altogether and uses that to target you. >> watch the communicators tonight at 8:00 eastern on c-span2. >> tonight, on landmark cases, the des moines independent community school district. a case about free speech. in 1965 five students from des moines, iowa wore black arm bands to protest the vietnam war, violating school policy. and they challenged the free speech restrictions and the resulting supreme court decision established that the students keep their first amendment rights on school grounds. our guest to discuss this landmark case are mary beth tinker, one of the five students who challenged the des moines school district, she was 13 at the time. after two decades as a pediatric nurse she began working as a free speech advocates for students, touring

nationally at schools and youth centers. and eric jaffe, an independent litigator, including work on more than 100 cases he charged for justice clarence thomas. watch landmark cases tonight on c-span and join the conversation. our hash tag is landmark cases. we have research for each case on the website, the companion book, a link to the national constitution center's interactive constitution and the landmark cases podcast at c-span.org/landmarkcases. >> next, a hearing examines how medicare, medicaid and other hhs programs can better address the opioid epidemic. lawmakers asked how to reduce the cost of drugs to treat overdoses and what alternative options there are for pain

treatment. held by the senate finance committee, this is two hours, 15 minutes. >> i'd like to welcome everyone for attacking substance disorders in medicare, medicaid and human services programs. i start with the news that i wish were untrue, more than 60,000 americans died from a drug overdose in 2016. 60,000. the majority of these overdoses involved prescription opioids or illicit opioids like heroin or fentanyl. these numbers are more than mere statistics, they represent our constituents, our friends, our loved ones. my home state of utah continues to be hard-hit. an alarm being number of utahs have visits due to overdoses.

2016 allow over 450 utahans died. and americans recognize the challenges posed by the epidemic and are fighting against it. president trump and secretary of health and human services alex azar made tackling opioid epidemic a priority. and i look forward to working with them to advance policy solutions. congress continues to support states and communities in their efforts and has a record of working in a bipartisan manner to identify solutions that can have a meaningful impact for struggling individuals and families. i was pleased to work with ranking member wyden and other members of this committee to lead an effort that makes significant strides to address the opioid epidemic. the family first prevention services act, enacted last

february. this bill would provide states with access to funds to help families with substance abuse disorders, and allow more children to stay safely with their families, instead of being placed in foster care. i'm also pleased that congress wisely opted to build on the foundation of the family first prevention services act in the march omnibus law by providing states with additional funds to ramp up these services immediately. this will allow states to develop more evidence-based services that will make a real difference in the lives of families affected by substance abuse disorders. the federal government cannot, and i should say substance use disorders. the federal government cannot solve this crisis alone, but my hope is that we can work together to ensure that our federal programs such as medicare, medicaid and human

services program are innovative and responsive to the needs of americans with chronic pain or opioid use disorders. my ranking member, senator wyden and i have successfully partnered to make numerous recent improvements in health care and i appreciate him for this. he's been a great partner and i've enjoyed working with him. we worked together to realize an extension of the children's hell program. we pushed tew a package of policies known as chronic care accurate that improved medicare for people with chronic conditions. i'd be remiss if i didn't point out none of this would be possible out the bipartisan engagement of members on this committee, identifying policies to evaluate and improve the federal response to the opioid

epidemic will be no difference and depend on committee-wide support. today members have an opportunity to speak with two of the administration's leading experts on opioid related policies. how medicare, medicaid, and human services programs can adapt and be improved to address the crisis and what this administration and congress can do to save lives together. it is my hope that members take the opportunity to drill down into policies that are likely to garner bipartisan support to help this committee advance its long record of working together collaboratively. anything less would be a missed opportunity to help individuals, families and communities across the nation. in fact, through outreach to stakeholders and soliciting input from members of the

committee, we've identified areas of potential bipartisan support. these include the need to evaluate access to and utization of nonopioid treatment options for managing pain, enhancing data sharing to promote appropriate health care interventions and strengthen program integrity and ensure evidence-based care is available for patients to identify and treat opioid use disorders. in closing, my view is that the committee must do all it can to prevent and relieve opioid related suffering from implementing effective policies in medicare, medicaid, and human services programs. we have a unique opportunity to do so in the near-term. we'll hear the ranking members thoughts on this momentarily, but i did 0 hope that he agrees to work on bipartisan solutions that would add to the

committee's long list of bipartisan commishments, i'm sure he does. the witnesses will get a proper introduction shortly, but i'd like to briefly say a few words before i have to attend a committee member markup i have to attend. i apologize. i'd like to welcome dr. bret giroir. his recent appointment as secretary azar's point person on opioid policy speaks highly of his capabilities. i am greatful that the finance committee will be the first congressional committee to hear. him in this capacity. how do i pronounce that, is it giroir? okay. i'm also absoluted to have cms kim brandt appear before the committee today. miss brandt likely needs no introduction to my fellow committee members as she was on my staff six years before

assuming the role of deputy administrators for operations at cms last year. very proud of her. would like to quickly say while i certainly gave my blessing to miss brandt before she moved on to a cms leadership role. it was difficult for me to see kim go. she's that great a person. i ask you all indulge a point of personal privilege who explain now. i no longer get those uplifting visits from her puppy sherlock. >> the cookie, here they come. >> and those incredible cookies and other goodies. and i don't want this it take away from your expertise. [laughter] >> she frequently provided all of these to members and staff. they're much harder to come by now, i have to say, but i'm glad to know that kim is helping to steer the ship at cms. could not be in better hands.

kim served this committee and all of this committee on both sides of the aisle with great distinction and i'm glad to have her here today. with that, i'd like to recognize my friend who has worked so well with me and who i have such great respect for, the ranking member for his opening statement. >> mr. chairman, thank you. and i know your time is short. i'll just make a couple of points, first, i want to thank you for the comments about the bipartisanship and we are definitely going to continue that at we tackle this opioid issue. i have said to friends in town meetings, if somebody had said in january of 2017 in a very polarized congress that we would get the children's health insurance program reauthorized for a decade, we would transform the foster care

system in america under families first, we would begin the transformation of medicare from being an acute care program to a chronic care program, while updating the medicare guarantee, mr. chairman, if somebody had said that was doable in january of 2017, they would have been accused of hallucinating. people would say there's no way that this can happen. and it took place under your leadership, under your chairmanship. i very much appreciated-- >> with your help. >> well, we incorporated values from both sides and i want it understood that we are going to work on this issue in a bipartisan way. >> right. >> as well. >> that's great. >> let me make a comment on an important point that many senators have brought to my

attention and that is, i do think it is-- i do think it is long past time to get the opioid executives before the committee, have them raise their right hands and hold them accountable for their role in creating a public health calamity that is killing tens of thousands of americans each year. ... the tobacco executives denied they were at the date. nowadays the opioid companies, including those that manufacture

the drugs and those that distribute the drugs that have misled the country about the dangers of their products. the opioid executives, however, have avoided spotlight that congress put some executives that the big tobacco companies. colleagues, we have colleagues and friends now from both sides of the aisle. that has got to change. the executives need to be brought forth. this committee pays for so much of american health care and be held accountable. flooding american communities but these drugs is big, big business in so-called safer opioids have just kept the cash registers running. they would be derelict in responsibilities if it pretends there is no profit motive behind

the addiction crisis. in 2015, more than 52,000 americans died of a drug overdose. i'm glad the chairman touched on the statistics because it increased 64,000 in 2016 and 2017 with 71,000. there is a tragic and well documented pattern of opioid addictions escalating into abusive and fentanyl. now an even stronger narcotic called carbon moment is spreading. carbonyl is supposed to be used as a sedative for elephants. it is so potent and dangerous. first responders around the country have to run around in hazmat suits when they are around it. that is a horrifying level of danger plaguing our community with this epidemic. on a bipartisan basis, we pretty begun the work to financiers.

and when you get into this come you deal with the paradox that cutting down the supply of opioid depending on how you do it could drive even more people to and other drugs leading to even more overdose deaths. that is obviously nothing that any member of this committee could possibly want. with that said, i want to stress that we have a big-time opportunity for bipartisan action. i'm going to touch on just a couple issues that have been important to me and at the top of my list is addressing what i've come to call the prescription pendulum. doctors used to be criticized for prescribing too conservatively. now they are criticized and i believe fairly for prescribing too much.

there's got to be a two-goal approach that really meets the needs of our people and strikes a responsible balance. for me, this all began back in the days and chairman roberts heard the stories about the gray panthers. iran illegally program for the elderly and they think about 40 or so and said his 92-year-old dad was in pain and couldn't get a prescription. his father was 92 and the doctor said no, no, no, i am not going to prescribe for pain because the risk of addiction is too great. compare that with the fact that today one in three medicare patients has a prescription for opioids and of course my friend senator isakson has been part of our effort on chronic care.

i have also heard more recently agonizing stories from parents at home who lost kids to the epidemic. i met carrie strickland who lost her son george into an overdose. jordan was a star athlete in a tiny columbia town of napa appear when he suffered an injury, he was prescribed opioid and i guess he may have gone to a party, gotten involved for some of his friends. he started using heroin and for years he struggled in the battle between addiction and recovery. colleagues, i know we've got a lot of athletes. i went to school on a basketball scholarship. i was too small in a made up for it by being slow. but nobody, nobody you throughout their knee and i think dr. cassidy knows more

about it on the back when i was coming up, throughout their knee and suddenly became addicted to painkillers. that was unheard of. and i'm sure my colleagues are all hearing these stories. as chairman hatch noted and i want to come back to it, we can come up with a partisan proposals to help make the difference. the chronic care legislation that the chairman mentioned, i've mentioned for senator isakson joined me on. we were kicking off and began literally to transform medicare in the acute care program to be in the chronic care program, which is where most of the money is now being spent. senator isakson deserves an enormous amount of credit as does the chairman because we made it a bipartisan process. we can do that again.

