[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
COMBATING THE OPIOID CRISIS: IMPROVING THE ABILITY OF MEDICARE AND
MEDICAID TO PROVIDE CARE FOR PATIENTS
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED FOURTEENTH CONGRESS
SECOND SESSION
__________
APRIL 11 & 12, 2018
__________
Serial No. 115-116
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
_________
U.S. GOVERNMENT PUBLISHING OFFICE
31-268 WASHINGTON : 2018
COMMITTEE ON ENERGY AND COMMERCE
GREG WALDEN, Oregon
Chairman
JOE BARTON, Texas FRANK PALLONE, Jr., New Jersey
Vice Chairman Ranking Member
FRED UPTON, Michigan BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois ANNA G. ESHOO, California
MICHAEL C. BURGESS, Texas ELIOT L. ENGEL, New York
MARSHA BLACKBURN, Tennessee GENE GREEN, Texas
STEVE SCALISE, Louisiana DIANA DeGETTE, Colorado
ROBERT E. LATTA, Ohio MICHAEL F. DOYLE, Pennsylvania
CATHY McMORRIS RODGERS, Washington JANICE D. SCHAKOWSKY, Illinois
GREGG HARPER, Mississippi G.K. BUTTERFIELD, North Carolina
LEONARD LANCE, New Jersey DORIS O. MATSUI, California
BRETT GUTHRIE, Kentucky KATHY CASTOR, Florida
PETE OLSON, Texas JOHN P. SARBANES, Maryland
DAVID B. McKINLEY, West Virginia JERRY McNERNEY, California
ADAM KINZINGER, Illinois PETER WELCH, Vermont
H. MORGAN GRIFFITH, Virginia BEN RAY LUJAN, New Mexico
GUS M. BILIRAKIS, Florida PAUL TONKO, New York
BILL JOHNSON, Ohio YVETTE D. CLARKE, New York
BILLY LONG, Missouri DAVID LOEBSACK, Iowa
LARRY BUCSHON, Indiana KURT SCHRADER, Oregon
BILL FLORES, Texas JOSEPH P. KENNEDY, III,
SUSAN W. BROOKS, Indiana Massachusetts
MARKWAYNE MULLIN, Oklahoma TONY CARDENAS, California
RICHARD HUDSON, North Carolina RAUL RUIZ, California
CHRIS COLLINS, New York SCOTT H. PETERS, California
KEVIN CRAMER, North Dakota DEBBIE DINGELL, Michigan
TIM WALBERG, Michigan
MIMI WALTERS, California
RYAN A. COSTELLO, Pennsylvania
EARL L. ``BUDDY'' CARTER, Georgia
JEFF DUNCAN, South Carolina
Subcommittee on Health
MICHAEL C. BURGESS, Texas
Chairman
BRETT GUTHRIE, Kentucky GENE GREEN, Texas
Vice Chairman Ranking Member
JOE BARTON, Texas ELIOT L. ENGEL, New York
FRED UPTON, Michigan JANICE D. SCHAKOWSKY, Illinois
JOHN SHIMKUS, Illinois G.K. BUTTERFIELD, North Carolina
MARSHA BLACKBURN, Tennessee DORIS O. MATSUI, California
ROBERT E. LATTA, Ohio KATHY CASTOR, Florida
CATHY McMORRIS RODGERS, Washington JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey BEN RAY LUJAN, New Mexico
H. MORGAN GRIFFITH, Virginia KURT SCHRADER, Oregon
GUS M. BILIRAKIS, Florida JOSEPH P. KENNEDY, III,
BILLY LONG, Missouri Massachusetts
LARRY BUCSHON, Indiana TONY CARDENAS, California
SUSAN W. BROOKS, Indiana ANNA G. ESHOO, California
MARKWAYNE MULLIN, Oklahoma DIANA DeGETTE, Colorado
RICHARD HUDSON, North Carolina FRANK PALLONE, Jr., New Jersey (ex
CHRIS COLLINS, New York officio)
EARL L. ``BUDDY'' CARTER, Georgia
GREG WALDEN, Oregon (ex officio)
C O N T E N T S
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April 11, 2018
Page
Hon. Michael C. Burgess, a Representative in Congress from the
State of Texas, opening statement.............................. 1
Prepared statement........................................... 3
Hon. Gene Green, a Representative in Congress from the State of
Texas, opening statement....................................... 4
Hon. Greg Walden, a Representative in Congress from the State of
Oregon, opening statement...................................... 6
Prepared statement........................................... 8
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 9
Witnesses
Kimberly Brandt, Principal Deputy Administrator for Operations,
U.S. Centers for Medicare and Medicaid Services................ 11
Prepared statement........................................... 13
Answers to submitted questions............................... 419
April 12, 2018
Witnesses
Michael Botticelli, Executive Director, Grayken Center for
Addiction, Boston Medical Center............................... 60
Prepared statement........................................... 63
Answers to submitted questions............................... 432
Toby Douglas, Senior Vice President for Medicaid Solutions,
Centene Corporation............................................ 68
Prepared statement........................................... 70
Answers to submitted questions............................... 437
David C. Guth, Jr., Chief Executive Officer, Centerstone......... 81
Prepared statement........................................... 83
Answers to submitted questions............................... 443
John M. Kravitz, Chief Information Officer, Geisinger Health
System......................................................... 95
Prepared statement........................................... 97
Answers to submitted questions............................... 454
Sam K. Srivastava, Chief Executive Officer, Magellan Healthcare.. 103
Prepared statement........................................... 105
Answers to submitted questions............................... 458
Submitted Material
Article entitled, ``Medicare is cracking down on opioids. Doctors
fear pain patients will suffer,'' New York Times, April 6, 2018 174
Statements of various pharmacy associations...................... 177
Statement of the Washington State Pharmacy Association........... 198
CMCS Informational Bulletin...................................... 200
Statement of the National Association of Counties................ 215
Statement of the American Medical Association.................... 217
Statement of the American Society of Addiction Medicine.......... 218
Statement of the American Psychiatric Association................ 220
Statement of the Community Resources for Justice................. 222
Statement of the International Community Corrections Association. 223
Statement of the National Commission on Correctional Healthcare.. 225
Statement of the American College of Obstetricians and
Gynecologists.................................................. 226
Statement of telehealth and technology stakeholders.............. 234
Statement of treatment providers in support of the access to
telehealth services for their opioid and use disorders......... 236
Statement of Members of Congress supporting the Pharmacy and
Medically Underserved Areas Enhancement Act.................... 238
Statement of Walgreens supporting the Pharmacy and Medically
Underserved Areas Enhancement Act.............................. 241
Statement of the American Association of Oral and Maxillofacial
Surgeons....................................................... 243
the Association for Behavioral Health and Wellness............... 246
Statement of AdvaMed............................................. 248
Statement of the American Hospital Association................... 251
Statement of the American Psychological Association.............. 253
Statement of the American Society of Health-System Pharmacists... 257
Statement of the Association for Community Affiliated Plans...... 259
Statement of the College of Healthcare Information Management
Executives..................................................... 264
Statement of the ePrescribing Coalition.......................... 268
Statement of the National Association for Behavioral Healthcare.. 270
Statement of the National Association of Chain Drug Stores....... 274
Statement of the National Association of Medicaid Directors...... 287
Statement of the National Indian Health Board.................... 290
Statement of the Oregon Community Health Information Network..... 297
Statement of the Partnership to Amend 42 CFR Part 2.............. 298
Statement of the Pharmaceutical Care Management Association...... 301
Statement of the Property Casualty Insurers Association of
America........................................................ 309
Statement of Shatterproof........................................ 311
Statement of Imprivata........................................... 315
Statement of the Pharmacy Coalition.............................. 317
Statement of the National Association of Counties................ 319
Statement of Trinity Health...................................... 321
Statement of the Infectious Disease Society of America, the HIV
Medicine Association, and the Pediatric Infectious Disease
Society........................................................ 328
Study entitled, ``States With Prescription Drug Monitoring
Mandates Saw a Reduction in Opioids Prescribed to Medicaid
Enrollees,'' Health Affairs, April 1, 2017..................... 332
Study entitled, ``Medicaid Drug Utilization Review State
Comparison/Summary Report FFY 2016 Annual Report,'' Centers for
Medicare & Medicaid Services, October 2017..................... 348
COMBATING THE OPIOID CRISIS: IMPROVING THE ABILITY OF MEDICARE AND
MEDICAID TO PROVIDE CARE FOR PATIENTS, DAY 1
----------
WEDNESDAY, APRIL 11, 2018
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 3:25 p.m., in
room 2322, Rayburn House Office Building, Hon. Michael Burgess,
M.D. (chairman of the subcommittee) presiding.
Present: Representatives Burgess, Guthrie, Upton, Shimkus,
Blackburn, Latta, McMorris Rodgers, Lance, Griffith, Bilirakis,
Long, Bucshon, Brooks, Mullin, Hudson, Carter, Walden (ex
officio), Green, Schrader, Kennedy, Cardenas, Eshoo, Pallone
(ex officio).
Also Present: Representatives Tonko and Peters.
Staff Present: Adam Buckalew, Professional Staff Member,
Health; Karen Christian, General Counsel; Paul Edattel, Chief
Counsel, Health; Caleb Graff, Professional Staff Member,
Health; Jay Gulshen, Legislative Associate, Health; Ed Kim,
Policy Coordinator, Health; Drew McDowell, Executive Assistant;
James Paluskiewicz, Professional Staff, Health; Mark Ratner,
Policy Coordinator; Jennifer Sherman, Press Secretary; Austin
Stonebraker, Press Assistant; Josh Trent, Deputy Chief Health
Counsel, Health; Everett Winnick, Director of Information
Technology; Jacquelyn Bolen, Minority Professional Staff;
Tiffany Guarascio, Minority Deputy Staff Director and Chief
Health Advisor; Una Lee, Minority Senior Health Counsel; Rachel
Pryor, Minority Senior Health Policy Advisor; Samantha
Satchell, Minority Senior Policy Analyst; Theresa Tassey,
Minority Health Fellow.
OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF TEXAS
Mr. Burgess. The Subcommittee on Health will now come to
order. The chair will recognize himself 5 minutes for the
purposes of an opening statement.
This afternoon the Health Subcommittee marks its third in a
series of hearings this spring on legislation addressing the
opioid epidemic. By the end of this week's hearing we will have
considered a total of 67 opiate-related bills. In our last
hearing we discussed 25 public health and prevention-focused
bills over the course of 2 days. Today the subcommittee will be
breaking a record by examining 34 bills centered around
improving Medicaid and Medicare programs at the Center for
Medicare and Medicaid Services.
While committee members on both sides of this dais have put
in a lot of time and thought in developing these bills, a
majority are still in discussion draft form. And this is a
feature not a bug. It is intentional. We seek to explore
promising ideas while collecting important feedback from
Members, providers, plans, patients, and other stakeholders.
Some of these bills challenge the status quo for some practices
within Medicaid and Medicare. But with more than 110 Americans
dying daily from an opiate overdose, we must be willing to ask
hard questions and seek solutions.
With the crisis devastating our country and eroding our
economic productivity, all of us must be willing to take a
fresh and fair look at each of the policies presented today. We
should think creatively about how to help strengthen Medicaid
and Medicare's ability to combat this scourge of opiate abuse
because without adequate tools and accountability our largest
public players will be unable to handle the challenge that is
before them.
So today we are joined by Kimberly Brandt, who has been
charged to lead the efforts addressing the opiate crisis at the
Center for Medicaid and Medicare Services. Ms. Brandt, thank
you for being here testifying before us and providing your
insights on ways that we can partner together to turn the tide
in this fight.
Tomorrow we will hear from individuals representing
healthcare providers, health plans, behavioral health
specialists who provide the critical treatment to Americans
with opiate addiction and substance use disorder. It is my
expectation that our conversations will help us adopt effective
policies that have a meaningful impact.
One issue that has repeatedly come up is our physician
workforce. Congress can pass bills to increase access to
evidence-based treatment, but if we do not have enough
physicians equipped with proper tools and training we will not
have the sufficient capacity to provide treatments for
individuals suffering from this disorder.
To this end, I have worked on draft legislation that will
provide Congress with more robust transparency about how
graduate medical education dollars under current law are
helping equip the next generation of doctors to better identify
and treat patients with substance use disorder.
Prescription drug monitoring programs are important
informational tools that help track prescriptions and identify
patients at risk of overdosing on opiates. The Medicaid
Partnership Act would require State Medicaid programs to
integrate these monitoring programs into Medicaid providers'
and pharmacists' clinical workflows while establishing basic
criteria for qualified prescription drug monitoring programs. I
think it is common sense to ask one of our largest payers to
access one of our most powerful data tools to care for some of
our most at-risk patients.
Another useful tool already in place in many State Medicaid
programs are pharmaceutical homes. The Medicaid Pharmacy Home
Act would codify the commonsense idea of requiring States to
have provider and pharmacy assignment programs that identify
at-risk Medicaid beneficiaries and set reasonable limits on the
number of prescribers and dispensers that they can utilize.
Given what we know, it is good medicine for all of us to ensure
that States are using this effective approach to identify at-
risk beneficiaries.
We certainly have much to consider, but we are building on
years of previous bipartisan efforts, and we know our work is
important to our families and our communities and our
constituents affected by this epidemic.
Before I close, I want to touch on the growing fear that I
am hearing from many patients suffering from a chronic pain
condition who have actually been successfully managed by long-
term opiate administration, especially when these drugs are
drugs of last resort. I anticipate some discussion on the
recent CMS rule to limit the amount and length of opiate
prescriptions. Our effort to overcome this crisis is vital, but
I want us to keep these patients in mind and not, as we say
down south, overtorque the bolt. I have a submission from The
New York Times that I would like to add to the record for this.
[The information appears at the conclusion of the hearing.]
Mr. Burgess. Again, I want to thank our witness for
testifying today and our witnesses tomorrow. I look forward to
learning from your insights.
And I want to yield time to the vice chairman of the Health
Subcommittee, Mr. Guthrie of Kentucky, for his statement.
[The prepared statement of Mr. Burgess follows:]
Prepared statement of Michael C. Burgess
This afternoon, the Health Subcommittee marks its third in
a series of hearings this spring on legislation addressing the
opioid epidemic. By the end of this week's hearing, we will
have considered a total of 67 opioid-related bills. In our last
hearing, we discussed 25 public health and prevention-focused
bills over the course of two days. And today the subcommittee
will be breaking a record by examining 34 bills, centered
around improving Medicaid and Medicare programs at the Center
for Medicare and Medicaid Services (CMS).
While committee members on both sides of the aisle have put
a lot of time and thought into developing these bills, a
majority are still in discussion draft form. This is
intentional, as we seek to explore promising ideas, while
collecting important feedback from members, providers, plans,
and other key stakeholders. Some of these bills challenge the
status quo for some practices within Medicaid and Medicare, but
with more than 110 Americans dying daily from opioid overdoses,
we must be willing to ask hard questions and find solutions.
With the opioid crisis devastating our country and eroding
our economic productivity, all of us must be willing to take a
fresh and fair look at each of the policies presented today. We
should think creatively about how to help strengthen Medicaid
and Medicare's ability to combat the scourge of opioid abuse--
because without adequate tools and accountability, our largest
public payers will be unable to handle the challenge before
them.
Today, we are joined by Kimberly Brandt, who has been
charged to lead the efforts addressing the opioid crisis at
CMS. Ms. Brandt, thank you being testifying before us and
providing your insights on ways we can partner together and
turn the tide in our fight.
Tomorrow, we will hear from individuals representing health
care providers, health plans, and behavioral health specialists
who provide critical treatment to Americans with opioid
addiction and substance use disorder. It is my expectation our
conversations will help us adopt effective policies that have
meaningful impact.
One issue area that repeatedly comes up is our physician
workforce. Congress can pass bills that increase access to
evidence-based treatment, but if we do not have enough
physicians equipped with proper tools and training, we will not
have sufficient capacity to provide effective treatments for
individuals suffering from substance use disorder.
To this end, I have authored draft legislation that will
provide Congress with more robust transparency about how
graduate medical education dollars under current law are
helping equip the next generation of doctors to better identify
and treat patients with substance use disorder.
Prescription Drug Monitoring Programs (PDMPs) are important
informational tools that help track prescriptions and identify
patients at risk of abusing or overdosing on opioids. The
Medicaid PARTNERSHIP Act would require the state Medicaid
programs to integrate PDMP usage into Medicaid providers' and
pharmacists' clinical workflow while establishing basic
criteria for qualified PDMPs. As a physician, I think it's
common sense to ask one of our largest payers to access one of
our most powerful data tools to care for some of our most at-
risk patients.
Another useful tool already in place in many state Medicaid
programs are pharmaceutical homes. The Medicaid Pharmacy Home
Act would codify the common-sense idea of requiring states to
have a provider and pharmacy assignment program that identifies
at-risk Medicaid beneficiaries and sets reasonable limits on
the number of prescribers and dispensers they can utilize.
Given what we know, it's good medicine for us to ensure all
states are using this effective approach to identify at-risk
beneficiaries and improve care.
We certainly have much to consider. But, we are building on
years of previous bipartisan efforts, and we all know our work
is important to the families and communities--our
constituents--affected by the opioid epidemic.
Before I close, I would like to touch upon the growing fear
of many patients suffering from chronic pain who have been
successfully managed by opioids, especially when these drugs
are the last resort. I anticipate some discussions on the
recent CMS rule to limit the amount and length of opioid
prescriptions. Our effort to overcome this crisis is vital, but
I want us to keep these patients in mind and not ``over-torque
the bolt.''
I again thank our witnesses for testifying today and
tomorrow, and I look forward to learning your insights on
making improvements in the Medicare and Medicaid system.
I would like to yield the balance of my time to the Vice
Chairman of the Health Subcommittee, Mr. Guthrie of Kentucky,
for a statement.
Mr. Guthrie. Thank you, Mr. Chairman.
I appreciate the chairman's diligent efforts to ensure our
committee responds quickly and meaningfully to our Nation's
opioid crisis. Just last week I heard another awful story about
how the destructive path of the opioid crisis harmed a family
in Cecilia, Kentucky, all caused because of a motorcycle
accident that led to back surgery that led to addiction.
I would like to ask unanimous consent to submit a number of
letters in the record on how pharmacists and the Pharmacy and
Medically Underserved Areas Enhancement Act can help address
these in the opioid epidemic.
Mr. Burgess. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Guthrie. Thank you, Mr. Chairman. I yield back.
Mr. Burgess. The gentleman yields back. The chair thanks
the gentleman.
The chair recognizes the gentleman from Texas, Mr. Green,
the ranking member of the subcommittee, 5 minutes for an
opening statement, please.
OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF TEXAS
Mr. Green. Thank you, Mr. Chairman.
This is the third in a series of hearings on the opioid
epidemic and its impact on individuals, families, and
communities in our nation. Our committee has heard from Federal
agencies and stakeholders on the terrible cost of opioid abuse,
which takes the lives of 115 Americans each day and is
estimated to cost our national economy over $78 billion
annually.
Today's hearing will focus on the role that Medicaid and
Medicare play in providing health coverage for Americans in
need of comprehensive treatment and recovery services. Medicaid
is the largest payer for behavioral health services, mental
health, and substance use disorder, or SUD, in the United
States. Medicaid delivers care to 4 of 10 nonelderly adults
with opioid use disorder.
Nearly 12 percent of adults enrolled in Medicaid have SUD.
Adults on Medicaid are more likely than other adults to receive
substance use disorder treatment.
Medicaid plays a critical role for children either
suffering from substance use disorder or born with neonatal
abstinence syndrome, NAS. Medicaid covers more than 80 percent
of the NAS babies nationwide.
Medicaid expansion provided under the Affordable Care Act
has played a critical role in providing comprehensive coverage
for Americans suffering from substance abuse disorder who live
in 31 States that have expanded.
Data recently published by the Center for Budget and Policy
Priorities found that under Medicaid expansion the uninsured
rate among people with opioid-related hospitalizations fell
dramatically in States that expanded, from 13.4 percent in
2013, the year before the expansion took effect, to just 2.9
percent 2 years later.
For example, after Kentucky expanded Medicaid in 2014,
Medicaid beneficiaries' use of substance use treatment services
in the State rose by 700 percent. My home State of Texas and 18
other States continue to refuse to expand Medicaid, denying
millions of Americans the comprehensive services and continuum
of care necessary to treat and recover from opioid addiction
and other substance use disorders. Medicaid expansion includes
substance use services as mandatory benefit.
The reality is that if folks want to save lives of these
individuals, we have got to focus first on getting those people
health insurance so they can access treatment. Continuity of
comprehensive health insurance makes the difference between
life and death.
Two weeks ago the Texas Department of State Health Services
released a report that found opioid overdoses as the leading
cause of death for new mothers in our State, with the most
occurring after a pregnant woman's Medicaid benefits end 60
days after delivery.
Last year, I introduced the Incentivizing Medicaid
Expansion Act, H.R. 2688, in order to incentivize States to
provide critical Medicaid coverage for Americans in need and to
avoid the kinds of tragedies that have led to the rising rate
of maternal mortality in our home State. My legislation would
guarantee that the Federal Government covers 100 percent of
expansion costs for the first 3 years for States that have not
yet expanded and no less than 90 percent afterwards.
Medicare also plays an important role in the opioid crisis.
According to SAMHSA, more than one million seniors suffered
from substance use disorders in 2014. While Medicare part B and
part D provide SUD treatment services, there are significant
gaps in Medicare's benefits, including no coverage for
substance abuse treatment at opioid treatment programs or
methadone clinics.
We also need to ensure that Americans on Medicaid or
Medicare are not overprescribed opioids. HHS' Office of
Inspector General found that more than 500,000 part D
beneficiaries received high amounts of opioids in 2016, with
the average dose far exceeding the manufacturers' recommended
amount. Additionally, nearly one-third of the beneficiaries in
Medicare part D or C had an opioid prescription in 2016.
Before closing, I would like to voice my concern over the
number of bills and discussions drafts being considered at the
hearing, 34 in total. Never in my time on Energy and Commerce
have we had legislative hearings on so many bills and drafts.
Combined with the bills and discussion drafts from the two
previous opioid hearings, we are looking at over 70 pieces of
legislation. I am concerned that the majority is planning to
mark up legislation later this month, and that has not been
fully vetted by our staffs, stakeholders, and the appropriate
Federal agencies.
The opioid crisis is hitting communities throughout America
regardless of location or political affiliation. We can and
must advance opioid legislation in a bipartisan manner that the
American people deserve. I ask for the majority to work with us
and provide the necessary time to vet legislation being
considered and ensure the anticipated markup will not become a
partisan exercise.
Thank you, and I yield the balance of my time.
Mr. Burgess. The chair thanks the gentleman.
The chair would just observe that the gentleman has never
served with the current chairman before. And you may have
recognized by now you do have a very active and an activist
chairman and that will continue for the balance of the year.
Mr. Green. Well, I like activism, Mr. Chairman, but I also
like substance.
Mr. Burgess. There is substance, I guarantee you, with
these 34 bills.
The chair recognizes the chairman of the full committee,
Mr. Walden, for 5 minutes for an opening statement.
OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF OREGON
Mr. Walden. With these 34 on top of the other 24 on top of
the other 6 or 7, we are going to have our hands full of good
legislation, because today marks our third and final
legislative hearing this spring aimed at advancing targeted,
timely, and bipartisan legislative solutions to help combat the
opioid crisis.
This committee has already been instrumental in working in
a bipartisan manner to devote a record--let me underscore
record--amount of Federal resources toward the opioid epidemic,
namely through passage of the CARA and 21st Century Cures Act
last Congress. My colleague here, Fred Upton, led the effort
with Diana DeGette to get that done. This hearing continues the
work to address the crisis that has impacted virtually every
neighborhood, every community, and so many families across our
country.
At roundtables I have done in my district, across Oregon,
most recently in Pendleton and Madras, I have met with people
on the front lines of this fight and with those who have lost a
friend, lost a child, lost a sister, lost a loved one, lost a
neighbor. These meetings have been crucial to my efforts to put
forth concrete solutions to stem the tide and save lives, and I
am not alone doing these roundtables around the country.
With more than 100 Americans estimated to die every day
from opioid overdoses, we simply have to do everything within
our power. We must continue to push forward. And I would
respectfully ask everyone involved, stakeholders and Members of
Congress alike, to push beyond our comfort zones and think
creatively and boldly about how we can help, because the status
quo is simply not acceptable. The unprecedented scope of this
crisis requires an unprecedented response, and that is what we
are able to provide at the Energy and Commerce Committee.
To that end, over the span of 2 days, we will consider 34
bills from Members on both sides of the aisle. These bills have
a common theme: They seek to improve the roles Medicaid and
Medicare can play in helping combat this crisis. This marks the
largest numbers of bills noticed in a legislative hearing
before this committee. But the number and scope of the bills
helps underscore how important this topic is to all of us and
how many good ideas there are to help patients. While
considering this many bills does require some extra work on
behalf of the staff and our members, I think we should see this
as not an inconvenience, but rather as an opportunity.
Just look at how many promising ideas there are to help
patients who are served by these two programs who represent
roughly one in three Americans. Certainly both programs play
key roles in identifying at-risk beneficiaries, providing
treatment, and decreasing overdose deaths.
The bills we will consider today cover a range of important
issues, including provisions to remove barriers to treatment,
improve data to identify and help at-risk patients, provide
incentives for greater care coordination and enhanced care.
Many of the bills before us build on efforts in Medicaid and
Medicare that are already yielding positive benefits for
patients and reducing dependency or misuse of opioids.
As we move forward, we look forward to stakeholders and
others providing feedback on these proposals. The input of the
Congressional Budget Office will also help shape our
decisionmaking on several pieces of legislation before us
today. But our aim remains the same: moving through committee
in regular order to advance legislation to the House floor
before the Memorial Day recess. That is our goal.
We have seen announcements in sister committees recently as
they are also developing and advancing legislation, and we look
forward to continuing our work with them to get a robust
bipartisan package of proposals to the White House for
signature of the President in the coming months.
The urgency of the crisis demands an urgent response, and
the challenges facing our communities demand action now.
So I would like to thank our witnesses for taking time to
share their expertise with us today and tomorrow and for
Members on both sides of the aisle for making this fight a top
priority.
With that, I would yield the balance of my time to my
friend and colleague from Tennessee, Mrs. Blackburn.
[The prepared statement of Mr. Walden follows:]
Prepared statement of Hon. Greg Walden
Today marks our third and final legislative hearing this
spring aimed at advancing targeted, timely, and bipartisan
legislative solutions to help combat the opioid crisis.
This committee has already been instrumental in working in
a bipartisan manner to devote a record amount of Federal
resources towards the opioid epidemic, namely through the
passage of CARA and 21st Century Cures last Congress. This
hearing continues our work to address a crisis that has
impacted virtually every neighborhood across our country.
At roundtables throughout Oregon, most recently in
Pendleton and Madras, I've met with the people on the
frontlines of this fight and with those who have lost a friend
or loved one to this epidemic. These meetings are crucial to
our efforts to put forth concrete solutions to stem the tide
and save lives. With more than 100 Americans estimated to die
each day from opioid overdoses, we simply must do more.
We must continue to push forward, and I would respectfully
ask everyone involved--stakeholders and members alike--to push
beyond their comfort zones and think creatively and boldly
about how we can help. The status quo is not acceptable. The
unprecedented scope of the opioid crisis requires an
unprecedented response.
To that end, over the span of 2 days, we will consider 34
bills from members on both sides of the aisle. These bills have
a common theme--they seek improve the roles Medicaid and
Medicare can play in helping combat the crisis.
This marks the largest number of bills noticed in a
legislative hearing before this committee. But the number and
scope of bills helps underscore how important this topic is to
all of us and how many good ideas there are to help patients.
While considering this many bills requires some extra work from
members and staff, I think we should see this not as an
inconvenience, but as an opportunity.
Just look at how many promising ideas there are to help
patients who are served by these two programs-who represent
roughly one in three Americans. Certainly, both programs play
key roles in identifying at-risk beneficiaries, providing
treatment, and decreasing overdose deaths. The bills we will
consider today cover a range of important issues--including
provisions to: remove barriers to treatment, improve data to
identify and help at-risk patients, provide incentives for
greater care coordination and enhanced care.
Many of the bills before us build on efforts in Medicaid
and Medicare that are already yielding positive benefits for
patients and reducing dependency or misuse of opioids.
As we move forward, we look forward to stakeholders and
others providing feedback on the proposals before us. The input
of the Congressional Budget Office will also help shape our
decision-making on several pieces of legislation before us
today.
But our aim remains the same--moving through committee in
regular order to advance legislation on the House Floor before
the Memorial Day recess. We have seen announcements in sister
committees recently as they are also developing and advancing
legislation, and we look forward to continuing our work with
them to get a robust, bipartisan package of proposals to the
White House for signature in the coming months. The urgency of
the crisis demands our response, and the challenges facing our
communities demands action.
