in-depth fiction edition. featuring best selling fiction writers. contemporary novelist gish jen will be our guest. >> i would have to say if we are talking about creativity and of course i know many writers and so on, that people who have a lot to say are not -- are completely undaunted by being told the rules perspective or for that matter the rules of story telling. the whole idea that there is, you know, a story telling -- you know, that there is a fry tag triangle, you must learn to do this if you are going to go on to be a writer, it's necessary but not sufficient. your learning to do this is not going to make you a great writer, but then you sit down with faulkner and everybody and you discover that actually they could all do it. i think that there's nothing about learning to do those things that impedes creativity. >> her books include typical american. mona in the promised land and

"who's irish." watch our special series in-depth fiction with gish jen on c-span 2. >> next, a hearing examines how medicare, medicaid and other health and human services programs can better address the opioid epidemic and substance abuse disorders. held by the senate finance committee, this is two hours, 20 minutes. >> i'd like to welcome everyone to today's hearing on tackling opioid and substance abuse dis cords, medicare, medicaid and human service programs. i feel compelled to start with news that we all wish was untrue. more than 60,000 americans died from a plug overdose in 2016. 60,000. the majority of these overdoses

involved prescription opioids or elicit 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 alarming number of utahness have undergone hospital stays and emergency room visits due to opioid overdoses. in 2016 alone over 450 utahns died from an opioid overdose. americans across the country recognize the challenges posed by the epidemic and are fighting against it. president trump and secretary of health and human services alexa czar have made sackling the opioid epidemic a top priority and i look forward to working with them to advance policy

solutions. congress conditions 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 wiyden and other members of this committee to make 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. 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 disorde disorders. the federal government cannot solve this cries alone but my hope is that we can work together to ensure that our federal programs such as medicare, medicaid and human services programs are innovative and responsive to the needs of americans can chronic pain or opioid use disorders. my ranking member senator wyden and i have successfully partnered to make numerous recent improvements in healthcare and i really appreciate him for this. he has been a great partner and i've really enjoyed working with him. we worked together to realize a

ten-year extension of the children's health insurance program, we pushed through a package of policies known as the chronic care act that improve medicare for beneficiaries with chronic conditions. i would be remiss if i didn't point out that none of these accomplishments would have been possible without the bipartisan engagement of members on this committee. identified policies to evaluate and improve the federal response to the opioid epidemic will be no different. and the success of these efforts will depend upon bipartisan 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

advantage of this hearing and the expertise of our two witnesses 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 each member of the committee, we have already identified areas of -- areas of potential bipartisan support. these include the need to evaluate access to and utilization of nonopioid treatment options for managing pain, enhancing data sharing to promote appropriate healthcare interventions and strengthen program integrity and ensuring 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 open noid-related suffering by implementing effective policies in medicare, medicaid and human services programs. we have a unique opportunity to do so in the near term. we will hear the ranking member's thoughts on this momentarily but i do hope that he agrees on the need to work toward bipartisan solutions that would add to the committee's long list of bipartisan healthcare accomplishments and i'm sure he does. the witnesses will get a proper introduction shortly but i would like to briefly say a few words before i have to attend a judiciary committee markup that i have to attend. i apologize. first i'd like to welcome dr. brett b. giroir. his recent appointment as secretary azar's point person on opioid policy speaks highly of his capabilities. i am grateful that the finance

committee will be the first congressional committee to hear from him in this capacity. how do i pronounce that name? is it giroir? >> yes, sir. >> okay. >> i'm also delighted to have cms kim brandt appear before the committee today. miss brandt likely needs no introduction to my fellow committee members as she served as a senior member of my staff for six years before assuming the role of principal deputy administrator for operations at cms last year. i'm very proud of her. i would like to quickly say that while i certainly gave me blessing to ms. brandt before she moved on to a cms leadership role, it was really difficult for me to see kim go. she's that great a person. i ask that you all indulge a point of personal privilege to allow me to explain why. i no longer get those uplifting visits from her puppy sherlock. >> the cookies. >> yeah.

>> oh, here they come. >> and those incredible cookies and other goodies. i don't want this to take away from your expertise. she frequently provided all these to members and staff. they are 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. truly, it cannot be in better hands. as we all know, kim served this committee and all of us members of this committee on both sides of the aisle with great distinction. 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 will 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 as 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 is no way that this can happen. 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 as well. >> right. 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. some years ago i participated in

a house hearing where a panel of tobacco executives said under oath that their products weren't addictive. in my view there is a clear parallel you can draw to the opioid issue today. back then it was tobacco executives that concealed the dangers of their products and denied they were addictive. now it's 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 the spotlight that congress puts on the executives of the big tobacco companies. colleagues -- we have colleagues and friends now from both sides of the aisle. that's got to change. the executives need to be brought before this committee that pays for so much of

american healthcare and be held accountable. flooding american communities with these drugs is big, big business and so-called safer opioid pills have just kept the cash registers running. congress would be derelict in its responsibilities if it pre tends there is no profit motive or corporate scheming behind the addiction crisis. in 2015 more than 52,000 americans died of a drug overdose. i'm glad the chairman touched on those statistics because it increased to 64,000 in 2016 and in 2017 it was 71,000. there is a tragic and well documented pattern of opioid addiction escalating into abuse of heroin and fentanyl. now an even stronger narcotic called carfentanil is spreading.

carfentanil is supposed to be use, colleagues, as a sedative for elephants. it is so potent and dangerous first responders apparently around the country have to run around in hazmat suits when they are around it. that's the horrifying level of danger plaguing our communities as a result of this epidemic. so on a bipartisan basis we have already begun the work to financiers and when you get into this you deal with the paradox that cutting down the supply of opioids, depending on how you do it, could drive even more people to heroin 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 as chairman hatch has, that

we've got a big time opportunity for bipartisan action. i'm going to touch on just a couple of issues that had 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 practical 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 has heard some of these stories about the great panthers. i ran the legal aid program with the elderly with the director of the great panthers and i think there were about 40 or so, a fellow called 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 opioi opioids. of course, i see my friend senator isakson, this has been part of our effort on chronic care, our bipartisan effort on chronic care. i have also heard more recently agonizing stories from parents at home who have lost kids to the epidemic. at one of my round tables i met karrie strickland who lost her son jordan to an overdose. jordan was a star athlete in napa. when he suffered an injury he was prescribed opioids and i guess he may have gone to a party, gotten involved with some

of his friends, he started using heroin and for years he struggled in the battle between addiction and recovery. colleagues, i know we have a lot of lathe leets here, i went to school on a basketball scholarship, i was too small and i made up for it by being slow. but nobody -- nobody who threw out their knee -- and i think dr. cassidy i'm sure knows more about it -- back when i was coming up threw out their knew and suddenly became addicted to painkillers. that was unheard of. just unheard of. i'm sure my colleagues are all hearing these stories. so as chairman hatch noted, and i want to come back to it, we can come up with bipartisan proposals to help make a difference. the chronic care legislation that the chairman mentioned, i have mentioned, which senator

isakson joined me on, we were kicking off and nobody hardly figured it had a chance began literally to transform medicare from being acute care program to being a chronic care program which is where most of the money is now being spent. and senator isakson deserves an enormous amount of credit as does the chairman because we made it a bipartisan process. we can do that again. looking at the three colleagues on my side, you know, here, senator stabenow has worked hard on this, senator mccaskill. nobody has worked harder on the opioid issue than senator mccaskill in terms of investigating the crisis, holding people accountable. so we have colleagues here and i don't want to overlook the fact that i see colleagues on the other side of the who have also put in a lot of time on this. so we can address these issues in a bipartisan way and i think

particularly important for us is the vital role that medicaid plays in treatment. four out of ten working age americans suffering from an opioid addiction rely on medicaid. it's the largest source of funding for treatment in the country so it is going to have to be a key part of the solution. as the chairman noted, the family first legislation provides a real tool to deal with the epidemic. family first is about keeping the 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 grandparent could, for example, step in to care for the youngsters while mom or dad got the treatment they needed. it would provide support for both the parents treatment and services for the relatives. end result you've got a family

that can stay together and now we are in the period where welk working with the department, we have two of their representatives here in the states to prepare for the major reform, but chairman hatch and i are determined to see this federal state partnership so that families first gives us a fresh new tool for fighting back against opioid addiction and keeping the families together in the process. last point, warm welcome to our witnesses. all of us have enjoyed ms. brandt's cookies and that has been referenced, but i want it understood that we very much appreciate her professionalism. virtually everybody on this committee has had a good experience late at night, struggling to try to put together the details on an important piece of domestic legislation. ms. brandt, dr. giroir, we

welcome both of you and i guess the kansans are in charge of the committee now. >> it's a coup. i would like to join the bipartisan remarks stated by my colleague and friend from oregon who did start out in kansas. >> my roots. >> i would like to read the statement by the distinguished chairman sandra hatch and so extend a warm welcome to our two witnesses here today. our first witness today will be dr. brett giroir who was confirmed by the senate by a voice vote, something that rarely happenings, just two months ago in february and is currently serving as our assistant secretary for health and the department of health and human services. dr. giroir's confirmation hearing was not in this committee but we are pleased his

appointment as secretary, czar's opioid policy lead brings him before us today. prior to his current position dr. giroir was a physician, a scientist and also an inn spray ter. he is a former medical school executive, biotech startup ceo and served in a number of leadership positions 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 is quite a gentleman, but let me include just a few highlights. he chaired 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 a&m's health science center from 2013 and '15, he directed darpa from 2006 to

