PHP Midterm 2

path from payer to patients 1

$ (individual patients, employers, federal and state taxes-medicare, medicaid, veterans administration, tricare) → insurance functions → delivery of health care services → recipient of health care services (patients)

Pharmaceuticals make their way from

(drug) manufacturers → wholesaler / distributors → retailers (pharmacies) → patients

Porter and Jick Letter in 1980

-"Addiction rare in patients treated with narcotics" statement from doctors at the Boston University Medical Center -This letter was invoked by doctors, academics, pharmaceutical companies and others as evidence that few users would develop addictions and that liberal prescription was justified -The analysis proved nothing of the sort, nor did it set out to; blamed for fueling the country's opioid epidemic

The Three Waves of Opioid Overdose Deaths

-*Prescription opioids* : the first wave began with increased prescribing of opioids in the 1990s, with overdose deaths involving prescription opioids (natural and semi-synthetic opioids and methadone) increasing since at least 1999 -*Heroin* : The second wave began in 2010, with rapid increases in overdose deaths involving heroin. -*Fentanyl* : The third wave began in 2013, with significant increases in overdose deaths involving synthetic opioids--particularly those involving illicitly-manufactured fentanyl (IMF). The IMF market continues to change, and IMF can be found in combination with heroin, counterfeit pills, and cocaine

In 2015, an estimated _____ drug prescriptions were dispensed in the United States, and generic or branded generic prescriptions represented _____ of that volume

-4.4 billion -89%

Pharmacy buying from Manufacturers -more or less leverage to negotiate rebates or discounts? -purchase prescription drugs from wholesalers at a ___ -rate varies based upon... -pharmacies contract with...

-Because pharmacies keep a wide range of drugs in stock so that they can be prepared to meet demand immediately, they have less leverage to negotiate rebates or discounts with manufacturers of single-source brand name prescription drugs -Typically, pharmacies purchase prescription drugs from wholesalers at a contracted discount off the WAC -The rate varies based upon the size and purchasing power of the pharmacy -Pharmacies contract with wholesalers to stock their facilities with prescription medicines and use agreements with facilitate full, timely payment for drug product purchases and fulfillment of other obligations in exchange for a discount

Study 1 results in racial bias study

-Demonstrates that white adults without medical training endorse at least some beliefs about biological differences between blacks and whites, many of which are false and fantastical in nature (e.g., black people's blood coagulates more quickly than white people's blood) -Also demonstrates that these beliefs are related to racial bias in pain perception among a sample of white adults without medical training

Value-based benefit design examples from simulation modeling

-Diabetes Mellitus: Medicare first-dollar coverage of ACE-inhibitors results in nearly one million life years gained and saved $7.4 billion over the lifetime of the cohort -Cardiovascular disease: Eliminating co-payments for statins for patients at medium or high risk of coronary heart disease averted 110,000 hospitalizations or ER visits and saved $1 billion annually

Table 1: Direct Medical Costs and Indirect Costs of Anaphylaxis Due to Food Allergy alone (in 2007 US dollars)

-Direct costs: +Most costly measures: $4719 per patient for inpatients; annual costs is $118.2 million in office visits +Epinephrine autoinjector is the lowest mean cost per patient ($51) +Total costs are $224.9 million in annual costs -Indirect costs: +Most costly measures: $80.2 million for office visits morbidity (general health) and $12.2 million for inpatients mortality (risk of death)

There are still barriers to implementation that have impeded growth of VBC

-Federal regulations, such as the Medicaid Best Price ruling and the Anti-Kickback Statute -Issues related to data collection and analysis

Graph: Anaphylaxis by region between 2004-2016

-Highest in the northeast (3,500 in 2016), followed by south, midwest (kind of overlap), then west (2,000 in 2016) -Though all increase slightly overtime -Why could this be?

Overview of Intervention cont. --> Copay reductions maintain existing incentive structure

-Medications -> tier 1 (generics) copays waived, tier 2 (preferred brand) → copays reduced 50%, tier 3 (non-preferred brand) copays reduced 25% -Diabetes eye exams → copays waived

Infographic risk of heroin addiction

-Nearly all people who used heroin also used at least 1 other drug → Most used at least 3 other drugs -People who are addicted to alcohol (2x), marijuana (3x), cocaine (15x), and opioid painkillers (40x) are more likely to be addicted to heroin

Under the buy and bill system, the provider is responsible for (5)

