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

                      EXAMINING ADVERTISING AND MARKETING
             PRACTICES WITHIN THE SUBSTANCE USE TREATMENT INDUSTRY

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

                                    HEARING

                                   BEFORE THE

                  SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                     OF THE

                        COMMITTEE ON ENERGY AND COMMERCE
                            HOUSE OF REPRESENTATIVES

                         ONE HUNDRED FIFTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 JULY 24, 2018

                                   __________

                               Serial No. 115-155

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

          Printed for the use of the Committee on Energy and Commerce

                            energycommerce.house.gov

                                    __________

                        U.S. GOVERNMENT PUBLISHING OFFICE
    35-759                       WASHINGTON : 2019

    -----------------------------------------------------------------------------------
    For sale by the Superintendent of Documents, U.S. Government Publishing Office,
    http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center,
    U.S. Government Publishing Office. Phone 202-512-1800, or 866-512-1800 (toll-free).E-mail,
    gpo@custhelp.com.

                        COMMITTEE ON ENERGY AND COMMERCE

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

                  Subcommittee on Oversight and Investigations

                           GREGG HARPER, Mississippi
                                     Chairman
    H. MORGAN GRIFFITH, Virginia         DIANA DeGETTE, Colorado
      Vice Chairman                        Ranking Member
    JOE BARTON, Texas                    JANICE D. SCHAKOWSKY, Illinois
    MICHAEL C. BURGESS, Texas            KATHY CASTOR, Florida
    SUSAN W. BROOKS, Indiana             PAUL TONKO, New York
    CHRIS COLLINS, New York              YVETTE D. CLARKE, New York
    TIM WALBERG, Michigan                RAUL RUIZ, California
    MIMI WALTERS, California             SCOTT H. PETERS, California
    RYAN A. COSTELLO, Pennsylvania       FRANK PALLONE, Jr., New Jersey (ex
    EARL L. ``BUDDY'' CARTER, Georgia        officio)
    GREG WALDEN, Oregon (ex officio)

                                 C O N T E N T S

                                  ----------
                                                                       Page
    Hon. Gregg Harper, a Representative in Congress from the State of
      Mississippi, opening statement.................................     1
        Prepared statement...........................................     3
    Hon. Diana DeGette, a Representative in Congress from the state
      of Colorado, opening statement.................................     4
        Prepared statement...........................................     6
    Hon. Greg Walden, a Representative in Congress from the State of
      Oregon, opening statement......................................     7
        Prepared statement...........................................     8
    Hon. Frank Pallone, Jr., a Representative in Congress from the
      State of New Jersey, opening statement.........................    10
        Prepared statement...........................................    11

                                   Witnesses

    Marvin Ventrell, Executive Director, National Association of
      Addiction Treatment Providers..................................    13
        Prepared statement...........................................    15
    Mark Mishek, President and CEO, Hazelden Betty Ford Foundation...    26
        Prepared statement...........................................    28
    Michael Cartwright, Chairman and CEO, American Addiction Centers.    38
        Prepared statement...........................................    40
    Robert Niznik, CEO, Addiction Recovery Now and Niznik Behavioral
      Health.........................................................    43
        Prepared statement...........................................    45
    Jason Brian, Founder, Redwood Recovery Solutions and
      Treatmentcalls.Com.............................................    49
        Prepared statement...........................................    52
    Kenneth Stoller, Director, Johns Hopkins Hospital Broadway Center
      for Addiction..................................................    56
        Prepared statement...........................................    58

                               Submitted Material

    Subcommittee memorandum..........................................    94
    List of websites, submitted by Ms. DeGette.......................   102
    Letter of July 24, 2018, from the Federal Trade Commission to
      Members of the Committee, submitted by Ms. DeGette.............   105

    EXAMINING ADVERTISING AND MARKETING PRACTICES WITHIN THE SUBSTANCE USE
                               TREATMENT INDUSTRY

                                  ----------

                             TUESDAY, JULY 24, 2018

                      House of Representatives,
          Subcommittee on Oversight and Investigations,
                              Committee on Energy and Commerce,
                                                        Washington, DC.
        The subcommittee met, pursuant to call, at 10:00 a.m., in
    room 2123, Rayburn House Office Building, Hon. Gregg Harper
    (chairman of the subcommittee) presiding.
        Present: Representatives Harper, Griffith, Burgess, Brooks,
    Collins, Walberg, Walters, Costello, Carter, Walden (ex
    officio), DeGette, Schakowsky, Castor, Tonko, Clarke, Ruiz, and
    Pallone (ex officio).
        Also Present: Representative Bilirakis.
        Staff Present: Jennifer Barbla, Chief Counsel, Oversight
    and Investigations; Adam Fromm, Director of Outreach and
    Coalitions; Ali Fulling, Legislative Clerk, Oversight and
    Investigations, Digital Commerce and Consumer Protection;
    Brighton Haslett, Counsel, Oversight and Investigations;
    Brittany Havens, Professional Staff, Oversight and
    Investigations; Ed Kim, Policy Coordinator, Health; Andrea
    Noble, Fellow, Oversight and Investigations; Jennifer Sherman,
    Press Secretary; Austin Stonebraker, Press Assistant; Hamlin
    Wade, Special Advisor, External Affairs; Everett Winnick,
    Director of Information Technology; Julie Babayan, Minority
    Counsel; Jeff Carroll, Minority Staff Director; Waverly Gordon,
    Minority Health Counsel; Zach Kahan, Minority Outreach and
    Member Services Coordinator; Chris Knauer, Minority Oversight
    Staff Director; Jourdan Lewis, Minority Staff Assistant; Miles
    Lichtman, Minority Policy Analyst; Perry Lusk, Minority
    Government Accountability Office Detailee; Kevin McAloon,
    Minority Professional Staff Member; and C.J. Young, Minority
    Press Secretary.

      OPENING STATEMENT OF HON. GREGG HARPER, A REPRESENTATIVE IN
                 CONGRESS FROM THE STATE OF MISSISSIPPI

        Mr. Harper. The subcommittee will come to order.
        Today, the subcommittee holds a hearing entitled examining,
    advertising, and marketing practices within the substance abuse
    treatment industry. This hearing builds on the subcommittee's
    extensive work over the past 4 years examining the causes and
    scope of the opioid epidemic including ways to effectively
    treat individuals with a substance use disorder.
        The opioid epidemic continues to ravish our nation.
    According to the Centers for Disease Control approximately, 2.1
    million Americans over the age of 12 suffer from an opioid use
    disorder. Meanwhile, the number of Americans dying from opioid
    overdoses has increased in recent years to 115 deaths per day.
        As the opioid epidemic continues to take its toll, the
    demand for treatment has dramatically increased. According to
    the Substance Abuse and Mental Health Services Administration,
    the number of treatment facility admissions for opiate use
    increased 58 percent from 2005 through 2015. With rising
    demand, the number of treatment facilities has also grown.
    However, the increased demand for treatment and attendant
    proliferation of treatment facilities has raised a number of
    concerns about practices within the industry.
        Our December hearing examined ``patient brokering,'' the
    practice of recruiting individuals with a substance use
    disorder and luring them to treatment facilities and sober
    living homes, often in other States, in return for financial
    kickbacks. We also heard testimony about the problems stemming
    from the dramatic surge and substance use disorder treatment
    facilities including practices employed by businesses known
    generally as ``call aggregators.'' These practices incentivize
    profit over the recovery and well-being of the individual
    seeking treatment.
        The information we learned at the hearing in December,
    along with additional reports and research that the Committee
    conducted, led us to dig deeper into these marketing and
    advertising practices within the drug treatment industry.
        If you compare how one seeks care for a substance use
    disorder to how one would seek care for any other illness or
    disease, the differences are staggering. For example, if you
    aren't feeling well, most people would go to their primary care
    physician, or if it's an emergency, the ER, and that doctor is
    likely to refer you to another doctor or specialist, depending
    upon what's wrong. Here, individual seeking treatment for
    themselves or loved one often turn to the Internet to find
    resources to guide them in choosing a treatment center. One
    study found that 61 percent of people who went to rehab used
    the Internet to find treatment. Such online searches can prove
    overwhelming. Patients are often at the mercy of what they find
    online with little or no guidance from a medical professional.
        Many treatment-focused websites advertise hotlines that
    purport to direct individuals to a trained professional that
    can help the individual assess what treatment facilities will
    best meet their needs. These call centers may appear to be
    unaffiliated third-party referral services, but they are often
    either owned and operated by treatment facilities or are paid
    by facilities to refer calls. While some centers disclose their
    relationship with treatment facilities, others may engage in
    deceptive marketing tactics to hide them. Moreover, these call
    centers are often staffed by sales representatives rather than
    medical professionals. In some cases, the individual staffing
    the company's call center receive a bonus each month based on
    the number of callers that are successfully admitted into one
    company's facilities.
        In some of the worst cases, call aggregators, or call
    centers, may refer patients to facilities that don't meet their
    needs based on a financial arrangement. And once patients enter
    treatment, they may be vulnerable to exploitation by
    unscrupulous business owners.
        Concerns raised about deceptive advertising and marketing
    practice have already led to action. For example, several
    States have passed legislation, the National Association For
    Addiction Treatment Providers updated its code of ethics, and
    Google placed a temporary restriction of online advertising by
    treatment providers due to misleading experiences among
    rehabilitation treatment centers.
        As the opioid epidemic continues to claim lives, it is
    vital that we ensure individuals seeking treatment for
    themselves or loved ones are able to find treatment that best
    meets their needs without being misled by those who would
    prioritize financial gain over saving lives.
        We thank our panel of witnesses for joining us this
    morning. I hope that today's hearing will shed light on how we
    can combat deceptive marketing practices while protecting
    legitimate treatment centers and the individuals desperately
    seeking their care.
        We thank you for appearing before the subcommittee today,
    and we will look forward to hearing your testimony shortly.
        At this time, the chair will recognizes the ranking member
    of this subcommittee Ms. DeGette for 5 minutes for the purposes
    of an opening statement.
        [The prepared statement of Mr. Harper follows:]

                    Prepared statement of Hon. Gregg Harper

        The Subcommittee will come to order. Today the Subcommittee
    holds a hearing entitled ``Examining Advertising and Marketing
    Practices within the Substance Use Treatment Industry.'' This
    hearing builds on the Subcommittee's extensive work over the
    past four years examining the causes and scope of the opioid
    epidemic, including ways to effectively treat individuals with
    a substance use disorder.
        The opioid epidemic continues to ravage our nation.
    According to the Centers for Disease Control, approximately 2.1
    million Americans over the age of 12 suffer from an opioid use
    disorder. Meanwhile, the number of Americans dying from opioid
    overdoses has increased in recent years to 115 deaths each day.
        As the opioid epidemic continues to take its toll, the
    demand for treatment has dramatically increased. According to
    the Substance Abuse and Mental Health Services Administration,
    the number of treatment facility admissions for opiate use
    increased 58 percent between 2005 and 2015. With rising demand,
    the number of treatment facilities has also grown. However, the
    increased demand for treatment and attendant proliferation of
    treatment facilities have raised a number of concerns about
    practices within the industry.
        Our December hearing examined ``patient brokering,'' the
    practice of recruiting individuals with a substance use
    disorder and luring them to treatment facilities and sober
    living homes, often in other states, in return for financial
    kickbacks. We also heard testimony about the problems stemming
    from the dramatic surge in substance use disorder treatment
    facilities, including practices employed by businesses known
    generally as ``call aggregators.'' These practices incentivize
    profit over the recovery and well-being of the individual
    seeking treatment.
        The information we learned at the hearing in December,
    along with additional reports and research that the Committee
    conducted, led us to dig deeper into these marketing and
    advertising practices within the drug treatment industry.
        If you compare how one seeks care for a substance use
    disorder to how one would seek care for any other illness or
    disease, the difference is staggering. For example, if you
    aren't feeling well most people would go to their primary care
    doctor or if it's an emergency, the ER, and that doctor is
    likely to refer you to another doctor or specialist depending
    on what's wrong. Here, individuals seeking treatment for
    themselves or a loved one often turn to the internet to find
    resources to guide them in choosing a treatment center--one
    study found that 61 percent of people who went to rehab used
    the internet to find treatment. Such online searches can prove
    overwhelming, patients are often at the mercy of what they find
    online with little or no guidance from a medical professional.
        Many treatment-focused websites advertise hotlines that
    purport to direct individuals to a trained professional that
    can help the individual assess what treatment facility will
    best meet their needs. These call centers may appear to be
    unaffiliated third-party referral services, but they are often
    either owned and operated by treatment facilities or are paid
    by facilities to refer calls. While some centers disclose their
    relationship with treatment facilities, others may engage in
    deceptive marketing tactics to hide them. Moreover, these call
    centers are often staffed by sales representatives rather than
    medical professionals. In some cases, the individuals staffing
    the company's call center receive a bonus each month based on
    the number of callers that are successfully admitted into one
    of the company's facilities.
        In some of the worst cases, call aggregators or call
    centers may refer patients to facilities that don't meet their
    needs based on a financial arrangement and once patients enter
    treatment they may be vulnerable to exploitation by
    unscrupulous business owners.
        Concerns raised about deceptive advertising and marketing
    practices have already led to action. For example, several
    states have passed legislation, the National Association for
    Addiction Treatment Providers updated its code of ethics, and
    Google placed a temporary restriction of online advertising by
    treatment providers due to ``misleading experiences among
    rehabilitation treatment centers.''
        As the opioid epidemic continues to claim lives, it is
    vital that we ensure individuals seeking treatment for
    themselves or loved ones are able to find treatment that best
    meets their needs without being misled by those who would
    prioritize financial gain over saving lives.
        We thank our panel of witnesses for joining us this
    morning. I hope that today's hearing will shed light on how we
    can combat deceptive marketing practices while protecting
    legitimate treatment centers and the individuals desperately
    seeking their care.
        We thank you for appearing before the Subcommittee today
    and look forward to hearing your testimony.

     OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN
                  CONGRESS FROM THE STATE OF COLORADO

        Ms. DeGette. Thank you very much, Mr. Chairman.
        Mr. Chairman, throughout the several years that we have
    been holding a series of hearings in this subcommittee and
    other subcommittees of the Energy and Commerce Committee, one
    of the themes that has emerged is that families need good
    information about the types of treatments that are available.
    And also we've heard from the medical experts that evidence-
    based treatment, including medication-assisted treatment is the
    most effective means for overcoming opioid use disorders.
        But this is echoing what your concern is. Not all
    facilities provide that treatment. Some facilities make only
    vague promises about the effectiveness of various treatment
    models they offer. And in addition, when you're finding your
    facility online, most patients will have no idea if the
    facilities that they're identifying would have the types of
    treatment that would actually work in dealing with this opioid
    crisis.
        We've been seeing through this committee's investigation
    that we've got nefarious or unqualified actors out there who
    are taking advantage of those who are suffering in order to
    capitalize on this condition.
        Last year, this subcommittee had a hearing where we heard
    about individuals known as ``patient brokers'' who profit from
    recruiting patients with opioid addiction and then send them to
    dubious treatment centers in other States.
        We have heard that the operators of many of these centers
    sometimes have no training or expertise in drug treatment and
    once the patients arrive, they may receive substandard or no
    care at all. And then in December, the subcommittee heard from
    law enforcement officials in States that were affected by these
    schemes.
        They testified about the wide variation and the quality of
    care provided at some of the facilities and how we lack
    sufficient national standards.
        Now, today, we're looking at another feature of the opioid
    epidemic that shows the challenges patients with opioid use
    disorder currently face. And that is, how the treatment
    providers advertise, market, or locate prospective patients
    seeking treatment and guide them to appropriate treatment.
        In other words, are patients prioritized when it comes to
    finding and directing those seeking care for opioid use
    disorders and for those patients who are the target of
    aggressive marketing practices, how should they evaluate a
    possible treatment facility for its effectiveness?
        As you noted, Mr. Chairman, this committee has seen reports
    of call centers that sell customer referrals to treatment
    providers. Some also hide the fact that they're making
    referrals for a fee or that the call centers actually owned by
    the same company that owns the treatment center.
        We've also seen aggressive advertising and marketing
    strategies by treatment facilities such as websites and 1-800
    numbers that do not clearly disclose who a patient is
    contacting or where they're being referred. And some facilities
    try to lure in patients with promises of luxurious treatment
    such as daily yoga sessions and free housing. And I think that
    the experts who are here today will tell you that things like
    daily yoga sessions, while they might be great for a spa, are
    not going to cure opioid addiction.
        So how pervasive are these problems in the industry, and
    how many of these practices, like having multiple websites or
    purchasing calls in bulk, actually provide the treatment that
    helps people recover?
        So for today's discussion, here is what I'm looking to hear
    from the witnesses: What are good practices when it comes to
    marketing treatment services and what are dubious practices?
        We need to hear whether there are certain quality
    indicators patients should look for when seeking a treatment
    and just as important, are there certain red flags that
    indicate questionable services?
        In other words, Mr. Chairman, opioid use disorder and its
    treatment is complicated enough for any prospective patient to
    navigate.
        We need to make sure that existing practices are not making
    it more difficult for people seeking treatment by obscuring
    what's really being provided and what they need to treat their
    addiction.
        And so we need to find out how treatment providers find
    patients, educate them, and then guide them into appropriate
    treatment.
        I look forward to hearing from all of the witnesses about
    these issues, and I yield back.
        [The prepared statement of Ms. DeGette follows:]

