[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]




 
  COMBATING THE OPIOID CRISIS: IMPROVING THE ABILITY OF MEDICARE AND 
                 MEDICAID TO PROVIDE CARE FOR PATIENTS

=======================================================================

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                          APRIL 11 & 12, 2018

                               __________

                           Serial No. 115-116
                           
                           
                           

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]      

                           


      Printed for the use of the Committee on Energy and Commerce

                        energycommerce.house.gov
                        
                        
                        
                               _________ 

                     U.S. GOVERNMENT PUBLISHING OFFICE
                   
 31-268                       WASHINGTON : 2018                             
 
 
                        
                        
                        
                    COMMITTEE ON ENERGY AND COMMERCE

                          GREG WALDEN, Oregon
                                 Chairman
JOE BARTON, Texas                    FRANK PALLONE, Jr., New Jersey
  Vice Chairman                        Ranking Member
FRED UPTON, Michigan                 BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois               ANNA G. ESHOO, California
MICHAEL C. BURGESS, Texas            ELIOT L. ENGEL, New York
MARSHA BLACKBURN, Tennessee          GENE GREEN, Texas
STEVE SCALISE, Louisiana             DIANA DeGETTE, Colorado
ROBERT E. LATTA, Ohio                MICHAEL F. DOYLE, Pennsylvania
CATHY McMORRIS RODGERS, Washington   JANICE D. SCHAKOWSKY, Illinois
GREGG HARPER, Mississippi            G.K. BUTTERFIELD, North Carolina
LEONARD LANCE, New Jersey            DORIS O. MATSUI, California
BRETT GUTHRIE, Kentucky              KATHY CASTOR, Florida
PETE OLSON, Texas                    JOHN P. SARBANES, Maryland
DAVID B. McKINLEY, West Virginia     JERRY McNERNEY, California
ADAM KINZINGER, Illinois             PETER WELCH, Vermont
H. MORGAN GRIFFITH, Virginia         BEN RAY LUJAN, New Mexico
GUS M. BILIRAKIS, Florida            PAUL TONKO, New York
BILL JOHNSON, Ohio                   YVETTE D. CLARKE, New York
BILLY LONG, Missouri                 DAVID LOEBSACK, Iowa
LARRY BUCSHON, Indiana               KURT SCHRADER, Oregon
BILL FLORES, Texas                   JOSEPH P. KENNEDY, III, 
SUSAN W. BROOKS, Indiana                 Massachusetts
MARKWAYNE MULLIN, Oklahoma           TONY CARDENAS, California
RICHARD HUDSON, North Carolina       RAUL RUIZ, California
CHRIS COLLINS, New York              SCOTT H. PETERS, California
KEVIN CRAMER, North Dakota           DEBBIE DINGELL, Michigan
TIM WALBERG, Michigan
MIMI WALTERS, California
RYAN A. COSTELLO, Pennsylvania
EARL L. ``BUDDY'' CARTER, Georgia
JEFF DUNCAN, South Carolina
                         Subcommittee on Health


                       MICHAEL C. BURGESS, Texas
                                 Chairman
BRETT GUTHRIE, Kentucky              GENE GREEN, Texas
  Vice Chairman                        Ranking Member
JOE BARTON, Texas                    ELIOT L. ENGEL, New York
FRED UPTON, Michigan                 JANICE D. SCHAKOWSKY, Illinois
JOHN SHIMKUS, Illinois               G.K. BUTTERFIELD, North Carolina
MARSHA BLACKBURN, Tennessee          DORIS O. MATSUI, California
ROBERT E. LATTA, Ohio                KATHY CASTOR, Florida
CATHY McMORRIS RODGERS, Washington   JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey            BEN RAY LUJAN, New Mexico
H. MORGAN GRIFFITH, Virginia         KURT SCHRADER, Oregon
GUS M. BILIRAKIS, Florida            JOSEPH P. KENNEDY, III, 
BILLY LONG, Missouri                     Massachusetts
LARRY BUCSHON, Indiana               TONY CARDENAS, California
SUSAN W. BROOKS, Indiana             ANNA G. ESHOO, California
MARKWAYNE MULLIN, Oklahoma           DIANA DeGETTE, Colorado
RICHARD HUDSON, North Carolina       FRANK PALLONE, Jr., New Jersey (ex 
CHRIS COLLINS, New York                  officio)
EARL L. ``BUDDY'' CARTER, Georgia
GREG WALDEN, Oregon (ex officio)
  
                             C O N T E N T S

                              ----------                              

                             April 11, 2018

                                                                   Page
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, opening statement..............................     1
    Prepared statement...........................................     3
Hon. Gene Green, a Representative in Congress from the State of 
  Texas, opening statement.......................................     4
Hon. Greg Walden, a Representative in Congress from the State of 
  Oregon, opening statement......................................     6
    Prepared statement...........................................     8
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     9

                               Witnesses

Kimberly Brandt, Principal Deputy Administrator for Operations, 
  U.S. Centers for Medicare and Medicaid Services................    11
    Prepared statement...........................................    13
    Answers to submitted questions...............................   419

                             April 12, 2018
                               Witnesses

Michael Botticelli, Executive Director, Grayken Center for 
  Addiction, Boston Medical Center...............................    60
    Prepared statement...........................................    63
    Answers to submitted questions...............................   432
Toby Douglas, Senior Vice President for Medicaid Solutions, 
  Centene Corporation............................................    68
    Prepared statement...........................................    70
    Answers to submitted questions...............................   437
David C. Guth, Jr., Chief Executive Officer, Centerstone.........    81
    Prepared statement...........................................    83
    Answers to submitted questions...............................   443
John M. Kravitz, Chief Information Officer, Geisinger Health 
  System.........................................................    95
    Prepared statement...........................................    97
    Answers to submitted questions...............................   454
Sam K. Srivastava, Chief Executive Officer, Magellan Healthcare..   103
    Prepared statement...........................................   105
    Answers to submitted questions...............................   458

                           Submitted Material

Article entitled, ``Medicare is cracking down on opioids. Doctors 
  fear pain patients will suffer,'' New York Times, April 6, 2018   174
Statements of various pharmacy associations......................   177
Statement of the Washington State Pharmacy Association...........   198
CMCS Informational Bulletin......................................   200
Statement of the National Association of Counties................   215
Statement of the American Medical Association....................   217
Statement of the American Society of Addiction Medicine..........   218
Statement of the American Psychiatric Association................   220
Statement of the Community Resources for Justice.................   222
Statement of the International Community Corrections Association.   223
Statement of the National Commission on Correctional Healthcare..   225
Statement of the American College of Obstetricians and 
  Gynecologists..................................................   226
Statement of telehealth and technology stakeholders..............   234
Statement of treatment providers in support of the access to 
  telehealth services for their opioid and use disorders.........   236
Statement of Members of Congress supporting the Pharmacy and 
  Medically Underserved Areas Enhancement Act....................   238
Statement of Walgreens supporting the Pharmacy and Medically 
  Underserved Areas Enhancement Act..............................   241
Statement of the American Association of Oral and Maxillofacial 
  Surgeons.......................................................   243
the Association for Behavioral Health and Wellness...............   246
Statement of AdvaMed.............................................   248
Statement of the American Hospital Association...................   251
Statement of the American Psychological Association..............   253
Statement of the American Society of Health-System Pharmacists...   257
Statement of the Association for Community Affiliated Plans......   259
Statement of the College of Healthcare Information Management 
  Executives.....................................................   264
Statement of the ePrescribing Coalition..........................   268
Statement of the National Association for Behavioral Healthcare..   270
Statement of the National Association of Chain Drug Stores.......   274
Statement of the National Association of Medicaid Directors......   287
Statement of the National Indian Health Board....................   290
Statement of the Oregon Community Health Information Network.....   297
Statement of the Partnership to Amend 42 CFR Part 2..............   298
Statement of the Pharmaceutical Care Management Association......   301
Statement of the Property Casualty Insurers Association of 
  America........................................................   309
Statement of Shatterproof........................................   311
Statement of Imprivata...........................................   315
Statement of the Pharmacy Coalition..............................   317
Statement of the National Association of Counties................   319
Statement of Trinity Health......................................   321
Statement of the Infectious Disease Society of America, the HIV 
  Medicine Association, and the Pediatric Infectious Disease 
  Society........................................................   328
Study entitled, ``States With Prescription Drug Monitoring 
  Mandates Saw a Reduction in Opioids Prescribed to Medicaid 
  Enrollees,'' Health Affairs, April 1, 2017.....................   332
Study entitled, ``Medicaid Drug Utilization Review State 
  Comparison/Summary Report FFY 2016 Annual Report,'' Centers for 
  Medicare & Medicaid Services, October 2017.....................   348


  COMBATING THE OPIOID CRISIS: IMPROVING THE ABILITY OF MEDICARE AND 
              MEDICAID TO PROVIDE CARE FOR PATIENTS, DAY 1

                              ----------                              


                       WEDNESDAY, APRIL 11, 2018

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 3:25 p.m., in 
room 2322, Rayburn House Office Building, Hon. Michael Burgess, 
M.D. (chairman of the subcommittee) presiding.
    Present: Representatives Burgess, Guthrie, Upton, Shimkus, 
Blackburn, Latta, McMorris Rodgers, Lance, Griffith, Bilirakis, 
Long, Bucshon, Brooks, Mullin, Hudson, Carter, Walden (ex 
officio), Green, Schrader, Kennedy, Cardenas, Eshoo, Pallone 
(ex officio).
    Also Present: Representatives Tonko and Peters.
    Staff Present: Adam Buckalew, Professional Staff Member, 
Health; Karen Christian, General Counsel; Paul Edattel, Chief 
Counsel, Health; Caleb Graff, Professional Staff Member, 
Health; Jay Gulshen, Legislative Associate, Health; Ed Kim, 
Policy Coordinator, Health; Drew McDowell, Executive Assistant; 
James Paluskiewicz, Professional Staff, Health; Mark Ratner, 
Policy Coordinator; Jennifer Sherman, Press Secretary; Austin 
Stonebraker, Press Assistant; Josh Trent, Deputy Chief Health 
Counsel, Health; Everett Winnick, Director of Information 
Technology; Jacquelyn Bolen, Minority Professional Staff; 
Tiffany Guarascio, Minority Deputy Staff Director and Chief 
Health Advisor; Una Lee, Minority Senior Health Counsel; Rachel 
Pryor, Minority Senior Health Policy Advisor; Samantha 
Satchell, Minority Senior Policy Analyst; Theresa Tassey, 
Minority Health Fellow.

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE 
              IN CONGRESS FROM THE STATE OF TEXAS

    Mr. Burgess. The Subcommittee on Health will now come to 
order. The chair will recognize himself 5 minutes for the 
purposes of an opening statement.
    This afternoon the Health Subcommittee marks its third in a 
series of hearings this spring on legislation addressing the 
opioid epidemic. By the end of this week's hearing we will have 
considered a total of 67 opiate-related bills. In our last 
hearing we discussed 25 public health and prevention-focused 
bills over the course of 2 days. Today the subcommittee will be 
breaking a record by examining 34 bills centered around 
improving Medicaid and Medicare programs at the Center for 
Medicare and Medicaid Services.
    While committee members on both sides of this dais have put 
in a lot of time and thought in developing these bills, a 
majority are still in discussion draft form. And this is a 
feature not a bug. It is intentional. We seek to explore 
promising ideas while collecting important feedback from 
Members, providers, plans, patients, and other stakeholders. 
Some of these bills challenge the status quo for some practices 
within Medicaid and Medicare. But with more than 110 Americans 
dying daily from an opiate overdose, we must be willing to ask 
hard questions and seek solutions.
    With the crisis devastating our country and eroding our 
economic productivity, all of us must be willing to take a 
fresh and fair look at each of the policies presented today. We 
should think creatively about how to help strengthen Medicaid 
and Medicare's ability to combat this scourge of opiate abuse 
because without adequate tools and accountability our largest 
public players will be unable to handle the challenge that is 
before them.
    So today we are joined by Kimberly Brandt, who has been 
charged to lead the efforts addressing the opiate crisis at the 
Center for Medicaid and Medicare Services. Ms. Brandt, thank 
you for being here testifying before us and providing your 
insights on ways that we can partner together to turn the tide 
in this fight.
    Tomorrow we will hear from individuals representing 
healthcare providers, health plans, behavioral health 
specialists who provide the critical treatment to Americans 
with opiate addiction and substance use disorder. It is my 
expectation that our conversations will help us adopt effective 
policies that have a meaningful impact.
    One issue that has repeatedly come up is our physician 
workforce. Congress can pass bills to increase access to 
evidence-based treatment, but if we do not have enough 
physicians equipped with proper tools and training we will not 
have the sufficient capacity to provide treatments for 
individuals suffering from this disorder.
    To this end, I have worked on draft legislation that will 
provide Congress with more robust transparency about how 
graduate medical education dollars under current law are 
helping equip the next generation of doctors to better identify 
and treat patients with substance use disorder.
    Prescription drug monitoring programs are important 
informational tools that help track prescriptions and identify 
patients at risk of overdosing on opiates. The Medicaid 
Partnership Act would require State Medicaid programs to 
integrate these monitoring programs into Medicaid providers' 
and pharmacists' clinical workflows while establishing basic 
criteria for qualified prescription drug monitoring programs. I 
think it is common sense to ask one of our largest payers to 
access one of our most powerful data tools to care for some of 
our most at-risk patients.
    Another useful tool already in place in many State Medicaid 
programs are pharmaceutical homes. The Medicaid Pharmacy Home 
Act would codify the commonsense idea of requiring States to 
have provider and pharmacy assignment programs that identify 
at-risk Medicaid beneficiaries and set reasonable limits on the 
number of prescribers and dispensers that they can utilize. 
Given what we know, it is good medicine for all of us to ensure 
that States are using this effective approach to identify at-
risk beneficiaries.
    We certainly have much to consider, but we are building on 
years of previous bipartisan efforts, and we know our work is 
important to our families and our communities and our 
constituents affected by this epidemic.
    Before I close, I want to touch on the growing fear that I 
am hearing from many patients suffering from a chronic pain 
condition who have actually been successfully managed by long-
term opiate administration, especially when these drugs are 
drugs of last resort. I anticipate some discussion on the 
recent CMS rule to limit the amount and length of opiate 
prescriptions. Our effort to overcome this crisis is vital, but 
I want us to keep these patients in mind and not, as we say 
down south, overtorque the bolt. I have a submission from The 
New York Times that I would like to add to the record for this.
    [The information appears at the conclusion of the hearing.]
    Mr. Burgess. Again, I want to thank our witness for 
testifying today and our witnesses tomorrow. I look forward to 
learning from your insights.
    And I want to yield time to the vice chairman of the Health 
Subcommittee, Mr. Guthrie of Kentucky, for his statement.
    [The prepared statement of Mr. Burgess follows:]

                Prepared statement of Michael C. Burgess

    This afternoon, the Health Subcommittee marks its third in 
a series of hearings this spring on legislation addressing the 
opioid epidemic. By the end of this week's hearing, we will 
have considered a total of 67 opioid-related bills. In our last 
hearing, we discussed 25 public health and prevention-focused 
bills over the course of two days. And today the subcommittee 
will be breaking a record by examining 34 bills, centered 
around improving Medicaid and Medicare programs at the Center 
for Medicare and Medicaid Services (CMS).
    While committee members on both sides of the aisle have put 
a lot of time and thought into developing these bills, a 
majority are still in discussion draft form. This is 
intentional, as we seek to explore promising ideas, while 
collecting important feedback from members, providers, plans, 
and other key stakeholders. Some of these bills challenge the 
status quo for some practices within Medicaid and Medicare, but 
with more than 110 Americans dying daily from opioid overdoses, 
we must be willing to ask hard questions and find solutions.
    With the opioid crisis devastating our country and eroding 
our economic productivity, all of us must be willing to take a 
fresh and fair look at each of the policies presented today. We 
should think creatively about how to help strengthen Medicaid 
and Medicare's ability to combat the scourge of opioid abuse--
because without adequate tools and accountability, our largest 
public payers will be unable to handle the challenge before 
them.
    Today, we are joined by Kimberly Brandt, who has been 
charged to lead the efforts addressing the opioid crisis at 
CMS. Ms. Brandt, thank you being testifying before us and 
providing your insights on ways we can partner together and 
turn the tide in our fight.
    Tomorrow, we will hear from individuals representing health 
care providers, health plans, and behavioral health specialists 
who provide critical treatment to Americans with opioid 
addiction and substance use disorder. It is my expectation our 
conversations will help us adopt effective policies that have 
meaningful impact.
    One issue area that repeatedly comes up is our physician 
workforce. Congress can pass bills that increase access to 
evidence-based treatment, but if we do not have enough 
physicians equipped with proper tools and training, we will not 
have sufficient capacity to provide effective treatments for 
individuals suffering from substance use disorder.
    To this end, I have authored draft legislation that will 
provide Congress with more robust transparency about how 
graduate medical education dollars under current law are 
helping equip the next generation of doctors to better identify 
and treat patients with substance use disorder.
    Prescription Drug Monitoring Programs (PDMPs) are important 
informational tools that help track prescriptions and identify 
patients at risk of abusing or overdosing on opioids. The 
Medicaid PARTNERSHIP Act would require the state Medicaid 
programs to integrate PDMP usage into Medicaid providers' and 
pharmacists' clinical workflow while establishing basic 
criteria for qualified PDMPs. As a physician, I think it's 
common sense to ask one of our largest payers to access one of 
our most powerful data tools to care for some of our most at-
risk patients.
    Another useful tool already in place in many state Medicaid 
programs are pharmaceutical homes. The Medicaid Pharmacy Home 
Act would codify the common-sense idea of requiring states to 
have a provider and pharmacy assignment program that identifies 
at-risk Medicaid beneficiaries and sets reasonable limits on 
the number of prescribers and dispensers they can utilize. 
Given what we know, it's good medicine for us to ensure all 
states are using this effective approach to identify at-risk 
beneficiaries and improve care.
    We certainly have much to consider. But, we are building on 
years of previous bipartisan efforts, and we all know our work 
is important to the families and communities--our 
constituents--affected by the opioid epidemic.
    Before I close, I would like to touch upon the growing fear 
of many patients suffering from chronic pain who have been 
successfully managed by opioids, especially when these drugs 
are the last resort. I anticipate some discussions on the 
recent CMS rule to limit the amount and length of opioid 
prescriptions. Our effort to overcome this crisis is vital, but 
I want us to keep these patients in mind and not ``over-torque 
the bolt.''
    I again thank our witnesses for testifying today and 
tomorrow, and I look forward to learning your insights on 
making improvements in the Medicare and Medicaid system.
    I would like to yield the balance of my time to the Vice 
Chairman of the Health Subcommittee, Mr. Guthrie of Kentucky, 
for a statement.

    Mr. Guthrie. Thank you, Mr. Chairman.
    I appreciate the chairman's diligent efforts to ensure our 
committee responds quickly and meaningfully to our Nation's 
opioid crisis. Just last week I heard another awful story about 
how the destructive path of the opioid crisis harmed a family 
in Cecilia, Kentucky, all caused because of a motorcycle 
accident that led to back surgery that led to addiction.
    I would like to ask unanimous consent to submit a number of 
letters in the record on how pharmacists and the Pharmacy and 
Medically Underserved Areas Enhancement Act can help address 
these in the opioid epidemic.
    Mr. Burgess. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Guthrie. Thank you, Mr. Chairman. I yield back.
    Mr. Burgess. The gentleman yields back. The chair thanks 
the gentleman.
    The chair recognizes the gentleman from Texas, Mr. Green, 
the ranking member of the subcommittee, 5 minutes for an 
opening statement, please.

   OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF TEXAS

    Mr. Green. Thank you, Mr. Chairman.
    This is the third in a series of hearings on the opioid 
epidemic and its impact on individuals, families, and 
communities in our nation. Our committee has heard from Federal 
agencies and stakeholders on the terrible cost of opioid abuse, 
which takes the lives of 115 Americans each day and is 
estimated to cost our national economy over $78 billion 
annually.
    Today's hearing will focus on the role that Medicaid and 
Medicare play in providing health coverage for Americans in 
need of comprehensive treatment and recovery services. Medicaid 
is the largest payer for behavioral health services, mental 
health, and substance use disorder, or SUD, in the United 
States. Medicaid delivers care to 4 of 10 nonelderly adults 
with opioid use disorder.
    Nearly 12 percent of adults enrolled in Medicaid have SUD. 
Adults on Medicaid are more likely than other adults to receive 
substance use disorder treatment.
    Medicaid plays a critical role for children either 
suffering from substance use disorder or born with neonatal 
abstinence syndrome, NAS. Medicaid covers more than 80 percent 
of the NAS babies nationwide.
    Medicaid expansion provided under the Affordable Care Act 
has played a critical role in providing comprehensive coverage 
for Americans suffering from substance abuse disorder who live 
in 31 States that have expanded.
    Data recently published by the Center for Budget and Policy 
Priorities found that under Medicaid expansion the uninsured 
rate among people with opioid-related hospitalizations fell 
dramatically in States that expanded, from 13.4 percent in 
2013, the year before the expansion took effect, to just 2.9 
percent 2 years later.
    For example, after Kentucky expanded Medicaid in 2014, 
Medicaid beneficiaries' use of substance use treatment services 
in the State rose by 700 percent. My home State of Texas and 18 
other States continue to refuse to expand Medicaid, denying 
millions of Americans the comprehensive services and continuum 
of care necessary to treat and recover from opioid addiction 
and other substance use disorders. Medicaid expansion includes 
substance use services as mandatory benefit.
    The reality is that if folks want to save lives of these 
individuals, we have got to focus first on getting those people 
health insurance so they can access treatment. Continuity of 
comprehensive health insurance makes the difference between 
life and death.
    Two weeks ago the Texas Department of State Health Services 
released a report that found opioid overdoses as the leading 
cause of death for new mothers in our State, with the most 
occurring after a pregnant woman's Medicaid benefits end 60 
days after delivery.
    Last year, I introduced the Incentivizing Medicaid 
Expansion Act, H.R. 2688, in order to incentivize States to 
provide critical Medicaid coverage for Americans in need and to 
avoid the kinds of tragedies that have led to the rising rate 
of maternal mortality in our home State. My legislation would 
guarantee that the Federal Government covers 100 percent of 
expansion costs for the first 3 years for States that have not 
yet expanded and no less than 90 percent afterwards.
    Medicare also plays an important role in the opioid crisis. 
According to SAMHSA, more than one million seniors suffered 
from substance use disorders in 2014. While Medicare part B and 
part D provide SUD treatment services, there are significant 
gaps in Medicare's benefits, including no coverage for 
substance abuse treatment at opioid treatment programs or 
methadone clinics.
    We also need to ensure that Americans on Medicaid or 
Medicare are not overprescribed opioids. HHS' Office of 
Inspector General found that more than 500,000 part D 
beneficiaries received high amounts of opioids in 2016, with 
the average dose far exceeding the manufacturers' recommended 
amount. Additionally, nearly one-third of the beneficiaries in 
Medicare part D or C had an opioid prescription in 2016.
    Before closing, I would like to voice my concern over the 
number of bills and discussions drafts being considered at the 
hearing, 34 in total. Never in my time on Energy and Commerce 
have we had legislative hearings on so many bills and drafts. 
Combined with the bills and discussion drafts from the two 
previous opioid hearings, we are looking at over 70 pieces of 
legislation. I am concerned that the majority is planning to 
mark up legislation later this month, and that has not been 
fully vetted by our staffs, stakeholders, and the appropriate 
Federal agencies.
    The opioid crisis is hitting communities throughout America 
regardless of location or political affiliation. We can and 
must advance opioid legislation in a bipartisan manner that the 
American people deserve. I ask for the majority to work with us 
and provide the necessary time to vet legislation being 
considered and ensure the anticipated markup will not become a 
partisan exercise.
    Thank you, and I yield the balance of my time.
    Mr. Burgess. The chair thanks the gentleman.
    The chair would just observe that the gentleman has never 
served with the current chairman before. And you may have 
recognized by now you do have a very active and an activist 
chairman and that will continue for the balance of the year.
    Mr. Green. Well, I like activism, Mr. Chairman, but I also 
like substance.
    Mr. Burgess. There is substance, I guarantee you, with 
these 34 bills.
    The chair recognizes the chairman of the full committee, 
Mr. Walden, for 5 minutes for an opening statement.

  OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF OREGON

    Mr. Walden. With these 34 on top of the other 24 on top of 
the other 6 or 7, we are going to have our hands full of good 
legislation, because today marks our third and final 
legislative hearing this spring aimed at advancing targeted, 
timely, and bipartisan legislative solutions to help combat the 
opioid crisis.
    This committee has already been instrumental in working in 
a bipartisan manner to devote a record--let me underscore 
record--amount of Federal resources toward the opioid epidemic, 
namely through passage of the CARA and 21st Century Cures Act 
last Congress. My colleague here, Fred Upton, led the effort 
with Diana DeGette to get that done. This hearing continues the 
work to address the crisis that has impacted virtually every 
neighborhood, every community, and so many families across our 
country.
    At roundtables I have done in my district, across Oregon, 
most recently in Pendleton and Madras, I have met with people 
on the front lines of this fight and with those who have lost a 
friend, lost a child, lost a sister, lost a loved one, lost a 
neighbor. These meetings have been crucial to my efforts to put 
forth concrete solutions to stem the tide and save lives, and I 
am not alone doing these roundtables around the country.
    With more than 100 Americans estimated to die every day 
from opioid overdoses, we simply have to do everything within 
our power. We must continue to push forward. And I would 
respectfully ask everyone involved, stakeholders and Members of 
Congress alike, to push beyond our comfort zones and think 
creatively and boldly about how we can help, because the status 
quo is simply not acceptable. The unprecedented scope of this 
crisis requires an unprecedented response, and that is what we 
are able to provide at the Energy and Commerce Committee.
    To that end, over the span of 2 days, we will consider 34 
bills from Members on both sides of the aisle. These bills have 
a common theme: They seek to improve the roles Medicaid and 
Medicare can play in helping combat this crisis. This marks the 
largest numbers of bills noticed in a legislative hearing 
before this committee. But the number and scope of the bills 
helps underscore how important this topic is to all of us and 
how many good ideas there are to help patients. While 
considering this many bills does require some extra work on 
behalf of the staff and our members, I think we should see this 
as not an inconvenience, but rather as an opportunity.
    Just look at how many promising ideas there are to help 
patients who are served by these two programs who represent 
roughly one in three Americans. Certainly both programs play 
key roles in identifying at-risk beneficiaries, providing 
treatment, and decreasing overdose deaths.
    The bills we will consider today cover a range of important 
issues, including provisions to remove barriers to treatment, 
improve data to identify and help at-risk patients, provide 
incentives for greater care coordination and enhanced care. 
Many of the bills before us build on efforts in Medicaid and 
Medicare that are already yielding positive benefits for 
patients and reducing dependency or misuse of opioids.
    As we move forward, we look forward to stakeholders and 
others providing feedback on these proposals. The input of the 
Congressional Budget Office will also help shape our 
decisionmaking on several pieces of legislation before us 
today. But our aim remains the same: moving through committee 
in regular order to advance legislation to the House floor 
before the Memorial Day recess. That is our goal.
    We have seen announcements in sister committees recently as 
they are also developing and advancing legislation, and we look 
forward to continuing our work with them to get a robust 
bipartisan package of proposals to the White House for 
signature of the President in the coming months.
    The urgency of the crisis demands an urgent response, and 
the challenges facing our communities demand action now.
    So I would like to thank our witnesses for taking time to 
share their expertise with us today and tomorrow and for 
Members on both sides of the aisle for making this fight a top 
priority.
    With that, I would yield the balance of my time to my 
friend and colleague from Tennessee, Mrs. Blackburn.
    [The prepared statement of Mr. Walden follows:]

                 Prepared statement of Hon. Greg Walden

    Today marks our third and final legislative hearing this 
spring aimed at advancing targeted, timely, and bipartisan 
legislative solutions to help combat the opioid crisis.
    This committee has already been instrumental in working in 
a bipartisan manner to devote a record amount of Federal 
resources towards the opioid epidemic, namely through the 
passage of CARA and 21st Century Cures last Congress. This 
hearing continues our work to address a crisis that has 
impacted virtually every neighborhood across our country.
    At roundtables throughout Oregon, most recently in 
Pendleton and Madras, I've met with the people on the 
frontlines of this fight and with those who have lost a friend 
or loved one to this epidemic. These meetings are crucial to 
our efforts to put forth concrete solutions to stem the tide 
and save lives. With more than 100 Americans estimated to die 
each day from opioid overdoses, we simply must do more.
    We must continue to push forward, and I would respectfully 
ask everyone involved--stakeholders and members alike--to push 
beyond their comfort zones and think creatively and boldly 
about how we can help. The status quo is not acceptable. The 
unprecedented scope of the opioid crisis requires an 
unprecedented response.
    To that end, over the span of 2 days, we will consider 34 
bills from members on both sides of the aisle. These bills have 
a common theme--they seek improve the roles Medicaid and 
Medicare can play in helping combat the crisis.
    This marks the largest number of bills noticed in a 
legislative hearing before this committee. But the number and 
scope of bills helps underscore how important this topic is to 
all of us and how many good ideas there are to help patients. 
While considering this many bills requires some extra work from 
members and staff, I think we should see this not as an 
inconvenience, but as an opportunity.
    Just look at how many promising ideas there are to help 
patients who are served by these two programs-who represent 
roughly one in three Americans. Certainly, both programs play 
key roles in identifying at-risk beneficiaries, providing 
treatment, and decreasing overdose deaths. The bills we will 
consider today cover a range of important issues--including 
provisions to: remove barriers to treatment, improve data to 
identify and help at-risk patients, provide incentives for 
greater care coordination and enhanced care.
    Many of the bills before us build on efforts in Medicaid 
and Medicare that are already yielding positive benefits for 
patients and reducing dependency or misuse of opioids.
    As we move forward, we look forward to stakeholders and 
others providing feedback on the proposals before us. The input 
of the Congressional Budget Office will also help shape our 
decision-making on several pieces of legislation before us 
today.
    But our aim remains the same--moving through committee in 
regular order to advance legislation on the House Floor before 
the Memorial Day recess. We have seen announcements in sister 
committees recently as they are also developing and advancing 
legislation, and we look forward to continuing our work with 
them to get a robust, bipartisan package of proposals to the 
White House for signature in the coming months. The urgency of 
the crisis demands our response, and the challenges facing our 
communities demands action.
    I'd like to thank our witnesses for taking the time to 
share their expertise with us today and tomorrow, and for our 
members--on both sides of the aisle--for making this fight a 
top priority.