I'd like to thank our witnesses for taking the time to
share their expertise with us today and tomorrow, and for our
members--on both sides of the aisle--for making this fight a
top priority.
Mrs. Blackburn. Thank you, Mr. Chairman, and thank you, Dr.
Burgess, for the hearing on these issues.
There are two components that I am looking forward to. And
I will tell you, Ms. Brandt, I appreciate the work of the
administration to support the State Medicaid programs in their
efforts to examine combat these programs.
Tennessee's TennCare program recently implemented some new
policies, and I had some good discussion this past weekend with
some of our State legislators and some physicians who are hard
at work on that with a 5-day limit on the prescriptions, prior
authorization for any refills, a robust buyback program.
And I am looking forward also to discussing with you the
IMD exclusion. Some of those that treat substance abuse have
talked about this as a barrier to getting individuals into
beds, into the treatment that they need.
So we really appreciate the work that you all are doing and
look forward to getting the legislation across the finish line.
I yield back.
Mr. Burgess. The gentlelady yields back. The chair thanks
the gentlelady.
The chair yields to the gentleman from, New Jersey, Mr.
Pallone, ranking member of the full committee, 5 minutes for an
opening statement, please.
OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. Thank you, Mr. Chairman.
Today's hearing is the third in a series to address the
opioid and substance abuse crisis that is ravaging communities
across the country, and our focus today is on the role of the
two largest public health insurance programs, Medicaid and
Medicare.
A lot needs to be done to address this epidemic, but we
should focus our time on what is most meaningful and impactful.
While I support addressing this crisis through a bipartisan
process, I am concerned that the sheer quantity of bills before
the committee today and the chairman's extremely ambitious
timeframe will not leave us much time to get these policies
right.
Today we will discuss 34 bills in one 2-day hearing, the
vast majority of which the members of the committee have seen
for less than a week. So I am concerned that many of the
proposals have not been introduced. Most have not had the
benefit of technical assistance or a CBO score. In fact, CMS'
own testimony today I don't believe discusses any of the bills
under consideration.
So at times to me this process feels more like an opioids
media blitz than a thoughtful discussion about our national
public health crisis, and this is not the deliberative process
that the members of this committee and the American people
deserve.
But with that important caveat aside, I will say that many
of the proposals we are examining today have merit and strive
to address a number of policy problems that Medicaid and
Medicare face in combating the opioids epidemic. In Medicaid,
we are considering legislation that would strengthen the
continuity of coverage that people receive, particularly
vulnerable populations, like adults and children leaving the
justice system and former foster youth. And I know that the
best way to combat the opioids crisis is for people to have
access to strong and consistent health coverage that provides
the treatment they need.
You also will hear about policies that invest in our
providers on the ground, and our State Medicaid infrastructure
helps States to build on what works, like Medicaid health
homes, and promote new models of care to expand treatment
capacity of providers.
We are also looking at complex issues related to how our
Medicaid programs track and dispense prescribing of opioids and
relieving barriers to lifesaving treatment, like naloxone and
MAT. And I think we could do even more in this area. There are
bills to improve quality and data on how this crisis impacts
Medicaid that will also be important to know in the coming
years.
In addition, Mr. Chairman, there is legislation related to
repealing the so-called IMD exclusion for a 5-year period.
Medicaid IMDs are one very important piece of the treatment
puzzle that States are incorporating into their delivery
systems already through Medicaid's special Substance Use
waivers. This is an example of a bill that needs a very
thoughtful approach so we do not hurt the efforts that are
already occurring in States today.
And we are also considering legislation regarding the role
of Medicare parts B and D to address the rising epidemic of
opioid overprescription and misuse among seniors. For example,
we will discuss legislation under Medicare part B to expand
opioid disorder treatment options through telehealth and also
legislation under part D to ensure e-prescribing is utilized
when prescribing controlled substances. And we will also
discuss legislation to create an alternative payment model to
incentivize the delivery of high-quality, evidence-based opioid
treatment service for Medicare beneficiaries.
These bills are important because evidence suggests that
opioid use among older adults is a significant and growing
problem. According to the OIG, more than 500,000 part D
beneficiaries received high amounts of opioids in 2016, with
the average dose far exceeding the manufacturers' recommended
amount.
So I want to be clear, this committee must focus on
meaningful proposals that will address the opioid crisis. I
intend to oppose any bill that has nothing to do with opioids,
that makes the problem worse, or that is simply not ready and
vetted in the time that we have allotted. Our policy goal
should always be to first do no harm, and without the proper
time to vet the legislation before us I can't be sure that we
are meeting that goal.
For instance, I have significant concerns regarding one of
the discussion drafts to add a pain assessment to the Welcome
to Medicare physical. While well intentioned, I am concerned
that this bill could actually exacerbate our opioid crisis.
I have heard from numerous stakeholders in the medical
community that a similar approach adopted by the Joint
Commission in 2001 to treat pain as a fifth vital sign actually
contributed to the opioid epidemic, because by requiring
healthcare providers to ask every patient about their pain and
incentivizing aggressive management of pain these measures may
have resulted in the overprescribing of opioids.
So finally, Mr. Chairman, I hope to work with my colleagues
to address these concerns so that we can all support concrete
and thoughtful legislation that will actually help address the
crisis. And thank you again. I yield back.
Mr. Burgess. The gentleman yields back. The chair thanks
the gentleman.
That concludes member opening statements. The chair reminds
members that, pursuant to committee rules, all members' opening
statements will be made part of the record.
And we do want to thank our witness for being here this
afternoon, staying with us through the previous full committee
hearing, taking the time to testify before the subcommittee.
Today our witness will have the opportunity to give an
opening statement, followed then by questions from members. The
panel today, of course, will be Dr. Kimberly Brandt, the
Principal Deputy Administrator for Operations for the United
States Centers for Medicare and Medicaid Services.
We appreciate you being here today, Dr. Brandt, and you are
recognized for 5 minutes to summarize your opening statement,
please.
STATEMENT OF KIMBERLY BRANDT, PRINCIPAL DEPUTY ADMINISTRATOR
FOR OPERATIONS, U.S. CENTERS FOR MEDICARE AND MEDICAID SERVICES
Ms. Brandt. Chairman Burgess, Ranking Member Green, and
members of the subcommittee, thank you for inviting me to
discuss CMS' work to address the opioid epidemic.
CMS understands the magnitude and impact the opioid
epidemic has had on our communities and is committed to a
comprehensive and multipronged strategy to combat this public
health emergency.
As the principal deputy administrator for operations at
CMS, I am charged with addressing cross-cutting issues that
affect our programs, with the efforts to fight the opioid
epidemic being one of our agency's and the administration's top
priorities.
Over 130 million people receive health coverage through CMS
programs, and the opioid epidemic affects every single one of
them, as a patient, family member, caregiver, or community
member. This theme has been repeated throughout multiple
stakeholder listening sessions that CMS has facilitated to
discuss best practices and brainstorming solutions.
As a payer, CMS plays an important role by incentivizing
providers to provide the right services to the right patients
at the right time. Our work at CMS is focused mainly on three
areas: prevention, treatment, and data. Due to the structure of
our programs, Medicare part D plan sponsors in State Medicaid
programs are well positioned to prevent improper opioid
utilization by working with prescribing physicians. Our job at
CMS is to oversee these efforts and to make sure that plan
sponsors in States have the tools they need to be effective.
Beginning in 2019, CMS expects all part D sponsors to limit
initial opioid prescription fills for acute pain to no more
than 7 days' supply, which is consistent with the guidelines
set by the Centers for Disease Control and Prevention.
Additionally, we expect all sponsors to implement a new care
coordination safety edit that would create an alert for
pharmacists when a beneficiary's daily opioid usage reaches
high levels. Pharmacists would then consult with the prescriber
to confirm intent.
Thanks to recent action taken by Congress, CMS now has the
authority to allow part D plan sponsors to implement lock-in
policies that limit certain beneficiaries to specific
pharmacies and prescribers. We recently finalized a proposal to
integrate lock-in with our Overutilization Monitoring System,
or OMS, to improve coordination of care. The administration
also has put forth legislation to require plan sponsors to
implement lock-in policies.
These new tools will add on to existing innovative
approaches in part D to track high-risk beneficiaries through
OMS and to work with plan sponsors to address outlier
prescribers and pharmacies. We have seen a 76 percent decline
in the number of beneficiaries meeting the OMS high-risk
criteria from when we started this in 2011 through 2017, even
at the same time that part D enrollment was increasing.
We also support State efforts to reduce opioid misuse.
Medicaid programs can utilize medical management techniques
such as step therapy, prior authorization, and quantity limits
for opioids. In this year's President's budget, CMS proposed
establishing minimum standards for the Medicaid Drug
Utilization Review program, a tool that we use to oversee State
activities in this area.
In addition to our prevention measures, ensuring that
Medicaid and Medicare beneficiaries with substance use disorder
have access to treatment is also a critical component to
addressing the epidemic. Our aim is to ensure the right
treatment for the right beneficiary in the right setting, and
we are working to increase access to medication assisted
treatment, or MAT, as well as naloxone.
The President's budget also includes a proposal to conduct
a demonstration to cover comprehensive substance abuse
treatment in Medicare through a bundled payment for methadone
treatment or similar MAT. Because current statute limits CMS'
ability to pay for methadone, we are focused on ensuring access
to other evidence-based MAT.
The administration is also committed to increasing
treatment access for Medicaid beneficiaries as well through our
1115 waiver authority. CMS recently announced a streamlined
process last November providing more flexibility for States
seeking to expand access to treatment. Already we have approved
five State demonstrations, which include services provided to
Medicaid enrollees in residential treatment facilities.
As this committee knows, ordinarily residential treatment
services are not eligible for Federal Medicaid reimbursement
due to the statutory exclusion related to institutions for
mental disease or IMDs. Combined with the full spectrum of
treatment services, we believe the new residential treatment
flexibility is a powerful tool for States, and we look forward
to reviewing more requests.
Finally, CMS is utilizing the vast amount of data that we
have at our disposal to better understand and address the
opioid crisis to share with our partners and to ensure program
integrity. This includes active monitoring of trends, sharing
prescribing patterns publicly through heat maps, and various
other efforts to ensure the effectiveness of prevention and
treatment policies.
While CMS has taken numerous steps in the areas of
prevention, treatment, and data to address this national
epidemic, we know there is more we can do. We appreciate the
work that your subcommittee has already done to highlight the
importance of addressing this crisis, and we look forward to
engaging with you on the legislative solutions that you are
developing.
Thank you for your interest in our efforts to protect our
beneficiaries, and I look forward to answering your questions.
[The prepared statement of Ms. Brandt follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. Thank you, Dr. Brandt. Thank you for your
testimony. Thank you for being here today.
We will move on to the question portion of the hearing, and
I would like to first recognize the vice chairman of the
committee of the Health Subcommittee, Mr. Guthrie, 5 minutes
for your questions, please.
Mr. Guthrie. Thank you very much.
Thank you, Ms. Brandt.
Thank you, Mr. Chairman, for the time.
Thank you for being here, Ms. Brandt.
As you know, there is a lot of interest in the committee on
more timely, accurate, and complete Medicaid data, whether it
is the Transformed Medicaid Statistical Information System,
otherwise known as T-MSIS, or basic Medicaid expenditure data.
I think having more timely data is important in the opioid
fight for targeting, funding, and understanding how the program
is evolving.
One of the bills before the Committee would amend the law
to allow States only 1 year instead of 2 to submit claims for
Federal matching. This deadline does not include adjustments to
prior year spending, and the Secretary is allowed to waive the
requirement if needed. The requirement in current law was added
by Senator Moynihan in 1980. Yet today nearly 99 percent of
Medicaid claims are submitted within 1 year.
Ms. Brandt, can you talk about why we would have providers
in 2018 that are still taking up to 2 years to submit claims?
Ms. Brandt. Thank you for the question, sir.
As you noted, the T-MSIS system is one of our big
priorities at CMS. Moving to get more accurate and timely data
from the States is one of the Administrator's top priorities.
We are pleased at this point that we have 49 States, the
District of Columbia, and recently, just as of a week ago,
Puerto Rico now reporting in. So we have 98 percent of Medicaid
data now being reported in.
We share your goal in working to make sure that data is as
timely as possible, and one of our challenges right now is
ensuring that we have good quality data. As much as the
timeliness of the data is an issue, we want to make sure that
it is good quality data, as well.
So now that we have the data being reported in, we are
working to scrub the data and try and make it as good a quality
of data as possible, and we are focusing particularly on the
pharmacy files from the data so that we can begin to get
information that will particularly help us with the opioid
issue because of the State data that they report.
Mr. Guthrie. You said 49 States plus District of Columbia,
Puerto Rico, are you using the system. They report within 1
year?
Ms. Brandt. It is the most recent data that they have. It
is not all within 1 year, and that is something we are working
on with them. It is as timely as the States have the ability to
report it.
Mr. Guthrie. But I guess my question is States should be
able to do that within 1 year. I know that is one of the bills
that we are looking at.
Ms. Brandt. We are working with them to try and get them to
transmit it as timely as possible.
Mr. Guthrie. OK. I want to transition then.
According to NIH, every 25 minutes a baby is born suffering
from opioid withdrawal. These are the most vulnerable victims
of the opioid epidemic. I, along with Congressman Lujsn, plan
to introduce a bill on this important issue later this week.
Do you believe that we should facilitate public-private
partnerships to provide additional information in support to
women, children, and those tasked with their care?
Ms. Brandt. Yes. In fact, CMS is very much dedicated to
committing resources to help mothers and their infants
struggling with opioid addiction, and we actually approved a
State plan amendment for West Virginia back in February to
provide additional treatment services and additional resources
to help target just that issue.
Mr. Guthrie. OK. And my final question, as you know, in
November of 2017 the President's Commission on Combating Drug
Addiction and the Opioid Crisis recommended that CMS revise
reimbursement policies that limit patient access to non-opioid
drugs used to treat post-surgical pain. Would you please
provide the committee an update on where CMS is on the report
and specifically on this issue?
Ms. Brandt. I am sorry, can you repeat the part of the
question?
Mr. Guthrie. Yes. The President's Commission revised
reimbursement policies that limit patient access to non-opioid
drugs used to treat post-surgical pain.
Ms. Brandt. So we are committed to working to make sure
that we get the right treatment in the right setting, and that
certainly includes making sure that we explore non-opioid
alternatives to treat pain, and it is something that we are
continuing to look at as an agency to determine how we can best
address it from a reimbursement perspective.
Mr. Guthrie. Thank you.
Mr. Chairman, in the spirit of today, I used 4 minutes. So
I will yield back a minute.
Mr. Burgess. The chair thanks the gentleman.
The chair recognizes the gentleman from Texas, Mr. Green, 5
minutes for your questions, please.
Mr. Green. Thank you, Mr. Chairman.
Ms. Brandt, thank you for being here.
For years, States and the Federal Government have
underinvested in building the necessary infrastructure for
provider treatment capacity, workforce development, and
wraparound services needed to help Americans suffering from
opioid abuse.
Do you agree that the administration should work with
States to strengthen the Medicaid coverage and infrastructure
and remove the barriers for coverage for people that need the
treatment?
Ms. Brandt. Yes. In fact, that is the whole point. As I
mentioned in my testimony, we have already been working to give
States as much flexibility as possible. We have, as of last
November, since then approved five States to have more
flexibility through our 1115 waiver authority and are very much
committed to continuing to work with States to give them the
flexibilities they need so that they can determine the right
types of coverage to address the opioid crisis.
Mr. Green. Well, let me ask another question. I just see
that CMS is finalizing a rule allowing more State options in
the essential health benefits package. Is that essential
benefit package going to include mental and substance abuse?
Ms. Brandt. I can't speak specifically to what was just
included in the recent benefits package, but I can say that as
a whole we have been committed to trying to work with States to
allow more support for behavioral health services and those
types of support services.
Mr. Green. Well, in the Affordable Care Act there was
essential benefits package, and substance abuse and mental
health was included in there. We didn't get as much as we
should. I know a lot of folks wanted parity, and I support it,
but we just couldn't afford it.
But my concern is that we can pass all 70 of the bills, and
if we limit States to making sure that they don't cover
substance abuse all this paperwork is not going to be worth it.
So that is the issue, whether it is through Medicaid or through
an insurance policy bought through the ACA. That is my concern,
and particularly with the cutting in cost-sharing reduction
payments last year.
Do you think CMS plans to continue these efforts to
sabotage the ACA marketplaces and endanger healthcare coverage
of the millions of Americans? Because, again, if CMS is not
making sure that that essential benefits package covers mental
health and also substance abuse, it doesn't do us any good to
have you and to have these hearings.
If you would take that back.
Ms. Brandt. I will take that back certainly, sir.
Mr. Green. OK. And I appreciate it.
The other concern, I think, when Congress did recently
authorize $6 billion in Federal grants for opioids for 2018 and
2019, this additional funding still falls short of the
treatment for Americans struggling with opioid use. Even more
troubling is the uncertainty for the new funding stream for
2019. This uncertainty may keep States from fully spending the
funds without a commitment of long-term stable funding.
Will CMS urge the Department of Health and Human Services
to request increased block grant funding for opioid abuse and
other substance use disorders beyond 2019?
Ms. Brandt. Well, as you are probably aware, sir, the
President's budget does advocate for block grants to States for
more flexibility, and we believe that that is appropriate
because that gives States the right to decide the right type of
coverage that they need for the opioid crisis and to address
their own individual needs.
Mr. Green. Well, and again, one of the reasons we have on
the ACA side the essential benefits package, and, frankly, even
in Medicaid. Medicaid is the predominant server for mental
health and for substance abuse, and if we don't fund those
programs, like I said, we can pass all the bills we want, it
just won't help us with people being treated out in the street.
And so I appreciate you being here.
And thank you, Mr. Chairman.
Ms. Brandt. Thank you.
Mr. Burgess. The chair thanks the gentleman.
The chair recognizes the gentleman from Michigan, 5 minutes
for your questions, please.
Mr. Upton. Thank you, Mr. Chairman.
Ms. Brandt, welcome.
Last week I--actually it was this week, Monday--Debbie
Dingell, my colleague, we were in west Michigan, and we sat
down with a good number of our local mental health providers in
my district to talk about pressing issues facing them, how we
can be of more help. And I want to flag one of those issues for
you and ask that you might be able to work with us on resolving
it.
As part of an 1115 waiver, our providers were told that
they had to adopt a universal assessment tool called GAIN, G-A-
I-N. It is a 77-page assessment tool that takes more than a
couple of hours to complete. It is completely duplicative, as
every agency already does a comprehensive assessment for each
beneficiary. Our providers were told by the Michigan PIHPs that
it has to do with the Federal 1115 waiver requirement and that
the reason for completing the tool is that we have to do this,
we are only the messenger.
And they read some of the questions they are going to
actually provide with me later on. Again, I didn't realize this
hearing was already scheduled when we sat down Monday
afternoon. They are going to share with me that document. But
it seems, as they said, they want to practice medicine, often
this document turns people away from even continuing the
process.
And I just wonder if you can work with us and see if this
is really the right approach for them to look at. I know it
came, the regs, I think, were written before, but they have
been finalized, and it is just something else.
Ms. Brandt. Well, certainly we welcome if you could provide
us with the information and the tool I will take it back.
Mr. Upton. I will. I will get it to you next week.
Ms. Brandt. But I will say that one of the Administrator's
top priorities has been patients over paperwork, which has been
an effort that I know that she has talked to many of you about,
to reduce regulatory burden and to try and put patients first
over paperwork, hence the name. So it is something that we
certainly will go back and look at and appreciate you flagging
for us.
Mr. Upton. Great. I will follow up with you on that next
week.
The last question I have is a 2018 report notes that
psychotherapeutic drugs might account for up to 4 in 10 drugs
prescribed to kids in Medicaid. HHS' Office of the IG has
recommended that CMS work with the State Medicaid programs to
perform utilization reviews on the use of second-generation
antipsychotic drugs prescribed to kids.
The Medicaid Drug Improvement Act seeks to codify that
recommendation by requiring that every State have a program to
protect kids from unnecessary utilization of these powerful
drugs, which could place them at a greater risk for substance
abuse.
Do you think that such a requirement on States could help
CMS better monitor how States are providing care for kids in
their State programs?
Ms. Brandt. Well, we have read the OIG report and are
familiar with their recommendations and are committed to
working with them to see how we can reduce the high number of
drugs that kids would be potentially subject to. We are
committed to making sure that kids get the right treatment in
the right setting, and we will work with the OIG and with you
all to see what we can do to address that.
Mr. Upton. Great. Thank you.
I yield back.
Mr. Burgess. The gentleman yields back. The chair thanks
the gentleman.
The chair recognizes the gentleman from Oregon, 5 minutes,
for your questions, please.
Mr. Schrader. Thank you, Mr. Chairman.
Thank you very much, Ms. Brandt, for all the work you are
doing at CMS to help deal with the opioid prescription issues.
At least I think that we are seemingly getting somewhere. A
recent Post article indicated some substantial reduction.
Our medical and dental colleagues are getting on board with
prescribing less long-term doses, seems like much in line,
might be some incentivized by CMS, but in any case helping
drive down the prescription drug abuse problem. And I think
that is huge. We work together both in your office and here,
frankly, at the practice level. I think that is a big deal.
Are you getting any pushback with regard to some of the
guidelines you are putting out there? It seems to be in line
with what I am hearing from my medical colleagues.
Ms. Brandt. I think that the biggest thing we got comments
on when we put out the proposals that we codified in our call
letter in our proposed regs was making sure that we were
striking the right balance.
And that is something that I have heard several of you as
well mention today, and that is making sure that the people who
have a chronic illness or cancer or a real need for these types
of drugs are able to have the access to them while still making
sure that we put the safeguards in place on our side to ensure
that those who maybe are just taking it for acute pain or maybe
should not be having it at the full level are not at risk of
getting addicted.
And I think that is a balance we are striking to get, and
that is really where I wouldn't say it is pushback, I think it
has just been a constructive dialogue that we have been having
with the community on that issue.
Mr. Schrader. It is a work in progress as we work through
this. There is some recent evidence that even for chronic pain
you can manage--depending on the person and the situation--
chronic pain with modest anti-inflammatories as opposed to
having to go to the narcotic.
Ms. Brandt. Correct. And that is why we are looking at
other types of MAT and other solutions to be able to work that
and try and provide as much flexibility on that as possible.
Mr. Schrader. Would you comment at all on the other, the
flip side of this, unfortunately, is that creative people,
unfortunately, find alternate ways to satisfy their habits, and
there has been a huge rise in the deaths with regard to
synthetic opioids and fentanyl, very dangerous, tainted
products out there in the market.
What does CMS or how is CMS responding to that and what
might we want to help you do.
Ms. Brandt. Well, it certainly is a real risk, and it is
something we have taken several steps to address. I mentioned
our Overutilization Monitoring System that we have, OMS. That
allows us to put alerts in place to tell us when we see a high
number of beneficiaries that are using drugs.
So, for instance, if a beneficiary has 90 morphine
milligram equivalents or higher for a sustained period of time,
say 6 months, and has been using either three or more providers
or three or more pharmacies during that time, it puts an alert
in place.
I mentioned the 76 percent reduction that we have been able
to see as a result of some of those alerts on the part D side,
and we are very encouraged by that. But we are really working
to put additional edits in place. These are really checks, if
you will, that allow it so that the pharmacist, who is
obviously a big part of the care team, can work with the
provider to ensure that the beneficiary is getting what they
need.
I mentioned we have the new 7-day initial fill limit for
acute pain. That is, again, intended to make it so that it is
part of a discussion. If there is a need to have something more
than that, great, but if not, that really would stop that
supply because really, as the CDC has pointed out, there is no
need to go beyond that. So we have got that.
We are also looking at prescribers. Unfortunately, while
most providers are good, upstanding individuals, we do have a
number of people who are overprescribers. And so, we work with
our MEDIC, who is our sort of fraud integrity contractor, to
really look at identifying the outliers.
They provide reports on who those outliers are. And we rely
on our plans to really be able to monitor for that. And then,
obviously, States use their PDMPs and other things to help them
identify where they see outliers, as well. It is really a
multipronged approach.
Mr. Schrader. Yes, we have that issue in my part of the
profession, also. There are a few outliers, unfortunately, that
give the rest of us grief and lead to sometimes more
overregulation.
I certainly appreciate your approach and CMS' approach to
work with the providers to come up with that right balance to
get good results, and it looks like we are getting there.
Ms. Brandt. Slow but sure. We still have a ways to go.
Mr. Schrader. I yield back, Mr. Chairman.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back.
The chair recognizes the gentlelady from Tennessee, 5
minutes, for questions, please.
Mrs. Blackburn. Thank you, Mr. Chairman.
I have two questions that I wanted to talk with you about.
The Medicaid Drug Improvement Act, which is going to look at
the States' drug utilization review or the DUR programs and
would put in place the minimum standards for the States while
giving them some flexibility to determine what is and isn't
going to work.
But they would have to have a minimum standard for the
limitations in place for the opioid refills, monitor concurrent
prescribing of opioids and other drugs, monitor the
antipsychotic prescribing for children, and have at least one
of the naloxone-buprenorphine combination drugs on their
formulary.
And as I mentioned in my opening statement, TennCare has
already put in place some of these limitations, but as we have
seen the growth of Medicaid and with the Medicaid expansion, I
wanted you just to talk a little bit about what you think
putting these guidelines in place, passing this legislation,
what that would do to help with clinical care and the health
outcomes for our Medicaid enrollees.
Ms. Brandt. Thank you. It is a great question. And as you
may be aware, actually in the fiscal year 2019 budget there is
a proposal to establish minimum standards for Medicaid drug
utilization review programs, and that is something that we
think is an important first step.
We have already seen that States have been using many tools
to address this. We get reports through our DUR report each
year that let us know this, and States have been using a lot of
medical management techniques like step therapy, prior
authorization----
Mrs. Blackburn. What are the outcomes when they report them
to you?
Ms. Brandt. I think thus far, from what we have seen in
some of the initial outcomes that we have gotten from our DUR
reports, is that it seems to be going well, that these things
are making a difference and it is starting to make an impact.
Mrs. Blackburn. How many States are doing this, electing to
do this, to move forward with it?
Ms. Brandt. Well, right at the moment we have 37 States
that limit the short-acting opioids, and we have 39 States that
limit the quantity of long-acting opioids.
Mrs. Blackburn. So we have got different components that
are being implemented in different States?
Ms. Brandt. Correct.
Mrs. Blackburn. Would it be helpful if you had the
benchmarks that they had to hit across the board?
Ms. Brandt. Well, I think that is one of the reasons that
the President's budget proposal advocates for minimum
standards, so that there would be something unified across the
board.
Mrs. Blackburn. OK. That is great.
Let's talk about the IMD exclusion, because this comes up
in nearly every provider meeting that I have, and in my
district in Tennessee I have constituents who are so involved
in the delivery of substance abuse and mental health programs.
And so the IMD exclusion comes up a good bit.
So if you will elaborate on your efforts there. I know that
Ms. Verma is working on this issue. She has mentioned that she
is. But we want to ensure that Medicaid enrollees are going to
be able to get access to the needed care.
Ms. Brandt. Well, as I mentioned in my testimony, our goal
is to make sure there is the right treatment in the right
setting for the right individual, and a big part of that is
allowing flexibilities for IMD.
So as I mentioned, since last November we have implemented
some new demonstration projects in five States--Louisiana, New
Jersey, Utah, Indiana, and Kentucky--all of which have
flexibility to be able to waive IMD requirements and allow them
to have greater residential flexibility.
We have gotten a lot of interest from other States and we
are talking with them about giving similar flexibilities, and
look forward to working with you all as a committee to
determine how we can address this from a statutory perspective.
Mrs. Blackburn. Thank you. I yield back.
Mr. Burgess. The chair thanks the gentlelady.
The chair recognizes the gentlelady from California, Ms.
Eshoo, 5 minutes for your questions.
Ms. Eshoo. Thank you, Mr. Chairman.
And thank you, Ms. Brandt, for your testimony and your work
at CMS.
Ms. Brandt. Thank you.
Ms. Eshoo. I have several questions.
Let me start with this, and it is hard to get the exact
amount. Do you know how much we spend today, what the Federal
Government spends on services related to opioids?
Ms. Brandt. I do not have an exact number for you.
Ms. Eshoo. Approximate?
Ms. Brandt. I would say that it is definitely in the
hundreds of millions, but I couldn't give you an exact number.
I am happy to get back to you.
Ms. Eshoo. I think it would be helpful because the
committee staff doesn't have it either.
Ms. Brandt. We are happy to look from our perspective.
Ms. Eshoo. But at any rate, it comes from different places,
and I understand that, and there are grants and all of that.
I believe the majority of it is funded through Medicaid,
though, correct?
