[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
U.S. GOVERNMENT PRINTING OFFICE
79-378 WASHINGTON : 2012
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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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