    Mrs. Blackburn. Thank you, Mr. Chairman, and thank you, Dr. 
Burgess, for the hearing on these issues.
    There are two components that I am looking forward to. And 
I will tell you, Ms. Brandt, I appreciate the work of the 
administration to support the State Medicaid programs in their 
efforts to examine combat these programs.
    Tennessee's TennCare program recently implemented some new 
policies, and I had some good discussion this past weekend with 
some of our State legislators and some physicians who are hard 
at work on that with a 5-day limit on the prescriptions, prior 
authorization for any refills, a robust buyback program.
    And I am looking forward also to discussing with you the 
IMD exclusion. Some of those that treat substance abuse have 
talked about this as a barrier to getting individuals into 
beds, into the treatment that they need.
    So we really appreciate the work that you all are doing and 
look forward to getting the legislation across the finish line.
    I yield back.
    Mr. Burgess. The gentlelady yields back. The chair thanks 
the gentlelady.
    The chair yields to the gentleman from, New Jersey, Mr. 
Pallone, ranking member of the full committee, 5 minutes for an 
opening statement, please.

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Mr. Chairman.
    Today's hearing is the third in a series to address the 
opioid and substance abuse crisis that is ravaging communities 
across the country, and our focus today is on the role of the 
two largest public health insurance programs, Medicaid and 
Medicare.
    A lot needs to be done to address this epidemic, but we 
should focus our time on what is most meaningful and impactful. 
While I support addressing this crisis through a bipartisan 
process, I am concerned that the sheer quantity of bills before 
the committee today and the chairman's extremely ambitious 
timeframe will not leave us much time to get these policies 
right.
    Today we will discuss 34 bills in one 2-day hearing, the 
vast majority of which the members of the committee have seen 
for less than a week. So I am concerned that many of the 
proposals have not been introduced. Most have not had the 
benefit of technical assistance or a CBO score. In fact, CMS' 
own testimony today I don't believe discusses any of the bills 
under consideration.
    So at times to me this process feels more like an opioids 
media blitz than a thoughtful discussion about our national 
public health crisis, and this is not the deliberative process 
that the members of this committee and the American people 
deserve.
    But with that important caveat aside, I will say that many 
of the proposals we are examining today have merit and strive 
to address a number of policy problems that Medicaid and 
Medicare face in combating the opioids epidemic. In Medicaid, 
we are considering legislation that would strengthen the 
continuity of coverage that people receive, particularly 
vulnerable populations, like adults and children leaving the 
justice system and former foster youth. And I know that the 
best way to combat the opioids crisis is for people to have 
access to strong and consistent health coverage that provides 
the treatment they need.
    You also will hear about policies that invest in our 
providers on the ground, and our State Medicaid infrastructure 
helps States to build on what works, like Medicaid health 
homes, and promote new models of care to expand treatment 
capacity of providers.
    We are also looking at complex issues related to how our 
Medicaid programs track and dispense prescribing of opioids and 
relieving barriers to lifesaving treatment, like naloxone and 
MAT. And I think we could do even more in this area. There are 
bills to improve quality and data on how this crisis impacts 
Medicaid that will also be important to know in the coming 
years.
    In addition, Mr. Chairman, there is legislation related to 
repealing the so-called IMD exclusion for a 5-year period. 
Medicaid IMDs are one very important piece of the treatment 
puzzle that States are incorporating into their delivery 
systems already through Medicaid's special Substance Use 
waivers. This is an example of a bill that needs a very 
thoughtful approach so we do not hurt the efforts that are 
already occurring in States today.
    And we are also considering legislation regarding the role 
of Medicare parts B and D to address the rising epidemic of 
opioid overprescription and misuse among seniors. For example, 
we will discuss legislation under Medicare part B to expand 
opioid disorder treatment options through telehealth and also 
legislation under part D to ensure e-prescribing is utilized 
when prescribing controlled substances. And we will also 
discuss legislation to create an alternative payment model to 
incentivize the delivery of high-quality, evidence-based opioid 
treatment service for Medicare beneficiaries.
    These bills are important because evidence suggests that 
opioid use among older adults is a significant and growing 
problem. According to the OIG, more than 500,000 part D 
beneficiaries received high amounts of opioids in 2016, with 
the average dose far exceeding the manufacturers' recommended 
amount.
    So I want to be clear, this committee must focus on 
meaningful proposals that will address the opioid crisis. I 
intend to oppose any bill that has nothing to do with opioids, 
that makes the problem worse, or that is simply not ready and 
vetted in the time that we have allotted. Our policy goal 
should always be to first do no harm, and without the proper 
time to vet the legislation before us I can't be sure that we 
are meeting that goal.
    For instance, I have significant concerns regarding one of 
the discussion drafts to add a pain assessment to the Welcome 
to Medicare physical. While well intentioned, I am concerned 
that this bill could actually exacerbate our opioid crisis.
    I have heard from numerous stakeholders in the medical 
community that a similar approach adopted by the Joint 
Commission in 2001 to treat pain as a fifth vital sign actually 
contributed to the opioid epidemic, because by requiring 
healthcare providers to ask every patient about their pain and 
incentivizing aggressive management of pain these measures may 
have resulted in the overprescribing of opioids.
    So finally, Mr. Chairman, I hope to work with my colleagues 
to address these concerns so that we can all support concrete 
and thoughtful legislation that will actually help address the 
crisis. And thank you again. I yield back.
    Mr. Burgess. The gentleman yields back. The chair thanks 
the gentleman.
    That concludes member opening statements. The chair reminds 
members that, pursuant to committee rules, all members' opening 
statements will be made part of the record.
    And we do want to thank our witness for being here this 
afternoon, staying with us through the previous full committee 
hearing, taking the time to testify before the subcommittee.
    Today our witness will have the opportunity to give an 
opening statement, followed then by questions from members. The 
panel today, of course, will be Dr. Kimberly Brandt, the 
Principal Deputy Administrator for Operations for the United 
States Centers for Medicare and Medicaid Services.
    We appreciate you being here today, Dr. Brandt, and you are 
recognized for 5 minutes to summarize your opening statement, 
please.

 STATEMENT OF KIMBERLY BRANDT, PRINCIPAL DEPUTY ADMINISTRATOR 
FOR OPERATIONS, U.S. CENTERS FOR MEDICARE AND MEDICAID SERVICES

    Ms. Brandt. Chairman Burgess, Ranking Member Green, and 
members of the subcommittee, thank you for inviting me to 
discuss CMS' work to address the opioid epidemic.
    CMS understands the magnitude and impact the opioid 
epidemic has had on our communities and is committed to a 
comprehensive and multipronged strategy to combat this public 
health emergency.
    As the principal deputy administrator for operations at 
CMS, I am charged with addressing cross-cutting issues that 
affect our programs, with the efforts to fight the opioid 
epidemic being one of our agency's and the administration's top 
priorities.
    Over 130 million people receive health coverage through CMS 
programs, and the opioid epidemic affects every single one of 
them, as a patient, family member, caregiver, or community 
member. This theme has been repeated throughout multiple 
stakeholder listening sessions that CMS has facilitated to 
discuss best practices and brainstorming solutions.
    As a payer, CMS plays an important role by incentivizing 
providers to provide the right services to the right patients 
at the right time. Our work at CMS is focused mainly on three 
areas: prevention, treatment, and data. Due to the structure of 
our programs, Medicare part D plan sponsors in State Medicaid 
programs are well positioned to prevent improper opioid 
utilization by working with prescribing physicians. Our job at 
CMS is to oversee these efforts and to make sure that plan 
sponsors in States have the tools they need to be effective.
    Beginning in 2019, CMS expects all part D sponsors to limit 
initial opioid prescription fills for acute pain to no more 
than 7 days' supply, which is consistent with the guidelines 
set by the Centers for Disease Control and Prevention. 
Additionally, we expect all sponsors to implement a new care 
coordination safety edit that would create an alert for 
pharmacists when a beneficiary's daily opioid usage reaches 
high levels. Pharmacists would then consult with the prescriber 
to confirm intent.
    Thanks to recent action taken by Congress, CMS now has the 
authority to allow part D plan sponsors to implement lock-in 
policies that limit certain beneficiaries to specific 
pharmacies and prescribers. We recently finalized a proposal to 
integrate lock-in with our Overutilization Monitoring System, 
or OMS, to improve coordination of care. The administration 
also has put forth legislation to require plan sponsors to 
implement lock-in policies.
    These new tools will add on to existing innovative 
approaches in part D to track high-risk beneficiaries through 
OMS and to work with plan sponsors to address outlier 
prescribers and pharmacies. We have seen a 76 percent decline 
in the number of beneficiaries meeting the OMS high-risk 
criteria from when we started this in 2011 through 2017, even 
at the same time that part D enrollment was increasing.
    We also support State efforts to reduce opioid misuse. 
Medicaid programs can utilize medical management techniques 
such as step therapy, prior authorization, and quantity limits 
for opioids. In this year's President's budget, CMS proposed 
establishing minimum standards for the Medicaid Drug 
Utilization Review program, a tool that we use to oversee State 
activities in this area.
    In addition to our prevention measures, ensuring that 
Medicaid and Medicare beneficiaries with substance use disorder 
have access to treatment is also a critical component to 
addressing the epidemic. Our aim is to ensure the right 
treatment for the right beneficiary in the right setting, and 
we are working to increase access to medication assisted 
treatment, or MAT, as well as naloxone.
    The President's budget also includes a proposal to conduct 
a demonstration to cover comprehensive substance abuse 
treatment in Medicare through a bundled payment for methadone 
treatment or similar MAT. Because current statute limits CMS' 
ability to pay for methadone, we are focused on ensuring access 
to other evidence-based MAT.
    The administration is also committed to increasing 
treatment access for Medicaid beneficiaries as well through our 
1115 waiver authority. CMS recently announced a streamlined 
process last November providing more flexibility for States 
seeking to expand access to treatment. Already we have approved 
five State demonstrations, which include services provided to 
Medicaid enrollees in residential treatment facilities.
    As this committee knows, ordinarily residential treatment 
services are not eligible for Federal Medicaid reimbursement 
due to the statutory exclusion related to institutions for 
mental disease or IMDs. Combined with the full spectrum of 
treatment services, we believe the new residential treatment 
flexibility is a powerful tool for States, and we look forward 
to reviewing more requests.
    Finally, CMS is utilizing the vast amount of data that we 
have at our disposal to better understand and address the 
opioid crisis to share with our partners and to ensure program 
integrity. This includes active monitoring of trends, sharing 
prescribing patterns publicly through heat maps, and various 
other efforts to ensure the effectiveness of prevention and 
treatment policies.
    While CMS has taken numerous steps in the areas of 
prevention, treatment, and data to address this national 
epidemic, we know there is more we can do. We appreciate the 
work that your subcommittee has already done to highlight the 
importance of addressing this crisis, and we look forward to 
engaging with you on the legislative solutions that you are 
developing.
    Thank you for your interest in our efforts to protect our 
beneficiaries, and I look forward to answering your questions.
    [The prepared statement of Ms. Brandt follows:]
    