-Ordering and purchasing the drug -Managing drug inventory at the practice -Prescribing and administering the drug to a patient -Submitting reimbursement claims for a drug and related professional services -Collecting a patient's share of drug reimbursement—the copayment or coinsurance

Results and Conclusions from Opioid Prescription Disparities Study

-Our study shows that there are significant racial-ethnic disparities in opioid prescription and administration in ED visits for non-definitive conditions -These disparities may reflect inherent biases that health care providers hold unknowingly, leading to differential treatment of patients based on their race -Such biases could have serious implications by widening existing disparities, especially since racial-ethnic minorities already experience greater barriers to accessing health care -On the other hand, opioid prescriptions are associated with the risk of initiating long-term addiction and abuse -non-Hispanic whites are disproportionately affected by the prescription opioid epidemic, with age-adjusted death rates more than thrice that among non-Hispanic blacks -our findings raises a perplexing question as to whether it is non-Hispanic blacks who are being under-prescribed, or is it non-Hispanic whites who are being over-prescribed

Graph: Anaphylaxis by Age between 2004 and 2016

-Pediatric (0-17) always in the lead, increasing dramatically from 2004 to 2016 to 5,000 incidents -Followed by adults and older adults around the same rate but steady increase to 2,000 incidents by 2016

DIR Fees and Penalties

-Penalties that can be assessed by insurer/PBM if insured lives don't meet performance goals which are often tied to Medicare star ratings Ex) if adherence measurement is not 0.80 or above over the past 6-months then Pharmacy will face financial penalties over the next 6-months -Can lose network status if consistent poor performance

Composition of drug market

-Pharmacies account for 75% of the prescription drug market -Non-retail providers such as hospitals, some HMOs, clinics, nursing homes and federal facilities comprise the remaining 25% of the prescription drug market (Biologics end up in non-retail end because need to be administrated carefully; especially hospitals and physician offices)

"University of Michigan unveils innovative medication program for employees and dependents with diabetes" --> Overview of Intervention

-Phased co-payment reductions for evidence-based therapies for diabetes and CVD -All UM employees & dependants with diabetes eligible for 2 -yr pilot intervention of co-payment reductions for: Antihyperglycemic medications, Antihypertensive medications, Cholesterol lowering medications, Antidepressant medications, Dilated retinal examinations

There are two potential ways by which racial disparities in pain management could arise

-Physicians recognize black patients' pain, but do not to treat it, perhaps due to concerns about noncompliance or access to health care -Physicians do not recognize black patients' pain in the first place, and thus cannot treat it --> Research has shown that people assume a priori that blacks feel less pain than do whites

Interventions to Control Health Care Costs

-Prior authorization -Disease management (Improves outcomes, May or may not reduce costs) -Cost-sharing

pharmaceutical wholesaler who is responsible for:

-Purchasing products from manufacturers -Negotiating the drug's cost with the provider -Delivering the specialty drug to the provider's location -Collecting payment from the provider

Study 2 results in racial bias study

-Study 2 demonstrates that, similar to white laypersons in study 1, many white medical students and residents hold beliefs about biological differences between blacks and whites, many of which are false and fantastical in nature, and that these false beliefs are related to racial bias in pain perception -Study 2 also reveals that white medical students and residents who endorsed false beliefs showed racial bias in the accuracy of their pain treatment recommendations -Specifically, participants who endorsed more of these beliefs reported that a black (vs. white) target patient would feel less pain and they were less accurate in their treatment recommendations for the black (vs. white) patient

Fentanyl analogs

-Such as acetylfentanyl, furanylfentanyl, and carfentanil, which are similar in chemical structure to fentanyl but not routinely detected because specialized toxicology testing is required -Recent surveillance has also identified other emerging synthetic opioids, like U-47700 -Estimates of the potency of fentanyl analogs vary from less potent than fentanyl to much more potent than fentanyl, but there is some uncertainty because potency of illicitly manufactured fentanyl analogs has not been evaluated in humans -Carfentanil, the most potent fentanyl analog detected in the U.S., is estimated to be 10,000 times more potent than morphine

Conclusions racial bias study

-The present work sheds light on a heretofore *unexplored source of racial bias in pain assessment and treatment recommendations* within a relevant population (i.e., medical students and residents), in a context where racial disparities are well documented (i.e., pain management) -It demonstrates that *beliefs about biological differences between blacks and whites—beliefs dating back to slavery— are associated with the perception that black people feel less pain than do white people* and with inadequate treatment recommendations for black patients' pain

Wholesaler's role -Some wholesalers...

