[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

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                    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:]
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