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    
    
    
    Mr. Burgess. Thank you, Dr. Brandt. Thank you for your 
testimony. Thank you for being here today.
    We will move on to the question portion of the hearing, and 
I would like to first recognize the vice chairman of the 
committee of the Health Subcommittee, Mr. Guthrie, 5 minutes 
for your questions, please.
    Mr. Guthrie. Thank you very much.
    Thank you, Ms. Brandt.
    Thank you, Mr. Chairman, for the time.
    Thank you for being here, Ms. Brandt.
    As you know, there is a lot of interest in the committee on 
more timely, accurate, and complete Medicaid data, whether it 
is the Transformed Medicaid Statistical Information System, 
otherwise known as T-MSIS, or basic Medicaid expenditure data. 
I think having more timely data is important in the opioid 
fight for targeting, funding, and understanding how the program 
is evolving.
    One of the bills before the Committee would amend the law 
to allow States only 1 year instead of 2 to submit claims for 
Federal matching. This deadline does not include adjustments to 
prior year spending, and the Secretary is allowed to waive the 
requirement if needed. The requirement in current law was added 
by Senator Moynihan in 1980. Yet today nearly 99 percent of 
Medicaid claims are submitted within 1 year.
    Ms. Brandt, can you talk about why we would have providers 
in 2018 that are still taking up to 2 years to submit claims?
    Ms. Brandt. Thank you for the question, sir.
    As you noted, the T-MSIS system is one of our big 
priorities at CMS. Moving to get more accurate and timely data 
from the States is one of the Administrator's top priorities. 
We are pleased at this point that we have 49 States, the 
District of Columbia, and recently, just as of a week ago, 
Puerto Rico now reporting in. So we have 98 percent of Medicaid 
data now being reported in.
    We share your goal in working to make sure that data is as 
timely as possible, and one of our challenges right now is 
ensuring that we have good quality data. As much as the 
timeliness of the data is an issue, we want to make sure that 
it is good quality data, as well.
    So now that we have the data being reported in, we are 
working to scrub the data and try and make it as good a quality 
of data as possible, and we are focusing particularly on the 
pharmacy files from the data so that we can begin to get 
information that will particularly help us with the opioid 
issue because of the State data that they report.
    Mr. Guthrie. You said 49 States plus District of Columbia, 
Puerto Rico, are you using the system. They report within 1 
year?
    Ms. Brandt. It is the most recent data that they have. It 
is not all within 1 year, and that is something we are working 
on with them. It is as timely as the States have the ability to 
report it.
    Mr. Guthrie. But I guess my question is States should be 
able to do that within 1 year. I know that is one of the bills 
that we are looking at.
    Ms. Brandt. We are working with them to try and get them to 
transmit it as timely as possible.
    Mr. Guthrie. OK. I want to transition then.
    According to NIH, every 25 minutes a baby is born suffering 
from opioid withdrawal. These are the most vulnerable victims 
of the opioid epidemic. I, along with Congressman Lujsn, plan 
to introduce a bill on this important issue later this week.
    Do you believe that we should facilitate public-private 
partnerships to provide additional information in support to 
women, children, and those tasked with their care?
    Ms. Brandt. Yes. In fact, CMS is very much dedicated to 
committing resources to help mothers and their infants 
struggling with opioid addiction, and we actually approved a 
State plan amendment for West Virginia back in February to 
provide additional treatment services and additional resources 
to help target just that issue.
    Mr. Guthrie. OK. And my final question, as you know, in 
November of 2017 the President's Commission on Combating Drug 
Addiction and the Opioid Crisis recommended that CMS revise 
reimbursement policies that limit patient access to non-opioid 
drugs used to treat post-surgical pain. Would you please 
provide the committee an update on where CMS is on the report 
and specifically on this issue?
    Ms. Brandt. I am sorry, can you repeat the part of the 
question?
    Mr. Guthrie. Yes. The President's Commission revised 
reimbursement policies that limit patient access to non-opioid 
drugs used to treat post-surgical pain.
    Ms. Brandt. So we are committed to working to make sure 
that we get the right treatment in the right setting, and that 
certainly includes making sure that we explore non-opioid 
alternatives to treat pain, and it is something that we are 
continuing to look at as an agency to determine how we can best 
address it from a reimbursement perspective.
    Mr. Guthrie. Thank you.
    Mr. Chairman, in the spirit of today, I used 4 minutes. So 
I will yield back a minute.
    Mr. Burgess. The chair thanks the gentleman.
    The chair recognizes the gentleman from Texas, Mr. Green, 5 
minutes for your questions, please.
    Mr. Green. Thank you, Mr. Chairman.
    Ms. Brandt, thank you for being here.
    For years, States and the Federal Government have 
underinvested in building the necessary infrastructure for 
provider treatment capacity, workforce development, and 
wraparound services needed to help Americans suffering from 
opioid abuse.
    Do you agree that the administration should work with 
States to strengthen the Medicaid coverage and infrastructure 
and remove the barriers for coverage for people that need the 
treatment?
    Ms. Brandt. Yes. In fact, that is the whole point. As I 
mentioned in my testimony, we have already been working to give 
States as much flexibility as possible. We have, as of last 
November, since then approved five States to have more 
flexibility through our 1115 waiver authority and are very much 
committed to continuing to work with States to give them the 
flexibilities they need so that they can determine the right 
types of coverage to address the opioid crisis.
    Mr. Green. Well, let me ask another question. I just see 
that CMS is finalizing a rule allowing more State options in 
the essential health benefits package. Is that essential 
benefit package going to include mental and substance abuse?
    Ms. Brandt. I can't speak specifically to what was just 
included in the recent benefits package, but I can say that as 
a whole we have been committed to trying to work with States to 
allow more support for behavioral health services and those 
types of support services.
    Mr. Green. Well, in the Affordable Care Act there was 
essential benefits package, and substance abuse and mental 
health was included in there. We didn't get as much as we 
should. I know a lot of folks wanted parity, and I support it, 
but we just couldn't afford it.
    But my concern is that we can pass all 70 of the bills, and 
if we limit States to making sure that they don't cover 
substance abuse all this paperwork is not going to be worth it. 
So that is the issue, whether it is through Medicaid or through 
an insurance policy bought through the ACA. That is my concern, 
and particularly with the cutting in cost-sharing reduction 
payments last year.
    Do you think CMS plans to continue these efforts to 
sabotage the ACA marketplaces and endanger healthcare coverage 
of the millions of Americans? Because, again, if CMS is not 
making sure that that essential benefits package covers mental 
health and also substance abuse, it doesn't do us any good to 
have you and to have these hearings.
    If you would take that back.
    Ms. Brandt. I will take that back certainly, sir.
    Mr. Green. OK. And I appreciate it.
    The other concern, I think, when Congress did recently 
authorize $6 billion in Federal grants for opioids for 2018 and 
2019, this additional funding still falls short of the 
treatment for Americans struggling with opioid use. Even more 
troubling is the uncertainty for the new funding stream for 
2019. This uncertainty may keep States from fully spending the 
funds without a commitment of long-term stable funding.
    Will CMS urge the Department of Health and Human Services 
to request increased block grant funding for opioid abuse and 
other substance use disorders beyond 2019?
    Ms. Brandt. Well, as you are probably aware, sir, the 
President's budget does advocate for block grants to States for 
more flexibility, and we believe that that is appropriate 
because that gives States the right to decide the right type of 
coverage that they need for the opioid crisis and to address 
their own individual needs.
    Mr. Green. Well, and again, one of the reasons we have on 
the ACA side the essential benefits package, and, frankly, even 
in Medicaid. Medicaid is the predominant server for mental 
health and for substance abuse, and if we don't fund those 
programs, like I said, we can pass all the bills we want, it 
just won't help us with people being treated out in the street.
    And so I appreciate you being here.
    And thank you, Mr. Chairman.
    Ms. Brandt. Thank you.
    Mr. Burgess. The chair thanks the gentleman.
    The chair recognizes the gentleman from Michigan, 5 minutes 
for your questions, please.
    Mr. Upton. Thank you, Mr. Chairman.
    Ms. Brandt, welcome.
    Last week I--actually it was this week, Monday--Debbie 
Dingell, my colleague, we were in west Michigan, and we sat 
down with a good number of our local mental health providers in 
my district to talk about pressing issues facing them, how we 
can be of more help. And I want to flag one of those issues for 
you and ask that you might be able to work with us on resolving 
it.
    As part of an 1115 waiver, our providers were told that 
they had to adopt a universal assessment tool called GAIN, G-A-
I-N. It is a 77-page assessment tool that takes more than a 
couple of hours to complete. It is completely duplicative, as 
every agency already does a comprehensive assessment for each 
beneficiary. Our providers were told by the Michigan PIHPs that 
it has to do with the Federal 1115 waiver requirement and that 
the reason for completing the tool is that we have to do this, 
we are only the messenger.
    And they read some of the questions they are going to 
actually provide with me later on. Again, I didn't realize this 
hearing was already scheduled when we sat down Monday 
afternoon. They are going to share with me that document. But 
it seems, as they said, they want to practice medicine, often 
this document turns people away from even continuing the 
process.
    And I just wonder if you can work with us and see if this 
is really the right approach for them to look at. I know it 
came, the regs, I think, were written before, but they have 
been finalized, and it is just something else.
    Ms. Brandt. Well, certainly we welcome if you could provide 
us with the information and the tool I will take it back.
    Mr. Upton. I will. I will get it to you next week.
    Ms. Brandt. But I will say that one of the Administrator's 
top priorities has been patients over paperwork, which has been 
an effort that I know that she has talked to many of you about, 
to reduce regulatory burden and to try and put patients first 
over paperwork, hence the name. So it is something that we 
certainly will go back and look at and appreciate you flagging 
for us.
    Mr. Upton. Great. I will follow up with you on that next 
week.
    The last question I have is a 2018 report notes that 
psychotherapeutic drugs might account for up to 4 in 10 drugs 
prescribed to kids in Medicaid. HHS' Office of the IG has 
recommended that CMS work with the State Medicaid programs to 
perform utilization reviews on the use of second-generation 
antipsychotic drugs prescribed to kids.
    The Medicaid Drug Improvement Act seeks to codify that 
recommendation by requiring that every State have a program to 
protect kids from unnecessary utilization of these powerful 
drugs, which could place them at a greater risk for substance 
abuse.
    Do you think that such a requirement on States could help 
CMS better monitor how States are providing care for kids in 
their State programs?
    Ms. Brandt. Well, we have read the OIG report and are 
familiar with their recommendations and are committed to 
working with them to see how we can reduce the high number of 
drugs that kids would be potentially subject to. We are 
committed to making sure that kids get the right treatment in 
the right setting, and we will work with the OIG and with you 
all to see what we can do to address that.
    Mr. Upton. Great. Thank you.
    I yield back.
    Mr. Burgess. The gentleman yields back. The chair thanks 
the gentleman.
    The chair recognizes the gentleman from Oregon, 5 minutes, 
for your questions, please.
    Mr. Schrader. Thank you, Mr. Chairman.
    Thank you very much, Ms. Brandt, for all the work you are 
doing at CMS to help deal with the opioid prescription issues. 
At least I think that we are seemingly getting somewhere. A 
recent Post article indicated some substantial reduction.
    Our medical and dental colleagues are getting on board with 
prescribing less long-term doses, seems like much in line, 
might be some incentivized by CMS, but in any case helping 
drive down the prescription drug abuse problem. And I think 
that is huge. We work together both in your office and here, 
frankly, at the practice level. I think that is a big deal.
    Are you getting any pushback with regard to some of the 
guidelines you are putting out there? It seems to be in line 
with what I am hearing from my medical colleagues.
    Ms. Brandt. I think that the biggest thing we got comments 
on when we put out the proposals that we codified in our call 
letter in our proposed regs was making sure that we were 
striking the right balance.
    And that is something that I have heard several of you as 
well mention today, and that is making sure that the people who 
have a chronic illness or cancer or a real need for these types 
of drugs are able to have the access to them while still making 
sure that we put the safeguards in place on our side to ensure 
that those who maybe are just taking it for acute pain or maybe 
should not be having it at the full level are not at risk of 
getting addicted.
    And I think that is a balance we are striking to get, and 
that is really where I wouldn't say it is pushback, I think it 
has just been a constructive dialogue that we have been having 
with the community on that issue.
    Mr. Schrader. It is a work in progress as we work through 
this. There is some recent evidence that even for chronic pain 
you can manage--depending on the person and the situation--
chronic pain with modest anti-inflammatories as opposed to 
having to go to the narcotic.
    Ms. Brandt. Correct. And that is why we are looking at 
other types of MAT and other solutions to be able to work that 
and try and provide as much flexibility on that as possible.
    Mr. Schrader. Would you comment at all on the other, the 
flip side of this, unfortunately, is that creative people, 
unfortunately, find alternate ways to satisfy their habits, and 
there has been a huge rise in the deaths with regard to 
synthetic opioids and fentanyl, very dangerous, tainted 
products out there in the market.
    What does CMS or how is CMS responding to that and what 
might we want to help you do.
    Ms. Brandt. Well, it certainly is a real risk, and it is 
something we have taken several steps to address. I mentioned 
our Overutilization Monitoring System that we have, OMS. That 
allows us to put alerts in place to tell us when we see a high 
number of beneficiaries that are using drugs.
    So, for instance, if a beneficiary has 90 morphine 
milligram equivalents or higher for a sustained period of time, 
say 6 months, and has been using either three or more providers 
or three or more pharmacies during that time, it puts an alert 
in place.
    I mentioned the 76 percent reduction that we have been able 
to see as a result of some of those alerts on the part D side, 
and we are very encouraged by that. But we are really working 
to put additional edits in place. These are really checks, if 
you will, that allow it so that the pharmacist, who is 
obviously a big part of the care team, can work with the 
provider to ensure that the beneficiary is getting what they 
need.
    I mentioned we have the new 7-day initial fill limit for 
acute pain. That is, again, intended to make it so that it is 
part of a discussion. If there is a need to have something more 
than that, great, but if not, that really would stop that 
supply because really, as the CDC has pointed out, there is no 
need to go beyond that. So we have got that.
    We are also looking at prescribers. Unfortunately, while 
most providers are good, upstanding individuals, we do have a 
number of people who are overprescribers. And so, we work with 
our MEDIC, who is our sort of fraud integrity contractor, to 
really look at identifying the outliers.
    They provide reports on who those outliers are. And we rely 
on our plans to really be able to monitor for that. And then, 
obviously, States use their PDMPs and other things to help them 
identify where they see outliers, as well. It is really a 
multipronged approach.
    Mr. Schrader. Yes, we have that issue in my part of the 
profession, also. There are a few outliers, unfortunately, that 
give the rest of us grief and lead to sometimes more 
overregulation.
    I certainly appreciate your approach and CMS' approach to 
work with the providers to come up with that right balance to 
get good results, and it looks like we are getting there.
    Ms. Brandt. Slow but sure. We still have a ways to go.
    Mr. Schrader. I yield back, Mr. Chairman.
    Mr. Burgess. The chair thanks the gentleman. The gentleman 
yields back.
    The chair recognizes the gentlelady from Tennessee, 5 
minutes, for questions, please.
    Mrs. Blackburn. Thank you, Mr. Chairman.
    I have two questions that I wanted to talk with you about. 
The Medicaid Drug Improvement Act, which is going to look at 
the States' drug utilization review or the DUR programs and 
would put in place the minimum standards for the States while 
giving them some flexibility to determine what is and isn't 
going to work.
    But they would have to have a minimum standard for the 
limitations in place for the opioid refills, monitor concurrent 
prescribing of opioids and other drugs, monitor the 
antipsychotic prescribing for children, and have at least one 
of the naloxone-buprenorphine combination drugs on their 
formulary.
    And as I mentioned in my opening statement, TennCare has 
already put in place some of these limitations, but as we have 
seen the growth of Medicaid and with the Medicaid expansion, I 
wanted you just to talk a little bit about what you think 
putting these guidelines in place, passing this legislation, 
what that would do to help with clinical care and the health 
outcomes for our Medicaid enrollees.
    Ms. Brandt. Thank you. It is a great question. And as you 
may be aware, actually in the fiscal year 2019 budget there is 
a proposal to establish minimum standards for Medicaid drug 
utilization review programs, and that is something that we 
think is an important first step.
    We have already seen that States have been using many tools 
to address this. We get reports through our DUR report each 
year that let us know this, and States have been using a lot of 
medical management techniques like step therapy, prior 
authorization----
    Mrs. Blackburn. What are the outcomes when they report them 
to you?
    Ms. Brandt. I think thus far, from what we have seen in 
some of the initial outcomes that we have gotten from our DUR 
reports, is that it seems to be going well, that these things 
are making a difference and it is starting to make an impact.
    Mrs. Blackburn. How many States are doing this, electing to 
do this, to move forward with it?
    Ms. Brandt. Well, right at the moment we have 37 States 
that limit the short-acting opioids, and we have 39 States that 
limit the quantity of long-acting opioids.
    Mrs. Blackburn. So we have got different components that 
are being implemented in different States?
    Ms. Brandt. Correct.
    Mrs. Blackburn. Would it be helpful if you had the 
benchmarks that they had to hit across the board?
    Ms. Brandt. Well, I think that is one of the reasons that 
the President's budget proposal advocates for minimum 
standards, so that there would be something unified across the 
board.
    Mrs. Blackburn. OK. That is great.
    Let's talk about the IMD exclusion, because this comes up 
in nearly every provider meeting that I have, and in my 
district in Tennessee I have constituents who are so involved 
in the delivery of substance abuse and mental health programs. 
And so the IMD exclusion comes up a good bit.
    So if you will elaborate on your efforts there. I know that 
Ms. Verma is working on this issue. She has mentioned that she 
is. But we want to ensure that Medicaid enrollees are going to 
be able to get access to the needed care.
    Ms. Brandt. Well, as I mentioned in my testimony, our goal 
is to make sure there is the right treatment in the right 
setting for the right individual, and a big part of that is 
allowing flexibilities for IMD.
    So as I mentioned, since last November we have implemented 
some new demonstration projects in five States--Louisiana, New 
Jersey, Utah, Indiana, and Kentucky--all of which have 
flexibility to be able to waive IMD requirements and allow them 
to have greater residential flexibility.
    We have gotten a lot of interest from other States and we 
are talking with them about giving similar flexibilities, and 
look forward to working with you all as a committee to 
determine how we can address this from a statutory perspective.
    Mrs. Blackburn. Thank you. I yield back.
    Mr. Burgess. The chair thanks the gentlelady.
    The chair recognizes the gentlelady from California, Ms. 
Eshoo, 5 minutes for your questions.
    Ms. Eshoo. Thank you, Mr. Chairman.
    And thank you, Ms. Brandt, for your testimony and your work 
at CMS.
    Ms. Brandt. Thank you.
    Ms. Eshoo. I have several questions.
    Let me start with this, and it is hard to get the exact 
amount. Do you know how much we spend today, what the Federal 
Government spends on services related to opioids?
    Ms. Brandt. I do not have an exact number for you.
    Ms. Eshoo. Approximate?
    Ms. Brandt. I would say that it is definitely in the 
hundreds of millions, but I couldn't give you an exact number. 
I am happy to get back to you.
    Ms. Eshoo. I think it would be helpful because the 
committee staff doesn't have it either.
    Ms. Brandt. We are happy to look from our perspective.
    Ms. Eshoo. But at any rate, it comes from different places, 
and I understand that, and there are grants and all of that.
    I believe the majority of it is funded through Medicaid, 
though, correct?
    Ms. Brandt. Medicaid is certainly a part of it. There are 
multiple funding streams in the Federal Government, including 
NIH, CDC, SAMHSA, FDA. So there are multiple components.
    Ms. Eshoo. But I do think that Medicaid is the single 
largest payer both of mental health services and substance 
abuse, or a major player in it.
    Ms. Brandt. It definitely is for behavioral health, yes.
    Ms. Eshoo. All right.
    Now, this is a little bit of a tough question, but the 
agency I am sure had done some kind of analysis of this. The 
President's fiscal year 2019 budget proposal slashes $1.4 
trillion from Medicaid. So have you done an analysis of that 
and the impact it will have on the very issue that we have 35 
bills on in this committee, on opioids?
    Ms. Brandt. I think that the challenges with the opioid 
epidemic is it is not something that we can necessarily spend 
our way out of. We want to make sure that----
    Ms. Eshoo. Well, that is not what I am asking you. I am not 
asking you that.
    Ms. Brandt. We have not done an analysis, specifically.
    Ms. Eshoo. Money provides access to fill in the blank. This 
is not a partisan issue, Member after Member has spoken to the 
needs of people in their communities, the needs for access to a 
variety of services, one of the most important being treatment 
for this after people are hooked, after they are addicted. So 
there is a direct correlation between dollars and services.
    So maybe you haven't done an analysis, you can tell me 
that, but I think that it is important to put this on the 
table. Otherwise this is an extraordinarily serious issue that 
is plaguing the country, and we are going to reduce it, 
diminish it to next to nothing if, in fact, this $1.4 trillion 
is cut from Medicaid. I mean, this is reality. That is the 
proposal, the President's budget.
    So I would like to hear back from the agency as to what 
your analysis is to the impact of Medicaid and the issue of 
opioids, otherwise we are just fooling ourselves here.
    I mean, it is important to have the discussion, but if, in 
fact, there is going to be a balanced budget amendment that 
comes up on Friday, what is contained in that? How is it going 
to affect this issue? There is a linkage between all of these. 
And I think unless and until we acknowledge that, that we are 
really not being straight up.
    Now, I am very proud that Stanford University is in the 
heart of my congressional district. I think they are doing 
great work in the telemedicine space, specifically for opioid 
and pain management treatment. They have told me that there are 
barriers to Medicare and Medicaid reimbursing telemedicine, 
such as originating site requirements.
    Does telemedicine, do you think, save the Federal 
Government money compared to in-person medicine?
    Ms. Brandt. We absolutely----
    Ms. Eshoo. That is such a softball question. So there is 
the softball.
    Ms. Brandt. We appreciate the question, and it is one of 
the top priorities of the current CMS Administrator.
    Ms. Eshoo. That is not what I asked you. I asked you if you 
believe----
    Ms. Brandt. And she does believe it has money-saving 
possibilities, and it is something we are pursuing as part of 
our proposed payment rules for this next year.
    Ms. Eshoo. Do you think the patients, whether they are in a 
rural setting or an urban setting, should be able to access 
telemedicine if it is appropriate, obviously, for them?
    Ms. Brandt. We absolutely believe it is a very critical 
tool, particularly for the rural areas and for underserved 
communities.
    Ms. Eshoo. Has CMS identified any barriers that providers 
face when trying to use non-opioid treatments for pain?
    Ms. Brandt. We have been working with the providers to 
discuss how we can eliminate some of the barriers for treatment 
and are trying to work with them on solutions.
    Ms. Eshoo. Well, that is pretty broad. What steps has the 
agency taken to reduce the barriers?
    She can answer. I won't ask anymore.
    Ms. Brandt. We have had a number of stakeholder sessions, 
as I said, and have been engaged in lots of discussions with 
the industry to figure out where the barriers are and how best 
to address them.
    Ms. Eshoo. Thank you.
    Mr. Burgess. The chair thanks the gentlelady. The 
gentlelady yields back.
    The chair recognizes the gentleman from Ohio, Mr. Latta, 5 
minutes for your questions, please.
    Mr. Latta. Thanks, Mr. Chairman, and thank you very much 
for holding today's hearing.
    Again, the opioid epidemic is a scourge on this country. 
And in the State of Ohio, I am sure, Ms. Brandt, you are aware, 
that we are about the third hardest hit State. We had 5,232 
people lose their lives because of it by the end of the fiscal 
year of June 30 of last year.
    But in 2015, six newborns a day were admitted to Ohio 
hospitals for neonatal abstinence syndrome, NAS, because of 
drug use by their mothers, and the cost to Medicaid is $133 
million. The State of Ohio has been diligently working to 
address this issue and helping to improve health outcomes for 
the moms and the babies out there.
    Could you point to any CMS efforts to prevent and treat 
neonatal abstinence syndrome? For example, States may also 
include funding for facilities that provide care for infants 
with NAS to an 1115 demonstration waiver. That is correct, I 
believe.
    Ms. Brandt. Certainly. Certainly this is an issue that we 
know is very important not only in Ohio, but lots of other 
States. And we have been working to commit resources to really 
help mothers and their infants that are struggling with opioid 
addiction.
    One of the ways that we have been doing it is through the 
Early and Periodic Screening, Diagnostic, and Testing services, 
or EPSDT. We are requiring States to provide a comprehensive 
array of prevention, diagnostic, and treatment services for 
low-income infants, children, and adolescents under age 21. 
This would include providing treatment services for conditions 
such as neonatal abstinence.
    I mentioned earlier, but in February we approved a State 
plan amendment for West Virginia to provide additional 
treatment services for neonatal abstinence syndrome in NAS 
treatment centers. This would allow West Virginia to reimburse 
all medically necessary NAS services through an all-exclusive 
bundled cost per diem rate based on a prospective payment 
methodology. And it also would allow them to fund things like 
nursing salaries, supportive counseling, and case management, 
which are important wraparound services.
    Mr. Latta. Thank you.
    And last week in my district I held a roundtable with 
pharmacists also to talk about the opioid crisis in Ohio, and 
most of the pharmacists agree that we need to have non-opioid 
alternatives for pain treatment and management; furthermore, 
that payments need to be expanded to alternative drugs and 
therapies outside of opioids.
    Should CMS be taking the lead in setting the example to 
private payers by encouraging non-opioid alternatives for pain 
management?
    Ms. Brandt. Absolutely. As I mentioned in my oral 
testimony, we are looking very aggressively at MAT and how we 
can provide that, including things such as naloxone, to be able 
to have other non-opioid treatment alternatives to be able to 
address the problem.
    Mr. Latta. How do you get that information out to everybody 
out in the real world who are treating folks and saying that we 
need to make sure we are using non-opioids? How are you doing 
that? How are you getting that information out?
    Ms. Brandt. We have a variety of methods that we use. We 
have Medicare Learning Network, MLN, which allows us to get 
information out. We have open door forums. We have our plan 
sponsors communicate directly with their providers, and we 
communicate directly with Medicare providers through various 
listserves and emails and other things.
    We have also partnered with the Centers for Disease Control 
and other Federal partners to try and get the word out. But we 
can always work with you all to do more and to try and figure 
out how to do that more effectively.
    Mr. Latta. OK. And also there is often a lot of discussion 
about developing new drugs for pain treatment, but also new 
medical devices have also shown promise in effectively managing 
pain.
    What has CMS done to make sure that medical devices are 
included in CMS' efforts to address this crisis?
    Ms. Brandt. That is actually a big area. I can tell you 
during our stakeholder sessions and during the meetings that 
myself and other members of the CMS team have had we have had 
probably hundreds of people come in with various alternatives 
and other things.
    And we have been working very closely with the FDA, who is 
our partner in this, to be able to figure out a parallel track 
process so that as they are approving new alternatives we can 
simultaneously be looking at coverage and reimbursement for 
them to help get those alternatives in the system as quickly as 
possible.
    Mr. Latta. Well, thank you very much.
    Mr. Chairman, I yield back the balance of my time.
    Mr. Burgess. The chair thanks the gentleman. The gentleman 
yields back.
    The chair recognizes the gentleman from California, Mr. 
Cardenas, 5 minutes for questions.
    Mr. Cardenas. Thank you very much, Mr. Chairman. I am glad 
we have an opportunity once again to speak about this very, 
very important issue that is crushing our communities and 
individuals and families.
    Ms. Brandt, what is your current title?
    Ms. Brandt. Principal Deputy for Operations.
    Mr. Cardenas. OK. And do you report to somebody who is a 
permanent person in that position or are you reporting to 
somebody who is actually temporary as you go up the ladder?
    Ms. Brandt. Well, I report directly to the Administrator 
for CMS, who is appointed by the President.
    Mr. Cardenas. OK. All right. Thank you. Many times when we 
have these hearings there are a lot of vacancies in and around 
the people who are testifying. I am glad to hear that they have 
a permanent person in that position.
    Ms. Brandt. I am, too.
    Mr. Cardenas. I want to point something out and then ask 
you a question. And what I want to point out is that often when 
we talk about healthcare we never mention how it interacts with 
the justice system, and when we talk about improving the 
justice system we leave out healthcare for children. Even if we 
do talk about both of them at the same time once again, with 
the children we tend to leave them out of the dialogue.
    My bill, which is in our committee, which is being 
discussed today, the At-Risk Youth Medicaid Protection Act, 
does just that. This bipartisan bill, which I was proud to work 
on with Congressman Morgan Griffith of western Virginia, keeps 
the government from kicking at-risk youth off of Medicaid if 
they come into contact with the justice system.
    With this bill, when a child returns home she would 
immediately be able to see a doctor again and have access to 
any physical, mental health, and addiction treatments that she 
may need. Right now children are left out in the cold to battle 
with the bureaucracy on their own because many States are 
automatically kicking them off.
    The opioid epidemic has grown in a way that the country was 
not ready for. According to a June 2017 MACPAC report, the 
opioid epidemic disproportionately affects Medicaid 
beneficiaries, and thus, State Medicaid programs are taking the 
lead in identifying and tailoring strategies to prevent and 
treat opioid use disorders.
    It does not matter whether it is on the streets of Los 
Angeles or the hills of Appalachia; opioid addiction can 
cripple communities and destroy families. But among those 
affected the most are our most vulnerable, which is our youth.
    Kids suffering from addiction need to be able to see a 
doctor and get better quick. In some States, when a child comes 
in contact with the justice system, her access to Medicare is 
permanently terminated.
    Imagine her leaving the facility without family support, 
wanting to get better, and trying to figure out how to continue 
with her recovery, manage her mental health issues though she 
has no ability to refill her medication, get back into school, 
and find housing.
    On top of all that, do we really expect her to have to fill 
out a bunch of Federal forms and wait until she can get the 
support that she deserves and needs so badly? The bill that I 
am talking about does, in fact, fix that.
    The need for continuous access to healthcare goes beyond 
the opioid crisis and not just benefits to children, but also 
their families, their communities, and the society they will 
continue to be successful as adults in.
    This bill will ensure that children do not fall through the 
cracks because of red tape that adults created. The legislation 
has broad support in the law enforcement, healthcare, and 
social justice communities. I appreciate the ability to discuss 
this bill and look forward to seeing it advance through the 
legislative process.
    Ms. Brandt, currently Federal law prohibits States from 
receiving Federal financial participation for individuals 
covered by Medicaid while they are incarcerated. It does not, 
however, specify how each State should handle the Medicaid 
enrollment of these individuals once they get back in the 
community.
    While some States are beginning to suspend instead of 
terminating Medicaid enrollment of incarcerated individuals, 19 
States still permanently terminate healthcare coverage of 
incarcerated individuals.
    Therefore, I ask you, do you agree that these policies 
limit the ability of most incarcerated children who are covered 
by Medicaid to access treatment for substance use disorders 
once they are back in their community?
    Ms. Brandt. Well, I am not familiar entirely with the 
policies that you are describing, but as I said before, we are 
committed to working with States to be able to provide 
flexibility so that they can get the right treatment to the 
right people, whether that is juveniles, infants, or others.
    And so, we are happy to work with you to provide technical 
assistance and work with the issues. I can't speak specifically 
beyond that, because I am not familiar, but we are committed to 
providing the right treatment and the right setting to the 
right people.
    Mr. Cardenas. Well, I am familiar with that one point that 
is affecting so many young people in our country. And the point 
here is that we can and hopefully will clarify in the law that 
the States do have that option right now to continue to remove 
them--right now they have the option to remove them once they 
come in contact with the justice system.
    But what should be happening, they should be suspended, 
because they are going to get out. And for a person with any 
medical need, mental or otherwise, shouldn't have to go a 
month, 2, 3, 4, 5, 6, without the care that has already been 
identified for them, and that is the rub and that is the part 
that we are trying to fix. So hopefully we will do that and 
then you will be able to follow suit.
    Ms. Brandt. Very good. Happy to follow.
    Mr. Cardenas. Thank you. I yield back.
    Mr. Burgess. The chair thanks the gentleman.
    The chair would observe we have a series of votes that have 
been called on the floor. We will entertain questions from Mr. 
Shimkus, and which we will then recess until after the vote 
series.
    Mr. Shimkus, you are recognized for 5 minutes, please.
    Mr. Shimkus. Thank you, Mr. Chairman.
    So Dr. Burgess, and also, really, Dr. Schrader, mentioned 
the concern on the chronic pain end of these folks. And I have 
been trying to carry that message, because they are different, 
right? They are not addicted. They need it to just live normal 
lives.
    Having said that, could you--because I get a lot of 
questions on this issue of the editing process that you have. 
Can you briefly explain that. I know that there is a soft edit, 
hard edit, and that is milligram based, and what the purpose is 
and why we do it that way.
    Ms. Brandt. Sure. So the whole purpose, again, of the edits 
is to make sure that if you see folks who are potentially over-
utilizers, for instance, someone, as I mentioned before, who 
would be receiving maybe 90 morphine milligram equivalents or 
higher on a sustained basis for up to 6 months or more, maybe 
getting prescriptions from three or more providers, three or 
more pharmacies, people who look like they really are not 
someone who maybe has a dedicated physician, a dedicated care 
issue.
    The whole point is that the pharmacist works with the 
provider to be able to have a discussion about whether or not 
that pain treatment is right for that individual. The whole 
point of the edits is to serve as a flag, if you will, to be 
able to highlight it so that if you have something that looks 
like an aberrancy, we can stop it early.
    The 76 percent number that I keep going back to, I think, 
is an important example of this, because by using those types 
of edits, we have been able to really reduce those numbers by 
over 25,000 individuals, and that is a significant step forward 
in that program.
    So the point of the edits is more to ensure that there is 
the right treatment being provided to the right person, and to 
have that discussion among the care team about what that is.
    Mr. Shimkus. So are we seeing any response by the chronic 
pain community that this is inhibiting their ability and 
slowing up the process of prescriptions for them?
    Ms. Brandt. Well, as I said, that is something that we have 
had a very active dialogue with the community on. We got a lot 
of comments on that back in response to our call letter. And we 
have really been working with them to try and make sure that we 
are striking that right balance.
    That is one of the reasons in the call letter that we went 
to a 7-day initial fill for acute pain, and to make it so that 
there was the ability to have that conversation between the 
pharmacist and the provider about the needs of the individual 
so that hopefully someone who has cancer or some other disease 
that requires them to need these drugs would be able to get 
them and to keep getting them as appropriate.
    Mr. Shimkus. And Illinois is an 1115 waiver State. Can you 
explain some of the issues with applying for that? I think it 
is going to end up being a big discussion within the committee 
about, if it is working, then we need to make sure that that is 
working and why versus other responses to this issue that we 
may hear from some of our other colleagues.
    Ms. Brandt. Well, again, the whole goal of our waiver 
process is to allow States more flexibility, and it is to allow 
them more flexibility to be able to utilize their resources to 
treat the opioid crisis in their State as best fits the needs 
of their State.
    Each State is very unique and has different populations and 
different needs and different resource constraints, so the idea 
is to be able to work with the States to give them the 
flexibility.
    Mr. Shimkus. And how many States do we have in that process 
right now?
    Ms. Brandt. Well, as I mentioned, since we started the new 
process in November, we have gotten five States that have 
gotten substance use disorder waivers. I can't speak to the 
total number because there were waivers before that, but since 
we sort of began the new process, there are five States that 
have been approved. And we have discussions ongoing with 
several others.
    Mr. Shimkus. And I would just like to end on the--obviously 
in the coding issue and reimbursement on nonopioid pain 
management treatments. Obviously, you have heard the concern 
that if we don't adequately reimburse them, it may move to pain 
management through a different venue by which we would end up 
having more challenges than we would like. Can you talk about 
your involvement or your concern about CMS and coding?
    Ms. Brandt. Certainly. Again, that is an area where we are 
having an ongoing dialogue with the provider community to 
determine what the right levels are there in terms of coding 
and how we can work with them to make sure to balance the 
burden with the appropriate targeting of treatment and codes 
for that.
    Mr. Shimkus. I appreciate you being here. Thank you for 
your time.
    And, Mr. Chairman, I yield back.
    Mr. Burgess. The chair thanks the gentleman. The gentleman 
yields back.
    And once again, the chair observes we have a series of 
three votes on the floor of the House. The Committee is going 
to briefly recess while we record those votes over the in the 
House Chamber, and we will reconvene immediately after the last 
vote.
    I thank the witness for the forbearance during that time.
    Ms. Brandt. Thank you.
    Mr. Burgess. The committee stands in recess.
    [Recess.]
    Mr. Burgess. I call the subcommittee back to order. I want 
to thank everyone for their forbearance while the vote series 
occurred.
    At this point, I would like to recognize for 5 minutes the 
vice chairwoman of the conference, Cathy McMorris Rodgers, 5 
minutes for your questions, please.
    Mrs. McMorris Rodgers. Thank you, Chairman, Ms. Brandt.
    I want to first applaud CMS for clarifying in the final 
part D rule that MTM programs will fall under quality 
improvement activities when calculating the medical loss ratio 
requirements. This should encourage plan sponsors to expand 
access to MTM programs, which will ensure a greater number of 
patients can benefit.
    Given the important role pharmacists can play in addressing 
the opioid epidemic, we are considering legislation today to 
add patients at risk for prescription drug abuse to the list of 
eligible beneficiaries for MTM under Medicare Part D. Can you 
please give us your thoughts on utilizing pharmacists to help 
address the opioid epidemic?
    Ms. Brandt. Thank you.
    We think that pharmacists are a very important part of the 
care coordination. As I mentioned in several of my answers 
today, pharmacists play a vital role and are on the frontline 
in helping work with providers to address this. And we think 
the MTM treatments, in particular, have been very beneficial to 
beneficiaries, and we look forward to working with you to 
expand that.
    Mrs. McMorris Rodgers. And while we are on the topic of 
MTM, can you provide us with a quick update on where CMS is 
ensuring sufficient retail pharmacy representation in the CMMI 
enhanced MTM model demonstration project?
    Ms. Brandt. I can't speak specifically to that, but I am 
happy to get back to you with some more information about how 
that is going. I am sorry, I am just not familiar with that 
particular one.
    Mrs. McMorris Rodgers. OK. That would be great.
    I am interested in how existing dollars can be leveraged in 
the effort to help educate providers providing care for 
patients with substance abuse disorder. When we spend more than 
$2 billion in Medicaid-funded GME programs each year, it is 
just common sense for Congress to better understand how these 
programs are helping to train providers on pain management and 
substance use disorder.
    For example, the University of South Carolina implemented a 
program into their medical school curriculum to address the 
opioid crisis using case studies, panel discussions, and group 
work.
    By the end of medical school, all USC-trained medical 
students will be able to recognize patients that are at risk 
for substance abuse, and have solutions for treatment. I think 
that this is a great model for other medical schools.
    Do you think that it is appropriate use of GME dollars, 
particularly since Medicaid beneficiaries represent a 
disproportionately large share of those with substance abuse 
disorder?
    Ms. Brandt. Well, we certainly agree that education is an 
important component. And we agree that we want to continue, as 
we have been doing, to work with States in the accrediting 
organizations to make sure that GME dollars are put towards 
education to help make sure that that is targeted in the 
appropriate way.
    Mrs. McMorris Rodgers. Thank you.
    I would also like to take this opportunity to submit for 
the record from the Washington State Pharmacy Association, 
pharmacists play a unique role in patient care and are 
frequently the healthcare professional that a patient sees the 
most, especially in our rural communities.
    Authorizing pharmacists clinical services under Medicare 
Part B, which H.R. 529 accomplishes, will go a long way to 
empower pharmacists and give them an opportunity to help 
address prescription drug misuse and abuse.
    So I would like to submit this letter for the record, Mr. 
Chairman, and with that, I will yield back.
    Mr. Burgess. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Burgess. The chair thanks the gentlelady. The 