Ms. Brandt. Medicaid is certainly a part of it. There are
multiple funding streams in the Federal Government, including
NIH, CDC, SAMHSA, FDA. So there are multiple components.
Ms. Eshoo. But I do think that Medicaid is the single
largest payer both of mental health services and substance
abuse, or a major player in it.
Ms. Brandt. It definitely is for behavioral health, yes.
Ms. Eshoo. All right.
Now, this is a little bit of a tough question, but the
agency I am sure had done some kind of analysis of this. The
President's fiscal year 2019 budget proposal slashes $1.4
trillion from Medicaid. So have you done an analysis of that
and the impact it will have on the very issue that we have 35
bills on in this committee, on opioids?
Ms. Brandt. I think that the challenges with the opioid
epidemic is it is not something that we can necessarily spend
our way out of. We want to make sure that----
Ms. Eshoo. Well, that is not what I am asking you. I am not
asking you that.
Ms. Brandt. We have not done an analysis, specifically.
Ms. Eshoo. Money provides access to fill in the blank. This
is not a partisan issue, Member after Member has spoken to the
needs of people in their communities, the needs for access to a
variety of services, one of the most important being treatment
for this after people are hooked, after they are addicted. So
there is a direct correlation between dollars and services.
So maybe you haven't done an analysis, you can tell me
that, but I think that it is important to put this on the
table. Otherwise this is an extraordinarily serious issue that
is plaguing the country, and we are going to reduce it,
diminish it to next to nothing if, in fact, this $1.4 trillion
is cut from Medicaid. I mean, this is reality. That is the
proposal, the President's budget.
So I would like to hear back from the agency as to what
your analysis is to the impact of Medicaid and the issue of
opioids, otherwise we are just fooling ourselves here.
I mean, it is important to have the discussion, but if, in
fact, there is going to be a balanced budget amendment that
comes up on Friday, what is contained in that? How is it going
to affect this issue? There is a linkage between all of these.
And I think unless and until we acknowledge that, that we are
really not being straight up.
Now, I am very proud that Stanford University is in the
heart of my congressional district. I think they are doing
great work in the telemedicine space, specifically for opioid
and pain management treatment. They have told me that there are
barriers to Medicare and Medicaid reimbursing telemedicine,
such as originating site requirements.
Does telemedicine, do you think, save the Federal
Government money compared to in-person medicine?
Ms. Brandt. We absolutely----
Ms. Eshoo. That is such a softball question. So there is
the softball.
Ms. Brandt. We appreciate the question, and it is one of
the top priorities of the current CMS Administrator.
Ms. Eshoo. That is not what I asked you. I asked you if you
believe----
Ms. Brandt. And she does believe it has money-saving
possibilities, and it is something we are pursuing as part of
our proposed payment rules for this next year.
Ms. Eshoo. Do you think the patients, whether they are in a
rural setting or an urban setting, should be able to access
telemedicine if it is appropriate, obviously, for them?
Ms. Brandt. We absolutely believe it is a very critical
tool, particularly for the rural areas and for underserved
communities.
Ms. Eshoo. Has CMS identified any barriers that providers
face when trying to use non-opioid treatments for pain?
Ms. Brandt. We have been working with the providers to
discuss how we can eliminate some of the barriers for treatment
and are trying to work with them on solutions.
Ms. Eshoo. Well, that is pretty broad. What steps has the
agency taken to reduce the barriers?
She can answer. I won't ask anymore.
Ms. Brandt. We have had a number of stakeholder sessions,
as I said, and have been engaged in lots of discussions with
the industry to figure out where the barriers are and how best
to address them.
Ms. Eshoo. Thank you.
Mr. Burgess. The chair thanks the gentlelady. The
gentlelady yields back.
The chair recognizes the gentleman from Ohio, Mr. Latta, 5
minutes for your questions, please.
Mr. Latta. Thanks, Mr. Chairman, and thank you very much
for holding today's hearing.
Again, the opioid epidemic is a scourge on this country.
And in the State of Ohio, I am sure, Ms. Brandt, you are aware,
that we are about the third hardest hit State. We had 5,232
people lose their lives because of it by the end of the fiscal
year of June 30 of last year.
But in 2015, six newborns a day were admitted to Ohio
hospitals for neonatal abstinence syndrome, NAS, because of
drug use by their mothers, and the cost to Medicaid is $133
million. The State of Ohio has been diligently working to
address this issue and helping to improve health outcomes for
the moms and the babies out there.
Could you point to any CMS efforts to prevent and treat
neonatal abstinence syndrome? For example, States may also
include funding for facilities that provide care for infants
with NAS to an 1115 demonstration waiver. That is correct, I
believe.
Ms. Brandt. Certainly. Certainly this is an issue that we
know is very important not only in Ohio, but lots of other
States. And we have been working to commit resources to really
help mothers and their infants that are struggling with opioid
addiction.
One of the ways that we have been doing it is through the
Early and Periodic Screening, Diagnostic, and Testing services,
or EPSDT. We are requiring States to provide a comprehensive
array of prevention, diagnostic, and treatment services for
low-income infants, children, and adolescents under age 21.
This would include providing treatment services for conditions
such as neonatal abstinence.
I mentioned earlier, but in February we approved a State
plan amendment for West Virginia to provide additional
treatment services for neonatal abstinence syndrome in NAS
treatment centers. This would allow West Virginia to reimburse
all medically necessary NAS services through an all-exclusive
bundled cost per diem rate based on a prospective payment
methodology. And it also would allow them to fund things like
nursing salaries, supportive counseling, and case management,
which are important wraparound services.
Mr. Latta. Thank you.
And last week in my district I held a roundtable with
pharmacists also to talk about the opioid crisis in Ohio, and
most of the pharmacists agree that we need to have non-opioid
alternatives for pain treatment and management; furthermore,
that payments need to be expanded to alternative drugs and
therapies outside of opioids.
Should CMS be taking the lead in setting the example to
private payers by encouraging non-opioid alternatives for pain
management?
Ms. Brandt. Absolutely. As I mentioned in my oral
testimony, we are looking very aggressively at MAT and how we
can provide that, including things such as naloxone, to be able
to have other non-opioid treatment alternatives to be able to
address the problem.
Mr. Latta. How do you get that information out to everybody
out in the real world who are treating folks and saying that we
need to make sure we are using non-opioids? How are you doing
that? How are you getting that information out?
Ms. Brandt. We have a variety of methods that we use. We
have Medicare Learning Network, MLN, which allows us to get
information out. We have open door forums. We have our plan
sponsors communicate directly with their providers, and we
communicate directly with Medicare providers through various
listserves and emails and other things.
We have also partnered with the Centers for Disease Control
and other Federal partners to try and get the word out. But we
can always work with you all to do more and to try and figure
out how to do that more effectively.
Mr. Latta. OK. And also there is often a lot of discussion
about developing new drugs for pain treatment, but also new
medical devices have also shown promise in effectively managing
pain.
What has CMS done to make sure that medical devices are
included in CMS' efforts to address this crisis?
Ms. Brandt. That is actually a big area. I can tell you
during our stakeholder sessions and during the meetings that
myself and other members of the CMS team have had we have had
probably hundreds of people come in with various alternatives
and other things.
And we have been working very closely with the FDA, who is
our partner in this, to be able to figure out a parallel track
process so that as they are approving new alternatives we can
simultaneously be looking at coverage and reimbursement for
them to help get those alternatives in the system as quickly as
possible.
Mr. Latta. Well, thank you very much.
Mr. Chairman, I yield back the balance of my time.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back.
The chair recognizes the gentleman from California, Mr.
Cardenas, 5 minutes for questions.
Mr. Cardenas. Thank you very much, Mr. Chairman. I am glad
we have an opportunity once again to speak about this very,
very important issue that is crushing our communities and
individuals and families.
Ms. Brandt, what is your current title?
Ms. Brandt. Principal Deputy for Operations.
Mr. Cardenas. OK. And do you report to somebody who is a
permanent person in that position or are you reporting to
somebody who is actually temporary as you go up the ladder?
Ms. Brandt. Well, I report directly to the Administrator
for CMS, who is appointed by the President.
Mr. Cardenas. OK. All right. Thank you. Many times when we
have these hearings there are a lot of vacancies in and around
the people who are testifying. I am glad to hear that they have
a permanent person in that position.
Ms. Brandt. I am, too.
Mr. Cardenas. I want to point something out and then ask
you a question. And what I want to point out is that often when
we talk about healthcare we never mention how it interacts with
the justice system, and when we talk about improving the
justice system we leave out healthcare for children. Even if we
do talk about both of them at the same time once again, with
the children we tend to leave them out of the dialogue.
My bill, which is in our committee, which is being
discussed today, the At-Risk Youth Medicaid Protection Act,
does just that. This bipartisan bill, which I was proud to work
on with Congressman Morgan Griffith of western Virginia, keeps
the government from kicking at-risk youth off of Medicaid if
they come into contact with the justice system.
With this bill, when a child returns home she would
immediately be able to see a doctor again and have access to
any physical, mental health, and addiction treatments that she
may need. Right now children are left out in the cold to battle
with the bureaucracy on their own because many States are
automatically kicking them off.
The opioid epidemic has grown in a way that the country was
not ready for. According to a June 2017 MACPAC report, the
opioid epidemic disproportionately affects Medicaid
beneficiaries, and thus, State Medicaid programs are taking the
lead in identifying and tailoring strategies to prevent and
treat opioid use disorders.
It does not matter whether it is on the streets of Los
Angeles or the hills of Appalachia; opioid addiction can
cripple communities and destroy families. But among those
affected the most are our most vulnerable, which is our youth.
Kids suffering from addiction need to be able to see a
doctor and get better quick. In some States, when a child comes
in contact with the justice system, her access to Medicare is
permanently terminated.
Imagine her leaving the facility without family support,
wanting to get better, and trying to figure out how to continue
with her recovery, manage her mental health issues though she
has no ability to refill her medication, get back into school,
and find housing.
On top of all that, do we really expect her to have to fill
out a bunch of Federal forms and wait until she can get the
support that she deserves and needs so badly? The bill that I
am talking about does, in fact, fix that.
The need for continuous access to healthcare goes beyond
the opioid crisis and not just benefits to children, but also
their families, their communities, and the society they will
continue to be successful as adults in.
This bill will ensure that children do not fall through the
cracks because of red tape that adults created. The legislation
has broad support in the law enforcement, healthcare, and
social justice communities. I appreciate the ability to discuss
this bill and look forward to seeing it advance through the
legislative process.
Ms. Brandt, currently Federal law prohibits States from
receiving Federal financial participation for individuals
covered by Medicaid while they are incarcerated. It does not,
however, specify how each State should handle the Medicaid
enrollment of these individuals once they get back in the
community.
While some States are beginning to suspend instead of
terminating Medicaid enrollment of incarcerated individuals, 19
States still permanently terminate healthcare coverage of
incarcerated individuals.
Therefore, I ask you, do you agree that these policies
limit the ability of most incarcerated children who are covered
by Medicaid to access treatment for substance use disorders
once they are back in their community?
Ms. Brandt. Well, I am not familiar entirely with the
policies that you are describing, but as I said before, we are
committed to working with States to be able to provide
flexibility so that they can get the right treatment to the
right people, whether that is juveniles, infants, or others.
And so, we are happy to work with you to provide technical
assistance and work with the issues. I can't speak specifically
beyond that, because I am not familiar, but we are committed to
providing the right treatment and the right setting to the
right people.
Mr. Cardenas. Well, I am familiar with that one point that
is affecting so many young people in our country. And the point
here is that we can and hopefully will clarify in the law that
the States do have that option right now to continue to remove
them--right now they have the option to remove them once they
come in contact with the justice system.
But what should be happening, they should be suspended,
because they are going to get out. And for a person with any
medical need, mental or otherwise, shouldn't have to go a
month, 2, 3, 4, 5, 6, without the care that has already been
identified for them, and that is the rub and that is the part
that we are trying to fix. So hopefully we will do that and
then you will be able to follow suit.
Ms. Brandt. Very good. Happy to follow.
Mr. Cardenas. Thank you. I yield back.
Mr. Burgess. The chair thanks the gentleman.
The chair would observe we have a series of votes that have
been called on the floor. We will entertain questions from Mr.
Shimkus, and which we will then recess until after the vote
series.
Mr. Shimkus, you are recognized for 5 minutes, please.
Mr. Shimkus. Thank you, Mr. Chairman.
So Dr. Burgess, and also, really, Dr. Schrader, mentioned
the concern on the chronic pain end of these folks. And I have
been trying to carry that message, because they are different,
right? They are not addicted. They need it to just live normal
lives.
Having said that, could you--because I get a lot of
questions on this issue of the editing process that you have.
Can you briefly explain that. I know that there is a soft edit,
hard edit, and that is milligram based, and what the purpose is
and why we do it that way.
Ms. Brandt. Sure. So the whole purpose, again, of the edits
is to make sure that if you see folks who are potentially over-
utilizers, for instance, someone, as I mentioned before, who
would be receiving maybe 90 morphine milligram equivalents or
higher on a sustained basis for up to 6 months or more, maybe
getting prescriptions from three or more providers, three or
more pharmacies, people who look like they really are not
someone who maybe has a dedicated physician, a dedicated care
issue.
The whole point is that the pharmacist works with the
provider to be able to have a discussion about whether or not
that pain treatment is right for that individual. The whole
point of the edits is to serve as a flag, if you will, to be
able to highlight it so that if you have something that looks
like an aberrancy, we can stop it early.
The 76 percent number that I keep going back to, I think,
is an important example of this, because by using those types
of edits, we have been able to really reduce those numbers by
over 25,000 individuals, and that is a significant step forward
in that program.
So the point of the edits is more to ensure that there is
the right treatment being provided to the right person, and to
have that discussion among the care team about what that is.
Mr. Shimkus. So are we seeing any response by the chronic
pain community that this is inhibiting their ability and
slowing up the process of prescriptions for them?
Ms. Brandt. Well, as I said, that is something that we have
had a very active dialogue with the community on. We got a lot
of comments on that back in response to our call letter. And we
have really been working with them to try and make sure that we
are striking that right balance.
That is one of the reasons in the call letter that we went
to a 7-day initial fill for acute pain, and to make it so that
there was the ability to have that conversation between the
pharmacist and the provider about the needs of the individual
so that hopefully someone who has cancer or some other disease
that requires them to need these drugs would be able to get
them and to keep getting them as appropriate.
Mr. Shimkus. And Illinois is an 1115 waiver State. Can you
explain some of the issues with applying for that? I think it
is going to end up being a big discussion within the committee
about, if it is working, then we need to make sure that that is
working and why versus other responses to this issue that we
may hear from some of our other colleagues.
Ms. Brandt. Well, again, the whole goal of our waiver
process is to allow States more flexibility, and it is to allow
them more flexibility to be able to utilize their resources to
treat the opioid crisis in their State as best fits the needs
of their State.
Each State is very unique and has different populations and
different needs and different resource constraints, so the idea
is to be able to work with the States to give them the
flexibility.
Mr. Shimkus. And how many States do we have in that process
right now?
Ms. Brandt. Well, as I mentioned, since we started the new
process in November, we have gotten five States that have
gotten substance use disorder waivers. I can't speak to the
total number because there were waivers before that, but since
we sort of began the new process, there are five States that
have been approved. And we have discussions ongoing with
several others.
Mr. Shimkus. And I would just like to end on the--obviously
in the coding issue and reimbursement on nonopioid pain
management treatments. Obviously, you have heard the concern
that if we don't adequately reimburse them, it may move to pain
management through a different venue by which we would end up
having more challenges than we would like. Can you talk about
your involvement or your concern about CMS and coding?
Ms. Brandt. Certainly. Again, that is an area where we are
having an ongoing dialogue with the provider community to
determine what the right levels are there in terms of coding
and how we can work with them to make sure to balance the
burden with the appropriate targeting of treatment and codes
for that.
Mr. Shimkus. I appreciate you being here. Thank you for
your time.
And, Mr. Chairman, I yield back.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back.
And once again, the chair observes we have a series of
three votes on the floor of the House. The Committee is going
to briefly recess while we record those votes over the in the
House Chamber, and we will reconvene immediately after the last
vote.
I thank the witness for the forbearance during that time.
Ms. Brandt. Thank you.
Mr. Burgess. The committee stands in recess.
[Recess.]
Mr. Burgess. I call the subcommittee back to order. I want
to thank everyone for their forbearance while the vote series
occurred.
At this point, I would like to recognize for 5 minutes the
vice chairwoman of the conference, Cathy McMorris Rodgers, 5
minutes for your questions, please.
Mrs. McMorris Rodgers. Thank you, Chairman, Ms. Brandt.
I want to first applaud CMS for clarifying in the final
part D rule that MTM programs will fall under quality
improvement activities when calculating the medical loss ratio
requirements. This should encourage plan sponsors to expand
access to MTM programs, which will ensure a greater number of
patients can benefit.
Given the important role pharmacists can play in addressing
the opioid epidemic, we are considering legislation today to
add patients at risk for prescription drug abuse to the list of
eligible beneficiaries for MTM under Medicare Part D. Can you
please give us your thoughts on utilizing pharmacists to help
address the opioid epidemic?
Ms. Brandt. Thank you.
We think that pharmacists are a very important part of the
care coordination. As I mentioned in several of my answers
today, pharmacists play a vital role and are on the frontline
in helping work with providers to address this. And we think
the MTM treatments, in particular, have been very beneficial to
beneficiaries, and we look forward to working with you to
expand that.
Mrs. McMorris Rodgers. And while we are on the topic of
MTM, can you provide us with a quick update on where CMS is
ensuring sufficient retail pharmacy representation in the CMMI
enhanced MTM model demonstration project?
Ms. Brandt. I can't speak specifically to that, but I am
happy to get back to you with some more information about how
that is going. I am sorry, I am just not familiar with that
particular one.
Mrs. McMorris Rodgers. OK. That would be great.
I am interested in how existing dollars can be leveraged in
the effort to help educate providers providing care for
patients with substance abuse disorder. When we spend more than
$2 billion in Medicaid-funded GME programs each year, it is
just common sense for Congress to better understand how these
programs are helping to train providers on pain management and
substance use disorder.
For example, the University of South Carolina implemented a
program into their medical school curriculum to address the
opioid crisis using case studies, panel discussions, and group
work.
By the end of medical school, all USC-trained medical
students will be able to recognize patients that are at risk
for substance abuse, and have solutions for treatment. I think
that this is a great model for other medical schools.
Do you think that it is appropriate use of GME dollars,
particularly since Medicaid beneficiaries represent a
disproportionately large share of those with substance abuse
disorder?
Ms. Brandt. Well, we certainly agree that education is an
important component. And we agree that we want to continue, as
we have been doing, to work with States in the accrediting
organizations to make sure that GME dollars are put towards
education to help make sure that that is targeted in the
appropriate way.
Mrs. McMorris Rodgers. Thank you.
I would also like to take this opportunity to submit for
the record from the Washington State Pharmacy Association,
pharmacists play a unique role in patient care and are
frequently the healthcare professional that a patient sees the
most, especially in our rural communities.
Authorizing pharmacists clinical services under Medicare
Part B, which H.R. 529 accomplishes, will go a long way to
empower pharmacists and give them an opportunity to help
address prescription drug misuse and abuse.
So I would like to submit this letter for the record, Mr.
Chairman, and with that, I will yield back.
Mr. Burgess. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Burgess. The chair thanks the gentlelady. The
gentlelady yields back.
The chair recognizes the gentleman from Massachusetts, Mr.
Kennedy, 5 minutes for your questions, please.
Mr. Kennedy. Thank you, Mr. Chairman. I appreciate the
opportunity to have this hearing.
Thank you, Ms. Brandt, for being here as well, answering
our questions.
Mr. Chairman, I would like to start just by submitting or
requesting an opportunity to submit for the record a letter of
support from about 2 dozen or so organizations in support of
our mental health parity bill, if you would be so kind.
Mr. Burgess. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Kennedy. Thank you, sir.
Ms. Brandt, I wanted to drill down a little bit your
understanding and the administration's understanding about the
current status of Medicaid with regard to the two areas of
focus, substance abuse and mental illness, with regards to some
of the policies that I think have been put forth from a couple
of States that you mentioned earlier.
Do you have any information or data that indicates how long
it takes the average patient to recover from a substance use
disorder?
Ms. Brandt. I don't know exactly the amount of time, but I
can get back to you with any information that we have.
Mr. Kennedy. Yes. And I would imagine that it obviously is
going to vary quite a bit individual to individual.
Ms. Brandt. Yes. I think it depends on the type of person,
the type of treatment, and the setting.
Mr. Kennedy. Yes. And I would assume, with regards to a
broader mental health issue, some of that is, obviously, a
lifelong condition and some of that with adequate treatment and
access to care can be successfully managed. Is that fair?
Ms. Brandt. That is fair, yes.
Mr. Kennedy. So you can imagine my concern, Ms. Brandt,
when I hear that five States, Maine, Arizona, Utah, Wisconsin,
and Kansas, have applied for waivers to impose lifetime limits
on Medicaid patients in their States, knowing that substance
use orders and mental health problems are often lifetime
challenges, and knowing that Medicaid is a single largest payer
of behavioral health service in this country.
How do I understand the testimony that you have given so
far, and this administration's stated commitment to provide
access to care, particularly in the midst of an opioid
epidemic, recognizing that for the young people that are
afflicted with this epidemic, it is going to be a lifelong
issue and a lifelong challenge with a policy of lifetime caps?
How do I rectify that?
Ms. Brandt. Well, as I mentioned before, we have been
working to try and work with States to try and give them as
much flexibility as they can to manage the populations in their
area to hopefully get the right treatment in the right setting
for the right duration.
Mr. Kennedy. I appreciate your answer, but how is a
lifetime limit ever going to be the appropriate response for
somebody facing a lifetime illness?
Ms. Brandt. Well, I can't speak to that specifically, but,
again, we are committed to working to give the States the
flexibility they need to hopefully provide the right types of
treatments for their individual constituents.
Mr. Kennedy. So with regards to a similar policy and a work
requirement, is there a study that you are aware of that
indicates that Medicaid--that people are healthier, not the
causation between health and work, but between work and health?
Are you aware of a study that shows that work will make
somebody healthier?
Ms. Brandt. I cannot speak to such a study.
Mr. Kennedy. I can't either. I am not sure there actually
is one. And so I am curious as the administration tries to push
forward with a Medicaid work requirement, you had said earlier
that the philosophy of this administrator was to put patients
over paperwork.
I think we can agree that when it comes to a work
requirement, the paperwork necessary for an individual patient
to try to either, one, prove that they are working is an
additional administrative burden; and two, to try to provide,
assuming that you are carving out some sort of exemption for
people under certain conditions, mental illness, caregiver,
student, others, that that is an additional administrative
hurdle on top of that. How is that putting patients above
paperwork?
Ms. Brandt. Well, with the States where we have already
gone ahead and worked with them, one of the things that we
tried to do was to make sure that the States would make
reasonable modifications.
And we are trying to work with them to ensure that they are
striking that appropriate balance, to ensure that they are
getting people access to the treatment they need without
hopefully having additional bureaucratic requirements.
Mr. Kennedy. And if somebody is suffering with a mental
illness, such that they--as I know over the course of--you have
been dedicated to public health and health policy for a long
time, the challenges that those individuals and families have
with getting access to care and maintaining the care that they
need, and the struggles that they go on on a daily basis to
sometimes get through the day, the administrative burden added
for them to prove that they are--should be exempt for those
work requirements, does that not make it even harder for them
to do so? And if so, isn't the risk of them losing access to
their healthcare and Medicaid even higher to one of the most
at-risks populations we have got?
Ms. Brandt. Well, to your point, that is one of the reasons
that we remain committed to trying to work with States to sort
of strike that reasonable balance I talked about. We want to
make sure people have reasonable access and the appropriate
access to the care they need in those States, and, hopefully,
balance that with the requirements needed to be able to show
that they need that care.
Mr. Kennedy. And how would a work requirement ever tilt in
the way of a patient for access to health?
Ms. Brandt. As I said, we are working with States to try
and make sure to assure that balance.
Mr. Kennedy. Appreciate that. Thank you.
Yield back.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back.
The chair recognizes the gentleman from Virginia, Mr.
Griffith, 5 minutes for your questions.
Mr. Griffith. Thank you, Mr. Chairman.
Appreciate you being here this afternoon.
The Medicaid Pharmacy Home Act that the Committee is
considering would require that States take into account a
patient's history of receiving care in geographic proximity to
providers and pharmacies when locking a patient into two
providers and two pharmacies. How would CMS define proximity?
Ms. Brandt. Well, that is a good question and something
that in each of our rulemaking, we actually look to do. We
recognize that we are always looking to make sure that we can
ensure appropriate access for patients.
As I said, we want to make sure people are getting the
right treatment in the right setting, and so it is something
that we are definitely always looking to determine what is the
right proximity. Is it driving distance? Is it actual mileage
distance? What is the appropriate balance? And that is
something that we do through notice-and-comment rulemaking and
working with individuals such as yourself.
Mr. Griffith. And you anticipated the next part of my
question, because I was going to go to, historically it has
been a mileage requirement, but in districts like mine, which
have mountains in them, one town might be closer as the crow
flies, but not nearly as close on driving time.
I have got a classic situation in one of my areas where in
Dickenson County, Haysi, and Clintwood, on the map may look
like they are 15 miles apart but there is a mountain in
between.
And because of the road that goes around the mountain, I
have been advised by the mayor of Haysi that he allots--it
doesn't always take him that long, but he allots an hour to get
from one down to the other. When he has a meeting over in
Clintwood, he has to allocate an hour on his calendar, weather,
coal trucks, timber trucks, a slow driver worried about the
curves, all can make that trip a lot longer, and there may be
closer facilities that the drive time is better for, or
whatever, and keeping that in mind. And I just ask that as you
all look at this--and we will too--if you would keep that in
mind, I would greatly appreciate it.
Ms. Brandt. We certainly will.
Mr. Griffith. Thank you.
In MACPAC's report this past June, the commission noted
research in health affairs that found States with prescription
drug monitoring programs requirements saw reduction in opioids
prescribed to Medicaid enrollees, reducing the total scripts in
the dosage as well, and a reduction in Medicaid spending on
those prescriptions. A 2016 CMS bulletin also highlighted
similar findings.
Wouldn't you agree that this evidence demonstrates the
critical role of the PDMPs in addressing the opioid epidemic,
saving both lives and dollars?
Ms. Brandt. Yes. We absolutely think the PDMPs play an
important role. Forty-nine States currently have a PDMP, and we
are very much committed to continuing to work with them to
ensure that they are as effective as possible.
For instance, the State of New York, which has been
requiring prescribers to access a PDMP, has seen a 75 percent
drop since 2013 and the number of patients who use multiple
prescribers and pharmacies for controlled prescription drugs
just because of the PDMP.
Mr. Griffith. And appreciate that.
The Medicaid Partnership Act draft before us allows States
flexibility in how they design their programs. However, it also
ensures that PDMPs are a part of Medicaid's provider clinical
flow work. If more physicians and pharmacists were checking the
PDMP, would you expect the number of opioid prescriptions to
decrease? I would.
Ms. Brandt. Well, as stated with the example I just gave
you from New York, we think that there is a lot of promise to
having greater access to PDMPs, and to making sure that people
are utilizing them.
Mr. Griffith. Now, here is an interesting twist that we
have to try to figure out. If you have the prescribers checking
it, is it duplicative to have the pharmacy checking it also?
Ms. Brandt. Well, it is a good question. And, as I
mentioned before, we view the pharmacist as well as the
prescriber as part of that care coordination team. So it is
something where prescribers have been checking this, but we
also view the pharmacist as a part of the discussion, and it is
something we are certainly open to discussing with you all.
Mr. Griffith. Yes. I think we do need to discuss it,
because one of the things that it also says is is that if there
is a patient in hospice or palliative care, they would be
exempt from the requirement to consult the PDMP. How is a
pharmacist going to know that? The prescriber should know that,
but----
Ms. Brandt. At this point in time, I do not believe that
type of information would be available to people checking the
PDMP, so that would be an impediment.
Mr. Griffith. Right. So we have got to figure that out if
we are going to go forward on that particular line of the bill.
But I do think we are all trying to work in the same direction,
and I appreciate any input that you can give us to make our
bill, as we go forward and discuss it, better and practical.
Ms. Brandt. Well, we look forward to offering technical
assistance, and this is an area that we have been very focused
on, so thank you.
Mr. Griffith. Thank you, and I yield back.
Mr. Burgess. The chair thanks the gentleman.
The chair recognizes the gentleman from Florida, Mr.
Bilirakis, 5 minutes for your questions, please.
Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it.
I appreciate your testimony as well.
Ms. Brandt. Thank you.
Mr. Bilirakis. Thanks for your patience.
Ms. Brandt. No problem. It has been a long day for
everyone.
Mr. Bilirakis. Yes. Not over yet.
