opioid epidemic. answered questions on alternative pain treatment, programs,d recovery and the role of pharmaceutical companies. this is two hours and 15 minutes. >> i would like to welcome everyone. disorders ande medicare, medicaid. i feel compelled to start with news we wish that was untrue. more than 60,000 americans died from a drug overdose in 2016.

60,000. the majority involved opioids or illicit opioids like heroin or fentanyl. these numbers are more than statistics, they represent our constituents, friends and loved ones. ones. my home state continues to be hard-hit. utahansing number of have undergone hospital stays and emergency room visits due to opioid and overdose visits. in 2016 alone, over 450 you taunts died from opioid overdoses. 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 made tackling the opioid epidemic a

top priority. i look forward to working with them to advance policy solutions. congress continues to support states and communities and therefore it's and have worked in a bipartisan manner to identify bipartisan solutions that have a meaningful impact for struggling individuals and families. with pleased to work ranking members of this committee to lead an effort that makes significant strides to address the opioid epidemic. the family first prevention service, in fact, enacted since february. it will provide states with access to funds for families with substance abuse disorders and allow more children to stay safely with their families instead of being placed in foster care. i'm also pleased of congressman wisely opting for the family first prevention services act in

the march omnibus law by providing states with additional funds to ramp up the 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. -- federal government substance use disorders. the federal government cannot solve this crisis alone. my hope is we can work together to ensure that all federal programs, such as medicare, medicaid, and human services, our innovative and responsive to the needs of americans with chronic pain or opioid use disorders. member have successfully partnered to make numerous recent improvements in health care. i really appreciate him for this. he has been a great partner and

i have enjoyed working with him. we work together to realize a 10 year extension of the children's health insurance program. 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 these accomplishment wouldn't have been possible without bipartisan engagement with members of this committee. identifying policies to evaluate and improve the federal response to the opioid epidemic will be no different. the success of these efforts will depend upon bipartisan committee wide support. today, members have an opportunity to speak with 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 members take advantage of this hearing at the toertise of our witnesses drill down into policies that are likely to garner bipartisan support to help this committee advance its record of working collaboratively. a missedless would be opportunity to help individuals, families, and communities across the nation. through outreach to stakeholders and soliciting input from each member of the committee, we have identified areas of potential bipartisan support. these include the need to evaluate access to and utilization of non-opioid treatment options for managing ton, enhancing data sharing promote appropriate health care interventions, and strengthen program integrity. and ensuring evidence-based care

is available for patients to identify and treat opioid use disorders. my view is the committee must do all it can to prevent and relieve opioid related supplementing 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 members thoughts on this. on the need tos work towards bipartisan solutions that will add to the long list of bipartisan health-care accomplishments. the witnesses will get a proper introduction shortly. i would like to say a few words before i have to attend a judiciary committee markup that i have to attend. first, i would like to welcome his recent

appointment is secretary azores point person on opioid policy rated he speaks highly of his capabilities. i am grateful the finance committee will be the first to hear from him in this committee. i am also delighted to have kim brant before the committee today. she 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 rentable deputy administrator for operations at cms last year. i am proud of her. iwould like to say that while certainly gave my blessing to her before she moved on to a cms leadership role, it was really difficult for me to see her go. she is that great a person. i ask you all indulge a point of

personal privilege to allow me to explain why. i no longer get those uplifting visit from her puppy. those incredible cookies printed i don't want this to take away from your expertise. she frequently provided all of these members of staff. they are much harder to come by. i am glad to know kim is helping steer the ship. truly we cannot be in better hands. andserved this committee all of us members on both sides of the aisle with great distinction. i am glad to have her here today. with that, i would like to recognize my friend, who has worked so well with me and who i have such great respect for his opening statement.

>> i know your time is short, i will make a couple of points. i want to thank you for the comment about bipartisanship. we are definitely going to continue that. i have said to friends and town meetings, if somebody had said january of 2017 in a very polarized congress that we would get the children's health insurance program reauthorized transformde, we would 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 medicare guarantee great if somebody had said that january 2017, they would have been accused of

hallucinating. people would say there is no way this could happen. it took place under your leadership, your chairmanship, i would very -- we incorporated values on both sides. i am going to make it understood we are going to work on this issue. >> let me make a comment on an important point that many senators have brought to my attention. i do think it is long past time to get the opioid executives before the committee, have them raise their right hand, 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 who concealed the dangers of their products and denied they were addictive. companies,he opioid including those who manufacture the drugs, those that distribute the drugs, and have misled the country about the dangers of their product. the opioid executives have thated the spotlight congress puts on the executives of the big tobacco companies. friendscolleagues and from both sides of the aisle.

that has to change. the executives need to be brought before this committee that pays for so much of american health care and be held accountable. letting american communities with these drugs is big business. so-called safer opioid pills have kept the cash registers running. derelict inld be its responsibilities if it presented there was no profit motive for steaming behind the addiction crisis. in 2015, more than 52,000 americans died of a drug overdose. on glad the chairman touched those statistics. it increased to 64,000 in 2016. 2017 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. as a supposed to be used sedative for elephants. it is so potent and dangerous. first responders around the country have to run around in hazmat suits when they are around it. that is the horrifying level of danger plaguing our communities through this epidemic. on a bipartisan basis, we have begun the work to find answers. 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. stressat said, i want to , as chairman hatch has, that we have a big time opportunity for bipartisan action. i'm going to touch on a couple of issues that have been important to me. at the top of my list is addressing what i have come to call the prescription pendulum. doctors used to be criticize for prescribing too conservatively. for they are criticized prescribing too much. there has to be a practical approach that really meets the needs of our people and strikes a responsible balance. for me, this began back in the days. chairman roberts told stories about the gray panthers. .ran the legal aid program

i think there are about 40 or so instead of 19-year-old -- my 92-year-old dad was in pain and could get a prescription. his father was 92 and the doctor said no. i am not going to prescribe for pain because the risk of addiction is too great. compare that with the fact that one in three medical -- medicare patients as a prescription for opioids. this has been my effort on chronic care. i have also heard more recently agonizing stories from parents at home who lost kids to the epidemic. my roundtables, i met carrie strickland, who lost her son to an overdose. he was a star athlete in napa.

when he suffered an injury, he was prescribed opioids. i guess he may have gone to a party, gotten involved with some of his friends. he started using heroin. for years, he struggled in the battle between addiction and recovery. colleagues, i know we have had a lot of athletes here. i went to school on a basketball scholarship. nobody who throughout their need, i think dr. cassidy knows more about it, when i was coming and thenghout the knee becoming addicted to painkillers. of.t was unheard o i'm sure my colleagues are all hearing these stories. noted, we cantch come up with bipartisan proposals to help make a

difference. the chronic care legislation , we the chairman mentioned were kicking off and nobody figured out it had a chance. we began 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. senator isakson deserves an enormous amount of credit. because we made it a bipartisan process. we can do that again. i am looking at the colleagues on my side. we have all worked hard on this. thedy has worked harder on opioid issue than senator mccaskill in terms of investigating the crisis, holding people accountable, we have colleagues here, and i don't want to overlook the fact that i see colleagues on the other side of the aisle who also

put in a lot of time on this. address these issues in a bipartisan way. i think particularly important for us is the vital role that medicaid plays in treatment. four out of 10 of working age americans suffering from opioid addiction rely on medicaid. source ofargest funding for treatment, so it will have to be a key part of the solution. as the chairman noted, the families first legislation provides a real tool to deal with the epidemic. keepingirst is about the families together wherever you can. under this law, let's make sure everybody knows what it means for opioids. if a parent is swept up in opioid addiction, a grandparent could step into care for the youngsters while mom or dad got

