get after them with regard to this combination, especially Talwin. You heard the testimony of the pharmaceutical house. And to me, it was very irresponsible.

And you heard another drug company that was very responsible. They voluntarily submitted their drug to schedule II procedure and would do so again if they had similar threats.

Thank you, gentlemen.

[Whereupon, at 5:30 p.m., the hearing was adjourned.]

SUBMISSIONS FOR THE RECORD

STATE OF ILLINOIS, DEPARTMENT OF PUBLIC AID, Springfield, Ill., October 27, 1978.

HOUSE SELECT COMMITTEE ON NARCOTICS ABUSE AND CONTROL,
House Office Building, Annex 2,

Washington, D.C.

GENTLEMEN: At the October 6, 1978, Hearing of the Select Committee on Narcotics Abuse and Control, additional information was requested from the Department of Public Aid. Enclosed herewith are the following:

An extension of the graph introduced during the hearing to cover May through August of 1978. There has been a marked decrease in the number of prescriptions for these drugs since March, 1978, as shown in this graph.

The identity of all providers terminated from the program (Attachment II). This listing totals 131 providers-four more than included in my testimonybecause of additional terminations since then. Of these providers terminated, 28 were physicians; 32 pharmacies; 11 Nursing Homes; 32 optometrists, opticians or optical companies; 6 podiatrists; 6 dentists; and 16 laboratories. Four of the physicians (Brandt, T.; Chin, J.; Lewis, C.; and Roque, F.) and one of the pharmacies (Mohawk) were terminated as a result of the special project currently underway, dealing with Talwin and PBZ abuse.

An identification by type of provider of providers against whom the Department currently has a termination proceeding underway (Attachment III).

A written narrative describing the special project currently underway involving the most abusive patterns of prescribing and dispensing Talwin (Attachment IV).

Correspondence with various State and Federal officials interested in or responsible for controlling drugs (Attachment V).

The Illinois Supreme Court decision which held that the Department did not have the power to terminate providers or recover monies improperly paid (Attachment VI).

A copy of the statute under which the Department was granted authority to terminate or suspend providers from the program and recover monies improperly paid, and the regulations promulgated by the Department to implement these regulations (Attachment VII).

Finally, the Committee Chairman, Congressman Murphy, requested that we determine from other States, whether they experienced a similar ratio of Talwin to PBZ prescriptions. We are contacting other States in this region, and other large industrial States to inform them of our experience in Illinois and solicit information regarding their experience in this area.

Thank you for the opportunity to participate in your deliberations concerning the abuse of licit drugs. We would be happy to supply any additional information at the Committee's request.

Sincerely,

Attachments.

JEFFREY C. MILLER, Administrator, Medical Assistance Program.

ATTACHMENT III

Number of providers by provider type facing termination action by the Illinois Department of Public Aid1

1 Providers who have been notified by the Department of our intent to terminate their participation and the grounds for this action who have not yet completed the administrative hearing process.

ATTACHMENT IV

SPECIAL PROJECT-IDENTIFICATION AND ELIMINATION OF POTENTIAL DRUG ABUSE IN THE ILLINOIS MEDICAL ASSISTANCE PROGRAM

(Illinois State Medical Society and Illinois Department of Public Aid, May 15,

1978)

DRUG UTILIZATION PROJECT

The Bureau of Program Integrity, Illinois Department of Public Aid, in attempting to identify drug overutilization and prescribing patterns detrimental to the health of clients of the Medical Assistance Program proposes the following special project concentrating staff efforts on the single goal of identification an elimination of potential drug abuse. The project will attempt to dichotomize the act of obtaining pharmaceutical products into prescribing and dispensing. Each can be an area of potential abuse. To combat these potential abuses, the Bureau will conduct peer reviews of 50 physicians identified as either over or misprescribers and limited scope audits of 50 pharmacies identified as potentially overdispensers of controlled substances. This project will take the combined efforts of the Illinois State Medical Society (ISMS), State Medical Advisory Committee (SMAC), Department auditors, nurses and attorneys.

PEER REVIEW

One goal of the project will be the review of 50 physicians identified as potentially prescribing in either quantity or frequency which is possibly detrimental to the health of the recipient. The selection process will be initiated by requesting and reviewing drug case detail reports on recipients identified as receiving an excessive number of prescriptions from Mohawk and/or Monarch Pharmacy. The review of the case details will provide physicians whom recipients with drug-related problems believe can be used to obtain abusable substances. To date twenty-one physicians have been selected using this technique. If needed, additional physicians will be selected by using the Department's computer edits, past referrals or a special analysis of pharmacy billings.