gentlelady yields back.
    The chair recognizes the gentleman from Massachusetts, Mr. 
Kennedy, 5 minutes for your questions, please.
    Mr. Kennedy. Thank you, Mr. Chairman. I appreciate the 
opportunity to have this hearing.
    Thank you, Ms. Brandt, for being here as well, answering 
our questions.
    Mr. Chairman, I would like to start just by submitting or 
requesting an opportunity to submit for the record a letter of 
support from about 2 dozen or so organizations in support of 
our mental health parity bill, if you would be so kind.
    Mr. Burgess. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Kennedy. Thank you, sir.
    Ms. Brandt, I wanted to drill down a little bit your 
understanding and the administration's understanding about the 
current status of Medicaid with regard to the two areas of 
focus, substance abuse and mental illness, with regards to some 
of the policies that I think have been put forth from a couple 
of States that you mentioned earlier.
    Do you have any information or data that indicates how long 
it takes the average patient to recover from a substance use 
disorder?
    Ms. Brandt. I don't know exactly the amount of time, but I 
can get back to you with any information that we have.
    Mr. Kennedy. Yes. And I would imagine that it obviously is 
going to vary quite a bit individual to individual.
    Ms. Brandt. Yes. I think it depends on the type of person, 
the type of treatment, and the setting.
    Mr. Kennedy. Yes. And I would assume, with regards to a 
broader mental health issue, some of that is, obviously, a 
lifelong condition and some of that with adequate treatment and 
access to care can be successfully managed. Is that fair?
    Ms. Brandt. That is fair, yes.
    Mr. Kennedy. So you can imagine my concern, Ms. Brandt, 
when I hear that five States, Maine, Arizona, Utah, Wisconsin, 
and Kansas, have applied for waivers to impose lifetime limits 
on Medicaid patients in their States, knowing that substance 
use orders and mental health problems are often lifetime 
challenges, and knowing that Medicaid is a single largest payer 
of behavioral health service in this country.
    How do I understand the testimony that you have given so 
far, and this administration's stated commitment to provide 
access to care, particularly in the midst of an opioid 
epidemic, recognizing that for the young people that are 
afflicted with this epidemic, it is going to be a lifelong 
issue and a lifelong challenge with a policy of lifetime caps? 
How do I rectify that?
    Ms. Brandt. Well, as I mentioned before, we have been 
working to try and work with States to try and give them as 
much flexibility as they can to manage the populations in their 
area to hopefully get the right treatment in the right setting 
for the right duration.
    Mr. Kennedy. I appreciate your answer, but how is a 
lifetime limit ever going to be the appropriate response for 
somebody facing a lifetime illness?
    Ms. Brandt. Well, I can't speak to that specifically, but, 
again, we are committed to working to give the States the 
flexibility they need to hopefully provide the right types of 
treatments for their individual constituents.
    Mr. Kennedy. So with regards to a similar policy and a work 
requirement, is there a study that you are aware of that 
indicates that Medicaid--that people are healthier, not the 
causation between health and work, but between work and health? 
Are you aware of a study that shows that work will make 
somebody healthier?
    Ms. Brandt. I cannot speak to such a study.
    Mr. Kennedy. I can't either. I am not sure there actually 
is one. And so I am curious as the administration tries to push 
forward with a Medicaid work requirement, you had said earlier 
that the philosophy of this administrator was to put patients 
over paperwork.
    I think we can agree that when it comes to a work 
requirement, the paperwork necessary for an individual patient 
to try to either, one, prove that they are working is an 
additional administrative burden; and two, to try to provide, 
assuming that you are carving out some sort of exemption for 
people under certain conditions, mental illness, caregiver, 
student, others, that that is an additional administrative 
hurdle on top of that. How is that putting patients above 
paperwork?
    Ms. Brandt. Well, with the States where we have already 
gone ahead and worked with them, one of the things that we 
tried to do was to make sure that the States would make 
reasonable modifications.
    And we are trying to work with them to ensure that they are 
striking that appropriate balance, to ensure that they are 
getting people access to the treatment they need without 
hopefully having additional bureaucratic requirements.
    Mr. Kennedy. And if somebody is suffering with a mental 
illness, such that they--as I know over the course of--you have 
been dedicated to public health and health policy for a long 
time, the challenges that those individuals and families have 
with getting access to care and maintaining the care that they 
need, and the struggles that they go on on a daily basis to 
sometimes get through the day, the administrative burden added 
for them to prove that they are--should be exempt for those 
work requirements, does that not make it even harder for them 
to do so? And if so, isn't the risk of them losing access to 
their healthcare and Medicaid even higher to one of the most 
at-risks populations we have got?
    Ms. Brandt. Well, to your point, that is one of the reasons 
that we remain committed to trying to work with States to sort 
of strike that reasonable balance I talked about. We want to 
make sure people have reasonable access and the appropriate 
access to the care they need in those States, and, hopefully, 
balance that with the requirements needed to be able to show 
that they need that care.
    Mr. Kennedy. And how would a work requirement ever tilt in 
the way of a patient for access to health?
    Ms. Brandt. As I said, we are working with States to try 
and make sure to assure that balance.
    Mr. Kennedy. Appreciate that. Thank you.
    Yield back.
    Mr. Burgess. The chair thanks the gentleman. The gentleman 
yields back.
    The chair recognizes the gentleman from Virginia, Mr. 
Griffith, 5 minutes for your questions.
    Mr. Griffith. Thank you, Mr. Chairman.
    Appreciate you being here this afternoon.
    The Medicaid Pharmacy Home Act that the Committee is 
considering would require that States take into account a 
patient's history of receiving care in geographic proximity to 
providers and pharmacies when locking a patient into two 
providers and two pharmacies. How would CMS define proximity?
    Ms. Brandt. Well, that is a good question and something 
that in each of our rulemaking, we actually look to do. We 
recognize that we are always looking to make sure that we can 
ensure appropriate access for patients.
    As I said, we want to make sure people are getting the 
right treatment in the right setting, and so it is something 
that we are definitely always looking to determine what is the 
right proximity. Is it driving distance? Is it actual mileage 
distance? What is the appropriate balance? And that is 
something that we do through notice-and-comment rulemaking and 
working with individuals such as yourself.
    Mr. Griffith. And you anticipated the next part of my 
question, because I was going to go to, historically it has 
been a mileage requirement, but in districts like mine, which 
have mountains in them, one town might be closer as the crow 
flies, but not nearly as close on driving time.
    I have got a classic situation in one of my areas where in 
Dickenson County, Haysi, and Clintwood, on the map may look 
like they are 15 miles apart but there is a mountain in 
between.
    And because of the road that goes around the mountain, I 
have been advised by the mayor of Haysi that he allots--it 
doesn't always take him that long, but he allots an hour to get 
from one down to the other. When he has a meeting over in 
Clintwood, he has to allocate an hour on his calendar, weather, 
coal trucks, timber trucks, a slow driver worried about the 
curves, all can make that trip a lot longer, and there may be 
closer facilities that the drive time is better for, or 
whatever, and keeping that in mind. And I just ask that as you 
all look at this--and we will too--if you would keep that in 
mind, I would greatly appreciate it.
    Ms. Brandt. We certainly will.
    Mr. Griffith. Thank you.
    In MACPAC's report this past June, the commission noted 
research in health affairs that found States with prescription 
drug monitoring programs requirements saw reduction in opioids 
prescribed to Medicaid enrollees, reducing the total scripts in 
the dosage as well, and a reduction in Medicaid spending on 
those prescriptions. A 2016 CMS bulletin also highlighted 
similar findings.
    Wouldn't you agree that this evidence demonstrates the 
critical role of the PDMPs in addressing the opioid epidemic, 
saving both lives and dollars?
    Ms. Brandt. Yes. We absolutely think the PDMPs play an 
important role. Forty-nine States currently have a PDMP, and we 
are very much committed to continuing to work with them to 
ensure that they are as effective as possible.
    For instance, the State of New York, which has been 
requiring prescribers to access a PDMP, has seen a 75 percent 
drop since 2013 and the number of patients who use multiple 
prescribers and pharmacies for controlled prescription drugs 
just because of the PDMP.
    Mr. Griffith. And appreciate that.
    The Medicaid Partnership Act draft before us allows States 
flexibility in how they design their programs. However, it also 
ensures that PDMPs are a part of Medicaid's provider clinical 
flow work. If more physicians and pharmacists were checking the 
PDMP, would you expect the number of opioid prescriptions to 
decrease? I would.
    Ms. Brandt. Well, as stated with the example I just gave 
you from New York, we think that there is a lot of promise to 
having greater access to PDMPs, and to making sure that people 
are utilizing them.
    Mr. Griffith. Now, here is an interesting twist that we 
have to try to figure out. If you have the prescribers checking 
it, is it duplicative to have the pharmacy checking it also?
    Ms. Brandt. Well, it is a good question. And, as I 
mentioned before, we view the pharmacist as well as the 
prescriber as part of that care coordination team. So it is 
something where prescribers have been checking this, but we 
also view the pharmacist as a part of the discussion, and it is 
something we are certainly open to discussing with you all.
    Mr. Griffith. Yes. I think we do need to discuss it, 
because one of the things that it also says is is that if there 
is a patient in hospice or palliative care, they would be 
exempt from the requirement to consult the PDMP. How is a 
pharmacist going to know that? The prescriber should know that, 
but----
    Ms. Brandt. At this point in time, I do not believe that 
type of information would be available to people checking the 
PDMP, so that would be an impediment.
    Mr. Griffith. Right. So we have got to figure that out if 
we are going to go forward on that particular line of the bill. 
But I do think we are all trying to work in the same direction, 
and I appreciate any input that you can give us to make our 
bill, as we go forward and discuss it, better and practical.
    Ms. Brandt. Well, we look forward to offering technical 
assistance, and this is an area that we have been very focused 
on, so thank you.
    Mr. Griffith. Thank you, and I yield back.
    Mr. Burgess. The chair thanks the gentleman.
    The chair recognizes the gentleman from Florida, Mr. 
Bilirakis, 5 minutes for your questions, please.
    Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it.
    I appreciate your testimony as well.
    Ms. Brandt. Thank you.
    Mr. Bilirakis. Thanks for your patience.
    Ms. Brandt. No problem. It has been a long day for 
everyone.
    Mr. Bilirakis. Yes. Not over yet.
    Last week, CMS issued final rules for Medicare Part C and 
D, which include the rules for the lock-in program. This 
program is important for me not only because I authored the 
provision, but also because addiction is a serious problem that 
cuts across age, gender, and income.
    Programs like Medicare need to have and use all the tools 
available to help beneficiaries. Let's see, can you update the 
Committee on what changes CMS did with this implementation of 
the drug management program for at-risk beneficiaries, also 
known as lock-in, in Medicare's Part D program, please.
    Ms. Brandt. Certainly. As I mentioned in my oral testimony, 
we were very appreciative of the additional tool that Congress 
gave us. This is a very important tool in our fight at the 
Federal level against the opioid epidemic.
    Starting next year, plan sponsors have the option to go 
ahead and implement a lock-in requirement, which would require 
a beneficiary to use certain providers and/or certain 
pharmacies, depending on what is deemed appropriate.
    There is also a proposal in the President's budget to do 
mandatory lock-in for plans. Again, ours is a ``may'' not a 
``shall'' right at the moment, but the President's budget has a 
``shall.'' But we think that the lock-in authority is something 
that will be very helpful.
    We have seen a lot of good results from States. Many of the 
States have been using lock-in authority. And we think that 
some of the early results from States we have seen, such as 
Pennsylvania, which has saved about $55 million in 2016 from 
using lock-in authority, are a good indicator of where we can 
go with this authority going forward.
    Mr. Bilirakis. The President's budget has a ``shall,'' 
recommends a ``shall''----
    Ms. Brandt. Right.
    Mr. Bilirakis [continuing]. As opposed to the ``may''?
    Ms. Brandt. Correct.
    Mr. Bilirakis. And my original bill had a ``shall'' as 
opposed to the ``may.'' Why do you think it is so important 
to--if that is your position as well, because I agree it should 
be a ``shall.'' Why do you think it is so important that we say 
``shall,'' and require them to have the lock-in program under 
Medicare as opposed to giving them a choice?
    Ms. Brandt. Again, it is an important extra tool for our 
toolbox. And if the tool is optional, it doesn't mean it can 
always be used. But if the tool is mandatory, that means it can 
and should be used.
    And it is just another important tool to allow us to 
address those really high over-utilizers and to be able to take 
important steps to limit their usage and to be able to protect 
the program.
    Mr. Bilirakis. And, again, we want to emphasize this is 
only for high risk?
    Ms. Brandt. Only for high risk. Only for those who are 
particularly high risk. And as I indicated from the results we 
saw from the State of Pennsylvania, we think they will also 
have cost implications to the programs in terms of savings, 
which is something that we are always looking for, particularly 
in the Medicare side of the house.
    Mr. Bilirakis. Very good. Thank you. Under Medicare, yes. 
Thank you.
    Next question. Do I have time? Yes, I think I am all right. 
Almost every State Medicaid program runs or authorizes a lock-
in program using, physicians or pharmacies, or a combination of 
both. Every State Medicaid program runs their program 
differently from each other.
    Does CMS currently collect data from States on their 
Medicaid lock-in programs, such as how it is structured, 
eligibility triggers, estimated cost savings, outcome measures, 
or other data that could help States with establishing best 
practices?
    Ms. Brandt. So we are starting to do that through our 
Medicaid drug utilization review program. Our DUR reports that 
we get are allowing us to start to get that sort of 
information.
    We are still sort of, I would say, solidifying exactly what 
requirements we are getting, but it does allow us to get a 
snapshot of what is working. And that is how I was able to give 
you an example from Pennsylvania, where we were able to see 
some initial positive results from their lock-in program. So it 
is something that we are starting to collect.
    Mr. Bilirakis. How many States actually collect this data?
    Ms. Brandt. I would have to get back to you with that. I 
don't know the exact number of States.
    Mr. Bilirakis. But there are advantages for the States to 
collect this data?
    Ms. Brandt. Absolutely. Because as you can tell, you can 
provide savings data. It also provides data on how it reduces 
over utilization and other important markers that we can use 
from a program management perspective.
    Mr. Bilirakis. OK. Very good. Thank you.
    I yield back, Mr. Chairman. Appreciate it.
    Mr. Burgess. The chair thanks the gentleman.
    The gentleman yields back.
    The chair recognizes the gentleman from Indiana, Dr. 
Bucshon, 5 minutes for your questions, please.
    Mr. Bucshon. Thank you, Mr. Chairman.
    I was a surgeon before, and I was in healthcare. I have 
seen this problem coming for 25 years, caught up to us pretty 
quickly for a variety of reasons. There is no one particularly 
at fault, but I think we kind of got caught with that.
    And, it is going to take us a while to get out of this 
problem. It is a multifactorial in origin as well as the 
solutions to it, all the way from border security and 
preventing the 90 percent of heroin that comes to the United 
States from coming across our southern border, all the way to 
the other end of the spectrum where we have to provide 
affordable treatment options for people who are currently 
addicted.
    I have seen countless families in my district, in the 8th 
District of Indiana, destroyed due to this. We are losing a lot 
of people in all of my counties. Rural America is devastated by 
this problem.
    And I believe that some more emphasis maybe should be 
placed on innovative treatments, including medications and 
devices, to help individuals manage pain without becoming 
dependent on opioids.
    And CMS plays a critical role in this effort. That is why I 
have worked with Scott Peters, who is down at the end, on the 
Postoperative Opioid Prevention Act to create a temporary pass-
through payment to encourage development of nonopioid drugs for 
post-surgical pain management and Medicare.
    Additionally, I am working on a draft legislation to add an 
evaluation of management of chronic pain to the Medicare 
initial assessment, which would include an emphasis on 
nonopioid pain management alternatives. Have you had a chance 
to look at those options?
    Ms. Brandt. I have not personally, but I know that our 
office has been reviewing them for technical assistance.
    Mr. Bucshon. OK. It is important to remove barriers to 
access for patients new options for management of post-surgical 
and chronic pain in order for society to shift from the 
overreliance on opioids.
    My daughter, for example, had her wisdom teeth taken out, 
and her dentist wrote a prescription for 60 opioids. Of course, 
my wife and I are doctors. We never filled it. We said, some 
ice on the cheeks and a little bit of Advil and Tylenol. But 
you see the extent of this problem.
    We still, even as a provider, I will say that providers are 
part of the solution, and I think we are doing much better, but 
we have a way to go. It is a cultural shift that we need. It is 
starting in training, I think, all the way up through current 
practitioners, and I think that we are going to get there.
    I know there are barriers to nonpharmaceutical therapies 
for chronic pain. I think someone asked you earlier about that. 
How can those barriers be addressed and primarily its coverage 
decisions from CMS, honestly, to increase the utilization of 
evidence-based therapies, particularly FDA-approved medical 
devices for pain?
    Ms. Brandt. So as I mentioned earlier, we are constantly 
looking at CMS to determine how we can look at evidence-based 
criteria to improve our coverage decisions. One of the things 
we really would like to do and are trying to do is, within our 
statutory authority, to expand the amount of nonopioid 
alternative treatments that we can cover as much as possible.
    And we are committed to working with the FDA and our other 
partners to really try and expand our reach of that as much as 
possible. We have been working very much with NIH to get more 
clinical evidence to support our coverage decisions and are 
continuing to try and fast track all of that to open up as many 
new options as we can.
    Mr. Bucshon. And administrator Verma met with the Doctors 
Caucus this morning, and we talked a little bit about that. And 
I know that that is a goal to try to, and you may need some 
more authority legislatively, I think, to adapt, because we 
need to be more nimble here. If we have something that is FDA 
approved, we need to get coverage decisions in a more nimble 
way, not reinvent the wheel.
    And I have found, since I have been in Congress--this is my 
8th year--that coverage decisions are a barrier to access more 
than, I think, I really realized. And it is nobody's fault; it 
is just the way it is.
    Some of the bills before us today will increase access to 
methadone also. An informational bulletin on best practices for 
addressing prescription opioid overdoses, misuse, and addiction 
in Medicaid was issued by your predecessors in the Obama 
administration. That bulletin cautioned that methadone, in 
particular, accounts for a disproportionate share for opioid-
related overdoses and death. Methadone, as everyone knows, is 
an opioid.
    The bulletin also warned of an increased risk of morbidity, 
mortality associated with methadone in the Medicaid population. 
Mr. Chairman, I ask for unanimous consent to submit that CMS 
report for the record.
    Mr. Burgess. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Bucshon. I know every member here wants the patients to 
get the care they need, but we also need to make sure it is the 
right treatment from the right provider at the right time.
    Can you talk about CMS's current work--briefly, because I 
am almost out of time--to better understand the clinical risks 
the literature associates with methadone?
    Ms. Brandt. Certainly. Again, we have been looking at 
different ways that methadone can be utilized where it is 
appropriate, both for opioid use disorder and how it is 
currently being utilized for acute pain, in determining whether 
or not there are alternative treatments or other ways that we 
can work with you all in Congress to expand our statutory 
ability to be able to use methadone where appropriate for OUD.
    Mr. Bucshon. OK. Thank you.
    Mr. Chairman, I yield back.
    Mr. Burgess. The gentleman yields back. The chair thanks 
the gentleman.
    The chair recognizes the gentleman from New Jersey, Mr. 
Lance, 5 minutes for questions, please.
    Mr. Lance. Thank you very much.
    And good afternoon to you all.
    In a CMS report on the Medicaid Health Home State Plan 
option, CMS noted States report that they plan to continue the 
Health Home Programs after the current law 8-quarter enhanced 
Federal match ends--and I think it is a 90 percent match--in 
part, because they are saving money.
    CMS explained States believe that the cost savings are a 
result of the improved health status and reduced utilization, 
which are expected to, at a minimum, cover the costs of the 
Health Home Program and anticipate savings in excess of health 
home costs.
    Mr. Chairman, I ask that the report be submitted for the 
record.
    Mr. Burgess. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Lance. Thank you.
    Given these findings, what impact would an additional year 
of enhanced Federal matching for Health Homes have for States? 
Do you think more States would adopt this special model to 
provide care coordination and wraparound services for patients 
with substance abuse disorders?
    Ms. Brandt. We have seen good initial results from the 
Health Home, particularly in Vermont, with the hub-and-spoke 
model that we have there. The Health Home has seemed to be very 
positive and had very good results.
    So it is something that we are supportive of because the 
Health Homes do provide us with another option to provide the 
right care in the right setting, and Health Home can be an 
important part of that.
    Mr. Lance. I would imagine that funding is safe if patients 
are permitted to stay in their homes. I think that that 
probably is a cost saver.
    Ms. Brandt. I can't speak to that specifically, because I 
haven't seen numbers to support that. But like I said, at least 
initially, based on the Vermont model, it does seem that they 
have achieved some savings using the Health Home model.
    Mr. Lance. I thank you very much.
    And, Mr. Chairman, I yield back 3 minutes.
    Mr. Burgess. The chair thanks the gentleman.
    The chair recognizes the gentlelady from Indiana, Mrs. 
Brooks, 5 minutes for your questions, please.
    Mrs. Brooks. Thank you, Mr. Chairman.
    And thank you for being here and for your work.
    One of the reasons why I think the opioid epidemic has 
become so pervasive is because of the prevalence of pain, and 
pain being the most common reason Americans access the 
healthcare system to begin with, and number one cause of 
disability in the country. We know pain is a major contributor 
to healthcare costs, not to mention societal costs and the 
economic loss because of the opioid crisis.
    But how can HHS and CMS ensure that educators, or providers 
rather, are better educated about pain management alternatives, 
including the technological alternatives to opioids that Dr. 
Bucshon was just talking about?
    In a previous answer, I know you mentioned the Medicare 
Learning Network. I would like to know a little bit more about 
how you are doing more of the education for providers?
    Ms. Brandt. Ma'am, it is a great question. I think the pain 
issue is one that we have really tried to address through 
multiple fronts at CMS. Part of it is having more of a 
discussion with providers about pain.
    Our quality measures used to have pain management survey 
questions in them. We have changed those to have it be more of 
a discussion about pain instead of how can we just manage your 
pain. It is having a discussion about the type of pain and sort 
of why that is happening and trying to figure out the right 
solution.
    We have also been working on quality reporting on adverse 
events in the hospital to sort of work with physicians to say, 
OK, how can we have a better understanding of this? How do you 
know what the alternatives are?
    So part of that is through the outreach we do through our 
quality improvement organizations, our QIOs, and our quality 
improvement network. They do a lot of outreach in physician and 
hospital education.
    We use the Medicare Learning Network, MLN, that I talked 
about before, where we issue a lot of bulletins electronically 
that go to physicians and hospitals to update them on, Hey, 
here is a new treatment that you might not be aware of, or, 
Here is some new developments that we have on coverage for 
alternative treatments.
    We have also tried very much to have more of an ongoing 
dialogue through open-door forums and just more one-on-one 
educational interactions with various medical societies and 
others, to really educate them about what we are doing, and to 
hear from them about how we can do better.
    So I think there is always more that we can do, but we have 
really been trying to do it through both an in-person and 
virtual approach, and think we can do more.
    Mrs. Brooks. How do you know about the utilization of that 
type of information?
    Ms. Brandt. Well, that is the challenge. We have a good 
idea of how many people subscribe, for instance, to our 
Medlearn Matters articles. We have a good idea of how many 
people participate in our open-door forums and things like 
that.
    But a lot of that information then gets disseminated on 
even further from there, so it is hard for us to completely 
track. But we are trying to do a better job of targeting our 
outreach.
    And one of the things that our stakeholder sessions taught 
us was that we really are thinking through how we can better 
partner with our Federal partners and our private sector 
partners, the plans, a lot of the associations and others, to 
do more coordinated outreach and education in this space, and 
that is something we are currently working on.
    Mrs. Brooks. When we passed in CARA, the interagency group 
that was formed with various Federal partners to focus on 
prescribing practices? Are you familiar with that group?
    Ms. Brandt. I know that we have participation in many types 
of groups like that. I am not sure if it is the one 
specifically described in CARA. I can get back to you. But we 
are in active coordination and discussions with CDC, NIH, 
SAMHSA-HRSA, all of the different components within HHS, DEA, 
and others to kind of work and sort of figure out how our piece 
as a payer impacts with the different pieces that they have 
from the other perspectives.
    Mrs. Brooks. I would be interested in you getting back to 
us as to whether or not----
    Ms. Brandt. We will certainly follow up.
    Mrs. Brooks [continuing]. This was part of CARA. And I 
would like to know, and I think it would be important for you 
to participate.
    Would you agree, however, that we could continue to do even 
more prescriber education? And I am working on a bill to 
require more prescriber education, but to allow it to be 
focused at the State level, and to have the societies and the 
other entities at the State level oversee that type of 
training, because not all States require continuing medical 
education. Were you aware of that?
    Ms. Brandt. I did not know that.
    Mrs. Brooks. So that is something that not all States 
currently have, and so right now, it is all voluntary. 
Everything is voluntary, is it not?
    Ms. Brandt. Yes.
    Mrs. Brooks. Unless the State is requiring it. Some States 
do. Indiana happens to now require it.
    Ms. Brandt. Right.
    Mrs. Brooks. Thank you.
    I yield back.
    Ms. Brandt. Thank you.
    Mr. Burgess. The chair thanks the gentlelady.
    The gentlelady yields back.
    The chair recognizes the gentleman from Georgia, Mr. 
Carter, 5 minutes for your questions, please.
    Mr. Carter. Thank you, Mr. Chairman.
    Thank you, Ms. Brandt, for being here. Appreciate it very 
much.
    I want to talk to you, first of all, about abuse deterrent 
formulations. To be quite honest with you, in my years of 
practice in pharmacy, when this first came out, I wasn't too 
high on it.
    But now that we have developed as much of a problem as we 
have with the opioids and drugs of abuse, I am beginning to 
warm up to it quickly. And I see the usefulness of it and the 
fact that you won't be able to crush it so that you can't snort 
it or turn it into an injection.
    I understand that there might be some extra cost involved. 
I am wondering what kind of barriers that your agency is seeing 
in using these medications, and what is limiting the use to 
access to these types of medications?
    Ms. Brandt. So right at the moment, we agree that abuse 
deterrent opioids are definitely a potential tool in tackling 
this epidemic. At this point, the epidemic is so pervasive that 
we are looking at any and all tools.
    Mr. Carter. Exactly. I would agree with that.
    Ms. Brandt. We need to explore all. I think under our 
current statute, we cannot tell our plan sponsors what to 
negotiate and what types of drugs that they have to cover on 
their formularies. It is the plan sponsors' responsibility to 
do negotiations and negotiate with drug manufacturers and 
determine which of the FDA-approved medications to make 
available to the----
    Mr. Carter. Now, who sets forth those results and 
regulations? Is that in the statute?
    Ms. Brandt. It is under current statute, yes, sir.
    Mr. Carter. So that is something we in Congress can help 
you with?
    Ms. Brandt. You have the ability to influence that, yes.
    Mr. Carter. OK. Well, that was my next question, how can we 
help you? And you just answered it. We can help you by 
rewriting those rules and regulations to include this.
    Ms. Brandt. As I said, right at the moment, we cannot 
interfere in those negotiations under the statute as it is 
currently written. If you all were to change that, that could 
potentially give us more flexibility.
    Mr. Carter. Right. Well, as this evolves and as it 
continues, it is certainly something we need to be looking at 
from a perspective here.
    I want to go now to the Medicaid Pharmacy Home Act. And 
before I ask you just a couple of questions about it, I want to 
compliment my colleague, Mr. Bilirakis, in his work on this. I 
think this is good.
    I have been involved during my time of practicing pharmacy 
with lock-ins, and I see the advantage of them, but I also see 
some concerns. I do think that they can help lower the 
incidents of fraud and abuse.
    But at the same time, I am just wondering in the 
legislation--pharmacy preference is very important. And I have 
often wondered when these programs are used how they determine 
which pharmacy is going to be the lock-in pharmacy.
    What do you think about pharmacy preference and about the 
patient having the ability to request a certain pharmacy?
    Ms. Brandt. Well, I think, as I said, we currently have 
this as an optional authority, starting in 2019, for our plan 
sponsors to do lock-in. And part of it is working with the 
beneficiary to make sure that it is a pharmacy that fits for 
them, that is geographically appropriate, that is somewhere 
that they can access.
    And part of that is the right care and the right setting 
that I was talking about before. So I think that our 
expectation is that pharmacies and plans will work with the 
patients and the providers to make that best fit.
    Mr. Carter. Well, one of my concerns is access to the 
medication. I have seen situations where they are locked in to 
a pharmacy. That is the only place they can get it, and that 
pharmacy might not have a certain product that they need, and, 
therefore, the access is denied.
    What do you think about having more than one pharmacy in 
that situation?
    Ms. Brandt. Well, that is one of the reasons where we gave 
some flexibility to be able to potentially have, in certain 
instances, pharmacies or providers and, again, trying to do so 
in a limited way to sort of limit the potential for abuse, but 
yet, still be able to give those options that you are talking 
about.
    Mr. Carter. Well, I am glad to hear you say that, because I 
think that is going to be extremely important. I know that the 
lock-in provisions can work, but I am very concerned about 
accessibility and particularly about patient preference. That 
is very important.
    And certainly, in this situation, I think it would be most 
important in working with the patient to make sure that they 
are getting the pharmacy preference of their choice would be 
paramount, I think, in this situation.
    Well, thank you for what you are doing. Appreciate you 
being here today.
    Mr. Chairman, I yield back.
    Ms. Brandt. Thank you.
    Mr. Burgess. The gentleman yields back. The chair thanks 
the gentleman.
    All members of the subcommittee having had an opportunity 
to ask questions with the exception of the chairman, the 
chairman will now recognize the gentleman from the full 
committee, Mr. Tonko of New York, 5 minutes for your questions.
    Mr. Tonko. Thank you, Mr. Chair. Thank you for letting me 
waive onto the subcommittee.
    Before I begin, Mr. Chair, I have a unanimous consent 
request. I have here letters of support for the Medicaid 
Reentry Act from National Association of Counties, the American 
Medical Association, the American Society of Addiction 
Medicine, the American Psychiatric Association, Community 
Resources for Justice, the International Community Corrections 
Association, the National Commission on Correctional 
Healthcare, and the Coalition to Stop Opioid Overdose.
    I would ask unanimous consent, Mr. Chair, that these 
letters be entered into the record.
    Mr. Burgess. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Tonko. Thank you, Mr. Chair, for holding this important 
hearing and for including legislation that I have authored, the 
Medicaid Reentry Act, as a part of this conversation.
    And welcome, Ms. Brandt.
    My goal with the Medicaid Reentry Act is simple: To reduce 
overdose deaths among individuals leaving jail or prison and 
returning to the community. We have heard from earlier hearings 
in this committee that this is a uniquely vulnerable population 
with the risk of overdose reaching as high as 129 times that of 
the general population during the first 2 weeks of post 
release.
    To reiterate, 129 times more likely to die of an overdose 
during the period in time when an individual is supposed to be 
getting a second chance at life. That number is astounding and 
should serve as a moral call to action for our nation.
    The good news is that we are not helpless when it comes to 
solutions. We just need to have the will to see them through. 
Expanding quality addiction treatment to individuals while 
incarcerated can dramatically improve health outcomes and 
reduce overdose deaths and recidivism.
    Early reviews of a groundbreaking program in Rhode Island 
that provides access to all forms of medication-assisted 
treatment in jails and prisons resulted in a 61 percent decline 
in overdose deaths post release.
    However, widespread implementation of programs like this 
still face a number of obstacles, not least of which is 
funding. That is where my legislation enters in, as it would 
grant States new flexibility to draw Federal Medicaid funds for 
services provided to existing incarcerated Medicaid 
beneficiaries in the 30-day period prior to release.
    It is just common sense to initiate treatment for 
incarcerated individuals who are about to be released while 
they are in a stable, controlled setting rather than the moment 
they are thrown back out into the often chaotic environment to 
which they will be returning.
    I would like to get some feedback from CMS on ways that the 
agency can utilize Medicaid as a tool to help this vulnerable 
population. And so, Ms. Brandt, given this administration's 
openness to providing States with structured waiver guidance 
when it comes to outdated payment restrictions in Medicaid when 
these policies stand in the way of providing beneficiaries 
quality addiction treatment such as the IMD waiver guidance, I 
am wondering if CMS has contemplated, or would be open to, 
promoting limited waiver opportunities around the inmate 
payment restriction that would similarly promote the agency's 
goal of reducing overdose deaths and improving care 
coordination for beneficiaries?
    Ms. Brandt. Well, this is an issue actually that we have 
heard from several stakeholders about. And we have had some 
very extended conversations internally, and I think we are very 
much willing to work with you and this committee to look at 
what the options are, because we understand that this is a big 
issue. It is one that several States have come to us about, and 
we would be very much willing to talk with you all about where 
we could potentially have some flexibilities.
    Mr. Tonko. That is wonderful. It is just encouraging that 
the agency would commit to working with me and other interested 
stakeholders to explore the possibilities of developing 1115 
waiver guidance around the inmate payment restriction issue, so 
I appreciate that.
    One other obstacle that Medicaid beneficiaries leaving 
correction settings face is that many States terminate rather 
than suspend Medicaid coverage for incarcerated individuals. 
When States terminate benefits, this can lead to a lengthy 
reapplication process and gaps in care at a time when these 
beneficiaries are most vulnerable.
    How can CMS take a leadership role in encouraging States to 
suspend rather than terminate Medicaid benefits for 
incarcerated individuals which public health advocates 
overwhelmingly agree is a best practice?
    Ms. Brandt. That is another issue that has come to our 
attention and that we have been talking about how we can work 
with States to perhaps share best practices or better guidance, 
and look forward to continuing to work with you and the 
Committee on possible solutions.
    Mr. Tonko. Well, whatever we can come up with. I am open to 
suggestions that your agency can offer us in terms of speaking 
to the needs of the incarcerated population. The stats are very 
much a guiding tool.
    And we need to develop policy, I believe, that will 
substantiate the effective use of taxpayer dollars and not have 
recidivism be part of it, and in a bolder sense, save lives.
    So I thank you very much for your kind attention and look 
forward to working with the agency, with you, in particular.
    And, Mr. Chair, I yield back.
    Ms. Brandt. Thank you.
    Mr. Burgess. The chair thanks the gentleman. The gentleman 
yields back.
    I am going to recognize myself for questions.
    And, Mr. Tonko, I will just point out the--that is an issue 
that has been worked on in the past, in particular, with 
individuals who have been charged but then released so they 
were not actually found guilty.
    And they fall into that conundrum that you describe, and 
they have to go through the reapplication process. And that is 
really not an agency problem; that is a legislative problem at 
some point in the distant past governed by offset, and that was 
an offset that produced a pay-for for some other policy that 
some other Congress thought was important. But I agree with 
you, that needs to be remedied, and I have heard from people as 
well.
    Mr. Tonko. All right. Well, I thank you, and I look forward 
to working with you also, Mr. Chair.
    Mr. Burgess. Let me just ask you--and, Ms. Brandt, I also 
want to just address the Bilirakis bill on the lock-in. Many, 
many, many years ago when I was a resident in training an 
attending physician pointed out to us that one of the highest 
risk situations in medicine was when two doctors were writing 
insulin orders or more than one doctor was writing insulin 
orders.
    He said, in fact, the only thing more dangerous than two 
doctors writing insulin orders is two doctors writing pain med 
orders. Any way you stop and think about it, in the continuity 
of care and do people communicate with each other, and you can 
very quickly get into a high-risk situation.
    So I think the lock-in provision is--and some people see 
that as a restriction of access, but actually, I see that as 
continuity of care and actually good patient care. And I hope 
we get a chance to work on that when we do our formal markup.
    Mr. Bucshon talked about the methadone program. When I was 
in medical school in the 1970s, I actually spent a month in a 
methadone clinic. I don't think it has changed a lot since the 
1970s.
    Ms. Brandt. Probably not.
    Mr. Burgess. And it was hard on people to--you have to go 
every day. You have to sign in. You have to wait your turn. You 
have to take your stuff. People have to see you take your 
stuff. It becomes very, very hard to maintain outside 
employment because you are spending so much time dealing with 
the methadone maintenance. I don't know if there is a way to 
change that, but I think Dr. Bucshon is onto something. We do 
need to think about how we are administering that.
    We have a GME transparency bill, one that I have been 
interested in. There was a GAO report that said graduate 
medical education in 2015, State agencies--State and Federal 
Medicaid agencies spent over $16 billion for graduate medical 
education making Medicaid the second largest payer of graduate 
medical education.
    But they also pointed out a lack of transparency. Do you 
agree that it is important to know how those dollars are being 
spent and where they are being spent?
    Ms. Brandt. Absolutely. Transparency on spending of that is 
very important.
    Mr. Burgess. So you would be in agreement that better 
transparency going forward with our Medicaid GME dollars makes 
sense?
    Ms. Brandt. All Federal dollars need to be accounted for.
    Mr. Burgess. Thank you for that. I certainly agree.
    Now, I mentioned in my opening statement, and I think we 
heard from Mr. Shimkus on the protecting legitimate access to 
patients who are on--not just cancer patients but people who 
have chronic pain conditions and are maintained on an opiate 
and it works well, and, in fact, they are able to maintain 
outside employment and family relationships. So while they may 
be habituated they are not addicted, they don't exhibit 
addictive behavior, unless, of course, their chain of therapy 
is broken. So the forced attenuation of therapy or the rapid 
attenuation of therapy is something that many outside groups 
are concerned about. I am concerned about that because I think 
we will drive some of these individuals from their structured 
maintenance on an opiate for their chronic pain, and they will 
look for other avenues, and as we all know, those other avenues 
are heroin and fentanyl, and they are not safe because of the 
quality control that the criminal element does not participate 
in, and that is where our deaths come from.
    So I want us to be careful about the prescriptions going 
out, and I think your overuse of work that you are doing is 
extremely important, and I want to be supportive of that, but I 
think we also have to recognize there are people where, again, 
we can't tighten that bolt down any more without breaking it 
off, and that would be a bad thing.
    Ms. Brandt. No, absolutely. We absolutely concur.
    Mr. Burgess. Just on the issue of the overuse or 
overutilization, and I appreciate that you are focusing on 
providers, I appreciate you are focusing on patients, but I 
have got to tell you, one of the things that has been 
frustrating for me, the CMS has a lot of data at your disposal, 
and we have come up against problems where pharmacies in 
relatively small communities have received way too much product 
for the patient populations they are treating, and I hope you 
will use when you talk about overutilization, yes, focus on the 
doctors who are outliers, focus on the patients who are 
overconsumers, but really, those fact manufacturers who to whom 
you are then writing reimbursements, that needs to be part of 
the equation, as well. And I will just tell you here at the 
committee level we need help with that. While there are other 
agencies that have not been as helpful or as forthcoming as 
they could have been, but CMS does have that data, and we need 
your help on that.
    I have a number of other questions that I am going to 
submit in writing because I can see Mr. Green is getting 
nervous, but I do want to thank you for your time today, and I 
think we have learned a lot today in this hearing, and I know 
there was some criticism that we were taking on a little bit 
too much work, but I think it is important, and I don't think 
there was anything that we heard today that was superfluous or 
duplicative or anything that actually wasn't important for us 
to hear. But I thank you for your testimony.
    Let's see. We are going to recess until tomorrow morning at 
10:15 at which time we will reconvene with our second panel 
that is going in a room upstairs. Obviously, Ms. Brandt, you 
are excused, and we appreciate your participation, but without 
objection, the subcommittee will go into recess and convene 
tomorrow morning at 10:15 a.m.
    [Whereupon, at 6:00 p.m., the subcommittee recessed, to 
reconvene at 10:15 a.m., Thursday, April 12, 2018.]



