witnesses include representatives from the health and human services department and the centers for medicare and medicaid services. they were asked how to reduce the cost of drugs to treat overdoses and options for pain treatment. this is just under two and a half hours. i would like to welcome everyone to today's hearings on tackling opioids and substance abuse disorders and human service programs. i feel compelled to start with news we wish were untrue. diedthan 60,000 americans from a drug overdose in 2016.

60,000. the majority of these involved prescription opioids or illicit opioids like heroin or fentanyl. these are more than statistics. they represent our constituents, our friends. our loved ones. the home state of utah continues to be home -- hard hit. a alarming number have undergone hospital stays due to opioid overdoses. over 450 utahians died from a opioid overdose. americans recognize the challenges posed by the epidemic and are fighting against it. and thet trump secretary of health and human services have made tackling the opioid epidemic a priority and i

look forward to working with them to advance policy solutions. congress continues to support states and communities in their efforts and has a record of working in a bipartisan manner to identify solutions that can have a meaningful impact for struggling individuals and families. i was pleased to work with members of this committee to lead a effort that makes strides to address the epidemic. the family first prevention services act enacted last february. this would provide states with access to funds to provide families with substance abuse disorders. it would allow more children to stay safely with their families instead of being placed in foster care. opted tosed congress build on the foundation of the family first prevention services 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 offerences in the lives families affected by substance abuse disorders. -- federal government cannot and i should say substance use disorders. the federal government cannot solve this alone. i hope we can work together to ensure our federal programs are to theive and responsive needs of americans with chronic pain or opioid use disorders. number -- my ranking member and i have successfully partnered to make improvements in health care and i appreciate him for this. he has been a great partner and i have enjoyed working with him.

worked together to realize a extension of the children's health insurance program. we pushed through a package of policies known as the chronic medicarewhich improved for beneficiaries with chronic care conditions. none of these would have been possible without the bipartisan engagement of members on this committee. identifying policies to about you eight and improve the federal response to the epidemic -- toe no different -- identify and improve the federal response to the epidemic will be no different. today, we have the opportunity to speak with leading experts on opioid policies. medicare, medicaid, and human services programs can add that and be improved to address the congress -- to address the

crisis and what the administration and congress can do to save lives. it is my hope members take advantage of this hearing and the expertise of witnesses to policies that will garner bipartisan support. anything less would be a missed opportunity to help individuals across the nation. through outreach to stakeholders and soliciting input from each member of the committee, we have already identified areas of potential bipartisan support. these include the need to about you wait access to and utilization of non-opioid treatment options for managing pain, enhancing data sharing to promote appropriate health care and strengthen the program integrity, and isuring evidence taste care

available for patients to treat opioid use this orders. the committee must do all it can to prevent and sufferingioid related by implementing effective policies in medicare, medicaid, and human services programs. we have a opportunity to do so in the near term. we will hear the ranking member's thoughts in a moment but i do hope he agrees to work thatd bipartisan solutions would to the long list of accomplishments. the witnesses will get a proper introduction shortly. few wordske to say a before i have to attend a markup. i have to attend. i apologize. i would like to welcome dr. his recent appointment as point person on opioid policy

speaks highly. i am grateful the finance committee will be the first committee to hear from him and this capacity. -- from him in this capacity. kim also delighted to have brandt appear before the committee. needs no introduction as she served as a senior member of my staff for six years before assuming the role of principle deputy administrator last year. i am very proud of her. i would like to say that well i gave my blessing before she role,on to a leadership it was difficult for me to see kim go. she is the greatest person. i asked you indulge a point of personal privilege to allow me to explain why.

i no longer get those uplifting visits from her puppet, sherlock. and those cookies. another goodie. i do not want this to take away from your expertise. provided -- they are harder to come by now. i am glad to note she is helping to steer the ship. they could not be in better hands. as we also, kim served this committee and the members of this committee on both thirds of -- both sides of this i'll with great distinction. with that, i would like to recognize my friend who has worked so well with me and who i have such great respect for, the ranking member, for his opening statement. >> thank you and i know your time is short. i will make a couple of points.

i want to thank you for the comments about the bipartisanship here it we are going to -- bipartisanship. we are going to continue that as we tackle the opioid issue. if somebody had said in january congressn a polarized that we would get the children's health insurance program reauthorize for a decade, we would transform foster care system in america under families first, we would begin the transformation of medicare being a acute care program while updating the medicare guarantee. if somebody had said that was , they would have been accused of hallucinating. people would say there is no way

this could happen. it took place under your leadership and your chairmanship. weery much appreciated it incorporated values from both sides. i wanted understood we are going to work on this issue in a bipartisan way as well. >> that is great. >> let me make a comment on a important point that many senators have brought to my attention. longis, i do think it is past time to get the opioid executives before the committee, have them raise their right hands, and hold them accountable for their role in creating a public health calamity that is

killing thousands of americans each year. some years ago, i participated in a hearing where a panel of tobacco executives said under oath that their products were not addictive. in my view, there is a parallel you can draw to the opioid issue today. back then, these to back u.s. executives concealed the danger of these products -- these tobacco executives concealed the danger of these products. now it is the opioid executives. the countrysled about the dangers of their products. the opioid executives have avoided the spotlight that congress puts on the executives of the tobacco companies. , we have colleagues and friends from both sides, that has got to change.

