American Academy of Family Physicians Eric T. Schneiderman Attorney General of the State of New York February 23, 2013

I-STOP: Internet System for Tracking Over-Prescribing Act Paul J. Mahoney Assistant Deputy Attorney General Medicaid Fraud Control Unit

NEW YORK STATE MEDICAID FRAUD CONTROL UNIT Paul J. Mahoney Assistant Deputy Attorney General Josh Meltzer Deputy Chief of Staff Medicaid Fraud Control Unit – MFCU Created in 1975 as a result of abuses in the nursing home industry. In 1977 became model for federal legislation creating the state MFCUs. Team concept for fighting fraud: Attorneys Forensic Auditors Investigators Separate and distinct from Dept of Health Attorney General's Office ‑ Criminal Division

The Epidemic in New York Roots of the problem are two-fold: First, lack of education and communication between practitioners significantly increases the likelihood of over-prescribing and dangerous drug interaction

The Epidemic in New York Second, access to an ever-increasing supply of prescription narcotics, through legal or illegal means, has grown four-fold in the past decade

The War on Prescription Drugs : A Statewide Epidemic STATEWIDEPrescriptions for hydrocodone have increased 16.7%, while those for oxycodone have increased 82% NEW YORK CITYRate of prescription pain medication misuse among those age 12 and older increased 40% ( ) NASSAU COUNTY Medicaid prescriptions for OxyContin decreased 43%, while Medicaid prescriptions for Opana ER increased 45% during the same time period BUFFALONew York’s largest methadone clinic outside of New York City, Catholic Health System, is beginning to reorganize its service to accommodate an increase in care needed to treat addicted, expecting mothers and their newborns NORTH COUNTRY Health care facilities have experienced a staggering increase in percentage of non-crisis admissions for substance abuse involving prescription narcotics, eclipsing cocaine and heroin in Clinton and Franklin Counties, and surpassing marijuana in St. Lawrence County

New York: Recent Cases Amagansett, NY: o Chait = Amagansett, Long Island doctor o Wrote hundreds of illegal prescriptions for patients from New York City o Chait’s “patients” drove from Bronx and Manhattan to his practice on eastern Long Island, where they paid for controlled substance prescriptions. Scripts were filled at pharmacies at exits on Long Island Expressway o Chait went from prescribing controlled substances 18 times in 10 years to issuing over 380 scripts in three months, for drugs that cost Medicaid and other insurers over $940,000 o Chait was convicted and sentenced to three years in prison followed by five years of post- release supervision Medford, NY: o Laffer and Brady = prescription drug addicts o Prescribed total of 11,881 pills (June 2007 – June 2011) o Visited medical professionals eleven times over four year period o Pled guilty to a deadly robbery at Haven Drugs in Medford Seaford, NY: o Capano = victim, pharmacy customer, and off-duty agent for Federal Bureau of Alcohol, Tobacco, Firearms and Explosives o McGoey shot and killed Capano during a robbery for prescription pain killers o McGoey was convicted of four robberies in Long Island

New York’s Current Prescription Monitoring Program (PMP) Prescription drug monitoring programs currently operate in 43 states Practitioners transmit certain patient, practitioner, and drug information for every controlled substance prescription (PMP collects data on Schedules II-V controlled substances) ↓ Transmissions → Bureau of Narcotics Enforcement (BNE) as late as every 15 th day of month ↓ BNE oversees PMP and collects and analyzes data to identify abuse and diversion Pharmacists are REQUIRED to report any suspected drug diversion to BNE

Limitations of New York’s Current PMP System is based on older presumptions: o How and when data is collected o Who has access to data o How data is used Practitioners are NOT required to provide any data to PMP Most practitioners do NOT access patients’ controlled substance history NO mechanism for pharmacists to ensure prescription presented is valid PMP not designed to address stolen or forged prescription pads

Limitations of New York’s Current PMP Limited data access: o ONLY practitioners are permitted access o No singular patient identifier o No access protocol - patient’s data is only available to inquiring practitioner, If patient meets certain criteria, which flags patient as possible abuser/diverter: o Filling of two or more prescriptions for controlled substances from two or more physicians at two or more pharmacies o If a patient does NOT fit this profile, practitioner will get NO information

The Medicaid Fraud Control Unit Approach: Prescription Drug Abuse and Diversion FINANCIAL FRAUD Prosecution for fraudulent prescriptions average $1 Million loss to New York taxpayers per case

