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

Recent high profile case involving treatment scams in ohio, and investigations and partnership with the fbi and Law Enforcement generally, leading to the indictment of six people this year, all six pled guilty to medicaid fraud. Some have called for developing more by which the public could evaluate the effect in the Treatment Programs. Our last witness, has gone a step further not only identifying it core standards, he believes are key to any successful program, but also launching quality rating systems. This is uncharted area treatment sector, and we look forward to hearing from him, the progress thats been made there, with his Non Profit Organization. We are here today because two Many Americans have lost too many loved ones to addiction. Americas Opioid Crisis has left a trail of broken hearts and homes across our country. We are here to help communities get on a path towards health and wellness. Millions of americans are desperately seeking a path forward. Working together, we can save tax dollars and save lives. Senator . Mister 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 am, because we both know there are members who 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 a Substance Use disorder. An american battling this disease is often jostled and pushed around from one end of the Health Care System to the other. The last thing you need when you are suffering from this disease is yet more obstacles. Rip off 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 arrive at a legitimate Treatment Facility only to find that they have fallen prey to a scheme. The goal of which is to train their bank account and just milk their insurance for every thing it is worth, in some instances, on scrupulous operators are working to lure patients by paying a 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 fraud stirs just go out and build the Insurance Companies for Health Care Companies that may never been performed. One of the biggest problems involves facilities that treat Substance Abuse disorders but are actually set up to rip off taxpayers, they illegally recruit patients using bribes and kickbacks and then they milk the taxpayer by building the Patients Health plan for medically unnecessary drug tests, schemes like this, im very pleased to have this terrific group of witnesses today, they are going to outline in these schemes in detail and of course these schemes as well medicare, medicaid, cost them hundreds of millions of dollars a, rare justice on six people operating fragile and Treatment Centers pled guilty to submitting 130,000 medicaid claims that totaled more than 48 Million Dollars for medically assisted treatment and other services i would never legitimately provide, part of the reason this is so common is there is no way for a patient or family to learn about the quality of a Treatment Facility before they enroll. So today we are going to hear from an organization that is saying hey, wake up everybody, this has to change, shatter proof is currently developing public databases in multiple states that if successful will allow the public to identify, evaluate, and compare value substance Treatment Programs. This kinds of 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 is that we were preparing for this preparing hearing, is that it is particularly important now to set in place a kind of concrete policies to rip off, to make sure that these programs are not ripped off and that the patients are not taken advantage of because when you read in 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 help seed the epidemic, i can just look down the road because i have heard about this from virtually all of my colleagues, so if youre talking about a fund of tens of billions of dollars, a some of that size is going to be a magnet for the fraudster and rip off artists, so this will highlight the need to make sure that there are rules of the road so that those dollars actually go to help patients get proper care and all that new money doesnt just find its way into the roof off artists, i think the witnesses and miss chairman again we will work on this in a bipartisan way, and i look forward to the witnesses and colleagues hearings. Thank you mister chairman, thank you for giving me this courtesy, its a real pleasure to welcome all of our witnesses today, particularly welcome the syrian general doctor jerome adams, he hails from maryland, a proud son of maryland and had a glowing career, first winning the prestigious scholarship to county where he received both in a bachelor of science and biochemistry and a bio of bachelor of arts, i say it is because we had conversation before with doctor freemen at you nbc, he calls doctor adams is most accessible failure, thats because the Scholarship Program is a program that has been extremely successful and African Americans obtaining their phds and going on a two extraordinary successful lives, well doctor adams does not have a ph. D. But he does have a masters degree and an empty degree and of course is had very successful career, i want to congratulate him for his leadership in our country, the service to our nation, he attended Indiana University school of medicine and was a Company Scholar before serving as the United States Surgeon General, he was appointed by the Indiana State Health commissioner, he has found his time focusing on combatting the Opioid Epidemic, he has been an advocate of behalf of Public Health in our country and we are very proud of his service and very proud to have him hail from our state of maryland. Well the three of you if i can just go to the testimony on it. I have talked to all of you in my Opening Statement because of the time constrains, i want to start with the Surgeon General, will you start and then what we will do is, go in the order that you are sitting there in the table and then we will have questions after you all get done. Fantastical, good morning chairman, my wife says to tell barbara i and we cant wait to bring the kids out to the farm, i hope she told you about that. Everybody knows a bow my wife, does anybody know about me . Ranking member wide in and swedish members of the committee, will you give me a few minutes to acknowledge the flags flying at half mast and lift up the examples of representative cummings, his life was the very definition of Public Service and my condolences go to his family that are all blessed to know him. For