Transcripts For CSPAN2 Surgeon General Jerome Adams Testifies On Substance Abuse 20240713

Meeting i have to attend to make a quorum down the hall here. So im going to to start out. I know you want to introduce one person. Are you under a time constraint . Because if you are, ill give you the courtesy of going ahead. Mr. Chairman, i can wait until the regular okay. So i welcome our panelists today to our hearing on the oneyear anniversary of the support act. This landmark statute, which many of us had a hand in developing, responded to the Opioid Epidemic on multiple fronts. That crisis affected every corner of our nation with approximately 130 americans dying from an overdose every single day. Weve devoted a lot of federal resources to tackling the crisis, and i look forward to hearing from the Surgeon General on this, of this administrations efforts to implement the support act. Now its on its oneyear anniversary. I also commend dr. Adams for launching his own unique initiatives to help raise Public Awareness about the risk of the opioid misuse. Challenges remain, however, because roughly 20 million Americans Still struggle with substance disorder, addiction to other drugs including meth and heroin pose an equal or even greater challenge to some communities. And this is especially true in our rural areas of america. Another issue is that few battling addiction actually seek or receive treatment. Another issue is that even those who do seek help lack the expertise to distinguish the good treatment providers from the bad, and solving this issue which is the second focus of our hearing is easier said than done. The treatment sector includes not just extremely good and extremely bad actors, but those in between. Some, for example, havent updated their methods to incorporate the latest research about what works best for recovering people. Also state requirements for addiction counselors and recovery homes vary. Example, some states require licensing of recovering home operators while others might only use voluntary certification. That is why we have invited two government watchdog agencies and an Addiction Treatment advocate to our committee to share expertise. We welcome back dr. Mccauley of the gao who testified before this Committee Last year. Weve all seen the media reports about socalled sober homes in florida, pennsylvania, massachusetts and a few other states that exploited recovering addicts with private insurance benefits. We look forward to hearing from her on that subject of their work there. I also extend a warm welcome to Gary Cantrell who heads the inspector generals investigative team. His investigators worked on a recent high profile case involving treatment scams in ohio. That investigation in partnership with fb, and i Law Enforcement generally fbi and Law Enforcement generally led to indictment of six people this year. All sex pleaded guilty to medicaid all six pleaded guilty to medicaid fraud. Some havesi called for developmt of more uniform, measurable Addiction Treatment standards by which the public could evaluate the effectiveness of Substance Abuse Treatment Programs. Our last witness, gary mendell, has gone a step forward not only identifying eight core standards he believes are key to any successful program, but also launching a quality rating system. This iss uncharted area in the treatment sector, and we look forward to hearing from him the progress thats been made there with his Nonprofit Organization. Were here today because too Many Americans have lost too many loved ones to addiction and overdose deaths. Americas Opioid Crisis has left a trail of broken hearts and homes across our country. Were here to help communities get on a path towards or health and wellness. Areions of americans desperately seeking a path forward. Working together, we can save tax dollars and save lives. Senator wyden. Thank you very much, mr. Chairman. And, mr. Chairman, i want to thank you because this is an exceptionally important issue, and i think we do need to have our committee tackle it in a bipartisan way. And i also want to thank you for moving this mornings start time to 9 a. M. Because we both know that our members want to attend the Memorial Service to chairman cummings. Todays hearing is going to spotlight the pitfalls americans face when they try to find quality treatment for Substance Use disorder. An american battling this disease is often jostled and pushed around from one end of the Health Care System to other. The last thing you need when youre suffering from this disease is yet more obstacles; ripoff artists, empty promises or just out and out abuse. The last thing you need is that when all you want to do is get better. Too often people travel across the country expecting to aa legitimate Treatment Facility only to find that theyve fallen prey to a scheme, the goal of which is to drain their Bank Accounts and just milkey their insurance for everything its worth. In some instances, unscrupulous operators are working to lure patients by paying for plane tickets and promising free rent. Once the patients arrive, what they end up getting is lousy care or no care at all. And then the fraudsters just go ttout and bill the Insurance Companies for Health Care Services that a may never that may never have been performed. One of the biggest problems involves facilities that allegedly treat Substance Abuse disorders but are actually set up to rip off taxpayers. The fraudsters illegally recruit patients using bribes and then they bilk the taxpayer by billing the patientss health plan for medically unnecessary drug tests. Schemes like this and were very pleased to have this really terrific group of witnesses today, theyre going to outline these schemes in detail. And, of course, these schemes as well cost medicare, medicaid and private insurance hundreds of millionsns of dollars every yea. Just this month six people operating a network of fraudulent Treatment Centers in ohio pled guilty to submitting 130,000 medicaid claims that totaled more than 48 million for medicallyassisted treatment and other services that were never legitimately provided. Part of the reason this type of fraud is so common is because theres no way for a patient or their family to learn about the quality of a Treatment Facility beforeo they end roll. Enroll. So today were going to hear from an organization that is saying, hey, wake up, everybody. This has got to change. Shatter proof is currently developing public databases that, if successful, will allow the public to identify, evaluate andat compare Substance Use Treatment Programs. This kind of data base and transparency is the type of information that American Families deserve to have, and they deserve to have it now because itll be a key tool to find quality treatment and avoid sham operators trying to make a quick buck. One other point that occurred to me as we were preparing for this hearing is particularly important now to set in place the kind of concrete policies to rip off to make sure that these programs are not ripped off and the patients are not a taken advantage of because, when you read the morning newspaper, the fact is that states and communities may now be on the cusp of receiving tens of billions of dollars from the companies that helped seed the epidemic. I can look down the road because ive heard about this from virtually all of my colleagues. So if youre talking about a fund of tens of billions of dollars, a sum of that size is going to be a magnet for the fraudsters and the ripoff artists. This hearing is going to highlight the need to make sure that the rules of the road and vigorous oversight so that those dollars actually go to help patients get proper care, and all that new money doesnt just find its way into the ripoff artists. I thank the witnesses and, mr. Chairman, again, your leadership, were going to work on this in a bipartisan way, and i look forward to hearing from the witnesses and our colleagues. The senator from maryland to introduce the Surgeon General. Thank you, mr. Chairman. I thank you for giving me this courtesy. Its a real pleasure to welcome all of our witnesses today, but its particularly to welcome the Surgeon General of the United States, dr. Jerome adams. He hails from mechanicsville, maryland, a proud son of maryland, and has had a glowing career. Mr. Chairman, the first winning the prestigious meyerhoff scholarship, bachelors of science and biochemistry and a bachelor ofr arts in psycholog. I say that because we had a little conversation before. The president of umbc calls dr. Adams his most successful failure. Thats because the Scholarship Program is a program that has been extremely successful in africanamericanst obtaining their ph. D. S and going on to extraordinarily successful lives. Well, dr. Adams does not have a ph. D. , but he does have a masters degree and an m. D. Degree and, of course, has had a very, very successful career. I want to congratulate him for his leadership in our country, his service to our nation. He attended Indiana University school of medicine and eli lilly andon company scholar. Before serving as the United States surgeoni general, dr. Adams was appoint as the Indiana State Health commissioner, as the Surgeon General dr. Adams spends his time focusing on combating the Opioid Epidemic. He has been an advocate on behalf of Public Health in our country, and were just very proud of his service, and were proud to have him as, hail from our state of maryland. The three of you, if i just go to the testimony, dont feel bad i dont introduce you [laughter] i talked to all of you about it in my Opening Statement because of the time constraints, i want to start with the Surgeon General. So would you start and then what well do is, is go in the order that youre sitting there at the table, and then well have questions after you all get done. Fantastic. Well, good morning, chairman grassley, my wife lacey says to tell barbara hi, and we cant wait to bring the kids out to farm. I hope