Last week, CMS issued final rules for Medicare Part C and
D, which include the rules for the lock-in program. This
program is important for me not only because I authored the
provision, but also because addiction is a serious problem that
cuts across age, gender, and income.
Programs like Medicare need to have and use all the tools
available to help beneficiaries. Let's see, can you update the
Committee on what changes CMS did with this implementation of
the drug management program for at-risk beneficiaries, also
known as lock-in, in Medicare's Part D program, please.
Ms. Brandt. Certainly. As I mentioned in my oral testimony,
we were very appreciative of the additional tool that Congress
gave us. This is a very important tool in our fight at the
Federal level against the opioid epidemic.
Starting next year, plan sponsors have the option to go
ahead and implement a lock-in requirement, which would require
a beneficiary to use certain providers and/or certain
pharmacies, depending on what is deemed appropriate.
There is also a proposal in the President's budget to do
mandatory lock-in for plans. Again, ours is a ``may'' not a
``shall'' right at the moment, but the President's budget has a
``shall.'' But we think that the lock-in authority is something
that will be very helpful.
We have seen a lot of good results from States. Many of the
States have been using lock-in authority. And we think that
some of the early results from States we have seen, such as
Pennsylvania, which has saved about $55 million in 2016 from
using lock-in authority, are a good indicator of where we can
go with this authority going forward.
Mr. Bilirakis. The President's budget has a ``shall,''
recommends a ``shall''----
Ms. Brandt. Right.
Mr. Bilirakis [continuing]. As opposed to the ``may''?
Ms. Brandt. Correct.
Mr. Bilirakis. And my original bill had a ``shall'' as
opposed to the ``may.'' Why do you think it is so important
to--if that is your position as well, because I agree it should
be a ``shall.'' Why do you think it is so important that we say
``shall,'' and require them to have the lock-in program under
Medicare as opposed to giving them a choice?
Ms. Brandt. Again, it is an important extra tool for our
toolbox. And if the tool is optional, it doesn't mean it can
always be used. But if the tool is mandatory, that means it can
and should be used.
And it is just another important tool to allow us to
address those really high over-utilizers and to be able to take
important steps to limit their usage and to be able to protect
the program.
Mr. Bilirakis. And, again, we want to emphasize this is
only for high risk?
Ms. Brandt. Only for high risk. Only for those who are
particularly high risk. And as I indicated from the results we
saw from the State of Pennsylvania, we think they will also
have cost implications to the programs in terms of savings,
which is something that we are always looking for, particularly
in the Medicare side of the house.
Mr. Bilirakis. Very good. Thank you. Under Medicare, yes.
Thank you.
Next question. Do I have time? Yes, I think I am all right.
Almost every State Medicaid program runs or authorizes a lock-
in program using, physicians or pharmacies, or a combination of
both. Every State Medicaid program runs their program
differently from each other.
Does CMS currently collect data from States on their
Medicaid lock-in programs, such as how it is structured,
eligibility triggers, estimated cost savings, outcome measures,
or other data that could help States with establishing best
practices?
Ms. Brandt. So we are starting to do that through our
Medicaid drug utilization review program. Our DUR reports that
we get are allowing us to start to get that sort of
information.
We are still sort of, I would say, solidifying exactly what
requirements we are getting, but it does allow us to get a
snapshot of what is working. And that is how I was able to give
you an example from Pennsylvania, where we were able to see
some initial positive results from their lock-in program. So it
is something that we are starting to collect.
Mr. Bilirakis. How many States actually collect this data?
Ms. Brandt. I would have to get back to you with that. I
don't know the exact number of States.
Mr. Bilirakis. But there are advantages for the States to
collect this data?
Ms. Brandt. Absolutely. Because as you can tell, you can
provide savings data. It also provides data on how it reduces
over utilization and other important markers that we can use
from a program management perspective.
Mr. Bilirakis. OK. Very good. Thank you.
I yield back, Mr. Chairman. Appreciate it.
Mr. Burgess. The chair thanks the gentleman.
The gentleman yields back.
The chair recognizes the gentleman from Indiana, Dr.
Bucshon, 5 minutes for your questions, please.
Mr. Bucshon. Thank you, Mr. Chairman.
I was a surgeon before, and I was in healthcare. I have
seen this problem coming for 25 years, caught up to us pretty
quickly for a variety of reasons. There is no one particularly
at fault, but I think we kind of got caught with that.
And, it is going to take us a while to get out of this
problem. It is a multifactorial in origin as well as the
solutions to it, all the way from border security and
preventing the 90 percent of heroin that comes to the United
States from coming across our southern border, all the way to
the other end of the spectrum where we have to provide
affordable treatment options for people who are currently
addicted.
I have seen countless families in my district, in the 8th
District of Indiana, destroyed due to this. We are losing a lot
of people in all of my counties. Rural America is devastated by
this problem.
And I believe that some more emphasis maybe should be
placed on innovative treatments, including medications and
devices, to help individuals manage pain without becoming
dependent on opioids.
And CMS plays a critical role in this effort. That is why I
have worked with Scott Peters, who is down at the end, on the
Postoperative Opioid Prevention Act to create a temporary pass-
through payment to encourage development of nonopioid drugs for
post-surgical pain management and Medicare.
Additionally, I am working on a draft legislation to add an
evaluation of management of chronic pain to the Medicare
initial assessment, which would include an emphasis on
nonopioid pain management alternatives. Have you had a chance
to look at those options?
Ms. Brandt. I have not personally, but I know that our
office has been reviewing them for technical assistance.
Mr. Bucshon. OK. It is important to remove barriers to
access for patients new options for management of post-surgical
and chronic pain in order for society to shift from the
overreliance on opioids.
My daughter, for example, had her wisdom teeth taken out,
and her dentist wrote a prescription for 60 opioids. Of course,
my wife and I are doctors. We never filled it. We said, some
ice on the cheeks and a little bit of Advil and Tylenol. But
you see the extent of this problem.
We still, even as a provider, I will say that providers are
part of the solution, and I think we are doing much better, but
we have a way to go. It is a cultural shift that we need. It is
starting in training, I think, all the way up through current
practitioners, and I think that we are going to get there.
I know there are barriers to nonpharmaceutical therapies
for chronic pain. I think someone asked you earlier about that.
How can those barriers be addressed and primarily its coverage
decisions from CMS, honestly, to increase the utilization of
evidence-based therapies, particularly FDA-approved medical
devices for pain?
Ms. Brandt. So as I mentioned earlier, we are constantly
looking at CMS to determine how we can look at evidence-based
criteria to improve our coverage decisions. One of the things
we really would like to do and are trying to do is, within our
statutory authority, to expand the amount of nonopioid
alternative treatments that we can cover as much as possible.
And we are committed to working with the FDA and our other
partners to really try and expand our reach of that as much as
possible. We have been working very much with NIH to get more
clinical evidence to support our coverage decisions and are
continuing to try and fast track all of that to open up as many
new options as we can.
Mr. Bucshon. And administrator Verma met with the Doctors
Caucus this morning, and we talked a little bit about that. And
I know that that is a goal to try to, and you may need some
more authority legislatively, I think, to adapt, because we
need to be more nimble here. If we have something that is FDA
approved, we need to get coverage decisions in a more nimble
way, not reinvent the wheel.
And I have found, since I have been in Congress--this is my
8th year--that coverage decisions are a barrier to access more
than, I think, I really realized. And it is nobody's fault; it
is just the way it is.
Some of the bills before us today will increase access to
methadone also. An informational bulletin on best practices for
addressing prescription opioid overdoses, misuse, and addiction
in Medicaid was issued by your predecessors in the Obama
administration. That bulletin cautioned that methadone, in
particular, accounts for a disproportionate share for opioid-
related overdoses and death. Methadone, as everyone knows, is
an opioid.
The bulletin also warned of an increased risk of morbidity,
mortality associated with methadone in the Medicaid population.
Mr. Chairman, I ask for unanimous consent to submit that CMS
report for the record.
Mr. Burgess. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Bucshon. I know every member here wants the patients to
get the care they need, but we also need to make sure it is the
right treatment from the right provider at the right time.
Can you talk about CMS's current work--briefly, because I
am almost out of time--to better understand the clinical risks
the literature associates with methadone?
Ms. Brandt. Certainly. Again, we have been looking at
different ways that methadone can be utilized where it is
appropriate, both for opioid use disorder and how it is
currently being utilized for acute pain, in determining whether
or not there are alternative treatments or other ways that we
can work with you all in Congress to expand our statutory
ability to be able to use methadone where appropriate for OUD.
Mr. Bucshon. OK. Thank you.
Mr. Chairman, I yield back.
Mr. Burgess. The gentleman yields back. The chair thanks
the gentleman.
The chair recognizes the gentleman from New Jersey, Mr.
Lance, 5 minutes for questions, please.
Mr. Lance. Thank you very much.
And good afternoon to you all.
In a CMS report on the Medicaid Health Home State Plan
option, CMS noted States report that they plan to continue the
Health Home Programs after the current law 8-quarter enhanced
Federal match ends--and I think it is a 90 percent match--in
part, because they are saving money.
CMS explained States believe that the cost savings are a
result of the improved health status and reduced utilization,
which are expected to, at a minimum, cover the costs of the
Health Home Program and anticipate savings in excess of health
home costs.
Mr. Chairman, I ask that the report be submitted for the
record.
Mr. Burgess. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Lance. Thank you.
Given these findings, what impact would an additional year
of enhanced Federal matching for Health Homes have for States?
Do you think more States would adopt this special model to
provide care coordination and wraparound services for patients
with substance abuse disorders?
Ms. Brandt. We have seen good initial results from the
Health Home, particularly in Vermont, with the hub-and-spoke
model that we have there. The Health Home has seemed to be very
positive and had very good results.
So it is something that we are supportive of because the
Health Homes do provide us with another option to provide the
right care in the right setting, and Health Home can be an
important part of that.
Mr. Lance. I would imagine that funding is safe if patients
are permitted to stay in their homes. I think that that
probably is a cost saver.
Ms. Brandt. I can't speak to that specifically, because I
haven't seen numbers to support that. But like I said, at least
initially, based on the Vermont model, it does seem that they
have achieved some savings using the Health Home model.
Mr. Lance. I thank you very much.
And, Mr. Chairman, I yield back 3 minutes.
Mr. Burgess. The chair thanks the gentleman.
The chair recognizes the gentlelady from Indiana, Mrs.
Brooks, 5 minutes for your questions, please.
Mrs. Brooks. Thank you, Mr. Chairman.
And thank you for being here and for your work.
One of the reasons why I think the opioid epidemic has
become so pervasive is because of the prevalence of pain, and
pain being the most common reason Americans access the
healthcare system to begin with, and number one cause of
disability in the country. We know pain is a major contributor
to healthcare costs, not to mention societal costs and the
economic loss because of the opioid crisis.
But how can HHS and CMS ensure that educators, or providers
rather, are better educated about pain management alternatives,
including the technological alternatives to opioids that Dr.
Bucshon was just talking about?
In a previous answer, I know you mentioned the Medicare
Learning Network. I would like to know a little bit more about
how you are doing more of the education for providers?
Ms. Brandt. Ma'am, it is a great question. I think the pain
issue is one that we have really tried to address through
multiple fronts at CMS. Part of it is having more of a
discussion with providers about pain.
Our quality measures used to have pain management survey
questions in them. We have changed those to have it be more of
a discussion about pain instead of how can we just manage your
pain. It is having a discussion about the type of pain and sort
of why that is happening and trying to figure out the right
solution.
We have also been working on quality reporting on adverse
events in the hospital to sort of work with physicians to say,
OK, how can we have a better understanding of this? How do you
know what the alternatives are?
So part of that is through the outreach we do through our
quality improvement organizations, our QIOs, and our quality
improvement network. They do a lot of outreach in physician and
hospital education.
We use the Medicare Learning Network, MLN, that I talked
about before, where we issue a lot of bulletins electronically
that go to physicians and hospitals to update them on, Hey,
here is a new treatment that you might not be aware of, or,
Here is some new developments that we have on coverage for
alternative treatments.
We have also tried very much to have more of an ongoing
dialogue through open-door forums and just more one-on-one
educational interactions with various medical societies and
others, to really educate them about what we are doing, and to
hear from them about how we can do better.
So I think there is always more that we can do, but we have
really been trying to do it through both an in-person and
virtual approach, and think we can do more.
Mrs. Brooks. How do you know about the utilization of that
type of information?
Ms. Brandt. Well, that is the challenge. We have a good
idea of how many people subscribe, for instance, to our
Medlearn Matters articles. We have a good idea of how many
people participate in our open-door forums and things like
that.
But a lot of that information then gets disseminated on
even further from there, so it is hard for us to completely
track. But we are trying to do a better job of targeting our
outreach.
And one of the things that our stakeholder sessions taught
us was that we really are thinking through how we can better
partner with our Federal partners and our private sector
partners, the plans, a lot of the associations and others, to
do more coordinated outreach and education in this space, and
that is something we are currently working on.
Mrs. Brooks. When we passed in CARA, the interagency group
that was formed with various Federal partners to focus on
prescribing practices? Are you familiar with that group?
Ms. Brandt. I know that we have participation in many types
of groups like that. I am not sure if it is the one
specifically described in CARA. I can get back to you. But we
are in active coordination and discussions with CDC, NIH,
SAMHSA-HRSA, all of the different components within HHS, DEA,
and others to kind of work and sort of figure out how our piece
as a payer impacts with the different pieces that they have
from the other perspectives.
Mrs. Brooks. I would be interested in you getting back to
us as to whether or not----
Ms. Brandt. We will certainly follow up.
Mrs. Brooks [continuing]. This was part of CARA. And I
would like to know, and I think it would be important for you
to participate.
Would you agree, however, that we could continue to do even
more prescriber education? And I am working on a bill to
require more prescriber education, but to allow it to be
focused at the State level, and to have the societies and the
other entities at the State level oversee that type of
training, because not all States require continuing medical
education. Were you aware of that?
Ms. Brandt. I did not know that.
Mrs. Brooks. So that is something that not all States
currently have, and so right now, it is all voluntary.
Everything is voluntary, is it not?
Ms. Brandt. Yes.
Mrs. Brooks. Unless the State is requiring it. Some States
do. Indiana happens to now require it.
Ms. Brandt. Right.
Mrs. Brooks. Thank you.
I yield back.
Ms. Brandt. Thank you.
Mr. Burgess. The chair thanks the gentlelady.
The gentlelady yields back.
The chair recognizes the gentleman from Georgia, Mr.
Carter, 5 minutes for your questions, please.
Mr. Carter. Thank you, Mr. Chairman.
Thank you, Ms. Brandt, for being here. Appreciate it very
much.
I want to talk to you, first of all, about abuse deterrent
formulations. To be quite honest with you, in my years of
practice in pharmacy, when this first came out, I wasn't too
high on it.
But now that we have developed as much of a problem as we
have with the opioids and drugs of abuse, I am beginning to
warm up to it quickly. And I see the usefulness of it and the
fact that you won't be able to crush it so that you can't snort
it or turn it into an injection.
I understand that there might be some extra cost involved.
I am wondering what kind of barriers that your agency is seeing
in using these medications, and what is limiting the use to
access to these types of medications?
Ms. Brandt. So right at the moment, we agree that abuse
deterrent opioids are definitely a potential tool in tackling
this epidemic. At this point, the epidemic is so pervasive that
we are looking at any and all tools.
Mr. Carter. Exactly. I would agree with that.
Ms. Brandt. We need to explore all. I think under our
current statute, we cannot tell our plan sponsors what to
negotiate and what types of drugs that they have to cover on
their formularies. It is the plan sponsors' responsibility to
do negotiations and negotiate with drug manufacturers and
determine which of the FDA-approved medications to make
available to the----
Mr. Carter. Now, who sets forth those results and
regulations? Is that in the statute?
Ms. Brandt. It is under current statute, yes, sir.
Mr. Carter. So that is something we in Congress can help
you with?
Ms. Brandt. You have the ability to influence that, yes.
Mr. Carter. OK. Well, that was my next question, how can we
help you? And you just answered it. We can help you by
rewriting those rules and regulations to include this.
Ms. Brandt. As I said, right at the moment, we cannot
interfere in those negotiations under the statute as it is
currently written. If you all were to change that, that could
potentially give us more flexibility.
Mr. Carter. Right. Well, as this evolves and as it
continues, it is certainly something we need to be looking at
from a perspective here.
I want to go now to the Medicaid Pharmacy Home Act. And
before I ask you just a couple of questions about it, I want to
compliment my colleague, Mr. Bilirakis, in his work on this. I
think this is good.
I have been involved during my time of practicing pharmacy
with lock-ins, and I see the advantage of them, but I also see
some concerns. I do think that they can help lower the
incidents of fraud and abuse.
But at the same time, I am just wondering in the
legislation--pharmacy preference is very important. And I have
often wondered when these programs are used how they determine
which pharmacy is going to be the lock-in pharmacy.
What do you think about pharmacy preference and about the
patient having the ability to request a certain pharmacy?
Ms. Brandt. Well, I think, as I said, we currently have
this as an optional authority, starting in 2019, for our plan
sponsors to do lock-in. And part of it is working with the
beneficiary to make sure that it is a pharmacy that fits for
them, that is geographically appropriate, that is somewhere
that they can access.
And part of that is the right care and the right setting
that I was talking about before. So I think that our
expectation is that pharmacies and plans will work with the
patients and the providers to make that best fit.
Mr. Carter. Well, one of my concerns is access to the
medication. I have seen situations where they are locked in to
a pharmacy. That is the only place they can get it, and that
pharmacy might not have a certain product that they need, and,
therefore, the access is denied.
What do you think about having more than one pharmacy in
that situation?
Ms. Brandt. Well, that is one of the reasons where we gave
some flexibility to be able to potentially have, in certain
instances, pharmacies or providers and, again, trying to do so
in a limited way to sort of limit the potential for abuse, but
yet, still be able to give those options that you are talking
about.
Mr. Carter. Well, I am glad to hear you say that, because I
think that is going to be extremely important. I know that the
lock-in provisions can work, but I am very concerned about
accessibility and particularly about patient preference. That
is very important.
And certainly, in this situation, I think it would be most
important in working with the patient to make sure that they
are getting the pharmacy preference of their choice would be
paramount, I think, in this situation.
Well, thank you for what you are doing. Appreciate you
being here today.
Mr. Chairman, I yield back.
Ms. Brandt. Thank you.
Mr. Burgess. The gentleman yields back. The chair thanks
the gentleman.
All members of the subcommittee having had an opportunity
to ask questions with the exception of the chairman, the
chairman will now recognize the gentleman from the full
committee, Mr. Tonko of New York, 5 minutes for your questions.
Mr. Tonko. Thank you, Mr. Chair. Thank you for letting me
waive onto the subcommittee.
Before I begin, Mr. Chair, I have a unanimous consent
request. I have here letters of support for the Medicaid
Reentry Act from National Association of Counties, the American
Medical Association, the American Society of Addiction
Medicine, the American Psychiatric Association, Community
Resources for Justice, the International Community Corrections
Association, the National Commission on Correctional
Healthcare, and the Coalition to Stop Opioid Overdose.
I would ask unanimous consent, Mr. Chair, that these
letters be entered into the record.
Mr. Burgess. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Tonko. Thank you, Mr. Chair, for holding this important
hearing and for including legislation that I have authored, the
Medicaid Reentry Act, as a part of this conversation.
And welcome, Ms. Brandt.
My goal with the Medicaid Reentry Act is simple: To reduce
overdose deaths among individuals leaving jail or prison and
returning to the community. We have heard from earlier hearings
in this committee that this is a uniquely vulnerable population
with the risk of overdose reaching as high as 129 times that of
the general population during the first 2 weeks of post
release.
To reiterate, 129 times more likely to die of an overdose
during the period in time when an individual is supposed to be
getting a second chance at life. That number is astounding and
should serve as a moral call to action for our nation.
The good news is that we are not helpless when it comes to
solutions. We just need to have the will to see them through.
Expanding quality addiction treatment to individuals while
incarcerated can dramatically improve health outcomes and
reduce overdose deaths and recidivism.
Early reviews of a groundbreaking program in Rhode Island
that provides access to all forms of medication-assisted
treatment in jails and prisons resulted in a 61 percent decline
in overdose deaths post release.
However, widespread implementation of programs like this
still face a number of obstacles, not least of which is
funding. That is where my legislation enters in, as it would
grant States new flexibility to draw Federal Medicaid funds for
services provided to existing incarcerated Medicaid
beneficiaries in the 30-day period prior to release.
It is just common sense to initiate treatment for
incarcerated individuals who are about to be released while
they are in a stable, controlled setting rather than the moment
they are thrown back out into the often chaotic environment to
which they will be returning.
I would like to get some feedback from CMS on ways that the
agency can utilize Medicaid as a tool to help this vulnerable
population. And so, Ms. Brandt, given this administration's
openness to providing States with structured waiver guidance
when it comes to outdated payment restrictions in Medicaid when
these policies stand in the way of providing beneficiaries
quality addiction treatment such as the IMD waiver guidance, I
am wondering if CMS has contemplated, or would be open to,
promoting limited waiver opportunities around the inmate
payment restriction that would similarly promote the agency's
goal of reducing overdose deaths and improving care
coordination for beneficiaries?
Ms. Brandt. Well, this is an issue actually that we have
heard from several stakeholders about. And we have had some
very extended conversations internally, and I think we are very
much willing to work with you and this committee to look at
what the options are, because we understand that this is a big
issue. It is one that several States have come to us about, and
we would be very much willing to talk with you all about where
we could potentially have some flexibilities.
Mr. Tonko. That is wonderful. It is just encouraging that
the agency would commit to working with me and other interested
stakeholders to explore the possibilities of developing 1115
waiver guidance around the inmate payment restriction issue, so
I appreciate that.
One other obstacle that Medicaid beneficiaries leaving
correction settings face is that many States terminate rather
than suspend Medicaid coverage for incarcerated individuals.
When States terminate benefits, this can lead to a lengthy
reapplication process and gaps in care at a time when these
beneficiaries are most vulnerable.
How can CMS take a leadership role in encouraging States to
suspend rather than terminate Medicaid benefits for
incarcerated individuals which public health advocates
overwhelmingly agree is a best practice?
Ms. Brandt. That is another issue that has come to our
attention and that we have been talking about how we can work
with States to perhaps share best practices or better guidance,
and look forward to continuing to work with you and the
Committee on possible solutions.
Mr. Tonko. Well, whatever we can come up with. I am open to
suggestions that your agency can offer us in terms of speaking
to the needs of the incarcerated population. The stats are very
much a guiding tool.
And we need to develop policy, I believe, that will
substantiate the effective use of taxpayer dollars and not have
recidivism be part of it, and in a bolder sense, save lives.
So I thank you very much for your kind attention and look
forward to working with the agency, with you, in particular.
And, Mr. Chair, I yield back.
Ms. Brandt. Thank you.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back.
I am going to recognize myself for questions.
And, Mr. Tonko, I will just point out the--that is an issue
that has been worked on in the past, in particular, with
individuals who have been charged but then released so they
were not actually found guilty.
And they fall into that conundrum that you describe, and
they have to go through the reapplication process. And that is
really not an agency problem; that is a legislative problem at
some point in the distant past governed by offset, and that was
an offset that produced a pay-for for some other policy that
some other Congress thought was important. But I agree with
you, that needs to be remedied, and I have heard from people as
well.
Mr. Tonko. All right. Well, I thank you, and I look forward
to working with you also, Mr. Chair.
Mr. Burgess. Let me just ask you--and, Ms. Brandt, I also
want to just address the Bilirakis bill on the lock-in. Many,
many, many years ago when I was a resident in training an
attending physician pointed out to us that one of the highest
risk situations in medicine was when two doctors were writing
insulin orders or more than one doctor was writing insulin
orders.
He said, in fact, the only thing more dangerous than two
doctors writing insulin orders is two doctors writing pain med
orders. Any way you stop and think about it, in the continuity
of care and do people communicate with each other, and you can
very quickly get into a high-risk situation.
So I think the lock-in provision is--and some people see
that as a restriction of access, but actually, I see that as
continuity of care and actually good patient care. And I hope
we get a chance to work on that when we do our formal markup.
Mr. Bucshon talked about the methadone program. When I was
in medical school in the 1970s, I actually spent a month in a
methadone clinic. I don't think it has changed a lot since the
1970s.
Ms. Brandt. Probably not.
Mr. Burgess. And it was hard on people to--you have to go
every day. You have to sign in. You have to wait your turn. You
have to take your stuff. People have to see you take your
stuff. It becomes very, very hard to maintain outside
employment because you are spending so much time dealing with
the methadone maintenance. I don't know if there is a way to
change that, but I think Dr. Bucshon is onto something. We do
need to think about how we are administering that.
We have a GME transparency bill, one that I have been
interested in. There was a GAO report that said graduate
medical education in 2015, State agencies--State and Federal
Medicaid agencies spent over $16 billion for graduate medical
education making Medicaid the second largest payer of graduate
medical education.
But they also pointed out a lack of transparency. Do you
agree that it is important to know how those dollars are being
spent and where they are being spent?
Ms. Brandt. Absolutely. Transparency on spending of that is
very important.
Mr. Burgess. So you would be in agreement that better
transparency going forward with our Medicaid GME dollars makes
sense?
Ms. Brandt. All Federal dollars need to be accounted for.
Mr. Burgess. Thank you for that. I certainly agree.
Now, I mentioned in my opening statement, and I think we
heard from Mr. Shimkus on the protecting legitimate access to
patients who are on--not just cancer patients but people who
have chronic pain conditions and are maintained on an opiate
and it works well, and, in fact, they are able to maintain
outside employment and family relationships. So while they may
be habituated they are not addicted, they don't exhibit
addictive behavior, unless, of course, their chain of therapy
is broken. So the forced attenuation of therapy or the rapid
attenuation of therapy is something that many outside groups
are concerned about. I am concerned about that because I think
we will drive some of these individuals from their structured
maintenance on an opiate for their chronic pain, and they will
look for other avenues, and as we all know, those other avenues
are heroin and fentanyl, and they are not safe because of the
quality control that the criminal element does not participate
in, and that is where our deaths come from.
So I want us to be careful about the prescriptions going
out, and I think your overuse of work that you are doing is
extremely important, and I want to be supportive of that, but I
think we also have to recognize there are people where, again,
we can't tighten that bolt down any more without breaking it
off, and that would be a bad thing.
Ms. Brandt. No, absolutely. We absolutely concur.
Mr. Burgess. Just on the issue of the overuse or
overutilization, and I appreciate that you are focusing on
providers, I appreciate you are focusing on patients, but I
have got to tell you, one of the things that has been
frustrating for me, the CMS has a lot of data at your disposal,
and we have come up against problems where pharmacies in
relatively small communities have received way too much product
for the patient populations they are treating, and I hope you
will use when you talk about overutilization, yes, focus on the
doctors who are outliers, focus on the patients who are
overconsumers, but really, those fact manufacturers who to whom
you are then writing reimbursements, that needs to be part of
the equation, as well. And I will just tell you here at the
committee level we need help with that. While there are other
agencies that have not been as helpful or as forthcoming as
they could have been, but CMS does have that data, and we need
your help on that.
I have a number of other questions that I am going to
submit in writing because I can see Mr. Green is getting
nervous, but I do want to thank you for your time today, and I
think we have learned a lot today in this hearing, and I know
there was some criticism that we were taking on a little bit
too much work, but I think it is important, and I don't think
there was anything that we heard today that was superfluous or
duplicative or anything that actually wasn't important for us
to hear. But I thank you for your testimony.
Let's see. We are going to recess until tomorrow morning at
10:15 at which time we will reconvene with our second panel
that is going in a room upstairs. Obviously, Ms. Brandt, you
are excused, and we appreciate your participation, but without
objection, the subcommittee will go into recess and convene
tomorrow morning at 10:15 a.m.
[Whereupon, at 6:00 p.m., the subcommittee recessed, to
reconvene at 10:15 a.m., Thursday, April 12, 2018.]
COMBATING THE OPIOID CRISIS: IMPROVING THE ABILITY OF MEDICARE AND
MEDICAID TO PROVIDE CARE FOR PATIENTS, DAY 2
----------
WEDNESDAY, APRIL 12, 2018
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:16 a.m., in
room 2123 Rayburn House Office Building, Hon. Michael Burgess
(chairman of the subcommittee) presiding.
Members present: Representatives Burgess, Guthrie, Barton,
Shimkus, Latta, Lance, Griffith, Bilirakis, Bucshon, Brooks,
Mullin, Hudson, Collins, Carter, Walden (ex officio), Green,
Engel, Schakowsky, Butterfield, Matsui, Castor and Kennedy.
Also present: Representatives Kinzinger and Tonko.
