[BLANK_AUDIO] [SOUND] House Committee on Insurance come to order. [BLANK_AUDIO] Welcome everyone. First I wanna thank the house sergeant at arms for being here, David [INAUDIBLE], Warren Hawkins, [INAUDIBLE] Rick Foster,thank you all. The pages, [INAUDIBLE] thank you for being here Today I have an announcement to make that this meeting is gonna be for discussion only. So we're not gonna bother taking a vote to make sure we have a quorum. [BLANK_AUDIO] Hey men. >> [LAUGH] >> I'm gonna recognize Representative Louis to come and do his presentation on this bill. 1048 House Bill 1048 iii therapy and [INAUDIBLE] deterrence. [BLANK_AUDIO] [INAUDIBLE] Matthew and Jackson if you wanna have do the presentation come on up and do that. [BLANK_AUDIO] Dobson and And why else do you say? >> Dobson, Murphy and Jackson but it's [INAUDIBLE] >> Dr. Murphy and Dobson [BLANK_AUDIO] Mr Chairman, Mrs Chairman, members, ladies and gentlemen thank you for your time this afternoon. House Bill 1048 is a Bill in two parts that deals with two issues that were studied there in the By House Select Committee, the first issue is step therapy, step therapy is a tool that Insurers use to control or limit the amount Of money they spend on patient medication, under step therapy a patient must try one or more drugs as chosen by their insurer not their doctor, usually based on financial not on medical consideration Before coverage is granted for the drug prescribed by the patients healthcare header, step therapy can delay or lower the quality of care for patients because it requires patients to sometimes try several drugs before gaining access to the Drugs that could be the best therapy or cure for them. Step therapy can also prevent patients from receiving treatment at all, because of the delay in Access to the medicine that's prescribed by the health care provider. It is possible and the House Select Committee during the interim heard numerous examples of times when individuals actually got sicker because Because they did not get the medicine that the doctor asked for then to receive. So part one of this bill deals in my opinion with patient safety and with getting the correct medicine As prescribed by a doctor to the person to whom it was prescribed. Part two of this bill deals with opiolin abuse the terrence. Those of you that were on the House elected, media perhaps read about were able to see the various presentations that we received from law enforcement, where they talked about the epidemic of opioid drugs being abused and being used in ways in which they Were not prescribed.
This would move us to where doctors would prescribe and pharmacies would provide opioid drugs that were Were much, much harder if not impossible to tamper with. With that Mr. Chairman I would like to give my other bill sponsors a chance to say a few words. [BLANK_AUDIO]. Thank you Mr. Chairman, Chairman Louis thank you. >> Thanks for allowing me to be a part of this, was a good debate in the oversight committee and subcommittee, procedures were followed. I think we're going about this the right way, I'm proud to be a part of it and I don't think we can wait any longer Longer and we will appreciate your support at the time. >> Morgan. >> Thank you Mr. Chairman. I wanna thank the support of the staff for this. I will say as the person that actually prescribed these medications, that the time has come that we address the That's the Opioid crisis. The time is actually long passed, and I am exceedingly sensitive to the argument of calls containment, I see it every day. But there is a point where we have to make decisions about paying up front versus paying much more in the long term and we need to address this problem Problem and this is one issue, this is one way that I feel like we as a community and as a legislature should address this issue. Thank you. [BLANK_AUDIO] >> Thank you for that gentlemen. At this time if you have any questions for any of them ]you can ask it now Members, if not I'm gonna move to the comments in the public section. Any questions for the sponsors? >> [INAUDIBLE] >> Go ahead, state the question. I have been giving >> [COUGH] >> I've been on both side of this. One aspect of the bill about the step I really see where you are coming from. Help me with this opioid This particular opioid and why it’s a deterrent, because I'm hearing that it can be abused just like the->> Sure I'll speak to that. So a portion of what physicians do, a very small portions of the drugs that we prescribe are opioids, those are for chronic pain or acute Acute pain. I deal mostly with acute pain and so a very small sliver of all the prescriptions that physicians write are due with opioids. And we are now talking about another small sliver of that sliver, where this gives the physician, primarily pain physicians, people with chronic pain, chronic back pain lots of different issues, the option To say okay, I feel like this patient is a person who is at risk to abuse medications or their families is at risk to abuse medications and it gives them the option to say, you know what I don't need them to quote fail a drug that they'll abuse, because what narcotic abuser in their right mind would say that they failing a drug that's That they can crush or snort or do something else. And so what this does is it puts in a formulation that is exceedingly difficult to abuse, to snort, to inject, or do anything else. And so what we’re doing is we are taking again a very small sliver of all the prescriptions written on narcotic prescriptions and taking Taking the sliver of that maybe 2% at most to say look, it's time that we give them, they can get their drugs, they can still be go through a withdraw on this, you can still get addiction to them. No one's debating that fact whatsoever. What we're doing is we're is that we're saying that this were type of drugs That you can not readily abuse, okay. And I've seen this hands down many many times myself on people who have chronic pain medicine and I wished I had this tool, and so now I believe it's time we bring that to the forefront. Does that answer your question? >> Yes. Thank you very much. Representative Hamilton. >> [CROSSTALK] To representative Richardson. >> Your have a question to Doctor Murphy? >> Yes to representative Murphy. It's my understanding that they abuse deterrent label is derived from the fact that this drug can't be hit with a hammer and broken up snored it. When injected like any other opioid is the impact the same.