2008. dr. giroir has authored or co-authored almost 100 peer reviewed scientific invention. 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 that this committee will be the first congressional committee to hear from him in his capacity as senior advisor to the secretary on mental health and opioid policy. i'm also delighted to have cms's kim brandt appear before the committee. i was going to say that we used to refer to cms as it's a mess, but she has certainly done best to make it cms. so we will forget about that

remark. kim has had a lengthy list of credentials, she is currently serving as the principal deputy administrator for operations of the centers for medicaid and medicaid services. prior to that she was here with all of us serving as the chief oversight council on the majority staff from 2011 to 2017. prior to that work kim was a senior counsel at allston and bird so you know bob dole. after working for seven years as the cms director of the medicare program integrity group. prior to that she worked for five years at the hhs office of general counsel as director of external affairs. kim hods a bachelor's degree, a master's degree in legislative affairs from george washington university and a jd with a concentration in health law from the depaul school of law. so talk about two very qualified witnesses. without further adieu, let's get to the meat of this very

important hearing. dr. giroir, would you please get us started. >> yes, sir, senator roberts. thank you so much for that introduction. i want to first thank chairman hatch, ranking member wyden and 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 americans die of opioid overdoses predominantly caused by heroin and elicit synthetic opioids like fentanyl. behind these statistics i always see the individual patients. always. because i'm a pediatric critical care physician by training and fully feel the pain of needless suffering and death. last week i met a remarkable woman named missy owen. four years ago missy learned

that her precious son davis had been found dead in his car due to a heroin overdose. davis was president of his senior class, hall of fame in his high school and honor student and a community volunteer. but his journey with addiction began with use of opioids from the family medicine cabinet to address his difficulty sleeping. missy's story is just one example of why the department has made this crisis a priority and is committed to solving it through our five-point strategy. first, strengthen public health data reporting and collection to inform realtime responses. second, advance the practice of pain management to decrease the inappropriate use of opioids. third, improve access to prevention, treatment and recovery services. four, enhance the availability of overdosed reversing medications. and five, support cutting edge research that improves our understanding of pain and addiction, leads to new treatments and identifies effective public health interventions.

regarding public health data, the cdc currently provides funding and scientific support to equip states with tools to track and report opioid overdoses and deaths and to implement comprehensive prevention programs. states utilize cdc 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 of four people who used heroin this past year misused prescription drugs first. the cdc issued prescribing guidelines recommending no greater than seven days of opioids for use in acute pain and the use of nonopioid alternatives whenever possible. this guideline has recent -- and

recent educational efforts to raise awareness among providers and health systems have resulted in significant reductions in opioid prescribing nationwide already. to improve access to prevention, treatment and recovery support services the substance abuse and mental health service administration or samsa administers the state targeted response to the opioid crisis grants which enable states to focus on areas of their greatest need. this program provided $485 million to states and u.s. territories in fiscal year 2017 and just last evening we released funding for the 2018 allocation of another $485 million to states. because of the unprecedented funding requested by the president and appropriated by congress samsa will provide an additional $1 billion to states this year and this additional billion will be awarded to states likely in september. cms also has a significant role

in prevention, treatment and recovery and my colleague ms. brandt will speak to their role momentarily. regarding overdose reversing agents u.s. surgeon general vice admiral injury roam adams my colleague earlier this month issued the first surgeon general's advisory in 13 years which urged more americans to carry overdose reversing agents like naloxone. in addition multiple funding streams are in place to assist states, localities and first responders to obtain this agents. finally hhs is supporting cutting edge research. dr. francis collins has recently announced the helping to end addiction long-term intervention at the nih. in 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, no gender, no race, no socioeconomic status. victims are our sons and daughters, mothers and fathers, brothers and sisters, leaders and colleagues. solving this problem will require a whole of government approach. i look forward to working with you clap tifl. thank you very much. >> we thank you, doctor, for your most comprehensive statement. >> thank you. chairman hatch, ranking member wyden, senator roberts and members of the committee, thank you for inviting me to discuss the sent officers for medicare and medicaid services work to address the opioid epidemic. i'm honored to be back at the finance committee though i will say it's a little strange to be on this side of the witness stable. over 120 million people receive health coverage through cms programs and the ep yoid epidemic effects every single one of them as a patient, family member, caregiver or community member. this theme has been repeated throughout the multiple stakeholder listening sessions

that cms has facilitated to discuss best practices and plain storm solutions. as a payer cms plays an important role by i believe sent surprising providers to provide the right services to the right parents at the right time. our work at cms is focused mainly only three areas, prevention, treatment and data. due to the structure of our programs medicare part d plan sponsors and state medicaid programs are well positioned to help prevent improper opioid utilization by working with prescribing physicians. our job at cms is to oversee the efforts and make sure plan sponsors and states have the tools they need to be effective. beginning in 2019 cms expects all part d sponsors to limit initial opioid prescription fills for acute pain to no more than a seven-day supply, which is consistent with the guidelines issued by the centers for disease control and prevention. additionally, we expect all sponsors to implement a new care coordination safety edit that would create an alert for

pharmacists when a beneficiary's daily opioid usage reaches high levels. pharmacists would consult with the prescriber to confirm intent. thanks to recent action by congress, cms now also has the authority to allow part d plan sponsors to implement lock in policies that limit certain beneficiaries to specific pharmacies and prescribers. cms also recently finalized a proposal to integrate lock in with our overutilization monitoring system or oms to improve coordination of care. the administration also supports legislation which would require plan sponsors to implement lock in policies. these new tools will add on to existing innovative efforts in part d to track high risk beneficiaries through oms and to work with plan sponsors to address outlier prescribers and pharmacies. we have seen a 76% decline in the number of beneficiaries meeting the oms high risk criteria from 2011 to 2017, even while part d enrollment has been

increasing. we also support states efforts to reduce opioid misuse. medicaid programs can utilize medical management techniques such as step therapy, prior authorization and quantity limits for opioids. in this year's president's budget cms proposed establishing minimum standards for the medicaid drug utilization review program, a tool that we use to oversee state activities in this area. in addition to prevention measures, ensuring that medicare and medicaid beneficiaries with substance use disorder have access to treatment is also a critical component to addressing the epidemic. our aim is to ensure the right treatment for the right beneficiary in the right setting. we are working to increase access to medication assisted treatment or mat as well as naloxone. the president's budget also includes a proposal to conduct a demonstration to cover comprehensive substance abuse treatment and medicare through a bundle payment for methadone treatment for similar mat. because current statute limits

cms's ability to pay for methadone we are focused on providing access to other evidence based mat. the administration is dedicated to increasing access for medicaid beneficiaries. already we have approved five state demonstrations which include services provided to medicaid enrollees in residential treatment facilities. as this committee knows, ordinarily residential treatment services are not eligible for federal if he had kad reimbursement due to the statutory exclusion for institutions for mental disease or imd. combined with a full spectrum of treatment services we believe the residential treatment flexibility is a powerful tool for states. finally, cms is utilizing the vast amounts of data at our disposal to better understand and address the opioid crisis to share with partners and ensure program integrity. this includes active monitoring

of friends, sharing prescribing patterns through heat maps and other various efforts to ensure the effectiveness of our prevention and treatment policies. while cms has taken numerous steps to address this national epidemic we know there is more we can do. we appreciate the work that this committee is doing to highlight the importance of addressing this crisis and we look forward to engaging with you on solutions. thank you for your interest in our efforts to protect our beneficiaries and i look forward to answering your questions. >> thank you very much, kim. let's see, in the order of arrival and the order of being here, i think senator isakson -- i beg your pardon. it is senator portman. >> thank you, mr. chairman. thank you both for being here. we're fortunate to have your expertise there, we have enjoyed working with you all on a number

of issues. i want to start if i could on talking about an issue that's come before this committee which is the stop act, some of you know this is legislation that deals directly with the huge challenge we face with synthetic opioids coming into our country. we know it's coming mostly from china, we know it's coming mostly through the u.s. mail system, permanent subcommittee investigations did a year long study of this, in fact, earlier senator mccaskill was here who was involved in that, senator carper is the co-chair of that effort and very involved with it. we reported back in january something shocking, alarming, which is that if you go online and ask about opioids, people say, fine, we're happy to sell you synthetic opioids, but send it through the u.s. mail system because it's going to get there without any concern because the u.s. mail system, unlike the private carriers, doesn't require the advanced electronic data that helps law enforcement to be able to identify these packages. 60% of the people who died in

ohio of overdoses in the most recent data we have died of fentanyl overdoses, carfentanil, fentanyl, other synthetic opioids. the county that comprises columbus, ohio, came out with their report from last year, 47% increase in overdose deaths, two-thirds were related to fentanyl. this is a huge crisis and it is amazing to me that we are allowing our united states post office to be able to continue not to provide law enforcement the data they need to be able to find that needle in the haystack. we introduced this legislation back in february of 2017, it has 32 co-sponsors including a number of members of this committee on both sides of the aisle and i just am frustrated as the chairman and staff knows, we can't get it out of this committee. can't get it to the floor for a vote. theres a companion bill in the house, it's common sense legislation. is it the ultimate answer? no. the cara legislation which senator whitehouse and i

co-authored is working on treatment and recovery and prevention and helping on narcan, but this is -- this is a clear and present danger and we are not addressing it, we are allowing people to have access to this fentanyl in our communities, the poison is coming in. if we could stop it coming in from china through our u.s. mail system. admiral, are you aware of this issue and are you supportive of the stop act? the customs and border protection people are, the dea is, law enforcement is 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 carfentanil and similar drugs are to our fight. in the hospital setting to use fentanyl would be in icu, in anesthesia, by trained people and the thought of it being on

