yields an\u00a0unwieldy Excel file that\u00a0makes even my machine crash. If there is a reader who would like related\u00a0files from another state, feel free to contact me. \u00a0Perhaps I can help.<\/p>\n
\nThe CMS database does not make it possible to determine with precision which category of Medicare patients is being prescribed for.\u00a0 The provider-specific files include fields for the number of beneficiaries older than 65 together with the number of claims and total drug costs for each specific provider-drug pairing.\u00a0 However, on top of the overarching CMS patient-privacy protocol that does not include line item records for individual providers prescribing a specific drug to fewer than 11 patients, the numbers for the 65+ patients are subject to a second application of the restriction. The result is that a very large number of fields for unique total beneficiaries and beneficiaries over 65 are blank. Based on a first-pass estimate that ignores the blank cells, it is possible that as much as half of the opioid utilization is in the disabled group.\u00a0 It is fair to say that both groups are generously supplied with opioid analgesics. As important for public policy as this distinction is, for the purposes of this analysis, no attempt is made to separate the two Medicare entitlement groups.<\/p>\n
\n<\/b>Because of limitations in the number of lines the data-analysis program Excel can handle, the following discussion covers\u00a0a subset of opioids or combination opioid preparations whose generic names in the data set contain the strings cod<\/b> and morph<\/b>.\u00a0 As it happens, this data extraction captures all the commonly used (and abused) opioid narcotics.\u00a0 Alas, because of size limitations, I could not simultaneously include the other commonly used and abused drugs meperidine, fentanyl, and tramadol<\/a> in this analysis.\u00a0 Tramadol is opioid analog and is subject to abuse, but by a triumph of lobbying is not considered a controlled substance.\u00a0 The fentanyl preparations are probably both the most potent and expensive of the opioid narcotics. Time and interest permitting, I will perform a separate analysis at a later time. Let me know what other drugs should be included in future analyses.<\/p>\n
\n<\/b>\u2022 hydrocodone\/acetaminophen as mentioned above with 33.52 million claims;
\n<\/b>\u2022 oxycodone HCL\/acetaminophen (the ingredient in Percocet) at 7.72 million;
\n<\/b>\u2022 oxycodone HCL (as in Oxycontin at 6.42 million;
\n<\/b>\u2022 morphine sulfate (in MS Contin) at 3.45 million;
\n<\/b>and the last of those with more than 1 million claims,
\n<\/b>\u2022 acetaminophen-codeine (as in Tylenol #3) with 1.90 million.<\/p>\n
\nA single category of drug, oxycodone HCL, cost Medicare beneficiaries and their payers $1.04 billion<\/span> dollars.\u00a0 The next most expensive category of drugs was hydrocodone\/acetaminophen at $559.4 million; oxycodone HCL\/acetaminophen at $257.7 million; and morphine sulfate at $224.6 million.<\/p>\n
\nAccording to these data, collected by pharmacy drug benefit managers who should know, the differences between the prices paid for brand-name vs. generic can be frankly stupendous.\u00a0 For example, for the commonly marketed and prescribed and hydrocodone\/acetaminophen, the generic version costs a mere $17 per claim but Lortab and Vicodin cost $209 and $78 respectively. Other versions of the same drug cost up to $1159 per prescription. The reader will note several examples of similar or even greater differences.<\/p>\n
\nI must again ask the question, why is anything other than the generic version prescribed, dispensed, or paid for at all by any insurer?\u00a0 Is this the cost our legislators were content to pass on to the rest of us by forbidding Medicare to negotiate the price of drugs?\u00a0 In my opinion, this story\u2013 which can be retold a thousand times\u2013 is a national scandal.\u00a0 What a colossal waste of money that comes directly out of our tax- and insurance premium dollars.\u00a0 We are all paying for it.\u00a0 Why do we as professionals and citizens alike tolerate this waste\u2013 driven as it is purely by the pharmaceutical marketing engine.\u00a0 In my view, a provider or pharmacist who prescribes or dispenses by brand-name when reasonable generic alternatives are available, or who does not otherwise protect their patient from financial drug toxicity, is not doing their job.\u00a0 In the case of prescription of narcotics, I must wonder if demand from the patient or the street is playing any role in what specific drug is prescribed.\u00a0 Such unsavory factors are certainly involved in illegal or unethical pill-mills where profit is the underlying motive.\u00a0 Note that all of this is occurring under the supervision and supposed patient protection of the health insurers that manage Medicare drug plans.\u00a0 God only knows what is happening to traditional Medicare beneficiaries or to the public at large.\u00a0 Enough of this specific rant for now.<\/p>\n