the treatment they needed. it would provide support for the parents treatment and services for the relatives. the end result, you have a family that can stay together, now we are in the time were we are working with the department. we have the representatives in the states to prepare for the major reform. chairman hatch and i are determined to see this federal state partnership so that families first give us a fresh, new tool for fighting back against opioid addiction and keeping the families together in the process. witnesses, all of us have enjoyed misprints 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 the best it legislation. we welcome both of you, i guess the kansans are in charge of the committee now. .> it is a coup i would like to associate myself with the remarks, the bipartisan approach to the problem stated by my colleague and friend from oregon. i would like to read the statement by the distinguished chairman senator hatch, and to extend a warm welcome to our two witnesses here today. our first witness today will be dr. brett, who is confirm of the senate by a voice vote, something that rarely happens. just two months ago, in february, and is currently serving as our system secretary

for help in the department of health and human services. it was a physician, scientist, an innovator. he is a number of leadership positions in both federal government and also an academic. the rest of his professional career is far too long to describe here. he is quiet a gentleman, but let me include just a few highlights. he chaired the veteran's choice act blue-ribbon panel from 2014 and 20 -- 2015. he directed 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 barba from 2006-2008. co-authoredred or 100 peer-reviewed scientific publications and holds patents on a number of biomedical inventions. he holds a bachelor's degree in biology from harvard and a medical degree from the university of texas southwestern medical center in dallas. i'm grateful and i know all , thiss of this committee will be the first congressional committee will be the first to hear from him in his capacity as senior adviser to the secretary on mental health and opiate policy. also delighted to have cms's kim brandt appear before the committee. i was going to say that we used

a mess, to cms as its but she has done her best to make it cms, so we will forget about that remark. -- is currently serving as the principal deputy administrator or operations 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 of 2011-2017. just part that, she was a senior counsel at austin and burke. so you know bob dole. after working for seven years as a cms director of the medicare program integrity group, prior to that, she worked for five years at the hhs office of his actor general and special counsel and director of external affairs. kim holds a bachelors degree from valparaiso university, a masters in legislative affairs from george washington university with a concentration in health law from the depaul

school of law. talk about very qualified witnesses. without further do, that's get to the meat of this very important hearing. please get us started. adm. giroir: thank you so much for the introduction. i want to first think chairman hatch, ranking member on and all the members of the committee for holding this important hearing. mostpioid epidemic is the pressing public health challenge of our time. the data are staggering. each year, nearly 12 million americans issues opioids. according to the latest cdc statistics, each day, 125 ,mericans i of opioid overdoses predominantly caused by heroin opioidscit synthetic like fentanyl. behind the statistics, i always see the individual patient, always. i am 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 owing. four years ago she learned that her precious son david has been found dead in his car due to a heroine overdose. davis was president of the 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 on the family medicine cabinet to sleeping. this story is one example of why the department has made this crisis priority and is committed to solving through our five-point strategy. first, strength and that strengthen reporting to inform real-time responses. second, advance the practice of pain management to decrease the use of opioids. there, improve access to , treatment, and recovery services. enhancing availability of overdose reversing medications and 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 cook states with 23 -- to track and report opioid use as a death -- as cause of death states utilize cdc funding to enhance prescription drug monitoring programs, which are increasingly powerful tool to ensure states prescribing practices and share information for multiple sectors. cdc has received an additional 300 $53 million in 2018 to enhance these practices are at improving pain management is critical because at chairman pointed out, three of four people who used heroine this past year issues prescription drugs first. ommending no

greater vince and days of opioids for use in acute pain and the use of non-opioid alternatives whatever possible. this guideline is recent educational efforts to raise awareness among providers in health system have resulted in significant reduction in opioid prescribing nationwide already. to improve access to prevention treatment and recovery support services, substance abuse and mental health sersadministratioe state targeted response to the opioid crisis grants which enable states to focus on areas of greatest need. this program provided $485 million to states and u.s. territories since fiscal year 2017 and just last evening, we release funding for the allocation of another 480 million dollars to states. because of the unprecedented funding requested by the president and appropriated by congress, samsa will provide an

findingal $1 million -- that will be awarded to states like in september. cms has significant role in prevention, treatment, recovery my colleague the stick to their role momentarily. regarding overdose reversing agents, vice admiral drumm adams, my colleague, earlier issued the first surgeon general's advisory in 13 years, which hurts more americans to carry overdose reversing agents like naloxone. multiple funding streams are in place to assist traits -- state and local -- anniversary founders to obtain the agent. dr. francis collins has recently announced the helping to end addiction long-term initiative at the nih and result of new funding recently provided by congress. they 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. sons andre our daughters, mothers and fathers, brothers and sisters, leaders and colleagues. solving this problem will whole of government approach. i look forward to working with you collaboratively. thank you very much. >> we thank you for your comprehensive statement. , memberst: thank you of the committee. thank you for inviting me to to address the opioid epidemic. i'm honored to be back in the finance committee. it felt a little strange to be on this side of the witness table. over 100 30 million people receive health coverage through cmis programs and the opioid epidemic affects every single

one of them. as a patient, family member, caregiver, or community member. team has been repeated throughout the sessions -- that the theme has been repeated. an important role by incentivizing providers to provide the right services to the right patient at the right time. our work is focused mainly on three areas, prevention, treatment, and data. due to the structure of our program, medicare artsy plan boxers and eight medicare programs are well-positioned to help prevent improper opioid utilization by working with physician. our job is to oversee these efforts and make sure the plan sponsors and say cap tools they need to be effective. beginning in 2019, cms expects initialsors to limit opioid prescription sales for acute pain to know more than a seven-day supply, which is consistent with the guidelines issued by the intervention.

additionally, we expect all an alertto implement for pharmacist when a usageciary's daily opioid reaches high levels. furnaces would consult with the prescriber to confirm intent. thanks to recent action by congress, cms now has the authority to allow sponsors to implement locking policies that limit certain beneficiaries to specific overseas and prescribers. cmis also recently finalized a proposal to integrate our monitoring system to improve coordination of care. administration supports legislation that would require sponsors to implement locking policies. these will add onto existing efforts in part be to attract high risk in a fisheries through oms and to work with plan sponsors to address outlier prescribers and pharmacies. we've seen a 76% decline in the

number of beneficiaries meeting the high risk criteria from 2011-2017, even while part be in roman has been increasing. we also support states efforts to reduce opioid misuse. programs can utilize medical management techniques. budget,urest presidents they establish him on standards for the drug utilization review program, a tool we use to abuse in -- oversee this area. ensuring that medicare and medicaid beneficiaries with substance abuse disorder have access to treatment is also critical 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 as well as naloxone. alsoresident's budget includes a proposal to conduct a demonstration to cover comprehensive substance abuse

treatment in medicare through bundled payment for methadone treatment or similar. because current statute limits the ability to pay for methadone, we're focused on ensuring access to other evidence-based mat's. through our 1115 waiver authority. cmis announced a streamlined process less november providing more flexibility for states seeking to expand access to and already we've approved by state demonstrations which include services provided to medicaid enrollees and residential treatment facilities. as the committee knows, ordinary services aretment not eligible for reimbursement due to the statutory exclusion to its two for mental disease. combined with the full spectrum of treatment services, we believe the new residents treatment but builds the is a powerful tool for states and we look forward to reviewing more requests. finally, she messes 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 trends, sharing prescribing patterns and other various efforts to ensure the effectiveness of our prevention and treatment policies. we've taken numerous steps to address this national epidemic. we know there's more we can do. we appreciate the work this committee is doing to highlight the importance of addressing this crisis and look forward to engaging with you on solutions. thank you for interest in our efforts to protect our beneficiaries and i look forward to answering your questions. to very much, cam -- thank you very much, kim. in the order of arrival and the order of eating here, i think senator isakson -- i beg your pardon, its central portland.

senator portland. >> thank you both for being here. we are fortunate to have your expertise. we've enjoyed working with you on a number of issues. i want to start by talking about an issue that comes before this committee which is the stop at. 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 and through the u.s. mail system. we did a year-long study of this. senator ms. gaskell -- sen. mccaskill:'s here and very involved with it. we reported back in january something shocking and alarming. about go online and ask opioids, people say we are happy to sell you synthetic opioids and send it through the u.s. mail system because it will get there without any concern.

