West Virginians filled an average of 17.2 prescriptions each in 2006, according to the Kaiser Family Foundation, and in a state where an aged and chronically ill population require more prescriptions than Carter's has Little Liver Pills, officials simply don't know what to do.

Forbes magazine recently featured the Kaiser numbers, giving the state yet another first-place ranking in a category it may be reluctant to claim, and the information spurred more thoughts and questions than actions and answers.

"There's a lot of facets to this topic," said Lara Ramsburg, Gov. Joe Manchin's spokeswoman. "In some areas, we need to continue to make prescription drugs more available, in other areas we don't; we simply are an older population -- that is always going to skew us.

"There are good things that are happening in the state in terms of health care, but just as anybody who's struggling with their health knows, it's something you have to be vigilant and patient with, and some of these things we can affect, and others we can't."

By the Numbers

Some officials question the means by which Forbes and the Kaiser Foundation calculated its numbers, but they say the discussion is a worthy one.

"While that Forbes number is extremely useful at launching a public dialogue about this important aspect of health care, we don't know enough about their methodology to know exactly what it means," said Shannon Landrum, Medicaid spokeswoman. "State Medicaid officials want to make sure we're comparing apples to apples."

Landrum offered as an example the fact that some states' Medicaid agencies allow three-month fills on some maintenance medication, but West Virginia's Medicaid program does not.

"We don't want to fill a three-month prescription when a member's eligibility expires in three weeks," she said. "But does a three-month fill count as one prescription filled or three? If the methodology didn't adjust for that, it could very much be that we have false lows reported."

At the West Virginia Medical Association, Executive Director Evan Jenkins, who also is a Democratic senator from Cabell County, said the numbers beg closer inspection.

"We should be turning now to get information that may better explain this high prescription rate," Jenkins said. "We need to not simply assume that we have an unhealthy population, and therefore that simply correlates to high prescription use. We must dig deeper, and the information is out there; we should be turning to sources for that to help us explain this number.

"It's interesting that this issue is front and center at the same time there are efforts to curtail the access to prescription information often called data mining."

Richard Stevens, executive director of the West Virginia Pharmacists Association, said the U.S. average for per-capita prescriptions per year was 11, according to more 2006 Kaiser numbers, and the biggest comparison stretch was for adults 65 and older -- West Virginians filled an average of 38 prescriptions per capita, while the U.S. average was 28.

"Unfortunately for our state and its citizens, (the high number of prescriptions) has pretty much been the case for a number of years," Stevens said. "We need to worry about it for a couple of reasons."

Why We Medicate

Even though the charge at the Pharmaceutical Cost Management Council is to provide access to life-sustaining drugs, Shana Phares, the designated chairwoman and acting pharmaceutical advocate, said the state is overly medicated.

"It's so easy to go to your doctor now and say 'I saw this, I need this,' and so easy for a doctor to give you a script and send you out the door," Phares said. "I think everybody owns a piece of this: the doctors, the consumers, the pharmaceutical companies -- everybody has a part in creating this culture of medicine and sickness rather than a culture of health."

Stevens said in short that the state's poor bill of health results in a greater number of prescriptions, but the Federal Drug Administration might have driven up drug demand by relaxing advertising guidelines about 10 years ago.

"I think several studies have concluded advertising has influenced prescriptions," he said. "For some people, it's increased their knowledge and informed them of the need for medications, but I think it's weighted more toward marketing than information."

The Mountain People's Co-op in Morgantown sells natural remedies, such as herbal supplements and teas. Erik Keane, employee and member of the Co-op's board of directors, said he's personally had success with fewer drugs.

Keane said something as simple as eating honey that comes from local bees that pick up weeds and pollen could build up a person's immunity, providing relief from a prescription to the latest allergy medicine du jour.

"I definitely think we can do more for ourselves, and herbs and natural remedies are way more safe and effective over the long term because there's a lot of side effects associated with prescriptions," Keane said. "I'm not a doctor, but that is the folk wisdom."

Stevens said scripts can easily pile up when patients visit a number of doctors.

"As individual patients, we should talk with our physicians and our pharmacists to make sure all the medications we're taking first of all are needed," he said. "At the Veterans' Administration, they're reviewing each individual veteran's medication and found they were taking drugs that weren't needed, and they've reduced the numbers."

But Landrum with Medicaid said pharmaceuticals are appropriate medical treatment, and Medicaid would rather pay for blood pressure and cholesterol medication than strokes and heart attacks.

Landrum said nursing homes are Medicaid's largest expense, and when her agency looked at per-capita prescriptions, the average among children in the program was less than one prescription per month. In the Kaiser numbers, individuals ages 18 and younger in West Virginia took an average of six prescriptions per capita per year compared to the U.S. average of four.

"A state with a high rate of diabetes, a high rate of heart disease and a high rate of hypertension like West Virginia, we would expect to have high drug spends," she said. "That, to me, shows that people are getting the drug therapy and medical care they need to manage their diseases."

Prescriptions for Prevention

The New England Journal of Medicine recently published that few preventive care programs have the financial benefit payout that the traditional wisdom of an ounce of prevention promotes. Felice Joseph, the state's Public Employees' Insurance Agency Pharmacy Benefits Administrator, said the agency always is trying to manage prescription numbers, and some of its biggest initiatives are on prevention.

"We're constantly worried about (prescriptions). It is such a growing aspect of health care, but we're trying to do new management programs to be sure they're used most appropriately," Joseph said. "In our top 10, we don't have anything for pain or controlled medications -- these are heart stents, blood clots and cholesterol."

Joseph said PEIA offers an intense weight management program, along with a diabetes program and a brand new worksite wellness initiative, which takes participants' blood glucose, body mass index, blood pressure and total cholesterol numbers. It provides rebates of $50 or $25 for good scores and information for others about how to improve their numbers next year.

"They're preventing in such a long range, you don't see the immediate return, but they improve lifestyle and quality of life," she said. "We've been fairly happy with our trends through the last plan year, which ended in June 2008."

Roman Prezioso, D-Marion, the state Senate's Health and Human Resources Committee chairman, said West Virginians' lifestyles put a tremendous burden on the health care system, and everyone involved is aware of the concerns.

"We know we're overmedicated, we know our lifestyles lead to a high amount of obesity, and we're trying to motivate people to have respect for themselves," Prezioso said.

"We have tried on several different venues, like our PEIA insurance, with discounts for not smoking, maintenance for high blood pressure or high cholesterol. ... We've created the medical home and our children's health insurance program.

"It's all free, and we don't get 100 percent, so I don't know what to do. We just chip away, and that's what we have to continue to do: hold steady and keep our goals in mind to continue to do what we need to do to turn this thing around, but it's not going to be overnight."