[Senate Hearing 115-441]
[From the U.S. Government Publishing Office]
S. Hrg. 115-441
UNINTENDED CONSEQUENCES: MEDICAID AND THE OPIOID EPIDEMIC
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HEARING
before the
COMMITTEE ON
HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
UNITED STATES SENATE
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
JANUARY 17, 2018
__________
Available via the World Wide Web: http://www.fdsys.gov
Printed for the use of the
Committee on Homeland Security and Governmental Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
U.S. GOVERNMENT PUBLISHING OFFICE
31-264 PDF WASHINGTON : 2019
COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
RON JOHNSON, Wisconsin, Chairman
JOHN McCAIN, Arizona CLAIRE McCASKILL, Missouri
ROB PORTMAN, Ohio THOMAS R. CARPER, Delaware
RAND PAUL, Kentucky HEIDI HEITKAMP, North Dakota
JAMES LANKFORD, Oklahoma GARY C. PETERS, Michigan
MICHAEL B. ENZI, Wyoming MAGGIE HASSAN, New Hampshire
JOHN HOEVEN, North Dakota KAMALA D. HARRIS, California
STEVE DAINES, Montana DOUG JONES, Alabama
Christopher R. Hixon, Staff Director
Gabrielle D'Adamo Singer, Chief Counsel
David N. Brewer, Chief Investigative Counsel
Douglas C. Geho, Counsel
Jerry F. Markon, Senior Policy Advisor
Margaret E. Daum, Minority Staff Director
Stacia M. Cardille, Minority Chief Counsel
Courtney C. Cardin, Minority Counsel
Laura W. Kilbride, Chief Clerk
Bonni E. Dinerstein, Hearing Clerk
C O N T E N T S
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Opening statement:
Page
Senator Johnson.............................................. 1
Senator Peters............................................... 4
Senator Paul................................................. 19
Senator Lankford............................................. 23
Senator Jones................................................ 26
Senator Harris............................................... 28
Senator Hoeven............................................... 30
Senator Daines............................................... 33
Prepared statement:
Senator Johnson.............................................. 45
Senator McCaskill............................................ 47
Senator Peters............................................... 52
WITNESSES
Wednesday, January 17, 2018
Sam Adolphsen, Former Chief Operating Officer, Department of
Health and Human Services, State of Maine, and Vice President,
Rockwood Solutions, and Senior Fellow, Foundation for
Government Accountability...................................... 6
Otto Schalk, Prosecuting Attorney, Harrison County, State of
Indiana........................................................ 8
Emmanuel Tyndall, Inspector General, State of Tennessee.......... 10
David A. Hyman, M.D., J.D., Professor of Law, Georgetown
University Law Center.......................................... 12
Andrew Kolodny, M.D., Co-Director, Opioid Policy Research
Collaborative, Heller School for Social Policy and Management,
Brandeis University............................................ 14
Alphabetical List of Witnesses
Adolphsen, Sam:
Testimony.................................................... 6
Prepared statement........................................... 56
Hyman, David A. M.D., J.D.:
Testimony.................................................... 12
Prepared statement........................................... 69
Kolodny, Andrew M.D.:
Testimony.................................................... 14
Prepared statement........................................... 74
Schalk, Otto:
Testimony.................................................... 8
Prepared statement........................................... 64
Tyndall, Emmanuel:
Testimony.................................................... 10
Prepared statement........................................... 66
APPENDIX
Charts submitted by Senator Johnson.............................. 83
Letter to HHS and CMS............................................ 87
Majority Staff Report............................................ 91
Minority Staff Memo with attachments............................. 255
Statements submitted for the Record from:
Center on Budget and Policy Priorities....................... 389
Andrew Goodman-Bacon, Assistant Professor of Economics,
Vanderbilt University Emma Sandoe, doctoral candidate,
Harvard University......................................... 392
Maine Attorney General Janet Mills........................... 405
Planned Parenthood........................................... 407
Brendan Saloner, Assistant Professor John Hopkins Bloomberg
School of Public Health.................................... 409
Responses to post-hearing questions for the Record from:
Mr. Kolodny.................................................. 412
UNINTENDED CONSEQUENCES: MEDICAID AND THE OPIOID EPIDEMIC
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WEDNESDAY, JANUARY 17, 2018
U.S. Senate,
Committee on Homeland Security
and Governmental Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10:03 a.m., in
room SD-342, Dirksen Senate Office Building, Hon. Ron Johnson,
Chairman of the Committee, presiding.
Present: Senators Johnson, Paul, Lankford, Hoeven, Daines,
Heitkamp, Peters, Hassan, Harris, and Jones.
OPENING STATEMENT OF CHAIRMAN JOHNSON
Chairman Johnson. Good morning. This hearing will come to
order.
I want to first of all thank all the witnesses for taking
the time to appear, for taking the time to prepare your
testimony, and I look forward to your oral testimony and your
answers to our questions.
On its surface, people may be scratching their heads going,
``Why is the Homeland Security and Governmental Affairs
Committee (HSGAC) holding a hearing on potential Medicaid or
other Government Federal funding of the opioid crisis? Why are
you doing that in this Committee?'' We actually have a pretty
long history of delving into this particular epidemic, this
particular health care crisis.
My own involvement started with reports at the Tomah
Veterans Affair (VA) health care facility where there was
overprescription, mixed toxicity of drugs resulting in the
death of a young Marine because of drug toxicity, and finding
that within that investigation we had, what was it, about a
350-page report, 5,000 pages of supporting documents we also
noticed a drug diversion potential within that investigation.
This Committee has held three field hearings in Wisconsin, a
field hearing in Ohio, one in New Hampshire, one in Arizona. I
proposed the Promoting Responsible Opioid Prescribing (PROP)
Act, which the Centers for Medicare and Medicaid Services (CMS)
actually viewed as so important that they implemented it
without us having passed the law, which is kind of nice.
Senator Portman has been very active on this front, coming
from Ohio--one of the States really stricken by this epidemic--
instrumental in the passage of Comprehensive Addiction and
Recovery Act (CARA), and in proposing the Synthetics
Trafficking and Overdose Prevention (STOP) Act. Both Senator
Portman and myself, and Senator Hassan, were at the White House
last week for the signing of the International Narcotics
Trafficking Emergency Response by Detecting Incoming Contrband
with Technology (INTERDICT) Act, which funded and authorized
detection devices for fentanyl, which is becoming more and more
of a problem. And, of course, my Ranking Member--I appreciate
Senator Peters filling in--but Senator McCaskill has been very
aggressively pursuing the marketing through pharmaceutical
companies and seeing how we can solve the problem from that
aspect.
So this Committee has been highly involved in this, and I
just want to kind of lay out specifically why I got involved in
this particular issue. It started with a pretty interesting,
pretty depressing article written in Commentary Magazine by
Nick Eberstadt, a demographer who works for the American
Enterprise Institute. In that article, he was quoting Alan
Krueger, the former Chairman of President Obama's Council of
Economic Analysis, and Mr. Krueger published a report talking
about prime, working-age male labor-force dropouts. He said
nearly half of all prime-age, working-age male labor-force
dropouts, an army now totaling roughly 7 million men, currently
take pain medication on a daily basis.
He went on to quote the author of ``Dreamland,'' Sam
Quinones. This resonated with me, having been a former
employer, and I realize that for an awful lot of people, one of
the primary motivating factors for getting a job is to get
health care. And when you combine government programs that
provide free health care and then on top of that a government
program that provides you a prescription card that allows you
access to products at a very low price that you can sell and
divert into illegal drug-trafficking markets and supplement
your income to the tune of thousands of dollars per year,
unfortunately some people take advantage of that.
Mr. Quinones is quoted in that article out of his book
``Dreamland,'' and I just want to read the quote. He was
actually referring to Portsmouth, Ohio, when he was talking
about this: ``The Medicaid card pays for medicine--whatever
pills a doctor deems that the insured patient needs. Among
those who receive Medicaid cards are people on State welfare or
on a Federal disability program known as Supplemental Security
Income (SSI). . . . If you could get a prescription from a
willing doctor--and Portsmouth had plenty of them--the Medicaid
health insurance cards paid for that prescription every month.
For a $3 Medicaid co-pay, therefore, addicts got pills priced
at thousands of dollars, with the difference paid for by U.S.
and State taxpayers. A user could turn around and sell those
pills, obtained for that $3 co-pay, for as much as $10,000 on
the street.''
Later on, Nick Eberstadt just writes, ``Disability checks
and means-tested benefits cannot support a lavish lifestyle.
But they can offer a permanent alternative to paid employment,
and for growing numbers of American men, they do.''
Now, again, that article piqued my interest, and so I asked
my staff--I said, OK, this is kind of being laid out there, not
necessarily as a theory but anecdotally, showing a real
problem. And so I asked my staff: Can you take a look, do a
data search and find out and just identify individuals that
have been either convicted or at least charged with taking
their Medicaid card, obtaining those pills, and then selling
those on the open market? In 4 days they identified 261
defendants that had either been charged or convicted of doing
just that.
OK. We have a problem that needs to be further explored,
and so we did explore it, and today we are issuing a report\1\
based on our further study in which, again, the staff has
uncovered over 1,000 defendants that have either been charged
or convicted of using their Medicaid cards and diverting in
some way, shape, or form.
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\1\ The staff report referenced by Senator Johnson appears in the
Appendix on page 91.
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Along the road, even though we are focusing on Medicaid, we
have discovered about 243 defendants in the context of
Medicare. In November 2017 there were 60 active criminal
investigations of opioid diversion through the VA health care
system. So, again, this is a governmentwide program phenomenon
where American taxpayers are providing well-intentioned funds
into some of these programs, and those funds are being utilized
to divert drugs, sell them on the open market, and in some
cases fuel some pretty interesting criminal enterprises or just
support a lifestyle of non-work, which is not healthy.
I have as a follow-up today issued a letter\2\ to the
Acting Secretary of Health and Human Services (HHS) asking what
controls, what can we do, to what extent are they tracking
this, to what extent are they aware of how much money we spend
on Medicaid and Medicare that is being used in this case.
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\2\ The letter to HHS referenced by Senator Johnson appears in the
Appendix on page 87.
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Now, I do want to point out what I am not saying either in
this report or in this hearing. I am not making the claim that
this
epidemic is just because of Medicaid expansion. Obviously,
there are more dollars available through Medicaid expansion.
There are some indications--HHS had a study that we had to
extract from them--showing that there may be a difference
between Medicaid expansion States versus non-expansion States.
But this crisis, this epidemic, began way before Medicaid
expansion.
I also am not saying that Medicaid does not help an awful
lot of people and the dollars used for treatment have not
helped untold numbers of people. I am not saying this is a
primary cause. I think what we are certainly saying is this is
an unintended consequence. It is certainly a contributing
factor, and it maybe enables something that maybe should not be
enabled, and it is a very serious problem that has to be looked
at. And, again, coming from the stand point of the problem-
solving process, I think it is kind of hard to deny when you
take a look at this report, take a look at some of these
examples--and we have 110 of some of the most egregious
examples in here involving drug rings, a grocery store being
used as kind of a central port, pharmacists, and nursing homes.
Again, it is almost hard to understand the complexity of some
of these schemes, for example a podiatrist actually injecting
chemicals to create pain so he can prescribe more opioids and
facilitate diversion for profit.
So the schemes are actually really beyond your imagination,
but people use their imagination, so it is kind of hard to
deny, when you take a look at these examples, that this is not
a problem that needs to be further explored. And I am just
saying that we ignore this aspect--and it is just an aspect of
this overall epidemic--we ignore that aspect, this particular
phenomenon, this reality, at our own peril.
So, again, I want to thank the witnesses. I look forward to
your testimony, and I will turn it over to my substitute
Ranking Member, Senator Peters, for his opening comments.
OPENING STATEMENT OF SENATOR PETERS\1\
Senator Peters. Well, thank you, Mr. Chairman. Today, as
you mentioned, I am filling in for Ranking Member McCaskill who
wanted to be here but due to extenuating circumstances cannot
be here. But I would like to ask unanimous consent to include
her opening statement\2\ and a memorandum prepared by the
Committee's Democratic staff into the hearing record today.\3\
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\1\ The prepared statement of Senator Peters appears in the
Appendix on page 52.
\2\ The prepared statement of Senator McCaskill appears in the
Appendix on page 47.
\3\ The Memorandum prepared by the Minority Staff appear in the
Appendix on page 255.
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Chairman Johnson. Without objection.
Senator Peters. Thank you, Mr. Chairman.
Before I begin my statement, I would also like to welcome
our new colleague to the Committee, Senator Doug Jones. Welcome
to this Committee. Congratulations on your election. You are
going to find this a very interesting Committee, one doing very
important work, and we know you are going to do an outstanding
job. Thank you for joining us.
Chairman Johnson. While you said that, I wanted to wait
until Senator Jones actually showed up. I also want to welcome
you to this Committee. I think you will find hopefully in the
hearing today, we do not do show trials here. This is really a
very bipartisan Committee. We conduct ourselves at that level
of decorum, and it is really about uncovering the truth, laying
out realities so you can solve problems. Again, I want to
congratulate you on your election and was really pleased--and
we spoke earlier--that you joined our Committee. I think you
will enjoy your time here as well.
Sorry for interrupting.
Senator Peters. No. That is good. Thank you.
At the start, I think before we start this hearing and hear
the testimony from the folks before us, I think it is important
to reiterate that Medicaid expansion has produced not only
historic coverage gains, but it also has very far-reaching
positive health effects for American families. At its core
Medicaid and the Affordable Care Act (ACA's) Medicaid expansion
are critical programs that help hardworking American families
enroll in health care coverage and protect our Nation's
vulnerable.
Nearly 80 percent of Medicaid enrollees come from a working
family, and over 40 percent of Medicaid enrollees are children.
Medicaid is a program that literally saves lives. I think we
can all agree that when you or your family member or friend
gets sick or hurt, we should be able to access affordable
health care coverage. Medicaid and Medicaid expansion serves as
a bridge to affordable health care for millions of working
families in our country. And I am sure we have all heard
stories, but just as a reminder, these programs are there to
make sure that someone's parent can have that needed surgery or
a child's family can afford the high cost of their cancer
treatment or that a person who has been injured can get care
that they need to get back to work.