the u.s. mail system doesn't electronic advanced data that helps law enforcement identify these packages. 60% of the people who died in ohio of overdoses died of fentanyl overdoses and others in that it opioids. comprises that columbus, ohio, just came out with a report from last year. deaths,ease in overdose and to thirst those related to fentanyl. this is a huge crisis and it is amazing to me that we're allowing our u.s. post office the data they need to find that needle in the haystack. we introduced this legislation back in february 2017. it has 32 cosponsors including a number of members of this committee, on both sides of the aisle. i am frustrated as the staff knows that we cannot get it out of the committee and to the floor for a vote.

there is a companion bill in the house. it's not the ultimate answer. senator whitehouse is here. on treatment and recovery and prevention and certainly on our can't, but this is a clear and present danger, and we are not addressing it. we are allowed people to have access to this poison coming in. i would ask you about that, and first, are you aware of this issue, and are you supporting of the stop act? the customs and border protection are and the dea and law-enforcement are. you'd -- would you be willing to help us to get this done? adm. giroir: thank you for that question. i want to reinforce our critical limitation of importation of fentanyl and carfentanil and similar drugs are to our fight.

in the hospital setting, to use icu, in would be in anesthesia by trained people. the thought of this being on the street with this deadly potency is absolutely frightening and astounding. , weould be very pleased worked very closely with customs and border patrol, as you know. the fda has increased its enforcement capability and the number of important investigators that they have in order to stop the importation of fentanyl and carfentanil so it does not enter our supply. and of course we would be very pleased to provide technical assistance and to work with you collaboratively because any effort that we can do to minimize fentanyl and carfentanil getting on the street greatly a our fight in prevention and treatment. they found the staff on this committee and leadership of this committee hears that, and i just

think it's one of those issues we should be ever to address quickly. i noticed that cms recently finalized their part d they are what sets they seven-day prescribing limit with acute pain. in our legislation, senator whitehouse co-authored that bill, we set a three day limit. we do that because of the science and because of what has told us. on the four days when there is a much higher chance of someone becoming addicted, and also with regard to pain, acute pain, that notfourth day is typically viewed as necessary from a scientific point of view. how did you choose the seven-day rather than a three day limit? ms. brandt: he chose it because it was consistent with the cdc guidelines. the guideline says seven-day supply limit is what they

recommended as the top in. we thought public comment on it and we were trying to strike the right balance. we recognize that often three days or less will be sufficient and that is certainly something, we have seven days as the top end. that is what we did consistent with the cdc. >> i would ask you to look at the data and look at what they say about that fourth day, because it's based on science and it might not seem common sense some people, but during that time after three days, there's a much less likelihood of addiction during that fourth or fifth day. someone can go back and get another prescription, but they have to go back and explain to the physician that's prescribing it my that is necessary. happeningk at what's around the country, almost

everyone who dies of an overdose started with prescription drugs. the ranking member has talked about the issue of the pain of families going through this with regard to prescription drugs being usually the gateway to the overdose and the death. thank you both for your service and we look forward to continuing to work do. for hisnk the senator very incisive comments. >> let me start with you if i could. i think we all understand we've got a public health calamity on our hands. thousands of deaths, something like a trillion dollars since 2000 terms of trying to pick up the pieces financially. i reviewed your written testimony carefully, and it almost suggests that the opioid epidemic happened by osmosis.

your written testimony role of thepen the pharmaceutical manufactories that put a greater emphasis on increasing sales rather than protecting the patient. you state in your written testimony, well-intentioned began tore providers prescribe opioids to treat paying 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 over prescribing practices on their own. in your view, who told the physicians that these doses, these amounts, were acceptable? thank you for that question. what i can tell you is, i was

part of the generation where my teachers, my professors told me, taught me that prescribing opioids in the setting of pain would not be addicted to the patient. we did not within the medical culture at that time at the appropriate information, nor with the 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. that is resting or an issue for the committee or other component. >> but you don't think that the fact that the manufacturers bankrolled patient advocacy groups and experts who played at outside influence on these over prescribing practice had anything to do with it? i have accumulated evidence showing conflicts on these.

one person has actually been removed. do you believe that that contributed to this problem? adm. giroir: i'm not here to defend or to place blame on any singular group. there was ahat 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. we now understand that this problem which led to heroin and fentanyl we started with prescription drugs. >> we are committed on this committee to being bipartisan. but we've got to make sure we get to the roots of the problem and pull them out and get on with the correction. i just want to wrap up this round and i have one question .or you, ms. brandt

to me, opioid manufacturers, through twisted research, effective marketing, and pay for patient advocacy groups had a significant role in fueling the crisis. you are going to be the point person for the trump team. do you share those kind of concerns that i have mentioned? 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 nine opioid uses an alternative care. absolutely i agree with you that opioid prescribing needs to be decreased. we need better science, better information. the key pillar of what we are doing is trying to decrease the unnecessary opioids, and i do

mean this respectfully, how we got here and who was responsible, i think it's a matter for the committee and others to answer. >> i want you to have the chance to respond in writing. i don't think we got here by sayingll-meaning people maybe i don't know how much to prescribe. i do think there was a strategy the opioid executives, and i laid it out item by item, hypeed research, excessive that downplayed the harmfulness, and stacking these advisory could -- advisory committees. if i could just get one question for ms. brandt. medicaid's largest provider covering four out of 10 you suffered in the states ravaged by the epidemic, medicaid paid for nearly half the treatments. medicaid expansion is clearly

going to be a major tool on the ground come and get i'm having trouble squaring the administration's commitment to expanding access to treatment with the president's budget proposal to drastically cut the program and rollback the medicaid expansion. sayingnot over here 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 in oregon are fighting this epidemic, and i would just like -- i'm over my time -- for you to tell us how ash $1 trillion in medicaid funding for these lifelike programs were going to be a to work the states to address epidemic. ms. brandt: we are 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 in the right setting. we have additional money that's been appropriated to go toward the opioid epidemic. some of the additional grants have just gone out and we are committed to trying to can best get as many resources put to this problem as possible. >> thank you, mr. chairman. you.me to both of first of follow up, is brandt. it's great that we were able to get the additional dollars or opioid and mental health services. in bright light consistent the president's budget as well has been the strong and consistent support mental health and addiction treatment services and i thank you your involvement and you were on this ade of the table, working in

bipartisan way with sen. blunt: myself. crisis,of the opioid for the 2019 budget specifically endorses the proposed funds to expand the program. you know this is really creating behavioral health center clinics like we do for health centers so that we have permanent structures on the ground and in the eight states where we are doing that now, a lot of what they are doing is opioid treatment. so it is a very important long-term way to treat this. as we in the finance committee contemplate the best approaches for addressing his crisis, with the secretary agree that the expansion of certified community behavioral health clinics to additional states as the president's budget poses is an important way to address this?

ms. brandt: thank you for the question. as you know, we have been very supportive, doing innovative approaches and we believe that behavior centers are part of that innovative solution. that's why the budget proposal includes the extra money and this is an issue where no amount of resources terms of things like this for you can target it can be ignored. this is about the food that we think and 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 overdose, with what is happening and this relates to the question of the for song -- naloxone and availability of the -- police and fire and others.