  COMBATING THE OPIOID CRISIS: IMPROVING THE ABILITY OF MEDICARE AND 
              MEDICAID TO PROVIDE CARE FOR PATIENTS, DAY 2

                              ----------                              


                       WEDNESDAY, APRIL 12, 2018

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:16 a.m., in 
room 2123 Rayburn House Office Building, Hon. Michael Burgess 
(chairman of the subcommittee) presiding.
    Members present: Representatives Burgess, Guthrie, Barton, 
Shimkus, Latta, Lance, Griffith, Bilirakis, Bucshon, Brooks, 
Mullin, Hudson, Collins, Carter, Walden (ex officio), Green, 
Engel, Schakowsky, Butterfield, Matsui, Castor and Kennedy.
    Also present: Representatives Kinzinger and Tonko.
    Staff present: Daniel Butler, Staff Assistant; Zachary 
Dareshori, Legislative Clerk, Health; Paul Eddatel, Chief 
Counsel, Health; Margaret Tucker Fogarty, Staff Assistant; 
Caleb Graff, Professional Staff Member, Health; Jay Gulshen, 
Legislative Associate, Health; Ed Kim, Policy Coordinator, 
Health; Drew McDowell, Executive Assistant; James Paluskiewicz, 
Professional Staff, Health; Kristen Shatynski, Professional 
Staff Member, Health; Jennifer Sherman, Press Secretary; Josh 
Trent, Deputy Chief Health Counsel, Health; Jacquelyn Bolen, 
Minority Professional Staff; Waverly Gordon, Minority Health 
Counsel; Tiffany Guarascio, Minority Deputy Staff Director and 
Chief Health Advisor; Una Lee, Minority Senior Health Counsel; 
and Samantha Satchell, Minority Policy Analyst.
    Mr. Burgess. The Subcommittee on Health will come back to 
order.
    We want to thank our witnesses for being here and joining 
us again this morning, taking their time to testify before the 
subcommittee. Each witness will have an opportunity to give an 
opening statement followed by questions from members.
    This is a continuation of yesterday's hearing, so we will 
not go through opening statements from the top of the dais. 
People heard enough from us yesterday.
    So, today we are going to hear from the Honorable Michael 
Botticelli, the Executive Director, Grayken Center for 
Addiction, Boston Medical Center; Mr. Toby Douglas, Senior Vice 
President for Medicaid Solutions, Centene Corporation; Mr. 
David Guth, CEO of Centerstone; Mr. John Kravitz, the Chief 
Information Officer from Geisinger Health System, and Mr. Sam 
Srivastava--close enough?--the CEO of Magellan Healthcare.
    And we do appreciate all of you being here with us today.
    Mr. Botticelli, you are now recognized for 5 minutes to 
give a summary of your opening statement, please.