and looking at the three colleagues on my side. senator stab at now has worked hard on this. senator mccaskill. nobody has worked harder on the opioid issues than senator mccaskill. investigating the crisis, holding people accountable. we've got colleagues here and i don't want to overlook the fact that i see colleagues on the other side of the aisle who've also put in a lot of time on this. we can address these issues in a bipartisan way and i think particularly important for us is the vital role that medicaid plays and treatment. four to 10 working age americans suffering from opioid addiction rely on medicaid. the largest funding for treatment in the country. it is going to have to be a key part of a solution. as the chairman noted, the family first legislation provides a real tool to deal

with the epidemic. family first is about keeping families together wherever you can. so under this law, let's just make sure everybody knows what it means for opioids. if a parent is swept up in opioid addiction, a grand parent could, for example, stepping to care for the youngsters while mom or dad got the treatment they needed. it would provide support for parents treatment services throughout. end result is that a family that can stay together and now we are in the period where we will be working with the department to their representatives here in the state to prepare for the major reform, the chairman hatch and i are determined to see this federal state partnership so that families first give us a fresh new tool for fighting back against opioid addiction,

keeping families together. the last point come a warm welcome to our witnesses. all of us have enjoyed ms. brandt's cookies and that has been referenced. i want it understood that we very much appreciate her professionalism. virtually everybody on this committee has had a good or late at night struggling to put together the details on an important piece of domestic legislation. mr. brandt, dr. giroir, we welcome both of you in a gas they are in charge of the committee now. >> i would like to associate myself with the remarks, the bipartisan remarks on approach. we have this problem stated by my colleague and friend from oregon who did start out in

kansas. and i would like to read the statement by the distinguished chairman senator hatch. warm welcome to our two witnesses here today. our first witness will be dr. giroir was confirmed by the senate by a voice vote, something that rarely happens come in just two months ago in february and is serving as her assistant secretary for the department of health and human services. doctors giroir hearing was not in this committee, but we are pleased his appointment as secretary opiate policy that brings him before us today. prior to his current position, dr. giroir was a physician, scientist and also an animator. the biotech startup ceo served in a number of leadership decisions in both the federal government and also in academia.

the rest of dr. giroir's professional career is far too long to describe here. he's quite a gentleman and let me just include a few highlights. each are the veterans choice act blue ribbon panel from 2014 and 2015. he directed the texas task force on infectious disease preparedness, responses during the ebola emergency. he was ceo of texas amm science center from 2013 and 2015. he directed darpa 2006 until 2008. he's authored or co-authored almost 100 peer-reviewed scientific publications and holds patents on a number of biomedical inventions. he holds a bachelor's degree in biology from harvard and a medical degree from the university of texas southwestern medical center in dallas. i am grateful and i know all members of this committee, this

committee will be the first congressional committee to hear from him and his capacity as senior advisor to the secretary and vital health and opiate policy. i'm also delighted to have cms can the brandt appeared before the committee. i was going to say we use to refer to cms, but she has certainly done best to make its cms. we'll forget about that remark. kim also has a lengthy list of credentials. she is currently serving as the deputy administrator for operations of the center for medicaid and medicaid services. prior to that she was here with all of us serving as the chief oversight council and the majority staff in 2011 to 2017. prior to that was senior counsel at holston and bird. after working for seven years as the cms director of the medicare

program integrity group. prior to that, worked for five years at the hhs office of inspector general, special counsel and director of external affairs. jim holds a bachelor's degree from university, master's degree in legislative affairs at george washington university and jd with the depaul school of law. so, talk about two very qualified witnesses. without further ado, let's get to the meat of this very important hearing. dr. giroir from which you get us started. >> senator roberts, thank you for that introduction. budgets first thing chairman hatch, all the members of the committee for holding this important hearing. the opioid epidemic is the most pressing public health challenge of our time. the data are staggering. each year nearly 12 million americans misuse opioids. according to the latest cdc

statistics, each day 125 american diet of opioid overdose is, predominantly caused by hair when analysts synthetic opioids like fentanyl. behind the statistics, i always see the individual patient, always because of the pediatric critical care physician by training and fully feel the pain of needless suffering and death. last week i met a a remarkable woman named misty islands. four years ago learned that her precious son had been found dead in his car due to a overdose. davis is president of the senior class, hall of fame in his high school and honor student and community volunteer. but his journey with addiction began with use of opioids from the family medicine cabinet to address difficulty sleeping. the story is just one example of why the department has made this crisis a priority and is committed to solving this type

of strategy. first come to strengthen public health data reporting and collection to inform real-time responses. second come against the practice of management and decrease the use of opioids. third, improve access to prevention treatment and recovery services. for, enhance the availability of overdose or bursting medications and five, support cutting-edge research that improves our understanding of pain and addiction leads to new treatments identified as public health intervention. regarding public health data from the cdc currently provides funding and scientific support with the tools to track and report opioids overdoses and deaths and to implement comprehensive prevention programs. states also utilize funding to enhance their prescription drug monitoring programs, which are an increasingly powerful tool to ensure safe prescribing practices and share information from multiple sectors.

cdc has received an additional $350 million in 2018 to enhance these initiatives. improving the practice of pain management is also critical because as the chairman pointed out, three or four people who use terror with this past year this year's prescription drugs first. the cdc issued prescribing guidelines recommended no greater than seven days of opioids for use in acute pain and the use of non-no good alternatives wherever possible. this guideline has recent educational efforts to raise awareness among providers and health systems have resulted in significant reductions of opioid prescribing nationwide already. to improve access to prevention treatment and recovery support services, substance abuse and mental health service administration administers the state targeted response video. crisis grants, which enable states to focus on areas of greatest need.

the program provided 485 million state and u.s. territories of fiscal year 2017. just last evening, we release funding for the 2018 allocation of another $485 million. because of the unprecedented funding requested by the president and appropriated by congress, we will provide additional $1 billion to states this year and the additional built and will be as likely in september. cms has a significant role in prevention treatment and recovery and a colleague, mr. angelo speak to the role momentarily appeared regarding the overdose reversing agents, vice admiral cheraw mountains, my colleague earlier this month issued the first surgeon general advisory in 13 years, which urged more americans to carry overdose agents like the locks on. hopeful funding strands are now in place and first responders to obtain the agent.

finally, hhs is supporting cutting-edge research. dr. francis collins has recently announced helping to to and addiction long-term initiative at nih and a result of new funding recently provided by congress. nih will double its investment in research on pain and addiction. in closing, the current opioid epidemic is enormously tragic, dauntingly complex, vastly widespread and scientifically and medically challenging. this epidemic respects no age, gender, race, socioeconomic status. the dems are sons and daughters, mothers and daughters, brothers and sisters, leaders and colleagues. solving this problem will require a wall of government approach. i look forward to working with you collaboratively. thank you very much. >> thank you for your most comprehensive statement.

>> chairman hatch and ranking member widened, members of the committee, thank you are invited to discuss center for medicare and medicaid services to address the opioid epidemic. i'm honored to be back at the finance committee so i will say it's a little strange to be at the witness table. over 130 million people received coverage through cms programs in the opioid epidemic affects every single one of them as a patient, family member, chair giver community member. this has been repeated throughout the multiple stakeholder sessions facilitated to discuss best practices and solutions. as a payer, cms plays an important role by incentivizing providers to provide great services to the right times. our work is cms is focused mainly on three areas. prevention, treatment and data. due to the structure of our program, medicare part d plans and state medicaid programs are positioned to help prevent improper opioid utilization by

working with prescribing physicians. our job is cms is to oversee the efforts and make sure that plan sponsors and the state have tools they need to be effective. beginning in 2019, cms expects all party sponsors to limit to no more than seven day supply, which is consistent with the guidelines issued for disease control and prevention. additionally we expect all sponsors to implement a new care coordination safety that would create an alert for pharmacists on daily usage of high levels. pharmacists have been keep out to confirm intent. thanks to recent action by congress, cms now also has the ability to allow sponsors to implement lock-in policies that limit certain beneficiaries to specific pharmacies and prescribers. cms recently finalized a proposal to integrate lock-in with her of her utilization

monitoring system to improve coordination of care. the administration also supports legislation which would require sponsors to implement lock-in policy. these new tools will add-on to existing innovative effort to track high-risk beneficiaries through all msn to work with sponsors to address pharmacies. we've seen a 76% decline in the number of beneficiaries with high risk criteria from 2001 until 2017 even while enrollment has been increasing. we also support state efforts to reduce opioid misuse. medicaid programs can utilize management techniques such as therapy, prior authorization for opioids. in this year's budget, cms proposed minimum standards for the medicaid review program, he told that we use to oversee activities in this area. in addition to prevention, insuring medicare and medicaid

beneficiaries have access to treatment is also a critical component of investing in the epidemic. making sure the right treatment for the right beneficiary in the right setting and we are working to increase access to medication assisted treatment as well as the locks on. the president's budget includes a proposal to conduct its demonstration to cover comprehensive substance abuse treatment and medicare for methadone treatment or a similar because current statue of them is cms ability, we are focused on ensuring access to other evidence-based. the administration is committed to treatment access for medicaid beneficiaries as well as our 1115 waiver authorities. cms announced providing more flexibility for states to withstand access to treatment. already we've approved demonstrations which include services provided to medicaid enrollees in residential treatment facilities.

as this committee knows, ordinarily residential treatment are not eligible for federal medicaid reimbursement due to the statutory exclusions institution. combined with the full spur job that services can we believe in a residential treatment flexibility is a powerful tool and we look forward to reviewing more. finally, cms is utilizing the data at our disposal to better understand the crisis and share with partners and ensure program integrity. this includes active monitoring of trends, sharing patterns to receive mask and other various efforts to ensure the impact of mist of our prevention and treatment policy. while cms has taken numerous steps to address the epidemic, we know there's more we can do. we appreciate the work the committee is doing to highlight the importance of addressing the crisis and look forward to engaging with you on the solution. thank you for interest in our efforts to protect her beneficiary to or to answering your questions.