the executives need to be brought before this committee that pays for so much of american health care and be held , flooding american communities with these drugs is big business. -- safer opioid pills have kept the cash registers running. be derelict in its responsibilities if it pretends there is no profit motive or corporate scheming behind the addiction crisis. , more than 52,000 americans died of a drug overdose. i am glad the chairman touched on those statistics. increased to 64,000 in 2016 and in 2017, it was 71,000. of opioid pattern addiction escalating into abuse of heroin and fentanyl. a even stronger narcotic called

car-fentanyl 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. oft is the horrifying level the danger plaguing our communities as a result of the epidemic. on a bipartisan basis, we have begun the work and when you get into this, you deal with the paradox that cutting down the supply of opioids, depending how you do it, could drive even more people to other drugs, leading to even more overdose deaths. that is nothing any member of this committee could possibly want. want tot said, i

stress, as chairman hatch has, that we've got a big 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 criticized for prescribing too conservatively. now, they are criticized, and i believe fairly, for prescribing too much. there has got to be a practical approach that meets the needs of our people and strikes a responsible balance. days,, this began in the chairman roberts has heard some of the stories about the panthers. program forl aid the elderly and was the director of the panthers.

i think you are about 40 or so. his 90 to youred old dad was in pain and could not get a prescription. the doctor said no. i'm am not going to prescribe for pain because the risk of addiction is too great. today where with one in three medicare patients has prescriptions for opioids. this was part of our effort on chronic care. i have also heard more recently more agonizing stories from parents at home who lost kids to the epidemic. lost carrie strickland who her son jordan to an overdose. he was a start athlete in the rivertown of napa. he was prescribed opioids. party ande gone to a

gotten involved with some of his friends. he started using heroin. he struggled between addiction and recovery. i know we have a lot of athletes. i went to school on a basketball scholarship. i am too small, and i made up for it by being slow. who throughout their knee -- back when i was coming up, throughout their knee and suddenly became addicted to painkillers. that was unheard of. just unheard of. i am sure my colleagues are all hearing these stories. , and irman hatch noted want to come back to it, we can come up with bipartisan proposals to help make a difference. the chronic care legislation that the chairman mentioned and

i mentioned. that senator isaacson joined me -- began literally to transfer medicare from being the kid care program to being a chronic care program, which is where most of the money is now being spent. senator isaacson deserves an anonymous amount of credit as the chairman has been made a bipartisan process. we can do that again. i'm looking at the three colleagues on my side. senator mccaskill -- no one has worked harder on the opioid issue then senator mccaskill in terms of investigating the crisis and holding people accountable. we have colleagues here. i do not want to overlook the fact that i see colleagues on the other side of the aisle who have also put in a lot of time on this.

we can address these issues in a bipartisan way. i think particularly important for us is the vital role that medicaid plays in treatment. medicaid is the largest source of funding for treatment in the country. it is going to have to be a key part of a solution. as the chairman noted, the family first legislation provides a real tool to deal with the epidemic. family first is about keeping the family together wherever you can. under this law, let's make sure everyone knows what this means for opioids. if a parent is swept up in opioid addiction, the grandparent could step in the care for the youngsters while mom or dad got the treatment they needed.

it would provide support for parents and relatives. have a family that can stay together. where we the period would be working in a department to prepare for the major reform. chairman hatch and i are determined to see this federal and state partnership so that -- family first gives us a fresh new tool for fighting against opioid addiction. keeping the family together in the process. i like to welcome to our witnesses. all of us have enjoyed ms. brandt's cookies. that has been referenced. toent to reference -- i want reference that we appreciate her professionalism. everyone has had a great experience trying to put

together details on an important piece of legislation. i guess the chance it -- i guess the kansans are in charge of the committee. >> it is a coup. i would like to associate myself with the remarks, the bipartisan remarks of the 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 assistant

secretary for the department of health and human services. prior to his current position, he was a physician, scientist, innovator. the rest of his professional career is far too long to describe here. he is quite a gentleman, but let me include a few highlights. he chaired the veteran's choice act blue-ribbon panel from 2014 and 2015. he directed the texas task force on infectious disease preparedness, responses during the ebola emergency. he was ceo of texas a&m's health science center from 2013 and 15,

darpa from 2060 2008. he has authored or co-authored 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 members of this committee, this 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. i am also delighted to have cms's kim brandt appear before the committee. i was going to say that we used to refer to cms as its a mess, but she has done her best to

make it cms, so we will forget about that remark. she 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 from 2011 to 2017 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 two 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. the opioid epidemic is the most pressing public health challenge of our time. the data are staggering. each year, nearly 12 million americans misuse opioids. according to the latest cdc statistics, each day, 125 americans die of opioid overdoses, predominantly caused by heroin and illicit synthetic opioids 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 a lynn. -- missy own. four years ago, she learned that her precious son david had been found dead in his car due to a heroin overdose. david 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 address his difficulty sleeping. this story is one example of why the department has made this crisis a 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. third, improve access to prevention, 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 track and report opioid use as a 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 $353 million in 2013 to enhance these practices are at improving pain management is critical because at chairman pointed out, three or four people use care when this past year misused prescriptions drugs -- perception drugs first. the cdc issued prescribing guidelines recommending no