the street with its deadly potency is absolutely frightening and astounding. we would be very pleased -- we work very closely with customs and border patrol, as you know, the fda has increased its enforcement capabilities and the number of import investigators that they have in order to stop the importation of fentanyl and carfentanil, so it does not enter our supply, and of course, senator portman, we would be very pleased to provide technical assistance or -- and to work with you collaboratively because any efforts that we can do to minimize fentanyl and carfentanil getting on the streets will greatly aid our fight in prevention and treatment. >> thank you, admiral. i hope the staff on this committee and leadership to this committee hears that. i just think it's one of those issues that we should be able on a nonpartisan basis to address and address quickly. with regard to prescribing limits i noticed that cms

recently finalized their part d call letter which sets a seven-day opioid prescribing limit for medicare beneficiary patients with acute pain. not talking about chronic pain or cancer, acute pain. in our care 2.0 legislation, senator whitehouse again is here, the co-author of that bill, we set a three-day limit. we do that because of the science and because of what cdc has told us which is on the fourth day is when there is a higher chance of someone becoming addicted and also with regard to pain, with regard to acute pain, that that fourth day 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? >> so thank you for that question, sir. we chose it because it was consistent with the cdc guidelines. the centers for disease control has a guideline that says a seven-day supply limit is what they recommended as the top end. we sought public comment on it

and we were trying to strike the right balance. we realize oftentimes three days or less would be sufficient. we have seven days as the top end, that doesn't mean that's what it has to be but that was what we did consistent with the cdc. >> i would ask you to go back and look at the cdc data and look at what they say about the fact that during the fourth day remarkably because it's -- you know, it's based on science and it might not seem common sense to some people but after that period of time after one, two, three days there's a less likely look at addiction under that four days. by the way, someone can go back and get another prescription but they have to go back and explain to the physician that's prescribing it why that's necessary and, you know, if you look at what's happening in my state and states around the country, almost everyone who dies of an overdose started with prescription drugs still and the ranking member senator wyden has talked about this issue of the pain of families going through

this with regard to prescription drugs being usually the gateway to the overdose and the deaths. thank you both for your service and we look forward to continuing to work with you. >> i thank the senator for his very insightful comments. senator wyden. >> thank you very much. mr. chairman, let me start with you if i could. dr. giroir, i think we all understand we've got a public health calamity on our hands. thousands of deaths, spent something like a trillion dollars since 2000 in terms of trying to pick up the pieces, you know, financially and i reviewed your written testimony carefully and it almost suggests that the opioid epidemic happened by osmosis. your written testimony completely omits the role of the pharmaceutical manufacturers that put a greater emphasis on

increasing sales rather than protecting the patients. you state in your written testimony, quote, well intentioned healthcare providers began to prescribe opioids to treat pain in ways that we now know are high risk and have been associated with opioid abuse addiction and overdose. now, it is hard to believe that trained physicians would just come up on their own with these pervasive overprescribing practices on their own. in your view who told the physicians that these doses, these amounts, were acceptable? >> so 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 patients. we did not within the medical culture at that time have the appropriate information nor was it transmitted. pain was the fifth vital sign, opioids were prescribed based on what we knew. i cannot tell you, sir, how this started and who is responsible for it. that's a question or an issue for the committee or other components. >> so you don't think that the fact that the manufacturers bank rolled patient advocacy groups and experts who played outside on these overprescribing practices had anything to do with it? i've accumulated evidence showing conflicts on these boards. one person has actually been removed. do you believe that that contributed to this problem? >> i'm not here to defend or to

place blame on any singular group. i will say that there was a confluence of factors that led to this, clearly opioids were overprescribed, they were overprescribed by well intentioned physicians who believed they were doing the best for the patients by other prescribers and we now understand that this problem which led to heroin and fentanyl really started with prescription -- >> we are committed here on this committee, you heard the chairman and i talk about to 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 then i have one question for you, ms. brandt. 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. now, you are going to be the point person for the trump team. do you share those kind of concerns that i mentioned? >> the -- i am doing everything and the department is doing everything we can to limit opioid prescriptions now to only when opioid prescriptions are important to the patient. we are supporting non-opioid uses. we are supporting alternative care. so absolutely i agree with you that opioid prescribing needs to be decreased, we need better science, better information, a key pillar of what we're doing is trying to decrease the unnecessary opioids. again, i do mean this respectfully. how we got here and who was responsible i think is a matter for the committee and others to

ascertain. >> i want you to have the chance to respond in writing. >> yes, sir. >> 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 item by item, twisted research, excessive hype that downplayed the harmfulness and stacking these advisory committees where they could so we will leave the record open. mr. chairman, if i could just get one question in for ms. brandt. medicaid the largest pair of substance abuse business cord services in the country covering four out of ten that suffer, in the states ravaged by the epidemic medicaid pays for nearly half of the treatments. medicaid expansion is clearly going to be a major tool on the ground and yet i'm going trouble squaring the administration's

commitment to expanding access to treatment with the president's budget proposal to drastically cut the program and roll back the medicaid expansion. now, we're not over here saying money is the sole answer, but i'm going to put into the record some programs that dollar for dollar are going to make a big difference in michigan and ohio and the states where my colleagues -- and oregon are fighting this epidemic. i would just like -- because i'm over my time, for you to tell us how when you slash a trillion dollars in medicaid funding for these lifeline programs we're going to be able to work with the states to address the epidemic. >> well, 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 their resources to maximum benefit so they can provide the right treatment to the right people in the right setting. we have additional money that has been appropriated to go

towards the opioid epidemic, the admiral mentioned some of the additional grants that have just gone out and we are committed to trying to continue to get as many resources to put towards this problem as possible. >> thank you, mr. chairman. >> senator stabenow. >> thank you, mr. chairman. i'm used to saying thank you mr. chairman in the agriculture committee so it's nice to see you in this role. welcome to both of you. first to follow up, ms. brandt, we could talk a lot about -- we already talked about the budget. it was great we were able to get the additional dollars for opioid and mental health services. one bright light consistent in the president's budget as well has been the strong and consistent support for the excellence in mental health and addiction treatment services. i thank you for your involvement when you were on this side of the table working in a bipartisan way. it was senator blount and myself. as part of the opioid crisis the

fy 2019 budget for the administration also explicitly endorses the excellence demonstration and proposed funds to expand the program. and you know this is really creating behavioral health center clinics, federally qualified clinics like we do for health centers so we have permanent structures on the ground in the eight states where we're doing that now a lot of what they're doing is opioid treatment. so it's a very important long-term way to treat this. so just a question. as we in the finance committee contemplate the best approaches for addressing this crisis, would the secretary agree that the expansion of certified community behavioral health clinics to additional states as the president's budget proposes 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 certified community behavioral health centers are part of that innovative solution. that's why the budget proposal includes the extra money and we think that this is an issue where no amount of resources in terms of things like this where you can target it can be ignored and this is a very valuable tool that we think could help with this crisis. >> thank you. i look forward to working with you on this. 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, and this relates to the question of naloxone and not only availability for police and fire and for others as has been suggested, but when we talk about root causes i just want to take a moment to lay out the fact that naloxone was approved by the fda as an opioid overdose reversal drug in 1971.

'71. generic versions have been available since 1985. for a while prices weren't an issue. in 2005 there were two manufacturers producing a generic version of naloxone and it cost $1 for a vile. $1 for a vile. but by 2013 both companies were selling the drug for 15 times that amount as the need went up, the price went up. which is very concerning to me. and in 20 14 mal auto injector was introduced, they introduced an auto injector, the first product approved by the fda for use by people without medical training. so what happened then? they came on the market with $690 for a two-pack and the price of the generic injectable actually went up a little bit that year.

so more need, price goes up. not exactly how it should operate when it relates to healthcare and something as serious as this. then less than a year later the price of evzio increased to $4,500. $4,500. in 2015 narcan, the nasal spray version of the drug also approved for use by people without medical training came on the market for $150 for a two pack. i just want to stress the actual drug was approved 47 years ago, the actual drug naloxone was approved 47 years ago and as recently as 2005 you could get a vile for $1. $1. and now taxpayers in order to support police and fire and if he had cal 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.

so i just want to ask, because this month the u.s. surgeon general called for more people to carry naloxone and you can get it without a prescription and so we go over and over again and we have this price now skyrocketing. dr. giroir, you are responsible for coordinating hhs efforts across the agency to fight the opioid crisis. the commission on combating drug addiction and the opioid crisis recommended that hhs use its appreciating power to reduce the prices. use the negotiating power of our government on behalf of our people to be able to bring prices down. and so i think we all want to know will you use that power to negotiate what is an uncontrollable situation with no accountability where frankly i think the drug companies are taking advantage of the pain and suffering and loss of life in this situation.