Staff present: Daniel Butler, Staff Assistant; Zachary
Dareshori, Legislative Clerk, Health; Paul Eddatel, Chief
Counsel, Health; Margaret Tucker Fogarty, Staff Assistant;
Caleb Graff, Professional Staff Member, Health; Jay Gulshen,
Legislative Associate, Health; Ed Kim, Policy Coordinator,
Health; Drew McDowell, Executive Assistant; James Paluskiewicz,
Professional Staff, Health; Kristen Shatynski, Professional
Staff Member, Health; Jennifer Sherman, Press Secretary; Josh
Trent, Deputy Chief Health Counsel, Health; Jacquelyn Bolen,
Minority Professional Staff; Waverly Gordon, Minority Health
Counsel; Tiffany Guarascio, Minority Deputy Staff Director and
Chief Health Advisor; Una Lee, Minority Senior Health Counsel;
and Samantha Satchell, Minority Policy Analyst.
Mr. Burgess. The Subcommittee on Health will come back to
order.
We want to thank our witnesses for being here and joining
us again this morning, taking their time to testify before the
subcommittee. Each witness will have an opportunity to give an
opening statement followed by questions from members.
This is a continuation of yesterday's hearing, so we will
not go through opening statements from the top of the dais.
People heard enough from us yesterday.
So, today we are going to hear from the Honorable Michael
Botticelli, the Executive Director, Grayken Center for
Addiction, Boston Medical Center; Mr. Toby Douglas, Senior Vice
President for Medicaid Solutions, Centene Corporation; Mr.
David Guth, CEO of Centerstone; Mr. John Kravitz, the Chief
Information Officer from Geisinger Health System, and Mr. Sam
Srivastava--close enough?--the CEO of Magellan Healthcare.
And we do appreciate all of you being here with us today.
Mr. Botticelli, you are now recognized for 5 minutes to
give a summary of your opening statement, please.
STATEMENTS OF MICHAEL BOTTICELLI, EXECUTIVE DIRECTOR, GRAYKEN
CENTER FOR ADDICTION, BOSTON MEDICAL CENTER; TOBY DOUGLAS,
SENIOR VICE PRESIDENT FOR MEDICAID SOLUTIONS, CENTENE
CORPORATION; DAVID C. GUTH, JR., CHIEF EXECUTIVE OFFICER,
CENTERSTONE; JOHN M. KRAVITZ, CHIEF INFORMATION OFFICER,
GEISINGER HEALTH SYSTEM; AND SAM K. SRIVASTAVA, CHIEF EXECUTIVE
OFFICER, MAGELLAN HEALTHCARE
STATEMENT OF MICHAEL BOTTICELLI
Mr. Botticelli. Thank you, Chairman Burgess, Ranking Member
Green, and members of the committee. It is a privilege and
honor to be before you again. And I really want to thank you
for your continued leadership on this issue.
I really want to focus today on how we can make progress,
continued progress, against the opioid epidemic, and
particularly the roles of Medicaid and Medicare in combating
this crisis.
As I said and as your introduction, I am the Executive
Director of the Grayken Center of Boston Medical Center. We are
the largest safety net provider in New England with
approximately 42 percent of our patients entering through
Medicaid and another 27 percent through Medicare.
For decades, BMC has been a leader in treating substance
use disorders. Many BMC programs have been replicated not only
across Massachusetts, but nationally. The Grayken Center for
Addiction at BMC encompasses over 18 clinical programs for
substance use disorders.
I offer my perspective not only as the Executive Director,
but with over 25 years' experience in addiction services,
having formerly the honor of serving as the Director of the
White House Office of National Drug Control Policy and as the
Director of the Massachusetts Department of Public Health. My
perspective is also as a person in long-term recovery with over
29 years in recovery.
The experience at BMC and in Massachusetts highlight the
critical role that Medicaid plays in addressing the opioid
epidemic, and this cannot be overstated. The vast majority of
BMC patients receiving treatments for opioid addiction have
Medicaid, which is widely available to low-income individuals
and families and covers a comprehensive set of benefits that
allow our providers at BMC to offer our patients the highest-
quality care while also at the same time reducing healthcare
costs.
Massachusetts Medicaid covers all three FDA-approved
medications, includes naloxone on its formulary, and will soon
cover residential rehabilitation services and recovery coaching
services, all benefits which are not available in many other
state Medicaid programs. Sadly, in America today access to
treatment is very much dependent on where a person lives.
Among the many bills under consideration by your committee
are new opportunities for Medicaid to play a more substantial
role in addressing the opioid epidemic, and here are a few, I
think, for action:
All FDA-approved medications for opioid use disorder should
be available to patients. Evidence for medication for addiction
and treatment is unequivocal. Patients with medication
experience significantly improved rates of recovery and, simply
put, they don't die. Yet, many settings do not make all or some
of the medications available because of coverage rates and
often ideas and philosophy. Only one in five people with opioid
use disorders receive medication, while the percentage for
youth is even less. In the words of Secretary of Health and
Human Services Alex Azar, ``Failing to offer medication is like
trying to treat an infection without antibiotics.''
And, like any disease, clinicians need as many treatment
tools as possible because what works for one person might not
work for the next. However, many patients are limited to what
medications they can access, if any. Medicare, for example,
does not cover outpatient opioid treatment programs, although
there are bills, including one by Ranking Member Pallone, to
address this. And also, any federally-funded substance use
disorder treatment program that bills Medicaid or Medicare
should be required to provide medications consistent with
approved best practices.
Medicaid and Medicare should make naloxone universally
available, preferably without a copay. In 2017, Massachusetts
for the first time saw an 8.3 percent drop in annual opioid
overdose deaths, the first year it decreased since 2010, but at
the same time the number of non-fatal overdoses went up. What
it suggests is that broad availability of naloxone in
Massachusetts is keeping more people alive while the epidemic
is continuing to grow. Just last week, the Surgeon General of
the United States urged people to carry naloxone.
Overdose data in Massachusetts also show that individuals
recently released from incarceration overdose at 120 times the
rate of the general public, most often within the first 2
weeks. This devastating trend emphasizes the need to focus on
transitions of care for patients leaving incarceration, as well
as treatment during incarceration, as several bills under
review by this committee have proposed.
Despite modest decreases in prescribing in the United
States over the past few years, prescribing opioids is still a
driver of this epidemic. Medicare and Medicaid should mandate
that prescribers have continuing medical education around safe
prescribing as well as they register and use state-based
prescription drug monitoring programs in order to more
appropriately treat pain and to diligently track prescribing
patterns.
To complement these successful efforts to reduce opioid
prescribing, we need to ensure that patients have access to
non-pharmacologic pain management strategies such as
acupuncture, physical therapy, and cognitive behavior therapy.
Unfortunately, only about half of state Medicaid programs
specifically support these services.
Access to services continues to be a barrier in many parts
of the country. One study showed that only 40 percent of
counties in the United States did not have an outpatient
treatment program that accepted Medicaid, and CMS could do more
to expand its network.
BMC has many treatment programs that have become national
models. The foundation of all these programs is the absence of
stigma. Without exception, patients who are aided to recovery
at BMC credit the lack of judgment they felt in our programs.
Medicaid and Medicare can and should do more to get evidence-
based addiction treatment to all these patients. Addiction is a
disease, and long-term recovery should be the expected outcome
of any treatment.
Thank you, and I look forward to your questions.
[The prepared statement of Mr. Botticelli follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. We thank you for your testimony.
Mr. Douglas, you are recognized for 5 minutes, please.
STATEMENT OF TOBY DOUGLAS
Mr. Douglas. Mr. Chairman, members of the committee, thank
you so much for inviting me to this hearing and your leadership
on this issue.
My name is Toby Douglas. I am the Senior Vice President for
Medicaid Solutions at Centene Corporation. Centene is the
largest Medicaid managed care plan in the country, serving 7.1
million members in 25 different States. I am also the
Commissioner on the Medicaid and CHIP Payment and Access
Commission, known as MACPAC, and a board member on Medicaid
Health Plans of America, a health plan association. And
previously, I was a longstanding Medicaid director and
behavioral health director in California for the Department of
Health Care Services. So, my testimony today is really based on
my experience in all these positions as well as my interactions
with colleagues in these various states and managed care
organizations who are all working together to combat this
epidemic.
The epidemic disproportionately affects Medicaid
beneficiaries. And a few facts from my written testimony:
Opioid addiction is estimated to be 10 times as high in
Medicaid as in commercial populations.
Medicaid beneficiaries are prescribed opioids twice as much
as individuals in commercial insurance.
And Medicaid has higher rates of hospitalization and
emergency department use for drug poisoning and six times the
risk of overdose death.
So, Centene, other Medicaid MCOs, and States are taking a
comprehensive approach on prevention, treatment, and recovery.
First, we are working with members and providers to prevent
addiction from occurring by curbing excessive prescribing
patterns. We are preventing overdose. And finally, we are
facilitating treatment and recovery in chronic opioid users.
I am going to lay out different areas where Congress can
enact policies that really further the ability of Medicaid
managed care organizations and states to take a comprehensive
approach to prevention and treatment.
First, there needs to be the adoption of best practices and
ensuring appropriate prescribing and utilization patterns and
increased member and provider education. For example, States
and MCOs are taking several actions related to improved
formulary management. MCOs and States are removing medications
from the formulary that could have a greater potential for
misuse. They are limiting early refills and prescription
quantities and duration. And finally, some plans, including
Centene, are using prescription data to lock in high-risk
individuals to one prescriber and/or one pharmacy to fill
opioid prescriptions.
Congress should also invest in the development of
continuum-of-treatment modalities, including the use of
medication-assisted treatment and ASAM criteria. Several States
as well as managed care organizations are working to expand the
availability of MAT, recognizing there is a significant
shortage in this area, and they are implementing very
innovative models that are using the expertise of both a hub,
which serves as kind of a center of excellence, and spokes to
expand the access to MAT in primary care settings.
Congress should eliminate the Medicaid payment restriction
on residential treatment, also known as the IMD restriction in
substance use. This is an important component of the overall
continuum-of-treatment modalities and should be done within
that context of ensuring there are a full continuum of
services.
Congress should invest in state adoption of prescription
drug monitoring programs and use strategies to ensure all
appropriate entities, including both the Medicaid agency
systems, managed care entities, and providers have efficient
access to PDMP data.
Congress should reform 42 CFR Part 2 to align substance use
disorder privacy protections with HIPAA. The lack of alignment
between Part 2 and HIPAA really is a challenge for overall
primary care and behavioral health integration, and there needs
to be the reform to align those privacy protections with HIPAA,
but at the same time maintaining the important patient
information around substance use from any type of use for
criminal, civil, or administrative proceedings.
And finally, the last point I leave you with is that
Congress should look to invest in State officials Medicaid
leadership as well as ensuring that leadership is investing
appropriately in managed care organizations. States continue to
face considerable staff turnover in their Medicaid agencies and
leadership. And in order to ensure that States have the right
leadership to address this epidemic as well as future public
health crises, there needs to be an investment in the
appropriate resources, so that both the States as well as the
MCOs can execute the right policies.
Thank you very much.
[The prepared statement of Mr. Douglas follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. We thank you for your testimony.
Mr. Guth, you are recognized for 5 minutes, please.
STATEMENT OF DAVID C. GUTH, JR.
Mr. Guth. Thank you, Mr. Chairman, and my thanks to the
Committee for your comprehensive work on this epidemic that is
ravaging our country. I want to say a special thank you to
Representatives from our service area: Congressmen Guthrie,
Bucshon, Brooks, Bilirakis, Shimkus, and Blackburn.
And I am honored to be here today not only as the voice of
my colleagues at Centerstone, but really on behalf of the
nearly 180,000 people at Centerstone that we serve each year.
So, a little bit about Centerstone. We are celebrating our
63rd year of service as a not-for-profit behavioral health
organization, and we provide a comprehensive set of services
throughout our footprint of Florida, Indiana, Illinois,
Kentucky, and Tennessee. We also serve individuals beyond that
footprint, principally through our network of specialized
therapists providing service to men and women who serve this
country in uniform and their loved ones.
Do we really know how to treat opioid addiction? Do we have
proven treatments and recovery strategies to move people out of
opiate dependency and into recovery? And the simple answer is,
yes, we do. But, unfortunately, far too few people have access
to comprehensive evidence-based treatment they need.
There are many reasons why this is the case. A major
challenge is a lack of providers. We know that there are more
than 30 million Americans, living principally in rural
communities, who have no access to treatment whatsoever for
their condition, let alone comprehensive evidence-based ones.
Another challenge is that in places where treatment options
do exist, many available are woefully inadequate. This stems
from the fact that fundamentally we do not as a Nation treat
opioid use disorder like the chronic disease that it is. And
despite the body of evidence, there are no standards of quality
care that providers are held to and no consistent protocols for
care. This is a dramatic departure from our treatment of other
severe health conditions. The experience for someone seeking
treatment for substance use, opioid use in this case, disorder
is entirely different than that of a heart patient. If an
opiate-addicted person visits five different treatment centers,
they might well receive five different treatment protocols.
What happens is where they present makes a greater difference
in terms of what they are offered than how they present, and we
must change that.
There is no set path a provider is encouraged to follow
when no one is holding that provider accountable for
administering an evidence-based protocol or for ensuring that
the patient has a positive outcome. It is often the case that
other healthcare providers that may be engaged in that
patient's care around other disorders may not even know that
their patient is in treatment for their addiction, let alone
have access to the full medical record.
In short, fragmented care and absence of quality standards
and immense workforce shortages result in delayed access or no
access at all to lifesaving care. This is what we have to
change.
Opioid use disorder is similar to heart disease in that
there is no one magic bullet for treating it. You cannot take a
pill so that it will disappear. It is a condition based on the
patient's presentation and severity that requires a combination
of treatments--medication, therapy, follow-up care--and a
condition that may require significant changes in a person's
life to overcome. Fortunately, there is data that shows what
can work. This is why we support treatment initiatives that
approach addiction as a chronic and relapsing disease with
emphasis on building a patient's recovery.
However, in order to ensure positive outcomes, we also need
to modernize our health IT infrastructure and optimize our
workforce. I realize that saying all of this is the solution is
much easier said than done. Getting people in need the right
care close to home means dealing with standards of care,
infrastructure issues, knowledge gaps, technology gaps, and
serious shortages among addiction treatment providers.
Fortunately, many of the bills that have been introduced
before this committee address these issues. Centerstone
supports all legislative action that eliminates barriers to
care and, instead, creates and rewards providers for following
quality standards, so that when a patient walks through the
door of any treatment provider, they have the best chance of
receiving the right services that will help them on the path to
recovery.
We support advances in technology-enabled solutions such as
prescription drug monitoring programs and incentives to
modernize behavioral health IT. Investments in the health IT
backbone of our behavioral health system are a critical tool in
improving care.
As our chief medical officer often says, the most costly
care that we provide across this nation is care that does not
work. We must address that.
I am going to leave you with a quick story of a gentleman
that received his care at Centerstone. His name is Keith Farah.
He is now a peer support specialist at Centerstone. He
struggled with severe and persistent addiction for years. As he
put it, ``I had given everyone who loved me more than enough
reasons to give up. I was homeless, unemployed, and a convicted
felon. Even worse, I was hopeless and terrified of living life
sober.'' He made the decision to enter into Centerstone's
Addiction Recovery Center, and today he celebrates a life he
never dreamed of.
So, I know I am out of time here. I just want to say, on
behalf of all of the teams that provide services to our
communities, on behalf of the board members that volunteer
their time and energies to advance this, I want to thank you
for your attention to this and the opportunity to provide
commentary. And I look forward to your questions. Thank you,
Mr. Chairman.
[The prepared statement of Mr. Guth follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. Thank you for your testimony.
Mr. Kravitz, you are recognized for 5 minutes, please, for
an opening statement.
STATEMENT OF JOHN M. KRAVITZ
Mr. Kravitz. Good morning, Chairman Burgess and members of
the Health Subcommittee of the House Energy and Commerce
Committee.
My name is John Kravitz. I am the Senior Vice President and
Chief Information Officer of Geisinger Health System. I want to
thank the Committee for holding this hearing on a key issue
facing the Nation, one that Geisinger and healthcare providers
are addressing. And that is to combat the national opioid
crisis.
Geisinger has employed a multifaceted approach to curb the
use of opioids, such as utilizing information technology and
electronic prescribing, implementing best practices for pain
management, embedding pharmacists in our primary care clinics,
establishing drug take-back programs, and others. Collectively,
these initiatives have significantly reduced the use of opioids
for our patients and members and increased quality of care and
outcomes by reducing costs.
With our history as an innovator of health IT and care
delivery models, we saw opportunity to reverse these trends.
Our physician leadership proposed, by limiting or eliminating
the prescribing of opioids in the clinical setting, Geisinger
could minimize and prevent patients' exposure to these drugs
and consequent risk of developing an addiction that could lead
to overdose or death.
Reducing opioid addictions could also ease the burden on
healthcare providers. In an analysis of 942 of our patients who
are also insured by our organization, overdoses were found in
opioids with steep increases in acute care cost as well as
emergency department services prior to an overdose.
We developed and initiated several approaches that focus on
changing physician practice patterns to reduce the prescribing
of opioids, including creating a provider dashboard which is
linked to our electronic health record to identify current
practice patterns for our providers. We found that providers
greatly vary in their approaches to prescribing opioids, and
the smallest number of providers are typically the ones that
prescribe the largest number of opioid prescriptions. When we
had this information, we could target the outliers and provide
them with the best practice for pain management.
This includes the pain management program for surgical
patients where we counsel patients and their families to expect
some manageable level of pain for minor procedures and the use
of non-addictive alternatives for managing pain. In cases where
our physicians believe an opioid prescription is in the best
interest, they are highly encouraged to order smaller
quantities, seven days or less.
While I am not a clinician, I am pleased that information
technology plays an important role in Geisinger's approach to
decreasing use of opioids. There are several concerns, for
example, with prescribing opioids through a paper process,
including drug diversion, prescription forgery, provider DEA
numbers being exposed to the public, and doctor shopping to
obtain opioids. We have implemented the following initiatives
to help alleviate these concerns:
We are tracking documentation on our electronic health
records and dashboards that show providers reviewed the
mandatory PDMP programs, documenting findings in the patient's
medical records. We are integrating specifically from a pain
app that we have developed on a mobile device that measures
physical activity, patient-reported pain, and other metrics
into the dashboard and feeding into the medical record. And
finally, we have deployed an EPCS program. Back in August 23rd
of 2017 and through February of 2018, 74 percent of our
providers of controlled medications have been prescribed
through the EPCS system. All 126 of our clinics are on this
process and having great success.
Our results are encouraging. We have reduced opioid
prescriptions by half since launching these initiatives two
years ago, and monthly average of opioids, we had been
prescribing about 60,000 per month; we are down to 31,000 and
that number is dropping.
Additional information on cost savings we realized from
implementing the electronic prescribing of controlled
substances were reducing by 50 percent the number of patient
calls to determine if their paper prescriptions had been ready
for them. So, we initially had about 660,000 calls per year
from our patients for opioid prescriptions. We have reduced
that to close to 330,000.
With the number of diversions decreasing, we are able to
decrease the size of our diversion staff to monitor and manage
those, and provider time, most importantly, to write an opioid
prescription with the EPCS system had gone from a time period
of 3 minutes to write a paper prescription to 30 seconds with
the EPCS system. Nursing time as well for opioid scripts went
from 5 minutes to 2 minutes. These cost savings accrued
approximately $1 million in savings in time and hard-dollar
savings for our organization.
Although the dashboard may be unique to Geisinger, we
believe other health systems and hospitals can generate similar
reports for opioid prescribing, and their electronic health
records and clinical entry systems can do the same work that we
have been doing. The initiatives rolled out by Geisinger are
broadly applicable to other healthcare systems across the
country, and we encourage others to apply these strategies to
their organizations. To succeed, organizations need the support
of their physician leadership. We are a physician-led
organization. This is a process change that has to occur with
physicians; it is not technology. Technology is told to support
this.
Everything we do at Geisinger is about caring. Part of our
caring means that we believe that our members and our patients
deserve the best care possible and the best outcomes. That is
why we emphasize and support evidence- based medicine and care
delivery, including e-prescribing of opioids. The evidence and
results are clear. E-prescribing has reduced forgery and
diversion while helping patients avoid all unnecessary exposure
to addiction and harm.
So, I would like to close out with a couple of concluding
comments. We have found that the electronic prescribing process
has led to quality improvements in care while reducing opioid
prescriptions, drug diversions, prescription forgery, and
reducing total cost of care.
Thank you again for the opportunity to provide these
thoughts on this critical issue, and I entertain any questions.
[The prepared statement of Mr. Kravitz follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. And thank you for your testimony.
Now, Mr. Srivastava, you are recognized for 5 minutes for
your opening statement, please.
STATEMENT OF SAM K. SRIVASTAVA
Mr. Srivastava. Thank you, Mr. Chairman. Mr. Chairman,
Ranking Member, and all members of the House Energy and
Commerce Committee, thank you for inviting me to testify today
on the challenges addressing the opioid crisis and offer
thoughts about legislative ideas within the Medicaid and
Medicare programs.
Magellan Health is a leader in the management of complex
population health. For over 40 years, we have been pioneers in
behavioral health, innovators in specialty health, and experts
in pharmacy services. We work with health plans, employers,
providers, and government agencies, and we serve 25 million
people with behavioral health services and 24 million people
with specialty health services. We are also privileged to be
able to serve a lot of the members here right on our panel
today.
We bring a wide range of experience and challenges facing
the country with regard to the terrible opioid epidemic. The
Committee is well aware of the facts of the opioid epidemic.
The most recent CDC report says that over 42,000 overdose
deaths occurred by opioids in 2016. This is truly a national
epidemic, and we commend the Committee for its work to develop
bipartisan legislation to reduce and prevent addiction and to
provide treatment and recovery for those facing this disabling
disease. We look forward to continuing to partner with all of
you as we move forward in the legislative process.
So, let me start by saying that the draft bills that have
been recently introduced are critically important components to
developing a comprehensive response to the crisis. While we
have not thoroughly reviewed all of these bills, our initial
takeaway is that they point in the right direction and the
Committee is on the right track.
We need to expand capacity for treatment and recovery
services, develop programs for at-risk populations that limit
access to highly addictive drugs. We need to allow further
access to drug monitoring program data, so providers, health
plan clinicians, and care coordinators can access an
individual's controlled substances history to identify
potentially inappropriate prescribing, dispensing, and the use
of opioids and other lethal drugs. We also need to update
privacy laws that limit the provider's ability to share
information on substance use which may hinder a provider from
making informed healthcare decisions. These are all critical
components for an overall framework to help address the opioid
crisis.
Let me offer a couple of observations. A more detailed
discussion of our organization's views can be found in my
written testimony to the Committee. But expanding access to
evidence-based medication-assisted treatment, or MAT, is an
important cornerstone to treatment and recovery. MAT combines
FDA-approved medications with evidence-based behavioral health
therapies and psychosocial interventions, such as peer recovery
and support services, to provide a whole patient approach to
treating substance abuse disorder. MAT is a highly effective
treatment option and has been shown to reduce drug use and
overdose deaths and improve retention in treatment. Now because
Magellan believes in MAT as an effective treatment, we are
committed to taking steps to ensure that it is more readily
available and paired closely to peer recovery and support
services.
To further improve the adoption and availability of
evidence-based MAT, we recommend expanding the ability to
prescribe MAT through the use of telehealth. We also recommend
and encourage the use of other practitioners to be eligible to
prescribe MAT, such as nurse practitioners and other medical
professionals. We ask that the Committee also consider a pay
bump or other incentives to provide treating patients with a
substance use disorder through MAT, and we also encourage that
all forms of MAT be covered under Medicare Part B.
A major barrier to care coordination for those who suffer
from opioid addiction is the limits of health privacy data
regulations placed on healthcare organizations for people with
substance use disorders. The vast majority of today's
integrated care models rely on HIPAA-permissible disclosures
and information sharing to support care coordination; that is,
without the need for the individual's written consent to share
relevant medical treatment details between providers.
42 CFR Part 2 currently does not allow the confidential
sharing of information on substance use disorder diagnosis and
treatment for care coordination or when individuals move from
one health plan to another. Excluding substance use disorder
from the care coordination hinders the ability to continue to
develop comprehensive treatment plans and coordination of
services.
Magellan recommends the statute be amended to permit
sharing of substance use disorder information for purposes of
treatment and healthcare operations, as defined by HIPAA and
for medical care. Also essential to the modernization of Part 2
is the express permissibility of substance use disorder
diagnosis and treatment information to be included in
electronic medical records.
We would like to thank again the Committee for the
opportunity to offer some thoughts and recommendations on how
to address the opioid crisis. Magellan has seen firsthand the
magnitude of this crisis, and we are fully committed to
continue to provide evidence-based, effective care services to
those with substance use disorders. We look forward to working
with the Committee in partnership to address the critical
crisis facing our nation. Thank you.
[The prepared statement of Mr. Srivastava follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. Thank you. I want to thank all of our
witnesses for your testimony and participating with us this
morning.
And now, we will move into the question-and-answer portion
of the hearing. Before beginning questioning, I would like to
submit into the record a statement from the American College of
Obstetricians and Gynecologists. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Burgess. I would also like to submit for the record a
New York Times article entitled, ``Medicare Is Cracking Down on
Opioids. Doctors Fear Patients Will Suffer.'' I would like to
submit that for the record. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Burgess. And let me recognize myself, 5 minutes for
questions.
Mr. Douglas, I think in your testimony--and I think it
actually comes up as a repetitive theme--but just looking at
your remarks that you have provided to the Committee, ``Opioid
addiction is estimated to be 10 times as high in Medicaid as in
commercial populations,'' and then, you go on to delineate some
other statistics that indicate Medicaid beneficiaries are
prescribed opiates twice as often as individuals with private
health insurance.
I am going to ask you this question; you may not know the
answer to it. I may be able to find the information elsewhere.
But when was this phenomenon recognized? Is this relatively
recent or this is something that has gone on for--I mean,
Medicaid has been around since 1965. Has this been recognized
in the '60s and '70s or is this a more recent phenomena?
Mr. Douglas. I don't have the exact timing. But what I
would say, given my previous life as a Medicaid director, that
part of the phenomena within Medicaid is the growing role of
Medicaid and being a broader program than just physical health.
This problem in many ways was siloed off, with substance use
being a separate program run in many cases in states by
separate agencies.
And what we went through in the evolution in around 2010
0911 was acknowledging the importance of integrating in
California behavioral and physical health. That started to
drive more of Medicaid and, then, our more integrated MCOs to
work to solve and recognize the impact it was having on
inpatient, on emergency room utilization. It was impacting
medical spend and the outcomes and the need to expand services,
which is why California started moving forward with how do we
expand and integrate, as well as acknowledging there was
actually with a siloed program a lot of unfortunate fraud going
on within our substance use program, and the need to integrate
into a system would allow for making sure the right care and
the continuum is being provided.
Mr. Burgess. And again, is that a more recent phenomenon or
was that something that has just been longstanding?
Mr. Douglas. As I said, the Medicaid agencies were starting
to deal with this. When I look back on my time around 2010,
around there, it was starting to become more and more of the
need to think holistically about behavioral and physical health
integration and brought these to the head.
Mr. Burgess. And I actually would be interested in what
other panel members have to say about this. I am not asking the
question to be provocative. It is just that we are the payer
here. The federal government is the Aetna, United, the Cigna.
We are the payer. And if there is something about our structure
that is putting people at risk, then I think we need to
recognize that, and if there is a way to mitigate that risk, we
ought to do so. So, are there any other thoughts that any of
you have as to whether the identification of the type of
coverage putting someone at risk, is that a real phenomenon or
is that an observer bias?
Mr. Botticelli, you look like you want to make a statement.
Mr. Botticelli. I do, and no disrespect to Mr. Douglas.
While we, I think, know the prevalence of substance use
disorder in both Medicaid populations is high, and higher than
the general population, there was a recent Kaiser health survey
that just came out that shows the growing trend of substance
use disorders and opioid use disorders prevalent in both
commercial and employer plans. So, again, I think that while we
do see slightly higher rates among Medicaid populations, I
don't think that the differences are as vast between kind of
the Medicaid population and the commercial market as one would
have previously thought.
Mr. Burgess. So, we can effectively ignore the type of
coverage? It is of no consequence?
Mr. Botticelli. No, coverage is significantly consequential
because I think what we also see in other studies is that
coverage, quite honestly, accelerates access to treatment, and
we have seen it with both Medicaid and commercial plans.
Mr. Burgess. So, intuitively, yes, that would be obvious.
I am going to run out of time.
And, Mr. Douglas, I also want to mention, thank you for
bringing up Project ECHO, which was a product of this
committee. And many of you have mentioned prescription drug
monitoring programs and, of course, the NASPER authorization
originated in this committee back in 2005. So, although the
focus recently has been more intense, this subcommittee has
been dealing with this problem for some time.