she told you about that. Everybody knows about my wife. Does anybody know about me . [laughter] Ranking Member wyden, distinguished members of the committee, if youll allow me just 20 extra seconds, i want to acknowledge the flags flying at halfmast over the capitol and lift up the example and accomplishments of representativell cummings. His life was the very definition of public service, and my condolences go to his family and to all who were blessed the know him. For my testimony today, id like to given by thanking all of you and your colleagues, mr. Chairman, for passing the support act which has enabled hhs l and our country the make progress in its fight against the Opioid Epidemic, and im so pleased to be here today on the oneyear anniversary. Americas overdose and addiction crisis with one of our most daunting and complex Public Health challenges ever. Recognizing its scale and scope, hhs launched thehe fivepoint strategy in 2017, and under that strategy we are achieving better addiction, prevention and Treatment Services, better data, better Pain Management, better targeting of overdose reversing drugsio and better research. Ive been engaged on this problem as an anesthesiologist involved inng acute and chronic Pain Management x as you heard, as head of a state Health Department dealinged with an unprecedented opioidfueled hiv outbreak. But my work is also sr. , very personal. My younger brother phillip struggles with the addiction of disease. His struggle began with untreated depression, leading to selfmedication and opioid misuse. And like many with cooccurring Mental Health and Substance Use disorders, my brother has cycled in and out of incarceration. Hes currently serving a tenyear prison sentence to crimes committed to support addiction. Addiction can happen to anyone, even the brother of the United States Surgeon General. And when stigma keeps people in the shadows, it impedes our collective recovery. To address this Opioid Epidemic, my Office Released a spotlight onnd opioids, a digital postcard which you can find at Surgeon General. Gov and which you have in front of you, senators, and ap advisory on opioid overdose. I want to leave you with five key messages that i detail in these publications. Number one, Early Intervention is critical. They need to be initiated early in life. We cant wait until someones in high school or college before we Start Talking to them about the dangers of opioid misuse. Number two, treatment one integrated musta be integrad into Mainstream Health care. In the course of a year, only one in four people with opioid use disorder receives specialty treatment. Number three, having naloxone can save of a life and serve as a bridge to treatment and recovery, and i hope all of you knowr about this and carry it. I carry it with me everywhere i go. Its literally that easy to save a life. Since my advisory was published, almost three million twodose units have been distributed to communities, but too many still needlessly die. Fourth, comprehensive communitybased support Recovery Services are essential, and i saw this firsthand when second lady pence and i i visited indiana, a unique Pilot Project called pathways to employment in which potential employees who fail drug tests are offered drug coming and then assured jobs. Overdoses. In conclusion, on this administration and through your support, and who strike investment has been made in combating the Opioid Crisis. In 2019, which its not full of awarded over 9 billion to local communities to combat addictions. This includes nearly 1 billion across 3175 projects in 41 states is part of nih is helping to end addiction longterm or heel initiative. It also includes more than 1. 8 billion and cdc funding the state announced lastt month. These funds expand access to treatment and strengthen data and surveillance. Since the start of the administration, loosing the amount of opioids nationally dropem, 31 percent in terms of prescriptions. Missing a number of americans receiving treatment grow. Now nearly 1. 27 million americans are receiving treatment. And number of providers that the data waivers to prescribe nat. The risen 378 percent, and provisional Drug Overdose deaths, have dropped by 5 percent. The first drop in over 20 years. We are making progress. Challenges remain including the resurgence of methamphetamines. The need to increase support for comprehensive Syringe Service programs, and is for the Emergency Department medication facility Treatment Programs with warm handoffs to care. We also must expand the behavioral workforce. We talked about that before the hearing. I promise you, that hhs and my office will to continue our commitment and hard focus on this critical Public Health issues and i thank you for the opportunity to testify. I look forward to questions. If i am again, with all your background in animal science, how did you end up in jail. Is you probably are aware, theres quite a pit of difference between Animal Health and like health and human health. I need it an a explanation proceed please. I am pleased to be here today to discuss recent report on the oversight of recovery homes. Substance abuse and illicit drug use is the persistent problem that is run families and taken lives. The dea reports that in 2011, drug over notions alone have been the leading cause t of deah by injury in the United States outnumbering just by guns, car crashes, suicides, and homicide. Recovery homes and offer safe and supportive housing. Unfortunately that actors have used these homes to take advantage of individuals during the time of need. Today i would like to highlight two key findings from our report. First, geo sound that all five states in our review, i received complaints of potential fraud elated to recovery homes. And for the five, florida massachusetts, ohio, and utah had orman in the process of conducting investigations. For example, officials told jail the fraud is in southeastern for florida. Operators were luring individuals to homes using substantive marketing techniqu techniques. Such is promises of free airfare and brent. Recruiters, then broker these individuals to providers to build their insurance for hundreds and thousands of dollars in unnecessary drug testing. Home operators are then paid three to 500 or more per week for every patient that they referred. At the time of our report, some arrests have been made. Massachusetts, the medicaid Fraud Control unit, found that some laboratories on referred residents to their own labs for drug testing and other labs were paying kickbacks to homes for patient referrals for testing that was not medically necessary. In between 2007, and 15, the state settled with nine labs for more than 40 million restitution. On the time of our report, ohio was investigating fraud at the breaking. Recovery center. This month, is senator white invention, the attorney his office reported that six people breaking points, pled guilty to Healthcare Fraud conspiracy, or billing medicaid more than 48 million in drug and alcohol Recovery Services that were not provided or not medically necessary. The increased oversight, florida, massachusetts, and utah establishedly either licensure r voluntary Certification Program that included incentives for recovery homes to participate. Our other two states, ohio and texas, did not have similar programs but were providing resources such is training to recovery homes. Despite such efforts though, fraud continues. For example, the pennsylvania and u. S. Attorney offices, recently completed an 18 month investigation looking into insurance card and Treatment Centers. Charges included, once again kickbacks for unnecessary drug testing and billing Insurance Companies at exorbitant rates. Those charged also directed patients to live and companyowned, unlicensed recovery homes where the housing was sometimes unsafe and employees and patients were engaged in sexual relationship, and their opportunities to relapse. And this is case of the bad guys getting caught. And thats what we leads to my second. We do not know the total number of recovery t homes so therefore we dont know the extent to which this is happening. In addition, no federal agency oversees the operations of these homes to provide the nationwide perspective. In tilting, when properly, recovery homes are an important part of the path to sobriety in combating the Opioid Crisis radar work and recovery homes, is part of jails brought her work on drug misuse. Recenter gao reports of export r example, federal oversight of opioid prescribing medicare, we also have ongoing work identifying barriers medicaid beneficiaries safe accessing important medications to treat opioid misuse. Much of our current work is the result of mandates from the support act which was signed into law one year ago from today. We highlight this and other work in our latest iris report where we identify federal efforts to prevent drug misuse is an issue requiring very close attention. Thank you chairman grassley, Ranking Member wyden, and members of the committee for holding this important hearing. And containing your oversight on this issue. This concludes my remarks and i am happy to respond to any questions you may have. In morning. Im Gary Cantrell, the Deputy Inspector at edge is. I appreciate the opportunity to up here here before you to combat the opioid congress efforts. Looking at a variety of issues above the prescribing and treatment dimensions of this crisis. It is addressing the crisis or expanded Law Enforcement activities, audits and data brief, our efforts to combat opioid related fraud abuse, while ensuring about Substance Use or treatment and care, continue in a top priority for oig. For example, we have expanded enforcement issues over the past several years. Resulting in increases of over 100 percent of open investigations in her office from 2015 from 2019. Just this year, the newly launched appellation regional prescription or kuwait strikeforce,2 a joint initiative between doj oig, sda and