>> so thank you, senator stabenow, and i appreciate the fact that you're helping us highlight the importance of naloxone. naloxone does not solve substance abuse disorder. >> correct. >> it does not get to the root cause, but it is an absolutely critical drug that brings -- literally brings life back to a person on the brink of death. so we certainly support that. let me give you an update of where we are. first of all, the state targeted grants that i talked about, the $485 million and the extra $485 million yesterday has increased flexibility for the states to use more of that money as needed for naloxone. >> and i'm only going to interrupt not to be rude but because i'm out of time my question was bringing the price down. it's great we're using taxpayer money to pay for these outrageous prices. the question is something that was on the market for $1 and now we're talking about these huge price increases, are you going to use the authority that the

commission, the president's commission, asked you to use to negotiate the best prices for americans and bring the price down? >> so if i could -- the nasal narcan, which is increasingly the choice reversal agent for first responders is now fairly significantly discounted and is now to the level of the gsa schedule. so all states and localities are now getting that for $75 for the two pack, which is consistent with the gsa schedule. >> so i'm sorry, the chairman is telling me to stop, but i assume your answer is no you are not going to be negotiating the best price because i'm not hearing a yes. >> so we are now getting that at the gsa schedule. the fda is looking at all aspects to bring naloxone to over the counter and also to increase the generic competition. so that is our current strategy

right now. we have seen the price go down by over 40%. >> i would hope so. it started at a dollar. it started at a dollar. and look at where we are right now. i think -- i think it's really outrageous what's happening and what people are having to spend and taxpayers having to spend. thank you, mr. chairman. >> i would just observe that the senator would never advise that the distinguished chairman emeritus of the agriculture committee to stop with regards to her -- >> thank you, mr. chairman. >> -- advice and consent on the committee. senator cassidy. >> thank you. thank you both for being here. mr. chairman, thank you. last week i was in lafayette, louisiana, announced our save your families community initiative and i would speak to folks back home and what i learned from them will be the basis of my questions for you.

i spoke to the father of the 17-year-old, the young man who eventually died who when he first went into treatment was asked by the insurance company to be released two weeks after treatment began. the fact that he died obviously indicates that this was not not effective strategy. then i contrast it with my next conversation, which is that if you're an impaired physician in louisiana, there's a minimum of three months inpatient therapy, then one month follow-up before you're allowed to practice once more. so contrast that, which is apparently effective, three months inpatient with a month of follow-up, with that which clearly was not, after two weeks they were asked to leave. lastly, i spoke to another physician who told me of the abuse potential after our medication assisted therapy. first, that there's a certain number of people who die from methadone overdose, and secondly, about the version of

suboxone. louisiana guy who does well. nice to see you here. i know how to pronounce your name, even if others don't. let me say, as you know, there's some forms of medication assisted treatment like buprenorhpine injections coming on to the market, next gen products that never go into the hands of the patient, therefore cannot be diverted, as i've learned suboxone is being diverted. the law is unclear whether or not the pharmacies can dispense this medication directly to the provider because current law says it has to go to the patient. makes sense you don't want the brother picking it up. dea has interpreted it as saying you cannot give it to the provider to then do the implant and therefore divert the potential -- avoid the potential for diversion.

senator bennett and i have legislation 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 combination with behavioral therapy to treat patients. yes, sir, i will go back. i'm not familiar with the specific bill, but we will go back. >> but we agree there's certainly abuse potential for the drugs used in m.a.t. >> there is abuse potential for the drugs used in m.a.t. part of the drugs, right. so there's not so much abuse potential, but there is potential diversion abuse potential with drugs, as you pointed out.

yes, sir. >> ms. brant, i'm struck. let me ask you, i've noticed in some localities there's less prescription opioid, but there's no decrease in the number of deaths from opioid overdose, suggesting that it is illegal drugs replacing or back filling the loss of opioid prescriptions. is that what your data is showing? >> actually, i'm going to defer to the admiral on that one. >> yes. the prescription opioids have been a gateway, if you will, in that three of four people who use heroin started that way, but clearly the deaths now are far overshadowed by heroin and fentanyl. >> in those areas using m.a.t. more extensively, are we seeing fewer deaths related to opioids? >> so the data we have is that m.a.t. is more effective than non-m.a.t. in prevents death and

providing long-term recovery. i do not have geographic data that correlates geographic use of m.a.t. with a lowering of the death rate within that geography. i will go back. >> could you get us that? >> yes, sir. i will go back and see if that data are available. clearly m.a.t. is associated with improved outcomes. we would tend to believe that's the case, but we need to verify those two things go together. >> i keep going back to the 17-year-old boy who was left -- who was asked to be discharged and then is now dead. so something is not working. ms. brant, 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 months inpatient followed up by a year follow-up as an outpatient works, but being discharged two weeks after being admitted and ultimately dying maybe doesn't. do we have best practices on this, and are we doing a proactive follow-up to see that,

oh, yeah, program rehab is doing really well, but beta rehab, not so well? >> well, speaking for the cms programs, we are starting to accumulate that type of data through our new medicaid information system through results of a lot of the demonstration projects we've been doing and testing a lot of our new innovative models. >> let me interrupt. does it actually get populated with state data? my understanding is that states were not as aggressively populating that as they should be. >> we are actually getting states. we now have 49 states, the district of columbia, and as of march 26th puerto rico actively reporting full data. >> that's great. i'm over time. i yield back. thank you. >> senator carden. >> thank you, mr. chairman. first, i want to concur with the comments that senator portman on the fentanyl and senator widen on the misuse of opioids --

prescription of opioids for management of pain. and senator stabenow's point on the pain. i've been around the entire state of maryland, and we have opioid problems in every part of our state from our most rural to our most urban. they're in desperate need of partnerships with the federal government. so i want to talk about two programs, one that is pretty well established and another that is becoming a popular option, perhaps an option. both are impeded by our reimbursement structure. we don't have an integrated care system that reimburses for integrated care. so you have to find creative sources in order to deal with a

lot of the treatment options. one of the more successful options in our state has been pierce support services where those that are recovering from drug addiction help get those that are in need to the appropriate care center. we have those programs in maryland, and they are extremely successful, by the way. the numbers are very, very popular. the problem is there is not a e reimbursement structure. a lot of this you have to find third-party sources to fund it or creative ways or hospitals coming in to help us because they know this will reduce their emergency rooms. so what i'm looking for is whether we can find a way to encourage these types of services. so let me stop with that first. what can we do at the national level, either in changing our reimbursement structures or providing direct funding? you look at the grant programs available from the federal

government's sources, it's really difficult to get support for peer support services. >> i'm actually going to take this one because this impacts a lot of the medicare and medicaid programs. we agree with you that peer support services are a key part of the continuum of care. one of the limits you asked about what can be done, one of the challenges here is that a lot of these types of services are not covered or not considered a provider for purposes of medicare. so 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've seen some success with this in states. as of 2016, there are a few states that are covering peer support services for substance use disorder and medicaid. that is something that could be encouraged more. it's in a few states right now, but at least on the medicare side, we'd need to provide texp

provider definition. >> i look forward to working with you on that because i think that's clearly a very fruitful model. the states that are changing it, they don't need waiver? >> they can do it under their current authority, that's correct. to the extent they hit roadblocks, we'll work with them on that. >> the other area, which is relatively new and has some concerns that it's used appropriately are stabilization centers that try to get individuals who are stressed out of the emergency rooms where they sometimes are -- 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, i believe, two stabilization centers in the state of 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's something we could work with you on. it's not something that i'm familiar with directly, but we could definitely work with you all to sort of find out more about that and see how we could help. >> we've had a couple of our communities say that they want to take care of people. everybody is in stress and need of care, but there are 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 and that for 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. admiral, is there hope for an alternative to using the emergency rooms to deal with this? >> we'd certainly hope so. the emergency room is great for emergencies, but it's not so great for everything else. so we certainly support in community-based programs. the str grants we have have a large amount of flexibility for states to institute programs. increasingly, as you suggest, with the numbers we have, with millions of americans misusing opioids, probably 2.4 million with substance use disorder, we're going to have to change the way we do things. it's going to have to be outpatient based primarily with the inpatient services for people with severe mental illness.

we're going to have to train more behavioral health professionals, not just psychiatrists, but levels all through. it has to be community based. again, we're all on the same page here. >> 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's a roadblock, i want to hear about it because part of my job is to make sure hhs is listening and understanding and can be responsive to those needs. i would appreciate that direct feedback. >> thank you. >> i mean that sincerely. >> thank you. >> senator menendez. >> thank you, chairman. ms. brant, children whose family have been impacted by the opioid

epidemic experience effects when that breaks down. given these programs spend multiple hhs agencies collaboration is critical. for example, new jersey has a mommy and me program to allow mothers 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 1st of this year, but we are still awaiting guidance from acf and cms on how to make that work. so my question is, can i count on you to work with acf to get that guidance out in time for

states like mine? >> certainly. happy to work with acf and with the admiral to ensure that we're coordinating to get that guidance out. >> okay. in your joint testimony, you talk about the role of medicaid data. some states have been able to take their 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. in fact, as i mentioned in my opening statement, data is one of the three main components of the cms opioid strategy. we now have 49 states and the district of columbia and puerto rico reporting in to our medicaid statistical information system, and we're using all of our data across cms and trying to use it to really target how we can better do prevention and treatment and really be able to help give feedback to stateds and others.