-To make the process of purchasing drug products from pharmaceutical manufacturers more efficient. -...specialize in dealing with a particular range of products, such as biologics or to specific types of customers, such as nursing care facilities

Opioid Prescription Disparities study methods

-Using data from the National Hospital Ambulatory Medical Care Survey for 5 years (2007-2011), the odds of opioid prescription during ED visits made by nonelderly adults aged 18-65 for 'non-definitive' conditions (toothache, back pain and abdominal pain) or 'definitive' conditions (long-bone fracture and kidney stones) were modeled -Opioid prescription at discharge and opioid administration at the ED were the primary outcomes

Against Methadone Maintenance Treatment

-While there is ample evidence supporting their use over non-medication abstinence based therapies most programs do not offer opioid agonist treatment (OAT) -Despite the effectiveness and widespread use of MMT, and the demonstrated benefit of combining MMT with other more intensive forms of treatment, integration remains a controversial topic -Many substance abuse treatment providers assert that MMT is incompatible with recovery and the abstinence-based treatment models of most residential treatment programs -Many state-licensed and publicly funded residential treatment programs have policies in place that explicitly deny access to care for MMT patients

Prescription opioid overdose deaths also often involve ___, central nervous system depressants used to ___ Examples of these medications:

-benzodiazepines -sedate, induce sleep, prevent seizures, and relieve anxiety -alprazolam (Xanax), diazepam (Valium), and lorazepam (Ativan)

Cost-sharing in 2007

-centerpiece of some health care reform proposals -assumes that consumer is informed -increases patient out of pocked costs +will reduce employer costs and possibly control cost growth +may lead to worse clinical outcomes

Not only are people using heroin, they are also abusing multiple other substances, especially ____. Nearly all people who use heroin also use ___

-cocaine and prescription opioids -at least 1 other drug.

Value-based benefit design

-cost-sharing determined by value, not price +highly valued services --> lowest co-pay +effective yet expensive --> middle co-pay +unproven or marginal benefit --> highest co-pay

impact of cost-sharing on utilization

-cost-sharing leads to decreases in both essential and excess care -utilization is dictated by affordability rather than medical need

Synthetic opioids include drugs like

-like tramadol and fentanyl. -Methadone is also a synthetic opioid; however, deaths involving this drug are tracked separately from deaths involving other synthetic opioids

-Most _____ are governed by the buy and bill process

-provider-administered outpatient drugs

As many as ___ patients receiving long-term opioid therapy in a primary care setting struggles with addiction

1 in 4

Signs and symptoms of anaphylaxis (6)

1) Trouble breathing, shortness of breath, wheezing, or coughing 2) Throat tightening, swelling of the lips or tongue, or trouble swallowing 3) Rash, hives, swelling, or itching 4) Nausea, vomiting, diarrhea, or abdominal cramps 5) Dizziness, lightheadedness, fainting, or confusion 6) Sudden behavior changes or irritability

Graph: 3 Waves of the rise in opioid overdose deaths

1) Wave 1 in 1999: rise in prescription opioid overdose deaths → continue to climb to the present day; around 500,000 deaths 2) Wave 2 in 2010: rise in heroin overdose deaths → today matches death counts for commonly prescribed opioids; hovering around 500,000 deaths 3) Wave 3 in 2013: Rise in synthetic opioid overdose deaths; other synthetic opioids e.g. tremadol and fentanyl, prescribed or illictly manufactured → dramatic increase to around 900,000 deaths today, surpassing deaths from both commonly prescribed opioids and other synthetic opioids

Retail pharmacy market can be divided into 3 major categories

1) chain pharmacies (CVS, Walgreens, Duane Reed) and mass merchants with pharmacies (Target, Kroger, Walmart) 2) independent pharmacies 3) mail-order pharmacies (PBMs)

In 2016, more than ___ Americans reported misusing prescription opioids in the past year

11.5 million

-On average, _ Americans die every day from an opioid overdose

130

More than ___ opioid prescriptions were dispensed to American patients in 2017--with wide variation across states

191 million

In the US, chronic pain accounts for up to ___ of all physician office visits, while acute pain is the ___

20% most common cause of emergency room visits

In __, more than 28,000 deaths involving ___ (other than methadone) occurred in the US, which is more deaths than from any other type of opioid

2017 -synthetic opioids

Deaths from synthetic opioids significantly increased in ____ from 2016 to 2017

23 states and the District of Columbia

In 2017, males aged ___ had the highest heroin death rate at 14.8 per 100,000, which was a ____ from 2016

25-44 -decrease of -4.5%

Among new heroin users during 2000 to 2013, approx. ____ report having misused prescription opioids prior to using heroin

3 out of 4

From 1999 to 2017, almost ___ people died from an overdose involving any opioid, including prescription and illicit opioids

400,000

In 2017, nearly ___ in the United States (12-years old or older) reported using heroin in the past year, which is an estimated rate of ___

494,000 people -0.2 per 100 persons.