the f fbi, and safe medicaid partners, took down 73 individuals. Sixtyfour of them medical professionals. Their alleged participation and the illegal prescribing and distribution of a poison through related Healthcare Fraud screams. Its a broad criminal activities. In Prescription Drug diversions to addiction drug treatment and billing schemes. Their drawings game is fraud in medically assisted treatment. Summer homes and services such is counseling and urine test readings. Is a number of Treatment Facilities and summer homes operating continues to increase, in conjunction with the increased demand and availability of federal funds, support needs to commit site increase and illicit schemes involving fraudulent billing and diversion. Is our enforcement and oversight efforts to address the Opioid Crisis have expanded, also come to understand the impact that our enforcement work can have on the patients that wex surf. We recognize that when a clinics whose patients are prescribed opiates, i may see it shut down due to Law Enforcement efforts, access to care can and will be disrupted. Rather than leaving these patients to potentially turn to another fraudulent provider, or street drugs to meet their needs. We believe it is vital that they have access to qualityer treatmt and Pain Management services with minimal disruption to care. But this its not something that lawt enforcement can do alone. Ensuring these patients have care requires a collaborationav with our federal state and local Public Health service officials. Is part of the appellation takedown, oig and our Law Enforcement partners work to close collaboration with hhs is the assistant secretary for health, center for Disease Control and prevention. And state Public Health agencies to deploy federal and state strategies and resources to provide assistance to patients impacted by the Law Enforcement operations. Oig will continue to work hand in hand Public Health partners to helpt ensure access to treatment and continuity of care for patients impacted by our efforts. None are enforcement efforts, only that she grow our portfolio of work related to the crisis. With new and ongoing work, the device opportunities to strengthen program integrity, and protect efforts and patience across the prescribing and dimensions of this crisis. We several audits in valuations in white. Examining issues such is access to medications for treatment. An deployment of ourd site state treatment plans. We look forward to sharing the results of this work with the committee and its complete. Thank you. Oig histo recent declines in opioid prescribing at the same time it also shows the number of patients receiving morphine and locks on, and medicare is increasing. This is the very positive sign. However there is still much work to be done to reduce the legal prescribing of opioids and treatment schemes. They only detract from the b efforts of those who seece to provide the help these patients truly need. Oig will resist gillette and investigating the broad screams and working to improve hhs efforts to provide quality Treatment Services. Thank you for allowing me the opportunity do to discuss this important topic with you and i did look forward to discussing this important topic with you. Any to recognize your success in the private sector and are bringing that to the Nonprofit Organization of the office his goal. I should of said that and i did so proceed. Chairman grassley, ranking mender member wyden and members of the committee, thank you for holding this hearing and treating substance is misuse in america. It wasle eerie and i am the founder and chief executive officer shatterproof. Im a national Nonprofit Organization dedicated to reversing the addiction crisis in america. A decade, my son brian struggled Substance Abuse disorder. Despite her family working tirelessly by my son the best possible care at eight different Treatment Programs, on october 20th 2011, with my son brian to the disease of date addiction. In the months that followed, i was destroyed all over again when i learned that research existed proving the types of interventions that would have significantly improved the outcome for brian and millions ofex others. We were in the treatment for addiction. If only we had known what to look for. Ist is why found shatterproof the First National Nonprofit Organization dedicated to reversing the addiction crisis in america. To accomplish this, we developed plan to transform the Addiction Treatment system in the United States. Number one. Of course thats of size based principles for care for treating addiction. Number two. A quality Measurement System. Number three. Payment reform. Number four treatment capacity and number five ending stigma. My remarks today will focus on the second of these five the treatment quality measurement. Addiction is the chronic disease despite the fact that there are clear clinical best practices, use of these practices varies widely across the Addiction Treatment field and some facilities are still implying techniques basics on ineffective and outdated methodologies. Unlike other healthcare services, comprehensive and standardized data, on the quality of Addiction Treatments just simply doesntr exist. Even worse, because consumers payers and state regulators, do not have access to quality measures and Market Forces have not been allying support these best practices. In 2006, and landmark report by the institute of medicine, and called for the development and dissemination of a common continuously improved set of measures in the treatment of Substance Abuse disorder to drive quality improvement. Seizing shatterproof longstanding recommendations to develop a public platform known is alice. For 3 amps. Number one. Providing patients and family members information they need to identify evidencebased treatment at of their loved ones. Number two, equipping providers with data to advance the use of evidencebased practices. And number three, ensuring folicy and payment decisions are data driven. The total bills about our eight National Principles of care which were developed with experts in the field to establish an addiction should be treated like any other chronic illness. We are currently in phase one. In six days. Delaware and louisiana, North Carolina, west virginia, massachusetts, and new york. Thus far, its included measure identification and refinement to the National Quality Forum Expert Panel strategy sessions and public common. Feasibility testing of survey items and flames measures, and a pilot Patient Experience survey across 50 Treatment Facilities in the state of new york. Quality data will be collected and triangulated from three sources. Flames data, Patient Experience survey, and Treatment Facility survey. And reported through alice through the site back to providers to the public and to payers and states. In raising the public, the families. Following evaluation of phase one, shatterproof will work with other states to bring this resource to surf more than 2 201000000 americans with a substance facilitator. Alice is part shatterproof strategical and transforming the Addiction Treatment system and in the United States to reverse the addiction crisis that has had such a severe and tragic toll and far is it too monday. And for which theve impact can absolutely be averted for so monday others. Thank you for the opportunity to testify today and c i look forwd to your questions. Thank you. Fiveminute rounds of questioning. Im going to start with the Surgeon General. First of all i know and thank you for the top priority you have given us a Surgeon General and even probably is an individual to making and addressing opioids in addiction is the top priority. And also think the administration for its efforts to prioritize the carrying out the immaculate of this legislation. Section 7031, of the new law calls for the development of best practices. It has the administration appointed a working members to develop such best practices are identified they could be used to identify potential recovery operators by support and if not, could you give us a timetable when that might happen. Think of the questionsor are and i want to recognize that iowa is on the way in 14. 7 percent decrease in overdose rates over the past year thats been recorded and so we need share more of whats working in iowa with the rest of the country including people with Recovery Services and other areas. I would see very specifically the spotlight on addiction which i highlighted, this came out last year. There was a much fanfare. A lot going on in dc nowadays. Folks dont always notice the Surgeon General put something out. But i highlighted what to look for in a Substance Use Disorder Treatment program. Personalized diagnoses and assessment and treatment planning longterm disease, management and is we learned in indiana, not just the disorder, hiv and hepatitis and its actually transmitted and mental illnesses. Fda medications, effective behavioral interventions, or to care for other occurring diseases and Recovery Support services. My role is to help give the public the information they need so they canor make informed decisions. We put that out, we also have the treatment finer when 866 to help, and beyond that in terms of that in, good for matt. I would turn it over to my friend mr. Cantrell. From oig. Edge 50 on the spots or. Unfortunatelyie sir, we only encountered the bed. What we see is our institutions that have no intent to provide the services that they are billing for. Individuals do not receive the dive boat counseling that they are supposed to receive. This sometimes we have seen prescriptions just left behind for staff nonqualified medical staff and facility to just write prescriptions is people walk through the door. There are zero in most of these cases that we are involved in, that actual interest in the care of these patients on the treatment. So not getting the services that they need and deserve and often times we are paying for