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Senate | June 11, 2014 | Committee Room | Finance Health Care

Full MP3 Audio File

Speaker: Committee come to order, thank you members of the committee we are getting the meeting by this morning by recognizing our shorts at arms staff for this committee earning ? is here ,Andersen Meadows,is here and Matt urban.Then pages for today we have the man that spills from ?? Also from ?? from Samuelson from Sal ma Andrew gadder,chapel hill ?? from Matthew Stevens ?? from Lawser Pardon Smith from Wilson and Robert Edwards from ?? Thank you all hope you weeks quite exciting moving forward looking to wrap this up,members we have one bill before the committee today and we don't have staff presentations on it but i want to have opened it up first for ?? senator Clark for any comments and statements they may have on the bill, Speaker Changes: Thank you Mr.Chairman and the members of the committee the bill that was actually a result of the study that has done by probable evaluation and innovation it was initially suggested in particular by senator Clark epidemic the use or prescribe buy over use or over prescribing with other kinds of situations in particularly the ?? and other ?? i don't think that was right.A number of members of this committee were on the evaluation committee in it ?? senator Clark was present ?? i think senator Clark was also reviewing this.This is a obviously a working process in terms of addressing and i had some conversations this morning with precisions they have some suggestion which may or may not be able to adopt these situations i think it's a subject and time whose time has come in order to address ?? but he never showed up.So Senator Clark, Speaker Changes: Just liking the few comments.When something like this comes before so lot of time people actually want to know what was the ?? going into the study of these nature.About lot of times ago may be 7 or 8 months ago cant remember exactly there was a various ?? which was my hometown newspaper talking about the epidemic that state with regard to prescription medication been additionally confirmed particularly someone that was really hurting hard ?? when you have large military populations.As a result of it being signed over Afghanistan and be prescribe these medications coming back develop ?? So we ask the program evaluation committee to study in the particularly ?? be significant problem not just a military and across the state and as a result of that study we have sledge ?? we have been presented through your consideration we are gonna have son program evaluation committee ?? person for the study and the ?? greatly we consider our improving this legislation, Speaker Changes: And my dad senator is ?? remember that committee, Speaker Changes: And thank you before we are moving into the presentation senator hearts will move for consideration.We do have a PCS the force others in favor of consideration ?? opposed thank you PCS

I’d just want to thank Senator Clark and Senator Hartsell for bringing this forward. I was not really aware until I visited two friends of mine who are disabled vets from Vietnam, and they have a unbelievable amount of pills. They get 100 hydrocodones every prescription. Every three months it comes in the mail. So, vets are prescribed, but the other thing is is in our area, my sheriff told me about what’s called pharma parties. P-H-A-R-M-A, pharma parties where folks, middle school, will get some of their parents’ drugs out of their medicine cabinet and all put it in a bowl. And they all get them a 6-pack of beer, and they take a pill or two and drink beer. It’s a really unbelievable problem, and Senator Hise and I have talked about it many times to try. Back medication, they’ll prescribe it, it does need to be. And I just thank both you senators and Program Eval and Senator Bingham, even though he approves most of this by osmosis. See, he’s gone now. I just want to thank, I want to thank you guys in all sincerity. I want to thank you as moving forward. We need to get a handle on this big time. Thank you. [SPEAKER CHANGES] I recognize Sean Hamel from Program Evaluation for a presentation on the bill. [SPEAKER CHANGES] Good morning, Mr. Chairman, members. I am Sean Hamel with the Program Evaluation Division. I’m a senior evaluator. Today I’m going to be briefing you on the recent report entitled North Carolina Needs to Strengthen its System for Monitoring and Preventing the Abuse of Prescribed Controlled Substances. Presentation is brief. It should take about 10 to 15 minutes, after which I’d be happy to answer any questions you all have. You should have in your packets a few handouts. I’ve included single page, one page of the executive summary of the full report, which is available downstairs in our office, but also online. I also put together a few slides that I’ll be briefing from. They’re all stapled together. And then to help me through my briefing, you guys also have a blue handout, four diagrams. These are intended to kind of lay out the state’s system for monitoring the abuse of prescribed controlled substances. As Senator Clark mentioned, last summer several concerns stemmed from a series of news articles out of the Fayetteville Observer that brought to light the issue of prescription drug abuse in the state. As a result, our committee amended our work plan and directed the division to evaluate the state’s system for monitoring the abuse of prescribed controlled substances. To begin, I’ll give you a little bit of background from the report. When the Centers for Disease Control defines an unintentional poisoning as a poisoning in which the individual exposed to the substance is not attempting to cause harm to themselves