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


                  THE OPIOID CRISIS: REMOVING BARRIERS
                   TO PREVENT AND TREAT OPIOID ABUSE
                       AND DEPENDENCE IN MEDICARE

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

                                 HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                      COMMITTEE ON WAYS AND MEANS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                            FEBRUARY 6, 2018

                               __________

                          Serial No. 115-HL03

                               __________

         Printed for the use of the Committee on Ways and Means
         
         
 [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
 
 
                               __________
                                
 
                     U.S. GOVERNMENT PUBLISHING OFFICE                    
 33-794                     WASHINGTON : 2019                     
          
         


                      COMMITTEE ON WAYS AND MEANS

                      KEVIN BRADY, Texas, Chairman

SAM JOHNSON, Texas                   RICHARD E. NEAL, Massachusetts
DEVIN NUNES, California              SANDER M. LEVIN, Michigan
DAVID G. REICHERT, Washington        JOHN LEWIS, Georgia
PETER J. ROSKAM, Illinois            LLOYD DOGGETT, Texas
VERN BUCHANAN, Florida               MIKE THOMPSON, California
ADRIAN SMITH, Nebraska               JOHN B. LARSON, Connecticut
LYNN JENKINS, Kansas                 EARL BLUMENAUER, Oregon
ERIK PAULSEN, Minnesota              RON KIND, Wisconsin
KENNY MARCHANT, Texas                BILL PASCRELL, JR., New Jersey
DIANE BLACK, Tennessee               JOSEPH CROWLEY, New York
TOM REED, New York                   DANNY DAVIS, Illinois
MIKE KELLY, Pennsylvania             LINDA SANCHEZ, California
JIM RENACCI, Ohio                    BRIAN HIGGINS, New York
PAT MEEHAN, Pennsylvania             TERRI SEWELL, Alabama
KRISTI NOEM, South Dakota            SUZAN DELBENE, Washington
GEORGE HOLDING, North Carolina       JUDY CHU, California
JASON SMITH, Missouri
TOM RICE, South Carolina
DAVID SCHWEIKERT, Arizona
JACKIE WALORSKI, Indiana
CARLOS CURBELO, Florida
MIKE BISHOP, Michigan
DARIN LAHOOD, Illinois

                     David Stewart, Staff Director

                 Brandon Casey, Minority Chief Counsel

                                 ______

                         SUBCOMMITTEE ON HEALTH

                  PETER J. ROSKAM, Illinois, Chairman

SAM JOHNSON, Texas                   SANDER M. LEVIN, Michigan
DEVIN NUNES, California              MIKE THOMPSON, California
VERN BUCHANAN, Florida               RON KIND, Wisconsin
ADRIAN SMITH, Nebraska               EARL BLUMENAUER, Oregon
LYNN JENKINS, Kansas                 BRIAN HIGGINS, New York
KENNY MARCHANT, Texas                TERRI SEWELL, Alabama
DIANE BLACK, Tennessee               JUDY CHU, California
ERIK PAULSEN, Minnesota
TOM REED, New York
MIKE KELLY, Pennsylvania


                            C O N T E N T S

                               __________

                                                                   Page

Advisory of February 6, 2018, announcing the hearing.............     2

                               WITNESSES

Philip B. Scott, Governor, State of Vermont, accompanied by Al 
  Gobeille, Secretary of Human Services..........................     7
Ramsin M. Benyamin, M.D., President and Founder, Millennium Pain 
  Center, and Board of Directors, American Board of 
  Interventional Pain Physicians.................................    30
Jason Kletter, Ph.D., President, BayMark Health Services and Bay 
  Area Addiction Research and Treatment (BAART)..................    42
Harold L. Paz, M.D., M.S., Executive Vice President and Chief 
  Medical Officer, Aetna, Inc....................................    51
Laura Hungiville, PharmD, Chief Pharmacy Officer, WellCare Health 
  Plans, Inc.....................................................    62

                        QUESTIONS FOR THE RECORD

Questions from the Majority Members of the Subcommittee on Health 
  of the Committee on Ways and Means, to Ramsin M. Benyamin, 
  M.D., President and Founder, Millennium Pain Center, and Board 
  of Directors, American Board of Interventional Pain Physicians.    83
Questions from Representative Adrian Smith, of Nebraska, to 
  Harold L. Paz, M.D., M.S., Executive Vice President and Chief 
  Medical Officer, Aetna, Inc....................................    84
Questions from Representative Judy Chu, of California, to Harold 
  L. Paz, M.D., M.S., Executive Vice President and Chief Medical 
  Officer, Aetna, Inc............................................    85
Questions from the Majority Members of the Subcommittee on Health 
  of the Committee on Ways and Means, to Harold L. Paz, M.D., 
  M.S., Executive Vice President and Chief Medical Officer, 
  Aetna, Inc.....................................................    86

                       SUBMISSIONS FOR THE RECORD

Pharmaceutical Care Management Association (PCMA)................    88
Philip B. Scott, Governor, State of Vermont......................    93

 
                  THE OPIOID CRISIS: REMOVING BARRIERS
                   TO PREVENT AND TREAT OPIOID ABUSE
                       AND DEPENDENCE IN MEDICARE

                              ----------                              


                       TUESDAY, FEBRUARY 6, 2018

             U.S. House of Representatives,
                       Committee on Ways and Means,
                                    Subcommittee on Health,
                                                    Washington, DC.

    The Subcommittee met, pursuant to call, at 3:07 p.m., in 
Room 1100, Longworth House Office Building, Hon. Peter Roskam 
[Chairman of the Subcommittee] presiding.
    [The advisory announcing the hearing follows:]

ADVISORY

FROM THE 
COMMITTEE
 ON WAYS 
AND 
MEANS

                         SUBCOMMITTEE ON HEALTH

                                                CONTACT: (202) 225-1721
FOR IMMEDIATE RELEASE
Tuesday, February 6, 2018
HL-03

                  Chairman Roskam Announces Hearing on

                  The Opioid Crisis: Removing Barriers

                   to Prevent and Treat Opioid Abuse

                       and Dependence in Medicare

    House Ways and Means Health Subcommittee Chairman Peter Roskam (R-
IL), announced today that the Subcommittee will hold a hearing on ``The 
Opioid Crisis: Removing Barriers to Prevent and Treat Opioid Abuse and 
Dependence in Medicare.'' The hearing will discuss the ongoing opioid 
crisis, and the important role data, addiction prevention, and access 
to treatment play in addressing the crisis. The hearing will also 
examine possible legislative solutions to combat opioid abuse. The 
hearing will take place on Tuesday, February 6, 2018, in room 1100 of 
the Longworth House Office Building, beginning at 3:00 p.m.
      
    In view of the limited time to hear witnesses, oral testimony at 
this hearing will be from invited witnesses only. However, any 
individual or organization may submit a written statement for 
consideration by the Committee and for inclusion in the printed record 
of the hearing.
      

DETAILS FOR SUBMISSION OF WRITTEN COMMENTS:

      
    Please Note: Any person(s) and/or organization(s) wishing to submit 
written comments for the hearing record must follow the appropriate 
link on the hearing page of the Committee website and complete the 
informational forms. From the Committee homepage, http://
waysandmeans.house.gov, select ``Hearings.'' Select the hearing for 
which you would like to make a submission, and click on the link 
entitled, ``Click here to provide a submission for the record.'' Once 
you have followed the online instructions, submit all requested 
information. ATTACH your submission as a Word document, in compliance 
with the formatting requirements listed below, by the close of business 
on Tuesday, February 20, 2018. For questions, or if you encounter 
technical problems, please call (202) 225-3625.
      

FORMATTING REQUIREMENTS:

      
    The Committee relies on electronic submissions for printing the 
official hearing record. As always, submissions will be included in the 
record according to the discretion of the Committee. The Committee will 
not alter the content of your submission, but we reserve the right to 
format it according to our guidelines. Any submission provided to the 
Committee by a witness, any materials submitted for the printed record, 
and any written comments in response to a request for written comments 
must conform to the guidelines listed below. Any submission not in 
compliance with these guidelines will not be printed, but will be 
maintained in the Committee files for review and use by the Committee.
      
    All submissions and supplementary materials must be submitted in a 
single document via email, provided in Word format and must not exceed 
a total of 10 pages. Witnesses and submitters are advised that the 
Committee relies on electronic submissions for printing the official 
hearing record.
      
    All submissions must include a list of all clients, persons and/or 
organizations on whose behalf the witness appears. The name, company, 
address, telephone, and fax numbers of each witness must be included in 
the body of the email. Please exclude any personal identifiable 
information in the attached submission.
      
    Failure to follow the formatting requirements may result in the 
exclusion of a submission. All submissions for the record are final.

    The Committee seeks to make its facilities accessible to persons 
with disabilities. If you are in need of special accommodations, please 
call 202-225-1721 or 202-226-3411 TDD/TTY in advance of the event (four 
business days notice is requested). Questions with regard to special 
accommodation needs in general (including availability of Committee 
materials in alternative formats) may be directed to the Committee as 
noted above.
      
    Note: All Committee advisories and news releases are available at
    http://www.waysandmeans.house.gov/

                                 

    Chairman ROSKAM. The Subcommittee will come to order.
    Welcome to the Ways and Means Health Subcommittee hearing 
on ``The Opioid Crisis: Removing Barriers to Prevent and Treat 
Opioid Abuse and Dependence in Medicare.'' I am pleased to take 
on this issue, along with Mr. Levin, as my first hearing as the 
new Subcommittee Chairman.
    This is the second hearing in a series held by the Ways and 
Means Committee on this crisis. And today we will explore 
opioid addiction and treatment in our Medicare population and 
ask the question how Congress can do more to improve detection, 
education, prevention, et cetera.
    Like many States, my home State of Illinois is experiencing 
an increase in opioid-related overdose deaths. According to the 
Illinois Department of Public Health, there has been a 44.3-
percent increase in drug overdoses from 2013 to 2016. I know 
this figure is consistent with other States and other 
experiences. Approximately 80 percent of drug overdose deaths 
in 2016 were opioid-related. Nationally, more than 42,000 
Americans died from opioid-related drug overdoses in 2016, 
according to the Centers for Disease Control. That is over 115 
people a day or the equivalent of over 14 people who would have 
lost their lives in the course of this upcoming hearing today.
    And while those are statistics and the statistics are 
compelling, we are talking about sons and daughters, brothers 
and sisters, mothers and fathers, and those who are dear to us 
who are struggling with this crisis in and around our 
communities. With 10,000 baby boomers joining Medicare each 
day, we must harness innovation, technology, and data to get 
ahead of this problem. Unfortunately, there is a lack of 
available data regarding the Medicare population and the extent 
to which opioid abuse, overprescribing, and diversion is an 
issue for seniors and the disabled. Additionally, gaps in 
coverage for those that suffer from opioid addiction exist as 
well.
    To help us examine what States are doing to address the 
opioid epidemic, we have Governor Phil Scott to discuss the 
tremendous efforts that the State of Vermont has undertaken to 
battle the crisis through expanded treatment options and 
substance abuse disorder management. We have representatives 
from two health plans that serve Medicare beneficiaries to 
discuss how payers are managing care for those that suffer from 
substance abuse disorder and the hurdles they face in doing so.
    And, finally, to round out our witness panel, we have two 
representatives from the medical field to discuss both 
medication-assisted treatment and other intervention pain 
services.
    I think all of us approach this issue with humility. All of 
us represent constituencies that are being overwhelmed by this 
crisis, and all of us are looking for solutions. And I think 
our constituents have sent us here with a disposition to get 
things done, and I look forward to working with both sides of 
the aisle to come up with commonsense solutions, to look at the 
things that work and celebrate them and pursue them, shun the 
things that don't work, and to do everything that we can to 
relieve this crisis and bring hope and optimism in a field that 
is really quite overwhelming.
    I am pleased that Mr. Neal, the Ranking Member of the Ways 
and Means Committee, is here, and I would yield to him for the 
purposes of an opening statement.
    Mr. NEAL. Thank you, Mr. Chairman. Let me congratulate you 
on your first hearing here. I would remind all that you served 
with me on the Tax Subcommittee, and it was very clear that you 
decided your future would lie in the Health Subcommittee after 
that.
    Mr. Chairman, I am pleased that we are holding this hearing 
to identify solutions to address the opiate abuse and 
dependence specifically in the Medicare space. Although 
overdose rates are highest for people 25 to 54, this public 
health emergency also affects Medicare beneficiaries. Everyone 
in this room has a family member or knows someone directly 
impacted by the opiate epidemic. It could be somebody down the 
street. It could be somebody in the next room. In my home State 
of Massachusetts, last year, there were 2,094 opiate-related 
deaths due to abuse. I thank my neighbor to the north, Governor 
Scott, and his Health Secretary, Al Gobeille, for joining us 
today. We share a border, and it also means that we share a 
common challenge in fighting the opiate crisis. Massachusetts 
Governor Charlie Baker, like Governor Scott, is working to 
employ all tools in this fight, ranging from expanding Medicaid 
coverage to provide treatment availability, data analytics, and 
treating addiction while stabilizing and supporting families.
    Opiate abuse and related deaths take a toll on all of our 
communities and on all of our families. There is no single 
cause and there certainly is no single solution. Expanding 
Medicaid under the Affordable Care Act to low-income working 
Americans who previously could not afford insurance has been 
the most significant step in recent years to stem the tide of 
the opiate crisis. Providing access to critical substance abuse 
and mental health services that previously were prohibitively 
costly has also worked.
    We need to look to Medicare beneficiaries' ability to 
access treatment as ofttimes providers aren't available to meet 
the needs. We know there are significant gaps in coverage and 
access under Medicare. For example, Medicare does not cover 
outpatient treatment programs that provide comprehensive opiate 
addiction treatments, nor does Medicare cover methadone for 
addiction, which is often the treatment of choice for longer 
term addicts. I recently introduced legislation that would 
allow methadone to be covered for outpatient services under 
Medicare.
    We also need to work with our partners to identify best 
practices. Late last week, I sent a letter to the Energy and 
Commerce Ranking Member Pallone about 14 Medicare plans and 
asked them to help compile the best practices that they are 
aware of to address opiate-related disorders. Evidence-based 
tested activities that are helping patients turn the corner 
will help us design sound policy. I look forward to these 
plans' responses, and I hope Dr. Paz from Aetna today will 
share his knowledge about what they are doing as well.
    We also need to explore how substance abuse is affecting 
children and families. The epidemic is fueling rising caseloads 
for children and adult protective services, for foster care, 
and also for caregivers as they attempt to battle addiction.
    I am pleased that our Committee has worked together on this 
bipartisan basis on legislation to support families and to help 
them keep children safe who would otherwise be in foster care 
while they can now remain safely at home with proper 
monitoring. We hope we can continue this partnership because we 
have much work to do.
    I hope as we move into the following year that we will not 
endorse or embrace plans to cut efforts that would, in fact, 
undermine what we are attempting to do here today. For example, 
the Social Security--Services Block Grant is the largest source 
of Federal funding for child protective services and the only 
major source of Federal funding for adult protective services 
in most States. We have a lot of work to do, and Congress could 
play a positive role in partnering with the States to provide 
resources and help to eliminate Federal barriers to treatment 
and access and support families and law enforcement.
    And, Mr. Chairman, to you for holding this hearing, I 
appreciate it. I also point out something that you and I have 
talked about a number of times. There are now 2 million people 
on the sidelines who formerly were in the workplace battling 
this epidemic. When you look at labor participation rates, it 
has had a huge impact on what has happened. So this is a very 
important hearing. Thank you.
    Chairman ROSKAM. Thank you, Mr. Neal.
    I now recognize Mr. Levin for his opening statement.
    Mr. LEVIN. Thank you, Mr. Chairman, and congratulations. We 
all look forward to working with you. You are surely a very 
articulate, knowledgeable person. We look forward to it. And 
thank you for letting us, in essence, make two opening 
statements. Mr. Neal comes from a State, I think, where there 
has been a strong wrestling with this issue. The same in 
Michigan.
    Welcome to the witnesses. A son, Matthew, lives in Vermont 
and is active representing mainly education groups. In the 
halls, he may have bumped into you.
    Mr. Chairman, the opioid epidemic is an enormous societal 
problem that demands a concerted effort at every level of 
government. The death toll is astonishing. Ninety-one Americans 
die every day from an opioid overdose, with five dying every 
single day in my home State. We have to stop this killer. 
Despite the urgency of this crisis, it is clear that, although 
President Trump has declared a public health emergency, to 
date, the Administration has not taken significant steps to 
address it.
    Last year, President Trump proposed a budget that would 
radically alter the Medicaid program while slashing its funding 
by 
$1.3 trillion. Medicaid is the largest payer for behavioral 
health services. It funds detoxification, maintenance therapy, 
medication-assisted treatment, and other crucial services. We 
cannot claim we are serious about addressing this crisis on the 
one hand while gutting one of the country's most important 
sources of treatment on the other.
    These efforts come on the heels of efforts within the 
Affordable Care Act that would have, I think, if repeal had 
occurred, undermined these efforts. I will look now to the 
future and leave those comments for the record.
    At this crucial time, the Administration has also 
undermined the Office of National Drug Control Policy, which 
for decades has helped fight drug abuse in this country. Last 
year, we fought against the Administration's efforts to 
eliminate all funding for the Drug-Free Community Program, an 
effective multisector community-based drug prevention program 
that was really started by a fellow Member of this Committee, 
Rob Portman, when he served, and myself in 1996. There have 
been thousands of community antidrug coalitions that have 
received seed money because of this program. The appropriation 
level now is $90 million.
    This year, we heard once again that the Administration 
intends to propose undercutting this office by eliminating its 
oversight of drug control and prevention programs. And I must 
confess, I was really alarmed, like so many, when the 
Administration suggested placing a 24-year-old with no relevant 
experience in the second highest position. Through the Drug-
Free Communities Act, we have had so much contact with this 
office. It needs the most talented personnel effort.
    A coordinated Federal response to this crisis is possible, 
but it will require a dramatic change of course. We must take 
immediate steps to ensure that we are effectively implementing 
programs that prevent flooding of our communities with 
unnecessary prescriptions. In Michigan, a State of less than 10 
million, more than 11 million opioid prescriptions are written 
annually, 11 million. This is more than enough to provide each 
resident of my home State with a bottle of opioids each year.
    Addressing the pervasiveness of this will require a broad-
based effort to revise clinical guidelines with the goal of 
improving provider behavior, leadership at the State and 
Federal level to monitor for harmful prescriptions and 
marketing practices, and other immediate steps that will reduce 
the prevalence.
    I just close. We all, Mr. Chairman, encounter this problem 
every time we go home, do we not? Every time. And we hear of 
deaths. It is younger people, but also people not so young, 
people sometimes under immense stress.
    And I think with the leadership of this Subcommittee and 
the entire Ways and Means Committee, Energy and Commerce, and 
the Congress, we need to do everything to fulfill our 
obligation. All the answers aren't in Washington, but some of 
them are.
    So we look forward to the testimony of you distinguished 
members of the public sector. Thank you, Mr. Chair.
    Chairman ROSKAM. Thank you, Mr. Levin.
    Let me describe how we will move the traffic today. We have 
two panels. The first panel will be the Governor. And we will 
have 5 minutes from each of the witnesses. If you are getting a 
little lengthy, I will tap my gavel gently. But I think most 
folks have had an opportunity to read all of the statements.
    To give us an introduction of the Governor is the 
distinguished gentleman and our friend from Vermont, Mr. Welch, 
who has this distinguishing gift of being able to tell someone 
to go jump in the lake but with such charm that you kind of 
look forward to the trip, actually.
    So, Mr. Welch, would you----
    Mr. LEVIN. And there aren't that many lakes in Vermont, 
either.
    Chairman ROSKAM. Could you introduce the Governor?
    Mr. WELCH. I thank the Chairman for that dubious 
introduction, but I am not here to tell you to jump in a lake. 
I am here to thank you for having a bipartisan hearing on an 
incredibly devastating problem. And, as Mr. Levin said, we here 
in the Federal Government can provide some help, but the hard 
work is done with first responders, with Mayors, and with 
Governors.
    One distinguishing thing about Vermont is we embraced the 
challenge on a bipartisan basis. The Democratic Governor, 
predecessor to Phil Scott, Peter Shumlin, spoke in his entire 
address in 2014 about the opioid crisis. And I remember talking 
to some of my colleagues here, saying, ``Peter, why would you 
be advertising that bad news,'' but then, as we talked, 
acknowledging that that was a devastating issue in their own 
communities.
    Phil Scott was then Lieutenant Governor. He has taken up 
the leadership in Vermont now to follow through, and we have 
this bipartisan approach to try to address the tragic 
circumstances of opioid addiction.
    So I thank all of the Members of this Committee.
    Mr. Chairman, thank you for being here.
    Ranking Member Neal is here as well. It shows the urgency 
of this Committee.
    And all of us are ready to work with you. Thank you.
    And I give you the Governor of the State of Vermont, my 
friend, former Lieutenant Governor, now Governor Phil Scott, of 
Middlesex, Vermont.
    Chairman ROSKAM. Governor, you are recognized. Thank you 
for being here.