Medicaid has also been critical in fighting the opioid
epidemic. Opioid abuse and its tragic impact continues to be a
growing problem in my home State of Michigan, as it is around
the Nation. Between 2014 and 2015, the Centers for Disease
Control (CDC) report that drug overdose deaths in Michigan
increased by over 13 percent. In 2015, more than 2 million
people across the Nation struggled with prescription pain
reliever substance abuse disorder, an unfortunate number that
continues to trend upward.
As we work to combat this very serious epidemic, the
Affordable Care Act has greatly expanded access to treatment in
Michigan and across the Nation, including for individuals with
substance abuse disorders. Prior to the passage of the ACA,
many individuals with substance abuse disorders were unable to
get the care that they needed.
Since the passage of the Affordable Care Act, the uninsured
rate in Michigan has been cut in half, and more than 600,000
individuals are now enrolled in our State's Healthy Michigan
expanded Medicaid program. Combined with the private exchanges
in our State, nearly 900,000 individuals in Michigan have
coverage through the Affordable Care Act. Many of these
individuals are now able to access health care insurance for
the very first time in their lives.
Since the ACA's Medicaid expansion went into effect, more
than 1.6 million Americans have gained access to this vital
treatment.
Last year, this Committee, the Homeland Security and
Governmental Affairs Committee, the Subcommittee that I am a
Member of, which is the Permanent Subcommittee on
Investigations, had a hearing on the opioid epidemic, and we
heard from witnesses who, like each of you here today, are
fighting on the front lines. I spoke with Dr. Thomas Gilson, a
medical examiner from Cuyahoga County, who told me how Medicaid
expansion is literally helping them save lives by getting
people suffering from addiction into treatment programs.
I also spoke with Thomas Synan, Jr., chief of police for
Newtown, Ohio, and he largely agreed with Dr. Gilson and went
on to tell me, and I am going to quote him here, ``To reduce
demand and in turn reduce supply, we have to get people into
treatment, and one of the programs our teams are doing out
there in the Hamlin County area is signing people up for
Medicaid to try to get them into that treatment.''
Their overwhelming message to me was that we must preserve
Medicaid and work to improve the critical health services that
the program offers because it is literally saving people's
lives each and every day.
And so today I appreciate each of you being here today, and
I look forward to hearing about how we can work to improve our
Nation's Medicaid program to better serve the families enrolled
and to continue our efforts to combat the abuse. I have no
doubt that there are improvements that can be made, and we are
going to hear about some of those improvements today, and I
look forward to your suggestions. But I want to end by
stressing as we make these improvements, we must do it in a way
that does not jeopardize the health care for those who so
desperately need it.
Thank you.
Chairman Johnson. Thank you, Senator Peters.
I would also ask consent that my prepared opening remarks
be entered into the record.\1\ Without objection.
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\1\ The prepared statement of Senator Johnson appears in the
Appendix on page 45.
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As we are welcoming Senator Jones, we also have to say
good-bye to Senator Tester, who has been a very valued Member
of this Committee. We hate to see him leave, but, again, we are
happy to have Senator Jones.
I do need to announce a change in the Subcommittee
membership to make it official: Senator Hassan will replace
Senator Tester on the Permanent Subcommittee on Investigations,
and Senator Jones will replace Senator Hassan on the
Subcommittee on Federal Spending Oversight and Emergency
Management. So that makes it all official.
Now, it is the tradition of this Committee to swear in
witnesses, so if you will all stand and raise your right hand.
Do you swear that the testimony you will give before this
Committee will be the truth, the whole truth, and nothing but
the truth, so help you, God?
Mr. Adolphsen. I do.
Mr. Schalk. I do.
Mr. Tyndall. I do.
Dr. Hyman. I do.
Dr. Kolodny. I do.
Chairman Johnson. Please be seated.
Our first witness is Sam Adolphsen. Mr. Adolphsen is Vice
President at Rockwood Solutions and a Senior Fellow at the
Foundation for Government Accountability (FGA). Mr. Adolphsen
previously served as the Chief Operating Officer (COO) at the
Maine Department of Health and Human Services. He also served
as Maine's Deputy Commissioner of finance with oversight over
the State's Medicaid budget. Mr. Adolphsen.
TESTIMONY OF SAM ADOLPHSEN,\2\ FORMER CHIEF OPERATING OFFICER,
DEPARTMENT OF HEALTH AND HUMAN SERVICES, STATE OF MAINE, AND
VICE PRESIDENT, ROCKWOOD SOLUTIONS, AND SENIOR FELLOW,
FOUNDATION FOR GOVERNMENT ACCOUNTABILITY
Mr. Adolphsen. Chairman Johnson, Members of the Committee,
thank you for the privilege of testifying.
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\2\ The prepared statement of Mr. Adolphsen appears in the Appendix
on page 56.
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For 3 years, starting in 2014, I sat in my office in Maine,
and I watched something terrible unfold right in front of me. I
would review Medicaid pharmacy spending in one meeting, and
then I would walk down the hall for my next meeting about the
opioid crisis and how to stop it. And the only thing increasing
as fast as the budget line for opioids was the body count from
overdose deaths.
In the morning I would read a newspaper account of someone
caught up in a drug arrest, and that afternoon I would see that
same person again when reviewing welfare enrollment data. It
happened far too often.
Our welfare fraud team worked daily with drug enforcement
agencies to investigate when Medicaid members sold their pills
or Suboxone strips or traded their welfare cards for heroin. I
worked with the Medicaid Fraud Control Unit as we reviewed
cases of caregivers diverting pain pills from desperate and
dying Medicaid patients. I wish these were isolated incidents,
but they are not. The paths of dependency on Medicaid and
addiction to opioids are often intertwined.
At the same time I was helping to run a Medicaid program
that was funding record-breaking amounts of opioids, the Nation
was being told that the solution to the drug problem was to put
more people on Medicaid. Medicaid expansion was held up as the
silver bullet solution to the drug crisis. But no one was
considering the dangerous side effects of Medicaid. And the
danger of prescription opioids is now better understood. They
are the gateway to addiction. Four out of five heroin users
started by abusing prescription drugs.
When that free plastic Medicaid card is issued, it does not
only pay for drug treatment. It also supplies opioids at a
staggering rate. The numbers are alarming. A quarter of
Medicaid members get an opioid prescription, and the highest
rate is among the Medicaid expansion population of able-bodied
adults. A CDC study done by the Obama Administration showed
that someone on Medicaid was six times more likely to die from
an opioid overdose. While one out of every five people is on
Medicaid, the program pays for two out of every five emergency
room trips for opioid and heroin poisonings. Medicaid expansion
has not fixed this problem, but it might have made the problem
worse.
Rhode Island increased their Medicaid enrollment by 66
percent, and their overdose deaths doubled. West Virginia,
Ohio, Pennsylvania, all expanded Medicaid, adding a total of a
million and a half adults to the program. They rank first,
second, and third, respectively, in the number of drug overdose
deaths.
Of the 10 States with the highest rate of opioid deaths,
nine have expanded Medicaid under Obamacare. This correlation
is very concerning, and the question of causation begs for more
inquiry.
As millions of adults have been added to the program,
prescription drug abuse has multiplied. With no out-of-pocket
costs and few restrictions on providers, prescription
painkillers have flowed unfettered to Medicaid recipients, and
this injected a whole new supply of free opioids into the
market.
I also witnessed people on Medicaid withdrawing from the
community, not working, living an isolated and idle life that
is more prone to drug abuse and addiction. Fifty-two percent of
able-bodied adults on Medicaid, half, do not work. And this is
really tragic because we know that for so many, work is the
best answer to move away from a life of crime or addiction.
Rather than expanding a broken program that funds pain
pills, we should focus on breaking the cycle of pain and
dependency by helping people get back to work.
This drug problem is bad enough. We have to make sure that
Medicaid is not throwing fuel on the fire. We need to make sure
that Medicaid is not funding the drug problem but instead is
structured to promote work and health for our neighbors.
Thank you.
Chairman Johnson. Thank you, Mr. Adolphsen.
Our next witness is Otto Schalk. Mr. Schalk is the
Prosecuting Attorney for Harrison County, Indiana. In addition,
Mr. Schalk produced the film ``A Hit of Hell,'' a documentary
about the opioid epidemic. Mr. Schalk.
TESTIMONY OF OTTO SCHALK,\1\ PROSECUTING ATTORNEY, HARRISON
COUNTY, STATE OF INDIANA
Mr. Schalk. Thank you. Good morning. My name is Otto
Schalk, and I am the prosecuting attorney for Harrison County,
Indiana. We are a community in southern Indiana that in many
ways is representative of much of our Nation. I am honored to
serve my county and my State as a prosecutor, and I am humbled
to be before you this morning. I embrace this opportunity to
share with you what many of us in law enforcement see and deal
with on a daily basis.
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\1\ The prepared statement of Mr. Schalk appears in the Appendix on
page 64.
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Every time a hardworking American pays their taxes, they
are inadvertently funding drug dealers with a new supply of
high-powered opioids that are poisoning our schools and our
streets. That is a bold claim; however, as a prosecutor, it is
something that I see routinely. It is no secret that our
Medicaid program is ripe for fraudulent activity. Prosecutors
knows this, doctors know this, and the reality is that drug
dealers know this as well. An individual need not only traffic
illegal street drugs to qualify as a drug dealer; a Medicaid
beneficiary that is selling their prescription pills is no
different in the eyes of the law.
It bears mentioning that those who are impoverished are far
more susceptible to end up in the criminal justice system.
Anyone who has spent a day in a criminal courtroom across
America knows this to be true. In my role as prosecuting
attorney, I have prosecuted at an extreme disproportionate rate
those that are Medicaid recipients. I see the disparity each
and every time I walk into court. For a reference point, just
looking at the reported data from our county from clients that
are on probation that are in an alcohol and drug rehabilitation
program, more than half of them are making less than $10,000
per year.
In the simplest of terms, whether it is labeled as Medicaid
fraud or drug dealing, it exists for the same reason that bank
robberies occur. There is a pile of cash, and those will ill
intentions will let greed lead them to commit crimes. Now,
common sense dictates that when we give someone making less
than $10,000 per year, that is struggling to keep the lights
on, that is struggling to put food in the refrigerator, and we
give a 90-count bottle of hydrocodone each and every month, and
some of these pills are going for $15 apiece on the street, tax
free, they are going to see the opportunity for financial gain.
If we believe otherwise, we are naive.
Unlike other street drugs such as heroin or meth, a dealer
in opioids does not need to have someone that is well connected
in the drug culture to funnel their supply. A dealer in opioids
simply needs to know a willing doctor and claim to have an
ailment. And if the opioid dealer is on Medicaid, they receive
their supply of high-powered narcotics for free or nearly free.
Simply polling our jail and our probation officers, I found
that most of our inmates and probation clients that are on
probation for drug-related charges are taking pursuant to a
valid prescription two to four high-powered opioids each and
every day. That is 60 to 120 pills they are being prescribed
each month.
Now, conservatively, some of these pills are going for $30
apiece on the street. The incentive to opt out of Medicaid, to
better one's lot in life, is drastically reduced for
individuals that are making $3,600 a month tax free in selling
their prescription pills that they are getting at no cost.
To that extent, the abuse that we see among Medicaid
recipients as it relates to misuse and/or selling their
prescriptions is rampant, and that is just based on what we are
seeing and what we are filing. And those of us in law
enforcement know that we are only catching a very small
percentage of those committing these crimes. A reactive justice
system, coupled with a shortage of resources, often leads to a
small percentage of the bad actors being caught. A true number
of those that are abusing the system would likely be
staggering.
Now, to be clear, I am not here this morning saying that
Medicaid is not a tremendous asset for our Nation, but I am
speaking from my own personal experiences as a prosecutor, a
prosecutor in the trenches. I see firsthand what is devastating
our communities. I see day in and day out individuals that are
Medicaid recipients dealing and abusing their prescription
pills that are government funded. It is simply a fact. I see
individuals getting arrested for selling their prescriptions,
and yet they test clean for them when they are drug-tested
during the jail booking process.
So is the opioid epidemic an unintended consequence of
Medicaid? Certainly, with the increased amount of the
impoverished having access to medical care, there is a greater
likelihood that those who are impoverished are going to see the
opportunity for turning a profit, albeit illegal, on the
street. Now, one obvious solution would be to create more
rigorous checks and balances of the medical bills being
submitted through Medicaid for payment. Are the prescriptions
necessary? Is the opiate prescriptions in line with the
treatment plan? I have never understood why so many of the
people that I am prosecuting are getting prescription after
prescription of high-powered opiates when a simple over-the-
counter drug would be just as effective.
The opioid epidemic has brought devastation to our schools
and our communities. The opioid epidemic is far too complex to
narrow its causation to one specific issue. And while the
issues are complex and many, there is one recurring theme, and
that is poverty. Until we take affirmative steps to create
jobs, grow businesses, and slowly diminish the gap between the
impoverished and the middle class, any changes that are made
will be a Band-Aid fix to the underlying problem.
I want to sincerely thank each of you for the opportunity
to be a part of the solution of this gripping epidemic. I look
forward to answering any questions that you may have.
Chairman Johnson. Thank you, Mr. Schalk.
Our next witness is Emmanuel Tyndall. Mr. Tyndall is the
Inspector General (IG) for the State of Tennessee. Prior to
becoming Inspector General, Mr. Tyndall served with the
criminal investigation division as a special agent for 10 years
investigating TennCare cases, TennCare is Tennessee's Medicaid.
He has approximately 35 years of law enforcement experience and
holds master's degrees in health and human performance,
management, and criminal justice administration. Mr. Tyndall.
TESTIMONY OF EMMANUEL TYNDALL,\1\ INSPECTOR GENERAL, STATE OF
TENNESSEE
Mr. Tyndall. Thank you, Mr. Chairman and Committee Members.
As the Chairman said, I am Manny Tyndall. I am the Inspector
General for the Office of Inspector General (OIG) in Tennessee.
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\1\ The prepared statement of Mr. Tyndall appears in the Appendix
on page 66.
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In 2004, the Office of Inspector General was created
specifically to root out fraud and abuse in the TennCare
program and criminally prosecute applicants and recipients who
game the system. And as the Chairman alluded to, TennCare is
simply our name for the Medicaid program in the State of
Tennessee.
