CHARGES FOR DRUG-RELATED INPATIENT HOSPITALIZATIONS AND EMERGENCY DEPARTMENT VISITS IN KENTUCKY,

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1 CHARGES FOR DRUG-RELATED INPATIENT HOSPITALIZATIONS AND EMERGENCY DEPARTMENT VISITS IN KENTUCKY, Prepared for the Kentucky Injury Prevention & Research Center by: Huong Luu, MD, MPH W. Jay Christian, PhD, MPH Department of Epidemiology, College of Public Health University of Kentucky 30 Sept 2015 This publication was supported by Cooperative Agreement Number, 5 U17 CE , funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services.

2 SUMMARY Drug overdose, misuse, and abuse cause a variety of adverse health effects and place heavy financial burden on society. This report examines recent trends in the charges associated with drug-related hospitalizations and emergency department (ED) visits in Kentucky from Kentucky hospitals charged approximately $936 million for residents drug-related hospitalizations in 2013, an increase of 49 compared to There was an increase of more than 67 in the total charges for drug-related visits by Kentucky residents to EDs in Kentucky during the same period. For the five-year report period combined, drug-related hospitalization and ED charges for residents of Jefferson County alone totaled approximately $1 billion. Clinical lab and pharmacology charges were the highest; ancillary charges increased sharply from $8 million for drug-related hospitalizations and $4 million for drug-related visits to the ED in 2009, to $117 million and $42 million, respectively, in Charges for both drug-related hospitalizations and ED visits were most often related to opiates and antidepressants (including benzodiazepines). The annual total of opiate-related charges increased from $137 to $252 million for hospitalizations, and from $11 to $27 million for ED visits. Medicaid and Medicare shouldered the largest burden of drug-related hospitalization charges (~60-62 of total charges annually) and ED visits, although self-pay charges were higher than either Medicaid or Medicare alone, and by 2013 were almost as high as both combined for ED visits. Hospitalization and ED charges tended to be higher in counties with higher populations. On a per capita basis, however, both were generally highest in the eastern region and Jefferson County. In the eastern region, residents of several contiguous counties accrued hospitalization charges in excess of $1700 per capita, and ED charges greater then $250 per capita, for a total of almost $2000 in drug-related charges per resident (of any age) over the five-year report period, or about $400 annually. In summary, drug-related hospitalization and ED charges in Kentucky grew considerably between 2009 and Most of this increase is related to opiates. Primary payers for these charges are most often Medicare, Medicaid, or self-pay. On a per capita basis, hospitalization and ED charges are highest in eastern Kentucky and Jefferson County, but appear to be rising elsewhere, especially in central and northern Kentucky. 1 P a g e

3 CHARGES FOR DRUG-RELATED INPATIENT HOSPITALIZATIONS IN KENTUCKY Total charges for drug-related hospitalizations in Kentucky grew every year from 2009 to 2013, increasing 49 from approximately $628 million to $936 million. Figure 1 shows this increase by type of service. Pharmacology and clinical laboratory charges were responsible for the largest shares of hospitalization charges. Charges in each category grew every year when compared to the previous year. Ancillary charges, however, ballooned from only $8 million in 2009 to $117 million in 2013, an increase of Figure 1: Charges by Service for Drug-Related in Kentucky, Kentucky Resident Drug-Related Charges, ,000 Dollars (in millions) Ancillary charges Clinical lab charges Operating room charges Other charges Pharmacology charges Radiology charges Data source: Kentucky Inpatient Database, Office of Health Policy 2 P a g e

4 Figure 2: Total Charges by Drug Involved for Drug-Related in Kentucky, Kentucky Resident Drug-Related Charges by Type of Drug, Antidepressants Cocaine Opiates Data source: Kentucky Inpatient Database, Office of Health Policy Figure 2 shows charges for drug-related hospitalizations by type of drug. Among all drug-related hospitalizations, charges for those related to opiates continued to grow faster than other types. The total charges for opiate-related hospitalizations increased 84 over the period covered by this report, from about $137 million in 2009 to $252 million dollars in On average, the total charges for opiate-related hospitalizations therefore increased almost $29 million per year. Antidepressants, a category that includes benzodiazepines, also contributed substantially to total charges for drug-related hospitalizations. Charges ranged from $97-$132 million per year, with an increase of 33 from 2009 to Total charges for cocaine-related hospitalizations increased less dramatically, from around $66- $70 million during each of the first three years, up to $83 and $88 million in the latter years. 3 P a g e

5 Table 1: Total Charges (in Dollars) by Principal Diagnosis for Drug-Related Inpatient in Kentucky, Principal Total Drug-Related Hospitalization Charges, $ ( of the annual charge) Diagnosis Total Mental 125,358, ,712, ,149, ,095, ,558, ,874,161 disorders Poisoning by drugs, medicinal and biological substances circulatory system respiratory system Injury Infectious and parasitic diseases digestive system Neoplasms musculoskeletal system and connective tissue Others 84,482, ,381, ,833, ,970, ,570, ,267, ,716, ,733, ,576, ,262, ,721, ,098, ,736, ,399, ,958, ,357, ,118, ,450, ,982, ,242, ,128, ,006, ,124, ,735, ,637, ,855, ,557, ,087, ,068, ,973, ,367, ,267, ,173, ,744, ,112, ,101, ,690, ,388, ,728, ,929, ,832, ,623, ,392, ,845, ,771, ,505, ,802, ,763, ,010, ,194, ,758, ,848, ,665, ,457, Total* 628,041, ,997, ,474, ,481, ,382,900 3,941,378,100 *The charges for this list of principal diagnosis do not add up the total charges because V-codes as the principal diagnosis are not included. Table 1 displays total charges for drug-related hospitalizations by principal diagnosis, which is the primary reason the patient was admitted to the hospital. Charges were highest for mental health disorders; poisoning by drugs, medicinal, or biological substances; diseases of the circulatory system; diseases of the respiratory system; and and injury. Poisoning and mental health diagnoses together comprised roughly 35 of the total charges. 4 P a g e