>> That's the reason you would write a prescription for a pain medicine that you would have the pain medicine work. That has a different entirely different from snoring injecting extra. >> Certainly >. Follow up >> Follow up. Thank you Mr. Chairman. But the drug itself its only deterrent quality that you can't break it up or dissolve it, drink it, snort it, but when ingested like any other opioid it has the same impact? >> Sure, it's a narcotic. It's written, the purpose of writing a prescription for narcotics is so that you have A narcotic written and that's orally, that's taken orally. >> Okay, final follow up. >> Follow up. >> My concern about this provision in the bill is that it's increasing access to opioid, and requiring insurance companies to cover that cost. So to label this as an abuse Well, I think it's really a stretch. Because it is an addictive drug. 90% of the people that are abusing opioids are generally swallowing them. Not snorting or lay lining I mean, some are but it's t's only deterrent and that it can't be best at a part snorted I don't really see that as a deterrent, it could still become abused, by the user. >> Can I ask her a question? >> Okay. >> I just want a clarification, can you clarify how it makes the drug more accessible, how it would increase It's not just particular drugs but opiates in general, the bill says, I believe it reads increase access to abuse deterrent opioids or at least that was in one of the versions. >> Sure. Follow up with that. >> It increases the access to it because those are denied by insurance companies So it's not increasing people to get drugs it's increasing the fact that if i'm a physician I want them to get an abuse deterrent drug. I don't have ti have them jump through a bunch of hoops to do it. That's what the word access means. >> Mr. Chairman I think I will save the debate for the floor. >> Anybody ask any question? >> Follow up on that- >> Representative Shepherd Question, so it's actually not a deterrent. It could be but it's not. >> It is gonna be a deterrent. Addictive drugs are used illicitly crushed, snorted, injected and these formulations prevent that. Somebody still can get Addicted to an oral pain medication. >> Get addicted then one like that. >> Sure it's a narcotic. >> It may not be a deterrent in some way? >> Correct if it's swallowed correct but abuse deterrent in that it's formulation is abused to turn. >. Thank you sir. >> Representative Horn. >> Perhaps Doctor Explain the difference in abuse, the potential for abuse as a pill, we'll use it as a pill, versus the type of abuse that would result by changing The nature of the bill that is crushing it, liquefying it and injecting it. Is there a difference in the addictive capacity or the satisfaction of the need? So what's the point, what would be the purpose of someone changing the nature of the tablet or pill into some other form instead of just taking the pill >> [UNKNOWN] not only the high that one develops From taking the drug orally versus taking on snorting or injecting is entirely different. >> I don't think that was clear. >> Okay, sorry. >> [BLANK_AUDIO] Any more questions from members of the committee. [UNKNOWN] I recognize representative [INAUDIBLE] >>Can I come up there an use the podium? You can. Why do you wanna do that? >> [LAUGH] >> State from there. >> All right. >> Go ahead. >> I like to look at people when I talk to them. >> Well stand up and look at them. >> [LAUGH] [LAUGH] >> Everybody in this room. I'm opposed to this and I will tell you why. I get very very tired all of reasoning insurance agents are opposed to it. We don't work for insurance companies we work for our clients. We have to go out every year and tell them you've got this big rate increase.
