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Mr. BUCKLEY. Prescription or what?

Mr. MILLER. The commonality among diagnoses was alarming. Backache, sinusitis, runny nose, was a complaint. And the prescription was Talwin.

Mr. RAILSBACK. Let me ask one other question. By reason of the tremendous scope and volume, the magnitude of the problem which caused you to focus on it, does our Department of Public Aid have any kind of an apparatus to oversee or monitor the medicaid program and drug prescriptions? In other words, it sounds to me that the program by reason of its size is really ripe for abuse.

What actions did you take before or what actions were available ? What have you done since to provide better monitoring and oversight of abuse?

Mr. MILLER. Let me respond to the two parts of that.

First, the most significant thing we have done, I think, is the legislative authority to act when we detect this kind of problem. We have over the last 2 years beefed up significantly a staff whose function it is we call it program integrity staff. Their sole function is to detect abuse within the program and to recommend the appropriate steps to alleviate that abuse.

Mr. RAILSBACK. Pardon me. How many people are we talking about?
Mr. MILLER. Staff ?
Mr. RAILSBACK. Yes.

Mr. MILLER. It stands now at 103. And the authorization for this year is 117. And next year, it will probably be 136 or 140.

Mr. RAILSBACK. Are they medical people? I'm sure some of them are.

Mr. MILLER. Some are, but the medical people are mostly nurse or paraprofessional type. Otherwise, we have auditors, accountants. We also have legal staff.

When it comes to the question of peer judgment, judgment of whether or not the practice pattern that one is looking at is appropriate, we refer that to standing committees of whatever discipline we are dealing with—dentists, physicians. Because we think that to get a competent peer review judgment that will stand up both in our own hearing process and in the subsequent judicial process, we need a committee independent of the department making that judgment.

We have physicians do the case workup, but the actual judgment of whether or not that practice is acceptable

Mr. RAILSBACK. Just one last question, and I think I have exhausted my time. In the case of the Talwin problem, you saw a need to, as I understand, hire an outside medical consultant to actually help you evaluate whether there had been abusive problems. I imagine that was a one-time hiring. Do

you feel now that you are able to have a handle on it without that kind of outside consultant ?

Mr. MILLER. We have contractual physicians from time to time to help us look at individual cases. I think I should point out that the department has a formula of drugs and whether or not we pay for a particular drug item is a decision that we refer again to an outside body of, in this case, physicians, the Drugs and Therapeutic Subcommittee of the State medical society.

This and several other drugs have significant medicinal value. They help in some cases, and they also have some significant abuse poten

tial. And we don't feel that it is really our place to make that kind of judgment. But when we uncover abuses, we feel it is our place to act within the scope of our statutory authority.

Mr. RAILSBACK. Thank you very much.
Mr. MURPHY. Mr. Nellis ?
Mr. NELLIS. Thank you, Mr. Chairman.

Mr. Miller, you are Director of Medical Services. Are you a medical doctor, may I ask!

Mr. MILLER. I am not.

Mr. NELLIS. Mr. Buckley is not a medical doctor He is your assistant.

Mr. MILLER. He is actually an assistant to the director of the department, but he is not a medical doctor.

Mr. NELLIS. Do you feel competent to pass on questions of medical prescription propriety and whether or not the pharmacists are passing out too many pills?

Mr. MILLER. No; I do not.

Mr. NELLIS. Then, you seek other physicians' opinion to this type of practices; is that right?

Mr. MILLER. That's correct.

Mr. NELLIS. Have you ever known of any organized medical society that is willing to openly criticize brother doctors who may be overprescribing ?

Mr. MILLER. We have, as I indicated earlier, a separate standing committee of 11 physicians.

Mr. NELLIS. How do they react when a physician is charged with 200 Talwin prescriptions in the course of a day?

Mr. MILLER. They have been—I don't want to characterize them as a hanging committee, but they have been as appalled as we have been by the abuses of those licensed to practice medicine. And they have recommended to us almost uniformly when we bring a case to them that we proceed to terminate that individual's authorization to participate.

Mr. NELLIS. OK, you have 50 of the worst-and I think these are your words—cases of physicians.