   STATEMENT OF PHILIP B. SCOTT, GOVERNOR, STATE OF VERMONT, 
    ACCOMPANIED BY AL GOBEILLE, SECRETARY OF HUMAN SERVICES

    Governor SCOTT. Thank you very much.
    And thank you, Congressman Welch. We served together in the 
Senate not long ago.
    Chairman Roskam, Ranking Member Levin--I do know your son. 
I played hockey with him a few years ago. He is a very good 
hockey player--and Members of the Subcommittee, I want to thank 
you for the honor of appearing before you today. My Secretary 
of Human Services, Al Gobeille; Commissioner of Health, Dr. 
Mark Levine; and the Director of the Blueprint for Health, Beth 
Tanzman, are here with me as well.
    As was mentioned, in Vermont, the Governor and Lieutenant 
Governor are elected separately. So, in 2014, when then-
Governor Peter Shumlin, a Democrat, devoted his state of the 
State address to the opioid epidemic, I was sitting there 
listening as the Republican Lieutenant Governor. And I must 
admit, I was more than just a bit skeptical. I was concerned 
calling so much attention to this problem would damage our 
image and hurt our State. And sure enough, initially, many at 
the national level portrayed this as only a Vermont problem. We 
now know all too well this was and is a national problem.
    Governor Shumlin was right to focus our attention on this 
epidemic, and I have since learned the incredible devastation 
opioids have had on our State and our people. I have met 
countless Vermonters impacted by addiction, some in recovery, 
some still struggling, and some who have had their families 
torn apart, changing their lives forever.
    We have made a lot of progress in Vermont, much of it with 
support from you and our Federal partners, although, today, I 
approach you humbly because we have not yet solved this 
problem. Even with our small population, we see two Vermonters 
die from a drug overdose every week. And nearly every day a 
baby is born exposed to opioids, something I have highlighted 
as one of Vermont's biggest challenges.
    We have some of the best access to treatment in the Nation, 
but too many Vermonters who need treatment have not sought it. 
And while Vermont's rate of overdose deaths is the lowest in 
New England, we still lost 106 people in 2016. In 2017, it 
looks like it will be similar. Tragically, we also experienced 
high numbers of children under the age of five who come into 
State custody due to this crisis. And I think we all would 
agree these kids don't deserve this. They need a better start.
    We have focused on what I refer to as the four legs of the 
stool: prevention, recovery, treatment, and enforcement. My 
first day in office I established by executive order the Opioid 
Coordination Council. This Council is made up of a wide range 
of perspectives, life experience, and different political 
philosophies. Importantly, this includes those who have 
suffered from the addiction themselves. I handpicked them and 
tasked them with providing recommendations to improve Vermont's 
response to each of the four legs of the stool.
    We know that too many Vermonters become addicted through 
prescription pain medication. Therefore, the State implemented 
strict prescriber rules around pain management and a 
prescription monitoring system. So, for the first time, we are 
beginning to see a reduction in prescribed opioids. 
Unfortunately, we still prescribe three times as much as we did 
in 1999.
    Vermont has also made Narcan widely available to first 
responders, law enforcement, people with addiction, and family 
members of those suffering. We have aggressively used a 
screening, brief intervention, and referral to treatment model, 
also known as SBIRT, to prevent the progression of addiction.
    Enforcement is another important piece, but we are all in 
agreement: we can't arrest our way out of this. Our courts, 
local police, and States attorneys have become important 
partners in addressing this epidemic, and we address it as a 
public health issue.
    To treat opioid addiction, Vermont operates a medication-
assisted treatment, or MAT system, called Hub and Spoke. With 
the support of our Federal partners, we established a help home 
for Vermonters with opioid addiction. Through well-coordinated 
and comprehensive services, we treat opioid addiction like we 
do any other chronic condition. Our Hubs provide all FDA-
approved medications. They also provide critical nursing, 
counseling, and care management. In our Spokes, primary care 
offices prescribing buprenorphine are supported by nurses and 
counselors who offer more complete care. Finally, coordination 
between Hubs and Spokes assures the patients receive the 
appropriate level of care as they need it.
    Vermont and the Federal Government have been effective 
partners in tackling healthcare challenges for many years. It 
is in this collaborative spirit that I offer four areas where 
together we can improve our response:
    First, Medicare needs to treat this as the chronic 
condition that it is. I have sent a letter to the Secretary of 
Health and Human Services asking that CMS work with Vermont and 
engage Medicare in Vermont's Hub and Spoke system. Working with 
our Federal partners, we hope to develop a path to make this a 
reality.
    Second, we need to make sure that SBIRT is fully supported 
within the billing system so Vermont can sustain and expand 
this important work.
    Third, we ask you to consider giving States relief from the 
IMD exclusion, which prohibits using Medicaid funds in mental 
health or treatment facilities of 16 or more beds.
    Finally, our small State could benefit tremendously from 
nationally supported research in the areas of alternative pain 
treatment and from expanded coverage for alternative chronic 
pain management.
    In closing, I would like to thank you for the opportunity 
to address this Committee. We have made great progress over the 
years, but we have much more to do if we are to improve the 
health of Vermonters and all Americans to truly end this crisis 
and this epidemic.
    Thank you.
    [The prepared statement of Governor Scott follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
     Chairman ROSKAM. Thank you, Governor. We really appreciate 
your insight. Don't go anywhere. I am now going to briefly 
introduce the other panelists for a little bit of a 
foreshadowing, and then we are going to come back for questions 
with you.
    So for our second panel, we are going to hear from Dr. 
Ramsin Benyamin, President and Founder of Millennium Pain 
Center, lo- 
cated in Bloomington, Illinois. We look forward to hearing from 
him.
    For our next few witnesses, I am going to yield to our 
colleagues. I will now yield to Mr. Thompson for the purpose of 
an introduction.
    Mr. THOMPSON. Thank you, Mr. Chairman, and congratulations 
on your new Chairmanship and thanks for having this hearing.
    Mr. Chairman, thanks for the opportunity to introduce and 
to welcome to the Committee Dr. Jason Kletter, the President of 
BayMark Health Services. Dr. Kletter has 20 years of experience 
in the addiction field and currently serves as President of the 
Bay Area Addiction Research and Treatment, headquartered in San 
Francisco in the bay area. His organization operates 20 opioid 
treatment programs in five States, serving 7,000 patients every 
day. Dr. Kletter also serves as the President of the California 
Opioid Maintenance Providers and as a board member of the 
American Association for the Treatment of Opioid Dependence. He 
has advised both Federal and State agencies, providing input on 
accreditation guidelines, physician training, and various State 
policies.
    As part of California's Hub and Spoke program, modeled off 
the program Governor Scott described earlier, Dr. Kletter's 
BAART program in Antioch, California, will serve as the Hub to 
a handful of Spokes that will provide treatment to constituents 
across my district. And I just learned today he is also a part-
time resident of my hometown.
    So, Dr. Kletter, thank you for your testimony. I look 
forward to hearing about your experience in the field and 
understanding how this Committee can best support your work. 
Thank you for being here.
    Chairman ROSKAM. Thank you, Mr. Thompson.
    Mr. Larson.
    Mr. LARSON. Thank you, Mr. Chairman. And let me echo the 
sentiments of the Members of the Committee and congratulate you 
on your new Chairmanship. And I know how well you work with Mr. 
Levin, and we thank you for hosting this very important hearing 
today.
    It is my honor to introduce Dr. Harold Paz, who is the 
Executive Vice President and Chief Medical Officer for Aetna in 
my home State of Connecticut.
    Aetna is blessed that it has probably one of the leading 
thought leaders around healthcare in the world in Mark 
Bertolini, and Connecticut as a region is blessed to have an 
industry that is focused on this, including David Cordani from 
Cigna as well. But as head of the Aetna's enterprisewide opiate 
task force, Dr. Paz is responsible for a companywide strategy 
to prevent the misuse and abuse of medications, something that 
is critical in this epidemic as it continues to wreck, savage 
this country of ours.
    Under his leadership, we have been able to follow examples 
and hope that we are able to follow examples that the private 
sector is setting, find ways to help our public health system, 
especially Medicare and Medicaid, and effectively and humanely 
care for those suffering from addiction. Aetna has used its 
valuable data to help identify what they call super-prescribers 
and work with hard-hit States to provide training and supplies 
of lifesaving treatments, like Narcan, as the Governor 
mentioned early on.
    So it is my high honor here today to introduce Dr. Paz. We 
look forward to your testimony, and we thank you for your 
leadership and acknowledge it is not just government but the 
private sector and, in fact, all of us that need to work in 
collaboration to solve this national epidemic.
    Thank you, Dr. Paz.
    Chairman ROSKAM. Thank you, Mr. Larson.
    And Mr. Buchanan.
    Mr. BUCHANAN. Thank you, Mr. Chairman, for holding this 
important hearing. I also want to congratulate you on your 
Chairmanship. I am excited about what you are going to be able 
to do with this Committee.
    I am pleased to welcome Laura Hungiville, Chief Pharmacy 
Officer of WellCare Health Plans based in Tampa, Florida, part 
of the region that I represent. They do a lot in our region, 
and throughout the State and the country. In this role, she 
helps implement programs to prevent opioid abuse, helps members 
living with chronic pain, and helps members battling addiction.
    WellCare insures 4.3 million members nationwide enrolled in 
Medicare Advantage, Medicare prescription drug plans, and 
Medicaid. Currently, this does not include mental health 
counseling, yet according to the HHS, approximately 13 percent 
of people age 65 and older suffer from mental illness.
    And, with that, I yield back.
    Chairman ROSKAM. Thank you all.
    Now we will turn to make inquiries of the Governor and his 
team. We are going to break with our normal tradition and, by 
agreement, we are limiting our Members to 4 minutes.
    And, with that, I yield back to Mr. Buchanan to begin the 
inquiry.
    Mr. BUCHANAN. Thank you, Governor, for being here. We also 
have a Governor Scott in Florida, and I don't know if you are 
related or not, but if you are nearly as talented as he is, you 
have to be a heck of a Governor.
    Governor SCOTT. If there is any controversy, I usually 
blame him.
    Mr. BUCHANAN. Let me just say, about 7 or 8 years ago, I 
had a lot of members from Kentucky and Tennessee and other 
places, and everybody would be coming to Florida. We had 1,300 
pill mills that were here, and they had come here because we 
didn't have a database. And it was a disaster. We were losing 
10 people a day. We have shut down a lot of those pill mills, 
but they have moved over to heroin and fentanyl and other drugs 
in our community. In fact, my main county is the epicenter of 
Florida per capita with a lot of these drugs.
    But I read something the other day. It just was a shocking 
statistic from the AARP on deaths from opioids. Of course, 
being in Florida, we have a lot of seniors. I think 60 percent 
of my constituents are 60 and older in my area. But deaths from 
opioids, they have increased seven times for a senior 65 to 74, 
because you always think sometimes about just younger people, 
over the past 15 years. This is an absolute tragic thing. And I 
guess I would be interested in what you have learned from 
Vermont, in terms of a lot of your seniors. Let's just take 
that initially, any thoughts that you have on that.
    Governor SCOTT. I will start off and then let my Secretary 
take over from there. But we are seeing--I think a lot of it is 
the prescription rate amongst seniors across the board that 
they store in their medicine cabinets and so forth. We have a 
drug take-back, a prescription drug take-back program, where in 
the first--what I thought was the first year they collected 
almost 6,000 pounds in our small State of Vermont. And I 
thought that was remarkable and that, for the first year, I 
would expect that with the pent-up reserves. And then they told 
me that was the third year, and they collected 5,000 the year 
before and 5,000 the year before that. So that tells me that 
the prescription rate is abusive and excessive.
    So I don't believe we are seeing the deaths of our seniors 
as we do with our youth, but I will let our Secretary answer 
that.
    Mr. BUCHANAN. Just for time, let me get to another 
question. I think one of my colleagues had mentioned how 
everybody is impacted. My family has been impacted. But what 
are you doing on a little different score? What are you doing 
in terms of prevention? I had a mother come in the other day, 
four kids, homeschooled, two of them are addicted.
    So the thought to me is, what do we do to prevent this in 
the first place? Because once they go through that door--she 
told me, crying, that after 2 weeks of being on these pills, 
the older brother brought it home and got his sister hooked. In 
a matter of a couple of weeks, they got addicted. It has been 
over a year for both of them to be able to get off this stuff, 
and they might have to deal with this for the rest of their 
lives.
    So the impact and the power of these drugs is incredible, 
but I have a lot of stories like that. I have had three mothers 
come in where they have lost their children, and that is what 
got me initially involved in this effort.
    But what is your thought about prevention? Because once 
they go through that door, in my opinion, it is nice to have 
all these other things and it is important, but how do we 
prevent it in the first place? What more can we be doing on the 
prevention front?
    Mr. GOBEILLE. Thank you. My answer to that would be, we 
need to do a lot more in prevention. Some of the things that we 
have done is that we have worked with the goal of setting up a 
prescription monitoring system in our State. We passed a law in 
2013. But we had done good work prior to that to try to get a 
database where we would know what specialties we are 
prescribing, at what levels, basically so that doctors would 
know who was prescribing what to their patients so that we 
could look inside our State, but also, because we are a small 
State, to our neighboring States and what was happening with 
our patients, basically, that could go there for pills. So it 
is a game of, how do you reduce the impact of the pills, 
because this is a pill-driven crisis? And so anything that can 
aid that upstream has a big benefit.
    Mr. BUCHANAN. Let me just close out, because I want to 
yield back.
    Chairman ROSKAM. Thank you. Let me just give you a little 
housekeeping here. I think we as Members have a lot to say. We 
are going to be well-served if we allow our witnesses to give 
us input. And so keep the time on your question a little more 
limited so that they can come back. You know what I am saying? 
We are varying from our normal procedure.
    Mr. Thompson.
    Mr. THOMPSON. Thank you, Mr. Chairman.
    Governor, thank you for being here. According to the CDC, 
42 percent of workers with back injuries got an opioid 
prescription in the first year after their injury, and then a 
year later, nearly one in five of those patients are still 
taking the same drug, despite the fact that the FDA has not 
approved opioids for long-term use. So, clearly, these people 
are still suffering serious pain or they are addicted.
    So how do we make sure that folks, workers who have been 
injured on the job and are under the protection of the State 
workers' comp system are getting appropriate treatment for 
their injury, and how can we ensure that they have access to 
treatment if they become addicted?
    Mr. GOBEILLE. Thank you. I think that the answer begins 
with taking a look at the way that pain clinics are formed, and 
I think you have a witness that will come up and describe it 
way better than I can. But, basically, there has to be a lot 
more avenues to treat the pain and to treat the rehabilitation 
for folks other than just opioids.
    So, while opioids may be an answer, there are a lot of 
other answers that need to--questions that need to be asked and 
potential remedies other than just simply prescribing long-term 
opioids.
    Mr. THOMPSON. Have you looked at the workers' comp system 
in your State? I know in my State, I have constituents who 
become injured and it takes forever to get through the system, 
and they rely on the opioids to relieve the pain while they are 
waiting for treatment, sometimes treatment that never comes. 
And I am just concerned that this may exacerbate the entire 
program.
    Governor SCOTT. I have lived that life. I was three decades 
in the construction business, so I had numerous of my employees 
out with injuries and so forth. And we have to be very, very 
careful. Once we open the door and they are prescribed opioids 
and the prescription drugs, to just shut them off without 
proper treatment leads them to other methods of heroin, 
fentanyl, and so forth. So we are monitoring that. We are 
taking a look at that as we speak with interest as to what we 
can do to make sure that we have a pathway for them to recover 
because, again, we don't want to just shut them off. We want to 
help them get through it so they can become more productive 
citizens back into the workforce, which is so important.
    And those are some of the opportunities that we see with 
our Opioid Coordination Council, to look for ways that we can 