song was approved by the fda is an opioid overdose reversal drug in 1971. generic versions have been available since 1985. for a while, prices were not an issue. in 2005, there were two manufactures producing a generic version of naloxone and it cost a dollar for a file -- for vial. i 2013 they were increased to 15 times. the naloxone autoinjector was introduced. the first product approved by the fda for use by people without medical training. what happened then? they came on the market with $690 for a two pack in 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 health care and something as serious as this. less than a year later, the price increased to $4500. 2015, narcan, the nasal spray version of the drug, also use by people without medical training, came on the market for $150 for a two pack. the actual drug was approved 47 years ago. as recently as 2005, you could a dollar. for now taxpayers, in order to support police and fire and medical personnel and others, are going to be spending

thousands and hundreds of thousands of dollars in order to address what is an extremely concerning price situation and lack of accountability. i just want to ask, because this month, the u.s. surgeon general called for more people to carry naloxone, and you can get it without a prescription. so we've got this price now skyrocketing. for are responsible coordinating agencies efforts across the agency to fight the opioid crisis. it was recommended that hhs use reduceotiating power to its negotiating power on behalf of our people to be able to bring prices down. know, willl want to you use that power to negotiate what is an uncontrollable situation with no accountability

or frankly i think the drug companies are taking advantage of the pain and suffering and loss of life in this situation. adm. giroir: thank you, senator stabenow. i appreciate the fact that you're helping us highlight importance of naloxone. solve substance abuse disorder and does not get to the root cause, but it is an absolutely critical drug literally brings life back to a person on the brink of death. so we certainly support that. they begins in update of where we are. first of all, the state targeted grants that i talked about, the $485 million and the extra yesterday has increased flexibility for the state to use more of that money is needed for naloxone. going to interrupt because i'm out of time. my question was bringing the price down. we're using taxpayer money to pay for these outrageous prices.

the question was, something that was on the market for a dollar, and now are talking about these huge price increases. are you going to use the authority that the president's commission asked you to use to negotiate the best prices for americans and bring the price down? adm. giroir: 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 state and locality are thegetting that for $75 for two pack, which is consistent with the gsa schedule. >> i'm sorry, the chairman is telling me to stop, but i senator telling me your answer is no, you're not going to be negotiating the best price. i'm not hearing a yes. we are now getting

that at the gsa schedule. the fda is looking at all aspects to bring the locks on to over-the-counter and also to increase the generic competition. so that is our current strategy right now. we've seen the price go down by over 40%. >> i would hope so. it started at a dollar, and look at where we are right now. i think it is really outrageous what is happening and what people are having to spend an taxpayers having to spend. thank you, mr. chairman. that theust observe senator would never advise that they -- the distinguished chairman emeritus of the agriculture committee to stop with regard to her advice and consent on the committee. senator cassidy. fleeingnk you both for -- for being here.

families community initiative. i spoke to the father of the the young men who originally died. 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 obvious he indicates that this is not an effective strategy. it my nextcontrast conversation which is that if you are a physician -- impaired contrast in louisiana, that which is a fairly effective, three months inpatient with the month of follow-up without 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 of our medication assisted therapy. first there is a certain number people who die from methadone overdose and secondly, about

their version of naloxone. and work backwards from a question. nice to see louisiana guy who does well. i know how to pronounce your name even if others don't. know, there as you are some forms of medication and -- injections and implants coming onto the market. nextgen products, are administered so they never go into the hands of the patient, therefore cannot be diverted as i learned this is being diverted. or law is unclear whether not the pharmacies can dispense this medication directly to the provider. current law says it has to go to the patient. it makes sense, you don't want the brother picking up. dea is interpreting it as saying you cannot give it to the

provider to then do the implant and therefore that were -- avoid the potential for diversion. and i havenet legislation in the help committee that would address this problem. can you go back to the apartment and see if you can get endorsement -- back to the department in cvt then get endorsement of our bill? adm. giroir: certainly i will go back to the department and discuss with the secretary, i want to state certainly that medication assisted treatment is in best route going forward combination with behavioral therapy to treat patients. yes, i will go back. i'm not familiar with the specific bill, but we will go back. next there certainly abuse potential. part of the drugs, right. there's not so much abuse potential for no tracks on which

is in antagonism -- four that drug. noticedme ask you, i've in some localities there's less prescription opioids but there is no decrease in the number of deaths from opioid overdose. is illegalthat it drugs replacing or backfilling the loss of opioid prescriptions. is that were your data showing? ms. brandt: i'm going to defer to the admiral on that one. adm. giroir: yes, the prescription opioids have been a gateway, if you will come in that three of four people who use heroin darted that way. but clearly the deaths now are far overshadowed by heroin and fentanyl. >> are we seeing fewer deaths adm. giroir:ioid

the data we have is that in metis is more effective than non-in metis in that do not geographic data that correlates theraphic use of mat of lowering of the death rate within that geography. i will go back and see if the data are available clear -- are available. we would tend to believe that is the case but we need to verify that those two things go together. keep going back to the 17-year-old boy who was asked to be discharge and then is now dead. so something is not working. ms. brandt, i thought this question might be for you. it may be for either of you. do we have a way to track treatment programs have better outcomes versus those which do not? i can say a physician with three months inpatient been followed by your follow up his outpatient twos, but being discharge

weeks after being admitted and then ultimately dying, do we have best practices on this and are we doing a proactive programp to see that acme rehab is doing really well, but they rehab, not so well. ms. brandt: we are starting to accumulate that type of data. through our results of a lot of demonstration products, we've been testing a lot of our new innovative models. was thatnderstanding states were not as aggressively populating that as they should be. ms. brandt: we now have 49 states, the district of columbia and puerto rico actively reporting full data. >> i yield back, thank you.

i want to concur on prescription opioids for management of pain and senator stabenow's point on the cost of management of pain. those are important aspects of dealing with the opioid crisis. i've been around the entire state of maryland and we have addiction problems in every part of our state from her most rural to our most urban. they are in desperate need of partnerships with the federal government. i want to talk about two programs, one that is pretty well established and another that is becoming perhaps an option. both are repeated by our reimbursement structure. we don't have it integrated care system that reimburses the

integrated care. we had 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 or thoseport services, that are recovering from drug addiction help get those that are in the to the appropriate care center. we have those programs in maryland and they are extremely successful. the numbers are very popular. problem is there is not a embarrassment structure. a lot of this you have to find third-party sources to find it or creative ways, or hospitals coming in to help us because they know this will reduce their emergency rooms. what i am looking for is whether we can find a way to encourage these types of services. let me start with that first.

what can we do at the national you look at the grant programs available from the federal government sources, it's difficult to get support for peers support services. going to takem this one because it impacts a lot of the medicare and medicaid program. we agree this is a key part of the continuum of care. one of the challenges is that a lot of these types of services are not covered or not considered a provider is a care. broadening the definition of what is the medicare provider to be able to encompass these types of services would give us more flexibility. currently the statute does not recognize them as appropriate medicare providers. we've seen some success with this in state and as of 2016 there are a few states that are .overing your support services that is something that could

being courage more. it's in a few states right now but on the medicaid side we need to be able to better cover. >> i look forward to working with you on that because it is clearly a fruitful model. ,he states that are changing they don't need a waiver, they can just do it under their current authority? ms. brandt: that is correct. to the extent that they hit roadblocks, we will work with them on that. >> the other area that is relatively new our stabilization centers to try and get individuals who are stressed out of the emergency rooms where affectingimes, it's the access to emergency care. into a facility that can refer again to the proper care that they need him more appropriate setting. believe to stabilization centers in the

state of maryland. the reimbursement structure does not provide for this. is there some way that we could try to encourage the appropriate placement of those that are in stress so that they can get referred to the appropriate care? either one, whoever feels more confident. ms. brandt: that is the thing we can work with you on. we can definitely work with you all to find a more about that is the how we could help. adm. giroir: we've had a couple of community say that they want to take care of people. everybody is stressed and in need of care. there are security issues with people who are coming out of an ,verdose that requires security but also compromises the ability of emergency rooms to do their intended purpose. individuals, what you really need is follow-up care. their life is no longer being threatened, but they need

follow-up treatment and care. yes, we need or community-based centers, but we also need to get the appropriate placement. admiral, is there hope for an alternative to using the emergency rooms to deal with this? adm. giroir: we certainly hope so. the emergency room is great for these, but not great for everything else. we certainly support community-based programs, the grants we have have a large amount of flexibility or state flexibility or state to both two programs in test program and increasingly, as you said just, with the numbers that we have, with millions of americans misusing opioids, probably 2.4 million with substance abuse disorder, we will have to change the way we do things.