it. Doctor, i like to refer to you about the question that you asked and about those homes that you dont know where they are. You have any way of telling us what opposite our homes exist to obtain this information because it seems like we need this information. And is difficult to obtain the information piece is i mentioned there is no federal oversight of the homes. It is left up to the state and states have varying practices for example, license and require certification and are is involved and some of it is volunteering in some of them just fly into the railroad. There are monday obstacles into identifying the homes that we have. I would highlight sir, this ties into your question today. Medicare, cms is going to be releasing us substantive issues disorder data book. That was a direct request from act which you all past a year ago. This will highlight the people and states who are getting recovery Treatment Services through medicaid. There will be a first important step to figuring out who is getting what and wait there are getting it and will better allow us to then assess the good from theta bad. Sue asked mr. Mundell, obviously i didnt t recognize you lost yr son and obviously thats a terrible loss for you. I hope you know that is not only your son, but everybody else that we arere trying to help in this regard. So that and we have to appreciate pictures. So i like to ask you this question and this will have to be muslim. Tell us more about what led you to develop National Standards of care. What i sigh out in the industry was literally three or 45 evidencebased practices that Treatment Programs should be following. Each with multiple published articles. Clinical trials showing that they work. If you do x, the patient does better. If you do abc the patient is better. There were 45 of these apparently. They werent all in one place per there were all in different Peer Reviewed medical journals. Theres not a business in america that notices anybody on 45, most businesses are successful in a row it down to less than ten. Core things that were freely move for success so i knew what we need it with less than ten Core Principles of care number one readily understood is a Surgeon General mentioned monday of those. Arliss was fairly close. Less than ten Core Principles up here to be easily understood, most portly number two, to be able to be measured. You cant measure 45 things. But you can measure less than ten. We purposely selected working with the leading researchers in the fig field. Factoring the researchers in crafting the 2006, Surgeon General his report, 16 Surgeon General his report which was followed up to the spotlight. Working with them to draft eight principles of care they can be easily measured that they were the most impactful to treatment. When it is inpatient and outpatient opioids alcohol adolescent or adults. Thank you chairman this is been an excellent panel. We thank you all for your commitment and compassion to the patients. Let me tellbe you what is foremt on my mind this morning. Every morning now, we wake up to these newsf reports. That there is a sever with the state the communities to work with pharmaceuticals and companies and come up with a settlement that deals with the opioid drug addiction and the overdose epidemic that the Drug Companies contributed mildly to facing in this country. If these Court Settlements go forward, it is almost certain that a significant portion of that her name is going to go to Substance Use treatment. And it ought to. But based on the fraud and the ripoff that you are already describing to us today, it seems to me that this lack of oversight, could mean it with a potential influx of more her name, we are creating a perfect storm for more fraud. So i think what i would like you to do doctor dunnigan, is tell us going forward, what should the federal government working with the states and the private sector do to make sure that if that settlement takes place, and there are billions of dollars telling you Substance Use Disorder Treatment, what should the state and private sector do to make sure the dollars go to reputable operators and not more prods. Thank you. It is they big question. However, our work would show that the certification process and the license process and the narc certification, the charter houses have oversightp so it would be good, to ensure the funds could at least go to those homes. Select one of the gaps in those areas. My understanding is youto all he already identified some gaps today in the oversight of some of those key areas. Gaps are numerous. Is a mentor before, there is no federal oversight to help us with this program is you had enntioned. To mix in you make the point person on the federal side. With the speed the center for medicare and medicaid. Who would you make the point person given the fact that you see that there is nobody coordinatingth this. We do not look at that directly. We do know that sam says providing grant her name and so that is one way to diet with the states are doing. Would that be the most costeffective. Based on your mark, what would be the most costeffective way starting a federal side, to fill the gaps. Perhaps it would be e better. Unfortunately, i havent looked at it which is better. Clearly samsara and samsung are one of the other gaps. The otherer gaps, we really just dont have an understanding of the states arent able to do various things. Not one program is all. This is the grassroots loophole and some of the state that we interviewed, dont want to actually have federal regulations because they are afraid than you would have less of these recovery homes. What would be the two mostf serious gas. In other words, youve got to start somewhere, you gotta have somebody at a federal loophole or donating it. And theyre going to see what are the two most serious gaps and if you dont deal with them the her name is going to get ripped off. I wish i could answered that, but i dont know the answered to that. Who would know the answered that. It would be able to tell us with all of this her name coming in and with the biggest gaps are. Is an excellent question because we do look at the number of individuals that we had interviewed just to get an understanding of the oversight of these homes. Let me go to mr. Mundell, i think you guys have alreadyde started on the way to answering this because you found some problems with the accrediting organizations and the like. Together that. I suspect monday in this room would agree that it is difficult forsp the federal government to get down to regulating at the local loophole. Only the feather federal government can do, is conditional the grants is giving to states and estates doing evidencebased practices. So for example, theyre going to be giving out billions of dollars to states. Samsara could very could condition that her name im going to states in states did the following five or six things my. Is Number One Center has been a leader in working on these kind of behavioral issues right now. Talking about the federal government. Taking this over correct, we are talking about the fact the federal government, Substance Abuse, significant amounts of dollars that the federal government has been involved with. And then being a partner with the accrediting organizations and with the states and the private sector, and the like. Will hold the record open to the chairman, i would be very interested in hearing from each of you that what youe think is the biggest gap are right now in fillideas for helping to them in a glass of like to throw the cake to my seatmate here, this and good work on being part of this Bipartisan Coalition that is coming up with the actual plan to deal with it. Thank you. Yes or two things enticing us. Thanks, one is the hhs pillars, better data. I stressed state Health Department. Again Substance Abuse data book is the big deal because it will give the states better information about what is going on where so they can make better choices and did hulu lift up and who needs to be investigated. Better data. Number two, again, is gary mentioned, is mr. Mundell mentioned, we need to let the consumers at the local loophole no what to look for in a good Treatment Center. Someplace, look at what shatterproof is put out and look at what we have put out. And use your centers to push that information out to individuals who are making those decisions. His parents are going to Treatment Center after Treatment Center and dont have a checklist to tell to tell good for matt. We have the checklist available. We need to help you havend you help us questions out. Keep the record open chairman must move quickly. The next ten days. We like to have recommendations to make sure that if we see this, influx of her name, its not going to be abused to more fraud. I just like to recognize this is exactly why worry are having this hearing. Very constructive conversation. Thanka you. Drug overdose overdose is now the leading cause of death. For those on the edge of 50. In the United States. Let that sink in for a moment. It is sobering fact. No doubt our country is in the middle of a major opioid and drug epidemic. My home state of montana, is math is destroying families and communities in fact from 2011 to that 2017 there was a 415 percent increase in math cases in montana. With methylated deaths rising 375 percent during those same years. Unfortunate, in my state of montana, the meth crisis is disproportionately impacting native american. Thats why we had the debate up here that included a piece of it legislation and helps strengthen Indian Tribes ability to combat drug use this i product which ws signed into law by the president last year. Is a good first step going others a lot more to do. We need to put an end to the tragic stories we are staying. Number babies being born addicted to meth. No more stories of meth breakig up families overwhelming our foster carer system. Numerous stories of individuals being taken advantage of who are desperately seeking Substance Abuse treatment. I know i can speak on behalf of montana, weve had enough. Doctor adams think for being here. First i like to invite you another h administrations officials to come to montana see firsthand how this meth crisis Mexican Cartel meth is affecting our m communities. The opioid academic has been felt there but one of the sheet Biggest Challenges we are facing is matthews. Doctor adams, can you speak to how meth is the next wave to the Opioid Crisis. You know right, in montana near meth overdose rates have gone up 26 percent actually inri all percentages. 