6 Figure 3: Total Charges by Expected Payer for Drug-Related in Kentucky, Kentucky Resident Drug-Related Charges By Expected Payer, ,000 Dollars (in millions) Commercial Medicaid Medicare Other Self-pay or charity Data source: Kentucky Inpatient Database, Office of Health Policy Medicaid and Medicare were the primary payers billed for the greatest share of drug-related hospitalization charges. Combined, Medicaid and Medicare were billed for $385 million to $563 million each year, accounting for about 60 of total charges. Self-pay or charity also increased sharply, accounting for nearly 20 of the total charges billed to patients. 5 P a g e

7 Figure 4: Hospitalization charges by county in Kentucky, Figure 4 shows the distribution of hospitalization charges by county of residence for the entire period. Total charges were greatest in counties with large populations, especially Jefferson, Fayette, and Kenton, as shown in the top map. In Jefferson County alone, drug-related hospitalization charges reached nearly $1 billion over the five-year period. When considered on a per capita basis (using 2011 population estimates), however, drug-related hospitalization charges were highest in southeastern Kentucky, as displayed in the bottom map. Outside of this region, per capita charges were also high in Bourbon, Carroll, Jefferson, and Nicholas counties. Note: Counties may differ considerably in utilization of out-of-state hospital inpatient services by their residents. 6 P a g e

8 Figure 5: Change in hospitalization charges by county in Kentucky, 2009 vs The county-level changes in drug-related hospitalization charges over the period examined in this report are displayed in Figure 5. The greatest absolute increases from 2009 to 2013 were in Jefferson and Fayette counties, followed by several other counties in central and eastern Kentucky. McCracken County stands out in the western region. When considered as a percent of charges in 2009, the greatest increases appear mostly in counties of central and northern Kentucky. 7 P a g e

9 CHARGES FOR DRUG-RELATED VISITS TO ED IN KENTUCKY As with drug-related hospitalizations, total charges for drug-related visits to the ED grew every year from 2009 to 2013, increasing 67 from roughly $73 million to $122 million during that period. By 2013, ancillary, clinical lab, and pharmacology were the greatest contributors to charges for drugrelated ED visits. Notably, ancillary charges jumped from roughly $4 million in 2009 to $42 million in 2013, an increase of 950. Figure 6: Charges by Service for Drug-Related ED Visits in Kentucky, Kentucky Resident Drug-Related Department Visit Charges, Dollars (in millions) Ancillary charges Clinical lab charges Operating room charges Other charges Pharmacology charges Radiology charges Data source: Kentucky Outpatient Services Database, Office of Health Policy 8 P a g e

10 Figure 7: Total Charges (in millions of dollars) by Drug Involved for Drug-Related ED Visits in Kentucky, Kentucky Resident Drug-Related Charges by Type of Drug, Antidepressants Cocaine Opiates Data source: Kentucky Outpatient Services Database, Office of Health Policy Opiates were reported for an increasing share of drug-related ED visits. In 2009, antidepressants, cocaine, and opiates were noted in a roughly equal proportion of ED visits. By 2013, charges for visits associated with opiates had grown 246, while those for cocaine- and antidepressant-related visits grew only by about 20 and 50, respectively. 9 P a g e

11 Table 2: Total Charges (in dollars) by Principal Diagnosis for Drug-Related ED Visits in Kentucky, Principal Drug-Related Department Visit Charges, $ ( of the annual charge) Diagnosis Total Poisoning by drugs, medicinal and biological substances 17,869, ,965, ,467, ,426, ,118, ,847, Mental disorders 16,626, ,673, ,814, ,236, ,800, ,150, Injury 7,053, ,644, ,174, ,787, ,214, ,874, digestive system 2,101, ,349, ,620, ,354, ,957, ,383, circulatory system 1,938, ,856, ,490, ,006, ,670, ,961, respiratory system 1,389, ,921, ,387, ,740, ,740, ,178, musculoskeletal system and connective tissue 1,574, ,129, ,425, ,582, ,726, ,439, Infectious and parasitic diseases 271, , , , , ,202, Neoplasms Other 113, ,066, , ,146, , ,553, , ,230, , ,071, , ,068, Total* 73,042,603 86,699, ,600, ,255, ,325, ,924,513 *The charges for this list of principal diagnosis do not add up the total charges because V codes as the principal diagnosis are not included. Charges associated with poisonings and mental disorders overshadowed all others for drug-related visits to the ED, with the possible exception of injuries. By 2013, charges associated with drug-related ED 10 P a g e

12 visits for these diagnoses totaled about $25 million and $26 million, respectively. Together, these accounted for almost 45 of all charges. Figure 8: Total Charges by Expected Payer for Drug-Related ED Visits in Kentucky, Kentucky Resident Drug-Related Charges By Expected Payer, Dollars (in millions) Commercial Medicaid Medicare Other Self-pay or charity Data source: Kentucky Outpatient Services Database, Office of Health Policy In contrast to the total charges for drug-related hospitalizations, self-pay appears to be the largest expected source of payment for ED visits, accounting for nearly 38 of the total charges billed to patients in Self-pay and Medicare grew the most during the reporting period; self-pay increased over 75 from 2009 to 2013, and Medicare increased over 90. Medicaid grew by about 50, while charges to commercial insurance increased more modestly. 11 P a g e

13 Figure 9: ED Charges by County in Kentucky, As illustrated in the top map in Figure 9, drug-related ED charges in Kentucky are closely related to population. Those counties with higher populations e.g., Jefferson, Fayette, Kenton, Warren, Pike tended to have higher total charges. When examined on a per capita basis, however, as in the bottom map in Figure 8, eastern Kentucky clearly exceeds the rest of the state in charges for drug-related ED visits, with the notable exceptions of Jefferson and Fulton counties. 12 P a g e