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 services administration administers the state targeted response to the opioid crisis grants which enable states to focus on areas of their greatest need. this program provided $485 million to states and u.s. territories since fiscal year 2017 and just last evening, we released 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 additional $1 billion to states this year. this additional building --

additional billion be awarded to states in september. cms has significant role in prevention, treatment, recovery my colleague the stick to their role momentarily. regarding overdose reversing vice admiral jerome adams earlier issued the first circle -- surgeon general's advisory in 13 years, which purges more americans to carry overdose -- overdose reversing agents like naloxone. multiple funding streams are in place to assist state and local founders to obtain 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. victims are our sons and daughters, mothers and fathers, brothers and sisters, leaders and colleagues. solving this problem will require a whole of government approach. i look forward to working with you collaboratively. thank you very much. >> we thank you for your comprehensive statement. ms. brandt: thank you, members of the committee. thank you for inviting me to discuss work 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 130 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. the theme has been repeated throughout the sessions.

cms plays 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 programs are well-positioned to help prevent improper opioid utilization by working with prescribing physicians. 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 all sponsors to limit initial opioid prescription sales for acute pain to no more than a seven-day supply which is , consistent with the guidelines issued by the intervention.

additionally, we expect all sponsors to implement an alert for pharmacist when a beneficiary's daily opioid usage reaches high levels. pharmacists would consult with the prescriber to confirm intent. thanks to recent action by congress, cms now has the authority to allow sponsors to implement locking policies that limit certain beneficiaries to specific pharmacies and prescribers. cms also recently finalized a proposal to integrate our monitoring system to improve coordination of care. the 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

enrollment has been increasing. we also support states efforts to reduce opioid misuse. programs can utilize medical management techniques. in this year's president's budget, they establish minimum standards for the drug utilization review program, a tool we use to oversee abuse in 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. the president's budget also 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. the administration is committed to increasing access through our 1115 waiver authority. announced a streamlined process less november providing more flexibility for states seeking to expand access to treatment and already we've approved by state demonstrations which include services provided to medicaid enrollees and residential treatment facilities. as the committee knows, ordinary resident treatment services are 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. >> thank you very much, kim. in the order of arrival and the order of being here, i think senator isakson -- i beg your pardon, it's 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. sen. mccaskill is here and very involved with it. we reported back in january something shocking and alarming. if you go online and ask about 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 require the advanced electronic 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. the county that comprises columbus, ohio, just came out with a report from last year. 47% increase in overdose deaths, and two thirds of those were 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. working on treatment and recovery and prevention and -- 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. would you be willing to help us to get this done? adm. giroir: thank you for that question. i want to reinforce how critical the limitation of importation of fentanyl and carfentanil and similar drugs are to our fight. in the hospital setting, to use fentanyl would be in icu, in

anesthesia by trained people. the thought of this being on the street with this deadly potency is absolutely frightening and astounding. we would be very pleased, we worked very closely with customs and border patrol, as you know. the fda has increased its enforcement capability and the number of import investigators that they have in order to stop the importation of fentanyl and carfentanil so it does not enter our supply. and of course 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 will greatly aid our fight in prevention and >> 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 the cdc 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 the fourth day is typically not 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 sought 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 in. 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 to 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 why that is necessary. if you look at what's happening 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 with you. >> i thank the senator for his 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 in 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 completely omits the role of the

pharmaceutical manufacturers that put a greater emphasis on increasing sales rather than protecting the patient. you state in your written testimony, well-intentioned health care providers began to prescribe opioids to treat pain in ways that we now know are high risk and have been associated with opioid abuse, addiction, and overdose. now, it is hard to believe that trained physicians would just come up on their own with these pervasive over prescribing practices on their own. in your view, who told the physicians that these doses, these amounts, were acceptable? adm. giroir: 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 it. that is a question 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 boards. 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. i will say that there was a confluence of factors that led to this. clearly opioids were overprescribed. they were overprescribed by well-intentioned physicians who believed they were doing the best for the patients by other prescribers. we now understand that this problem which led to heroin and fentanyl 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 for you, ms. brandt. to me, opioid manufacturers, through twisted research,

deceptive marketing, bought and paid for patient advocacy groups had a significant role in feeling 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? everything -- >> i am doing everything and the department is doing everything we can to limit opioid prescriptions now to only when opioid prescriptions are important to the patient. we are supporting non-opioid uses and alternative care. i 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 just well-meaning people saying maybe i don't know how much to prescribe. i think there was a strategy with the opioid executives, and dilated out -- and i laid it out item by item, twisted research, hype that downplay the harmfulness, and stacking these 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 and yet i am having trouble squaring the administration's commitment to expanding access to treatment with the president's budget proposal to drastically cut the program and roll back the medicaid expansion. we are not over here saying money is the sole answer, but i am 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 were my colleagues in oregon are fighting this epidemic. i would just like for you to tell us how when you/$1 trillion in medicaid funding for these lifeline programs, we are going to be able to work with the straits -- with the states to address the 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 continue to get as many resources put to this problem is possible. >> thank you, mr. chairman. welcome to both of you. first, to follow up ms. brandt, it's great that we were able to get the additional dollars or opioid and mental health services. one bright light consistent in the president's budget as well has been the strong and consistent support for mental health and addiction treatment services and i thank you your involvement and you were on this side of the table, working in a bipartisan way with sen. blunt:

myself. as part of the opioid crisis, 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 this crisis, would the secretary agree that the expansion of certified community behavioral health clinics to additional states as the president's budget proposes is one important way to address this?