Wholesale distributors connect ______ U.S. pharmacies and outpatient dispensing outlets

67,000

-Around _ of the more than _ drug overdose deaths in 2017 involved an opioid

68% 70,200

-In 2017, the number of overdose deaths involving opioids (including prescription opioids and illegal opioids like heroin and illicitly manufactured fentanyl) was _times higher than in _

6; 1999

-From 1999 to 2017, more than _ people have died from a drug overdose

700,000

And in 2015, ___ visits occurred for unintentional, heroin-related poisonings in America, which is an estimated rate of almost __ people.

81,326 emergency department -26 per 100,000

Distributors handle products representing ____ of overall pharmaceutical sales revenue

91%

Table 2: Multivariable logistic regression model predicting anaphylaxis

?

Value-based contracting

?

Synthetic Opioids

A class of drugs that are designed to provide pain relief, mimicking naturally occurring opioids such as codeine and morphine.

Anaphylaxis

A life-threatening allergic reaction that must be treated immediately. Your risk for anaphylaxis increases if you have asthma that is severe or not controlled. Medical conditions such as heart disease can also increase your risk.

White bagging

A specialty pharmacy ships a patient's prescription directly to the provider, such as a physician office or an outpatient clinic. The provider holds the product until the patient arrives for treatment.

Fentanyl

A synthetic (man-made) opioid 50x more potent than heroin and 100x more potent than morphine.

Buy and Bill

After the patient receives the drug and any other medical care, the provider submits a claim for reimbursement to a third-party payer. The process is called buy-and-bill, because the medical claim is submitted after the provider has purchased and administered the drug.

There is a wide variation of opioid prescription rates across states. Health care providers in the highest prescribing state, __, wrote almost ___ as many of these prescriptions per person as those in the lowest prescribing state, __

Alabama; 3x; Hawaii

Virginia's law, passed in 2012, came after

Amarria Johnson died at a Chesterfield County school from a reaction to peanuts. A Texas teenager's death from fire ant bites led to that state's law permitting epinephrine in schools

-The US distributor market is highly consolidated, with 3 companies accounting for more than 85-92% of market share... -The estimated combined revenues from drug distribution for the 3 largest firms in 2015 was

AmerisourceBergen, Cardinal Health, and McKesson -$378 billion

Graph: Etiology of hospitalizations between 2004-2016

Ang. edema highest (60,000 in 2016), followed by other and venom/sting, food, then drug (though spikes right at the beginning of 2014 while most others decrease in 2015)

__ who takes prescription opioids can become addicted

Anyone

Effect on OxyContin for physicians

At the time, this compound provided physicians a significant upgrade in their arsenal of pain management tools with superficially minimal risks to patients as reported by their producers

Prescription Opioids

Can be used to treat moderate-to-severe pain and are often prescribed following surgery or injury, or for health conditions such as cancer. In recent years, there has been a dramatic increase in the acceptance and use of prescription opioids for the treatment of chronic, non-cancer pain, such as back pain or osteoarthritis, despite serious risks and the lack of evidence about their long-term effectiveness.

DIR Fees (stands for, why it was originally created, plans have used the term DIR fee to describe...)

Direct and Indirect Renumeration -CMS originally created DIR as way to account for all costs associated with prescription medications, which included price concessions that would ultimately impact the gross prescription drug costs of Medicare Part D plans that were not captured at the point of sale. -According to the National Community Pharmacists Association, plans/PBMs have used the term "DIR Fee" to describe a "true-up" between a target reimbursement rate in a participating pharmacy agreement and the aggregated effective rate actually realized by a pharmacy

What are common prescription opioids?

