[PPT] - AMSUS 2018 ANNUAL MEETING Admiral Brett P. Giroir, M.D. Assistant PowerPoint Presentation

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Remarks to the

AMSUS 2018 ANNUAL MEETING

November 27, 2018

O F F I C E O F T H E A S S I S T A N T S E C R E T A R Y F O R H E A L T H

Admiral Brett P. Giroir, M.D.

Assistant Secretary for Health Senior Advisor for Opioid Policy

@HHS_ASH

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

30 40 50 60 70 80 90

1900 1903 1906 1909 1912 1915 1918 1921 1924 1927 1930 1933 1936 1939 1942 1945 1948 1951 1954 1957 1960 1963 1966 1969 1972 1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005 2008 2011 2014

U.S. LIFE EXPECTANCY: 1900 - 2015

https://www.cdc.gov/nchs/data-visualization/mortality-trends/index.htm

PUBLIC HEALTH SUCCESSES

Influenza and Pneumonia
Enteric Diseases
Stroke and CV Disease
Tuberculosis
Cancer
Accidents

Life Expectancy (years)

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

U.S. HEALTH CHALLENGES IN THE 21st CENTURY

Highest global spending

n health: $3.3 trillion

(17.9% of GNP) Health care spending is predicted to reach $5.7 trillion by 2026

MASS GENERAL’S INPATIENT ADJUSTED COSTS PER LIVE DISCHARGE

Meyer GS et al. N Engl J Med 2012;366:2147-2149

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

U.S. HEALTH CHALLENGES IN THE 21st CENTURY

Life Expectancy
Among the 36 OECD* nations, the U.S. ranks 28th in life expectancy; 33rd in infant mortality;

32nd in suicide rate

In 2015 and 2016 life expectancy decreased in the United States
Sexually Transmitted Diseases
Highest number ever reported in U.S. in 2016;
>2 million; 50% in adolescents and young adults
Influenza and Infectious Diseases
Enhanced risks from pandemic influenza, emerging infectious diseases, anti-microbial

resistance

Rogue States and Organizations
Intentional chemical, biological, radiological, and nuclear attack

*Organization for Economic Development and Cooperation

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

U.S. DRUG OVERDOSE DEATHS

THE MOST CRITICAL PUBLIC HEALTH CHALLENGE OF OUR TIME

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

OVERDOSE MORTALITY BY CLASS OF DRUG

ADAPTED FROM CDC STATISTICS, NOVEMBER 2018

HEROIN NAT & SEMI – SYNTHETIC METHADONE SYNTHETIC OPIOIDS COCAINE PSYCHO- STIMULANTS

APRIL 2017 * 16,345 15,405 3,419 24,234 12,565 8,787 APRIL 2018 * 15,357 14,264 3,279 30,545 14,830 11,398 Change

6.0%
7.4%
4.1%

+26.0% +18.0% +29.7%

* Number of deaths for the 12 months ending in April of the indicated year.

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

CRITICAL ROLE OF LAW ENFORCEMENT

CURBING ILLICIT IMPORTATION

State troopers seized 118

pounds of fentanyl

That amount of fentanyl

would contain enough lethal doses to potentially kill more than 26 million people

Largest fentanyl seizure in

state history and one of the largest in the United States

May 25, 2018 Nebraska State Patrol, courtesy

Inside a truck in Nebraska, troopers found enough fentanyl to kill millions of people

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

Recruits' Ineligibility Tests the Military

More Than Two-Thirds of American Youth Wouldn't Qualify for Service, Pentagon Says

“…the Defense Department estimates 71% of the roughly 34 million 17- to 24-year-olds in the U.S. would fail to qualify to enlist in the military if they tried....”