23 percent increase in overdose due to meth in stimulus. You know exactlyly right. I would look back to the edge is strategy put one better prevention treatment and recovery. Better research on pain and addiction. A third of my commission or officers. My surgeon and of Public Health, work at ihl his facilities. We see this firsthand. I visited tribes reservations all nation and what i want you to know is this Opioid Crisis its not a problem so much is it is a symptom. Is a symptom are for our failure to recognize behavior Health Issues. To build resilience into communities. A failure of our recognition to see that there are massive untreated and undertreated pain in our country both emotional and mental and physical and so we really need to lean into truly better prevention treatment and Recovery Services that include all of those things otherwise were just going to keep playing wacko over and over again. And will put out the opioid fire but a meth fire, will pop up again in our country were seeing you have any particularly in montana. On the west coast. Soon it once upon the time the homegrown meth, there used to be the source of meth at levels of about 25 percent. Today the Mexican Cartel meth, have north of 95 percent of these bad levels. It is much more potent and the prices have come down because there is so much more being produced and the distribution certainly has become much more sophisticated. Were literally, takes a couple of days to the time it crosses the southern border to the time it hits montana. We bring together Public Safety and Public Health and we need to work on the supply side and he talked a lot about the supply side. But i will tell you, but it deac withli demand, if we dont deal with people selfmedicating away their pain in the Mental Health issues, theres always going to be a supply. Somebodys going to find a way. I completely agree with you as well. Lastly, i do believe we need this multifaceted approach. You alluded to that. To combat this epidemic. Ive been pressing the nih medication assisted treatment format to treat meth addiction. While it exists for opioids and alcohol and other drugs, there is no match for beth. Doctor adams, are you familiar nihs. Specifically on this topic, i will tell you what she told me. Unfortunately, the research out there right now, its not promising in terms of developing mat format. They have spent millions of dollars, and they will continue to spend more her name to try development, but her best solution right now, is prevention. Trying to get upstream and try to deal with these problems before they turn into the nextry wave of a meth epidemic but we will still continue to devote research and find solutions for people who need to recover. You commit to working with me to advance these efforts to assist montana overcoming the meth epidemic. To make absolutely sir. The parts of our country, where our native American Tribal folks pireside, are very personal to. Swear i try to make a point of getting out to and visiting. I commit that we will not forget about those individuals there. They are citizens of our country and they should not be forgotten. Thank you. I ask unanimous consent to enter letters and others into the record these folksy devastating effects on Substance Abuse of our local communities. That went out objection so order. Senator. R. Thank you very much. Thank you so much for holding this hearing. And to each of you, on the panel thank you very much this is incredibly important topic that affects all of us and in some way. I am so sorry to hear about your son ryan and i am sure that he is part of the separate you have put into moving this forward. In making a meaningful difference. For so monday of the other families. Ive heard like everyone else so monday horrifying stories individuals and families struggling to get substanceth abuse as well is Mental Health and how they are very much together. We know very monday times mental illness, and people are selfmedicating. With alcohol andos drugs when underneath there is a Mental Health issue as well. People are trying to do the right thing trying to get the best possible treatment but ultimately, is youve shown shown, people could be taking advantageth of. Unfortunately i believe that this is happening and structurally we treat behavioral how addiction and Mental Health, differently for reimbursement. It is quality standards and is evidencebased but it is also, predominantly do this ingress ratherli than reimbursement ande do for healthcare so we have federally qualified Health Centers and reset high standards yet full investment if you are in a physician at this Health Center and we dont yet fully have that on Behavior Health learn the working hard on. We know right now based on eight state demonstration process theres a white right way of doing things. We can spend dollars much more wisely with high standards. Couple of years ago, i am so grateful for senator, the leadershipip on this table, we have people oklahoma oregon pennsylvania nevada new jersey, where we have not had two years of data what happens we do set quality standards on Addiction Treatment and Mental Health. And then see how it plays out free people going to jail, and more people getting the treatment that they need and i want to thank the chairman and Ranking Member and so monday people here for giving us the opportunity now through additional legislation to actually take the next step to more services and more states and to actually be able to put this into place. We havee seen, and just a short amount of time that this transformative, also grateful this is in the budget, and santa has been elite in making sure were doing grants to begin to set the structures. So general adams doctor adams, can you provide an update on the administration workrelated to have the limitation of what we have called the excellence of Mental Health and Addiction Treatment act as well is the Certified Community Behavior Health Center Grants that are beginning to move this structure forward. To make thank you that question again this is very personal to me, is i mentioned since in jail right now due to privacy committed to support his addiction and deftly started with and recognize and untreated anxiety. And depression. We know that monday of these Substance Use disorders are going. With behavioral Health Issues and its a priority for us to make sure the folks who are being treated for Substance Use disorders are harming the Behavioral Health taken into that recognize before they turn into substance issues and selfmedication. You asked for anali update. You spoken with rick secretary, and he shares their excitement about what is happening. I would tell you we have behavioral Work Force Training grants,h and 2 million in 2017. Mental health and Substance Use co occurring treatment expansion over 550 million distributed to 1200 Health Centers across our country. The pilot grant that you mentioned, so far the results look good. Physically we share your concerns, thank you for your support in michigan, your policy date 10 percent decrease in your overdoseu rate. You look to this is both a mental and behavioral issue in a substance is to disorder. Not separated out the two. I want to see quickly, i often tell folks a long time ago and partially, we cut off the head from the rest of the body what, i mean, by that is we said that anything that happens from here up or allow Efficient Health and Mental Health, is it hard to see somebody good luck. Anything that happens here then will take care of it is your primary care visit. The Surgeon General i am talking to providers in professional organizations and encourage them to integrate Behavior Health back into primary careur. We know weather its addiction or Mental Health, its a brain disease. This very important part of the body we should treat it is we treat every other part of the body and i think my time is up so i will indicate in the areas now we have Certified Community Behavior Health centers, we actuallyly have medication assisted treatment and specialists. Real trained people with evidencebased Treatment Options that are working with people in each of these centers are also 24 hour seven day a week access to services. Crisis or services. Folks are actually able to talk to somebody that is trying to help them. Think it was chairman and again i think all of our panelists. I certainly agree with the points of cinder wyden and others that we need morepa informationn for consumers and more transparency in order to prevent fraud i also agree that we have to get the for that. This notice easy to have to in a row it to consumers can use that information most effectively in making decisions. Ms. Miss does provide us some ability to look at a group that has looked into these issues. I want to go on to avoid doctor adams made we do talked about the five key messages for addressing Opioid Crisis specifically mentioning Recovery Support services. In maryland we have found that the heres the support is worthwhile in our communities. I included a provision and support act that dealt with and studying the Medicaid Programs, her support. In the county, derek county, they are working to increase the group is at capacity for peer support in Emergency Rooms. Bonner county looking at nontraditional hours to make sure we have spear support programs. Dorchester county there is one call peer support programs that are