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79–378—PDF 2012

S. HRG. 112–724 

PRESCRIPTION DRUG ABUSE: 

HOW ARE MEDICARE AND MEDICAID 

ADAPTING TO THE CHALLENGE? 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH CARE 

OF THE

COMMITTEE ON FINANCE 

UNITED STATES SENATE 

ONE HUNDRED TWELFTH CONGRESS 

SECOND SESSION 

MARCH 22, 2012 

( 

Printed for the use of the Committee on Finance 

COMMITTEE ON FINANCE 

MAX BAUCUS, Montana, Chairman 

JOHN D. ROCKEFELLER IV, West Virginia 

KENT CONRAD, North Dakota 

JEFF BINGAMAN, New Mexico 

JOHN F. KERRY, Massachusetts 

RON WYDEN, Oregon 

CHARLES E. SCHUMER, New York 

DEBBIE STABENOW, Michigan 

MARIA CANTWELL, Washington 

BILL NELSON, Florida 

ROBERT MENENDEZ, New Jersey 

THOMAS R. CARPER, Delaware 

BENJAMIN L. CARDIN, Maryland 

ORRIN G. HATCH, Utah 

CHUCK GRASSLEY, Iowa 

OLYMPIA J. SNOWE, Maine 

JON KYL, Arizona 

MIKE CRAPO, Idaho 

PAT ROBERTS, Kansas 

MICHAEL B. ENZI, Wyoming 

JOHN CORNYN, Texas 

TOM COBURN, Oklahoma 

JOHN THUNE, South Dakota 

RICHARD BURR, North Carolina 

RUSSELL SULLIVAN, Staff Director 

CHRIS CAMPBELL, Republican Staff Director 

SUBCOMMITTEE ON HEALTH CARE

JOHN D. ROCKEFELLER IV, West Virginia, Chairman 

JEFF BINGAMAN, New Mexico 

JOHN F. KERRY, Massachusetts 

RON WYDEN, Oregon 

DEBBIE STABENOW, Michigan 

MARIA CANTWELL, Washington 

ROBERT MENENDEZ, New Jersey 

THOMAS R. CARPER, Delaware 

BENJAMIN L. CARDIN, Maryland 

CHUCK GRASSLEY, Iowa 

JON KYL, Arizona 

PAT ROBERTS, Kansas 

MICHAEL B. ENZI, Wyoming 

JOHN CORNYN, Texas 

TOM COBURN, Oklahoma 

RICHARD BURR, North Carolina 

(II) 

C O N T E N T S 

OPENING STATEMENTS 

Page 

Rockefeller, Hon. John D., IV, a U.S. Senator from West Virginia, chairman, 

Subcommittee on Health Care, Committee on Finance .................................... 1 

Grassley, Hon. Chuck, a U.S. Senator from Iowa ................................................. 3 

Cornyn, Hon. John, a U.S. Senator from Texas .................................................... 5 

WITNESSES 

Coben, Jeffrey, M.D., director, Injury Control Research Center, West Virginia 

University, Morgantown, WV .............................................................................. 6 

Schwab, Timothy, M.D., F.A.C.P., chief medical officer, SCAN Health Plan, 

Long Beach, CA .................................................................................................... 8 

Millwee, Billy, M.H.A., State Medicaid Director, Texas Health and Human 

Services Commission, Austin, TX ....................................................................... 9 

Cahana, Alex, M.D., chief of anesthesiology and pain medicine, University 

of Washington, Seattle, WA ................................................................................ 11 

ALPHABETICAL LISTING AND APPENDIX MATERIAL 

Cahana, Alex, M.D.: 

Testimony .......................................................................................................... 11 

Prepared statement .......................................................................................... 33 

Coben, Jeffrey, M.D.: 

Testimony .......................................................................................................... 6 

Prepared statement .......................................................................................... 38 

Cornyn, Hon. John: 

Opening statement ........................................................................................... 5 

Grassley, Hon. Chuck: 

Opening statement ........................................................................................... 3 

Prepared statement .......................................................................................... 44 

Millwee, Billy, M.H.A.: 

Testimony .......................................................................................................... 9 

Prepared statement .......................................................................................... 46 

Rockefeller, Hon. John D., IV: 

Opening statement ........................................................................................... 1 

Prepared statement .......................................................................................... 52 

Schwab, Timothy, M.D., F.A.C.P.: 

Testimony .......................................................................................................... 8 

Prepared statement .......................................................................................... 54 

COMMUNICATIONS

Ameritox, Inc. ........................................................................................................... 61 

WellPoint, Inc. .......................................................................................................... 64 

(III) 

(1) 

PRESCRIPTION DRUG ABUSE: 

HOW ARE MEDICARE AND MEDICAID 

ADAPTING TO THE CHALLENGE? 

THURSDAY, MARCH 22, 2012 

U.S. SENATE, 

SUBCOMMITTEE ON HEALTH CARE, 

COMMITTEE ON FINANCE, 

Washington, DC. 

The hearing was convened, pursuant to notice, at 10:01 a.m., in 

room SD–215, Dirksen Senate Office Building, Hon. John D. Rockefeller IV (chairman of the subcommittee) presiding. 

Present: Senators Schumer, Grassley, and Cornyn. 

Also present: Democratic Staff: Jocelyn Moore, Staff Director; 

and Sarah Dash, Health Legislative Assistant. Republican Staff: 

Rodney Whitlock, Health Policy Director. 

OPENING STATEMENT OF HON. JOHN D. ROCKEFELLER IV, 

A U.S. SENATOR FROM WEST VIRGINIA, CHAIRMAN, SUBCOMMITTEE ON HEALTH, COMMITTEE ON FINANCE 

Senator ROCKFELLER. Good morning. Others will be coming. Senator Cornyn is here. The eminent senior Senator from Iowa is here. 

Senator GRASSLEY. Thank you. 

Senator ROCKFELLER. He will have to depart for 10 minutes to 

go do his duty as ranking member of the Judiciary Committee but 

will be back, he said, to ask particularly difficult questions. 

We are going to be talking about an epidemic of drug abuse, 

which is actually—this is such a timely hearing, and I know there 

are lots of hearings of this sort. But it is such a terrible problem 

in my State, and I suspect in all of our States. It is tragic, it is 

sad, it is needless, it is fraudulent, it is horrible, and it is costing 

so much needless money that could be spent elsewhere. 

So it is just the epidemic of drug abuse. Simply put, prescription 

drug abuse is what happens when people use prescription drugs for 

non-medical purposes, slipping into it sometimes without even 

knowing it. Opioid painkillers, antipsychotics, or stimulants are the 

ones that are most commonly used, but there are many others. 

The Centers for Disease Control has termed prescription drug 

use as an ‘‘epidemic.’’ I do not think they have done that—well, I 

guess they did in 1918, with the Great Influenza Epidemic, but 

they do not do it on a regular basis. And it is—it is a horrible problem. 

Overdose from prescription painkillers is now one of the leading 

causes of accidental death in the United States. In my State, which 

2 

is rural and not particularly wealthy, just between the years of 

2001 to 2008 the number of deaths from this kind of death went 

up 4 times. Why 4 times? I do not know. That is what we are going 

to talk about. 

And for every death, the CDC tells us there are 10 treatment admissions of abuse for what we are talking about, 32 emergency 

room visits, 130 people who abuse or are addicted to these drugs, 

and 825 non-medical users. There is no single solution, obviously, 

for all of this, but we cannot take that as a reason not to get at 

it. Today we will hear some stories that might shock and sadden 

us, but we will also hear some practical solutions. We will be hearing those from you. 

Prescription drug abuse is not just about some sensational thing 

that happens to celebrities like Michael Jackson—if you considered 

him a celebrity; I am not sure I did—who died before their time 

from tragic overdoses. 

The fact is, prescription drug abuse touches people from all 

walks of life. It is about an ordinary person, like a polite, stoic, 79- 

year-old man from Clay County, WV. 

Senator GRASSLEY. Clay County, IA. 

Senator ROCKFELLER. You have a Clay County? 

Senator GRASSLEY. Yes. 

Senator ROCKFELLER. Well, maybe he was from there. 

Senator GRASSLEY. Maybe he was. 

Senator ROCKFELLER. Well, it ends in a happy way, so probably 

it was Iowa rather than West Virginia. But he could not be here 

today because he has to stay home to take care of his wife. He was 

going to testify. She is partially paralyzed. His story, untypically, 

ends well, thanks to the primary care doctor that he visited. 

When she asked why the man was taking such a powerful opioid 

painkiller, he said very simply that he had a lot of back pain from 

lifting his wife day after day. So his doctor took him off the drugs, 

and it turns out this man has been addicted without even realizing 

it. Now that he is off the powerful painkiller, he is more clearheaded and without all the side effects, and he has been feeling 

well, better than he has for a long time. Untypical story. It is an 

untypical story. 

Now, of course, the prescription drugs can, and do, work wonders 

for millions of people. For people with conditions like chronic pain 

or severe mental illness, prescription drugs can be a godsend. But 

the availability of powerful prescription drugs has in some ways 

gotten ahead of our ability to prescribe them safely. 

Prescribers do not have the tools they need. They do not have, 

sometimes, the education in medical schools focused on this. Prescription drug monitoring programs—is that a mystery to doctors 

or is that something that all of them know? These things work 

across State lines. Patients need to be better educated. That is easy 

to say, but so hard to do because they react to their pains. 

Sadly, because prescription drug painkillers, stimulants, and 

antipsychotics are so powerful and so addictive, they are all too 

often the target of criminals. These criminals are worse than ordinary fraudsters. They not only steal taxpayer dollars through 

fraudulent schemes like pill mills or fraudulent prescriptions, they 

3 

also feed on people’s addictions and prey on the pain. Obviously 

this is not right. 

But prescription drug abuse is not limited to fraud. We do ourselves a disservice if we ignore the significant clinical implications 

of this problem. So today we will hear from our expert panel—and 

you are that—about the range of solutions that we can implement 

in Medicare and Medicaid, a subject which the two of us have a lot 

of interest in, and this committee obviously does. 

You will help us answer important questions such as, what tools 

and support systems do doctors, nurses, and other prescribers need 

to make sure people get the right care when it comes to controlled 

substances? How can Medicare and Medicaid help educate patients 

and coordinate care so that prescriptions are used correctly? Are 

we adequately identifying people at risk of addiction to controlled 

substances? Are there new models of treatment we should consider 

testing in Medicare and Medicaid, always trying to do the right 

thing and give people treatment and not waste money? Can existing fraud detection systems tell us the difference between deliberate fraud, addiction-driven behavior, and uncoordinated care that 

leads to beneficiaries obtaining the prescriptions from multiple 

sources? 