                    Prepared statement of Hon. Diana DeGette

        Thank you, Mr. Chairman.
        We have all heard the statistics about the opioid crisis:
    the thousands who die each year, and millions more who are
    suffering from addiction.
        But through this committee's investigation, we have seen
    another side of this crisis: some nefarious or unqualified
    actors are taking advantage of those who are suffering, out of
    the desire to capitalize on their condition.
        As the Committee learned last year, some individuals known
    as ``patient brokers'' profit from recruiting patients with
    opioid addiction, and then send them to dubious treatment
    centers in other states. We heard that the operators of many of
    these centers sometimes have no training or expertise in drug
    treatment, and once the patients arrive, they may receive sub-
    standard or no care at all.
        This past December, the subcommittee heard from law
    enforcement officials in States affected by these schemes. They
    testified about the wide variation in the quality of care
    provided at some facilities, and how we lack consistent
    standards.
        Today we are examining another feature of the opioid
    epidemic that again shows some of the challenges patients with
    opioid use disorder currently face. And that is how treatment
    providers advertise, market, or locate prospective patients
    seeking treatment and guide them to appropriate treatment.
        In other words, are patients prioritized when it comes to
    finding and directing those seeking care for opioid use
    disorders? And for those patients who are the target of
    aggressive marketing practices, how should they evaluate a
    possible treatment facility for its effectiveness?
        This Committee has seen reports of call centers, for
    example, that sell customer referrals to treatment providers.
    Some also hide the fact that they are making referrals for a
    fee, or that the call center is owned by the same company that
    owns the treatment center.
        We have also seen aggressive advertising and marketing
    strategies by treatment facilities, such as websites and 1-800
    numbers that do not clearly disclose who a patient is
    contacting or where they're being referred. Some facilities
    also try to lure in patients with promises of luxurious
    treatment, such as daily yoga sessions and free housing.
        How pervasive are these problems in the industry, and how
    do many of these practices--such as having multiple websites or
    purchasing calls in bulk--actually help individuals recover?
        For today's discussion, the witnesses need to articulate
    what they regard as good practices when it comes to marketing
    treatment services, and what they regard as dubious practices.
    Also, are there certain quality indicators that patients should
    look for when seeking a treatment option? As importantly, are
    there certain red flags that indicate questionable services?
        In other words, Mr. Chairman, opioid use disorder and its
    treatment is complicated enough for any prospective patient to
    navigate. We must make sure that existing practices are not
    making it harder for those seeking treatment by obscuring
    what's really being provided and what they need to treat their
    addiction.
        So today we have questions regarding how treatment
    providers find patients, educate them, and then guide them into
    appropriate treatment.
        The witnesses today can articulate how they do these things
    before referring or accepting a patient. And hopefully, they
    will also describe how pervasive certain questionable tactics
    are regarding treatment offerings.
        Mr. Chairman, one of the themes that has emerged in our
    years-long examination of the opioid crisis is that families
    need much better information about the types of treatment
    available.
        This Committee has long heard from the medical experts that
    evidence-based treatment- including medication-assisted
    treatment-is the most effective method for overcoming opioid
    use disorder. But not all facilities provide that treatment,
    and some make vague promises about the effectiveness of the
    various treatment models they offer.
        Our witnesses today can provide a benchmark of what they
    regard as quality treatment, and how that compares to some of
    the questionable treatment facilities we have seen reports
    about. This is critical because if patients don't know what to
    look for when they are seeking care, it is even easier for bad
    actors to take advantage of them.
        Mr. Chairman, the effects of the opioid crisis will be with
    us for decades. It is going to take a monumental effort by the
    medical community, public health agencies, Congress, and this
    Committee to climb out. That will be challenging enough. But in
    the process, we cannot let bad or ineffective actors make the
    problem even worse.
        I hope this Committee can shed some light on these problems
    and provide the tools and resources for people to get the
    treatment they need.
        I yield back.

        Mr. Harper. The gentlewoman yields back.
        The chair will now recognize the chairman of the full
    committee, Greg Walden for the purposes of his opening
    statement.

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

        Mr. Walden. Thank you very much, Mr. Chairman. I appreciate
    you holding this hearing.
        I want to thank our witnesses for being here today to
    inform our work.
        Today's hearing follows up on our year-long bipartisan
    investigation to patient brokering and the fraud and abuse
    within the substance use disorder treatment industry.
        Beginning in April of 2014, this subcommittee commenced a
    comprehensive examination into the causes of the opioid
    epidemic, the impact it's had on Americans and explored
    possible solutions to enable greater access to effective
    evidence-based treatment for substance use disorders.
        The House, as you know, recently passed H.R. 6. This is the
    Support For Patients and Communities Act, which includes 70
    provisions, largely from this committee, that seek to address a
    number of issues within the opioid epidemic. But our work here
    is not done. The committee continues to conduct its proper
    oversight, because our Nation is far from seeing the end of the
    opioid epidemic and its tragic and deadly effects.
        In December, the subcommittee held a hearing examining the
    patient brokering and addiction treatment fraud where concerns
    were raised about deceptive and sometimes predatory advertising
    and marketing practices within the treatment industry.
        In addition, we've read news reports, spoken to treatment
    facilities, doctors, associations and stakeholders within the
    industry, but most importantly, we've heard from individuals,
    their loved ones, who have faced some of these aggressive and
    deceptive advertising practices. In fact, in my own district
    out in Oregon, a father named Mike told me about the troubling
    experience he had when his son was seeking treatment for
    addiction. The recovery center that his son went to was located
    in another State. And he said it seemed more interested in
    cashing the check than actually caring for his son.
        As the committee dove deeper into the advertising and
    marketing practices within this industry, we found a Pandora's
    box of online advertisement, websites, phone numbers, lead
    generators, call centers, and television commercials. In some
    cases an individual or company may own dozens and dozens of
    websites, and some of these websites contain different 1-800
    numbers, despite all being owned by the same person were all
    leading to the same treatment company.
        Some websites and television commercials used pretty
    forceful language, such as, ``Call now, don't wait any
    longer,'' ``Get the help you need,'' ``Talk to someone who
    cares,'' ``End your addiction now,'' or ``For immediate
    treatment help.'' One individual the committee spoke with
    shared that the person on the other end of the phone went on to
    say, ``if you don't get your kid here now, your kid will die.''
        Further, some of the websites and advertisements purport to
    offer the ``best'' treatment in the country or claim high
    success rates to lure patients to their facilities. This all
    sounds great. We don't know what those statements are based
    upon. For example, does that mean someone successfully enrolled
    in the treatment, completed treatment, that they are still
    maintaining their sobriety one year later? What does success
    mean, and how do you measure it? These are the types of
    questions that individuals and their loved ones should be able
    to find answers for when they search their treatment that best
    meets their needs.
        These advertising practices lead to reputable and quality
    treatment. That's great. That's what we hope for. But deceptive
    practices can have consequences, whether it's online
    advertisements, websites, 1-800 numbers, or television
    commercials, individuals and their loved ones should be able to
    expect transparency, know who answers the phone or responds to
    an inquiry when they reach out for help. Individuals who call
    treatment hotlines are often in times of crisis and they had
    need help fast and from someone that can be trusted. They have
    a right to know what facilities they're calling and the type of
    treatment that facility offers so they can decide whether it's
    the right treatment for them or their loved one.
        So today's hearing will help bring much-needed attention to
    this issue, help us understand the scope of advertising and
    marketing practices within the treatment issue. Our hope is a
    thoughtful discussion will help us establish a baseline for
    best practices, help inform individuals or loved ones about how
    to seek treatment that best meets their needs.
        And I would yield the balance of the time to the chairman
    of the Subcommittee of Health, Dr. Burgess.
        [The prepared statement of Mr. Walden follows:]

                     Prepared statement of Hon. Greg Walden

        Thank you, Mr. Chairman, for holding this hearing. Today's
    hearing follows up on a year-long bipartisan investigation into
    patient brokering and the fraud and abuse within the substance
    use disorder treatment industry.
        Beginning in April 2014, this subcommittee commenced a
    comprehensive examination into the causes of the opioid
    epidemic, the impact it's had on Americans, and explored
    possible solutions to enable greater access to effective,
    evidence-based treatment for substance use disorders.
        The House recently passed H.R. 6, the SUPPORT for Patients
    and Communities Act, which includes 70 provisions--largely from
    this committee--that seek to address a number of issues within
    the opioid crisis. But our work here is not done and the
    committee continues to conduct oversight because our country is
    far from seeing the end of the opioid epidemic and its tragic
    effects.
        In December, this subcommittee held a hearing examining
    patient brokering and addiction treatment fraud where concerns
    were raised about deceptive and sometimes predatory advertising
    and marketing practices within the treatment industry.
        In addition, we've read news reports, spoken to treatment
    facilities, doctors, associations, and stakeholders within the
    industry, but most importantly, we've heard from individuals
    and their loved ones who have faced some of these aggressive
    and deceptive advertising practices. In my district in Oregon,
    a father named Mike told me about the troubling experience he
    had when his son was seeking treatment for addiction. The
    recovery center was located in another stated and seemed more
    interested in cashing a check rather than caring for his son.
        As the committee dove deeper into the advertising and
    marketing practices within this industry we found a Pandora's
    box of online advertisements, websites, phone numbers, lead
    generators, call centers, and television commercials. In some
    cases, an individual or company may own dozens and dozens of
    websites, and some of these websites contain different 1-800
    numbers, despite all being owned by the same person or all
    leading to the same treatment company.
        Some websites and television commercials use forceful
    language, such as: ``Call now,'' ``don't wait any longer,''
    ``get the help you need,'' ``talk to someone who cares,'' ``end
    your addiction now,'' or ``for immediate treatment help.'' One
    individual the committee spoke with shared that the person on
    the other end of the phone went as far to say, ``if you don't
    get your kid here now, your kid will die.''
        Further, some of the websites and advertisements purport to
    offer the ``best'' treatment in the country or claim high
    success rates to lure patients to their facilities. This all
    sounds great, but we don't know what those statements are based
    on. For example, does that mean someone successfully enrolled
    in treatment, completed treatment, that they are still
    maintaining their sobriety one year later? What does success
    mean and how do you measure it? These are the types of
    questions that individuals and their loved ones should be able
    to find answers for when they search for treatment that best
    meets their needs.
        If these advertising practices lead to reputable and
    quality treatment, that's great. But, these deceptive practices
    can have consequences. Whether it's online advertisements,
    websites, 1-800 numbers, or television commercials--individuals
    and their loved ones should be able to expect transparency and
    know who answers the phone or responds to an inquiry when they
    reach out for help. Individuals who call treatment hotlines are
    often in a time of crisis and they need help fast and from
    someone they can trust. They have a right to know what facility
    they are calling and the type of treatment that facility offers
    so they can decide whether it is the right treatment for them
    or their loved one.
        Today's hearing will help bring much needed attention to
    this issue and help us understand the scope of advertising and
    marketing practices within the treatment industry. Our hope is
    that a thoughtful discussion will help us establish a baseline
    for best practices and help inform individuals and their loved
    ones about how to seek treatment that best meets their needs.
        I welcome our witnesses and look forward to their
    testimony.

        Mr. Burgess. I thank the chairman for yielding. And the
    chairman makes an important point. H.R. 6 did pass through this
    committee and, indeed, on the floor of the House. And we do
    call on the Senate, the other body, to take that up.
        This is not the first hearing we've had on this subject.
    Last December, we did have a hearing, and we heard from the
    assistant attorney general from the Massachusetts attorney
    general's office, Eric Gold, was his name. And he provided for
    us three recommendations on the evaluation and solution for the
    problems that are existing at sober homes.
        He said we need additional resources for Federal, State and
    local law enforcement. OK, that's covered in H.R. 6. Second,
    patients need transparency into the quality of addiction
    treatment of the providers nationwide. I agree with that. I'm
    not sure we're there. And the third thing: We need to ensure
    that patients with substance use disorder have access to the
    treatment they need and we do not unintentionally limit access.
    And that is an important point as well.
        Additionally, we heard from a panel of family members who
    had been affected by family members who had problems with
    opioid addiction. And one of the statements of one of the
    witnesses really stands out.
        She said, ``the intent, of course, was not to kill Jaime,
    but to keep him in the system and continue to abuse his
    insurance.''
        Those are pretty apocryphal words, and I hope we get to
    explore some more of that. Mr. Chairman, thank you for the
    indulgence, and I yield back Mr. Walden's time.
        Mr. Harper. The gentleman yields back. The chair will now
    recognize the ranking member of the full committee, Mr.
    Pallone, for 5 minutes.

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

        Mr. Pallone. Thank you, Mr. Chairman.
        The opioid epidemic continues to devastate families and
    communities around the Nation. We still have a long way to go
    to climb out of this crisis. Opiates killed more than 115
    Americans a day in 2016, and millions more continue to suffer.
    That's bad enough, but to see people taking advantage of this
    crisis by preying on victims to make money is unconscionable.
        The Affordable Care Act expanded access to substance abuse
    treatment for millions of Americans. It also required insurance
    companies to cover this treatment just as they would cover any
    other chronic disease. Thanks to the ACA and Medicaid
    expansion, Americans who could not get access to this treatment
    before, now can. Unfortunately, people with substance use
    disorder still face barriers to accessing treatment. According
    to SAMHSA, of the 19 million adults who had a substance use
    disorder in 2016, 17 million did not receive treatment.
        We need to do everything we can to help more Americans
    access this treatment. Unfortunately, there are companies
    preying on individuals in desperate need of treatment services.
    Some of the companies this committee has been examining claim
    they are merely filling a market need, but anyone advertising
    treatment services must put the needs of the patient first, and
    they must employ well qualified staff that can provide quality
    treat or ensure that they are only referring patients to
    quality treatment providers.
        This committee's investigation into patient brokering
    revealed shocking examples of companies that claim to offer
    treatment and special perks to individuals suffering from
    opioid addiction. Families that were desperate to help their
    loved ones put their trust and hope in many of these treatment
    facilities. But as our investigation has found, many of those
    entities are a scam, and do not offer actual treatment. In some
    instances, these facilities are actually putting people's lives
    at risk.
        Now the Committee has broadened its focus to look at
    treatment call centers and marketing tactics. And
    unfortunately, we've discovered that some companies have looked
    at this devastating epidemic as an opportunity solely to make
    money.
        For instance, reports indicate that some of these call
    centers or ``call aggregators'' advertise opioid treatment to
    get people to call looking for help, and then sell those calls
    to various facilities. And it is unclear how this helps the
    patient.
        Other companies actually appear to offer treatment for
    opioid use disorder, but they also engage in aggressive
    marketing tactics. For example, some facilities operate
    multiple websites with different names and phone numbers, with
    the goal of maximizing the number of beds filled.
        And this raises questions about how transparent these
    companies are about the services they offer and how they help
    patients find the treatment that's right for them. It also
    raises questions about how a prospective patient is supposed to
    navigate the countless number of treatment offerings and find
    quality care against the backdrop of the array of services
    being advertised.
        So I'm hopeful our witnesses can shed some light on the
    types of marketing and treatment practices that are best
    designed to put the patient first and help them find quality
    care.
        And unless someone else wants my time, I yield back, Mr.
    Chairman.
        [The prepared statement of Mr. Pallone follows:]

                 Prepared statement of Hon. Frank Pallone, Jr.