break down the stigma as well as to appreciate when someone has 
a problem so that we make sure--again, we want to make sure 
that we reintegrate them back into the workforce, because we 
desperately need them in Vermont.
    Mr. THOMPSON. Thank you. Some have said that Medicaid 
expansion is behind the opioid epidemic, but everything that I 
have read suggests that the expansion happened in 2014, and 
this has been going on since the nineties.
    So, Governor, can you tell us about the role Vermont's 
Medicaid expansion is playing in your State's efforts to 
address this epidemic, and just how critical will Medicaid be 
in the recovery process?
    Mr. GOBEILLE. Yes. So, to be clear, we don't believe that 
Medicaid expansion caused this crisis. And, further, if we 
believe through fact that this is a chronic illness, then each 
payer should treat it like the chronic illness it is and be 
able to pay as a benefit for necessary treatment, counseling, 
et cetera. This really started in the late nineties, and I 
think that the evidence is clear.
    Mr. THOMPSON. Thank you very much. I yield back.
    Chairman ROSKAM. Mr. Smith.
    Mr. SMITH. Thank you, Mr. Chairman. Thank you to our 
witnesses for addressing what I think is a large problem across 
the country, both rural and urban. A lot of folks, as you know, 
are impacted.
    Governor, I am wondering if you think that the type of 
management and monitoring necessary to successfully guide 
patients through the process of medication-assisted treatment 
programs such as yours are possible under the Medicare program. 
Feel free to answer, either one of you.
    Mr. GOBEILLE. We do think they are possible, but the letter 
that we sent the HHS Secretary was basically a request not that 
Medicare just simply treat this like a chronic illness and 
begin to pay for the delivery of services, counseling, or 
medication-assisted treatment, for example, but to actually 
participate in Vermont's system of care, which is partially Hub 
and Spoke but also other treatment modalities.
    So it is not enough to just sort of pay the bill. It is 
about the way in which the services are delivered and organized 
that we want Medicare to fully participate in like other 
payers.
    Mr. SMITH. Okay. I think you have answered my next 
question, so I appreciate that. And I think the approach--I 
would hope that there is the flexibility offered to States to 
address as they see fit that not often comes from the Federal 
Government, but hopefully that can be offered in the future, if 
you will.
    Mr. GOBEILLE. Yes, sir. And what I would add is that 
recovery and healing should be a part of a conversation with 
your healthcare provider. And Hub and Spoke might be one 
answer. There might be residential treatment. There might be, 
you know, other paths to sobriety and getting back to living 
the life you wanted to live. And so Medicare should participate 
in all of that, just like we do with other, you know, 
illnesses.
    Mr. SMITH. There are a lot of Nebraskans, especially in the 
agriculture community, who are buying their health insurance 
through the individual market. They are telling me that their 
out-of-pocket expenses are $30,000 to $40,000 a year, with 
copays and deductibles contributing to that. That really puts a 
lot of access out of reach.
    And I am wondering if that will ultimately pose a barrier. 
Certainly, many of our hospitals are even getting stuck with 
those copays, unpaid copays and deductibles. And I am wondering 
how we might need to address that at the same time we are 
looking at these issues.
    Mr. GOBEILLE. So just an idea. The way that we treat 
colonoscopies, the way that we treat primary care services 
under the Affordable Care Act is that those are included, you 
know, as a benefit. Services like this could be included and 
not necessarily go against your deductible.
    And so it is a question of, you know, how you want to set 
up the insurance marketplace so that people actually 
participate, you know, in different types of prevention 
alternatives. And, you know, that would be, you know, for 
others denied, but I would think we would have to take a hard 
look at that.
    Mr. SMITH. Okay, very well.
    Thank you. I yield back.
    Chairman ROSKAM. Mr. Kind.
    Mr. KIND. Thank you, Mr. Chairman, and I welcome you and 
congratulate you on your new position. I look forward to 
working with you.
    Gentlemen, thank you for being here. And I, in particular, 
have been paying very close attention to the challenge you face 
in Vermont. I mean, you have a large rural State. I have a very 
large rural district in western Wisconsin. We face many of the 
same issues, and we appreciate your insight on this.
    And I also, Governor, appreciate your opening comments, as 
a former special prosecutor who dealt in the drug world for a 
long time. I have had a lot of forums, a lot of listening 
sessions back home, including with law enforcement, and I 
haven't met anyone yet who thinks we are going to be able to 
deal with this through the criminal justice system. This has to 
be a public health approach ultimately to break the cycle of 
addiction for us to have any fighting chance to get out ahead 
of that. So I appreciate your insight on that.
    Governor, I was wondering if you have been following 
closely the Trump Administration's Commission on Combating Drug 
Addiction and the Opioid Crisis, because last November, they 
did come out with a fairly detailed report and findings and 
recommendations that were submitted to us here in Congress for 
our consideration. Have you had a chance to look at that or 
review that at all?
    Governor SCOTT. Yes. Our team has taken a look at that. We, 
again, have set out on our own course that we think is working. 
Some of them were replicated within the report. But we are 
always looking for new information.
    And, again, one size doesn't fit all, as we have found out. 
And there are always new opportunities to do something better. 
So we are still looking at the report, determining if there is 
anything that we can use to make better use of our system.
    Mr. KIND. Some of the recommendations are kind of 
commonsense principles that do apply across the board. I mean, 
increasing access to substance abuse treatment programs. We are 
going to hear further testimony today on that. Also, under 
Federal law, insurers are already required to cover addiction 
treatment and mental health services. Many of them aren't, and 
many of them aren't including them within their networks. And 
it is especially difficult in rural areas, given what is 
available out there. They also recommended dedicating more 
money for treatment overall. They are encouraging greater use 
of alternative and complementary forms of medicine, rather than 
just a cocktail of prescription drugs that often lead to 
addiction and then contributing to the opioid epidemic.
    One of the recommendations--I am wondering if you had a 
chance to look at it or have an opinion--is recommending that 
we give the Department of Labor the authority to start 
penalizing insurance companies that aren't including it in the 
network and are not adequately providing coverage for addiction 
treatment or other mental health services.
    Is that something we ought to be considering?
    Mr. GOBEILLE. So what I would say is that while they were 
holding their meetings and writing their report, our Opioid 
Coordination Council, which I chaired, we were writing a report 
as well. And we came out almost the same on so many issues. It, 
you know, really came out right at the same time. And the NGA 
also has a report. So there is a lot of common sense in all the 
documents. So I agree with your points.
    The last question that you asked, I think that we have to 
embrace this as a chronic condition. And then, if we do, we 
should make Medicare, Medicaid, and commercial insurers treat 
this as an essential health benefit, like we would kidney 
disease or diabetes or some other chronic condition.
    So yes, I would think that would be----
    Mr. KIND. The other thing I think we ought to be 
considering is, since you guys are out front doing a lot of 
good work and trying to get out, and virtually every State is 
trying to do the same thing, is some type of national 
repository of best practices and best evidence medicine, what 
is working and what isn't, so each State isn't required to, you 
know, recreate the same wheel over again.
    Interesting. Even though we have been going through 
problems with VA reform lately, we have had some success in a 
bipartisan fashion implementing certain reforms with the VA 
Medical Center, especially when it comes to pain management and 
drug addiction. In fact, in my home area, Tomah, Wisconsin, the 
VA Center is developing a really interesting model with a 
tremendous track record of proven results that could become a 
model of care throughout the country if we do it right. So I 
would also take a closer look at what the VA has been doing on 
this front for some time.
    Thank you, Mr. Chairman.
    Chairman ROSKAM. Hold that thought and kind of weave your 
answer into an inquiry that is coming from Ms. Jenkins from 
Kansas.
    Ms. JENKINS. Thank you, Mr. Chairman.
    And thank you, Governor, for being with us on the 
Subcommittee. Like Vermont, my home State of Kansas is 
struggling with a nationwide opioid epidemic. In my view, it is 
particularly difficult for rural States to expand access to 
opioid treatment services, just because of a lack of treatment 
facilities and trained medical personnel. So Vermont's Hub and 
Spoke approach may very well be a model for our Nation.
    In your written testimony, you mentioned strategies for 
prevention, harm reduction, early intervention, criminal 
justice, treatment, and recovery. Your testimony brought to 
mind just a couple questions I would like to ask.
    The first is that it is my understanding that there is a 
low uptake in the electronic prescribing of controlled 
substances. Is the State of Vermont doing anything to encourage 
prescribers to utilize e-prescribing and, if so, can you just 
talk a little bit about any pushback the State may have 
received in implementing those proposals?
    Mr. GOBEILLE. I had to phone a friend. We use e-
prescribing, and according to the smarter people than me behind 
me, we are good in that area even though we are rural and 
small. And so we could get you more information and submit that 
in writing, if that would be okay.
    Ms. JENKINS. I would be interested if you had any pushback. 
Yeah, if you could get back to me, that would be great.
    Mr. GOBEILLE. But about the pushback, I think what is 
interesting, the way the Congressman from Vermont was 
introduced as somebody who could, you know, politely tell 
somebody to jump in a snowbank, in Vermont, it is really hard 
to fight back common sense, because we are so small and we all 
know each other. And so we don't run into that as much as you 
might think.
    Ms. JENKINS. Okay. I am told that substance abuse community 
clinics and residential treatment centers still use telephone, 
paper records, and faxes to communicate with each other and the 
larger medical systems. I have introduced H.R. 3331 with my 
friend, Congresswoman Doris Matsui, that would authorize a 
health IT demonstration for behavioral health providers.
    Do you think electronic health records can play a role in 
States' efforts to combat the opioid crisis? And how is it the 
State of Vermont is using electronic health records?
    Governor SCOTT. The simple answer is yes.
    Mr. GOBEILLE. No, the simple answer is that is brilliant. 
So I am a restaurant owner, got into this, you know, sort of 
later in life. He was a construction company owner. And we 
thought we were behind the 8-ball in terms of being modern 
until we really got to work in healthcare. I mean, I haven't 
seen a fax machine or a typewriter in a long time, but you can 
find them in some behavioral health clinics and some doctors' 
offices.
    So the point you are making is right on target. There is 
not the electronic systems that are necessary to run our 
community mental health agencies and the like at the level that 
most people would think they would have, FQHCs as well, et 
cetera.
    Governor SCOTT. I would like to offer as well that when we 
talk about some of the treatment centers in our rural areas, it 
does put a burden on many who are seeking treatment. And when 
you think about in some of our rural sections, we had a waiting 
list in one area of 700 waiting for treatment. And that doesn't 
lend itself well for those seeking treatment when they have to 
be put on a waiting list.
    As well, those who were in treatment at that time, it was 
so far away that they would spend 2 hours driving to or taking 
a bus going to a treatment center to receive their treatment on 
a daily basis, 2 hours one way and then 2 hours back, an hour's 
worth of treatment. So, for those who were expecting to 
reintegrate into the workforce and be part of society again, it 
doesn't lend itself well when you are trying to take care of 
your family and to find a job where it is flexible enough so 
you can receive treatment.
    So it is something--we did put a Hub in that area. We 
reduced that level from 700 to zero. We don't have a waiting 
list in that area anymore, and that is successful. I mean, that 
was a time when we took a moment to celebrate success because 
you don't have much success in some months. But that was a time 
when we said we are doing something fruitful in a positive way.
    Chairman ROSKAM. Thank you.
    Ms. Sewell.
    Ms. SEWELL. I want to thank the Chairman and Ranking Member 
for hosting today's forum.
    As many of us have seen, more Americans died from drug 
overdoses in 2016 than the number of those lost in the entirety 
of the Vietnam war. And preliminary data from CDC suggests that 
2017 was even worse than 2016.
    I want to thank you, Governor Scott, for your leadership on 
this topic as well as your testimony today. It is my hope that 
more States, including my own State of Alabama, will realize 
the successes achieved in Vermont and implement similar 
strategies to tackle this growing epidemic.
    You spoke a little to your administration's focus on the 
importance of helping people in recovery return to gainful 
employment. I, like you, Governor Scott, have met with many 
people who are in recovery who tell me that it is the dignity 
of a job that keeps them going and that keeps their families 
going as well. So I think it is really important that we have 
models that stress the importance of getting gainful employment 
even when you are still in treatment, as you suggested earlier.
    The way we address this public health crisis will serve as 
a model for decades to come on addiction treatment. I believe 
we made a terrible mistake in the 1980s as a country in our 
response to the crack cocaine epidemic, where we are seeing 
that the response we gave was for more jails and not for more 
treatment centers.
    I am very happy that, with this epidemic, we are seeing 
that it truly is a public health crisis, and it is a crisis 
that requires intergovernmental help and lots of wraparound 
services, and so figuring out how we can get best practices I 
think is really important.
    An issue I worked a lot with in my rural areas is 
transportation. And so often getting access to treatments has 
been a big problem in the State of Alabama. In fact, I 
introduced a bill with Congressman Meehan. It is a bipartisan 
legislation that would allow Medicare Advantage plans to offer 
a wider array of supplemental benefits to chronically ill 
enrollees, such as transportation and nutrition programs and 
mental health services. I believe we should implement this type 
of benefit expansion across Medicare programs.
    So I guess my question to you is, Governor Scott, would you 
recommend expanding coverage for treatment in Medicare, and can 
you explain why you believe improved Medicare coverage for 
treatment of opioid abuse is important in fighting this 
epidemic?
    Governor SCOTT. Absolutely. I am going to let our Secretary 
answer, fill in the gaps, but I did want to mention that is 
what the beauty is of this Hub and Spoke model, that we can 
have treatment facilities closer to those who need it. And when 
we see an area, such as we did, that needed more treatment, we 
set up another Hub. So it is essential that we react every time 
that we see an issue.
    I would also say, with the introduction and the use of 
Narcan in our State, I am afraid that the number of deaths that 
we are seeing, which is almost the same as the previous year, 
doesn't tell the whole story, because we are preventing a lot 
of deaths from happening. So that doesn't mean that--just 
because they are staying the same doesn't mean that we are 
necessarily making a lot of ground up. So we have to fulfill 
that.
    Stigma is an important part of reintegrating, again, those 
into the workforce. And I think we have made some positive 
gains in that respect. A lot of employers we are speaking with, 
we are making a concerted effort through our Labor Department 
to try to determine--you know, give those folks a second chance 
or third chance or fourth chance, because sometimes it is not 
the first time or the second time; it is the third time.
    I had employees of mine that we all are aware, more aware 
now than we were then, that were addicted, and I didn't know 
it. And they were great employees. And so we gave them that 
chance, that opportunity to succeed.
    Ms. SEWELL. Thank you.
    Chairman ROSKAM. Mr. Marchant.
    Mr. MARCHANT. Thank you, Mr. Chairman.
    Governor, you spent some time in the legislative branch. Do 
you think that your State has passed sufficient laws and 
statutes to give you the tools that you need to combat this? I 
have three questions. I will ask all three of them.
    Second, who in Vermont recognizes this dependency? Is it 
the State? Is it the doctor? Is it the person themself that 
recognizes that they are addicted, or is there a definition 
that the State has?
    And the last question is, is most of the acquisition of the 
opioid legal or illegal?
    Mr. GOBEILLE. Sorry, sir?
    Mr. MARCHANT. The acquisition of the pills. I mean, are 
they getting the pills legally, or are they buying them on the 
black market or from a dealer, as a percentage of the people 
that are----
    Governor SCOTT. I will try to answer some of those and, 
again, I would ask my Secretary to fill in the gaps. But what 
we are seeing is a lot of the crime rate is due to obtaining 