Well as you all know Blue Cross has delivered and others at none to say no united all of them have delivered humongous rate increase. Every year work something like this. Last year you all passed three. In favor one of them, I 'll tell. But I'll tell you any mandate is above Obama care. Yet the conservative member in here of conservative role is complaining about Obama care. I don't complain about it. Because when you vote for a mandate you are given something Obama care didn't even cover. You are raising the price to the consumer, and some of you think well insurance companies can afford it, they don't need it, they pass it right on the [INAUDIBLE] rate increase to the clientele. Cuz you want your consumers because some people have the [UNKNOWN] that whys it is called group insurance Everybody pays the premium, everybody. They just keep on doing it. But last year I went out. I said they did three this year and raised your rate 7%, three of them 7% plus ObamaCare. This was worse than ObamaCare. And I don't like going out saying that my people are increasing rates. And then the smaller employers, and they're the ones 30 and under, every time they go out deliver the rate increase. And they say I'm doing away with groupage/g. Doing away with it. And they do away with it. I'll lose the choir/g and all those people lose insurance. What have we accomplished doing all that? Now, I'm gonna go down my list. The North Carolina has more [UNKNOWN] in this state union. 57 of of them. These are all because of ObamaCare. The drugs. About 15 years ago, drugs Drugs were about 8% of the total cost per premium for health insurance. Now they run 19-24%. Why? The drug companies are out of control. They're out of control. This is a sweetheart sale for drug companies. This is nothing else but a sweetheart deal for drug Drug companies and they do with the doctors in it, by saying because the doctors wanna have their way. Well, how does it hurt if the doctor prescribe XYZ and the insurance company says try this drugs for 30 days, if it works fine, if not we will let you have their [UNKNOWN] plan So that's the reason for, look at all the ads that drug companies run. [UNKNOWN] I got [UNKNOWN] magazine the other day and there's a full page and provide with it. >> Representative [UNKNOWN]. [CROSS-TALK] The step [UNKNOWN] works [UNKNOWN] the only doctors wanna have their way, every type I have a position for [UNKNOWN] and they [UNKNOWN] have to go [UNKNOWN]6 o'clock broadcast to work or three days this week we're having a big drug company [INAUDIBLE] never thought they'd launch. See, every week they are in their feet to watch Brian entice the doctors to sell their public school, it is wrong and we need to stop it, the state employs health planners Supposed for this and many many bothers. North Carolina chambers others [UNKNOWN] >> Representative [UNKNOWN]. >> We dont take public comments in this, I'm recognized Representative dollars next. >> I ask more comments cuz I was only committe but I will save them for I guess whenever the meeting is, there might be a vote at some point, I don't know. But let me just mention one thing with respect to medications those budgets I know with medicaid with the rebates that we get have actually been Decrease, that's what's been going on with respect to medicaid and that's about two million of the ten million dollar and the people that live in this state. The other thing I would just throw out is that I think there's a lot on all sides that you can say about medicaid Medications but to balance it a little bit a lot of medications that we have today that we didn't have 20 years ago are actually helping us live longer. One of the issues that we have with our pension plan is that in the re-evaluation it was done this past year people Are actually living longer and medications among a host of other things are assisting that.