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 in terms of things like this where 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 overdoses, with what is happening and this relates to the question of naloxone and for availability of the -- police and fire and others. i just want to take a moment to lay out that nalaxone was approved by the fda as 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 manufacturers producing a generic version of naloxone and it cost one dollar for a vial. by 2013, both companies were selling the drug for 15 times that amount. as need went up, price went up. in 2014, 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. in 2015, narcan, the nasal spray version of the drug, also approved for use by people without medical training, came on the market for $150 for a two pack. the actual drug was approved 47 years ago. as recently as 2005, you could get a vial for a dollar. now taxpayers, in order to support police and fire and medical personnel and others, are going to be spending thousands and hundreds of thousands of dollars in order to address what is an extremely

concerning price situation and lack of accountability. i just want to ask, 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. you are responsible for coordinating agencies efforts across the agency to fight the opioid crisis. it was recommended that hhs use its negotiating power to reduce its negotiating power on behalf of our people to be able to bring prices down. i think we all want to know, will 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. it does not solve substance abuse disorder and does not get to the root cause, but it is an absolutely critical drug that literally brings life back to a person on the brink of. -- on the brink of death. 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. >> i'm only 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 states and localities are now getting getting that for $75 for the 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. adm. giroir: we are now getting that at the gsa schedule. the fda is looking at all toects to bring naloxone

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. i would just observe that the 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. >> thank you both for being here. our healthier families community initiative.

i spoke to the father of the 17-year-old, 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 obviously indicates this was not an effective strategy. and then i contrast it my next conversation which is that if you are a physician -- impaired physician in louisiana, contrast that which is a fairly effective, three months inpatient with the month of follow-up with that which clearly was not. after two weeks, they were asked to leave. lastly i spoke to another physician who told me of the abuse potential of our medication assisted therapy. first there is a certain number people who die from methadone overdose and secondly, about their version of naloxone.

i'm going to use that and work backwards from a question. a louisiana guy who does well. i know how to pronounce your name even if others don't. there are some forms of medication and treatment like -- 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. the law is unclear whether or 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 do not want the brother picking it 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. senator bennet and i have legislation in the help committee that would address this problem. can you go back to the department and see if you can get endorsement of our bill? 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 our best route going forward in 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. >> there is certainly abuse potential. adm. giroir: part of the drugs, right. there's not so much abuse potential for that drug.

>> i've noticed in some localities there's less prescription opioids but there is no decrease in the number of deaths from opioid overdose. suggesting that it is illegal 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 related to opioids? adm. giroir: the data we have is

that mat is more effective than .on-mat i do not have geographic data that correlates geographic use of mat of the lowering of the death rate within that geography. i will go back and see if the data are available. we would tend to believe that is the case but we need to verify that those two things go together. i 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 works, but being discharge two weeks after being admitted and then ultimately dying, do we have best practices on this and

are we doing a proactive follow-up to see that program acme rehab is doing really well, but rate -- but beta 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. 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 the most rural to the 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 in tea did 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 peers support services, or those that are recovering from drug addiction help get those that that are in need to the appropriate care center. we have those programs in maryland, and they are extremely successful. the numbers are very popular. the problem is there is not a reimbursement structure. you have to find third-party sources to fund it or creative ways or hospitals coming in to help us because they know this will reduce their emergency rooms. what i am looking for is whether we can find a way to encourage these types of services. let me start with the first -- with that first. what can we do at the national you look at the grant

programs available from the federal government sources. it is difficult to get support for peers support services. ms. brandt: i'm going to take 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 for purposes of medicare. 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 covering peers support services. that is something that could be encouraged more in a few states 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. the 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 and has some concerns are stabilization centers to try and get individuals who are stressed out of the emergency rooms where they sometimes -- it's affecting the access to emergency care. and a facility that can refer them to the proper care that they need in a more appropriate setting. does stabilization centers in the state of maryland. two 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 overdose that requires security, but also compromises the ability of emergency rooms to do their intended purpose. for these individuals, what you really need is follow-up care. their life is no longer being threatened, but they need follow-up treatment and care.

yes, we need more community-based centers, but we individual, get the 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 for states to both institute programs and increasingly,and as you suggest, with the numbers that we have with millions of americans misusing opioids, 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. we 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. i look forward to removing the roadblocks that we have in the 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 listening and 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,

trauma 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 span multiple hhs agencies, collaboration is critical to it. new jersey has a mommy and me program that allows mothers and treatment for substance abuse to get inpatient treatment without giving up the custody of their children. i believe programs like mommy and me help avoid the trauma of taking children away from parents and help keep families intact. the family first act allows states to draw down funds starting on october 1 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 acf to get that guidance out in time for states like mine? ms. brandt: certainly happy to work with acf to coordinate that we are getting that guidance out. he took 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? ms. brandt: we absolutely do. 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 support these types of activities? ms. brandt: we coordinate with states on the data they report in and that allows us to take out for instance 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 plans to provide new jersey and other states 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.