14 Figure 10: Change in ED Charges by County in Kentucky, 2009 vs The top map in Figure 10 displays the change in drug-related ED charges by county during the report period. Jefferson County saw the largest increase over $12 million annually but Fayette, Kenton, Perry, and Pike also saw increases exceeding $2 million. Robertson County in north-central Kentucky experienced the largest percentage increase over 1630 as seen at the bottom. Otherwise, several counties in eastern Kentucky, south-central Kentucky, and far western Kentucky saw the largest percentage growth in ED charges. This contrasts with growth in hospitalization charges, which was generally higher in central and northern Kentucky. 13 P a g e

15 Data Source The only data sources for this report were the Kentucky Inpatient Hospitalization and Outpatient Service Discharge Files, Cabinet for Health and Family Services, Office of Health Policy. The data were coded according to the International Classification of Disease, 9 th revision, Clinical Modification (ICD-9-CM, Technical Notes This report presents the total charges for drug-related hospitalizations and ED visits made by Kentucky resident treated in Kentucky acute care hospitals or EDs. Therefore, they do not include other types of charges such as follow-up care. For this report, drug-related hospitalizations were defined as those with any of the ICD-9-CM codes listed below in any of the 25 fields available for recording diagnoses. o Definitions: A hospitalization or ED visit was considered a drug-related condition if drug overdose or/and drug-induced disease was indicated. A hospitalization or ED visit was considered drug overdose if any of the ICD-9-CM codes listed were in the range , or E850-E858, E950.0-E950.5, E962.0, or E980.0-E A hospitalization or ED visit was considered drug-induced disease if any of the ICD-9- CM codes were listed: , , , , 292, , , , , , , , , , , , , , , , , , , 332.1, , 336.8, 357.6, , 648.3, 655.5, 692.3, 693.0, , o Classifications: A visit to the ED or a hospitalization could involve more than one type of drug. Drug types involved in a condition were classified based on the following ICD-9-CM codes appearing in any diagnosis or E-code fields: Type of Drug Drug Overdose Drug-induced Disease Non-opioid Analgesics, E850.3-E850.8, Antipyretics, and Antirheumatics 4 Aminophenol derivatives E850.4, Opiates/opioids E850.0-E850.2, , * *, Pharmaceutical Opioids E850.1-E850.2, , Heroin E850.0, Methadone E850.1, P a g e

16 Type of Drug Drug Overdose Drug-induced Disease E854.3*, E855.2*, 968.5*, , , Cocaine narcotics E851-E853, E854.0-E854.2, E854.8, E855.0, E950.1-E950.3, E Antidepressants E980.3, 966, 967, 969, , , , , Psycho-stimulants E854.2, , Benzodiazepines E853.2, Anticoagulants Other specified and unspecified drugs *Not only drug in this category. E850.9, E855.1, E855.3-E855.9, E856-E858, E950.0, E950.4, E950.5, E962.0, E980.0, E980.4, E980.5, , 964.0, 964.1, , 965.9, , , 970.9, , , , , , , , , , , , Expected payers were categorized into five classes based on primary expected sources of payment: (1) Commercial, including Indemnity, PPO, HMO, Managed Care, mix, and unknown; (2) Self-pay or charity; (3) Medicare; (4) Medicaid including Passport Medicaid Managed Care, Kentucky Spirit Medicaid Managed Care, Coventry Cares of Kentucky Medicaid Managed Care, Well Care of Kentucky Medicaid Managed Care; and (5) Others. Types of charges were grouped into clinical lab, radiology, pharmacology, ancillary, operating room, other (room and board, oncology, labor, and other) charges. The principal diagnosis (the first diagnosis code) in the hospitalization data is the main reason for the patient s hospital stay and is based on the clinical findings during the patient s stay. The firstlisted diagnosis for an ED visit is assumed to represent the main reason for the visit to the ED. Eighteen categories were established based on ICD-9-CM principal diagnosis codes as below, but these were collapsed to ten for this report: Principal Diagnosis Codes 1 Mental disorders Poisoning by drugs, medicinal and biological substances circulatory system respiratory system Injury Infectious and parasitic diseases digestive system Neoplasms musculoskeletal system and connective tissue Other Symptoms, signs, and ill-defined conditions Complications of pregnancy, childbirth, and the puerperium Certain conditions originating in the perinatal period nervous system and sense organs P a g e

17 genitourinary system Endocrine, nutritional and metabolic diseases, and immunity disorders skin and subcutaneous tissue blood and blood-forming organs Congenital anomalies Toxic effects of substances chiefly non-medicinal as to source effect of external causes; complications Maps: The choropleth maps in this report were created with ArcGIS 10.3 (ESRI; Redlands, CA), using Natural Breaks (Jenks method) for classifying data. 16 P a g e

18 APPENDIX Table 1: Total Charges (in Dollars) for Drug-Related Inpatient by Drug Involved in Kentucky, Year Type of Drug Drug Overdose Drug Induced Disease Drug-Related 2009 All drug 87,816, ,225, ,041,620 Non-opioid Analgesics 12,137,240 4 Aminophenol 8,188,275 Opiates/opioids 24,908, ,974, ,883,337 Heroin 1,063,292 Pharmaceutical Opioids 23,915,392 Methadone 4,148,375 Cocaine 1,986,890 65,451,664 67,438,554 narcotics 2,781,151 Antidepressants 45,505,147 51,319,860 96,825,007 Psycho-stimulants 1,831,233 10,237,552 12,068,785 Benzodiazepines 24,720,891 Anticoagulants 2,431,450 Other specified and unspecified drugs 41,137, ,883, ,020, All drug 92,975, ,022, ,997,980 Non-opioid Analgesics 14,140,056 4 Aminophenol 9,926,244 Opiates/opioids 25,975, ,893, ,869,108 Heroin 664,975 Pharmaceutical Opioids 25,372,026 Methadone 4,968,649 Cocaine 2,348,897 63,968,799 66,317,696 narcotics 3,389,187 Antidepressants 44,564,943 54,217,413 98,782,356 Psycho-stimulants 1,510,824 9,164,873 10,675,697 Benzodiazepines 25,056,551 Anticoagulants 2,038,035 Other specified and 48,613,144 unspecified drugs 245,729, ,342, All drug 121,126, ,348, ,474,300 Non-opioid Analgesics 15,064,925 15,064,925 4 Aminophenol 10,100,038 10,100,038 Opiates/opioids 38,149, ,524, ,674,565 Heroin 1,199,303 Pharmaceutical Opioids 36,981, P a g e