So there is a lot to learn today, and you all are incredibly wise 

and gifted, and we are very honored that you have taken the time 

to be with us. 

[The prepared statement of Chairman Rockefeller appears in the 

appendix.] 

Senator ROCKFELLER. At this point I will call upon my distinguished friend, Senator Charles Grassley from Iowa. 

OPENING STATEMENT OF HON. CHUCK GRASSLEY, 

A U.S. SENATOR FROM IOWA 

Senator GRASSLEY. Well, I thank you for holding this hearing. I 

appreciate your leadership on this issue. 

Let me give you two measures of why we ought to appreciate 

your leadership on this issue. Number one, the Office of National 

Drug Control Policy describes prescription drug abuse as ‘‘the Nation’s fastest-growing problem.’’ The Centers for Disease Control 

and Prevention has classified prescription drug abuse as an ‘‘epidemic.’’ According to the most recent National Survey on Drug Use 

and Health, a survey conducted by HHS, roughly 2.5 million people 

aged 18 and older used prescription drugs non-medically for the 

first time in 2010. This averages out about 6,000 people per day 

abusing prescription drugs just for the first time. 

For Iowans, prescription drugs account for the fastest-growing 

form of substance abuse. Overdose deaths in Iowa from nonmedical use of hydrocodone and oxycontin pills have increased 

1,233 percent since the year 2000. Over-prescription of these types 

of drugs strains the financial viability of Medicaid and Medicare 

systems and threatens the health and well-being of our people. 

As health care payers, Medicare and Medicaid have a significant 

role to play in guiding solutions to this growing problem. To highlight how much of an impact prescription drug abuse has on Medicaid, I want to tell you about an ongoing investigation of mine. 

4 

In 2010, I sent a letter to all 50 State Medicaid directors, asking 

them for their top 10 prescribers of the top 8 most over-prescribed 

drugs on the market. Many States provided the data I requested, 

and statistics are alarming. 

For example, in Maine, the top prescriber of Oxycodone wrote 

1,867 prescriptions in 2009, nearly double the number of prescriptions of the second top prescriber. The same provider wrote 1,723 

prescriptions of Roxicodone, nearly 3 times the number of the other 

two top prescribers. 

In January, I followed up on this information and wrote again to 

all 50 States, requesting updated data and asking the States what, 

if any, action they took with the top prescribers, and what systems 

they had in place to prevent excessive prescribing from taking 

place. 

I also asked what, if any, training or guidance CMS has offered 

the States in preventing prescription drug abuse from occurring. 

While the responses from the States are still being received, many 

States are still reporting a selection of top 10 providers who are 

prescribing at rates double or triple that of peers. 

While some of these outliers are legitimate providers working in 

high-volume practices such as mental hospitals, many cannot be 

explained. For example, the top prescriber of antipsychotics in Nevada wrote nearly 6,800 prescriptions for drugs over the years 2010 

and 2011, more than 10 times some of the other top prescribers 

identified. For context, no individual prescriber in Colorado wrote 

more than 2,000 prescriptions for the same drug over the same period. This single doctor in Nevada accounted for $2.75 million in 

payments from the Medicaid system. 

As a result of my request, South Carolina has investigated 34 of 

83 providers who appeared on those lists for possible Medicaid 

abuses. South Carolina’s investigation resulted in the repayment— 

repayment—of nearly $1.9 million that more than 30 of the health 

care providers inappropriately billed to the State Medicaid agency. 

Texas has opened investigations into dozens of prescribers identified in the list, making several referrals for criminal prosecution to 

the State licensing board. California, Wisconsin, Tennessee, Nevada, New Hampshire, Minnesota, Kansas, Hawaii, and even my 

State of Iowa have taken similar actions against prescribing outliers in their Medicaid programs. 

The steps taken by these States highlight the aggressive role 

that each and every State should be taking in monitoring and investigating prescription drug practices in the Medicaid program. 

Further, States have overwhelmingly confirmed that CMS has been 

an absent partner in helping to lower prescription drug abuses in 

Medicaid. 

I look forward to hearing from our witnesses today about what 

steps physicians, hospitals, States, and the Federal Government 

could be taking to curb abuse of prescription drugs. Not only 

should we put an end to the lives lost for over-prescribing drug 

abuse in Medicare and Medicaid, we should be working collaboratively to find meaningful solutions. The cost of doing nothing is 

too high already. 

Thank you. 

5 

Senator ROCKEFELLER. Thank you, Senator Grassley. I read your 

study, and it is excellent. 

Senator GRASSLEY. Well, thank you. 

Senator ROCKEFELLER. It is excellent. 

Senator GRASSLEY. Thank you. 

[The prepared statement of Senator Grassley appears in the appendix.] 

Senator ROCKEFELLER. Senator Cornyn, you may have a statement, but more importantly you may have somebody you wish to 

introduce. 

OPENING STATEMENT OF HON. JOHN CORNYN, 

A U.S. SENATOR FROM TEXAS 

Senator CORNYN. Thank you, Mr. Chairman. I do, and I will take 

no more than 3 minutes. But I want to thank you for convening 

this very important hearing on a very serious topic, and Senator 

Grassley for his leadership in investigations. 

But I want to introduce Billy Millwee, who is one of the witnesses here from my State of Texas. Mr. Millwee serves as a Deputy Executive Commissioner for Health and Human Services Operations at the Texas Health and Human Services Commission. Since 

January of 2010, he has been the Texas Medicaid Director. 

He received his bachelor of science degree in business administration from the University of Maryland, a master’s of science in 

health care administration from Central Michigan University, and 

a master of arts and sociology from Texas State University. 

The Texas Medicaid program, I trust Mr. Millwee will explain, 

has made great strides in addressing over-utilization of drugs on 

the front end and on the back end. Both are critically important 

for stemming this growing trend of prescription drug abuse, which 

unfortunately is the Nation’s fastest-growing drug problem. It is 

also a fiscal problem for the States and for the Federal Government 

because of the burgeoning costs associated with Medicaid. 

Using edits at the point of sale, pharmacists are able to catch potential problems, and HHSC is working to educate physicians 

about prescribing patterns that are outside the norm. 

I want to specifically thank Mr. Millwee for his efforts following 

Senator Grassley’s request to identify the high-volume prescribers 

of certain often-abused drugs. Texas responded with immediate action which has led to Medicaid exclusions and investigations. 

As a former State Attorney General, I appreciate the close collaboration Mr. Millwee has had with Attorney General Greg Abbott 

and his office in these investigations and litigation. These are proactive steps that will go a long way toward curbing this disturbing 

epidemic of prescription drug abuse. 

These are just a few of the proactive things that Texas is doing. 

I look forward to hearing more about them in detail from Mr. 

Millwee and hope he can help inform this committee—as will the 

other witnesses, no doubt—on things we can do to address this 

problem. 

Mr. Chairman, as you know, all of us have multiple committee 

assignments that may take us in and out. Thank you for your courtesy and for your leadership. 

6 

Senator ROCKEFELLER. No, thank you. Thank you very much, 

Senator. 

First, all of you have biographies, and it is just criminal to introduce a person with a few short sentences without talking about all 

that you have done, where you have been to school, and this, that, 

and the other thing. But for the sake of brevity, I have to do that. 

First is Dr. Jeffrey Coben, who, happily, is director of Injury Control Research Center at West Virginia University in Charleston. 

Well, it says here Charleston. I thought maybe you were at the 

hospital there. Well, I know where WVU is, but it has branches. 

So, I apologize. 

First, I would like to extend that welcome to you. You are a practicing emergency medicine physician and have conducted research 

on prescription drug overdoses. We would like very much to hear 

what you have to say. 

STATEMENT OF JEFFREY COBEN, M.D., DIRECTOR, INJURY 

CONTROL RESEARCH CENTER, WEST VIRGINIA UNIVERSITY, 

MORGANTOWN, WV 

Dr. COBEN. Thank you, Mr. Chairman. Chairman Rockefeller, 

Ranking Member Grassley, and distinguished subcommittee members, thank you very much for inviting me to discuss this critically 

important issue. 

The alarming increase in prescription drug abuse is clearly a crisis that demands our attention, but the statistics and the numbers 

do not adequately describe the ravages of prescription drug abuse. 

As a practicing emergency physician, I have seen the pain and torment of families who have lost a family member from overdose; I 

have seen children removed from their homes; and I have seen 

shootings, stabbings, and suicide all as a direct consequence of prescription drug abuse. 

I can also attest to the benefits of prescription opioid analgesics, 

and I think anyone here who has suffered with a painful condition 

can probably provide their own commentary. In fact, in many 

cases, providing adequate pain relief can be the best, or only, thing 

that we as health care providers can do for our patients. 

Fifteen years ago in this country, physicians were being heavily 

criticized for not adequately addressing pain. Now, only a short 

time later, we are faced with a rising epidemic of prescription drug 

overdoses, fueled in part by a dramatic increase in the sale of these 

strong painkillers. 

Balancing the appropriate use of prescription drugs with efforts 

to prevent their abuse is a complex and difficult challenge, and addressing this problem will require a multi-factorial approach. For 

example, we need to address societal attitudes towards the recreational use of prescription drugs. 

The majority of teens in this country believes that using an 

opioid medication without a prescription does not pose a great 

health risk. We also need to do a better job educating health care 

providers on the broader use of pain management, opioid prescribing guidelines, and on the best approach to screen and refer 

patients with substance abuse problems. 

Efforts to improve, standardize, and facilitate the more widespread use of prescription drug monitoring programs are also needVerDate Nov 24 2008 14:14 Mar 12, 2013 Jkt 000000 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 R:\DOCS\79378.000 TIMD
7 

ed. There is, of course, a critically important role for law enforcement and the DEA in detecting and intervening with illegal efforts 

to obtain and distribute prescription drugs. 

Focusing now more specifically on public insurance programs, 

there are several strategies I think that need to be considered. 

These include the expanded use of real-time analysis of claims data 

to identify potential cases of doctor shopping and other forms of 

abuse; the expanded use of drug utilization reviews, particularly 

those that can be implemented at the point of sale; and the expanded use of single-provider/single-pharmacist lock-in programs 

for individuals who have been identified as abusers. 

Medicare and Medicaid have also had an important role in promoting the use of electronic health records and e-prescribing. These 

systems have great potential for not only reducing fraudulent prescriptions, but also for identifying potentially lethal combinations 

of prescription drugs. 