it's going to have to be outpatient based primarily with the in-service reserve for people with severe mental illness as well as opioid. he will have to train more behavioral health professionals and it will have to be community-based. we are all on the same page here. thank you for that. removing thed to roadblocks we have it is system that prevent communities from pursuing innovative ways, less expensive and more effective ways to deal with those that are stressed. >> in my new role, if there is a roadblock, i want to hear about it. part of my job is to make sure that hhs is listing an understanding and can be responsive to those needs. i would appreciate that direct feedback, and i mean that sincerely. >> thank you, mr. chairman.

ms. brandt, children whose families have been impacted by the opioid epidemic experienced, when their family structure breaks down. one program that is important to new jersey in helping these children is the family first prevention services act which allows states to draw down funds for evidence-based practices such as mental health, parenting programs as well as kinship navigator's to help grandparents. given these programs been multiple hhs's collaboration is critical to it. mommy and mes a program that allows mothers and treatment for substance abuse to get inpatient treatment without giving up the custody of their children. i believe programs like mommy and me help avoid the trauma of taking children away from parents and help keep families intact. this act allows states to draw 1wn funds starting on october of this year, but we are still awaiting guidance on how to make

that work. my question is, can i count on you to work with a cf to get that guidance out in time for states like mine? ms. brandt: certainly happy to cf to coordinate that we are getting that guidance out. catch 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? do.brandt: we absolutely as i mentioned in my opening statement, data is one of the three main components of the opioid strategy. we now have 49 states and the district of columbia and puerto rico reporting into our medicaid statistical information system and we are using all of our data

to really target how we can better to prevention and treatment and really be able to help give feedback to states and others working with their data. >> that was going to be my second question. how is cms working with states like mine to these types of activities? withrandt: we coordinate states on the data they report in and that allows us to take out for instant the pharmacy file which is all the claims related to things like fiction of opioids and be able to tell them where we see patterns and work with their information that they get from their prescription drug monitoring program to be able to detail how we can do intervention. >> you mentioned the medicaid intervention accelerator program. does cms have lands to provide new jersey and other states with tape: assistance -- with technical assistance in this space? ms. brandt: we want to be up to

have our technical assistance and technical support to provide a program. to think additional federal support would be beneficial to better support these types of activities? ms. brandt: we want to really support states ongoing payment and delivery system reforms and were looking to see how we continue to look at different program innovations and how we can best support them. >> we would like to follow up with you on that. and prescription drug minor programs have been helpful in curbing the flow of opioids, but according to the american p's are managed-care, pdm not associated with the reduction in overdoses. this may be due to the fact that individuals already addicted to opioids will switch to illegal archives when their supply prescription painkillers is cut off. what opportunities are there to prevent and opioid addiction from becoming a heroine addiction?

adm. giroir: thank you for that. first i want to say that pdmp's are rapidly developing. in then important tool cdc is sporting states of further you -- utilize them. have at level is to not pdmp sit on the sideline. 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 and stays there early. we don't want to wait until they are on heroin and fentanyl and come to the emergency room. i agree with you 100%. >> i hope what the congress did in this omnibus is going to help us focus a significant part of that money toward that exact purpose. afteriroir: the omnibus

sa,lion dollars through sam we expect that to be out to the states by september. >> thank you, mr. chairman. ms. brandt, welcome. we all know medicare is the largest purchaser of prescription opioids in the country. i was little shocked to learn , 2016,typical year anyway, one out of three beneficiaries received and opioid prescription from a is counterintuitive to me that one of three people needs to be given a drug that is so powerful and so dangerous, but that is case. it's even more surprising that

medicare actually paid more on a per patient basis for opioids than either commercial insurance or medicaid. so over $4 billion on opioid alone in 2016. i really wonder about the total consumption levels. i know that medicare and medicaid have over utilization monitoring systems and i know that is been some respect to the people that are being tracked, but i am concerned that the over utilization monitoring distance 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 beneficiaries,id that they believe are at particularly high risk. 727,000. 500,000 weremined

receiving high dosages of opioids for at least three consecutive months, and is excluded cancer and hospice patients. but the over utilization monitoring system, to my understanding, cover something on the order of 60,000-70,000 beneficiaries. i am wondering if the right number would not be 10 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? ms. brandt: a couple of things, and i thank you for the question because this is an area where we've been working to improve our oversight and see how we can address the concern. first of all, the oms system beneficiariesrt b , which is subsection of our

larger medicare and medicaid population. feedback, wef the significantly strengthen and do anythingability oversight through the oms distant. enabled us to be a to show that we cut over 85% of them with our new improved expansion of the system and additional edits that we put in place. we've been continuing to implement the cdc guidelines, our new safety edits and a overlooking how we can expand it to cover the rest of the program. >> could you send us the backup documentation on that? it looks like we're falling way short of the total goal. let me go to a specific subset of folks. it's my understanding that people who experience a non-fatal overdose, that that

experience alone is not a sufficient criteria for being part of the opiate utilization monitoring system, but yet we have had a spike in nonfatal overdoses. my understanding is almost half the time there is a nonfatal overdose that precedes a fatal overdose, so it is obviously a very dangerous event. inuld a nonfatal overdose and of itself be sufficient criteria for including someone in the opiate utilization monitoring? ms. brandt: i'm not a doctor, i cannot speak if that is an .ppropriate criterion we consider the continuum of care to be very important and we want to make sure there is that coordination. >> what would it take to adopt

if it turns out that's appropriate criteria, what would it take to make it a criteria for inclusion? >> i be happy to go back and look at the authorities. >> a true fentanyl event, a proper help, as it stands today that is not a sufficient criteria for being included in over utilization monitoring. i'm not a doctor either, but that is extremely counterintuitive. >> will take that back and provide responses. >> senator mccaskill. >> in reference to the ranking member's comments about the contributions by the manufacturers of opioids to the public policy groups, we've been investigating the manufacturers

of >we have issued a report that shows the american academy of pain management receiving big-money from opioid manufacturers and collect a deadly, they issued a statement that said that they were not -- opioids were not significantly addictive. to enter that report into the record. theink it is important that work that we have done on that committee be added to this hearing record because it is relevant. . there's another report that we have issue of a sentinel -- fentanyl manufacturer where -- e is a sales motto was start them high and hope they

don't die. areahad a fraudulent posing as doctors office and calling the managers to try to get approval for fentanyl. this was fentanyl. i would like that report to be made. >> without objection. >> as her own little with a lot of work, after this report was issued, the ceo was criminally arrested. that is major progress. we are continuing to look at the manufacturers and how they contributed to the problem. we want the plans to require to submit to you potential fraud abuse. is there some reason why you're not requiring the plans to give you the evidence of fraud and

abuse that they uncovered. that is something we have been re-examining and are exploring making that mandatory so that there would be mandatory reporting of that. >> i hope that it does not take very long. we have people dropping dead. in my state, every day. talk about common sense, why would this be hard to not do immediately? what studies do you need to do if a party plan that is making money off of our program, the taxpayers support, is not reporting the fraud and abuse that they find. than what chance do we have on getting a handle on it? ms. brandt: we concur it is an important part of the program. we are working to see how we can implement it. i think we implemented by saying, you have to report fraud and abuse. can you do that for the next 30 days? ms. brandt: i would get back to you.

a 30ot sure if we can do day thing. >> really? a drug around 47 years ago that is life-saving increases from -- ton 2014 240 $500 $4500. where is the outrage and cms in this? these price increases are not driven by our and the, they are driven by greed. in an areaed greed where people are dying. i think it is great, sir, that about the75, but what member that they knows addicted. how much is accosting them to get naloxone or narcan? at aan they afford it

price increase of more than 600%. why aren't we being more aggressive in going after these .ompanies going to do this what is their excuse? have you asked them? no i have not asked. >> would u.s. them? we asked them why they are making these prices this i? adm. giroir: yes. we want naloxone to be more available and affordable. there's no question about that. the nasal spray naloxone, the prices are going down, as we talked about before, but we are going to do everything we can to increase generic competition to potentially have it over the counter to prevent competition and -- encourage competition and lowered further. doses is where we

are. i would love to see that lower. the naloxone product jumped from $690 to $4500. that was in three years. adm. giroir: right. >> i would appreciate a yes or no, will you like them a letter to ask them why the price increased by that much? what was their justification for that price increase? would you do that? i will get back to you on whether or not i can write a letter. let me tell you, the $4000 doses are not being used primarily by first responders and state. familieslking about trying to save family numbers lives. you know how many parents walked into their bedroom and their child was overdosing and they can't afford this drug to save their life? they may need it before the first responders get there. i just want you all, this hands-off deal about pharma is wrong. i want you to be as mad as i am about it.

