    [Senate Hearing 112-724]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 112-724

                            PRESCRIPTION DRUG ABUSE:
                         HOW ARE MEDICARE AND MEDICAID
                           ADAPTING TO THE CHALLENGE?

    =======================================================================

                                    HEARING

                                   before the

                          SUBCOMMITTEE ON HEALTH CARE

                                     of the

                              COMMITTEE ON FINANCE
                              UNITED STATES SENATE

                          ONE HUNDRED TWELFTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 MARCH 22, 2012

                                   __________

                Printed for the use of the Committee on Finance

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    -----------------------------------------------------------------------
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    20402-0001

                              COMMITTEE ON FINANCE

                         MAX BAUCUS, Montana, Chairman

    JOHN D. ROCKEFELLER IV, West         ORRIN G. HATCH, Utah
    Virginia                             CHUCK GRASSLEY, Iowa
    KENT CONRAD, North Dakota            OLYMPIA J. SNOWE, Maine
    JEFF BINGAMAN, New Mexico            JON KYL, Arizona
    JOHN F. KERRY, Massachusetts         MIKE CRAPO, Idaho
    RON WYDEN, Oregon                    PAT ROBERTS, Kansas
    CHARLES E. SCHUMER, New York         MICHAEL B. ENZI, Wyoming
    DEBBIE STABENOW, Michigan            JOHN CORNYN, Texas
    MARIA CANTWELL, Washington           TOM COBURN, Oklahoma
    BILL NELSON, Florida                 JOHN THUNE, South Dakota
    ROBERT MENENDEZ, New Jersey          RICHARD BURR, North Carolina
    THOMAS R. CARPER, Delaware
    BENJAMIN L. CARDIN, Maryland

                        Russell Sullivan, Staff Director

                   Chris Campbell, Republican Staff Director

                                     ______

                          Subcommittee on Health Care

                JOHN D. ROCKEFELLER IV, West Virginia, Chairman

    JEFF BINGAMAN, New Mexico            CHUCK GRASSLEY, Iowa
    JOHN F. KERRY, Massachusetts         JON KYL, Arizona
    RON WYDEN, Oregon                    PAT ROBERTS, Kansas
    DEBBIE STABENOW, Michigan            MICHAEL B. ENZI, Wyoming
    MARIA CANTWELL, Washington           JOHN CORNYN, Texas
    ROBERT MENENDEZ, New Jersey          TOM COBURN, Oklahoma
    THOMAS R. CARPER, Delaware           RICHARD BURR, North Carolina
    BENJAMIN L. CARDIN, Maryland

                                      (ii)

                                C O N T E N T S

                                   __________

                               OPENING STATEMENTS

                                                                       Page
    Rockefeller, Hon. John D., IV, a U.S. Senator from West Virginia,
      chairman, Subcommittee on Health Care, Committee on Finance....     1
    Grassley, Hon. Chuck, a U.S. Senator from Iowa...................     3
    Cornyn, Hon. John, a U.S. Senator from Texas.....................     5

                                   WITNESSES

    Coben, Jeffrey, M.D., director, Injury Control Research Center,
      West Virginia University, Morgantown, WV.......................     6
    Schwab, Timothy, M.D., F.A.C.P., chief medical officer, SCAN
      Health Plan, Long Beach, CA....................................     8
    Millwee, Billy, M.H.A., State Medicaid Director, Texas Health and
      Human Services Commission, Austin, TX..........................     9
    Cahana, Alex, M.D., chief of anesthesiology and pain medicine,
      University of Washington, Seattle, WA..........................    11

                   ALPHABETICAL LISTING AND APPENDIX MATERIAL

    Cahana, Alex, M.D.:
        Testimony....................................................    11
        Prepared statement...........................................    33
    Coben, Jeffrey, M.D.:
        Testimony....................................................     6
        Prepared statement...........................................    38
    Cornyn, Hon. John:
        Opening statement............................................     5
    Grassley, Hon. Chuck:
        Opening statement............................................     3
        Prepared statement...........................................    44
    Millwee, Billy, M.H.A.:
        Testimony....................................................     9
        Prepared statement...........................................    46
    Rockefeller, Hon. John D., IV:
        Opening statement............................................     1
        Prepared statement...........................................    52
    Schwab, Timothy, M.D., F.A.C.P.:
        Testimony....................................................     8
        Prepared statement...........................................    54

                                 Communications

    Ameritox, Inc....................................................    61
    WellPoint, Inc...................................................    64

                                     (iii)

                            PRESCRIPTION DRUG ABUSE:

                         HOW ARE MEDICARE AND MEDICAID

                           ADAPTING TO THE CHALLENGE?

                                  ----------

                            THURSDAY, MARCH 22, 2012

                                   U.S. Senate,
                           Subcommittee on Health Care,
                                          Committee on Finance,
                                                        Washington, DC.
        The hearing was convened, pursuant to notice, at 10:01
    a.m., in room SD-215, Dirksen Senate Office Building, Hon. John
    D. Rockefeller IV (chairman of the subcommittee) presiding.
        Present: Senators Schumer, Grassley, and Cornyn.
        Also present: Democratic Staff: Jocelyn Moore, Staff
    Director; and Sarah Dash, Health Legislative Assistant.
    Republican Staff: Rodney Whitlock, Health Policy Director.

           OPENING STATEMENT OF HON. JOHN D. ROCKEFELLER IV,
     A U.S. SENATOR FROM WEST VIRGINIA, CHAIRMAN, SUBCOMMITTEE ON
                      HEALTH, COMMITTEE ON FINANCE

        Senator Rockfeller. Good morning. Others will be coming.
    Senator Cornyn is here. The eminent senior Senator from Iowa is
    here.
        Senator Grassley. Thank you.
        Senator Rockfeller. He will have to depart for 10 minutes
    to go do his duty as ranking member of the Judiciary Committee
    but will be back, he said, to ask particularly difficult
    questions.
        We are going to be talking about an epidemic of drug abuse,
    which is actually--this is such a timely hearing, and I know
    there are lots of hearings of this sort. But it is such a
    terrible problem in my State, and I suspect in all of our
    States. It is tragic, it is sad, it is needless, it is
    fraudulent, it is horrible, and it is costing so much needless
    money that could be spent elsewhere.
        So it is just the epidemic of drug abuse. Simply put,
    prescription drug abuse is what happens when people use
    prescription drugs for non-medical purposes, slipping into it
    sometimes without even knowing it. Opioid painkillers,
    antipsychotics, or stimulants are the ones that are most
    commonly used, but there are many others.
        The Centers for Disease Control has termed prescription
    drug use as an ``epidemic.'' I do not think they have done
    that--well, I guess they did in 1918, with the Great Influenza
    Epidemic, but they do not do it on a regular basis. And it is--
    it is a horrible problem.
        Overdose from prescription painkillers is now one of the
    leading causes of accidental death in the United States. In my
    State, which is rural and not particularly wealthy, just
    between the years of 2001 to 2008 the number of deaths from
    this kind of death went up 4 times. Why 4 times? I do not know.
    That is what we are going to talk about.
        And for every death, the CDC tells us there are 10
    treatment admissions of abuse for what we are talking about, 32
    emergency room visits, 130 people who abuse or are addicted to
    these drugs, and 825 non-medical users. There is no single
    solution, obviously, for all of this, but we cannot take that
    as a reason not to get at it. Today we will hear some stories
    that might shock and sadden us, but we will also hear some
    practical solutions. We will be hearing those from you.
        Prescription drug abuse is not just about some sensational
    thing that happens to celebrities like Michael Jackson--if you
    considered him a celebrity; I am not sure I did--who died
    before their time from tragic overdoses.
        The fact is, prescription drug abuse touches people from
    all walks of life. It is about an ordinary person, like a
    polite, stoic, 79-year-old man from Clay County, WV.
        Senator Grassley. Clay County, IA.
        Senator Rockfeller. You have a Clay County?
        Senator Grassley. Yes.
        Senator Rockfeller. Well, maybe he was from there.
        Senator Grassley. Maybe he was.
        Senator Rockfeller. Well, it ends in a happy way, so
    probably it was Iowa rather than West Virginia. But he could
    not be here today because he has to stay home to take care of
    his wife. He was going to testify. She is partially paralyzed.
    His story, untypically, ends well, thanks to the primary care
    doctor that he visited.
        When she asked why the man was taking such a powerful
    opioid painkiller, he said very simply that he had a lot of
    back pain from lifting his wife day after day. So his doctor
    took him off the drugs, and it turns out this man has been
    addicted without even realizing it. Now that he is off the
    powerful painkiller, he is more clear-
    headed and without all the side effects, and he has been
    feeling well, better than he has for a long time. Untypical
    story. It is an untypical story.
        Now, of course, the prescription drugs can, and do, work
    wonders for millions of people. For people with conditions like
    chronic pain or severe mental illness, prescription drugs can
    be a godsend. But the availability of powerful prescription
    drugs has in some ways gotten ahead of our ability to prescribe
    them safely.
        Prescribers do not have the tools they need. They do not
    have, sometimes, the education in medical schools focused on
    this. Prescription drug monitoring programs--is that a mystery
    to doctors or is that something that all of them know? These
    things work across State lines. Patients need to be better
    educated. That is easy to say, but so hard to do because they
    react to their pains.
        Sadly, because prescription drug painkillers, stimulants,
    and antipsychotics are so powerful and so addictive, they are
    all too often the target of criminals. These criminals are
    worse than ordinary fraudsters. They not only steal taxpayer
    dollars through fraudulent schemes like pill mills or
    fraudulent prescriptions, they also feed on people's addictions
    and prey on the pain. Obviously this is not right.
        But prescription drug abuse is not limited to fraud. We do
    ourselves a disservice if we ignore the significant clinical
    implications of this problem. So today we will hear from our
    expert panel--and you are that--about the range of solutions
    that we can implement in Medicare and Medicaid, a subject which
    the two of us have a lot of interest in, and this committee
    obviously does.
        You will help us answer important questions such as, what
    tools and support systems do doctors, nurses, and other
    prescribers need to make sure people get the right care when it
    comes to controlled substances? How can Medicare and Medicaid
    help educate patients and coordinate care so that prescriptions
    are used correctly? Are we adequately identifying people at
    risk of addiction to controlled substances? Are there new
    models of treatment we should consider testing in Medicare and
    Medicaid, always trying to do the right thing and give people
    treatment and not waste money? Can existing fraud detection
    systems tell us the difference between deliberate fraud,
    addiction-driven behavior, and uncoordinated care that leads to
    beneficiaries obtaining the prescriptions from multiple
    sources?
        So there is a lot to learn today, and you all are
    incredibly wise and gifted, and we are very honored that you
    have taken the time to be with us.
        [The prepared statement of Chairman Rockefeller appears in
    the appendix.]
        Senator Rockfeller. At this point I will call upon my
    distinguished friend, Senator Charles Grassley from Iowa.