I see my time has expired. I am going to yield to Mr. Green
5 minutes for questions, please.
Mr. Green. Thank you, Mr. Chairman.
And again, I thank all our panelists.
One of the biggest issues of Americans struggling with
opioid addiction and substance abuse generally are the barriers
to treatments and ensuring there is a continuity of coverage,
and particularly for vulnerable populations. Just that
exchange, Dr. Botticelli, the compare between private insurance
and Medicaid, at one time I assumed Medicaid was more. Coming
from an urban area in Houston, Medicaid is such a predominant
care for not only physical care, but also mental care. And my
concern, Mr. Douglas, is that, if you are splitting off that, I
think it ought to be a continuity of care between the physical
doctor and--because, obviously, we know the behavioral and the
physical is important. So, we need to have that coordination of
care, whether it is through Medicare or the private sector, or
whatever.
What would be the consequences if it becomes more difficult
for Americans struggling with substance use disorders to
receive Medicaid coverage?
Mr. Botticelli. I think we have seen, yes, we would not be
able to do what we do at Boston Medical Center were it not for
a generous benefit through Medicaid. And not only do we see
successful clinical outcomes on both the behavioral and the
physical side, but we have also been able to demonstrate that
we can actually lower healthcare costs by giving people good,
comprehensive, quality care. We have seen, if we can get people
in treatment, we can reduce emergency department admissions and
hospitalizations, as well as get them to long-term recovery and
really kind of miraculously return people to jobs, to the
community.
I think, without coverage--and we have seen time and time
again the devastating impact--that one would anticipate that we
will see significant increases not only in mortality, but we
are also dealing with other epidemic issues of hepatitis C. We
are seeing outbreaks of HIV across the United States. And so,
you are entirely correct that this is not just about adequate
access to substance use treatment, but people need adequate
access to the entire spectrum of physical health issues.
Mr. Green. I was interested, Mr. Douglas, in saying, in
2010, you saw the more concern or interest, and it was because
of the separation maybe from behavioral care as compared to
physical care. Was that because of the Affordable Care Act
getting ready to kick in or expansion of private sector funding
because of the Exchanges?
Mr. Douglas. So, again, this is really, I want to say,
through my lens in California as well as on the National
Association of Medicaid Directors, working with Medicaid
directors at that time again, of Medicaid directors'
acknowledgment. And I would believe that there were many
factors. I think the Affordable Care Act was one of them, of
understanding both looking more at how we were--at that time
the Affordable Care Act, besides the expansion, was really
focused on integrating care, as you said, of physical and
behavioral health and aligning the right payment incentives and
outcomes. And so, States were really looking holistically and
realizing that, to address better health outcomes, there needed
to be more integration and expansion of treatment modalities
within behavioral health and substance use.
And so, we are now in Centene, and where we stand is we do
still see differences by States in the availability and access
to substance use treatment services, and it varies. While
Medicaid has a richer benefit, it still varies in terms of the
availability of substance use. In States where we do have
Medicaid expansion, we are seeing the ability in the data of
being able to address unmet need more within the substance use
area.
So, it is a combination of factors. I don't want to say
that the ACA didn't; the ACA spurred both expansion of benefits
as well as thinking through how to integrate physical and
behavioral health, as you said is so important.
Mr. Green. Thank you.
Mr. Chairman, you and I have had the opportunity, and a
number of our members on both sides of the aisle, to attend the
Commonwealth and the Alliance. Once a year we go off for a long
weekend and have folks.
Mr. Kravitz, Geisinger, for a number of years, has been at
those facilities. And coming from a guy from Texas with my
accent, I didn't know anything about Geisinger until then. But,
then, I happened to have my father who moved back home, so to
speak, from Houston, to northern Pennsylvania. He was a patient
there. During his lifetime--he lived to be 91 and a half, a
great life--but I was really impressed by Geisinger's facility
there treating the whole person.
Mr. Kravitz. Thank you.
Mr. Green. Anyway, I am out of time, Mr. Chairman. Thank
you.
Mr. Burgess. The Chair thanks the gentleman.
The Chair recognizes the gentleman from Virginia, Mr.
Griffith, 5 minutes for your questions, please.
Mr. Griffith. Thank you very much, Mr. Chairman.
And thank you all for being here today to testify.
Mr. Douglas, the Centers for Medicare and Medicaid Services
recently released its 2016 Drug Utilization Review Report. The
report noted that 26 Medicaid agencies have access to
prescription drug monitoring program data. States can use this
data from the PDMPs to manage the overutilization of opioids
and detect fraud, waste, and abuse. On the other hand, 23 State
Medicaid agencies report that they do not have access to the
PDMP data. Can you describe how Medicaid agency officials would
use PDMP data to combat opioid misuse?
Mr. Douglas. So, both, again, from the view of talking with
both current and former State Medicaid directors as well as
managed care organizations, the use of PDMP is really, really
important in combating. We have seen effective use in ability
to both make sure that our providers, they understand and have
a clear sense of where our members are receiving other opioid
prescriptions. And so, it creates alerts. It creates
information that we can then, as we go through utilization
management back as a managed care organization, to be able to
create and prevent prescribing from occurring.
And so, in the cases where we have it, it effectively
improves our ability to combat inappropriate prescribing
patterns and utilization. And so, as I noted in my remarks,
this is an area where I think Congress could do a lot in both
incenting states to make sure that all entities, both the
agencies, the Medicaid agencies, the providers, as well as the
managed care organizations across all States and territories,
have access to the data to combat and ensure there is judicious
prescribing.
I would note--and I think you heard from some of my
colleagues--that that is not going to be sufficient. We have to
also figure out how to overlay this into EHRs and make sure it
is as easy as possible for our providers. We are at Centene
trying to do that, but it is more than just a role of managed
care organizations to be able to solve this. It takes
investment in IT systems and prescribing to make sure that
there is easy utility and it fits into the workflow of our
providers.
Mr. Griffith. One of your suggestions for ensuring all
appropriate entities have access to PDMP data is to proactively
share that data, the data reports, with each other. Can you
explain how this would work in practice?
Mr. Douglas. Well, this gets, again, to in practice the
importance of IT, because, as providers work, it needs to be
real-time. In terms of our responsibility for utilization
management of pharmacy, there are requirements on turnaround
times. And so, if the information is not shared quickly and
through electronic means, we are either going to be out of
compliance with our utilization management or providers are
going to have problems within their workflow.
And so, in practice, it makes sense. In the actual real
life right now, until we get better IT systems across all
systems--I am sure in Geisinger and others it is there--but we
need, especially with Medicaid providers, more investment.
Mr. Srivastava. So, Congressman, if I could add?
Mr. Griffith. Yes, sir.
Mr. Srivastava. One is it is spot on that with PDMP we are
data-rich, but we are processing-poor in this construct. You
need interoperability to share it with health plans that share
it with pharmacy providers and with providers. It needs to be
at the workflow level, so that it is in an EMR. But, also, you
are getting data that is not just those that are prescribed,
but also cash pay. So, if a person seeks drugs, and it is
through the benefit in Medicaid or the benefit within your
employer, you are going to get information. But, if you are
actually going and cash paying for drugs, that processed claim
would also show up in this report. So, we are getting more data
sources, and it needs to be at the point of care, where the
individual can act and understand whether there is a lot of
drug history there, to be able to change the regimen.
Mr. Kravitz. I would like to also add a comment, if you
don't mind.
Mr. Griffith. Yes, sir.
Mr. Kravitz. From an information technology perspective, we
use PDMP before any opioid is being prescribed for a patient.
What is important, though, is not all States have reciprocity
where they can go through and exchange information. We actually
need to go to a level where we are closer to a national PDMP
for patients traversing different State lines. Where there are
reciprocal arrangements that are occurring, not all States
participate. The other problem that is a national problem is a
national patient identifier to make sure we have the right
patient identified in the PDMPs.
The other component of that, while we have advanced IT
systems, we don't have the ability to put it into our workflow
because our Commonwealth of Pennsylvania does not have APIs
established yet to do that. We will have those in the next 3
months. We will automate that entire process, so that it
doesn't have to take the provider out of the workflow, but
trigger those events in the background. So that they know if a
patient is traversing multiple locations to try to get opioids.
Mr. Griffith. I appreciate that, and I will have additional
questions for the record.
Thank you, Mr. Chairman. I yield back.
Mr. Burgess. The Chair thanks the gentleman.
And, Mr. Kravitz, I would point out that NASPER, which was
the national PDMP authorized by this committee in 2005, for the
first time it was funded in the last funding bill that we just
passed a few weeks ago. So, we are moving in that direction. It
takes us some time, but we are getting there.
The Chair now recognizes the gentlelady from Illinois, Ms.
Schakowsky, for 5 minutes for your questions, please.
Ms. Schakowsky. Thank you, Mr. Chairman.
And speaking of what direction we are moving in, today's
hearing on Medicaid and Medicare proposals to address the
opioid epidemic actually comes on the same day that the House
is considering the balanced budget amendment. I just want to
comment on the effect that would have.
If enacted, the balanced budget amendment would undercut
the structure of Medicare and Medicaid by opening both to
dramatic cuts in funding. Republicans passed what I believe is
a misguided tax bill that blows a $1.5 trillion hole in the
budget, gives 83 percent of these tax cuts to the wealthiest
among us. And we see Republicans offer budgets that would fill
that gap by cutting more than $1.5 trillion in Medicare,
Medicaid, and Social Security. And now, Republicans want to
amend our Constitution to require that we can only spend in any
given year what we raise in tax revenue in that same year,
after just cutting those revenues. So, this is a serious threat
to Medicaid, which is on the frontline of fighting the opioid
epidemic, as we have been talking about.
So, let's see, who am I asking? Mr. Botticelli, what are
some examples of the actual services that Medicaid programs
cover for substance use disorder treatment?
Mr. Botticelli. So, Medicaid--and I will talk specifically
about a program that we have at Boston Medical Center----
Ms. Schakowsky. OK.
Mr. Botticelli [continuing]. Where we have virtually 100
percent of our people who are Medicaid-eligible. That program
serves over 700 people within the context of our adult primary
care clinic. What we have been able to demonstrate through that
is, at 12 months, we have 65 percent of people still engaged in
treatment at 12 months or longer.
But I also think what is important, too, is, as I
indicated, because of that program, we have been able to do a
retrospective study of utilization of healthcare services prior
to people getting treatment and, then, in the duration of
treatment afterwards. What we have been able to show is we
could actually reduce--emergency department admissions go down
by two times and inpatient hospitalizations go down three
times. So, not only do we see our ability to provide good,
high-quality care for treatment, but, simultaneously, we are
able to reduce healthcare costs for some of the highest
utilizers of health care, not only within Boston Medical
Center, but within our larger healthcare delivery system.
So, I think that is a really good example, and part of the
reason that we are able to do that is through our Medicaid
program, and largely because they also fund a whole host of
medication-assisted treatment, a wide variety of other recovery
support services that our patients need access to. So, I think
it is a good example of the critical nature of our ability to
execute high-quality care because of our patients' access to
Medicaid.
Ms. Schakowsky. So, I am assuming, then--my next question,
you sort of answered it in the positive--it would be the
negative. What would a drastic cut in Medicaid specifically
mean for those enrollees receiving the care that you have
outlined?
Mr. Botticelli. I think it would be devastating, and I
don't think I am overexaggerating kind of the impact that that
would have for our patients' ability to access care. I think it
is very hard.
And I was actually the Director of Treatment Services in
Massachusetts prior to healthcare reform and prior to Medicaid.
So, I saw the issues that people had not only in terms of their
ability to access care, but also some of the devastating
consequences that we see.
I think Massachusetts is a good example of being able to
achieve some modest reduction in overdose deaths, unlike many,
many states across the country. And I think part of the reason
that we are able to do that is because of our patients'
abilities to be able to access treatment when they need it.
Ms. Schakowsky. So, you are saying ``modest''. Why isn't it
robust, for example, in lives that are saved?
Mr. Botticelli. Well, if you are one of the 10 percent of
people that your life was saved in Massachusetts, that is
robust. I think why I am kind of cautious is because deaths are
still too high. Again, I think while we are all cautiously
optimistic that a 10 percent reduction is good----
Ms. Schakowsky. It is good.
Mr. Botticelli [continuing]. It is moving in the right
direction, it is still way too high. And we still had over
2,000 people in Massachusetts die in 2017, and that is just way
too high, despite a 10 percent decrease.
Ms. Schakowsky. I am just going to skip to, what services
can health homes provide for those with substance use disorder?
Mr. Botticelli. Actually, Mr. Douglas mentioned one.
Vermont is a really great example of how you use health homes
to not only increase access to treatment, but increase access
in rural parts of the country. So, they use what is called a
hub-and-spoke model where they induct people in the hubs and,
then, move people to primary care sites in the spokes. And I
don't know the latest data, but they have been able to really
significantly increase access to treatment. I think Rhode
Island as well has utilized the health home model to
dramatically increase access to treatment. So, I think a number
of states have used this, but I also think it is really
important, as we think about how do you push out treatment to
rural parts of the country that don't have a treatment program
and don't have providers. I think medical homes, some States
have really implemented innovative programs to be able to do
that.
Ms. Schakowsky. So, I am out of time. Mr. Douglas, so
Vermont is an example of how it can work?
Mr. Douglas. That is correct, and it is spreading to other
States. California, too, is doing it. It is an investment, and
this is an important piece. The resource shortage can't just be
dealt with on substance use providers. We need to spread the
best practices back into the physical health and the primary
care, knowing that the expertise would be in the substance use
treatment centers, but this hub-and-spoke, this idea of working
together and providing the expertise and creating the
incentives to do that through health homes and ways to share.
And telehealth and other opportunities are great ways that we
can better integrate the systems.
Mr. Burgess. So, the short answer was yes.
Ms. Schakowsky. Thank you.
Mr. Burgess. The gentlelady's time has expired.
The Chair recognizes the Vice Chair of the subcommittee,
Mr. Guthrie, 5 minutes for questions.
Mr. Guthrie. Thank you very much. I appreciate it very
much.
These questions are for Mr. Srivastava. Johns Hopkins
University and the Clinton Health Foundation released a
document in 2017 that contained a number of recommendations for
combating the opioid crisis. One recommendation was to support
restricted recipient programs, otherwise known as lock-in
programs, for at-risk populations. From what I understand,
lock-in programs are designed to restrict overutilization of
opioids and to identify potential fraud and abuse of controlled
substances.
Mr. Srivastava, can you talk about if your organization has
been involved in a lock-in program and if you have found the
program to be useful in combating opioid abuse?
Mr. Srivastava. Thank you, Congressman.
In terms of lock-in programs, we actually support over 100
health plans across the country and serve their Medicaid and
commercial and Medicare needs. So, we have experience working
with Medicaid lock-in across the country. We also have our own
special needs plans in Florida, Massachusetts, New York, and
Virginia.
Our experience has been in our special needs plans where
within Medicaid we have had the ability to lock in on
prescribers where there was a lot of overutilization. There was
multiple providers as well as multiple use within a period of
time.
Today what we are finding is State by State there is
different criteria. So, for example, in Florida, you have to
have three prescriptions, three providers, and three different
settings, and claims within the last 180 days. But we found
that lock-in allows for, one, an integrated care plan to be
developed for the individual. Two, it eliminates a lot of drug-
seeking behavior. And then, three, it allows for transition
beyond managing the pills themselves, but actually helping the
individual to get support cycle social support services and
treatment and recovery services afterwards.
So, we are finding that there has been good evidence that
lock-in programs work in Medicaid. It will be launched, I
believe, in 2019 for Medicare as well. And so, general
expectation is you will see a broader user of that program.
Mr. Guthrie. OK. Thank you. And I have another question for
you. Some have expressed concern with going to the HIPAA
standard for substance abuse/use disorder records for the
purposes of treatment, payment, and healthcare operations
because they are afraid the record will get into the wrong
hands and they will be fired from their job.
Can you tell me what are the activities that fall under
these three categories, so we have a better understanding of
why it is so important to have access to a patient's record for
treatment, payment, and healthcare operations?
Mr. Srivastava. So, confidentiality is critical and
important. And this kind of speaks to CFR 42 Part 2.
Historically, all of how providers communicate and coordinate
with health plans and with facilities to coordinate care has
been to get a release under HIPAA to be able to maintain
confidentiality to provide care.
And what is happening is we have stigmatized those
individuals with substance use disorder and created CFR 42 as
an added layer of protection. It has actually limited a
provider's ability to actually coordinate care effectively.
And so, our recommendation is to think through and expand
and modernize CFR to be regulated under HIPAA, which is
confidentiality. But that, if an individual happens to have
diabetes and has a substance abuse issue that they are seeking
care from a provider, and then, they go to an outpatient
setting or they go for treatment and recovery services, or they
go to a dentist, that we are not having to, as a health plan be
able to, or as a PCP be able to get permission from each
individual provider to be able to coordinate the care.
At times, we don't know that that occurs. And so, as a
result, there can be misuse, and as a result, can also be
adverse outcomes.
Mr. Guthrie. So, if you use that information, what prevents
an employer from having access to it?
Mr. Srivastava. Under HIPAA guidelines today, we are
managing, as a health plan or as a provider, we are
confidentially treating individuals who have cancer,
individuals who might have AIDS/HIV, or any sort of kind of
behavioral health SMI disorder, and we don't communicate that
with the employers. So, we are kind of bound by HIPAA. We are
also bound additively by CFR 42. So, from our perspective, it
is confidentiality, and we are kind of trained as healthcare
professionals not to be able to share that information beyond
what is needed for a treatment plan and to be able to service
the provider.
Mr. Guthrie. OK. Thank you. I thank you for your answers.
And I yield back my time.
Mr. Burgess. The Chair thanks the gentleman. The gentleman
yields back.
The Chair recognizes the gentleman from New York, Mr.
Engel, 5 minutes for your questions, please.
Mr. Engel. Thank you, Mr. Chairman, for holding another
hearing on this important topic.
In Westchester County, part of which is in my district, 124
people died due to opioids in 2016, and in the Bronx, New York,
which is part of my district, more in New York have died of
overdoses than in any other borough of New York City.
We must do more to turn the tide of the opioid epidemic,
and we cannot hope to do that if we fail to recognize the
importance of Medicaid. Medicaid covers nearly 4 in 10 non-
elderly Americans grappled with an opioid addiction. Through
the Medicaid expansion under the Affordable Care Act, states
were afforded new resources to cover Americans living with
substance use disorders and get them the treatment they need.
We must continue to expand States' capacity to combat the
opioid crisis and take care to avoid hamstringing that capacity
in any way.
This brings me to a number of bills we are considering
today that I fear could hinder States' ability to address this
crisis, the Medicaid Pharmacy Home Act, the Medicaid Drug
Improvement Act, and the Medicaid Partnership Act. I worry that
asking States to make complicated changes to their Medicaid
programs in less than a year sets them up for failure. And
since non-compliant States would be punished with FMAP
penalties, States' ability to deliver treatment and recovery
services could be hampered as a result.
I also have concerns regarding the Medicaid Graduate
Medical Education Transparency Act. In my opinion, the
reporting required under this bill is overly prescriptive and
burdensome and may take the limited resources states have for
Medicaid GME and offer reporting that will not tell us very
much. And I have heard similar concerns from stakeholders as
well. After all, Medicaid spending constitutes just 16 percent
of Federal spending on GME. So, this reporting would offer an
extremely narrow picture of the training physicians are
getting.
I also worry that the information gleaned from these
reporting requirements could be viewed as a microcosm for State
Medicaid programs' holistic efforts to combat the opioid
crisis, but it is my understanding that those efforts involve
many facets of the healthcare system, not just physician
training.
So, Mr. Douglas, I want to ask you, is that a fair
assessment, that the efforts involve many facets of the
healthcare system, not just physician training, and that
information gleaned from these reporting requirements could be
viewed as a microcosm for State Medicaid programs' holistic
efforts to combat the opioid crisis?
Mr. Douglas. I am sorry, the question?
Mr. Engel. OK. Let me move on. I am not opposed to
collecting more data on Medicaid GME or other GME programs.
However, I think we need to be more thoughtful about the data
we are asking states to collect when facing a shortage of
providers, of said providers. But I don't believe this bill
would address that, and solving the problem cannot be left
solely to a group of specialists with specific training in
substance use and addiction. A more comprehensive approach is
needed. We need to be thinking about the full spectrum of
providers and their roles in solving this crisis.
Mr. Douglas, let me try again. How can we improve and build
our workforce so that said providers and others can help end
this epidemic?
Mr. Engel. Great. As I noted in my written testimony, as
well as the chairman mentioned, I think an important area we
are focusing, as a managed care organization at Centene as well
as States, is around ways to make sure that we are educating
providers and disseminating that education. Project ECHO is a
great way of doing telementoring opportunities and really
spreading, especially as it gets to rural and underserved
areas. So, we have to focus both from making sure we are
educating on the prevention side, but, then, as you noted,
there has to be a continuum of service as the treatment
modalities. From the lens of MACPAC that we have seen
identified, there is a wide disparity, that you might have in
Boston a larger rate of treatment modalities, but in many
States the modalities aren't all there. And so, the continuum
of services on the treatment side from both outpatient to peer
support, to MAT-related services, and, of course, as I
mentioned before, there needs to be residential, where
appropriate, on the evidence-based, and that means eliminating
the IMD exception. So, those are all approaches that need to be
taken.
Mr. Engel. Thank you.
Let me quickly go to Mr. Botticelli, based on some of the
comments that were made before I gave my question. Do you have
any concerns about rolling back 42 CFR Part 2?
Mr. Botticelli. I do, both as a policymaker and a person in
long-term recovery. Unfortunately, substance use disorders are
different from other diseases. They are still highly
stigmatized. They are subject to discrimination and criminal
penalties.
SAMHSA, I think--and this is fully supporting the fact to
give people good care, we need to integrate physical care with
part of their substance use disorder treatment. I think all of
us support better integrated and holistic care. But I do think
a patient should have a right to consent to disclose their
records. The Substance Abuse and Mental Health Services
Administration actually just modified their regulations twice
to support enhanced integration of 42 CFR Part 2 information,
treatment information, into primary care records.
Mr. Engel. Thank you.
Thank you, Mr. Chairman.
Mr. Burgess. The Chair thanks the gentleman. The gentleman
yields back.
The Chair recognizes the gentleman from Illinois, 5 minutes
for your questions, please, Mr. Shimkus.
Mr. Shimkus. Thank you, Mr. Chairman.
Great to have you all here.
Mr. Botticelli, you were with the previous administration,
were you not?
Mr. Botticelli. I was.
Mr. Shimkus. And what was that position again?
Mr. Botticelli. I was the Director of the White House
Office of National Drug Control Policy.
Mr. Shimkus. Yes, great. Thank you for your service. And to
segue now into what you do in Massachusetts, I think it is
important. And this is an all-hands-on-deck process. Obviously,
we are trying to do our best to affect the public policy and to
help you all do your job.
But let me go to, in your testimony you mentioned one
report which found only about half of the State Medicaid
programs currently cover non-pharmacological alternatives to
pain such as, as you have talked about, cognitive behavior
therapy and physical therapy. Mr. Douglas, the Committee has
heard from Medicaid directors about the importance of Federal
funding for evaluation of non-pharmacological alternatives to
build strong empirical basis for making coverage decisions.
Could you both please talk about the degree to which you
think this research about the utility and cost-effectiveness of
non-opioid alternatives already exists and what more Congress
or CMS can do to help state Medicaid programs have the
information needed in making coverage decisions that ultimately
impact patients?
Mr. Botticelli. Great. I will start and, then, turn to Mr.
Douglas.
Throughout the course of our work area, I think we have to
be very careful, while we know we want to make sure that we are
diminishing opioid prescribing, that we are giving patients
access to really good pain management therapies. I think we are
hearing more and more stories, quite honestly, of patients in
legitimate pain not being able to access non-pharmacologic
approaches. And so, I think we have to couple our efforts with
not only opioid reducing, but making sure that we are giving
people good access. We do have a number of evidence- based--and
we need to continue to research non-pharmacologic approaches.
We know acupuncture works. We know physical therapy works,
yoga, exercise.
And so, again, I think if you talk to our clinicians at
Boston Medical Center who deal with both substance use disorder
and pain, that because our Medicaid program actually supports a
wide variety of non-pharmacologic approaches, we are able to
give patients good pain care and at the same reduce opioid
prescribing.
Mr. Shimkus. Mr. Douglas?
Mr. Douglas. Yes, I would just echo the points of Mr.
Botticelli that there needs to be more work on this. Both from
a state as well as an MCO perspective, we are continuing to
want to ensure that we are doing evidence-based practices on
treatment modalities. And that gets to being able both from a
state policymaker to be able to give the Medicaid agencies the
ability to test new treatment modalities or ensure that those
modalities are being executed on. And so, without the evidence,
you have disparity across States as well as you have a harder
time for MCOs to get the best practices and the right care and
the right setting to be provided. And so, we encourage there
continue to be work in this area.
Mr. Shimkus. Yes. So, I will ask you to take this back and
maybe submit some more information. And I appreciate that, but
the question is, what more can we do legislatively or what can
CMS do to help fill this space to give the information needed
to help?
So, my follow-up question is going to be, one of the most
dangerous things about opioids is that they are cheap or at
least much cheaper than non-opioid alternatives, some. And your
testimony and Mr. Botticelli also underscores the need to
complement the largely successful efforts to reduce opioid
prescribing. We need to ensure patients have access to non-
pharmacological pain management practices. To that end, several
of us on this committee have expressed concerns about the
declining Medicare reimbursements for certain pain management
procedures frequently performed by the ambulatory surgical
centers because they are more expensive.
Can you talk about the importance of incentivizing non-
opioid, non-pharmacological treatments and stemming the tide of
opioid addiction, particularly as it relates to patients'
access, Mr. Botticelli? And then, I want to go to Mr. Kravitz
to answer this.
Mr. Botticelli. I think part of the reason that we are in
the predicament that we are in is that writing a prescription
for opioids is not only far cheaper, but it is also far easier
for the clinician to be able to write a prescription versus
having a conversation with their patient on pain and pain
expectations and pain management.
So, I think both CMS and Medicare need to do everything
that they can, quite honestly, to provide financial incentives
that drive toward those other kind of pain management
therapies. While there might be some modest cost increases in
the short term in terms of those strategies, I think the return
on investment of not getting people addicted and not having to
go through all the other medical expenses probably far
outweighs any modest increase in cost for those therapies.
Mr. Shimkus. Thank you.
And, Mr. Chairman, can Mr. Kravitz answer that?
Mr. Kravitz. Yes. So, at Geisinger Health System, we are
very much in a consultative measure with our patients as well
on the same topic. We take the time to counsel them and to look
at all other alternatives for treatment for these patients. So,
especially chronic disease patients, as I stated in my opening
statement, we utilize things like rehabilitation, Tai Chi,
yoga, things of that nature, to alleviate pain. And they have
been proven to be successful.
In cases where they are not the case, where opioids do have
to be prescribed, we are very careful and judicious to not
extend an extensive prescription quantity for those patients.
So, they don't have the opportunity to get addicted to opioids.
Mr. Shimkus. Thank you very much.
Thank you, Mr. Chairman.
Mr. Burgess. The Chair thanks the gentleman. The gentleman
yields back.
The Chair recognizes the gentlelady from California, Ms.
Matsui, 5 minutes for your questions, please.
Ms. Matsui. Thank you, Mr. Chairman.
And I want to thank the witnesses for being here today.
I also want to say, Mr. Chairman, thank you for holding
this third hearing today on legislation to address this opioid
epidemic. It is so important that we are focusing on a variety
of perspectives on how to solve this crisis. We know the
problem is multifaceted and the solution will be, too.
And I just want to also point out the importance of the
Medicaid program in addressing this crisis. Medicaid serves a
large proportion of the population with substance use disorder,
and any effort to cut the program's funding will severely
jeopardize access to those services.
I also must say, while we must act urgently, I am concerned
that, if we move the nearly 70 bills through our committee too
quickly, some of the policies will have unintended consequences
that will contribute to the problem rather than the solution.
And I look forward to further discussions with my colleagues
and stakeholders as we ensure that these policies are going to
be as effective as possible.
I think that the biggest potential for transforming our
healthcare system lies in the power of technology. Electronic
health records have the potential to streamline care, increase
coordination of care across providers, and aggregate data for
population health management and research purposes. Telehealth
provides the opportunity to get care to patients faster or in
cases where they can't otherwise have the access to the
appropriate provider.
This has a huge potential to help us address the opioid
epidemic. Technology can help us to integrate the behavioral
health care and physical health care, treating a person as a
whole and ensuring that all of their needs are met in a timely
manner. Most people with a substance use disorder have an
underlying mental health issue and/or physical condition. If
all conditions are not addressed, we will have less success in
treating the addiction.