        The opioid epidemic continues to devastate families and
    communities around the nation. We still have a long way to go
    to climb out of this crisis. Opioids killed more than 115
    Americans a day in 2016, and millions more continue to suffer.
    That is bad enough--but to see people taking advantage of this
    crisis by preying on victims to make money is unconscionable.
        The Affordable Care Act expanded access to substance abuse
    treatment for millions of Americans, and it also required
    insurance companies to cover this treatment just as they would
    cover any other chronic disease. Thanks to the ACA and Medicaid
    Expansion, Americans who could not get access to this treatment
    before now can. Unfortunately, people with substance use
    disorder still face barriers to accessing treatment. According
    to SAMHSA, of the 19 million adults who had a substance use
    disorder in 2016, 17 million did not receive treatment.
        We need to do everything we can to help more Americans
    access this treatment. Unfortunately, there are companies
    preying on individuals in desperate need of treatment services.
    Some of the companies this Committee has been examining claim
    they are merely filling a market need. But anyone advertising
    treatment services must put the needs of the patient first, and
    they must employ well-qualified staff that can provide quality
    treatment or ensure that they are only referring patients to
    quality treatment providers.
        This Committee's investigation into patient brokering
    revealed shocking examples of companies that claimed to offer
    treatment and special perks to individuals suffering from
    opioid addiction. Families that were desperate to help their
    loved ones put their trust and hope in many of these treatment
    facilities. But as our investigation has found, many of those
    entities are a scam and do not offer actual treatment. In some
    instances, these facilities are actually putting people's lives
    at risk.
        Now the Committee has broadened its focus to look at
    treatment call centers and marketing tactics. And
    unfortunately, we've discovered that some companies have looked
    at this devastating epidemic as an opportunity solely to make
    money.
        For instance, reports indicate that some of these call
    centers or ``call aggregators'' advertise opioid treatment to
    get people to call looking for help, and then sell those calls
    to various facilities. It is unclear how this helps the
    patient.
        Other companies actually appear to offer treatment for
    opioid use disorder, but they also engage in aggressive
    marketing tactics. For example, some facilities operate
    multiple websites with different names and phone numbers, with
    the goal of maximizing the number of beds filled.
        This raises questions about how transparent these companies
    are about the services they offer, and how they help patients
    find the treatment that's right for them. It also raises
    questions about how a prospective patient is supposed to
    navigate the countless number of treatment offerings and find
    quality care against the backdrop of the array of services
    being advertised.
        I am hopeful our witnesses can shed some light on the types
    of marketing and treatment practices that are best designed to
    put the patient first and help them find quality care.
        For example, Dr. Kenneth Stoller from the Johns Hopkins
    Hospital Broadway Center for Addiction can tell us about how
    they conduct outreach to individuals who may be in need of
    substance use disorder services and enroll patients seeking
    care. He can also tell us about how treatment providers should
    clinically assess the needs of each patient to determine the
    best course of treatment, and the role of medication-assisted
    treatment (or MAT) for opioid addiction.
        I also look forward to hearing from some of the other
    treatment providers on their marketing and treatment practices
    to understand if they are designed to always put the patient
    first and guide them to the care most appropriate for their
    condition.
        This is important considering that not all families seeking
    help have access to objective information or even know what to
    look for in evaluating treatment options.
        And this problem is especially complicated when families
    stumble upon misleading or confusing websites, designed not to
    educate people about the best forms of treatment available. So
    we need to hear from the panel about what they regard as
    quality care, and what a family in crisis should look for in a
    treatment program as they struggle to find help with their
    addiction.
        I support efforts that get more people into quality
    treatment. Marketing and advertising can be important tools in
    educating people about the different treatment options
    available to meet their needs, but if these companies want to
    be in the treatment business, they simply must put the patient
    first. And this Committee must continue to work to ensure that
    any American suffering from this terrible disorder gets the
    treatment they need.
        Thank you, I yield back.

        Mr. Harper. The gentleman yields back.
        I ask unanimous consent that the members' written opening
    statements be made a part of the record.
        Without objection, so ordered.
        Additionally, I ask unanimous consent that Energy and
    Commerce members not on the subcommittee on Oversight and
    Investigations be permitted to participate in today's hearing.
        Without objection, so ordered.
        I would now like to introduce our witnesses for today's
    hearing.
        Today, we have Dr.Marvin Ventrell, who is the Executive
    Director of the National Association of Addiction Treatment
    Providers. Next, is Mr. Mark Mishek, President and CEO of the
    Hazelden Betty Ford Foundation. Third, is Mr. Michael
    Cartwright, who is the Chairman and CEO of American Addiction
    Centers. Mr. Robert Niznik, who is the CEO of Addiction
    Recovery Now and Niznik Behavorial Health. Then we have Mr.
    Jason Brian, Founder of Redwood Recovery Solutions and
    TreatmentCalls.com. And finally, Dr.Kenneth Stoller, who serves
    as the Director of John Hopkins Hospital Broadway Center For
    Addiction.
        We welcome each of you here.
        You are all aware that the Committee is holding an
    investigative hearing. And when doing so, we have had the
    practice of taking testimony under oath.
        Do any of you have any objection to testifying under oath?
        Every witness has replied no.
        The chairman then advises you that under the rules of the
    House and the rules of the committee, you are entitled to be
    accompanied by counsel.
        Do you desire to be accompanied by counsel during your
    testimony today?
        Let the record reflect that all the witnesses have replied
    no.
        In that case, if you would please rise and raise your right
    hand, I will swear you in.
        [Witnesses Sworn.]
        You may be seated.
        All the witnesses responded affirmatively. And you are now
    under oath and subject to the penalties set forth in Title 18
    Section 1001 of United States Code. And you may now give a 5-
    minute summary of your written statement.
        There should be a light system that will tell you when that
    time is come, so you'll have 5 minutes. It should go yellow at
    1 minute, at red when your time is up.
        And I will now start with Mr. Ventrell. You may begin. Make
    sure your mic is up close and you turn your button on when you
    testify.

      TESTIMONY OF MARVIN VENTRELL, EXECUTIVE DIRECTOR, NATIONAL
      ASSOCIATION OF ADDICTION TREATMENT PROVIDERS; MARK MISHEK,
      PRESIDENT AND CEO, HAZELDEN BETTY FORD FOUNDATION; MICHAEL
       CARTWRIGHT, CHAIRMAN AND CEO, AMERICAN ADDICTION CENTERS;
         ROBERT NIZNIK, CEO, ADDICTION RECOVERY NOW AND NIZNIK
       BEHAVIORAL HEALTH; JASON BRIAN, FOUNDER, REDWOOD RECOVERY
      SOLUTIONS AND TREATMENTCALLS.COM; AND DR. KENNETH STOLLER,
     DIRECTOR, JOHNS HOPKINS HOSPITAL BROADWAY CENTER FOR ADDICTION

                      TESTIMONY OF MARVIN VENTRELL

        Mr. Ventrell. Thank you, Chairman Harper. Thank you,
    Ranking Member DeGette. I also recognize the comments of
    Ranking Member Pallone and the comments made by the committee
    at large chair, Mr. Walden.
        Thank you for the opportunity to be here today to present
    this testimony. I represent the National Association of
    Addiction Treatment Providers. I am the Executive Director of
    the National Association, also known from time to time as
    NAATP. Our folks will say NAATP. That all refers to us.
        It is an honor to be here. I'm excited to give this
    testimony because our association is fully supportive of the
    work of this subcommittee. This has in fact been the focus of
    the National Association for the past several years.
        We are horrified by the behaviors that have occurred in
    this field. They are not us. It is not unusual for a trade
    association such as ours to perhaps object or resist certain
    regulation. We do not do so in this instance. In fact, we have
    been at the forefront of asking for this sort of regulation for
    some time. That is why, among other things, we developed our
    new code of ethics and are in the process of writing a resource
    guidebook for the ethical and proper operation of addiction
    treatment centers.
        So thank you again for this opportunity. We wholeheartedly
    support what you are doing. We want to be part of that. We want
    to provide as much information as we possibly can for you. And
    I look forward to giving this testimony today and answering
    your questions.
        Ranking Member DeGette specifically asked in her opening
    comments for recommendations for choosing treatment centers and
    for red flags in understanding what is not an appropriate
    center. We have worked diligently on these very things. Much of
    that resource is attached to my written testimony as a
    supplement, and it should be ultimately in the record. And I
    look forward, again, to articulating any of those principles.
        Our association is grateful for this opportunity. On behalf
    of our members and the thousands of patients that they serve,
    and we support this committee's efforts to clean up the
    practices that are harming us all.
        This matter, ethical operation, professional operation, and
    legal operation of addiction treatment is at the forefront of
    our work. What has happened in our industry is among the
    greatest threats to the success of our work as an addiction
    treatment field that we have ever seen.
        Historically, the practice of addiction treatment has been
    marginalized. It has been stigmatized. And we have functioned
    on the outskirts of healthcare. We are poised to make a change
    in this regard now. We are poised with all of the developments
    that have occurred in terms of science, social science, and
    opportunity for funding and treatment. We are poised to do the
    best work we have ever been able to do. That is what we wish to
    do, and we are being delayed, and we are being impeded from
    that by bad actors.
        These bad actors that are the source of comments that the
    committee made are a minority. They are a small minority, but
    they are an effective and very damaging minority. They are not
    our members. I wish to say that they are not we.
        The National Association of Addiction Treatment Providers
    is comprised of approximately 850 treatment campuses around the
    country. These are good centers doing good work. The source of
    the problem is not the national association. It is not common,
    as I indicated, for a trade association to resist regulation.
    Once again, we do not, in fact, we are promulgating much of
    that within our practices now.
        The primary issues have been accurately identified. I
    applaud the subcommittee's staff memorandum. It is accurate,
    and I adopt all of it. The problems we are facing are primarily
    these.
        Patient brokering, billing and insurance abuses, credential
    misrepresentation, predatory web practices and foremost, in
    predatory web practices is the matter of deceptive, unbranded
    or inadequately branded websites.
        While a trade association is not typically in the business
    of policing, we have undertaken that role as it concerns our
    members, and we have adopted an initiative called of the
    quality assurance initiative, which has 11 components.
        I would like to explain all of them to you. Of course, I
    don't have time do that, but hopefully, you will ask me
    questions about those.
        In each of these 11 initiatives, many of which are focused
    specifically on deceptive advertising matters are addressed in
    the quality assurance initiative which will be fully
    articulated in the guidebook that will be published later this
    year.
        I see that my time is up, and I thank you for the
    opportunity.
        [The prepared statement of Mr. Ventrell follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Mr. Harper. Thank you, Mr. Ventrell.
        The chair will now recognize Mr. Mishek for 5 minutes for
    the purposes of his opening statement.

                        TESTIMONY OF MARK MISHEK

        Mr. Mishek. Thank you, Chairman Harper, Ranking Member
    DeGette, and members of the subcommittee for inviting me. It is
    an honor.
        I am grateful for your leadership in addressing the opioid
    crisis and addiction, and for the opportunity to testify today
    about business practices and quality standards in the addiction
    treatment industry.
        My name is Mark Mishek, and I am the President and CEO of
    the Hazelden Betty Ford Foundation, a non-profit addiction
    treatment provider with 17 sites in 9 States. We treat over
    21,000 people annually and are also engaged in prevention,
    education, publishing, research and advocacy related to the
    disease of addiction.
        On behalf of the millions of vulnerable people and families
    suffering from substance use disorders, thank you again, for
    your bipartisan look into patient brokering and related issues.
        Growing market demand for addiction treatment, driven by
    the opioid crisis and expanded insurance coverage has attracted
    unprecedented investment and an influx of new providers all
    operating in a field that is under-regulated and lacks
    consistent quality standards. It is in this environment that
    our industry has seen the rise of unprofessional, unethical,
    and sometimes illegal practices such as deceptive marketing and
    patient brokering--not to mention excessive consumer billing
    and insurance fraud. In too many cases, people who need help
    are instead being harmed.
        Most in our field do great work. But to ensure ethical,
    quality care for all who seek help for addiction, we believe it
    is time to establish quality standards and a consistent,
    enforceable regulatory framework for the addiction treatment
    industry. The stakes--patient safety and public confidence in
    addiction treatment--are high.
        Now, patient referrals, of course, are not bad, per se. The
    problem is when referrals are made with little or no regard to
    what is clinically appropriate for the patient when there is a
    lack of transparency in the process and especially when
    financial kickbacks are involved. That's when referrals become
    patient brokering. Many brokering schemes begin with deceptive
    marketing.
        Now, at Hazelden Betty Ford, all of our treatment marketing
    leads to one website, one consumer website,
    HazeldenBettyFord.org. That is not the case for others who use
    multiple sites and multiple brands to acquire patients.
        Often, it is not clear who is behind ads for addiction
    treatment or who consumers will get when they reach out for
    help. Some providers obscure their affiliations to other
    organizations or misrepresent the services they provide, the
    conditions they treat, the credentials of their staff, or the
    insurance that they actually accept. And some use online bait-
    and-switch techniques to get calls from people intending to
    call a different treatment center. Something, unfortunately, we
    see frequently with our name.
        All of this can lead to bad treatment for consumers. The
    lack of transparency on top of minimal quality standards in the
    industry puts patients at risk. These kinds of practices
    certainly would not be tolerated in any other area of
    healthcare. And in light of them and because of the life saving
    work that we do, it is more imperative than ever for the
    addiction treatment field to hold itself to the highest
    ethical, legal, and quality standards.
        Ultimately, we think reforms are needed to bolster State
    licensure requirements, accreditation standards, clinician
    education qualifications and access to comprehensive evidence-
    based care.
        Beyond State initiatives, Federal oversight through the
    Federal Trade Commission, for example, is essential. Fraudulent
    advertising and patient brokering obviously cross State lines.
    Finally, we think a Federal law explicitly outlawing patient
    brokering is critical.
        Without such accountability, our field will continue to
    evolve into a sector where success is predicated not on whether
    patients get well or families heal, but on the size of your
    advertising budget, your website analytics, your search engine
    optimization, and your call center tactics.
        Now is the time to restore faith and accountability in the
    addiction treatment field, and it's time to establish quality
    standards in that enforceable regulatory framework.
        Thank you for the opportunity to share my testimony. And I
    look forward to answering your questions.
        [The prepared statement of Mr. Mishek follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Mr. Harper. Thank you, Mr. Mishek. The chair will now
    recognize Mr. Cartwright for 5 minutes for the purposes of his
    opening statement.

                    TESTIMONY OF MICHAEL CARTWRIGHT

        Mr. Cartwright. Thank you, Chairman Harper and Ranking
    Member DeGette. Thank you for having me here.
        My name is Michael Cartwright I'm the Chairman and CEO of
    American Addiction Centers.
        Thank you Chairman Harper and Ranking Member DeGette. Thank
    you for having me here.
        My name is Michael Cartwright I'm the Chairman and CEO of
    American Addiction Centers. We operate in 9 States. We offer 39
    treatment centers.
        I've been a treatment counselor and executive for 23 years.
    For 12 of those years, I operated a not-for-profit
    organization. I've also run both publicly traded, as well as
    privately funded drug and alcohol treatment centers. I have
    actually advised the U.S. Senate Health Subcommittee on
    Substance Abuse and Mental Health Services back in the early
    2000s when we were looking at co-occurring disorders in this
    country and how we could better implement that.
        I also serve on the board of directors of the National
    Association for Behavorial Healthcare, which for 85 years has
    advocated nationally for mental healthcare and substance abuse.
    Its members include American Addiction Centers and other
    publicly traded healthcare companies like HCA and Acadia UHS,
    among others.
        I've been in recovery for 26 years. As a young man, I
    struggled with addiction. I know the pain of untreated
    addiction. AACs mission is to help with those who are
    struggling like I did, find the right treatment for psychiatric
    and community support. I'm glad that Congress is looking into
    treatment marketing practices. Treatment providers and
    government officials should work together not just to keep bad
    actors out, but to let potential patients and their loved ones
    know who they can trust.
        I'm glad that Congress is continuing to look at marketing
    practices and treatment providers and government officials.
    AAC's recovery brands business operates online treatment
    directories, including Recovery.org and Rehabs.com. These
    directories provide information about treatment centers across
    the country. Centers that are also approved and listed by the
    Federal Government Substance Abuse and Mental Health Services
    Administration on SAMHSA.gov.
        In fact, about 300 treatment providers, who are members of
    the National Association of Addiction Treatment Providers or
    NAATP, Marvin's association, either list or advertise on our
    websites. A lot of treatment centers don't have large online
    presences in their own right. Addicts who need help reach these
    treatment centers through our website.
        We don't engage in unethical market practicing like
    hijacking phone numbers. We are not a call center aggregator.
    We don't take calls for other treatment centers, just for our
    own. We don't sell information gathered on calls, AAC opposes
    this kind of lead generation.
        We make sure that our website visitors know who they are
    contacting. Under our transparency guidelines, we work with
    treatment centers across the country to make sure their
    listings are up-to-date and accurate. We make clear that users
    know which treatment centers are going to answer the numbers
    they call. We make clear that AAC's toll-free numbers go to
    AAC's call center. And when they pick up, AAC's call center
    reps identify themselves as an AAC employee.
        Not all treatment centers market honestly, but they should.
    AAC supports legislation that criminalizes fraudulent
    advertising, outlaws tactics like hijacking of treatment center
    phone numbers, requires disclosures about who owns and operates
    call centers, and bans kickbacks and bribes. AAC has supported
    this kind of legislation in its home State of Tennessee and
    elsewhere.
        I have the following recommendations. Congress should ask
    the National Association of Insurance Commissioners or the
    National Alliance For Model Drug Laws to draft a model law
    banning deceptive marketing. Number two, existing or proposed
    laws in Tennessee, Florida, and California should be considered
    as models for reform. Number three, SAMHSA should update its
    treatment center locator regularly, and should include sober
    homes in its listings. SAMHSA should prioritize sober homes
    that are members of the National Association of Recovery
    Residences. Number four, existing FTC Truth in Advertising
    Guidelines should be used to stop misleading addiction
    treatment marketing.
        While there is rightfully a lot of attention being paid to
    bad marketing practices, I hope we don't lose sight of all the
    great work that treatment centers do. Treatment does work. I've
    been clean and sober now for 26 years. And throughout this
    country we have great treatment centers, just like Hazelden
    Betty Ford.
        We need help. We have tens of thousands, almost 100,000
    people a year dying from this disease.
        We definitely need to look into this as a matter of a
    marketing practice, but we also need to be looking at what are
    some of the solutions to solve this epidemic.
        Thank you very much for having me here today.
        [The prepared statement of Mr. Cartwright follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Mr. Harper. Thank you, Mr. Cartwright.
        The chair will now recognize Mr. Niznik for 5 minutes for
    his opening statement.