or others. As this map shows, from 1999 to 2001, there were fewer than 7.4 deaths from unintentional poisonings per 100,000 residents for most North Carolina counties. By 2012 these death rates had tripled in the majority of counties with 21 counties having more than 18.5 deaths per 100,000 residents. More than 90% of these deaths can be attributed to medications. Many of the medications are what’s considered controlled substances. These are opioids, stimulants, and depressants, also commonly known as benzodiazepines. They are the most commonly abused prescribed controlled substances. Now, opioids are of particular concern because their use in treatment of chronic pain and their relationship to unintentional poisoning and even overdose. The relationship between opioid prescribing and overdose deaths is demonstrated by this map of the state. The darker the shading, the greater the prescribing volume. You look to the southern and mountain counties, and you can see where the volume of prescribing occurs. This also happens to coincide with the greater number of overdose deaths. The red dots that faded in over each county represent the number of opioid-related overdoses. The larger the dot, the greater the number of deaths per 100,000 residents. The number of deaths is a growing concern. However, there are additional societal costs associated with this epidemic. The CDC estimates that for every 1 death associated with unintentional poisoning, 10 individual are admitted to treatment facilities. And 32 individuals are admitted to emergency rooms. The cost to public and private insurers nationwide has estimated to be as much as $72.5 billion per year.

Now as I mentioned at the beginning of the briefing that we were charged with valuing the State System for monitoring the abuse of prescribed controlled substances. This exhibit, as well as the first one, first page on the blue handout shows the system for monitoring abuses for prescribed controlled substances. Now, in the center of the State is an over-simplified picture of supply chain for the prescribed controlled substances. Typically, patients suffering from ailments such as pain, anxiety and depression seek assistance from their healthcare providers as a part of treatment. They often receive prescription which they take to a pharmacy to have filled. This exhibit also identifies four mechanisms the State has for monitoring and intervening in the supply chain for these controlled substances. I’m gonna work around from each box starting from the upper left hand corner, each of the next slides. This diagram begins again with the supply chain for the prescribed controlled substances. In supply chain, healthcare providers are the prescribers, the patients receive the prescription from them and have them filled at hospitals and pharmacies and clinics. These are the dispensers. There are more than 41,000 prescribers and more than 3300 pharmacies authorized to dispense prescribed control substances in the states. Now, there are 5 occupational licensing boards that oversee and regulate prescribers and dispensers. The occupational licensing boards oversee and regulate prescribers and dispensers to ensure clinical care standards are being met. This is done through licensure, enforcement, education and the implementation of clinical care guidelines. The next tool the state has, is the CSRS. Flip the page and there’s the third handout shows prescription drug monitoring programs, controlled substance reporting system and how it intervenes in the supply chain. Now for all schedule 2 through 5 control substances, pharmacies are required to report to the CSRS, the information listed on the right of the slide. This data is then stored in the information system and creates a full record of patients, doctors and pharmacies prescribing a dispensing record. Healthcare providers and pharmacies are then encouraged to register for and check the database for unusual patterns prior to prescribing or dispensing controlled substances. Therefore, the registration in use of the CSRS are very important performance measures. Last page on the blue handout, shows the Medicaid lock in program. The Medicaid lock in programs are important because prescription drug abuse is a problem within the Medicaid community. A 2009 GAO report sided one Medicaid in North Carolina in Rawley who received 1300 oxycodone pills over a 24 month period. These prescriptions came from 25 different prescribers and were filled by 9 different pharmacies. Now lock in programs were intended to identify and eliminate this type of fraud and abuse. This graphic on the slide and handout shows and describes the process, criteria and operations of lock in program. Now, lock in program utilizes the Medicaid claim system to identify if beneficiaries meet the program eligibility criteria listed on the top right hand side of the picture. Medicaid in Roweys? Whose claims meter exceeds this criteria are then restricted to obtaining prescriptions from one prescriber and one pharmacy for a period of 1 year. Based on the components of the system this evaluation had 5 findings. First, we found the state lacks adequate prescribing guidelines and continuing education requirements for prescribers of controlled substances. Second, Controlled Substances Reporting System, CSRS is hindered by access barriers, a lack of data connectivity and limited analytical capacity. Third, the State’s Medicaid lock in program is not currently operational which has cost the Medicaid program an estimated $1.3 to $2 million but even when it was operational, we identified that the program had several shortcomings. Fourth, the contract for the controlled substances reporting system lack important features and cost the state.