Hydrocodone (vicodin) and oxycodone (OxyContin, Percocet) Oxymorphone (Opana) Morphine (Kadian, Avinza) Codeine Fentanyl

Non-pharmaceutical fentanyl

Illicitly manufactured fentanyl (IMF), often mixed with heroin and/or cocaine or pressed into counterfeit pills--with or without the user's knowledge. ~From infographic: illegally sold for its heroin-like effect, and linked to recent increases in overdose deaths; fentanyl analogs are drugs that are chemically related to fentanyl and mimic the effects of the drug

FDA approval of OxyContin

In 1996, in the setting of a national push for the identification of pain as a primary medical disorder, oxycodone hydrochloride, commonly known as OxyContin™, was approved by the Food and Drug Administration (FDA) as a "minimally addictive pain reliever"

Graph: Synthetic Opioids Are Driving Up the Overdose Rate, Overdose deaths in thousands in preceding 12 months

In order from most overdose to least: synthetic opioids, other opioids (heroin, cocaine), psychostimulants, and methadone

Racial Bias Study summaries

In two studies, we asked people to make judgments about another person's pain -In study 1, we used a between-participants design in which laypeople were randomly assigned to rate the pain of either a black or a white target -In study 2, we used a within-participants design in which medical students and residents provided pain ratings and treatment recommendations for both a black and a white target -In addition to pain ratings, we measured beliefs about biological differences between blacks and whites using 15 items (e.g., black people's skin is thicker than white people's skin)

Epinephrine

Medicine used to treat severe allergic reactions such as anaphylaxis. Given as a shot into the outer thigh muscle. +A chemical that narrows blood vessels and opens airways in the lungs. These effects can reverse severe low blood pressure, wheezing, severe skin itching, hives, and other symptoms of an allergic reaction + *Epinephrine injection* is used to treat severe allergic reactions (anaphylaxis) to insect stings or bites, foods, drugs, and other allergens

Common triggers of anaphylaxis include

Milk, peanuts, tree nuts, eggs, shellfish, wheat, and soy; Stings from bees, wasps, or fire ants; Antibiotics, NSAIDs, or aspirin; Latex; Exercise following exposure to another trigger, such as after you eat a trigger food

Effect of these laws on Mylan --> recent news

Mylan's EpiPens are at 63,000 schools nationwide and the company has distributed 500,000 of them for free through EpiPens4Schools. -In 2016, New York State's Attorney General announced Tuesday it will investigate Mylan to determine whether it introduced "anticompetitive terms" into school contracts -It has been reported that participants of Mylan's EpiPen4schools program had to agree not to purchase EpiPen-like products for twelve months in order to get a discount.

___ appears to have been the first state with a school epinephrine requirement. why?

Nebraska -High asthma rates in the state, as well as a couple of school-based child fatalities due to the respiratory illness, created an emergency response protocol that became law in 2006

Graph Number of Reported Law Enforcement Encounters Testing Positive for Fentanyl in the US: 2010-2015

Number of encounters increased from under 2,000 in 2013 to 5,000 in 2014 to 14,000 in 2015

Graph: Hospitalizations by Age between 2004 and 2016

Older adults (60+) highest incidence (around 50,000), then adults (around 20,000) then pediatric (around 10,000)

Covariates for Opioid Prescription Disparities study methods

One particular important covariate was severity of pain, with a rationale that the odds of prescribing opioids would be determined by pain severity. Pain severity was categorized into none (pain score = 0), mild/moderate (pain score = 1-6), severe (pain score = 7-10) and unknown (pain score = 99 or missing)

Graph: Urban counties vs. rural countries

Opioid deaths in urban counties higher than rural counties for blacks and whites, not hispanics though

The strongest risk factor for starting heroin use -indicates that widespread opioid exposure and increasing rates of opioid addiction have...

Past misuse of prescription opioids -played a major role in the growth of heroin use

path from payer to patients 2

Payers (insurance companies, medicare, medicaid) with responsibility for both quality and costs → prepaid group practice (PGP) with all services under 1 roof, independent practice association (IPA), or preferred provider organization (PPO) → health care services

Challenge to VBC

Payments are tied to easily measurable, clinically meaningful, short-term outcomes rather than longer-term outcomes, such as survival, that may be more meaningful to the patient affected by the VBC.

People most at risk of heroin addiction

People addicted to prescription opioids, those addicted to cocaine, those without insurance or enrolled in Medicaid, non-hispanic whites, males, those addicted to marijuana and alcohol, those living in a large metropolitan area, 18-25 year olds

the primary sites of administration for such provider-administered drugs as biologics, injectables, IVIG, and other products. -_____are the largest share of spend.