available. I would like to get your view is to how effective you think pierce support programs have been and what we can do to try to encourage more opportunity for peer support to color in nonconventional nontraditional hours in Emergency Rooms and things like that. Ive been all over the country in the communities that ive seen that have been able to turn around the overdoses and opioids have done for key things. Number one they saturated their communities with lockdown. Peace cant get somebody into treatment if the dead. They had a warm handoff usually through some sort of peer recovery dive boat program. Number three they have provided medication assisted treatment because that is the Gold Standard in a report and had strong publicro safety and publc Health Cooperation said again we can go from criminalizing the problem to medical lysing problem. You asked what we can do, i would tell you that i am very proud of the fact that during this administration, we have increased the number of medicaid 1115 waivers substantially. Trying to have been approved during this administration. That is giving the flexibility to pay for things they feel are appropriate to improve success rates in treatment and recoverya including peer recovery. Including housing and child care and transportation, we need to provide Wraparound Services. You are rightdi senator, the recovery is one of the key tenets in making sure that you can stop your overdose reversal rates to get people in the becoming productive citizens again. In some states, have implemented on medicaid program, do you have any information is to the effectiveness of the peer support programs on the medicaid program. Is good that you mention the support act because they are getting ready to begin a review of this beginning to look at medicaid use of peer support in the various states iic dont hae an answered for you now but we do have work that is beginning. It will provide those answers. Am pleased to see that. Keep t us informed him that i would very much appreciate that. I like to get on to one more issue. In maryland we are looking at Stabilization Centers. Two counties have started them. To get those who are only out of the Emergency Rooms. I certainly agree doctor adams, let them live, so Emergency Rooms are not good places for people needing care. The current Reimbursement Structure sort of works against stabilization center. What an emergency room, coast is covered. What can we do to encourage that dive boat care that a person who is stressed needs. Usually nonconventional hours, during the middle of the night, and allow for the funding of programs such is Stabilization Centers and communities. I would highlight given states the flexibility to fund these types of programs. Such is we have done through the 111515 waivers. Mr. Mindel, you can speak from personal expense about the struggles of bring your son in over and over and not having a place for him to go. And it will help him. Absolutely, and i think, it comes back to quality measures is far is measuring and finding through science, were the most effective methods hard to treat people. And having a transparent set of quality measures for the information is published on a regular basis we have talked about consumers seeing the informationor where they can len just in the family members and its also for failure. To understand which providers are most appropriate in their networks in which was or not. It is also for state regulators. Also information the providers can learn from each other. We talked a little bit here about theat unscrupulous provids out there. But theres a lot of good people in the provider community. The law and scrupulous. They dont have the information about what programs are most effective existing tactics are most effective. And if we have transparent quality information, that even having to regulate, they will learn from each other and have the information they need to improve. So its not just ratings, its quality measurements and quality improvement. Senator hasnt, you brought up doctor allen than my wife, so heres what i found out. [laughter] your wife sat beside my wife at the international meeting. We had lunch, at the Indian Museum and she was the hostess at the International Club meeting in the childrens and at nih. Your wife really that active. My wife yes and she shared her his story. Monday of you know this, my wife just finished treatment for melanoma at the National Institute of health. Work is a freak based on the last pet scan but she shared her straight and your wife was so incredibly kind. She was nervous telling her story. Shes not a public speaker andnd you can tell im pretty nervous about talking in public two. Butf she did a great job and she appreciated the support from barbara. My wife is the 33 survivor of breast cancer. Yes exactly, she shared that. Thankmy you. I just got a promotion. Thank you chairman presley and Ranking Member quite and for holding todays hearing. I want to thank all of our distinguishedu, witnesses for being here today. Doctor adams and mr. Mindel, i particularly want to thank you both for sharing your family stories because in doing that you really do help combat the stigma that is such a part of this disease and undermines our capacity to treat it so thank you. O is monday of mention today, a year ago today, the sport for patients have community exactly signed into law, passive to the legislation was a critical step in addressing the Opioid Crisis. The crisis didnt happen overnight and we note that it will take those continuous and sustained investment at the federal loophole to curb and ultimately reverse the tide of what is truly a horrible epidemic. I look forward to continue to work on a bipartisan basis to adequately fund the support act in building the support act, and expand access to prevention treatment and Recovery Services. I wanted to start with a question to doctor adams and doctor denman mccauley, about services and access for women in particular. Does the office on Womens Health estimates that 70 percent of women injuring Substance Abuse Disorder Treatment of children. And monday residential Treatment Programs to allow children to be present when the mother is receiving treatment. This is obviously a real barrier. We have good examples of what works. Residential recovery homesr have offered services for pregnant and postpartum moms. Like help on haven hill in rochester New Hampshire. When proven to be really effective. Data shows that when pregnant women and new moms have access to longterm treatment, that its improve for the entire family. Unfortunately recovery homes are few and far between. Is one of only a handful of them available to women in New Hampshire. Throughout newbe england, report were discussing today, have shown that some recovery homes are skinny patients and their not using evidencebased treatments need it to be used. On the best means for recovery for monday womans his residency in oxford house. Is an evidencebased recovery home model that addresses addiction. And according to the gao reports, only 29 percent of oxford houses in the United States provide Recovery Housing for women. So doctor adams what is hs doing tong expand access to longterm evidencebased prompts, that allows them to remain with the children in a safe environment and how can congress support those efforts, thus the question that i want you to answered. Then to doctor mccauley, after doctor adams, do we ensure that we are providing access to the increasing number of women in need of treatment and Recovery Services and especially given the relatively limited number of high quality recovery homes deserve women. Admitted New Hampshire monday times. Few places have suffered is much from the Opioid Epidemic but also few places have had is much success in overcoming the Opioid Epidemic. You decrease by 10 percent. A lot of that is been due for your focus on nas. Have been in hospitals in New Hampshire learn about the work theyre doing there. Doing. Acl has an innate neonatal training initiative. Best practices including keeping mom and the baby together. Ive partnered with doctor mccain task write an article calling on more ob gyn providers to become trained in atc we are playing hot potato with a mom is has these disorders. So we take care of her. And to other models i mentioned frequently the maternal opioid misuse model will increase access to effective Substance Abuse Disorder Treatment to a focus on improving the quality of care for pregnant and postpartum patients and created one for kids the again emphasis providing support pritikin agree with the more we are trying to do all we can to provide that flexibly. New hampshire also has 1115 waiver. Thank you. Its similarly and we looked at reports on neonatal syndrome. Ongoing work on mood work eternal. We have a report that is coming out and looking at medicated Opioid Use Disorder Services for pregnant and postpartum women is a part of the support act. I think its actually being released today. There will be some more information there. Thank you. I know im running out of time. A follow up with you doctor adams we have a bill to help remove the waywardness necessary for physicians to be able to do medications assisted treatment. I am concerned that people dont understand is the Gold Standard and how important it is and im concerned about the stigma attached to mat still and so i have a question for the record for you to follow up on that because we really need to get the word out there how important it is. See mcafee to follow up. I apologize for passing over you. Thank you. Doctor adams and i recently spoke with the constituent who son is grappling with the substance based problem. And she mentioned there is a disconnect between and she is been told by experts is the appropriate time for her son to be in a Treatment Center. And what her insurance will cover. So now cycle through treatments a couple of times and its not the first time i heard this. Which drives me to the