>> that was going to be my second question. how is cms working with states like mine to support these types of activities? >> so a couple of different ways. we certainly coordinate with states on the data they report in through their program. that allows us to take out, for instance, the pharmacy file which is all of the claims that are related to things like prescription of opioids and really be able to help tell them where it is that we see patterns and work with their information that they get from their prescription drug monitoring programs to be able to really more detail how we can do interventions. >> now, i know you also mentioned medicaid innovation accelerator program. does cms have plans to provide new jersey and other states with technic technical assistance in this space? >> we're certainly continuing to offer ongoing support to the states, and we think that's something where we want to be able to have more technical assistance and support to provide on that program. >> do you think additional

federal support would be beneficial to better support these types of activities? >> we really think that we want to support states' ongoing payment and delivery system reforms. as i said, we're really looking to see how we continue to look at different program innovations and how we can best support -- >> we'd like to follow up with you on that. finally, prescription drug monitoring programs have been helpful in curbing the flow of opioids, but according to the american general of managed care, bdmps are not necessarily associated with a reduction in overdoses. and i think this may be due to the fact that individuals already addicted to opioids will switch to illegal narcotics as their supply of prescription painkillers is cut off. what tubtopportunities are ther prevent an opioid addiction from becoming a heroin addiction? >> thank you for that. first of all, i want to say pdmps are rapidly developing. i think they're a very important

tool, and the cdc is supporting states to further utilize them. i think the next level is to not have a pdmp sit on the side of the equation but be integrated in the work flow of physicians, which is the next level. how to prevent people with opioid use disorder from going to heroin is strictly a 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 they're on heroin and fentanyl and come into the emergency room. a lot of the state-targeted grants and technical assistance is really working on that question specifically. but i agree with you 100%. >> i'm hoping what the congress did in this omnibus is going to help us focus a significant part of that money towards that exact purpose. >> yes, sir. the omnibus extra billion dollars, we expect that to be out to the states by september, in addition to the 485 million

extra from the original act released yesterday. >> thank you, mr. chairman. >> senator toomey. >> thank you, mr. chairman. ms. brant, welcome. you know, we all know medicare is the largest purchaser of prescription opioids in the country. i'm a little shocked to learn that in a typical year, 2016 anyway, one at out of three beneficiaries received an opioid prescription. not a doctor, not an expert on this, but it is counterintuitive to me that one out of three people needs to be given a drug that is so powerful and so dangerous, but that's the case. it's further even more surprising that medicare actually pays more on a per patient basis for opioids than either commercial insurance or

medicaid. so over $4 billion on opioids alone in 2016. so i really, really wonder about the total consumption levels. i know that medicare and medicaid have overutilization monitoring systems. i know there's been some progress with respect to the people being tracked, but i am concerned that the overutilization monitoring systems are, in fact, monitoring a tiny percentage of the people that maybe 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. 727,000. the oig determined 500,000 were receiving high dosages of opioids for at least three consecutive months, and this excluded cancer and hospice

patients. but the overutilization monitoring system, it's my understanding, covers something on the order of 60,000 to 70,000 beneficiaries. and i'm wondering if the right number wouldn't be ten times as high based on the gao and the oig reports. so what do you think of the number of folks that are being monitored compared to the number of folks that ought to be monitored? >> well, a couple of things. and i thank you for the question because this is an area where we've really been working to improve our oversight and to see how we can address the oig and gao concerns. first of all, the oms system only covers part d beneficiaries, which is a subsection of our larger medicare and medicaid population. so as a result of the oig and gao feedback, we significantly

strengthened and significantly improved our ability to do edits and oversight through the oms system, which when we reran at least the oig beneficiaries that they had identified, enabled us to show we caught over 85% of them with our new improved expansion of the system and with the additional edits that we put in place. we've been continuing to implement the cdc guidelines, our new safety edits, and a number of other coordination edits, but we're looking at how we can expand this to cover the rest of the program. >> could you send us the back-up documentation on that? >> sure, i'd be happy to do that. >> i'm seeing it looks like we're falling way, way short of the total goal. let me 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 overutilization monitoring system. yet, we've had a spike in nonfatal overdoses. my understanding is almost half the time there's a nonfatal overdose that preseecedes a fat overdose, so it's obviously a very, very dangerous event. should a nonfatal overdose in and of itself be sufficient criteria for including someone in the overutilization monitoring? >> well, i'm not a doctor. i can't speak to whether or not that's an appropriate criteria for us to use, but i think it's something we want to look at because we consider the continuum of care to be very important. we want to make sure that there is that coordination. >> so do you have the authority to adopt that as a criteria? what would it take to adopt, for instance, if it turns out that that's an appropriate criteria, what would it take to make it the criteria for inclusion? >> i'm happy to go back and get to you exactly what it would

take for us to include that. >> great. admiral, do you have any thoughts on this? >> no, sir. i'd be happy to go back and look at what authorities, but clearly a nonfatal overdose is a risk factor moving forward, a true sentinel event, a cry for help. >> exactly. but as it stands today, that is not a sufficient criteria for being included in overutilization monitoring. i'm not a doctor either, but that's extremely counterintuitive. >> we will certainly take that back and provide responses. >> thanks very much, mr. chairman. >> senator msenator. >> we have issued a report that shows, for example, the american

academy of pain management receiving big money from opioid manufacturers and then coincidentally, they 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 is another report we issued about a fentanyl manufacturer who their internal sales slogan after we got into the documents and started really getting into the weeds, their internal sales slogan was start 'em high and hope they don't die. they had a fraudulent unit within their company that was posing as doctor's offices and actually calling pharmacy managers to try to get approval

for fentanyl. i'd like that report also to be made into the record. >> without objection. >> i'm pleased to say as a result of a lot of work, 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 as how they have contributed to this problem. the next report we'll be issuing is on the distribution of opioids, which brings me to 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 the question because that is something we have been re-examining, and we are now exploring making that mandatory

so there would be mandatory reporting of fraud, waste, and abuse. >> well, i just hope that the exploration doesn't take very long. we got people dropping dead in my state every day. 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 our program that the taxpayers support is not reporting to you the fraud and abuse they find, then what chance do we have of really getting a handle on this? >> we concur it's a very important part of the program. as i said, we're working to see how we can begin to implement that. >> i think you implement it by saying we're going to have a rule you have to report fraud and abuse. can you do that sometime in the next 30 days? >> i will get back to you. i'm not sure we can do that in 30 days. >> you can certainly announce you're doing a rule. >> i'm happy to get back to you. >> these hands off with these

pharmaceutical manufacturers and companies -- i mean, senator stabenow, really? a drug that's been around 40 years that's life saving increases from $690 in 2014 to $4500 at the beginning of 2017, more than 600%? where's the outrage? where is cms on this? this hands off, this incredibly unconscionable price increases that are not driven by r&d, they're 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 that has a member they know is addicted? how much is it costing them to get naloxone or narcan? how can they afford it at a price increase of more than 600%? why aren't we being more aggressive and going after these companies that are doing this?

what is their excuse for raising these prices? because 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. >> would you ask them? >> but -- >> sir, would you ask them why they're raising these prices this high? >> so, yes. we will -- we are -- we want naloxone to be more available and affordable. there's absolutely no question about that. >> well, how about -- >> and the nasal spray naloxone, the prices are going down as we talked about before, but we're going to do everything we can to increase generic competition to potentially have it over the counter to promote competition to lower that even further. again, this is the predominant forum being used by states and first responders. $75 for two days are where we are. i'd love to see that lower and work on mechanisms to do that. >> the naloxone product jumped from 690 to 4500 in three years.

>> right. >> 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. what was their justification for that price increase? would you do that? >> i will certain -- i will get back to you on whether i could write a letter. but let me just tell you, the $4,000 doses are not being used primarily by first responders and by states. >> i'm talking about families that are trying to save their family members' lives. you know how many parents i've talked to who walked into the bedroom and their child was overdosing and they had nothing? they can't afford this drug to save their life. i mean, they may need it before the first responders get there. i just want you all -- this hands-off deal about pharma is wrong. and i want you to be as mad as i am about it. >> so i am absolutely aware that naloxone needs to be with

families. again, the inhaled naloxone, the nasal spray is generally preferred because it's easy to administer, a new form. so i agree with you, it needs to be less expensive, but now we're at $75 for two life-saving doses. >> for first responders. >> for first responders, you're right. >> listen, i'm going to hold you accountable on this. i want you to write the letter. i want somebody at cms to begin to express the outrage towards these pharmaceutical companies that i hear from missourians every single day. thank you, mr. chairman. >> coop, you're up. thank you, mr. chairman. you know, no state is immune from this issue. our state doesn't have some of the data that other states have in terms of opioid use disorder.

obviously we're very interested in working with the members of this committee. i want to help ensure our committee activity addresses not only the opioid epidemic but substance use disorder broadly. i hope our witnesses from the administration will also keep this issue in mind as you continue your efforts to coordinate the department's activities. in face of provider shortages, south dakota's health systems have worked to innovate through teleheath. several senators have been working on the connect for health act, which has the broad goal of expanding access to telehealth. one provision that would provide the secretary -- i should say would provide the secretary of hhs authority to waive certain

medicare restrictions in current law where telehealth would reduce spending or improve quality of care. we're 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're looking at administratively to expand access via telehealth? >> yes, sir. 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 reach out to where patients are in their community. i think telehealth is a really critical and important tool. the one thing we're exploring and working with our dea partners on now is to be able to expand not only telehealth treatment but telehealth medication assistant treatment so that can be given by a

qualify prod vied-- provider ac telehealth. again, we're in very active work with dea to see how we could make that come about in a very short term. >> good. in your written testimony, you highlight 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 help committee is also working on further proposals in this space. ms. brant, has cms put in place procedures to ensure timely medicare coverage determination of new therapies once they're approved by the fda? >> yes, actually, it's a great question and because we know the importance of this, we have been working on a parallel process with the fda. so as the fda is determining whether or not it will be a drug or a device that's approved, we're parallel looking at coverage and reimbursement on our side so that hopefully once the fda approves their piece, we

can very quickly move into getting it approved for medicare. >> seems like a big part of the solution to this problem. just one last question. indiana health service does not fall directly into this committee's jurisdiction, but i'm sure you're aware that many south dakota tribal members are also eligible for medicaid, which is the single largest payer for behavioral health services. through your efforts to coordinate the department's response, what recent engagement has taken place with tribes and other stakeholders working with them to address substance use disorder in tribal communities? has the national committee on heroin, opioid, and pain efforts made any changes or suggestions for improving access to culturally appropria culturally treatment? >> i could say in the two weeks i've had this position, i've probably met with the ihs three times, including an eight-hour retreat at hhs where we were all

together, working to, and focusing specifically on what we can do to support each other throughout this process. as you know, because you're passing the $1 billion that's coming through the omnibus that will be released in september has a specific $50 million allocation to the tribes specifically. so i think we are highly coordinated and sensitive to that. my other job as the assistant secretary for health, our office of minority affairs, which focuses on culturally and linguistically appropriate, even in the last week, done visits to multiple tribes to make sure that we're reaching them. >> very good. thank you. i hope you'll continue those efforts. mr. chairman, thanks. >> thank you.