The Office of Inspector General receives and triages more
than 4,000 complaints each year. I think you will find that
Tennessee is one of a few, if not the only State that
criminally prosecutes Medicaid applicants and recipients who
engage in drug-seeking behavior or prescription drug diversion
at the cost of the TennCare program. Our research indicates
that States bordering Tennessee address recipient fraud
administratively. I believe that suggests that Medicaid fraud
is probably underreported nationwide.
What I would like to share with you today is some examples
of how the TennCare program is defrauded and how prescription
drugs paid for by TennCare are diverted for illegal use.
Approximately 80 percent of all arrests--2,400 of our
arrests--were prescription drug diversion or doctor-shopping
related; the ages ranged between 21 and 78; 1,678 arrests were
for drug diversion, which includes sale and forgery.
The courts have ordered approximately $315,000 in
restitution to be repaid to the Bureau of TennCare for these
offenses; 709 arrests were for doctor shopping. Our doctor-
shopping law became effective June 18, 2007. Since that date,
the courts have ordered approximately $292,000 in restitution
to be repaid to the Bureau of TennCare for those offenses.
Some of the schemes I have been witness to include:
Recipients receiving valid prescriptions for prescription
drugs, having it filled and paid for by TennCare, and then
selling a portion of the medication on the street.
Recipients are calling in prescriptions to pharmacies
pretending to be employees of a medical practice and having
TennCare pay for that medication.
Recipients are passing forged or altered prescriptions,
written by other parties, and then passing those prescriptions
at pharmacies and having TennCare pay for that medication.
Recipients are adding medication to a prescription being
hand-carried between doctor's office and the pharmacy and
having TennCare pay for that medication. For example, they may
receive a prescription for amoxicillin and between the doctor's
office and the pharmacy, they will add hydrocodone to that
prescription and have TennCare pay for that medication.
Doctor shopping. Doctor shopping is where a recipient fails
to advise a provider that within the last 30 days they have
already received the same or similar narcotic medication that
is being prescribed. There are usually multiple counts of this
offense.
Nurses and medical technicians are selling prescriptions
already signed by the doctor. Some of those prescriptions have
sold for as much as $80.
We work very closely with our drug task forces who make the
buys. Normally, one, two or three pills are purchased each time
during a drug transaction, and usually three buys are made
before we seek an indictment.
Depending on the type of medication and the milligram,
prescription medication can sell for $5 to $10 per pill or some
medications as much as $1 per milligram.
With there being little or no cost/overhead to the Medicaid
recipient, if they were to sell an entire prescription of 90
hydrocodone 5-milligram tablets for $5 per pill, they would
make approximately $450. If they did this every month it would
garner approximately $5,400 a year, and that is a very
conservative estimate. That is for one person for 1 year, and
we make approximately 140 or more arrests each year. I am
confident that many instances of TennCare fraud are not
identified.
The following cases demonstrate the lengths some people
will go to to obtain pain medication:
A husband and wife would take turns intentionally burning
themselves on their lower legs with boiling water and go to a
different emergency room to obtain pain medication and have
TennCare pay for the ER visit and the medication.
We have charged four individuals for a fourth offense of
doctor shopping.
We have charged one individual with 25 counts of
prescription drug fraud where she forged or altered
prescriptions in order to obtain hydrocodone and oxycodone and
used her TennCare benefits to pay for the medication. She
admitted to selling the pills to support her lifestyle.
I personally worked a case where I charged a young woman
with 87 counts of obtaining a controlled substance by fraud,
TennCare fraud, and identity theft. She was the office manager
at a doctor's office and would steal several prescription slips
from a prescription pad each week. She would forge the doctor's
signature and the Drug Enforcement Administration (DEA) number
on prescriptions in her name, her husband's name, many of her
friends, and even her grandmother's name. Some prescriptions
were paid for by TennCare, and some she would trade for half of
the medication that person received.
Mr. Chairman, thank you for the opportunity to speak, and I
am willing to answer any questions the Committee might have.
Chairman Johnson. Thank you, Mr. Tyndall.
Our next witness is Dr. David Hyman. Dr. Hyman is a
physician and a professor of law at the Georgetown University
Law Center. Dr. Hyman focuses his scholarship on the regulation
and financing of health care. Dr. Hyman.
TESTIMONY OF DAVID A. HYMAN, M.D., J.D.,\1\ PROFESSOR OF LAW,
GEORGETOWN UNIVERSITY LAW CENTER
Dr. Hyman. Thank you, Mr. Chairman and Members of the
Committee. Much of my testimony is drawn from a book that is
going to be coming out in April, co-authored with Professor
Charles Silver, on the American health care system. The book is
titled ``Overcharged: Why Americans Pay Too Much for Health
Care, and it explains how the ways in which we have decided to
pay for health care services have predictable consequences on
the cost and quality of those services, as well as the rates of
waste, fraud, and abuse. Our public programs are particularly
vulnerable to the latter set of problems.
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\1\ The prepared statement of Dr. Hyman appears in the Appendix on
page 69.
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Today we are here to focus on the opioid epidemic. I
commend the Committee for holding this hearing. Although a lot
of what we have heard so far has been about the death rate, it
is also important to note the opioid crisis has consequences in
terms of destroyed lives, broken families and marriages,
medical expenses, and lost productivity.
My testimony flags four distinct issues: the seriousness of
the problem; the complexity of the causes; the ways in which
the design of our public programs make them particularly
vulnerable to the sorts of abuse and overuse of the sort that
you have already heard about; and the role that patients have
played in this particular problem. In the interest of time, I
am going to focus on the latter two issues.
In terms of the role of the causes, it is important to note
that these are prescription opioids, and apart from outright
theft, you need a prescription from a physician in order to get
them. There is a serious problem with overprescription. The
causes of that are somewhat complex, but there are certainly
bad-actor physicians out there who are willing to meet their
patients in coffee shops and restaurants, write them
prescriptions in exchange for cash. The book talks about one
Dr. Yee who was responsible for essentially a mini-epidemic of
opioid usage. There are particular parts of the country that
have these problems. South Florida had so many pain clinics
that the State earned the nickname ``Oxy Express.'' And so that
again is an indication of the nature of the reimbursement
system that enables these situations to develop.
Now, both Medicare and Medicaid were designed to mimic Blue
Cross and Blue Shield programs circa 1965, that is, indemnity-
based insurance where the amount that was paid was tightly
controlled but the volume of services was really not
controlled. If a physician said you needed something, the
insurance paid for it. There was not much in the way of
networks or preapprovals or utilization review.
Over time the private market has evolved, but the public
payers have remained largely passive bill payers. The results,
as we observe in our book, are easy to observe with
prescription drug fraud. The government has studied
prescription drug fraud in public programs repeatedly, and each
time it has concluded that fraud is rampant. A 2009 Government
Accountability Office (GAO) report on the Medicaid programs in
five large States opened with the observation that
investigators ``found tens of thousands of Medicaid
beneficiaries and providers involved in potential[ly]
fraudulent purchases of controlled substances, abusive
purchases of controlled substances, or both.'' Sixty-five
thousand beneficiaries had engaged in ``doctor shopping.'' Four
hundred individuals had gotten prescriptions for controlled
substances from between 21 to 112 medical practitioners and
visited up to 46 different pharmacies to get them filled. As
long as you have a prescription, it will be filled, and the
public payers will pay for it.
Now, we have taken various steps to try and address these
problems, including surveillance, prior approval, limitations
on the number of pills that can be dispensed, disclosure of
information to physicians about the risks of overprescription,
and prescription drug monitoring databases. Each of these
reforms has the potential to help reduce inappropriate
prescribing, but design details make a big difference, as does
implementation. And the fact they are necessary shows how the
design features of Medicare and Medicaid make them vulnerable
to waste, fraud, and abuse.
Last, the role of patients. The tendency is to focus on
providers, but patients are often involved in prescription drug
fraud. A 2011 GAO report involving Medicare found that doctor
shopping was widespread, with more than 170,000 Medicare
beneficiaries receiving prescriptions for controlled substances
from five or more medical practitioners. Another study found
that half a million Medicare beneficiaries were prescribed
excessive amounts of opioids, including 22,000 who appeared to
be doctor shopping. So the problem is not limited to Medicaid.
It is not limited to public programs. But the design features
of the public programs make them more vulnerable.
Thank you very much.
Chairman Johnson. Thank you, Dr. Hyman.
Our final witness is Dr. Andrew Kolodny. Dr. Kolodny is a
physician and the co-director of Opioid Policy Research at the
Heller School for Social Policy and Management at Brandeis
University. He previously served as chief medical officer for
Phoenix House and as chair of psychiatry at Maimonides Medical
Center, New York.
Chairman Johnson. Dr. Kolodny.
TESTIMONY OF ANDREW KOLODNY, M.D.,\1\ CO-DIRECTOR, OPIOID
POLICY RESEARCH COLLABORATIVE, HELLER SCHOOL FOR SOCIAL POLICY
AND MANAGEMENT, BRANDEIS UNIVERSITY
Dr. Kolodny. Thank you for the opportunity to appear before
you today. I would like to also thank Ranking Member McCaskill
and Members of the Committee for this opportunity.
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\1\ The prepared statement of Dr. Kolodny appears in the Appendix
on page 74.
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The opioid crisis is an epidemic of opioid addiction,
meaning that the reason the United States is experiencing
record-high levels of opioid overdoses, the reason we are
seeing a soaring increase in infants born opioid-dependent,
outbreaks of injection-related infectious diseases, impact on
the workforce, the driver behind all of these health and social
problems has been a sharp increase in the number of Americans
suffering from opioid addiction.
The primary driver of the opioid addiction epidemic has
been made clear by the CDC. This slide is a CDC graph.\2\ It
shows that as opioid prescribing began to soar in the 1990s, it
led to parallel increases in opioid addiction and overdose
deaths. This is an epidemic caused by the medical community
overprescribing opioids. On this graph the green line
represents opioid prescribing, the red line represents opioid
deaths, and the blue line represents opioid addiction. As the
green line went up, as opioid prescriptions began to soar, it
led to parallel increases in addiction and overdose deaths.
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\2\ The graph referenced by Mr. Kolodny appears in the Appendix on
page 78.
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The reason the green line began rising, the reason the
medical community began prescribing so aggressively is because
we--doctors--were responding to a brilliant, multifaceted
marketing campaign that changed the culture of opioid
prescribing. Starting in the 1990s, we began hearing that
patients were suffering because we were too stingy with
opioids. We began hearing that we should stop worrying about
getting patients addicted. We began hearing that even with
long-term use, the risk that a patient would get addicted was
much less than 1 percent.
We would have been less gullible if we were only hearing
these messages from drug company sales reps. But we were
hearing these messages from pain specialists, eminent in the
field of pain medicine; we were hearing it from professional
societies, from the Joint Commission, which accredits our
hospitals; we were hearing it from the Federation of State
Medical Boards--all of whom had financial relationships with
opioid manufacturers.
I would like to thank Ranking Member McCaskill for
launching an investigation of these relationships.
It is fair for you to ask about the role played by
Medicaid, and it is fair to assume that access to medical
providers offered by the Medicaid program could increase the
risk that an individual would develop a disease frequently
caused by doctors' prescriptions. I believe that access to
prescribers that Medicaid, Medicare, and commercial insurance
offers does increase the likelihood that someone might develop
a disease caused by prescriptions. But I do not believe that
Medicaid should be singled out in this regard. Opioid overdoses
have been increasing in people with all types of insurance and
in people from all economic groups from rich to poor.
If you look at this graph--it is from a recent Health
Affairs paper--you will see the orange line at the top of this
graph.\1\ That represents people admitted to hospitals being
treated for overdose insured by Medicare. You can see with all
of the colors of the lines rising on this graph, they show that
we have seen a rise in hospital admissions for opioid overdoses
for all types of insurance, but what we see on this graph is
that the fastest-growing share of hospitalizations for opioid
overdose has been Medicare, not Medicaid. Medicare
beneficiaries went from the smallest proportion of these
hospitalizations in the 1990s to the largest share by the mid-
2000s.
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\1\ The graph referenced by Mr. Kolodny appears in the Appendix on
page 79.
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I also do not believe Medicaid expansion is making the
epidemic worse. Medicaid expansion is not responsible for the
very sharp increase we have seen in opioid overdose deaths over
the past few years. The reason we are seeing a sharp increase
in opioid overdose deaths, as you know, is because of fentanyl.
Medicaid expansion has not led to more aggressive opioid
prescribing. Since 2012, we have seen opioid prescribing
trending down, thank heavens. The opioid crisis is getting
worse, again, most rapidly in the States that have the most
fentanyl.
Chairman Johnson, you have made the point that Medicaid is
not a silver bullet for tackling opioid addiction. I agree with
you. Medicaid is far from a silver bullet. With regard to
improving access to effective addiction treatment, Medicaid is
necessary, but it is not sufficient. The addiction treatment
services that health insurance, including Medicaid, can pay for
must also be available. The first-line treatment for opioid
addiction is buprenorphine, also called ``Suboxone.'' Access to
this treatment is not sufficient. For opioid-addicted
individuals who are fortunate enough to access buprenorphine,
too often their health insurance, including Medicaid, is only
paying for the prescription. Patients with insurance must often
pay out of their own pocket for the visit to the doctor. This
is because there are not enough doctors prescribing
buprenorphine, and the few who do do not accept insurance,
including commercial and Medicare. And many State-licensed drug
and alcohol treatment programs that do accept Medicaid are not
offering medication-assisted treatment.
If you look at the last chart with these horizontal
lines,\2\ that is showing you individuals who are receiving
medication-assisted treatment within the State-licensed system.
The fact that these lines are pretty much flat shows that,
despite our worsening opioid addiction epidemic, we have not
been increasing access adequately to medication-assisted
treatment.
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\2\ The chart referenced by Mr. Kolodny appears in the Appendix on
page 82.
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If we want to see opioid overdose deaths start to decline,
there will need to be a massive Federal investment to build a
treatment system that does not exist yet. I believe Medicaid is
a necessary ingredient to make these programs viable. We must
ensure that in every county in the United States an opioid-
addicted American can walk into an outpatient treatment center
and on that same day receive effective treatment regardless of
their ability to pay for it. Until that happens, I believe
overdose deaths will remain at record-high levels.
Thank you.
Chairman Johnson. Thank you, Dr. Kolodny.