some of the prescription drugs even and some of the unused 
prescription drugs in medicine cabinets. That is why the take-
back program is so necessary. Those who have been utilizing 
opioids, their kids get involved. They take the drugs. They 
sell them or utilize them themselves. That is an issue.
    I am trying to recall the rest of your question.
    Mr. MARCHANT. Has your legislature passed the statutes that 
you need?
    Governor SCOTT. Continually. I think we have a good working 
relationship. Again, I have served in the Minority, but we have 
always worked together, trying to do whatever we can, because 
we recognize this isn't a partisan issue. This is an issue that 
faces each and every one of us. It doesn't discriminate. 
Whether you are Republican or Democrat, it doesn't 
discriminate. It doesn't discriminate from a social standpoint 
either. So we recognize that, and we have been given many of 
the tools, and we continually seek resolutions to try to obtain 
more.
    Mr. GOBEILLE. And I think the last question you asked is, 
what door do you walk through to get treatment in Vermont? And 
we try to----
    Mr. MARCHANT. Who declares that you need treatment? Is it 
usually self-declared or----
    Mr. GOBEILLE. So what I would say is that, for treatment to 
work, it pretty much has to be self-declared, meaning on a base 
level, it has to be a recognition that the person has to make.
    But, also, through the screening tool that the Governor 
talked about in his opening remarks that we use in primary care 
offices, in emergency rooms, and in other healthcare delivery 
sites in our State, it allows for the conversation to happen 
with your healthcare provider or a healthcare provider where 
you may become aware of your behavior to help you get there.
    But, also, our Hub and Spoke model, the Hub is actually not 
just a Hub for treatment. It is a Hub of activity where you can 
go to receive counseling on your addiction and your options. We 
also have recovery centers in the State where you can go to 
basically reach out and get peer support for recovery.
    So we have a lot of different doors you can open. We are in 
the position now of how do we get more people into treatment, 
because now we can meet the needs of treatment. The Governor 
articulately went through our waiting list. We just recently in 
the last 6 months have gotten to the point where we have 
eliminated the waiting list. So now we are trying to figure out 
how to get more people into treatment.
    Mr. MARCHANT. Thank you.
    Chairman ROSKAM. Mr. Blumenauer.
    Mr. BLUMENAUER. Thank you very much for joining us. I 
appreciate your efforts to kind of put a comprehensive picture 
on the table for us, and I think each and every one of us on an 
ongoing basis is struck by how complex and interdependent these 
elements are in our own community.
    We are troubled with addiction, homelessness, mental 
illness, nothing rising probably to the level in terms of the 
death and destruction of opioids, but there are a whole series 
of interrelated pieces. And there is lots of blame to go 
around: the Federal Government was asleep at the switch; 
problems with the pharmaceutical industry; with the medical 
profession.
    And I appreciate your taking us through your outline of 
what we could be doing. I was particularly struck by your 
fourth point: Your small State could benefit tremendously from 
nationally supported research for areas of alternative 
treatment for pain. People are driven to opioids often when 
there are, in fact, cheaper and more effective alternatives, 
starting with therapy, but I would also point out one that my 
State has been a pioneer in, and that happens to be medical 
marijuana.
    There is pretty strong evidence that where medical 
marijuana is available, there are fewer opioid deaths. I think 
in the State of California, it is a third less than the 
national average.
    And I have had countless people, veterans, tell me what a 
difference it made for them to be able to have an alternative 
that was cheaper, less toxic, they played--they felt more 
comfortable with.
    NFL players are suspended routinely, maybe not the wife 
beaters, but the people who are caught self-medicating with pot 
because they don't want to get shot up with painkillers, in 
some cases leading to tragic, tragic consequences.
    I am hopeful that this might be an area that we can 
explore. You just became the first State to have the 
legislature approve adult use of marijuana, something every 
other State in the Union, 30 States, have done by a vote of the 
people who have been ahead of the politicians on this.
    And I wonder if you have some thoughts about opportunities 
to use medical marijuana as an area to expand these treatment 
options to be able to properly research it, to get rid of the 
Federal prohibition on robust medical marijuana research and be 
able to explore this as an alternative to this plague.
    Governor SCOTT. We passed medical marijuana when I was in 
the Senate, and I voted in favor and was one of the few 
Republicans that did. I was serving with Congressman Welch at 
the time.
    We recognize that one size doesn't fit all, that that is 
why we need as much flexibility as possible, all different 
types of treatment on the table so to speak, so that we have 
everything at our--in our power to confront this.
    My wife is an RN. She lives this on a daily basis. She sees 
it in the office on a daily basis, all the abuse in terms of 
prescription drugs. But my wife is a runner as well, an 
athlete. And she has had a number of knee surgeries. She 
thought her running was over.
    And she started using this oil therapy about a year and a 
half ago, and she is back to running. She did a 10-miler about 
2 months ago. So this works for her. My point is we just need 
everything on the table. We can't allow ourselves to be--put 
blinders on in terms of what might work for one that might not 
work for another.
    Chairman ROSKAM. Mrs. Black, another RN.
    Mrs. BLACK. Yes, and thank you, Mr. Chairman.
    And thank you to your wife who is an RN and a runner. So I 
applaud you for tackling this issue that is a very large 
problem.
    And I want to go to the side, as you would expect an RN to 
do, and that is, how can we stop this from happening to begin 
with, because the cost of life, the cost of treatment, and the 
cost of the illegal activity is certainly very, very large?
    And so I am very interested in what you said in your 
opening statement about the prevention piece of it and how your 
State is using the prescription monitoring system to help 
physicians. However, I do see in here, later on, you say that, 
for the first time, we are beginning to see the amount of 
opioid prescriptions decline. It is discouraging to note, 
however, that we still prescribe three times as much as we did 
in 1999.
    So there is a little bit of a contrast there about having a 
system where we can see what is going on, and yet there still 
seems to be more of this being prescribed. Can you help me out 
with that?
    Governor SCOTT. Well, again, in 1999, it went--it 
skyrocketed after that. There was just much more opioid 
prescription use. So we have seen, since we implemented that 
policy, we have seen it go down significantly. So--but still, 
compared to 1999, we are still using three times as much.
    Mrs. BLACK. So is this real time for your physicians that 
they can get into a computer and see whether someone has a 
prescription filled? And this is real time?
    Governor SCOTT. Yeah, I believe it is. Yes, go ahead.
    Mrs. BLACK. Okay. So that is very, very helpful.
    Mr. GOBEILLE. So it is real time, yeah.
    Mrs. BLACK. Okay. Let me go to the second piece, the early 
intervention and the prevention piece, the screening, the brief 
intervention referral to the treatment protocol, all of those 
things that are done in the emergency rooms and primary care.
    Is someone coming in that is self-referred, or is this 
happening when they come in for other kinds of treatment that 
the practitioner would say, ``Maybe this is something I need to 
address,'' and talk about how is that actually done?
    Governor SCOTT. I think it is all of the above, actually. 
It could be from many different situations to at least make 
others aware of the situation.
    Mr. GOBEILLE. Yes. So the way we did this was we received a 
grant and some Federal money to be able to do this in one 
hospital, and we started there and we have kind of spread out. 
And we don't do it everywhere in the State yet, but we do it 
across a large part of--the majority of the State.
    And it isn't just if you come in saying you think you have 
an issue with addiction or substance use disorder. It is 
literally if you come in for something else, we begin a 
screening process that sort of--that begins the conversation. 
And depending on how you answer questions and interactions, we 
go further and further and further.
    Mrs. BLACK. So you do the screening process on every 
patient that comes in; they answer a screen, and then, from 
there, you make a determination?
    Mr. GOBEILLE. Right.
    Mrs. BLACK. Okay. I had one additional question. In many 
other States, we see doctor shopping. Have you seen that in 
your State? Do you have pill mills? Do you see that doctor 
shopping?
    And do you also have those pain management facilities that 
are for cash only? Are you experiencing that in your State?
    Governor SCOTT. I don't think we see the pill mills in 
Vermont, but certainly we see the doctor shopping, and some of 
this electronic monitoring would help preclude that.
    Mr. GOBEILLE. Yeah. So what is interesting is we don't have 
what you think of as the traditional pill mill, but we 
certainly had the issues you are describing. Doing the Spokes 
and having over 200 primary care providers working together to 
try to basically deal with treatment, it has been really good 
for communication across the practice, and so it has cut down 
on doctor shopping.
    But also, our prescription monitoring system has improved 
every year, and it is at the point now where doctors can see 
that going on through software.
    Mrs. BLACK. Thank you. My time is expired.
    Thank you, Mr. Chairman.
    Governor SCOTT. Keep in mind as well, if I could add--just 
add----
    Chairman ROSKAM. Wow, sliding into home. Nice.
    Governor SCOTT. Keep in mind that if you shut someone off 
from the prescription drug, the opioid, they find another 
method. They go to heroin or fentanyl. I mean, it is cheaper 
sometimes, so that is the problem.
    Chairman ROSKAM. Mr. Higgins.
    Mr. HIGGINS. Thank you, Mr. Chairman. And congratulations 
as well on your ascension to the Subcommittee Chair.
    My community, too, is devastated by the opioid deaths and 
overdoses. There were 316 in Erie County in New York State. 
Half of those were in the city of Buffalo. I just want to focus 
in on fentanyl. Fentanyl is a--it is a powerful artificial 
opioid, and it accounted for about 60 percent of the deaths in 
my community of Buffalo and Erie County.
    Mexico is a source of much of the illicit fentanyl that is 
for sale in the United States. Starting in 2015, Canada has 
seen a massive increase in fentanyl overdoses. You know, we are 
currently engaged in a renegotiation of the North American Free 
Trade Agreement.
    And I have always believed that the United States and 
Canada--the United States, a Nation of 323 million people, 
Canada, a nation of 36 million people--doesn't effectively use 
its leverage in trade negotiations with a place like Mexico.
    You know, Mexico's minimum wage is $4.70, not an hour, a 
day, which, if you assume it is an 8-hour day, is 57 cents an 
hour. In free trade, we should be using our leverage to stop 
this illicit transport, export of fentanyl to the United States 
and Canada. It is a new twist on a larger problem. I am just 
curious as to your thoughts about the viability of something 
like that.
    Governor SCOTT. Well, again, we watch with interest the 
NAFTA negotiation. We share as well a border with Canada, and 
they are our largest trading partner, essential to the vitality 
of Vermont's economy.
    So we are hopeful that we can get through some of those, 
but I think that there should be an update to NAFTA, and I 
believe that we should be trying to do whatever we can to level 
the playing field, and that may be an area that we should look 
at.
    Mr. HIGGINS. Okay. The President in October declared that 
the opioid epidemic was a national health emergency. As you 
know, we have been kind of stuck in terms of doing a series of 
continuing resolutions, which is really a failure to do 
fundamentally what Congress needs to do.
    But, obviously, money is a big issue here as it relates to 
treatment. Have you seen any change, at least in terms of your 
personal experiences, since that declaration was made in 
October, or is that something prospective that just hasn't 
gained traction yet?
    Governor SCOTT. I don't believe we have seen any difference 
since that declaration because we were--have been actively 
pursuing that. And we have been blessed with having good 
partners, again, with the Congress as well as with our--the 
Administration and this previous Administration as well in 
trying to confront this.
    So we have--they have given us some flexibility, and I 
think that has been essential. And if there is one thing that I 
can underscore and emphasize it is this: Allow us flexibility, 
and we will find the pathway forward.
    Mr. HIGGINS. I yield back, Mr. Chairman. Thank you.
    Chairman ROSKAM. Thank you.
    Well, Governor, thank you, and, Mr. Secretary, thank you. I 
just want to say thank you very much for your time today. We 
are being called in for votes.
    Let me ask you one wrapup question, if I could. Our 
Subcommittee, and this Committee in particular, is focused on 
Medicare. The first point that you made in your four points was 
in particular as it relates to Medicare.
    Let me just restate that part to refresh everybody's 
recollection, and then I just want you to give us a little bit 
of commentary about what this means. So what you have proposed 
is Medicare needs to treat addiction as the chronic health 
condition that it is.
    And then you said you sent a letter to the Secretary of 
Health and Human Services asking that CMS work with Vermont to 
engage Medicare in Vermont's system of care, specifically the 
Hub and Spoke system: Working with our Federal partners, we 
hope to develop a path to make this a reality; Medicare could 
also assure that the FDA-approved medications for opioid 
addiction are available for beneficiaries.
    I want to sort of go back to Mr. Marchant's inquiry when he 
was asking about sort of the declaration of who is addicted. 
Can you just give us a little bit more insight?
    Is this a situation where, in order for this to be 
successful at all, someone has to self-identify as an addict, 
or does the Hub and Spoke system work for folks that are not 
acknowledging themselves as addicts but who are clearly 
addicts? Can you speak to that tension? Maybe it is a question 
for the Secretary or medical professionals.
    Governor SCOTT. Yeah, I am going to let him answer the rest 
of the question, so to speak. But I would, again, underscore 
that if they are not ready to admit they have an issue and to 
seek treatment, it is probably going to fail. And so to force 
someone into treatment is probably a recipe for failure as 
well.
    Secretary.
    Mr. GOBEILLE. Yeah. So what I would say is there is a 
definition of opioid use disorder, and, you know, they would 
have to meet that clinical definition. And so, you know, that 
is sort of the black-and-white answer.
    But I think from a--you know, from a human perspective, 
when you think about caring for the whole patient or the whole 
population, to have something that is such a fundamental 
problem with someone's health and not be able to treat it as 
basically the illness that it is with the payer that they have 
sort of distorts the healthcare system.
    And so what we are trying to do is work with CMMI and CMS 
to say we have an all-payer model that we have agreed to with 
the Federal Government to really take responsibility for what 
we spend on healthcare. And in order to do that, you have to 
treat the whole person and the whole population, and this needs 
to be an integral part of that.
    Governor SCOTT. And if you want to break down the stigma, 
this is one way to do it, to treat them the same.
    Chairman ROSKAM. Well, your insights have been really 
helpful today. And you didn't clear the room, by the way. You 
didn't clear the dais; it was the fact that we have been called 
for a vote.
    But I just want to let you know how much I appreciate--and 
I know I speak on behalf of the Ranking Member as well--your 
willingness to come and share your experience. We appreciate 
your forthrightness with the strengths and weaknesses, the 
things that you have learned, and the things that you have 
struggled with.
    And I know that we are going to continue to be interacting 
on this issue because this is a problem that is very dear to 
all of us, and I mean literally all of us. And it is an area 
where there is good work that can be done. And I think people 
of good will and tenacity willing to give others the benefit of 
the doubt as we move forward can be really, really significant.
    So I sense you have something else to say, Governor, so why 
don't you respond?
    Governor SCOTT. Well, I only wanted to say that we extend 
an invitation to anyone on your Subcommittee who would like to 
come up and see it for themselves. We would happily show them 
what we have done so that they can see it.
    Chairman ROSKAM. Thank you.
    So the Committee stands in recess subject to the call of 
the Chair. We are going to go into recess and vote, and we will 
look forward to hearing from our next panel.
    So thank you very much. We will be back shortly.
    [Recess.]
    Chairman ROSKAM. The Committee will come to order. Thank 
you, all. I know I speak on behalf of everybody who is 
reassembling here and thank you for your patience.
    As I mentioned, your opening statements are a part of the 
record, and the Members have had an opportunity to review them. 
I think that in the interest of time, why don't we begin to 
proceed. I will recognize each of you for 5 minutes, and we 
will give you a little bit of guidance in terms of the timing, 
and then we will open it up for questions from our Members.
    So, again, thank you for your patience. We really, really 
appreciate it. Dr. Benyamin, you are recognized for 5 minutes.