               OPENING STATEMENT OF HON. CHUCK GRASSLEY,
                        A U.S. SENATOR FROM IOWA

        Senator Grassley. Well, I thank you for holding this
    hearing. I appreciate your leadership on this issue.
        Let me give you two measures of why we ought to appreciate
    your leadership on this issue. Number one, the Office of
    National Drug Control Policy describes prescription drug abuse
    as ``the Nation's fastest-growing problem.'' The Centers for
    Disease Control and Prevention has classified prescription drug
    abuse as an ``epidemic.'' According to the most recent National
    Survey on Drug Use and Health, a survey conducted by HHS,
    roughly 2.5 million people aged 18 and older used prescription
    drugs non-medically for the first time in 2010. This averages
    out about 6,000 people per day abusing prescription drugs just
    for the first time.
        For Iowans, prescription drugs account for the fastest-
    growing form of substance abuse. Overdose deaths in Iowa from
    non-
    medical use of hydrocodone and oxycontin pills have increased
    1,233 percent since the year 2000. Over-prescription of these
    types of drugs strains the financial viability of Medicaid and
    Medicare systems and threatens the health and well-being of our
    people.
        As health care payers, Medicare and Medicaid have a
    significant role to play in guiding solutions to this growing
    problem. To highlight how much of an impact prescription drug
    abuse has on Medicaid, I want to tell you about an ongoing
    investigation of mine.
        In 2010, I sent a letter to all 50 State Medicaid
    directors, asking them for their top 10 prescribers of the top
    8 most over-prescribed drugs on the market. Many States
    provided the data I requested, and statistics are alarming.
        For example, in Maine, the top prescriber of Oxycodone
    wrote 1,867 prescriptions in 2009, nearly double the number of
    prescriptions of the second top prescriber. The same provider
    wrote 1,723 prescriptions of Roxicodone, nearly 3 times the
    number of the other two top prescribers.
        In January, I followed up on this information and wrote
    again to all 50 States, requesting updated data and asking the
    States what, if any, action they took with the top prescribers,
    and what systems they had in place to prevent excessive
    prescribing from taking place.
        I also asked what, if any, training or guidance CMS has
    offered the States in preventing prescription drug abuse from
    occurring. While the responses from the States are still being
    received, many States are still reporting a selection of top 10
    providers who are prescribing at rates double or triple that of
    peers.
        While some of these outliers are legitimate providers
    working in high-volume practices such as mental hospitals, many
    cannot be explained. For example, the top prescriber of
    antipsychotics in Nevada wrote nearly 6,800 prescriptions for
    drugs over the years 2010 and 2011, more than 10 times some of
    the other top prescribers identified. For context, no
    individual prescriber in Colorado wrote more than 2,000
    prescriptions for the same drug over the same period. This
    single doctor in Nevada accounted for $2.75 million in payments
    from the Medicaid system.
        As a result of my request, South Carolina has investigated
    34 of 83 providers who appeared on those lists for possible
    Medicaid abuses. South Carolina's investigation resulted in the
    repayment--repayment--of nearly $1.9 million that more than 30
    of the health care providers inappropriately billed to the
    State Medicaid agency.
        Texas has opened investigations into dozens of prescribers
    identified in the list, making several referrals for criminal
    prosecution to the State licensing board. California,
    Wisconsin, Tennessee, Nevada, New Hampshire, Minnesota, Kansas,
    Hawaii, and even my State of Iowa have taken similar actions
    against prescribing outliers in their Medicaid programs.
        The steps taken by these States highlight the aggressive
    role that each and every State should be taking in monitoring
    and investigating prescription drug practices in the Medicaid
    program. Further, States have overwhelmingly confirmed that CMS
    has been an absent partner in helping to lower prescription
    drug abuses in Medicaid.
        I look forward to hearing from our witnesses today about
    what steps physicians, hospitals, States, and the Federal
    Government could be taking to curb abuse of prescription drugs.
    Not only should we put an end to the lives lost for over-
    prescribing drug abuse in Medicare and Medicaid, we should be
    working collaboratively to find meaningful solutions. The cost
    of doing nothing is too high already.
        Thank you.
        Senator Rockefeller. Thank you, Senator Grassley. I read
    your study, and it is excellent.
        Senator Grassley. Well, thank you.
        Senator Rockefeller. It is excellent.
        Senator Grassley. Thank you.
        [The prepared statement of Senator Grassley appears in the
    appendix.]
        Senator Rockefeller. Senator Cornyn, you may have a
    statement, but more importantly you may have somebody you wish
    to introduce.

                OPENING STATEMENT OF HON. JOHN CORNYN,
                       A U.S. SENATOR FROM TEXAS

        Senator Cornyn. Thank you, Mr. Chairman. I do, and I will
    take no more than 3 minutes. But I want to thank you for
    convening this very important hearing on a very serious topic,
    and Senator Grassley for his leadership in investigations.
        But I want to introduce Billy Millwee, who is one of the
    witnesses here from my State of Texas. Mr. Millwee serves as a
    Deputy Executive Commissioner for Health and Human Services
    Operations at the Texas Health and Human Services Commission.
    Since January of 2010, he has been the Texas Medicaid Director.
        He received his bachelor of science degree in business
    administration from the University of Maryland, a master's of
    science in health care administration from Central Michigan
    University, and a master of arts and sociology from Texas State
    University.
        The Texas Medicaid program, I trust Mr. Millwee will
    explain, has made great strides in addressing over-utilization
    of drugs on the front end and on the back end. Both are
    critically important for stemming this growing trend of
    prescription drug abuse, which unfortunately is the Nation's
    fastest-growing drug problem. It is also a fiscal problem for
    the States and for the Federal Government because of the
    burgeoning costs associated with Medicaid.
        Using edits at the point of sale, pharmacists are able to
    catch potential problems, and HHSC is working to educate
    physicians about prescribing patterns that are outside the
    norm.
        I want to specifically thank Mr. Millwee for his efforts
    following Senator Grassley's request to identify the high-
    volume prescribers of certain often-abused drugs. Texas
    responded with immediate action which has led to Medicaid
    exclusions and investigations.
        As a former State Attorney General, I appreciate the close
    collaboration Mr. Millwee has had with Attorney General Greg
    Abbott and his office in these investigations and litigation.
    These are pro-active steps that will go a long way toward
    curbing this disturbing epidemic of prescription drug abuse.
        These are just a few of the proactive things that Texas is
    doing. I look forward to hearing more about them in detail from
    Mr. Millwee and hope he can help inform this committee--as will
    the other witnesses, no doubt--on things we can do to address
    this problem.
        Mr. Chairman, as you know, all of us have multiple
    committee assignments that may take us in and out. Thank you
    for your courtesy and for your leadership.
        Senator Rockefeller. No, thank you. Thank you very much,
    Senator.
        First, all of you have biographies, and it is just criminal
    to introduce a person with a few short sentences without
    talking about all that you have done, where you have been to
    school, and this, that, and the other thing. But for the sake
    of brevity, I have to do that.
        First is Dr. Jeffrey Coben, who, happily, is director of
    Injury Control Research Center at West Virginia University in
    Charleston. Well, it says here Charleston. I thought maybe you
    were at the hospital there. Well, I know where WVU is, but it
    has branches. So, I apologize.
        First, I would like to extend that welcome to you. You are
    a practicing emergency medicine physician and have conducted
    research on prescription drug overdoses. We would like very
    much to hear what you have to say.

      STATEMENT OF JEFFREY COBEN, M.D., DIRECTOR, INJURY CONTROL
       RESEARCH CENTER, WEST VIRGINIA UNIVERSITY, MORGANTOWN, WV

        Dr. Coben. Thank you, Mr. Chairman. Chairman Rockefeller,
    Ranking Member Grassley, and distinguished subcommittee
    members, thank you very much for inviting me to discuss this
    critically important issue.
        The alarming increase in prescription drug abuse is clearly
    a crisis that demands our attention, but the statistics and the
    numbers do not adequately describe the ravages of prescription
    drug abuse. As a practicing emergency physician, I have seen
    the pain and torment of families who have lost a family member
    from overdose; I have seen children removed from their homes;
    and I have seen shootings, stabbings, and suicide all as a
    direct consequence of prescription drug abuse.
        I can also attest to the benefits of prescription opioid
    analgesics, and I think anyone here who has suffered with a
    painful condition can probably provide their own commentary. In
    fact, in many cases, providing adequate pain relief can be the
    best, or only, thing that we as health care providers can do
    for our patients.
        Fifteen years ago in this country, physicians were being
    heavily criticized for not adequately addressing pain. Now,
    only a short time later, we are faced with a rising epidemic of
    prescription drug overdoses, fueled in part by a dramatic
    increase in the sale of these strong painkillers.
        Balancing the appropriate use of prescription drugs with
    efforts to prevent their abuse is a complex and difficult
    challenge, and addressing this problem will require a multi-
    factorial approach. For example, we need to address societal
    attitudes towards the recreational use of prescription drugs.
        The majority of teens in this country believes that using
    an opioid medication without a prescription does not pose a
    great health risk. We also need to do a better job educating
    health care providers on the broader use of pain management,
    opioid prescribing guidelines, and on the best approach to
    screen and refer patients with substance abuse problems.
        Efforts to improve, standardize, and facilitate the more
    widespread use of prescription drug monitoring programs are
    also needed. There is, of course, a critically important role
    for law enforcement and the DEA in detecting and intervening
    with illegal efforts to obtain and distribute prescription
    drugs.
        Focusing now more specifically on public insurance
    programs, there are several strategies I think that need to be
    considered. These include the expanded use of real-time
    analysis of claims data to identify potential cases of doctor
    shopping and other forms of abuse; the expanded use of drug
    utilization reviews, particularly those that can be implemented
    at the point of sale; and the expanded use of single-provider/
    single-pharmacist lock-in programs for individuals who have
    been identified as abusers.
        Medicare and Medicaid have also had an important role in
    promoting the use of electronic health records and e-
    prescribing. These systems have great potential for not only
    reducing fraudulent prescriptions, but also for identifying
    potentially lethal combinations of prescription drugs.
        Many State Medicaid programs have also been at the
    forefront of efforts to promote the use of the patient-centered
    medical home model of primary care. The medical home model has
    the potential to also help curb the problem of prescription
    drug abuse by promoting better coordination of care.
        We must also, I think, recognize the important role for
    substance abuse treatment, and the very real and critical
    shortage of treatment service availability throughout the
    country. Providing beneficiaries with coverage for treatment
    and reimbursing providers for screening is another important
    role for Medicaid programs.
        Finally, we need to consider the drugs themselves. Safer
    and equally effective pain relievers can be developed, and
    tamper-proof drug dispensing units can limit the quantity of
    medications available. As these products increasingly come to
    market, both Medicare Part D and Medicaid programs will need to
    consider the potential benefits and costs of adding them to
    their formularies.
        Approximately 50 years ago, the United States was
    experiencing a similar dramatic increase in deaths, this time
    from motor vehicle trauma. We responded by developing a wide
    array of interventions that have been integrated, systematic,
    and sustained. The result has been a great success story. In
    the first decade of this century, while the poisoning death
    rate has climbed by 130 percent, the motor vehicle death rate
    has dropped by 25 percent.
        As we now confront the problem of prescription drug abuse,
    a similar integrated and sustained strategy is needed. While
    regulations and other approaches involving Medicare and
    Medicaid cannot solve this problem alone, they can certainly
    play an important role.
        Thank you.
        Senator Rockefeller. Thank you, Dr. Coben. That calls for
    some questioning.
        [The prepared statement of Dr. Coben appears in the
    appendix.]
        Senator Rockefeller. Dr. Timothy Schwab. Welcome to you,
    sir. Dr. Schwab manages pharmacy and medical informatics and
    sets medical policies for SCAN Health Plan, which is a Medicare
    Advantage plan serving more than 128,000 members in California,
    I would guess.
        So, we welcome your testimony, sir.