Many State Medicaid programs have also been at the forefront 

of efforts to promote the use of the patient-centered medical home 

model of primary care. The medical home model has the potential 

to also help curb the problem of prescription drug abuse by promoting better coordination of care. 

We must also, I think, recognize the important role for substance 

abuse treatment, and the very real and critical shortage of treatment service availability throughout the country. Providing beneficiaries with coverage for treatment and reimbursing providers for 

screening is another important role for Medicaid programs. 

Finally, we need to consider the drugs themselves. Safer and 

equally effective pain relievers can be developed, and tamper-proof 

drug dispensing units can limit the quantity of medications available. As these products increasingly come to market, both Medicare 

Part D and Medicaid programs will need to consider the potential 

benefits and costs of adding them to their formularies. 

Approximately 50 years ago, the United States was experiencing 

a similar dramatic increase in deaths, this time from motor vehicle 

trauma. We responded by developing a wide array of interventions 

that have been integrated, systematic, and sustained. The result 

has been a great success story. In the first decade of this century, 

while the poisoning death rate has climbed by 130 percent, the 

motor vehicle death rate has dropped by 25 percent. 

As we now confront the problem of prescription drug abuse, a 

similar integrated and sustained strategy is needed. While regulations and other approaches involving Medicare and Medicaid cannot solve this problem alone, they can certainly play an important 

role. 

Thank you. 

Senator ROCKEFELLER. Thank you, Dr. Coben. That calls for 

some questioning. 

[The prepared statement of Dr. Coben appears in the appendix.] 

Senator ROCKEFELLER. Dr. Timothy Schwab. Welcome to you, sir. 

Dr. Schwab manages pharmacy and medical informatics and sets 

medical policies for SCAN Health Plan, which is a Medicare Advantage plan serving more than 128,000 members in California, I 

would guess. 

So, we welcome your testimony, sir. 

8 

STATEMENT OF TIMOTHY SCHWAB, M.D., F.A.C.P., CHIEF 

MEDICAL OFFICER, SCAN HEALTH PLAN, LONG BEACH, CA 

Dr. SCHWAB. Thank you, Chairman Rockefeller, Senator Grassley, and members of the committee. My name is Tim Schwab. I am 

chief medical officer of SCAN Health Plan in Long Beach, CA. I am 

a board certified internist and have been working at SCAN for 

nearly 25 years. I have been very active in geriatric programs, academic programs, and California State policy committees looking at 

seniors, people with disabilities, and individuals eligible for both 

Medicare and Medicaid. I appreciate the opportunity to appear before you today to discuss the innovative programs SCAN has in 

place to protect our members from the dangerous effects of prescription drug abuse. 

SCAN Health Plan is the fourth-largest not-for-profit Medicare 

HMO in the country. We primarily serve seniors who have multiple 

chronic conditions and/or frailty. We have served this population 

since 1985, with the mission to help seniors maintain their health 

and independence. SCAN has always provided a strong geriatricfocused pharmacy benefit for our members. 

I would like to share with you a composite that illustrates many 

of the medication challenges being faced by SCAN beneficiaries, 

our providers, and payers. 

Ms. J is an 81-year-old member who is widowed and lives alone 

in a senior independent living unit. She has a longstanding history 

of diabetes, high blood pressure, atrial fibrillation, and severe osteoarthritis. She had a stroke 5 years ago and has some residual 

right-sided weakness. 

This weakness, in addition to her severe arthritis, limits her mobility and activities. Her diabetes has caused reduced vision and 

impaired kidney function. Despite these challenges, she is still able 

to live alone, and take care of herself. 

Prior to joining SCAN, Ms. J was on eight regular medications, 

plus occasional sleeping pills. She was seeing three different specialists in addition to her primary care physician. She utilized 

three different pharmacies. During the previous year, she had six 

emergency room visits for increasing pain, two for falls, and she 

was hospitalized twice. 

When a new member enrolls in SCAN, we conduct a comprehensive risk assessment. We flagged Ms. J to be at high risk for hospitalization given her history. She was referred to our geriatric 

health management team for further evaluation. 

Our interdisciplinary team—a geriatric care manager, a geriatrician, and a geriatric pharmacist—identified the following issues: 

poly-pharmacy with several medications from the same therapeutic 

class, potential drug-drug interactions, potential dosage adjustments needed to compensate for her reduced kidney function, and 

a high risk of falling due to medications affecting her gait and balance. 

So we contacted Ms. J’s physicians. We found they had little 

awareness of all the different medications that she was being prescribed from the different physicians. They were unaware that several of those medications were causing her falls and emergency 

room visits. Those medications were changed at that time. 

9 

Her primary care physician then referred her to a pain management specialist. Her pain is now much better controlled, and she 

has had no emergency visits in the last year. Her assigned care 

manager, a nurse, continues to regularly talk to her and to her primary care physician to make sure her pain is being managed to her 

satisfaction and that she is experiencing no other untoward medication effects. 

Ms. J, who represents so many of the frail elderly, has benefitted 

from a model of care that focuses on the specific needs of the geriatric population. SCAN has developed a very patient-centric geriatric model that utilizes individual assessments, utilization data, 

and pharmacy data to identify and create early interventions for 

pharmacy management. These include: real-time edits at the pharmacy to identify and notify the physician of dosage errors and 

drug-drug interactions; medications not to be utilized in the geriatric population; inappropriate early refills; identification of same 

or similar medications filled at different pharmacies and different 

prescribers of the same medications; a medication therapy management program for poly-pharmacy; geriatric continuing medical education for physicians, nurses, pharmacists, and case managers on 

specific geriatric conditions; and pharmacy management. This program also includes a module on pain management. 

Drugs can ease pain and prolong life, but we must make sure 

that what is meant to help does no harm. We take that mission 

very seriously at SCAN. Thank you. 

Senator ROCKEFELLER. Thank you, Dr. Schwab, very much. 

[The prepared statement of Dr. Schwab appears in the appendix.] 

Senator ROCKEFELLER. I am going to skip over to Mr. Millwee. 

You have been introduced already, and you have a very distinguished history. You are the Medicaid Director of the State of 

Texas. 

Mr. MILLWEE. Yes, sir, I am. 

Senator ROCKEFELLER. Yes. So we would like to hear what you 

have to say, sir. 

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

Mr. MILLWEE. Well, good morning, Chairman Rockefeller, Ranking Member Grassley, committee members. My name is Billy 

Millwee, and I serve as the Texas Medicaid Director. I am very 

honored to be with you today to talk about what Texas is doing to 

address prescription drug abuse in Medicaid. 

The approach in Texas is one of collaboration. We have worked 

with the various Health and Human Services agencies. It is not 

just a Medicaid issue; it is an issue around our Health and Human 

Services agencies that we need collaboration to address. It involves 

the Texas Attorney General as well as the provider community. 

That collaboration has developed into a comprehensive approach. 

The elements of that include prevention, education, intervention, 

treatment, and improved use of technology. 

Let me cover each of those very briefly with you. Strategy one 

is prevention. Here is what I mean by that. Through our Medicaid 

drug utilization process, we employ both point-of-service edits and 

10 

prior authorization. The point-of-service edits look at the maximum 

quantities, early refills, and therapeutic duplication. 

If those things are present, then we do not pay for that prescription. We do not allow that prescription. Prior authorization is used 

extensively for opiates and antipsychotics. Absent prior approval, if 

the clinical criteria are not met, then we will not fill that prescription. 

Along the same lines of prevention, effective March 1, 2012, 

about 22 days ago, we implemented a managed care model for 3.5 

million Medicaid clients. Not only do they get their health services 

through these HMOs or managed care, but also their prescription 

drugs. We believe that will result in improvements in utilization 

management and align the financial incentives as well. 

We have made great progress in our foster care program. Texas, 

in conjunction with some leading physicians, has developed psychotropic medication utilization review processes for children in foster 

care. We implemented a State-wide managed care program exclusively for foster care children, and the managed care program includes a robust medical home—patient-centered medical home— 

electronic health passport, and intense utilization review using the 

guidelines I mentioned earlier. 

The program has worked. Since 2005, we have seen a tremendous decrease in the use of psychotropic drugs in foster care children. Prior to the program, we had about 30 percent of the children 

in foster care receiving psychotropics. That has declined to about 

20 percent today, and it is decreasing every year. 

Strategy two is education. We use retrospective drug utilization 

review. We identify providers with high utilization patterns outside 

the norm. Those prescribers are sent education letters, with specific 

clients listed, and some clinical criteria that may apply. That program has been successful. We find generally that, 6 months after 

that intervention or education letter is sent, we see a 3- to 6- 

percent decrease in the utilization of that prescription for that particular provider. 

Let me talk a little bit about strategy three, intervention. We 

have an Office of Inspector General that conducts data mining to 

identify and take action on providers, as well as clients. Of the 

high-volume providers identified in a 2010 letter from Senator 

Grassley, four have been excluded from the program, 39 are under 

investigation, three have been referred to the Attorney General for 

prosecution, and two have been referred to the licensing board for 

action. 

For clients, we operate a lock-in program. We identify clients 

who have a suspected pattern of drug-seeking behavior. At first a 

notice is sent advising them that we have noticed these patterns 

in their use of drugs and offer some potential management solutions if they do not respond. Then they are put on a lock-in program and locked in to a particular pharmacy so that we can better 

monitor utilization. 

Strategy four is treatment. During 2010, we implemented a Medicaid substance abuse treatment program. Treatment consists of 

outpatient as well as residential treatment. Services are provided 

by licensed therapists in appropriately licensed facilities. The reVerDate Nov 24 2008 14:14 Mar 12, 2013 Jkt 000000 PO 00000 Frm 00014 Fmt 6633 Sfmt 6633 R:\DOCS\79378.000 TIMD
11 

sults look promising. We believe that the cost of the program may 

well be paid for through savings in the program in other areas. 

Strategy five is technology. We believe technology offers great 

promise. We implemented this year an e-prescribing process. We 

will soon deploy a Medicaid electronic health record so that providers can access information about clients with the swipe of a 

magnetic card and some other security precautions. 

Texas is very active in promoting electronic medical records. Through our EMR incentive program, we have granted about $300 

million over the past 2 years to providers to develop these electronic medical records. 

We certainly can, and will, do more. We believe we have made 

some significant progress, and really we appreciate the work of this 

committee in bringing this issue to the forefront. When you shine 

a bright light on something, I think that is how you get it fixed. 

Thank you very much. 