>> do you 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 we are 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 general managed-care, pdmp's are not associated with the reduction in overdoses. this may be due to the fact that individuals already addicted to opioids will switch to illegal narcotics when their supply of prescription painkillers is cut off. what opportunities are there to addictiond opioid from becoming a heroin addiction? adm. giroir: thank you for that.

first i want to say that pdmp's are rapidly developing. they are an important tool, and the cdc is supporting states to utilize them. the next level is to not have a 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 stage them 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. adm. giroir: the omnibus after billion dollars through samsa, we expect that to be out to the states by september.

>> sen. toomey: are you : 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 that a typical year, 2016, anyway, one out of three beneficiaries received and opioid prescription from a doctor 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 there has been some progress with 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 727,000, medicaid beneficiaries, that they believe are at particularly high risk. 727,000. the oig determined 500,000 were receiving high dosages of opioids for at least three consecutive months, and is

-- this excluded cancer and hospice patients. but the over utilization monitoring system, to my understanding, covers 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 only covers part d beneficiaries, which is subsection of our larger medicare and medicaid population. as a result of the feedback, we

significantly strengthened and improved our ability do anything oversight through the oms system. that 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 number of edits overlooking how we can expand it to cover the rest of the program. >> could you send us the backup documentation on that? ms. brandt: sure, i would be happy to. >> 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 monitoringlization 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. should a nonfatal overdose in and of itself be sufficient criteria for including someone in the opiate utilization -- over utilization monitoring? ms. brandt: i'm not a doctor, i cannot speak if that is an appropriate criterion. it is something we want to look at. we consider the continuum of care to be very important and we want to make sure there is that coordination. >> do you have the authority to adopt that as the criteria? 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 am happy to go back and look at the authorities. >> do you have any thoughts on this? look have to go back and here clearly a nonfatal overdose is a risk your moving forward. help.a cry for >> as it stands today, that is not a sufficient criteria for being included in utilization monitoring. i'm not a doctor either, but that is extremely counterintuitive. >> will take that back and provide responses. >> thank you very much, mr. chairman. >> senator mccaskill. >> thank you very much, mr. chairman. 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 opioids in the government oversight committee, the minority staff. we have issued a written order.

-- we have issued a report that shows the american academy of pain management receiving big money from opioid manufacturers. coincidentally, they issued a statement that said they were not-- opioids are significantly addictive. i would like to enter that report into the record. i think it is important that the work we have done in the committee be added to this hearing record because it is relevant. >> without objection. there is another report issued emily fed no -- fentanyl got into the documents and got into the weeds, the internal sales was high and hope they don't die. >> ahead of fraudulent unit in their office calling pharmacy

manager is to try to get .pproval for fentanyl toould like that report also be made on the record. >> without objection. >> as a result of a lot of work, the ceo was criminally arrested, which is major progress. we are continuing to look at the manufacturers to see how they have 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. -- they uncover?

ms. brandt: 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 part d plan that is making money off of our program, the taxpayers support, is not reporting the fraud and abuse that they find, then what chance do we have on getting a handle on this? ms. brandt: we concur it is an important part of the program. we are working to see how we can implement that. >> 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. i'm not sure if we can do a 30 day thing. >> you can certainly amount you are doing it. ms. brandt: i am happy to get

back with you. >> these hands off, senator stabenow, really? a drug around 47 years ago that is life-saving increases from $690 in 2014 to $4500. where is the outrage and cms in this? this hands-off and incredibly unconscionable price increases that are not driven by r&d, they are driven by greed. d in an aread gree where people are dying. i think it is great, sir, that you have $75, but what about the member they know is addicted? how much is accosting them to get naloxone or narcan? how can they afford it at a price increase of more than 600%. why aren't we being more aggressive in going after these

companies that are doing this? what is their excuse for raising these prices, because they know they can make more money? have you asked them? adm. giroir: no i have not asked. >> would u.s. them? >> would you ask them why they are raising the prices so high? 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 promote petition and lower it further. this is the predominant form being used by states and first responders. $75 for two 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, we write 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? adm. giroir: 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. >> i'm talking about families trying to save family numbers -- members' 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 for two life-saving doses. >> for first responders. adm. giroir: you are right. >> i'm going to hold you accountable on this. i want you to write the letter. i want someone at cms to express the outraged for the pharmaceutical companies that i hear from missourians every day. thank you, mr. chairman. p, you are up. >> thank you mr. chairman. no state is immune from this issue. our state does not have data that other states have in terms of violence of opiate use disorder.