June 27, 2014

Physical Fitness, Drug Abuse, Education

U.S. HEALTH CHALLENGES IN THE 21ST CENTURY

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H Ward ZJ et al. N Engl J Med 2017;377:2145-2153

PREDICTED OBESITY OF TODAY’S TWO YEAR OLDS

N Engl J Med Volume 377(22):2145-2153, November 30, 2017

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

INEQUALITIES IN LIFE EXPECTANCY AMONG U.S. COUNTIES

1980 – 2014 (DWYER-LINDGREN, 2017)

Inequalities in life expectancy

among counties are large and increasing over time

Difference in life expectancy

between the lowest ranking county and the highest ranking county is 20.1 years (66.8 – 86.9 years)

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

GLOBAL HEALTH CHALLENGES IN THE 21st CENTURY

Malaria: 216M cases and 445,000 deaths annually
Tuberculosis: 25% of world population infected 1.7M deaths annually
HIV/AIDS: 36.9M people infected 1.8M new cases in 2017
Neglected Tropical Diseases: >140 diverse communicable diseases

affecting the poorest 1B people on the planet (examples include Dengue, Hookworm, Schistosomiasis)

Ebola Cases, DRC 16,000+ Children Die Every Day of Preventable Diseases

Cancer, Cardiovascular Disease, Diabetes, Chronic Lung Disease

caused 37% of deaths even in low income countries

INFECTIOUS DISEASE NON COMMUNICABLE DISEASE

RISKS OF PANDEMICS: Influenza, SARS, MERS, Ebola, others

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

HHS PRIORITIES

THE OPIOID CRISIS

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DRUG PRICING HEALTH INSURANCE REFORM VALUE-BASED CARE

HHS is committed to ending the crisis of opioid addiction and

verdose in America

HHS is working to improve the availability and affordability

f health insurance

HHS is determined to lower the costs of prescription drugs for all Americans without discouraging innovation HHS is working to transform

ur system to one that pays

for value

Secretary Alex M. Azar II

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

OPPORTUNITIES TO EFFECT CHANGE

Assistant Secretary for Health Senior Advisor for Opioid Policy USPHS Commissioned Corps World Health Organization

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

OASH OPPORTUNITY

Develop and coordinate the implementation of policies, investments, and frameworks to

transform the current “sick-care system” into a “health-promoting system”

OPIOID POLICY OPPORTUNITY

Whole of society, evidence-based, public health approach emphasizing prevention, naloxone

access, treatment of addiction as a disease, and holistic needs for successful recovery

USPHS OPPORTUNITY

Modernize the Commissioned Corps and employ it as an “agent of change” for those with the

highest acute and/or chronic public health needs

WHO OPPORTUNITY

Build resilient national public health primary care systems to enhance global health security

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

OASH: DEVELOPING THE ROADMAP FOR A HEALTHIER NATION

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

BULLY PULPIT OF THE SURGEON GENERAL

VADM Jerome Adams

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

SELECT OASH PRIORITY INITIATIVES

Infectious Diseases
Reducing new cases of HIV by 50% within 5 years
Increasing HPV coverage rate to 80% within 5 years
Incentivizing adult vaccination through reimbursement reform
Developing a national plan to combat STDs
Meeting the Physical Activity Guidelines for Americans
Developing a national plan for youth sports participation

and physical activity targeting underserved communities and girls

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

SELECT OASH PRIORITY INITIATIVES

Digital Determinants of Health
Developing the ethical, legal, and scientific frameworks to fully

leverage social media for public health applications

Chronic Kidney Disease
HHS wide comprehensive plan to improve the outcomes and cost of

chronic renal failure

Implementing the revised “Common Rule”

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

SELECT OASH PRIORITY INITIATIVES

Health Disparities
Developing Office of Minority Health programs that serve as a catalyst

and new framework for change

Implementing public health “turn around teams” focused on zip codes

suffering worst health inequities

Improving sudden cardiac death and availability of CPR
Developing exemplar initiatives

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

SICKLE CELL DISEASE

NEW FEDERAL WORKING GROUP

Together with OASH and multi- sector partners, developing a national action plan for sickle cell disease OMH’s #SickleCellStories

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

TOOLS AND APPROACHES

Reimbursement and Workforce

Grants and Contracts

Guidelines Global Agreements

Regulations

Policies

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

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https://www.hhs.gov/opioids/

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

HHS OPIOIDS STRATEGY UPDATE

23 “The five-point HHS strategy to end the opioid crisis, unveiled under President Trump in 2017, uses the best science and evidence to directly address this public health emergency. Now, HHS is expanding the scope and improving the effectiveness of the strategy.” Secretary Alex Azar

RELEASED SEPTEMBER 17, 2018

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

WHAT DOES EVIDENCE-BASED TREATMENT LOOK LIKE?