So I do think that there needs to be balance when we're talking about prescriptions that Dr. Murphy and others are using to do Do a lot of good for the people in our state and around this country. >> Thank you. Next I'm gonna recognize Representative Browley. >> I just wanted point out the lunch that I was eating while Representative Pillman was talking was not provided by a drug company it was purchased in the legislative cafeteria. >> [LAUGH]. Browly, Representative Collins be next. >> I just wanna point one of the reason that the call is not going up on medication for medicaid is because like our state health plan and like medicare unlike the self founded plan, that large companies run. This bill does apply their. [UNKNOWN] We dont put the [UNKNOWN] date from our sale. We just pick on one group, the smaller group in [UNKNOWN] and in the [UNKNOWN] indiviadual health insurance. [UNKNOWN] people [UNKNOWN] one of the most [UNKNOWN] and the [UNKNOWN] back on top of that and making their calls [UNKNOWN] 30% of people covered by Those covered by small business and those people who by their own. So remember that if this is not good for our state employees it is not good for people on medicare and medicaid it's not good for the rest of the state. >. Thank you representative Concon. Anybody else representative Hamilton >> Thank you Mr. chairman I think that lead onto this question. What representative Collins sure said if the state health plan excluded from having to cover this. Yes it is. >> Mr. chairman. >> Yes sir. >> As the members are aware the state health plan only has one step. They only require one step. But they testified publically before the committee. That they only have one step that is required so the bill sponsors didn't see a need to address an entry that has just one step which is not a part of this bill, it's why they are neutral on the bill not opposed to the bill as was misstated earlier. >> Representative Hamilton Wants to follow up.>. One quick follow up but then Representative Louis says that if they would not [INAUDIBLE] be increasing access to abuse [INAUDIBLE] would not affect the state health plan. >> I understand the step pay that you just explained. That makes sense but the second part of this bill. Which is the one I'm concerned about is that will the state health plan be intact a body idea. >> Representative at this time best the first time I have heard this question, I will find out a better answer my initial answer would be. That the bill was not written to include but I think you make a very good point. >> Representative horn is recognized.>> Thank you Mr. chairman. Seems to be that part of the problem with all due respect doctor. The doctors. And I've used an example that I may have used before. Someone near injured [UNKNOWN] went into the hospital for an operation. The operation is over she's in recovery nurse came in to offer her an opioid Tablet to relieve pain, she declined. When we checked out of the hospital got all of our goodies and paper work we got home and we find that in there we have a prescription for 60 opioid tablets. Now she'd already declined using it Works late on the day of the operation and then I vaguely remember we were told well it's here if you need it. And I'm thinking there are gonna be an awful lot of people that get that kind of a prescription. Gonna go fill it because it's there if they need it Need it [COUGH] they don't ever use it they don't need it and somehow it disappears over the next several months it disappears on the medicine cabinet. If perhaps the doctors could entertain a different protocol for writing prescriptions for the Highly addictive drugs may be a two step therapy, how about a step therapy for prescriptions, where you write a prescription, let's say for a three day supply and a second prescription for a longer supply because the odds are I would think that a great many people and maybe even most people Would never need to fill that second prescription and therefore the cost to the consumers across the insurance company that cost everybody will go down.
I understand that might not be the best interest of drug companies but it could be in the best interest for the rest of us. Maybe that's piece and part of step therapy as the step therapy Before frustration/g protocol is that at all realistic? >> Yeah, it's wrong sure coming around your point is well taken I would take that as an exceeding rare instance and let me just bring a few facts to bare. In 2009, a national institutes of health brought forth a study that said basically That we as physicians were not treating pain well enough, that we were not prescribing enough pain medications and so as pendulum swing we became more educated in trying to treat pain and unfortunately there are not to many non-narcotics that are available that can treat chronic pain okay. One of the logistical issues is if I I send someone home with no pain medications since they have not required pain medications they call me at eight o'clock or ten o'clock that night in severe pain, I can't do anything about it because I can't call in a pharmacy and say I need you to give these people prescription so then they're going to the emergency department, running up the healthcare cost bill or I'm having to meet them on the Street in the middle of nowhere, pharmacy is not open to get them pain medications. So we can't converse this is just a detail at first would not understand, if somebody calls for pain medicines at home they've run out or is not working for them cuz right there are several different types of pain medications they have to physically come and get it because of the way it is Drugs so your point is taken, very well taken and I think with the education of our community about the opioid problem you're gonna see a market change in prescribing habits but that doesn't really talk to the essence of this bill. >> Thank you Representative [INAUDIBLE]. >> Chairman Senator is recognized. >> In reference to Representative Horn talking about the segregated prescription if one's ever suffered through a kidney stone you know sometimes you don't have time to go to get that set of prescription so that's just a phone on my part that would make a, I gave birth to twins one time [LAUGH] >> And I was very thankful for the [INAUDIBLE], that was very [INAUDIBLE] >> [LAUGH] >> Thank you representative [INAUDIBLE] for that information. And since everybody else Weighing in. I'll make a comment about that myself. I once had minor surgery, it was 20 years ago and they gave me a whole bottle full of medicine for pain and I took it home. And I think I took one and the rest of them disappeared I lost them down the commode so nobody got a hold of those but it We don't have any more comments from members. I wanna have the public make a comment and if you signed