More, for less functionality. Our last finding, there is no coordinated strategy, or performance management system for monitoring the abuse of prescribed substances in the state. Based on those five findings, P.E.D. has the following recommendations, the general assembly should consider directing the development of state-wide opioid prescribing guidelines. Should also consider requiring continuing education on the abuse of prescribed controlled substances. Should consider enabling improved csrs access and utilization through contract modifications, modify the contract for csrs to improve performance and functionality. The general assembly should also consider directing dahs to expand the monitoring capacity by establishing data use agreements, with the prescription behavior surveillance system, a federally funded analytical monitoring initiative and directed the vision of medical assistance to improve effectiveness and efficiency of the Medicaid lock-in program. And lastly direct the hhs to establish a strategic plan and performance management system to monitor prescription drug abuse in the state. As the senators mention this briefing was given to our committee this past April. At the time the committee accepted the report and directed staff to begin drafting legislation based on the recommendations. The recommendations have resulted in senate bill 749, which I will allow one of my collegues to walk you through at this time. This conclude my presentation full report is available online and I would be happy to answer any questions at the direction of the chair. [Speaker changes] Any questions? For the B&E staff. Senator Tucker. [Speaker Changes] Just a question Mr. Chair on so doing the evaluation and development of P.E.D. report was there input from the retail pharmacies, about additional cost of making more stringent guidelines, which I’m in favor of obviously, but I’m also asking about the impact on their business, what did you find from input from some of the stake holders that are prescribers, or that dispensing the drugs? [Speaker Changes] We did not include the individual retail pharmacies. We did include the pharmacy board as a stake holder and met with them and collected information from them regarding their roll in the monitoring process. None of that included any sort of estimate as additional cost that would be incurred upon them, but again they had the opportunity to respond to the recommendations and findings in this report and they didn’t raise any issue. With the finding or recommendations as they were. [Speakcer Changes] Thankyou sir. [speaker changes]? Any other questions? [speacjer changes] Senator Parmen. [speaker changes] Yes thank you mr. chair, in your presentation you said the lock-in program is now non-operational, is that correct? [Speakcer Changes] That’s correct. [Speaker Changes] And bill 749, your recommendation is that it becomes on operational function? Is that correct? [Speakcer Changes] We certainly recommend that the lock-in program become operational, but the lock-in program is currently challenged by NCTracks. It is entirely dependant on the functionality of NCTracks as it bounces claims off of that system. It was our understanding when we begin this, or in wrapping up this evaluation, we were informed by staff that that functionality or the requirements for the lock-in program, should be incorporated and ready to be rolled into NCTracks by this summer. [Speakcer Changes] Follow-up, we here that dreaded word again NCTracks, but did we take into consideration the cost for this, and we understand arolean and how many challenges weve had with NCTracks and FAST. Is there any consideration if this would cause additional problems and challenges for the department in trying to get the lock-in program up and going with NCTracks? [Speakcer Changes] This was actually functionality that was already built into the csc contract, but as I assume they, and I’m no expert on how Tracks and was being rolled out, I assume in a spiral development of the system, they got the most important features working first and as they ironed out bugs additional

Capability, what was going to be integrated in, and I would assume that this lock in was some of that additional capability. SPEAKER CHANGES: Mr. Chairman, I'm just always cautioned when we are talking about a system we're having problems with. Thank you. SPEAKER CHANGES: Senator Wade. SPEAKER CHANGES: Thank you Mr. Chairman. What is the procedure now if you go to a pharmacy and fill a prescription, and then you're back two weeks later to get another refill? Do they deny you that if it's supposed to be a 30 day supply? Or do they call your physician and let them know you're back, or how does that work? SPEAKER CHANGES: As I mentioned, each of the pharmacies are required to submit dispensing information in to the CSRS. I'm not aware of individual pharmacy policies. They're encouraged to check the CSRS to see if there are multiple prescriptions out there for an individual. But again, I'm not aware of individual pharmacy policies on dispensing