Senator ROCKEFELLER. That should be the way we get things 

fixed. Then there is the problem of writing legislation, and trying 

to make it on a bipartisan basis and getting it past the Senate, and 

then getting the House to do something similar, then conferencing, 

and then having both houses vote on it, and then having the President sign it. 

I mean, this is all very rigorous, but the dimensions are so shocking, and they are exploding right in front of us, as you all know 

better than—well, we all know too. So this is why your being here 

is so important. 

[The prepared statement of Mr. Millwee appears in the appendix.] 

Senator ROCKEFELLER. Alex Cahana, Dr. Cahana, is chief of anesthesiology and pain medicine at the University of Washington in 

Seattle. He is a specialist who promotes measurement-based care— 

I am interested in that phrase—as standard of care in pain medicine. 

Welcome, sir. 

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

SEATTLE, WA 

Dr. CAHANA. Thank you, Chairman Rockefeller, Ranking Member 

Grassley. I would like to thank this committee for inviting me to 

discuss the clinical aspects of good pain management, but, more 

importantly, I want to tell you about the applied solutions that we 

have put in place at the University of Washington, and in the State 

of Washington. 

I am pleased to report to you the very promising preliminary results of these interventions were significant reductions of deaths 

from opioids in the Medicaid population and the Worker’s Compensation population. 

I will preamble by saying that it is unfortunate that in the 

English language we use the same word for pain as a symptom and 

pain as a disease. Pain as a symptom is a by-product of a disease. 

Take care of the disease, the pain goes away. However, when pain 

becomes the disease, when there is nothing broken to fix, no infection to cure or tumor to operate upon, treating pain as if it was a 

12 

symptom simply does not work. It actually makes things worse. 

This is why we are seeing so much harm with high-dose prescription pain drugs. 

To treat chronic non-cancer pain as a disease, a treatment plan 

may sometimes include opioids but always includes listening to the 

patient, determining what is interfering with his or her life, defining functional goals, and individually tailoring a variety of medical, 

exercise, mind-body treatments, and healthy life choices. 

A large volume of material has been recently published, but 

there are a few things that need to be remembered. First, there is 

virtually no evidence that high-dose opioids relieve pain or improve 

function in chronic non-cancer pain. 

Senator ROCKEFELLER. In chronic what? 

Dr. CAHANA. Chronic non-cancer pain. 

Senator ROCKFELLER. All right. 

Dr. CAHANA. Second, there is growing evidence that shows that 

opioid treatments over 90 days are usually a commitment for life. 

Third, it is usually the most vulnerable, sickest, and disadvantaged 

patients like Medicare, Medicaid, and the veterans’ population who 

receive the most opioids, oftentimes because that is what their 

health care professionals know, and what the insurance will cover. 

Now, in the written material you will find seven solutions that 

we have put in place. In my opening statement I have time only 

to go over three, the three most important, and hopefully for the 

rest of the discussion we can go over the rest. 

The first and most important is that measuring pain, mood, and 

function at each clinical encounter is key to understanding patients 

and the effectiveness of treatments. So, since November of 2008 at 

the University of Washington Pain Center, we have been using an 

assessment tool with every clinical encounter. 

This tool allows patients to describe how pain impacts key domains of their lives, including pain interference to essential activities, status of their physical functioning, emotional well-being, satisfaction, and the potential risk for prescription opioid abuse and 

misuse. 

Combined with routine urine drug tests, this model of 

measurement-based care informs clinicians about important patient characteristics, treatment progress, and overall satisfaction 

from the visit. It also permits us to decide on and identify exceptional outcomes, efficiencies, and needed resources for expansion of 

services to provide effective and efficient outcomes—not how to 

treat pain, but who to treat pain with what. 

The second-most important solution is that, in order to increase 

the availability of specialty care, we initiated twice a week a 90- 

minute tele-pain provider-to-provider consultation. 

This service, called ECHO—Extension for Community Health 

Outcomes—was developed at the University of New Mexico and is 

designed to improve access to specialty care for under-served populations with complex health problems. It uses video conferencing 

technology to train primary care providers to treat complex situations and has been shown already to be as effective and safe as 

specialty care. 

Since March 2011, we have trained close to 1,500 professionals, 

with thousands of training hours, from 76 locations, with 40 to 50 

13 

providers dialing in at each session from Nome, AK all the way to 

Pocatello, ID. We have documented an improved sense of knowledge of prescriptions among our providers, and an even higher decrease in mortality rate in counties receiving education compared 

to the State average. 

Last, since 2010, we have provided a second opinion consultation 

for Medicare and Medicaid beneficiaries receiving ultra-high doses 

of over 1,000 milligrams of opioids equivalent a day. This follows 

the model of the second opinion consultation which was developed 

for children treated with antipsychotics, which was shown to improve patient outcome and be a cost benefit. 

We started a targeted mentoring program for top prescribers, 

and it is called Look Over the Expert’s Shoulder, which is a postgraduate educational program allowing advanced training and certification in the communities of practice. Look Over the Expert’s 

Shoulder-trained pain champions are expected to serve as educators, leaders, and resources in their communities where specialty 

pain clinics are unavailable or inconvenient due to excessive distance. 

In summary, over-reliance on opioids is poor pain management 

and it is a result of, yes, insufficient provider training and patient 

education, but more so the lack of accessible real-time, patientreported outcomes for the prescriber to tell, are these prescriptions 

or other treatments effective and safe? There is a presence of 

strong financial incentives to over-prescribe, over-proceduralize 

pain complaints, especially in the vulnerable population. 

I urge the committee to consider these three elements to improve 

outcome. Thank you. 

Senator ROCKEFELLER. Thank you very much, Dr. Cahana. 

[The prepared statement of Dr. Cahana appears in the appendix.] 

Senator ROCKEFELLER. I am going to turn, first, to Senator 

Grassley because he has to give a speech. Are you addressing the 

Pentagon, or the President, or who? 

Senator GRASSLEY. No, my fellow colleagues. 

Senator ROCKEFELLER. Oh, your fellow colleagues. All right. 

[Laughter.] 

He has to leave, so I want him to have a chance to ask some 

questions. 

Senator GRASSLEY. I do not think it is anything you would disagree with. Thank you for the courtesy. 

The first question: Dr. Schwab, in your testimony you talked 

about the system SCAN has in place to weed out potential problematic prescribers, including physicians, dentists, physician assistants, and nurse practitioners. I want to applaud SCAN. However, 

it is not enough just to identify these prescribers. That information 

has to be shared. 

For example, look at the recent case in Texas where a practitioner—one practitioner—defrauded Medicare and Medicaid of $375 

million. He had already been disciplined by the Texas board. He 

had to surrender his controlled substance permit due to inappropriate prescribing. He was sanctioned for unprofessional conduct, 

yet he was still able to bill Medicare and Medicaid. 

14 

Now, the general public is going to wonder, how could that be? 

But it is. So, when you identify a bad practitioner, do you pass on 

that information to both the State in which the prescriber is licensed and to CMS? If not, why not? 

Dr. SCHWAB. The answer is ‘‘yes.’’ If we have identified that person and, after due diligence and discussing that with the provider, 

we have determined that there still is a problem, that information 

is turned over both to the State licensing board and to the Federal 

databank. 

Senator GRASSLEY. All right. 

And for the director from Texas, does Texas also pass this type 

of information on to CMS? 

Mr. MILLWEE. Yes, sir, we do. We disclose our investigations, 

once they are completed, to CMS and also to our Attorney General. 

Senator GRASSLEY. All right. 

Well, thank you very much. It seems like the steps that both 

SCAN and Texas are taking ought to be recognized as being admirable and effective, and a pattern for everybody else. If we could 

learn to coordinate with all the players in the system, I am confident that we could do a better job of not only reducing drug 

abuse, but also waste and fraud in our two Federal programs. 

For Dr. Cahana, in response to my letter to the States about 

their top prescribers of pain management drugs, I have begun to 

receive information. Some States have improved over previous 

years and some, despite their best efforts, have not. 

An example is Florida. One doctor wrote nearly 7,000 prescriptions for Oxycodone HCL in 2010 alone. This doctor holds himself 

out to the public not as a pain specialist, but rather as a pain medicine specialist. 

Dr. Cahana, is 7,000 prescriptions in 1 year unusual, in your experience? Also, before you answer that, are you surprised, given the 

advances in recent years to reduce prescriptions of these opiatebased painkillers, that a doctor is so blatantly holding himself out 

to the public as a ready and willing prescriber of these drugs? 

Dr. CAHANA. We are always attracted by the outliers and the excessive activities of either patients or providers, and one of the 

problems that we see is education and the lack of a clear statement 

of what is the education knowledge base that is necessary to actually handle these type of prescriptions. 

I think that using video mentoring, and making sure specialists 

reach out to these prescribers in the community, and providing 

them the latest information can transform them from outliers to 

pain champions, to actually have them in the community and say, 

you can help and give patients the feeling that specialists in tertiary care settings can give them a shoulder and a hand. 

Senator GRASSLEY. This will have to be my last question, so my 

last one would go to Director Millwee. 

On January 1, I sent letters to all 50 States requesting data on 

their top 10 prescribers. I also asked if CMS had provided the 

State Medicaid departments with any training or guidance to help 

identify potential issues with prescription drugs. Most Medicaid directors responded that they had not received any such training. 

If there were more open communication and collaboration between States and the Federal Government, we would have a better 

15 

outcome for patients and taxpayers, States, and the Federal Government. 

So, in your case, has the Texas Medicaid department received 

any training from CMS? Let me add to that, do you think any of 

the successful programs that Texas has implemented could have 

been enacted sooner if CMS had offered guidance? 

Mr. MILLWEE. No, sir. We have not had any discussions with 

CMS about this issue. I think that potentially it could help, particularly if States develop these innovative ideas. If CMS could 

share those ideas among all the States, then there is some opportunity there to leverage what other States have learned and maybe 

put it in place faster. 

Senator GRASSLEY. Thank you. 

Thank you, Mr. Chairman, for letting me go ahead. 

Senator ROCKEFELLER. Well, give a good speech. 

Senator GRASSLEY. All right. I will. You know how that goes. 

[Laughter.] 

Senator ROCKEFELLER. Senator Schumer, we welcome you. If it 

is all right with you, I would like to ask a question or two, then 

go right to you. 

Senator SCHUMER. Of course. 

Senator ROCKEFELLER. This is really to Dr. Coben and Dr. 

Cahana, but really could be to any of you. But it is so mystifying. 