                       TESTIMONY OF ROBERT NIZNIK

        Mr. Niznik. Chairman Harper, Ranking Member DeGette, and
    members of the subcommittee.
        Thank you for the opportunity to share my perspective as
    you continue your important investigation into various aspects
    of the opioid crisis confronting our country.
        Our focus at Niznik Behavorial Health is in offering
    quality treatment to those seeking help at a time when such
    services are most in demand and when there's a shortage of
    available providers.
        We help kids, mothers, fathers, individuals from a variety
    of walks of life as they seek to take control of their lives,
    overcome their battles with addiction, and return to their
    families. We've helped thousands of individuals through our
    inpatient and outpatient services at facilities we operate in
    Texas, Florida, and in California, several of which fill a need
    in underserved markets. In Texas, for example, our inpatient
    facilities in our rural county is served by only one other
    provider. We will soon be opening an additional facility in New
    Jersey which will also help individuals in an underserved
    market.
        At the outset, I want to emphasize that neither NBH nor ARN
    has ever operated as a patient broker, nor have we made any
    payments to any intermediary or third parties for referrals. We
    have not engaged in any of the activities that would appear to
    be of concern to your and your colleagues as expressed in the
    committee's May 29th letter. NBH is in the business of treating
    patients. All of our NBH programs are licensed, in good
    standing, and are accredited by the Joint Commission.
        Our staff include board-certified psychiatrists, licensed
    masters and doctorate-level clinicians as well as a
    comprehensive nursing team. We offer a variety of specialized
    programs, including an adolescent program.
        I am very proud of what we have accomplished in only 5
    years. We started with one facility in Miami, and upon being
    licensed by the State of Florida, that facility began answering
    calls from individuals seeking its services. As we added other
    facilities, the customer service function relating to all
    facilities was assumed by NBH. We now employ over 500
    individuals and support hundreds of additional jobs. In fact,
    I'm proud to say that we've given jobs to people in recovery.
        Based on our experience, I would be pleased to share with
    you how we market and advertise our services with full
    transparency. Like you, we want to make sure that prospective
    patients and their families are as well-equipped as possible
    when they're seeking treatment for a loved one or for
    themselves.
        Choosing a healthcare provider is an important decision. We
    believe it is essential that prospective patients know who a
    provider is and that it described with full transparency what
    services it offers, where it makes them available so that
    prospective patients can make an informed decision.
        When one of our customer service representatives receives a
    call, the individual answering the call immediately identifies
    himself or herself as an NBH employee. That way, all callers
    know at all times that they are speaking directly with NBH.
        If a caller seeks admission to an NBH facility, trained and
    licensed medical and clinical personnel determine the medical
    necessity and the clinical appropriateness of the services to
    offer that individual.
        The work of an NBH customer service representative is akin
    to a receptionist in a doctor's office. A person who answers a
    call, provides information regarding the service that the
    doctor offers, and then schedules an appointment for the doctor
    if a patient requests help.
        We believe there are several factors that a patient should
    consider when looking to identify a quality provider such as
    whether they are accredited. They also want to know what
    programs, therapies, and specialty that provider offers. They
    will then be in a position to determine whether a provider can
    help them or a loved one.
        We're in the business of helping people and are only able
    to succeed as a company when we provide quality and effective
    care. Our patients consistently report that they are
    overwhelmingly pleased with the quality of care and the
    services they have received.
        We have helped thousands of individuals get control of
    their lives. And as part of our goal of helping people in need,
    we have provided 296 full scholarships. With a full
    scholarship, the patient's entire stay through all levels of
    care and services is free.
        In closing, I want to emphasize that we appreciate this
    opportunity to put in perspective how we operate our business,
    how our license and medical and clinical personnel help people
    in need and how we believe individuals seeking treatment can
    identify a quality provider.
        Thank you again for the opportunity to make this opening
    statement. I will be glad to answer your questions.
        [The prepared statement of Mr. Niznik follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Mr. Harper. Thank you, Mr. Niznik.
        The chair will now recognize Mr. Brian for 5 minutes for
    his opening.

                        TESTIMONY OF JASON BRIAN

        Mr. Brian. Thank you. My name is Jason Brian, and I founded
    Redwood Recovery Solutions, the organization that owns
    TreatmentCalls.com. It is my pleasure to be here today to share
    with this committee my perspective on marketing and treatment.
        My background prior to this industry is in insurance and
    automotive marketing. Although we were successful in those
    areas, my team and I shared the vision of wanting to make a
    difference. And so Redwood started by quoting projects where
    this was a strong purpose motivator not just a profit
    motivator.
        Redwood's model was at its core simply an advertising and
    marketing firm that worked closely with many different types of
    media companies that operated in TV, radio, search engine
    advertising, and other marketing channels to generate inbound
    phone calls from persons seeking substance abuse help and then
    get them connected with a licensed treatment center. Redwood
    did not own these sources or the agencies that ultimately built
    or controlled the distribution of the media companies'
    advertisements. Due to this, Redwood developed a strict set of
    marketing standards and requirements for these agencies to
    follow in order to work with us as an affiliate. These rules
    forbid the use of any sort of incentive to the caller for
    making the call. The use of any treatment centers intellectual
    property, any attempt at intentionally deceiving the caller, or
    any provision of any clinical guidance, just to name a few.
        These affiliates were compensated a flat pre-negotiated
    rate per call to Redwood. And at no time was their fee
    structure contingent on the outcome of any call or the
    placement of any patient. After receiving a call from an
    affiliate, Redwood would then route this inbound phone call
    directly to a licensed treatment provider within its network.
    Redwood did not answer any of these inbound phone calls, but
    rather, the licensed treatment providers were responsible to
    answer the calls. It was in the sole discretion and
    professional judgment of the licensed treatment program
    answering the inbound call along with the caller themselves, to
    make any decision about the appropriateness or lack thereof, of
    a program best suited for the caller or their loved one. If a
    referral was needed to another facility or level of care, it
    would have been done solely by the licensed treatment provider
    as Redwood made no referrals whatsoever.
        I need to add clarity surrounding my past tense use of
    Redwood, and share my brief opinion on the unfortunate reality
    of painting with broad strokes. In January of this year,
    collectively with my team, Redwood decided it was time to move
    on from this industry. Far too often this industry and those
    watching it from the sidelines, want to typecast marketing
    companies as bad and unethical because of the abuse of a few
    immoral, disgusting individuals. I would liken this to saying
    that all treatment centers are bad simply because a few have
    given the industry a black eye. That would be wrong and
    misleading and unfortunate to those that they could have
    ultimately served. Inevitably, when I discussed this topic
    within the industry, people want to use a crisis moment and
    vulnerability as a supporting argument for why companies like
    mine are bad or unethical.
        This past week, a good friend of mine lost her husband to
    an overdose. He went to the best treatment money could buy, she
    said. We all prayed this day would not happen, but his family
    and I knew that this day might come. And indeed, our worst
    nightmare came true.
        The reality is that people seeking treatment do so for some
    time. They search for months and even years in some instances
    for a solution. This disease often gets worse over years or
    even decades. I am in no way downplaying the seriousness of, or
    the importance of, making the phone call, but to suggest that
    the calls received are random impromptu decisions caught in a
    moment of vulnerability is simply inaccurate.
        The second point that always comes up pertains to the
    appropriateness of a facility that the call is routed to. If
    you find yourself asking how do you know if a generic help line
    call was a good fit for a specific center, consider this. If
    you search for treatment online and called any treatment center
    that came up directly, would you finding them online qualify
    that center to be the best fit for you or your loved one? If
    you used a phone book and called one listed there, would that
    be a perfect fit? If a center placed an advertisement on
    television directly, might that do the trick in finding the
    right one?
        Of course, none of these things independently change
    anything about the quality of care or experience one might
    receive at any given center. Don't lose sight that these
    treatment providers are licensed to do the work that they are
    doing. And outside of gross negligence, these centers who share
    the same licensure, even internally, still disagree largely on
    what type of treatment is best for the same client. And
    ultimately, that subjectivity is largely part of the
    disparagement on where a call would be best suited. We've never
    entered that conversation and have always taken the stance that
    their licensure was good enough for us to work with them.
        Placing a scarlet letter on marketing companies like so
    many have doesn't change how treatment centers will handle the
    phone call. And in fact, at least in our case, actually chases
    away good people and good corporations that want to do good
    work helping people.
        Over 519,000 individuals place calls that were routed
    through my company to facilities licensed to provide them with
    help. Regardless of anything anyone may claim, lives have been
    changed and saved because Redwood cared enough to do something
    that made a difference. And I'm proud of that.
        I would strongly urge anyone in this industry and those who
    are tasked with creating legislation in it, to reconsider how
    they look at marketing companies.
        Quickly summarized, without them less money will be spent
    connecting people with the help that they desperately need, and
    even if all the marketing companies were gone, there wouldn't
    be any fewer people in need of help and the bad centers would
    still exist.
        I'm happy to be part of this conversation and continue any
    dialogue that helps accomplish the initial goal Redwood set out
    on of helping people.
        [The prepared statement of Mr. Brian follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Mr. Harper. Thank you, Mr. Brian. The chair will now
    recognize Dr.Stoller for his testimony.