fortunately, for us, we do have 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 and the ranking member to help ensure that our community activity addresses not only the opioid epidemic, but substance use disorder broadly. 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 patient monitoring services in medicare. one provision that would provide the secretary of hhs to reserve

restrictionsertain , 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. is this something that the secretary would support and are there other opportunities that you are looking at administratively to expand access? adm. giroir: yes, sir. 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 ensure timely medicare coverage determination of new their views once they are approved by the fda? ms. brandt: yes, it is a great 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. -- getting it approved for medicare. >> seems like a big part of the solution of this problem. one last question, any health service does not fall directly into this committee's jurisdiction, but many south dakota tribal members are eligible for medicaid, which is the single largest payer for behavioral health services. through your efforts to coordinate the department response, what recent engagement has taken place with tribes in -- and other stakeholders working with them to address substance abuse disorder in tribal communities? have the national committee on heroine, opioids, and pain efforts or the committee may last year doing anything? adm. giroir: in the two weeks i have had this position, i have met with the ihf three times. that includes an eight-hour principals retreat where the director and his deputies, cdc,

myself, and secretaries were together focusing on specifically what we can do to support each other during the process. because of your that isthe $1 million coming to the omnibus has a specific $50 million allocation to the tribes specifically. i think we are highly coordinated and sensitive to that. and my other job, a house of has even in the last week done visits to multiple tribes to make sure we have the grassroots effort reaching them. >> thank you. 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. for me, in nevada substance , abuse hits close to home. i read about it in constituent letters and calls to my office. like many of my colleagues, i've heard from those struggling with addiction, or those who have lost loved ones to this epidemic. in my home state of nevada, there were 665 drug overdoses, deaths in 2016. in the same year, opioids were involved in over 40,000 american deaths. statistics you are well familiar with. 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 are equipped to address this crisis. i'm pleased to have the panel before us. ms. brandt, welcome back to the committee. it is great to see you. i want to thank both of the witnesses for taking a few moments of your time to be with us today. admiral, i just had a meeting in my office where i met with the boys and girls club of western nevada. they were discussing programs that they had that were available to these young adults. 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. i was 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 therapy 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, based on 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 state activity. as you stated, 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?

once it gets down to the state level, school levels, education levels, can the dollar prevent get those dollars to the places where we need them 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 actually 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. that is another 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 youth sports 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. >> ms. brandt, i want to ask you about electronic prescribing. senator bennett and i have acteduced every securely plan. i would like to cement a record for the record 20 groups and organizations support this piece , of legislation that i have introduced. the question is, to you ms.

brandt, what impact will electronic prescribing have? ms. brandt: we had a number of stakeholders last fall and e 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 is very 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. my time has run out, mr. chairman. >> thank you, senator heller. >> 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] >> maybe not here but in other communities. >> i yield to the senator from texas. [laughter] >> senator, i want to talk to you 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 that requires for medication and assisted treatments for opioid abuse. increasing the odds they will relapse and return through their use of opioids. the use of electronic writer

would increasingthe use of electronic writer -- prior authorization, in medicaid and medicare, private health insurance plans will help , 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? i think senator roberts, if you were here, he would talk about legislation that he and i cooperated on. but let me just ask you, what do you think? ms. brandt: from our perspective, there is great potential for prior authorization. it is something that electronic prior authorization -- >> 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 we can do that helps us to see in real time what is

happening and what is being requested, especially being able to tell who is requesting different types of services. that is helpful from a program management perspective. >> to you agree with what she decide? adm. giroir: i do. >> would you go so far as to say you approve of this message? >> yes sir, i do. >> ok. going back to the prior question, i find whenever i'm asked to do something or make a phone call or write a letter, i finally to say, i will do it. it saves us all time and trouble . what they're asking is probably the right thing to do. i have another question. when i was privileged to be governor of delaware, we establish a pharmaceutical -- established a pharmaceutical cabinet council and it included half of my cabinet secretaries

who met every month, developed a strategy that we pursued for eight years. we 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 epidemic, i want to urge you to focus not only on treatments, but also to focus on the root causes for this crisis. i know 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 just want to ask that what our hh s doing to make sure they have adequate methods of prevention that can reduce drug abuse and addiction, and how can we make better use of telehealth question mark in medicaid and in the chip program for at risk children?

ms. brandt. from our perspective, -- 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." through the medicaid program, we do a program that allows us to do prevention services. we have been looking at ways to expand telehealth for, particularly for areas where they don't have a great access to you that as a tool to fight this epidemic. >> doctor? >> i agree completely. looking at some demonstrations particularly for children that would put met told mental and physical properties and have been working

with our nonprofit partners to do that. i understand the importance of that. the second issue is, there are degrees of susceptibility. i absolutely agree with you mental health, adverse childhood , experiences always make it much more likely. but i think the point is, everybody in this room is susceptible to addiction. if you are on prescription opioids for too long, it is like asking yourself not to breathe after a while. you can't do it. i just want to make it clear that you are absolutely right that we need to target high risk 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. two great texas institutions. and in addition, the united states military. ms. brandt, it is good to see you. i would like to talk about the elephant in the room.