Mr. MILLER. That's correct.

Mr. NELLIS. How many of those have been told they can no longer prescribe under the medicaid program!

Mr. MILLER. We are in the process, as I indicated, of working those up now. Mr. NELLIS. Not one has been stopped; is that right?

Mr. MILLER. No; that's not right. We have terminated some of those physicians. As was indicated in the film by Peter Karl, some of the physicians

Mr. NELLIS. Do you have their names?

Mr. MILLER. Not with me, but I can furnish the names of physicians who have terminated from the program. As I indicated in that, 127 providers have been terminated. I will be happy to furnish the names.

Mr. NELLIS. Mr. Chairman, with your permission, I would like to have that for the record.

Mr. MURPHY. Without objection, so ordered.

[The information referred to appears in the witnesses' response on p. 448.]

p. 448.7

Mr. NELLIS. The same question, I would like to ask with respect to pharmacies. How many pharmacies have been investigated and found to be overselling.

Mr. MILLER. As part of the special project, we have concluded our action against three pharmacies. And they have been terminated.

Mr. NELLIS. They have been terminated ? What are their names?
Mr. MILLER. I will furnish those to the committee.
[The information referred to appears in the witnesses' response on
Mr. NELLIs. You didn't bring any of that with you here today?
Mr. MILLER. No; I didn't.

Mr. NELLIS. Didn't you think the committee would be interested in knowing what your track record was in this ?

Mr. MILLER. The track record, absolutely; the names of individual clinics, I didn't think so.

Mr. MURPHY. But you will furnish them?
Mr. MILLER. I certainly will, Mr. Chairman.

Mr. NELLIS. What about wholesalers and manufacturers! I realize you don't have any particular jurisdiction over manufacturers who are out of the State, but you do have jurisdiction over wholesalers, do you not?

Mr. MILLER. Drug wholesalers ?
Mr. NELLIS. Yes.
Mr. MILLER. No; I do not.

Mr. NELLIS. They are the ones who furnish the drugs to the pharmacists who fill the prescriptions. Are you saying you stop at the level of the pharmacy?

Mr. MILLER. That's correct.

Mr. NELLIS. You don't investigate to see whether a wholesaler is inordinately ordering from a manufacturer and distributing to the manufacturers: is that correct?

Mr. MILLER. That's correct.
Mr. NELLIS. Is that because of a flaw in your enabling legislation?

Mr. MILLER. I'm not sure I characterize it as a flaw. I'm not sure what business the Department of Public Aid, which has the primary purpose of alleviating poverty, providing cash assistance and medical assistance, to people who can't afford such services would have getting into the drug wholesaling end of it.

Mrs. COLLINS. Do you know whether the Illinois Commission of Drugs would have that responsibility!

Mr. MILLER. I don't know. I would guess that they have some relationship there.

Mr. NELLIS. Well, my problem is that up to about March of this year, your payments have been supporting a major street addiction. Payments that you have made to doctors and to pharmacists have largely supported a serious street addiction in the city of Chicago. Is that not correct?

Mr. RAILSBACK. Mr. Chairman, I feel I am going to have to object to that question. We are talking about the Department of Public Aid. Their primary purpose is to serve. I think the idea that they have responded to what they have been advised was an abuse and that they have been willing to furnish us all the information that they have

available—I just kind of want to indicate my objection to the kind of line of questioning.

I don't think they are on trial here.
Mr. NELLIS. If I may proceed, Mr. Chairman, briefly?
Mr. MURPHY. Certainly.

Mr. NELLIS. The only purpose for this questioning is to obtain for the committee a record of situations that are not peculiar to Illinois where public funds are being used to support street addiction and street violence. This is true in Pennsylvania, it is true in New York, it is true in other States.

And since it is no longer true here because we do have corrective type of action being taken here, I wanted the record to show that until that corrective action was taken, we had a situation in which public funds were being used for that purpose.

Mr. MURPHY. I understand the witness to have answered that to some degree.

You said that there was a Supreme Court decision that the State of Illinois—that up until the early part of 1977, you could not refuse to pay to any recipient his medical service under this program. And I think you indicated that Talwin, the pharmaceutical needs of Illinois needy people, was somewhere like $600,000 on the drug side of it?