19 Year Type of Drug Drug Overdose Drug Induced Disease Drug-Related Methadone 5,198,325 Cocaine 5,431,115 64,150,835 69,581,950 narcotics 5,985,715 Antidepressants 59,992,558 64,945, ,937,895 Psycho-stimulants 3,656,165 13,653,200 17,309,365 Benzodiazepines 34,135,682 Anticoagulants 1,727,619 Other specified and 61,469,394 unspecified drugs 275,614, ,083, All drug 130,885, ,595, ,481,300 Non-opioid Analgesics 14,744,271 4 Aminophenol 10,012,236 Opiates/opioids 41,382, ,210, ,592,970 Heroin 4,190,442 Pharmaceutical Opioids 37,741,396 Methadone 4,714,383 Cocaine 7,506,884 75,027,422 82,534,306 narcotics 7,023,288 Antidepressants 63,136,982 68,413, ,550,934 Psycho-stimulants 3,721,653 15,708,212 19,429,865 Benzodiazepines 33,289,768 Anticoagulants 1,746,125 Other specified and 72,023,067 unspecified drugs 308,078, ,101, All drug 129,427, ,955, ,382,900 Non-opioid Analgesics 14,079,996 4 Aminophenol 8,273,260 Opiates/opioids 44,077, ,431, ,508,933 Heroin 6,826,222 Pharmaceutical Opioids 37,501,505 Methadone 4,818,478 Cocaine 5,906,132 81,768,178 87,674,310 narcotics 7,048,818 Antidepressants 59,271,922 69,707, ,979,837 Psycho-stimulants 3,503,828 22,059,074 25,562,902 Benzodiazepines 29,774,928 Anticoagulants 1,455,473 Other specified and 71,747,285 unspecified drugs 334,433, ,180, P a g e

20 Table 2: Total Kentucky Resident Charges (in Dollars) for Drug-Related Inpatient by Principal Diagnosis, Year Type of Charge Drug Overdose Drug Induced Disease Total Drug-Related 2009 Total charges 87,816, ,225, ,041,620 Mental disorders 5,188, ,169, ,358,181 Poisoning by drugs, medicinal and biological substances 61,486,880 22,996,010 84,482,890 circulatory system 2,990,372 69,390,820 72,381,192 respiratory system 5,376,892 45,457,100 50,833,992 Injury 1,062,130 44,908,110 45,970,240 Infectious and parasitic diseases 28,954 28,541,820 28,570,774 digestive system 1,439,574 34,828,390 36,267,964 Neoplasms 1,174,021 19,542,600 20,716,621 musculoskeletal system and connective tissue 1,245,905 20,487,710 21,733,615 Other 7,640, ,936, ,576,871 Symptoms, signs, and illdefined conditions 1,075,421 14,254,180 15,329,601 Complications of pregnancy, childbirth, and the puerperium 274,144 13,904,080 14,178,224 Certain conditions originating in the perinatal period 164,927 13,622,890 13,787,817 nervous system and sense organs 3,316,327 10,075,340 13,391,667 genitourinary system 1,087,053 11,954,590 13,041,643 Endocrine, nutritional and metabolic diseases, and immunity disorders 601,938 9,968,857 10,570,795 skin and subcutaneous tissue 179,187 10,198,340 10,377,527 blood and blood-forming organs 134,879 8,499,380 8,634,259 Congenital anomalies 38,590 5,513,078 5,551,668 Toxic effects of 369,098 1,022,703 1,391, P a g e

21 Year Type of Charge Drug Overdose Drug Induced Disease Total Drug-Related substances chiefly nonmedicinal as to source effect of external causes; complications 398,479 12,923,390 13,321, Total charges 92,975, ,022, ,997,980 Mental disorders 5,274, ,438, ,712,619 Poisoning by drugs, medicinal and biological substances 68,692,260 26,570,380 95,262,640 circulatory system 2,491,459 70,230,490 72,721,949 respiratory system 4,035,872 52,062,310 56,098,182 Injury 315,041 49,420,970 49,736,011 Infectious and parasitic diseases 44,217 35,355,040 35,399,257 digestive system 1,419,931 34,538,080 35,958,011 Neoplasms 437,317 23,920,310 24,357,627 musculoskeletal system and connective tissue 720,326 20,398,670 21,118,996 Other 9,377, ,073, ,450,564 Symptoms, signs, and illdefined conditions 1,541,361 15,774,280 17,315,641 Complications of pregnancy, childbirth, and the puerperium 368,955 16,214,460 16,583,415 Certain conditions originating in the perinatal period 14,262,980 14,262,980 nervous system and sense organs 3,123,751 10,733,750 13,857,501 genitourinary system 1,168,781 13,356,160 14,524,941 Endocrine, nutritional and metabolic diseases, and immunity disorders 732,698 12,811,230 13,543,928 skin and subcutaneous tissue 194,447 13,212,660 13,407,107 blood and blood-forming 772,101 9,334,062 10,106, P a g e