      STATEMENT OF TIMOTHY SCHWAB, M.D., F.A.C.P., CHIEF MEDICAL
               OFFICER, SCAN HEALTH PLAN, LONG BEACH, CA

        Dr. Schwab. Thank you, Chairman Rockefeller, Senator
    Grassley, and members of the committee. My name is Tim Schwab.
    I am chief medical officer of SCAN Health Plan in Long Beach,
    CA. I am a board certified internist and have been working at
    SCAN for nearly 25 years. I have been very active in geriatric
    programs, academic programs, and California State policy
    committees looking at seniors, people with disabilities, and
    individuals eligible for both Medicare and Medicaid. I
    appreciate the opportunity to appear before you today to
    discuss the innovative programs SCAN has in place to protect
    our members from the dangerous effects of prescription drug
    abuse.
        SCAN Health Plan is the fourth-largest not-for-profit
    Medicare HMO in the country. We primarily serve seniors who
    have multiple chronic conditions and/or frailty. We have served
    this population since 1985, with the mission to help seniors
    maintain their health and independence. SCAN has always
    provided a strong geriatric-focused pharmacy benefit for our
    members.
        I would like to share with you a composite that illustrates
    many of the medication challenges being faced by SCAN
    beneficiaries, our providers, and payers.
        Ms. J is an 81-year-old member who is widowed and lives
    alone in a senior independent living unit. She has a
    longstanding history of diabetes, high blood pressure, atrial
    fibrillation, and severe osteoarthritis. She had a stroke 5
    years ago and has some residual right-sided weakness.
        This weakness, in addition to her severe arthritis, limits
    her mobility and activities. Her diabetes has caused reduced
    vision and impaired kidney function. Despite these challenges,
    she is still able to live alone, and take care of herself.
        Prior to joining SCAN, Ms. J was on eight regular
    medications, plus occasional sleeping pills. She was seeing
    three different specialists in addition to her primary care
    physician. She utilized three different pharmacies. During the
    previous year, she had six emergency room visits for increasing
    pain, two for falls, and she was hospitalized twice.
        When a new member enrolls in SCAN, we conduct a
    comprehensive risk assessment. We flagged Ms. J to be at high
    risk for hospitalization given her history. She was referred to
    our geriatric health management team for further evaluation.
        Our interdisciplinary team--a geriatric care manager, a
    geriatrician, and a geriatric pharmacist--identified the
    following issues: poly-pharmacy with several medications from
    the same therapeutic class, potential drug-drug interactions,
    potential dosage adjustments needed to compensate for her
    reduced kidney function, and a high risk of falling due to
    medications affecting her gait and balance.
        So we contacted Ms. J's physicians. We found they had
    little awareness of all the different medications that she was
    being prescribed from the different physicians. They were
    unaware that several of those medications were causing her
    falls and emergency room visits. Those medications were changed
    at that time.
        Her primary care physician then referred her to a pain
    management specialist. Her pain is now much better controlled,
    and she has had no emergency visits in the last year. Her
    assigned care manager, a nurse, continues to regularly talk to
    her and to her primary care physician to make sure her pain is
    being managed to her satisfaction and that she is experiencing
    no other untoward medication effects.
        Ms. J, who represents so many of the frail elderly, has
    benefitted from a model of care that focuses on the specific
    needs of the geriatric population. SCAN has developed a very
    patient-centric geriatric model that utilizes individual
    assessments, utilization data, and pharmacy data to identify
    and create early interventions for pharmacy management. These
    include: real-time edits at the pharmacy to identify and notify
    the physician of dosage errors and drug-drug interactions;
    medications not to be utilized in the geriatric population;
    inappropriate early refills; identification of same or similar
    medications filled at different pharmacies and different
    prescribers of the same medications; a medication therapy
    management program for poly-pharmacy; geriatric continuing
    medical education for physicians, nurses, pharmacists, and case
    managers on specific geriatric conditions; and pharmacy
    management. This program also includes a module on pain
    management.
        Drugs can ease pain and prolong life, but we must make sure
    that what is meant to help does no harm. We take that mission
    very seriously at SCAN. Thank you.
        Senator Rockefeller. Thank you, Dr. Schwab, very much.
        [The prepared statement of Dr. Schwab appears in the
    appendix.]
        Senator Rockefeller. I am going to skip over to Mr.
    Millwee. You have been introduced already, and you have a very
    distinguished history. You are the Medicaid Director of the
    State of Texas.
        Mr. Millwee. Yes, sir, I am.
        Senator Rockefeller. Yes. So we would like to hear what you
    have to say, sir.

     STATEMENT OF BILLY MILLWEE, M.H.A., STATE MEDICAID DIRECTOR,
         TEXAS HEALTH AND HUMAN SERVICES COMMISSION, AUSTIN, TX

        Mr. Millwee. Well, good morning, Chairman Rockefeller,
    Ranking Member Grassley, committee members. My name is Billy
    Millwee, and I serve as the Texas Medicaid Director. I am very
    honored to be with you today to talk about what Texas is doing
    to address prescription drug abuse in Medicaid.
        The approach in Texas is one of collaboration. We have
    worked with the various Health and Human Services agencies. It
    is not just a Medicaid issue; it is an issue around our Health
    and Human Services agencies that we need collaboration to
    address. It involves the Texas Attorney General as well as the
    provider community. That collaboration has developed into a
    comprehensive approach. The elements of that include
    prevention, education, intervention, treatment, and improved
    use of technology.
        Let me cover each of those very briefly with you. Strategy
    one is prevention. Here is what I mean by that. Through our
    Medicaid drug utilization process, we employ both point-of-
    service edits and prior authorization. The point-of-service
    edits look at the maximum quantities, early refills, and
    therapeutic duplication.
        If those things are present, then we do not pay for that
    prescription. We do not allow that prescription. Prior
    authorization is used extensively for opiates and
    antipsychotics. Absent prior approval, if the clinical criteria
    are not met, then we will not fill that prescription.
        Along the same lines of prevention, effective March 1,
    2012, about 22 days ago, we implemented a managed care model
    for 3.5 million Medicaid clients. Not only do they get their
    health services through these HMOs or managed care, but also
    their prescription drugs. We believe that will result in
    improvements in utilization management and align the financial
    incentives as well.
        We have made great progress in our foster care program.
    Texas, in conjunction with some leading physicians, has
    developed psychotropic medication utilization review processes
    for children in foster care. We implemented a State-wide
    managed care program exclusively for foster care children, and
    the managed care program includes a robust medical home--
    patient-centered medical home--electronic health passport, and
    intense utilization review using the guidelines I mentioned
    earlier.
        The program has worked. Since 2005, we have seen a
    tremendous decrease in the use of psychotropic drugs in foster
    care children. Prior to the program, we had about 30 percent of
    the children in foster care receiving psychotropics. That has
    declined to about 20 percent today, and it is decreasing every
    year.
        Strategy two is education. We use retrospective drug
    utilization review. We identify providers with high utilization
    patterns outside the norm. Those prescribers are sent education
    letters, with specific clients listed, and some clinical
    criteria that may apply. That program has been successful. We
    find generally that, 6 months after that intervention or
    education letter is sent, we see a 3- to 6-
    percent decrease in the utilization of that prescription for
    that particular provider.
        Let me talk a little bit about strategy three,
    intervention. We have an Office of Inspector General that
    conducts data mining to identify and take action on providers,
    as well as clients. Of the high-volume providers identified in
    a 2010 letter from Senator Grassley, four have been excluded
    from the program, 39 are under investigation, three have been
    referred to the Attorney General for prosecution, and two have
    been referred to the licensing board for action.
        For clients, we operate a lock-in program. We identify
    clients who have a suspected pattern of drug-seeking behavior.
    At first a notice is sent advising them that we have noticed
    these patterns in their use of drugs and offer some potential
    management solutions if they do not respond. Then they are put
    on a lock-in program and locked in to a particular pharmacy so
    that we can better monitor utilization.
        Strategy four is treatment. During 2010, we implemented a
    Medicaid substance abuse treatment program. Treatment consists
    of outpatient as well as residential treatment. Services are
    provided by licensed therapists in appropriately licensed
    facilities. The results look promising. We believe that the
    cost of the program may well be paid for through savings in the
    program in other areas.
        Strategy five is technology. We believe technology offers
    great promise. We implemented this year an e-prescribing
    process. We will soon deploy a Medicaid electronic health
    record so that providers can access information about clients
    with the swipe of a magnetic card and some other security
    precautions.
        Texas is very active in promoting electronic medical
    records. Through our EMR incentive program, we have granted
    about $300 million over the past 2 years to providers to
    develop these electronic medical records.
        We certainly can, and will, do more. We believe we have
    made some significant progress, and really we appreciate the
    work of this committee in bringing this issue to the forefront.
    When you shine a bright light on something, I think that is how
    you get it fixed.
        Thank you very much.
        Senator Rockefeller. That should be the way we get things
    fixed. Then there is the problem of writing legislation, and
    trying to make it on a bipartisan basis and getting it past the
    Senate, and then getting the House to do something similar,
    then conferencing, and then having both houses vote on it, and
    then having the President sign it.
        I mean, this is all very rigorous, but the dimensions are
    so shocking, and they are exploding right in front of us, as
    you all know better than--well, we all know too. So this is why
    your being here is so important.
        [The prepared statement of Mr. Millwee appears in the
    appendix.]
        Senator Rockefeller. Alex Cahana, Dr. Cahana, is chief of
    anesthesiology and pain medicine at the University of
    Washington in Seattle. He is a specialist who promotes
    measurement-based care--I am interested in that phrase--as
    standard of care in pain medicine.
        Welcome, sir.