I am going to defer my questions except for one, and if you
would quickly put up the chart with opioid-related hospital
stays,\1\ because you had a similar chart and I just kind of
want to get your reaction to this. We actually developed this
off of the hard numbers in terms of the numbers of tens of
thousands of people, and we plotted this chart with, inpatient
stays per 100,000, the difference between Medicaid-paid versus
private insurance-paid, and it reflects a pretty large
difference dating back many years, with a slight uptick from
about 350 per 100,000 to close to 450 per 100,000 for Medicaid-
paid stays. Can you kind of explain that difference right
there?
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\1\ The chart referenced by Senator Johnson appears in the Appendix
on page 85.
---------------------------------------------------------------------------
Dr. Kolodny. It would be difficult to explain without
reading through the full paper. The chart that I showed is from
a Health Affairs paper that was published a few weeks ago,
which has very current data in it, and I am more familiar with
that data. Those were hospital admissions involving opioid
overdoses, and what we saw in that chart was a very significant
rise for all payer types, including self-pay. And what we saw
in the Health Affairs paper is a very substantial increase for
Medicaid but an even greater increase for Medicare.
Chairman Johnson. Medicare, OK. Again, these numbers come
from Health and Human Services, and all we did is just take it
and put it to number of stays per 100,000 just to make it a
little bit more relatable.
With that, I will turn it over to Senator Peters.
Senator Peters. Thank you, Mr. Chairman, and thank you to
each of our witnesses for your testimony today.
If I could summarize what I heard from everyone--hopefully
this is accurate--there is a recognition as to how important
Medicaid is as a health provider for Americans who have the
ability to access that and that health care should be quality
health care that is affordable and accessible to everyone, and
that this is not an indictment on that part of Medicaid, that
we are going to continue to strengthen that if we can and make
it work better. But there are some issues that we should be
talking about, and certainly dealing with the opioid addiction,
these are important issues that should be discussed and we
should figure out what is going on.
Dr. Kolodny, I want to pick up on your comments in
particular and have you expand. I understand that Medicaid
beneficiaries do fill more opioid prescriptions. We do know
that from some of the evidence out there. But I also know that
during your time in New York City, you worked with Medicaid
beneficiaries extensively. You served as a Medicaid provider at
one point. Could you help this Committee understand why
Medicaid patients, particularly individuals who qualify through
disability and other issues related to that, would be
prescribed more opioids? Is there something unique about the
Medicaid population that we should be aware of?
Dr. Kolodny. I would really like to see that data. I am not
certain that we see far more opioid prescribing in Medicaid
populations. One of the populations, for example, where we have
seen very aggressive prescribing would be workers' comp. We see
very aggressive prescribing in Medicare Part D. So we know that
people with access to doctors and, in particular, people who
are prone to injuries are going to be--and older people who are
going to complain of pain are going to be most likely to be
prescribed opioids. It is older Americans that are receiving
the most opioid prescriptions.
Senator Peters. Dr. Hyman, if you could talk a little bit
about some of the work that you have done in this area and
tracking use from folks in various medical plans as well. There
is certainly a difference, and what we have heard here is that
wherever there has been Medicaid expansion, there is increased
opioid use and addiction. That may very well be a correlation,
and correlations do exist, but it does not necessarily mean
there is causation.
Do you believe this is merely a correlation or is there
also causation that Medicaid expansion has led to increases in
opioid addiction?
Dr. Hyman. I believe correlation.
Senator Peters. Simply correlation. Would you elaborate?
Dr. Hyman. Based on the evidence that I have seen, it
appears to be correlation, not causation--I am sorry. I
neglected my thing. Based on the evidence I have seen, I would
classify it as correlation, not causation.
Senator Peters. Could you expand on some of that evidence?
Dr. Hyman. So, the first thing that you--this is a general
observation that I tell my students. Just because A comes
before B does not mean that A causes B. Right? You need to look
at preexisting trends, and if you look at preexisting trends in
the States that expanded Medicaid, you see that they had higher
opioid usage before the Medicaid expansion, which obviously was
2014. And so, you need to control for that prior trend in order
to infer whether there is a sort of bump that is attributable
to Medicaid. But even then, you need to control for other
differences between the States that did not expand Medicaid,
and you cannot do that just by cherrypicking individual States.
The other thing you want to do, obviously, is look not just
at the States that expanded Medicaid but also the States that
did not expand Medicaid and see what happened there, and look
at the States that expanded Medicaid that did not experience
finding themselves at the top of the distribution of States in
terms of their death rate. And so, just because A precedes B or
seems to go along with B does not mean that A causes B. It is
sort of Statistics 101.
Senator Peters. You also talked in your testimony about
some of the structural aspects of Medicaid, and I have heard
directly from physicians in Michigan with concerns that
insurers in Federal health programs in particular like Medicaid
often have policies that limit access to less addictive pain
medications. I think our goal should be to look for
alternatives that are not as addictive. You mentioned the issue
in your testimony briefly and suggested that we need to change
the ways that we reimburse for certain pain management
treatments.
So within our Federal health programs, how can we do more
to incentivize less addictive pain treatments?
Dr. Hyman. So to the extent less addictive pain treatments
are more expensive, you are going to need to start paying for
more expensive pain treatments rather than just the cheapest
one, and that is an issue that, as my written testimony
indicates, has been leveled against private payers as well as
public payers.
Second is you basically need to move away from an open-
ended passive payer of bills to a much more active monitoring
role in dealing with the, thankfully, relatively small number
of true bad actors but also creating better incentives for both
providers and patients not to overprescribe opioids nor to
abuse them.
Senator Peters. Dr. Kolodny, in your written testimony, you
talked about the need to improve access to medication-assisted
treatments, and I have recently introduced some bipartisan
legislation with Senators Capito and Murkowski in the Senate
called the ``YOUTH Act,'' which aims to increase access to
these treatments, particularly for young adults and adolescents
who, as you know, are often precluded from receiving these
treatments.
I would like you to comment on that and whether or not it
is necessary for us to expand some of these treatment options
for adolescents, who are also very susceptible to these
addictions.
Dr. Kolodny. It absolutely is necessary, and adolescents
are a group that may have even less access to some of the most
effective treatments for opioid addiction because of the bias
or stigma against treating opioid addiction with medication.
Something I would just like to add a little more to was my
comment about patients not having access to buprenorphine
treatment paid for by their insurance. What is all too often
the problem is that patients can access the medication, their
Medicaid or their private insurance will pay for the
prescription, but there really is not enough access to
treatment programs that accept the patient's insurance. So with
Medicaid expansion, I think there are people who now are on
buprenorphine for their opioid addiction because they have
Medicaid that will pay for that prescription, and that
prescription may be keeping them alive, but the Medicaid
expansion has not helped them access the visit. And if we
really want to see overdose deaths go down, where we want to be
is in a place where someone who is opioid addicted, when they
get up in the morning, and they are going to need to use very
quickly after they get up, or they are going to be feeling very
sick. People who continue to use, it is not because it is fun.
They are using because they have to keep using to avoid feeling
awful. If for that individual finding a treatment center that
can treat their opioid addiction with medication is more
difficult, more expensive, they have to pay that doctor out of
their own pocket, even if they have the prescription coverage,
if all of that is more expensive than calling a drug dealer and
buying a bag of heroin, they are going to buy the bag of
heroin. If we want to see overdose deaths come down, we have to
change that balance. Effective treatment for opioid addiction
has to be easier and less expensive than buying a bag of dope
if we want to see deaths come down.
Senator Peters. Great. Thank you.
Chairman Johnson. Before I turn it over to Senator Paul, I
just want to chime in one more time.
Put up the one chart. Again, I think I have been very
careful. Let me repeat, I agree that correlation does not mean
causation, but this was an analysis that we got from HHS last
year, and what they are just trying to show is, anecdotally,
they compared States with a similar type of demographics,
similar type of population, expansion versus non-expansion, and
from my standpoint the results were somewhat stark: West
Virginia, 27 percent increase in overdoses; Mississippi, 11
percent; Ohio, 41 percent, versus Wisconsin, 3 percent;
Maryland, 44 percent now; Virginia, 22 percent; New Hampshire,
108 percent, versus Maine at 55 percent; North Dakota, 205
percent, versus South Dakota at 18 percent. Again, expansion
versus non-expansion. Again, not saying it is causation, but it
is this kind of information that would--and I will just ask,
Dr. Hyman, it at least makes you curious and suggests that
something ought to be further explored, don't you agree?
Dr. Hyman. Oh, I certainly agree it should be further
explored, and you have 10 States. There are obviously 50,
right?
Chairman Johnson. Right. Again, this is just an analysis
based on data, not a scientific study by any means. But you
have other data that also says once Medicaid has been funding
this, you throw more money into Medicaid, it might kind of help
fuel it as well.
Dr. Hyman. I think it is certainly worth study. I would
note that the four States on the right have relatively low
populations, and so even a small increase can have a big
percentage impact. This is part of the process that you have to
go through.
Chairman Johnson. Right. Again, all I am saying is it is
worth dismissing. Let us put it that way. We should not dismiss
it. Senator Paul.
OPENING STATEMENT OF SENATOR PAUL
Senator Paul. I think we can argue that the increase in
opioids that we have seen with Medicaid expansion might be
unintended, but I do not think we can argue that it is
unforeseen. You can argue causation and correlation all day
long, but if the Medicaid population was using opioids at a
greater amount than the non-Medicaid population before the
expansion, if you give Medicaid more money, you are going to
see the same thing, and more money will simply exacerbate
something. So if they were prescribing opioids at twice the
rate before, maybe they are still doing it at twice the rate.
So Medicaid expansion did not cause prescribers to prescribe it
more, but if they are already doing it and you fuel it with
more money, you are going to get more of a problem.
So I think it is very predictable, and if you throw more
money at Medicaid now and you do not have rules on prescribing
or you do not have significant changes on prescribing, you are
going to get more of the problem.
I agree with some of the issues on Suboxone and replacement
and rehab. All of those things would be good. But if you do not
fix the rules on prescribing--and normally I would say this is
a State problem and we should not be involved. But all the
money is Federal now, so it is 100 percent Federal in the
Medicaid expansion.
So I guess one question I would have for the Chairman is:
Do you have any ideas or thoughts--we want to do problem
solving--about how we would change the prescribing habits other
than just suggestions? I think suggestions are not enough here,
actually.
Chairman Johnson. Well, again, I am not the witness here,
but actually, what I want coming out of this hearing is to
focus on that thought process. One of the reasons I have
written a letter to HHS, is to let us get the information, let
us get the data, and then we can work with the experts. What
can we do to change the prescribing methodology, those types of
procedures so that we stop overprescribing and we can actually
effectively address this?
Senator Paul. Mr. Adolphsen, do you have any ideas on how
we would change prescribing habits through law?
Mr. Adolphsen. Thank you, Senator. There are a couple of
things that are already in law that I think States are not
using well. I know Maine was not when we arrived there.
Prescription monitoring in the Medicaid program, there is a
program called ``Lock-In'' where you restrict a Medicaid member
to one pharmacy, one doctor, one prescriber. Those programs are
not used very effectively or are not used extensively in
States. There is somewhat of an obsession with access in the
Medicaid departments around the country, I think, and so it
seems that folks are sometimes shy to do things that might
restrict someone from that access. But I think the Lock-In
program is good.
There are other controls, certainly. There is a drug
utilization review program that is already in Medicaid, again,
but not being used well. The bottom line is the money flows
through Medicaid, and people, I think, view Medicaid as more
than it is. It is really, as another witness said, a passive
payer. And so they are not looking at a person holistically.
And, causation, I have seen it line by line. I have seen a
person access their welfare benefit, and a couple days later we
see them in the data with an overdose. That is causation, and I
think we can find that level of detail if you look at the
States. But it needs more control.
Senator Paul. I think, though, overall we are going to need
a much more dramatic change in how we prescribe. I mean, Sam
Quinones in his book talks about that it used to be physicians
were worried about addiction, and in chronic pain we did not
tend to use opioids as much. And some of this came from Big
Pharma trying to change patterns of prescriptions; it came from
within the pain community. And it came from distorting one
study that talked about inpatient people on opioids that had
really nothing to do with outpatient treatment and was misused
to say that we could use opioids on an outpatient without any
consequences.
So I think it has to be very dramatic, and I think it is
going to have to actually be in law. As much as I am for
freedom of the physician to prescribe stuff, if it is Federal
money, we are going to have to oversee the Federal money, and
we are going to have to figure out a way to say maybe other
than terminal patients and a few other people, it needs to be
something else. And you talk about expense. I have had a lot of
experience with pain myself. Ibuprofen I think works in a
fabulous way, and it is very cheap. But we have convinced
patients that it is not good unless it is prescription, unless
it is good stuff, unless it is a narcotic it is somehow not a
good painkiller. But ibuprofen is a very potent painkiller,
particularly in higher doses.
But something dramatic is going to have to happen, and I
promise you, if we just throw more money at this, the problem
will get worse. We have one county in Appalachia, and we got
rid of the really bad doctors. We have done some of the
controls that the States have tried. And last year, I think it
was 20,000 people got 2.8 million doses of opioids in one
county, 150 doses per man, woman, and child. And this is after
we have spent years in Kentucky really rooting out the bad
doctors and doing some good things, and yet it is still an
enormous problem.
So I think what we have to look at, Mr. Chairman, I think
we have to look at the money. We are in charge of the money for
the Medicaid expansion, and we are in charge of a good chunk of
the Medicaid program. We need to put in place some rules on
this. There is going to have to be a dramatic change in this. I
am not so sure OxyContin should be used for chronic pain at
all. So, I mean, we really probably need to get away from that,
but we cannot have suggestions. What we tend to do up here is
we write into law suggestions, and they never happen. This is a
real epidemic, and we are fools to sit up here and say
causation versus correlation. People are dying in Medicaid, and
we are giving it away for $3. If we cannot get over the fact
that you give people free medication and then we overprescribe
it that there is going to be a problem. We have to have
significant rules in place.
And, Mr. Schalk, you mentioned something about the payment
with Medicaid, whether or not there could be more rules
attached to how we pay people for opioids that might lead to
improvement. Do you want to expound on that?