22 Year Type of Charge Drug Overdose Drug Induced Disease Total Drug-Related organs Congenital anomalies 144,817 6,063,039 6,207,856 Toxic effects of substances chiefly nonmedicinal as to source 707,173 1,645,225 2,352,398 effect of external causes; complications 622,984 15,665,650 16,288, Total charges 121,126, ,348, ,474,300 Mental disorders 5,327, ,821, ,149,323 Poisoning by drugs, medicinal and biological 122,982,750 substances 87,658,990 35,323,760 circulatory system 3,458,519 84,783,750 88,242,269 respiratory system 6,158,912 51,969,970 58,128,882 Injury 2,667,084 44,339,800 47,006,884 Infectious and parasitic diseases 21,936 43,102,760 43,124,696 digestive system 1,779,045 38,956,140 40,735,185 Neoplasms 2,327,454 27,309,700 29,637,154 musculoskeletal system and connective tissue 514,931 18,340,630 18,855,561 Other 11,125, ,432, ,557,658 Symptoms, signs, and illdefined conditions 1,104,734 19,861,150 20,965,884 Complications of pregnancy, childbirth, and the puerperium 296,831 19,964,160 20,260,991 Certain conditions originating in the perinatal period 19,049,290 19,049,290 nervous system and sense organs 4,261,722 14,945,450 19,207,172 genitourinary system 1,918,602 15,204,770 17,123,372 Endocrine, nutritional and metabolic diseases, and immunity disorders 768,252 13,467,560 14,235,812 skin and 211,123 14,777,910 14,989, P a g e

23 Year Type of Charge Drug Overdose Drug Induced Disease Total Drug-Related subcutaneous tissue blood and blood-forming organs 510,605 10,336,180 10,846,785 Congenital anomalies 3,935,480 3,935,480 Toxic effects of substances chiefly nonmedicinal as to source 674,069 1,159,118 1,833,187 effect of external causes; complications 1,379,182 17,731,470 19,110, Total charges 130,885, ,595, ,481,300 Mental disorders 6,214, ,880, ,095,340 Poisoning by drugs, medicinal and biological 96,993, ,087,180 substances 39,093,960 circulatory system 3,907,278 86,161,360 90,068,638 respiratory system 5,761,548 61,212,110 66,973,658 Injury 2,052,677 55,314,700 57,367,377 Infectious and parasitic diseases 43,694 56,224,010 56,267,704 digestive system 1,943,963 35,229,860 37,173,823 Neoplasms 588,776 26,155,270 26,744,046 musculoskeletal system and connective tissue 634,016 21,478,300 22,112,316 Other 11,958, ,142, ,101,433 Symptoms, signs, and illdefined conditions 1,269,926 17,843,600 19,113,526 Complications of pregnancy, childbirth, and the puerperium 357,518 26,393,800 26,751,318 Certain conditions originating in the perinatal period 19,060,120 19,060,120 nervous system and sense organs 5,245,998 15,593,760 20,839,758 genitourinary system 1,705,096 17,686,810 19,391,906 Endocrine, nutritional 372,885 14,269,600 14,642, P a g e

24 Year Type of Charge Drug Overdose Drug Induced Disease Total Drug-Related and metabolic diseases, and immunity disorders skin and subcutaneous tissue 80,619 17,502,660 17,583,279 blood and blood-forming organs 159,537 10,286,820 10,446,357 Congenital anomalies 10,702,000 10,702,000 Toxic effects of substances chiefly nonmedicinal as to source 888,730 1,137,956 2,026,686 effect of external causes; complications 1,878,548 23,665,450 25,543, Total charges 129,427, ,955, ,382,900 Mental disorders 8,141, ,417, ,558,698 Poisoning by drugs, medicinal and biological substances 92,853,300 38,837, ,690,510 circulatory system 6,086, ,301, ,388,168 respiratory system 1,433,140 60,295,460 61,728,600 Injury 2,432,943 56,496,600 58,929,543 Infectious and parasitic diseases 658,304 64,173,770 64,832,074 digestive system 1,828,264 44,795,670 46,623,934 Neoplasms 807,154 26,585,710 27,392,864 musculoskeletal system and connective tissue 23,845,220 23,845,220 Other 14,952, ,818, ,771,094 Symptoms, signs, and illdefined conditions 715,926 17,089,170 17,805,096 Complications of pregnancy, childbirth, and the puerperium 449,354 29,447,320 29,896,674 Certain conditions originating in the perinatal period 21,603,110 21,603,110 nervous system and sense organs 4,135,934 16,863,090 20,999, P a g e

25 Year Type of Charge Drug Overdose Drug Induced Disease Total Drug-Related genitourinary system 325,132 15,939,650 16,264,782 Endocrine, nutritional and metabolic diseases, and immunity disorders 293,356 15,358,670 15,652,026 skin and subcutaneous tissue 1,311,424 17,633,450 18,944,874 blood and blood-forming organs 6,411,342 9,712,425 16,123,767 Congenital anomalies 10,246,420 10,246,420 Toxic effects of substances chiefly nonmedicinal as to source 729,694 1,403,562 2,133,256 effect of external causes; complications 580,035 21,522,030 22,102, P a g e

26 Table 3: Kentucky Resident Charges (in Dollars) for Drug-Related Inpatient, Year Type of Charge Drug Overdose Drug Induced Disease Total Drug-Related 2009 Total charges 87,816, ,225, ,041,620 Operating room charges 1,690,273 30,463,550 32,153,823 Radiology charges 8,226,291 44,278,870 52,505,161 Clinical lab charges 16,516,040 68,181,680 84,697,720 Ancillary charges 1,418,945 6,654,592 8,073,537 Pharmacology charges 14,058,690 83,955,210 98,013,900 Other charges 45,905, ,688, ,594, Total charges 92,975, ,022, ,997,980 Operating room charges 1,785,803 34,024,680 35,810,483 Radiology charges 8,865,623 50,357,800 59,223,423 Clinical lab charges 17,787,250 75,799,090 93,586,340 Ancillary charges 7,717,528 36,702,490 44,420,018 Pharmacology charges 14,797,390 88,295, ,093,240 Other charges 42,021, ,843, ,864, Total charges 121,126, ,348, ,474,300 Operating room charges 2,416,752 37,738,480 40,155,232 Radiology charges 11,335,400 54,612,760 65,948,160 Clinical lab charges 22,971,950 84,120, ,092,520 Ancillary charges 19,968,240 84,873, ,841,780 Pharmacology charges 19,689,950 97,077, ,767,810 Other charges 44,743, ,925, ,668, Total charges 130,885, ,595, ,481,300 Operating room charges 2,662,069 44,836,810 47,498,879 Radiology charges 12,246,590 58,911,180 71,157,770 Clinical lab charges 23,941,000 92,818, ,759,150 Ancillary charges 22,426,720 91,420, ,847,020 Pharmacology charges 19,945, ,926, ,872,010 Other charges 49,664, ,682, ,346, Total charges 129,427, ,955, ,382,900 Operating room charges 3,060,503 52,281,660 55,342,163 Radiology charges 11,670,420 62,835,990 74,506,410 Clinical lab charges 22,755,110 96,145, ,900,790 Ancillary charges 21,454,440 95,780, ,234,580 Pharmacology charges 21,576, ,732, ,309,110 Other charges 48,911, ,178, ,089, P a g e