      STATEMENT OF ALEX CAHANA, M.D., CHIEF OF ANESTHESIOLOGY AND
          PAIN MEDICINE, UNIVERSITY OF WASHINGTON, SEATTLE, WA

        Dr. Cahana. Thank you, Chairman Rockefeller, Ranking Member
    Grassley. I would like to thank this committee for inviting me
    to discuss the clinical aspects of good pain management, but,
    more importantly, I want to tell you about the applied
    solutions that we have put in place at the University of
    Washington, and in the State of Washington.
        I am pleased to report to you the very promising
    preliminary results of these interventions were significant
    reductions of deaths from opioids in the Medicaid population
    and the Worker's Compensation population.
        I will preamble by saying that it is unfortunate that in
    the English language we use the same word for pain as a symptom
    and pain as a disease. Pain as a symptom is a by-product of a
    disease. Take care of the disease, the pain goes away. However,
    when pain becomes the disease, when there is nothing broken to
    fix, no infection to cure or tumor to operate upon, treating
    pain as if it was a symptom simply does not work. It actually
    makes things worse. This is why we are seeing so much harm with
    high-dose prescription pain drugs.
        To treat chronic non-cancer pain as a disease, a treatment
    plan may sometimes include opioids but always includes
    listening to the patient, determining what is interfering with
    his or her life, defining functional goals, and individually
    tailoring a variety of medical, exercise, mind-body treatments,
    and healthy life choices.
        A large volume of material has been recently published, but
    there are a few things that need to be remembered. First, there
    is virtually no evidence that high-dose opioids relieve pain or
    improve function in chronic non-cancer pain.
        Senator Rockefeller. In chronic what?
        Dr. Cahana. Chronic non-cancer pain.
        Senator Rockfeller. All right.
        Dr. Cahana. Second, there is growing evidence that shows
    that opioid treatments over 90 days are usually a commitment
    for life. Third, it is usually the most vulnerable, sickest,
    and disadvantaged patients like Medicare, Medicaid, and the
    veterans' population who receive the most opioids, oftentimes
    because that is what their health care professionals know, and
    what the insurance will cover.
        Now, in the written material you will find seven solutions
    that we have put in place. In my opening statement I have time
    only to go over three, the three most important, and hopefully
    for the rest of the discussion we can go over the rest.
        The first and most important is that measuring pain, mood,
    and function at each clinical encounter is key to understanding
    patients and the effectiveness of treatments. So, since
    November of 2008 at the University of Washington Pain Center,
    we have been using an assessment tool with every clinical
    encounter.
        This tool allows patients to describe how pain impacts key
    domains of their lives, including pain interference to
    essential activities, status of their physical functioning,
    emotional well-being, satisfaction, and the potential risk for
    prescription opioid abuse and misuse.
        Combined with routine urine drug tests, this model of
    measurement-based care informs clinicians about important
    patient characteristics, treatment progress, and overall
    satisfaction from the visit. It also permits us to decide on
    and identify exceptional outcomes, efficiencies, and needed
    resources for expansion of services to provide effective and
    efficient outcomes--not how to treat pain, but who to treat
    pain with what.
        The second-most important solution is that, in order to
    increase the availability of specialty care, we initiated twice
    a week a 90-minute tele-pain provider-to-provider consultation.
        This service, called ECHO--Extension for Community Health
    Outcomes--was developed at the University of New Mexico and is
    designed to improve access to specialty care for under-served
    populations with complex health problems. It uses video
    conferencing technology to train primary care providers to
    treat complex situations and has been shown already to be as
    effective and safe as specialty care.
        Since March 2011, we have trained close to 1,500
    professionals, with thousands of training hours, from 76
    locations, with 40 to 50 providers dialing in at each session
    from Nome, AK all the way to Pocatello, ID. We have documented
    an improved sense of knowledge of prescriptions among our
    providers, and an even higher decrease in mortality rate in
    counties receiving education compared to the State average.
        Last, since 2010, we have provided a second opinion
    consultation for Medicare and Medicaid beneficiaries receiving
    ultra-high doses of over 1,000 milligrams of opioids equivalent
    a day. This follows the model of the second opinion
    consultation which was developed for children treated with
    antipsychotics, which was shown to improve patient outcome and
    be a cost benefit.
        We started a targeted mentoring program for top
    prescribers, and it is called Look Over the Expert's Shoulder,
    which is a post-
    graduate educational program allowing advanced training and
    certification in the communities of practice. Look Over the
    Expert's Shoulder-trained pain champions are expected to serve
    as educators, leaders, and resources in their communities where
    specialty pain clinics are unavailable or inconvenient due to
    excessive distance.
        In summary, over-reliance on opioids is poor pain
    management and it is a result of, yes, insufficient provider
    training and patient education, but more so the lack of
    accessible real-time, patient-
    reported outcomes for the prescriber to tell, are these
    prescriptions or other treatments effective and safe? There is
    a presence of strong financial incentives to over-prescribe,
    over-proceduralize pain complaints, especially in the
    vulnerable population.
        I urge the committee to consider these three elements to
    improve outcome. Thank you.
        Senator Rockefeller. Thank you very much, Dr. Cahana.
        [The prepared statement of Dr. Cahana appears in the
    appendix.]
        Senator Rockefeller. I am going to turn, first, to Senator
    Grassley because he has to give a speech. Are you addressing
    the Pentagon, or the President, or who?
        Senator Grassley. No, my fellow colleagues.
        Senator Rockefeller. Oh, your fellow colleagues. All right.
    [Laughter.]
        He has to leave, so I want him to have a chance to ask some
    questions.
        Senator Grassley. I do not think it is anything you would
    disagree with. Thank you for the courtesy.
        The first question: Dr. Schwab, in your testimony you
    talked about the system SCAN has in place to weed out potential
    problematic prescribers, including physicians, dentists,
    physician assistants, and nurse practitioners. I want to
    applaud SCAN. However, it is not enough just to identify these
    prescribers. That information has to be shared.
        For example, look at the recent case in Texas where a
    practitioner--one practitioner--defrauded Medicare and Medicaid
    of $375 million. He had already been disciplined by the Texas
    board. He had to surrender his controlled substance permit due
    to inappropriate prescribing. He was sanctioned for
    unprofessional conduct, yet he was still able to bill Medicare
    and Medicaid.
        Now, the general public is going to wonder, how could that
    be? But it is. So, when you identify a bad practitioner, do you
    pass on that information to both the State in which the
    prescriber is licensed and to CMS? If not, why not?
        Dr. Schwab. The answer is ``yes.'' If we have identified
    that person and, after due diligence and discussing that with
    the provider, we have determined that there still is a problem,
    that information is turned over both to the State licensing
    board and to the Federal databank.
        Senator Grassley. All right.
        And for the director from Texas, does Texas also pass this
    type of information on to CMS?
        Mr. Millwee. Yes, sir, we do. We disclose our
    investigations, once they are completed, to CMS and also to our
    Attorney General.
        Senator Grassley. All right.
        Well, thank you very much. It seems like the steps that
    both SCAN and Texas are taking ought to be recognized as being
    admirable and effective, and a pattern for everybody else. If
    we could learn to coordinate with all the players in the
    system, I am confident that we could do a better job of not
    only reducing drug abuse, but also waste and fraud in our two
    Federal programs.
        For Dr. Cahana, in response to my letter to the States
    about their top prescribers of pain management drugs, I have
    begun to receive information. Some States have improved over
    previous years and some, despite their best efforts, have not.
        An example is Florida. One doctor wrote nearly 7,000
    prescriptions for Oxycodone HCL in 2010 alone. This doctor
    holds himself out to the public not as a pain specialist, but
    rather as a pain medicine specialist.
        Dr. Cahana, is 7,000 prescriptions in 1 year unusual, in
    your experience? Also, before you answer that, are you
    surprised, given the advances in recent years to reduce
    prescriptions of these opiate-based painkillers, that a doctor
    is so blatantly holding himself out to the public as a ready
    and willing prescriber of these drugs?
        Dr. Cahana. We are always attracted by the outliers and the
    excessive activities of either patients or providers, and one
    of the problems that we see is education and the lack of a
    clear statement of what is the education knowledge base that is
    necessary to actually handle these type of prescriptions.
        I think that using video mentoring, and making sure
    specialists reach out to these prescribers in the community,
    and providing them the latest information can transform them
    from outliers to pain champions, to actually have them in the
    community and say, you can help and give patients the feeling
    that specialists in tertiary care settings can give them a
    shoulder and a hand.
        Senator Grassley. This will have to be my last question, so
    my last one would go to Director Millwee.
        On January 1, I sent letters to all 50 States requesting
    data on their top 10 prescribers. I also asked if CMS had
    provided the State Medicaid departments with any training or
    guidance to help identify potential issues with prescription
    drugs. Most Medicaid directors responded that they had not
    received any such training.
        If there were more open communication and collaboration
    between States and the Federal Government, we would have a
    better outcome for patients and taxpayers, States, and the
    Federal Government.
        So, in your case, has the Texas Medicaid department
    received any training from CMS? Let me add to that, do you
    think any of the successful programs that Texas has implemented
    could have been enacted sooner if CMS had offered guidance?
        Mr. Millwee. No, sir. We have not had any discussions with
    CMS about this issue. I think that potentially it could help,
    particularly if States develop these innovative ideas. If CMS
    could share those ideas among all the States, then there is
    some opportunity there to leverage what other States have
    learned and maybe put it in place faster.
        Senator Grassley. Thank you.
        Thank you, Mr. Chairman, for letting me go ahead.
        Senator Rockefeller. Well, give a good speech.
        Senator Grassley. All right. I will. You know how that
    goes. [Laughter.]
        Senator Rockefeller. Senator Schumer, we welcome you. If it
    is all right with you, I would like to ask a question or two,
    then go right to you.
        Senator Schumer. Of course.
        Senator Rockefeller. This is really to Dr. Coben and Dr.
    Cahana, but really could be to any of you. But it is so
    mystifying. What we are talking about is pain prescription
    medicines, and we are not even mentioning any of the other
    addictions: meth, or anything else that is just disintegrating
    families, communities, States, and ruining budgets, and much
    more importantly, ruining lives.
        Dr. Coben and Dr. Cahana, are some people actually sort of
    under-treated for pain while some people are being over-treated
    for pain? How can these two things exist? Which may lead you to
    talk about what you get taught when you go to medical school.
        Dr. Coben. Senator Rockefeller, yesterday I worked in the
    emergency department before coming here, and, during the course
    of that 8-hour shift, I can probably recall at least half a
    dozen patients who were struggling one way or another with pain
    issues, and with medication issues. Part, I think, of that
    problem is the fragmented primary care system, and that
    patients are seeking out relief wherever they can obtain it.