up the stake I'm gonna call your name and if you would step to the microphone and state your name, and where you work, and try and keep it to a couple of minutes. If you would but Imma try to give everyone a chance to speak and say what they wanna say so first up, Nathan Babcock [NOISE] >> Thank you Mr. Chairman Nathan Babcock, North Carolina chamber, the chamber representative of 35,000 businesses with over 1.2 million North Carolinians employed and we regularly hear from our members about the burden of rapidly increasing healthcare costs and the added cost of government imposed health insurance mandates. I think has been referenced earlier according to recent studies North Carolina has 57 coverage mandate that's the second most in the South East. Government health insurance mandates both federal and state add to the unpredictability of an already volatile and quickly growing cost of employers mandates are one of the biggest drivers In health care cost and disproportionately impact small business. With regards to this bill. HB1048 effectively eliminates an important cost containment measure for prescription drug which results in a significant cost increase to employers and to individuals. This bill makes it easier for doctors to prescribe. Describe certain opiolades which cost up to 1000% more. We understand that new drugs and treatment become available and is necessary to for discussion to take place on access and appropriate therapy . However we question mandates placed on the private sector that are not also On the state health plan. We believe that all proposedto health insurance mandate should apply to the state health plan and include a fiscal note. We, the chamber, recently connived a meeting between stakeholders
on both sides of this bill. And we didn't reach a con censors but their was an agreement that market driven and not. Legislative solutions is a better way to go especially focused on value and they are preferable to government health insurance mandates. The group pledged to work on an honest legislative solution over the next few months. We do appreciate your consideration of this important issue. Thank you. >> Thank you Mr. [UNKNOWN] Next up I have Ms. Chris Evans with Blue Cross Blue Shield. >> [SOUND] [BLANK_AUDIO] Good afternoon. My name is Chris Evans I'm here on behalf of Blue Cross. Thank you for letting me explain why Blue Cross Opposes this bill and it's on behalf of our members. House Bill 1048 as you've discussed only affects the private, fully funded markets as individual and small employer groups. Now the statehouse plan, medicaid, medicare or self funded plans or third party administrators. Well we don't believe that this mandate should be imposed on on groups that the state can regulate, we also don't believe that the general assembly should impose an expensive mandate on private citizens and small businesses that the state is not willing to pay for itself. All due respect therapy program, a step approach is required to receive coverage for certain high cost medications. This means that to receive coverage a patient may need to try First a proven cost effective medication before using a more costly treatment if needed. This bill does not impact the use of experimental drugs and this is not the same as step therapy. Rather with step therapy a team of independent physicians and pharmacists develops and approves the clinical programs and criteria for medication That are appropriate for step therapy by reviewing US student drug administration approved labeling, scientific literature and nationally recognized studies and guide lines. Blue Cross uses no more than two steps for drug subjects to our step therapy program, in fact most of our drugs on our formula only require one step. We do not Require step therapy for cancer drugs. Our system is flexible. We allow exceptions to our policies when a members medical conditions requires a certain medication, and our system is also transparent. Anyone including non members can go to our website and look up a drug whether it is subject to step therapy, the number of steps and drugs that they are The number of steps and drugs that they are asked to try first. Over 90% of our customers who are asked to use drugs subject to step therapy stay with the first drug they are asked to try. Step therapy is a tool employers and insurance companies use for high quality lower cost safer drugs for patients. These are proven methods that work, according to Recent study by the congressional budget office, in the absence of common utilization techniques like step therapy premiums for health plans would increase by 5% to 10%. Our numbers back this up. For an employer with 25 employees that's an average of approximately $7000 to $15,000 more in insurance premiums per year just for this bill. Step therapies are necessary to balance out the push for new higher priced drugs put out by pharmaceutical companies. Employers and insurance companies need a way to balance out the marketing and sales tactics used to encourage doctors to prescribe and patients to use the most expensive drugs even if they aren't more effective than cheaper drugs. Unrestricted access to drugs would mean that employees would be constantly steered to the most expensive drugs on the market with no checks and balances. It is not unreasonable to ask our members and employees to try less expensive treatments first especially treatments that work just as well as the expensive ones. Blue Cross opposes this particular bill because it has dropped it so broadly in that it completely guts our step program. It does not not just when it steps, it drives a whole in the whole program. Not only does this very impact stop therapy for patients with psoriasis and arthritis, it would impact prescriptions for hartburn, arcny, high cholesterol, asthma and other common ailments. They will impact our customers, for there is 90% of customers who participate in stuff therapy that's stick with their first drug, this in an out of pockets savings for them on a monthly basis that they would loose if this go apart, and this is not just about cost, our guidelines flash probably national protocols which recommend using time tested in proving effective drugs first, not all of our drugs are subject to sub therapy are they just on cost, some of them are just purely for safety purposes. >> Thank you Ms. Evans. We're running short on time here. Thank you for those comments. Next step Ben Coley with express scripts. >> Good afternoon my name is Ben Coley, I'm with express scripts weary, pharmacy benefit manager and a Currently we manage the prescription benefits for the state health plan. I agree with everything Ms. Evans said and just to talk a little bit about Express Scripts specifically. We have one step, we require you to take the lower cost generic.