Mr. MILLER. That's correct.

Mr. MURPHY. So I think as to those amounts, we will let into the record. As to the inference that the Illinois Public Aid Department is supporting crime and violence on the street, I will strike that end of the question, but will permit how much money you spent in supplying the drug to the Illinois recipients of public aid. That will be let into the record.

The inference you are supporting crime in the street, that will be struck, I think it could be the result of it. I don't think it was an intentional doing on the part of the Illinois Public Aid Department.

Mr. NELLIS. Well, Mr. Chairman, yes, thank you. There is no intention on my part to say that it was an intentional act on the part of the Illinois Public Aid, but we do have a serious problem throughout the country in this medicaid funds and medicare funds, which are part Federal, part State, that are being used by physicians who are termed croakers—you have heard that term, haven't you—and clinics like the ones you have experienced here to use those funds as a means of getting very rich very easily.

. Well, I will pass to another question, a final question.

Mr. Miller, I have here a chart, and I wonder if you have seen it. Could I pass it to you please?

I will give you an opportunity to look at it.

I think it is based on figures you furnished to the Illinois Dangerous Drugs Commission. And I want to ask you if that is correct.

Mr. MILLER. I am not positive. I believe it is.
Mr. NELLIS. Does the graph look familiar to you?
Mr. MILLER. Yes: it does.

Mr. NELLIS. It does show an almost parallel track, does it not, between the sales of Talwin and Pyribenzamine over the period July 1976 through April 1978 ?

a

Mr. MILLER. Yes; it does. I am aware that that relationship exists.

Mr. NELLIS. When did you become aware of that relationship of this parallel track between these two drugs?

Mr. MILLER. As we started pulling data together in order to support the efforts of the Danger Drugs Commission on the use of these drugs.

Mr. NELLIS. Up to that time, you had not made this analysis; is that correct ?

Mr. MILLER. That's correct.

Mr. NELLIS. And had you had any notice in your own shop of the increased number prescriptions for these two drugs?

Mr. MILLER. As I indicated, during 1977, we noticed an increase in the number of prescriptions of Talwin.

Mr. NELLIS. And that would be when, in 1977 ?
Mr. MILLER. Approximately the mid-point of the year.
Mr. NELLIS. I beg your pardon!
Mr. MILLER. Approximately the mid-point of the year.

Mr. NELLIS. Sometime in June or July of 1977? In August of 1977, if

you look at this chart, based on your figures, you will see the highest incidence of prescriptions were made for both these drugs. And is that when you first became aware of it?

Mr. MILLER. I believe it was before that. We analyzed expenditure trends by major drug items on a quarterly basis. And the figures during 1977 were running about 33 percent higher than they had run during 1976. So I would guess that flushed out all the June report.

But I'm not positive precisely when.

Mr. NELLIS. I also point out that beginning in April of 1978, the figures are parallel, but the figures seemed to be going down. Mr. MILLER. That's right. And it has continued. Mr. NELLIS. I was going to ask you, what is the trend after October?

Mr. MILLER. As I tried to indicate, we have noticed what appears to be a 50-percent reduction in the number of prescriptions for these two drugs funded under the program since March of this year.

Mr. NELLIS. Over what?

Mr. MILLER. Fifty percent over the rate that appears on this chart; 50 percent over, say, the 1977 annual rate.

Mrs. COLLINS. Why does the trend go down, way down? I'm looking at April and May of 1978.

Mr. MILLER. I think it is partly as a result of the investigative report and partly as a result of our actions against physicians and pharmacists they deal with.

It may also be the drug being scheduled. But I think it is the threat of it being scheduled.

Mrs. COLLINS. May I ask one more question, Mr. Chairman?

We were discussing some of the abuses and monitoring. We were talking about licensing and so on. I believe you indicated it is more effective to remove a physician's license through the Department of Registration and Education. Couldn't you just withhold funding?

Mr. MILLER. We could. And I'm sorry if my remarks were misunderstood or created that inference. What I was trying to draw is the distinction between our authority to terminate a physician for the medical assistance program

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