        Now, clearly some patients are seeking prescription
    medications for the purposes of the drug itself, but I think
    just as frequently patients are seeking care for the pain that
    they have, and not the recreational use of the medication. This
    fragmented care is really contributing, I think, quite a bit,
    which is why the coordination of care is so important.
        To your point, I think there are clearly situations where
    there is under-prescribing, and physicians, for many, many
    years, have worried about the dangers of getting patients
    addicted to medications. But finding that balance and--as Dr.
    Cahana has spoken eloquently of and I am sure will talk more
    about in terms of measuring it and being able to understand
    what patients need at the time of care--having that information
    in front of us is a critically important contributor to how we
    can do a better job of matching the need with what we provide
    to patients.
        Senator Rockefeller. I am going to follow up on that.
        Dr. Cahana?
        Dr. Cahana. Thank you, sir, for this question. Obviously,
    we are finding out that there are biological reasons for how
    something that was designed to be a very potent and reliable
    pain reliever under certain conditions actually increases pain
    and causes a whole host of untoward side effects that we were
    not aware of.
        The problem with the over-prescription in certain
    conditions, which is a certain way of under-treatment by over-
    treatment, is that pain pills are not a panacea. There is an
    over-reliance embedded culturally on thinking that existential
    suffering can, and should, be treated by pills and devices. But
    what we are finding out is that other treatments, as I
    mentioned in my opening statement--healthy life choices,
    smoking cessation, weight reduction, integrative medicine--all
    these low-tech approaches to better health are turning out to
    be very promising. So, in order to determine what works--we
    say, does this work? yes? no?--it is important to measure at
    each clinical encounter what is going on.
        When you come to my office, then you fill out a battery of
    questionnaires that allows me to see what you think about your
    pain, and are you sad, or are you anxious, or are you
    frustrated, and in that brief conversation I am able to very
    quickly concentrate on what things that you think are
    important.
        So we are moving away from how to treat pain to whom to
    treat, with what, and what are the best treatments and not
    saying this is good or this is bad.
        Senator Rockfeller. Can people sometimes declare to you
    that they have pain, but what you know is that somehow it is in
    their--not imagination, but they have decided they have pain
    because perhaps they had pain a week ago, and then there was a
    little sort of something that reminded them that that occurred.
    So my question really would be about people who really do have
    pain and need to be treated as opposed to people who are so
    accustomed, in their own minds, to having pain that they seek
    out medication just as a stabilizer for general purposes.
        Dr. Cahana. So, first of all, when we say ``pain is in the
    head,'' it is to some extent accurate because pain is in the
    brain, and the only way of not having pain is not having a
    brain. But pain is not felt by the brain; pain is felt by
    people.
        People express that in combination with what is going on in
    their life. This is why we call it the bio-psycho-social model
    that has biology in the brain, it is genetic, but also has our
    psychological characteristics and our traits as individuals,
    and then afterwards what life has given to us and how we are
    adapting to our current circumstances.
        So every patient who comes and complains about pain, they
    are not imagining or inventing it; they are in true distress.
    The point is, what is the correct treatment that would help
    them out to relieve that distress and improve function? So it
    is not the pain, per se, that we are interested in, it is the
    functional recovery.
        So if, for example, I look at a cohort of patients, and I
    look at just how many opioids did they use, and I look before
    treatment and after treatment, and I do a total average of
    totals, I will see that, after seeing me, they have reduced
    maybe their consumption by 3 percent. That is not very
    successful.
        So why are we doing all this investment for a 3-percent
    reduction? But if I start to stratify patients into different
    groups, I will see that I have three types of patients. I have
    those who are well-engaged; they want to get better but they
    just do not know how. Then I have a group of minimally engaged
    patients. They are upset, they do not know, they are not sure
    that they want to, or can, get better. Then I have a group of
    patients who are fine. They do not see a problem. They do not
    understand what the problem is.
        So, when we look at the well-engaged patients, we see
    reductions of up to 56 percent in opiod consumption, whereas in
    the other two groups you do not see those reductions. So it is
    clear that the first group coming to us has the right address
    for them.
        For the second group, perhaps intensive counseling, mental
    health services would be the better thing to do.
        For the third, if they are fine and they are stable, then
    there are maintenance programs and addiction medicine
    specialists that can continue to work on their health. So it is
    very important to be able to not talk about how to treat pain,
    but whom to treat, with what, and what are the alternatives.
        Senator Rockfeller. Thank you, sir.
        I call on Senator Schumer.
        Senator Schumer. Well, thank you. I want to thank Chairman
    Rockefeller for holding a hearing on this critical issue. The
    crisis of prescription drug abuse is shocking. In New York, our
    law enforcement officials believe it is the greatest drug
    problem we have now, greater than crack or cocaine or heroin,
    and growing at clearly the most rapid rate.
        We have seen all kinds of suffering in New York. There was
    a horrible incident in Seaford, Long Island, where an off-duty
    ATF agent was fatally shot when he was trying to intervene in a
    robbery of a local pharmacy. Another time in Medford, Long
    Island, where there seems to be a growing problem, four people,
    including an on-duty pharmacist, were murdered during a robbery
    of a pharmacy.
        So we have to change the course of this epidemic. One of
    the reasons I am so glad that Senator Rockefeller has had the
    hearing, and I am proud to co-sponsor his bill, is I remember
    crack and even crystal meth, where we did not do enough early
    on, and it got its tentacles in our society, both of those
    drugs, and it took a long time to get them out. But we can stop
    that if we really move quickly here.
        So the reason I like Senator Rockefeller's bill is because
    we need these painkillers, as you all stressed, but we do not
    want them to get into the wrong hands. The only way we are
    going to get after this is if we can identify patients who are
    doctor shopping and wasting taxpayer dollars through Medicare
    and Medicaid. That is not the only way, but that is an
    important way. We have a group in our State called Physicians
    for Responsible Opioid Prescribing. The group includes non-
    physicians, and it is doing good work. So there is a lot to do
    here as this bill moves along. I hope we can move it quickly.
        So I have a few questions in the remainder of my time. I
    thank you for coming. Thank you. I care a lot about this issue.
        Senator Rockefeller. No, you go right ahead.
        Senator Schumer. The first question I have is, how much of
    the problem is over-prescribing? CDC found, from 1997 to 2007,
    that the milligram-per-person use of prescription opioids in
    the U.S. went from 74 milligrams to 369. That is a 400-percent
    increase. In 2000, retail pharmacies dispensed 174 million
    prescriptions for opioids, and 257 million by 2009, up 48
    percent.
        So would any of you want to comment on how much of the
    crisis is over-prescribing?
        Dr. Cahana. I would like to say that, absolutely, when we
    look at prescription trends, also in other countries, we see
    that it is specific to what I would call the impoverished
    dialogue that we have with our patients. When you walk into my
    office for a follow-up and I have only a few minutes and I say,
    how are you doing, sir, and you go like this with your head,
    then the first thing I do is I look at the clock behind you and
    I say, all right, I have a few minutes. What are you taking?
    Here, take a little bit of this. So, prescription has become
    the passport to continue our day. I am saying this in the most
    constructive way.
        Senator Schumer. Right.
        Dr. Cahana. It is something that we are incented to do, it
    is something that we are taught to do. For many of us, it is
    something that we believe is the right thing to do.
        Senator Schumer. Right.
        Dr. Cahana. But very quickly, we find ourselves escalating
    on doses that we have no exit strategy for. Like I mentioned in
    my opening statement, if you are more than 90 days on these
    prescription drugs, then probably you are committed to life for
    that. I am sure that if that would have been the discussion
    when we started, then we would have a different decision in
    place.
        Senator Schumer. Anyone else?
        Dr. Coben. Senator, if I could also comment.
        Senator Schumer. Dr. Coben?
        Dr. Coben. Thank you. You mentioned the dramatic escalation
    since 1997. I think it is difficult to quantify exactly how
    much of this is over-prescribing. However, clearly there is
    some, but I will remind folks that in 1997, there were some
    guidelines and recommendations that were put forth saying that
    physicians were not adequately prescribing, and calling for
    increasing in prescribing of medications at that time. So I
    think some of that has been a response. Now, we clearly have
    swung too far in the opposite direction, so finding the
    appropriate middle ground is what we really have to concentrate
    on.
        Senator Schumer. Did you want to say something, Dr. Schwab?
        Dr. Schwab. Yes. I agree with both of my colleagues. I
    think, though, that especially in the Medicare population that
    I represent, the problem is inappropriate prescribing a lot of
    times, where they are using short-acting opioids instead of
    long-acting, and they are not coordinating with the other
    physicians, so that there may be multiple physicians
    prescribing medications for the same person, and they are
    unaware that they are all giving these medications.
        So we need more of the educational side towards the
    physician and coordination and an individual, patient-centered
    model--what is your problem, finding out what they are treating
    the person for.
        Senator Schumer. Right. My time is up.
        Senator Rockfeller. But just barely.
        Senator Schumer. I have a few more questions.
        Senator Rockfeller. Go ahead.
        Senator Schumer. All right.
        The next question I have is, we have a database in New York
    where you are supposed to be able to log in, the physician is,
    to make sure that there are not people getting multiple
    prescriptions in multiple places. Some might do that benignly
    if you will, trying to relieve their pain; others might do it
    because they want to sell the drugs.
        So my two questions are--but our doctors complain about our
    database being incomplete, and it takes too long. You cannot
    wait 20 minutes for the database to come back while you have a
    busy practice and you are watching the clock, as Dr. Cahana
    said.
        So this bill would help to make the database better. I am
    interested in the databases that exist--I think there are 20
    some-odd States that have them--do they work better, would this
    bill help them work better? I will ask one other question
    rolled into this.
        How much of the abuse--when we have a high school kid in
    New York buying these drugs in the schoolyard, or addicted to
    these drugs, let us say--let us make it that. How much of that
    comes from just taking the pills out of his parents'--that were
    legally prescribed and needed--out of the parents' medicine
    cabinet? How much is from the drugs being stolen or in
    pharmacies, on trucks? They rob the trucks that carry the drugs
    and put them into the black market in a similar way that an
    illegal drug would be used. So that is a lot of questions, but
    all in the same sort of area. Who would like to respond? Dr.
    Coben?
        Dr. Coben. With regard to the prescription drug monitoring
    programs, I think it is fair to say that, since they are all
    State-based, there is quite a bit of variation, and variability
    in the quality and the issues in using all of them. I know that
    there are difficulties that relate to the frequency and