>> thank you very much. in the order of arrival and the order of eating here, i think senator isakson -- i beg your pardon, it is senator portman. thank you, mr. chairman. thank you oath for being here. we've enjoyed working with you all on a number of issues. i want to start if i could talking about an issue that comes before this committee. we should let you know this is legislation that deals directly with a huge challenge we face with synthetic opioids coming into our country. we know it's coming mostly through the u.s. mail system. the subcommittee investigation said the year-long study of this. in fact, earlier, senator mccaskill was here who's very

involved in that. senator carper is the cochair. we reported back in january something shocking, alarming, which is if you go online and ask about opioids, people say we are happy to sell you synthetic opioids for senator the u.s. mail system because it would get there without any concern because the u.s. mail system unlike private care require the advanced law enforcement to identify these packages. 50% of the people who died in ohio of overdoses by a sense of overdoses. other synthetic opioids. the county that comprises came out with a report from last year. 47% increase in overdose deaths. two thirds of those related to fentanyl. this is a huge crisis and it is amazing to me that we are allowing the united states post office to be able to continue to

not provide the data they need to find a needle in a haystack. we introduce the legislation back in february of 2017. it is 32 cosponsors include a number of members of this committee on both sides of the aisle and i am frustrated as the chairman knows that as the staff knows we can't get it out of this committee. there's a companion bill in the house. it common sense legislation. is it the ultimate answer? no. the legislation which senator whitehouse tonight authorities working on treatment of recovery and prevention hoping arcand. that this is a clear and present danger and we are not addressing it. we are allowing people to have access to fentanyl in our communities and at a minimum if we could do more in terms of stopping it coming in through the u.s. mail system. i would ask you about this. are you aware of this issue and are you supportive of the stock

back. the custom border protection people law enforcement and would you be willing to help us to get this done? >> thank you for that question. i want to reinforce how critical the limitation of importation of fentanyl and similar drugs are to our fight. in the hospital setting, to use fentanyl in icu in anesthesia by trained people in the thought of this speed on the street but did deadly potency is absolutely frightening than astounding. we would be very pleased the crew worked closely with customs and border patrol as you know. they have increased capabilities and a number of investigators that they have in order to stop the importation of fentanyl and kara fenton also it does not enter our supply and of course

we would be very pleased to provide technical assistance and to work with you collaboratively because any efforts that we can do to minimize fentanyl getting on the streets will greatly aid our fight and prevention and treatment. >> thank you, admiral. the staff on this committee and leadership to this committee hears back then i just think it is one of those issues that we should be able on a nonpartisan issue to address in address quickly. i noticed a cms recently finalized a call letter which had a prescribed limit for medicare beneficiary patients with acute pain. not talking about cancer. talking about acute pain. as you know, senator whitehouse is here. we set a three day limit. we do that because what they have told us which is the fourth day there's a much higher chance of someone becoming a tape date

and also with regard to pain, with regard to acute pain and that is typically not viewed as necessary from a scientific point of view. how did you choose a seven day rather than a three day limit? >> thank you for that question, sir. he was consistent with the guidelines. the center for disease control has a guideline that says the limit is what they recommended at the top end. we got public comment on it and they supported us and we were really trying to strike the right balance. we think it will be sufficient and that is certainly something. it doesn't mean that's what it has to be. >> i would ask you to do care what they say about the fact during the fourth day remarkably because it is based on science and it might not seem common sense to some people. during that period of time after one, two, three days there is a much less likelihood of

addiction during the fourth day. i hope you take another look at that and consider a three day limit again for acute pain. go back and get another prescription and explained to the physician as prescribing it why that is necessary. if you look at what is happening in my state and states around the country, almost or one who dies of an overdose starts with prescription drugs still. .. we have a public health calamity on our hand.

thousands of death, a trillion dollars since 2000 in terms of trying to pick up the pieces financially, and i reviewed your written testimony and it almost suggests that the opioid epidemic happened by acidosis. it completely puts the role on manufacturers who put greater emphasis on increasing sales rather than protecting the patient. you state in your written testimony well-intentioned healthcare providers began to prescribe opioid to treat pain in ways that we now know are high-risk and associated with opioid abuse addiction overdose. it is hard to believe that train physicians would just come up on their own with

these pervasive overprescribing practices. in your view who told the physician that these doses, these amounts were acceptable. >> thank you for that question. what i can tell you is i was part of the generation where my teachers, my professors told me, taught me that prescribing opioids in the setting of pain would not be addictive to the patient. we did not, within the medical culture have the appropriate information, nor was it transmitted. opioids were prescribed based on what we knew. i cannot tell you how this started. that's a question or an issue

for the committee or other component. >> so you don't think the fact that the manufacturers tank rolled patient advocacy groups and experts who played an outside influence on these overprescribing practices had anything to do with it? i keep related evidence, one person has actually been remove removed. do you think that has contributed to this problem? >> i am not here to defend or to place blame on any singular group. i will say there was a confluence of factors that led to this, clearly opioids were overprescribed. there overs prescribed by well-intentioned physicians and we now understand that

this problem which led to heroin and fentanyl really started with prescription. >> we are committed, here on this committee, the chairman and i have talked about this, but, being bipartisan, but we have to make sure we get the roots of the problem right so we can pull them out and get on with the correction. i just want to wrap up this round with one question for you. to me, opioid manufacturers through twisted research, deceptive marketing, and bought and paid for patient advocacy groups had a significant role in fueling the crisis. you will be the point person for the trump team. do you share those concerns that i've mentioned? >> i am doing everything in the department is doing every thing we can to limit opioid prescriptions now to only when

opioid prescriptions are important to the patient. we are supporting non- opioid use. we are supporting alternative care. absolutely i agree with you that it needs to be decreased, we need better information, a key pillar of what were doing is trying to decrease the unnecessary opioids. i do mean this respectfully, how we got here and who was responsible i think is a matter for the committee and others. >> i want you to have the chance to respond in writing, because i don't think we got here by just well-meaning people saying gee, maybe i don't know how much to prescribe. i think there was a strategy with the opioid executives and i laid it out. it was research, except of heights that downplayed the

harmfulness and stacking these advisory committees where they could. we will leave the record (if i could just get one question in for misprint. medicaid largest pair of substance abuse disorder service in the country cover for ten who suffer in the states ravaged by the epidemic medicaid pays nearly half of the treatment. medicaid expansion is clearly going to be a major tool on the ground, and yet i'm having trouble squaring the administration's commitment to expand the access to treatment with the budget proposal to drastically cut the program and rollback the medicaid expansion. now, were not over here saying money is the sole answer, but i'm going to put into the record some programs that dollar. dollar will make a big difference in michigan and ohio and the states were my colleagues and oregon where

their fighting this epidemic and i would just like, i'm over my time but i would like for you to tell us how, when you/trillion dollars in medicaid funding for these lifeline programs how are we going to be able to work with the state to address the epidemic. >> as i mentioned in my oral testimony, we are really committed to working with the states to allow them as much flexibility as possible to use the resources and maximum benefit so they can provide the right treatment to the right setting. we have additional money that has been appropriated to go toward the weight opioid epidemic and some the additional grants i have just gone out. we are committed to trying to continue to get as many resources to put toward this problem as possible. >> thank you. >> thank you, mr. chairman. it's nice to see you in this role. welcome to both of you. first, to follow up we could

talk a lot about the budget. it's great that we were able to get the additional dollars for opioid and mental health services. one bright light consistent in the present budget as well has been the strong and consistent support for the addiction treatment services and i thank you for your involvement working in a bipartisan way with senator blunt and myself. as part of the opioid crisis, the 2019 fy 2019 budget also explicitly endorses the demonstration. this is really creating clinics like we do for health centers so we have permanent structures on the ground and eight states were were doing that now, a lot of what

they're doing is opioid treatment. it's a very important long-term way to treat this. as we in the finance committee contemplate the best approaches for addressing this crisis, with the secretary agree that the expansion of certified community behavioral health clinics to additional states as the president's budget proposals, is one important way to address this. >> thank you for the question. as you know, we have been very supportive of doing innovative approaches and we believe that the centers are part of that innovative solution. that's why the budget proposal includes the extra money and we think this is an issue where no amount of resources in terms of things like this we can target it can be ignored. this is a very valuable tool that we think can help with this crisis. >> thank you. i look forward to working with you. >> let me talk specifically about a critical part of the