Mr. Schalk. Sure. So, in addition to--I said that I
ordinarily see the impoverished that walk through the courtroom
doors, but I have also prosecuted a prominent medical doctor in
my community for committing Medicaid fraud, and what that
illustrated to me was how susceptible Medicaid patients are to
being victims of doctors that are committing Medicaid fraud
themselves. And I want to say, as a whole, I believe the
medical community is well intentioned and is seeking out a
healthier community. But as we all know, it only takes one bad
actor in a community to really exploit an already dangerous
situation.
And so what we were seeing was that this doctor's Medicaid
patients, his prescription practices were far different than
his prescription practices with non-Medicaid patients. And due
to how vulnerable that segment of the community is, whether
that is through drug addiction or criminal behavior, what we
were finding was they were being treated differently. And I
think if you talk to any prosecutor in any part of the country,
they are going to tell you all their defendants, they always
have that one go-to doctor that they seek out. We call them
``pill mills'' in law enforcement because that is really how we
view them.
By regulating what the doctors are doing--and just like
you, I am all for freedom in the medical community. However, I
think we need to hold doctors more accountable. Are there
prescriptions in line with the treatment program? As a
prosecutor, it is very difficult to go after a medical doctor
that is committing Medicaid fraud because they are insulated
under this treatment of care defense.
However, what is the difference between a doctor that is
prescribing pills that are not necessary and the person who is
dealing heroin on the street? They are both making a profit by
selling something that is not needed.
And so I think that we need to hold our medical community
to a higher standard as it relates to the egregious
prescription practices. I think you are absolutely correct,
Senator, that we have to regulate prescriptions.
Chairman Johnson. I am going to burn up more of my first-
round time here. Your comment begs the question: How are they
treating the Medicaid patient differently than their normal
patients?
Mr. Schalk. What we found was that the volume of
prescriptions that were being prescribed, what was different
than the non-Medicaid prescription clients--now, in the case
that we had, it was a very intricate set of facts, but in terms
of--they were coming in testing dirty for meth, testing dirty
for heroin, and yet they were still being given prescription
after prescription, and from a medical perspective, I do not
see how that is a viable or plausible solution.
Chairman Johnson. I want to quickly ask the doctors. We
held a roundtable in Oshkosh, and I asked the doctors--I did
not intend to bring this up, but it ties into this--we probably
had a couple dozen doctors, and I just said, if there is one
thing--this is about health care in general--if there is one
thing that was a problem in health care, can you say what it
was? And one doctor brought it up: Medicaid. And they all shook
their head. And it shocked me. I said, ``Describe that.'' And
they were talking about the high percentage of no-shows in
appointments in Medicaid versus non-Medicaid patients. The
reason I bring it up is because I wonder to what extent are
doctors just giving somebody on Medicaid a month or 2-month
supply of opioids so they do not have to schedule another
appointment to have a no-show? Is that part of the kind of
real-world reality that occurs? I will just ask the doctors on
that. A legitimate question.
Dr. Kolodny. So I do not think that the problem you are
describing is unique to Medicaid, no-shows, for example. You
could see it with patients with any type of insurance. I think
there are problems that add to overprescribing that have to do
with our health care system, so that if a doc has 10 or 15
minutes to spend with a patient, writing a prescription is
usually the quickest way to get the patient out of your office.
And, it was mentioned earlier about paying for alternatives to
treating pain with medication. It is not so much that payers
will not cover physical therapy. But if you are a doctor with
10 minutes to spend with a patient, finding an in-network
physical therapist for your patient, then making that referral
is going to take a lot more time than writing the prescription.
And usually the patient just wants the prescription.
So, I think we have a health care system that incentivizes
treating lots of medical problems with a prescription pad.
Chairman Johnson. Well, again, across the board patients do
not pay for the products they get, by and large.
Dr. Hyman, do you want to quickly chime in? Then we will go
to Senator Lankford.
Dr. Hyman. Yes, I certainly agree that writing a
prescription is often an easy way to bring the clinical
interaction to a close. I have also heard from many physicians
about frustrations of dealing with Medicaid. Sometimes that is
about the populations covered by Medicaid. Sometimes that is
about the Medicaid program itself, which has bureaucratic rules
and often pays slow and not very much. And that is at least the
perception among physicians.
Chairman Johnson. Thank you. Senator Lankford.
OPENING STATEMENT OF SENATOR LANKFORD
Senator Lankford. Thank you, Mr. Chairman.
Let me bounce several questions and give you a practical
example of this, what we have talked about already. In
Oklahoma, there is currently a physician going through the
process right now that saw 90 patients a day and was writing
narcotics 'scripts to almost every one of them as they came
through. Ninety a day, on average, between 15 to 30 seconds per
person that he actually saw them before he was writing a
'script. So it is an issue that we have to resolve, and
obviously locating these individuals and then identifying them
and prosecuting them becomes exceptionally important.
I have a different angle on this that I want to be able to
bring up. Mr. Schalk, you brought up in your testimony about
Suboxone. You brought that up as well. The question I have is:
In your testimony you had mentioned that that is being
diverted. That is a drug designed to be able to help people get
off of narcotics. That is now being diverted to being on the
street as well as a narcotic. Can you talk me through what you
are seeing there?
Mr. Schalk. Yes, well, first, I am not an expert in
addiction, but from a street-level prosecutor, we see Suboxone
being heavily trafficked in our community.
Now, the flip side of that is we see other forms of opiate
treatment, like Vivitrol, for instance, it is an injection, and
we see the success rates far higher in our community with those
having an injection as an opioid blocker as opposed to
Suboxone. That is not taking away from the benefits of
Suboxone, but I can tell you in southern Indiana, it is heavily
trafficked illegally.
Senator Lankford. OK. Any other comments on that? Go ahead.
Dr. Kolodny. I think that the diversion of Suboxone onto
the black market needs to be understood. Many of the
individuals who are buying Suboxone on the black market are
using it in a somewhat self-therapeutic way, and I think with
diversion of opioids onto the black market, there are really
two things that you have to think about and that we would have
to be concerned about.
One is whether or not the diverted opioids onto the black
market are causing new cases of addiction or more people
becoming addicted because of that diversion, which, if that is
happening, it would be making our opioid addiction epidemic
worse.
And the other thing you would want to be concerned about is
whether or not the diverted opioid is contributing to overdose
deaths. In the case of diverted buprenorphine, buprenorphine is
a very different type of opioid. A young person who is
interested or curious about experimenting with opioids, if that
young person makes the mistake of experimenting with
buprenorphine, they are very likely to have a bad reaction to
that drug, and it is not like they are going to be feeling
lousy for a few hours and then they go home at the end of the
party. It is a very long-lasting drug. They are likely to feel
very sick. They are likely to not want to do that again.
Where you can see people get a euphoric effect from
diverted buprenorphine is if they are an experienced opioid
user and they have been off of opioids. Then they can feel good
about it.
So I do not think that diverted buprenorphine is becoming a
recreational drug causing new cases of addiction. And one of
the unique properties of buprenorphine is that it is quite hard
to overdose on. It has a ceiling on its effect. So even a
patient who takes an extremely large dose or someone trying to
get high by taking extra doses is unlikely to overdose, is
unlikely to have respiratory depression. So I think the
existence of this black market for buprenorphine has more to do
with the fact that we are not making that treatment available
to the people who need it.
Senator Lankford. OK. Thank you, by the way.
Senator Paul was mentioning as well that we are trying to
figure out some way to be able to actually come up with some
solutions in the process of this. Mr. Adolphsen, you had
mentioned about pharmacy lock-ins. Oklahoma uses that, my
State. Has that been successful? Not successful? What have you
seen in locations like that?
Mr. Adolphsen. So my impression of it, Senator, is that it
is being used in a number of States, but not very aggressively.
So you might find in a State with hundreds of thousands of
people on Medicaid, a couple hundred people in the lock-in
program because the parameters of----
Senator Lankford. They are identifying high risk.
Mr. Adolphsen. Yes, the parameters are designed, though,
again, with access in mind. They do not want to----
Senator Lankford. OK. What about States experimenting with
limiting dosage for opioids?
Mr. Adolphsen. I can say in my State of Maine we were very
aggressive a couple years ago in limiting both the strength and
length of prescriptions. It was not without controversy, but
the early data coming back from Maine is that it has been very
effective.
Senator Lankford. What about electronic prescriptions
rather than paper prescriptions for opioids?
Mr. Adolphsen. In that same law that was passed in Maine,
they did a required prescription monitoring program requiring
docs to enter it each time. Again, not without controversy, but
it has so far early on proven to be helpful.
Senator Lankford. Obviously, there was a question on cost
on that for physicians. There is a difference in input in
personnel time to be able to do it as well as the equipment
itself to be able to do it in the system. What have you seen on
that versus what was threatened to be what the cost is and what
the actual cost is in the transition?
Mr. Adolphsen. I do not have the exact cost, but I know at
the department level we provided free training. We used the
number of grants that we had for fighting the opioid crisis in
order to help educate doctors, go into a hospital, help set it
up. I think that is probably something that is a good thing to
do, help on the cost side. But, it is an administrative burden,
but I would argue probably one that could be worth it in this
case.
Senator Lankford. Mr. Tyndall, did you all experiment with
any of that in Tennessee?
Mr. Tyndall. Yes, sir. Senator, thank you for the question.
We started our monitoring database in 2006. We did not have
anything before that, and we started it in 2006, and we have
had a number of enhancements since then. And it is free to all
physicians. Any medical provider that is enrolled, it is free
of charge. And now we have had some enhancements where it is
mandated that every medical professional has to enroll into the
system as well as the pharmacist. So we monitor any drug
prescribed or dispensed in the State of Tennessee, two through
four. It is somewhat similar to the Kentucky All Schedule
Prescription Electronic Reporting (KASPER) program in Kentucky,
and that is the only State we kind of communicate with.
Senator Lankford. That was actually my next question. Is
there cooperation with other States and sharing that
information? If you live in Memphis, that is very different
than a number of States that you might have the opportunity to
be able to go outside of the State to be able to use it.
Mr. Tyndall. Right. There are eight States that border
Tennessee, and the only one that we really communicate with is
Kentucky. We have a reciprocal agreement, I guess, to share the
monitoring of prescription drugs two through four.
Senator Lankford. But they could not use, for instance,
Medicaid, which is just part of what we are talking about
today, but the Medicaid portion of it, they could not use in an
out-of-State pharmacy, or they could?
Mr. Tyndall. There are a number of rules, exceptions to all
of that. Sometimes if it is an emergency and you are out of
State, you can use your Medicaid benefits to do that. But I am
not sure about all those exceptions that go with that.
Senator Lankford. One last quick question. If you are
buying Sudafed in Oklahoma, you have to be able to show a
driver's license to be able to do that, and it is tracked on
just the usage of Sudafed regardless of where you get that. Is
there any system like that that has been discussed or is in
place on narcotics?
Mr. Tyndall. Very similar in Tennessee. You have to sign a
log and produce a photo ID to get Sudafed.
Senator Lankford. What about for narcotics?
Mr. Tyndall. Part of our Controlled Substance Monitoring
Database (CSMD) now, you have to present an ID when you pick up
any kind of narcotic from the pharmacy. You also have to do
that as well.
Senator Lankford. OK. Thank you.
Mr. Tyndall. And one more thing, if I could add. Effective
yesterday, with few exceptions TennCare will only pay for a 15-
day supply of opioid medication within a 6-month period. So we
have reduced it significantly to get opioids for a 6-month
period in Tennessee.
Senator Lankford. OK. Thank you.
Thank you, Mr. Chairman.
Chairman Johnson. Senator Jones, you are next in line for
questioning.
OPENING STATEMENT OF SENATOR JONES
Senator Jones. Thank you, Mr. Chairman.
Having come from a State that did not expand Medicaid and
probably has one of the most restrictive Medicaid eligibility
requirements in the country, we still have an incredible opioid
problem. And I appreciate Senator Paul's comments because what
I am seeing in Alabama is a prescriber problem more than
anything else. And I am curious, having been an old prosecutor
myself, Mr. Schalk, can you give me an idea of--and I know this
may be difficult, but how many of those folks that are being
prosecuted for taking those prescriptions and selling the pills
or doctor shopping, do you have an idea, a sense of how many of
those people actually started out addicted to those opioids and
they need the money and that is driving it, as well as just
being generally impoverished?
Mr. Schalk. Sure. I think certainly addiction plagues the
criminal justice system, and we often throw around the term
``drug dealer'' very loosely. And we have many kinds of drug
dealers in the criminal justice system. We have those that deal
for profit, and then we have those that deal to feed their own
addiction.
Senator Jones. Right.
Mr. Schalk. I would say those that deal to feed their own
addiction make up the overwhelming majority of those that are
in our prisons.
Senator Jones. So if that is the case, do you have a
process in place when you arrest somebody, do they get
treatment? Is there a drug court or something like that that
you can put these folks in to try to keep them out of the
system a little bit better but to try to deal with that
addiction so there is not recidivism?
Mr. Schalk. We are blessed in my county to be small enough
to have a tailor-made program for many of the individuals that
are coming through the criminal justice system. If you go just
a few minutes down the road to Louisville, which is, obviously,
a much larger metropolitan area, it is much more streamlined.
They just simply do not have the resources or ability. And so,
yes, I think being able to make a tailor-made treatment program
for an individual is a key ultimately to their success, and
that includes--and a lot of time defendants do not want to hear
this--being sober. And when you are struggling with opiate
withdrawals, in my opinion, the best place sometimes to
experience those are within a jail where we know you are going
to be sober, you are not going to go out, and you are not going
to use again.
But once we can have 90 days of sobriety, at that point we
can then start exploring options, treatment programs that are
available.
Senator Jones. I have also noticed in some of the charts
that we have seen, I guess, there seems to be--the private
payers seem to be doing a little bit better in terms of the
opioid problem. What are the private payers doing differently
than Medicaid that Medicaid can learn from to try to stem the
prescriptions to begin with, which I think is a big problem? I
will just throw that open to anybody that might have a proposal
or an answer.
Dr. Kolodny. The explanation for why in the past few years
we are seeing, for example, less hospitalizations paid for by a
private insurance versus Medicare involving opioid overdose is
not really clear. It is possible, as your question suggests,
that there are things that the private payers are doing that
maybe Medicare or Medicaid should replicate. I am not sure that
that is the case. In the past couple of years, we have seen
commercial private insurance companies begin to implement
policies to promote more cautious prescribing, but it has been
pretty new.