senator heller. >> mr. chairman, thank you. i want to thank you and the committee for putting together this particular hearing. it's important, and it's important for my state, important across the country. i'm pleased that we have this opportunity. for many nevadans, substance is a problem that hits close to home. like many of my colleagues, i've heard from those struggling with addiction or for that matter those who have lost loved ones to this epidemic. in my home state of nevada, there were 665 drug overdoses, deaths, in 2016. in that same year, opioids were involved in over 40,000 american deaths, statistics i'm sure you're well familiar with. opioid abuse is a major public health concern. more steps need to be taken.

i'm sure we're all in agreement on that to make sure our communities are equipped to address this crisis. i'm pleased to have the panel here before us. ms. brant, welcome back to the committee. great to see you. i want to thank both of our witnesses for taking a new moments of your time to be with us. i just had a meeting in my office. i met with boys and girls club of western nevada. obviously they were discussing their after-school activities and programs they had that were available to these young adults. they were talking about some of the programs, in particular when it comes to trying to prevent students from being involved in drugs and opioids in particular. i'm just curious, since it was timely, what the department has in mind and what the department of health and human services is doing -- any work they're doing on early prevention. >> so you highlight a very

important point because obviously 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're in the middle of assessing what are the best evidence-based practices to reach different communities. we're going to have to reach them specifically based on age, based on where they interact. this is an active, ongoing effort with the cdc and other parts of our agency to target information across the board. secondly, the state targeted research -- the state-targeted grants aspoke about has a significant component of prevention that we could support states' activities. as you stated, every state is a little bit different, has different organizations that 23450 need to be supported and reach those. so i absolutely agree with you. >> who directins those dollars?

if the needs are at the school levels, education levels, can the dollars, or for that matter, does hhs have an educational program to get those dollars down there? who moves the dollars? and if every state is a little different, how do we get those dollars to the places they need them most? >> you may have programs, and this is well, but these specific grants, they're awarded to the states, and the states can subcontract with any variety of organizations they want to fulfill their mission with those dollars. it's going to be very similar. it's highly flexible funding. we want to make sure there's actually prevention and treatment that's covered, but avied from that, the states have tremendous flexibility to subcontract with whomever. >> and i would just jump in from the medicaid program side, i'm sure you're familiar with the early and periodic screening diagnostic and testing. it's mandated they provide prevention and other types of services for children and

adolescents up to age 21. so that's another way through the medicaid programs and the flexibilities they have and resource there is that they can do that. >> that's helpful. >> i just want to emphasize, a couple weeks ago, the president issued an executive order on youth sports participation. i look at this as a great opportunity to provide opportunities not just for youth sports participation in underserved communities but to have that as a platform for health in general that we could state many messages about appropriate nutrition and opioids, et cetera. >> thank you. ms. brant, i wanted to ask you about electronic prescribing. senator bennett and i have introduced every prescription conveyed securely act. mr. chairman, i have a letter i'd like to submit for the record. 20 groups and organizations that support this particular piece of legislation. >> without objection. >> i guess the question is, what impact would electronic

prescribing have on addressing the opioid epidemic? >> well, there's a couple of things. first of all, we had a number of stake holder sessions last fall with various stakeholders across the spectrum and e-prescribing was one of the top four things that came up across all those stake holder sessions. we really think that the data from that is very important. it has a lot of benefits to the plans, pharmacies, prescribers, and the states. it also is something that our part d sponsors are required to support electronic prescribing as part of their participation in the part d program ping it's something we think has a lot of potential, and we're aware of your legislation and would be happy to continue to support technical assistance. >> ms. brant, thank you. doctor, thank you for taking time. my time's run out. mr. chairman. >> thank you, senator. senator carper. >> welcome. we're happy you're here and appreciate your appearance. i've been writing down the number of times you two have

said, well, that's a great question, or i'm glad you asked that question or that was an important question. over 25 times so far. that's a record. i was just wondering, do you ever get questions where you want to say, god, that's a dumb question? why are you asking that question? maybe not here. some other committees. >> don't answer that question. >> i yield to the senator from texas. >> senator heller talked to you about electronic prescribing. i want to talk to you about that's quite different. electronic prior authorization. patien patients in medicaid, their providers oftentimes wrestle with the prior authorization requirements for medication, assisted treatments, for opioid abuse. increasing the odds these patients will relapse and return to their use of opioids. would increasing the use of electronic prior authorization in medicaid, in medicare help

improve access to medicaid assisted treatment? and what do you need from us? what do you need from congress in order to increase the use of electronic preauthorization for treatment? i think senator roberts, if you were here, talked about legislation he and i have collaborated on. let me just ask you, what do you think? >> well, from our perspective, we think there's great potential for prior authorization. >> you go so far as to say you're glad i asked this question? >> well, i decided not to say that, but i am glad you asked that question. yes, sir. thank you. it is something we have been looking at and we think is one of another potential good tools that we have along with e-prescribing. anything we can do that helps us to be able to see in real teem what's happening and what's being requested, especially if

it helps us to be able to tell who's requesting different types of services. that's very helpful for us from a program management perspective. >> doctor, do you agree? >> i do. >> would you go so far as to say you approve of this message? >> yes, sir, i do. >> oh, good. i would say going back to senator mccaskill's question, i find wherever claire mccaskill asks me to do something, i say i'll do it. it saves us all time and trouble. what she's asking is probably the right thing. i have another question. i'm a recovering governor. when i was privileged to be governor of delaware for eight years, we established a family services cabinet council. it included basically half of my cabinet secretaries. we met every month. we developed a strategy that we pursued for eight years to strengthen families, a basic

building block of our society. rather than just address the symptoms and problems, why don't we go at root causes. several people mentioned today root causes. as we confront the opioid epidemic, i want to urge you to focus not just on treatment but also for us to focus on the root causes for this crisis. i know there's several. our child and family experts tell us individuals with mental health conditions are at a greater risk for abusing drugs. what are hhs and cms doing to ensure at-risk children and families have adequate access to early treatment and intervention that could reduce drug abuse and addiction, and how can we make better use of telehealth in medicaid and the c.h.i.p. program? >> 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 real mantras with the opioid ep dem sick the right services to the right person in the right setting and making sure particularly with children as i mentioned to senator heller through our medicaid program, we do the epsdd program, which allows us to do prevention services. and we've really been looking at ways to expand the use of telehealth, particularly for rural areas and areas where they just don't have as great of access to be able to really use that as an important tool as part of our efforts to fight this epidemic. >> doctor? >> i agree completely. we are also very actively looking at some 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. i think that's very, very important, and that's one way that we can do that. having been in a children's hospital and worked there for many years, i understand the importance of that.

the second issue is there are degrees of susceptibility. i absolutely agree with you. mental health, adverse childhood experiences always make it much more likely, but i think the point is everybody in this room is susceptible to addiction. if you are on prescription opioids for too long, it's like asking yourself not to breathe. after a while, you can't do it. i just want to make it clear you are absolutely right. we need to target the high risk. we need to work on adverse childhood experiences. we need to co-locate those services, but everybody is at risk. >> thanks very, very much. >> admiral, it's good to see you again. thank you for being here and for your distinguished service at two great texas institutions, texas a&m and the university of texas. in addition, of course, the united states military. ms. brant, good to see you. i'd like to talk about the elephant in the room. is heroin an opioid, admiral?

>> yes, sir. >> when people can't get prescription drugs for some reason, do they frequently -- do addicts frequently resort to heroin? >> yes, sir. >> because it's cheaper, right? >> yes, sir. >> more readily available. >> yes, sir. >> but the addiction that it produces is just as bad, maybe worse, than from prescription drugs. would you agree with that? >> the addiction is the addiction. the consequences of heroin and fentanyl are much more severe because of their potency, yes, sir. >> and are you aware that one of the major sources of heroin into the united states is across our southwestern border? >> it is, sir. that's for sure. >> and along with tons of heroin come tons of methamphetamine, tons of cocaine, but i know we're talking primarily about opioids. i heard it described to me

recently by the head of 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 addict so many americans, they're commodity agnostic, he put it. they'll traffic in drugs. they'll traffic in children. they'll traffic in whatever will make them a dollar. that's all they really care about. they care nothing for the human misery they cause as a result of their illegal activity. which is why i -- it causes me great pain and disappointment to see that 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, even when it's coupled together with

a pathway to citizenship for 1.8 million young people, people vote no. we abdicate our responsibility when we fail to live up -- i'm talking about congress now -- our responsibility to deal with this whole epidemic. would you agree with me, admiral, if we just dealt with the prescription drug part but 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, but i cannot overemphasize the importance of limiting heroin, fentanyl to the solution set. >> i've heard general kelly, now chief of staff at the white house, formerly head of southern command, and who bemoaned the fact that many of our military and law enforcement who are stationed in places to be able