refills and the regularity of that. SPEAKER CHANGES: Follow up. So there's no, there isn't a law that says that if you're a pharmacist and you see maybe the use is a little more frequent than it should be, that they have to call the physician's office to let the physician know that that's going on? SPEAKER CHANGES: I am not aware of any law, but doesn't mean it doesn't exist. There is representatives from the North Carolina Board of Pharmacy here that could likely speak to whether it's policy law or such rule. SPEAKER CHANGES: Senator ??. One of the recommendations from this is to develop prescribing guidelines that are issued there. That they, some law enforcement have told me, and others, there is not a barrier between a physician makes a medical diagnosis and how much medication is required to deal with that diagnosis. We don't have the guidelines out there to make those type of processes right now. It goes back generally, I think, to the medical society to make determinations from other doctors if someone's over prescribing. I had a specific situation when I represented Haywood County of someone who had was caught with 430 milligram OxyContins in a one month cycle, and could not be charged because they produced prescriptions for all 400 of those pills. SPEAKER CHANGES: Mr. Chair, this is for you then. Not that I want to involve veterinarians in this, but sometimes we do script out Phenobarbital. And we have to monitor very closely, because sometimes our little pets use a lot more than they should every month. And I just wondered, my pharmacist will call me on my patients. And I wondered if that was a problem that you had considered? Because believe it or not, they will use veterinarians for that type of problem. SPEAKER CHANGES: I don't know if any of the others have talked. I don't on how they relate, but I do think that quality pharmacists do move ??. SPEAKER CHANGES: Mr. Chairman. I do have a comment on that. We did have a problem in the Senate last year with one of our members accidentally taking his dog's medication in the place of his own. And I wonder if there are any protections like that in the bill for Senator Bingham. Senator ??. SPEAKER CHANGES: It's sort of along the same lines as Senator Wade. I'm hearing a lot of monitoring, and I'm hearing a lot of reporting, and the nearest I can tell the equation is about like a three legged stool. You got the dispenser, you got prescriber, and you got the person who's receiving. Is there a provision anywhere in the loop, if we really want to get something done, for sanctioning over subscribers and or over dispensers? Or do we just say no, no, that you shouldn't do that? Or, I can't see another law going out that has no sanction in it. SPEAKER CHANGES: Yeah, in fact the provision in the law relates to the guidelines. The report found, our first finding found that the guidelines that are currently in place for this state are incredibly weak next to national standards for what guidelines should look like. When you have strong guidelines in place, doctors are encouraged and should be following guidelines. They establish a standard of care for practice. If doctors are found to be violating guidelines, it would be then the medical board that would respond to the violation of those guidelines, and take the appropriate sanctions, as they are the oversight board. As Senator Hise had mentioned pharmacists are simply carrying out the direction of a doctor.

00:00 when they fill a prescription and again that's the function of the board to ensure that pharmacists are following guidelines as well as laws. Quick follower yes sir, so does anybody have a handle on how many times a prescriber has had any kind of sanctioning done for over prescribing meds and or over-dispensing is there anything out there that tells us because to me that is the centro-id of the problem. During the evaluation we looked into the number of sanctions that have been issued to doctors and they were very minimal few in number and we believe it's a result that there were nothing to hold them to there were no set of guidelines in place to determine what the appropriate standard of care prescribing practices should have been. I think we're looking at staff without other questions go ahead and walk through the bill [??] with regard to senator Rabin question the fact is senator Rabin with weak or no guidelines there's nothing for a licensing board or anybody else to guide against or sanction or otherwise that's the problem what we're trying to do at least in the near term is to create those guidelines or encourage the creation of them so that we can have something to monitor against. Thank you Mr chairman first section of Senate bill 749 is the section that directs the group of state health officials and health care providers that are outlining the bill there to go ahead and develop a state wide opioids prescribing guidelines in doing this they are to refer to reference and use as models some of the other state and federal models was [??] being prominent I think among those who have effective prescribing