my testimony today i would like to begin by thanking all of you mister chairman for passing the support act, which has enabled our country to make progress in the fight against the Opioid Epidemic, i am pleased to be here today on the one year anniversary, americas overdose an addiction crisis is one of our most daunting Public Health challenges, recognizing its scale and scope it launched the five point strategy in 2017 and under that strategy we are achieving better addiction, prevention and Treatment Services, better data, better paid management, better targeting of overdose drugs and Better Research. Ive been engaged on this policy, and as you heard from senator nick cardin, dealing with an unprecedented hiv outbreak, but my work on the Opioid Epidemic is very personally. Younger brother philippe struggled with the addiction, he struggled again with untreated depression, getting to self medication and opioid use. And like many with Health Issues he has support in and out of course ration, he is currently serving a tenyear mark this guy can happen to anyone even in the brother of the United States Surgeon General and when stigma keeps people and shadow, it mps our collective recovery. To address this epidemic, my Office Released a spotlight on huawei its, a digital postcard which you can find at Surgeon General dog in which you have in front of me janet senators, and an advisory on opioids, i want to leave you with five key messages at a detail on these publications. Number one Early Intervention is critical, Evidence Based prevention screening programs work but they need to be initiated early in life, we can wait until someone is in a high school or college to talk about the dangers of opioid issues. Number two must be integrated into mainstream health, care as an example medicare assistant treatment is the Gold Standard but in the course of the year only one in four people with opioid use disorder receive special treatment. Number three having the bloc zone, can save a life and me i hope you know about, this i carry this wherever i, go its literally that easy to save a life. Since it was published, almost 3 million to davos units have been distributed, but too many needlessly die. Fourth comprehensive Communities Support Services are essential, and i saw this firsthand when we visited the industries and indiana, they came up with pathways to recovery, and where failed drug test offer drug counseling and participants that state have assured jobs, and this is also vital to the degree in new york that provides Employment Services for out judgment, no, resume no work history, no background check is required, at the bakeries model which i love is, we dont hire people to bake brownies we bake brownies to hire people. And when it comes to opioid uses, this inside he must to continue u. S. Front can criminal justice used to a Partnership Based run, stigma and judgment are keeping people from disease of, addiction people like my brother from getting the help they need and is in my opinion is killing more people than overdoses. In conclusion, under this administration and through your support, a historic investment has been made in combatting the Opioid Crisis, by the end of 2019, hhs will have awarded nine billion dollars to states and tribes and local communities to combat addiction. This includes nearly one billion across 375 projects and 41 states as part of their and for ending addiction long term hell initiative. And if these funds expand access to agreement, and surveillance, insist artisan ministration, we have seen the amount of opioids nationally drop in terms of prescriptions, we have seen a number of americans receiving treatment grow, now nearly 1. 2 7 million americans are receiving treatment and we have doubled the number of providers who have their data waiver. And the drug quo provisional death drop by 5 , our first draw wage many, years we are making progress, but challenges remain including the resurgence of meth amphetamines, we need to increase support for comprehensive support programs and to support assisted Treatment Programs with warm me and in, care we also must expand the behave real workforce and we talk about that before the hearing, i promised you, i promise you that hhs in my office will continue to focus on this critical Public Health issue and i thank you for the opportunity to testify and i look forward to your questions. Doctor before you began, with a lawyer background and animal science, how did you end up doing this . As you probably are aware there is a nexus between Animal Health and Public Health and i think they recognize that. Well i needed that explanation. Sure. Proceeds these. And chairman grassley and members of the committee, i am pleased to discuss on the oversight of recovering homes, Substance Abuse and drug use is a problem that is ruined families and take analyze the da reports that since 2011 Drug Overdose has allowed alone ive been leading cause of death in the United States, outnumbering deaths by, guns car crashes, suicide, and homicide, recovering homes can offer safe and supporting houses, unfortunately bad actors have use 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 g eight oh found that all five states have received complaints of fraud related to recovery homes, four of the five, florida, massachusetts, ohio, and utah had or were in the process of conducting investigations. For example, officials told gao, that fraud was extensive in southeastern florida, a Task Force Found that operators were lowering individuals using deceptive marketing techniques, such as promising of free airfare and rent. Recruiters then broker these individuals to providers who builds their and sirens for hundreds and thousands of dollars for unnecessary drug testing, home operators were then paid 300 or more per week for every patient they referred. At the time of our arm hurt some arrests had been made, and mass since two since they found that some owned recovery homes and referred patients to, labs other labs are paying kickbacks to home for a patient referral for testing that was not medically necessary and between 2007 and 15 they settled with an iron labs in 4 Million Dollars of restitution, and the time of our report ohio was investigating fraud at the recovery center, this monday reported that six people planning guilty on for building medicaid more than 40 Million Dollars in drug and Alcohol Recovery Services that were not provided or not medically