What we are talking about is pain prescription medicines, and we 

are not even mentioning any of the other addictions: meth, or anything else that is just disintegrating families, communities, States, 

and ruining budgets, and much more importantly, ruining lives. 

Dr. Coben and Dr. Cahana, are some people actually sort of 

under-treated for pain while some people are being over-treated for 

pain? How can these two things exist? Which may lead you to talk 

about what you get taught when you go to medical school. 

Dr. COBEN. Senator Rockefeller, yesterday I worked in the emergency department before coming here, and, during the course of 

that 8-hour shift, I can probably recall at least half a dozen patients who were struggling one way or another with pain issues, 

and with medication issues. Part, I think, of that problem is the 

fragmented primary care system, and that patients are seeking out 

relief wherever they can obtain it. 

Now, clearly some patients are seeking prescription medications 

for the purposes of the drug itself, but I think just as frequently 

patients are seeking care for the pain that they have, and not the 

recreational use of the medication. This fragmented care is really 

contributing, I think, quite a bit, which is why the coordination of 

care is so important. 

To your point, I think there are clearly situations where there is 

under-prescribing, and physicians, for many, many years, have 

worried about the dangers of getting patients addicted to medications. But finding that balance and—as Dr. Cahana has spoken eloquently of and I am sure will talk more about in terms of measuring it and being able to understand what patients need at the 

time of care—having that information in front of us is a critically 

important contributor to how we can do a better job of matching 

the need with what we provide to patients. 

Senator ROCKEFELLER. I am going to follow up on that. 

16 

Dr. Cahana? 

Dr. CAHANA. Thank you, sir, for this question. Obviously, we are 

finding out that there are biological reasons for how something that 

was designed to be a very potent and reliable pain reliever under 

certain conditions actually increases pain and causes a whole host 

of untoward side effects that we were not aware of. 

The problem with the over-prescription in certain conditions, 

which is a certain way of under-treatment by over-treatment, is 

that pain pills are not a panacea. There is an over-reliance embedded culturally on thinking that existential suffering can, and 

should, be treated by pills and devices. But what we are finding out 

is that other treatments, as I mentioned in my opening statement—healthy life choices, smoking cessation, weight reduction, integrative medicine—all these low-tech approaches to better health 

are turning out to be very promising. So, in order to determine 

what works—we say, does this work? yes? no?—it is important to 

measure at each clinical encounter what is going on. 

When you come to my office, then you fill out a battery of questionnaires that allows me to see what you think about your pain, 

and are you sad, or are you anxious, or are you frustrated, and in 

that brief conversation I am able to very quickly concentrate on 

what things that you think are important. 

So we are moving away from how to treat pain to whom to treat, 

with what, and what are the best treatments and not saying this 

is good or this is bad. 

Senator ROCKFELLER. Can people sometimes declare to you that 

they have pain, but what you know is that somehow it is in their— 

not imagination, but they have decided they have pain because perhaps they had pain a week ago, and then there was a little sort 

of something that reminded them that that occurred. So my question really would be about people who really do have pain and need 

to be treated as opposed to people who are so accustomed, in their 

own minds, to having pain that they seek out medication just as 

a stabilizer for general purposes. 

Dr. CAHANA. So, first of all, when we say ‘‘pain is in the head,’’ 

it is to some extent accurate because pain is in the brain, and the 

only way of not having pain is not having a brain. But pain is not 

felt by the brain; pain is felt by people. 

People express that in combination with what is going on in their 

life. This is why we call it the bio-psycho-social model that has biology in the brain, it is genetic, but also has our psychological characteristics and our traits as individuals, and then afterwards what 

life has given to us and how we are adapting to our current circumstances. 

So every patient who comes and complains about pain, they are 

not imagining or inventing it; they are in true distress. The point 

is, what is the correct treatment that would help them out to relieve that distress and improve function? So it is not the pain, per 

se, that we are interested in, it is the functional recovery. 

So if, for example, I look at a cohort of patients, and I look at 

just how many opioids did they use, and I look before treatment 

and after treatment, and I do a total average of totals, I will see 

that, after seeing me, they have reduced maybe their consumption 

by 3 percent. That is not very successful. 

17 

So why are we doing all this investment for a 3-percent reduction? But if I start to stratify patients into different groups, I will 

see that I have three types of patients. I have those who are wellengaged; they want to get better but they just do not know how. 

Then I have a group of minimally engaged patients. They are 

upset, they do not know, they are not sure that they want to, or 

can, get better. Then I have a group of patients who are fine. They 

do not see a problem. They do not understand what the problem 

is. 

So, when we look at the well-engaged patients, we see reductions 

of up to 56 percent in opiod consumption, whereas in the other two 

groups you do not see those reductions. So it is clear that the first 

group coming to us has the right address for them. 

For the second group, perhaps intensive counseling, mental 

health services would be the better thing to do. 

For the third, if they are fine and they are stable, then there are 

maintenance programs and addiction medicine specialists that can 

continue to work on their health. So it is very important to be able 

to not talk about how to treat pain, but whom to treat, with what, 

and what are the alternatives. 

Senator ROCKFELLER. Thank you, sir. 

I call on Senator Schumer. 

Senator SCHUMER. Well, thank you. I want to thank Chairman 

Rockefeller for holding a hearing on this critical issue. The crisis 

of prescription drug abuse is shocking. In New York, our law enforcement officials believe it is the greatest drug problem we have 

now, greater than crack or cocaine or heroin, and growing at clearly the most rapid rate. 

We have seen all kinds of suffering in New York. There was a 

horrible incident in Seaford, Long Island, where an off-duty ATF 

agent was fatally shot when he was trying to intervene in a robbery of a local pharmacy. Another time in Medford, Long Island, 

where there seems to be a growing problem, four people, including 

an on-duty pharmacist, were murdered during a robbery of a pharmacy. 

So we have to change the course of this epidemic. One of the reasons I am so glad that Senator Rockefeller has had the hearing, 

and I am proud to co-sponsor his bill, is I remember crack and even 

crystal meth, where we did not do enough early on, and it got its 

tentacles in our society, both of those drugs, and it took a long time 

to get them out. But we can stop that if we really move quickly 

here. 

So the reason I like Senator Rockefeller’s bill is because we need 

these painkillers, as you all stressed, but we do not want them to 

get into the wrong hands. The only way we are going to get after 

this is if we can identify patients who are doctor shopping and 

wasting taxpayer dollars through Medicare and Medicaid. That is 

not the only way, but that is an important way. We have a group 

in our State called Physicians for Responsible Opioid Prescribing. 

The group includes non-physicians, and it is doing good work. So 

there is a lot to do here as this bill moves along. I hope we can 

move it quickly. 

So I have a few questions in the remainder of my time. I thank 

you for coming. Thank you. I care a lot about this issue. 

18 

Senator ROCKEFELLER. No, you go right ahead. 

Senator SCHUMER. The first question I have is, how much of the 

problem is over-prescribing? CDC found, from 1997 to 2007, that 

the milligram-per-person use of prescription opioids in the U.S. 

went from 74 milligrams to 369. That is a 400-percent increase. In 

2000, retail pharmacies dispensed 174 million prescriptions for 

opioids, and 257 million by 2009, up 48 percent. 

So would any of you want to comment on how much of the crisis 

is over-prescribing? 

Dr. CAHANA. I would like to say that, absolutely, when we look 

at prescription trends, also in other countries, we see that it is specific to what I would call the impoverished dialogue that we have 

with our patients. When you walk into my office for a follow-up and 

I have only a few minutes and I say, how are you doing, sir, and 

you go like this with your head, then the first thing I do is I look 

at the clock behind you and I say, all right, I have a few minutes. 

What are you taking? Here, take a little bit of this. So, prescription 

has become the passport to continue our day. I am saying this in 

the most constructive way. 

Senator SCHUMER. Right. 

Dr. CAHANA. It is something that we are incented to do, it is 

something that we are taught to do. For many of us, it is something that we believe is the right thing to do. 

Senator SCHUMER. Right. 

Dr. CAHANA. But very quickly, we find ourselves escalating on 

doses that we have no exit strategy for. Like I mentioned in my 

opening statement, if you are more than 90 days on these prescription drugs, then probably you are committed to life for that. I am 

sure that if that would have been the discussion when we started, 

then we would have a different decision in place. 

Senator SCHUMER. Anyone else? 

Dr. COBEN. Senator, if I could also comment. 

Senator SCHUMER. Dr. Coben? 

Dr. COBEN. Thank you. You mentioned the dramatic escalation 

since 1997. I think it is difficult to quantify exactly how much of 

this is over-prescribing. However, clearly there is some, but I will 

remind folks that in 1997, there were some guidelines and recommendations that were put forth saying that physicians were not 

adequately prescribing, and calling for increasing in prescribing of 

medications at that time. So I think some of that has been a response. Now, we clearly have swung too far in the opposite direction, so finding the appropriate middle ground is what we really 

have to concentrate on. 

Senator SCHUMER. Did you want to say something, Dr. Schwab? 

Dr. SCHWAB. Yes. I agree with both of my colleagues. I think, 

though, that especially in the Medicare population that I represent, 

the problem is inappropriate prescribing a lot of times, where they 

are using short-acting opioids instead of long-acting, and they are 

not coordinating with the other physicians, so that there may be 

multiple physicians prescribing medications for the same person, 

and they are unaware that they are all giving these medications. 

So we need more of the educational side towards the physician 

and coordination and an individual, patient-centered model—what 

is your problem, finding out what they are treating the person for. 

19 

Senator SCHUMER. Right. My time is up. 

Senator ROCKFELLER. But just barely. 

Senator SCHUMER. I have a few more questions. 

Senator ROCKFELLER. Go ahead. 

Senator SCHUMER. All right. 

The next question I have is, we have a database in New York 

where you are supposed to be able to log in, the physician is, to 

make sure that there are not people getting multiple prescriptions 

in multiple places. Some might do that benignly if you will, trying 

to relieve their pain; others might do it because they want to sell 

the drugs. 

So my two questions are—but our doctors complain about our 

database being incomplete, and it takes too long. You cannot wait 

20 minutes for the database to come back while you have a busy 

practice and you are watching the clock, as Dr. Cahana said. 

So this bill would help to make the database better. I am interested in the databases that exist—I think there are 20 some-odd 

States that have them—do they work better, would this bill help 

them work better? I will ask one other question rolled into this. 

How much of the abuse—when we have a high school kid in New 

York buying these drugs in the schoolyard, or addicted to these 

drugs, let us say—let us make it that. How much of that comes 

from just taking the pills out of his parents’—that were legally prescribed and needed—out of the parents’ medicine cabinet? How 

much is from the drugs being stolen or in pharmacies, on trucks? 