    rapidity with which the information gets into the database. So,
    for example, it may be up to 2 weeks in a State before the
    pharmacy actually reports a prescription.
        During that time, lots of prescriptions can be filled.
    There are issues with regards to accessing the data and the
    timeliness of accessing the data from the provider side, from
    the physician side. One of the biggest challenges that I have
    dealt with in my practice is finding a unique identifier for
    each individual whom I see.
        Senator Schumer. Sure.
        Dr. Coben. The same last name, same first initial, can get
    recorded lots of different ways in a particular database. So I
    think efforts to improve and standardize these, and also to
    share the data across State lines, are vitally important and
    can really be very helpful. Also, not only would this be
    helpful in curbing abuse and doctor shopping, but also helpful
    in reducing physicians' withholding medications from people who
    really need them, because many of us have suspected drug-
    seeking when in fact, when we go to the database, we find that
    it is not drug-seeking. So, I think it could be very helpful. I
    think if the bill can address that issue, it would be extremely
    beneficial.
        On your second question regarding where the medications are
    obtained, we know from at least self-reported data that teens
    report they are obtaining prescription drugs from family
    members and friends, and from the medicine cabinets. Now, where
    those are coming from, and exactly the friends, and where they
    are getting them from, I think is still unclear.
        Senator Schumer. Any others?
        Dr. Cahana. So, in regard to that question, a survey that
    was done in the State of Washington put the number at 57
    percent of teens, in our last youth survey, who said that they
    took prescription drugs from their family medicine cabinet, and
    10 percent of our 10th graders said that they have tried
    prescription drugs at least once, for recreational use, at
    something that they call a pharm party. So that is the first
    question.
        The second is, we added----
        Senator Schumer. Just to sort of--but sometimes they will
    start with the drugs in the medicine cabinet and then they get
    so addicted, they need to go on. Is that 57 percent where they
    started with prescription drugs or is it teens who generally
    use them? You are talking, with these pharm parties, I take it,
    occasional use and not real addiction?
        Dr. Cahana. Well, they said that the first source----
        Senator Schumer. First source. Got it. That was my
    question. Thank you.
        Dr. Cahana. And there is a parallel increase in
    prescription drug abuse and heroin abuse, as well as referrals
    to treatment centers. It is parallel because it is very
    expensive to maintain a prescription drug abuse habit.
        The second thing is--I agree with my colleague--the
    technological limitations that we have on the usefulness of
    prescription monitoring programs. What we have done very
    specifically in the State of Washington is develop a program
    called EDIEP, the Emergency Department Information Exchange
    Program, where all our EDs have better penetration in the
    eastern part than in the western part of the State where they
    are networked, so if someone walks in, then the name is
    flagged.
        It is not so much as withholding, as Dr. Coben spoke about,
    but really contacting, through a call center, the primary care
    doctor to say, did you know that Mr. Smith has visited, in the
    last 24 hours, three emergency rooms on the I-5 corridor, and,
    if the patient does not have a primary care provider, to assign
    them one, because that is the whole idea, taking this
    vulnerable population and assigning them to some primary care.
    So it is not so much the policing, but identifying and using
    that as an opportunity to improve their care.
        Senator Schumer. Anyone else? Dr. Schwab?
        Dr. Schwab. Yes. In the Medicare population under Part D,
    and in our program, one of the ways you identify this is
    through early refill identification. With the early refill, you
    do not know why that early refill is. It could be someone who
    is themselves abusing more drugs, but it could also be someone
    in the family stealing that out of the medicine cabinet.
        Just identifying the early refill does not solve the
    problem. You then have to contact both the primary care
    physician and the member themselves and ask them, do you have
    more pain or more need now or is it that someone has stolen the
    medication, and doing a referral that way.
        Senator Schumer. Thank you.
        Thank you, Mr. Chairman. That was great.
        Senator Rockfeller. Thank you, Dr. Schumer. [Laughter.]
        This question is to any or all of you. There is a lack of
    geriatricians--I am just trying to make a comparison here--in
    this country. There is not a lack of geriatricians being
    trained in medical schools, but they get out, and they start to
    practice, and they find out that other specialties are doing
    far better than they are. They have children, and they just
    gravitate towards other specialties, and thus the geriatricians
    are not available to the people who need them.
        This is sort of the way the world works. Now, what I am
    leading to, therefore, is the need for more knowledge and
    training about pain as a symptom, as a disease, as a reality,
    as a not-reality in medical school. Obviously, I have never
    been to medical school, and I know the horrors of the schedule
    and becoming a resident, and are you allowed to sleep now after
    2 days or are you down to 1 day? I mean, it is just so hard.
    There is so much to learn, so much new technology.
        The video conversations that you were talking about, or
    maybe you, Dr. Cahana, where people can just talk, from WVU, to
    anybody in West Virginia just because they have that capacity
    now because of the technology. But with doctors, how much time
    did you spend on pain? But not just pain as a disease, but pain
    as sort of a very special problem in our society? Do you get
    training in that?
        Now, that may not be fair to ask you because I do not think
    any of you graduated within the last 2 or 3 years, but still it
    is a fair question. What are we teaching in medical schools and
    residencies about this subject? In West Virginia, some people
    go to residents rather than doctors because they feel they may
    be easier to get at. Can you help me with this subject?
        Dr. Cahana. The Institute of Medicine report dwelt on that
    issue quite a bit. In their recommendations, the paucity of
    undergraduate training in pain is very present. I think the
    national average is about 7 hours in 4 years, which is clearly
    not enough. So there needs to be a revision of the curricula to
    see how to insert pain training in the undergraduate arena.
        At the University of Washington, in our School of Medicine,
    we have revised it up to 24 hours and created electives that
    are actually sought after by medical students who say, I cannot
    believe at the end of the rotating, that I missed this
    training. So medical students want to do this. In a recent
    survey that we completed on 261 medical students, they all
    ranked their knowledge in their 4th year, last year, as poor to
    fair prior to when we started this, and they also want to go
    and get this.
        In terms of post-graduate training, I think we are looking
    at two different subpopulations. One is, how do we train the
    community? Most of pain management is done in the community and
    in emergency rooms, and I think that video mentoring and tele-
    health solutions are very powerful tools to help specialists
    reach out in the community and create, as I mentioned earlier,
    outliers to pain champions and to help physicians and providers
    feel more comfortable in their prescription habits.
        Then there is a whole discussion of the quality of training
    of specialists themselves. It has been recognized that not all
    training programs emphasize a multi-disciplinary approach, and
    they are more geared into the technical or technological
    aspects of pain management. So there is both undergraduate and
    post-graduate education to the community and to specialty care
    that needs to be addressed, and I want to thank the committee
    for highlighting this.
        Senator Rockfeller. It is interesting. Mr. Millwee, you
    join in this, too. I was actually surprised, and I forget which
    one of you said it, that after 6 weeks you are addicted for
    life. You said that, did you not? That is opioids. It is hard
    for me to actually believe that. I mean, I do because you say
    it. But if patients believe they could get away from addiction,
    that there would be sort of booklets out in the community, and
    what do you do, or do your doctors sort of gradually reduce
    medication, or whatever----
        But if you just feel that you have been doing this for 6
    weeks because you have certainly had pain for 6 weeks, then
    sort of you are in a hopeless land, and you just go ahead
    because you can get them, unless somebody says no. But what
    about this problem of getting off of the addiction? Because I
    would think that would be a source of great hope for opiod-
    addicted people as they look at their futures, even if it would
    not be applicable right away, because they were still suffering
    from that pain. But then how do they know if they are suffering
    if they are using the opioids?
        Dr. Cahana. What we found in that study that included two
    cohorts of patients, one Medicare and Medicaid patients and the
    other private paying patients, was that, if you are over 90
    days on chronic opioids, the chance of you being on them 5
    years from that date is over 50 percent. So that is what we
    found.
        Senator Rockfeller. I accept that. But I am trying----
        Dr. Cahana. That physician needs to convey to the patient
    that they are committing them to this. Now, in the context of
    perioperative pain or after surgery or trauma, there is a
    healing process where, of course, opioids and the use of
    powerful pain relievers is appropriate and necessary and
    warranted. This is the transition I mentioned of pain as a
    symptom when there is an ongoing disease, and pain when it
    becomes the disease within itself.
        Now, there is nothing wrong with being on chronic
    medications. There are multiple chronic diseases that
    necessitate taking a pill. It is the destructive behavior, it
    is the lack of functional recovery, and it is a burden that is
    associated with that that is troublesome.
        So we do not focus so much on the pain, but we focus on the
    wellness, and the well-being, and that is what the dialogue
    needs to be with patients. It is not about negotiating, do I
    think I need a pill, yes or no? It is, let us understand, what
    are the functional goals, what do you want to achieve, and how
    do we reach that? It cannot be only by using pills.
        Senator Rockfeller. Please?
        Mr. Millwee. We considered that very issue in 2009-2010 and
    decided to add a Medicaid benefit, after discussion with
    physicians, for substance abuse treatment, because the problem
    many times might be that the physician finds that, but there is
    no resource to refer a Medicaid client to get help.
        So we added a substance abuse treatment program, so now you
    have a referral. So, if you do wind up in this chronic
    condition, you have had chronic pain and now you have some
    addiction to pain drugs, there is a treatment alternative as
    well.
        Senator Rockfeller. Please?
        Dr. Coben. The other area that I think Medicaid and
    Medicare, in particular, can be very helpful in this regard, is
    by promoting the use of electronic health technology whereby
    one can then easily identify when they are reaching that
    threshold.
        If electronic health records are in place in the
    physician's office, then that threshold that is approaching,
    the 90 days or the 6 weeks or beyond, can be flagged so the
    physician is reminded and can start to intervene, wean
    patients, or refer them to substance abuse treatment.
        Senator Rockfeller. Please?
        Dr. Schwab. Yes. I would like to tie in to your previous
    question of lack of geriatricians. For the older population
    there is the added complication, not of just the pain
    medication treatment, but the issue that they probably have
    multiple other co-morbid conditions and other medications that
    cause drug-drug interactions and other side effects.
        In our lifetime, we probably will never see enough
    geriatricians trained to take care of this population and to be
    able to recognize how to manage all these medications. So it is
    going to take a whole team, whether it is the geriatrician
    helping support some primary care physicians, whether it is a
    continuing medical education, programs like we and other people
    do to train primary care physicians how to recognize and deal