27 Table 4: Total Charges (in Dollars) for Drug Related by Expected Payer in Kentucky, Year Source of Payment Drug Overdose Drug Induced Disease Total Drug-Related 2009 Total 87,816, ,225, ,041,620 Commercial 15,832, ,288, ,121,458 Medicaid 20,823, ,307, ,130,627 Medicare 31,132, ,171, ,304,351 Other 1,272,022 8,929,332 10,201,354 Self-pay or charity 18,755,935 96,527, ,283, Total 92,975, ,022, ,997,980 Commercial 17,476, ,297, ,773,901 Medicaid 23,401, ,554, ,956,422 Medicare 30,082, ,164, ,246,654 Other 2,021,787 11,916,746 13,938,533 Self-pay or charity 19,992, ,090, ,082, Total 121,126, ,348, ,474,300 Commercial 21,358, ,131, ,489,652 Medicaid 33,361, ,254, ,616,243 Medicare 40,605, ,328, ,934,108 Other 1,781,603 8,815,586 10,597,189 Self-pay or charity 24,018, ,818, ,837, Total 130,885, ,595, ,481,300 Commercial 21,983, ,706, ,689,695 Medicaid 34,611, ,950, ,562,004 Medicare 42,263, ,701, ,964,387 Other 2,280,459 21,481,729 23,762,188 Self-pay or charity 29,747, ,755, ,503, Total 129,427, ,955, ,382,900 Commercial 19,188, ,545, ,733,395 Medicaid 29,769, ,633, ,403,151 Medicare 47,058, ,912, ,970,442 Other 4,929,608 33,775,110 38,704,718 Self-pay or charity 28,482, ,088, ,571, P a g e

28 Table 5: Total Charges (in Dollars) for Drug-Related by Drug Involved in Kentucky, Year Type of Drug Drug Overdose Drug Induced Disease Drug-related 2009 All drug 18,169,863 54,872,740 73,042,603 Non-opioid Analgesics 2,489,517 4 Aminophenol 1,464,570 Opiates/opioids 2,979,412 8,165,084 11,144,496 Heroin 292,302 Pharmaceutical Opioids 2,690,173 Methadone 317,831 Cocaine 287,470 9,622,003 9,909,473 narcotics 850 Antidepressants 7,964,682 4,436,861 12,401,543 Psycho-stimulants 399,256 1,254,288 1,653,544 Benzodiazepines 3,956, ,532 4,193,060 Anticoagulants 236,532 Other specified and unspecified drugs 10,399,999 34,267,745 44,667, All drug 20,037,167 66,662,770 86,699,937 Non-opioid Analgesics 2,668,580 4 Aminophenol 1,629,306 Opiates/opioids 3,579,455 10,292,228 13,871,683 Heroin 418,269 Pharmaceutical Opioids 3,182,530 Methadone 309,936 Cocaine 224,828 8,780,639 9,005,467 narcotics 204 Antidepressants 9,086,046 5,719,735 14,805,781 Psycho-stimulants 440,799 1,666,121 2,106,920 Benzodiazepines 4,626,811 Anticoagulants 257,466 Other specified and unspecified drugs 11,424,889 44,424,692 55,849, All drug 23,358,300 77,242, ,600,890 Non-opioid Analgesics 2,832,490 4 Aminophenol 1,651,308 Opiates/opioids 4,663,604 13,167,775 17,831,379 Heroin 637,281 Pharmaceutical Opioids 4,056,668 Methadone 314, P a g e

29 Year Type of Drug Drug Overdose Drug Induced Disease Drug-related Cocaine 422,056 8,904,343 9,326,399 narcotics Antidepressants 10,219,369 6,075,572 16,294,941 Psycho-stimulants 692,990 2,075,877 2,768,867 Benzodiazepines 4,863,952 Anticoagulants 235,110 Other specified and unspecified drugs 13,558,119 52,228,497 65,786, All drug 25,311,632 89,944, ,255,902 Non-opioid Analgesics 3,003,026 4 Aminophenol 1,677,439 Opiates/opioids 6,040,276 18,365,934 24,406,210 Heroin 2,208,353 Pharmaceutical Opioids 3,921,154 Methadone 325,680 Cocaine 438,687 10,216,433 10,655,120 narcotics 4,748 Antidepressants 10,311,196 7,255,252 17,566,448 Psycho-stimulants 639,280 2,816,439 3,455,719 Benzodiazepines 4,812,168 Anticoagulants 334,259 Other specified and unspecified drugs 14,386,011 58,764,921 73,150, All drug 25,226,951 97,098, ,325,181 Non-opioid Analgesics 2,703,570 4 Aminophenol 1,429,810 Opiates/opioids 6,161,240 20,919,640 27,080,880 Heroin 2,972,801 Pharmaceutical Opioids 3,249,779 Methadone 210,831 Cocaine 577,381 11,552,198 12,129,579 narcotics Antidepressants 9,590,831 8,149,937 17,740,768 Psycho-stimulants 658,303 3,793,945 4,452,248 Benzodiazepines 3,719,796 Anticoagulants 423,243 Other specified and unspecified drugs 14,257,673 62,285,661 76,543, P a g e