Physician offices and hospital outpatient clinics -Oncology drugs and related products; These medications are typically covered under a patient's medical benefit

2013 federal "EpiPen law"

President Barack Obama disclosed his daughter's peanut allergy when he signed off on the 2013 federal "EpiPen law," which gives financial incentives to states that require the medication in schools. +Co-author of the federal legislation, Rep. Steny Hoyer, D-Md., cited his 11 year-old granddaughter's peanut allergy when the EpiPen law passed the House. +FARE and Mylan supported that effort as well.

Pharmaceutical fentanyl

Primarily prescribed to manage severe pain, such as with cancer and end-of-life palliative care. ~From infographic: Prescribed in the form of transdermal patches, tablets, lozenges, or nasal sprays; can also be illegally made and mixed into other drugs

Maximum Allowable Cost (MAC)

Refers to a payer or PBM-generated list of products that includes the upper limit or maximum amount that a plan will pay for generic drugs and brand name drugs that have generic versions available ("multi-source brands") -no two MAC lists are alike and each PBM has free reign to pick and choose products for their MAC lists -There is no standardization in the industry as to the criteria for the inclusion of drugs on MAC lists or for the methodology as to how the PBM will determine the maximum price or how it's changed or updated -These are typically not e-list and can cover a few NDCs, drug classes or the entire Red Book -A pharmacy may lose money if acquisition cost > MAC price

Joint Commission on Accreditation of Health Care Organizations (JCAHO)

The growing burdens of pain management were originally recognized in the 1990s when the Joint Commission on Accreditation of Health Care Organizations (JCAHO) identified a need to make pain "visible" and promoted new national standards wherein healthcare workers would have the proper tools to improve the quality of pain control for patients

Graph: Total incidence of anaphylaxis cases.

The incidence appears to increase, reaching a peak in 2013 (3.2 per 1,000 person-years) and followed by a decrease in 2014-2016 (2.80 per 1,000 person-years 2016)

Brown bagging

The patient picks up a prescription at a pharmacy and then takes the drug to the provider's office for administration. I'm guessing that many people transport the medications in paper lunch bags, hence the name.

# of pharmacies in the US, breakdown retail vs independent pharmacies

There are approximately 67,000 pharmacies in the United States, of which 43,000 are part of retail chains and 24,000 are independent pharmacies

Wholesalers responsibilities

They purchase products from manufacturers, provide warehousing services, and ship drugs to retailers

Opioid Prescription Disparities study Summary

We examined racial-ethnic disparities in opioid prescription at ED visits for pain-related complaints often associated with drug-seeking behavior and contrasted them with conditions objectively associated with pain.

Opioid Prescription Disparities study hypothesis

We hypothesized a priori that racial-ethnic disparities will be present among opioid prescriptions for conditions associated with non- medical use, but not for objective pain-related conditions

Racial bias study prediction

We predicted that these beliefs would be associated with racial bias in pain perception

States with the highest death rates from synthetic opioids

West Virginia, Ohio, and New Hampshire

Opioid addiction treatment

When used appropriately, treatments involving the opioid agonist medications methadone or buprenorphine are clinically similar in their effectiveness and are considered the highest standard of care for treating opioid use disorders (OUDs)

Hospital outpatient clinics and hospital-based practices typically receive products from

a hospital pharmacy, which purchases drugs from a full-line pharmaceutical wholesaler

Synthetic opioid overdose death rates increased across

all demographics, county urbanization levels, and numerous states

Heroin

an illegal, highly addictive opioid drug.

Figure 16 percentage of firms with prescription drug coverage who have reduced or no cost sharing for maintenance drugs for chronic conditions 2019

around 30% for all firms over 1,000 workers

two most persistent physiological myths that wormed their way into scientific consensus, and they remain rooted in modern-day medical education and practice

black people were impervious to pain and had weak lungs that could be strengthened through hard work

3 treatments for anaphylaxis

epinephrine, medicines, oxygen

As heroin use has increased, so have ____ - ___ people died in 2017 alone. Between 2010 and 2017, the rate of heroin-related overdose deaths increased by almost ___

heroin-related overdose deaths -15,482 people -400%.

More than half of outpatient commercial medical benefit drug spending occurred in

hospital outpatient locations

Most of the increases in fentanyl deaths over the last three years do not involve prescription fentanyl but are related to

illicitly-made fentanyl that is being mixed with or sold as heroin—with or without the users' knowledge and increasing as counterfeit pills

Heroin-related overdose deaths ___ from 2010 to 2017

increased 5-fold

Heroin is typically __ but is also smoked and snorted. When people inject heroin, they are at risk of

injected -serious, long-term viral infections such as HIV, Hepatitis C, and Hepatitis B, as well as bacterial infections of the skin, bloodstream, and heart.