question of treating people right now involved with opioid addiction, with possible overdoses, with what is happening in this relates to the question of mark's own you not only availability but when we talk about root causes, i just want to take a moment to lay out the fact that melodic sound was approved by the fda as an opioid overdose reversal drug in 1971. generic versions have been available since 1985. for a while, prices went any issue. in 2005 there were two manufacturers producing a generic version of it and it cost a dollar. vial but by 2013, both companies were selling the drug for 15 times that amount as the need when up, the price

went up. that's very concerning to me. the autoinjector was introduced, the first product approved they came on the market with $690 for a two pack the price of the generic injectable also went up a little bit that year. more need, prices up. later the price increased to $4500. in 2015, the nasal spray version of the drug also approved by use without people

of medical training came on the market for $150 for two pack that i just want to stress the actual drug was approved 47 years ago. the drug was approved 47 years ago and as recently as 2005 you could get vial for a dollar. now taxpayers, in order to support police and fire and medical personnel and others are going to be spending thousands and hundreds of thousands of dollars in order to address what is an extremely concerning price situation and lack of accountability. i just want to ask, this month the u.s. surgeon general called for more people to carry the drug and you can get it without a prescription and we have this price now skyrocketing. doctor, you are responsible

for coordinating hhs efforts across the agency to fight the opioid crisis. the commission on combating the opioid crisis recommended that hhs use its negotiating power to reduce the prices on behalf of our government and our people to bring prices down. think we all want to know, will you use that power to negotiate what is an uncontrollable situation with no accountability and frankly i think the drug companies are taking advantage of the pain and suffering and loss of life in this situation. >> thank you, senator step it out. i appreciate the fact that you are helping us highlight the importance of the locks on. the locks on does not solve substance abuse disorder. it does not get to the root cause but it is a critical drug that brings life back to the person on the brink of death. let me give you an update of where we are.

the state targeted grants that i talked about has increased flexibility for the state to use more of that money. >> that's. but i'm out of time, my question was bringing the price down. it's great that were using taxpayer money to pay for these outrageous prices but something that was on the market for a dollar an hour talking about these huge price increases. they want to negotiate the press price for americans and bring the price down. >> the nasal version which is increasingly the choice reversal agent for first responders is fairly significantly discounted and

now to the level of a gsa schedule. all states and localities are doing that for $75 for the two pack which is consistent with the gsa schedule. >> i'm sorry, chairman is telling me too stop but i assume your answer is no. you won't be negotiating the best price because i'm not hearing a yes. >> we are now getting that at the gsa schedule. the fda is looking at all aspects to bring it over the counter and to increase the generic competition. that is our current strategy right now. >> it started at a dollar and look at where we are now. i think it's outrageous what people in taxpayers have to spend. >> i would just observe that the senator would never advise

they distinguish chairman emeritus of the agricultural committee to stop with regard to her advice and consent. [laughter] >> senator cassidy. >> thank you. >> thank you both for being here. i am part of the healthier communities initiatives and i just want to thank the folks back home. my question is for you. i spoke to the father of the 17-year-old man who eventually died but when he first went into treatment he was asked by the insurance company to be released two weeks after treatment began. the fact that he died indicates that this was not an effective strategy. then i contracted with my next conversation which is if you're an impaired physician in louisiana there's a minimum of three month inpatient therapy in one mont one month

follow-up before you're allowed to practice once more. after two weeks they were asked to leave. lastly i spoke to another physician. first there's a certain number of people who die from methadone overdose and secondly about the version of the drug. i'm going to use that and work backwards. nice to see a louisiana guy who does well. it's nice to have you here. i know how to pronounce your name even if others don't. >> as you know, there are some forms of medication treatment coming onto the market. the nexgen products are provider administered so they never go into the hands of the patient, therefore cannot be

diverted as i have learned that it is being diverted. the law is unclear whether the pharmacies can dispense with medication directly to the provider. current losses it has to go to the patient. it makes sense you want the brother picking it up. dea has interpreted this as saying you cannot give it to the provider to then do the importanimplant and divert the potential for diversion. senator bennett and i have legislation on the help committee that would address this problem. can you go back to the department and see if you can get endorsement of our bill. >> certainly, i will go back to the department and discuss with the secretary. i want to state certainly that medication assisted treatment is our best route going forward in commendation with

behavioral therapy to treat patients and yes, i will go back to i'm not familiar with this pacific bell, what we will go back. >> we agree there certainly abuse potential for the drugs used. >> there is abuse potential for the drugs used, part of the drugs. there is potential abuse with drugs as you pointed out. >> i'm struck, let me ask you, i've noticed in some locale there's less prescription opioid that there's no decrease in the number of deaths from opioid overdose. it suggests that it is illegal drugs replacing or backfilling the loss of opioid prescriptions. is that what your data showing? >> i'm actually going to

differ on that one. >> yes, the prescription opioids have been a gateway in that three of four people who used heroin started that way but clearly the deaths are far overshadowed by heroin in fentanyl. >> in those areas, are we seeing fewer deaths related to opioids? >> the data we have is that mat is more effective than non- mat in preventing death and providing long-term recovery. i do not have geographic data that correlates geographic use with a lowering of the death rate within that geography. i will go back and see if that data is available. clearly it's associated with improved outcomes. we tend to believe that the case but we need to verify those two things go together. >> i keep going back to the 17-year-old boy who was asked

to be discharged and is now dead. something's not working. i thought this question might be for you. it may not be. do we have a way to track which treatment programs have better outcomes versus those which do not? if empirically i can say a physician with three month inpatient then followed up by the outpatient works but being discharged two weeks after being admitted and then ultimately dying maybe doesn't. we have best practices on this? are we doing a proactive follow-up? rehab is doing really well but data rehab, not so well. >> we are starting to accumulate that type of data. our new medicaid information system and results of the demonstration product project we been doing. >> let me interrupt. is it actually getting

populated with state data because my understanding states were not as aggressively populating that as they should be. >> we are getting states, we have 49 states and the district of columbia and their actively reporting. >> that's great. i yield back. >> thank you, mr. chairman. first i want to concur with the comments that senator portman and senator wyden on the misuse of prescription opioids management of pain. to the senators.on the cost of medicine, i think all those are important aspects of dealing with the opioid crisis. i've been around the entire state of maryland and we have opioid problems in every part of our state. they are in desperate need of partnerships with the federal

government. i want to talk about another option that's becoming popular. both are impeded by our reimbursement structure. we don't have an integrated care system that reimburses. you have to find creative sources. one of the more successful options has been peers support services. those that are recovering from drug addiction help get those who are in need to the appropriate care center. the problem is there's not a

reimbursement structure, a lot of this year defined third-party sources to fund it for creative ways or hospitals coming in to help us because they know this will affect their emergency rooms. what i'm looking for is whether we can find a way to encourage these types of services. let me stop at that. what can we do at the national level either in changing our reimbursement structures or providing direct funding. you look at the grant funding available from the federal government, it's really difficult to get support for peers support services. >> i'm actually going to take this one because it impacts a lot of the medicare and medicaid programs. we agree with you that the services are key part of the continuum of care. one of the limits, you asked about what can be done, one of the challenges is that a lot of these types of services are not covered or not considered a provider for purposes of medicare.

broadening the definition of what is a medicare provider to be able to encompass these types of services would give us more flexibility because currently the statute does not recognize them as appropriate medicare providers. we have seen some success with this and states, as of 2016 there are few states that are covering peers support services for substance abuse and that's also something that could be encouraged more in a few states but on the medicare side we would need to expand the provider definition to better cover it. >> i look forward to working with you on that. i think that is clearly a very fruitful model. other states that are changing, they don't need waiver, they can just do it under their current authority. >> that's correct. if they hit roadblocks, we will work with them. >> the other area which is relatively new and has some concerns are stabilization centers that tried to get

individuals who are stressed out of the emergency rooms where they sometimes, it's affecting the access to emergency care into a facility that can refer them to the proper care that they need in a more appropriate setting. we have now to stabilization centers in the state off marylan maryland, again, the reimbursement structure doesn't provide for this, is there some way that we could try to encourage the appropriate placement of those that are in stress so they can get referred to the appropriate care? >> either one. whoever feels more confident. >> that is something we could work with you on. it's not something unfamiliar with directly but we could definitely work with you all to find out more about that and how we can help. >> we've had a couple of our communities saying that they want to take care people, but

their security issues with people who are coming out of an overdose that requires security, but also compromises the ability of emergency rooms to do their intended purpose in that these individuals, what you really need is follow-up care. their life is no longer being threatened, but they need follow-up treatment and care, and yes, we need more community-based centers, but we also need to get the individual the appropriate, when we have their attention, the appropriate placement. we hope there's an alternative to using the emergency rooms. >> we certainly hope so. the emergency room is great for emergencies, but it's not so great for every thing else. we certainly support

community-based programs, the grant that we have have a large amount of flexibility for states to both institute programs and test programs, and increasingly, as you suggest, with the numbers that we have, with millions of americans misusing opioids, probably 2.4 million with substance use disorder, we have to change the way we do things. it will have to be outpatient based primarily with the inpatient services primarily reserved for people with severe mental illness as well as the opioid part we have to train more behavior health professionals, not just psychiatrist but levels all through the community and were all on the same page here and we'd be delighted to work with you. >> thank you for that. i look forward to removing the roadblocks that we have in the system that prevent communities from pursuing innovative ways, less expensive ways and more effective ways to deal with those that are stressed.