They rob the trucks that carry the drugs and put them into the 

black market in a similar way that an illegal drug would be used. 

So that is a lot of questions, but all in the same sort of area. Who 

would like to respond? Dr. Coben? 

Dr. COBEN. With regard to the prescription drug monitoring programs, I think it is fair to say that, since they are all State-based, 

there is quite a bit of variation, and variability in the quality and 

the issues in using all of them. I know that there are difficulties 

that relate to the frequency and rapidity with which the information gets into the database. So, for example, it may be up to 2 

weeks in a State before the pharmacy actually reports a prescription. 

During that time, lots of prescriptions can be filled. There are 

issues with regards to accessing the data and the timeliness of accessing the data from the provider side, from the physician side. 

One of the biggest challenges that I have dealt with in my practice 

is finding a unique identifier for each individual whom I see. 

Senator SCHUMER. Sure. 

Dr. COBEN. The same last name, same first initial, can get recorded lots of different ways in a particular database. So I think 

efforts to improve and standardize these, and also to share the data 

across State lines, are vitally important and can really be very 

helpful. Also, not only would this be helpful in curbing abuse and 

doctor shopping, but also helpful in reducing physicians’ withholding medications from people who really need them, because 

many of us have suspected drug-seeking when in fact, when we go 

to the database, we find that it is not drug-seeking. So, I think it 

could be very helpful. I think if the bill can address that issue, it 

would be extremely beneficial. 

20 

On your second question regarding where the medications are obtained, we know from at least self-reported data that teens report 

they are obtaining prescription drugs from family members and 

friends, and from the medicine cabinets. Now, where those are 

coming from, and exactly the friends, and where they are getting 

them from, I think is still unclear. 

Senator SCHUMER. Any others? 

Dr. CAHANA. So, in regard to that question, a survey that was 

done in the State of Washington put the number at 57 percent of 

teens, in our last youth survey, who said that they took prescription drugs from their family medicine cabinet, and 10 percent of 

our 10th graders said that they have tried prescription drugs at 

least once, for recreational use, at something that they call a 

pharm party. So that is the first question. 

The second is, we added—— 

Senator SCHUMER. Just to sort of—but sometimes they will start 

with the drugs in the medicine cabinet and then they get so addicted, they need to go on. Is that 57 percent where they started 

with prescription drugs or is it teens who generally use them? You 

are talking, with these pharm parties, I take it, occasional use and 

not real addiction? 

Dr. CAHANA. Well, they said that the first source—— 

Senator SCHUMER. First source. Got it. That was my question. 

Thank you. 

Dr. CAHANA. And there is a parallel increase in prescription drug 

abuse and heroin abuse, as well as referrals to treatment centers. 

It is parallel because it is very expensive to maintain a prescription 

drug abuse habit. 

The second thing is—I agree with my colleague—the technological limitations that we have on the usefulness of prescription 

monitoring programs. What we have done very specifically in the 

State of Washington is develop a program called EDIEP, the Emergency Department Information Exchange Program, where all our 

EDs have better penetration in the eastern part than in the western part of the State where they are networked, so if someone 

walks in, then the name is flagged. 

It is not so much as withholding, as Dr. Coben spoke about, but 

really contacting, through a call center, the primary care doctor to 

say, did you know that Mr. Smith has visited, in the last 24 hours, 

three emergency rooms on the I–5 corridor, and, if the patient does 

not have a primary care provider, to assign them one, because that 

is the whole idea, taking this vulnerable population and assigning 

them to some primary care. So it is not so much the policing, but 

identifying and using that as an opportunity to improve their care. 

Senator SCHUMER. Anyone else? Dr. Schwab? 

Dr. SCHWAB. Yes. In the Medicare population under Part D, and 

in our program, one of the ways you identify this is through early 

refill identification. With the early refill, you do not know why that 

early refill is. It could be someone who is themselves abusing more 

drugs, but it could also be someone in the family stealing that out 

of the medicine cabinet. 

Just identifying the early refill does not solve the problem. You 

then have to contact both the primary care physician and the member themselves and ask them, do you have more pain or more need 

21 

now or is it that someone has stolen the medication, and doing a 

referral that way. 

Senator SCHUMER. Thank you. 

Thank you, Mr. Chairman. That was great. 

Senator ROCKFELLER. Thank you, Dr. Schumer. [Laughter.] 

This question is to any or all of you. There is a lack of geriatricians—I am just trying to make a comparison here—in this country. There is not a lack of geriatricians being trained in medical 

schools, but they get out, and they start to practice, and they find 

out that other specialties are doing far better than they are. They 

have children, and they just gravitate towards other specialties, 

and thus the geriatricians are not available to the people who need 

them. 

This is sort of the way the world works. Now, what I am leading 

to, therefore, is the need for more knowledge and training about 

pain as a symptom, as a disease, as a reality, as a not-reality in 

medical school. Obviously, I have never been to medical school, and 

I know the horrors of the schedule and becoming a resident, and 

are you allowed to sleep now after 2 days or are you down to 1 day? 

I mean, it is just so hard. There is so much to learn, so much new 

technology. 

The video conversations that you were talking about, or maybe 

you, Dr. Cahana, where people can just talk, from WVU, to anybody in West Virginia just because they have that capacity now because of the technology. But with doctors, how much time did you 

spend on pain? But not just pain as a disease, but pain as sort of 

a very special problem in our society? Do you get training in that? 

Now, that may not be fair to ask you because I do not think any 

of you graduated within the last 2 or 3 years, but still it is a fair 

question. What are we teaching in medical schools and residencies 

about this subject? In West Virginia, some people go to residents 

rather than doctors because they feel they may be easier to get at. 

Can you help me with this subject? 

Dr. CAHANA. The Institute of Medicine report dwelt on that issue 

quite a bit. In their recommendations, the paucity of undergraduate training in pain is very present. I think the national average is about 7 hours in 4 years, which is clearly not enough. So 

there needs to be a revision of the curricula to see how to insert 

pain training in the undergraduate arena. 

At the University of Washington, in our School of Medicine, we 

have revised it up to 24 hours and created electives that are actually sought after by medical students who say, I cannot believe at 

the end of the rotating, that I missed this training. So medical students want to do this. In a recent survey that we completed on 261 

medical students, they all ranked their knowledge in their 4th 

year, last year, as poor to fair prior to when we started this, and 

they also want to go and get this. 

In terms of post-graduate training, I think we are looking at two 

different subpopulations. One is, how do we train the community? 

Most of pain management is done in the community and in emergency rooms, and I think that video mentoring and tele-health solutions are very powerful tools to help specialists reach out in the 

community and create, as I mentioned earlier, outliers to pain 

22 

champions and to help physicians and providers feel more comfortable in their prescription habits. 

Then there is a whole discussion of the quality of training of specialists themselves. It has been recognized that not all training programs emphasize a multi-disciplinary approach, and they are more 

geared into the technical or technological aspects of pain management. So there is both undergraduate and post-graduate education 

to the community and to specialty care that needs to be addressed, 

and I want to thank the committee for highlighting this. 

Senator ROCKFELLER. It is interesting. Mr. Millwee, you join in 

this, too. I was actually surprised, and I forget which one of you 

said it, that after 6 weeks you are addicted for life. You said that, 

did you not? That is opioids. It is hard for me to actually believe 

that. I mean, I do because you say it. But if patients believe they 

could get away from addiction, that there would be sort of booklets 

out in the community, and what do you do, or do your doctors sort 

of gradually reduce medication, or whatever—— 

But if you just feel that you have been doing this for 6 weeks because you have certainly had pain for 6 weeks, then sort of you are 

in a hopeless land, and you just go ahead because you can get 

them, unless somebody says no. But what about this problem of 

getting off of the addiction? Because I would think that would be 

a source of great hope for opiod-addicted people as they look at 

their futures, even if it would not be applicable right away, because 

they were still suffering from that pain. But then how do they 

know if they are suffering if they are using the opioids? 

Dr. CAHANA. What we found in that study that included two cohorts of patients, one Medicare and Medicaid patients and the 

other private paying patients, was that, if you are over 90 days on 

chronic opioids, the chance of you being on them 5 years from that 

date is over 50 percent. So that is what we found. 

Senator ROCKFELLER. I accept that. But I am trying—— 

Dr. CAHANA. That physician needs to convey to the patient that 

they are committing them to this. Now, in the context of perioperative pain or after surgery or trauma, there is a healing process where, of course, opioids and the use of powerful pain relievers 

is appropriate and necessary and warranted. This is the transition 

I mentioned of pain as a symptom when there is an ongoing disease, and pain when it becomes the disease within itself. 

Now, there is nothing wrong with being on chronic medications. 

There are multiple chronic diseases that necessitate taking a pill. 

It is the destructive behavior, it is the lack of functional recovery, 

and it is a burden that is associated with that that is troublesome. 

So we do not focus so much on the pain, but we focus on the 

wellness, and the well-being, and that is what the dialogue needs 

to be with patients. It is not about negotiating, do I think I need 

a pill, yes or no? It is, let us understand, what are the functional 

goals, what do you want to achieve, and how do we reach that? It 

cannot be only by using pills. 

Senator ROCKFELLER. Please? 

Mr. MILLWEE. We considered that very issue in 2009–2010 and 

decided to add a Medicaid benefit, after discussion with physicians, 

for substance abuse treatment, because the problem many times 

23 

might be that the physician finds that, but there is no resource to 

refer a Medicaid client to get help. 

So we added a substance abuse treatment program, so now you 

have a referral. So, if you do wind up in this chronic condition, you 

have had chronic pain and now you have some addiction to pain 

drugs, there is a treatment alternative as well. 

Senator ROCKFELLER. Please? 

Dr. COBEN. The other area that I think Medicaid and Medicare, 

in particular, can be very helpful in this regard, is by promoting 

the use of electronic health technology whereby one can then easily 

identify when they are reaching that threshold. 

If electronic health records are in place in the physician’s office, 

then that threshold that is approaching, the 90 days or the 6 weeks 

or beyond, can be flagged so the physician is reminded and can 

start to intervene, wean patients, or refer them to substance abuse 

treatment. 

Senator ROCKFELLER. Please? 

Dr. SCHWAB. Yes. I would like to tie in to your previous question 

of lack of geriatricians. For the older population there is the added 

complication, not of just the pain medication treatment, but the 

issue that they probably have multiple other co-morbid conditions 

and other medications that cause drug-drug interactions and other 

side effects. 