 STATEMENTS OF MICHAEL BOTTICELLI, EXECUTIVE DIRECTOR, GRAYKEN 
  CENTER FOR ADDICTION, BOSTON MEDICAL CENTER; TOBY DOUGLAS, 
     SENIOR VICE PRESIDENT FOR MEDICAID SOLUTIONS, CENTENE 
   CORPORATION; DAVID C. GUTH, JR., CHIEF EXECUTIVE OFFICER, 
   CENTERSTONE; JOHN M. KRAVITZ, CHIEF INFORMATION OFFICER, 
GEISINGER HEALTH SYSTEM; AND SAM K. SRIVASTAVA, CHIEF EXECUTIVE 
                  OFFICER, MAGELLAN HEALTHCARE

                STATEMENT OF MICHAEL BOTTICELLI

    Mr. Botticelli. Thank you, Chairman Burgess, Ranking Member 
Green, and members of the committee. It is a privilege and 
honor to be before you again. And I really want to thank you 
for your continued leadership on this issue.
    I really want to focus today on how we can make progress, 
continued progress, against the opioid epidemic, and 
particularly the roles of Medicaid and Medicare in combating 
this crisis.
    As I said and as your introduction, I am the Executive 
Director of the Grayken Center of Boston Medical Center. We are 
the largest safety net provider in New England with 
approximately 42 percent of our patients entering through 
Medicaid and another 27 percent through Medicare.
    For decades, BMC has been a leader in treating substance 
use disorders. Many BMC programs have been replicated not only 
across Massachusetts, but nationally. The Grayken Center for 
Addiction at BMC encompasses over 18 clinical programs for 
substance use disorders.
    I offer my perspective not only as the Executive Director, 
but with over 25 years' experience in addiction services, 
having formerly the honor of serving as the Director of the 
White House Office of National Drug Control Policy and as the 
Director of the Massachusetts Department of Public Health. My 
perspective is also as a person in long-term recovery with over 
29 years in recovery.
    The experience at BMC and in Massachusetts highlight the 
critical role that Medicaid plays in addressing the opioid 
epidemic, and this cannot be overstated. The vast majority of 
BMC patients receiving treatments for opioid addiction have 
Medicaid, which is widely available to low-income individuals 
and families and covers a comprehensive set of benefits that 
allow our providers at BMC to offer our patients the highest- 
quality care while also at the same time reducing healthcare 
costs.
    Massachusetts Medicaid covers all three FDA-approved 
medications, includes naloxone on its formulary, and will soon 
cover residential rehabilitation services and recovery coaching 
services, all benefits which are not available in many other 
state Medicaid programs. Sadly, in America today access to 
treatment is very much dependent on where a person lives.
    Among the many bills under consideration by your committee 
are new opportunities for Medicaid to play a more substantial 
role in addressing the opioid epidemic, and here are a few, I 
think, for action:
    All FDA-approved medications for opioid use disorder should 
be available to patients. Evidence for medication for addiction 
and treatment is unequivocal. Patients with medication 
experience significantly improved rates of recovery and, simply 
put, they don't die. Yet, many settings do not make all or some 
of the medications available because of coverage rates and 
often ideas and philosophy. Only one in five people with opioid 
use disorders receive medication, while the percentage for 
youth is even less. In the words of Secretary of Health and 
Human Services Alex Azar, ``Failing to offer medication is like 
trying to treat an infection without antibiotics.''
    And, like any disease, clinicians need as many treatment 
tools as possible because what works for one person might not 
work for the next. However, many patients are limited to what 
medications they can access, if any. Medicare, for example, 
does not cover outpatient opioid treatment programs, although 
there are bills, including one by Ranking Member Pallone, to 
address this. And also, any federally-funded substance use 
disorder treatment program that bills Medicaid or Medicare 
should be required to provide medications consistent with 
approved best practices.
    Medicaid and Medicare should make naloxone universally 
available, preferably without a copay. In 2017, Massachusetts 
for the first time saw an 8.3 percent drop in annual opioid 
overdose deaths, the first year it decreased since 2010, but at 
the same time the number of non-fatal overdoses went up. What 
it suggests is that broad availability of naloxone in 
Massachusetts is keeping more people alive while the epidemic 
is continuing to grow. Just last week, the Surgeon General of 
the United States urged people to carry naloxone.
    Overdose data in Massachusetts also show that individuals 
recently released from incarceration overdose at 120 times the 
rate of the general public, most often within the first 2 
weeks. This devastating trend emphasizes the need to focus on 
transitions of care for patients leaving incarceration, as well 
as treatment during incarceration, as several bills under 
review by this committee have proposed.
    Despite modest decreases in prescribing in the United 
States over the past few years, prescribing opioids is still a 
driver of this epidemic. Medicare and Medicaid should mandate 
that prescribers have continuing medical education around safe 
prescribing as well as they register and use state-based 
prescription drug monitoring programs in order to more 
appropriately treat pain and to diligently track prescribing 
patterns.
    To complement these successful efforts to reduce opioid 
prescribing, we need to ensure that patients have access to 
non-pharmacologic pain management strategies such as 
acupuncture, physical therapy, and cognitive behavior therapy. 
Unfortunately, only about half of state Medicaid programs 
specifically support these services.
    Access to services continues to be a barrier in many parts 
of the country. One study showed that only 40 percent of 
counties in the United States did not have an outpatient 
treatment program that accepted Medicaid, and CMS could do more 
to expand its network.
    BMC has many treatment programs that have become national 
models. The foundation of all these programs is the absence of 
stigma. Without exception, patients who are aided to recovery 
at BMC credit the lack of judgment they felt in our programs. 
Medicaid and Medicare can and should do more to get evidence-
based addiction treatment to all these patients. Addiction is a 
disease, and long-term recovery should be the expected outcome 
of any treatment.
    Thank you, and I look forward to your questions.
    [The prepared statement of Mr. Botticelli follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    
   
    
    Mr. Burgess. We thank you for your testimony.
    Mr. Douglas, you are recognized for 5 minutes, please.

                   STATEMENT OF TOBY DOUGLAS

    Mr. Douglas. Mr. Chairman, members of the committee, thank 
you so much for inviting me to this hearing and your leadership 
on this issue.
    My name is Toby Douglas. I am the Senior Vice President for 
Medicaid Solutions at Centene Corporation. Centene is the 
largest Medicaid managed care plan in the country, serving 7.1 
million members in 25 different States. I am also the 
Commissioner on the Medicaid and CHIP Payment and Access 
Commission, known as MACPAC, and a board member on Medicaid 
Health Plans of America, a health plan association. And 
previously, I was a longstanding Medicaid director and 
behavioral health director in California for the Department of 
Health Care Services. So, my testimony today is really based on 
my experience in all these positions as well as my interactions 
with colleagues in these various states and managed care 
organizations who are all working together to combat this 
epidemic.
    The epidemic disproportionately affects Medicaid 
beneficiaries. And a few facts from my written testimony:
    Opioid addiction is estimated to be 10 times as high in 
Medicaid as in commercial populations.
    Medicaid beneficiaries are prescribed opioids twice as much 
as individuals in commercial insurance.
    And Medicaid has higher rates of hospitalization and 
emergency department use for drug poisoning and six times the 
risk of overdose death.
    So, Centene, other Medicaid MCOs, and States are taking a 
comprehensive approach on prevention, treatment, and recovery. 
First, we are working with members and providers to prevent 
addiction from occurring by curbing excessive prescribing 
patterns. We are preventing overdose. And finally, we are 
facilitating treatment and recovery in chronic opioid users.
    I am going to lay out different areas where Congress can 
enact policies that really further the ability of Medicaid 
managed care organizations and states to take a comprehensive 
approach to prevention and treatment.
    First, there needs to be the adoption of best practices and 
ensuring appropriate prescribing and utilization patterns and 
increased member and provider education. For example, States 
and MCOs are taking several actions related to improved 
formulary management. MCOs and States are removing medications 
from the formulary that could have a greater potential for 
misuse. They are limiting early refills and prescription 
quantities and duration. And finally, some plans, including 
Centene, are using prescription data to lock in high-risk 
individuals to one prescriber and/or one pharmacy to fill 
opioid prescriptions.
    Congress should also invest in the development of 
continuum-of-treatment modalities, including the use of 
medication-assisted treatment and ASAM criteria. Several States 
as well as managed care organizations are working to expand the 
availability of MAT, recognizing there is a significant 
shortage in this area, and they are implementing very 
innovative models that are using the expertise of both a hub, 
which serves as kind of a center of excellence, and spokes to 
expand the access to MAT in primary care settings.
    Congress should eliminate the Medicaid payment restriction 
on residential treatment, also known as the IMD restriction in 
substance use. This is an important component of the overall 
continuum-of-treatment modalities and should be done within 
that context of ensuring there are a full continuum of 
services.
    Congress should invest in state adoption of prescription 
drug monitoring programs and use strategies to ensure all 
appropriate entities, including both the Medicaid agency 
systems, managed care entities, and providers have efficient 
access to PDMP data.
    Congress should reform 42 CFR Part 2 to align substance use 
disorder privacy protections with HIPAA. The lack of alignment 
between Part 2 and HIPAA really is a challenge for overall 
primary care and behavioral health integration, and there needs 
to be the reform to align those privacy protections with HIPAA, 
but at the same time maintaining the important patient 
information around substance use from any type of use for 
criminal, civil, or administrative proceedings.
    And finally, the last point I leave you with is that 
Congress should look to invest in State officials Medicaid 
leadership as well as ensuring that leadership is investing 
appropriately in managed care organizations. States continue to 
face considerable staff turnover in their Medicaid agencies and 
leadership. And in order to ensure that States have the right 
leadership to address this epidemic as well as future public 
health crises, there needs to be an investment in the 
appropriate resources, so that both the States as well as the 
MCOs can execute the right policies.
    Thank you very much.
    [The prepared statement of Mr. Douglas follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    
    
    Mr. Burgess. We thank you for your testimony.
    Mr. Guth, you are recognized for 5 minutes, please.

                STATEMENT OF DAVID C. GUTH, JR.

    Mr. Guth. Thank you, Mr. Chairman, and my thanks to the 
Committee for your comprehensive work on this epidemic that is 
ravaging our country. I want to say a special thank you to 
Representatives from our service area: Congressmen Guthrie, 
Bucshon, Brooks, Bilirakis, Shimkus, and Blackburn.
    And I am honored to be here today not only as the voice of 
my colleagues at Centerstone, but really on behalf of the 
nearly 180,000 people at Centerstone that we serve each year.
    So, a little bit about Centerstone. We are celebrating our 
63rd year of service as a not-for-profit behavioral health 
organization, and we provide a comprehensive set of services 
throughout our footprint of Florida, Indiana, Illinois, 
Kentucky, and Tennessee. We also serve individuals beyond that 
footprint, principally through our network of specialized 
therapists providing service to men and women who serve this 
country in uniform and their loved ones.
    Do we really know how to treat opioid addiction? Do we have 
proven treatments and recovery strategies to move people out of 
opiate dependency and into recovery? And the simple answer is, 
yes, we do. But, unfortunately, far too few people have access 
to comprehensive evidence-based treatment they need.
    There are many reasons why this is the case. A major 
challenge is a lack of providers. We know that there are more 
than 30 million Americans, living principally in rural 
communities, who have no access to treatment whatsoever for 
their condition, let alone comprehensive evidence-based ones.
    Another challenge is that in places where treatment options 
do exist, many available are woefully inadequate. This stems 
from the fact that fundamentally we do not as a Nation treat 
opioid use disorder like the chronic disease that it is. And 
despite the body of evidence, there are no standards of quality 
care that providers are held to and no consistent protocols for 
care. This is a dramatic departure from our treatment of other 
severe health conditions. The experience for someone seeking 
treatment for substance use, opioid use in this case, disorder 
is entirely different than that of a heart patient. If an 
opiate-addicted person visits five different treatment centers, 
they might well receive five different treatment protocols. 
What happens is where they present makes a greater difference 
in terms of what they are offered than how they present, and we 
must change that.
    There is no set path a provider is encouraged to follow 
when no one is holding that provider accountable for 
administering an evidence-based protocol or for ensuring that 
the patient has a positive outcome. It is often the case that 
other healthcare providers that may be engaged in that 
patient's care around other disorders may not even know that 
their patient is in treatment for their addiction, let alone 
have access to the full medical record.
    In short, fragmented care and absence of quality standards 
and immense workforce shortages result in delayed access or no 
access at all to lifesaving care. This is what we have to 
change.
    Opioid use disorder is similar to heart disease in that 
there is no one magic bullet for treating it. You cannot take a 
pill so that it will disappear. It is a condition based on the 
patient's presentation and severity that requires a combination 
of treatments--medication, therapy, follow-up care--and a 
condition that may require significant changes in a person's 
life to overcome. Fortunately, there is data that shows what 
can work. This is why we support treatment initiatives that 
approach addiction as a chronic and relapsing disease with 
emphasis on building a patient's recovery.
    However, in order to ensure positive outcomes, we also need 
to modernize our health IT infrastructure and optimize our 
workforce. I realize that saying all of this is the solution is 
much easier said than done. Getting people in need the right 
care close to home means dealing with standards of care, 
infrastructure issues, knowledge gaps, technology gaps, and 
serious shortages among addiction treatment providers.
    Fortunately, many of the bills that have been introduced 
before this committee address these issues. Centerstone 
supports all legislative action that eliminates barriers to 
care and, instead, creates and rewards providers for following 
quality standards, so that when a patient walks through the 
door of any treatment provider, they have the best chance of 
receiving the right services that will help them on the path to 
recovery.
    We support advances in technology-enabled solutions such as 
prescription drug monitoring programs and incentives to 
modernize behavioral health IT. Investments in the health IT 
backbone of our behavioral health system are a critical tool in 
improving care.
    As our chief medical officer often says, the most costly 
care that we provide across this nation is care that does not 
work. We must address that.
    I am going to leave you with a quick story of a gentleman 
that received his care at Centerstone. His name is Keith Farah. 
He is now a peer support specialist at Centerstone. He 
struggled with severe and persistent addiction for years. As he 
put it, ``I had given everyone who loved me more than enough 
reasons to give up. I was homeless, unemployed, and a convicted 
felon. Even worse, I was hopeless and terrified of living life 
sober.'' He made the decision to enter into Centerstone's 
Addiction Recovery Center, and today he celebrates a life he 
never dreamed of.
    So, I know I am out of time here. I just want to say, on 
behalf of all of the teams that provide services to our 
communities, on behalf of the board members that volunteer 
their time and energies to advance this, I want to thank you 
for your attention to this and the opportunity to provide 
commentary. And I look forward to your questions. Thank you, 
Mr. Chairman.
    [The prepared statement of Mr. Guth follows:]
    
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    Mr. Burgess. Thank you for your testimony.
    Mr. Kravitz, you are recognized for 5 minutes, please, for 
an opening statement.

                  STATEMENT OF JOHN M. KRAVITZ

    Mr. Kravitz. Good morning, Chairman Burgess and members of 
the Health Subcommittee of the House Energy and Commerce 
Committee.
    My name is John Kravitz. I am the Senior Vice President and 
Chief Information Officer of Geisinger Health System. I want to 
thank the Committee for holding this hearing on a key issue 
facing the Nation, one that Geisinger and healthcare providers 
are addressing. And that is to combat the national opioid 
crisis.
    Geisinger has employed a multifaceted approach to curb the 
use of opioids, such as utilizing information technology and 
electronic prescribing, implementing best practices for pain 
management, embedding pharmacists in our primary care clinics, 
establishing drug take-back programs, and others. Collectively, 
these initiatives have significantly reduced the use of opioids 
for our patients and members and increased quality of care and 
outcomes by reducing costs.
    With our history as an innovator of health IT and care 
delivery models, we saw opportunity to reverse these trends. 
Our physician leadership proposed, by limiting or eliminating 
the prescribing of opioids in the clinical setting, Geisinger 
could minimize and prevent patients' exposure to these drugs 
and consequent risk of developing an addiction that could lead 
to overdose or death.
    Reducing opioid addictions could also ease the burden on 
healthcare providers. In an analysis of 942 of our patients who 
are also insured by our organization, overdoses were found in 
opioids with steep increases in acute care cost as well as 
emergency department services prior to an overdose.
    We developed and initiated several approaches that focus on 
changing physician practice patterns to reduce the prescribing 
of opioids, including creating a provider dashboard which is 
linked to our electronic health record to identify current 
practice patterns for our providers. We found that providers 
greatly vary in their approaches to prescribing opioids, and 
the smallest number of providers are typically the ones that 
prescribe the largest number of opioid prescriptions. When we 
had this information, we could target the outliers and provide 
them with the best practice for pain management.
    This includes the pain management program for surgical 
patients where we counsel patients and their families to expect 
some manageable level of pain for minor procedures and the use 
of non-addictive alternatives for managing pain. In cases where 
our physicians believe an opioid prescription is in the best 
interest, they are highly encouraged to order smaller 
quantities, seven days or less.
    While I am not a clinician, I am pleased that information 
technology plays an important role in Geisinger's approach to 
decreasing use of opioids. There are several concerns, for 
example, with prescribing opioids through a paper process, 
including drug diversion, prescription forgery, provider DEA 
numbers being exposed to the public, and doctor shopping to 
obtain opioids. We have implemented the following initiatives 
to help alleviate these concerns:
    We are tracking documentation on our electronic health 
records and dashboards that show providers reviewed the 
mandatory PDMP programs, documenting findings in the patient's 
medical records. We are integrating specifically from a pain 
app that we have developed on a mobile device that measures 
physical activity, patient-reported pain, and other metrics 
into the dashboard and feeding into the medical record. And 
finally, we have deployed an EPCS program. Back in August 23rd 
of 2017 and through February of 2018, 74 percent of our 
providers of controlled medications have been prescribed 
through the EPCS system. All 126 of our clinics are on this 
process and having great success.
    Our results are encouraging. We have reduced opioid 
prescriptions by half since launching these initiatives two 
years ago, and monthly average of opioids, we had been 
prescribing about 60,000 per month; we are down to 31,000 and 
that number is dropping.
    Additional information on cost savings we realized from 
implementing the electronic prescribing of controlled 
substances were reducing by 50 percent the number of patient 
calls to determine if their paper prescriptions had been ready 
for them. So, we initially had about 660,000 calls per year 
from our patients for opioid prescriptions. We have reduced 
that to close to 330,000.
    With the number of diversions decreasing, we are able to 
decrease the size of our diversion staff to monitor and manage 
those, and provider time, most importantly, to write an opioid 
prescription with the EPCS system had gone from a time period 
of 3 minutes to write a paper prescription to 30 seconds with 
the EPCS system. Nursing time as well for opioid scripts went 
from 5 minutes to 2 minutes. These cost savings accrued 
approximately $1 million in savings in time and hard-dollar 
savings for our organization.
    Although the dashboard may be unique to Geisinger, we 
believe other health systems and hospitals can generate similar 
reports for opioid prescribing, and their electronic health 
records and clinical entry systems can do the same work that we 
have been doing. The initiatives rolled out by Geisinger are 
broadly applicable to other healthcare systems across the 
country, and we encourage others to apply these strategies to 
their organizations. To succeed, organizations need the support 
of their physician leadership. We are a physician-led 
organization. This is a process change that has to occur with 
physicians; it is not technology. Technology is told to support 
this.
    Everything we do at Geisinger is about caring. Part of our 
caring means that we believe that our members and our patients 
deserve the best care possible and the best outcomes. That is 
why we emphasize and support evidence- based medicine and care 
delivery, including e-prescribing of opioids. The evidence and 
results are clear. E-prescribing has reduced forgery and 
diversion while helping patients avoid all unnecessary exposure 
to addiction and harm.
    So, I would like to close out with a couple of concluding 
comments. We have found that the electronic prescribing process 
has led to quality improvements in care while reducing opioid 
prescriptions, drug diversions, prescription forgery, and 
reducing total cost of care.
    Thank you again for the opportunity to provide these 
thoughts on this critical issue, and I entertain any questions.
    [The prepared statement of Mr. Kravitz follows:]
    
    
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    Mr. Burgess. And thank you for your testimony.
    Now, Mr. Srivastava, you are recognized for 5 minutes for 
your opening statement, please.

                 STATEMENT OF SAM K. SRIVASTAVA

    Mr. Srivastava. Thank you, Mr. Chairman. Mr. Chairman, 
Ranking Member, and all members of the House Energy and 
Commerce Committee, thank you for inviting me to testify today 
on the challenges addressing the opioid crisis and offer 
thoughts about legislative ideas within the Medicaid and 
Medicare programs.
    Magellan Health is a leader in the management of complex 
population health. For over 40 years, we have been pioneers in 
behavioral health, innovators in specialty health, and experts 
in pharmacy services. We work with health plans, employers, 
providers, and government agencies, and we serve 25 million 
people with behavioral health services and 24 million people 
with specialty health services. We are also privileged to be 
able to serve a lot of the members here right on our panel 
today.
    We bring a wide range of experience and challenges facing 
the country with regard to the terrible opioid epidemic. The 
Committee is well aware of the facts of the opioid epidemic. 
The most recent CDC report says that over 42,000 overdose 
deaths occurred by opioids in 2016. This is truly a national 
epidemic, and we commend the Committee for its work to develop 
bipartisan legislation to reduce and prevent addiction and to 
provide treatment and recovery for those facing this disabling 
disease. We look forward to continuing to partner with all of 
you as we move forward in the legislative process.
    So, let me start by saying that the draft bills that have 
been recently introduced are critically important components to 
developing a comprehensive response to the crisis. While we 
have not thoroughly reviewed all of these bills, our initial 
takeaway is that they point in the right direction and the 
Committee is on the right track.
    We need to expand capacity for treatment and recovery 
services, develop programs for at-risk populations that limit 
access to highly addictive drugs. We need to allow further 
access to drug monitoring program data, so providers, health 
plan clinicians, and care coordinators can access an 
individual's controlled substances history to identify 
potentially inappropriate prescribing, dispensing, and the use 
of opioids and other lethal drugs. We also need to update 
privacy laws that limit the provider's ability to share 
information on substance use which may hinder a provider from 
making informed healthcare decisions. These are all critical 
components for an overall framework to help address the opioid 
crisis.
    Let me offer a couple of observations. A more detailed 
discussion of our organization's views can be found in my 
written testimony to the Committee. But expanding access to 
evidence-based medication-assisted treatment, or MAT, is an 
important cornerstone to treatment and recovery. MAT combines 
FDA-approved medications with evidence-based behavioral health 
therapies and psychosocial interventions, such as peer recovery 
and support services, to provide a whole patient approach to 
treating substance abuse disorder. MAT is a highly effective 
treatment option and has been shown to reduce drug use and 
overdose deaths and improve retention in treatment. Now because 
Magellan believes in MAT as an effective treatment, we are 
committed to taking steps to ensure that it is more readily 
available and paired closely to peer recovery and support 
services.
    To further improve the adoption and availability of 
evidence-based MAT, we recommend expanding the ability to 
prescribe MAT through the use of telehealth. We also recommend 
and encourage the use of other practitioners to be eligible to 
prescribe MAT, such as nurse practitioners and other medical 
professionals. We ask that the Committee also consider a pay 
bump or other incentives to provide treating patients with a 
substance use disorder through MAT, and we also encourage that 
all forms of MAT be covered under Medicare Part B.
    A major barrier to care coordination for those who suffer 
from opioid addiction is the limits of health privacy data 
regulations placed on healthcare organizations for people with 
substance use disorders. The vast majority of today's 
integrated care models rely on HIPAA-permissible disclosures 
and information sharing to support care coordination; that is, 
without the need for the individual's written consent to share 
relevant medical treatment details between providers.
    42 CFR Part 2 currently does not allow the confidential 
sharing of information on substance use disorder diagnosis and 
treatment for care coordination or when individuals move from 
one health plan to another. Excluding substance use disorder 
from the care coordination hinders the ability to continue to 
develop comprehensive treatment plans and coordination of 
services.
    Magellan recommends the statute be amended to permit 
sharing of substance use disorder information for purposes of 
treatment and healthcare operations, as defined by HIPAA and 
for medical care. Also essential to the modernization of Part 2 
is the express permissibility of substance use disorder 
diagnosis and treatment information to be included in 
electronic medical records.
    We would like to thank again the Committee for the 
opportunity to offer some thoughts and recommendations on how 
to address the opioid crisis. Magellan has seen firsthand the 
magnitude of this crisis, and we are fully committed to 
continue to provide evidence-based, effective care services to 
those with substance use disorders. We look forward to working 
with the Committee in partnership to address the critical 
crisis facing our nation. Thank you.
    [The prepared statement of Mr. Srivastava follows:]
    