guidelines already in place section two of the bill deals with the issue of continuing education and would require that the board of general examiners board of nursing board of pediatry examiners and the North Carolina medical board establish some continuing education standards including the requirement of a course designed specifically to address prescribing practices and this course will have to be taken as a condition of renewing your license section three of the bill deals with improving the existing control substance reporting system this would require the data within the current CSRS we modify the law to allow use of that information to inform medical records and clinical care and also that CSRS would be directly accessible by the US drug enforcement agency and that the information within the CSRS be transferred to patients' electronic medical records within the North Carolina health information exchange and the reason for the change to allow the information to be used to inform medical records and clinical cares that is the purpose of the North Carolina HIE so that's all that works subsection B of section three requires the department of health and human services to adopt policies and to modify the consoled substance reporting services system to modify their contract by December 31st 2014 in order to expand this additional functionality section four of the bill directs the department of health and human services to modify its current CSRS contract in order to improve its performance it would establish user access controls establish data security protocols. 04:59

… and ensure the availability of data for advanced analytics. DHHS has to report to legislative committees on the progress of these contract modifications by November 15th of 2014 and complete these contract changes by December 31st of 2014. Sub-section C of Section 4 directs department to apply for grant funding for connection costs and ongoing inner state connectivity service costs. Sub-section D is an appropriations section. Sub-section D would appropriate 5,100 dollars for fiscal year 2014 for the purposes of connecting the CSRS and the NCHIE. It would appropriate the sum of 15,000 dollars for the fiscal year 2014-2105 which will be a reoccurring amount for the cost of maintaining a connection between the CSRS and the NCHIE. It would appropriate the sum of 40,035 dollars for the fiscal year 21014-2015 to establish the initial interface with for the PNP inter-connect required by section two of the bill, section 2 of the sub-section. This 40,000 dollars and the next amount which is 15,0000 dollars non-reoccurring for the cost of annual service fees. Both these amounts are covered, or would be covered by the grants the department is directed to apply for if in fact those grants are obtained or if the department is able to use other receipts to cover those amounts. Then, the amounts appropriated will be either reduced or eliminated. Section 5 directs the expansion of the controlled substances reporting system. It is to establish data use agreements with the prescription behavior surveillance system which is run out of Grandise (??) University. Section 6 requires a number of modifications to the Medicaid lock-in program. It would require the division of medical assistants to report to the joint legislative program evaluation oversight committee by September 30, 2014. The list of those changes is on page 4, lines 12-33. They include establishing written procedures for the operation of a lock-in program, establishing procedures for the sharing of both data with the controlled substances regulatory branch, extending the lock-in duration from one year to two years, developing a website and communication to inform lock-in enrollees and prescribers, pharmacists and others about the program, increasing the program capacity to insure that all individuals that meet the program criteria are covered currently or prior to when it was last operational (they were only covering about 200 enrollees), and to conduct an audit of the lock-in program within 6 months of that program again becoming functional. Section 7 creates the prescription drug abuse advisory committee and directs them to develop a statewide strategic plan. After developing the plan, the committee is to be the state steering committee to monitor the achievement of the strategic objectives. The committee is to complete a series of steps including identifying emission and vision for the system, scanning the internal and external environment of the system’s strengths and weaknesses, comparing threats and opportunities, identifying strategic issues, and formulating strategies and resources for addressing these issues. The act is effective when it becomes law. [SPEAKER CHANGES] Thank you. One thing I want to comment on. Gordon and Joan may come in for an explanation. For the DEA data access, it is not access to the database. It is merely the ability to request from the department data. I don’t know if Shawn wanted to comment on those or moving forward about the DEA access to the data. I guess not.