FDA-approved medication (MAT)
Naltrexone: once a month injectable medication, blocks effects of opioids;
Methadone: long acting, once-daily, opioid from specially licensed programs;
Buprenorphine/naloxone: long acting, once daily/once monthly, opioid from prescriber offices
Psychosocial Therapies
Education, coping skills, relapse prevention, PDMP monitoring and toxicology screening
Recovery Services - Rebuilding One’s Life
Social supports to welcome into a healthy community: family, friends, peers, faith-based supports
Assistance with needs that can impact treatment - recovery housing, transportation and child care
Employment/Vocational training/education
Naloxone

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

ACHIEVING RESULTS IN COMBATTING THE OPIOID EPIDEMIC

SINCE JANUARY 2017

The total morphine milligram equivalents dispensed monthly by retail and mail-order pharmacies declined by 27.8%. Number of unique patients receiving buprenorphine monthly from retail pharmacies increased by 21%. The number of naltrexone prescriptions per month from retail pharmacies has increased more than 47%. Naloxone prescriptions dispensed monthly by retail and mail-order pharmacies have increased by 367%.

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

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PAIN RELIEVER USE DISORDER IS DECREASING

NSDUH, 2017 Data; published Sept. 2018

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

NATIONAL SURVEY ON DRUG USE AND HEALTH, 2017

FIRST TIME HEROIN USERS DROPPED BY >50% (2016-2017)

27 Past Year Heroin Initiates among People Aged 12 or Older (in Thousands): 2002-2017

NSDUH, 2017 Data; published Sept. 2018

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

ED VISITS FOR SUSPECTED DRUG OVERDOSE (% CHANGE) Q3 2017 – Q4 2017

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* 21 States Reporting * 25 States Reporting

Source: CDC Enhanced State Opioid Overdose Surveillance Program (ESOOS)

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

12 MONTH OVERDOSE MORTALITY: CDC NOVEMBER 2018

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50000 55000 60000 65000 70000 75000

12 MONTH MORTALITY

12 MONTHS ENDING IN MONTH 12-months ending in April 2018

HHS OPIODS TEAM GOAL:

Reduce US drug overdose mortality by at least 15% (>10,000 lives annually) by January 2021

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

NALOXONE: AN ESSENTIAL PART OF THE OPIOIDS SOLUTION

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

LACK OF NALOXONE CO-PRESCRIBING TO PATIENTS AT RISK

PDX, Inc
April – June 2018 (verbal report to HHS)
8600 pharmacies nationwide
For patients on MME > 50, rate of naloxone co-prescribing was 0.3%
For those prescribed naloxone, 40% never picked up prescription
MEDICARE, 2017
MME > 50: rate of naloxone co-filling was 1.3%
MME = 90 – 120: rate of naloxone co-filling was 1.6%
MME > 120: rate of naloxone co-filling was 5.2%

 Primary drivers of co-prescribing are states with mandatory co-prescription laws

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

NALOXONE PREFILLED SYRINGE OUT OF POCKET COSTS 2017

Payers Average OOP % Total Prefilled Syringe Rx % of Rx < $10 OOP % of Rx < $20 OOP