                    TESTIMONY OF DR. KENNETH STOLLER

        Dr. Stoller. Chairman Harper, Ranking Member DeGette, and
    members of the subcommittee, thank you for giving me the
    opportunity to speak with you today.
        With 64,000 overdose fatalities in 2016, we are fortunate
    to have at our disposal effective evidence-based approaches to
    treating substance use disorders.
        In my experience, the impact of treatment is optimized when
    three sequential actions are taken. Number one, using
    opportunistic times and settings to engage potential patients.
    Number two, completing a comprehensive initial assessment to
    determine the best setting and type of treatment for each
    individual. And number three, offering treatments that are
    evidence-based, high quality, and dynamically adjusted.
        Regarding action number one, I focus on referrals from
    locations where people are most in need of treatment. Accepting
    patients who have already been engaged in the healthcare system
    prevents lost opportunities for lifesaving treatment. Hospital
    emergency rooms and inpatient units have patients who survived
    overdoses, are being treated for medical problems, resulting
    from injection drug use, or are contemplating suicide. Other
    referrals come from medical offices, other treatment programs,
    and, of course, community walk-ins. By focusing on these
    sources of referral, we serve patients who are most in need and
    who otherwise would incur tremendous costs to the healthcare
    system as high utilizers of costly services.
        Regarding action number two, a comprehensive assessment is
    done by my clinical staff as each patient is unique in terms of
    their disorder, as well as their personal strength,
    liabilities, and resources. Past treatment experiences can also
    inform what to try next. For example, for those who have
    repeatedly failed limited time episodes without medications, I
    may recommend a medication trial in a setting of long-term
    outpatient counseling and those who have severe mental health
    and social problems might best succeed in a comprehensive
    program with resources to effectively address all of those
    problems.
        Regarding action number three, the actual treatment, I
    consider there to be five critical approaches that providers of
    high quality treatment aspire to offer. Number one, they use
    medications as clinically appropriate, including the three FDA
    approved medications for opioid use disorder and three for
    alcohol use disorder. They should be started, stopped, and
    switched over time according to ongoing response. Number two,
    they combine it with psychosocial treatments, including
    counseling delivered by skilled professionals. Number three,
    they use behavorial therapies that motivate positive change and
    increase treatment adherence. Number four, they use adaptive
    step care models. This means they use ongoing measurement of
    outcomes to continually adjust the intensity and types of
    treatment and to motivate engagement. And number five, they
    incorporate wraparound services provided within the program or
    through linkages with outside agencies to support a holistic
    approach to recovery. This can include, medical, mental health,
    housing, vocational, 12-step, and certified peer support
    services.
        Solid linkages to aftercare must be facilitated at the time
    of discharge to ensure continuation of the recovery process.
        As an illustration of some of these points, Mr. A was a 55-
    year old man referred after a hospital detox admission to us
    for alcohol and heroin use. He had HIV, hepatitis, and a
    multitude of other medical problems. We began him on
    buprenorphine and later switched him to methadone. We provided
    him with counseling and housing when needed, and coordinated
    with his local medical providers.
        One day I received an inquiry from his managed care
    organization after they determined that over the prior 17
    months, he had 81 ER visits incurring tremendous cost.
        On further examination, I discovered that only 4 of the 81
    visits were during his time with us. The reduction in cost for
    ER visits was ten-fold from a monthly average of over $3,000 to
    $325 when he was with us, illustrating that fiscal gains can
    result from comprehensive addiction treatment.
        In conclusion, we are fortunate to have the ability to meet
    these challenges head on with effective treatments for the
    opioid epidemic. Comprehensive opioid treatment programs are
    well-positioned to be hubs of expertise and coordination and
    can be scaled up nationally to narrow the gap between
    treatment, need, and availability.
        I applaud your recent work in Congress to both increase
    access and quality of substance use disorder treatment.
        Thank you.
        [The prepared statement of Dr. Stoller follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Mr. Harper. Thank you, Dr.Stoller.
        It is now time for the members to each ask questions of you
    as witnesses. And I'll begin by recognizing myself for 5
    minutes.
        As part of its investigation, the committee has learned
    about a variety of advertising and marketing business models
    within the treatment industry, including the use of websites
    and phone numbers. There is a wide variation within the
    industry. For example, Hazelden Betty Ford Foundation has three
    websites that advertise its hotline.
        Niznik Behavorial Health has ten websites. American
    Addiction Centers has 13 facility-specific websites, and in
    addition, has a subsidiary Recovery brands who operates a
    portfolio of websites.
        And Jason Brian of Redwood Recovery, TreatmentCalls.com has
    84 domains, most of which appear to be related to substance use
    disorder treatment.
        So my question is, and I'll start with you, Mr. Mishek, but
    also Mr. Cartwright, Niznik, and Brian, do each of your
    websites contain information that discloses which company or
    which facilities the websites are affiliated with?
        Mr. Mishek. Our main website, HazeldenBettyFord.org, most
    of our web hits come to that website. The other two that you
    referenced are prior to our merger with the Betty Ford Center.
        The Hazelden.org is about our publishing, and the other
    website relates to philanthropy. So for consumers seeking
    treatment, they go to one website, HazeldenBettyFord.org.
        Mr. Harper. And have those disclosures always been on your
    website?
        Mr. Mishek. Absolutely.
        Mr. Harper. OK. Mr. Cartwright.
        Mr. Cartwright. Thank you, Mr. Chairman.
        Yes, we have a variety of websites that specifically to
    American Addiction Centers or our drug and alcohol treatment
    centers in the different States, Desert Hope, Green House and
    Texas, we have a treatment center. And then we have Recovery
    Brands, which is the portfolio that you are concerned about.
        Mr. Harper. OK. My question is, to be sure that I'm clear
    here, do those disclose which company or which facilities those
    websites are affiliated with at that point?
        Mr. Cartwright. Yes, sir, they do.
        Mr. Harper. OK. And have those disclosures always been on
    those websites? And if not, when were they added?
        Mr. Cartwright. They were not. We had bought Recovery
    Brands. It was a company that was out of the State of
    California. And when we bought that company, one of the things
    that we do as a publicly traded company, we have a group of
    lawyers that vetted those sites, went through them, looked at
    those websites, looked at where we should be, make sure we're
    in compliance. And we've done that over about a 2-year period.
        Mr. Harper. Were they----
        Mr. Cartwright. Go ahead.
        Mr. Harper. Were they operational while they were being
    reviewed and looked at by your team?
        Mr. Cartwright. They were. They were owned by another
    company. We had a group of attorneys that reviewed them, looked
    over the websites, and we found that they were the most
    ethical, straightforward websites that we saw as related to
    third-party websites that we could find out there.
        We asked them to do some changes, which they did, and
    before we bought that organization. When we bought that
    organization and since we've operated, it has absolutely been
    100 transparent websites.
        Mr. Harper. Mr. Niznik.
        Mr. Niznik. Of the websites you mentioned, the majority of
    them are facility websites. And when you go on the website you
    know that it is the facility you're calling, or the NBH
    websites, so you know who you're reaching. And then of the
    other two websites we operate that are now branded as our
    programs, they do disclose who owns them, who answers the
    calls, and then when someone does call, the employee answering
    the call identifies themselves as an employee of the company.
        Mr. Harper. Have those disclosures always been on those
    websites?
        Mr. Niznik. They have.
        Mr. Harper. From the beginning?
        Mr. Niznik. They have.
        Mr. Harper. OK. Then Mr. Brian?
        Mr. Brian. Thank you. You referenced that we own 84
    websites.
        The question that was directed to me prior to this in the
    phone call that I had was to provide a list of any domains that
    I owned. Those 84 domains, I own. The company owns.
        None of which are geared towards addiction treatment
    outside of TreatmentCalls.com and Redwood Recovery Solutions.
        Mr. Harper. OK.
        Mr. Brian. And so those two sites are business-to-business
    sites. So we don't have any sites. We've never owned sites that
    induced a call from a treatment-seeking individual to a
    treatment center. That wouldn't be our model.
        Mr. Harper. OK. So those other 82 domains?
        Mr. Brian. Yes, sir.
        Mr. Harper. Are not related to addiction or recovery?
        Mr. Brian. They were domains that were purchased. They
    probably, most of which don't even have any content on them.
    They were just websites that were listed that we purchased from
    an online domain buying service.
        Mr. Harper. Are they operational today?
        Mr. Brian. No, sir.
        Mr. Harper. Not operational?
        Mr. Brian. I would imagine that less than a dozen of those
    are operational, which are business-to-business like
    TreatmentCalls.com is.
        Mr. Harper. All right. And those dozen or so, they are set
    up to, if you contact them, where does it go?
        Mr. Brian. It would ring directly into TreatmentCalls, to
    Redwood Recovery Solution, to our organization. There's no
    business-to-consumer or consumer-facing sites designed to have
    somebody call in for addiction help.
        Mr. Harper. Does that domain, does it show on its face that
    it's affiliated with Redwood?
        Mr. Brian. Yes, sir.
        Mr. Harper. All of those?
        Mr. Brian. To other businesses, to treatment centers
    seeking our service? Yes, it would say that.
        Mr. Harper. All right. And my time is expired. So I will
    now recognize the ranking member of the subcommittee, Ms.
    DeGette for 5 minutes.
        Ms. DeGette. Thank you very much, Mr. Chairman. Mr.
    Chairman, I have here in my hand a list of Mr. Brian's websites
    that you were referring to. I would ask unanimous consent to
    put it in the record.
        Mr. Harper. Without objection.
        [The information appears at the conclusion of the hearing.]
        Ms. DeGette. So Mr. Brian, I'm looking at all this list of
    websites. I'm trying to figure out exactly how your business
    worked.
        Mr. Brian. Yes, ma'am.
        Ms. DeGette. So what would happen is somebody--here's one,
    TreatmentCalls.com. Somebody might go on to that website and
    see a phone number and call, and that would go into your call
    center. And then you would, your business would refer that off
    to a certified treatment center, is that correct?
        Mr. Brian. No, ma'am. And I can----
        Ms. DeGette. OK. Tell me what happened, please, briefly.
        Mr. Brian. Yes, ma'am. So TreatmentCalls.com is a site that
    offers treatment call services to treatment centers. It's not a
    site designed for consumers who might be looking for help.
        Ms. DeGette. I see. So the way your business works though--
    --
        Mr. Brian. Yes, ma'am.
        Ms. DeGette [continuing]. Is treatment centers would pay
    you to refer calls to them. So there would be advertising,
    people would call in----
        Mr. Brian. Yes, ma'am.
        Ms. DeGette [continuing]. To your phone numbers, and then
    they would be referred out, right?
        So there was no judgment on the part of your business about
    which centers would be appropriate to send the calls to. The
    calls would be referred to the centers based on who, which
    centers paid you money to refer the calls to them, right?
        Mr. Brian. If I can just correct one portion of it.
        Ms. DeGette. Please.
        Mr. Brian. We did not own the phone numbers or the
    websites. We worked with third-party affiliates that we----
        Ms. DeGette. OK.
        Mr. Brian [continuing]. Made a per call fee.
        Ms. DeGette. Right.
        Mr. Brian. We paid them.
        Ms. DeGette. Right.
        Mr. Brian. And the treatment centers ultimately paid us a
    per call fee for sending them calls.
        Ms. DeGette. So people called the phone number.
        Mr. Brian. Yes, ma'am.
        Ms. DeGette. And then that went somewhere else.
        Now, Dr.Stoller, has your organization ever used a system
    like this to get patients for your facility?
        Dr. Stoller. Well, fortunately or unfortunately, the
    prevalence of substance use disorders----
        Ms. DeGette. Yes or no will work.
        Dr. Stoller. No.
        Ms. DeGette. Have you ever used a substance like this, and
    why not?
        Dr. Stoller. No, we haven't.
        Ms. DeGette. Why not.
        Dr. Stoller. We don't need to do that sort of outreach for
    patients.
        Ms. DeGette. Do you think that's an effective way for
    patients to get matched with an appropriate treatment facility?
        Dr. Stoller. We prefer to link with other providers who
    have already engaged with patients.
        Ms. DeGette. So, in other words, you think the best
    practice, as you testified in your testimony, is when a doctor
    or somebody else sees a patient or an emergency room refers
    them to you. Is that right?
        Dr. Stoller. I do.
        Ms. DeGette. Now, Dr. Mishek, let me ask you that same
    question. Does your organization use call centers like this
    where people come in and are referred to you?
        Mr. Mishek. Absolutely not.
        Ms. DeGette. And why not?
        Mr. Mishek. Well, we don't need to. Number one, we're
    overwhelmed with calls directly into our call center. And
    number two, we need to take the people who come to us and
    assess them. We don't need a third party to be funneling
    someone to us who may have an eating disorder and shouldn't be
    coming to us in the first place.
        Ms. DeGette. Well, this is an interesting question to me
    because the two of you gentlemen are here representing two of
    the premier centers in this country, but there are thousands of
    people who need addiction services who might be going to other
    centers. So do you think there's some kind of inherent problem
    with using these call aggregators like we heard about from Mr.
    Brian?
        Mr. Mishek. I certainly do. Only 1 out of 10 people who
    need help get help, so there are plenty of patients out there
    who need help. It's not like there's a scarcity of patients and
    we're all fighting over the next patient.
        Ms. DeGette. Right.
        Mr. Mishek. It's not that way at all.
        Ms. DeGette. Right.
        Mr. Mishek. So, treatment centers that are accredited, have
    good, licensed staff, and are doing great work generally don't
    have any trouble acquiring and attracting patients, both
    through professional referrals, through word of mouth, and
    through community reputation.
        Ms. DeGette. Mr. Ventrell, you look like you want to add.
        Mr. Ventrell. Well, I was nodding along, Congresswoman. The
    issue becomes whether a clinical assessment is being made or--
    --
        Ms. DeGette. Right.
        Mr. Ventrell [continuing]. A sales assessment is being
    made----
        Ms. DeGette. Right.
        Mr. Ventrell [continuing]. And that's essentially the
    distinction that's drawn here today by Dr. Stoller and Mr.
    Mishek. People are looking for healthcare.
        Ms. DeGette. Right.
        Mr. Ventrell. The word ``rehab'' itself has caused us to go
    down the wrong path, but people are looking at healthcare and
    you look for healthcare at the hospital. You look for
    healthcare at the facility that provides that healthcare. To
    have a website that does not identify primarily as its owner,
    the clinical provider is fundamentally deceptive, in our view.
        Let me just also say quickly that the little ``I'' isn't
    good enough. The little ``I'' isn't good enough. So one of the
    questions that the chairman asked is, does your site identify
    or disclose your identity?
        Ms. DeGette. Yes.
        Mr. Ventrell. That's a very thoughtful question, but I
    don't think it should even have--that question shouldn't even
    have to be asked.
        Ms. DeGette. Right. They should know who they're calling.
        Mr. Ventrell. It should simply be the site of the
    individual.
        Ms. DeGette. Right.
        Mr. Ventrell. I don't go to the little ``I,'' and consumers
    in crisis certainly don't know how to do that. And the fact
    that it ultimately identifies it is, frankly, wholly
    inadequate.
        Ms. DeGette. Thank you very much. Thank you, gentlemen.
        Mr. Harper. Ranking Member DeGette yields back.
        The chair will now recognize the chairman of the full
    committee, Chairman Walden, for 5 minutes.
        Mr. Walden. Thank you very much, Mr. Chairman.
        Again, thanks to everybody on the panel as we try and dig
    into this issue and figure out how things are working, how
    they're not working, and where there needs to be improvement.
        So I guess one of the questions I'd have off the top is,
    the business model for one of today's witnesses, Mr. Brian of
    Redwood Recovery, appears to be entirely based on the sale of
    prospective patient calls to treatment facilities. And my
    question is, have your companies, your facilities, or your
    subsidiaries ever paid or sold for leads? And I would address
    that to Mr. Niznik, Mr. Cartwright, and Mr. Mishek.
        Mr. Niznik. So we advertise in a lot of mediums online, on
    television, on the radio. So the only sorts of advertising we
    do is that sort, the traditional advertising where someone sees
    an ad or comes across our website and calls us.
        Mr. Walden. OK. So the question is, have your facilities or
    your subsidiaries ever paid for or sold leads?
        Mr. Niznik. No, we haven't.
        Mr. Walden. OK. Next, Mr. Cartwright.
        Mr. Cartwright. With Recovery Brands' websites, it's a
    business model very similar to YP.com, yellowpages.com, or
    WebMD. We have advertisers on those websites. Three hundred
    advertisers are NAATP members. Actually, Betty Ford Center used
    to be a pretty large advertiser of ours as well. So we have
    advertisers on our websites, recoverybrands.com.
        So thank you very much.
        Mr. Walden. All right.
        Mr. Mishek. No, we never have.
        Mr. Walden. Never paid or sold leads?
        Mr. Mishek. No, we never have.
        Mr. Walden. OK. Mr. Ventrell, the National Association of
    Addiction Treatment Providers recently updated its code of
    ethics, with particular focus in the advertising and marketing
    space, to fight back against practices of patient brokering,
    including this kind of lead generation. Can you explain and
    perhaps write a few examples for what practices the Association
    was seeing in the substance use disorder treatment industry
    that led it to revise its code of ethics? What did you see?
        Mr. Ventrell. Yes, Mr. Chairman. Thank you. National
    Association had a code of ethics for some time. In spirit, it
    prohibited all the kinds of practices that have been discussed
    here today. However, it wasn't thought necessary, prior to last
    year, that we specifically articulate exactly what right and
    wrong is. Our good providers didn't need to be told right and
    wrong. They were just doing right. But we came to understand
    that that's not true across the board, and we approved our new
    ethics code 2.0 on December 31, 2017, and it became effective
    on January 1. It specifically defines and prohibits the kinds
    of conduct we're talking about today.
        The first and foremost of these would be patient brokering.
    Under no circumstances may an NAATP member or under any
    circumstances should any treatment provider, in our view, buy
    leads or sell leads. And so if there's a connection with doing
    that, it is prohibited by our code and you may not be an NAATP
    member.
        A second area that came up frequently was licensing and
    accreditation misrepresentation. It is difficult enough for the
    consumer to understand what they need. When the provider
    misrepresents or does not adequately display precisely what
    they are licensed or accredited for, the consumer can't know
    what they are getting, and that lack of regulation is extremely
    dangerous.
        The third and most prevalent reason why we removed certain
    members from our rolls, Mr. Chairman, is what we call unbranded
    or inadequately branded sites. You received information from
    your staff that indicates, among other things, that we have
    sacrificed approximately $100,000 in dues revenue and removed
    24 parent companies from our membership rolls primarily for
    this reason.
        There are multiple reasons, but the primary reason why
    members were not renewed, or as incoming applications occur and
    are denied, is because we find that there is inadequate
    branding on the site for the same reason that I just discussed
    with Ranking Member DeGette: The ability to somehow investigate
    and determine ultimately that the site is connected to a
    provider is simply not adequate. It should be branded as, for
    example, the Hazelden Betty Ford site is.
        So for the most part, where we have removed members or not
    invited members or declined an application it has been because
    of the deceptive websites.