 STATEMENT OF RAMSIN M. BENYAMIN, M.D., PRESIDENT AND FOUNDER, 
MILLENNIUM PAIN CENTER, AND BOARD OF DIRECTORS, AMERICAN BOARD 
               OF INTERVENTIONAL PAIN PHYSICIANS

    Dr. BENYAMIN. Chairman Roskam, Ranking Member Levin, and 
distinguished Members of the Committee, thank you for the 
opportunity to provide my views on behalf of American Society 
of Interventional Pain Physicians, known as ASIPP.
    I am Dr. Ramsin Benyamin, and I am the Medical Director of 
Millennium Pain Center in Illinois. I have been practicing 
interventional pain management for over 20 years. My academic 
appointments are with the University of Illinois, Illinois 
Wesleyan University, and A.T. Still University of Missouri.
    I serve on the editorial board of several pain management 
peer-reviewed journals and have over 150 publications, the most 
recent of which is our society's 2017 guidelines for 
responsible, safe, and effective prescription of opioids.
    In the past, I have served as the President of ASIPP, and I 
am currently on the board of directors. I am also the President 
of Illinois' Society of Interventional Pain Physicians.
    ASIPP is a not-for-profit professional organization founded 
in 1998, now comprising over 4,500 members who are dedicated to 
ensuring safe and appropriate access to pain management 
services using interventional techniques in addition to medical 
management.
    As an organization, ASIPP has always been cognizant of 
prescription opioid dangers and began issuing warnings and 
offering preventive measures in early 2000 with its proposal of 
a national program known as NASPER, which eventually was signed 
into law as a State-run prescription drug monitoring program in 
2005.
    Despite challenges in implementation of the national 
program, all 50 States now have prescription drug monitoring 
programs. Many of the common painful ailments, like spine 
degeneration, disk herniations, spinal stenosis, headache, 
pathologic fractures, and postsurgical chronic pain, if not 
managed timely by interventional pain techniques, would result 
in more invasive and costly procedures, raising the risk of 
dependency on more or higher doses of opioids.
    Currently, one in every three Medicare Part D recipients is 
on prescription opioids. Based on current data, despite 
reduction in opioid prescriptions since 2010, the majority of 
overdose deaths are mainly due to synthetic fentanyl and heroin 
abuse.
    Mr. Chairman, the pill-to-heroin shift has occurred, and 
that also involves lacing of marijuana with heroin or fentanyl. 
That is killing many of my fellow citizens in Illinois.
    As a result of this disturbing trend, on behalf of ASIPP, I 
am suggesting legislative reforms to curb opioid abuse and 
reduce opioid deaths while maintaining appropriate access and 
promoting nonopioid modalities like interventional techniques.
    Unfortunately, reductions and cuts continue to limit access 
to physical therapy, interventional techniques, and even 
nonopioid medical therapies while the opioid death rate 
continues to escalate.
    Our proposal includes a three-tier approach. Tier one: An 
aggressive public education campaign focused on the dangers of 
illicit drugs, specifically heroin and fentanyl; a public 
education campaign relating to the adverse consequences of 
prescription opioid abuse, particularly in combination with 
benzodiazepines; and a mandatory 4 hours of continuing 
education for all prescribers of any amount of opioids or 
benzodiazepines.
    Tier two: Improved access to nonopioid techniques, 
including physical therapy and interventional techniques, by 
lowering or eliminating copayments; expanded low-threshold 
access to buprenorphine for opioid use disorder treatment; 
enhanced prescription drug monitoring program, including a 
national program like NASPER, which States having mandated 
capability to interact with the rest of the States or at least 
the neighboring States; and mandated review of prescription 
drug monitoring data by all prescribers prior to prescribing a 
controlled substance.
    Tier three: Buprenorphine must be available for chronic 
pain management with rescheduling it to a schedule two; and 
removing methadone from formulary. This medication, despite 
being only 1 percent of total prescription opioids, results in 
more than 3,000 deaths every year.
    Thank you, again, for allowing our organization the 
opportunity to testify. I will be glad to answer any questions.
    [The prepared statement of Dr. Benyamin follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Chairman ROSKAM. Thank you.
    Mr. Kletter.

 STATEMENT OF JASON KLETTER, PH.D., PRESIDENT, BAYMARK HEALTH 
 SERVICES AND BAY AREA ADDICTION RESEARCH AND TREATMENT (BAART)

    Mr. KLETTER. Chairman Roskam, Ranking Member Levin, and 
Members of the Subcommittee, I appreciate the opportunity to 
testify today about the opioid epidemic that is ravaging our 
country and important steps this Committee can take to help 
address this crisis.
    I am Dr. Jason Kletter, President of BayMark Health 
Services. BayMark provides treatment for opioid use disorder, 
or OUD, using medication-assisted treatment and outpatient 
detoxification services in 95 facilities across 26 States, 
including many of the States you represent. We are the largest 
organization in the country focused primarily on treatment 
services for opioid use disorder treating over 33,000 patients 
each day.
    I also serve on the Board of the American Association for 
the Treatment of Opioid Dependence, and I am also here today on 
behalf of the OTP consortium, a trade association comprised of 
more than 300 opioid treatment programs across 37 States. I 
have 25 years of experience in OUD treatment.
    I want to start by highlighting two data points: First, 
according to the CDC, opioids killed more than 42,000 people in 
2016. That is about 115 people every day in our country. These 
are our friends, our family, our neighbors, our coworkers.
    Second, the White House Council of Economic Advisers 
estimates the economic cost of the opioid crisis was $504 
billion in 2015 alone. Of course, these statistics do nothing 
to describe the devastating effects on our families and 
communities.
    OUD is regarded by experts to be a disease of the brain, 
not a moral downfall. This concept of OUD as a chronic disease 
is essential to understanding successful treatment solutions, 
the most effective of which is medication-assisted treatment.
    MAT is the integration of medication and psychosocial 
services to provide individualized care that will have the 
greatest likelihood of helping people with OUD transition to 
recovery and lead healthy, socially productive lives.
    There are three federally approved medications for use as 
part of MAT, methadone, buprenorphine, and naltrexone, all of 
which must be used in conjunction with psychosocial services to 
have the greatest likelihood of success.
    The benefits of MAT are substantial and have been proven 
repeatedly through rigorous scientific studies. MAT has been 
shown to improve patient survival, increase retention in 
treatment, decrease opioid use and criminal activity, increase 
patient's ability to gain and maintain employment, and lower 
person's risk of contracting HIV or hepatitis C.
    Those who receive MAT are 75 percent less likely to have an 
addiction-related death than those who don't. There are roughly 
1,500 opioid treatment programs, or OTPs, 
across the United States providing treatment to approximately 
400,000 patients. OTPs are highly regulated, comprehensive 
treatment programs that are required by law to provide MAT.
    OTPs provide medication, individual and group counseling, 
random drug testing, and other supportive services, such as 
case management, primary care, mental health services, HIV, and 
hepatitis C testing.
    Methadone, which is most commonly administered as part of 
MAT, has been used in OTPs for more than 50 years. It has been 
rigorously researched and considered to be the gold standard in 
treatment of opioid dependence. MAT with methadone is highly 
regulated and can only be dispensed for OUD by clinics that 
have been certified by SAMHSA, the DEA, and other agencies. It 
is an excellent medication when used as part of MAT with 
patients having very high retention and success rates.
    Retention in treatment over an extended period of time is 
essential for positive outcomes. At BayMark, about 61 percent 
of our patients are retained in treatment for at least 90 days. 
Furthermore, while 100 percent of our patients are using 
opioids multiple times each day upon admission, about 50 
percent of those folks in treatment less than 30 days are free 
from illicit opioids. That number jumps to 82 percent for 
patients in treatment more than 1 year. This is proof that MAT 
delivered in OTPs is saving hundreds of thousands of lives.
    According to CMS, 30 percent of Part D enrollees used 
prescription opioids in 2015. So we should not be surprised 
that more than 300,000 Medicare beneficiaries have been 
diagnosed with opioid use disorder. Moreover, Medicare 
beneficiaries have the highest and fastest growing rate of OUD.
    Unfortunately, Medicare does not cover comprehensive 
treatment services in OTPs. Instead, Medicare pays for more 
expensive treatments in less effective settings. This must 
change.
    We respectfully request that Congress pass legislation to 
pro- 
vide Medicare beneficiaries with coverage for MAT with all FDA-
approved medications to help treat OUD in the OTP setting. We 
recommend that Medicare adopt a bundled payment methodology 
where MAT-related services provided in the OTP setting are 
reimbursed under a capitated rate. This model has proven to be 
successful in Medicaid and TRICARE and could be quickly 
implemented by the 1,500 OTPs across the country, rapidly 
increasing access to lifesaving treatment for Medicare 
beneficiaries.
    While our country is in the throes of a tragic epidemic, 
the silver lining here is that we have a very effective 
treatment and a dedicated and compassionate workforce ready and 
able to save lives and build communities.
    Thank you for the opportunity to testify today. I am happy 
to answer any questions that you have.
    [The prepared statement of Mr. Kletter follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Chairman ROSKAM. Thank you very much.
    Dr. Paz.

    STATEMENT OF HAROLD L. PAZ, M.D., M.S., EXECUTIVE VICE 
        PRESIDENT AND CHIEF MEDICAL OFFICER, AETNA, INC.