30 Table 6: Total Kentucky Resident Charges (in Dollars) for Drug-Related by Principal Diagnosis, Year Type of Charge Drug Overdose Drug Induced Disease Drug-Related 2009 Total charges 18,169,863 54,872,740 73,042,603 Mental disorders 1,204,036 15,422,310 16,626,346 Poisoning by drugs, medicinal and biological substances 14,760,930 3,108,545 17,869,475 circulatory system 214,478 1,723,753 1,938,231 respiratory system 142,426 1,247,328 1,389,754 Injury 233,043 6,820,636 7,053,679 Infectious and parasitic diseases 3, , ,950 digestive system 97,543 2,003,814 2,101,357 Neoplasms 113, ,016 musculoskeletal system and connective tissue 37,321 1,537,308 1,574,629 Other 1,329,423 21,737,359 23,066,782 Symptoms, signs, and illdefined conditions 938,415 14,377,730 15,316,145 Complications of pregnancy, childbirth, and the puerperium 47, , ,544 Certain conditions originating in the perinatal period 1,448 1,448 nervous system and sense organs 37,681 1,504,987 1,542,668 genitourinary system 84,568 1,773,234 1,857,802 Endocrine, nutritional and metabolic diseases, and immunity disorders 83, , ,608 skin and subcutaneous tissue 12,822 1,678,079 1,690,901 blood and blood-forming organs 16, , ,552 Congenital anomalies 1,056 26,614 27, P a g e

31 Year Type of Charge Drug Overdose Drug Induced Disease Drug-Related Toxic effects of substances chiefly nonmedicinal as to source 75, , ,112 effect of external causes; complications 33, , , Total charges 20,037,167 66,662,770 86,699,937 Mental disorders 1,246,634 17,426,570 18,673,204 Poisoning by drugs, medicinal and biological substances 16,140,830 3,824,251 19,965,081 circulatory system 174,513 1,681,493 1,856,006 respiratory system 195,506 1,725,919 1,921,425 Injury 324,776 8,319,531 8,644,307 Infectious and parasitic diseases , ,760 digestive system 82,922 2,266,358 2,349,280 Neoplasms 17, , ,322 musculoskeletal system and connective tissue 59,116 2,070,036 2,129,152 Other 1,614,094 27,532,002 29,146,096 Symptoms, signs, and illdefined conditions 1,103,854 18,481,240 19,585,094 Complications of pregnancy, childbirth, and the puerperium 99, ,825 1,001,772 Certain conditions originating in the perinatal period 6,418 6,418 nervous system and sense organs 68,513 1,795,511 1,864,024 genitourinary system 105,429 2,296,781 2,402,210 Endocrine, nutritional and metabolic diseases, and immunity disorders 85, ,267 1,056,640 skin and subcutaneous tissue 9,372 2,177,682 2,187, P a g e

32 Year Type of Charge Drug Overdose Drug Induced Disease Drug-Related blood and blood-forming organs 9, , ,042 Congenital anomalies 7,223 7,223 Toxic effects of substances chiefly nonmedicinal as to source 94, , ,244 effect of external causes; complications 37, , , Total charges 23,358,300 77,242, ,600,890 Mental disorders 1,152,434 20,661,820 21,814,254 Poisoning by drugs, medicinal and biological substances 18,915,930 4,552,014 23,467,944 circulatory system 204,412 2,286,272 2,490,684 respiratory system 317,530 2,069,486 2,387,016 Injury 262,035 8,912,662 9,174,697 Infectious and parasitic diseases , ,511 digestive system 50,234 2,569,978 2,620,212 Neoplasms ,778 84,752 musculoskeletal system and connective tissue 81,767 2,344,227 2,425,994 Other 2,085,098 31,467,963 33,553,061 Symptoms, signs, and illdefined conditions 1,323,548 21,052,500 22,376,048 Complications of pregnancy, childbirth, and the puerperium 66, , ,045 Certain conditions originating in the perinatal period 6,909 6,909 nervous system and sense organs 63,933 2,244,261 2,308,194 genitourinary system 107,019 2,749,856 2,856,875 Endocrine, nutritional 238,852 1,028,592 1,267, P a g e

33 Year Type of Charge Drug Overdose Drug Induced Disease Drug-Related and metabolic diseases, and immunity disorders skin and subcutaneous tissue 60,312 2,642,680 2,702,992 blood and blood-forming organs 18, , ,781 Congenital anomalies 11,975 11,975 Toxic effects of substances chiefly nonmedicinal as to source 120, , ,568 effect of external causes; complications 85, , , Total charges 25,311,632 89,944, ,255,902 Mental disorders 1,265,024 23,971,060 25,236,084 Poisoning by drugs, medicinal and biological substances 21,134,910 5,291,329 26,426,239 circulatory system 211,724 2,794,302 3,006,026 respiratory system 229,769 2,510,356 2,740,125 Injury 321,347 9,466,443 9,787,790 Infectious and parasitic diseases 546, ,371 digestive system 67,708 3,286,988 3,354,696 Neoplasms 11, , ,690 musculoskeletal system and connective tissue 39,451 2,543,391 2,582,842 Other 1,774,387 37,456,546 39,230,933 Symptoms, signs, and illdefined conditions 1,186,055 25,167,680 26,353,735 Complications of pregnancy, childbirth, and the puerperium 48,314 1,003,650 1,051,964 Certain conditions originating in the perinatal period 10,708 10,708 nervous system and sense 134,145 2,511,403 2,645, P a g e