        Mr. Walden. All right.
        Mr. Ventrell. It's just a question of transparency, Mr.
    Chairman.
        Mr. Walden. Thank you. Thank you.
        I want to go back, because I maybe didn't hear this right,
    to Mr. Cartwright. I was looking at my notes here. Just yes or
    no, have your companies, your facilities, or your subsidiaries
    ever paid for or sold leads?
        Mr. Cartwright. No, we don't pay for or sell leads.
    Recovery Brands has an advertising model very similar to WebMD
    or yellowpages.com, and I'm assuming that Hazelden Betty Ford
    and NAATP must like that model, because about 300 of the NAATP
    members are advertisers of ours. About half of our advertising
    revenue comes from NAATP members, so we hold ourselves up as a
    solid organization of the way you can do and should do
    advertising on the internet.
        Mr. Walden. I'm just sensing, Mr. Chairman, with your
    indulgence, maybe a disagreement on the other end of the panel.
    Is that accurate? Mr. Cartwright----
        Mr. Ventrell. Mr. Chairman, are you recognizing me?
        Mr. Walden. Yes.
        Mr. Ventrell. Thank you. I--Mr. Cartwright's written
    testimony, which I saw for the first time yesterday, indicated
    this 300 number, that there are 300 NAATP members which
    advertise on the site. I am unfamiliar with this. I'm surprised
    to hear this information, but I am entirely open to finding out
    exactly what it is.
        I would ask for the opportunity to determine whether that's
    true by being provided a list of those 300 members, and then
    also ask ourselves what do we mean by advertising, right. There
    is a common practice generally among the problems on the
    website to bring in good providers, put them on the site.
        I'm not saying this is the case here. I don't know that.
    But there is a common practice to grab a Hazelden Betty Ford or
    a Caron or a Harmony Foundation and put their information on
    the site as if it were part of when, in fact, there is not a
    motive to produce that----
        Mr. Walden. Right, OK. Mr. Cartwright, are you OK sharing
    that information with them so we can get to the bottom of this?
        Mr. Cartwright. I would be happy to share it. And the
    easiest way to look at it is, we generate about $8 million a
    year of our $400 million annual budget through advertising. And
    about one-half of that $4 million a year is coming from NAATP
    members.
        Mr. Walden. Thank you for your indulgence, Mr. Chairman.
        Mr. Harper. Chairman Walden yields back.
        So if you'll make sure, Mr. Cartwright, you get us that
    list, that would be very helpful.
        The chair will now recognize the gentlewoman from Florida,
    Ms. Castor, for 5 minutes.
        Ms. Castor. Thank you, Mr. Chairman and Ms. DeGette, for
    calling this hearing.
        There are all sorts of press reports out there about
    unscrupulous actors that engage in deceptive marketing
    practices and who take advantage of patients, and I've heard
    directly from many families back home in Florida. And I'd like
    to discuss some of the problems and what we can do to solve it.
        Mr. Ventrell, you've gone into some detail here with--could
    you further expand on what you see as major problems with
    deceptive sales in the addiction treatment industry and how
    they prevent patients from getting the care that they need?
        Mr. Ventrell. Thank you, Congresswoman. If one begins by
    assuming that we need a transparent clinical assessment, much
    of the problem goes away. The fundamental problem is that most
    of the problematic areas do not promote a clinical assessment
    where the patient or the consumer understands who is performing
    that assessment. It's compounded by the fact that folks don't
    know what clinical assessment that they need.
        The primary areas continue to be licensing and
    accreditation confusion and misrepresentation, unbranded or
    inadequately branded sites. And toward those goals, we have
    been very clear in two ways: One, you must have that clearly
    branded site, and now our association has, as of this month,
    adopted a new requirement that all NAATP members must be
    accredited.
        There needs to be a system whereby quality and safety are
    adequately regulated and business operations are adequately
    regulated. The accrediting, certifying, licensing bodies
    traditionally and appropriately handle quality and safety.
    There has been very little regulatory oversight as it concerns
    business operations, and that is why we are producing the
    guidebook for operations, which I will hopefully commend to the
    committee for study.
        Ms. Castor. First of all, you have a family or an
    individual that is searching for information on how to get
    substance use treatment, you're not shopping for clothing or
    something else.
        And, Dr. Stoller, you highlight this problem too. Is it
    appropriate to go shopping on the internet for how you're going
    to be treated for addiction?
        Dr. Stoller. I would recommend somebody looking for
    treatment on the internet to go to particular sites, such as
    the SAMHSA treatment locater. The National Institute on
    Alcoholism and Alcohol Abuse has recently created a website
    that helps consumers to look at those sorts of things.
        The other thing is that jurisdictional entities, such as
    county health departments, are really good sources for
    information about substance use disorders and also where they--
    that people might be able to go to achieve the best match for
    the person's needs with the treatment program that can provide
    them with those services.
        Ms. Castor. Rather than shop in general on the internet and
    see what comes up in the ranking on that page and then hit the
    first one and----
        Dr. Stoller. That's correct.
        Ms. Castor. So, Mr. Ventrell, you said your organization
    has removed members for failing to adhere to the code of
    ethics. You went into some detail on that, on patient brokering
    and buying and selling leads. Is it possible that conduct by
    one of your former member organizations that violated the code
    of ethics also violated the law?
        Mr. Ventrell. It's possible, Congresswoman, but I don't
    know specifically of an instance of that. Certainly, it is
    possible.
        Ms. Castor. Does that need to be clarified? What do you
    understand the law to say?
        Mr. Ventrell. Relative to what precisely?
        Ms. Castor. To patient brokering.
        Mr. Ventrell. Well, the law of patient brokering has been
    very confusing and, to some extent, nonexistent and State-by-
    State based. It needs to be clarified, and I would support Mr.
    Mishek's recommendation that there be a Federal law in this
    regard.
        So we've all heard of the horrors that occurred in south
    Florida. Certainly, there was similar activity in Arizona and
    also southern California, and it's probably not isolated to
    those States. If patient brokering, body brokering, paying for
    the delivery of a body for care was made, one would have to
    determine what the State regulation was and that would be a
    legal determination.
        I will say, however, that if Federal moneys were being
    involved in the treatment of that individual, Medicare,
    Medicaid, that I believe I would be correct in saying that that
    would have been a legal violation, irrespective of State law.
        Ms. Castor. Thank you very much. I yield back.
        Mr. Harper. The gentlewoman yields back.
        The chair will now recognize the vice chairman of the
    subcommittee, Mr. Griffith, for 5 minutes.
        Mr. Griffith. Thank you very much, Mr. Chairman.
        I'm going to build on some of the prior testimony and
    questions about NAATP's updated code of ethics.
        Mr. Cartwright, as you've indicated to Chairman Walden,
    there are about 300 treatment providers that are members of
    NAATP who advertise on your website. So my question is, if I go
    to your website later today, am I just going to find your
    traditional straight advertising, treatment center A, treatment
    center B, treatment center C, and it just rotates based on
    who's up next like the line of cabs? Is that how your system
    works?
        Mr. Cartwright. No, sir, it doesn't. It operates very
    similar to YP.com, yellowpages.com. If you go into a particular
    area in the State of Colorado and you went into Denver, it
    would only list operators within that State, and then there
    would--I'm sorry.
        Mr. Griffith. No, that's fine. I got it.
        And so the question is, it helps focus where you're going,
    is what you're saying. But my question is, is it just
    advertising? Are you telling us that you don't get paid
    anything for a straight referral or for a head count?
        Mr. Cartwright. That is correct. It's straight advertising.
        Mr. Griffith. And that's never been the case?
        Mr. Cartwright. That's never been the case.
        Mr. Griffith. And so when these ads are up there, your
    folks don't actually talk to the people, and it just focuses
    them in and--the next question is, what sort of vetting, if
    any, does AAC do before letting another treatment provider
    advertise on your website?
        Mr. Cartwright. They would need to be on the samhsa.gov. We
    really take that website very seriously, that we're assuming
    the Substance Abuse and Mental Health Administration in their
    listing is vetting folks. They have to be licensed, joint
    commission accredited or CARF accredited.
        Mr. Griffith. OK. Is AAC itself a member of the NAATP?
        Mr. Cartwright. We're a member of a different organization,
    National Association of Behavioral Healthcare. It's been around
    for about 85 years. A lot of the larger companies join that.
    You've got to remember, most of NAATP is smaller, not-for-
    profit organizations. We feel like that with HCA and Acadia and
    UHS, some of the larger organizations, that's meeting our needs
    more appropriately.
        Mr. Griffith. Prior to the new ethics standards that we've
    talked about today, weren't you all a member of the NAATP?
        Mr. Cartwright. I go back two decades being a member of
    NAATP, back to when I was on their board of directors. So,
    again, back when I was a not-for-profit agency, I thought that
    was a very effective organization. I could go back and look at
    the exact date that we're no longer members, but you're right,
    Marv asked us not to be members based on their new marketing
    practices or ethical guidelines that he has.
        I really don't think he fully understood, though, our
    websites. I think he got confused with some other websites that
    are absolutely websites that are nontransparent. And we're
    supportive of new marketing standards. In the State of
    Tennessee we just passed the toughest law on marketing
    standards, and we would recommend, just like Mr. Mishek did,
    let's take that national. Let's do that on a national basis and
    take a law like Tennessee or take a law like Florida--they've
    been working very, very hard in the State of Florida to get
    this right. We would support that. We actually were extreme
    supporters of that measure that passed in the State of Florida,
    California, and Tennessee. If you want to talk to some of the
    legislators in those States about our activity, I'm happy to
    put you in touch with them.
        Mr. Griffith. Mr. Ventrell, you want to make any comment on
    that?
        Mr. Ventrell. I must be demonstrative in my demeanor that
    suggests to the members of the committee to call on me when I
    haven't raised my hand, but thank you.
        Mr. Griffith. Was there merely a misunderstanding? That's
    what I'm trying to find out. Did you not understand what he's
    doing?
        Mr. Ventrell. Mr. Cartwright just suggested that I might
    not fully have understood what American Addiction Centers was
    doing. What happened was at the expiration of American
    Addiction Centers term, which was December 31 of 2017, we
    reviewed its practices and determined that it wasn't in
    sufficient compliance with our ethical rules. The primary
    reason for that was the website issue, the inadequately branded
    or unbranded website, so we did not invite them back.
        Mr. Griffith. OK.
        Mr. Ventrell. It's as simple as that.
        Mr. Griffith. So the primary issue was that you couldn't
    tell--if you just went there--you couldn't tell whether it was
    one of theirs or somebody else's or what treatment center was
    being referred and who was telling folks to do that. Is that
    accurate?
        Mr. Ventrell. Yes. We believed it was inadequately
    transparent.
        Mr. Griffith. All right. I've got to move on to some other
    questions.
        Mr. Cartwright, I'm going to switch gears on you. AAC
    operates several websites that might appear to consumers--and
    it gets to the same vein--but it might appear to consumers to
    be unaffiliated third-party resources, such as drugabuse.com,
    rehabs.com, projectknow.com.
        Mr. Niznik, your company does the same thing through its
    operation of addictionrecoverynow.net and
    findingtreatmentnow.com. Unless consumers click on the
    information buttons next to the 1-800 numbers advertised on the
    website, isn't it true they may not realize who is behind the
    websites or answering their calls?
        First, Mr. Cartwright, yes or no. And then, Mr. Niznik,
    isn't it true they may not realize who's behind the websites or
    answering their calls?
        Mr. Cartwright. I think it's very clear on our websites
    that they know who they're calling.
        Mr. Griffith. Mr. Niznik?
        Mr. Niznik. I also believe it's pretty transparent on our
    sites who they're calling, and then, more importantly, when
    they do call, they immediately know who they're talking to. So
    even if they've read a blog or content online, as soon as they
    speak to someone, they know who they're dealing with.
        Mr. Griffith. And I see I'm over my time. But Mr. Ventrell
    earlier said pushing on the ``I'' doesn't work. I'm out of
    time. I apologize.
        I yield back.
        Mr. Harper. The chair will now recognize Mr. Tonko for 5
    minutes.
        Mr. Tonko. Thank you, Mr. Chair. Thank you to our
    witnesses.
        When opioid addiction patients are seeking help, what
    matters most is that they get the quality care that they need.
    The problem is many families don't know what to look for in an
    addiction treatment provider. And the promises that some
    facilities make, such as expensive housing and various forms of
    therapy, sound enticing, but families need to know what will
    actually help their loved ones in their treatment.
        So, Dr. Stoller, you run the addiction center at Johns
    Hopkins, which has an excellent reputation for high-quality
    treatment. And I understand you also provide all of the
    medication-assisted treatment options such as buprenorphine and
    methadone with that MAT concept. How do you determine whether a
    patient should receive MAT and which MAT therapy is
    appropriate?
        Dr. Stoller. Thank you. We do a comprehensive evaluation
    upon consideration of admission of any patient. At the end of
    that comprehensive evaluation, we might recommend that the
    person go someplace else. Maybe they need an inpatient
    admission for alcohol detoxification or something else.
        The most important thing is that the patient has particular
    needs that we feel like we can match. The way that we match
    that, let's just look at medication-assisted treatment, is that
    we look at, number one, patient preference. So some people come
    with a particular preference. Number two, we look at their past
    history of treatment, both their successes and their failures.
    Both are important in determining what the person might need
    right now. We also look at other medications that they might be
    on, their particular symptoms of disorder, how long they've
    been using, and the severity of their use.
        Mr. Tonko. Thank you.
        And as we know, millions of Americans are affected by this
    crisis, and not every family can afford the higher-end
    facilities. Dr. Stoller, what treatment options are there for
    people with limited means, and do you have to spend a lot of
    money to get quality care?
        Dr. Stoller. So I'll go back to my written and oral
    presentation. I think that there are particular requirements of
    a treatment program in terms of delivering care that is
    comprehensive. The use of medication-assisted treatments for
    people with opioid use disorder is very important, and if the
    particular program doesn't deliver it themselves, for whatever
    reason, then connections and very strong linkages with programs
    and physicians who do is very important.
        We have a hub-and-spoke model where we use our opioid
    treatment program as a hub, and we work very closely with area
    primary care providers and psychiatrists who might be providing
    that medication-assisted treatment.
        Mr. Tonko. Thank you. And what are some reliable metrics to
    use to demonstrate a success rate for opioid addiction
    treatment?
        Dr. Stoller. One of the most important ones is retention
    within the system of care at a level of care that matches the
    person's need. So when somebody leaves treatment with us,
    despite the fact that they need ongoing treatment and they're
    leaving the treatment system, that's not an indication of
    success. That said, if the person is leaving with a very
    positive sense of hope of what a treatment program can offer
    them and they come back to us, that could be good. We also----
        Mr. Tonko. OK. I've got a few questions here to go, so I
    want to get to everyone.
        Mr. Mishek, Hazelden Betty Ford is another gold standard in
    this industry. Your written testimony speaks to quality
    standards you've identified for addiction treatment providers.
    Briefly, how do you determine what a successful treatment is,
    and how do you measure outcome for your patients?
        Mr. Mishek. We measure outcomes by checking back with our
    patients at 1 month, 3 months, 6 months, 9 months, and 1 year
    after they leave our care, at whatever point they leave our
    care, whether it's after an extensive long-term treatment or
    after, let's say, 3 weeks of residential care. We measure three
    things: continuous abstinence during that period of time;
    second of all, we measure percent days abstinent. That is, they
    may have relapsed during that period of time, but if they got
    right back into the program with hope and move forward, that's
    great, and we would consider that a success. And then finally,
    we have a series of quality-of-life measures that we measure
    over that period of time. So those are the metrics that we have
    in place that we've had for a number of years.
        Mr. Tonko. Thank you.
        And, Mr. Cartwright, turning to you, I'll ask you about how
    your facility ensures high-quality care. And first of all, in
    your response to the committee's letter, you provided your
    client outcome study that found ``63 percent of AAC patients
    maintain abstinence 1 year after treatment.'' How many patient
    responses is that 63 percent success rate based upon, and just
    how many patients enter the doors of AAC treatment centers each
    year?
        Mr. Cartwright. Thank you very much. I'm most proud of the
    outcome studies. We partnered with an organization in
    Nashville, Centerstone Research Institute, to do a 3-year
    longitudinal study. Many times you'll see SAMHSA do these
    studies or NAADAC do these studies. We had 4,000 patients that
    went through this study with Centerstone Research Institute.
    They're the ones that conducted the followup calls, very
    similar to Mr. Mishek. They did that on the intake process, 2
    months, 6 months, and 1-year posttreatment. And we have an
    entire study. We can get all the members of the committee that
    study. Be happy to dig in and get you in touch with Centerstone
    Research Institute that actually conducted the study.
        Mr. Tonko. And how many are you saying completed that 1
    year?
        Mr. Cartwright. Four thousand. Four thousand people went
    through the study, and I can get you the details on the entire
    study. TCenterstone Research Institute is the one that did the
    study. We didn't do that ourselves. We didn't have our staff
    members calling the patients back. It was a research institute
    that did that for us.
        Mr. Tonko. So I'm clear on the response, so you said you
    sent--you had--approached how many people to respond?
        Mr. Cartwright. Four thousand.
        Mr. Tonko. And how many responded that had that 63 percent
    success rate? How many of those 4,000 responded?
        Mr. Cartwright. Again, I can get you the exact numbers from
    Centerstone Research Institute. They're the ones that conducted
    the study. My staff didn't conduct the study, but I can get you
    the details on that study if you'd like it.
        Mr. Tonko. Thank you very much, Mr. Chair. I yield back.
        Mr. Harper. The gentleman yields back.
        Before I recognize the next member for questions, I just
    want to be clear, Mr. Ventrell, you had stated earlier that the
    little ``I'' isn't good enough. And I assume by that you're
    referring to the little circle, the information button on a
    website that you have to click on?
        Mr. Ventrell. That's correct.
        Mr. Harper. OK. With that, the chair will now recognize Dr.
    Burgess for 5 minutes.
        Mr. Burgess. Well, thank you, Mr. Chairman.
        And, Dr. Stoller, thank you for your testimony, and thank
    you for your honesty when you address the fact that it's
    complicated. In the treatment of these patients, the disease
    itself is complicated. The people who are affected by the
    disease themselves can be sometimes very complex individuals
    with very complex histories and, oftentimes, there are
    confounding comorbidities that have to be taken into
    consideration. And as a consequence--well, let me just back up
    a little bit.
        Your expertise that you bring to this, you are a board
    certified psychiatrist? Is that correct?
        Dr. Stoller. Yes, I am, and with additional qualifications
    in addiction medicine.
        Mr. Burgess. So the committee had the ability to refer
    everyone with this problem to you or someone of similar
    qualifications, but unfortunately, that's not always the case.