\nAttached is a list of 149 different provider specialties<\/a> as recognized by Medicare in this database\u2013 together with the total number of prescriptions written, their total cost, and a calculated field of cost per prescription.\u00a0 The list is ranked by total claim (prescription) count. (Here is an Excel file of the data<\/a> you can play with.) \u00a0Some may be surprised that more prescriptions for these opioids are written not by cancer doctors or pain specialists, but family practitioners and internists.\u00a0 These two specialties provide the bulk of primary care, along with the nurse practitioners and physician assistants that occupying the number 3 and 4 slots in terms of total number of opioid prescriptions written.\u00a0 Given the legislative battles in Kentucky over prescribing privileges for nurses in general, and for controlled drugs specifically, I was personally surprised to see nurses and physicians assistants so far up on the national list.\u00a0 Interestingly, the cost per prescription for these latter two classes of providers was higher than that for most of the physician provider groups. It is often argued that nurses and physician assistants provide more economical medical care.\u00a0 These numbers call that assumption into question. It must be recognized however, that internists, nurse practitioners and physician assistants also include individuals working in specialty areas.<\/p>\n
\nSticking out like a sore tooth are dentists at #14 by prescription volume but at peanuts for cost.\u00a0 Are these clinicians under-treating their patients? Their drug of choice is generic hydrocodone\/acetaminophen (675,616 claims); and much further down the list, generic acetaminophen\/codeine (105,063 claims); and oxycodone\/acetaminophen (29,776 claims). Only a handful of dentists used brand-name narcotics. Do dentists only prescribe a few pills at a time? \u00a0In my opinion these professionals are teaching us physicians something about cost-effective practice.\u00a0 Having a bias consequent to tooth troubles of my own in the past, I offer no judgment about the clinical indications for these dental prescriptions!<\/p>\n
\nThere were 388,192 unique providers in the CMS database who prescribed one or more of these 74 different products to more than 10 patients.\u00a0 I have not yet figured out how to count the number of unique practitioners in each specialty category within the provider-specific file because a single practitioner can appear in the list up to 21 different times, depending on the number of different drugs prescribed. This later statistic is of interest in itself.\u00a0 Of the total number of providers, 82.6% prescribed 3 or fewer different opioid formulations.\u00a0 Only 7.9% prescribed 5 or more different formulations. Rather amazingly in my view is the fact that 206 providers prescribed 15 or more different formulations of these codeine and morphine derivatives.\u00a0 A single provider prescribed 21 different drug products, and 39 used 17 or more!\u00a0 These figures have bearing on the cost and safety of medical practice.\u00a0 In my medical teaching, I adhered to the principle that a physician should use a limited number of drugs, but to know each of them well.\u00a0 In the case of these narcotics, I cannot believe so many narcotic analgesics stand out because of efficacy, safety, cost, or even convenience!\u00a0 In my opinion prescription drug use is driven in large measure by the commercial success of marketing, or alas, for even unprincipled reasons.\u00a0 Other opinions in the comment section below are welcome.<\/p>\n
\nWhen someone from a third-world or even our own country markets and sells narcotics to addicted or abusing Americans in a non-medical endeavor, we call them pushers and drug dealers. We criminalize their activities.\u00a0 Much harm to us as a society and to individuals results from this illegal activity.\u00a0 How then should we feel when the same basic products are promoted, prescribed, and sold to the same public by high-profile advertising agencies, pharmaceutical companies, pharmacies, and providers within the healthcare marketplace?\u00a0 Are these two commercial enterprises clearly distinguishable?\u00a0 I want to believe that they are, but I cannot. Our newspapers are too full of evidence to the contrary.<\/p>\n
\nPresident, KHPI
\nEmeritus Professor of Medicine, UofL
\nJune 12, 2015<\/p>\nShare this:<\/h3>