One possibility is that for people who become opioid
addicted who fall out of the workplace because of their opioid
addiction and become poor because of their opioid addiction,
they may more likely wind up insured by Medicaid and fall out
of the private system. So it is hard to say why we might see a
greater problem in people insured by Medicare or Medicaid.
Senator Jones. All right. Yes?
Mr. Adolphsen. Senator, I think it is because they are
trying. Cigna announced that they pledged to lower prescription
painkillers by 25 percent in 3 years. So they have acknowledged
they have a role here that they might be playing in this issue.
So I think Medicaid has acknowledged that, and it is a little
ironic because Cigna is using the CDC's guidelines--the CDC
right down the street from Medicaid--but they have not seemed
to get together on it. So I do think there is a level of
acknowledgment and effort that the private insurers have made.
Senator Jones. What about the role of the prescription drug
companies that are manufacturing these opioids? What role
should they play?
Dr. Kolodny. Well, something that the manufacturers of
opioids should stop doing and I think something the Food and
Drug Administration (FDA) could require them to stop doing if
it properly enforced the Food, Drug, and Cosmetic Act (FDC),
they should immediately cease promoting opioids for chronic
pain. As Senator Paul mentioned earlier, opioids have not been
shown to be safe and effective for long-term use for common
chronic conditions like low back pain, fibromyalgia, chronic
headache. These are good medicines to ease suffering at the end
of life. They are good medicines when you are using them from a
couple of days after major surgery. But for daily long-term
use, they may be more likely to harm the patient than help the
patient. Right now we have a law that says that drug companies
are only allowed to promote products for conditions where the
benefits are likely to outweigh the risks, and those
conditions, they become the indication on the label. And if the
company gets caught promoting use not on the label, they get
into trouble. The label on opioid analgesics is very broad,
which has allowed the manufacturers to promote for conditions
where we really should not be prescribing opioids.
Senator Jones. Does anybody else want to take a shot at
that? Otherwise, Mr. Chairman, that is all I have. Thank you.
Chairman Johnson. I just wanted to quickly follow up. That
is a problem with FDA approval on that particular drug, right,
too expansive an approval?
Dr. Kolodny. Yes, I mean, if we could go back in time to
the introduction of OxyContin, if FDA had properly enforced the
Food, Drug, and Cosmetic Act, they would have told Purdue,
``Great, you have extended-release oxycodone. That sounds like
a good drug for cancer patients. We are going to let you send
your sales force to the hospices and to the oncologists and to
palliative care doctors.'' FDA did not do that. And there would
not have been that much money for Purdue to make if their
product had only been prescribed to patients at the end of
life. So they promoted broadly, and FDA allowed it. But with
every manufacturer of opioids, they have done the same thing
because the big market is chronic pain. Millions of Americans
suffer from chronic pain. That is where they are going to make
their money, and so that is what they have been promoting use
for.
Chairman Johnson. Well, it is never too late for the FDA to
change it.
Dr. Kolodny. That is correct, and our new FDA Commissioner
may be finally the FDA Commissioner to do that. He has
certainly made some statements leading us to believe he may
take some of the steps necessary.
Chairman Johnson. OK. I will follow up later.
Dr. Hyman. If I could just add, I would point out once the
FDA approves a drug, physicians can use it for off-label
indications. They do not require the FDA's permission. And once
it has been approved, notwithstanding some people's views on
the scope of the FDC, there are serious constitutional
questions raised by attempts to prohibiting pharmaceutical
companies unless they are engaging in false and misleading
speech.
Chairman Johnson. OK. Senator Harris.
OPENING STATEMENT OF SENATOR HARRIS
Senator Harris. Thank you.
Dr. Kolodny, I was struck by your fourth slide which showed
that hospitalizations for opioid overdose are increasing most
rapidly, as you have mentioned, in Medicare but also increasing
for people with private insurance and people without insurance
and people with Medicaid. These facts make it clear, to me at
least, that diversion is a risk regardless of the type of
insurance coverage a person may have.
To follow up on this conversation, in 1996 Purdue Pharma
released OxyContin, an opioid that they falsely claimed would
deter addiction, as you have mentioned. In the 5 years from
1997 to 2002, OxyContin prescriptions grew from 670,000 to 6.2
million. And overall sales of prescription opioids increased
roughly four times between the years of 1999 and 2014.
A number of Senators--Senator Claire McCaskill and myself
included--have ongoing investigations of drug companies and
distributors who helped cause and exacerbate the opioid
epidemic. To that end, you have mentioned a bit about what the
FDA responsibilities are. Can you talk about what you believe
Congress can do to hold pharmaceutical companies responsible
for its role in causing the opioid epidemic?
Dr. Kolodny. That is a really good question. I think one
thing that Congress could do is hold FDA's feet to the fire
through your oversight role of FDA because FDA really has
failed to properly enforce the laws and has allowed opioid
manufacturers to improperly promote opioids.
I do think that I am very pleased by your investigation and
Ranking Member McCaskill's investigation of the role that
manufacturers have played. I do want to point out, though, that
Senator Grassley and former Senator Baucus launched a similar
investigation in 2011. The Senate Finance Committee began an
investigation, and the Senate Finance Committee has yet to
release its findings from that investigation. So I think,
making those findings public would be very helpful, I think,
for changing the behavior of the manufacturers. Many of the
organizations or front groups that they give money to, they are
continuing to fund, and they are front groups that are blocking
Federal and State efforts to promote more cautious prescribing.
The Associated Press and the Center for Public Integrity did
investigations showing that the opioid lobby, the
manufacturers, the distributors, have spent more than $880
million over the past decade blocking efforts to promote more
cautious prescribing, and I think the findings from these
investigations may make it more difficult for them to continue
doing that.
Senator Harris. And you mentioned front organizations. Can
you talk about who and what they are?
Dr. Kolodny. These would be organizations that in some
cases are pure AstroTurf organizations created by industry----
Senator Harris. AstroTurf, what do you mean?
Dr. Kolodny. AstroTurf is an organization meant to look
like a grassroots organization, but it has been artificially
created by industry. One of the organizations that was very
damaging was the American Pain Foundation, which was an
AstroTurf organization. That shut down on the day that the
Senate Finance Committee launched its investigation.
There are also medical societies, professional
organizations that ``front group'' might be a bit strong, but
that take very significant funding from opioid manufacturers
and promote the interests of opioid manufacturers rather than
the interests of patients. So, for example, the American
Academy of Pain Medicine and the American Pain Society have
promoted very aggressive prescribing of opioids and have really
come to the defense of manufacturers every time efforts are
raised that could potentially better regulate them.
Senator Harris. Thank you, and I plan to follow up on your
suggestions. Thank you.
Medicaid is, of course, one of the leading sources of
substance abuse treatment, covering about one-third of opioid
addiction treatment. In June of last year, I toured and met
with the patients at the Martin Luther King, Jr. Outpatient
Center in Los Angeles. I will tell you that Medi-Cal pays for
70 percent of the care there.
The nonpartisan Government Accountability Office found that
Medicaid expansion increased access to substance abuse
treatment, and the Urban Institute found much more rapid growth
in spending on opioid treatment medications and overdose
reversal medications in States that expanded Medicaid,
suggesting, of course, that more of those who need treatment
are getting it thanks to Medicaid expansion.
The President's own opioid commission called for the
expansion of Medicaid by having the administration grant
waivers for all 50 States to eliminate barriers within the
Medicaid program in order to help more people have access to
treatment.
My question is: If Medicaid funding is cut, what happens to
the one in three people who receive treatment under Medicaid
for opioid addiction?
Dr. Kolodny. So I think that there are individuals right
now who are, thanks to Medicaid expansion, alive, who are
having their opioid addiction effectively treated. If they were
to lose Medicaid coverage, for example, I think that there
would be a very high likelihood that these individuals would
relapse, and if relapsing, a high likelihood that they could
die from an overdose.
We have an exceptionally dangerous black market opioid
supply. We have never had heroin as dangerous as we do today
because of fentanyl that is in it or fentanyl that is sold as
heroin. A relapse is not a benign event. One relapse can be
fatal. And if patients lose health coverage that is paying for
their addiction treatment, they are at very high risk for
relapse and loss of life.
Senator Harris. Thank you. And, Mr. Schalk, I appreciate
your comments as a fellow prosecutor. I think we both
appreciate--and certainly your work has pointed this out--that
one of the best ways that we can be smart on crime is to follow
what the public health model has taught us, which is if you
want to deal with an epidemic, be it drug, crime, or health,
one of the most effective and smartest and efficient ways to
deal with it is not reacting after but actually preventing
before these crimes occur. So I appreciate your comments and
the work that you have done highlighting that point.
Mr. Schalk. Thank you, Senator.
Senator Harris. It is in the best interest of public safety
and also taxpayer dollars.
Mr. Schalk. Thank you.
Senator Harris. Thank you, Mr. Chairman.
Chairman Johnson. Senator Hoeven.
OPENING STATEMENT OF SENATOR HOEVEN
Senator Hoeven. Thank you, Mr. Chairman.
I expect that each of you have looked at Chairman Johnson's
chart\1\ on the rise in overdose deaths increasing from 2013 to
2015, and also comparing the number of overdose deaths in
expansion and non-Medicaid expansion States. So I would ask
each of you, starting with Mr. Adolphsen. Thank you for putting
the chart up. To what do you attribute it? What is causing it?
What should be done about it?
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\1\ The chart referenced by Senator Hoeven appears in the Appendix
on page 86.
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Mr. Adolphsen. Thank you, Senator. I think we have heard
from a number of folks, not just in this hearing but in
previous hearings, that we have a real supply side problem on
opioids. And I think when you are in a hole, you stop digging.
And expansion has really opened the door to a massive increase
in these opioids in the market on the supply side. So I think
when you look at a State that has expanded, that has added
hundreds of thousands of people who suddenly are not just
eligible for the treatment that we have heard about but they
are also eligible to receive no-cost prescriptions, you are
inevitably driving up the supply of this into the market.
Senator Hoeven. And what should be done?
Mr. Adolphsen. Well, I think there are some options. One of
the things that ought to be considered is maybe disconnecting
substance abuse treatment from the rest of the benefit. So, for
example, there obviously are millions of Americans out there
who need substance abuse treatment. No one would argue that
fact. However, is it best delivered with an entire Medicaid
package that includes access to more opioids? And that is
really the problem that I saw, was we had folks over on one
side of the house getting treatment, and those same folks were
still getting opioids that caused the addiction in the first
place. And those two kind of butt heads.
So I think it does not necessarily have to be one without
the other. The substance abuse treatment should be very
targeted and focused and not necessarily come with all of these
unintended consequences.
Senator Hoeven. Mr. Schalk?
Mr. Schalk. Senator, looking at these numbers, what is
clear to me is when we give more prescriptions, when we give
greater access to those that are most susceptible to addiction,
that are most susceptible to the criminal justice system, at a
certain point they are going to transition from these opioids
that a doctor is prescribing, and they are going to start
seeking their high from somewhere else. Perhaps that is because
the doctor said, ``I am no longer going to write you a
prescription. I cannot justify this.'' At a certain point, when
they transition from the pills that their doctor is prescribing
them, they transition from there to fentanyl and heroin laced
with fentanyl, that is where these deaths are coming from. It
is from injecting heroin after--and no one just starts on
heroin. It is a progression. And almost without fail, before
someone begins down the path of injecting heroin, they are
abusing their prescription pills. And I think just looking at
the fact when we are making these prescription pills more
readily available to a greater segment of our population, this
is what happens.
Senator Hoeven. And what should be done?
Mr. Schalk. I believe that while this is a multifaceted
issue, we need to hold the medical community more accountable,
would be one key aspect, as it relates to their prescription
practices. We are giving doctors in many ways complete
discretion to prescribe synthetic heroin, and that is a lot of
power. And so I think we need to take a closer look at the
prescription practices. Are they in line with the treatment
plan? Are they improving quality of life? And if those answers
cannot be met, then we need to hold the doctor accountable as
to why were they prescribing this unneeded and unnecessary drug
to this individual?
Senator Hoeven. Mr. Tyndall?
Mr. Tyndall. Thank you, Senator. And I do not know that I
could speak to expansion and non-expansion. That is probably
above my pay grade in Tennessee, but certainly I think that the
more people who have access to low-cost and no-cost
prescription drug medication, the probability of drug-seeking
behavior and prescription drug diversion increases.
Senator Hoeven. What would you do?
Mr. Tyndall. Well, I think there ought to be penalties if
you are involved in drug-seeking behavior or selling your
medications, especially by Medicaid. The penalties need to be
more severe for that.
Senator Hoeven. Dr. Hyman?
Dr. Hyman. So I would echo what has been said about the
supply side aspects, that, there are physicians who will write
prescriptions for opioids, and there are patients who will take
them and get those prescriptions filled. And that is a gateway
for some of them to more severe drugs once they are cutoff.
I think on the solution side, so far we have talked a lot
about the patient and doctor shopping. It is important to
recognize, as I said at the outset, it takes a physician to
write the prescription. And so we ought to be looking for
outliers in the frequency of prescribing, both relative to the
patients that they are seeing and also relative to the doses
that they are basically writing on the prescription pad. And,
you may be an outlier because you are in the pain management
business and you see a population of patients that badly need
pain management. Or you may be an outlier because you will
basically write a 'script for everybody who comes through the
door. My suggestion would be not necessarily criminal sanctions
as your starting point, given the difficulties that Mr. Schalk
has already talked about, but some combination of financial
incentives and licensure sanctions. State medical boards ought
to be more active in this space.
Senator Hoeven. Dr. Kolodny?
Dr. Kolodny. So I think this is an interesting association,
and it is worth investigating to see if this really holds out
if you were to compare the specific timeframes of Medicaid
expansion, were to look at States, and it is certainly worth
looking at.
I do believe that we have a good understanding of why the
opioid addiction epidemic is getting worse and why in States
where it has gotten much worse, why that happened.
Something that is important to understand is we have two
groups of Americans who are opioid addicted: we have a younger
group and an older group.