    
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    Mr. Burgess. Thank you. I want to thank all of our 
witnesses for your testimony and participating with us this 
morning.
    And now, we will move into the question-and-answer portion 
of the hearing. Before beginning questioning, I would like to 
submit into the record a statement from the American College of 
Obstetricians and Gynecologists. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Burgess. I would also like to submit for the record a 
New York Times article entitled, ``Medicare Is Cracking Down on 
Opioids. Doctors Fear Patients Will Suffer.'' I would like to 
submit that for the record. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Burgess. And let me recognize myself, 5 minutes for 
questions.
    Mr. Douglas, I think in your testimony--and I think it 
actually comes up as a repetitive theme--but just looking at 
your remarks that you have provided to the Committee, ``Opioid 
addiction is estimated to be 10 times as high in Medicaid as in 
commercial populations,'' and then, you go on to delineate some 
other statistics that indicate Medicaid beneficiaries are 
prescribed opiates twice as often as individuals with private 
health insurance.
    I am going to ask you this question; you may not know the 
answer to it. I may be able to find the information elsewhere. 
But when was this phenomenon recognized? Is this relatively 
recent or this is something that has gone on for--I mean, 
Medicaid has been around since 1965. Has this been recognized 
in the '60s and '70s or is this a more recent phenomena?
    Mr. Douglas. I don't have the exact timing. But what I 
would say, given my previous life as a Medicaid director, that 
part of the phenomena within Medicaid is the growing role of 
Medicaid and being a broader program than just physical health. 
This problem in many ways was siloed off, with substance use 
being a separate program run in many cases in states by 
separate agencies.
    And what we went through in the evolution in around 2010 
0911 was acknowledging the importance of integrating in 
California behavioral and physical health. That started to 
drive more of Medicaid and, then, our more integrated MCOs to 
work to solve and recognize the impact it was having on 
inpatient, on emergency room utilization. It was impacting 
medical spend and the outcomes and the need to expand services, 
which is why California started moving forward with how do we 
expand and integrate, as well as acknowledging there was 
actually with a siloed program a lot of unfortunate fraud going 
on within our substance use program, and the need to integrate 
into a system would allow for making sure the right care and 
the continuum is being provided.
    Mr. Burgess. And again, is that a more recent phenomenon or 
was that something that has just been longstanding?
    Mr. Douglas. As I said, the Medicaid agencies were starting 
to deal with this. When I look back on my time around 2010, 
around there, it was starting to become more and more of the 
need to think holistically about behavioral and physical health 
integration and brought these to the head.
    Mr. Burgess. And I actually would be interested in what 
other panel members have to say about this. I am not asking the 
question to be provocative. It is just that we are the payer 
here. The federal government is the Aetna, United, the Cigna. 
We are the payer. And if there is something about our structure 
that is putting people at risk, then I think we need to 
recognize that, and if there is a way to mitigate that risk, we 
ought to do so. So, are there any other thoughts that any of 
you have as to whether the identification of the type of 
coverage putting someone at risk, is that a real phenomenon or 
is that an observer bias?
    Mr. Botticelli, you look like you want to make a statement.
    Mr. Botticelli. I do, and no disrespect to Mr. Douglas. 
While we, I think, know the prevalence of substance use 
disorder in both Medicaid populations is high, and higher than 
the general population, there was a recent Kaiser health survey 
that just came out that shows the growing trend of substance 
use disorders and opioid use disorders prevalent in both 
commercial and employer plans. So, again, I think that while we 
do see slightly higher rates among Medicaid populations, I 
don't think that the differences are as vast between kind of 
the Medicaid population and the commercial market as one would 
have previously thought.
    Mr. Burgess. So, we can effectively ignore the type of 
coverage? It is of no consequence?
    Mr. Botticelli. No, coverage is significantly consequential 
because I think what we also see in other studies is that 
coverage, quite honestly, accelerates access to treatment, and 
we have seen it with both Medicaid and commercial plans.
    Mr. Burgess. So, intuitively, yes, that would be obvious.
    I am going to run out of time.
    And, Mr. Douglas, I also want to mention, thank you for 
bringing up Project ECHO, which was a product of this 
committee. And many of you have mentioned prescription drug 
monitoring programs and, of course, the NASPER authorization 
originated in this committee back in 2005. So, although the 
focus recently has been more intense, this subcommittee has 
been dealing with this problem for some time.
    I see my time has expired. I am going to yield to Mr. Green 
5 minutes for questions, please.
    Mr. Green. Thank you, Mr. Chairman.
    And again, I thank all our panelists.
    One of the biggest issues of Americans struggling with 
opioid addiction and substance abuse generally are the barriers 
to treatments and ensuring there is a continuity of coverage, 
and particularly for vulnerable populations. Just that 
exchange, Dr. Botticelli, the compare between private insurance 
and Medicaid, at one time I assumed Medicaid was more. Coming 
from an urban area in Houston, Medicaid is such a predominant 
care for not only physical care, but also mental care. And my 
concern, Mr. Douglas, is that, if you are splitting off that, I 
think it ought to be a continuity of care between the physical 
doctor and--because, obviously, we know the behavioral and the 
physical is important. So, we need to have that coordination of 
care, whether it is through Medicare or the private sector, or 
whatever.
    What would be the consequences if it becomes more difficult 
for Americans struggling with substance use disorders to 
receive Medicaid coverage?
    Mr. Botticelli. I think we have seen, yes, we would not be 
able to do what we do at Boston Medical Center were it not for 
a generous benefit through Medicaid. And not only do we see 
successful clinical outcomes on both the behavioral and the 
physical side, but we have also been able to demonstrate that 
we can actually lower healthcare costs by giving people good, 
comprehensive, quality care. We have seen, if we can get people 
in treatment, we can reduce emergency department admissions and 
hospitalizations, as well as get them to long-term recovery and 
really kind of miraculously return people to jobs, to the 
community.
    I think, without coverage--and we have seen time and time 
again the devastating impact--that one would anticipate that we 
will see significant increases not only in mortality, but we 
are also dealing with other epidemic issues of hepatitis C. We 
are seeing outbreaks of HIV across the United States. And so, 
you are entirely correct that this is not just about adequate 
access to substance use treatment, but people need adequate 
access to the entire spectrum of physical health issues.
    Mr. Green. I was interested, Mr. Douglas, in saying, in 
2010, you saw the more concern or interest, and it was because 
of the separation maybe from behavioral care as compared to 
physical care. Was that because of the Affordable Care Act 
getting ready to kick in or expansion of private sector funding 
because of the Exchanges?
    Mr. Douglas. So, again, this is really, I want to say, 
through my lens in California as well as on the National 
Association of Medicaid Directors, working with Medicaid 
directors at that time again, of Medicaid directors' 
acknowledgment. And I would believe that there were many 
factors. I think the Affordable Care Act was one of them, of 
understanding both looking more at how we were--at that time 
the Affordable Care Act, besides the expansion, was really 
focused on integrating care, as you said, of physical and 
behavioral health and aligning the right payment incentives and 
outcomes. And so, States were really looking holistically and 
realizing that, to address better health outcomes, there needed 
to be more integration and expansion of treatment modalities 
within behavioral health and substance use.
    And so, we are now in Centene, and where we stand is we do 
still see differences by States in the availability and access 
to substance use treatment services, and it varies. While 
Medicaid has a richer benefit, it still varies in terms of the 
availability of substance use. In States where we do have 
Medicaid expansion, we are seeing the ability in the data of 
being able to address unmet need more within the substance use 
area.
    So, it is a combination of factors. I don't want to say 
that the ACA didn't; the ACA spurred both expansion of benefits 
as well as thinking through how to integrate physical and 
behavioral health, as you said is so important.
    Mr. Green. Thank you.
    Mr. Chairman, you and I have had the opportunity, and a 
number of our members on both sides of the aisle, to attend the 
Commonwealth and the Alliance. Once a year we go off for a long 
weekend and have folks.
    Mr. Kravitz, Geisinger, for a number of years, has been at 
those facilities. And coming from a guy from Texas with my 
accent, I didn't know anything about Geisinger until then. But, 
then, I happened to have my father who moved back home, so to 
speak, from Houston, to northern Pennsylvania. He was a patient 
there. During his lifetime--he lived to be 91 and a half, a 
great life--but I was really impressed by Geisinger's facility 
there treating the whole person.
    Mr. Kravitz. Thank you.
    Mr. Green. Anyway, I am out of time, Mr. Chairman. Thank 
you.
    Mr. Burgess. The Chair thanks the gentleman.
    The Chair recognizes the gentleman from Virginia, Mr. 
Griffith, 5 minutes for your questions, please.
    Mr. Griffith. Thank you very much, Mr. Chairman.
    And thank you all for being here today to testify.
    Mr. Douglas, the Centers for Medicare and Medicaid Services 
recently released its 2016 Drug Utilization Review Report. The 
report noted that 26 Medicaid agencies have access to 
prescription drug monitoring program data. States can use this 
data from the PDMPs to manage the overutilization of opioids 
and detect fraud, waste, and abuse. On the other hand, 23 State 
Medicaid agencies report that they do not have access to the 
PDMP data. Can you describe how Medicaid agency officials would 
use PDMP data to combat opioid misuse?
    Mr. Douglas. So, both, again, from the view of talking with 
both current and former State Medicaid directors as well as 
managed care organizations, the use of PDMP is really, really 
important in combating. We have seen effective use in ability 
to both make sure that our providers, they understand and have 
a clear sense of where our members are receiving other opioid 
prescriptions. And so, it creates alerts. It creates 
information that we can then, as we go through utilization 
management back as a managed care organization, to be able to 
create and prevent prescribing from occurring.
    And so, in the cases where we have it, it effectively 
improves our ability to combat inappropriate prescribing 
patterns and utilization. And so, as I noted in my remarks, 
this is an area where I think Congress could do a lot in both 
incenting states to make sure that all entities, both the 
agencies, the Medicaid agencies, the providers, as well as the 
managed care organizations across all States and territories, 
have access to the data to combat and ensure there is judicious 
prescribing.
    I would note--and I think you heard from some of my 
colleagues--that that is not going to be sufficient. We have to 
also figure out how to overlay this into EHRs and make sure it 
is as easy as possible for our providers. We are at Centene 
trying to do that, but it is more than just a role of managed 
care organizations to be able to solve this. It takes 
investment in IT systems and prescribing to make sure that 
there is easy utility and it fits into the workflow of our 
providers.
    Mr. Griffith. One of your suggestions for ensuring all 
appropriate entities have access to PDMP data is to proactively 
share that data, the data reports, with each other. Can you 
explain how this would work in practice?
    Mr. Douglas. Well, this gets, again, to in practice the 
importance of IT, because, as providers work, it needs to be 
real-time. In terms of our responsibility for utilization 
management of pharmacy, there are requirements on turnaround 
times. And so, if the information is not shared quickly and 
through electronic means, we are either going to be out of 
compliance with our utilization management or providers are 
going to have problems within their workflow.
    And so, in practice, it makes sense. In the actual real 
life right now, until we get better IT systems across all 
systems--I am sure in Geisinger and others it is there--but we 
need, especially with Medicaid providers, more investment.
    Mr. Srivastava. So, Congressman, if I could add?
    Mr. Griffith. Yes, sir.
    Mr. Srivastava. One is it is spot on that with PDMP we are 
data-rich, but we are processing-poor in this construct. You 
need interoperability to share it with health plans that share 
it with pharmacy providers and with providers. It needs to be 
at the workflow level, so that it is in an EMR. But, also, you 
are getting data that is not just those that are prescribed, 
but also cash pay. So, if a person seeks drugs, and it is 
through the benefit in Medicaid or the benefit within your 
employer, you are going to get information. But, if you are 
actually going and cash paying for drugs, that processed claim 
would also show up in this report. So, we are getting more data 
sources, and it needs to be at the point of care, where the 
individual can act and understand whether there is a lot of 
drug history there, to be able to change the regimen.
    Mr. Kravitz. I would like to also add a comment, if you 
don't mind.
    Mr. Griffith. Yes, sir.
    Mr. Kravitz. From an information technology perspective, we 
use PDMP before any opioid is being prescribed for a patient. 
What is important, though, is not all States have reciprocity 
where they can go through and exchange information. We actually 
need to go to a level where we are closer to a national PDMP 
for patients traversing different State lines. Where there are 
reciprocal arrangements that are occurring, not all States 
participate. The other problem that is a national problem is a 
national patient identifier to make sure we have the right 
patient identified in the PDMPs.
    The other component of that, while we have advanced IT 
systems, we don't have the ability to put it into our workflow 
because our Commonwealth of Pennsylvania does not have APIs 
established yet to do that. We will have those in the next 3 
months. We will automate that entire process, so that it 
doesn't have to take the provider out of the workflow, but 
trigger those events in the background. So that they know if a 
patient is traversing multiple locations to try to get opioids.
    Mr. Griffith. I appreciate that, and I will have additional 
questions for the record.
    Thank you, Mr. Chairman. I yield back.
    Mr. Burgess. The Chair thanks the gentleman.
    And, Mr. Kravitz, I would point out that NASPER, which was 
the national PDMP authorized by this committee in 2005, for the 
first time it was funded in the last funding bill that we just 
passed a few weeks ago. So, we are moving in that direction. It 
takes us some time, but we are getting there.
    The Chair now recognizes the gentlelady from Illinois, Ms. 
Schakowsky, for 5 minutes for your questions, please.
    Ms. Schakowsky. Thank you, Mr. Chairman.
    And speaking of what direction we are moving in, today's 
hearing on Medicaid and Medicare proposals to address the 
opioid epidemic actually comes on the same day that the House 
is considering the balanced budget amendment. I just want to 
comment on the effect that would have.
    If enacted, the balanced budget amendment would undercut 
the structure of Medicare and Medicaid by opening both to 
dramatic cuts in funding. Republicans passed what I believe is 
a misguided tax bill that blows a $1.5 trillion hole in the 
budget, gives 83 percent of these tax cuts to the wealthiest 
among us. And we see Republicans offer budgets that would fill 
that gap by cutting more than $1.5 trillion in Medicare, 
Medicaid, and Social Security. And now, Republicans want to 
amend our Constitution to require that we can only spend in any 
given year what we raise in tax revenue in that same year, 
after just cutting those revenues. So, this is a serious threat 
to Medicaid, which is on the frontline of fighting the opioid 
epidemic, as we have been talking about.
    So, let's see, who am I asking? Mr. Botticelli, what are 
some examples of the actual services that Medicaid programs 
cover for substance use disorder treatment?
    Mr. Botticelli. So, Medicaid--and I will talk specifically 
about a program that we have at Boston Medical Center----
    Ms. Schakowsky. OK.
    Mr. Botticelli [continuing]. Where we have virtually 100 
percent of our people who are Medicaid-eligible. That program 
serves over 700 people within the context of our adult primary 
care clinic. What we have been able to demonstrate through that 
is, at 12 months, we have 65 percent of people still engaged in 
treatment at 12 months or longer.
    But I also think what is important, too, is, as I 
indicated, because of that program, we have been able to do a 
retrospective study of utilization of healthcare services prior 
to people getting treatment and, then, in the duration of 
treatment afterwards. What we have been able to show is we 
could actually reduce--emergency department admissions go down 
by two times and inpatient hospitalizations go down three 
times. So, not only do we see our ability to provide good, 
high-quality care for treatment, but, simultaneously, we are 
able to reduce healthcare costs for some of the highest 
utilizers of health care, not only within Boston Medical 
Center, but within our larger healthcare delivery system.
    So, I think that is a really good example, and part of the 
reason that we are able to do that is through our Medicaid 
program, and largely because they also fund a whole host of 
medication-assisted treatment, a wide variety of other recovery 
support services that our patients need access to. So, I think 
it is a good example of the critical nature of our ability to 
execute high-quality care because of our patients' access to 
Medicaid.
    Ms. Schakowsky. So, I am assuming, then--my next question, 
you sort of answered it in the positive--it would be the 
negative. What would a drastic cut in Medicaid specifically 
mean for those enrollees receiving the care that you have 
outlined?
    Mr. Botticelli. I think it would be devastating, and I 
don't think I am overexaggerating kind of the impact that that 
would have for our patients' ability to access care. I think it 
is very hard.
    And I was actually the Director of Treatment Services in 
Massachusetts prior to healthcare reform and prior to Medicaid. 
So, I saw the issues that people had not only in terms of their 
ability to access care, but also some of the devastating 
consequences that we see.
    I think Massachusetts is a good example of being able to 
achieve some modest reduction in overdose deaths, unlike many, 
many states across the country. And I think part of the reason 
that we are able to do that is because of our patients' 
abilities to be able to access treatment when they need it.
    Ms. Schakowsky. So, you are saying ``modest''. Why isn't it 
robust, for example, in lives that are saved?
    Mr. Botticelli. Well, if you are one of the 10 percent of 
people that your life was saved in Massachusetts, that is 
robust. I think why I am kind of cautious is because deaths are 
still too high. Again, I think while we are all cautiously 
optimistic that a 10 percent reduction is good----
    Ms. Schakowsky. It is good.
    Mr. Botticelli [continuing]. It is moving in the right 
direction, it is still way too high. And we still had over 
2,000 people in Massachusetts die in 2017, and that is just way 
too high, despite a 10 percent decrease.
    Ms. Schakowsky. I am just going to skip to, what services 
can health homes provide for those with substance use disorder?
    Mr. Botticelli. Actually, Mr. Douglas mentioned one. 
Vermont is a really great example of how you use health homes 
to not only increase access to treatment, but increase access 
in rural parts of the country. So, they use what is called a 
hub-and-spoke model where they induct people in the hubs and, 
then, move people to primary care sites in the spokes. And I 
don't know the latest data, but they have been able to really 
significantly increase access to treatment. I think Rhode 
Island as well has utilized the health home model to 
dramatically increase access to treatment. So, I think a number 
of states have used this, but I also think it is really 
important, as we think about how do you push out treatment to 
rural parts of the country that don't have a treatment program 
and don't have providers. I think medical homes, some States 
have really implemented innovative programs to be able to do 
that.
    Ms. Schakowsky. So, I am out of time. Mr. Douglas, so 
Vermont is an example of how it can work?
    Mr. Douglas. That is correct, and it is spreading to other 
States. California, too, is doing it. It is an investment, and 
this is an important piece. The resource shortage can't just be 
dealt with on substance use providers. We need to spread the 
best practices back into the physical health and the primary 
care, knowing that the expertise would be in the substance use 
treatment centers, but this hub-and-spoke, this idea of working 
together and providing the expertise and creating the 
incentives to do that through health homes and ways to share. 
And telehealth and other opportunities are great ways that we 
can better integrate the systems.
    Mr. Burgess. So, the short answer was yes.
    Ms. Schakowsky. Thank you.
    Mr. Burgess. The gentlelady's time has expired.
    The Chair recognizes the Vice Chair of the subcommittee, 
Mr. Guthrie, 5 minutes for questions.
    Mr. Guthrie. Thank you very much. I appreciate it very 
much.
    These questions are for Mr. Srivastava. Johns Hopkins 
University and the Clinton Health Foundation released a 
document in 2017 that contained a number of recommendations for 
combating the opioid crisis. One recommendation was to support 
restricted recipient programs, otherwise known as lock-in 
programs, for at-risk populations. From what I understand, 
lock-in programs are designed to restrict overutilization of 
opioids and to identify potential fraud and abuse of controlled 
substances.
    Mr. Srivastava, can you talk about if your organization has 
been involved in a lock-in program and if you have found the 
program to be useful in combating opioid abuse?
    Mr. Srivastava. Thank you, Congressman.
    In terms of lock-in programs, we actually support over 100 
health plans across the country and serve their Medicaid and 
commercial and Medicare needs. So, we have experience working 
with Medicaid lock-in across the country. We also have our own 
special needs plans in Florida, Massachusetts, New York, and 
Virginia.
    Our experience has been in our special needs plans where 
within Medicaid we have had the ability to lock in on 
prescribers where there was a lot of overutilization. There was 
multiple providers as well as multiple use within a period of 
time.
    Today what we are finding is State by State there is 
different criteria. So, for example, in Florida, you have to 
have three prescriptions, three providers, and three different 
settings, and claims within the last 180 days. But we found 
that lock-in allows for, one, an integrated care plan to be 
developed for the individual. Two, it eliminates a lot of drug-
seeking behavior. And then, three, it allows for transition 
beyond managing the pills themselves, but actually helping the 
individual to get support cycle social support services and 
treatment and recovery services afterwards.
    So, we are finding that there has been good evidence that 
lock-in programs work in Medicaid. It will be launched, I 
believe, in 2019 for Medicare as well. And so, general 
expectation is you will see a broader user of that program.
    Mr. Guthrie. OK. Thank you. And I have another question for 
you. Some have expressed concern with going to the HIPAA 
standard for substance abuse/use disorder records for the 
purposes of treatment, payment, and healthcare operations 
because they are afraid the record will get into the wrong 
hands and they will be fired from their job.
    Can you tell me what are the activities that fall under 
these three categories, so we have a better understanding of 
why it is so important to have access to a patient's record for 
treatment, payment, and healthcare operations?
    Mr. Srivastava. So, confidentiality is critical and 
important. And this kind of speaks to CFR 42 Part 2. 
Historically, all of how providers communicate and coordinate 
with health plans and with facilities to coordinate care has 
been to get a release under HIPAA to be able to maintain 
confidentiality to provide care.
    And what is happening is we have stigmatized those 
individuals with substance use disorder and created CFR 42 as 
an added layer of protection. It has actually limited a 
provider's ability to actually coordinate care effectively.
    And so, our recommendation is to think through and expand 
and modernize CFR to be regulated under HIPAA, which is 
confidentiality. But that, if an individual happens to have 
diabetes and has a substance abuse issue that they are seeking 
care from a provider, and then, they go to an outpatient 
setting or they go for treatment and recovery services, or they 
go to a dentist, that we are not having to, as a health plan be 
able to, or as a PCP be able to get permission from each 
individual provider to be able to coordinate the care.
    At times, we don't know that that occurs. And so, as a 
result, there can be misuse, and as a result, can also be 
adverse outcomes.
    Mr. Guthrie. So, if you use that information, what prevents 
an employer from having access to it?
    Mr. Srivastava. Under HIPAA guidelines today, we are 
managing, as a health plan or as a provider, we are 
confidentially treating individuals who have cancer, 
individuals who might have AIDS/HIV, or any sort of kind of 
behavioral health SMI disorder, and we don't communicate that 
with the employers. So, we are kind of bound by HIPAA. We are 
also bound additively by CFR 42. So, from our perspective, it 
is confidentiality, and we are kind of trained as healthcare 
professionals not to be able to share that information beyond 
what is needed for a treatment plan and to be able to service 
the provider.
    Mr. Guthrie. OK. Thank you. I thank you for your answers.
    And I yield back my time.
    Mr. Burgess. The Chair thanks the gentleman. The gentleman 
yields back.
    The Chair recognizes the gentleman from New York, Mr. 
Engel, 5 minutes for your questions, please.
    Mr. Engel. Thank you, Mr. Chairman, for holding another 
hearing on this important topic.
    In Westchester County, part of which is in my district, 124 
people died due to opioids in 2016, and in the Bronx, New York, 
which is part of my district, more in New York have died of 
overdoses than in any other borough of New York City.
    We must do more to turn the tide of the opioid epidemic, 
and we cannot hope to do that if we fail to recognize the 
importance of Medicaid. Medicaid covers nearly 4 in 10 non-
elderly Americans grappled with an opioid addiction. Through 
the Medicaid expansion under the Affordable Care Act, states 
were afforded new resources to cover Americans living with 
substance use disorders and get them the treatment they need. 
We must continue to expand States' capacity to combat the 
opioid crisis and take care to avoid hamstringing that capacity 
in any way.
    This brings me to a number of bills we are considering 
today that I fear could hinder States' ability to address this 
crisis, the Medicaid Pharmacy Home Act, the Medicaid Drug 
Improvement Act, and the Medicaid Partnership Act. I worry that 
asking States to make complicated changes to their Medicaid 
programs in less than a year sets them up for failure. And 
since non-compliant States would be punished with FMAP 
penalties, States' ability to deliver treatment and recovery 
services could be hampered as a result.
    I also have concerns regarding the Medicaid Graduate 
Medical Education Transparency Act. In my opinion, the 
reporting required under this bill is overly prescriptive and 
burdensome and may take the limited resources states have for 
Medicaid GME and offer reporting that will not tell us very 
much. And I have heard similar concerns from stakeholders as 
well. After all, Medicaid spending constitutes just 16 percent 
of Federal spending on GME. So, this reporting would offer an 
extremely narrow picture of the training physicians are 
getting.
    I also worry that the information gleaned from these 
reporting requirements could be viewed as a microcosm for State 
Medicaid programs' holistic efforts to combat the opioid 
crisis, but it is my understanding that those efforts involve 
many facets of the healthcare system, not just physician 
training.
    So, Mr. Douglas, I want to ask you, is that a fair 
assessment, that the efforts involve many facets of the 
healthcare system, not just physician training, and that 
information gleaned from these reporting requirements could be 
viewed as a microcosm for State Medicaid programs' holistic 
efforts to combat the opioid crisis?
    Mr. Douglas. I am sorry, the question?
    Mr. Engel. OK. Let me move on. I am not opposed to 
collecting more data on Medicaid GME or other GME programs. 
However, I think we need to be more thoughtful about the data 
we are asking states to collect when facing a shortage of 
providers, of said providers. But I don't believe this bill 
would address that, and solving the problem cannot be left 
solely to a group of specialists with specific training in 
substance use and addiction. A more comprehensive approach is 
needed. We need to be thinking about the full spectrum of 
providers and their roles in solving this crisis.
    Mr. Douglas, let me try again. How can we improve and build 
our workforce so that said providers and others can help end 
this epidemic?
    Mr. Engel. Great. As I noted in my written testimony, as 
well as the chairman mentioned, I think an important area we 
are focusing, as a managed care organization at Centene as well 
as States, is around ways to make sure that we are educating 
providers and disseminating that education. Project ECHO is a 
great way of doing telementoring opportunities and really 
spreading, especially as it gets to rural and underserved 
areas. So, we have to focus both from making sure we are 
educating on the prevention side, but, then, as you noted, 
there has to be a continuum of service as the treatment 
modalities. From the lens of MACPAC that we have seen 
identified, there is a wide disparity, that you might have in 
Boston a larger rate of treatment modalities, but in many 
States the modalities aren't all there. And so, the continuum 
of services on the treatment side from both outpatient to peer 
support, to MAT-related services, and, of course, as I 
mentioned before, there needs to be residential, where 
appropriate, on the evidence-based, and that means eliminating 
the IMD exception. So, those are all approaches that need to be 
taken.
    Mr. Engel. Thank you.
    Let me quickly go to Mr. Botticelli, based on some of the 
comments that were made before I gave my question. Do you have 
any concerns about rolling back 42 CFR Part 2?
    Mr. Botticelli. I do, both as a policymaker and a person in 
long-term recovery. Unfortunately, substance use disorders are 
different from other diseases. They are still highly 
stigmatized. They are subject to discrimination and criminal 
penalties.
    SAMHSA, I think--and this is fully supporting the fact to 
give people good care, we need to integrate physical care with 
part of their substance use disorder treatment. I think all of 
us support better integrated and holistic care. But I do think 
a patient should have a right to consent to disclose their 
records. The Substance Abuse and Mental Health Services 
Administration actually just modified their regulations twice 
to support enhanced integration of 42 CFR Part 2 information, 
treatment information, into primary care records.
    Mr. Engel. Thank you.
    Thank you, Mr. Chairman.
    Mr. Burgess. The Chair thanks the gentleman. The gentleman 
yields back.
    The Chair recognizes the gentleman from Illinois, 5 minutes 
for your questions, please, Mr. Shimkus.
    Mr. Shimkus. Thank you, Mr. Chairman.
    Great to have you all here.
    Mr. Botticelli, you were with the previous administration, 
were you not?
    Mr. Botticelli. I was.
    Mr. Shimkus. And what was that position again?
    Mr. Botticelli. I was the Director of the White House 
Office of National Drug Control Policy.
    Mr. Shimkus. Yes, great. Thank you for your service. And to 
segue now into what you do in Massachusetts, I think it is 
important. And this is an all-hands-on-deck process. Obviously, 
we are trying to do our best to affect the public policy and to 
help you all do your job.
    But let me go to, in your testimony you mentioned one 
report which found only about half of the State Medicaid 
programs currently cover non-pharmacological alternatives to 
pain such as, as you have talked about, cognitive behavior 
therapy and physical therapy. Mr. Douglas, the Committee has 
heard from Medicaid directors about the importance of Federal 
funding for evaluation of non-pharmacological alternatives to 
build strong empirical basis for making coverage decisions.
    Could you both please talk about the degree to which you 
think this research about the utility and cost-effectiveness of 
non-opioid alternatives already exists and what more Congress 
or CMS can do to help state Medicaid programs have the 
information needed in making coverage decisions that ultimately 
impact patients?
    Mr. Botticelli. Great. I will start and, then, turn to Mr. 
Douglas.
    Throughout the course of our work area, I think we have to 
be very careful, while we know we want to make sure that we are 
diminishing opioid prescribing, that we are giving patients 
access to really good pain management therapies. I think we are 
hearing more and more stories, quite honestly, of patients in 
legitimate pain not being able to access non-pharmacologic 
approaches. And so, I think we have to couple our efforts with 
not only opioid reducing, but making sure that we are giving 
people good access. We do have a number of evidence- based--and 
we need to continue to research non-pharmacologic approaches. 
We know acupuncture works. We know physical therapy works, 
yoga, exercise.
    And so, again, I think if you talk to our clinicians at 
Boston Medical Center who deal with both substance use disorder 
and pain, that because our Medicaid program actually supports a 
wide variety of non-pharmacologic approaches, we are able to 
give patients good pain care and at the same reduce opioid 
prescribing.
    Mr. Shimkus. Mr. Douglas?
    Mr. Douglas. Yes, I would just echo the points of Mr. 
Botticelli that there needs to be more work on this. Both from 
a state as well as an MCO perspective, we are continuing to 
want to ensure that we are doing evidence-based practices on 
treatment modalities. And that gets to being able both from a 
state policymaker to be able to give the Medicaid agencies the 
ability to test new treatment modalities or ensure that those 
modalities are being executed on. And so, without the evidence, 
you have disparity across States as well as you have a harder 
time for MCOs to get the best practices and the right care and 
the right setting to be provided. And so, we encourage there 
continue to be work in this area.
    Mr. Shimkus. Yes. So, I will ask you to take this back and 
maybe submit some more information. And I appreciate that, but 
the question is, what more can we do legislatively or what can 
CMS do to help fill this space to give the information needed 
to help?
    So, my follow-up question is going to be, one of the most 
dangerous things about opioids is that they are cheap or at 
least much cheaper than non-opioid alternatives, some. And your 
testimony and Mr. Botticelli also underscores the need to 
complement the largely successful efforts to reduce opioid 
prescribing. We need to ensure patients have access to non-
pharmacological pain management practices. To that end, several 
of us on this committee have expressed concerns about the 
declining Medicare reimbursements for certain pain management 
procedures frequently performed by the ambulatory surgical 
centers because they are more expensive.
    Can you talk about the importance of incentivizing non-
opioid, non-pharmacological treatments and stemming the tide of 
opioid addiction, particularly as it relates to patients' 
access, Mr. Botticelli? And then, I want to go to Mr. Kravitz 
to answer this.
    Mr. Botticelli. I think part of the reason that we are in 
the predicament that we are in is that writing a prescription 
for opioids is not only far cheaper, but it is also far easier 
for the clinician to be able to write a prescription versus 
having a conversation with their patient on pain and pain 
expectations and pain management.
    So, I think both CMS and Medicare need to do everything 
that they can, quite honestly, to provide financial incentives 
that drive toward those other kind of pain management 
therapies. While there might be some modest cost increases in 
the short term in terms of those strategies, I think the return 
on investment of not getting people addicted and not having to 
go through all the other medical expenses probably far 
outweighs any modest increase in cost for those therapies.
    Mr. Shimkus. Thank you.
    And, Mr. Chairman, can Mr. Kravitz answer that?
    Mr. Kravitz. Yes. So, at Geisinger Health System, we are 
very much in a consultative measure with our patients as well 
on the same topic. We take the time to counsel them and to look 
at all other alternatives for treatment for these patients. So, 
especially chronic disease patients, as I stated in my opening 
statement, we utilize things like rehabilitation, Tai Chi, 
yoga, things of that nature, to alleviate pain. And they have 
been proven to be successful.
    In cases where they are not the case, where opioids do have 
to be prescribed, we are very careful and judicious to not 
extend an extensive prescription quantity for those patients. 
So, they don't have the opportunity to get addicted to opioids.
    Mr. Shimkus. Thank you very much.
    Thank you, Mr. Chairman.
    Mr. Burgess. The Chair thanks the gentleman. The gentleman 
yields back.
    The Chair recognizes the gentlelady from California, Ms. 
Matsui, 5 minutes for your questions, please.
    Ms. Matsui. Thank you, Mr. Chairman.
    And I want to thank the witnesses for being here today.
    I also want to say, Mr. Chairman, thank you for holding 
this third hearing today on legislation to address this opioid 
epidemic. It is so important that we are focusing on a variety 
of perspectives on how to solve this crisis. We know the 
problem is multifaceted and the solution will be, too.
    And I just want to also point out the importance of the 
Medicaid program in addressing this crisis. Medicaid serves a 
large proportion of the population with substance use disorder, 
and any effort to cut the program's funding will severely 
jeopardize access to those services.
    I also must say, while we must act urgently, I am concerned 
that, if we move the nearly 70 bills through our committee too 
quickly, some of the policies will have unintended consequences 
that will contribute to the problem rather than the solution. 
And I look forward to further discussions with my colleagues 
and stakeholders as we ensure that these policies are going to 
be as effective as possible.
    I think that the biggest potential for transforming our 
healthcare system lies in the power of technology. Electronic 
health records have the potential to streamline care, increase 
coordination of care across providers, and aggregate data for 
population health management and research purposes. Telehealth 
provides the opportunity to get care to patients faster or in 
cases where they can't otherwise have the access to the 
appropriate provider.
    This has a huge potential to help us address the opioid 
epidemic. Technology can help us to integrate the behavioral 
health care and physical health care, treating a person as a 
whole and ensuring that all of their needs are met in a timely 
manner. Most people with a substance use disorder have an 
underlying mental health issue and/or physical condition. If 
all conditions are not addressed, we will have less success in 
treating the addiction.
    One of the ideas I am working on with Representatives 
Mullin and Blumenauer is how we can assure that substance use 
information can be shared for the purposes of care coordination 
and patient safety without infringing on patient privacy 
rights. None of that work will have any effect, though, if 
substance use and behavioral health providers don't even have 
electronic health records to facilitate the data sharing.
    That is why I co-lead H.R. 3331 with my colleague on the 
Ways and Means Committee, Representative Jenkins. Behavioral 
health providers were left out of the Meaningful Use Program 
which encouraged adoption of electronic health records by 
hospitals and doctors. This would certainly extend an incentive 
to behavioral health providers via a demonstration project.
    Mr. Kravitz, my understanding is that your organization has 
been successful as a result of investing in electronic health 
records. Could you please describe how electronic health 
records have improved quality of care and reduced cost?
    Mr. Kravitz. Yes, I am happy to, Congresswoman. So, we have 
invested in electronic health records back in 1995. I think we 
were one of the earlier adopters of the EPIC electronic health 
record system, which has been predominantly used between EPIC 
and Cerner across the country with all scripts.
    We have also invested heavily in analytics. In fact, we 
have a big data platform similar to Google, and we look at that 
data all the time. We analyze the data very carefully. In fact, 
one of our scenarios, we did a 10-year study with Geisinger 
Health Plan, which has 580,000 members in our population. We 
looked at that data very, very carefully, and that is where we 
recognized and realized that patients on opioids that were part 
of that process had higher levels of acute care stays before 
they had overdoses as well as ED visits were tremendously 
increased over the last 22 to 12 months prior to an overdose 
occurring.
    So, information is key. The ability to integrate that data 
and interoperate that data with other systems is extremely 
important.
    Ms. Matsui. So, you believe that this will be helpful to 
extend this to behavioral health providers?
    Mr. Kravitz. Absolutely.
    Ms. Matsui. OK, great.
    Mr. Kravitz. Absolutely.
    Ms. Matsui. Well, let me just right now, also, submit for 
the record here a letter from the Behavioral Health IT 
Coalition, which includes the American Psychological Academy, 
NAMI, Mental Health America, the National Council of Behavioral 
Health, in support of H.R. 3331, for the record.
    Mr. Burgess. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Ms. Matsui. I also want, Mr. Douglas, thank you for your 
past service as a Medicaid director.
    I currently have another bill coauthored with my colleague, 
Representative Harper, that will allow behavioral health 
clinics to register with the DEA to be able to use telemedicine 
to prescribe controlled substances, increasing access to 
medication-assisted treatments in our communities.
    Can you describe the benefits of medication-assisted 
treatment and detail the current barriers you see that might 
prevent its expansion?
    Mr. Douglas. Thank you.
    So, as I mentioned in my written testimony, the expansion 
of medication-assisted treatment is a really important 
component of the overall continuum, especially as we learn and 
have substance use treatment providers working with primary 
care. As you said, being able to create more technology 
interfaces will be an important way to work across this idea of 
a hub-and-spoke with our primary care and sharing data back and 
forth. And so, as we are looking at more a holistic approach to 
medication-assisted treatment and primary care integrating with 
it, what you are laying out would really solidify and improve 
the infrastructure.
    Ms. Matsui. OK. Thank you.
    And I have run out of time. I yield back.
    Mr. Burgess. The Chair thanks the gentlelady. The 
gentlelady yields back.
    The Chair recognizes the gentleman from Texas, Mr. Barton, 
5 minutes for your questions, please.
    Mr. Barton. Thank you, Mr. Chair.
    I have a question for the chairman before I ask a question 
of----
    Mr. Burgess. The answer is no.
    [Laughter.]
    Mr. Barton. I was going to say, did you think you are the 
greatest Health Subcommittee chairman we have ever had?
    [Laughter.]
    Mr. Burgess. No, that would be Governor Deal.
    Mr. Barton. We have got about three dozen bills that we are 
looking at. Is it your plan to move all of these bills 
individually, collectively, some of them, none of them? What is 
the----
    Mr. Burgess. Well, as you will recall from my opening 
statement yesterday and previous opening statements in previous 
hearings that we have had--I am assuming the gentleman is 
yielding to me for an answer.
    Mr. Barton. Yes, sir, of course. I wouldn't ask a question 
if I didn't want you to answer it.
    Mr. Burgess. I don't have a precise answer to your 
question, but the fact that we are considering so many bills, 
and some of the bills we are considering are, in fact, still in 
draft form, we do want to be inclusive. We have done a 
significant amount of outreach. As you will recall, we had a 
many-hour hearing in this subcommittee in October where we 
invited every Member, not just from the committee and 
subcommittee, but from the entire Congress to come and share 
with us their thoughts on what the opioid epidemic looked like 
in their districts and how they were reacting to it, and ideas 
that they had. As a consequence of that interaction, a number 
of ideas were presented to the subcommittee, and we have been 
over the last several months going through those. Right now, 
most of them are in individual bill forms. It is quite likely 
there is some duplication; there is some consolidation that is 
available.
    And as you will recall from bills like the Comprehensive 
Addiction Recovery Act from the last Congress, the Cures for 
the 21st Century, ultimately, numerous bills were consolidated 
into one larger bill. That could still happen, but also a part 
of me wants to consider them as individual bills. So that, as 
we go through at least the subcommittee markup and the full 
committee markup, there will be ample opportunity for people's 
ideas to be heard.
    Mr. Barton. OK.
    Mr. Burgess. I hope that satisfies your request for 
information. And I will yield back.
    Mr. Barton. Well, you used half of my time. Well, I think 
it is important to give the subcommittee and the stakeholders 
some idea of the potential plan. And I wasn't here yesterday. I 
was at the Zuckerberg hearing on Facebook. So, I am just asking 
for my own illumination.
    One of the bills is a bill by Mr. Tonko, H.R. 4005. He has 
actually introduced it. He is ahead of the curve here, which is 
kind of normal for him. He is one of our more energetic 
Members.
    But this particular bill, I wish he wasn't so energetic, 
actually, because it allows Medicaid programs to receive 
matching Federal dollars for medical services to an 
incarcerated individual, which in Texas means somebody in jail 
for the 30-day period right before they are released. I have a 
real concern about that for a number of reasons.
    So, I am going to ask Mr. Douglas if, under current law, 
the states couldn't ask CMS to use their 1115 waiver for a 
demonstration project to test this idea, instead of actually 
passing a federal statute.
    Mr. Douglas. So, current Federal law prohibits payment, 
Medicaid payment, for individuals who are in prison, except for 
the one exception relates to for inpatient settings when they 
leave the actual prison facility and go to an inpatient 
setting. And that is clear in Federal law. So, even under an 
1115 waiver, that could not occur.
    Now, that being said, there are creative alternatives. 
Centene, as a managed care plan, are working in Ohio, for 
example. Ohio is very concerned, given recidivism. The high 
rate of individuals within the prison system, as they 
transition, have needs of social services, medical care, 
behavioral health, to do early transition work as a 
responsibility, knowing that they are going to be assigned to a 
managed care plan, and the managed care plan is going to have 
increased costs if they don't work in the transition. And so, 
that is occurring right now in states. And other states are 
doing that. There are different creative approaches, but there 
is no ability from a payment standpoint right now under Federal 
law.
    Mr. Barton. OK. Well, thank you for that answer.
    In my one second that I don't have, I want Mr. Kravitz to 
talk about e-prescribing and if he thought that could help in 
some other areas, in addition to what has been done under his 
business.
    And I am only asking this question because the chairman 
took two-and-a-half minutes of my time.
    [Laughter.]
    Mr. Kravitz. So, we feel at Geisinger e-prescribing is very 
valuable to our organization. It is very much a patient or 
customer satisfier as well compared to the old process of a 
paper script that oftentimes was not available to them and 
would cause multiple visits to come back to a physician's 
office and able to get those.
    What I can tell you is use of e-prescribing is very much 
endorsed by our physicians. The second-factor authentication is 
seamless, works very well. And that is why we are able to 
reduce the amount of time for prescribing an opioid 
prescription from 3 minutes to 30 seconds, because of the new 
process that we followed.
    What I can also tell you is the first day--and we, 
typically, at Geisinger don't do things small, unfortunately--
we did not do a proof-of-concept with a small group of 
physicians. We hit 1330 physicians day one to enroll them in 
the program, and we have other physicians that are requesting 
to be part of this process because it is so efficient and it 
has worked so well for them.
    The other point that I made about the PDMP, we are 
clamoring to get the APIs or the integration points, so that we 
can do a lot more automation behind the scenes and not obstruct 
the workflow process or the physicians, so they could see more 
patients, to provide better quality care for more patients. 
That will be coming in the next 3 months, and we are very eager 
to have that happen, so that we can encourage that be part of 
the process.
    Mr. Barton. Thank you.
    Thank you, Mr. Chairman, for your courtesy.
    Mr. Burgess. The Chair thanks the gentleman.
    The Chair recognizes the gentleman from Massachusetts, Mr. 
Kennedy, 5 minutes for questions, please.
    Mr. Kennedy. Thank you, Mr. Chairman. Thank you for 
continuing the hearing.
    Thank you to our witnesses for being here.
    Mr. Botticelli, wonderful to be with you again. Thank you 
for your service and your outspokenness on these incredibly 
important issues.
    I know we are here on a series of several dozen bills that 
are before this committee, which I hope many of them will see 
action, including, Mr. Chairman, our own. Thank you for putting 
that on the list.
    I wanted to get your thoughts and members' of the panel 
thoughts on some of the broader priorities of this 
administration, recognizing that the administration has 
acknowledged that there is an opioid and behavioral health 
epidemic across this country. They have indicated that they 
want to prioritize it. Yet, we have also some policies come out 
of this White House that I was curious to get your thoughts on. 
I did have a chance to question our CMS witness yesterday. So, 
maybe just going right down the list.
    And, Mr. Botticelli, I was wondering, given your expertise 
on this issue, can you explain to me how cutting Medicaid by 
$800 billion, as the Trump administration budget does, is 
effective in addressing behavioral health and addiction?
    Mr. Botticelli. First of all, thank you, Congressman, for 
the question and for your leadership not only here, but in 
Massachusetts.
    I think we have broadly acknowledged that this is a public 
health crisis that we have and we have got to focus these 
issues largely on health responses to this issue. Tantamount to 
that response is making sure that people have adequate access 
to insurance and coverage. And when you ask historic data, when 
you look at why people can't get treatment, the No. 1 reason 
why people can't get treatment is because they don't have 
adequate access to insurance.
    Mr. Kennedy. And so, does cutting $800 billion from 
Medicaid help or hurt?
    Mr. Botticelli. It hurts, and it hurts dramatically.
    Mr. Kennedy. And I am sorry to cut you off; I just want to 
get everybody else on the record.
    Mr. Douglas, how would you respond to that? And be quick, 
just because I have got a couple of more of these.
    Mr. Douglas. Yes. No, I am going to turn this around. As 
you know, as a former Medicaid director and as a managed care, 
our responsibility is how to use the resources most effectively 
as possible. And so, the idea of cutting $800 billion, there 
are ways to achieve savings, but it has to be rational.
    Mr. Kennedy. So, does a $800 billion cut help or hurt an 
administration's ability to----
    Mr. Douglas. I can't answer without understanding what the 
flexibilities and the ability to provide the right services and 
the right setting.
    Mr. Kennedy. And, Mr. Guth?
    Mr. Guth. Yes, so this is a complex situation we are 
dealing with. This really goes back to the first question we 
had before this panel. And that is about the disparity in 
presentation with Medicaid and with private insurance. For a 
long time, people with private insurance didn't have access to 
substance use treatment, or very limited access. Most of the 
people I know that went through private insurance with these 
issues ended up spending college funds and retirement funds, in 
order to get care.
    Mr. Kennedy. So, Mr. Guth, would you support greater 
enforcement of mental health parity?
    Mr. Guth. I think we have got to do everything we can right 
now, Congressman, to ensure that people have access to care. 
And for the majority of Americans, that means access through 
some form of third-party coverage, and for many of them, that 
means either Medicaid or some other form of Federal funding.
    Mr. Kennedy. Mr. Kravitz?
    Mr. Kravitz. I would say at Geisinger Health System we 
treat all patients equally. Eighteen percent of our patient 
population in our provider network are medical assistance 
patients; 44 percent are Medicare. We have a number of 
programs, and there are care management programs that address 
this. It would be my impression that it would hurt.
    Mr. Kennedy. Sir?
    Mr. Srivastava. From Magellan's perspective, we 
fundamentally believe that health care needs to be not just 
below the neck, but above the neck. And so, it is a full whole 
patient approach. And so, to the extent we have adequacy of 
funding, to be able to have behavioral health, improve access 
for behavioral and physical health issues, then we are a 
proponent of that.
    Mr. Kennedy. I have got about a minute and a half left and 
two more issues I want to address with the panel. So, Mr. 
Botticelli, I will address them both to you, and just go down 
the line.
    Given your expertise, how long does it take for somebody to 
recover from a mental/behavioral illness?
    Mr. Botticelli. So, this is a chronic disorder, and one 
