[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
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing 
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC 
area (202) 512-1800 Fax: (202) 512-2104  Mail: Stop IDCC, Washington, DC 
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

              Additional Material Submitted for the Record

                              ----------                              




[GRAPHIC] [TIFF OMITTED] 79378.002

[GRAPHIC] [TIFF OMITTED] 79378.003

[GRAPHIC] [TIFF OMITTED] 79378.004

[GRAPHIC] [TIFF OMITTED] 79378.005

[GRAPHIC] [TIFF OMITTED] 79378.006

[GRAPHIC] [TIFF OMITTED] 79378.007

[GRAPHIC] [TIFF OMITTED] 79378.008

[GRAPHIC] [TIFF OMITTED] 79378.009

[GRAPHIC] [TIFF OMITTED] 79378.010

[GRAPHIC] [TIFF OMITTED] 79378.011

[GRAPHIC] [TIFF OMITTED] 79378.012

[GRAPHIC] [TIFF OMITTED] 79378.013

[GRAPHIC] [TIFF OMITTED] 79378.014

[GRAPHIC] [TIFF OMITTED] 79378.015

[GRAPHIC] [TIFF OMITTED] 79378.016

[GRAPHIC] [TIFF OMITTED] 79378.017

[GRAPHIC] [TIFF OMITTED] 79378.018

[GRAPHIC] [TIFF OMITTED] 79378.019

[GRAPHIC] [TIFF OMITTED] 79378.020

[GRAPHIC] [TIFF OMITTED] 79378.021

[GRAPHIC] [TIFF OMITTED] 79378.022

[GRAPHIC] [TIFF OMITTED] 79378.023

[GRAPHIC] [TIFF OMITTED] 79378.024

[GRAPHIC] [TIFF OMITTED] 79378.025

[GRAPHIC] [TIFF OMITTED] 79378.026

[GRAPHIC] [TIFF OMITTED] 79378.027

                             Communications

                              ----------                              




[GRAPHIC] [TIFF OMITTED] 79378.029

[GRAPHIC] [TIFF OMITTED] 79378.030

[GRAPHIC] [TIFF OMITTED] 79378.031

[GRAPHIC] [TIFF OMITTED] 79378.032

[GRAPHIC] [TIFF OMITTED] 79378.033

[GRAPHIC] [TIFF OMITTED] 79378.034

[GRAPHIC] [TIFF OMITTED] 79378.035




                                   