    with multiple co-morbid conditions, and the treatment, and also
    the ancillary personnel, geriatric pharmacists, the case
    managers, that whole team working together with the individual.
        Senator Rockfeller. I know in West Virginia there is one
    area where a group of doctors have just sort of had it with
    this problem and want to do something about this problem. They
    are not all doctors. You get social workers, you get a group, a
    team which works with a patient.
        Now, I say that and feel very good about it. Then I say
    that and I also feel like the world does not work like that.
    There is not enough time in a doctor's schedule, in a hospital
    schedule, or in anybody's schedule, so that people can coalesce
    over a patient. But it seems to me that, in life, when people
    have serious addictions or serious problems, a team concept, a
    group working with them, frees up people to be more helpful as
    a concept. You would probably agree with the concept, but do
    you think that it is not realistic? Please? Now, you have ECHO,
    do you not? Is that Robert Wood Johnson?
        Dr. Cahana. Yes.
        Senator Rockfeller. I meant to see them at 12:30, but we
    have seven votes, so it is going to be a little hard. They are
    good, are they not?
        Dr. Cahana. Yes.
        Senator Rockfeller. Anyway, who would like to answer the
    question?
        Dr. Schwab. I agree with the team concept. I think we need
    to get away from the idea that the team has to always be in the
    room all together at the same time.
        Senator Rockfeller. All together.
        Dr. Schwab. So the team can provide input in multiple ways
    either through other electronic communications, which are so
    available now, even things like video teleconferencing, so the
    team member could be at the university, and the rest of the
    team out in the field.
        So, I think that is the way. It reduces the need for the
    physician to spend all that time and gets some of the support
    of other people, as you say, social workers, pharmacists,
    individuals like that.
        Senator Rockfeller. What role can nurses play in all of
    this? Just talk.
        Dr. Cahana. A central role. We found out that, by hiring
    nurses as care managers coordinating the care, they become the
    gravitas around everybody, around the coordination. The
    coordination means not only to make sure that patients follow
    up on whatever the multi-disciplinary team comes up with, but
    also to prepare the patients, follow up, and monitor adherence.
        So, having access to that information is important, and
    actually reaching out to the patient, educating the patient in
    real time, discussing findings, discussing a urine drug test,
    and if there are unexpected findings, how to do this, how to
    encourage the patient to understand that this is not a forensic
    test, but this is part of monitoring adherence and making sure
    that they are doing well, using every opportunity of surprise
    to be an opportunity of education and showing the intent to
    have patients be better and well.
        Senator Rockfeller. Dr. Coben, before I go to you, is
    electronic data, just data information, is that available at
    every nurse's station? Is that available in every ward, or is
    that only available in doctors' offices? Are we using that to
    the extent that we can so people can find out who is taking
    what?
        Dr. Cahana. So I would say that currently this is a system
    that is growing, and that our coordinating nurse that is
    working as a hub between the pain center and the neighborhood
    clinics has that access, and nurses in the neighborhood clinics
    also have access.
        So we can engage in what we call panel management, where we
    actually say, oh, I see Mr. Smith actually is not doing well.
    He was not supposed to come to the clinic. But because we are
    able to find that they are not doing well, we can call up
    either the patient or the nurse and find out what is going on.
        The key, of course, is to make sure that we have these
    measurements in place and incent the behavior of assessing it.
    It is almost like a hemoglobin A1C for diabetes. You have to
    measure that in order to say that the patient is doing better.
        So I would urge us to add that element of measuring.
    Without measuring, we cannot determine value, and then there is
    nothing to coordinate. Obviously there are administrative tasks
    to coordinate, but, in terms of patient well-being, we have to
    rely on the surrogate measurements that the patients report to
    us and on biological specimens like urine drug tests.
        Senator Rockfeller. All right. Thank you.
        Dr. Coben?
        Dr. Coben. I was just going to reiterate, in my comments
    earlier I had mentioned the patient-centered medical home
    approach, and I know that Mr. Millwee also commented on that as
    well. I think that that really does talk to the essential role
    of an extended care team so that the physician is not
    necessarily the one that spends all the time doing the
    assessments, and even the interventions.
        Of course, the patient-centered medical home model is not
    just a model of care, but it is also a model of financing that
    care, obviously relevant to the committee. So I think that
    promoting its use can really help in terms of removing this
    fragmented care model of delivery that is really contributing
    to part of the problem, and engaging other extended care
    providers like nurses and mid-level providers in the care of
    the patient.
        Senator Rockefeller. Physicians' assistants?
        Dr. Coben. Yes. Absolutely.
        Senator Rockefeller. I can remember, in West Virginia we
    were one of the first that had a school for physicians'
    assistants. There was a lot of laughing going on. Well, there
    is no laughing going on anymore. Dr. Cahana, I loved it when
    you described--because you were so honest about it--being in an
    appointment and you are late getting there, the patient is late
    getting there.
        I mean, everything has to work perfectly for you to have
    the time that you need, and nothing ever does work perfectly,
    so that you are reduced to getting the basic information and
    making a basic decision, knowing that you are not doing all
    that you can do or that you should be doing, but there is
    nothing you can do about that.
        So, I mean, it does argue for having other people share
    your burden with you. So having said that, how would you
    recommend--let us say, Medicare and Medicaid, the older,
    fragile population where it seems to me it would be much harder
    for a doctor to say, no, you should not be taking that pain
    medication, because that is a very different psychology.
        If you feel that you only have a few years to live, or you
    have so many illnesses built up inside of you that having a
    pain medication is like eating, every day you just have to do
    it, and therefore it puts a great burden on a doctor. How would
    you suggest, each of you, that we best approach this problem in
    Medicare and Medicaid?
        Mr. Millwee. In Texas, we found care coordination is really
    what works. When you look at your population, about 70 percent
    of the people in Medicaid generally just need some basic
    primary care. About 30 percent have chronic health care
    conditions that really benefit from care coordination.
        So we have created a model, we call it Star Plus, where we
    have that care coordinator who is working on, not just the
    acute care needs, but also long-term care needs, and is very
    much attuned with that client in understanding if there is a
    deterioration in their condition. They have that time to spend
    with them that maybe the physician does not have, and around
    that person you are building that primary patient-centered
    medical home. We include our dual-eligibles in that population.
        Even though we are not responsible for the acute care piece
    of that, we help manage that as well and coordinate on the
    Medicare side. So it really comes down to targeting the
    population that really can benefit from that care coordination.
    When you look at it, it is a small subset that really drives
    cost and has the potential for prescription drug abuse, we
    believe.
        Senator Rockefeller. Thank you.
        Dr. Cahana. I want to thank you for this opportunity really
    to share, how did we come up with these solutions. The system
    is, as Dr. Coben mentioned, fragmented, inconsistent, and the
    cost is unsustainable. So the strategies that we brought to the
    table are just to address those. So for the fragmentation, we
    are talking about coordination. For the inconsistency, we talk
    about the education. Education can be done in many ways, but
    the video mentoring and the ECHO project are very exciting.
        The unsustainability of things that lack value can only
    come out by measurement. If I measure, then I can know if that
    thing helps or not, and to whom. So I would submit to the
    committee that if you would help us, encourage us, and incent
    us to measure as standard of care--that is the measurement-
    based care part--that me looking at patient-reported outcomes
    of patients telling me about their pain, their mood, their
    function, looking at their urine or any other biological fluid,
    and looking at things that are either expected or not expected,
    at a frequency that has been determined in the literature as
    standard of care, and to be paid for that, that is, for me, the
    most important thing.
        The second most important thing is to pay for video
    mentoring, or to encourage us to use and subscribe to the video
    mentoring, which by the way, we do during lunchtime because we
    do not want to interrupt the work flow. So for the University
    of Washington, and the Specialty Services, we do it very early
    in the morning before we start our day. For the community, we
    do it during lunchtime. That is not a desired situation.
        It has to be part of our practice where we know that we
    have our daily, or bi-weekly dial-ins, where we talk to the
    specialists and we present patients, and we can follow up on
    how they are doing, and you have that multiplier effect of
    saying, oh, so this is how you treat a patient who is elderly
    and has these co-morbidities, et cetera.
        So those two things, in addition to what was submitted in
    507 of the training, the education, the clinical guidelines,
    and the prescription monitoring program support, encouraging us
    to measure, incenting us, paying us to measure, and paying us
    to do the video mentoring.
        Senator Rockefeller. Thank you.
        Dr. Schwab?
        Dr. Schwab. Well, for nearly 30 years we have known that
    care coordination in the Medicare population works to do this.
    But it is not just simply care coordination. You really need to
    target the people whom you provide that care coordination to.
    To do the targeting, you need data. The data comes from both
    Medicare sources and from the individual themselves, and then
    you put together a team that has shared responsibilities for
    managing and making sure that that person is identified and
    gets their needs met.
        In addition, data that I do not think we do a very good job
    now of coordinating is entire data. There are promising things,
    like the Health Information Exchanges, where data coming in
    from all sources--like right now in the Medicare population we
    have no data from the Veterans Administration for people who
    share those two services. We know there are some, a small
    amount.
        Senator Rockfeller. But how can that be? I mean, they are
    the ones who are really good at having data. DoD is terrible at
    it, but the Veterans Administration----
        Dr. Schwab. The Veterans Administration is great at having
    data.
        Senator Rockefeller. But they will not share it?
        Dr. Schwab. If they go out to the private community, there
    is no information from the private community to the veterans,
    or vice versa, from the veterans to the private community.
    Small numbers, but there is no communication there, and through
    other programs, too.
        If someone just buys drugs on their own with their own
    money, that communication is not provided to either a health
    plan or to the Veterans Administration. In a Health Information
    Exchange that really works well, all pharmacy information would
    be in one database and everyone would share that information.
        Senator Rockefeller. Well, that is very helpful. That is
    very helpful. Thank you.
        Dr. Coben?
        Dr. Coben. The only thing that I would add to the earlier
    comments is, I think the critically important role for
    screening is brief interventions and referral to treatment for
    patients with substance abuse. We know from a variety of
    research projects that have been implemented across the country
    that screening and intervention programs work, they are cost-
    effective, but they have not really been sustainable.