is heroine an opioid, admiral? adm. giroir: yes, sir. >> and people can't get drugs were some reason, to prescription addicts resort to heroin? adm. giroir: yes, sir. >> because it is cheaper and more readily available? adm. giroir: yes, sir. >> but sometimes the use is 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 drugs, poison, if you will, they are commodity agnostic. they will traffic in drugs, children, whatever will make them a dollar. that is all they really care about. they care 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 southwestern border even , when it is coupled together with the pathway to citizenship for 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. would you agree with me, admiral, that if we dealt with the prescription drug part in part -- part, but did not deal with the heroine and fentanyl problems, that we would not be able to get our arms around this epidemic? >> we absolutely need a comprehensive program that includes prescription drugs. i cannot emphasize the importance of limiting heroin and fentanyl to the set. general kellyd who bemoaned the fact that many of our military or law

enforcement who are stationed in places to be able to intercept the movement of illegal drugs into the united states 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 demand that is equally, or maybe 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 too 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? adm. giroir: two comments, first, we know the demand side

today, much of which was created by prescription opioid. -- opioids. three out of four users of heroine started on prescription opioids. one of the principal strategists to decrease the demand side is to reduce the prescribing of prescription opioids across the board. >> absolutely. >> the second comment is, with opioids, supply does create demand? once you are on it, you cannot get off of it. it is a disease, an 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 their strategies that you re strategies that you think the federal government could embrace?

ande dealt with the supply did not do anything on the demand aside, i think we would find ourselves pretty much in the same mess we are in right now. >> yes sir. >> other strategies that the federal government could embrace to deal with the demand side? >> i think with the unprecedented amount of programs that we have, we need to evaluate the effectiveness over the next months. do believe by decreasing prescription opioids, and we are already seeing a very significant decrease nationwide, even more in the medicare population and v.a., that the demand has gone down. it has to be coupled for treatment for those who are arty misusing or have disorders. part of the grant process that we are in supports medication assisted treatment. it is an important confidence of service. i want everybody to understand that as good as they are, the are still only

partially effective. we need tremendous increase in provee look at as how to -- improve the effectiveness paid one of the major thoughts is to start looking in a way to understand how do you put all the services together to be more effective? therapy, it is only 50% or 60% effective for six months. we need to improve that. agree 100%. i would submit that unless we come to grips with not just the prescription drug side, what of the heroine and opioid component of both supply and demand that we will find ourselves -- >> there are tons of heroin coming over. the problem with fentanyl is that it is very cheap. the profitability is high. and because it is so potent, 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. >> senator cantwell. sen. cantwell: 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 classifies opioids as a substance with potential for high abuse and leading to severe psychological and physical dependence. because of that, that is why we created a strong network of laws on distribution. we basically said substances like this need to be tracked and reported and suspicious orders ged, the distribution communicated so that drug enforcement agencies can work through this. despite the fact that the law

exists, there have been large quantities of opioids flooding our areas with manufacturers filling large orders in distribution. one 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 ring in california allowed more than one million opioids were distributed into a community. my point is -- where is the accountability for drug manufacturers not tracking and using that information with the drug enforcement agency to work cost effectively to try to stop this distribution? the fines for manufacturing are a mere $10,000 for neglected in reporting on it.

to me, that is hardly a deterrent. that is why i am asking legislatively for a tenfold increase or not -- 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 what was just mentioned giving , law enforcement the tools to deal with the heroin epidemic. the heroin epidemic is also part of the problem. we want to make sure that they have resources to deal with heroin traffic. we think the frontline of that is our law enforcement entities, and they need that help and support. the question i have about this on the distribution is does hhs have a system to track

prescription opioids covered by medicaid and medicare, knowing how they might be falling into the wrong hands? ms. brandt: 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. we also have our medic, which is our fraud investigations unit which looks at prescriber data to work with the inspector general to track those prescribers and look at pharmacies and prescribers who are high over utilizer's and hopefully take action against them. >> you don't work with the dea? ms. brandt: we do not work directly with them. our law enforcement partners do,

but we do not. >> do you think we need larger controls in place? ms. brandt: 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 physician who 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 on it. and also think about what improper prescribing, billing, and dispensing, what are the -- what other methods we need for medicare and medicaid to be part of that?

ms. brandt: 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. we have are unbelievable stories of what has happened in our state. people are getting opioids just so they can sell them for the heroin because they can get that three times the rate. we need to combat both. 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. >> senator brown. sen. brown: thank you, mr. chairman. i know you are a native of ohio, and understand how difficult it is. 11 people died on tuesday, 11 people died yesterday, 11 people died today, 11 people will die tomorrow. that is on the average, as you know. 11 isn't the only number that matters. another number -- 10,769, according to the american academy of pediatrics, that's how many ohio children were placed in foster care in 2016. many of them are a direct result of addiction. the bipartisan family first act just signed into law requires the guard -- program to provide servicess on

authorized by october 1 of this year. 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. i encourage you to solicit input. before i get to my only question, 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 for-profit charter schools of use. we're doing really innovative things on babies.