    Dr. PAZ. Thank you, Chairman Roskam, Ranking Member Levin, 
and Members of the Subcommittee, for holding today's hearing on 
the opioid abuse epidemic. I appreciate the opportunity to 
share Aetna's perspective on this critical public health issue.
    Aetna is a leading diversified health company that serves 
over 38 million individuals in the United States and around the 
world. I currently serve as the company's Executive Vice 
President and Chief Medical Officer, a role I have held since 
2014.
    In my capacity as CMO, I lead clinical strategy and policy 
across Aetna's lines of business and am responsible for driving 
clinical innovation to improve member experience, quality, and 
cost. I am also a practicing physician.
    The opioid epidemic is the leading public health issue 
facing our Nation. We have already lost far too many of our 
friends, family, and neighbors to this unprecedented health 
crisis. Aetna is taking a holistic approach to addressing the 
opioid epidemic.
    The various segments of Aetna's businesses are all working 
to help our members struggling with addiction and to prevent 
future opioid dependency. To that end, Aetna has created an 
enterprisewide opioid task force, which I chair, to drive a 
multifaceted strategy to help stem the tide of overuse.
    We have developed a strategy focused on preventing misuse 
and abuse, intervening when we identify at-risk provider and 
member behavior, and supporting members by providing access to 
evidence-based treatments.
    I am pleased to share with this Subcommittee three examples 
of Aetna's efforts to fight the opioid epidemic as well as 
recommendations for Congress and the Administration. We believe 
important efforts in our commercial lines of business can 
inform how CMS regulates Medicare Advantage and Part D plans to 
allow for similar programs in the Medicare space.
    First, within our commercial business, Aetna is leveraging 
formulary and plan design tools, such as quantity limits and 
prior authorization, to reduce opioid misuse and encourage 
evidence-based treatments.
    For example, as of January 1, Aetna is limiting initial 
opioid prescriptions for acute pain to a 7-day supply. These 
stricter daily and dosage limits are in alignment with CDC 
guidelines and will help to reduce the potential for abuse and 
addiction.
    Second, effective January 1, Aetna became the first and 
only national payer to waive copays for Narcan, a lifesaving, 
highly effective opioid overdose reversal agent, for our fully 
insured commercial members once their deductible is met. We 
hope this copay waiver will increase access to remove possible 
financial barriers to the use of naloxone.
    Third, within Aetna's Medicare business, we are striving to 
be part of the solution. Aetna has taken steps to promote 
appropriate prescribing and coordination of care for our 
Medicare members who utilize opiate drug therapies.
    Aetna has instituted interventions in its Medicare 
formularies to assist members in receiving appropriate opioid 
medication when necessary while preventing inappropriate use 
and addiction. We also support pharmacists in utilizing opioid 
controls as well.
    Aetna is committed to continuing to work with CMS to 
highlight areas of opportunity for change to better combat the 
opioid epidemic. We believe there are three specific areas 
where Congress and CMS can take additional steps to help remove 
barriers currently limiting the ability of plans to combat the 
epidemic itself.
    First, while Aetna now limits initial fills of acute opioid 
prescriptions to a 7-day supply in our commercial business, 
Medicare Advantage and Part D plans are precluded from 
unilaterally limiting the duration of a prescription. We are 
encouraged that CMS in its recently released call letter is 
proposing significant steps to allow Medicare and Part D plans 
to take more action to preventing over prescribing.
    We strongly encourage CMS to finalize provisions that allow 
additional point-of-sale edits and supply limits of 
prescription opioids that limit initial prescribing to a 7-day 
supply.
    Second, we also support CMS' continued efforts to address 
the opioid epidemic and believe the implementation of CARA and 
the adoption in Part D of a lock-in mechanism will prevent 
sponsors with a critical tool to help--will provide sponsors--
excuse me--with a critical tool to help curtail the abuse of 
opioids.
    Still, we believe there are several changes CMS should make 
in implementing the lock-in program to ensure its success, such 
as allowing Part D sponsors to retain the ability to use point-
of-sale claim edits to address other frequently abused drugs 
and allowing plans to maintain the lock-in status of a member 
until notified by the applicable provider that the member is no 
longer at risk.
    And, finally, we strongly support modernizing privacy 
regulations to provide access to a patient's entire medical 
record, including substance use disorder records, and to ensure 
that providers and organizations have all the necessary 
information to provide safe, effective, high-quality treatment 
and care.
    We urge Congress to expeditiously pass the bipartisan 
legislation introduced in the Senate and here in the House by 
Representatives Mullin and Blumenauer to align this outdated 
regulation with already strict HIPAA standards.
    In conclusion, Aetna is deeply committed to doing its part 
to turn the tide on the epidemic. We look forward to continuing 
to play a productive role in the dialogue with the Subcommittee 
and with other policymakers to help find solutions to this 
epidemic.
    Thank you, again, for your leadership on this issue and for 
inviting Aetna to be here today.
    [The prepared statement of Dr. Paz follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Chairman ROSKAM. Thank you very much.
    Ms. Hungiville.

STATEMENT OF LAURA HUNGIVILLE, PHARMD, CHIEF PHARMACY OFFICER, 
                  WELLCARE HEALTH PLANS, INC.