question. Do you think there is a disconnect between what we know our evidencebased best practices for Substance Use Disorder Treatments and the coverage of such programs. I cant stand any plainer than that. We think you are going to put somebody in a Treatment Program and then four to six weeks are going to be magically cared. The recovery is the lifetime is one of the reasons that hhs is focusing on trying to emphasize treatment and recovery and provide the flexibility for safe to be able to provide this Wraparound Services that transition in recovery moving forward. What would you recommend then to close the gap between what is paid for and what is recommended. Tonight i can only speak on best practices but i will see that its important to folks look at the fact that you know not going to solve this problem with a short four week fix treatment and that we need to fund that spectrum. And were trying to use the flexibility we have within cms through 1115 waivers to give stateses the ability to do that. Seems to me that this is more consequential, the way it is operating. To the live of the individual and when we rotate people in and out to get paid for distancing with services. What now came based system that will help. Captured certainly pushing towards that. The whole service world, i think needs to be looked at very closely. We need to make sure we are paying people to actually create health and wellness and not paying people to do procedures or to keep someone is an inpatient untilno the funding rs out. Again hhs is committed to providing that flexibility but also to incentivize new payment models. We look at what we are doing through ccm i, weth are trying o help states andal local entities figure out what works best for them but to show proof of concept so we can scale it up. I have wanting to give my deepest sympathies for the loss of your son. As part of their dea license of prescribing controlled substances. And because doctors right now prescribe oxycontin. Vicodin, percocet all opioids. Without having any training. And then to be trained in basic prediction one education of addiction thats t what the federal government can do and then to leverage what the government can do like the speed limit number one performance state medical society conforming to cdc prescribingt, guidelines. And to follow that quality Measurement System there could be others. Not specific to us but tying it to the state only going to state funding only going to evidencebased Treatment Programs of evidencebased practices so you can determine which programs are evidencebased practices. Requiring medical schools in their state to have basicl training on prevention and treatment of addiction and their right there are three that are significant improvements to the system. One more federal to have federal legislation to require any doctor in this country who wants to prescribe you pin or freeing to go through significant process with the dea like hours of training, oversight by the dea, doctors can prescribe oxycontin without any additionalni training. White after with the whole process to prescribe epinephrine cracks less than 5 percent can prescribe that less than 50 percent of the counties in the United States even have one doctor prescribing eppendorf rain. There is legislation now told him that in mind a limit that 2000. Thank you very much. Other witnesses welcome. Doctor adams we are proud of you and the state of indiana and doing the countryry proud. I was glad to see you highlight the important work in richmond indiana in your testimony they are really making a difference as well. Doctor todd graham is a physician with over three decades of service was senselessly killed july 26, 2017 for refusing to prescribe an opioid to a patient. Tragic. In his memory i worked with then son senator donna lee in a provision to reduce the overprescribing of opioids by examining ways to expand the use of non opioids alternatives within the medicare program. How is hhs working on increasing the utilization of the Pain Management approaches . I have to tell you this is a major precipice for us with our fivepoint strategy on addiction and it cannot happen fast enough. What folks dont realize 25 years ago when they told me to come from another place so we do still have annd epidemic of untreated and undertreated pain in the country. Now were pulling those opioids back now we have a decrease in prescribing but what i say is that we are also measuring and substituting in its place and people will continue to self medicate and be angry when they dont get their pain treated we will continue to play whack a mole. Initiative grants grants to increase research in terms of pain and addiction we have gone around the country to lift up these mechanisms and that has done a lot to pay for the right thing perk i have looked at this this is. We put a lot on cms but the gorilla in the room are the employerbased and not being the first drug dealer to pay for vicodin but not one of those alternatives. Thank you. Thatat is important and appropriately on that treatment i know you agree with this but we also need to make sure people are ines Treatment Services that are actually working. This is something i put great emphasis on on the Health Committee hearings during the Opioid Crisis last congress. In testimony to say there is a mass of evidence on prevention treatment and recovery strategies. Can you elaborate in terms of treatment . As i travel around indiana and talk to Different Service providers and doctors and others, have to say there is heterogeneity often times varying perspectives on what works and what doesnt. I highlighted one because we need to make sure that someone has done the treatment they can be reintegrated back into Society Stigma is killing more people and it causes them to relapse if they cannot find a job and be reintegrated into the workforce. There is a very important part looking at that Scarlet Letter we attached to people when they come out of a Treatment Center that prevents them from getting a job. With Treatment Centers you are right there is too much hetero and ginny eddie and i would like to turn thiss over to my colleague. Absolutely. The Treatment Center we have identified has seven principles every program can have everyone a full and complete not just addiction but mental or physical issues and needs to be complete with an evidencebased instrument that is reliable and validal delivered by somebody who has the credentials to deliver it the right way. Number two once you have the assessment continually reassess and care adjusted if i have chest pain today they will not tell me based on the first 15 minutes of questions here is what your treatment will look like for the next 28 days. They wont tell me for the next two days or one day. T they will test me again and readjust all along the way. Many Treatment Programs dont do that so to continue to reassess and care is adjusted. Number three evidence to evidencebased medications even for alcohol. Number four access to behavioral therapies. Theres only six that were in the Surgeon Generals report in 2016 to highlight in the spotlight that randomly controlled trials to be proven to work i go on and on its on the website but they are easily measured. I also note it takes 17 years on average for evidence to reach the field that is unacceptable perk i would welcome a future dialogue about things we could do at the federal level to compress that timeframe. E to use the bully pulpit of the Surgeon General chair the criteria to look for at the Treatment Centers we do want to help share that. I will be the last one and will you close the meeting . I have to go to a meeting in my office so i call this panel for this very fruitful meeting. Thank you. I will reconcile as much time as needed. [laughter] thank you for being here. Doctor adams everything hhs has done with the task force on Pain Management which is really good because your statement earlier said there is still untreated pain be a people are dying from addiction and as you know they differentiate between the patients in chronic pain never escalating or working in society from the person who breaks into a car to steal a purse. That is a distinction as a physician do we turn our back on this person to turn our back on theseh people. Second, to my two folks in the middle you feel ignored but i have been thinking about you. I hear private Insurance Companies are very capable to look at Pain Management and the outcomes but who is released but then it goes back into more care versus those who have the same response. We hear that medicaid does a poor job of that. It would seem that this could be done in terms of diagnostic codes if somebody has a billing for admission to a Pain Management center and then ade readmission related to Drug Overdose within a period of time and you compare everybody against everybody you look at improving their work and then you should just be kicked out. So what are the obstacles to doing so . Either of you . From the oig perspective we do a lot of analysis similar in the medicare space. We have great access to medicare claims perk on the medicare side we dont have that same level. So we do have to transform medicaid is not ready for prime time . Not quite ready yet. But it is rapidlyly improving which makes me think some states i know the 48 that are currently participating. So can we take those as a proven concept that are already submitting and then create a system of scale as others come on board . That is something we could explore. Why not something we do . I dont want to commit our auditors but that something we are very interested and i will take it back and follow up with you. Similarly what we have done that i am familiar with is related to the medicare data and has been reported. I have spoken to the people who work for the clearinghouse if they choose a medicaid plan they have to do data. It has to be with a unique lyidentifier because it transmit data from plan aletter to