One of the ideas I am working on with Representatives
Mullin and Blumenauer is how we can assure that substance use
information can be shared for the purposes of care coordination
and patient safety without infringing on patient privacy
rights. None of that work will have any effect, though, if
substance use and behavioral health providers don't even have
electronic health records to facilitate the data sharing.
That is why I co-lead H.R. 3331 with my colleague on the
Ways and Means Committee, Representative Jenkins. Behavioral
health providers were left out of the Meaningful Use Program
which encouraged adoption of electronic health records by
hospitals and doctors. This would certainly extend an incentive
to behavioral health providers via a demonstration project.
Mr. Kravitz, my understanding is that your organization has
been successful as a result of investing in electronic health
records. Could you please describe how electronic health
records have improved quality of care and reduced cost?
Mr. Kravitz. Yes, I am happy to, Congresswoman. So, we have
invested in electronic health records back in 1995. I think we
were one of the earlier adopters of the EPIC electronic health
record system, which has been predominantly used between EPIC
and Cerner across the country with all scripts.
We have also invested heavily in analytics. In fact, we
have a big data platform similar to Google, and we look at that
data all the time. We analyze the data very carefully. In fact,
one of our scenarios, we did a 10-year study with Geisinger
Health Plan, which has 580,000 members in our population. We
looked at that data very, very carefully, and that is where we
recognized and realized that patients on opioids that were part
of that process had higher levels of acute care stays before
they had overdoses as well as ED visits were tremendously
increased over the last 22 to 12 months prior to an overdose
occurring.
So, information is key. The ability to integrate that data
and interoperate that data with other systems is extremely
important.
Ms. Matsui. So, you believe that this will be helpful to
extend this to behavioral health providers?
Mr. Kravitz. Absolutely.
Ms. Matsui. OK, great.
Mr. Kravitz. Absolutely.
Ms. Matsui. Well, let me just right now, also, submit for
the record here a letter from the Behavioral Health IT
Coalition, which includes the American Psychological Academy,
NAMI, Mental Health America, the National Council of Behavioral
Health, in support of H.R. 3331, for the record.
Mr. Burgess. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Ms. Matsui. I also want, Mr. Douglas, thank you for your
past service as a Medicaid director.
I currently have another bill coauthored with my colleague,
Representative Harper, that will allow behavioral health
clinics to register with the DEA to be able to use telemedicine
to prescribe controlled substances, increasing access to
medication-assisted treatments in our communities.
Can you describe the benefits of medication-assisted
treatment and detail the current barriers you see that might
prevent its expansion?
Mr. Douglas. Thank you.
So, as I mentioned in my written testimony, the expansion
of medication-assisted treatment is a really important
component of the overall continuum, especially as we learn and
have substance use treatment providers working with primary
care. As you said, being able to create more technology
interfaces will be an important way to work across this idea of
a hub-and-spoke with our primary care and sharing data back and
forth. And so, as we are looking at more a holistic approach to
medication-assisted treatment and primary care integrating with
it, what you are laying out would really solidify and improve
the infrastructure.
Ms. Matsui. OK. Thank you.
And I have run out of time. I yield back.
Mr. Burgess. The Chair thanks the gentlelady. The
gentlelady yields back.
The Chair recognizes the gentleman from Texas, Mr. Barton,
5 minutes for your questions, please.
Mr. Barton. Thank you, Mr. Chair.
I have a question for the chairman before I ask a question
of----
Mr. Burgess. The answer is no.
[Laughter.]
Mr. Barton. I was going to say, did you think you are the
greatest Health Subcommittee chairman we have ever had?
[Laughter.]
Mr. Burgess. No, that would be Governor Deal.
Mr. Barton. We have got about three dozen bills that we are
looking at. Is it your plan to move all of these bills
individually, collectively, some of them, none of them? What is
the----
Mr. Burgess. Well, as you will recall from my opening
statement yesterday and previous opening statements in previous
hearings that we have had--I am assuming the gentleman is
yielding to me for an answer.
Mr. Barton. Yes, sir, of course. I wouldn't ask a question
if I didn't want you to answer it.
Mr. Burgess. I don't have a precise answer to your
question, but the fact that we are considering so many bills,
and some of the bills we are considering are, in fact, still in
draft form, we do want to be inclusive. We have done a
significant amount of outreach. As you will recall, we had a
many-hour hearing in this subcommittee in October where we
invited every Member, not just from the committee and
subcommittee, but from the entire Congress to come and share
with us their thoughts on what the opioid epidemic looked like
in their districts and how they were reacting to it, and ideas
that they had. As a consequence of that interaction, a number
of ideas were presented to the subcommittee, and we have been
over the last several months going through those. Right now,
most of them are in individual bill forms. It is quite likely
there is some duplication; there is some consolidation that is
available.
And as you will recall from bills like the Comprehensive
Addiction Recovery Act from the last Congress, the Cures for
the 21st Century, ultimately, numerous bills were consolidated
into one larger bill. That could still happen, but also a part
of me wants to consider them as individual bills. So that, as
we go through at least the subcommittee markup and the full
committee markup, there will be ample opportunity for people's
ideas to be heard.
Mr. Barton. OK.
Mr. Burgess. I hope that satisfies your request for
information. And I will yield back.
Mr. Barton. Well, you used half of my time. Well, I think
it is important to give the subcommittee and the stakeholders
some idea of the potential plan. And I wasn't here yesterday. I
was at the Zuckerberg hearing on Facebook. So, I am just asking
for my own illumination.
One of the bills is a bill by Mr. Tonko, H.R. 4005. He has
actually introduced it. He is ahead of the curve here, which is
kind of normal for him. He is one of our more energetic
Members.
But this particular bill, I wish he wasn't so energetic,
actually, because it allows Medicaid programs to receive
matching Federal dollars for medical services to an
incarcerated individual, which in Texas means somebody in jail
for the 30-day period right before they are released. I have a
real concern about that for a number of reasons.
So, I am going to ask Mr. Douglas if, under current law,
the states couldn't ask CMS to use their 1115 waiver for a
demonstration project to test this idea, instead of actually
passing a federal statute.
Mr. Douglas. So, current Federal law prohibits payment,
Medicaid payment, for individuals who are in prison, except for
the one exception relates to for inpatient settings when they
leave the actual prison facility and go to an inpatient
setting. And that is clear in Federal law. So, even under an
1115 waiver, that could not occur.
Now, that being said, there are creative alternatives.
Centene, as a managed care plan, are working in Ohio, for
example. Ohio is very concerned, given recidivism. The high
rate of individuals within the prison system, as they
transition, have needs of social services, medical care,
behavioral health, to do early transition work as a
responsibility, knowing that they are going to be assigned to a
managed care plan, and the managed care plan is going to have
increased costs if they don't work in the transition. And so,
that is occurring right now in states. And other states are
doing that. There are different creative approaches, but there
is no ability from a payment standpoint right now under Federal
law.
Mr. Barton. OK. Well, thank you for that answer.
In my one second that I don't have, I want Mr. Kravitz to
talk about e-prescribing and if he thought that could help in
some other areas, in addition to what has been done under his
business.
And I am only asking this question because the chairman
took two-and-a-half minutes of my time.
[Laughter.]
Mr. Kravitz. So, we feel at Geisinger e-prescribing is very
valuable to our organization. It is very much a patient or
customer satisfier as well compared to the old process of a
paper script that oftentimes was not available to them and
would cause multiple visits to come back to a physician's
office and able to get those.
What I can tell you is use of e-prescribing is very much
endorsed by our physicians. The second-factor authentication is
seamless, works very well. And that is why we are able to
reduce the amount of time for prescribing an opioid
prescription from 3 minutes to 30 seconds, because of the new
process that we followed.
What I can also tell you is the first day--and we,
typically, at Geisinger don't do things small, unfortunately--
we did not do a proof-of-concept with a small group of
physicians. We hit 1330 physicians day one to enroll them in
the program, and we have other physicians that are requesting
to be part of this process because it is so efficient and it
has worked so well for them.
The other point that I made about the PDMP, we are
clamoring to get the APIs or the integration points, so that we
can do a lot more automation behind the scenes and not obstruct
the workflow process or the physicians, so they could see more
patients, to provide better quality care for more patients.
That will be coming in the next 3 months, and we are very eager
to have that happen, so that we can encourage that be part of
the process.
Mr. Barton. Thank you.
Thank you, Mr. Chairman, for your courtesy.
Mr. Burgess. The Chair thanks the gentleman.
The Chair recognizes the gentleman from Massachusetts, Mr.
Kennedy, 5 minutes for questions, please.
Mr. Kennedy. Thank you, Mr. Chairman. Thank you for
continuing the hearing.
Thank you to our witnesses for being here.
Mr. Botticelli, wonderful to be with you again. Thank you
for your service and your outspokenness on these incredibly
important issues.
I know we are here on a series of several dozen bills that
are before this committee, which I hope many of them will see
action, including, Mr. Chairman, our own. Thank you for putting
that on the list.
I wanted to get your thoughts and members' of the panel
thoughts on some of the broader priorities of this
administration, recognizing that the administration has
acknowledged that there is an opioid and behavioral health
epidemic across this country. They have indicated that they
want to prioritize it. Yet, we have also some policies come out
of this White House that I was curious to get your thoughts on.
I did have a chance to question our CMS witness yesterday. So,
maybe just going right down the list.
And, Mr. Botticelli, I was wondering, given your expertise
on this issue, can you explain to me how cutting Medicaid by
$800 billion, as the Trump administration budget does, is
effective in addressing behavioral health and addiction?
Mr. Botticelli. First of all, thank you, Congressman, for
the question and for your leadership not only here, but in
Massachusetts.
I think we have broadly acknowledged that this is a public
health crisis that we have and we have got to focus these
issues largely on health responses to this issue. Tantamount to
that response is making sure that people have adequate access
to insurance and coverage. And when you ask historic data, when
you look at why people can't get treatment, the No. 1 reason
why people can't get treatment is because they don't have
adequate access to insurance.
Mr. Kennedy. And so, does cutting $800 billion from
Medicaid help or hurt?
Mr. Botticelli. It hurts, and it hurts dramatically.
Mr. Kennedy. And I am sorry to cut you off; I just want to
get everybody else on the record.
Mr. Douglas, how would you respond to that? And be quick,
just because I have got a couple of more of these.
Mr. Douglas. Yes. No, I am going to turn this around. As
you know, as a former Medicaid director and as a managed care,
our responsibility is how to use the resources most effectively
as possible. And so, the idea of cutting $800 billion, there
are ways to achieve savings, but it has to be rational.
Mr. Kennedy. So, does a $800 billion cut help or hurt an
administration's ability to----
Mr. Douglas. I can't answer without understanding what the
flexibilities and the ability to provide the right services and
the right setting.
Mr. Kennedy. And, Mr. Guth?
Mr. Guth. Yes, so this is a complex situation we are
dealing with. This really goes back to the first question we
had before this panel. And that is about the disparity in
presentation with Medicaid and with private insurance. For a
long time, people with private insurance didn't have access to
substance use treatment, or very limited access. Most of the
people I know that went through private insurance with these
issues ended up spending college funds and retirement funds, in
order to get care.
Mr. Kennedy. So, Mr. Guth, would you support greater
enforcement of mental health parity?
Mr. Guth. I think we have got to do everything we can right
now, Congressman, to ensure that people have access to care.
And for the majority of Americans, that means access through
some form of third-party coverage, and for many of them, that
means either Medicaid or some other form of Federal funding.
Mr. Kennedy. Mr. Kravitz?
Mr. Kravitz. I would say at Geisinger Health System we
treat all patients equally. Eighteen percent of our patient
population in our provider network are medical assistance
patients; 44 percent are Medicare. We have a number of
programs, and there are care management programs that address
this. It would be my impression that it would hurt.
Mr. Kennedy. Sir?
Mr. Srivastava. From Magellan's perspective, we
fundamentally believe that health care needs to be not just
below the neck, but above the neck. And so, it is a full whole
patient approach. And so, to the extent we have adequacy of
funding, to be able to have behavioral health, improve access
for behavioral and physical health issues, then we are a
proponent of that.
Mr. Kennedy. I have got about a minute and a half left and
two more issues I want to address with the panel. So, Mr.
Botticelli, I will address them both to you, and just go down
the line.
Given your expertise, how long does it take for somebody to
recover from a mental/behavioral illness?
Mr. Botticelli. So, this is a chronic disorder, and one
could argue that it is a lifelong issue. The biggest predictor
of success is duration and time in treatment.
Mr. Kennedy. And so, two policies put forth by this
administration, lifetime caps and work requirements, if you
think work requirements could, in fact, be helpful to people
suffering from mental/behavioral illness, I would ask anybody
on the panel to point me to one single study that says so. So,
your opinion on those two, lifetime caps and work requirements,
coming from this administration?
Mr. Botticelli. So, lifetime caps seem to me to be a
violation of parity because I think that we understand that
that has been a historic discriminatory tool that insurance
companies have implemented to not treat this as a chronic
disease and give people long-term care.
Mr. Kennedy. OK. And work requirements?
Mr. Botticelli. So, one, we know people on Medicaid
generally now are working, and often working more than one job.
And I think the ultimate goal of treatment, quite honestly, is
to get people and restore them.
Mr. Kennedy. Is there any study that you are aware of that
says a work requirement increases health, understanding that
people who are working can be healthier, but that causation
goes the other direction?
Mr. Botticelli. I have nothing.
Mr. Kennedy. Mr. Douglas?
Mr. Douglas. I don't know of studies on that. What I say is
that this gets to the issue of underlying social determinants
and making sure from States, as well as Medicaid organizations,
Medicaid managed care plans, that we are working on how to
engage people into ensuring they are getting both the right
social and getting back into the workforce.
Mr. Kennedy. Mr. Guth?
Mr. Guth. Yes. So, we were working with two of our States
that have these, are implementing work requirements, and the
devil is in the detail because what you don't want to do is
insist that somebody who is very, very sick get a job before
they can have access to treatment. On the other hand, the plans
that we are working with in the two States that we work with,
Indiana and Kentucky, we are seeing administration--
understanding that and making sure that we are not asking
people who are actively sick to become employed before they
become stable. So, I think it is all about the implementation.
Mr. Kennedy. The CMS witness yesterday said they are trying
to put patients before paperwork. Is there a work requirement
initiative out there that does, in fact, lead to less
administrative burden for somebody that is suffering from
mental/behavioral illness to make sure that they stay on
Medicaid?
Mr. Guth. Can you ask that question again?
Mr. Douglas. What I would say is that what we are seeing in
Indiana as well as in Arkansas, there are exceptions for
certain populations such as those with substance use disorders.
Mr. Kennedy. I am about a minute over time. Thank you for
your generosity, Mr. Chairman.
Mr. Burgess. That is all right. I have subtracted it from
Mr. Latta's time.
Mr. Green. Mr. Chairman, I ask unanimous consent----
Mr. Burgess. Oh, I beg your pardon. Does the gentleman have
a unanimous consent request?
Mr. Green. The gentleman does. I ask unanimous consent that
a letter from the telehealth and technology stakeholders and a
letter from treatment providers in support of the access to
telehealth services for their opioid and use disorders, I ask
unanimous consent to place it in the record.
Mr. Burgess. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Burgess. The gentleman from Ohio is recognized for 5
minutes for your questions, please, Mr. Latta.
Mr. Latta. Thank you very much, Mr. Chairman. And thanks
again for holding this hearing today, because, again, combating
this opioid epidemic is something we are all in and we have to
do, because we are looking at these very sobering statistics
that 115 Americans are dying every day in the State of Ohio.
And I hate to keep repeating these statistics, but in 2015 we
lost 3,050 people. In 2016, that number went up to 4,050. And
then, the fiscal year ending at June 30th of last year, it was
5,232. So, it is an epidemic that we have got to take on and
fight.
And I appreciate you all being here today.
Last week I held a roundtable in my district with local
pharmacists to discuss the opioid crisis in Ohio. Most of the
pharmacists agreed that prescription limits would help prevent
addiction. Overprescribing of opioids for acute episodes of
care can have dire consequences as pills can be diverted,
misused, and perpetuate addiction.
In response to this problem, over 20 States, including
Ohio, have adopted laws limiting the number of pills that a
patient new to therapy prescribed an opioid for an acute
episode can receive. These laws reflect guidelines promulgated
by CDC which note that, for the vast majority of acute
procedures, 3 to 7 days' worth of therapy is sufficient. They
also respect the judgment of the prescribing practitioner by
providing for exceptions if a prescriber thinks in his or her
best judgment that a longer duration of treatment is medically
necessary.
Furthermore, we recently saw CMS finalize a similar policy
for beneficiaries and wrote in Medicare Part D, driving home
the severity of the problem and the belief that such rules will
have a measured impact on opioid diversion and misuse.
Mr. Douglas, what impact would expanding this type of
policy beyond Medicare have on the diversion and misuse of
opioids?
Mr. Douglas. As I noted in my written testimony as well as
earlier, we are doing a lot within Centene, as well as a lot of
States are working on making sure that we are reducing the
limits on duration as well as refills. And so, creating clear
policies on that, where we have been able to do that and work
with the State, it helps on overprescribing as well as reduced
inappropriate utilization. And so, this is an important area
that we are seeing. In many States we can work and partner with
our State agencies and be able to put in place those types of
utilization controls. But incenting States and incenting
managed care organizations, that is an important part of the
overall continuum of how we need to prevent this epidemic.
Mr. Latta. Thank you.
Mr. Guth, my district ranges from densely populated cities
and towns to very rural areas. And we all know that the opioid
epidemic knows no boundaries. Therefore, health access in rural
America is vital, especially as it relates to the opioid
epidemic. It is hard enough for individuals to make the
decision to overcome addiction without the added barriers to
access to treatment due to their location.
Would you go into some detail about the barriers are out
there for opioid treatment for individuals in rural communities
and what they face, and how we have to address those issues?
Mr. Guth. Thank you. Yes, Congressman. There are several
issues that jump out. One is that we have a shortage nationwide
of professionals who are certified and trained in addiction
services. So, that permeates the whole country, and it is most
acutely felt in our rural areas.
Centerstone, most of the communities we serve are very
small rural communities across the five states that we serve.
So, we are very attuned to this issue.
Telemedicine can make a huge difference. There are current
challenges with telemedicine, but we have been involved with
telemedicine services since the early '90s. And we would wheel
in these great big, giant monitors on these enormous carts.
That was really to address the issue of access to care in our
rural areas. In many cases it was the first time we could get a
child psychiatrist into some of these communities. The very
first time.
So, this issue is true with opioid use as well. We have to
be able to provide expert care into our rural communities, but
we have to address the overall shortage of practitioners
nationwide in order to do that.
The other is we have to also recognize that there are other
specialists involved in this care that are very important. Mr.
Douglas mentioned peer support services. Those are critical,
and we find that those services, if we can get them funded,
which is very spotty, if we can get those services funded, we
can provide some really vital linkages in our rural
communities. We generally can have access to those individuals.
So, telemedicine, we are using apps right now to help
people be connected remotely from their service provider. But
when somebody is dealing with an acute psychiatric disorder or
an acute addiction challenge, asking them from a rural
community to drive hours into an urban area to seek service is
really an insurmountable barrier for most of them. And what
they will do is they will end up in the emergency room in a
really critical state.
So, those are all issues that I think we would need to
address. Technology plays a role. Workforce improvements play a
role. And the other is we really do need to be advancing the
use of peer specialists. And we found peer specialists--we have
got the data--peer specialists make a huge difference in the
continuum of care.
Mr. Latta. Thank you very much. Mr. Chairman, my time has
expired and I yield back.
Mr. Burgess. The gentleman is correct, his time has
expired.
Does the gentlelady from Florida wish to be recognized?
Ms. Castor. Yes, sir.
Mr. Burgess. The gentlelady from Florida is recognized, 5
minutes for questions, please.
Ms. Castor. Well, thank you, Mr. Chairman.
And thank you to all the witnesses. I have been monitoring
this hearing from another E&C hearing, and I am heartened by
the discussion and the commitment, particularly relating to
Medicaid and Medicare, and how we have to strengthen and
modernize Medicaid to tackle all these challenges that we face,
particularly opioids.
And I noted some of the discussion, coming from Florida, on
the difference in treatment between expansion States and non-
expansion States. We have hundreds of thousands, if not
millions, of Floridians who really would benefit with
consistent treatment, if we had expanded Medicaid. So, I know
that is going to continue to be an issue.
A lot of these bipartisan bills are very positive, in my
opinion, and I have heard what you have said about a number of
them. But I don't think we are yet at the scale we need to
really tackle the problem. I have heard others talk about a
Ryan White type of commitment, something that is dependable and
consistent moving forward that aren't relying on the budget
battles of the Congress, so that providers and law enforcement,
everyone across the board can really tackle the problem the way
we need to.
Does anyone have a comment on that and about creating more
of a Ryan White type of consistent commitment?
Mr. Kravitz. I will just mention this: I think when we look
at the financial crisis, one of the things that our medical
director points out is that a huge amount of the resources we
are spending, we are spending on people that are returning for
care. They are returning for care because they didn't get
proper care to begin with. And we also look at the cost that we
are spending in emergency rooms and acute care hospitalizations
for folks that have untreated or undertreated substance use
disorders or psychiatric disorders.
And I appreciate the breadth of bills that are before this
committee and the work that everybody here has done on this
crisis. But I think this is a huge call to action for all of
us. And it is not just about doing more of what we are doing.
We have to change.
I want you to think about this. I represent one of the
largest nonprofit providers in this space nationwide, and we
are saying to you we need more regulation in this field; we
need to be held to a higher standard; we need to be accountable
for outcomes, and we also need to be accountable for providing
a full continuum of care, so that people get the care they
need, not the one specialty service that a provider has found a
business model to support.
So, long answer to your question. Absolutely, it should be
a huge call to action. We can't let this epidemic continue to
rage across this country. This is a complex problem. It didn't
happen overnight. You heard the talk today about the different
presentations, why people get into addiction to begin with,
whether it is because of unmanaged pain or because of a co-
occurring psychiatric disorder. There are lots of reasons for
it. This is not a simple solution. But I would say a big focus
needs to be on we have got to quit doing things that don't
work, and also understanding that the investment we make here
will be more than realized with the savings in other areas, not
even just the social impact of these issues, but in the medical
costs in other areas of health care.
Ms. Castor. Thank you.
Mr. Kravitz. I hope that answers your question,
Congressman.
Ms. Castor. Yes, and I have one more question, but if
somebody wants to add quickly--yes, sir?
Mr. Botticelli. For many years I presided over the
treatment system in Massachusetts. I think if you talk to many
providers, while grant funding is great, having a stable
insurance-based program really ensures that we are going to
have--we have been talking about provider workforce here and
how critical it is. So, I think we need to make sure that we
particularly ensure Medicaid coverage for people with substance
use disorders. I think grants are great, but providers, I
think, are often reluctant to get into this business----
Ms. Castor. Yes.
Mr. Botticelli [continuing]. And stay in this business
without a stable insurance base from which to build.
Mr. Douglas. And if I could just say that, from both a
state as well as an MCO, the idea of, well, Ryan White is
really a trusted and needs to be an integrated approach. And
so, looking at this through the lens of not creating a siloed
solution, but how it integrates into the continuum of health
and behavioral health.
Ms. Castor. Yes. Thank you.
Mr. Srivastava, in your testimony you mentioned that the
number of physicians that prescribe MAT pales in comparison to
providers able to prescribe oxycodone. And SAMHSA estimates
over 48,000 providers currently certified to prescribe MAT
versus 900,000 providers prescribing oxycodone. The lack of
providers is undoubtedly more extreme in areas with a high
proportion of Medicaid beneficiaries or in rural areas. How can
we both increase the capacity to prescribe evidence-based
treatment like MAT and realize the benefits? Could you expand
specifically on the key lessons Magellan learned working in
Pennsylvania and how that could be expanded elsewhere?
Mr. Srivastava. Absolutely. So, in Pennsylvania, for
example, we recently launched, in partnership with the
governor, we provide county-based behavioral health services.
And so, we have created 20 centers of excellence which look at
both primary care coupled with behavioral health care in an
integrated fashion, connected by telehealth, and all evidence-
based. And it allows for substance use disorder to be kind of
effectively treated and managed. We also partner with Geisinger
as well on some behavioral health----
Ms. Castor. And you had a specific recommendation on a
temporary FMAP increase?
Mr. Srivastava. Correct. So, roughly, about 900,000 doctors
today are licensed to be able to prescribe. Only 48,000 can
prescribe MAT services. So, there is a need to be able to, one,
educate more providers and, two, to be able to potentially
offer a pay bump, if you will, in order to incent those
providers to take 8 hours out of their day to get certification
and, then, training wrapped around that as well. And so, our
sense is that there should be funding set aside to be able to
drive more certifications, so that providers know how to
prescribe medication-assisted therapy. We would augment that
with tele-behavioral health, digital therapy, text therapy, and
coupled with peer supports and care coordination.
Ms. Castor. Thank you. I will yield back.
Mr. Carter [presiding]. The gentlelady has yielded.
The Chair recognizes the chairman of the Full Committee,
the gentleman from Oregon, the Honorable Mr. Walden.
Mr. Walden. Thank you. Thank you, Mr. Carter. I appreciate
it.
And thanks to all our witnesses. Sorry I wasn't here at the
beginning. We have a concurrent hearing going on with the
Secretary of Energy on energy-related issues before the
Committee. But we really appreciate your participation.
So, I have a couple of questions I wanted to make sure and
get in this morning. I think we all recognize the importance of
ensuring that patients in Medicaid with substance use disorder
have access to a continuum of care. One of the bills before the
Committee is a targeted proposal that would remove a barrier to
care and allow care in an IMD for up to 90 days in a 12-month
period. Now this allows for longer treatment periods for all
beneficiaries, not just selected subpopulations. And we believe
this is budgetarily responsible as well. Virtually every
stakeholder group that I have met with suggests that some of
the IMD exclusions should be repealed or at least recalibrated,
since residential treatment may be needed for some
beneficiaries with substance use disorder.
So, my question for each of you is, do you agree that the
bill before the Committee which offers a partial repeal of IMD
is a helpful step to ensuring that Medicaid beneficiaries
receive the care that they need? So, do you think this makes
sense? We will start with you.
Mr. Botticelli. Chairman Walden, I think while we are
trying to do everything that we can to expand access to
treatment, and particularly looking at Medicaid, I think just
looking at the categorical waivering of IMD requirements, quite
honestly, I think has a potential to exacerbate our problem.
Mr. Walden. Why is that?
Mr. Botticelli. Well, one, I think we want to ensure, and I
think CMS's approach to looking at this issue through the 1115
waiver I think makes a lot of sense. Because what they have
been saying to states is you need to demonstrate to us that you
are not just providing residential and often expensive levels
of care, but that you have a full continuum of care, outpatient
services, medication-assisted treatment.
The other piece, too, and I think we have seen this and we
are all talking about increasing access to medication-assisted
treatment, but the reality is that only about 20 percent of our
programs now provide access to medication-assisted treatment.
And so, I worry that we are, in our efforts and, then, I think
our good intents to expand access to treatment, we are focusing
not necessarily on the most effective treatment needed for
people with substance use disorders----
Mr. Walden. All right.
Mr. Botticelli [continuing]. Which is often outpatient
care.
Mr. Walden. Mr. Douglas?
Mr. Douglas. So, I agree with a lot of what Mr. Botticelli
said, but I would say the waiver process is still cumbersome. I
have gone through it from California, seen it in other States.
The regulation on the managed care side doesn't go far enough.
That being said, so the idea of eliminating the IMD rule on
substance use is very important from an MCO, and States support
it, but it does need to be part of an overall continuum. It
can't be siloed because there are many cases where residential
is not appropriate. We need to ensure that we are using ASAM
evidence criteria and other treatment modalities within that
and creating the right incentives----
Mr. Walden. Right.
Mr. Douglas [continuing]. That there is in a continuum.
Mr. Walden. All right. Mr. Guth?
Mr. Guth. So, I'm just going to reiterate very quickly some
of the same things you have heard. We think it does need to be
expanded. But I think, absolutely, we must have requirements on
continuum of care, accountability around outcome, really
criteria that places people in the right level of care. What we
are all worried about--and I know this is the issue around this
bill--is that, suddenly, we are going to have this plethora of
very expensive care that is now just exploding across the
country.
Mr. Walden. Right.
Mr. Guth. The answer to that is to ensure that when these
expansions are permitted, that they are coupled with
requirements around continuum of care and documented evidence
that people are placed in the least restrictive care
appropriate to their presentation. That is known. We can do
that, but we don't do it in isolation. Like everything else we
have talked about today, these are complex issues. So, we have
to have solutions that have the complexity associated with
them.
Mr. Walden. All right. Thank you.
Mr. Kravitz?