34 Year Type of Charge Drug Overdose Drug Induced Disease Drug-Related organs genitourinary system 118,486 3,195,012 3,313,498 Endocrine, nutritional and metabolic diseases, and immunity disorders 108,984 1,148,480 1,257,464 skin and subcutaneous tissue 18,766 3,635,027 3,653,793 blood and blood-forming organs 12, , ,673 Congenital anomalies 17,216 17,216 Toxic effects of substances chiefly nonmedicinal as to source 67, , ,601 effect of external causes; complications 80, , , Total charges 25,226,951 97,098, ,325,181 Mental disorders 1,208,859 23,591,690 24,800,549 Poisoning by drugs, medicinal and biological substances 20,570,130 5,548,422 26,118,552 circulatory system 217,795 3,452,946 3,670,741 respiratory system 310,307 3,430,120 3,740,427 Injury 324,947 9,889,269 10,214,216 Infectious and parasitic diseases , ,363 digestive system 96,996 4,860,832 4,957,828 Neoplasms 8, , ,334 musculoskeletal system and connective tissue 85,197 2,641,287 2,726,484 Other 2,075,973 40,995,622 43,071,595 Symptoms, signs, and illdefined conditions 1,348,404 26,736,450 28,084,854 Complications of pregnancy, childbirth, and the puerperium 86,742 1,669,277 1,756,019 Certain conditions 2,019 10,141 12, P a g e

35 Year Type of Charge Drug Overdose Drug Induced Disease Drug-Related originating in the perinatal period nervous system and sense organs 162,066 2,698,852 2,860,918 genitourinary system 119,062 3,344,824 3,463,886 Endocrine, nutritional and metabolic diseases, and immunity disorders 150,817 1,726,982 1,877,799 skin and subcutaneous tissue 22,048 3,733,104 3,755,152 blood and blood-forming organs 16, , ,752 Congenital anomalies 32,288 32,288 Toxic effects of substances chiefly nonmedicinal as to source 117, , ,307 effect of external causes; complications 50, , , P a g e

36 Table 7: Kentucky Resident Drug-Related Charges (in Dollars), Year Type of Charge Drug Overdose Drug Induced Disease Drug-Related 2009 Total charges 18,169,863 54,872,740 73,042,603 Operating room charges 19, , ,991 Radiology charges 1,695,624 13,355,930 15,051,554 Clinical lab charges 5,965,127 14,562,680 20,527,807 Ancillary charges 1,190,339 2,942,101 4,132,440 Pharmacology charges 1,643,798 4,275,701 5,919,499 Other charges 7,655,484 19,298,830 26,954, Total charges 20,037,167 66,662,770 86,699,937 Operating room charges 31, , ,618 Radiology charges 1,987,650 16,084,700 18,072,350 Clinical lab charges 6,381,218 17,235,860 23,617,078 Ancillary charges 4,363,793 12,582,560 16,946,353 Pharmacology charges 1,810,867 4,948,746 6,759,613 Other charges 5,462,119 15,305,820 20,767, Total charges 23,358,300 77,242, ,600,890 Operating room charges 20, , ,231 Radiology charges 2,410,036 18,203,480 20,613,516 Clinical lab charges 7,214,277 19,246,020 26,460,297 Ancillary charges 8,473,008 25,348,990 33,821,998 Pharmacology charges 2,193,439 5,809,601 8,003,040 Other charges 3,047,357 8,211,457 11,258, Total charges 25,311,632 89,944, ,255,902 Operating room charges 41, , ,377 Radiology charges 2,571,463 20,347,080 22,918,543 Clinical lab charges 7,420,465 21,329,310 28,749,775 Ancillary charges 9,896,889 31,251,560 41,148,449 Pharmacology charges 2,304,587 7,019,822 9,324,409 Other charges 3,076,990 9,045,360 12,122, Total charges 25,226,951 97,098, ,325,181 Operating room charges 27,236 1,033,802 1,061,038 Radiology charges 2,784,816 22,698,190 25,483,006 Clinical lab charges 7,102,665 21,809,510 28,912,175 Ancillary charges 9,631,946 32,495,010 42,126,956 Pharmacology charges 2,437,729 8,464,565 10,902,294 Other charges 3,242,558 10,597,150 13,839, P a g e

37 Table 8: Total Charges (in Dollars) for Drug Related by Expected Payer in Kentucky, Year Source of Payment Drug Overdose Drug Induced Disease Drug-Related 2009 Total 18,169,863 54,872,740 73,042,603 Commercial 4,537,206 10,470,819 15,008,025 Medicaid 5,310,383 14,925,269 20,235,652 Medicare 2,997,569 8,032,582 11,030,151 Other 327, ,970 1,188,922 Self-pay or charity 4,996,754 20,583,103 25,579, Total 20,037,167 66,662,770 86,699,937 Commercial 4,800,513 11,971,506 16,772,019 Medicaid 5,723,148 16,205,887 21,929,035 Medicare 3,257,519 9,006,650 12,264,169 Other 409,941 1,108,350 1,518,291 Self-pay or charity 5,846,045 28,370,378 34,216, Total 23,358,300 77,242, ,600,890 Commercial 5,472,879 14,194,747 19,667,626 Medicaid 6,311,669 19,117,727 25,429,396 Medicare 4,421,774 10,968,728 15,390,502 Other 411,664 1,132,901 1,544,565 Self-pay or charity 6,740,315 31,828,493 38,568, Total 25,311,632 89,944, ,255,902 Commercial 5,610,337 14,547,281 20,157,618 Medicaid 7,095,068 22,707,006 29,802,074 Medicare 4,530,856 13,527,943 18,058,799 Other 394,648 2,489,374 2,884,022 Self-pay or charity 7,680,723 36,672,669 44,353, Total 25,226,951 97,098, ,325,181 Commercial 5,639,969 14,875,234 20,515,203 Medicaid 6,375,354 23,542,830 29,918,184 Medicare 4,979,660 15,664,463 20,644,123 Other 600,240 4,191,171 4,791,411 Self-pay or charity 7,631,728 38,824,531 46,456, P a g e

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