plan b so they actually have it with a point of information. As gao we work for you and we would welcome a conversation to have a discussion about what we couldat do in this area. I will ask one more time. Roughly in the time it takes you to complete a study, it takes a little while. We need real time. So is it possible for hhs to stand up and do the analysis may be getting a system from one of theseit two to employ so you dont have to wait for a year and a half for an excellent study but by that time the situation on the ground has changed. I will take that back and you know i will follow up with you. I appreciate your leadership is one of the few physicians in congress i i that is a very good point and question and issue. I have done a lot ofer work in jails. And 15 percent of males in a jail have a Mental Health issue 30 percent of females. Currentis law is if you are jailed even before adjudicated you lose your Veterans Administration and medicaid benefits perk i have been arrested and then you have to spend months in jail before you go to court i am mentally ill now ive lost mymohs benefis and then im found to be not guilty perk on that making things up this is fairly common. That the formulary in the jail does not include those psychotropics for those people on medicaid in the free world that my care could be disrupted and my condition may decline. I am begging the question but gived it a thought for review as to whatever the score, the wisdom of allowing medicaid and v. A. Benefits to continue with someone who is incarcerated at least prior to the point to be declared guilty or not guilty. You bring up two important points. Number one jails and prisons are the de facto Mental Health providers and we have to dig our way out of that. I saw that first and we had to work with the jails to solve the hiv outbreak related to prescription opioid use because we know that so many would cycle on and off a significant proble problem. So they are admitted for hiv so they are disrupted because they get off the one that controls it. It certainly is not optimal. We need to look at how we can transition but i will also save plainly and a frankly i learned in indiana flexibility at the state level is because of the law as written we need to take a lookta at that and care the person and the patient because they were implicationsat. Senator brown is here from ohio. I think the score is 10 billion over ten years as i have described. As they are adjudicated. I would like to add something for over the last hour we have talked about the we havef of theabout components and solutions but i think it would be helpful to go back to Surgeon General adams has mentioned three times in the lasty hour Something Else that has gotten any airtime which is the stigma which is the biggest killer out there and not talking about the specific issues why has he said that . Because stigma reaches everything we have been talking about for the last hour. That there are policies in jails where people lose their insurance, why is that . Because most people in america think bad people do bad things who cant make decisions. But science shows thats not the case. It is our payment policies that are equal to other physical diseases. Because its a Healthcare Industry that says it is their fault. 20 percent of doctors in this country in a recent study we did which c i suspect is relative to the rest of the country dont want people in their waiting rooms that might affect their practice 80 percent of americans in recent poll said i am uncomfortable associating with somebody that is addicted to prescription opioids. My friend or coworker or neighbor. If we overheard those we were talking about and someone gets the treatment even though 20 percent it is the key reason they dont go to treatment is they dont want anyone to know. Once they get past the hurdle and their parents for seven they get the treatment. Even though there are very few providers and then that delivers quality care. That want you working next to them were working in their neighborhood or marrying or dating their daughter. Im sure we did not see the statistics the 20 million americans not just opioids those that were addicted to drugs or alcohol. But they feel it every day you thank you for being so honest with your experience. Senator brown. Thank you for coming to my office several months ago i know there is a lot of pain in this panel deaths or incarcerations we dont think should have happened and then t help others that many of us have had and then to start and then there is a couple of questions for you first. So working on this report how many instances of Substance Abuse Disorder Treatment related medicare or medicaid fraud did you investigate across these five states where patient was the perpetrator quick. Thank you for the question we are concerned we dont do the investigation of the case that is a better question for camister cantrell but we did find all five states had fraud and then we spoke with the various actors involved including the medicaid fraudud unit and to our knowledge for example in florida unknowingly they brokered and were sent to other places without their knowledge. Based on your work is it your opinion the individuals with a Substance Use disorder are generally the culprits of fraud or the victims quick. Overwhelmingly it seems we have had some participating patients maybe they were a patient or they tried to solicit other individuals but they are the victims of these crimes. Do you both believe that states are doing a good job to address fraud and they maintained the tools that they have . And that is necessary to police this fraudulent behavior committed much less often by the victim in the perpetrator quick. Certainly on the Health Care Fraud even if they are very active in this space but it has been a need forr additional oversight with the oversight of the Treatment Facilities that there are quality treatments to receive federal funding and the treatment we all expect. We found florida and massachusetts and utah but in iowa they didnt have those programs that they were provided trading and other services to the operators of the home. They were very concerned. I preface this that every one of us inin this committee doing enough with prevention education and i applied doctor cassidy for his interest in those incarcerated to keep them on medicaid it is just upside down thinking that you take away their medicaid when they need i it. Clearly we are not doing enough to provide those Treatment Options with the overall number of those of Substance Abuse disorder and those that receive treatment over private coverage thousands of ohioans are receiving Addiction Treatment right now because of medicaid. A man put his hand on his daughters arm and said my daughter would not be alive if not for medicaid. We know those stories. Soi my question is answer as close as you can has it put additional burdens that makes it hard to access and maintain that it could compromise efforts to Substance Abuse disorder arere those additional burdens quick. Talk about medicaid quick. Make it as effective as we possibly can. Which provision you are talking to but it with the Record Number of waivers to draft those programs in the in theirworks constituents. We currently have work to medicated assistant treatment. We look at eligibility but im not the expert in that. I would completely with the premise of the Surgeon General specifically that any barriers for dont have insurance to get medicaid would create more loss of life. People going to pr rooms and prisons, the more people that can be on medicaid that need it that are qualified for medicaid without the barriers absolutely 100 percent. So that imposition of theci state Medicaid Programs will have a Chilling Effect on roaccess to treatment to underscore the ludicrous far too many people that they are trying to repeal the Affordable Care act they are trying very hard they want to do it through the courts. It is stupid and it means a lot more people die. 900,000 people have insurance that did not havee it. So thats what it means to youngg people on their parents plan or for the expansion. We had one who showed most courage than members and expanded medicaid aches saving thousands of lives. It is a stupid policy to think to be on the Affordable Care act could be good for the country. Can i make oneab quick comment . Very quickly i would say i ran the state department when we expanded coverage to several hundred thousand city citizens and to hear that wacess to Quality Affordable Health Care is Important Administration believes we should have that flexibility for what works best for them. Again the Record Number shows a commitment of that flexibility and in that Opening Statement and in indiana and in new york. So we talk about work, we understand one of the biggest predictors that will be successful of longterm notvery is whether or they can get back to work per guy will be the first to admit it is a hot button political topic but to say we need to think about ways to help people reintegrate back into society. That is what i am focused on. How do we lower the barriers for people getting back to work . Thank you so much for the opportunity to testify. It is criticallyy important. I also want to give you a shout out for that work in ohio. And by over 10 percent. In large part because we expanded medicaid in the United States want to take it away. I appreciate your comments on work requirements but the fact is the president of the United States once to wipe off the book with no replacement of medicaid we have driven down the death rate and addiction rate because we have that very important to all. Thank you all for your testimony we will leave the record open for two weeks of submissions we are adjourned. [inaudible conversations] [inaudible conversations]. Welcome. I serve as president of the jesse helms center. Located in North Carolina just outside of charlotte we are a 501 c 3 nonprofit that houses youth programming