Mr. Kravitz. We are very much affiliated with continuum of
care. And so, we just launched a new program last week, and
it's called Geisinger at Home, where a physician actually goes
into the patient's home. It sounds like old times, but that is
the way it is going in the future. And so, the technician
supports all of that. It is based upon chronic diseased
patients. These are the same types of patients that we will be
treating in the home setting with telemedicine and other
opportunities, as well as documentation and electronic feeds
right into our electronic health record.
Mr. Walden. OK.
Mr. Srivastava. In short, although we have the 1115 waiver
process, supportive of an overall process. However, it is just
one kind of solution in a suite of solutions. So, I don't want
to overprescribe the fact of the value created with this. It
could create capacity, but at a cost that may not be
sustainable.
Mr. Walden. All right. My time has expired again. Thank you
all for your testimony and your answers to that question and
others today.
I yield back.
Mr. Carter. The gentleman yields.
The Chair recognizes the gentleman from Florida, Mr.
Bilirakis, for 5 minutes.
Mr. Bilirakis. Thank you. I appreciate it, Mr. Chairman.
And I wanted to thank Mr. Botticelli for coming down to my
district in the Tampa Bay area when he was the drug czar about
a couple of years ago. It was very informative, the forum we
had. So, I appreciate it very much.
Also, I want to talk about and I want to ask some questions
on the lock-in. I know we have covered it a little bit, but I
have a couple of bills with regard to that. So, I want to start
with Mr. Douglas, if that is OK.
Yesterday CMS talked about the importance of lock-in as a
tool to manage prescription drug abuse in Medicare Advantage
and Medicare Part D. Lock-in is not new and has been used for
years in Medicaid and commercial insurance. Since you run a
Medicaid managed care plan, you might be able to talk about how
lock-in programs operate and what you have seen.
Does your plan run a Medicaid lock-in program and, if so,
can you tell me how you structure the program and what triggers
you are looking for in identifying an at-risk beneficiary,
please? Thank you.
Mr. Douglas. So, yes, as you said, lock-in programs have
been around for a long time, both from a State agency as well
as from managed care programs. And Centene, in our States we
have over 10 States where we do have lock-in programs. We work
in partnership with the Medicaid agency to structure and be
able to create the policies and procedures. There is no, I
would say, one-size-fits-all approach to lock-in programs. In
some States, the lock-in is around the prescriber; in other
cases, it is about lock into a pharmacy. Or, it could be both
prescriber and pharmacy being locked in and having the member
have one prescriber and one pharmacy. So, it varies.
Now there are triggers in terms of the types of
utilization, looking at how, for example, in one criteria I
will go through they are looking at using three or four
pharmacies within a 30-day period. Three or more prescribers
within a 30-day period become triggers, utilizing five or more
controlled substances in a 30-day period, different drug
classes. So, we look at all different types of triggers and
create that policy.
In many cases, the pharmacy board is part of the process,
too, to make sure that they are integrated into the policy
development along with the Medicaid agency. We, then, also,
before we do the lock-in, there are notices sent out to
members, notices sent out to prescribers and the pharmacies.
So, everyone is onboard and understands the new process that is
in place.
We have found this to be very effective. Again, you need to
cast the net appropriately, and that is where having the right
triggers and knowing who that you are bringing into the
program, so you are not inappropriately restricting access to
needed services. But, where done, we have some evidence and
data that has shown that we have been able to bend the cost
curve and be able to still provide the right outcomes in these
lock-in programs.
Mr. Bilirakis. Mr. Srivastava, do you want to elaborate? I
know you answered that question when Mr. Guthrie asked you that
question. But do you want to elaborate as to the triggers?
Mr. Srivastava. Sure.
Mr. Bilirakis. And how do you identify the at-risk
beneficiaries?
Mr. Srivastava. Absolutely. Just to add on what I said
previously, we operate two plans, in Florida and in
Massachusetts today where we have a lock-in place on Medicaid.
And we see kind of expanding that into Medicare Advantage in
2019.
Really, it is a community-based outreach effort to do lock-
in effectively. So, it is engaging with the individual. Each
State has different criteria as it relates to Medicaid. And so,
we are kind of following the State's guidelines and trying to
be coordinated. But it is coordinating with the individual and
coordinating with primary care as well as specialty care. In a
lot of these cases, these are individuals with physical health
as well as comorbid behavioral health issues. And so, as a
result, we are working with community-based mental health
centers as well to be able to have a coordinated approach
towards a lock-in related to a prescriber at a location, so
that we can kind of reduce overuse or misuse of drugs.
But I think another key element is simply making sure that
we have care management wrapped around that, as well as in-home
services, peer supports, and access to tele-behavioral health
and telehealth services as well, to make sure there is a
coordination of care.
Mr. Bilirakis. How effective has the program been?
Mr. Srivastava. So, we have seen it has been effective in
Florida, from our perspective, in your area, and we have been
able to see kind of reduced utilization and stability in terms
of outcomes. So, the recidivism or kind of admissions and
readmissions related to things have gone down.
Mr. Bilirakis. Mr. Douglas, how effective has the program
been?
Mr. Douglas. Again, very effective, that we have seen a
reduction in costs, overutilization, primarily from pharmacy
spend, but also on the medical side as well from inpatient as
well as emergency room. So, when done right, it has been very
effective.
Mr. Bilirakis. OK. Very good.
I will yield back, Mr. Chairman. Appreciate it.
Mr. Carter. The gentleman yields.
The Chair recognizes the gentleman from Indiana, Dr.
Bucshon.
Mr. Bucshon. Thank you, Mr. Chairman.
Mr. Kravitz, prior to becoming a Member of Congress, I was
a cardiovascular and thoracic surgeon. As a physician, I
believe that in order to properly address some part of the
opioid crisis, we need to address the causes, one of which is
how we diagnose and manage chronic pain. From your experience
as a system, what is the most effective way for providers to
engage patients about pain and pain management?
Mr. Kravitz. So, I have a personal situation. My wife today
had a pain management visit due to an injury to her neck.
Mr. Bucshon. Yes, particularly new patients and seniors
also?
Mr. Kravitz. OK. So, she is a new patient, and seniors, the
same way. Our prescribers and our specialty physicians--and I
attended the visit with her to see a neurologist--they take the
opportunity to counsel and discuss, to review what actually the
injury is for that particular patient. Again, firsthand, I saw
where opioids were not even introduced. That was discussed as
not being an option in this case. Other methods with regard to
physical therapy, behavioral therapy, things of that nature, in
this case it is physical therapy, which will begin immediately.
Injections and things like that which are non-opioid type of
medications.
But we take the initiative to work with the patients, the
same as with our Medicaid or Medicare population patients. We
would much prefer not to go down the path of opioids because of
the risk associated with opioids. And so, I think that has been
our process, and I have seen it firsthand.
Mr. Bucshon. The gist of it is it is critical to have the
good evaluation of the causes of pain----
Mr. Kravitz. Absolutely.
Mr. Bucshon [continuing]. And, also, proper counseling with
the patient and family about alternative treatment? I will
speak for the physicians. I am a physician. Historically, I
think maybe we haven't done that as well as a society as maybe
we could have, right?
Mr. Kravitz. I think being part of a physician-led
organization like Geisinger, and known for the innovation that
our physicians lead and our technology supports, that has been
our mantra, so to speak, that that is the direction we want to
go. Is it a perfect organization? No, far from it, but we will
continue to iterate and make it better and tighter as time goes
by.
Mr. Bucshon. Yes, and it is also pretty clear that it is
important for care providers to have a complete understanding
of not only the current pain problem, but their pain history.
CMS testified yesterday and it was mentioned that the way
we look at pain needs to evolve from just treating the pain to
a full conversation about pain management, and I think you
would agree with that.
Mr. Kravitz. Yes, absolutely.
Mr. Bucshon. So, we had that yesterday.
Mr. Srivastava. Congressman, if I could just add?
Mr. Bucshon. Yes.
Mr. Srivastava. Geisinger is a vertically-integrated system
that has complete access to data and a strong delivery model--
we were on a network model. So, we serve about 7.5 million
people today with chronic pain management services where we
partner with health plans and partner with providers.
I think the key there is having strong data and analytics
and offering up alternative therapies, as you outlined. The one
piece that I will just add is that the alternative therapies
wrapped around virtual care delivery is really a first-line
therapy for us. So, how can you manage pain with cognitive-
based therapy? Second, then, with telehealth or tele-behavioral
health as well, text therapy as well, in order to kind of
augment. So, there is a level of that compounded with home care
services that could also alleviate pain beyond just opioid use.
Mr. Bucshon. Yes. And again, for you, Mr. Srivastava, in
your testimony you suggested that any willing provider
requirements are problematic for health plans due to the
behavior of some rogue pharmacies who engage in fraud. I would
like to try to get a better understanding for that because I
have a little bit of a skeptical view on that. It is my
understanding that fraudulent behavior from a pharmacy is
prosecuted by CMS and other state authorities. Is the concern
that managed care plans have to take any pharmacy willing to
accept the plan's contract and maybe they don't want to do
that? Or, is the concern that pharmacies with problematic
business patterns are not identified and pursued quickly
enough?
Mr. Srivastava. It does not have to do with kind of
building a network and accessing discounts. It has everything
to do with having a quality network where things are
credentialed and there is high-quality delivery. And if there
is aberrant behavior, things that are outside the norm, that we
should be able to not have to be required to contract with that
entity. And we are not speaking to the majority or a large
portion, but a very small portion.
Mr. Bucshon. OK, yes, because, from my standpoint also not
only as a Member of Congress, but as a physician, it is
important for me to ensure that our Medicaid or Medicare
patients have access to high-quality providers and pharmacies,
and that situation not to be restricted in a way that makes it
difficult for people to access their pharmacies.
Mr. Srivastava. It is all about the quality----
Mr. Bucshon. Yes.
Mr. Srivastava [continuing]. And making sure there is a
level there. Thank you.
Mr. Bucshon. Fair enough. Thank you.
I yield back, Mr. Chairman.
Mr. Carter. The gentleman yields.
The Chair recognizes the gentlelady from Indiana, Ms.
Brooks.
Mrs. Brooks. Thank you, Mr. Chairman.
Mr. Douglas, in your testimony you mentioned the
importance--and a few of you did as well, and so, I would like
to hear more from others--but you mentioned specifically the
importance of provider education as one way to reduce opioid
use and abuse, and including educating providers about the
risks of high-dose prescribing and best practices in the
treatment of pain and addiction risk associated with
prescribing opioids for pain. I would like to hear a little bit
more about the outcomes that you have seen, and others have
seen, about provider education policies and whether or not it
has led to a reduction in opioids prescriptions, and whether,
with those outcomes and since you have implemented policies
like this for your providers, how has it impacted the numbers
of patients actually using opioids? And has there been a
noticeable decrease in patients seeking treatment for their
addiction? A lot of different----
Mr. Douglas. Yes, a great question.
What I would say, first of all, I have seen directly from
Centene that, for example, we offer free continuing medical
education as one way to make sure on alternatives--we have
talked about alternative therapies and treatment and better
ways of pain management. Too, there are different projects--
ECHO is going on--as ways to do this. And then, there is also,
through 1115 waivers, a lot of work going on where you see
collaborative models of the best and evidence-based approaches
on pain management.
What I would say in terms of outcomes is the hard thing to
pinpoint on education is this is a continuum of prevention
approaches, from what is going on out front, and we have talked
about everything from very, very aggressive approaches around
lock-in to really limiting prescription refills, to the length.
So, we from Centene, and I have put it in my write-up, have
seen significant reductions, in overall numbers. That being
said, I can't tell you it is just about education. It is about
the comprehensive nature and approach, that you need to create
the right incentives for States and Medicaid managed care
organizations to be looking comprehensively and not just
thinking education is going to solve it, but around all of the
different approaches.
Mrs. Brooks. Oh, certainly. No, there is no question that
it needs to have a lot of different approaches.
Have your prescribers complained about prescriber
education?
Mr. Douglas. I would have to get back to you on it. I think
this gets to a broader issue, and this is where you need to
create the right investment. It is our providers, you know, we
ask a lot of our providers. And so, we try to create the right
platforms--and this gets to how, for example, CME, they already
need to do it--ways that we are not just adding another
additional burden without any payment. And so, it has got to be
the balance between creating the right incentives and the right
venues and right financing to ensure we are getting the high-
performing providers who are paid adequately to provide the
right access and the right types of treatment.
Mrs. Brooks. Thank you.
You brought up provider education, Mr. Botticelli. Can you
expand on either Mr. Douglas' points or any additional of your
own----
Mr. Botticelli. Sure.
Mrs. Brooks [continuing]. With respect to prescriber
education? And prescribers meaning physicians, nurse
practitioners, dentists, everyone.
Mr. Botticelli. One of the issues that we saw driving
overprescribing was, quite honestly, misleading information. As
you talk to many prescribers, they will tell you that they were
trained that these were not addictive drugs, that these should
be prescribed liberally. And while I agree with Mr. Douglas
that you can't kind of pinpoint to one specific thing, I think
it makes intuitive sense to give providers good, fact-based
education as it relates to this issue.
Again, while I do think we need to provide incentives, and
I say this not to overexaggerate, but while we have seen some
modest declines in prescribing, we are still prescribing at
three times the level that we were in 1999. And I don't think
it is unreasonable to ask a physician, kind of 15 years into
this epidemic, to take some modicum of continuing medical
education, either on safe prescribing or just on substance use
issues in general.
Mrs. Brooks. Thank you.
Mr. Kravitz, or any of the others, comments?
Mr. Kravitz. Yes, I would love to comment on that. So, I
had mentioned in my testimony we have a provider dashboard. So,
that tracks providers that are high prescribers for opioids. We
use that as part of our continuous monitoring for our
physicians who we have educated and trained on this. We will
continuously go back and address issues if we still see a
persistent level of prescriptions being prescribed--overusing
that term--but by these particular providers. And they could be
nurse practitioners, physician assistants, anyone who has a DEA
license number in this case. So, we address it. We are very
much concerned about the quality of care delivered to our
patients, and that is one of the areas where we focus on very
heavily with analytics.
Mrs. Brooks. Thank you.
I am out of time. I yield back. Thank you.
Mr. Carter. The gentlelady yields.
The Chair now will recognize the gentleman from New York,
Mr. Tonko, for 5 minutes.
Mr. Tonko. Thank you, Mr. Chair.
I don't see Mr. Barton in the room, but I do want to
address my colleague's concerns and I appreciate his kind
comments. But I want to make it abundantly clear, my bill does
not expand Medicaid eligibility in any way. It simply would
allow States the flexibility to provide for existing Medicaid
beneficiaries who are returning into the community in less than
a month.
Vast bodies of evidence confirm that individuals engaged in
addiction treatment have lower rates of recidivism and lower
healthcare costs, and we have undone many, many situations
where they would have overdosed and died. That is what my bill
does, straightforward. It is about being smart on crime and
effective for the taxpayer.
In trying to address the opioid epidemic, one of the
populations I have the greatest concerns about is individuals
who have had involvement with the criminal justice system. As I
mentioned during the first panel, for individuals reentering
society after a stay in jail or prison, the risk of overdose is
as high as 129 times that of the general population during the
first 2 weeks of post-release.
In States that have specifically collected data on this
population, such as Rhode Island, we have seen that justice-
involved individuals can account for at least 15 percent of the
total overdose deaths. If we extrapolated that figure
nationwide, we are talking about 10,000 deaths a year among
individuals less than a year removed from correctional
settings.
Mr. Botticelli, let me welcome you back to this committee
and direct the question your way. Drawing on your previous role
at ONDCP or your current position at BMC, what are some of the
unique challenges that this justice-involved population faces
in accessing effective addiction treatment, and how can we do a
better job of meeting the needs of this population?
Mr. Botticelli. Thank you for the opportunity to address
you again.
Our data in Massachusetts underscores some data that you've
already said, and we see people who are coming out of our jails
and prisons overdose and die at one hundred and twenty times
the rate of the general population. And while we've made
success with many populations, that is one area where we need
to have concern.
And I will tell you that, very interestingly, Boston
Medical Center is right across from the Suffolk County Jail,
and we actually try to make sure that we are getting people as
they come out of prison into our services. But it often can be
challenging. And even though we do a good job of trying to get
people on insurance, being able to have that seamless coverage,
actually start people on treatment while they are in jail
becomes important.
And the last point that I will make is we have a
significant number of sheriffs in Massachusetts who operate
county houses of correction, who I think would have greater
uptake of medication-assisted treatment while people are in
jail. But part of the predicament that they run into is cost.
To your point, with already Medicaid-eligible folks, if we have
some modicum of transition services to be able to make sure
that folks have that seamless bridge back to the community,
that, to your point, not only can we reduce overdose deaths,
but we would reduce costs and we would reduce recidivism.
Mr. Tonko. That is a smarter use of the taxpayer dollar.
Mr. Botticelli. It is.
Mr. Tonko. Thank you, Mr. Botticelli.
In an attempt to address some of the challenges you spoke
about, I introduced the Medicaid Reentry Act, which would
provide States with new flexibility to draw Federal matching
funds for care provided to Medicaid- eligible, already
Medicaid-eligible incarcerated individuals in the 30-day period
prior to release, rather than waiting until the day of release
itself.
Mr. Douglas, as a former State Medicaid director, would
this type of increased flexibility have been useful to you as
you crafted a response to the opioid epidemic?
Mr. Douglas. Absolutely. What we see, we have innovative
programs now. I can see, and I mentioned earlier, in Ohio,
where there is a lot of work going on between the correctional
system and the managed care organizations where there is a pre-
release program in place, that we do a lot of work.
Mr. Tonko. I am going to cut you short because I only have
about 35 seconds left.
Mr. Douglas. OK, fine.
Mr. Tonko. But I appreciate it.
Mr. Douglas. Yes.
Mr. Tonko. For the rest of the panel, do you agree that
initiating addiction treatment and care coordination services
for reentering Medicaid beneficiaries before they leave a
correction setting would improve their health outcomes,
including overdose deaths for these individuals upon reentry,
yes or no?
Mr. Kravitz. Yes.
Mr. Douglas. Yes, sir.
Mr. Guth. Yes.
Mr. Srivastava. We have experience in three States. Yes.
Mr. Tonko. OK. Mr. Douglas, coming back to you, your
company has done some innovative work in the reentry space with
subsidiary Buckeye Health Plan, a Medicaid managed care
organization operating in Ohio. Buckeye participates in Ohio's
Medicaid Pre-Release Enrollment Program under which managed
care organizations provide care coordination services through
videoconferencing to certain high-risk incarcerated individuals
prior to release from prison. Beneficiaries are provided an
insurance card and a care plan the moment they walk out of a
corrections facility.
I was hoping you could briefly describe Buckeye's
participation in this program and share any data that you
believe are significant for the previously-incarcerated
beneficiaries who have enrolled with Buckeye.
Mr. Douglas. Yes, and I am happy afterwards to provide for
the record--we have a flyer that gives more detail on this--
knowing that we are out of time.
But, just in a nutshell, we work 90 to 120 days before
release getting them, making sure they are going to be enrolled
in Medicaid, so that they are actually Medicaid-eligible. We
develop a transition plan. We, through a videoconference,
review that with their care manager. We schedule post-release
appointments. Then, we make sure that pre-release that they are
getting a 30-day supply of medicine, especially for those with
behavioral health needs. And then, we do a care outreach 5 days
after release to make sure they are connected to both
integrated behavioral health services as well as social
services. Across not just with Buckeye, our plan, but all of
Ohio has had 20,000 former inmates enrolled in this program.
Mr. Tonko. Thank you, Mr. Douglas.
Finally, I will just state--and I know my time is out--but
I will state that, if with this human health crisis, this
opioid epidemic, our goal is to save lives, I challenge this
committee to say no to addressing those who are incarcerated.
It should not be a caste system here. Many people find
themselves incarcerated because of this illness, and we need to
be compassionate and I think effective with the taxpayers'
dollars.
With that, I yield back, Mr. Chair.
Mr. Carter. The gentleman yields.
The Chair now will recognize himself for 5 minutes.
I would like to ask unanimous consent to submit two letters
for the record supporting the Pharmacy and Medically
Underserved Areas Enhancement Act. Without objection.
[The information appears at the conclusion of the hearing.]
Mr. Carter. Mr. Guth, I am going to start with you. I
wanted to ask you, the recommendations that have been put forth
by the President's Commission on Combating Drug Addiction and
the Opioid Crisis stated that, ``There is a great need to
ensure that healthcare providers are screening for SUDs and
know how to appropriately counsel or refer to a patient.'' It
would appear to me that this is an opportunity for Congress to
direct CMS that CPT codes be expanded or added to, and that we
identify patients at risk for opioid use disorders.
Mr. Guth. Absolutely.
Mr. Carter. Would you agree with that?
Mr. Guth. Absolutely.
Mr. Carter. Should we be looking at creating or amending
CPT codes? As I understand it, it is done in other areas. In
fact, it is done for chronic care with alcohol and substance
abuse, and other areas as well.
Mr. Guth. Absolutely. I am very much supportive of that.
Mr. Carter. OK. Should we be encouraging the use of OUD
tapering strategies that have been proven to work?
Mr. Guth. Yes, and I think those go back to the fact that
you have very different presentations for folks. You have
individuals with very different recovery capital themselves.
So, not everybody needs to be on medication-assisted therapy
for the duration. I think this gets back to one size doesn't
fit all.
Mr. Carter. Right, right.
Mr. Guth. So, the short answer to your question is, yes, we
ought to be including in the continuum of care tapering
strategies.
Mr. Carter. OK. I want to talk real quickly about one of
the bills that is under consideration. That is the Partnership
Act, and that is the use of the PDMPs, and specifically as it
relates to pharmacists. And full disclosure is, I suspect you
know, currently, I am the only pharmacist serving in Congress.
I have over 30 years of experience in a retail setting. And I
acknowledge the responsibility of pharmacists. We have an
important responsibility, a very important responsibility, as
possibly the last line of defense in the opioid crisis.
But, having said that, I will tell you we are not
policemen. And to require pharmacists to be the only ones to be
looking at a PDMP, and to be policing physicians who are
writing the prescriptions, I think is somewhat unfair. I have
often said the only thing worse for me, as a practicing
pharmacist, to fill a prescription for someone who is going to
be abusing it, would be to not fill a prescription for someone
who truly needs it. It is unfair to expect a pharmacist to
profile a patient and say, no, that patient doesn't need that
medication. That is unfair.
Now I get it. I understand a PDMP is different. I have
sponsored the legislation creating the PDMP in the State of
Georgia back in 2009. But, at the same time, I just want to get
your thoughts on this. Without having the prescriber have to
look at the PDMP, why are we having the pharmacist to look at
it? To police the doctors? Anyone want to jump on that?
Yes, sir, Mr. Kravitz?
Mr. Kravitz. I think it is imperative that the provider be
held accountable, prior to providing the prescription, that
they must check the PDMP. And they are the source of this
process. I think the pharmacist, which I have a daughter who is
a pharmacist as well, and I think they are a checkpoint in the
process. They should not be held accountable as the policing
act.
Mr. Carter. Thank you.
Any other comments? OK, and let me go back to you, Mr.
Guth, because I thought it was interesting. In your opening
statement, you said that the number of programs that are out
there--and this is something that I have been very concerned
about, the fact that I look at the opioid crisis and I look at
two different components of it.
First of all, there is that tangible part, if you will,
that I feel like we can get our arms around. How do we control
the number of prescriptions, the pills that are going out? And
what are those things that we do to limit the access to them?
But, then, there is the second component that is more
challenging in my mind, and that is, how do we treat those
people who are already addicted? You said that, quite often, it
depends on what program you enter into.
Mr. Guth. Yes. And let me give you an example close to home
of how we have addressed this. So, Centerstone has a five-state
primary footprint for our services, and we are the result of an
affiliation of nonprofit providers who are all mission-driven
organizations. As we brought these organizations together, we
realized that the systems of care in each of these states vary
dramatically, not only in the area of substance use treatment--
--
Mr. Carter. Right.
Mr. Guth [continuing]. But across the board, not based on
the science of care, but based on how services evolved in those
areas, access to human capital, state regulations, and, more
often than not, funding, access to funding.
And so, what happens today is, let's take this shortage of
services for the 30 million people in rural communities. We can
quickly go to a solution that says let's give them access to
medication-assisted therapy, light on the therapy, without all
the continuum-of-care services. And we can turn around and say,
hey, 30 million people now have access to substance abuse care.
But that is not a single solution that addresses all the people
that present.
Think about the fact that, if you or I present with an
opioid disorder, we have got a lot of human capital support
around us in our family, in our friends, or networks. We have
got jobs. We have got a safe place to live. But, if that is not
our situation, which is the case for many people that are
battling this disorder, we need to make sure they have got
access to----
Mr. Carter. Right, right.
Mr. Guth [continuing]. A sober living community, that they
have got access to peer support.
Mr. Carter. Well, and it is one concern that I have because
a lot of my colleagues--and I am not being critical; I just
don't think they understand--think all we have got to do is
throw money at it, and if we can get to a certain point, then
that is where we need to be. But my point is that not all
programs are going to work for all people.
Mr. Guth. That is right.
Mr. Carter. That is difficult for us in Congress to
disseminate. How do we know which programs work and which ones
don't?
Mr. Guth. I think you start by looking at whether the
provider has access to, either directly or through strong
referral relationships, a continuum of care.
Mr. Carter. A continuum of care is extremely important.
Mr. Guth. If anybody comes to you today and says, look, we
have got the one solution, we have got the one program, the one
protocol that is going to work for everybody, I think you ought
to be looking very closely at that.
Mr. Carter. Right.
Let me ask one more thing. Mr. Douglas, or any of you, did
I hear you say that only one out of five people in treatment
are getting medication-assisted treatment? Are most of the
patients who are under treatment for opioid addiction, are they
getting medication-assisted treatment or are they just getting
therapy? Almost all of them getting medication-assisted
therapy?
Yes, I'm sorry?
Mr. Botticelli. So, despite the fact that I think all the
data support that people on medication, as long as they are
getting all the other behavioral and recovery supports, do far
better on a medication versus treatment without the
medications. But only a very small percentage of people are
getting on it. And we still have a small percentage of our
treatment programs who are even offering it.
But, while I agree with you that there are multiple
pathways to treatment, I do think that every licensed substance
use treatment provider who is getting a Federal dollar should
be offering access to medication-assisted treatment. And I
think it is really important because the data are pretty clear
that people get into long-term recovery when they are on a
medication versus when they are not.
And again, this is not saying ``either/or''. People need
all the other recovery supports.
Mr. Carter. Right, right.
Mr. Botticelli. They need behavioral therapy. They need
peer support services. But it is very clear, and again, I go
back to Secretary Azar who said treating substance use
disorders and treating opioid addiction without a medication is
like treating an infection without an antibiotic.
Mr. Carter. Right.
Mr. Guth. And for the record, I absolutely agree with that.
So, it is a point about having the other constellation services
available.
Mr. Carter. Right. But you see what a difficult situation
it puts us in. I mean, all of you know that this is a lifelong
challenge. I mean, and you have to continue it, and it is
expensive and everything else.
But I want to thank all of you for being here. This is
extremely important. This is part of what, as I said earlier,
the second component that I consider to be so very challenging
for us, but so very necessary for those who need help. And we
need them. We need them back to being productive members of our
society.
So, I will yield back the remainder of my time.
Seeing there are no further members wishing to ask
questions, I would like to thank all of our witnesses again for
being here today.
I would like to submit statements from the following for
the record: the American Association of Oral and Maxillofacial
Surgeons, the Association for Behavioral Health and Wellness,
AdvaMed, the American Hospital Association, the American
Psychological Association, the American Society of Health
System Pharmacists, the Association for Community Affiliated
Plans, the College of Healthcare Information Management
Executives, ePrescribing Coalition, the National Association
for Behavioral Healthcare, the National Association of Chain
Drug Stores, the National Association of Medical Directors, the
National Indian Health Board, the Oregon Community Health
Information Network, the Partnership to Amend Part 2, the
Pharmaceutical Care Management Association, Property Casualty
Insurance Association of America, Shatterproof, Imprivata, the
Pharmacy Coalition, Express Scripts, the National Association
of Counties, and Trinity Health.
[The information appears at the conclusion of the hearing.]
Mr. Carter. I would also like to submit a joint statement
from the Infectious Disease Society of America, the HIV
Medicine Association, and the Pediatric Infectious Disease
Society; a study entitled, ``States With Prescription Drug
Monitoring Mandates Saw a Reduction in Opioids Prescribed to
Medicaid Enrollees,'' published in Health Affairs, and the
Center for Medicare and Medicaid Services 2016 Medicaid Drug
Utilization Review Annual Report.
[The information appears at the conclusion of the hearing.]
Mr. Carter. Pursuant to committee rules, I remind members
that they have 10 business days to submit additional questions
for the record, and I ask that witnesses submit their responses
within 10 business days upon receipt of the questions.
Without objection, the subcommittee is adjourned.
[Whereupon, at 12:37 p.m., the subcommittee was adjourned.]
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