    And we are left with trying to provide as much care as possible
    to protect the greatest number of people, but recognize that
    it's an imperfect process.
        But at some point I would love to visit with you and get
    your perspectives on how much is OK, how much is too much. And
    I suspect you have some pretty keen insights into this, and I
    really would welcome the opportunity to follow up with you on
    your experience in treating, again, this very complex type of
    patient.
        Dr. Stoller. My pleasure.
        Mr. Burgess. Mr. Ventrell, let me ask you a question.
        And thank you for that answer.
        Your organization, the National Association of Addiction
    Treatment Providers, so you had some people that you did not
    renew because they did not meet your standards. Is that
    correct?
        Mr. Ventrell. That's correct.
        Mr. Burgess. And tell me again how many different centers
    you did not renew?
        Mr. Ventrell. Yes. First of all, let me explain that
    sometimes we will hear a number that represents campuses, other
    times you will hear a number that represents the parent
    corporation.
        The answer to your question is 24 parent corporations, 99
    facilities. And that is the number, sir, as of last week,
    Friday.
        And so what has happened is the majority of NAATP
    membership functions on a calendar year. The majority of
    members expire on December 31 of the calendar year. So that is
    why the vast majority of those who are no longer part of our
    rolls were deleted at that time. But this continues to go on
    throughout the year, and as we receive applications or see
    other issues, we may remove based on that.
        So the number has increased since December 31, which was
    the number that that your committee staff gave you.
        Mr. Burgess. So you're in the rehabilitation business or
    you represent companies that are. Are there some of those
    people who fell through that--some of those organizations or
    those facilities that were just one or two clicks off of being
    OK where you could work with them and bring them back into the
    fold, or was it once you're done, you're done?
        Mr. Ventrell. Thank you for that question, because our goal
    is not to remove members. Our goal is to create a society, a
    professional society of treatment providers that are aligned in
    terms of values-based care and ethics. And so what we want to
    do when we receive a complaint or become aware of an act is to
    contact that treatment provider and say, this is a problem. Can
    you fix it?
        Mr. Burgess. Let me ask you about that, that becoming aware
    of something. And I'm purposely not asking our other witnesses
    about any history of lawsuit activity or pending litigation. I
    don't want to get into that. But is that something that you
    consider through NAATP, if there has been a settlement, if
    there has been an action or an allegation, is that something
    that you evaluate?
        Mr. Ventrell. As it concerns potential liability to our
    organization, is that your question?
        Mr. Burgess. No. The liability experience of one of the
    providers. Is that something that would be a red flag?
        The reason I bring that up is I cited the testimony that we
    had last December from Eric Gold, who was an assistant attorney
    in the Massachusetts Attorney General's Office. And I asked him
    the question, I said, look, I'm a doctor. I practiced for
    years. If things are not going well, you worry about liability
    lawsuits, and where are those liability lawsuits for the types
    of organizations that he brought before our committee that
    morning. And he said, well, it just doesn't happen. And that
    was a little bit astounding to me. I've got to believe that
    sometimes litigation does result.
        Do you evaluate that litigation when that's all public
    knowledge, correct?
        Mr. Ventrell. Certainly. We want to know what all of our
    centers are doing in terms of clinical and business operation,
    and if we become aware of that, that would certainly be a red
    flag that concerns us.
        Mr. Burgess. And so has that happened?
        Mr. Ventrell. Not specifically to my knowledge, no.
        Mr. Burgess. Has not. And, again, I find that surprising.
        I just have one last observation, and I want to ask our
    treatment centers predominantly to get back to me with this
    information. One of the family members that was interviewed in
    our roundtable earlier this year talked about her son. She said
    it was continued on her medical insurance up to age 26,
    eventually died of an overdose, but not before he had been
    resuscitated seven times with Narcan in emergency rooms.
        And her question to us was, how can he still be on my
    insurance and I not be informed of this type of activity, and
    what was preventing someone from telling me that my son was in
    an emergency room seven times requiring Narcan? So, again, I'm
    going to submit that question for the record, but I would be
    interested in your responses to that.
        And I yield back, Mr. Chairman.
        Mr. Harper. The gentleman yields back.
        The chair will now recognize the gentlewoman from Indiana,
    Chairman of our Ethics Committee, Mrs. Brooks, for 5 minutes.
        Mrs. Brooks. Thank you, Mr. Chairman.
        And I would like to talk a little bit about the call center
    employees and concerned about the types of incentives that
    might happen relative to call centers and connecting. Although
    I certainly appreciate that, as we've talked and heard, those
    with addictions that I've talked to or their families, I
    appreciate that it is incredibly difficult work that treatment
    centers provide. And success rates are very difficult. Relapses
    are common. Dropping out of centers is common. This is an
    incredibly difficult group of people to work with.
        Unfortunately, it's large and growing, and we've got to
    make sure, in our oversight role, that we are providing and
    making sure that these folks are not being taken advantage of.
        And addicts that I have talked to, by the time they get to
    the point where they're ready for treatment, they are that
    desperate or their families are that desperate and have usually
    tried many centers. The last center I visited, one young man
    said it was about his third or fourth center he had been in.
        And so I think that this is a really difficult problem
    we're trying to work on, and that's why we want to make sure,
    whether they go to the internet, whether they're going to a
    phone book--I don't even know that anybody is using that
    anymore--but whatever they're doing, we want to connect them
    with the best treatment possible.
        And with all due respect, no one knows what SAMHSA is. An
    addict doesn't. I would say, we as government and providers do,
    but we have got to get this figured out. And there also aren't
    nearly enough psychiatrists coming out of our med school
    classes and addiction specialists. And so we've got to keep
    focused on this problem because we are losing far too many
    people.
        I'd like to know, maybe Mr. Cartwright, Mr. Mishek, and Mr.
    Niznik, how are your call center employees paid, and are they
    given bonuses?
        Mr. Cartwright?
        Mr. Cartwright. Yes. Thank you very much. And I appreciate
    your comments. You're so right in terms of the devastation of
    this disease in keeping it on treatment and quality of care.
    I'm in a unique position because I----
        Mrs. Brooks. And I'm sorry, I have several questions. And I
    appreciate that, comments on my comments. But how are your call
    center employees paid and what fact--and are they given bonuses
    and what determines whether or not they receive a bonus?
        First, how are they paid, Mr. Cartwright?
        Mr. Cartwright. Today they're paid a salary.
        Mrs. Brooks. OK. A salary. No bonuses?
        Mr. Cartwright. Today it's a salary. Prior to July 1--and
    again, I go back to the Tennessee State law that was passed. I
    think it's the most aggressive law in the State related to
    these bad practices that we all want rid of. They were paid on
    a commission basis.
        Mrs. Brooks. And you've changed that?
        Mr. Cartwright. Yes, ma'am.
        Mrs. Brooks. Mr. Niznik, how about you, how are your call
    center employees paid?
        Mr. Niznik. So our call center employees are all salaried
    employees who also do receive a discretionary bonus. It's based
    on many factors that you'd expect someone who answers calls to
    measure, so courtesy, returning calls, not missing calls.
        But I think what's important is that no one that answers
    these calls has any impact on the sort of care someone
    receives. So when a patient comes to us, the doctors, the
    nurses, the therapists, they make that determination. Really
    just being measured how good of a job they do in explaining the
    services that we offer and performing just the typical job
    duties of answering calls.
        Mrs. Brooks. But how would one call center employee get a
    bonus versus another call center employee? How does that
    information come to you or whoever their supervisor is as to
    whether or not they receive a bonus? And is it monthly? How is
    it determined?
        Mr. Niznik. The bonus is monthly. And, again, it is
    discretionary. It's based on maybe 7, 8, 10--it's based on a
    list of factors that I provided in my written testimony. But
    you measure things like do they answer the call? Have they
    missed calls? Are they helpful? When the managers walk around
    and hear a call, are they being polite? Are they knowledgeable
    in the program? So all these factors are relevant in
    determining is the person answering the call doing a good job.
        Mrs. Brooks. OK. Mr. Mishek, are your call center people
    paid?
        Mr. Mishek. Our call center employees have always been
    salaried?
        Mrs. Brooks. Without bonuses?
        Mr. Mishek. Correct.
        Mrs. Brooks. Are there any minimum admissions goals for any
    employees, kind of like sales quotas?
        Mr. Mishek. No.
        Mrs. Brooks. Mr. Cartwright?
        Mr. Cartwright. Today, no.
        Mrs. Brooks. OK. There have been in the past, but there are
    not any longer?
        Mr. Cartwright. Yes, ma'am. Again, I go back to the State
    law in Tennessee, and we'd love to see that nationwide.
        Mrs. Brooks. OK. Thank you.
        Mr. Niznik, are there any imposed minimum admission goals?
        Mr. Niznik. There's no minimum admission goals per person,
    but collectively as a group, we want to make sure that people
    answering the calls are doing a good job. And like I said in my
    oral testimony, that like a receptionist in a doctor's office,
    you want to make sure the person answering your questions is
    being polite and doing a good job.
        Mrs. Brooks. I'm sorry. My time is up, and I may submit a
    couple of more written questions. Thank you. Thanks for your
    work.
        Mr. Harper. The gentlewoman yields back.
        The chair will now recognize the gentleman from New York,
    Mr. Collins, for 5 minutes.
        Mr. Collins. Thank you, Mr. Chairman.
        And the witnesses, it's an intriguing hearing because this
    problem is almost insidious in its nature and it's almost hard
    to begin. Let's start with the Federal regulations versus
    Tennessee.
        Mr. Mishek, you pretty much were calling on Congress to do
    something and to call on the FTC to regulate.
        Mr. Mishek. That's correct.
        Mr. Collins. Maybe quickly, if I could ask the other
    witnesses, do you agree that this situation we need--in this
    case, Mr. Cartwright, you talked about Federal law versus State
    law, which is popping up here or there, you believe this is a
    place the Federal Government should step in and broadly
    regulate what's going on, especially in the advertising area?
        Mr. Cartwright. I do. I think there are existing FTC laws
    that get to this, that need to be enforced. But I also think
    your attention to this is much welcomed.
        Mr. Collins. Yes.
        Mr. Niznik. I think it's important that, just broadly, all
    providers are transparent in the service they offer, that when
    someone receives a call, they identify themselves. So I think,
    even though we practice that in all of our facilities, even the
    States where there isn't necessarily regulation, I think it
    would be helpful. And I think equally as important would be
    regulation that would look at standardizing care so that
    providers----
        Mr. Collins. But you're talking about in Federal--but
    you're saying some States aren't doing anything, others,
    Tennessee, may be doing a lot----
        Mr. Niznik. Right.
        Mr. Collins [continuing]. In which case you're saying the
    Federal Government, in this case, should step in. We're always
    somewhat cautious about Federal versus States' rights and so
    forth, but it's sounding like, in this instance, you're calling
    for the Federal Government to step in?
        Mr. Niznik. Right. Because, for example, the standard of
    care, there isn't a national one that's consistent from
    provider to provider. So even as a facility, we defer to the
    professional judgment of our doctors and clinicians, but I
    think it would be better if they knew exactly what was, at
    least at a minimum level, expected from them.
        Mr. Collins. Mr. Cartwright.
        Mr. Cartwright. I do think we need Federal intervention and
    not just in marketing practices. We have a similar issue
    related to licensure. Licensure standards in the State of
    Minnesota or the State of Tennessee or the State of California
    can be completely different where, for example, out in
    California, in six-bed houses, you could be doing detox
    services. We both, Mishek and myself, through our organizations
    have CDRHs. They're hospitals for detoxification services. So
    we should have some standardizations across the country.
        One of the difficulties is we have 19,000 different
    treatment centers across the United States with an annual
    budget of about $5 million. We've never really caught the
    attention of the Federal Government or even the healthcare
    system. And today we do, right. We have people dying in the
    streets all over this country, and we really do need to do
    something about this.
        And I'm very impressed with Congress in respect to what all
    you all have done over the last 2 years on this issue. But now
    I think we're starting to get to the things that Mr. Ventrell,
    Mishek, myself want to see, and that's consistency around
    advertising and marketing, but also consistency around quality
    of care and licensure standards.
        Thank you.
        Mr. Collins. Mr. Brian.
        Mr. Brian. From the advertisement perspective, I couldn't
    agree more. We want nothing more, wanted nothing more than to
    work with great centers that were licensed to do what they were
    tasked to do. And I think that the ultimate underlying message
    that I would like to leave is that people will search however
    they choose to search, not how we think might be most
    appropriate for them to search. So if they decide to go online,
    they're going to go online. That's what they're going to do.
        And so if we are holding our treatment programs to a higher
    standard and ultimately the licensure required for them, I
    think we'll be in much better shape regardless of who's on the
    other end of the phone call.
        Mr. Collins. Dr. Stoller.
        Dr. Stoller. I'm afraid my work doesn't overlap advertising
    enough to render a very informed opinion, but what I would say
    is that access is very important. And I really appreciate the
    work that the Congress has done to increase access, for
    example, through Medicare reimbursement for opioid treatment
    programs and anything else that could be done to make sure that
    treatment is accessible and that parity is enforced.
        Mr. Collins. So, Mr. Ventrell, finishing with you, NAATP is
    the organization that is certifying and riding herd on these.
    Is that organization well known like almost we think of the
    Good Housekeeping Seal or something as in the vernacular?
    Somebody searching would know, I've got to start with do I see
    NAATP stamp of approval?
        Mr. Ventrell. Well, I would hope so. And that certainly
    would be----
        Mr. Collins. Or is there work to be done there?
        Mr. Ventrell. There is work to be done, Congressman, as is
    demonstrated by the fact that we removed certain members so
    that we could have a moral high ground in order to say, look,
    if you want to be a member of the society, you have to follow
    these rules.
        So NAATP has been in existence for 40 years, so certainly
    we're the longstanding trade association. I think that what you
    will find as this process develops and we continue to
    articulate best practices, that that is, in fact, the case,
    that you need to be part of this national association and that
    demonstrates a meaningful----
        Mr. Collins. That would certainly be one way to weed out
    the very bad actors because they're not part of the NAATP. So
    we'd encourage you to continue to promote your brand.
        Mr. Ventrell. Thank you.
        Mr. Collins. With that, Mr. Chairman, I yield back.
        Mr. Harper. The gentleman yields back.
        The chair will now recognize the gentleman from
    Pennsylvania, Mr. Costello, for 5 minutes.
        Mr. Costello. Thank you, Mr. Chairman.
        Mr. Brian, information your company provided committee
    staff as well as your testimony indicates you routed more than
    519,000 calls to treatment providers from December 2014 to the
    present. Can you describe how those calls were generated?
        Mr. Brian. Yes, sir, of course. We work with third-party
    media agencies that operate in television, radio, search engine
    advertising, amongst other avenues, and they generate--in
    advertisement, typically it would be in the form of a help-line
    related call that clearly indicates that their call will be
    routed to a treatment center who pays to receive that phone
    call. That call is then routed directly to the treatment center
    through our platform, never stopping with us.
        Mr. Costello. Contractually, do you have any approval over
    the type of language that they utilize in their advertising in
    order to generate that call?
        Mr. Brian. Yes, sir. Indirectly, we have what we call our
    marketing standards and practices attestation form, which
    allows and provides them a very clear guideline of what we
    allow and what we don't allow, most of which is congruent and
    consistent with the same dialogue that we've had today.
        Mr. Costello. Do you pre-approve that?
        Mr. Brian. Not in all instances, but in most instances,
    yes.
        Mr. Costello. Have you ever had occasion to tell them to
    remove a particular type of advertisement that did not accord
    with those guidelines that you just referenced?
        Mr. Brian. Yes, sir.
        Mr. Costello. How much did you pay per call?
        Mr. Brian. It would vary depending on the type of call. It
    would range anywhere from $10, $15, $20 dollars on up to $60 or
    $70, depending on how the call was originated.
        Mr. Costello. How did treatment facilities find Redwood?
        Mr. Brian. We participated in numerous trade shows,
    conferences. I've spoken at several of these conferences, and
    ultimately the organizations would find us typically through
    that. We also had a strong web presence where we would
    advertise directly to the treatment programs through our
    website, which was treatmentcalls.com.
        Mr. Costello. So did Redwood find the facilities online?
        Mr. Brian. In some instances, yes, sir. Not in all
    instances.
        Mr. Costello. OK. Let me shift gears. This is for everyone
    but Mr. Ventrell. I want to talk about success rates, because
    in a lot of these advertisements you hear talk of there being a
    successful treatment. We don't necessarily know what success
    means.
        So for each of you, what is your facility's success rate,
    and how do you define success? Is it admission to your
    facility? Completion of the program? Maintaining sobriety for a
    month? Six months? One year? Five years? Starting with Mr.
    Mishek.
        Mr. Mishek. Thank you, Congressman. First of all, we don't
    use that word, ``success.'' It's outcomes. This is a chronic
    disease. You're going to have it for your lifetime. Hopefully,
    you are in recovery and are happy, joyous, and free, as they
    say in the big book.
        We measure, as I said earlier, outcomes after 1 year of
    being with us, whatever point you leave us, and----
        Mr. Costello. Do you list that in your advertisement at
    all, what's your outcome----
        Mr. Mishek. We don't advertise it.
        Mr. Costello. OK. And I want to hone in on the
    advertisement and the use of the word ``success'' or anything
    related thereto. Mr. Cartwright.
        Mr. Cartwright. We don't use success rate on our
    advertising. We conducted an outcome study that we've published
    and put out there just recently over the last several months
    where 4,000 patients went through that, that I'm very, very
    pleased and proud of. But that doesn't encompass all of our
    folks that are going through treatment annually.
        Mr. Costello. Mr. Niznik.
        Mr. Niznik. We don't advertise what our success rate is or
    define it in any of our ads.
        Mr. Brian. We don't have treatment centers at all----
        Mr. Costello. Right.
        Mr. Brian [continuing]. So we don't have success rates.
        Mr. Costello. Dr. Stoller.
        Dr. Stoller. Our position is similar to Mr. Mishek's. We
    measure outcome over a continual time period.
        Mr. Costello. Mr. Mishek, share with me some of the other
    challenges in tracking success within the substance abuse
    industry.
        Mr. Mishek. Well, again, success for us is lifetime
    recovery. It's a chronic disease. One of the unfortunate
    features of it being a chronic disease is people relapse.
    People come back to treatment often many times. It's important
    never to give up hope, to bring them back, get them back in the
    continuum.
        So success for us are things like, yes, completion of a
    particular episode of care is really important; participating
    in recovery management is really important; making it to 12-