>> and in my new role, if there is a road roadblock, i want to hear about it because part of my job is to make sure that hhs is listening and understanding and can be responsive to those needs. i would appreciate that direct feedback. i mean that sincerely. >> thank you. >> senator menendez. >> thank you, mr. chairman. misprint, children whose families have been impacted by the opioid epidemic experienced trauma when their family structure breaks down. one program that's important to new jersey in helping these children is the family first prevention services act which allows states to draw down funds for evidence-based practices such as mental health, substance abuse treatment, parenting programs as well as kinship navigators to help grandparents. given these programs span multiple hhs agencies, collaboration is critical. for instance, new jersey has a mommy and me program that allows mothers and treatment

for substance abuse to get inpatient treatment without giving up the custody of their children. i believe programs like mommy and me help avoid the trauma of taking children away from parents, help keep families intact, the family act allows states to draw down funds starting on october 1 of this year, but we are still awaiting guidance from acf and cmf on how to make that work. my question is, can i count on you to work with acf to get back items out in time for states like mine. >> certainly. we are happy to work with them to make sure we are coordinating to get back items out. >> in your joint testimony you talk about the role of medicaid data. some states have been able to take the medicaid data and analyze it to inform their intervention approach. given your statements about the value of medicaid data to

address this epidemic, do you see value in these types of proactive analysis? >> speaking for cms, we absolutely do. as i mentioned in my opening statement, data is one of the three main components of the cms opioid strategy paid we now have 49 states and the district of columbia and puerto rico reporting in to our medicaid statistical information system and we are using all of our data across to target how we can better do prevention and treatment. we really want to be able to give feedback to the states and others. >> that was when to be my second question. how is cms working with states like mine to support these types of activities? >> a couple of different ways. we certainly correlate with states on the date of a report in through their program, and that allows us to take the pharmacy pile which is all the claims related to things like prescription of opioid and really be able to help tell them where we see patterns and

work with their information that they get from their prescription drug monitoring program to more detail how we can do intervention. >> i know you also mention the medicaid accelerator program. does cms have plans to provide others with technical assistance. >> we are certainly continuing to offer ongoing support to the states and we think that it's something we want to have more technical assistance and support to provide on that program. >> do think additional federal support would be beneficial to better support these types of activities? we really think we want us support ongoing payment and we are really looking to see how we can continue to look at different program innovations and how we can best support. >> we would like to follow up with you. finally prescription drug monitoring programs have been helpful in curbing the flow of opioids, but according to the

american journal of managed care, pd mps are not necessarily associated with a reduction in overdose. i think this may be due to the fact that individuals already addicted will switch to illegal narcotics as their supply of perception painkillers is cut off. what opportunities are there to prevent and opioid addiction from becoming a heroin addictio addiction. >> thank you for that. first of all, i want to say that pd mps are rapidly developing. i think they are very important tool in the cdc is supporting states to further utilize them. i think the next level is to not have a pdm piece it on the side but the integrated workflow of physicians and other providers which is sort of the next level. how to prevent people with opioid use disorder from going to heroin is to clear matter of treatment. we have to get people into the

appropriate treatment. we have to stage them early. we don't want to wait until there on heroin and fentanyl and come into the emergency room. a lot of the state targeted grandson the technical assistance is really working on that question specifically. i agree with you one 100%. >> i hope that the congress did in the omnibus will help us focus a significant part of money for that purpose. >> yes, sir. the omnibus extra billion dollars, we hope that gets out of the state in addition to the original cures act that was released yesterday. >> thank you. >> senator to me. >> thank you, mr. chairman. misprint, welcome. we all know that medicare is the largest purchaser of prescription opioids in the

country. i was a little shocked to learn that in a typical year, 2016, one out of three beneficiaries received and opioid prescription, the doctor but it's just counterintuitive to me that one out of three people need to be given a drug that so powerful and so dangerous. it's furthermore surprising that medicare actually pays more on a. patient basis for opioids then either commercial insurance or medicaid. so, over $4 billion on opioids alone in 2016. i really wonder about the total consumption levels. i know that medicare and medicaid have overutilization monitoring systems. i know there has been some progress with respect to the people who are being tracked but i am concerned that the overutilization monitoring

systems are monitoring a tiny percentage of the people that should be monitored. i say that because in november of last year the gao identified 727,000 people, medicaid beneficiaries that they believe are at particularly high-risk. 720,000. the oig determined 500,000 were receiving high dosages of opioids for at least three consecutive months and this excluded cancer in hospice patients. the monitoring system covers something on the order of 60 to 70 beneficiaries. i'm wondering if the right number wouldn't be high based on the oig reports. so, what you think of the

number of folks that are being monitored compared to the folks that ought to be monitored? >> a couple of things, thank you for the question because this is an area we where we have been working to improve our oversight and see how we can address the concern. first of all, the oms system only covers part d beneficiaries which is a subsection of our larger medicare and medicaid population. as a result of that feedback, we significantly strengthened and significantly improve our ability to do but it's an oversight through the lms system which, when we reran the oig beneficiaries they had identified, it enabled us to show we caught over 85% of them with our new improved expansion of the system and with the additional edits we put in place. we've been continuing to implement the cdc guidelines, our new safety edits and a

number of other coronation edits are really good at that but were looking at how we can expand this to cover the rest of the program. >> can you send us the backup documentation on that. >> sure. >> it looks like we're falling way short of the total goal. to go to a specific subset of folks, it's my understanding, anyway that people who experience a nonfatal overdose , that that experience alone is not a sufficient criteria for being part of the system, that by itself it's not sufficient, but yet we've had a spike in nonfatal overdoses, my understanding is almost half the time there is a nonfatal overdose that precedes a fatal overdose so it is obviously a very dangerous event. should a nonfatal overdose in and of itself be sufficient criteria for including someone?

>> i'm not a doctor, i can't speak to whether that's an appropriate criteria for us but i think it's something we want to look at because we consider the continuum of care to be very important and we want to make sure there is that coronation. >> do you have the authority to adopt that as a criteria? what would it take to adopt if that's an appropriate criteria, what would it take to make the criteria for inclusion. >> i'm happy to go back and get to you exactly what it would take to include that. >> to have any thoughts on that. >> i'd be happy to go back and look at what authorities but clearly a nonfatal overdoses a risk factor moving forward. >> as it stands today, that is not a sufficient criteria for being included in

overutilization monitoring. i'm not a doctor either but that is extremely counterintuitive. >> we certainly will take that back and provide responses. >> thank you very much. >> senator mccaskill. >> thank you, mr. chairman. in reference to the ranking members comments about the contributions by the manufacturers of opioids to the policy groups, we have been investigating the manufacturers of opioids in the government oversight committees, we have issued a report that shows for example, the american academy of pain management receiving big money from opioid manufacturers and then coincidently, they actually issued the statement that said that they were not opioids were not significantly addictive. i would like to enter that report into the record, i think it's important that the work we've done on that

committee be added to this hearing record because it's relevant. >> without objection. >> there's another report we issued about a fentanyl manufacture who their internal sales after we got into the documents and started really getting into the weeds, their internal sales slogan was start them high and hope they don't die. they had a fraudulent unit within the company that was posing as doctors offices and actually calling pharmacy managers to try to get approval for fentanyl, this was, i would like that report also to be made. >> without objection. >> am pleased to say as a result of a lot of work, but after this report was issued the ceo of that company was criminally arrested which is major progress. we are continuing to look at

the manufacturers on how they been contributing to this problem for the next report we will issue is on the distribution of opioids which brings me too opioid misuse and the failure of cms part d to actually require the plans to submit to you potential fraud and abuse. is there some reason why you are not requiring the plans to give you the evidence of fraud and abuse they uncover. >> i really appreciate that. we have been re-examining it and exploring making that mandatory so there would be mandatory reporting. >> i just hope the exploration doesn't take very long. we have people dropping dead in my state everyday. talk about common sense, why would this be hard to not do immediately. what studies would you need to do if a part d plan that is making money off your program at the taxpayer support is not

recording the fraud and abuse they find, then what chance do we have a really getting a handle on this? >> we are working to see how we can begin to implement that. >> i think you implemented by saying we will have a role that you have to report fraud and abuse. can you do that sometime in the next 30 days? >> i will get back to print a national we can do a role in 30 days. >> what you announced are doing a role in 30 days. >> i'm happy to get back to you. >> this hands-off with these pharmaceutical manufacturers and companies, senator stevan now, really, drug that's been around 47 years ago that life-saving increases from $690 in 2014 to $4500 at the beginning of 2017, more than six 100%? where's the outrage? where is cms in this? this hands-off for this incredibly unconscionable

price increases that are not driven by r&d, there driven by greed, unadulterated greed in an area where people are dying so i think it's great, sir, that you got 75 bucks but what about the family who has a member who they know is addicted. how much is it costing them to get the medicine part how can they afford it at a price increase of more than six 100%? why are we being more aggressive and going after these companies that are doing this? what is there excuse for raising these prices? they know they can make more money. is there any other excuse they've given you? have you asked them? >> no i have not asked him. >> would you asked them. >> sir, would you ask them why they're raising these prices this high. >> yes, we are, we want it to be more available and affordable. there's absolutely no question about that as well as the