The older group are people who are becoming opioid addicted
mostly through medical treatment. That older group has not been
turning to the black market. They are getting opioids
prescribed to them for chronic pain. Up until around 2011, we
were seeing most of the overdose deaths in older people getting
pills prescribed to them by doctors. It is possible in that
older group, because prescribing has become a bit more
cautious, overdose deaths may be stabilizing, coming down a
bit.
The younger group are people in their 20s, 30s, and early
40s, they are becoming opioid addicted from using prescription
opioids, either medically or recreationally, or sometimes a
combination of both. That younger group, when they become
opioid addicted, has a hard time maintaining their supply
visiting doctors. Doctors and dentists, as we have been
discussing, are too comfortable giving young people lots of
opioids, but we do not like to give healthy-looking 25-year-
olds a large quantity on a monthly basis. So the young person
who becomes opioid addicted winds up on the black market. The
pills are very expensive on the black market, and something we
have seen happening steadily over the past 20 years is a rising
use of heroin in these young people who wind up on the black
market and switch to it because it is much cheaper.
Beginning in around 2013, overdose deaths in this younger
group, in the group that has been switching to the black
market, the group that has been using heroin, overdose deaths
are soaring because of fentanyl, because the heroin supply is
so dangerous right now. I think that is really the primary
driver. I do not believe it is Medicaid expansion. I do not
think Medicaid expansion is helping us as much as it could in
terms of addiction treatment because the services are not
there. I think people are getting their prescription paid for.
So we have to do a lot more if we want to see overdose
deaths come down, but I do not believe that overdose deaths are
rising because of Medicaid expansion. I think it is fentanyl
that is causing the very sharp rise that we have seen in recent
years.
Senator Hoeven. Thank you.
Thank you, Mr. Chairman.
Chairman Johnson. Senator Daines.
OPENING STATEMENT OF SENATOR DAINES
Senator Daines. Mr. Chairman, thank you. And I want to
thank the Chairman for producing this report. It raises some
serious questions about whether Medicaid expansion is having a
counterproductive impact on the opioid epidemic by
proliferating prescription opioid pills. I come from a State
that is an expansion State, the State of Montana. I am
particularly concerned by the report's exposure of how Medicaid
expansion dollars have resulted in addiction among some
recipients and facilitated illicit distribution of these drugs
to others struggling with substance dependence. In short, the
report provides, I would argue, a more complete picture on the
consequences of Medicaid expansion, and we must not ignore its
conclusions.
The first question is for Mr. Adolphsen. You mentioned in
your testimony that 52 percent of able-bodied adults on
Medicaid do not work and that only 16 percent work full-time.
Can you share more about the positive correlation that you have
found between having a job and reducing drug dependency among
healthy working-age Americans?
Mr. Adolphsen. Thank you, Senator. That is right, that data
that you referenced is very clear. The number of able-bodied
adults on Medicaid has quadrupled from 7 million in 2000 to 28
million today. Half of those do not work at all. We know from
the addiction specialists, the recovery community, that work is
a pillar of recovery, and certainly in a program that is paying
for the amount of substance abuse treatment that Medicaid is,
we think it makes a lot of sense to encourage and assist people
getting back to work.
Unfortunately, that is not what we see. We are seeing the
rolls, particularly for able-bodied adults, continue to grow,
and many of those people are not working at all.
Senator Daines. Are you aware of what percentage of able-
bodied Medicaid recipients actually return to full-time gainful
employment?
Mr. Adolphsen. Well, what we are seeing is enrollment
continue to go up, so if they were moving into full-time
employment, if you work even at minimum wage full-time, you are
out of poverty. So if folks were quickly getting back in the
work force, working a full-time job or a couple part-time jobs,
they would quickly cycle off of Medicaid because they would be
earning income above the threshold. That is just not what we
are seeing. We are seeing folks come on to the program, stay on
the program. So, unfortunately, that is an indicator that has
not been successful at returning people to work the way we
would like to see.
Senator Daines. Why is that? What do you see? It is usually
all about incentives. What is the incentive to stay on Medicaid
versus move and become gainfully employed?
Mr. Adolphsen. Sure, there are probably a lot of things
that go into that, but I think one thing we probably can all
agree on is we all need deadlines and a push in our life to
accomplish certain things, and Medicaid has been free of any
requirement for kind of community engagement or work
activities. That has not been a hallmark of the program, which
historically might have made more sense when there were not
able-bodied working-age adults on the program. But as I
mentioned, that number has grown dramatically with the
expansion under ACA, and I think that kind of incentive
structure is needed within the program to help clear that
pathway and encourage people to get back into the workforce or
into training or volunteering and community engagement.
Senator Daines. Medicaid has been held up as a cure-all
silver bullet for opioid treatment, which, by its own right, is
critical to helping addictions. However, the evidence seems to
suggest that Medicaid is a two-edged sword by proliferating
prescription opioid pills due to the ease of access. There is
always going to be leakage of diverted prescription opioids
with or without Medicaid expansion. I think we probably would
all agree with that.
Mr. Adolphsen, what makes those eligible under Medicaid
expansion more susceptible to facilitating illicit drug
diversion?
Mr. Adolphsen. Thank you, Senator. I think we have heard a
lot of great examples of that here in the testimony, the
temptation to turn a free prescription into several thousand
dollars in those types of things. I know one of the disconnects
I saw in our Medicaid program in Maine was someone would have
this access to Medicaid, and they might come into substance
abuse treatment possibly, funded by Medicaid. But the success
rate, unfortunately, is not very high in some of those
programs, typically under 30 percent, sometimes in the teens.
It is a difficult addiction to beat, so it is tough.
So what happens, if somebody is in treatment for, say, a
week or a couple of weeks even, but then they come out of
treatment, and they still have the rest of their Medicaid
benefit, they still have their full pharmacy benefit, they
still have access to some of these other more dangerous drugs
that may have led them into the addiction in the first place.
So I think we need to do a better job of connecting those
two dots within the program.
Senator Daines. So when you look at those individuals who
are getting hooked on diverted drugs--we have kind of been
looking at the balance here of those coming on, those coming
off. Do you believe that more individuals are getting hooked on
diverted drugs than successfully completing opioid treatment?
Mr. Adolphsen. Yes, 12.5 million self-reported opioid abuse
last year, painkiller abuse last year, and I think we heard
from another witness already that something like a couple
million people are trying to get into treatment. So it is
pretty clear that on the supply side, the number of people
misusing or becoming addicted is growing and outpacing the
number of folks that are going into treatment and completing
it.
Senator Daines. Mr. Schalk, in your experience as a
prosecutor, and, Mr. Tyndall, as the Tennessee IG, you both
have indicated the extent of Medicaid prescription fraud is
unknown due to underreporting and other barriers. How expansive
do you think the fraud might be?
Mr. Schalk. Staggering. Based on the limited numbers that
we see as opposed to what we know is going on, what we see is
going on, I believe that if we were to look at the amount of
Medicaid fraud that was happening just in my own community,
Members would be outraged.
Senator Daines. So ``staggering'' is a strong word.
``Outraged'' is a strong word. I guess maybe it goes back to my
background in chemical engineering. I tend to be more of a
quantitative guy. I know the Chairman is a numbers guy, too. Do
you have any sense of kind of trying to quantify the size of
the bread box here without--``staggering'' is related--there is
something in your mind saying it is large. Can you maybe try to
quantify that for us?
Mr. Schalk. To sit and quantify with a number I would not
be able to do. I can only ascertain from my own experiences
that I see from an investigative side, from a courtroom side.
Unfortunately, Senator, I am not able to sit and quantify with
a particular number.
Senator Daines. Mr. Tyndall?
Mr. Tyndall. Thank you, Senator. I can only echo what Mr.
Schalk just said. I have to cover 95 counties in Tennessee. I
have 14 agents. I have not had 100 percent of everybody 100
percent of the time, and we stay pretty busy just working the
cases that we are aware of.
Senator Daines. So what steps would you advise Congress--
this is a great opportunity for you all to put it in the record
here and instruct this Committee. What would you advise
Congress, the States, or CMS do to take up, to address this
problem? A couple things.
Mr. Schalk. Well, as has been echoed throughout this
hearing, I believe that reexamining the prescriptions that are
being written is an essential element to being a key part of
the solution. And, obviously, when doctor bills are being
submitted through Medicaid, it is no secret that the checks and
balances are far less than when they are being submitted
through a for-profit payer.
So, with that, I think when we are looking at
prescriptions, is this prescription being written to pad a
Medicaid fraud on behalf of the doctor? Again, is this
prescription improving quality of life? Is it medically
necessary? Is it within the scope of the treatment? And,
frankly, can I go and get an over-the-counter that can be just
as effective? As Senator Paul said, ibuprofen is very
effective. However, an overwhelming majority of the people that
come through my courtroom, they do not believe ibuprofen is
appropriate. They believe they need a high-powered painkiller.
And I think we need to as a society take a step back from that
and say ibuprofen sometimes is appropriate. Now, it is not
always appropriate, and I recognize that. But I think
recognizing that ibuprofen is appropriate more often than not
is a good step toward reducing this problem.
Senator Daines. I am out of time. Mr. Chairman, thank you
for allowing me additional time.
Chairman Johnson. Well, I will say I want to finish up with
my questions here. I am going to ask the exact same questions.
So each one of you, if you had one recommendation in terms of a
law change that would help solve this crisis, I will give you
the opportunity to address that as well. But thank you, Senator
Daines, for your questions.
I want to start with the two doctors and just ask a
question. Why did it take so long for the medical community to
just recognize the extent of the opioid addiction? Why did you
not have the feedback loop? You have ongoing education. You
have your medical journals. I mean, why did it take so long?
And why did it take this epidemic just bursting onto the scene
here before--and I am not even sure all doctors are aware of it
still. I hope they are, but we----
Dr. Kolodny. Yes, I----
Chairman Johnson. Well, let me finish up. We held a
roundtable in Wisconsin, and that is when I was shocked that
you had an entire generation of doctors trained that these were
not a problem. Again, that goes to marketing or whatever. But
why wasn't this known really within a couple years?
Dr. Kolodny. Yes, that is a great question. I think for
many years the feeling in the medical community and even the
position of the American Medical Association (AMA) was that the
opioid problem was about the bad apples, that there were some
doctors out there that are really drug dealers running pill
mills, and that there are some people out there pretending to
be patients but they are really drug abusers and they want to
get their hands on these drugs, and that the opioid crisis had
nothing to do with well-meaning doctors taking care of their
legitimate patients. I think that was the thinking for quite a
while when the reality is that the opioid crisis is really
driven by well-meaning doctors who have been overprescribing to
patients, getting patients addicted, but also indirectly
causing addiction by stocking homes with a highly addictive
drug, creating customers for the drug-dealing doctors, the pill
mills, for the diversion and the fraud. So the bigger problem
has been the well-meaning doctors.
I think part of the problem is it is not just the medical
community, but policymakers really for many years failed to
look at the root of the problem, which was overprescribing.
Instead, what they accepted was the way industry had been
framing the problem and the way that the pain organizations
funded by industry were framing the problem. What policymakers
such as yourself were told was that all of this bad stuff that
you are hearing about involving opioids, that is the drug
abusers. There is a subset of our population that wants to get
high off of drugs, and maybe because doctors are prescribing
more, the drug abusers are getting their hands on these drugs.
And, yes, we should do something about the drug abuse problem
and diversion, but let us not forget that tens of millions, a
hundred million Americans have chronic pain, they are being
helped by these medicines, and that your job as a policymaker
is to balance these two competing problems. You want to do
something about the pain problem and do something about the
drug abuse problem, but do not make the pain problem worse, do
not punish the pain patients for the bad behavior of the drug
abusers. So it was framed as if we had these two distinct
groups and the harms were limited to so-called drug abusers.
Policymakers accepted that.
If you look at what was coming out of the Federal
Government even over the past Administration, if you look at
what was coming out of Substance Abuse and Mental Health
Services Administration (SAMHSA), National Institute on Drug
Abuse (NIDA), Office of National Drug Control Policy (ONDCP),
it was almost an exclusive focus on the issue of non-medical
use, kids getting into Grandma's medicine chest. Nobody was
asking why does every Grandma now have opioids in her medicine
chest. Now we are finally asking that question.
Chairman Johnson. The whole point of the PROP Act was to
acknowledge the fact that government policy was requiring
providers to ask the question: ``Are you satisfied with your
pain medication?'' And if you got a bad survey result, it
affected your reimbursement, so, government policy actually
fueled that.
Dr. Hyman, at what point did the medical community all of a
sudden wake up and say, ``This is a real problem?'' Has it
literally just been the last couple years even though this has
been around for a couple decades?
Dr. Hyman. I think it is quite recent that the medical
community has woken up to it, and you have already alluded to
some of the incentives that they had to--I do not want to say
``not wake up to it,'' but to focus their attention on other
areas. Lots of aspects of the health care system more or less
run on autopilot. People keep doing things the way they were
trained to do them. New information may not be available, or if
it is available, they may say, oh, that is just one study.
And this is not just about opioids, right? I can tell you
story after story where there is a surgery or a treatment that
gets deployed, it sort of spreads like wildfire, subsequent
research indicates that it is not such a great treatment, and
it is very hard to stamp out once it is out there because the
same sort of passive payer of bills creates an incentive for
people to keep doing what they are doing.
Chairman Johnson. So a one-number answer out of both of
you. What percentage of the medical community do you think get
it now, fully understand it? We will start with Dr. Hyman.
Dr. Kolodny. It is age-related. Young doctors get it. They
have come of age during the opioid crisis. In some cases they
have lost peers to opioid overdoses. Older doctors, in my
experience, doctors maybe older than 50, tend to still--many of
them tend to be prescribing pretty aggressively.
Chairman Johnson. So what percent? Only half of doctors, 50
percent are getting----
Dr. Kolodny. It is very difficult to give you an answer.
Chairman Johnson. I realize that. I am not going to hold
you to it. Would you venture a guess?
Dr. Kolodny. I would guess that maybe a third of--it is a
wild guess, that maybe a third of the prescribers are still
very misinformed about opioids and are prescribing very
aggressively.
Chairman Johnson. They do not read the news? Dr. Hyman, do
you agree with that or----
Dr. Hyman. Well, even if they read the news, they may not
view themselves as part of the problem, right? They may view
themselves as treating with compassion and care the patients
that present in front of them. If you made me give a number, I
would fall back on my medical school training where an
attending told me, ``There are only two numbers in medicine--80
percent and 20 percent.'' So I would give you the 20 percent
number, which is a little lower. I think it is higher among
younger physicians for the reasons that Dr. Kolodny has already
alluded to.