could argue that it is a lifelong issue. The biggest predictor 
of success is duration and time in treatment.
    Mr. Kennedy. And so, two policies put forth by this 
administration, lifetime caps and work requirements, if you 
think work requirements could, in fact, be helpful to people 
suffering from mental/behavioral illness, I would ask anybody 
on the panel to point me to one single study that says so. So, 
your opinion on those two, lifetime caps and work requirements, 
coming from this administration?
    Mr. Botticelli. So, lifetime caps seem to me to be a 
violation of parity because I think that we understand that 
that has been a historic discriminatory tool that insurance 
companies have implemented to not treat this as a chronic 
disease and give people long-term care.
    Mr. Kennedy. OK. And work requirements?
    Mr. Botticelli. So, one, we know people on Medicaid 
generally now are working, and often working more than one job. 
And I think the ultimate goal of treatment, quite honestly, is 
to get people and restore them.
    Mr. Kennedy. Is there any study that you are aware of that 
says a work requirement increases health, understanding that 
people who are working can be healthier, but that causation 
goes the other direction?
    Mr. Botticelli. I have nothing.
    Mr. Kennedy. Mr. Douglas?
    Mr. Douglas. I don't know of studies on that. What I say is 
that this gets to the issue of underlying social determinants 
and making sure from States, as well as Medicaid organizations, 
Medicaid managed care plans, that we are working on how to 
engage people into ensuring they are getting both the right 
social and getting back into the workforce.
    Mr. Kennedy. Mr. Guth?
    Mr. Guth. Yes. So, we were working with two of our States 
that have these, are implementing work requirements, and the 
devil is in the detail because what you don't want to do is 
insist that somebody who is very, very sick get a job before 
they can have access to treatment. On the other hand, the plans 
that we are working with in the two States that we work with, 
Indiana and Kentucky, we are seeing administration--
understanding that and making sure that we are not asking 
people who are actively sick to become employed before they 
become stable. So, I think it is all about the implementation.
    Mr. Kennedy. The CMS witness yesterday said they are trying 
to put patients before paperwork. Is there a work requirement 
initiative out there that does, in fact, lead to less 
administrative burden for somebody that is suffering from 
mental/behavioral illness to make sure that they stay on 
Medicaid?
    Mr. Guth. Can you ask that question again?
    Mr. Douglas. What I would say is that what we are seeing in 
Indiana as well as in Arkansas, there are exceptions for 
certain populations such as those with substance use disorders.
    Mr. Kennedy. I am about a minute over time. Thank you for 
your generosity, Mr. Chairman.
    Mr. Burgess. That is all right. I have subtracted it from 
Mr. Latta's time.
    Mr. Green. Mr. Chairman, I ask unanimous consent----
    Mr. Burgess. Oh, I beg your pardon. Does the gentleman have 
a unanimous consent request?
    Mr. Green. The gentleman does. I ask unanimous consent that 
a letter from the telehealth and technology stakeholders and a 
letter from treatment providers in support of the access to 
telehealth services for their opioid and use disorders, I ask 
unanimous consent to place it in the record.
    Mr. Burgess. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Burgess. The gentleman from Ohio is recognized for 5 
minutes for your questions, please, Mr. Latta.
    Mr. Latta. Thank you very much, Mr. Chairman. And thanks 
again for holding this hearing today, because, again, combating 
this opioid epidemic is something we are all in and we have to 
do, because we are looking at these very sobering statistics 
that 115 Americans are dying every day in the State of Ohio. 
And I hate to keep repeating these statistics, but in 2015 we 
lost 3,050 people. In 2016, that number went up to 4,050. And 
then, the fiscal year ending at June 30th of last year, it was 
5,232. So, it is an epidemic that we have got to take on and 
fight.
    And I appreciate you all being here today.
    Last week I held a roundtable in my district with local 
pharmacists to discuss the opioid crisis in Ohio. Most of the 
pharmacists agreed that prescription limits would help prevent 
addiction. Overprescribing of opioids for acute episodes of 
care can have dire consequences as pills can be diverted, 
misused, and perpetuate addiction.
    In response to this problem, over 20 States, including 
Ohio, have adopted laws limiting the number of pills that a 
patient new to therapy prescribed an opioid for an acute 
episode can receive. These laws reflect guidelines promulgated 
by CDC which note that, for the vast majority of acute 
procedures, 3 to 7 days' worth of therapy is sufficient. They 
also respect the judgment of the prescribing practitioner by 
providing for exceptions if a prescriber thinks in his or her 
best judgment that a longer duration of treatment is medically 
necessary.
    Furthermore, we recently saw CMS finalize a similar policy 
for beneficiaries and wrote in Medicare Part D, driving home 
the severity of the problem and the belief that such rules will 
have a measured impact on opioid diversion and misuse.
    Mr. Douglas, what impact would expanding this type of 
policy beyond Medicare have on the diversion and misuse of 
opioids?
    Mr. Douglas. As I noted in my written testimony as well as 
earlier, we are doing a lot within Centene, as well as a lot of 
States are working on making sure that we are reducing the 
limits on duration as well as refills. And so, creating clear 
policies on that, where we have been able to do that and work 
with the State, it helps on overprescribing as well as reduced 
inappropriate utilization. And so, this is an important area 
that we are seeing. In many States we can work and partner with 
our State agencies and be able to put in place those types of 
utilization controls. But incenting States and incenting 
managed care organizations, that is an important part of the 
overall continuum of how we need to prevent this epidemic.
    Mr. Latta. Thank you.
    Mr. Guth, my district ranges from densely populated cities 
and towns to very rural areas. And we all know that the opioid 
epidemic knows no boundaries. Therefore, health access in rural 
America is vital, especially as it relates to the opioid 
epidemic. It is hard enough for individuals to make the 
decision to overcome addiction without the added barriers to 
access to treatment due to their location.
    Would you go into some detail about the barriers are out 
there for opioid treatment for individuals in rural communities 
and what they face, and how we have to address those issues?
    Mr. Guth. Thank you. Yes, Congressman. There are several 
issues that jump out. One is that we have a shortage nationwide 
of professionals who are certified and trained in addiction 
services. So, that permeates the whole country, and it is most 
acutely felt in our rural areas.
    Centerstone, most of the communities we serve are very 
small rural communities across the five states that we serve. 
So, we are very attuned to this issue.
    Telemedicine can make a huge difference. There are current 
challenges with telemedicine, but we have been involved with 
telemedicine services since the early '90s. And we would wheel 
in these great big, giant monitors on these enormous carts. 
That was really to address the issue of access to care in our 
rural areas. In many cases it was the first time we could get a 
child psychiatrist into some of these communities. The very 
first time.
    So, this issue is true with opioid use as well. We have to 
be able to provide expert care into our rural communities, but 
we have to address the overall shortage of practitioners 
nationwide in order to do that.
    The other is we have to also recognize that there are other 
specialists involved in this care that are very important. Mr. 
Douglas mentioned peer support services. Those are critical, 
and we find that those services, if we can get them funded, 
which is very spotty, if we can get those services funded, we 
can provide some really vital linkages in our rural 
communities. We generally can have access to those individuals.
    So, telemedicine, we are using apps right now to help 
people be connected remotely from their service provider. But 
when somebody is dealing with an acute psychiatric disorder or 
an acute addiction challenge, asking them from a rural 
community to drive hours into an urban area to seek service is 
really an insurmountable barrier for most of them. And what 
they will do is they will end up in the emergency room in a 
really critical state.
    So, those are all issues that I think we would need to 
address. Technology plays a role. Workforce improvements play a 
role. And the other is we really do need to be advancing the 
use of peer specialists. And we found peer specialists--we have 
got the data--peer specialists make a huge difference in the 
continuum of care.
    Mr. Latta. Thank you very much. Mr. Chairman, my time has 
expired and I yield back.
    Mr. Burgess. The gentleman is correct, his time has 
expired.
    Does the gentlelady from Florida wish to be recognized?
    Ms. Castor. Yes, sir.
    Mr. Burgess. The gentlelady from Florida is recognized, 5 
minutes for questions, please.
    Ms. Castor. Well, thank you, Mr. Chairman.
    And thank you to all the witnesses. I have been monitoring 
this hearing from another E&C hearing, and I am heartened by 
the discussion and the commitment, particularly relating to 
Medicaid and Medicare, and how we have to strengthen and 
modernize Medicaid to tackle all these challenges that we face, 
particularly opioids.
    And I noted some of the discussion, coming from Florida, on 
the difference in treatment between expansion States and non-
expansion States. We have hundreds of thousands, if not 
millions, of Floridians who really would benefit with 
consistent treatment, if we had expanded Medicaid. So, I know 
that is going to continue to be an issue.
    A lot of these bipartisan bills are very positive, in my 
opinion, and I have heard what you have said about a number of 
them. But I don't think we are yet at the scale we need to 
really tackle the problem. I have heard others talk about a 
Ryan White type of commitment, something that is dependable and 
consistent moving forward that aren't relying on the budget 
battles of the Congress, so that providers and law enforcement, 
everyone across the board can really tackle the problem the way 
we need to.
    Does anyone have a comment on that and about creating more 
of a Ryan White type of consistent commitment?
    Mr. Kravitz. I will just mention this: I think when we look 
at the financial crisis, one of the things that our medical 
director points out is that a huge amount of the resources we 
are spending, we are spending on people that are returning for 
care. They are returning for care because they didn't get 
proper care to begin with. And we also look at the cost that we 
are spending in emergency rooms and acute care hospitalizations 
for folks that have untreated or undertreated substance use 
disorders or psychiatric disorders.
    And I appreciate the breadth of bills that are before this 
committee and the work that everybody here has done on this 
crisis. But I think this is a huge call to action for all of 
us. And it is not just about doing more of what we are doing. 
We have to change.
    I want you to think about this. I represent one of the 
largest nonprofit providers in this space nationwide, and we 
are saying to you we need more regulation in this field; we 
need to be held to a higher standard; we need to be accountable 
for outcomes, and we also need to be accountable for providing 
a full continuum of care, so that people get the care they 
need, not the one specialty service that a provider has found a 
business model to support.
    So, long answer to your question. Absolutely, it should be 
a huge call to action. We can't let this epidemic continue to 
rage across this country. This is a complex problem. It didn't 
happen overnight. You heard the talk today about the different 
presentations, why people get into addiction to begin with, 
whether it is because of unmanaged pain or because of a co-
occurring psychiatric disorder. There are lots of reasons for 
it. This is not a simple solution. But I would say a big focus 
needs to be on we have got to quit doing things that don't 
work, and also understanding that the investment we make here 
will be more than realized with the savings in other areas, not 
even just the social impact of these issues, but in the medical 
costs in other areas of health care.
    Ms. Castor. Thank you.
    Mr. Kravitz. I hope that answers your question, 
Congressman.
    Ms. Castor. Yes, and I have one more question, but if 
somebody wants to add quickly--yes, sir?
    Mr. Botticelli. For many years I presided over the 
treatment system in Massachusetts. I think if you talk to many 
providers, while grant funding is great, having a stable 
insurance-based program really ensures that we are going to 
have--we have been talking about provider workforce here and 
how critical it is. So, I think we need to make sure that we 
particularly ensure Medicaid coverage for people with substance 
use disorders. I think grants are great, but providers, I 
think, are often reluctant to get into this business----
    Ms. Castor. Yes.
    Mr. Botticelli [continuing]. And stay in this business 
without a stable insurance base from which to build.
    Mr. Douglas. And if I could just say that, from both a 
state as well as an MCO, the idea of, well, Ryan White is 
really a trusted and needs to be an integrated approach. And 
so, looking at this through the lens of not creating a siloed 
solution, but how it integrates into the continuum of health 
and behavioral health.
    Ms. Castor. Yes. Thank you.
    Mr. Srivastava, in your testimony you mentioned that the 
number of physicians that prescribe MAT pales in comparison to 
providers able to prescribe oxycodone. And SAMHSA estimates 
over 48,000 providers currently certified to prescribe MAT 
versus 900,000 providers prescribing oxycodone. The lack of 
providers is undoubtedly more extreme in areas with a high 
proportion of Medicaid beneficiaries or in rural areas. How can 
we both increase the capacity to prescribe evidence-based 
treatment like MAT and realize the benefits? Could you expand 
specifically on the key lessons Magellan learned working in 
Pennsylvania and how that could be expanded elsewhere?
    Mr. Srivastava. Absolutely. So, in Pennsylvania, for 
example, we recently launched, in partnership with the 
governor, we provide county-based behavioral health services. 
And so, we have created 20 centers of excellence which look at 
both primary care coupled with behavioral health care in an 
integrated fashion, connected by telehealth, and all evidence-
based. And it allows for substance use disorder to be kind of 
effectively treated and managed. We also partner with Geisinger 
as well on some behavioral health----
    Ms. Castor. And you had a specific recommendation on a 
temporary FMAP increase?
    Mr. Srivastava. Correct. So, roughly, about 900,000 doctors 
today are licensed to be able to prescribe. Only 48,000 can 
prescribe MAT services. So, there is a need to be able to, one, 
educate more providers and, two, to be able to potentially 
offer a pay bump, if you will, in order to incent those 
providers to take 8 hours out of their day to get certification 
and, then, training wrapped around that as well. And so, our 
sense is that there should be funding set aside to be able to 
drive more certifications, so that providers know how to 
prescribe medication-assisted therapy. We would augment that 
with tele-behavioral health, digital therapy, text therapy, and 
coupled with peer supports and care coordination.
    Ms. Castor. Thank you. I will yield back.
    Mr. Carter [presiding]. The gentlelady has yielded.
    The Chair recognizes the chairman of the Full Committee, 
the gentleman from Oregon, the Honorable Mr. Walden.
    Mr. Walden. Thank you. Thank you, Mr. Carter. I appreciate 
it.
    And thanks to all our witnesses. Sorry I wasn't here at the 
beginning. We have a concurrent hearing going on with the 
Secretary of Energy on energy-related issues before the 
Committee. But we really appreciate your participation.
    So, I have a couple of questions I wanted to make sure and 
get in this morning. I think we all recognize the importance of 
ensuring that patients in Medicaid with substance use disorder 
have access to a continuum of care. One of the bills before the 
Committee is a targeted proposal that would remove a barrier to 
care and allow care in an IMD for up to 90 days in a 12-month 
period. Now this allows for longer treatment periods for all 
beneficiaries, not just selected subpopulations. And we believe 
this is budgetarily responsible as well. Virtually every 
stakeholder group that I have met with suggests that some of 
the IMD exclusions should be repealed or at least recalibrated, 
since residential treatment may be needed for some 
beneficiaries with substance use disorder.
    So, my question for each of you is, do you agree that the 
bill before the Committee which offers a partial repeal of IMD 
is a helpful step to ensuring that Medicaid beneficiaries 
receive the care that they need? So, do you think this makes 
sense? We will start with you.
    Mr. Botticelli. Chairman Walden, I think while we are 
trying to do everything that we can to expand access to 
treatment, and particularly looking at Medicaid, I think just 
looking at the categorical waivering of IMD requirements, quite 
honestly, I think has a potential to exacerbate our problem.
    Mr. Walden. Why is that?
    Mr. Botticelli. Well, one, I think we want to ensure, and I 
think CMS's approach to looking at this issue through the 1115 
waiver I think makes a lot of sense. Because what they have 
been saying to states is you need to demonstrate to us that you 
are not just providing residential and often expensive levels 
of care, but that you have a full continuum of care, outpatient 
services, medication-assisted treatment.
    The other piece, too, and I think we have seen this and we 
are all talking about increasing access to medication-assisted 
treatment, but the reality is that only about 20 percent of our 
programs now provide access to medication-assisted treatment. 
And so, I worry that we are, in our efforts and, then, I think 
our good intents to expand access to treatment, we are focusing 
not necessarily on the most effective treatment needed for 
people with substance use disorders----
    Mr. Walden. All right.
    Mr. Botticelli [continuing]. Which is often outpatient 
care.
    Mr. Walden. Mr. Douglas?
    Mr. Douglas. So, I agree with a lot of what Mr. Botticelli 
said, but I would say the waiver process is still cumbersome. I 
have gone through it from California, seen it in other States. 
The regulation on the managed care side doesn't go far enough.
    That being said, so the idea of eliminating the IMD rule on 
substance use is very important from an MCO, and States support 
it, but it does need to be part of an overall continuum. It 
can't be siloed because there are many cases where residential 
is not appropriate. We need to ensure that we are using ASAM 
evidence criteria and other treatment modalities within that 
and creating the right incentives----
    Mr. Walden. Right.
    Mr. Douglas [continuing]. That there is in a continuum.
    Mr. Walden. All right. Mr. Guth?
    Mr. Guth. So, I'm just going to reiterate very quickly some 
of the same things you have heard. We think it does need to be 
expanded. But I think, absolutely, we must have requirements on 
continuum of care, accountability around outcome, really 
criteria that places people in the right level of care. What we 
are all worried about--and I know this is the issue around this 
bill--is that, suddenly, we are going to have this plethora of 
very expensive care that is now just exploding across the 
country.
    Mr. Walden. Right.
    Mr. Guth. The answer to that is to ensure that when these 
expansions are permitted, that they are coupled with 
requirements around continuum of care and documented evidence 
that people are placed in the least restrictive care 
appropriate to their presentation. That is known. We can do 
that, but we don't do it in isolation. Like everything else we 
have talked about today, these are complex issues. So, we have 
to have solutions that have the complexity associated with 
them.
    Mr. Walden. All right. Thank you.
    Mr. Kravitz?
    Mr. Kravitz. We are very much affiliated with continuum of 
care. And so, we just launched a new program last week, and 
it's called Geisinger at Home, where a physician actually goes 
into the patient's home. It sounds like old times, but that is 
the way it is going in the future. And so, the technician 
supports all of that. It is based upon chronic diseased 
patients. These are the same types of patients that we will be 
treating in the home setting with telemedicine and other 
opportunities, as well as documentation and electronic feeds 
right into our electronic health record.
    Mr. Walden. OK.
    Mr. Srivastava. In short, although we have the 1115 waiver 
process, supportive of an overall process. However, it is just 
one kind of solution in a suite of solutions. So, I don't want 
to overprescribe the fact of the value created with this. It 
could create capacity, but at a cost that may not be 
sustainable.
    Mr. Walden. All right. My time has expired again. Thank you 
all for your testimony and your answers to that question and 
others today.
    I yield back.
    Mr. Carter. The gentleman yields.
    The Chair recognizes the gentleman from Florida, Mr. 
Bilirakis, for 5 minutes.
    Mr. Bilirakis. Thank you. I appreciate it, Mr. Chairman.
    And I wanted to thank Mr. Botticelli for coming down to my 
district in the Tampa Bay area when he was the drug czar about 
a couple of years ago. It was very informative, the forum we 
had. So, I appreciate it very much.
    Also, I want to talk about and I want to ask some questions 
on the lock-in. I know we have covered it a little bit, but I 
have a couple of bills with regard to that. So, I want to start 
with Mr. Douglas, if that is OK.
    Yesterday CMS talked about the importance of lock-in as a 
tool to manage prescription drug abuse in Medicare Advantage 
and Medicare Part D. Lock-in is not new and has been used for 
years in Medicaid and commercial insurance. Since you run a 
Medicaid managed care plan, you might be able to talk about how 
lock-in programs operate and what you have seen.
    Does your plan run a Medicaid lock-in program and, if so, 
can you tell me how you structure the program and what triggers 
you are looking for in identifying an at-risk beneficiary, 
please? Thank you.
    Mr. Douglas. So, yes, as you said, lock-in programs have 
been around for a long time, both from a State agency as well 
as from managed care programs. And Centene, in our States we 
have over 10 States where we do have lock-in programs. We work 
in partnership with the Medicaid agency to structure and be 
able to create the policies and procedures. There is no, I 
would say, one-size-fits-all approach to lock-in programs. In 
some States, the lock-in is around the prescriber; in other 
cases, it is about lock into a pharmacy. Or, it could be both 
prescriber and pharmacy being locked in and having the member 
have one prescriber and one pharmacy. So, it varies.
    Now there are triggers in terms of the types of 
utilization, looking at how, for example, in one criteria I 
will go through they are looking at using three or four 
pharmacies within a 30-day period. Three or more prescribers 
within a 30-day period become triggers, utilizing five or more 
controlled substances in a 30-day period, different drug 
classes. So, we look at all different types of triggers and 
create that policy.
    In many cases, the pharmacy board is part of the process, 
too, to make sure that they are integrated into the policy 
development along with the Medicaid agency. We, then, also, 
before we do the lock-in, there are notices sent out to 
members, notices sent out to prescribers and the pharmacies. 
So, everyone is onboard and understands the new process that is 
in place.
    We have found this to be very effective. Again, you need to 
cast the net appropriately, and that is where having the right 
triggers and knowing who that you are bringing into the 
program, so you are not inappropriately restricting access to 
needed services. But, where done, we have some evidence and 
data that has shown that we have been able to bend the cost 
curve and be able to still provide the right outcomes in these 
lock-in programs.
    Mr. Bilirakis. Mr. Srivastava, do you want to elaborate? I 
know you answered that question when Mr. Guthrie asked you that 
question. But do you want to elaborate as to the triggers?
    Mr. Srivastava. Sure.
    Mr. Bilirakis. And how do you identify the at-risk 
beneficiaries?
    Mr. Srivastava. Absolutely. Just to add on what I said 
previously, we operate two plans, in Florida and in 
Massachusetts today where we have a lock-in place on Medicaid. 
And we see kind of expanding that into Medicare Advantage in 
2019.
    Really, it is a community-based outreach effort to do lock-
in effectively. So, it is engaging with the individual. Each 
State has different criteria as it relates to Medicaid. And so, 
we are kind of following the State's guidelines and trying to 
be coordinated. But it is coordinating with the individual and 
coordinating with primary care as well as specialty care. In a 
lot of these cases, these are individuals with physical health 
as well as comorbid behavioral health issues. And so, as a 
result, we are working with community-based mental health 
centers as well to be able to have a coordinated approach 
towards a lock-in related to a prescriber at a location, so 
that we can kind of reduce overuse or misuse of drugs.
    But I think another key element is simply making sure that 
we have care management wrapped around that, as well as in-home 
services, peer supports, and access to tele-behavioral health 
and telehealth services as well, to make sure there is a 
coordination of care.
    Mr. Bilirakis. How effective has the program been?
    Mr. Srivastava. So, we have seen it has been effective in 
Florida, from our perspective, in your area, and we have been 
able to see kind of reduced utilization and stability in terms 
of outcomes. So, the recidivism or kind of admissions and 
readmissions related to things have gone down.
    Mr. Bilirakis. Mr. Douglas, how effective has the program 
been?
    Mr. Douglas. Again, very effective, that we have seen a 
reduction in costs, overutilization, primarily from pharmacy 
spend, but also on the medical side as well from inpatient as 
well as emergency room. So, when done right, it has been very 
effective.
    Mr. Bilirakis. OK. Very good.
    I will yield back, Mr. Chairman. Appreciate it.
    Mr. Carter. The gentleman yields.
    The Chair recognizes the gentleman from Indiana, Dr. 
Bucshon.
    Mr. Bucshon. Thank you, Mr. Chairman.
    Mr. Kravitz, prior to becoming a Member of Congress, I was 
a cardiovascular and thoracic surgeon. As a physician, I 
believe that in order to properly address some part of the 
opioid crisis, we need to address the causes, one of which is 
how we diagnose and manage chronic pain. From your experience 
as a system, what is the most effective way for providers to 
engage patients about pain and pain management?
    Mr. Kravitz. So, I have a personal situation. My wife today 
had a pain management visit due to an injury to her neck.
    Mr. Bucshon. Yes, particularly new patients and seniors 
also?
    Mr. Kravitz. OK. So, she is a new patient, and seniors, the 
same way. Our prescribers and our specialty physicians--and I 
attended the visit with her to see a neurologist--they take the 
opportunity to counsel and discuss, to review what actually the 
injury is for that particular patient. Again, firsthand, I saw 
where opioids were not even introduced. That was discussed as 
not being an option in this case. Other methods with regard to 
physical therapy, behavioral therapy, things of that nature, in 
this case it is physical therapy, which will begin immediately. 
Injections and things like that which are non-opioid type of 
medications.
    But we take the initiative to work with the patients, the 
same as with our Medicaid or Medicare population patients. We 
would much prefer not to go down the path of opioids because of 
the risk associated with opioids. And so, I think that has been 
our process, and I have seen it firsthand.
    Mr. Bucshon. The gist of it is it is critical to have the 
good evaluation of the causes of pain----
    Mr. Kravitz. Absolutely.
    Mr. Bucshon [continuing]. And, also, proper counseling with 
the patient and family about alternative treatment? I will 
speak for the physicians. I am a physician. Historically, I 
think maybe we haven't done that as well as a society as maybe 
we could have, right?
    Mr. Kravitz. I think being part of a physician-led 
organization like Geisinger, and known for the innovation that 
our physicians lead and our technology supports, that has been 
our mantra, so to speak, that that is the direction we want to 
go. Is it a perfect organization? No, far from it, but we will 
continue to iterate and make it better and tighter as time goes 
by.
    Mr. Bucshon. Yes, and it is also pretty clear that it is 
important for care providers to have a complete understanding 
of not only the current pain problem, but their pain history.
    CMS testified yesterday and it was mentioned that the way 
we look at pain needs to evolve from just treating the pain to 
a full conversation about pain management, and I think you 
would agree with that.
    Mr. Kravitz. Yes, absolutely.
    Mr. Bucshon. So, we had that yesterday.
    Mr. Srivastava. Congressman, if I could just add?
    Mr. Bucshon. Yes.
    Mr. Srivastava. Geisinger is a vertically-integrated system 
that has complete access to data and a strong delivery model--
we were on a network model. So, we serve about 7.5 million 
people today with chronic pain management services where we 
partner with health plans and partner with providers.
    I think the key there is having strong data and analytics 
and offering up alternative therapies, as you outlined. The one 
piece that I will just add is that the alternative therapies 
wrapped around virtual care delivery is really a first-line 
therapy for us. So, how can you manage pain with cognitive-
based therapy? Second, then, with telehealth or tele-behavioral 
health as well, text therapy as well, in order to kind of 
augment. So, there is a level of that compounded with home care 
services that could also alleviate pain beyond just opioid use.
    Mr. Bucshon. Yes. And again, for you, Mr. Srivastava, in 
your testimony you suggested that any willing provider 
requirements are problematic for health plans due to the 
behavior of some rogue pharmacies who engage in fraud. I would 
like to try to get a better understanding for that because I 
have a little bit of a skeptical view on that. It is my 
understanding that fraudulent behavior from a pharmacy is 
prosecuted by CMS and other state authorities. Is the concern 
that managed care plans have to take any pharmacy willing to 
accept the plan's contract and maybe they don't want to do 
that? Or, is the concern that pharmacies with problematic 
business patterns are not identified and pursued quickly 
enough?
    Mr. Srivastava. It does not have to do with kind of 
building a network and accessing discounts. It has everything 
to do with having a quality network where things are 
credentialed and there is high-quality delivery. And if there 
is aberrant behavior, things that are outside the norm, that we 
should be able to not have to be required to contract with that 
entity. And we are not speaking to the majority or a large 
portion, but a very small portion.
    Mr. Bucshon. OK, yes, because, from my standpoint also not 
only as a Member of Congress, but as a physician, it is 
important for me to ensure that our Medicaid or Medicare 
patients have access to high-quality providers and pharmacies, 
and that situation not to be restricted in a way that makes it 
difficult for people to access their pharmacies.
    Mr. Srivastava. It is all about the quality----
    Mr. Bucshon. Yes.
    Mr. Srivastava [continuing]. And making sure there is a 
level there. Thank you.
    Mr. Bucshon. Fair enough. Thank you.
    I yield back, Mr. Chairman.
    Mr. Carter. The gentleman yields.
    The Chair recognizes the gentlelady from Indiana, Ms. 
Brooks.
    Mrs. Brooks. Thank you, Mr. Chairman.
    Mr. Douglas, in your testimony you mentioned the 
importance--and a few of you did as well, and so, I would like 
to hear more from others--but you mentioned specifically the 
importance of provider education as one way to reduce opioid 
use and abuse, and including educating providers about the 
risks of high-dose prescribing and best practices in the 
treatment of pain and addiction risk associated with 
prescribing opioids for pain. I would like to hear a little bit 
more about the outcomes that you have seen, and others have 
seen, about provider education policies and whether or not it 
has led to a reduction in opioids prescriptions, and whether, 
with those outcomes and since you have implemented policies 
like this for your providers, how has it impacted the numbers 
of patients actually using opioids? And has there been a 
noticeable decrease in patients seeking treatment for their 
addiction? A lot of different----
    Mr. Douglas. Yes, a great question.
    What I would say, first of all, I have seen directly from 
Centene that, for example, we offer free continuing medical 
education as one way to make sure on alternatives--we have 
talked about alternative therapies and treatment and better 
ways of pain management. Too, there are different projects--
ECHO is going on--as ways to do this. And then, there is also, 
through 1115 waivers, a lot of work going on where you see 
collaborative models of the best and evidence-based approaches 
on pain management.
    What I would say in terms of outcomes is the hard thing to 
pinpoint on education is this is a continuum of prevention 
approaches, from what is going on out front, and we have talked 
about everything from very, very aggressive approaches around 
lock-in to really limiting prescription refills, to the length. 
So, we from Centene, and I have put it in my write-up, have 
seen significant reductions, in overall numbers. That being 
said, I can't tell you it is just about education. It is about 
the comprehensive nature and approach, that you need to create 
the right incentives for States and Medicaid managed care 
organizations to be looking comprehensively and not just 
thinking education is going to solve it, but around all of the 
different approaches.
    Mrs. Brooks. Oh, certainly. No, there is no question that 
it needs to have a lot of different approaches.
    Have your prescribers complained about prescriber 
education?
    Mr. Douglas. I would have to get back to you on it. I think 
this gets to a broader issue, and this is where you need to 
create the right investment. It is our providers, you know, we 
ask a lot of our providers. And so, we try to create the right 
platforms--and this gets to how, for example, CME, they already 
need to do it--ways that we are not just adding another 
additional burden without any payment. And so, it has got to be 
the balance between creating the right incentives and the right 
venues and right financing to ensure we are getting the high-
performing providers who are paid adequately to provide the 
right access and the right types of treatment.
    Mrs. Brooks. Thank you.
    You brought up provider education, Mr. Botticelli. Can you 
expand on either Mr. Douglas' points or any additional of your 
own----
    Mr. Botticelli. Sure.
    Mrs. Brooks [continuing]. With respect to prescriber 
education? And prescribers meaning physicians, nurse 
practitioners, dentists, everyone.
    Mr. Botticelli. One of the issues that we saw driving 
overprescribing was, quite honestly, misleading information. As 
you talk to many prescribers, they will tell you that they were 
trained that these were not addictive drugs, that these should 
be prescribed liberally. And while I agree with Mr. Douglas 
that you can't kind of pinpoint to one specific thing, I think 
it makes intuitive sense to give providers good, fact-based 
education as it relates to this issue.
    Again, while I do think we need to provide incentives, and 
I say this not to overexaggerate, but while we have seen some 
modest declines in prescribing, we are still prescribing at 
three times the level that we were in 1999. And I don't think 
it is unreasonable to ask a physician, kind of 15 years into 
this epidemic, to take some modicum of continuing medical 
education, either on safe prescribing or just on substance use 
issues in general.
    Mrs. Brooks. Thank you.
    Mr. Kravitz, or any of the others, comments?
    Mr. Kravitz. Yes, I would love to comment on that. So, I 
had mentioned in my testimony we have a provider dashboard. So, 
that tracks providers that are high prescribers for opioids. We 
use that as part of our continuous monitoring for our 
physicians who we have educated and trained on this. We will 
continuously go back and address issues if we still see a 
persistent level of prescriptions being prescribed--overusing 
that term--but by these particular providers. And they could be 
nurse practitioners, physician assistants, anyone who has a DEA 
license number in this case. So, we address it. We are very 
much concerned about the quality of care delivered to our 
patients, and that is one of the areas where we focus on very 
heavily with analytics.
    Mrs. Brooks. Thank you.
    I am out of time. I yield back. Thank you.
    Mr. Carter. The gentlelady yields.
    The Chair now will recognize the gentleman from New York, 
Mr. Tonko, for 5 minutes.
    Mr. Tonko. Thank you, Mr. Chair.
    I don't see Mr. Barton in the room, but I do want to 
address my colleague's concerns and I appreciate his kind 
comments. But I want to make it abundantly clear, my bill does 
not expand Medicaid eligibility in any way. It simply would 
allow States the flexibility to provide for existing Medicaid 
beneficiaries who are returning into the community in less than 
a month.
    Vast bodies of evidence confirm that individuals engaged in 
addiction treatment have lower rates of recidivism and lower 
healthcare costs, and we have undone many, many situations 
where they would have overdosed and died. That is what my bill 
does, straightforward. It is about being smart on crime and 
effective for the taxpayer.
    In trying to address the opioid epidemic, one of the 
populations I have the greatest concerns about is individuals 
who have had involvement with the criminal justice system. As I 
mentioned during the first panel, for individuals reentering 
society after a stay in jail or prison, the risk of overdose is 
as high as 129 times that of the general population during the 
first 2 weeks of post-release.
    In States that have specifically collected data on this 
population, such as Rhode Island, we have seen that justice-
involved individuals can account for at least 15 percent of the 
total overdose deaths. If we extrapolated that figure 
nationwide, we are talking about 10,000 deaths a year among 
individuals less than a year removed from correctional 
settings.
    Mr. Botticelli, let me welcome you back to this committee 
and direct the question your way. Drawing on your previous role 
at ONDCP or your current position at BMC, what are some of the 
unique challenges that this justice-involved population faces 
in accessing effective addiction treatment, and how can we do a 
better job of meeting the needs of this population?
    Mr. Botticelli. Thank you for the opportunity to address 
you again.
    Our data in Massachusetts underscores some data that you've 
already said, and we see people who are coming out of our jails 
and prisons overdose and die at one hundred and twenty times 
the rate of the general population. And while we've made 
success with many populations, that is one area where we need 
to have concern.
    And I will tell you that, very interestingly, Boston 
Medical Center is right across from the Suffolk County Jail, 
and we actually try to make sure that we are getting people as 
they come out of prison into our services. But it often can be 
challenging. And even though we do a good job of trying to get 
people on insurance, being able to have that seamless coverage, 
actually start people on treatment while they are in jail 
becomes important.
    And the last point that I will make is we have a 
significant number of sheriffs in Massachusetts who operate 
county houses of correction, who I think would have greater 
uptake of medication-assisted treatment while people are in 
jail. But part of the predicament that they run into is cost. 
To your point, with already Medicaid-eligible folks, if we have 
some modicum of transition services to be able to make sure 
that folks have that seamless bridge back to the community, 
that, to your point, not only can we reduce overdose deaths, 
but we would reduce costs and we would reduce recidivism.
    Mr. Tonko. That is a smarter use of the taxpayer dollar.
    Mr. Botticelli. It is.
    Mr. Tonko. Thank you, Mr. Botticelli.
    In an attempt to address some of the challenges you spoke 
about, I introduced the Medicaid Reentry Act, which would 
provide States with new flexibility to draw Federal matching 
funds for care provided to Medicaid- eligible, already 
Medicaid-eligible incarcerated individuals in the 30-day period 
prior to release, rather than waiting until the day of release 
itself.
    Mr. Douglas, as a former State Medicaid director, would 
this type of increased flexibility have been useful to you as 
you crafted a response to the opioid epidemic?
    Mr. Douglas. Absolutely. What we see, we have innovative 
programs now. I can see, and I mentioned earlier, in Ohio, 
where there is a lot of work going on between the correctional 
system and the managed care organizations where there is a pre-
release program in place, that we do a lot of work.
    Mr. Tonko. I am going to cut you short because I only have 
about 35 seconds left.
    Mr. Douglas. OK, fine.
    Mr. Tonko. But I appreciate it.
     Mr. Douglas. Yes.
    Mr. Tonko. For the rest of the panel, do you agree that 
initiating addiction treatment and care coordination services 
for reentering Medicaid beneficiaries before they leave a 
correction setting would improve their health outcomes, 
including overdose deaths for these individuals upon reentry, 
yes or no?
    Mr. Kravitz. Yes.
    Mr. Douglas. Yes, sir.
    Mr. Guth. Yes.
    Mr. Srivastava. We have experience in three States. Yes.
    Mr. Tonko. OK. Mr. Douglas, coming back to you, your 
company has done some innovative work in the reentry space with 
subsidiary Buckeye Health Plan, a Medicaid managed care 
organization operating in Ohio. Buckeye participates in Ohio's 
Medicaid Pre-Release Enrollment Program under which managed 
care organizations provide care coordination services through 
videoconferencing to certain high-risk incarcerated individuals 
prior to release from prison. Beneficiaries are provided an 
insurance card and a care plan the moment they walk out of a 
corrections facility.
    I was hoping you could briefly describe Buckeye's 
participation in this program and share any data that you 
believe are significant for the previously-incarcerated 
beneficiaries who have enrolled with Buckeye.
    Mr. Douglas. Yes, and I am happy afterwards to provide for 
the record--we have a flyer that gives more detail on this--
knowing that we are out of time.
    But, just in a nutshell, we work 90 to 120 days before 
release getting them, making sure they are going to be enrolled 
in Medicaid, so that they are actually Medicaid-eligible. We 
develop a transition plan. We, through a videoconference, 
review that with their care manager. We schedule post-release 
appointments. Then, we make sure that pre-release that they are 
getting a 30-day supply of medicine, especially for those with 
behavioral health needs. And then, we do a care outreach 5 days 
after release to make sure they are connected to both 
integrated behavioral health services as well as social 
services. Across not just with Buckeye, our plan, but all of 
Ohio has had 20,000 former inmates enrolled in this program.
    Mr. Tonko. Thank you, Mr. Douglas.
    Finally, I will just state--and I know my time is out--but 
I will state that, if with this human health crisis, this 
opioid epidemic, our goal is to save lives, I challenge this 
committee to say no to addressing those who are incarcerated. 
It should not be a caste system here. Many people find 
themselves incarcerated because of this illness, and we need to 
be compassionate and I think effective with the taxpayers' 
dollars.
    With that, I yield back, Mr. Chair.
    Mr. Carter. The gentleman yields.
    The Chair now will recognize himself for 5 minutes.
    I would like to ask unanimous consent to submit two letters 
for the record supporting the Pharmacy and Medically 
Underserved Areas Enhancement Act. Without objection.
    [The information appears at the conclusion of the hearing.]
    Mr. Carter. Mr. Guth, I am going to start with you. I 
wanted to ask you, the recommendations that have been put forth 
by the President's Commission on Combating Drug Addiction and 
the Opioid Crisis stated that, ``There is a great need to 
ensure that healthcare providers are screening for SUDs and 
know how to appropriately counsel or refer to a patient.'' It 
would appear to me that this is an opportunity for Congress to 
direct CMS that CPT codes be expanded or added to, and that we 
identify patients at risk for opioid use disorders.
    Mr. Guth. Absolutely.
    Mr. Carter. Would you agree with that?
    Mr. Guth. Absolutely.
    Mr. Carter. Should we be looking at creating or amending 
CPT codes? As I understand it, it is done in other areas. In 
fact, it is done for chronic care with alcohol and substance 
abuse, and other areas as well.
    Mr. Guth. Absolutely. I am very much supportive of that.
    Mr. Carter. OK. Should we be encouraging the use of OUD 
tapering strategies that have been proven to work?
    Mr. Guth. Yes, and I think those go back to the fact that 
you have very different presentations for folks. You have 
individuals with very different recovery capital themselves. 
So, not everybody needs to be on medication-assisted therapy 
for the duration. I think this gets back to one size doesn't 
fit all.
    Mr. Carter. Right, right.
    Mr. Guth. So, the short answer to your question is, yes, we 
ought to be including in the continuum of care tapering 
strategies.
    Mr. Carter. OK. I want to talk real quickly about one of 
the bills that is under consideration. That is the Partnership 
Act, and that is the use of the PDMPs, and specifically as it 
relates to pharmacists. And full disclosure is, I suspect you 
know, currently, I am the only pharmacist serving in Congress. 
I have over 30 years of experience in a retail setting. And I 
acknowledge the responsibility of pharmacists. We have an 
important responsibility, a very important responsibility, as 
possibly the last line of defense in the opioid crisis.
    But, having said that, I will tell you we are not 
policemen. And to require pharmacists to be the only ones to be 
looking at a PDMP, and to be policing physicians who are 
writing the prescriptions, I think is somewhat unfair. I have 
often said the only thing worse for me, as a practicing 
pharmacist, to fill a prescription for someone who is going to 
be abusing it, would be to not fill a prescription for someone 
who truly needs it. It is unfair to expect a pharmacist to 
profile a patient and say, no, that patient doesn't need that 
medication. That is unfair.
    Now I get it. I understand a PDMP is different. I have 
sponsored the legislation creating the PDMP in the State of 
Georgia back in 2009. But, at the same time, I just want to get 
your thoughts on this. Without having the prescriber have to 
look at the PDMP, why are we having the pharmacist to look at 
it? To police the doctors? Anyone want to jump on that?
    Yes, sir, Mr. Kravitz?
    Mr. Kravitz. I think it is imperative that the provider be 
held accountable, prior to providing the prescription, that 
they must check the PDMP. And they are the source of this 
process. I think the pharmacist, which I have a daughter who is 
a pharmacist as well, and I think they are a checkpoint in the 
process. They should not be held accountable as the policing 
act.
    Mr. Carter. Thank you.
    Any other comments? OK, and let me go back to you, Mr. 
Guth, because I thought it was interesting. In your opening 
statement, you said that the number of programs that are out 
there--and this is something that I have been very concerned 
about, the fact that I look at the opioid crisis and I look at 
two different components of it.
    First of all, there is that tangible part, if you will, 
that I feel like we can get our arms around. How do we control 
the number of prescriptions, the pills that are going out? And 
what are those things that we do to limit the access to them?
    But, then, there is the second component that is more 
challenging in my mind, and that is, how do we treat those 
people who are already addicted? You said that, quite often, it 
depends on what program you enter into.
    Mr. Guth. Yes. And let me give you an example close to home 
of how we have addressed this. So, Centerstone has a five-state 
primary footprint for our services, and we are the result of an 
affiliation of nonprofit providers who are all mission-driven 
organizations. As we brought these organizations together, we 
realized that the systems of care in each of these states vary 
dramatically, not only in the area of substance use treatment--
--
    Mr. Carter. Right.
    Mr. Guth [continuing]. But across the board, not based on 
the science of care, but based on how services evolved in those 
areas, access to human capital, state regulations, and, more 
often than not, funding, access to funding.
    And so, what happens today is, let's take this shortage of 
services for the 30 million people in rural communities. We can 
quickly go to a solution that says let's give them access to 
medication-assisted therapy, light on the therapy, without all 
the continuum-of-care services. And we can turn around and say, 
hey, 30 million people now have access to substance abuse care. 
But that is not a single solution that addresses all the people 
that present.
    Think about the fact that, if you or I present with an 
opioid disorder, we have got a lot of human capital support 
around us in our family, in our friends, or networks. We have 
got jobs. We have got a safe place to live. But, if that is not 
our situation, which is the case for many people that are 
battling this disorder, we need to make sure they have got 
access to----
    Mr. Carter. Right, right.
    Mr. Guth [continuing]. A sober living community, that they 
have got access to peer support.
    Mr. Carter. Well, and it is one concern that I have because 
a lot of my colleagues--and I am not being critical; I just 
don't think they understand--think all we have got to do is 
throw money at it, and if we can get to a certain point, then 
that is where we need to be. But my point is that not all 
programs are going to work for all people.
    Mr. Guth. That is right.
    Mr. Carter. That is difficult for us in Congress to 
disseminate. How do we know which programs work and which ones 
don't?
    Mr. Guth. I think you start by looking at whether the 
provider has access to, either directly or through strong 
referral relationships, a continuum of care.
     Mr. Carter. A continuum of care is extremely important.
    Mr. Guth. If anybody comes to you today and says, look, we 
have got the one solution, we have got the one program, the one 
protocol that is going to work for everybody, I think you ought 
to be looking very closely at that.
    Mr. Carter. Right.
    Let me ask one more thing. Mr. Douglas, or any of you, did 
I hear you say that only one out of five people in treatment 
are getting medication-assisted treatment? Are most of the 
patients who are under treatment for opioid addiction, are they 
getting medication-assisted treatment or are they just getting 
therapy? Almost all of them getting medication-assisted 
therapy?
    Yes, I'm sorry?
    Mr. Botticelli. So, despite the fact that I think all the 
data support that people on medication, as long as they are 
getting all the other behavioral and recovery supports, do far 
better on a medication versus treatment without the 
medications. But only a very small percentage of people are 
getting on it. And we still have a small percentage of our 
treatment programs who are even offering it.
    But, while I agree with you that there are multiple 
pathways to treatment, I do think that every licensed substance 
use treatment provider who is getting a Federal dollar should 
be offering access to medication-assisted treatment. And I 
think it is really important because the data are pretty clear 
that people get into long-term recovery when they are on a 
medication versus when they are not.
    And again, this is not saying ``either/or''. People need 
all the other recovery supports.
    Mr. Carter. Right, right.
    Mr. Botticelli. They need behavioral therapy. They need 
peer support services. But it is very clear, and again, I go 
back to Secretary Azar who said treating substance use 
disorders and treating opioid addiction without a medication is 
like treating an infection without an antibiotic.
    Mr. Carter. Right.
    Mr. Guth. And for the record, I absolutely agree with that. 
So, it is a point about having the other constellation services 
available.
    Mr. Carter. Right. But you see what a difficult situation 
it puts us in. I mean, all of you know that this is a lifelong 
challenge. I mean, and you have to continue it, and it is 
expensive and everything else.
    But I want to thank all of you for being here. This is 
extremely important. This is part of what, as I said earlier, 
the second component that I consider to be so very challenging 
for us, but so very necessary for those who need help. And we 
need them. We need them back to being productive members of our 
society.
    So, I will yield back the remainder of my time.
    Seeing there are no further members wishing to ask 
questions, I would like to thank all of our witnesses again for 
being here today.
    I would like to submit statements from the following for 
the record: the American Association of Oral and Maxillofacial 
Surgeons, the Association for Behavioral Health and Wellness, 
AdvaMed, the American Hospital Association, the American 
Psychological Association, the American Society of Health 
System Pharmacists, the Association for Community Affiliated 
Plans, the College of Healthcare Information Management 
Executives, ePrescribing Coalition, the National Association 
for Behavioral Healthcare, the National Association of Chain 
Drug Stores, the National Association of Medical Directors, the 
National Indian Health Board, the Oregon Community Health 
Information Network, the Partnership to Amend Part 2, the 
Pharmaceutical Care Management Association, Property Casualty 
Insurance Association of America, Shatterproof, Imprivata, the 
Pharmacy Coalition, Express Scripts, the National Association 
of Counties, and Trinity Health.
    [The information appears at the conclusion of the hearing.]
    Mr. Carter. I would also like to submit a joint statement 
from the Infectious Disease Society of America, the HIV 
Medicine Association, and the Pediatric Infectious Disease 
Society; a study entitled, ``States With Prescription Drug 
Monitoring Mandates Saw a Reduction in Opioids Prescribed to 
Medicaid Enrollees,'' published in Health Affairs, and the 
Center for Medicare and Medicaid Services 2016 Medicaid Drug 
Utilization Review Annual Report.
    [The information appears at the conclusion of the hearing.]
    Mr. Carter. Pursuant to committee rules, I remind members 
that they have 10 business days to submit additional questions 
for the record, and I ask that witnesses submit their responses 
within 10 business days upon receipt of the questions.
    Without objection, the subcommittee is adjourned.
    [Whereupon, at 12:37 p.m., the subcommittee was adjourned.]
    
    
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