to intercept the movement of illegal drugs into the united states that because they're inadequately resourced in terms of the equipment, airframes, and the like, boats, that they have to simply sit there and watch it pour into 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 too 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 know that the demand side today, much of which was

created by prescription opioids, so three out of four uses of heroin started on prescription opioids. so one of our principle strategies to decrease the demand side is to reduce the unnecessary prescribing of prescription opioids across the board. >> absolutely. >> the second comment is with opioids, supply does create demand because once you're on it, you can't get off of it. it's a disease. it's an addiction. i fully agree it's like telling someone not to breathe once you're addicted to these drugs. in addition to decreasing the demand, we have to understand we have to decrease the supply and also the supply creates demand. once you're on heroin, fentanyl, or any of these drugs, it's very, very difficult to get off. >> are there strategies that you think the federal government could embrace to try to deal with that demand component? i hear what you're saying about supply and demand, but 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're in right now. >> yes, sir. >> other strategies that the federal government can embrace to deal with the demand side? >> you know, i think with the unprecedented amount of funding and the programs that we have, we need to evaluate their effectiveness over the next months, but i do believe by decreasing prescription opioids, and we're already seeing a very significant decrease nationwide, even more in the medicare population, even more in the va, that the demand is going down, but it has to be coupled with treatment for those who are already misusing or have substance use doisorder. part of the grant process we're in supports medication assists treatment. it supports comprehensive services. i want everybody to understand that as good as they are, the best m.a.t. and 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. we're actually one of our major thoughts it to work with francis collins and the nir to really start looking in a way to understand how do you put all the services together to be even more effective. most m.a.t., even with good therapy, is only 50% or 60% effective for six months. that's the state and we need to improve that. >> i would agree 100%. i would submit unless we come to grips with not just the prescription drug side but with the heroin opioid component, both supply and demand, that we're going to find ourselves -- >> there are tons of heroin literally coming over. the problem with fentanyl, among all the problems, is it's very cheap. the profitability is high. because it's so potent, you don't have to carry truckloads of it. there's only small amounts that

can have an impact that could kill tens of thousands of individuals. >> senator cantwell. >> thank you, mr. chairman, and thank you for your questions. e i think it is a good precursor to some of the things we're interested in. i don't know if either one of you know -- well, i'm assuming you do. the drug enforcement agency classifies opioids as a dangerous substance with potential for high abuse. so because of that, that's why we created a strong network of laws on distribution. we basically said that substances like this needed to be tracked and reported and suspicious orders red flagged and the distribution of these drugs communicated so that the drug enforcement agency, dea, could work through this. but despite the fact that law exists, there's been large quantities of opioids flooding

our communities with manufacturers filling excessively large orders in distribution. one example, a physician in everett, washington, wrote more than 10,000 prescriptions of the highly addictive oxycontin. then there were 26 times higher than the average for everett prescriber. in another case in a legal opioid distribution ring in california allowed more than 1 million opioids to be distributed into a community. so my point is where's the accountability? where's the accountability for drug manufacturers not tracking and using that information with the drug enforcement agency to work cost effectively to try to stop this kind of distribution? currently, the fines for manufacturing are a mere $10,000 for neglect and reporting on that distribution. so to me, that's hardly a

deterrent. that's why i'm asking legislatively for a tenfold increase for not reporting negligent distribution. and to me, we have to get at this problem of not tracking and seeing the signs of that distribution. my colleague, senator harris, and i also want to address what senator cornyn just mentioned, which is giving law enforcement the tools to also deal with the heroin epidemic. the heroin epidemic is also part of the problem. we want to make sure that they have resources to deal with heroin traffic. we think the front line of that is our law enforcement entities, and they need that help and support. but 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? >> so speaking for medicare and medicaid, we do through our medicare program, particularly the part d program, have what's called the overutilization monitoring system, which allows us to be able to track, for instance, you were talking about beneficiaries who receive high amounts of opioids, we're able to be able to see if they receive 90 or more morphine milligrams equivalent for a sustained period of time, say six months, from up to three or more prescribers or three or more pharmacies. we also have our medic, which is our fraud investigations unit, which looks at prescriber data to really be able to work with the inspector general to track those prescribers and to really look at pharmacies and prescribers who are high overutilizers and hopefully take action against them. >> so you don't work with the drug enforcement agency on this? >> we do not work directly with them. our law enforcement partners at the office of inspector general and department of justice do.

but we at cms did not work directly. >> do you think we need larger controls in place on improper prescribing and dispensing? >> we're working to try and put as many of those controls in place and agree that we need to really watch these patterns. >> i think we're beyond watching these patterns. i think that's why we're in this problem. because that's all we did, and we didn't penalize the manufacturer for failing to notify. we should be able to see some problem on distribution, whether that's a drug ring or individual physician who's gone awry. whatever the issue is, we should be able to see that's what the law requires. there's no penalty or penalty severe enough to get people's attention. so i would hope that you would look at this legislation and give us some feedback on it. and think about what improper prescribing, billing, and dispensing, what other methods we need for medicare and medicaid to be part of that equation. >> we'll definitely take a look at the legislation and get back to you.

>> and admiral, what about giving more resources for an anti-heroin enforcement ring with local law enforcement? >> you know, i can only comment generally. i think we have to be all on the page to the page to decrease the heroin supply. it's heroin and fentanyl that are now killing much more than prescription drugs, and we need to support a transgovernmental approach, including doj, local law enforcement, et cetera. both of my parents were police officers. i understand how important the front line is to this. >> well, i see my time is expired. i would say, i hope that we can come together on this, because you know, i'm -- we've toured our state. we've heard unbelievable stories of what's happening. people are getting opioids just so they can sell them for the heroin because they can get that three times the rate. so, we need to combat both. i agree with senator cornyn, that the heroin part of this is critical, but this is why we need law enforcement, and they need more resources and tools to

do that. so, i hope you'll look at this legislation and give us some feedback. thank you, mr. chairman. >> senator brown. >> thank you, mr. chairman. ms. brandt, i know that you as a native of ohio understand how hard this epidemic's hit our state. 11 people died on tuesday. 11 people died yesterday. 11 people will die today. 11 people will die tomorrow, on the average, as you know. 11 isn't the only number that matters. let me give you another number -- 10,769. according to the american academy of pediatrics, that's how many ohio children were placed in foster care in 2016. many of them, not all, many of them a direct result of addiction, of this epidemic. the bipartisan family first act just signed into law requires the department to issue guidelines on program criteria and provide a list of preventive services authorized under title 4e by october 1st 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 glad to hear you expect the department of states will come out in a timely manner this year. thank you both for that and thanks for your commitment. i have a few other questions i'll submit for the record in the implementation of family first, and i encourage you to solicit input and feedback. i know i don't need to admonish you to do that, from the states as you issue this guidance. before i get to my only question, ms. brandt, i'd like to share some of the things ohio's doing. we don't do well in infant mortality, compared to other states. we don't do well in education. we, unfortunately, lead the nation, almost, in for-profit charter schools abuse, but we're doing some really innovative things on babies and neonatal abstinence syndrome. i want to talk for a moment about it. every 25 minutes, a baby is born

suffering from opioid withdrawal in this country. 2,100 babies, six babies a day were admitted to a hospital in ohio for nas. just a decade earlier, just 300 cases were reported nationwide. so, the explosion of numbers, you two are all too familiar with. ohio's doing a lot of creative things. cincinnati children's established universal screening program that's helped to identify babies born with nas and get them to treatment faster. in previous finance committee hearings, senator portman and i have talked about work on the crib act to help pediatric recovery centers receive reimbursement through medicaid. secretary azar made the trip to kettering, ohio. i thank all of you for that. to see firsthand the work happening in our first pediatric recovery center, bridget's path. i want to continue our work together to pass the crib act to make sure these recovery centers have the funding necessary. another initiative that our state's been working on is through the ohio perinatal

corroberative nas practice to help babies born with nas. other states are looking to adopt this successful model. but our providers are overwhelmed, as you know. i hosted a conference yesterday for ceos from a handful of ohio's smaller and rural hospitals. they spoke about nas babies, how hard they are for hospitals to treat. not all of them have nicus. some of the smaller hospitals do not have providers who are experienced or specialized enough to care for these babies. as a result, they transfer these high-need infants to other facilities with more resources that are already themselves overwhelmed. but they realize the system isn't sustainable. one of the ceos of these 100-200-bed hospitals, smaller than that, even, shared hospitals collaborating with another larger system to utilize telehealth technology to keep babies closer to home while they undergo treatment. the larger system will share

their resources and expertise, through that technology when babies are born with nas at the smaller hospital with the hope of reducing burden on regional hospitals that currently are caring for those babies. they anticipate a savings, obviously, from cutting back on transfer costs. and my question to you is, my request is, ms. brandt, talk to me about what cms is doing to help nas babies improve care for moms and babies suffering from the addiction epidemic? what tools do you have to improve care options for these individuals? how does congress support additional federal initiatives in that space through multistate demonstrations? and then, if you would answer that and then commit to working, if you would give us specifically on the record a commitment to work with us on these innovative solutions. so, thank you. >> thank you for the question. i absolutely recognize the issues back home in my home state of ohio. the county i'm from back home is one of the hardest hit, and it's a really big issue, and at cms, we have been particularly focused on the issues you're talking about in terms of