adm. giroir: i'm absolutely aware that naloxone needs to be with families. again, the inhaled naloxone, the nasal spray is generally preferred useful because it is easy to administer in its new form. i agree with you, it needs to be less expensive, but now we are at $75 or two decent -- two lifesaving doses. >> for first responders. adm. giroir: you are right. >> i'm going to hold you accountable for you -- accountable for this. i want you to write a letter. thank you, mr. chairman. up.ope, you're >> thank you mr. chairman. no state is immune from this issue. our state does not have data

that other states have in terms of opioid use disorder. havenately, for us, we do lots of substance use disorder issues which our governor is trying to address. we are obviously interested in working with the members of this committee and others of our colleagues in doing everything we can to take this issue head-on. i want to express my appreciation as chairman of this committee to help ensure that addressesity activity not only the opioid epidemic, but substance abuse wrongly. i hope our witnesses in the administration will 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, several centers have been working on expanding access to remote payment service in

medicare. that would provide the secretary of hhs to reserve -- wave certain restrictions, would reduce spending, or improve quality of care. we are hopeful this is something the department would have an interest in in a means to expand access to opioids and substance abuse treatment. that theomething secretary would support and are there other opportunities that you are looking at administratively to expand access? yes sir.ir: thank you for the question. i want to reaffirm that they are part of the solution. we have to get into an outpatient mentality, reach out to patients in their community, and i think telehealth is an important tool. one thing we are working with our dea partners on is to be able to expand not only

telehealth treatment but telehealth medication assisted treatment so that that may be given by a qualified provider across telehealth and monitored by a variety of professionals. that is the next step that is important. we are in very active talks with the dea to make that come about in a very short term. >> in your written testimony, you highlighted the work being done by the nih to advance the research and availability of nonaddictive pain medications and devices, which i applaud. i know the health committee is also working on further proposals in this space. has cms put in place procedures to which you are timely medicare coverage termination of new therapies was they are approved by the fda? adm. giroir: it is a great question -- a greatdt: yes, it is question. because of the important, we have been working on a parallel process with the fda. as they are determining whether or not it will be a drug or

device approved, we are also looking at coverage and reimbursement on our side. once the fda approves their piece of it, we can then very quickly get it into the care. >> seems like a big part of the solution of this problem. question, any health service does not fall directly into this committee's jurisdiction, but many south dakota tribal members are available for medicare -- medicaid. three or efforts to coordinate the department response, what recent engagement has taken place with tribes in other cultures working with them to address substance abuse disorder in trouble communities? have the national committee on heroine, opioids, and pain mayrts or the committee last year doing anything? weeks ioir: in the two have had this position, i have met with the ihf three times.

including an eight hour principals retreat where the and his deputies, cdc, myself, and secretaries were together focusing on we can do towhat support each other during the process. because of your passing, the $1 coming through the on the this that will be released in september has a specific $50 million allocation to the tribes specifically. i think we are highly --rdinated in a sense coordinated and sensitive to that. my affairs, in the last week, has done in multiple tribes to make sure that we are reaching them. >> thank you.

i hope to continue those efforts -- i hope you continue those efforts. mr. chairman, thanks. >> senator heller. >> mr. chairman thank you. i want to thank the committee for putting together this particular hearing as it is important. it is important for my states, across the country, and i'm pleased that we have this opportunity. it me, substance abuse that -- substance abuse hits close to home. of my colleagues, i've heard from those struggling with addiction, or those who have lost loved ones to this epidemic. nevada, thereof were 665 drug overdoses, deaths in 2016. in the same year, opioids were involved in over 40 thefts -- deaths and american deaths.

opioid abuse is a major public health concern. more steps need to be taken, and i'm sure we are in agreement of that to make sure our communities can address the crisis. i'm pleased to have the panel before us. ms. brandt, welcome back to the committee. it is a pleasure to see you. they keep are taking a few moments of your time to both of you for being with us today. admiral, i just had a meeting in my office where i met with the boys and girls club of western nevada. ing programsscusse that they had that were available to these young adult. they were talking about some of the programs, in particular when it comes to try to prevent students from being involved in drugs and opioids in particular. --as curious as to what since it was timely, what the department has in mind -- the

department of health and human services is doing, working on early prevention. adm. giroir: you highlighted very important points. obviously prevention is where it is at. once you are addicted to opioids, it is a long road even with the best air of the and cognitive behavioral therapy. a couple things regarding that, number one, we are in the middle of assessing what are the best evidence-based practices to reach different communities. we are going to have to reach them specifically based on age, where they interact, and 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 -- grant that i spoke about as a significant component of prevention that we could support. , every state is a little different and has different organizations that need to be supported and reach

those. i agree with you. >> who directs those dollars? schoolstate level, levels, education levels, can anything? prevent if every state is a little different, how do we get those dollars to the places that need than the most? adm. giroir: the specific grants, they are awarded to the states in the states can subcontract with any variety of organizations that they want to fulfill their mission. it could be very similar, highly flexible funding. we want to make sure there is prevention and treatment that is covered, but aside from that, states have flexibility to subcontract with whoever. ms. brandt: from the medicaid programs, i'm sure you are familiar with the diagnostic

testing, it is mandated they provide prevention and other types of services for children and adolescents up to age 21. way, through the medicaid programs and flexibilities they have, that they can do that. >> i just want to emphasize, a couple of weeks ago, the president issued an order on participation. this is a great opportunity to provide opportunities not just for eastport, but to have that as a platform for health in general that we could put many messages about appropriate nutrition, opioids, etc. on. i want to ask you about electronic prescribing. we have looked through every act on the subject, and i have a letter that i would like to submit for the record. 20 groups and organizations support this piece of

legislation that i have introduced. the question is, to you ms. -- whatwill it impact impact will electronic prescribing have? ms. brandt: we had a number of and eolders and last fall prescribing was one of the top for things that came up across all of the stakeholders sessions. we really think that the data from that experience is important, has a lot of benefits to the plans, and it is also something that our part b sponsors are required to support electronic prescribing as part of their participation in the program. it is something we think has a lot of potential and we are aware of your legislation and we would continue to support that. >> doctor, and ms. brandt, thank you. >> we appreciate your

appearance. i have been writing down the number of times the two of you have said that is a great question, or i'm glad you asked that question, or that was an important question. over 25 times so far. that is a record. would you ever say, gosh that is a dumb question? don't answer that question. ms. brandt: [laughter] i yield to the senator from texas. [laughter] to talk to yount about something that sounds like electronic prescribing but it is quite different. it is electronic prior authorization. patients in medicaid, their providers often times wrestle with the prior authorization for medication and assisted treatments for opioid abuse. increasing the odds they will

relapse and return through their use of opioids. increasing the use of electronic writer authorization, and , will helpd medicare improve access to assisted treatment. what you need from us, this committee, congress in order to increase the use of electronic prior authorization for medication assisted treatment? roberts, if you were here, he would talk about legislation that he and i cooperated on. but ask you, what do you think? ms. brandt: from our perspective, there is great potential for prior authorization. it is something that -- >> would you be glad i asked this question? ms. brandt: i decided not to say that but i am glad you asked the question. thank you. it is something we have been looking at that we think is one of the other potential tools that we have along with e

prescribing. anything that allows us to see in real time what is happening in what is being requested. especially being able to tell who is requesting different types of services. that is helpful from a program management perspective. >> dr., do you agree with her? adm. giroir: i do. >> would you go so far as to say you approve of this message? ms. brandt: yes or i do. -- do. giroir: yes sir, i whenever the senator asks me to write a letter or call somebody, i just do it. it is probably the right thing for you to do as well. i have another question. when i was privileged to be governor of delaware, we established a cabinet council and it included half of my

cabinet secretaries who met every month, developed a strategy that we pursued for eight years. said, rather than address the symptoms and problems, let's go to the root causes. several people mentioned root causes. as we confront the opioid todemic, i want to urge you focus not only on treatments, but also to focus on the root causes for this crisis. there are several. our child and family experts tell us individuals with mental health conditions, adverse child experiences, are at a greater risk for abusing drugs. i want to make sure that the hhs has adequate methods of prevention i can reduce drug abuse and prevention.