necessary. To increase over saint, florida, massachusetts, and utah establish either a licensed or or a voluntary Certification Program that included incentives for recovery homes to participate. Our other two states, ohio and texas, do not have similar programs but we are providing programs and resources such as training to recovery homes. Despite such efforts fraud continues, for example the Pennsylvania Attorney officers recently completed an 18 month investigation looking into Insurance Fraud Treatment Centers, charges included kickbacks for unnecessary drug testing and billing Insurance Companies at exorbitant rates. Those charges actually got them working in unlicensed recovery homes where the houses were sometimes unsafe, employees and patients were engaged in sexual relationships and there are opportunities to realize, this is the case of the bad guys getting caught and that is what raised me to my second point. We do not know the total number of recovery homes and therefore we dont know the extent to which this is happening. In addition no federal agency oversees the operations of these homes to provide a nationwide perspective, in closing when run properly recovery homes are an important part two nations path to serve right in combatting the Opioid Crisis. Our work on recovery homes as part of the gao broader work on drug misuse, we have explored federal oversight in medicare, we also have ongoing work on identifying accessing important overweight misuse, much of our work is as a result of mandates from the support act which was signed one year ago from, today we highlight this another work in our latest highrisk report where we identified as federal efforts to prevent drug misuse as an issue requiring very close attention. Thank you chairman and grassley, Ranking Member widen, and members of the committee for holding this committee, this concludes my remarks, im happy to answer any questions you may have. Good morning chairman grassley and member widen and other distinguished members of the committee, i am the deputy neill or i appreciate you coming here for you to combat the Opioid Crisis, our ongoing work is taking a multi faceted, approach looking at a variety of issues for prescribing and treatment to this crisis, they are addressing it through expanded Law Enforcement activities, audience, and data briefs, our efforts to combat this wall ensuring both substance and treatment and continuity of care continue in our top priority, we have expanded enforcement efforts the, resulting in an increase of over 100 percent of open investigations at our office from 2015 to 2019, just this year the newly launched appalachian regional strikeforce, a joint initiative between do i jay, oig, and fbi and, partners took down 73 individuals. 64 of them medical professionals, for participation and illegal prescribing of opioids and related to Health Care Fraud schemes. Opioid fraud comes from a broad range of criminal activity and addiction Treatment Services and billing schemes, our growing concern is fraud and medication, sober homes and ancillary services such as counseling and drug test screening, and sober homes continue to increase in conjunction with increased demand and availability of federal funds to support the services we have seen in the commensurate increase in illicit schemes, as our enforcement in oversight efforts to address this crisis have expanded we have also come to understand the impact of that are enforcement where we can have on the patients that we served. We recognize that when i clinic whose patients are was just prescribed avoids, are shut down, access to care can and will be disrupted. Rather than leaving these patients to potentially turn into another fraudulent provided or stream drug, we want them to have access to quality treatment and Pain Management services with minimal disruption to conduct, but this is not something that Law Enforcement can do alone. Ensuring these patients have care requires a collaboration with our federal state and local Public Health service officials. As part of the appalachian takedown, the Law Enforcement partners in us work with age ages offices for secretary of health and the center of Disease Control and prevention, and state Public Health agencies, to prove or state and federal Level Strategies and resources to provide assistance to patients. Oig will continue to work hand in hand to help ensure access to treatment and continuity of care for patients impacted by our efforts. Beyond our enforcement efforts we grow our roast best performance of work related to the crisis, ongoing work that identifies opportunity to strengthen the Program Integrity and protect on patients across the treatment i mention of this crisis, we have treatment related audience and evaluations underway, examining issues such as access to medications, and employment an oversight of state treatment grants, we look forward to sharing the results of this work with the committee when it is complete. Oh i jeez reason did a brief shows significant declines and opioid prescribing, at the same time in show that the number of patients receiving medicare is increasing, this is a very positive sign, however there is still much work to be done to reduce illegal prescribing of opioids, was only to track from the efforts to provide these that the visions truly need. Thank you for allowing me to discuss this important topic what, do i look forward to any questions you may have. I realize a little bit i said about you in our Opening Statement, i need to recognize your success in the private sector and now bringing that to the Non Profit Organization jar to help us accomplish this goal, as you have said that and so proceed. Chairman grassley, Ranking Member wide, and members of the committee, thank you for holding this hearing, lie name is gary vandal and im the founder and chief executive officer of shadow proof, a National Nonprofit organization dedicated to review forcing the addiction crisis in america. For nearly a decade my son brian struggled with Substance Abuse disorder, despite as working tirelessly to find the best possible care, on october 20th 2011 we lost my son to the disease of addiction, in the months that followed i was destroyed all over again when i learned that research existed, proving the type of interventions that would significantly improve the outcome of brian and millions of others who were in treatment for addiction. If only we had known what to look