    Ms. HUNGIVILLE. Mr. Chairman, Ranking Member Levin, Members 
of the Committee, I am Laura Hungiville, Chief Pharmacy Officer 
for WellCare Health Plans. I want to thank you for your 
invitation to appear today to share with you our experiences 
regarding the opioid epidemic and the variety of practices we 
have employed aimed at curbing the overuse and misuse of 
prescription opiates.
    It is important that the Committee is addressing this vital 
issue, and managed healthcare companies are equally committed 
to finding solutions. First, though, let me tell you a little 
bit about WellCare. Headquartered in Tampa, Florida, WellCare 
focuses exclusively on provider government-sponsored managed 
healthcare services through Medicaid, Medicare Advantage, and 
Medicare prescription drug plans.
    WellCare prides itself on managing healthcare services for 
the underserved and most vulnerable populations. We serve 4.3 
million members nationwide with roughly 1 million members 
relying on WellCare for prescription drug services.
    In any given State our beneficiary population ranges from 
40 to 50 percent dual eligible. While certainly not the only 
population at high risk of controlled substance misuse, mental 
illness and poverty often go hand in hand with substance abuse 
disorders.
    We have spent the last several years investing resources 
and time into innovative methods for decreasing the misuse of 
controlled substances among our beneficiaries, culminating most 
recently in the launch of an opioid task force.
    This task force was created to ensure that we are taking an 
integrated approach to helping our members. Our company has in-
sourced medical, pharmacy, and behavioral departments, a rarity 
among managed care plans, to ensure that we are looking at the 
member in a holistic manner.
    First and foremost, our goal is to prevent abuse and 
addiction. Our second goal is to help our members who are 
battling addiction and often chronic pain to help them manage 
both conditions. Those members who are at the greatest risk of 
overdose and death receive the highest attention.
    One of our key programs involves monitoring doctor and 
pharmacy shopping so we can flag high utilizers. WellCare works 
with patients to enter into medical service agreements, which 
patients benefit from having a single doctor focused on 
prolonged pain management therapies to deter opioid misuse.
    For several years, WellCare's pharmacy-run opioid 
overutilization case management program has been using 
predictive modeling to identify at-risk individuals. As a 
result, WellCare proactively identified over 200 at-risk 
members nationally in 2017 based on specific criteria, 
including prescription dispensing, provider, and emergency 
department utilization.
    We placed these individuals into a lock-in program 
connected to one pharmacy, one healthcare provider, and a care 
manager who helps connect members to needed physical, 
behavioral, pharmacy, and social services.
    In regard to the CMS standard for morphine-equivalent 
dosage, we have also identified 2,100 additional members who 
have received prescriptions over the previous CMS standard of 
120 milligrams of opioids per day. We intervene with these 
members through member education on alternative medications, 
outreach to prescribers, and have begun including integration 
point with our behavioral health case management team. For our 
noncancer members, this translated into utilization reduction 
of over 43 percent between 2015 and 2017.
    Since the transition to the lower daily ceiling of 90 
milligrams of morphine-equivalent doses, WellCare continues to 
see increased numbers of members captured through our 
overutilization case management program.
    We also recognize that we must look beyond the treatment of 
pain to address opioid overuse. Our multifaceted set of 
interventions includes the creation of the CDC-compliant task 
force and engaging policy groups at the State level to include 
prescription drug monitoring program training, and CME for 
physicians on the training of using opiates.
    Some of these partnerships also include working with the 
YMCA to educate teens on the risk of opioid use, especially in 
the foster care system. At the organizational level, we are 
rolling out telehealth programs for use in emergency rooms to 
help increase medication-assisted treatment.
    And, finally, we are also developing incentive programs for 
physicians to become SAMHSA certified, given the increased 
demand for addiction specialists.
    Much of which I have outlined has been possible because of 
States like Kentucky where Medicaid regulations allowed us to 
be aggressive in targeting opioid misuse. In Kentucky, we are 
able to see a decrease of nearly 50 percent.
    We would also like to recommend CMS incentivize other 
providers to become SAMHSA certified, allow health plans to be 
empowered to have more restrictive lock-in programs, mandate 
electronic prescribing of opioids, and address the gaps that 
create barriers for plans by providing PDP plans with access to 
medical claims, and allow health plans access to PDMPs as well.
    Lastly, Congress, CMS, and the FDA should create 
educational campaigns similar to the one deployed for tobacco 
cessation to educate consumers about the dangers of the opioids 
and remove the stigmatization and encourage people to seek 
help.
    In conclusion, ending this opioid crisis will require a 
partnership with all stakeholders, and WellCare looks forward 
to being an active participant as the Committee and Congress 
work to combat this epidemic. Thank you.
    [The prepared statement of Ms. Hungiville follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Chairman ROSKAM. Thank you very much. You have given us 
great insight and very valuable perspectives.
    We are in a very uncertain time right now in terms of 
scheduling and the chatter that we are getting about being 
called back in. Since this has been a two-panel hearing today, 
I would ask unanimous consent to limit the Members' questions 
to 3 minutes.
    And, without objection, so ordered.
    And, with that, we will yield to recognize Mr. Kelly.
    Mr. KELLY. Thank you, Mr. Chairman.
    Thank you all for being here.
    Dr. Benyamin, I was fascinated by your testimony. And I 
think last year when President Trump talked about this war on 
drugs, he had talked about nonaddictive painkillers because we 
are a Nation now of dependence or codependence. I don't think 
there is any doubt about that.
    If you could just go a little bit further into that. I 
marvel at the fact that we have 50 laboratories around this 
country that are collecting all this type of data. But your 
testimony, more than anything, appealed to me because I have 
been so close to this issue.
    Would you expand a little bit more on the fact that we do 
have a way of keeping pain down? But I think the development of 
those drugs also had to do with reimbursements, right? If we 
can keep the pain down and the patient says, ``I am not feeling 
the pain,'' it is a better result. But it involves an 
addiction. So please hit the nonaddictive ways of killing pain.
    Dr. BENYAMIN. Thank you, Congressman. That's a very good 
question.
    We can divide that into two sections, the medication part 
and 
the interventional part. So, on the medication front, we have 
had challenges as far as funding and research funding for 
nonad- 
dictive medication, as you know. And we do not have many 
choices. 
Our choices are between scheduled prescription drugs and anti-
inflammatories. And we all know that anti-inflammatories have 
their own side effects.
    One of the issues is access. Many of the health plans do 
not cover nonopioid medications. Like, I will give you a good 
example of a patch that is anti-inflammatory. If you call for a 
preauthorization, unanimously, they all will deny the patch. 
They will say to you: Well, we do not cover the anti-
inflammatory patch, but we do cover the fentanyl patch. That is 
the answer that you get. So that tells you part of the problem 
that we face.
    On the nonmedication front, I think we are a young 
specialty. Interventional pain management is a young specialty. 
And we have been adding to our tools to treat, as I mentioned, 
the spinal disorders, like spinal stenosis, and fractures in 
the spine. These are conditions that, in the past, we did not 
have any solution for between surgery and opioids. And now we 
are providing solutions that are minimally invasive techniques 
that can prevent these patients from getting to the point of 
becoming dependent on opioids or having all these invasive 
surgeries and, as a result, becoming dependent on opioids.
    Mr. KELLY. Sir, I want to thank you. I am running out of 
time. I want to thank you all for being here. We have run out 
of options as a country. We have to get this fixed. So thank 
you so much for what you are doing. Please continue your work. 
We really appreciate you being here. Thanks so much.
    I yield back, Mr. Chairman.
    Chairman ROSKAM. Mr. Levin.
    Mr. LEVIN. Well, I join in our appreciation for all of your 
efforts.
    Just quickly--and then I wanted to ask you another 
question--why do you think it took us so long to recognize this 
epidemic? Anybody want to venture? It did take us a long time.
    Dr. BENYAMIN. Can I take a shot at that?
    Mr. LEVIN. Please.
    Dr. BENYAMIN. So I think part of it is a lack of awareness 
and a lack of knowledge, a lack of public information, and 
usually we react. You know, we always react, we go from one 
extreme to the other.
    As I said before, this is not just a pill problem anymore. 
The shift has occurred from the pill to heroin and synthetic 
fentanyl. And I will be glad if we take some precautionary 
legislation that will prevent that from happening and reduce 
the supply of these drugs in our country.
    In my community, the rate of death from opioid overdose had 
tripled in 3 years. And, you know, I would like you to 
understand that it is very hard for the coroner to determine 
the exact cause of death. You know, all these data are based on 
coroners' reports, which is based on what pathologists find in 
the system.
    Now, if you have five, six, seven medications or drugs in 
the system, who is to say which one of these is the real cause 
of death? That is why they mark them all as opioid overdose.
    Mr. LEVIN. So let me ask you then, in terms of awareness, 
expanding Medicare treatment, isn't that a very good idea, 
Doctor?
    Mr. KLETTER. So, if I could add to that, I think, to your 
first question, the reason it has taken so long to recognize is 
less about not recognizing it and more about the stigma 
associated with the disease.
    People with the disease of addiction are sort of shunned 
and kept in the shadows and embarrassed and shamed, and 
treatment has been sort of similarly treated. There hasn't been 
a lot of attention or focus on treatment services. In fact, 
physicians are not taught how to treat addiction in medical 
school generally. They are not taught a lot about opioids and/
or addiction.
    Mr. LEVIN. So expanding Medicare----
    Mr. KLETTER. So how can expanding Medicare help? Well, 
first of all, making it part of mainstream medicine, helping to 
sort of acknowledge the disease as just that, as a disease.
    We heard Governor Scott of Vermont earlier say we need to 
do a better job of making--of acknowledging the disease and 
thinking of it as a disease rather than thinking of it as a 
lack of will power or a moral downfall.
    Mr. LEVIN. Okay. So----
    Mr. KLETTER. And so Medicare contributes to that by, you 
know, legitimizing the treatment that we have as a medical 
treatment.
    Mr. LEVIN. Thank you.
    Chairman ROSKAM. Mr. Paulsen.
    Mr. PAULSEN. Thank you, Mr. Chairman.
    I want to follow up a little bit on some of the 
perspectives that were offered on the minimally invasive 
procedures. And, look, I mean, historically, the practice of 
providers has been to prescribe opioids to patients for years, 
and it is hard to stray away from that course and then to try 
new different therapies for pain management.
    Now, I also understand that there are about 200 FDA-
approved devices for which CMS does reimburse, but it seems 
that not enough providers or Medicare Advantage plans, for 
instance, are alerting patients to some very effective and 
efficient ways to manage pain outside of the risk of addiction.
    One example is a spinal cord stimulator that involves a 
minimally invasive procedure and uses electrical signals to 
block pain signals from reaching the person's brain. It has 
about a 50 percent or greater opportunity for reduction in 
pain, and more than half of the patients don't need to have any 
pain medication for that management. And it is FDA-approved. It 
is Medicare reimbursed. It has helped about 500,000 patients.
    So I am just curious, maybe Dr. Paz and Ms. Hungiville 
first, what are your health plans doing in general to ensure 
that providers are aware and that patients have access to some 
of these covered nonopioid treatments?
    Dr. PAZ. So thank you very much for the question.
    So we, as you indicated, cover these types of devices for 
patients that appropriately fit the criteria. And where we 
spend a great deal of our emphasis at our opioid-wide task 
force is really looking at patients with acute pain because 
that becomes the entry point for them being exposed to opioids 
in the first place. And that is where alternative types of--my 
colleagues mentioned, alternative types of treatment come into 
play, physical therapy, chiropractic, osteopathic, manipulative 
therapy, different types of approaches, the use of 
nonsteroidals, SSRIs, for example. These are things that we can 
do for acute pain. And, frankly, there is data that shows that 
some of the over-the-counter treatments of pain, acetaminophen 
even, nonsteroidals, can be equally effective, if not more so, 
for the treatment of those situations.
    When a patient has long-term chronic pain, that is a 
different matter altogether. And, quite frankly, in those 
situations, if we think it is appropriate, we will cover 
opioids because that may be the only treatment that is 
effective. But, certainly, also if a physician is recommending 
or prescribing a device, that is something that would be 
covered as well.
    Mr. PAULSEN. Ms. Hungiville, are there any barriers to 
nonpharmaceutical therapies for chronic pain that currently 
exist, or can you expand on----
    Ms. HUNGIVILLE. It is awareness, and through our case 
management, we are trying to educate providers as well as our 
beneficiaries that there are alternatives to the opioid 
treatment. And so that is one of the interventions that we 
employ: to make them aware of other alternatives.
    Mr. PAULSEN. Good. I mean, this seems to absolutely make 
sense based on the testimony we are hearing. So I appreciate 
your perspectives and yield back, Mr. Chairman.
    Chairman ROSKAM. Mr. Reed.
    Mr. REED. Well, thank you, Mr. Chairman.
    And the question I have is for Dr. Benyamin. I am sorry. Is 
that it?
    Dr. BENYAMIN. Benyamin.
    Mr. REED. Oh, okay. Thank you. I appreciate that, Doctor.
    The question I have for you is, pain, in and of itself, is 
that a bad thing, from a physician's perspective?
    Dr. BENYAMIN. It depends on the condition. If it is acute, 
it is always an alarming sign that there is something 
happening.
    Mr. REED. So as a physician--and I see two doctors up 
there--what is a successful outcome of pain management? Is it 
zero pain? Or is there some level of pain that to me is a 
natural response of the body telling a doctor, ``Hey, there is 
an issue here''? And are doctors and physicians trained to 
overmedicate in order to get to an unlikely outcome of zero 
pain, which is probably not, in my humble opinion, the best 
outcome that we can anticipate from physicians?
    Dr. BENYAMIN. Absolutely, Congressman.
    Mr. REED. So could you explain that a little bit?
    Dr. BENYAMIN. Yeah. This is how we--part of the reason why 
we got into this crisis is in all these regulations that we had 
by the hospitals. If you remember, there was a time they used 
to call pain the fifth vital sign.
    Mr. REED. Uh-huh.
    Dr. BENYAMIN. I mean, it cannot be ignored.
    Mr. REED. Where do those regulations come from? Government, 
right?
    Dr. BENYAMIN. From government, right.
    Mr. REED. We directed you to get to zero pain, did we not?
    Dr. BENYAMIN. Right. So that was enforced in the hospitals. 
All the accredited institutions, health institutions, needed to 
address--assess and address pain to a point that the pain level 
will go down to anywhere below four.
    Now, as you know, that is a very subjective number. And if 
you look at Medicare actually, they never talk about 
regulations. They usually talk about--they never talk about the 
numbers. They talk about quality and function of the patient.
    So I think we need to shift this emphasis toward quality of 
life and function, and those are the tools that we use in our 
practice. And we rely much less on that number unless it is 
required by a lot of insurance companies.
    I will give you an example. The Congressman mentioned the 
spinal cord stimulator. We have this arbitrary number of 50 
percent. If the patient's pain didn't go from 8 to 4, well, 
then, his implant will not be approved, right?
    Mr. REED. So, as we learn from that experience going 
forward and setting policies going forward, could you provide 
me some insight as to how we would do the new regulations to 
encourage a better outcome than what we may have, by unintended 
consequences, made in good faith to limit pain but had an 
unintended consequence of exacerbating this problem?
    Dr. BENYAMIN. Absolutely, unintended consequences. That is 
what we are facing. And that is why I was mentioning to the 
Chairman that we need to--if we are looking for a solution, 
there is no one magic wand that we are going to wave here and 
solve this problem. This has many aspects to it.
    As the Governor mentioned, I like that four pillars of the 
treatment on--how to address this issue. And you have to work 
at the prevention. You have to work on recognizing, what is the 
disease? Is the patient having a substance use disorder? Treat 
that, treat the consequences, prevent disasters, and limit the 
supply. If you look--or, you know, the studies have shown that 
when you limit the supply, we have less of a prescription 
writing and less deaths.
    Mr. REED. Thank you very much for the input.
    Chairman ROSKAM. Mr. Renacci.
    Mr. RENACCI. Thank you, Mr. Chairman.
    It is interesting what my colleague, Mr. Reed, mentioned, 
because I was 18 years old in a horrible motorcycle accident 
and went to school the next day with a bottle of aspirin. It is 
amazing how government has changed things.
    But, anyway, I have introduced legislation with Congressman 
Mark Meadows that would enact a 7-day limit on opioid 
prescriptions for acute pain with some exceptions. It was 
crafted in consultation with over 30 stakeholders to address 
what studies and researchers have proven time and time again: 
risk of addiction increases with the length of your opioid 
prescription.
    Dr. Paz, in your testimony, you state that Aetna limits 
opioid prescribing for acute pain to a 7-day supply. CMS has 
recently proposed limiting initial limit fills to 7 days. This 
would apply for all new opioid users in Medicare as well as 
require plans to implement a hard edit for beneficiaries 
prescribed more than a 7-day supply of opioids.
    Dr. Paz, what research led to Aetna's decision to adopt a 
stricter threshold before Medicare proposed it?
    Dr. PAZ. So this is in our commercial plans, and we base 
that on the CDC recommendations. Those are the same 
recommendations that we share with physician and dental 
superprescribers, who are prescribing large quantities of 
opioids to our members as well.
    We think that is very important guidance. It is something 
that should be used by the provider community, by physicians 
and dentists who have prescribing privileges. And we felt the 
first place to put that in place was in our commercial plans 
where we could, in fact, do that.
    Mr. RENACCI. So do you believe limiting opioid 
prescriptions for populations other than Medicare 
beneficiaries--I think you have said this--would have an effect 
similar to what CMS is hoping to achieve with Medicare 
beneficiaries?
    Dr. PAZ. So I would say that there is one exception to 
that, Congressman, and that is in individuals that are not 
suffering from acute pain but in individuals that are 
terminally ill with cancer, for example, in hospice. There are 
circumstances where there are very good reasons to have long-
term use of opioids. But we are focused here, and most of the 
situations we are looking at are, in fact, really 35 percent of 
the population are coming to us with acute pain situations.
    Mr. RENACCI. Well, it is interesting. My bill provides 
exceptions for cancer treatment, hospice care, palliative care, 
and chronic pain.
    The next question is for any of the witnesses: What 
exceptions would you all recommend for CMS as well as what 
should Congress consider as a nationwide prescription limit 
other than those four? You mentioned those. Are there any other 
exceptions that anyone on the panel thinks we should have?
    Okay. I yield back.
    Chairman ROSKAM. Mr. Thompson.
    Mr. THOMPSON. Thank you, Mr. Chairman.
    Dr. Kletter, you heard about the Hub and Spoke program, a 
program with the Spokes. What can we do or do better at the 
Federal level to enable the success of this program rather than 
to impede it?
    And I have a county that I represent, Lake County, which is 
contiguous to your second home, that has a high opioid--a 
terribly high opioid problem. And what can we do to make sure 
that they have long-term access to these services, and can you 
talk a little bit about the barriers in the Medicare program 
that would prevent treating those patients?
    Mr. KLETTER. Sure. So we heard quite a bit about the Hub 
and Spoke program from Governor Scott. It is a fantastic 
program. BayMark happens to operate three of the six Hubs in 
the State of Vermont, so we are very fond of it. And we are 
developing 4 of the 19 in California.
    While Vermont is a very small State, they have created what 
seems to be a no-brainer. This is one of the most effective 
approaches to treating the opioid epidemic we have seen in the 
treatment community.
    So what can Congress do? Well, as I said in my testimony, 
Congress can pass legislation that would allow Medicare to 
cover treatment services at OTPs. OTPs are the Hubs within this 
Hub and Spoke program. And the concept is that you get a Hub 
where all three federally approved medications can be provided 
and wraparound services, including counseling and drug testing, 
and other supportive services are provided.
    And then patients are admitted at the Hub, they are 
stabilized there, and then once they are stabilized, they are 
stepped down to a less-restrictive model of care, level of 
care, and those are the spokes. Those are primary care 
physicians generally.
    And the reason that the model was created was because, as 
we know, many primary care physicians have been reticent to 
prescribe medications to folks with opioid use disorder because 
it is a complicated disease and requires a lot of attention.
    The beauty of the Hub and Spoke system is that the Hub 
provides services in the form of a MAT team, a nurse, and a 
counselor, to the Spoke so that the physician has additional 
resources in dealing with the patients, in helping the patients 
manage their medications, making sure they are not being 
diverted, making sure they are taking them on time, making sure 
they are participating in all the services, like counseling, 
that are required for effective outcomes.
    So coverage in Medicare is important, and we work quite a 
bit with SAMHSA, who has been helpful in developing more OTPs 
around the country. The CURES funding that came out of Congress 
last year or this year has been used in California primarily 
for developing this Hub and Spoke model. It is being used in 
other States to develop the Hub and Spoke model.
    So we would encourage you to look very closely at how 
States are using their CURES funding and make sure that they 
are using it in ways that are evidence-based and are, in fact, 
intervening in this epidemic and reducing overdose deaths.
    Mr. THOMPSON. Thank you. I yield back.
    Chairman ROSKAM. Ms. Jenkins.
    Ms. JENKINS. Thank you, Mr. Chairman.
    And thank you all for being here today.
    I have introduced a piece of bipartisan legislation called 
the Furthering Access to Coordinated Treatment for Seniors Act, 
or the FACTS Act, which helps to bridge the gap in 
communication between the clinical setting, where patients are 
diagnosed and prescribed medication, and the pharmacy setting, 
where patients receive their medications. In particular, for 
opioids, having information about hospitalizations due to 
medication mismanagement can add in another layer of support 
from the Part D and pharmacy community. This coordination is 
something that is desperately needed in fee-for-service 
Medicare, and I really look forward to advancing it here in the 
House.
    With that said, Ms. Hungiville, as I understand, standalone 
Part D plans cannot review Part A and B claims data. Is that 
correct?
    Ms. HUNGIVILLE. That is correct.
    Ms. JENKINS. And Medicare Advantage prescription drug plans 
can review A and B data plans. What type of challenge does this 
lack of data present for standalone Part D plans in managing 
the benefit of a potential opioid abuser, and what could plans 
do to assist beneficiaries in claims if data were made 
available?
    Ms. HUNGIVILLE. Well, we are limited to identifying those 
members that are at the greatest risk. For the members in our 
Medicare Advantage plan, we are looking at their prescription 
utilization. We are looking at their hospitalizations. We are 
looking at their ER visits. And we are predicting, sometimes 
with their first opioid prescription, whether they are at risk 
for developing into addiction, and we are putting them into our 
treatment algorithms.
    In our standalone Part D plan, we don't have that 
visibility. So we have to rely on the traditional multiple 
prescriptions from multiple pharmacies and multiple providers. 
So we are not able to intervene as quickly as what we would 
like and hopefully prevent addiction rather than treating 
addiction.
    Ms. JENKINS. Okay.
    Thank you, Mr. Chairman. I yield back.
    Chairman ROSKAM. Mr. Blumenauer.
    Mr. BLUMENAUER. Thank you very much for being with us this 
afternoon.
    There are lots of things to chew on, but, Dr. Paz, I really 
appreciate your reference to the legislation we have to try to 
make sure that we take care of this disconnect between people 
who, in terms of unnecessarily restrictive information, for 
prescribing physicians to actually know that somebody has an 
opioid addiction problem. I think the legislation that we have 
would help remedy that.
    Do you have any sense why this is so hard to remedy? Is 
this just because any time we are dealing with patient privacy 
we are in kind of a never-never land, that it hasn't received a 
high enough priority? Are there examples that you or any of the 
panelists can help us with to show the disastrous consequences 
of a physician not having this information?
    Dr. PAZ. So, Congressman, thank you for the question. I 
think there are two parts to the answer. First is the general 
backdrop of the lack of interoperability of health information 
in general. We have real challenges in healthcare in terms of 
connecting data that sits in different places between providers 
with the patient and often having patient information that is 
patient-centric that is usable by a patient to make important 
health decisions. That is a challenge that is historical, 
longstanding, and, in fact, has become even more complicated 
with the use of electronic records to record and retain that 
information. So that is one issue. It is the backdrop for the 
challenges we have in really improving care in general in terms 
of wastefulness.
    But the other part of it is the part two reform that I 
mentioned in my testimony. HIPAA was written for many, many 
good reasons, and, obviously, we are in support of it, as I am 
sure everybody is, to protect patient health information. But 
at the same time, we have to have modernization of 
federalization around health information privacy so that, in 
certain circumstances like the one we are talking about today, 
providers, physicians have access to information to know if 
their patient is abusing or addicted to opioids so that they 
can make the important decisions they need to make to assist 
and help their patient. Absent that, they are operating without 
the useful information they need. And, in fact, that is to the 
detriment of their patient.
    Mr. BLUMENAUER. Mr. Chairman, I think this is just one 
area, but it speaks to a larger set of challenges. But I am 
hopeful that, shining a spotlight here, we can help avoid 
potentially disastrous consequences, but maybe it will guide us 
toward a broader conversation about some adjustments we can 
make to protect the confidentiality we all care about but not 
make it unduly restrictive in terms of people being able to do 
the job for their patients.
    Dr. BENYAMIN. Mr. Chairman, may I interject? Very briefly, 
this is one of the problems, Congressman, with the prescription 
monitoring program, in which we have limitations in accessing 
the private data from addiction management facilities. And 
those are not reflected in prescription monitoring programs. 
And a lot of small mom-and-pop types of pharmacies, they are 
not reporting to the data center.
    And, again, this is a State-run program. And, you know, as 
I mentioned in my testimony, we would like to see a national 
program so that the States can interact with each other. People 
who live in, you know, border cities, they can easily cross 
over and get prescriptions from two different providers and the 
providers not even know what is going on.
    Chairman ROSKAM. Thank you. Mr. Marchant.
    Mr. MARCHANT. Dr. Kletter, I see that your company is 
headquartered in Lewisville, Texas.
    Mr. KLETTER. That is correct.
    Mr. MARCHANT. That area is the entire northern border of my 
district. Can you tell me a little bit about the program that 
you provide to my constituents in Texas? And tell me a little 
bit about the opioid situation in Texas, specifically north 
Texas, if you could.
    Mr. KLETTER. Sure. I can tell you that the program that we 
operate in Lewisville in particular is under our AppleGate line 
of business. And AppleGate is an office-based practice that 
provides medication-assisted treatment, which is buprenorphine, 
along with counseling and drug testing. So it is sort of a 
hybrid between an opiate treatment program, which is a very 
highly structured program, and a typical office-based practice, 
which is a primary care physician prescribing medications.
    So what we do there is we prescribe medications and 
counseling and we do counseling and do drug testing to--it is a 
small number of folks so far. We have been open in Lewisville 
for just a short time. We have 12 sites in Texas in total. Most 
of those sites are opiate treatment programs. And, again, 
opiate treatment programs are the more structured, more 
regulated programs where we have more intensive services and we 
provide daily medication administration.
    The daily medication administration is part of the Federal 
regulations that help to prevent diversion of these very 
powerful medications. So what that means is a patient will come 
into treatment. They will get a history and physical with a 
physician. They will be provided a clinical assessment, 
generally an ASAM assessment, American Society of Addiction 
Medicine assessment, or an Addiction Severity Index assessment. 
They will be determined or diagnosed with opioid use disorder, 
and they will be provided with the appropriate dose--the 
appropriate type of medication and the appropriate dose of 
medication, based on a physician's order. And based on that 
physician's order, they will then participate--they will 
develop a treatment plan with a counselor, and every 90 days, 
that treatment plan will be updated so that we can make sure 
that they are doing well, they are progressing in treatment.
    We will do a monthly random drug test to make sure that 
they are not only taking the medication that we are giving them 
but that they are also not taking other illicit or prescribed 
opiates. And they will get their medication from a nurse every 
day who does sort of a very brief assessment to make sure that 
the dose is the right dose and that they are progressing well 
in treatment and getting some words of encouragement to follow 
their treatment plan.
    Mr. MARCHANT. Does Texas have an effective opioid policy, 
as far as assistance from the State?
    Mr. KLETTER. The Medicaid rates for reimbursement for the 
services that we provide are not good in and of themselves, but 
they have done a great job in using the STR money out of the 
CURES grant to supplement that program this year and next, 
hopefully. So, generally, the regulatory environment in Texas 
is good. Funding could be improved, but they are working on 
that, and they are doing better, and we are encouraged that 
they have been a good partner.
    Mr. MARCHANT. Thank you.
    Chairman ROSKAM. Mrs. Black.
    Mrs. BLACK. Thank you, Mr. Chairman.
    And I appreciate you all being here today. As a nurse for 
over 45 years, I have watched this scourge on our society 
occur. And I know we talk about chronic pain. We certainly want 
to take care of people that have chronic pain; there is no 
doubt about that. They suffer. You can see that by their blood 
pressures, by their anxiety, by their pulses. But what we did 
with this, ``how bad is your pain,'' the smiley face system, 
was not a very good thing for us to do, and I am glad that we 
have finally stopped doing that.
    Thank you, Dr. Benyamin, for what you are doing with the 
interventional pain management. And I would like at some point 
in time, and I know we don't have enough time here, to talk 
with you more about the results that you are getting from that. 
What percentage of your patients going through that kind of 
treatment have found success? Is there a number that you could 
give me on that of the----
    Dr. BENYAMIN. I would be glad to provide you with all the 
data.
    Mrs. BLACK. I would really like that.
    Dr. Kletter, I want to go to you and talk to you a little 
bit about--or excuse me, Mr. Kletter--or is it Dr. Paz? Which 
one of you is doing the program where you are using the 
medication-assisted treatment?
    Mr. KLETTER. We are.
    Mrs. BLACK. Dr. Kletter, okay. What percentage of your 
clients have eventually become drug-free with your medication-
assisted treatment? How do you move them to a drug-free 
situation?
    Mr. KLETTER. So, as I said in my testimony, it is important 