helping mothers and infants struggle with their opioid addiction. we've heard a lot about it. the secretary spoke very much about his visit in bridge's path and what he learned in ohio. in february, we approved a state plan amendment for west virginia, which we hope will be a model for other states to use. it's going to provide additional treatment services for neonatal abstinence syndrome in nas treatment centers. it basically allows west virginia to reimburse all medically necessary nas services through an all-inclusive, bundled cost. sorry, my voice is going out. bundled cost per dm rate based on a prospective payment methodology. this is a big shift from how we normally reimburse for these services and allow more services to be covered. some of the services they can fund through this would now include nursing salaries, supportive counseling and case management, which are currently not included. what it does not include, and this is part of what they could potentially take action on, are

room and board costs and physical treatment services. another thing that was raised when the secretary was at bridge's path, is the limitation on 60 days of coverage for mothers who are postpartum and the fact that they don't receive services beyond that. so, that's another thing that we've been looking at at cms and we've heard a lot of feedback on and would love to work with you all not only on that issue, but all of these issues, because we think they're critically important. >> i spoke at the cleveland study club the other day about opioids and our government looking at it in a big comprehensive public health way. and i used a couple of examples of when government -- and a lot of people here don't think there is a role for the federal government in a lot of health care issues when many of us on this side, at least, believe there is. but i used the example of tobacco in 1964, when the u.s. first -- when the u.s. surgeon general, i guess, yeah, first came out against -- first recognized tobacco's public

health crisis. 45% of american adults smoked. last year it was down to 15%. you can look at how we treated the hiv-aids. and at the beginning, i mean, we had a president and a bunch of politicians that would not, and many others, who wouldn't acknowledge it. yesterday, barbara, my wife writes a weekly newspaper column that's syndicated, and she wrote about how barbara bush, whatever year she did this, when people were so afraid of hiv, you wouldn't even want to touch anybody with it, even though there was no evidence at all that it was transmissible that way. barbara bush went into a clinic and held a baby that was hiv-positive. and then once we decided that what we'd been able to do in that public health arena, so we know how to do this as a country. this one looks more intractable than the others -- maybe it is, maybe it isn't, but we know how to do these things when we really put our minds to solving a public health crisis. so, you two are really on the front lines of that, and your whole careers have been dedicated to that kind of fight.

so, thank you both. >> well said, senator brown. senator casey. >> thanks very much. i know we're at the end and we're all running for time, but admiral, good to be with you. thank you for your service. >> thank you. >> i don't know which title you like better, admiral or doctor. we'll use them inchangeably. >> yes, sir. >> and ms. brandt, we're glad you're back here. thanks so much for your service. i wanted to just highlight what so many others have highlighted. i just have one question and i'll be quick. this opioid, and frankly, a larger substance use disorder crisis is hitting every state just as you've heard today in my state. the numbers are, as of '16, i think 4,624 was the number. that number was up 37% overall from '15 to '16. i don't think i have a '17 number yet. but in rural areas, it was up more than 37%. it was up in the mid-40s. so, higher in rural areas.

in one rural county i was in back in august, kind of on a tour of the state, the most graphic metric or snr scenario the coroner saying we don't have enough places to put the bodies, literally. they didn't have enough slabs or places to put bodies. so, it's horrific on every level. and one question i wanted to ask is about barriers. i know that we hear a lot about the barriers to accessing treatment being stigma, limited availability of providers, high out-of-pocket costs. so, just my only question, because we're all pressed for time, is do you agree that those barriers exist, and what is the administration doing to confront those? and it could be either -- i'm directing it to ms. brandt, but either or both. >> you can -- >> i certainly agree those barriers exist, and particularly for rural populations as well.

as i'm learning more about this, there is $100 million by hrsa that's going to be targeted specifically to rural areas. the str funding that we announced yesterday, which was, again, the cure's second tranche, plus the $1 billion. there's great flexibility for the states to use that to support urban or rural, depending on where the needs are. we talked about it earlier. i'm a big believer in telehealth for many issues and distributing health care out of the major centers to where the actual need is, and i think that's part of the answer. and again, we're exploring with dea sort of the next iteration of that, as how can we prescribe, have a telehealth prescription of an m.a.t. provider into a rural community where there may not be an m.a.t. provider. there are certain barriers to that, but we're working on that, because i think that's an important, you know, component as well. i don't want to take up all of your time, so i'll stop there and let ms. brandt, but i'd be happy to follow up on that.

>> very helpful, thank you. >> i'll follow up with what the admiral said. cms, we agree, there are a lot of barriers. one way we're working on those barriers are through demonstration projects. we've approved 1115 waferdz based on flexibility and guidance we issued last november. we have five states now using these flexibilities, including allowing them to do things like access residential treatment facilities, which as you're aware, has prior not been allowed under medicaid reimbursement. so, that's something we're very interested to see the results of those five states and sort of what's happening there and how we can work with other states to provide those flexibilities to help break down those barriers. >> great. thanks very much, and thanks for your help on will's eye hospital. >> happy to help. >> thank you. >> thank you, senator casey. so, we're going to wrap up here pretty quickly. we've got a little business left to do, and then i'm going to just reiterate a couple of

points from 2 1/2 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, by close of business on thursday, april 26th. we need responses to mr. roberts' very important questions. and i'm going to -- i thought i did it, but perhaps it wasn't clear, put into the record the various documents that attest to these very serious conflicts that i talked to you about, dr. giroir, with respect to the advisory boards. and one of our letters led to the removal of an official where the conflict was so extraordinarily outlandish, but there is a lot of heavy lifting to do here. all right, 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 tackle this issue in a bipartisan way. we are going to do that under the leadership of the chairman. this isn't going to be tackled in the same kind of way that we pursued the c.h.i.p. bill for ten years, the historic families first bill, the potentially transformative medicare legislation that we've spoken about. we are going to get this bill done. it is going to be done in a bipartisan way, period, full stop. now, having said that, i want to go back to one of the points that i did make earlier with you, dr. giroir, and make sure you understand my expectation. i continue, as i indicated in my opening statement, to be exceptionally troubled by the role of the opioid executives,

the manufacturers, and the distributors. and i don't believe we got in this situation, a public health calamity, by osmosis, and i don't think it was just because really well-meaning people missed some of the addictiveness. i think that the opioid manufacturers, through twisted research, deceptive marketing, and bought-and-paid-for advocacy groups had a significant role to play in creating and fueling the crisis. so, i asked for that answer in writing from you. i expect it within a week, because we need -- if we're going to get at the roots of this problem, we've got to go at some of what led us to get to this political calamity. will you get me an answer to my question within a week? >> yes, sir.

and i just want to be, you know, clear that i'm fully supportive of senate looking at the root causes of this and understanding it, and for whatever doj is doing, i fully support that. the only point i was trying to make is that we got here in a multifactorial way. we need to understand the roots so it doesn't happen again, but where we are is going to require the kind of activities we're doing right now. so, yes, sir, 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 you just completely overlooked, completely, the role of the manufacturers and the distributors, and i think that's a significant part of it. i appreciate your cooperation on this. we will look forward to your answer. as you could hear, there are differences of opinion on this

committee, and i happen to share the views with respect to the role of cost containment. we've got to use every effective tool to drive down the cost, because you can have really transformational health products, but people have got to be able to afford them, and it's also -- as brandt knows, it's a taxpayer issue as well, it's an individual issue. so, questions of costs, the question of urgency, as you heard colleagues talk about, is all fundamental. but we're going to get a bipartisan bill from the finance committee, because chairman hatch and i have have been talking about this for some time. there are colleagues with very good ideas on both sides of the aisle. that's the way we do it. and with that, we will thank you both. always good to see you, ms. brandt. you've had a lot of good ideas over the years with respect to putting together bipartisan legislation that is really

principled bipartisanship. and with that, the finance committee's adjourned.

tonight, american history tv is in prime time. from our series "the presidency," we'll hear from clifton truman daniel, president harry truman's eldest grandson, speaking about the restoration of the white house that took place between 1948 and 1952. american history tv prime time begins at 8:00 p.m. eastern here on c-span3. ♪ this weekend on "real america" on american history tv,

the 1988 u.s./moscow summit between president ronald reagan and soviet leader mikhail gorbachev. >> the way of democracy is sometimes a complicated way and sometimes trying, but it is a good way, and we believe the best way. and once again, mr. general secretary, i want to expend to you and to all those who labored hard for this moment my warmest personal thanks. >> watch "reel america" sunday at 4:00 p.m. eastern on american history tv on c-span3. >> join us live sunday at noon eastern for our year-long special "in depth fiction editi edition" featuring best-selling fiction writers. gish jen will be our guest. >> i will say if we're talking about creativity, and of course, i know many writers and so on,

that people who have a lot to say are completely undaunted by being told the golden rules are respected or the general rules of storytelling. the whole idea that there is a, you know, a storytelling -- you know, that there is a triangle, that you must learn to do this if you're going to go on to be a fiction writer. it's necessary, but not sufficient, right? you learning to do this is not going to make you a great writer. but then you'll sit down with people and discover that, actually, they could all do it, you know? and i think there's nothing about learning to do those things that impedes creativity. >> her books include "typical american," "mona in the promised land" and "who's irish." watch "in depth: fiction edition" with author gish jen sunday from noon to 3:00 p.m. eastern on book tv, on c-span2.

next, coverage of a day-long conference analyzing the u.s. versus microsoft antitrust law case and antitrust enforcement of today's big technology companies. the 2001 case in which microsoft was accused of holding a monopoly and engaging in anticompetitive practices was ultimately settled by the justice department. first, we'll see part of the conference that includes remarks by senate finance committee chair orrin hatch. >> okay, i think we're going to go ahead and get going. if folks back in the kitchen with kind of move up and sort of fill in, that be great. is my audio okay, joe? great.