In our lifetime, we probably will never see enough geriatricians 

trained to take care of this population and to be able to recognize 

how to manage all these medications. So it is going to take a whole 

team, whether it is the geriatrician helping support some primary 

care physicians, whether it is a continuing medical education, programs like we and other people do to train primary care physicians 

how to recognize and deal with multiple co-morbid conditions, and 

the treatment, and also the ancillary personnel, geriatric pharmacists, the case managers, that whole team working together with 

the individual. 

Senator ROCKFELLER. I know in West Virginia there is one area 

where a group of doctors have just sort of had it with this problem 

and want to do something about this problem. They are not all doctors. You get social workers, you get a group, a team which works 

with a patient. 

Now, I say that and feel very good about it. Then I say that and 

I also feel like the world does not work like that. There is not 

enough time in a doctor’s schedule, in a hospital schedule, or in 

anybody’s schedule, so that people can coalesce over a patient. But 

it seems to me that, in life, when people have serious addictions 

or serious problems, a team concept, a group working with them, 

frees up people to be more helpful as a concept. You would probably agree with the concept, but do you think that it is not realistic? Please? Now, you have ECHO, do you not? Is that Robert 

Wood Johnson? 

Dr. CAHANA. Yes. 

Senator ROCKFELLER. I meant to see them at 12:30, but we have 

seven votes, so it is going to be a little hard. They are good, are 

they not? 

Dr. CAHANA. Yes. 

24 

Senator ROCKFELLER. Anyway, who would like to answer the 

question? 

Dr. SCHWAB. I agree with the team concept. I think we need to 

get away from the idea that the team has to always be in the room 

all together at the same time. 

Senator ROCKFELLER. All together. 

Dr. SCHWAB. So the team can provide input in multiple ways either through other electronic communications, which are so available now, even things like video teleconferencing, so the team 

member could be at the university, and the rest of the team out 

in the field. 

So, I think that is the way. It reduces the need for the physician 

to spend all that time and gets some of the support of other people, 

as you say, social workers, pharmacists, individuals like that. 

Senator ROCKFELLER. What role can nurses play in all of this? 

Just talk. 

Dr. CAHANA. A central role. We found out that, by hiring nurses 

as care managers coordinating the care, they become the gravitas 

around everybody, around the coordination. The coordination 

means not only to make sure that patients follow up on whatever 

the multi-disciplinary team comes up with, but also to prepare the 

patients, follow up, and monitor adherence. 

So, having access to that information is important, and actually 

reaching out to the patient, educating the patient in real time, discussing findings, discussing a urine drug test, and if there are unexpected findings, how to do this, how to encourage the patient to 

understand that this is not a forensic test, but this is part of monitoring adherence and making sure that they are doing well, using 

every opportunity of surprise to be an opportunity of education and 

showing the intent to have patients be better and well. 

Senator ROCKFELLER. Dr. Coben, before I go to you, is electronic 

data, just data information, is that available at every nurse’s station? Is that available in every ward, or is that only available in 

doctors’ offices? Are we using that to the extent that we can so people can find out who is taking what? 

Dr. CAHANA. So I would say that currently this is a system that 

is growing, and that our coordinating nurse that is working as a 

hub between the pain center and the neighborhood clinics has that 

access, and nurses in the neighborhood clinics also have access. 

So we can engage in what we call panel management, where we 

actually say, oh, I see Mr. Smith actually is not doing well. He was 

not supposed to come to the clinic. But because we are able to find 

that they are not doing well, we can call up either the patient or 

the nurse and find out what is going on. 

The key, of course, is to make sure that we have these measurements in place and incent the behavior of assessing it. It is almost 

like a hemoglobin A1C for diabetes. You have to measure that in 

order to say that the patient is doing better. 

So I would urge us to add that element of measuring. Without 

measuring, we cannot determine value, and then there is nothing 

to coordinate. Obviously there are administrative tasks to coordinate, but, in terms of patient well-being, we have to rely on the 

surrogate measurements that the patients report to us and on biological specimens like urine drug tests. 

25 

Senator ROCKFELLER. All right. Thank you. 

Dr. Coben? 

Dr. COBEN. I was just going to reiterate, in my comments earlier 

I had mentioned the patient-centered medical home approach, and 

I know that Mr. Millwee also commented on that as well. I think 

that that really does talk to the essential role of an extended care 

team so that the physician is not necessarily the one that spends 

all the time doing the assessments, and even the interventions. 

Of course, the patient-centered medical home model is not just 

a model of care, but it is also a model of financing that care, obviously relevant to the committee. So I think that promoting its use 

can really help in terms of removing this fragmented care model 

of delivery that is really contributing to part of the problem, and 

engaging other extended care providers like nurses and mid-level 

providers in the care of the patient. 

Senator ROCKEFELLER. Physicians’ assistants? 

Dr. COBEN. Yes. Absolutely. 

Senator ROCKEFELLER. I can remember, in West Virginia we 

were one of the first that had a school for physicians’ assistants. 

There was a lot of laughing going on. Well, there is no laughing 

going on anymore. Dr. Cahana, I loved it when you described—because you were so honest about it—being in an appointment and 

you are late getting there, the patient is late getting there. 

I mean, everything has to work perfectly for you to have the time 

that you need, and nothing ever does work perfectly, so that you 

are reduced to getting the basic information and making a basic decision, knowing that you are not doing all that you can do or that 

you should be doing, but there is nothing you can do about that. 

So, I mean, it does argue for having other people share your burden with you. So having said that, how would you recommend—let 

us say, Medicare and Medicaid, the older, fragile population where 

it seems to me it would be much harder for a doctor to say, no, you 

should not be taking that pain medication, because that is a very 

different psychology. 

If you feel that you only have a few years to live, or you have 

so many illnesses built up inside of you that having a pain medication is like eating, every day you just have to do it, and therefore 

it puts a great burden on a doctor. How would you suggest, each 

of you, that we best approach this problem in Medicare and Medicaid? 

Mr. MILLWEE. In Texas, we found care coordination is really 

what works. When you look at your population, about 70 percent 

of the people in Medicaid generally just need some basic primary 

care. About 30 percent have chronic health care conditions that 

really benefit from care coordination. 

So we have created a model, we call it Star Plus, where we have 

that care coordinator who is working on, not just the acute care 

needs, but also long-term care needs, and is very much attuned 

with that client in understanding if there is a deterioration in their 

condition. They have that time to spend with them that maybe the 

physician does not have, and around that person you are building 

that primary patient-centered medical home. We include our dualeligibles in that population. 

26 

Even though we are not responsible for the acute care piece of 

that, we help manage that as well and coordinate on the Medicare 

side. So it really comes down to targeting the population that really 

can benefit from that care coordination. When you look at it, it is 

a small subset that really drives cost and has the potential for prescription drug abuse, we believe. 

Senator ROCKEFELLER. Thank you. 

Dr. CAHANA. I want to thank you for this opportunity really to 

share, how did we come up with these solutions. The system is, as 

Dr. Coben mentioned, fragmented, inconsistent, and the cost is 

unsustainable. So the strategies that we brought to the table are 

just to address those. So for the fragmentation, we are talking 

about coordination. For the inconsistency, we talk about the education. Education can be done in many ways, but the video mentoring and the ECHO project are very exciting. 

The unsustainability of things that lack value can only come out 

by measurement. If I measure, then I can know if that thing helps 

or not, and to whom. So I would submit to the committee that if 

you would help us, encourage us, and incent us to measure as 

standard of care—that is the measurement-based care part—that 

me looking at patient-reported outcomes of patients telling me 

about their pain, their mood, their function, looking at their urine 

or any other biological fluid, and looking at things that are either 

expected or not expected, at a frequency that has been determined 

in the literature as standard of care, and to be paid for that, that 

is, for me, the most important thing. 

The second most important thing is to pay for video mentoring, 

or to encourage us to use and subscribe to the video mentoring, 

which by the way, we do during lunchtime because we do not want 

to interrupt the work flow. So for the University of Washington, 

and the Specialty Services, we do it very early in the morning before we start our day. For the community, we do it during lunchtime. That is not a desired situation. 

It has to be part of our practice where we know that we have 

our daily, or bi-weekly dial-ins, where we talk to the specialists and 

we present patients, and we can follow up on how they are doing, 

and you have that multiplier effect of saying, oh, so this is how you 

treat a patient who is elderly and has these co-morbidities, et 

cetera. 

So those two things, in addition to what was submitted in 507 

of the training, the education, the clinical guidelines, and the prescription monitoring program support, encouraging us to measure, 

incenting us, paying us to measure, and paying us to do the video 

mentoring. 

Senator ROCKEFELLER. Thank you. 

Dr. Schwab? 

Dr. SCHWAB. Well, for nearly 30 years we have known that care 

coordination in the Medicare population works to do this. But it is 

not just simply care coordination. You really need to target the people whom you provide that care coordination to. To do the targeting, you need data. The data comes from both Medicare sources 

and from the individual themselves, and then you put together a 

team that has shared responsibilities for managing and making 

sure that that person is identified and gets their needs met. 

27 

In addition, data that I do not think we do a very good job now 

of coordinating is entire data. There are promising things, like the 

Health Information Exchanges, where data coming in from all 

sources—like right now in the Medicare population we have no 

data from the Veterans Administration for people who share those 

two services. We know there are some, a small amount. 

Senator ROCKFELLER. But how can that be? I mean, they are the 

ones who are really good at having data. DoD is terrible at it, but 

the Veterans Administration—— 

Dr. SCHWAB. The Veterans Administration is great at having 

data. 

Senator ROCKEFELLER. But they will not share it? 

Dr. SCHWAB. If they go out to the private community, there is no 

information from the private community to the veterans, or vice 

versa, from the veterans to the private community. Small numbers, 

but there is no communication there, and through other programs, 

too. 

If someone just buys drugs on their own with their own money, 

that communication is not provided to either a health plan or to 

the Veterans Administration. In a Health Information Exchange 

that really works well, all pharmacy information would be in one 

database and everyone would share that information. 

Senator ROCKEFELLER. Well, that is very helpful. That is very 

helpful. Thank you. 

Dr. Coben? 

Dr. COBEN. The only thing that I would add to the earlier comments is, I think the critically important role for screening is brief 

interventions and referral to treatment for patients with substance 

abuse. We know from a variety of research projects that have been 

implemented across the country that screening and intervention 

programs work, they are cost-effective, but they have not really 

been sustainable. 