to understand that medication--as we think about medication-
assisted treatment, it is important to understand the concept 
of opioid use as a chronic disease. And so, like any other 
chronic disease, we know that patients who suffer from opioid 
use disorder struggle with it in some cases for their entire 
life. We have very effective treatment, but we don't have a 
cure for the treatment.
    And so, generally, our approach is not to encourage people 
to get off of treatment immediately. We do encourage folks to 
stay in treatment at least a year, and in that way, we know 
that--although science tells us that you must stay in treatment 
for at least a year to sort of help heal the brain from the 
changes that have occurred, we know from science that there are 
changes that have occurred in the brain from overuse of 
opioids. So we encourage folks to stay in treatment at least a 
year. I can tell you that 60 percent of our patients are in 
treatment----
    Mrs. BLACK. I know my time is going to run out here in just 
a second. If I could get more information from you on looking 
further out and what all the results are, that would be great.
    And then, Ms. Hungiville, I would like to ask you about how 
you are using telehealth, since that is something that I am 
very interested in.
    Ms. HUNGIVILLE. Well, we are piloting a program where, in 
the ER, we are trying to get patients when they are in crisis, 
in overdose and/or even drug seeking, and making telehealth 
available to them to immediately start with medication-assisted 
treatment and then get them into counseling and into a program.
    Mrs. BLACK. I would love to hear more from you as well.
    And, Mr. Chairman, I am asking for a lot of information I 
guess will be sent back to your office so that you could share 
with us some of the results of what you are doing. Thank you so 
much.
    Chairman ROSKAM. Thank you. Just a couple questions in kind 
of summary.
    Dr. Kletter, in your testimony and in your statement, you 
used the phrase ``opioid use disorder.'' Is that a term of art? 
Is that somehow distinguishing between the word ``addiction,'' 
and are you communicating something else? I have a brother who 
is an emergency physician, and I noticed that at one point, the 
emergency physicians began to speak about the emergency 
department.
    So what is the story behind that phrase, and is there a 
subtlety that you are communicating there that we need to know 
about, or are these phrases interchangeable with addiction?
    Mr. KLETTER. So opioid use disorder is the term that is 
used in the Diagnostic and Statistical Manual of Mental 
Disorders, the DSM, which is sort of the tool that physicians 
use to diagnose disease, psychological disease generally.
    So there is a distinction between addiction and dependence. 
That is really critical to understand. The difference is, of 
course, addiction, which is--so opioid use disorder is what you 
might call an addiction, and it is characterized in the DSM by 
there being 11 criteria in order to meet the diagnosis of 
opioid use disorder.
    Two of those are physiological; they are tolerance and 
withdrawal. The other nine are behavioral, things like engaging 
in behaviors despite negative consequences, compulsive use, 
using increasing amounts over time even though you don't intend 
to. So there is an important distinction between opioid use 
disorder and tolerance--or, sorry, dependence, dependence being 
simply using a medication consistently--you could be dependent 
on a medication. For example, I take a statin. I am dependent 
on that medication to prevent my cholesterol from getting too 
high and having a heart attack. So I don't know if that answers 
your question.
    Chairman ROSKAM. Yes, it does. But there are some 
subtleties there that I need to learn more about. So, if you 
have any insight on the tutorial, I would be grateful.
    Mr. KLETTER. Sure. We are happy to tell you more and invite 
you or Mrs. Black or any of the Members of the Subcommittee to 
any of our facilities. We are happy to show you around, show 
you what we do, and how effective our services are.
    Chairman ROSKAM. Okay. That would be helpful.
    Dr. Paz, in your testimony, you spoke about intervening for 
those who are at risk. How are at risk individuals, patients or 
overprescribers identified, and what is the threshold, you 
know, based on Mr. Blumenauer's observations about the 
sensitivity around privacy and all that sort of stuff? How do 
you navigate through identifying someone who is at risk, and 
how do you walk through that carefully?
    Dr. PAZ. Thank you for the question, Mr. Chairman.
    So there are several different ways we do this, and one is 
we have access to our members' claims history, in terms of 
prescriptions of opioids. And we will find evidence of pharmacy 
shopping, physician shopping. Right there, that would be a risk 
factor. We have records of his prior history----
    Chairman ROSKAM. So you basically have predictive modeling. 
I mean, you have that access to those algorithms that say, 
``Hey, there is a problem here.''
    Dr. PAZ. And then we would intervene if there are 
circumstances where that occurs, again, within the boundaries 
of HIPAA requirements, certainly.
    Chairman ROSKAM. What does that intervention look like?
    Dr. PAZ. We have case managers, care managers that we 
actually have that intervene with our member, for example.
    Chairman ROSKAM. Is it explicit? I mean, is it a call from 
a case manager that says, ``I think you have a problem''?
    Dr. PAZ. Yeah.
    Chairman ROSKAM. Okay.
    Dr. PAZ. Yeah. We would certainly--our case managers would 
interface or interact with a member that has a set of 
conditions that requires some kind of an intervention that we 
can offer, not as a provider, though, which is key.
    We work with providers, and, again, being mindful of HIPAA 
requirements.
    Chairman ROSKAM. Say that again. You were just making an 
important point, and I didn't quite pick up on it. So the 
important point that you are making is a distinction between 
providers and carriers, based on what?
    Dr. PAZ. So, in terms of prescribing, a provider would 
prescribe.
    Chairman ROSKAM. Right.
    Dr. PAZ. We have access to information that would suggest 
overprescribing. And I gave a few examples earlier that putting 
in limits on how many days a prescription can be written for 
for acute pain, putting in a dosing limit as well. So these are 
things that we can do.
    We have done other things like partnered with a company, 
Pacira, which has produced a nonopioid pain reliever for oral 
surgery, post-oral surgery. We have created a partnership with 
them. It is a value-based contract that we have with them, so 
it is emphasizing quality outcomes for our members that receive 
that drug.
    But they are now going to receive a nonnarcotic after oral 
surgery as opposed to a 30-day supply of a narcotic post-oral 
surgery, which, interestingly, in our review of data and 
analytics, we find does, sadly, occur. It occurs even after a 
routine dental visit, unfortunately. So for a wisdom tooth 
extraction.
    So there are a number of different things that we can do 
including, for example, we have two programs that are 
noteworthy. One is the work that we are doing with mothers who 
have neonatal abstinence syndrome. We launched this program in 
several States. Again, our care managers intervene with mothers 
who have been identified as being neonatal abstinence, at risk 
for having children born with neonatal abstinence syndrome, and 
we put a program in place with ICUs, neonatal ICUs in their 
communities to address that.
    And, certainly, our program where we distribute naloxone 
and make sure that we are working to train first responders in 
communities to help members avoid death associated with 
overdose and addiction.
    Chairman ROSKAM. That is helpful. Thank you.
    What is the duration? And this is for the physicians on the 
panel. What is the duration that somebody can be taking an 
opioid and they become addicted? We have talked about a 7-day 
threshold. I have heard that referred to several times.
    You know, Doctor, you are shaking your head. There is not a 
magic number. What is a threshold? What is a range? What is a 
reasonable expectation?
    Dr. BENYAMIN. You know, again, it all depends on who is the 
patient, what is the pathology behind it, the reason. What is 
the reason that the patient is taking the medication? Is it a 
patient who just feels aches and pains all over their body, or 
is it a patient who has had five low back surgeries and three 
neck surgeries and two knee replacements? You know, these are 
all different patients. And, you know, we are human beings at 
the end of the day. We are not robots. So we react differently 
to disease, and we react differently to medications for the 
disease. So we have to allow for individualization of these 
treatments.
    Chairman ROSKAM. In your study and evaluation of this for 
any of the four of you, is there a spectrum in terms of 
addiction, or does somebody cross a line and they are addicted?
    Dr. PAZ. So, in general, that 7-day number that is in the 
CDC recommendations is there for a reason, because roughly--and 
this is, again, depending on the study you look at--about 14 
percent of individuals who are exposed to a week of a narcotic 
will become addicted.
    Chairman ROSKAM. Fourteen percent. So, in other words, 14 
percent of people who are on it 7 days or more, they are 
addicted.
    Dr. BENYAMIN. And, Mr. Chairman, the psychiatrists will 
argue that addiction is a disease in the person; it is not in 
the substance. So this is a continuous saga between one side of 
this equation and the other.
    Chairman ROSKAM. The medical spectrum. Yes, I understand.
    Ms. HUNGIVILLE. The dosage is also important, and the CDC 
guidelines also say that more than 50 morphine-equivalent 
dosages per day puts you at a higher risk of developing 
addiction.
    Dr. BENYAMIN. Mr. Chairman, if I have to point to one thing 
that is missing in a lot of medical specialties, we are good at 
writing prescriptions, at prescribing treatments, but we are 
not good at monitoring the treatment as far as effect and side 
effect.
    That is why it is very important that when we prescribe, 
that is what our guidelines say--how you need to monitor the 
effect and the side effects of medications, that is going to be 
the key.
    Chairman ROSKAM. That is a good summary. So let me ask each 
of you, in closing, if you had to communicate one thing, not 
four things, not a handful of things, one thing to this group 
today, what would it be? Doctor.
    Dr. BENYAMIN. Cut the supply of heroin and synthetic 
fentanyl. That is like a weapon of mass destruction affecting 
our communities.
    Chairman ROSKAM. Got it. Dr. Kletter.
    Mr. KLETTER. Increase access to evidence-based treatment 
services.
    Chairman ROSKAM. Dr. Paz.
    Dr. PAZ. Ensure education around use of nonopioid pain 
treatments.
    Chairman ROSKAM. Okay. Ms. Hungiville.
    Ms. HUNGIVILLE. And I would also add limiting dosages of 
opioids for acute conditions.
    Chairman ROSKAM. Okay. Mr. Thompson.
    Mr. THOMPSON. Thank you for indulging me.
    I mentioned to the Governor my concern about the treatment 
delay in the workers' compensation programs leading to opioid 
problems, and it is something I am very, very interested in.
    I have seen a lot of anecdotal evidence that this is true. 
In my State of California, there is just a long waiting period. 
Everybody is denied--a lot of people are denied the procedures 
that the medical profession recommends, so it stretches out the 
time that they are on painkillers. And I have just seen too 
many people who, because of this, become addicted.
    And I am looking at some different things to try to deal 
with this. So, if any of you have any information that would 
help me out in that, would you please send it to me?
    Chairman ROSKAM. We have been joined by our former 
colleague, Ed Whitfield, a great American from Kentucky and 
former Chairman of our partner Committee, the Energy and 
Commerce Committee, which has a lot to do with the solutions 
here. So it is good to have him back.
    For the record, Members are advised that they have 2 weeks 
to submit written questions that can be answered later in 
writing, and those questions and your answers will be made part 
of the formal hearing record.
    Finally, two things: Number one, thank you for your time. 
You have been very generous with your time today, and I know it 
is an adventure to schlepp out here and all that, so thank you 
for doing that and for the time that you put into your 
testimony. It was very helpful.
    Second, if you think of things subsequent to this, whether 
you are flying home, driving around, whatever you are doing, in 
the next several weeks or months, and you think, I wish I had 
said that or I have this article, and I think those people 
would benefit from it, send it to us. And I will make sure that 
it is distributed.
    You get the sense of the caliber of these people. These are 
serious, thoughtful people that are solution-oriented. We are 
not looking for pen pals, if you know what I am saying. But, 
things that you think we should be reading, would be very, very 
helpful.
    So, on behalf of the whole Subcommittee, I want to thank 
you for your time today and look forward to continuing to 
interact with you in the future. Thank you.
    The Committee stands adjourned.
    [Whereupon, at 6:31 p.m., the Subcommittee was adjourned.]
    [Questions for the Record follow:]
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