        Part of the reason that they are not sustainable is because
    insurers are not paying for the time that it takes to screen
    and refer and do these brief interventions. So, I think putting
    that into the armamentarium, if you will, for Medicare and
    Medicaid programs could be quite helpful.
        Senator Rockefeller. Let me ask another question. It is
    nice being all by myself here. [Laughter.]
        This is controversial, but not to me. I was responsible for
    getting it going, the Independent Payment Advisory Board, or
    IPAB. It has to do with reimbursements for physicians for
    durable medical equipment, DME, and for hospitals, and for all
    the rest of it. Several of you have mentioned measuring
    outcomes as a way of proceeding on what we have been talking
    about.
        Well, that is what the Independent Payment Advisory Board
    is all about, is measuring outcomes. In other words, if rural
    hospitals have bathrooms that are not clean, then all of a
    sudden MRSA emerges and spreads.
        You asked about having incentives. Well, there are positive
    incentives and there are negative incentives. A positive
    incentive comes out of IPAB because it says that, if your
    outcome of what you are doing--and this is not just
    prescription drugs we are talking about, but in general, a
    philosophy of how you carry on medicine--that if we have a
    system of lobbyists and then practitioners, then I will just be
    very honest with you, I speak a lot when the American Medical
    Association, the American Hospital Association comes to town.
        They take up the entire Washington Hilton, the largest
    ballroom in town, thousands and thousands of people. You look
    at the program, and often I am asked to speak, and then some
    Republican is asked to speak. Then you look at the program and
    the schedule is that everybody then goes to the Hill and visits
    all their Senators and Congressmen so that they can get more
    payment for here or there, a lot of which is all legitimate.
        With durable medical equipment, it may be, it may not be.
    With hospitals, it may be, it may not be. But, if you take that
    out of the hands of lawmakers, can you not agree that lawmakers
    are the worst possible group of people to determine how you
    should be reimbursed, because that is what is happening now.
        It works because, if you have the right lobbyists, often
    they have been people who have sat on this committee or some
    other and know about health care, and they go work on--I just
    turned down a lobbyist who served on this committee who wanted
    to come talk with me, and I am not going to see him because I
    just do not like that.
        I do not like that way of doing business. I think you ought
    to reimburse based upon outcomes and improvement compared to
    previous years, all the measurements that we have been talking
    about, people having cleaner hospitals, better hospitals, more
    coordinated care. All kinds of things that get encouraged by
    the incentivization of better reimbursement should be decided
    by 15 people--this is where people go crazy, until you mention,
    well, people like Gail Wilensky or Stuart Altman, and then they
    say, oh, well, I can trust them.
        This would be the next generation of Gail Wilenskys and
    Stuart Altmans, but there are people, and there are thousands
    of them in this country, who are really good on health care
    policy, and really good on reimbursement issues, and who have
    no axe to grind, cannot be pushed around by lobbyists. They end
    up making the decisions, which the Congress can only override
    by a two-thirds vote, of how people should be reimbursed each
    and every year.
        Now, that obviously is very complex. It has to be done
    fairly. Mistakes would be made at the beginning. But it seems
    to me getting away from Congress--and this is not sort of a
    right-wing thing I am talking about here, getting Congress out
    of your lives, but in this case I think you would do a lot
    better with Congress out of your lives with respect to
    reimbursement and incentivization for doing what you all seem
    to want to do anyway but cannot get done.
        Now, is that a program which horrifies you, which you have
    no particular opinions on, or you think is a good idea, or
    what? And just be honest with me. Look, I have free time here.
        Dr. Coben. Sounds good to me.
        Dr. Cahana. So we always strive to do educated policies
    that are based on evidence, and the quality of the decision
    really depends on the quality of the data, on the information
    that you use to make that decision, unless you decide that you
    want to ignore that.
        Traditionally, health technology assessment committees, or
    any type of committees that can be on a State or Federal level,
    or in any health system, are based on what we would call
    evidence-based medicine which relies on efficacy data, which
    basically means that these are studies that are done in sterile
    conditions. These are studies that are done not at the
    University of Washington or not where you practice. So there is
    a limitation on the generalizability of those studies.
        The idea of inserting measurement at every clinical
    encounter in your clinic is called effectiveness, not efficacy.
    Hence, the comparative effectiveness research that basically
    shows me, so my program is a large program, has a trauma
    hospital, Harbor View Medical Center, has the University of
    Washington Medical Center, has Children's, has the VA Puget
    Sound Health Care System.
        The results of the quality from treatments from opioids or
    epidurals or any other treatments are very different from site
    to site. So, without the ability to say what is the progress of
    our patients, it is very difficult to give an idea of what is
    the right thing to do.
        So again, in my disclosures, I always say I do not like
    opioids, I do not hate opioids; I do not like epidurals, I do
    not hate epidurals; and I am agnostic to integrative medicine.
    Just show me that it works. When I asked my providers before we
    had the system, how are your patients doing, they would say
    fine. I would say, how do you know? Because there are no
    complaints.
        The only feedback that we had at that time was if someone
    would knock on your door and say that one of your patients died
    from an overdose. That is too late. So I lead from the
    assumption that each and every provider in my large division
    wants patients to get better and would feel very uncomfortable
    if they would get a report card, either on each patient, or at
    the end of the month, that says these are the type of patients
    that you are not improving.
        So it is key, and it is unfortunately missing in many of
    the strategic plans of the large stakeholders, in the DoD-VA
    task force, in the Office of National Drug Control Policy
    strategies, even in the Institute of Medicine report. I do not
    think that the idea of measurement is explicit enough to allow
    policymakers to say, this simply has to be practiced, like in
    any other thing in medicine. We measure hemoglobin A1C for
    sugar, we measure blood pressure for hypertension. I do not ask
    someone, are you thirsty and they say, yes, and determine the
    dose of insulin according to that.
        I want to know pain, pain interference, mood, function,
    physical function. What do you want to achieve, and how are we
    going to get that? That transforms the way patients think about
    pain. It transforms the way we, as providers, think about it,
    so it improves the dialogue, and it also improves our ability
    to aggregate these reports and make decisions.
        Senator Rockefeller. Well, you are an extraordinary,
    thoughtful group, and very direct. So how is your morale as you
    go to work every day? This is a serious question. Do you jump
    out of bed and say, I cannot wait to get to work, or is the
    burden of practicing medicine in America these days--I mean,
    medical schools are filled with people. It used to be that we
    were losing doctors in West Virginia, now we are gaining
    doctors. They want to come.
        A lot of people want to go and practice rural medicine,
    maybe much more so than some years ago. The new health care
    bill, which everybody loves to hate but I do not, has I think
    $10 billion for rural health clinics, new ones, which can take
    advantage of all this mentoring over media. I mean, it is all
    very exciting to me. So, that was a rather awkward question on
    my part, but I am interested. Please?
        Dr. Schwab. Some days the morale is very low when you look
    at all the challenges, all the things that you cannot
    accomplish. However--and I wish I would have brought it with
    me--I just today received a letter from one of our members, an
    83-year-old gentleman who said, I cannot thank you enough for
    what you have done for me and my wife. I would not be here
    today if you had not done--and he went on to describe how his
    medications were changed and he was now able to be more
    cognizant and take care of his disabled wife. It is a letter
    like that that says this is all really worth it.
        Senator Rockfeller. Well, it is like the example I gave in
    my opening statement.
        Dr. Schwab. Very similar.
        Senator Rockfeller. Yes. Yes, that is great.
        Please?
        Dr. Coben. Senator, I am on the front lines in the
    emergency department. I enjoy what I do, and it is a privilege
    to serve the State of West Virginia and other places that I
    have worked throughout the country. I think there is great
    hope, great promise for some of the new technologies that are
    rolling out in health care.
        I think the parts that frustrate many of us are what I
    alluded to earlier: the fragmentation in care, the inability
    for patients to have primary care providers and gain access to
    those providers. That is not just in rural communities, that is
    everywhere.
        Gaining access to the physician in a timely manner, so that
    patients who come to the emergency department, who truly have
    emergencies and need emergent conditions addressed, that is the
    part that frustrates us. Of course, there are also the other
    business aspects of the chart-keeping and record-keeping, et
    cetera, et cetera. But the practice of medicine, I think, is
    exciting and still stimulating and invigorating.
        Senator Rockfeller. Well, is the computer helping you on
    the paper frustration part?
        Dr. Coben. No.
        Senator Rockfeller. No? All right.
        Dr. Coben. I think that it certainly has its benefits and
    has great potential. It is still yet to be realized, I think,
    in many places. But it has not diminished the time that we have
    to put into the record-keeping part of what we do.
        Senator Rockfeller. Any other comments? Then I promise to
    leave you alone.
        Dr. Cahana. Sir, I feel very fortunate, as chief of the
    Division of Pain Medicine at the University of Washington,
    which is the birthplace of modern pain medicine--the first pain
    clinic in the world was actually there----
        Senator Rockfeller. I did not know that.
        Dr. Cahana. And it is very appropriate that the thoughtful
    leaders that we have there are trying to use this epidemic, and
    true challenge, and turn it into an opportunity to reflect
    better about pain, suffering, and health care and health care
    delivery.
        So I do share Dr. Schwab's sentiment that one day we will
    laugh about this, it just simply will not be today. But this is
    a great opportunity, and I would not want to be anywhere else
    but in this place. Thank you, sir.
        Senator Rockfeller. Terrific. Thank you.
        Mr. Millwee. Well, I add to that enthusiasm. Now is the
    best time in the world, in my mind, to be a Medicaid director.
    There are so many things that are happening, and it is exciting
    being on the forefront of that and laying the groundwork for
    some things that will probably come to fruition in 2015 and
    2016 around how we are going to move this program from
    basically a transactional kind of payment process to really
    transformational.
        We are looking at improving quality, addressing potential
    preventable events, laying the groundwork for electronic
    medical records. We are building a great future right now.
    Sure, it is a lot of work, but it certainly is gratifying.
        Senator Rockfeller. Great. Well, I totally thank you all
    for coming. Hearings are important because often they are
    carried on C-SPAN. People learn from them, we learn from them.
    We cannot do this on our own. We need you to guide us and help
    us. The fact that you have been so honest has been very, very
    helpful to this hearing. So, I thank you for your cooperation.
    Whatever you are going to do for the rest of the day, I hope it
    is as helpful as this morning.
        The hearing is adjourned.
        [Whereupon, at 11:50 a.m., the hearing was concluded.]

                                A P P E N D I X

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