WASHINGTON — University of Kentucky hospital pharmacist Jared Combs, a former prescription drug abuser, knows the signs of addiction well.
He often feels powerless while moonlighting in pharmacies in Eastern Kentucky when Medicaid patients insisting on a pain medication by brand name such as Lortab or OxyContin — a likely sign that the drug is in demand on the street and could fetch a high price — come seeking refills.
"I highly question 50 percent of the prescriptions I fill. I'm kind of conflicted about that," Combs said. "I don't know how I could ever say I know there's something fishy going on but, until someone sets the standard, this thing is going to keep getting worse."
As Congress wrangles over the cost, shape and scope of health care legislation, doctors, nurses and rural hospital administrators say the plan must include stronger safeguards against abuses of the government health program and greater insurance coverage for drug treatment and rehabilitation.
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Many doctors and hospital administrators who serve Kentucky's small towns say they eagerly await changes in health care. But they also fear that Congress might not provide the right kind of incentives to allow rural hospitals to cover their costs and recruit talented medical professionals or go far enough in eliminating Medicaid waste and fraud related to prescription drugs.
Failure to do so, they say, will make health care providers' jobs tougher.
"I have seen some addicts being prescribed these drugs and it being paid for with Medicaid over and over and over again," said Karen Engle, director of Operation UNITE, a drug enforcement and treatment program in the state's 5th Congressional District. Since 2005, the program has provided $3 million in treatment vouchers to help low-income residents receive rehabilitation.
In a region that has historically struggled to lure and keep doctors, prescription-drug abuse and Medicaid fraud are sensitive issues. Both complicate rural health care providers' efforts to offer quality care.
At Marcum and Wallace Memorial Hospital, a 25-bed facility in Irvine, people without insurance or on Medicaid who come in seeking help for prescription-drug addictions must often wait for nearly a day in the waiting room as staffers phone the area's few rehabilitation facilities and beg them to take new patients. For those without insurance, the answer is often no, said Susan Starling, the hospital's president.
"The problem with that is there's a lack of community resources for anybody for drug rehab," she said. "When we have people coming into our emergency room for overdose, there's no resources to take these patients. We try to do whatever we can to help."
According to a recent report, between 2005 and 2007 the rate of prescriptions issued for controlled substances skyrocketed in Kentucky. Some of the biggest increases were among the state's least populated counties, areas with few full-time physicians or drug rehabilitation centers.
While officials do not have exact figures on how many of the prescriptions were paid for with Medicaid, drug enforcement officers and health providers say the abuses in the state- and federally-funded program, which helps low income elderly and disabled residents, are partly to blame for the increase.
In 2007, state and local officials filed a lawsuit against the makers of OxyContin, seeking reimbursement for costs incurred in drug-abuse programs, law enforcement and prescription payments through Medicaid and the Kentucky Pharmaceutical Assistance program.
A recent Government Accountability Office report found that tens of thousands of Medicaid beneficiaries and providers are involved in "potential fraudulent purchases of controlled substances, abusive purchases of controlled substances or both" in such places as California, Illinois, New York, North Carolina and Texas.
The GAO report also found that Medicaid paid more than $2 million in controlled-substance prescriptions during fiscal years 2006 and 2007 that were written or filled by 65 medical practitioners and pharmacies barred or excluded from federal health care programs, including Medicaid, for illegally selling controlled substances and other offenses.
In Kentucky, law enforcement officials and physicians can use the state's prescription tracking system, called the Kentucky All Schedule Prescription Electronic Reporting System, to see whether patients are visiting different doctors to get multiple prescriptions for drugs.
However, only about 26 percent of Kentucky's 14,000 medical professionals licensed to prescribe controlled substances have KASPER accounts, according to the state's Office of Drug Control Policy.
In the meantime, congressional Blue Dog Democrats, many of whom represent rural communities in the South and Midwest, are pushing for "rural health equity" with higher reimbursement rates for physicians and hospitals in areas of the country that struggle to recruit and retain health care providers.
However, including that type of language in the final bill will require lots of negotiation, said Rep. Ben Chandler, a Blue Dog Democrat from Versailles.
"This is an issue that is as old as the hills," Chandler said, adding that he doesn't think the current health care proposals go far enough in addressing the needs of rural health providers dealing with prescription-drug-addicted patients.
"The lack of rural parity is a big problem, and it's crucial to whether I vote for it or not. If you could stop some of the fraud and stop the drug abuse itself you could save a lot of money in societal costs."