every 25 minutes, a baby is born suffering from opioid withdrawal in this country. 2100 babies, six a day were admitted to a hospital. a hospital in ohio for nas just a decade earlier, just 300 cases were reported nationwide. the explosion of numbers you are all familiar with. ohio is doing a lot of things. cincinnati children's established a universal screening program that has helped identify babies born with nas and get them to treatment faster. in previous hearings we talk about helping pediatric recovery centers receiving aid. there were trips to see firsthand our pediatric recovery center. 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. other states are looking to adopt this this successful model. our providers are overwhelmed. i hosted a conference yesterday for ceos from a handful of ohio's smaller and rural hospitals. they spoke about babies, how hard they are for hospitals to treat. -- all of them have an icu nicu's. a lot of them don't have providers who are experienced or specialized enough to care for these babies. as a result, they transfer the needed to facilities with more resources that are already overwhelmed. they realize the system isn't sustainable. one of the ceos of these hospitals shared collaborating with another larger system to

utilize telehealth technology to keep babies close to home when they undergo treatment. the larger system will share resources and expertise when babies are born with nas at the smaller hospital. they hope to reduce burden that are currently caring for those babies. they anticipate a savings from cutting back on transfer costs. my question to you is -- talk to me about what cms is doing to help babies improve care for moms and babies suffering from the addiction epidemic. what tools do have to improve care options for these babies? 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 innovative solutions. ms. brandt: thank you for the i question. absolutely recognize the issues back home. the county i am from is one of the hardest hit and it is a really big issue. at cms, 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. one of the things we have done is in february of this year, we approved a plan amendment for 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 normally reimburse for these services. some of the services they can fund through this include nursing salaries, supportive counseling, management, which are currently not included. what it does not include, what

congress can take action on, art -- our room and board costs and physician treatment services. another thing we heard in that was with 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. i used a couple of examples of 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

that public health crisis. 45% of american adults smoked. last year, it was down to 15%. you look at how we treat aids. at the beginning, you had a president and a bunch of politicians and others that wouldn't acknowledge it. my wife 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 it, even though there was no information 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. this looks more intractable, 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. you are really on the front line of that.

your whole careers have been dedicated to that kind of fight. thank you both. >> well said, senator brown. senator casey. thank you very much. i know we are at the end and running for time, but good to be with you. ms. brandt, we are grateful you are back and we thank you 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. in my state, the numbers are as of 16, 4624 is the number, up 30% -- 37% overall. i don't think i have the 17 number yet. in rural areas, it was up more than 30% in the mid-40's.

higher in rural areas. in one rural county i was in, 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. my only question is do you agree 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 we prescribe -- have a telehealth prescription in a rural community where they may not be an mhc provider? -- a t provider? there are certain barriers to that, but we are working on that . i think that is an important component. i don't want to take up all the

time. but i would be happy to follow up. ms. brandt: 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. 1115 waivers based on issues of guidance we issued last november. we have states using them including access residential treatment facilities, which has partnered not been allowed under medicare reimbursement. that is something we are 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 to break down barriers. very much.u and thank you for your help with wills eye hospital. >> thank you, senator. we are going to wrap up for to -- wrap up pretty 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 -- roberts' questions on when we wrap up, we're going to ask that there be a response for questions on the record. i will do this on behalf of the chairman in a minute by the close of business thursday, april 26. we need responses from the administration to senator roberts, very good important questions. i am going to put into the record the various documents of -- document that attest to these very serious conflicts of interest. one of the instances led to the 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. first, i want to make clear how strongly i feel and how strongly our side feels that we tackled this issue in a bipartisan way. we are going to do that under the leadership of the chairman, and this will be tackled in the same kind of way that we pursued the chip bill for 10 years, the family's first hill, the 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. having said that, i want to go back to one of the points that i made with you earlier and make sure you understand my expectation. i continue, as i said in my opening statement to be

, exceptionally troubled by the role of opioids executive. the manufacturers and distributors. i don't believe we got in this situation, a public health 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, deceptive marketing, and bought and paid for advocacy groups had a significant role to play in in -- in creating and feeling the crisis. -- fueling the 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, 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. i just want to be clear that i am supportive of the senate looking at the root causes and understanding it and for 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 kind of activities we are doing right now. yes, sir, i will provide 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 -- overlooked the role of the manufacturers and distributors. i think that is a significant part of it. i appreciate your cooperation on this. we will look forward to your

answer. as you can hear, there are differences of opinions on this committee. i happen to share the views with respect to the role of cost containment. we have to use every effective tool to drive down the costs. you can have transformational health products, but people have to be able to afford them. it is a taxpayer issue and an individual issue. 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 for some time. the colleagues with very good ideas on both sides of the aisle, that's the way we do it. with that, thank you both. always good to see you ms. brandt. you have a lot of good ideas to put into perspective.

with that the finance committee , is adjourned.

the energy and commerce subcommittee is considering legislation aimed at combating the opioid depth -- opioid epidemic. members of the subcommittee spoke on the floor about the problem and more of the 60 bills that are being offered. mr. burgess: i thank the speaker. mr. speaker, the -- the opioid epidemic has swept across this country, impacting millions of americans who have lost loved ones to this preventable crisis. no community is immune.