The challenge of controlling costs of health care is sharply illustrated by Tennessee's overuse of prescription drugs.
Data for 2008 show Tennessee slightly behind West Virginia and Kentucky in numbers of retail prescriptions and dollars spent per capita. For Tennessee, each resident received 18.7 prescriptions, which cost $1,648. The national average was 12.7, costing $1,237. Californians ranked 50th with an average of 9.2 prescriptions per capita, which cost $865 for the year. Tennessee's numbers increased compared to the previous year.
Are Tennesseans that much sicker than Californians that we need twice as many prescriptions yearly? We may have more weight-related illnesses, and we are more prone to use tobacco than residents of some states. Are Tennessee physicians recognizing disorders that require drugs more frequently than their colleagues in other states?
While I practiced medicine it was not uncommon to encounter patients who regularly took 20 or more medications. These usually had been prescribed by two or more physicians who were often unaware of what the other had prescribed. Every medication carries a risk of allergy and adverse reaction. There is little information about drug-drug interactions, which can be severe. Risks of injury rise sharply as we take more medications simultaneously.
A physician friend in another city recently described to me two patients whom he had been asked to evaluate in a hospital setting. One was on 63 medications, the other 49.
Even more worrisome is Tennessee's continuing position at or near the top of the states for numbers of narcotic prescriptions. For example, for the narcotic Oxycodone, we rank third in usage, exceeding the national average by 68 percent. Usage within the state has increased by 1,250 percent from 1997 to 2006 when the data were gathered.
By contrast, Alabama ranks 32nd and Georgia ranks 40th in use of Oxycodone. Do Tennesseans experience more pain than residents of other states?
Powerful, long-acting narcotics are needed appropriately by patients with complex illnesses and injuries. But the data on our state's consumption of narcotics strongly suggest overprescription and overuse. Licit as well as illicit narcotics carry a substantial risk of addiction.
I believe the problem stems from the early years of TennCare when there were few restrictions upon prescriptions written for participants in that health insurance program. This led to lax habits generally among many care providers. A steady demand, even expectation, for narcotics and other medications steadily developed.
Four options are available:
1. Accept the status quo and move on. The problem is too complex to fix.
2. Promote educational programs and voluntary restraint among physicians and patients to eliminate unnecessary prescriptions and to limit narcotics to carefully defined clinical situations that can be closely monitored.
3. Regulate the total number of prescriptions permitted a patient. TennCare, for example, provides medications for management of all chronic illnesses such as diabetes, heart disease and seizure disorders. Beyond these medications, a person with TennCare is limited to a maximum of five additional generic prescriptions. For regulation to be effective, a central registry of all prescription medications would be necessary. This could be difficult to establish since patients may receive prescription medications from local pharmacies and mail-order programs.
4. Ration medications by requiring single-source prescriptions, an electronic record of all prescription transactions and automatic review when the number of prescriptions per person exceeds a certain limit, say 12 simultaneous medications. Require periodic review of all continuing narcotics prescriptions.
I favor intensive pursuit of the education option for a fixed period of time. If this did not establish a sustained reduction in overuse of prescription medications, I see no alternative to option 4.
What would you do?
Contact Clif Cleaveland at firstname.lastname@example.org.