ms. brandt: from our perspective, we absolutely agree with you it is important to get the right services to children. one of our real mantras with the opioid epidemic is the "right services to the right person in the right setting. -- setting." weough the medicaid program, do a program that allows us to do prevention services. we have been looking at ways to expand telehealth for, particularly, areas where don't -- where they don't have a great access to you that as a tool to fight this epidemic. >> doctor? ms. brandt: i agree -- adm. giroir: i agree completely. we are looking at things that -- we have been working with our nonprofit

partners to do that. that is one way we can do that. having been in the children's hospital, and worked there for many years, i understand the importance of that. there are issue is, degrees of susceptibility. 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 is like asking yourself not to breathe after a while. you can't do it. we need to target adverse childhood experiences but everybody is at risk. >> thank you. admiral, it is good to see you again. thank you for being here and for your distinguished service.

ms. brandt, it is good to see you. i would like to talk about the elephant in the room. is heroine and opioid, admiral? adm. giroir: yes sir. >> and people can't get prescription jumps -- drugs were some reason, to addicts resort to heroin? adm. giroir: yes or. >> because it is cheaper and more readily available? ms. brandt: -- adm. giroir: yes, sir. the use istimes worse than other opioids? are you aware one of the major sources of heroine is across our southwestern border? adm. giroir: that is for sure sir. along with tons of heroine from tons of methamphetamine

tons, tons of cocaine. i heard it described to me recently by the head of southern command, the commander in charge of that region of the world, he said that the criminal organizations that traffic in will, theyn, if you are commodity agnostic. they will traffic in drugs, children, whatever will make them a dollar. that is all they really care about, nothing for the human misery that 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 means by which to

provide greater security along the border, even when it is coupled together with the pathway to citizenship from one -- 1.8 million young people. people vote no. we advocate our responsibility, and i'm talking about congress now, our responsibility to deal with the whole epidemic. ,ould you agree with me admiral, that if we dealt with the prescription drug part in did not deal with the air when and fence and all -- erwin in fentanyl -- heroine and fentanyl issues, we could get around this problem? >> i cannot emphasize the importance of limiting heroin and fentanyl to the set. who bemoanedlly

the fact that many of our military or law enforcement to are stationed in places to be able to intercept the movement of illegal drugs into the united because they are inadequately resourced in terms of equipment, and the like, that they have to simply sit there and watch import into the united states. but as we know, there is a , or maybet is equally more important than the supply. do you have any suggestions? either one of you for what congress might be able to do to deal with the demand side of this terrible problem? it seems to me we throw up our hands and give up to readily on the demand side, and if we can figure out some way to dampen the demand side, that would be an important part of solving this problem.

would you agree? firstiroir: two comments, , we know the demand side today, much of which was created by prescription opioid. three out of four users of heroine started on prescription opioids. one of the principal strategists is reduce the prescribing of prescription opioids across the board. is, withd comment opioids, supply does create demand. once you are on it, you cannot get off of it. it is a disease, and addiction, and i fully agree it is like telling someone not to breathe once they are addicted to these drugs. to decrease the demand, we have to decrease the supply and also the supply creates demand. once you are on the drugs, it is very difficult to get off of it. >> are the strategies you think the federal government can embrace to try to deal with the

component? i hear what you're saying about supply and demand. if we dealt with the supply and didn't do anything on the demand side, i think we would find ourselves in the same mess we are in. are there strategies the federal government can embrace? with the young president did amount of funding we have, we need to evaluate the effectiveness over the next mongths. --elieve by disgracing decreasing opioids, we are finding a decrease nationwide, even more from the va, the demand is going down. it has to be coupled with treatment for those who were misusing and have substance use disorder. part of the grant process we are in supports medications in treatment and comprehensive services. i want everybody to understand that as good as they are, the

best mat and services are only partially effective. increase in what we look at as how to improve the effectiveness of these programs. one of our major thoughts is to work with friends and colleagues to really start looking in a way to understand how we put the services gathered to be more effective. most mat, even with good there be, is 60% effective in for six months. >> i agree 100%. grips with theto prescription drug side, and also component, both supply and demand that we find ourselves -- heroise are tons of coming overn -- there are tons of herion coming over.

potent,sentinel is so you don't have to carry truckloads of it. there are only small amounts that can have an impact that can kill tens of thousands of individuals. thank you for your questions. i think it is a good precursor to some of the things we are interested in. i don't know if either one of you know the drug enforcement asssifies import -- opioids a substance with potential for high abuse and leading to psychological and physical dependence. that, that is why we created a strong network of laws on distribution. we basically said substances like this need to be tracked and and suspicious orders red flags, the distribution communicated so that drug enforcement agencies can work

through this. despite the fact that the law exists, there have been large come -- quantities of opioids flooding our areas with manufacturers filling large orders in distribution. example, someone in washington wrote more than 10,000 prescriptions of oxycontin. there were 26 times higher than the average prescriber. in another case of the illegal distribution, more than one million opioids were distributed into a community. my point is where is the accountability for drug andfacturers not tracking using that information with the drug enforcement agency to work across -- cost to try to stop this distribution. the fines for manufacturing art $10,000 for mere

neglected reporting on it. that is hardly a deterrent. otherwise i am asking legislative ready -- legislatively for not reporting negligent distribution. to me, we have to get at this problem of not tracking and seeing the signs of the distribution. my colleagues want to address with was just mentioned, giving law enforcement the tools to deal with the heroin epidemic. it is also part of the problem. we want to make sure that they have resources to deal with heroin traffic. we think the frontline of that is law-enforcement. they need that help and support. the question i have about this on the distribution is does hhs

have a system to track prescription opioids discovered by medicaid and medicare, knowing how they might be falling into the wrong hands? >> speaking for medicare and medicaid, we do through our medicare program have what is called the overutilization monitoring system, which allows us to be able to track, you were talking about beneficiaries receive high amounts of opioids who are able to see if they receive 90 or more morphine milligrams per a sustained period of time, say six months for three or more pharmacies. , which isve our medic our investigations unit that to work prescriber data with the inspector general to track those prescribers and look at pharmacies and prescribers who are over utilizer's and hopefully take action against them. >> you don't work with the dea?