WORKERS COMP - EMPLOYER $0.00 1.30% 100.00% 100.00% MODA HEALTH $0.52 1.80% 100.00% 100.00%

FEDERAL EMPLOYEES/ FEHBP

$3.57 6.70% 100.00% 100.00% HUMANA $4.42 1.30% 100.00% 100.00% COMMONWEALTH OF VIRGINIA (VA) $4.45 1.10% 85.70% 100.00% UNIONS-NATIONAL $4.63 2.80% 94.10% 94.10% BCBS CAREFIRST $4.93 2.00% 91.70% 100.00% BCBS ANTHEM/WELLPOINT/WELLCHOICE $5.01 7.50% 100.00% 100.00% PROVIDENCE HEALTH SYSTEMS $6.53 1.10% 100.00% 100.00%

TRICARE

$6.59 9.40% 98.30% 100.00% BCBS FLORIDA (FL) $7.55 3.10% 84.20% 89.50% CIGNA $7.82 2.80% 76.50% 100.00% BCBS/THE REGENCE GROUP $8.06 1.10% 85.70% 100.00% BLUE CROSS PREMERA $9.02 2.30% 78.60% 100.00% UNITED HEALTHCARE $9.46 8.00% 79.60% 93.90% SELECT HEALTH $11.21 2.10% 84.60% 100.00% BCBS SOUTH CAROLINA (SC) $12.14 1.30% 75.00% 75.00% KAISER FOUNDATION HEALTH PLANS $12.91 4.20% 50.00% 96.20% BCBS HEALTHCARE SERVICE CORP $13.12 2.60% 50.00% 87.50%

OPTIMA HEALTH (VA) $17.12 1.50% 44.40% 55.60%

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

NARCAN OUT OF POCKET COSTS FOR LARGEST PAYERS 2017

Payers Average OOP % of Total Narcan Rx % Rx < $10 OOP % Rx < $20 OOP

WORKERS COMP - EMPLOYER $0.93 1.30% 99.90% 100.00% PRESBYTERIAN HEALTH PLAN (NM) $8.52 1.80% 95.10% 95.30%

TRICARE

$10.48 7.60% 97.40% 97.80% OPTIMA HEALTH (VA) $18.37 2.10% 65.10% 67.20% UNIONS-NATIONAL $20.79 2.90% 38.60% 52.20% CIGNA $21.76 4.30% 54.00% 57.70% BCBS FLORIDA (FL) $22.11 1.40% 68.10% 69.00% UNITED HEALTHCARE $23.74 5.60% 58.40% 59.60% COMMONWEALTH OF VIRGINIA (VA) $24.32 1.60% 41.10% 45.80% BCBS ANTHEM/WELLPOINT/WELLCHOICE $24.73 6.20% 40.40% 54.30% BCBS HEALTHCARE SERVICE CORP $26.04 2.80% 47.60% 60.60% BCBS NORTH CAROLINA (NC) $27.65 2.60% 60.20% 66.10% AETNA INC $28.12 4.30% 40.90% 44.90%

FEDERAL EMPLOYEES/ FEHBP

$28.24 7.20% 46.50% 46.90% BCBS TENNESSEE (TN) $28.75 1.20% 62.70% 63.70% BCBS MICHIGAN (MI) $29.66 1.00% 43.50% 51.80% BCBS HIGHMARK $30.65 1.00% 29.80% 40.50% BCBS CAREFIRST $34.92 1.70% 22.00% 36.90% HUMANA $35.89 0.80% 42.00% 54.60%

BLUE CROSS MASSACHUSETTS $48.02 0.90% 9.80% 23.20%

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

MEDICARE OUT OF POCKET COSTS

The CY 2018 Part D plan-level formulary inclusion and prior authorization (PA) rates are:
Naloxone PF syringes: on 99.3% of plan formularies, PA on 0.3%
Narcan: on 94.7% of plan formularies; no plans require PA
Evzio: on 5.9% of plan formularies; PA on 44.7%
The average cost-sharing (excludes low income subsidy enrollment)
Naloxone PF syringes: $13.86 per syringe (copay plans) or $4.57 (coinsurance plans)
Narcan: $51 per 2 nasal sprays (copay plans) or $39.20 (coinsurance plans)
Evzio: $90 per 2 injectors (copay plans) or $1,707.65 (coinsurance plans)

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

U.S. PUBLIC HEALTH SERVICE COMMISSIONED CORPS

“the Commissioned Corps… a mobile, duty-bound group of health officers willing to go anywhere, at any time, to meet the nation’s most urgent public health needs.”