nasal spray. the prices are going down for that, as we talked about before but we will do everything we can to increase generic competition, to potentially have a over-the-counter to promote competition to lower it even further. this is the predominant form is being used by states and first responders. seventy-five dollars for two doses but i would love to see a lower and work on mechanisms to do that. >> this product jumped from 690 up to 4500. i was in three years. i would really appreciate you either telling me yes or no, will you write them a letter asking them why the price increased by that much heard what was their justification for the price increase. would you do that? >> i will get back to you on whether i can write a letter. let me just tell you, the $4000 doses are not being used

primarily by first responders. >> i'm talking about families trying to save their family member lives. you know how many parents i talked to walked into the bedroom and the child was overdosing and they had nothing, they can afford this drug to save their life, they may need it before the first responders get there. i just want you all, this hands-off deal of our pharma is wrong and i want you to be as mad as i am about it. >> so, i am absolutely aware that it needs to be with families, and again, the inhaled version is generally preferred and useful because it's easy to administer, it's a new form so, i agree with you it needs to be less expensive, but now we are at $75 for two life-saving dose doses. >> for first responders. >> you right. >> i'm going to hold you

accountable on the sprint i want you to write the letter. i want somebody at cms to begin to express the outrage toward these pharmaceutical companies that i hear from missourians everyday. thank you. >> thank you, mr. chairman. no state is immune from this issue. our state doesn't have some of the data that other states have in terms of the prevalence of opioid use disorder. fortunately, for us we do have lots of substance use disorder issues which our governor is trying to address and obviously we are very interested in working with the members of this committee and others of our colleagues and doing everything we can to take this issue head-on. i do want to express my appreciation to the chairman of this committee to help ensure that our committee activity addresses not only the opioid epidemic but substance abuse disorder

broadly. i hope that our witnesses will also keep this issue in mind as you continue your efforts to courtney the department's activities. invasive provider shortages, health systems have worked to innovate through telehealth, several centers have been working on the connect for health act which has the broad goal of expanding access to telehealth and patient monitoring services. one provision that would provide the secretary of hhs authority to waive certain medicare restrictions in current law for telehealth would reduce spending or improve quality of care. we are hopeful this is something the department would have an interest in particularly as a means to expand access to opioid and substance use disorder treatment. is this something the secretary would support and are there other opportunities that you are looking at administrative lead to expand access via telehealth?

>> thank you for the question. i certainly want to reaffirm that telehealth is part of the solution. we have to get into an outpatient mentality, we have to recharge where patients are in their community and i think telehealth is a critical and important tool. the one thing i would say that we are exploring and working with our dea partners on now is to be able to expand not only telehealth treatment but telehealth medication assisted treatment so that can be given by a qualified provider across telehealth and monitored by a variety of different professionals. i think that's really the next step that's important. we are in very active work with dea to see how we can make that come about in a very short-term. >> in your written testimony you highlighted the important work being done by the nih to advance the research and availability of nonaddictive pain medications and devices which i applaud, and i know

the health community is working on further proposals in the space. has cms put in place procedures to ensure timely medicare coverage determination of new therapies once they are approved by the fda? >> yes. that's a great question. because we know the importance of this, we have been working on a parallel process with the fda so as the fda determines whether it will be a drug or device that's approved, we are parallel looking at coverage and reimbursement on our side so hopefully once the fda approves their piece we can them very quickly move into getting it approved for medicare. >> it seems like a big part of the solution to this problem. one last question, the health service does not fall directly into this committee's jurisdiction but i'm sure you are aware many south dakota tribal members are also eligible for medicaid which is the single largest pair for behavioral health services. through your efforts to courtney the department's response, what recent engagement has taken place

that tribes and other stakeholders working with them to address substance abuse disorder and tribal communities has a national committee on heroin opioids and pain efforts made any changes or suggestions for improving access to culturally appropriate treatment? >> i can send the two weeks that i've had this position i probably met with ihs three times including an eight hour principal retreat that hhs with the director of the nih, fda, ihs and deputies cdc, myself, the secretary were altogether working together and focusing specifically on what we can do to support each other throughout this process. as you know, because of your passing the $1 billion that's coming through the omnibus which will be released in september has a specific 50 million-dollar allocation to the tribe specifically.

i think we are highly correlated and sensitive to the. in my other hat job, our office of minority affairs which focused on culturally and linguistically appropriate has, even in the last week has done visits to ihs and multiple tribes to make sure the grassroots level is reaching them. >> thank you. i hope you will continue those efforts. >> senator heller. >> mr. chairman, thank you. i want to thank you in the committee for putting together this particular hearing. it's important for my states and across the country and i'm pleased that we have this opportunity. for many nevadans, substance abuse is an issue that hits close to home.

it's an issue i read about in letters and i hear about and calls to my office. like many my colleagues, i haven't heard from those who are struggling with addiction or those who have lost loved ones to this epidemic. in my home state of nevada there were 665 drug overdoses in 2016. in that same year opioids were involved in over 40000 american deaths. those are statistics i'm sure you're well familiar with. opioid abuse is a major public health concern, more steps need to be taken and i'm sure we all agree to ensure our communities are equipped to address this crisis. i am pleased to have the panel here before us and i want to welcome me back to the committee. it's great to see you. i want to thank both were witnesses for taking a few moments of your time to be with us today. would like to start with you, i just had a meeting in my office, i met with the boys and girls club of western nevada. others say they were discusse

discussing their afterschool activities and the programs they had that were available to these young adults. there were talking about some of the programs and in particular when it comes to trying to prevent students from being involved in drugs all and opioids in particular. i'm just curious as to what the department has in mind what the department of health and human services is doing working, any work they're doing on early prevention. >> you highlight a very important point. rbc prevention is where it's at. once you're addicted to opioids, it's a long road even with the best therapy and cognitive behavioral therapy. a couple things regarding that. number one, we are in the middle of assessing what are the best ways to reach them based on age, based on where they interact include active

ongoing effort with the cdc and other parts of our agency to target information across the board. secondly, the state targeted research, the grants that i spoke about has a significant component of prevention that we could support state activity because as you stated, every state is a little bit different and has different organizations that need to be supportive and reach those so i absolutely agree with you. >> who directs those dollars. once he gets down to the state level, if the needs are at the school level, education level, dollars or does hhs have a program with the educational system to get those dollars down there? i just want to know who moves the dollars and if every state is a little different, how do

we get those dollars to the place they need a most. >> you may have programs in this as well but these specific grants are awarded to the states and the states can subcontract with any variety of organizations they want to fulfill their missions with those dollars. it will be very similar, highly flexible funding, we want to make sure there's actually prevention and treatment that's covered, but aside from that the states have tremendous flexibility to subcontract. >> i would just jump in from the medicaid program side, i'm sure you're familiar with the early and periodic screening, it's mandated that they provide prevention and other types of services for children and adolescents up to age 21. that's another way through the medicaid program and the flex abilities that they have that they can do that. >> that's helpful. >> i just want to emphasize a couple weeks ago the president issued an executive order on sports participation for the youth and i look at this is a great opportunity for youth sports participation and underserved communities but to have that as a platform for

health that we can have many messages about proper nutrition and opioid abuse. >> will ask about electronic prescribing. senator bennett and i introduced every prescription securely act. i have a letter and like to submit for the record, 20 groups and organizations to support this particular piece of legislation. i guess the question is, to you, what impact would electronic prescribing have on addressing the opioid epidemic. >> there's a couple things. first of all i would just note we had a number of stakeholder sessions last fall with various stakeholders across the session and e prescribing was one of the top four things that came across all the stakeholder sessions. we really think the data from that is very important, it has a lot of benefits to the plans, pharmacy, prescribers and the states. it also is something that are

part d sponsors are required to support as part of their participation in part d programs. i think it is something we think has a lot of potential and were aware of your legislation and we'd be happy to continue to support. >> thank you for taking my time. >> thank you senator heller. >> welcome. i appreciate your parents. i've been writing down the number of times the two of you have said that's a great question or i'm graduate affect question or that was important. like over 25 times so far. that's a record. i was just wondering do you ever get questions that you say you you want to say that's a dumb question or why are you asking that question. maybe not here but maybe some other committees. don't answer that question. [laughter]

they talked about electronic prescribing. i want talk to that sounds like electronic prescribing but it's quite different. it's electronic prior authorization. their patients and providers who often times russell with prior authorization requirements for medication, assisted treatments for opioid abuse and increasing the odds of these patients will relapse and return to their use of opioids. what increasing use of electronic prior authorization and medicaid and medicare, private health insurance plans help improve access to medicaid medication assisted treatment and what you need from us in this committee and congress in order to increase the use of prior authorization for medication assisted treatment? i think senator roberts, if you were here he would talk about legislation that he and

i have actually collaborated on, but let me just ask you, what do you think? >> from our perspective we think there is great. potential for prior authorization. it's something that data. >> you go as far as to say you're glad i asked this question. >> i decided not to say that but i'm glad you asked it. it is something we been looking at and we think is another potential good tool that we have along with e prescribing. anything that we can do that helps us be able to see, in real time what happening and what's being requested, especially if it helps us be able to tell who's requesting different types of services. that's very helpful to us from the program management perspective. >> you could argue with jus what she just said? >> i do. : :

probably the right thing to do. i have another question. i'm a recovering governor and when i was governor of delaware for eight years, we establish a cabinet council and it would include basically half of my cabinet secretaries met every month. we developed a strategy we pursued for eight years to strengthen families basic building block of our society rather than just address the symptoms and the root causes. several people have mentioned today root causes. as we confront the opioid epidemic, on a focus not just on treatment, but also the root causes for this crisis. our child and an expert does the individuals of mental health