    step meetings, if that's the route you're going, is really,
    really important. Those are the things that we really focus on
    and those are the things we look to for success. I hope that
    answers your question.
        Mr. Costello. It does. Thank you.
        I yield back.
        Mr. Harper. The gentleman yields back.
        The chair will now recognize the gentleman from Georgia,
    Mr. Carter, for 5 minutes.
        Mr. Carter. Thank you all for being here. Very important
    subject. I've always described the opioid epidemic as being two
    types of problems: One is, how do we control that what I
    consider to be the tangible part, how do we control the number
    of pills out there, the number of prescriptions; and two, the
    intangible, and that is, what do we do with those 2.5 million
    people who are currently addicted? How do we help them? That's
    why you're here today because we need answers to that. That's
    very difficult.
        I'll start with you, Mr. Brian, and ask you this: Are you
    familiar with the Addiction Network?
        Mr. Brian. Yes, sir.
        Mr. Carter. You are familiar with that? As I understand
    that features a gentleman, a bearded gentleman in blue scrubs
    saying call this number and you can get help. And is that your
    company doing that or what?
        Mr. Brian. It's not our company doing that, sir. We----
        Mr. Carter. It's not your company doing it?
        Mr. Brian. No, sir.
        Mr. Carter. OK. So you have a list of companies that you
    refer people to,
        Mr. Brian. Yes.
        Mr. Carter. Is that correct?
        Mr. Brian. Yes, sir.
        Mr. Carter. OK. What are the qualifications for a company
    to be on that list?
        Mr. Brian. Licensed in the State that they are----
        Mr. Carter. Just licensed.
        Mr. Brian. Yes.
        Mr. Carter. Anything else?
        Mr. Brian. Not with us, no.
        Mr. Carter. Not with you.
        What about you, Mr. Cartwright? You do the same thing, the
    same business model. Is that correct?
        Mr. Cartwright. A little bit different business model, sir.
        Mr. Carter. OK. Very quickly, how different?
        Mr. Cartwright. It's an advertising model.
        Mr. Carter. It's an advertising model.
        Mr. Cartwright. They don't call into our call center, and
    then we don't refer them out.
        Mr. Carter. OK. Do you have any requirements for them to be
    on there?
        Mr. Cartwright. We do. They have to be part of SAMHSA's
    website----
        Mr. Carter. OK. You mentioned that earlier.
        Mr. Cartwright [continuing]. Which I'm assuming is vetted.
    They have to be a licensed organization with CARF or JCAHO
    accreditation.
        Mr. Carter. Do you take into consideration, as my colleague
    just asked, outcomes? Do you take that into consideration? Do
    you ask those companies before you put them on your list, tell
    me about your outcomes?
        Mr. Cartwright. We do not.
        Mr. Carter. You do not.
        Mr. Brian, do you?
        Mr. Brian. No, sir.
        Mr. Carter. You do not?
        Mr. Brian. No, sir.
        Mr. Carter. So the outcomes has nothing to do with it.
    They're just on the list.
        When you refer, Mr. Cartwright, a patient to one of these
    clinics, if you will, do they reimburse you for that?
        Mr. Cartwright. No, sir, we don't refer people to clinics.
        Mr. Carter. OK. When you refer people----
        Mr. Cartwright. Correct.
        Mr. Carter [continuing]. The company that you refer them
    to?
        Mr. Cartwright. If a call comes into our call center and we
    refer it out to another facility, no, we would never take money
    from them.
        Mr. Carter. Does that facility reimburse you in any way at
    all?
        Mr. Cartwright. No, sir.
        Mr. Carter. How do you make money then?
        Mr. Cartwright. We don't make money from that at all.
        Mr. Carter. Where do you make your money?
        Mr. Cartwright. We are a treatment organization. We have 39
    treatment centers in 9 States, and that's where we make the
    bulk of our revenue, just like Hazelden Betty Ford Center.
        Mr. Carter. Do you refer patients to other facilities
    besides yours?
        Mr. Cartwright. If somebody calls into our call center and
    they're in a local area and we don't have a treatment center in
    that area, absolutely, we'd refer them to the SAMHSA website.
    We may even walk through that SAMHSA website with them and let
    them know about local facilities in that area, but we would
    never take money from them.
        Mr. Carter. OK. What about you, Mr. Brian, when you give a
    referral to another clinic, do you get reimbursed?
        Mr. Brian. We don't make any referrals. So we don't have a
    call center that accepts phone calls.
        Mr. Carter. You don't have a call center. So when you route
    them----
        Mr. Brian. Yes, sir.
        Mr. Carter [continuing]. To that clinic----
        Mr. Brian. Yes, sir.
        Mr. Carter [continuing]. Do they reimburse you any at all
    for that referral, if you will?
        Mr. Brian. For the phone call, we receive compensation for
    it, yes, sir.
        Mr. Carter. Do you receive it from the clinic?
        Mr. Brian. For the phone call itself, yes.
        Mr. Carter. OK. So, again, you don't take into
    consideration, there's no prerequisites for that company, for
    that clinic to be on your list. You just simply go in and list
    them.
        Let me ask you something. When you make these kind of
    referrals, if you will, do you interview the patient? Do you
    sit there and say, OK, tell me what your problem is, tell me
    what your pay type is, tell me what you're looking for? Do you
    do anything like that or you just say, hey, this is in your
    area, this is who we recommend?
        Mr. Brian. We don't recommend. We don't talk to the client
    ever in that engagement at all. We don't have any interaction
    at all with the prospective----
        Mr. Carter. Then how do you know who to refer them to?
        Mr. Brian. We refer them to a licensed facility, sir. The
    prerequisite to work with us, if it was good enough for the
    State to issue licensure for them, that's our prerequisite in
    order to do business with us.
        Mr. Carter. OK. Do you think that serves the best interest
    of the patient?
        Mr. Brian. I believe it serves the law in the State of
    Florida that I live and work in. And I would welcome this
    conversation. I believe that a lot more can be done to route
    these calls to the appropriate facility.
        Mr. Carter. I would think so.
        Mr. Brian. I agree.
        Mr. Carter. I would think if I called that, I'd want to
    have some information before I said, OK, this is where you need
    to go.
        Mr. Cartwright, you've referred to State laws that have
    been passed. Have they addressed any of that?
        Mr. Cartwright. I think what you're getting at is the
    quality of the facility that you're referring someone to.
        Mr. Carter. The quality and the type of facility. If I say,
    I've got an addiction and I'm looking for something that's
    faith based and I need your recommendation, do you take into
    consideration anything like that?
        Mr. Cartwright. Again, if Congress would support something
    like that through SAMHSA, I think that would be excellent. I do
    think that this is where it needs to land is in Congress' lap,
    because each of the States are so different in terms of how
    they license----
        Mr. Carter. OK. I'm out of time. But listen, we're very
    responsible people up here, and we want to do and we're going
    to do what's right. But we also look to you to have a certain
    level of responsibility as well. So don't always look to
    Congress as being the ultimate answer here, OK.
        Thank you very much, Mr. Chairman. I yield back.
        Mr. Harper. The gentleman yields back.
        The chair will now recognize the gentleman from Florida,
    Mr. Bilirakis, for 5 minutes.
        Mr. Bilirakis. Thank you very much.
        Thank you for your testimony as well. And thank you, Mr.
    Chairman, for holding this very important hearing.
        If there's one thing that's been made clear in today's
    hearing is that there is a lack of clarity on how individuals
    can ensure they are seeking care that will best meet their
    needs. I want to better understand how we can serve our
    constituents by creating a clear path forward here.
        Mr. Ventrell, does the Association have a definition of
    what quality care is? And then, what resources exist for the
    consumers to seek out quality care?
        Mr. Ventrell. Thank you, Congressman. Yes. As part of the
    quality assurance initiative, NAATP developed a research called
    the NAATP Guide to Treatment Program Selection. It's a
    comprehensive consumer tool, also useful for the field, that
    provides red flags and positive references.
        It is premised on four principles. Addiction treatment is
    healthcare and should be chosen as such. There are knowable
    indicia of quality of care. It's not a mystery. We know what
    produces quality care. Third, there needs to be transparency in
    the marketing process. And fourth, the institution that you go
    to should adhere to a recognized code of ethics.
        Mr. Bilirakis. Let me ask you a question, and maybe this is
    for the panel as well. Would a star rating system be very
    helpful? Because that kind of simplifies it in certain areas
    rating the particular facility. I think that that might be
    simpler. Again, these are their loved ones and they want to
    make the right decision for them.
        So if anybody wants to chime in on that, I'd appreciate an
    answer.
        Yes, sir.
        Mr. Ventrell. May I, sir? It's an attractive solution, but
    I think it's a dangerous one. Things are more complicated than
    ranking by star. I don't think that that's achievable in a
    reliable way.
        Mr. Bilirakis. Well, we do it for nursing homes. I
    distinguish that a nursing home as opposed to a substance use
    disorder facility or mental health facility.
        Mr. Ventrell. Yes. Thank you. The floor needs to be clearly
    established in order for a process like that to work. In other
    words, nursing homes must exist, I believe, at a certain level
    of quality before you can start to talk about that.
        What I propose, or what we propose or suggest instead is
    that the floor, the basic operational requirements should be
    regulated sufficiently such that if you read, if they are, and
    then you read the services offered, the consumer can rely on
    that, and a star system wouldn't be necessary.
        Mr. Bilirakis. OK. I just want to make it clear and less
    complicated for the consumer. And I want them to know where to
    turn to, where to find this information out. I want it to be
    easily accessible.
        Let's see, a big concern that this committee has is
    ensuring that when an individual or their loved one is seeking
    substance use disorder treatment, they know what things to look
    for. And you mentioned the flags. What things to avoid, again,
    to best protect themselves from falling prey to any deceptive
    marketing schemes that may be out there, and there are plenty
    out there.
        Could you identify a few red flags that individual should
    be on the lookout for when seeking care, as well as a few green
    flags that might indicate that a treatment center provides
    quality care?
        For example, some reports suggest paying attention to
    whether or not the facility lists a staff page or asking the
    person who answers the phone whether or not they are actually
    at the treatment center.
        So, Mr. Ventrell, you can start, if you like.
        Mr. Ventrell. Sure. As part of the same document which I
    have referenced, we've listed red flags and questions to ask.
    Red flags generally that we believe should be observed are
    generic websites, call directories, or websites offering
    treatment placement. Many of these make referrals based on
    business relationships. That's the problem.
        Questions to ask include licensing, accreditation. It's all
    based on transparency. We would like them obviously to be
    members of our national association. How long has the facility
    been in operation? Who are the staff? What levels of care are
    provided? What are the placement criteria? What is your
    procedure for the continuum of care as the chronic disease
    exists one's entire life? The list goes on, and I'm happy to
    provide that. In fact, it is part of the record.
        Mr. Bilirakis. OK. Let me ask one more question. I do have
    several here, but with regard to payment, because it's
    difficult for a person to--obviously, you want to make the
    right decision, OK, but also, how many treatment centers take
    private insurance? What's a percentage?
        Whoever wants to answer that question would be fine with
    me, or you can even just talk about your particular treatment
    center, whether that center accepts private insurance.
        Mr. Cartwright. Congressman, thank you very much, and going
    back to your previous question as well. I do think that the
    addiction treatment industry is very similar to the nursing
    home industry. It's a maturing industry that could benefit from
    a star system like you were referring to. I think it's very,
    very similar to the nursing home space where Federal regulation
    needs to be tighter across the board. That would be my personal
    opinion. So I really appreciate you bringing that up.
        Mr. Bilirakis. Oh, absolutely. Thank you. Thank you for
    your opinion.
        Mr. Mishek. If I could talk about insurance.
        Mr. Bilirakis. I guess I probably have to yield back.
        Thank you very much. If maybe you can have some time, Mr.
    Chairman, for him to answer the question. But I'll yield back.
        Mr. Harper. The gentleman yields back, and I've got a
    couple of followup things, but I'll recognize Ranking Member
    DeGette for purposes of entering a document.
        Ms. DeGette. Mr. Chairman, thank you.
        We just received a letter from the Federal Trade Commission
    regarding this issue. And what Commissioner Chopra talks about
    in this letter is the for-profit treatment centers and what
    that can do in terms of driving up costs for insurance and for
    Medicare and Medicaid programs, as well as cost for patients
    out of their pockets.
        The letter also cautions about the deceptive trade
    practices in trying to match individuals to centers and the
    advertising. And it finally urges this committee to take a
    close look at the advertising and marketing practices in the
    industry to make sure that incentive compensation practices for
    employees and operators of treatment centers, as well as
    financial conflicts of interests with other firms, are
    addressed.
        And so I'd like unanimous consent to enter this into the
    record so that we can continue to look at these issues as we
    continue our investigation.
        Mr. Harper. Without objection, so entered.
        [The information appears at the conclusion of the hearing.]
        Mr. Harper. Any other comments, Ms. DeGette?
        Ms. DeGette. No.
        Mr. Harper. I had a couple of followup items I just wanted
    to touch on.
        Mr. Cartwright, how do companies and their phone numbers
    end up on their website?
        And I ask that because we understand that there's at least
    one phone number that doesn't call the named facility that it
    is listed with. So how do companies and those phone numbers end
    up on your websites?
        Mr. Cartwright. We utilize the SAMHSA website in terms of
    the listings on there. And so if it's not been updated through
    SAMHSA, maybe we didn't update that. I'd love to know the phone
    number that didn't go through correctly. We would certainly
    like to look at that.
        Mr. Harper. Sure. We will make sure you have that info to
    clear that up.
        Also, Mr. Cartwright, I know that you do operate, a
    portfolio of websites under your Recovery Brands business line.
    Are you able to tell us how many websites are operated under
    Recovery Brands and give us that information today?
        Mr. Cartwright. I can get you the exact websites
    themselves. I think we've been asked by staff to provide that,
    and we can certainly do that.
        Mr. Harper. That would be very helpful.
        One issue that this committee has explored, obviously, is
    abuse of billing practices, especially with urine drug testing.
    For example, the reports of clinics and labs charging more than
    $4,000 for a single urine test and for treatment facilities to
    test individuals two or three times a week.
        So for Mr. Mishek, Mr. Niznik, and Mr. Cartwright, can you
    explain how often your facilities test patients and what the
    average cost is? And answer, if you can, as quickly as you can.
        Mr. Mishek. Sure. We do a urine drug screen upon admission
    for any level of care: Residential, day treatment, intensive
    outpatient. During the course, the patient may get two or three
    additional tests, depending on whether they came up on the
    randomized thing we do or whether it was for cause.
        We don't charge. We have no revenue from drug testing. The
    cost that we incur is about $20 a test roughly. It's very, very
    low cost.
        Mr. Harper. Are those tests performed at your facility or
    sent out to a lab?
        Mr. Mishek. They are sent out to a national lab.
        Mr. Harper. OK. Mr. Cartwright.
        Mr. Cartwright. Very similar. We use the same guidelines
    just like Hazelden Betty Ford Center, very similar in terms of
    intake. We generate about $50 for a urine sample, but we also
    own and operate our own laboratories.Two of them, one in
    Tennessee and one in the State of Louisiana.
        Mr. Harper. So those are sent out to those facilities for
    testing?
        Mr. Cartwright. Correct.
        Mr. Harper. OK. Mr. Niznik.
        Mr. Niznik. We also test upon admission. And then on
    average, it's about 1 \1/2\ times per week, but it's generally
    in the discretion of the medical doctor that's overseeing the
    care of the patient to order whatever test they think is
    medically necessary. We send it out to the lab that we operate
    in Florida.
        Mr. Harper. Is your mic on?
        Mr. Niznik. Yes.
        Mr. Harper. How many labs and what do you charge, that you
    own.
        Mr. Niznik. We own one lab. We operate one lab. It services
    all of our facilities. And our average, I think, reimbursement
    is somewhere around $200 to $300.
        Mr. Harper. OK. I'll yield to Ms. DeGette for a followup.
        Ms. DeGette. So you say that you test on the average of 1
    \1/2\ times per week. You send it out to your lab. Are you then
    billing the insurance the $200 to $300?
        Mr. Niznik. Yes, that's the reimbursement we receive from
    the--no, that's the reimbursement we receive from the insurance
    company.
        Ms. DeGette. Right. So you're billing the insurance $200 to
    $300 per 1 \1/2\ times a week, whereas these other facilities
    aren't charging their people anything.
        Thank you, Mr. Chairman.
        Mr. Harper. Final question, and Mr. Cartwright, I pulled up
    drugabuse.com, which is yours. And going through the website it
    has lots of information. It talks about the opioid crisis. It
    has an 800 number. ``It's not too late to turn your life
    around,'' ``overcoming your addiction.''
        While we don't measure success or outcome, it certainly
    might imply to one, that I will get that outcome if I go there.
    But you have to go to the small ``I'' that I asked Mr. Ventrell
    about earlier to find out that your visit will be answered by
    American Addiction Centers, AAC, or a paid sponsor.
        Why wouldn't you just list that information at the top of
    your web page? You have to go hunt for that, either under the
    number or other things. Why wouldn't you do that?
        Mr. Cartwright. Again, our business model is very similar
    to WebMD. If you'd like us to change it and put it at the very
    top, I'm happy to do----
        Mr. Harper. I'm not asking about WebMD. I'm asking you, if
    we're talking about transparency and what we're looking at here
    so that it's nothing is viewed to be deceptive, wouldn't it be
    easy just at the beginning of your web page to say that
    information?
        Mr. Cartwright. Yes, sir, we can do that.
        Mr. Harper. Who are the paid sponsors?
        Mr. Cartwright. It's the advertisers that we were referring
    to earlier in the conversation.
        Mr. Harper. Who determines on that call whether or not it
    goes to AAC or to a paid sponsor?
        Mr. Cartwright. All of the phone calls that are coming in
    through the 1-800 number that is like that, they all come to
    American Addiction Centers.
        Mr. Harper. OK.
        Mr. Cartwright. The paid sponsors is referring to if they
    have an ad, and it's very clear who that company is.
        Mr. Harper. Do you send anything to an unpaid sponsor? Or
    is there such a thing as unpaid sponsor?
        Mr. Cartwright. Yes, there is.
        Mr. Harper. OK. And how do you rotate--a call comes in, how
    do you determine who it goes to?
        Mr. Cartwright. It's not a call that comes in. If they're
    looking on the website, and if you go down through the website
    and you look in Denver, Colorado, it would have all the local
    providers in that area. They wouldn't have to pay for that
    listing. It would have all of them listed there. All the not-
    for-profit agencies, all the hospitals, treatment centers.
        Mr. Harper. But if I call that 800 number, or 877 number,
    whatever it is, if I were to call that, it would go to a
    facility or go to the hotline?
        Mr. Cartwright. That would only come to American Addiction
    Centers.
        Mr. Harper. OK. All right. I got it.
        I want to thank everyone for their testimony. This is an
    issue that we're obviously concerned about, but I thank you for
    your time, your patience, for your responses.
        I would remind members that they have 10 business days to
    submit questions for the record. And I would ask the witnesses
    that you respond as promptly as possible when you get such
    questions.
        With that, the subcommittee is adjourned.
        [Whereupon, at 12:10 p.m., the subcommittee was adjourned.]
        [Material submitted for inclusion in the record follows:]
        [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                     [all]