Part of the reason that they are not sustainable is because insurers are not paying for the time that it takes to screen and refer and 

do these brief interventions. So, I think putting that into the armamentarium, if you will, for Medicare and Medicaid programs could 

be quite helpful. 

Senator ROCKEFELLER. Let me ask another question. It is nice 

being all by myself here. [Laughter.] 

This is controversial, but not to me. I was responsible for getting 

it going, the Independent Payment Advisory Board, or IPAB. It has 

to do with reimbursements for physicians for durable medical 

equipment, DME, and for hospitals, and for all the rest of it. Several of you have mentioned measuring outcomes as a way of proceeding on what we have been talking about. 

Well, that is what the Independent Payment Advisory Board is 

all about, is measuring outcomes. In other words, if rural hospitals 

have bathrooms that are not clean, then all of a sudden MRSA 

emerges and spreads. 

You asked about having incentives. Well, there are positive incentives and there are negative incentives. A positive incentive 

comes out of IPAB because it says that, if your outcome of what 

you are doing—and this is not just prescription drugs we are talking about, but in general, a philosophy of how you carry on mediVerDate Nov 24 2008 14:14 Mar 12, 2013 Jkt 000000 PO 00000 Frm 00031 Fmt 6633 Sfmt 6633 R:\DOCS\79378.000 TIMD
28 

cine—that if we have a system of lobbyists and then practitioners, 

then I will just be very honest with you, I speak a lot when the 

American Medical Association, the American Hospital Association 

comes to town. 

They take up the entire Washington Hilton, the largest ballroom 

in town, thousands and thousands of people. You look at the program, and often I am asked to speak, and then some Republican 

is asked to speak. Then you look at the program and the schedule 

is that everybody then goes to the Hill and visits all their Senators 

and Congressmen so that they can get more payment for here or 

there, a lot of which is all legitimate. 

With durable medical equipment, it may be, it may not be. With 

hospitals, it may be, it may not be. But, if you take that out of the 

hands of lawmakers, can you not agree that lawmakers are the 

worst possible group of people to determine how you should be reimbursed, because that is what is happening now. 

It works because, if you have the right lobbyists, often they have 

been people who have sat on this committee or some other and 

know about health care, and they go work on—I just turned down 

a lobbyist who served on this committee who wanted to come talk 

with me, and I am not going to see him because I just do not like 

that. 

I do not like that way of doing business. I think you ought to reimburse based upon outcomes and improvement compared to previous years, all the measurements that we have been talking 

about, people having cleaner hospitals, better hospitals, more coordinated care. All kinds of things that get encouraged by the 

incentivization of better reimbursement should be decided by 15 

people—this is where people go crazy, until you mention, well, people like Gail Wilensky or Stuart Altman, and then they say, oh, 

well, I can trust them. 

This would be the next generation of Gail Wilenskys and Stuart 

Altmans, but there are people, and there are thousands of them in 

this country, who are really good on health care policy, and really 

good on reimbursement issues, and who have no axe to grind, cannot be pushed around by lobbyists. They end up making the decisions, which the Congress can only override by a two-thirds vote, 

of how people should be reimbursed each and every year. 

Now, that obviously is very complex. It has to be done fairly. 

Mistakes would be made at the beginning. But it seems to me getting away from Congress—and this is not sort of a right-wing thing 

I am talking about here, getting Congress out of your lives, but in 

this case I think you would do a lot better with Congress out of 

your lives with respect to reimbursement and incentivization for 

doing what you all seem to want to do anyway but cannot get done. 

Now, is that a program which horrifies you, which you have no 

particular opinions on, or you think is a good idea, or what? And 

just be honest with me. Look, I have free time here. 

Dr. COBEN. Sounds good to me. 

Dr. CAHANA. So we always strive to do educated policies that are 

based on evidence, and the quality of the decision really depends 

on the quality of the data, on the information that you use to make 

that decision, unless you decide that you want to ignore that. 

29 

Traditionally, health technology assessment committees, or any 

type of committees that can be on a State or Federal level, or in 

any health system, are based on what we would call evidence-based 

medicine which relies on efficacy data, which basically means that 

these are studies that are done in sterile conditions. These are 

studies that are done not at the University of Washington or not 

where you practice. So there is a limitation on the generalizability 

of those studies. 

The idea of inserting measurement at every clinical encounter in 

your clinic is called effectiveness, not efficacy. Hence, the comparative effectiveness research that basically shows me, so my program 

is a large program, has a trauma hospital, Harbor View Medical 

Center, has the University of Washington Medical Center, has 

Children’s, has the VA Puget Sound Health Care System. 

The results of the quality from treatments from opioids or 

epidurals or any other treatments are very different from site to 

site. So, without the ability to say what is the progress of our patients, it is very difficult to give an idea of what is the right thing 

to do. 

So again, in my disclosures, I always say I do not like opioids, 

I do not hate opioids; I do not like epidurals, I do not hate 

epidurals; and I am agnostic to integrative medicine. Just show me 

that it works. When I asked my providers before we had the system, how are your patients doing, they would say fine. I would say, 

how do you know? Because there are no complaints. 

The only feedback that we had at that time was if someone 

would knock on your door and say that one of your patients died 

from an overdose. That is too late. So I lead from the assumption 

that each and every provider in my large division wants patients 

to get better and would feel very uncomfortable if they would get 

a report card, either on each patient, or at the end of the month, 

that says these are the type of patients that you are not improving. 

So it is key, and it is unfortunately missing in many of the strategic plans of the large stakeholders, in the DoD–VA task force, in 

the Office of National Drug Control Policy strategies, even in the 

Institute of Medicine report. I do not think that the idea of measurement is explicit enough to allow policymakers to say, this simply has to be practiced, like in any other thing in medicine. We 

measure hemoglobin A1C for sugar, we measure blood pressure for 

hypertension. I do not ask someone, are you thirsty and they say, 

yes, and determine the dose of insulin according to that. 

I want to know pain, pain interference, mood, function, physical 

function. What do you want to achieve, and how are we going to 

get that? That transforms the way patients think about pain. It 

transforms the way we, as providers, think about it, so it improves 

the dialogue, and it also improves our ability to aggregate these reports and make decisions. 

Senator ROCKEFELLER. Well, you are an extraordinary, thoughtful group, and very direct. So how is your morale as you go to work 

every day? This is a serious question. Do you jump out of bed and 

say, I cannot wait to get to work, or is the burden of practicing 

medicine in America these days—I mean, medical schools are filled 

with people. It used to be that we were losing doctors in West Virginia, now we are gaining doctors. They want to come. 

30 

A lot of people want to go and practice rural medicine, maybe 

much more so than some years ago. The new health care bill, 

which everybody loves to hate but I do not, has I think $10 billion 

for rural health clinics, new ones, which can take advantage of all 

this mentoring over media. I mean, it is all very exciting to me. So, 

that was a rather awkward question on my part, but I am interested. Please? 

Dr. SCHWAB. Some days the morale is very low when you look 

at all the challenges, all the things that you cannot accomplish. 

However—and I wish I would have brought it with me—I just 

today received a letter from one of our members, an 83-year-old 

gentleman who said, I cannot thank you enough for what you have 

done for me and my wife. I would not be here today if you had not 

done—and he went on to describe how his medications were 

changed and he was now able to be more cognizant and take care 

of his disabled wife. It is a letter like that that says this is all really worth it. 

Senator ROCKFELLER. Well, it is like the example I gave in my 

opening statement. 

Dr. SCHWAB. Very similar. 

Senator ROCKFELLER. Yes. Yes, that is great. 

Please? 

Dr. COBEN. Senator, I am on the front lines in the emergency department. I enjoy what I do, and it is a privilege to serve the State 

of West Virginia and other places that I have worked throughout 

the country. I think there is great hope, great promise for some of 

the new technologies that are rolling out in health care. 

I think the parts that frustrate many of us are what I alluded 

to earlier: the fragmentation in care, the inability for patients to 

have primary care providers and gain access to those providers. 

That is not just in rural communities, that is everywhere. 

Gaining access to the physician in a timely manner, so that patients who come to the emergency department, who truly have 

emergencies and need emergent conditions addressed, that is the 

part that frustrates us. Of course, there are also the other business 

aspects of the chart-keeping and record-keeping, et cetera, et 

cetera. But the practice of medicine, I think, is exciting and still 

stimulating and invigorating. 

Senator ROCKFELLER. Well, is the computer helping you on the 

paper frustration part? 

Dr. COBEN. No. 

Senator ROCKFELLER. No? All right. 

Dr. COBEN. I think that it certainly has its benefits and has 

great potential. It is still yet to be realized, I think, in many places. 

But it has not diminished the time that we have to put into the 

record-keeping part of what we do. 

Senator ROCKFELLER. Any other comments? Then I promise to 

leave you alone. 

Dr. CAHANA. Sir, I feel very fortunate, as chief of the Division of 

Pain Medicine at the University of Washington, which is the birthplace of modern pain medicine—the first pain clinic in the world 

was actually there—— 

Senator ROCKFELLER. I did not know that. 

31 

Dr. CAHANA. And it is very appropriate that the thoughtful leaders that we have there are trying to use this epidemic, and true 

challenge, and turn it into an opportunity to reflect better about 

pain, suffering, and health care and health care delivery. 

So I do share Dr. Schwab’s sentiment that one day we will laugh 

about this, it just simply will not be today. But this is a great opportunity, and I would not want to be anywhere else but in this 

place. Thank you, sir. 

Senator ROCKFELLER. Terrific. Thank you. 

Mr. MILLWEE. Well, I add to that enthusiasm. Now is the best 

time in the world, in my mind, to be a Medicaid director. There are 

so many things that are happening, and it is exciting being on the 

forefront of that and laying the groundwork for some things that 

will probably come to fruition in 2015 and 2016 around how we are 

going to move this program from basically a transactional kind of 

payment process to really transformational. 

We are looking at improving quality, addressing potential preventable events, laying the groundwork for electronic medical 

records. We are building a great future right now. Sure, it is a lot 

of work, but it certainly is gratifying. 

Senator ROCKFELLER. Great. Well, I totally thank you all for 

coming. Hearings are important because often they are carried on 

C–SPAN. People learn from them, we learn from them. We cannot 

do this on our own. We need you to guide us and help us. The fact 

that you have been so honest has been very, very helpful to this 

hearing. So, I thank you for your cooperation. Whatever you are 

going to do for the rest of the day, I hope it is as helpful as this 

morning. 

The hearing is adjourned. 

[Whereupon, at 11:50 a.m., the hearing was concluded.] 

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(61) 

COMMUNICATIONS


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Æ 


79378036.eps