Craig Collins The PHS Commissioned Corps Two Centuries and Counting

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

NOTABLE DEPLOYMENTS USPHS COMMISSIONED CORPS

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

PUBLIC HEALTH SERVICE COMMISSIONED CORPS

MODERNIZATION SELF ASSESSMENT

Strong HHS and inter-departmental support for Commissioned Officers

expertise and leadership

Between 2013 and 2018, officers deployed over 6,000 times, contributing

more than 116,000 deployment-days to more than 110 missions

~50% of officers participated in intra-agency response missions since 2016
Projected increase demand for officers: deployments and agency missions
Persistent provider shortages for underserved and vulnerable populations of

up to 25% could be best filled by officers A bold strategic vision to enhance the capabilities, responsiveness, mission set, and focus of our service

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

VISION FOR A 21st CENTURY COMMISSIONED CORPS

A highly-trained, always-ready, fully-deployable national asset to preserve public health

and national security during national or global public health emergencies

A fundamental instrument of national response for non-emergent, yet critical, public

health challenges within the United States and territories

A provider of direct health care, public health leadership, and scientific expertise when

specifically needed to fulfill U.S. Government requirements

An innovation engine for public health technologies, communications, systems, and

systems of systems

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MISSION DRIVES THE REQUIREMENTS; REQUIREMENTS DRIVE THE FORCE STRUCTURE

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

PUBLIC HEALTH INNOVATION CONTEXT AND CONTINUUM

TRANSFORMATIONAL APPLICATIONS TEST AND EVALUATION DISSEMINATION AND ADOPTION BASIC RESEARCH

NIH NSF NGOs Biotech

DARPA: High risk early and intermediate development (tech and capabilities push) BARDA: Intermediate and advanced development within authorized areas Accelerating Clinical Innovation: Clinical needs and opportunities pull; systems demonstrations USPHS Commissioned Corps:

Deployments and PHEs
Public health turnaround

teams and missions

Clinical care in under-

served and rural environments Military Medicine HHS Operational Divisions:

CMS, HRSA, CDC,

SAMHSA, others Federal Partners (VA, DoD) Integrated Health Systems NGOs, WHO, and international partners

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

Orthogonal technologies and paradigms for the current most costly medical issues

(for example, hemodialysis, falls, sepsis, pain)

Technologies and approaches that allow for more advanced care outside of hospital

settings including in rural environments (strong synergy with military medicine)

Socio-behavioral approaches and distributive technologies to transform the current

“sick care system” into a “health promoting system”

Big data, social networks, and digital platforms for public health, including epidemiology,

prediction, prevention, and treatment

PRIORITIES FOR PUBLIC HEALTH INNOVATION

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

PRIORITIES FOR PUBLIC HEALTH INNOVATION

Models to minimize U.S. regional health disparities
End U.S. infectious disease epidemics within our technical control:

HIV, HCV, HPV, influenza

Integration of genetic cures and immunotherapies as cornerstones of the

health care system

Developing a new paradigm for understanding and treating neurodegeneration
Global health security: an endogenous global capacity, early warning,

detection, diagnosis, rapid mitigation, and assured effective response

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

WHERE WILL WE STAND ON BEHALF OF PUBLIC HEALTH? The he New New Y York

rk T

Times es

“The flying machine which will really fly might be evolved by the combined and continuous efforts of mathematicians and mechanicians in from one million to ten million years”

October 9, 1903

“We started assembly today”

Orville Wright’s Diary

October 9, 1903

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O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R H E A L T H

WWW.HHS.GOV/ASH WWW.USPHS.GOV @HHS_ASH BRETT P. GIROIR, M.D.

ADM, U.S. Public Health Service Assistant Secretary for Health, Senior Advisor for Opioid Policy

Brett.Giroir@hhs.gov