>> we do not work directly with them. partners do,cement but we do not. >> do you think we need larger controls in place? >> we are working to try and put many controls, and agree that we need to watch these patterns. >> i think we are beyond watching the patterns, that's why we are in this problem. that's all we did and we didn't penalize the manufacturers for failing to notify. we should be able to see problems on the distribution, whether it is a drug ring, or individual position has gone awry, we should be able to see that is what the law requires. there is no penalty severe enough to get people's attention. i would hope you look at this legislation and give us feedback. think about what improper prescribing, billing, and dispensing, what are the methods

we need for medicare and medicaid to be part of that? >> we will definitely take a look at the legislation and get back to you. >> what about getting more resources for an antiheroin enforcement ring with local law enforcement? >> i can only comment generally. we have to be all in the page to decrease the heroin supply. it's heroin and fentanyl killing much more than prescription drugs. we absolutely need to support a trans government approach, including doj, local law enforcement, etc.. both of my parents were police officers. i understand how the frontline is important. >> i hope that we can come together on this. getting opioids just so they can sell them for the heroin because they can get that three times the rate. we need to combat those.

the heroin part of this is critical. this is why we need law enforcement and they need more resources and tools to do that. i hope you look at this and give us feedback. thank you, mr. chairman. are a native of ohio, and understand how difficult it is. tuesday, 11ed on people died yesterday, 11 people died today, 11 people will die tomorrow. 11 isn't the only number that matters. 10,769, according to the american academy of pediatrics, that's how many children were placed in foster care in 2016. many of them are a direct result of addiction. the bipartisan family first act has been signed into law and requires guidelines on program criteria and provides prevented

of services authorized -- preventive services authorized by october 1 of this year. in -- i understand down in the list, the family first, i am pleased to hear you expect the guidance of states to come out in a timely manner. thank you to both of you for that. thank you for your commitment. i have two additional questions i will submit for the record. --ncourage you to simplicity to solicit input. questionget to my only , i would like to share some things ohio is doing. we don't do well on infant mortality compared to other states. we don't do well in education. we unfortunately lead the nation in profit charter schools abuse. we're doing really innovative on babies.

a baby is borns, suffering from opioid withdrawal in this country. 2100 babies, six a day were admitted to a hospital. earlier, only 300 cases were reported. the explosion of numbers you are all familiar with. ohio is doing a lot of things. establish a universal screening program that has helped identify babies born with ans and get them to treatment after. hearings, -- in previous hearings we talk about helping pediatric recovery centers receiving aid. i want to continue our work

together to pass the crib act to make sure these recovery centers have the funding necessary. another initiative we have been working on is with the ohio perinatal project which has prescribed the best practices for treating babies born with nas. we are looking to adopt successful models. our providers are overwhelmed. conference for ceos and a handful of ohio's smaller and rural hospitals. they spoke about babies, how hard they are for hospitals to treat. not all of them have neck use. a lot of them don't have providers who are experienced or specialized enough to care for these babies. result, they transfer the site needed minsk to facilities with more resources that are already overwhelmed. they realize the system isn't sustainable. one of the ceos of these collaboratinged

with another larger system to tolize tele-tell technology keep babies close to home when they undergo treatment. no longer system will share resources and expertise. when babies are born with nas at this model hospital. -- the smaller hospital. they anticipate a savings from cutting back on transfer costs. my question is talk to me about what cms is doing to help babies improve care for moms and babies suffering from addiction . how does congress support additional federal initiative in that space to multistate demonstrations? if you would answer that and commit to work, give us specifically on the record a commitment to work with us on these solutions. >> i absolutely recognize the issues back home.

the county i am from is one of the hardest hit and it is a really big issue. we have been focused on the issues you are talking about, in terms of helping mothers and infants struggle with their opioid addiction. we heard a lot about it, the secretary spoke about it, and what he learned in ohio. in february of this year, we foroved a plan amendment west virginia, which we hope will be a model for other states to use. it will provide services for neonatal absence system in treatment centers. it allows west virginia to reimburse all medically necessary nas services through an all-inclusive bundled cost per diem rate based on a perspective methodology. this is a shift from how we would normally. some of the services they confront, the nursing salaries, supportive counseling,

management, which are currently not included. include, whatot congress can take action on, art room and board costs and physician treatment services. another thing we heard was the bridges path is the limitation on 60 days coverage for mothers who are postpartum and the fact that you don't receive services beyond that. that's another thing we have been looking at and expect feedback and would love to work with you all. we think they are critically important. >> i spoke at the cleveland city club about opioids and our government looking at it in a comprehensive public health way. ofsed a couple of examples when government, a lot of people think there is a role for the federal government in a lot of health care issues when many of us believe there is.

i used the example of tobacco in 1964, when the u.s. surgeon general came out and recognized the health crisis. .5% of american adults smoked last year it was down to 50%. you -- 15%. you look at how we treat aids. you have a bunch of politicians that wouldn't and knowledge it yesterday. writes a weekly newspaper column and indicates how barbara bush, whatever year she did this, when people were still afraid of hiv. you wouldn't want to touch anybody with a, even the other was no instance that it was transmissible. she went into a clinic and held up a baby that was hiv-positive. once we decided what we have been able to do in the public health, we know how to do this as a country. intractable,re maybe it is, maybe it isn't, but we know how to do these things

when we put our minds to solving the public health crisis. front linelly on the of that. your whole careers have been dedicated to that kind of fight. thank you both. >> thank you very much. i know we are at the end and running for time, but good to be with you. we are great for you are back your, thank you very much for your service. i want to highlight what so many others have highlighted and i have one question. this opioid crisis is hitting every state. are as of 16, 4624. that number is up 37% overall.

in rural areas, it was up more than 30% in the mid-40's. higher in rural areas. in,ne rural county i was the most graphic metric or scenario was the coroner saying we don't have enough places to put the bodies. they didn't have enough places to put bodies. it is horrific on every level. one question i wanted to ask was about barriers. we hear a lot about the barriers to accessing treatment being stigma, limited availability in providers, high out-of-pocket costs. agreey question is do you that those barriers exist, what is the administration doing to confront those? it could be either of you. >> i certainly agree those barriers exist and particularly

for rural populations, as well. as i am learning more about this, there is $100 million that is going to be targeted specifically to rural areas. the funding we announced yesterday, which was the cure second tranche. there is 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 am a big believer for telehealth. in disturbing health care out of the major centers to where the health care need is. and i think that is part of the answer. we are exploring with dea the next iteration of that, how can -- have abe telehealth prescription in a rural community where they may not be an mhc provider? there are certain barriers, but we are working with -- on that.

i don't want to take up all the time. but i would be happy to follow up. >> i will follow-up with what the admiral said. there are a lot of barriers. one of the ways we are working on them are through the projects we have approved. on issues ofbased guidance we stated last november. something we're very interested to see the results of those five states and what's happening there and how we can work with other states to provide flexibility. >> thank you, senator. we are going to wrap up for to quickly. we have a little business left

to do. i am going to reiterate a couple of points. first, i would like to enter into the record senator roberts questions on when we wrap up, we're going to ask that there be a response for questions on the record. need responses from the administration to senator roberts, very good important questions. i am going to put into the oford the various documents these very serious conflicts of interest. led to theinstances removal of an official where the conflict was so extraordinarily

outlandish. there is a lot of heavy lifting to do. having said that, let me recap where we are. clear howant to make strongly i feel and how strongly our side feels that we tackled this issue in a bipartisan way. we are going to do that under this chairman and in the exact same way we pursued the chip bill. potentially transformative medicare legislation that we have spoken about. we are going to get this bill done and it will be done in a bipartisan way. that, i want to go back to one of the points that i made with you earlier and make sure you understand my expectation. in my opening

statement to be exceptionally troubled by the role of opioids executive. andmanufacturers, distributors. i don't believe we got in this situation, a public health command many -- calamity by osmosis. i don't believe it was well-meaning people missed some of the addictiveness. i think the opioid manufacturers through twisted research, susceptible marketing, and bought and paid for advocacy groups had a significant role to play in creating in crisis. i ask for that answer in writing from you. i expect it within one week. if we are going to get at the roots of this problem company --, we have to go at some of what led us to get to this

political calamity. will you get me an answer in a week? >> yes, sir. just want to be clear that i am supportive of the senate looking at the root causes and whatever the doj is doing, i fully support that. the only point i was trying to make is we got here in a multifactorial way. we need to understand the roots. where we are is going to require the activities. i will provide you that within the timeframe. >> no one disagrees with the theory that there are a variety of factors. what i am concerned about is it just completely overlook the role of the manufacturers and distributors.

i appreciate your cooperation on this. there are differences of opinions. i happen to share the views with respect to the role of containment. we have to use every effective tool to ride out the costs. if you have transformational health products and people have to be able to afford them. question of costs, question of urgency is all fundamental. we are going to get a bipartisan bill from the finance committee. chairman hatch and i have been talking about this or some time. very goodgues with ideas on both sides of the aisle, that's the way we do it. that, thank you both.

to have a lot of good ideas put into perspective. the finance committee is adjourned.

ext, a confirmation hearing. topics included north korea's north korea program.