Questions, Senator Tarte. [speaker changes] Yeah, more a comment and this'll take a second just to share with everybody. This is really nothing more, at least in my view as we address this, as an IT solution. Now we have our challenges statewide with IT in some functions but this is related to the term and if anyone wants to look at the spelling it's syzyzgy s y z y z g y it's when three celestial bodies align and what's gonna have to align here is the number of databases and the number of systems, NCTracks, the HIE system as we talked about, GDAC eventually will eventually be part of this solution CSRC, CJLEADS will become a component of this and NCTracks as well as we talked about the pharmacies. All this stuff is most pharmacies, most hospitals, most providers, it's automated in an application called an MAR which is the medication administration record, which deals with the 5 rights of how you administer drugs and the pharmacy guys can correct me but it's looking at the right patient, right drug, right dose, right route, at the right time. All that can be done electronically. We have issues with that but this bill is absolutely necessary to enable us to start moving in that direction. Will it be successful immediately? Absolutely not. Is it imperative? Absolutely. I talked to docs in full disclosure, I been sleeping with a non-registered lobbyist for the pediatric society and children, and that happens to be my wife of 34 years who's a pediatrician, and she and the doctors that I talk to are absolutely supportive of this bill going forward. It is as senator Tucker pointed out, it is an epidemic and as Senator Rabin did this is imperative that we move forward on this, and I thank all my colleagues for the work they've done on this bill. [speaker changes] Before stepping on I do want to remind members we are trying to wrap this up and the time limit for the hour we have, but this bill does go to appropriations after leaving here before we go to the floor. Senator Tucker. [speaker changes] Thank you sir, I'll be brief. Could I ask you to ask someone from the department to be able to respond to program ?? suggested that NCTracks would be able to bring this online this summer? I know there's a report due by September 14th but if someone from the department here to go on record to state they can adhere and administrate and start up this lock in program? [speaker changes] I'm very aware that Adam is here I don't know if the team with him that he may have someone to better address that information so. [speaker changes] Thank you, Adam Schull with DHAS. Mr. Chairman and Senator Tucker we're a little dependent on our vendor's schedule for this but I'd be happy to update the committee in writing after this meeting about where we stand on that. Not exactly what you're looking for but it's the best that I can do. [speaker changes] Senator Randall. [speaker changes] Thank you, Mr. Chair and let me begin by saying this is a very important issue for me because in 2007-08 my county ranked number 2 in the nation for accidental overdose deaths, so it's very close to my heart. I am on program evaluation, and I know the addition of the release of information to the DEA was discussed in program evaluation and I would like to hear Sean's explanation for that and if there's someone here from the SBI I would also like to have their input as to why they proposed this request. [speaker changes] You can do it here that's fine. [speaker changes] Again Sean Hamill, program evaluation division. The purpose for giving DEA the opportunity to request data from CSR directly from the department is the way the current process works is the DEA and SBR are often working different investigative cases when it comes to prescription drug fraud and abuse and right now the DEA has to request data from the SBI to get that data SBI has to open up a case using their resources, using state resources, open up the case for the feds to be able to obtain the data. The data then has to go back, my understanding, through the AG's office to be approved to be released. The purpose of doing this is simply to remove the administrative barriers to obtain data from the CSRS. [speaker changes] Is there anyone here today with the SBI that has a comment? [speaker changes] They're packing boxes. [speaker changes] Followup Senator Randall? [speaker changes] Thank you, so I know the request did come from the SBI.

and you know, a couple years ago we added a provision that allows local law enforcement to have access to this same data information, but it has been reported to be by many law enforcement officers that they're having difficulty recovering this information even at the local level, so I wonder how this is gonna work at the federal level. [SPEAKER CHANGES] Yeah, I think some of that functionality may impact that as well that was coming through. I also had a request from Senator Bingham. We'll take about 2 minutes to hear from Dr. Sandra Brown that was with his district that wanted to comment on the issue. [SPEAKER CHANGES] She's not from his district. She's from my district. [SPEAKER CHANGES] Correction, I hear that she is from Senator Hartsell's district, so I will say that the request comes from both members. [laughs] [SPEAKER CHANGES] Well, thank you senators for allowing me to address you all on this very important topic, and let me say that I fully agree that the general assembly should be concerned about this issue and should take matters in hand. I learned today I'm part of a supply chain I hadn't thought of myself before, but I think the supply chain starts here with my pen and my prescription pad, and I'm 1 leg of Senator [Rabin or Rabon]'s 3-legged stool of prescription dope. So if ya'll wanna get on top of this problem, you have to change my behavior. And when I say my, I mean you need to change the behavior at the level of the individual physician. And I've had the opportunity to read this bill. There are some things in