Circling back to the question about the frequency of fraud
and a quantitative figure, the standard figure in the
literature is 10 percent. There is not a great empirical basis
for that number, but if you add in waste and overuse, you can
get much higher numbers. And I am happy to share with you some
of the research that has been done on that.
Chairman Johnson. One of the questions we have submitted to
CMS is how much are they spending reimbursing for opioids. That
would be just kind of a nice macro number to know.
I want to switch over to the prosecutor and inspector
general. An indicator of the problem we have here is there is
actually a website--and I am not going to promote it, but there
is a website you can check to see what the cost is to make sure
you are not getting ripped off by your drug dealer in terms of
these opioids. So, I mean, that is a problem. Can you speak to
the relative cost of street heroin versus opioids? Any of you
three.
Mr. Tyndall. I do not know that I can give any specifics,
but my understanding is that now because of the reformulation
of some of the narcotics that we receive, they are a bit harder
to use, and they are becoming more expensive. Heroin is growing
cheaper and cheaper by the day, so people are now turning to
heroin as opposed to prescription drugs.
Mr. Schalk. What we saw was at the pinnacle of Opana abuse,
they were going--we had high school kids that were spending
$200 a day on two Opanas, $100 apiece for a simple pill. Once
that supply ran up and the formulation changed where it was not
as easy to abuse, that is when heroin came in, and it
devastated our community. And heroin, from our experience, has
been easier to get, it is cheaper to get, and the effect--once
you go down the road of heroin, you do not want to go back to
pills because the high is not as good.
Chairman Johnson. Do people actually buy fentanyl, or do
they buy it because they think it is heroin?
Mr. Schalk. What we see are people buying heroin that is
laced with fentanyl.
Chairman Johnson. OK. I read something in a magazine
article, that $800 worth of fentanyl produces about $800,000 of
street value. So if you have the demand, the profit motivation
is so high you are going to have the supply.
When I started this inquiry, again, it was based on that
article talking about funding a lifestyle of not working,
supplying free health care, and access to products so
beneficiaries can sell opioids as an income supplement. In
terms of our actual investigation, though, we found far more
complex and larger schemes. Again, I want to ask the
prosecutor: is that just because we really do not go after the
single users, the people who have been using it, and we really
are focusing what limited investigation and prosecutorial
resources we have in terms of the larger schemes?
Mr. Schalk. I think, like any law enforcement agency, we
have to focus our resources and our efforts on the most
prominent issues, and oftentimes that is the bigger players
that we are going after. If we were to sit and--we would need
to expand our police agencies tenfold to have a direct--to hold
everyone directly accountable in our area.
Chairman Johnson. But with what you were talking about, you
think this is enormous. So you think it is enormous because
individuals literally are accessing, that is, using their
Medicaid cards, or Medicare or VA benefits, and they are
getting the pills, and they get a large quantity--by the way,
does anybody know what an average quantity is the doctors--I
mean, what would be a typical monthly supply of one of these
opioids?
Dr. Kolodny. Well, the vast majority of the prescriptions
are written for acute pain, so if you are looking at numbers of
prescriptions written, most of them are for acute pain, and
they are for a small quantity.
Chairman Johnson. Or short term.
Dr. Kolodny. Yes.
Chairman Johnson. What about chronic?
Dr. Kolodny. So when you measure consumption in terms of
weight of opioid consumed in the United States in terms of a
morphine equivalent, the bulk of our consumption is chronic
pain, and the average patient is given a 1-month prescription
with an enormous amount of opioid in it. So it could be about
70 milligram morphine equivalents or more per day. Some
patients are on even greater quantities that are very
dangerous.
Chairman Johnson. How many pills would that be a day or a
month? I mean, let us say the average size in terms of
milligrams.
Dr. Kolodny. So for a patient who is receiving opioids for
chronic pain, they could be taking one pill in the morning, one
pill at night. But each of those pills could be the equivalent
of 25 or 30 Vicodin in one pill. So it would be the equivalent
of taking 50 pills a day, only they are taking it in an
extended-release drug.
Chairman Johnson. So you really can, because of the street
value per milligram, or whatever it is.
Dr. Kolodny. It is about $1 a milligram. The most popular
opioid on the black market is the 30-milligram immediate-
release oxycodone, which will do what a $10 bag of heroin will
do. And the effect is actually almost identical. In fact, some
people prefer the effect of oxycodone. They are using heroin
because it is cheaper, not because it is a stronger effect.
Mr. Tyndall. Mr. Chairman, the prescriptions we are seeing
sometimes it is 90 to 120 pills per month, depending on the--
and hydrocodone tends to be kind of the drug of choice in
Tennessee. You may get 5 milligrams, 7.5 milligrams, or 10
milligrams. So depending on the milligram and the number of
pills, if a person wants to sell 120 10-milligram pills, that
is a pretty good chunk of change for a month's work.
Chairman Johnson. So when you have the difference between
acute versus chronic, how are you going to control
prescriptions based on chronic pain? You are not going to
require a doctor to keep writing that every 3 days. One of the
solutions sometimes is just limit it to a 3-day supply. But
that is just not--that may be appropriate for acute pain for a
dentist or something like that, but not for chronic pain.
Dr. Kolodny. So for chronic pain, we should not be putting
patients on long-term opioids. We have to prevent new starts.
For the vast majority of these patients, opioids are not safe
or effective. And I think that has been one of the main goals
of the CDC guideline, is to prevent more people from winding up
on long-term opioids. We have about 10 million Americans who
are on opioids chronically, so many Americans on opioids
chronically that we are seeing ads on television for drugs to
treat the side effects of being on opioids chronically, like
constipation. These 10 million Americans who are on opioids
chronically, many of them may not be able to come off. Even
though the medical community is figuring out we should not have
started them on opioids, we also do not want them to cut them
off abruptly. We have to try and help some of these patients
come off. Some of them can come off. Some of them need
addiction treatment. Some of them may just need to be
maintained on safer, lower doses of the medication they are
already on. The trick is to prevent more people from winding up
stuck in their shoes.
Chairman Johnson. So Mr. Adolphsen quoted some figures in
terms of, unfortunately, the ineffectiveness of treatment. Can
the doctors speak to that? What kind of success rates do we
have? And also just in terms of Suboxone, does that also give a
high? Why would that be diverted and be able to be sold?
Dr. Kolodny. So if you are an experienced opioid user and
let us say you are in jail, so you have been off of opioids,
and somebody smuggles buprenorphine--Suboxone--into you in jail
and you take it, you will feel a strong opioid effect as if you
have just used just about any opioid. If you are taking
buprenorphine the way you are supposed to on a regular basis,
you are not feeling high from it. Patients feel normal. They
look normal. I have had patients who are physicians who I would
allow them to operate on me while they were on buprenorphine
treatment. People can function very well.
Most patients who are treated with buprenorphine do well.
More than half of patients have good outcomes. Some younger
patients with more severe opioid addiction, when you try and
treat them with buprenorphine, in the first year or so they do
not do that great. They come on and off. Sometimes they will
trade it. But it is the first-line treatment, and people who
stick with it have good outcomes, and it is more effective than
the Vivitrol monthly injection.
Chairman Johnson. So successful treatment with Suboxone,
how long does that take? Months? Years?
Dr. Kolodny. What I can say is that short-term use of
buprenorphine, Suboxone, does not work well. When patients come
off, they are at very high risk of relapse. So we are talking
about a longer-term treatment. Some patients, maybe it means
for the rest of their lives. I would hope not. I think there
are people who can come off, and maybe we will come up with
other treatments for opioid addiction so that there are better
options available.
Chairman Johnson. How often do they take that?
Dr. Kolodny. It is taken every day. Some patients will take
it in the----
Chairman Johnson. So just once a day.
Dr. Kolodny. Yes, once a day or twice a day.
Chairman Johnson. So we would probably have to make sure
that we test to make sure they take----
Dr. Kolodny. Yes, you want to make sure you test so that it
is in their urine so that you know they are not trading it or
selling it.
Chairman Johnson. Dr. Hyman, do you have anything to add
about treatment?
Dr. Hyman. I agree with everything Dr. Kolodny said,
although you should count the people who drop out as failures
unless they re-enroll.
Dr. Kolodny. No. I agree.
Dr. Hyman. And the second point I would make--and this is
sort of the incidental consequence of once you start testing
people, you have suddenly created a Gold Rush for urine
testing. So there is a huge amount of money that is spent on
urine testing as part of the treatment.
Chairman Johnson. Buy the stock, huh? Well, again, those
are my questions, so I will just go starting from my left to
right: is there one overall suggestion you would have in terms
of a change in law or something we should do as a Nation to try
and solve this problem? Mr. Adolphsen.
Mr. Adolphsen. Thanks, Senator. I think incumbent on us
first is just to recognize that Medicaid has a large role as a
funder of opioids, and so we need to recognize that and
understand that we have to do something about it, admit we are
part of the problem, so to speak, in the Medicaid program. Slow
down the Medicaid rush. It is increasing the supply. There is
no question about it. Even if you go back before expansion,
Medicaid enrollment doubled from 2000 to 2013. So that is an
issue, so I think we need to slow that down.
I would target benefits. I think if somebody is in need of
substance abuse treatment, they are low-income, everybody in
this room, everybody around us wants that person to have the
substance abuse treatment. But it does not necessarily have to
come with all the other potential side effects of having that
Medicaid card and the free access it provides to other things
like opioids.
Chairman Johnson. So put some kind of controls around the
benefit. Mr. Schalk?
Mr. Schalk. Thank you, Senator. From a very broad
perspective, we need to obviously diminish the gap between the
impoverished and the middle class. We do that, in my opinion,
by creating jobs, incentivizing businesses to grow. When we
have people that are going to work in the morning, their
likelihood of walking through the courthouse doors as a
defendant reduces drastically, especially when we are talking
about drug abuse.
From a more narrow perspective, as we have echoed here
today, I believe that regulating the prescriptions that are
being written by our medical community would go a long way in
curbing the issues that we are seeing and discussing today.
Thank you.
Chairman Johnson. Mr. Tyndall.
Mr. Tyndall. I am going to brag on Tennessee just a little
bit, Mr. Chairman. Our Controlled Substance Monitoring Database
requires every drug, every narcotic that is dispensed, it has
to be entered into our Controlled Substance Monitoring Database
no later than the following business day. So if that is true--
and it also requires our physicians to check that CSMD prior to
prescribing a narcotic. So if that is true, the doctor should
see that this person has already received that narcotic within
24 or 48 hours and they should not, I would hope, be
prescribing the same or similar medication for that patient.
Chairman Johnson. Do you know relative to other States, are
you that much further advanced in terms of that type of
monitoring? Is it comparable?
Mr. Tyndall. I am not sure, but I think we are much more
progressive and aggressive in monitoring and trying to identify
people who are committing TennCare fraud, Mr. Chairman.
Chairman Johnson. OK. Dr. Hyman?
Dr. Hyman. I would change the incentives for physicians to
prescribe opioids to Medicare and Medicaid beneficiaries as
profligately as they do.
Chairman Johnson. OK. You have to describe that more
specifically. What are the incentives right now? And what is
the difference between the incentives as they prescribe in
Medicaid and Medicare versus private insurance?
Dr. Hyman. So the incentives for--as I said, Medicare and
Medicaid are both sort of passive payers of bills, and so
nobody is going to look too closely at your prescribing
practices unless, many years later somebody happens to be
paying attention. So, when you couple that with the reality
that the way you bring a clinical encounter to a close is by
filling out a prescription and handing it to the patient, what
you want is a system that does not pay providers to continue
that way of doing things, right? So you could use either
carrots or sticks to do so, and I would be happy to talk about
how you would design that.
Chairman Johnson. So it kind of goes back to how you have
to target the benefits, you have to control them. You have to
just make it more difficult for doctors to write prescriptions
for Medicaid and Medicare versus private insurance. There are
more controls in private insurance, is what you are telling me?
Dr. Hyman. Because of the limited networks and the sort of
for-profit nature of the insurer, there is going to be a
tighter feedback loop in the private sector than you will see
in the public programs.
Chairman Johnson. OK. Dr. Kolodny?
Dr. Kolodny. Yes, so to bring our opioid addiction epidemic
under control and ultimately to an end, First off, you have to
frame it the right way, and if you understand that it is an
addiction epidemic, an epidemic of people with the disease of
opioid addiction, what we need to do about it is very similar
to what you would do for any disease outbreak, any disease
epidemic. It is similar to what you would do for an Ebola
outbreak, a measles outbreak, an HIV epidemic. What we have to
do really are two things: We have to prevent more people from
becoming opioid addicted. We have to see that the people who
are opioid addicted have access to effective treatment.
To prevent more people from becoming opioid addicted, more
than anything else, what you are hearing today and what we know
is that we are going to need much more cautious prescribing.
Even though prescribing is trending in the right direction, we
are still massively overprescribing. Until prescribing becomes
more cautious, we are going to keep creating new cases of
addiction.
For the millions that are addicted, they really need access
to effective treatment. And when I say ``effective treatment,''
I am not really talking about detox or rehab, which does not
work well for most people who are opioid addicted. I am talking
about long-term outpatient treatment. And as you have pointed
out, Medicaid is not a silver bullet. I believe to really have
the right system available where someone in every county in the
United States can walk into a treatment center and be treated
that same day, regardless of their ability to pay for that
treatment, to really get there I think requires an investment
in the billions, I would estimate $6 billion a year to start to
build out these systems, and a commitment from Congress for 10
years of about $60 billion to get where we need to be. And when
you consider what this problem is costing us, both the human
cost and the economic cost, I think that investment is very
worthwhile.
Chairman Johnson. It will be interesting to see how much we
actually spend on opioids and how much money we might save by
spending on Suboxone or something like that.
Again, thank you all. I enjoyed the hearing. I learned an
awful lot, and that is because you folks did a great job. So I
appreciate your time, your testimony, and your answers to our
questions.
The hearing record will remain open for 15 days until
February 1 at 5 p.m. for the submission of statements and
questions for the record. This hearing is adjourned.
[Whereupon, at 12:17 p.m., the Committee was adjourned.]
A P P E N D I X
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