Once the peer review selections are completed, the Professional Standards Unit will obtain recapitulation vouchers for each physician identifying a minimum of 50 recipients under his care. Recipient ledgers and drug detail reports will be ordered, received, and screened by the staff reviewer. During the screening process, the reviewer will attempt to determine the area of potential abuse and draft a hypothesis statement which will state the methodology for further research. Upon approval of the hypothesis statement by the consulting physician, a letter will be forwarded to the subject physician notifying the date and time of the proposed peer review. Enclosed will be both a questionnaire and instructions to have available for inspection all medical records from January, 1977, to January, 1978.

Twenty-four hours prior to the scheduled on-site review, the staff reviewer will contact the subject physician identifying twenty-five medical records which will be reviewed the following day. The reviewer will ask the subject physician whether he was able to complete the questionnaire; if not, he will answer all questions and aid the physician in the completion of the questionnaire.

The on-site review will begin by the consulting physician familiarizing himself with the questionnaire and the practitioner's general office procedures. The consulting physician will, then, review twenty-five medical records and discuss the plan of care and appropriateness of the general treatment pattern. He may ask specific questions about prescribing habits per diagnosis or he may attempt to ascertain the subject physician's overall view of specific drug transactions or prescribing patterns. This is clearly an art, and would be presumptious for us to dictate the appropriate technique to be used by the consulting physician. However, it is important that an overall picture be gained of both the knowledge and the practical application of that knowledge by the subject physician. To aid in gaining consistency, we have attempted to outline some of the major questions the consulting physician's report should address. The outline is merely an attempt to aid the consulting physician in conceptionalizing a report of his observations. We would recommend that the consulting physician respond to the outlined questions immediately following the on-site review while the findings are fresh. We will have available a tape recorder for his use to dictate results. A transcript will be made of his dictation and submitted for his editing and approval. All clerical functions will be accomplished through the staff reviewer and Departmental resources. Finally, all medical records indicating an abhorrent pattern or identified as interesting by the consulting physician will be xeroxed on-site and available for the consulting physician. It must be noted that these copies must be initialed by the consulting physician for use in administrative review and as evidence for use in verifying statements which lead to his evaluation of the overall practice and pattern of prescribing.

PHARMACY AUDITS

The Pharmacy Audit Unit, Bureau of Program Integrity, will assume the responsibility of completing fifty limited scope audits of pharmacies displaying a pattern of overdispensing controlled substances. The selection process will consider pharmacies identified with two known locations of drug overprescribing. Other pharmacies will be selected based upon a high-utilization rate of fictitious Drug Enforcement Administration (DEA) numbers. The remaining pharmacies will be selected based on volume and referrals to the Illinois Department of Public Aid from numerous sources. Once the selection is completed, a letter will be forwarded to the pharmacy instructing it of the purpose of the audit, instructions for completing the questionnaire, and the need for all prescriptions and billing forms for the period of January, 1977 through January, 1978. On the assigned date, the audit team will review the questionnaire with the provider and with the assistance of the pharmacist and/or owner, will select a random sample using a table of random digits of twenty MMIS billing forms and corresponding prescriptions. The auditors will, then, ascertain the following areas of compliance:

Usual and customary fee verification.

Compliance with Section IX of the Illinois Pharmacy Practice Act (Fiveyear record retention).

Compliance with Section XIII-XIV of the Illinois Pharmacy Practice Act (Display of license and name tag).

Acquisition overcharge.

Duplicate payment.

Verification of dispensed quantity.

Verification of prescribing physician.

A prescription review for overutilization.

Each identified area of non-compliance will be noted and logged. The log will be analyzed and the dollar value of each discrepancy will be calculated. Results will be projected to the entire amount paid. The projection technique will be those presently used by the Bureau of Program Integrity in their current extrapolation audits and have been taken from Herbert Arkin's "Handbook of Sampling for Auditing and Accounting" (2nd Edition, 1974). An attempt will be made while conducting the audit to familiarize the owner to the technique and gain his compliance with the procedure. To aid the pharmacy auditors in accomplishing this goal they will discuss the sampling procedure during the selection process. An additional audit step specifically relating to controlled substances has been added. The auditors will analyze the sample and forward a letter to the prescribing physician identifying whether or not the controlled substances had been ordered and quantity of the prescription.