Thomas Jefferson, in "Notes on the State of Virginia"

listed what he proposed were "the real distinctions which nature has made," including a lack of lung capacity

Also in 2017, the largest increase in synthetic opioid overdose death rates was in ___

males aged 25-44

Oxygen

may be needed if your blood oxygen level is lower than it should be. You may be oxygen through a mask placed over your nose and mouth or through small tubes placed in your nostrils

The use of heroin has been increasing in recent years among

men and women, most age groups, and all income levels.

In 2013, ___ who used heroin also used at least one other drug

more than 9 in 10 people

Figure 17 among large firms offering health benefits, percentage of firms offering various wellness and health promotion activities and incentives, by firm size 2019:

most all large firms offer specific wellness programs and health risk assessment, less offer incentive for meeting biometric outcomes

Synthetic Opioids tend to be highly potent, which means

only a small amount of the drug is required to produce a given effect

People often use heroin along with ___. This practice is especially dangerous because it

other drugs or alcohol -increases the risk of overdose.

During 2017, ___ died from drug overdoses involving heroin in the US, a rate of almost ___

over 15,000 people -5 deaths for every 100,000 Americans

Two types of fentanyl

pharmaceutical fentanyl and non-pharmaceutical fentanyl

Third-party payers were dissatisfied with the buy-and-bill approach for specialty pharmaceuticals covered under a patient's medical benefit. Consequently, they permitted or encouraged a role for...

pharmacies in managing and distributing provider-administered specialty pharmaceuticals.

Community-based physician practices typically

purchase drugs from a specialty distributor.

In the buy-and-bill process for provider-administered outpatient drugs, a healthcare provider

purchases, stores, and then administers the product to a patient.

From 2016-2017, heroin overdose death rates

remained stable

Recent investigations in Ohio and Florida provide strong evidence of an association between

reported fentanyl encounters and fentanyl-involved overdose deaths due to illicitly-made fentanyl.

Manufacturers of multiple-source drug products (generics) compete to

sell drugs to pharmacies.

Since 2013, law enforcement encounters (drug submitted for analysis) testing positive for fentanyl reported by laboratories participating in NFLISi has ___

sharply increased in a growing number of states.

A 2016 survey of 222 white medical students and residents published in The Proceedings of the National Academy of Sciences -When asked to imagine how much pain white or black patients experienced in hypothetical situations,

showed that half of them endorsed at least one myth about physiological differences between black people and white people, including that black people's nerve endings are less sensitive than white people's -...the medical students and residents insisted that black people felt less pain. This made the providers less likely to recommend appropriate treatment.

A heroin overdose can cause

slow and shallow breathing, coma, and death

Taking too many prescription opioids can

stop a person's breathing--leading to death

Medicines

such as antihistamines, steroids, and bronchodilators decrease inflammation, open airways, and make breathing easier

Studies suggest that regional variation in use of prescription opioids cannot be explained by

the underlying health status of the population

In some instances, the reimbursement approaches that commercial payers use permit hospitals to get paid

two to three times as much as physician offices—and to inflate drug costs by thousands of dollars per claim

Rather than conceptualizing race as a risk factor that predicts disease or disability because of a fixed susceptibility conceived on shaky grounds centuries ago, we would do better to

understand race as a proxy for bias, disadvantage and ill treatment

Graph: Etiology of anaphylaxis in 2016

venom/sting 38%, ang. edem a 29%, food 23%, other 9%, drug 2.20%

Some of the greatest increases (in heroin use) occurred in demographic groups with historically low rates of heroin use:

women, the privately insured, and people with higher incomes.

Graph --> Drug overdose deaths, 1980 to 2017

~"New numbers Thursday from the CDC show that drug overdoses killed more than 70,000 Americans in 2017, a record. Overdose deaths are higher than deaths from HIV, car crashes, or gun violence at their peaks ~The data also show that the increased deaths correspond strongly with the use of synthetic opioids known as fentanyls On the graph → 28,466 deaths involved fentanyl or a similar drug out of the 70,237 people who died from drug overdoses in the US in 2017 ~Since 2013, the number of overdose deaths associated with fentanyls and similar drugs has grown to more than 28,000 from 3,000. Deaths involving fentanyl increased more than 45% in 2017 alone"

Figure 5: Among Firms Offering Health Benefits, How Broad the Firm Considers their Largest Plan's Provider Network, by firm size, 2019