it that definitely will help, and some things that won't help, and I'd like to address both. First of all, the CME requirement - continuing medical education - we all have to take hundreds of hours of CME every year to maintain our licensure. And I can assure you that even without CME, we know when we're writing for legitimate pain medication, and when we're writing for legal dope. Who deals dope in this country who wears a white coat? There are some unscrupulous individuals who are "pill-mill" providers, and they're a large portion of the problem. And you're not gonna shut them down with CME. So where else does it come from? Well it comes from individual providers who know right from wrong, but are under tremendous pressure to create satisfied patients. And you may be aware that there's a new concept in health care provision that we are graded on patient satisfaction. One really common method of requesting information from patients about satisfaction is to have them fill out an anonymous survey. And in almost all the major health care systems in the state, emergency department physicians and other providers have a certain proportion of their compensation at risk based on their patients' satisfaction. Imagine you're me and you're in the emergency department one evening. A guy comes in. You know he's just there for dope. He has a back ache, he has a tooth ache, he's had 15 CAT scans in the last 5 years. He just wants his roxies. And he says to you, "I'm in pain. You can't tell me I'm not in pain. You can't prove I'm not in pain. I need pain medication. If you don't give it to me, I'll be unsatisfied, and I'll fill out that anonymous survey and give you a terrible score." And the physician knows that he or she has absolutely no recourse; that the options are: start the supply chain, or have an unhappy patient whose survey result may lead to a reduction in compensation or actual termination. And this is really happening. So I can't support the requirement for CME, because it's not gonna remove from us this intolerable pressure to create satisfied patients. But I could definitely request that the general assembly reach out to the major health care systems in the state, speak to their powers that be, and ask them to back off the pressure of the patient satisfaction surveys, especially at the level of the emergency department, because these patients - these dealers - they travel up and down the interstates, they hit all the EDs, all the urgent cares with their fabricated complaints, and at the end of a hard weekend of work they've scored four hundred to six hundred tablets, a useful quantity of milligrams of opiate that they're gonna turn around and sell. Some to use, some to play with, some to give to friends, and some to make a profit off of. They do this for a living and we know it. But what are we gonna do about it? Just say no? If we just say no, we just lose our jobs. This is really happening. I'm not hyperbolating on this. So please keep this in mind, and please help us to be more honorable, ethical prescribers, because we want to be. Most of us want to be. A few of us don't. And the ones that are just the pill-mill docs, shut them down through the law. And that's what I would request. Thank you. [SPEAKER CHANGES] First I wanna thank my constituent for that information. I would advise this committee that with all due - unfortunately, the enemy of the perfect is the good, we think

Title: Date: Length: 00:02:57 Category: North Carolina Senate Speaker: What we have is good, and in talking with Doctor Brown just before this meeting, I've committed to her that we would address these issues with CME as best we can. And we're going to try to address, as we move forward, this if we can get some language to address.. I'm not sure how we can do it, in the short term. But hopefully we'll have the time to do it. That it is extraordinarily perverse incentive for individual subscribers to have to face the kind of situation that Doctor Brown has indicated. And we're going to try and see what we can do, going forward. But we, we have, and I would commit to this committee, and I think Senator Clark would do likewise. I would commit to the General Assembly that we will work on this issue as intensively as we can before we move. But we need, frankly, to get started on this process. And, if we can come up with language we will clearly seek to amend it to address those issues. Because I think they are real, and although my brother is an emergency physician, he is in San Antonio. So he's not addressed by this at the moment. But I have an expectation that I will probably hear from him because the medical society has sought him out in times past to give me advice, or direct me in certain other ways. And I am reasonably confident they will do so again under the circumstances. But I think it's useful to hear these kinds of (??) this is truly productive kinds of additions and ways that we can address these issues. Senate Chair: Senator Pate Senator Pate: Thank you, Mr. Chairman. I move for favorable report as to the proposed committee substitute on Senate Bill 749 unfavorable as to the original bill. With a referral finance. [00:02:00] Senate Chair: Appropriation Senator Pate: Appropriation I stand corrected. Senate Chair: We'll stay out of finance if we can avoid it. SPEAKER CHANGES: No problem Senate Chair: A little more controversy going on there right now so (??) Any other questions, comments from the members? Senator Parmon: Mr. Chair. Senator Parmon: Senator, I'm hearing from the doctor in her recommendation. So you are saying to the committee members as this bill moved forth you all will work on addressing her concern on the CME? Chair: Absolutely. .. Any other questions, comments? Being none, all those in favor of the PCS unfavorable to the original bill, please signify by saying aye. Members: Aye Chair: Opposed... The aye's have it. Having exhausted the agenda the committee will stand adjourned.