conditions. child experiences are at greater risk for abusing drugs. hhs and cms to ensure at risk children families have adequate access to early mental health treatment and intervention that can reduce drug abuse and addiction and how can we make better use of tele-health in medicaid and the chip program in order to improve access, especially for at-risk children. >> so i think from our perspective we absolutely agree with you that it's important to get the right services to children. as i mentioned, one of our mantras at the opioid epidemic is right services to the right person in the right setting and making sure particularly children through our medicaid program would do the eps program, which allows us to do prevention services family look for ways to expand mr. tele-health, particularly rural areas where they just don't have as great of access to

be able to use that as an important tool as part of our fight of this epidemic. >> dr. giroir. >> i agree completely. we are very actively looking at demonstrations particularly for children that would co-locate mental services with physical services and really been working with our academic and nonprofit partners to do that, expect dean that is very important and one way we can do that. having been in the children's hospital for many years, i understand the importance of that. the second issue is there are degrees of susceptibility and i absolutely agree with you. mental health come out first child experiences always make it much more likely. the point is everybody in this room is susceptible to addiction. if you are in prescription opioids for too long, it is like asking yourself not to breathe. after a while you can't do it. i want to make it clear you're

absolutely right when he did target the high risk. we need to co-locate services that everybody is at risk. >> thank you very, very much. >> admiral, good to see you again. thank you for being here and for your distinguished service at two great texas institutions. texas a&m in addition the united states military. ms. brand, good to see you. i'd like to talk about the elephant in the room. his and opioid, admiral? >> yes, sir. when people can't get them do addicts recurrently resort to heroin? cheaper, more readily available? >> yes, sir. >> with the addiction it produces is just as bad, maybe worse than prescription drugs. would you agree with that?

>> the addiction is the addiction. the consequence of as they are much more severe because of their potency. yes, sir. >> are you aware one of the major sources of heroin into the united states is across our southwestern border? >> it is. that's for sure. >> along with tens of contends methamphetamine, tons of, but i know we are talking primarily about opioid. i've heard it described to me recently by the head to southern command, the combatant commander in charge of that region of the world. he said the criminal organizations that traffic in drugs, poison if you will into the united states, that addicts so many americans are commodity agnostic is the way they put it. though traffic in drugs,

children, whatever will make them a dollar. that's all they care about. they care nothing for the human misery that they cause as a result of their illegal activity which is why it causes me great pain and disappointment to see when congress has an opportunity to live up to its responsibilities to provide the funds and the means by which to provide greater security along our southwestern border come even when it's coupled together with the pathway to citizenship for 1.8 million young people, people vote no. we abdicate our responsibility when we fail to live up talking about congress now. our responsibility to deal with the whole epidemic. would you agree with me, admiral, if we just do what the prescription drug part they didn't deal with the heroin and fentanyl problems that we would

not be able to get our arms around this epidemic? >> we absolutely need a comprehensive solution that includes prescriptions that i cannot over emphasize the importance of limiting heroin, fentanyl and departments at all. >> i have heard general kelly, now chief of staff at the white house, formally handed southern command and who bemoaned the fact that many of our military and law enforcement who were stationed in places to be out to intercept the movement of illegal drugs into the united state because they are inadequately resourced in terms of the equipment, airframes than the likes, boats, that they have to simply sit there and watch it pouring to the united states. but as we all know, the demand is equally or maybe even more important than the supply.

do you have any suggestions, either one of you, for what congress might be able to do to deal with the demand side of this terrible problem? it seems to me we throw up our hands and give up to readily on the demand side. if we could figure some way to dampen the demand side, that would be an important part of solving this problem. would you agree? >> two comments. first, we note that demand today, much of which was created a prescription opioids. three out of four users of heroin started on prescription opioids. one of our strategies to decrease the demand side is reduce unnecessary prescribing of prescription opioids across the board. the second comment is with opioids, supply does create demand. once you are on it, you can get off of it. the disease, addiction.

i fully agree it's like telling someone not to breathe once you are addicted to these drugs. in addition to decreasing demand, we have two decrease the supply of the soap quite creates demand. once you are on heroin, fentanyl, it's very difficult to get off. >> rather strategies you think the federal government could embrace to try to deal with that demand component? i hear what you are saying about and demand. if we dealt with the supply and did not do anything on the demand side, i think we would find ourselves pretty much in the same mess we are in right now. are there strategies that the federal government can embrace to deal with the demand side? >> i think with the unprecedented amount of funding we need to evaluate their effectiveness over the next month. i do believe by decreasing prescription opioids and we are

already seeing a very significant decrease nationwide come even more than medicare population, even more in the va that the demand is going to go down and has to be coupled with treatments for those already using or have substance use disorder. part of the process we are in supports medication assisted treatment. it supports comprehensive services. i want everybody to understand that is good as they are, the best services are still only partially effective. we need a tremendous increase in what we look at as how to improve the effectiveness of those programs and we are actually one of our major sister work with francis collins and the nih in a way to understand how you put all the services together to even be more to it. again, most even with good therapy is only 50% or 60% effect it for six months. that is the state-of-the-art in we need to improve that.

>> i agree 100%. i submit that unless we come to grips with not just a prescription drug side, but the heroin and opioid component of supply and demand that we are going to find ourselves -- >> is coming tons of heroin coming over. the problem with fentanyl is it's very cheap so the profitability of pie. because it is so potent come you don't have to carry truckloads of it. there's only mall amounts would have an impact that killed tens of thousands of individuals. >> senator cantwell. thank you, mr. chairman. thank you for your questions because i think it is a precursor to some of the things we are interested in. i don't know if either one of you know, i'm assuming you do, the drug enforcement classified opioid is a dangerous substance potential for high abuse and

leading to severe psychological and physical dependence. because of that, that is why we created the strong network of laws on distribution. we basically said that substances like this needed to be tracked and reported an suspicious orders red flagged in the distribution of these drugs communicated so that the drug enforcement agency, dea, could work through this. despite the fact the law exists, there has been large quantities of opioids but in our communities with manufacturers feeling excessively large orders and distribution. one example a physician average, washington wrote her than 10,000 prescriptions of the highly addictive oxycontin. there were 26 times higher than the average for every prescriber.

in california the ring a lot more than one dozen opioids to be distributed into a community. my point is, where's the accountability? where is the accountability for drug manufacturers not tracking and using that information with the driving force in ages he too were cost-effectively to try to stop this distribution. currently the fights in manufacturing are near $10,000 for neglect in reporting on the distribution. to me that is hardly a deterrent. that is why i'm asking legislatively for a tenfold increase for not reporting negligent distribution. to me, we have to get at this problem of not tracking and see the signs that distribution. my colleagues and i also want to address my colleague, senator cornyn just mentioned, giving law enforcement the tools to

also deal with the heroin epidemic. it is also part of the problem. thank you. we want to make sure that they have resources to deal with heroin traffic in the front line is that is our law enforcement entities and they need that help and support. the question i have about this on the distribution is does hhs have a system in place to track prescription opioids covered by medicaid and medicare and knowing how they might be falling into the wrong hands. >> speaking for medicare and medicaid, we do for medicare program have what is called the upper utilization monitoring system, which allows us to be able to track, for instance, you were talking about beneficiaries to receive high amounts of opioid were able to see if they received 90 or more morphine milligrams for a sustained period of time, say six months

to up to three or more prescribers or three or more pharmacies. we also have automatic, or investigations unit which looks at prescriber data to really be able to work with the inspector general to track those prescribers and look at pharmacies and prescribers who were hired over utilizer's and take action against them. >> you don't work with the drug enforcement agency on this? you bet we do not work directly with them. but we at cms do not work directly. >> you think we need larger controls in place on dispensing? >> we are working to try and get as many controls in place and agree we need to watch these patterns. >> i think we are beyond watching these patterns. that is why we are in this problem. that's how we did and we didn't penalize the manufacturer for failing to notify.