~All large firms: 74% very broad, 21% somewhat broad, 4% somewhat narrow ~All small firms: 54% very broad, 38% somewhat broad, 7% somewhat narrow ~All firms: 55% very broad, 37% somewhat broad, 7% somewhat narrow

Walmart as a Retailer

~Came into the pharmacy space very late; had $4 generics and only covered certain classes (hypertensives, anti-cholesterol, diabetes medications) ~Co-pay is usually $5, so wanted people to come into the market ~Criticisms of the PBMs or health plans that don't know whether there is a drug interaction because won't see that drug prescription is filled at Walmart; no way to put this into the record

Infographic "dying in middle age"

~Death rates are rising for middle-aged white Americans, while declining in other wealthy countries and among other races and ethnicities. The rise appears to be driven by suicide, drugs and alcohol abuse ~Hispanic americans drastically declining, also drastically declining for wealthy countries

Drug overdose deaths by race from article "The Opioid Crisis is Getting Worse, Particularly for Black Americans"

~Epidemic of drug overdoses are often perceived as a largely white rural problem but made striking inroads among black Americans last year, particularly in urban counties where fentanyl has become widespread ~Drug death rate is rising most steeply among blacks, rose by 41% in 2016 outpacing any other racial or ethnic group ~White and american indian still have highest amounts of drug overdose deaths, followed by blacks, hispanics, then asians

Figure 2) Changing population incidence of an anaphylaxis trigger. The dashed red lines indicate the 3 most common specific food triggers, which are included in the total incidence estimate for food (solid red line)

~In 2015 sudden spike in emergency visits for medication, with decreases in unknown and food categories ~The 3 most common specific food triggers have more emergency visits than insects and multiple

Figure 2: Distribution of Health Plan Enrollment for Covered Workers, by Plan Type, 1988-2019

~In 2019, less than 1% conventional, 19% HMO (health maintenance organization), 44% PPO (preferred provider organization), 7% POS (point of service), 30% HDHP/SO (high deductible health plan) ~Most used is a preferred provider organization (PPO) plan in 2019 ~Growing trend towards HDHP/SO plans ~HMO and PPO plans remained relatively steady in use overtime, while POS and conventional methods declined, HDHP/SO significantly grew

Figure 1) National population incidence of emergency department visits for anaphylaxis by age from 2008 to 2016; children and adolescents are shown in blue hues while adults are shown in orange hues

~Less than 5 years old and 15-17 years old are the highest (more than 400 million visits in 2016) ~Then 5-9, 18-20, and 10-14 year olds (around 300 million visits in 2016) ~Age increases with declining emergency visits after that point ~Though all have continued to increase from 2008 to 2016 (range from 50 to 200 million)

Net margins table for each sector in pharmaceutical industry

~Most margin made by brand manufacturers (gross: 76.3%) ~Behind that is the generic manufacturers (gross: 49.8%), then pharmacy (brand only gross: 3.5%; generic only gross: 42.7%) ~PBMs are a low-margin business (brand only gross: 2%; generic only gross: 8%) ~For all drugs gross: manufacturer (71.7%), insurer (22.2%), pharmacy (20.1%), PBM (6.3%), and wholesaler (3.7%)

Lost Lives graph: Drug overdose data available since 1999 from the Centers for Disease Control and Prevention

~Since around 2000 to 2015, all drug overdoses have risen from around 500,000 people to 2,000,000 people ~Since around 2000 to 2015, opioid overdoses have risen from around 300,000 people to 1,400,000 people ~HIV deaths peaked in 1995 at 1,600,000 people and then declined after that point to close to 100,000 people in 2015 ~Opioid deaths have come close to the peak of HIV but just under

Table: Top US Pharmacies Ranked by Prescription Drugs Market Share in 2017

~Walmart < UnitedHealth Group < Express Scripts < Walgreens < CVSHealth (23.8%) → CVS generating almost 24% of the total Rx drugs pharmacy revenues in the US

Figure: Buprenorphine visits by race/ethnicity and payment type, 2004 to 2015

~Whites have started to use more (increasing from 180,000 in 2008 to 2011 to 350,000 in period 2012 to 2015), whereas no use for blacks and people of other races ~Most increase in use of private and self-pay methods, slight increase in medicare/medicaid and less so but still increase in "other" payment

Graph: Opioid overdose deaths by race/ethnicity 1999 to 2017 in the US

~white non hispanic most, followed by black non-hispanic then hispanic ~Also see here sudden increase in black deaths