If that does not work for you, then you can move on to the Next, higher cost drugs and we do not have order known as duration limit. We don't require you to take it for 30 days, you can take it one time and say I don't like this, this isn't working for me and you can move on to the next step. We feel that that is a reasonable step, a reasonable requirement and often we see similar to what Ms. Southern said, our success rates for that, where we We find folks staying on the first line is around 94%. So lots of really good savings. Our clients come to us and that's the health plans and that could be our large employers as we know this doesn't, they have a limited amount of dollars that they can spend on healthcare and they wanna cover as many things as they possibly can, as many illnesses and cover as many drugs. Step therapy allows you to do that. It allows you to provide good care for the most amount of drugs and also as Ms. Evans says these are all, of our step therapy rules are based on medical guidelines. We use medical journals, well researched and well Known data that we use to develop these steps, so with that I will conclude my comment. >> Thank you [INAUDIBLE]. Next up, Abby Stoddard with [INAUDIBLE]. [BLANK_AUDIO] Good afternoon Mr. Chair. Thank you to the members of the committee for your time this afternoon. My name is Abby Stoddard, I'm with Prime Therapeutics, which is the Pharmacy benefits manager for across North Carolina, but I actually want to speak to you today as a Pharmacist, my background is in retail pharmacy. I'm a licensed Pharmacist in Minnesota Minnesota, and I just wanna speak a little bit about what we see in the retail world, on the front lines of the [UNKNOWN] issue. Abuse of tran oxycodone has actually been available sine 2010. So these technologies are new but they're not that new. I was practicing at a retail pharmacy in Bemidji Minnesota which is Which is way far up North Minnesota, small town, hypoclafes/g where they think 65 degrees is sweltering. So I was practicing in the [UNKNOWN] Minnesota at an independent pharmacy, we still came out and you could tell, everybody knew right away the old pills were shaped like a football then you would be used to turn pills around. And for about a week after they came out we had patients we had never seen before come to us with prescriptions [INAUDIBLE] and said I only want you to fill this if you can get me the football pills because the football pills were the old ones that were easier to get around. This one on for maybe a week and half at most and then all of a sudden it died down Died down and we weren't sure what's going on, one of our technicians then a few days later came across the street from the gas station and said that there was a group of folks gathered at the gas station practically in celebration waving around a prescription bottle from Iverson Corner Drugs which is us of the round Oxycontin pills and And telling everybody that they had figured out that if you put it in the microwave and then you put it in the freezer and then you hit it with a hammer then you can inject it. So that 's the story from 2010 with Oxycontin I guarantee you the scenario repeats itself every time a pharma company comes out with new patent and a new way If you google how to inject Oxycontin I'm sure by the time I'm done talking you can up on the internet with ten different ways to do it. So these drugs companies like Blue Cross cover them for pain medications, they're pain medications we respect them for that, they make them available for that purpose but don't think that they prevent The member who's taking it or anybody else who might have access to their medicine cabinet from overdosing on it orally or from putting it up their nose or in their veins they simply don't do that. So with that I'll conclude thank you. >> Thank you [INAUDIBLE] Next bill by Kim Louise/g [BLANK_AUDIO] He here? He's not here? Ken Lewis going once, twice, sold any other comments from the, any member of the public wanna speak on this bill? To about a minute, if not any members have any more comments? [BLANK_AUDIO] Meeting's adjourned [BLANK_AUDIO]