we should be odysseus and problems on distribution, whether that is a drug ring or individual physician gone awry. we should be able to see that is what the law requires. there is no penalty or no penalty is severe enough to get people's attention. i would hope you would look at this legislation and give us some feedback on it and think about what improper prescribing delayed and dispensing, what are the methods we need for medicare and medicaid to be part of that equation. >> will definitely take a look at the legislation and get back to you. >> admiral, what about more resources for antiheroine enforcement ring with local law enforcement? >> you know, i can only comment generally. we have to be all in the page to decrease the supply that are now killing much more than prescription drugs and we absolutely need to support a trans-government approach including doj, local law

enforcement. both my parents were police officers and i understand how important the frontline is to this. >> well, i see my time has expired. i hope we can come together on this because we've heard unbelievable stories of what is happening. people are getting opioids just so they can tell them for the heroin because they can get three times the rate. we need to combat those. i agree that the heroin part of this is critical. this is why we need law enforcement and resources and tools to do that. i hope you look at the legislation and give us feedback. thank you, mr. chairman. >> senator brown. thank you, mr. chairman. i know that you as a native of ohio understand how hard this epidemic has hit our stay. 11 people died on tuesday. 11 people died yesterday. 11 people died today and tomorrow in the averages 11 isn't the only number that

matters. 10,769 according to the american academy of pediatrics from another company ohio children were placed in foster care in 2016. many of them, not all, many a direct result of addiction. as you know, we signed into law an issue guidelines on program criteria in the list of preventive services authorized under title for that timber first of this year. i understand since i'm way down on the list today because of the banking committee i understand senator menendez asked about implementation of family first. i'm pleased to hear you expect them to come out in a timely manner late this year. thank you to both of you for that. thanks for your commitment. at a few additional questions will submit for the record but i encourage you to solicit input and feedback that i don't need to admonish you to do that from the state moving forward with

this guidance. before you get to my only question, i would like to just share some of the things ohio was doing. we don't do well on infant mortality compared to other states. we don't do well in education. we unfortunately lead the nation almost in for-profit charter schools, abused, but we are doing some really innovative things on babies in neonatal absence syndrome. every time the babies born suffering suffering from upriver from this country for 2100 babies, six babies a day submitted to the hospital. just a decade earlier, just 300 cases were reported nationwide. an explosion of members who are all too familiar with. a lot of creative things in them establishing universal screening program hoping to identify babies born and get them to

treatment faster. in previous finance committee hearings, senator portman i've talked about her work on the crib on the cravat on the crib at which adult pediatric recovery centers receive reimbursement for medicaid. secretary issa made the trip to ohio and i thank you all for that. working on her first pediatric recovery center. i want to continue her work together to make sure that these recovery centers have the funding necessary. another initiative interstate is through the ohio collateral nas project to develop best practices for treating babies born with nas. other states are looking to adopt the successful model. but our providers a rope and as you know. i hosted a conference yesterday for ceos from a handful of small rural hospitals. they spoke about nas babies, how hard they are for hospitals to treat. not all of them have make use.

some of these do not have providers who are experienced or specialized enough to care for these babies. as a result, they transfer highgate intends to other facilities with more resources that are already themselves overwhelmed. one of the ceos of these 100, 200 bed hospitals collaborated with another larger system to utilize tele-health technology to keep babies closer to home while they undergo treatment of the larger system will share their resources and expertise through the technology would babies are born to a smaller hospital. their hope is to reduce burden on the regional hospitals that currently are caring for those babies. the anticipated savings from cutting back on transfer costs. my question to you or my request is talked to me about what cms is doing to help babies improve care for moms and babies

suffering from the addiction epidemic. what tools do you have to improve care options for these individuals and how congress support initiatives and not based to multistate demonstration and if you would answer that and commit to working if you would give us specifically on the record a commitment to work with us on the solutions. >> thank you for the question. i absolutely recognize and the home state of cms we have been particularly focused on the issues in terms of helping mothers struggling with her opioid addiction. we've heard a lot about it. the secretary spoke very much about his visit. one of the things we have done in february this year we approved a state plan amendment for west virginia, which we hope will be a model for others dates to use. it's going to provide additional treatment services in nas treatment centers. it basically allows west virginia to reimburse all

medically necessary services to an all inclusive -- my voice is going out. bundle caused. this is a big shift from how we normally would reimburse for the services and allow more services to get covered. some services they find through this include nursing, salaries, supportive counseling, ent management currently not included. what it does not include in part of what congress can take action on our room and board costs and position treatment services. another thing we've heard and sent them that was introduced is the limitation on 60 days of coverage for mothers who are postpartum and the fact they don't receive services beyond that. it's another thing we've been looking at a cms and have a lot of feedback on and would love to work with you not only on that issue, but all these issues because we think they are critically important.

>> i spoke to cleveland city club the other day about opioid and our government took united in a big comprehensive public health way. i used a couple examples when government and a lot of people here don't think there's a role for the federal government in a lot of health care issues but many of us on this side at least believe there is. in 1964 when the u.s. first surgeon general first came out in first recognize the public health crisis, 45% of american adults. last year was down 15. you can look at how we treated the hiv/aids and in the beginning we had a president and a bunch of politicians and many others who would make knowledge appeared yesterday my wife and weekly newspaper column about how barbara bush, whatever you should did this and people were

so afraid of hiv, wouldn't touch anyone with even though there is no evidence at all was transmissible. barbara bush held a baby who is hiv-positive. once we decided that what we've been able to do in that public health arena. we been able to do this as a country. what looks more intractable maybe days, maybe it isn't that we know how to do these things when we really put our minds to solving the public health crisis. you two are really on the front lines of that in your whole careers have been dedicated to that kind of fight, so thank you both. >> well said, senator brown. senator casey. >> thanks so much. i know we are at the head, that thank you for your service. i do know which tell you like better. admiral or dr. appeared use them interchangeably. we are grateful you are back here. thank you for your service. i wanted to highlight what so many others have highlighted.

i have one question and i'll be quick. this opioid and frankly a larger substance abuse disorder crisis is hitting every state just as you've heard today. in my state the numbers are icing 4624. that number was up 37% overall from 15 to 16. i don't think i have a 17 member yet. rural areas up more than 37% in the mid-40s. higher rural areas. one rural county owes in back in august on a tour of this day, the most graphic metric or scenario was the coroner saying we don't have enough places to put the bodies. literally they didn't have enough slobs are places to put bodies. it is terrific on every level. one question i wanted to ask is the bare ears. know we hear a lot about

barriers to accessing treatment beans accessing treatment being stigma, limited availability of providers. so my only question because we are all pressed for time is do you agree those barriers exist and what is the administration doing to confront those? it could be either or both. >> i certainly agree those barriers exist in particularly for rural populations as well. as a learning more about this, there's $100 million targeted specifically to rural areas. the funding that we announced yesterday, which was the second tranche plus the billion dollars. there is great flexibility for the state to use that to support urban or rural depending where the needs are. we talked about it earlier. i'm a big lever until health for

many issues and distributing health care at the major centers to where the actual need is and i think that is part of the answer. again, we are exploring what dea is the next iteration of that is how can we prescribe having tele-health prescriptions into a rural community where there may not be a provider. there were certain barriers to that, barriers to that, but we've overcome that because it's an important component as well. i don't want to take up all of your time, but i'd be happy to follow up on that. >> to follow up with the admiral said, and we agree there's a lot of barriers. one way we are working on is through demonstration projects through 1115 waivers based on new flexibilities. we have five states that are now using flexibilities, including allowing them to do things like access residential treatment facilities which are you are aware has not been allowed under medicare reimbursement.

that is something we're very interested to see the resolve of those five states and how we can work with other states to provide those flexibilities to help break down barriers. >> thanks very much. and thanks for your help. >> thank you, senator casey. we are going to wrap up pretty quick. we've got a little business left to do and i'm going to just reiterate a couple points earned two and half hours ago. first, i would like to enter into the record senator roberts questions. when we wrap up, we are going to ask that there be a response to questions for the record and i'll do this on behalf of the chairman in a minute or the close of business on thursday, april 26th. we need responses from the administration to senator robert very good and important

question. and i thought he did it, that perhaps it wasn't clear. put into the record the various documents that a test to these very serious conflicts of interest that i talk to you about, dr. giroir with respect to the federal bench three boards. one of my letters led to the removal of an official where the conflict was so extraordinarily outlandish. but there's a lot of heavy lifting to do here. having said that, let me kind of recap where we are. first, i want to make clear how strongly i feel and how strongly our side feels that we tackled this issue in a bipartisan way. we are going to do that under the leadership of the chairman. this'll be tackled in the same kind of way that we pursed the chip built for 10 years, historic families first bill from a potentially

transformative medicare legislation that was spoken about. we are going to get this bill done and it's going to be done in a bipartisan way. full stop. having said that, i want to go back to one of the points that i did make earlier with you, dr. giroir make sure you understand my expectation. i continue as i indicated in my opening statements to be exceptionally troubled by the rule of the opioid executives. manufacturers and distributors and i don't believe we got in this situation, a public-health calamity by oslo says. -- oslo says. i don't think it's because well-meaning people miss the addictiveness. i think the opioid manufacturers through twisted research, receptive marketing bought and

paid for advocacy groups have a significant role to play in creating and filling the crisis. i asked where the answer in writing from you. i expect it within a week because if we are going to get up the roots of this problem, we've got to go out what led us to get to this political calamity. will you give me an answer to my question within a week? >> yes, sir. i just want to be, you know, clear than i am fully supportive of senate looking at the root causes of this and understanding it in for whatever doj is doing, i fully support that. the only point i was trying to make it that we got here in a multifactorial leg and we need to understand the roots that doesn't happen again. where we are will require the committees we are doing right

now. so i will provide you that within the time frame. >> no one disagrees with the theory that there are a variety of factors here. what i was concerned about in your written statement is it just completely overlooked, completely, the road to manufacturers and distributors and i think that's a significant part of it. i appreciate your cooperation on this. we look forward to your answer as you adhere to differences of opinions on this issue. i happen to share their views with respect to the role of cost containment. we've got to use every effect of tool to drive down the cost because you can have really transformational health products that people have to be able to afford them and its great nose at the taxpayer issue come individual issue. the question of cost of urgency as you heard them talk about is

all fundamental. we are going to get a bipartisan bill from the financial committee because chairman hatch and i have been talking about this for sometime. colleagues with very good ideas on both sides of the isle is the way we do it in with that, thank you both. always good to see you, mr. into. you've had a lot of good ideas over the years with respect to bipartisan legislation that is really principled bipartisanship. and with that, in the finance is adjourned. [inaudible conversations] [inaudible conversations]

[inaudible conversations] [inaudible conversations] [inaudible conversations]