Data from MFCU New York State Medicaid spent over $1 billion on controlled substance prescriptions The increase in Medicaid payments is due to the increase in prescriptions written for controlled substances during this period

MFCU’s Prescription Drug Cases Doctor Shopping Drug Diversion (Pill Mills and Drug Trafficking) Doc-in-a-Box Stolen Prescription Pads

I-STOP: Internet System for Tracking Over-Prescribing Act NYS Department of Health (DOH) will establish and maintain an online, real- time controlled substance reporting system to track prescribing and dispensing of controlled substances Practitioners (agents) and pharmacists (agents) required to review patient’s controlled substance history and report information on database when Schedule II through Schedule IV controlled substances are prescribed and dispensed. (Schedule V likely to be subject to Panel Recommendations.)↓ Practitioners will review patient's controlled substance prescription history on system prior to prescribing ↓ Practitioners will report prescription for all controlled substances at time of issuance, via E-Prescribing ↓ Pharmacists will review system to confirm person presenting such prescription possesses legitimate prescription prior to dispensing such substance, via E-Prescribing ↓ Pharmacists will report dispensation of such prescriptions to system upon dispensation

I-STOP: How It Works No fee/tax imposed on practitioners and pharmacists for using system Alternate electronic means will be in place for those without access to internet

New York’s Current PMP v. I-STOP Practitioner Reviewing Practitioner Reporting Pharmacist Reviewing Pharmacist Reporting Current PMP Optional; access to information restricted None Mandatory reporting of controlled substances at least once every 45 days I-STOP Mandated review of patient history prior to prescribing Report issuing prescription at time of issuance, via E-Prescribing Access to system is provided in “real time” Mandatory reporting of controlled substances as they are dispensed, in “real time”

I-STOP Will Enhance The Effectiveness of New York’s Current PMP System Increasing detection of: Patient addiction Drug diversion Doctor shopping Identification of pill mills Invalidating stolen prescription pads Providing practitioners and pharmacists with centralized information to avoid over-prescribing Substantially impairs prescription drug traffickers Bona fide practitioners will more effectively identify patients who are at risk of prescription drug abuse, allowing practitioners to intervene on patient’s behalf and assist patients in obtaining counseling and treatment

I-STOP & Institutional Dispensers Institutional Dispensers (i.e., Hospitals & Nursing Homes) licensed by DOH may cause controlled substances to be administered or dispensed, pursuant to regulation. -N.Y. Public Health Law § 3342 Institutional Dispensers are EXEMPT from the Duty to Consult the Database in the Following Circumstances: o Practitioner prescribing or ordering a controlled substance for use ON THE PREMISES of an institutional dispenser o Practitioner prescribing IN THE EMERGENCY ROOM of a general hospital, provided the quantity prescribed does not exceed a 5 DAY SUPPLY o Practitioner prescribing for a patient UNDER HOSPICE CARE

I-STOP : Necessary and Effective Supporters: Federal Governmental Accountability Office (GAO), Centers for Disease Control and Prevention (CDC), insurance industry, The White House, and independent researchers suggest expansion of PMPs as a key part of solution to prescription drug fraud, abuse, and diversion Most importantly… Enable practitioners and pharmacists to provide prescription pain medications, and other controlled substances, to patients who truly need them Will provide practitioners and pharmacists with necessary data: o Detect potentially dangerous drug interactions o Identify patterns of abuse by patients o Help those who suffer from crippling addictions o Prevent potential addiction before it starts

I-STOP Effective Dates (from August 27, 2012) ISTOP C/S Registry – Mandatory utilization takes effect in one year; DOH may promulgate regulations to be immediately effective on that date Electronic Prescribing – Mandatory utilization for all prescriptions takes effect in two years; DOH to have regulations as to C/S E-scripting by 12/31/12 Adjustments to Schedules of Controlled Substances o Immediately for most of the technical corrections to prior versions of Controlled Substance sections of Public Health Law o 90 days for most adjustments to the Schedules and to definitions of certain drugs o 180 days for most changes related to hydrocodone and tramadol Awareness Program – immediately effective Safe Disposal Program – immediately effective

I-STOP: Internet System for Tracking Over-Prescribing Act Paul J. Mahoney Assistant Deputy Attorney General Medicaid Fraud Control Unit 120 Broadway, 13 th Floor New York, NY

NEW YORK STATE MEDICAID FRAUD CONTROL UNIT Eric T. Schneiderman Attorney General of the State of New York February 23, 2013