for, that is why i found it shadow proof, the first Non Profit Organization dedicated to reversing the induction crisis in america, to accomplish this we developed a five point planned to transform the Addiction Treatment in the United States, never won a core set of science base principles for care and treating addiction, number two quality measurement system, number three payment reform, number for treatment capacity, and number five ending stigma. My remarks today will focus on the second of these five, treatment quality measurement, addiction is a chronic brain disease and despite the fact that there are clear best practices the use of these practices various widely, across the treatment field and some facilities are still employing tactics based on and effective and outdated methodologies and unlike other Health Care Services comprehensive and standardize data on the quality of Addiction Treatment does not exist, even worse because consumers, payers, and state regulators do not have access to quality measures, Market Forces have not been aligned to support these best practices. In 2006, in a landmark report by the institute of medicine, it calls for a development and dissemination of a common, continuously improving set of measures for the treatment of Substance Abuse disorder to drive Quality Improvement, seizing, on along this recommendation to develop a platform for three aims, number one providing patients and family members the information they need, to identify treatment for their loved, ones number two equipping providers with data to advance the use of Evidence Based Practices, and number three injuring policy and payment decisions are data driven, a tool builds upon our a National Principles of care that were developed with experts in the field to establish addiction should be treated like any other chronic is illness we are currently in phase one of that and i were in Treatment Facilities and other stake holders in six states, delaware, louisiana, north carolina, west virginia, massachusetts and new york, thus far this phase has included identification and refinement for the expert panel strategy sections and Public Comment period, and claims measures and a pilot of Patient Experience survey across different Treatment Facility in the state of new york, quality data will be collected and triangulated from three sources. Claims data, Patient Experience survey and Treatment Facility survey, and reported through our analysts saying back to providers, to the public, to paris, and to states you. When i say the public, the families, following Evaluation Phase one, shatter proof will work with other states to bring the resource to serve more than 21 million americans with Substance Abuse disorder. Alice is part of the strategic goal to transform the Addiction Treatment in the United States to reverse the addiction crisis that is had such a severe and tragic toll on far too many and to which the impact can absolutely be avoided for so many others, thank you for the opportunity for testifying today and i look for is your questions on. We will have fiveminute round of questioning, we will start with the Surgeon General, first of all i know and thank you for the top priority we have with Surgeon General and even probably as an individual to making and addressing addiction as a top priority, i also think the efforts to prioritize and carrying out the enactment of this legislation. Section 70 31 of the new law calls for the best practices, has the administration appointed members to develop such best practices or identify the factors that could identify fraudulent recovering operators by support and if not could you give us a timetable when that might happen . Thank you for that question sir and i want to recognize that iowa has led the way a 14. 7 decrease in overdose raids in the past year, it has been reported so we need to share more of what is working in iowa with the rest of the country including connecting people treatment and Recovery Services, i will tell you very specifically, in the spotlight on addiction which i highlighted, this came out last year, there wasnt much fanfare and theres a lot going on in d. C. Nowadays in folks dont always notice, but i highlighted what to look for in his Substance Abuse Treatment Program. Personalize diagnosis set cement, long term disease management, its not just Substance Use disorder, or its hiv, hepatitis is, for Mental Illness, and effective behavioral interventions, coordinated care for other diseases and diagnosis and Recovery Support services. So my role is to help give the Public Information they need to have informed decisions, we put that out, we also have the treatment finder, and beyond that in terms of bending good from bad i will turn over to my friend from oig. Unfortunately we only encounter the that, bc institutions that are not providing the institutions that they are willing for, they do not receive the type of counseling theyre supposed to receive, sometimes we see prescription pads just left behind for staff, not qualified staff at the facility right prescriptions as people walk through the door, there is zero and most of these occasions, we are involved in actual care for the treatment so they are not getting the services that they need and deserve and oftentimes are paying for. I wanted to ask you a question here for it in your testimony about not knowing how many homes or where those recovery homes are, do you have any way of telling us what obstacles exist to obtaining this information . It seems like we need this information. Yes it is difficult to obtain the information, as i mentioned there is no federal oversight of these homes, it is a left of to the states and states of varying practices, for example some license, some require certification, some of it is voluntary and some of them just lie under the radar, so there are many obstacles to identify these homes that we have. Sir i would highlight and this ties into your question, today medicare will be releasing a Substance Abuse disorder data book, that is a direct request from the support act then you supported a year ago, this will highlight the people in the state that are getting recovery and Treatment Services through medicaid, that will be an important step to figuring out who is getting what and where they are getting it and will better allow us to assess the good from the bad. Obviously, i didnt recognize that you lost your son and obviously that is a terrible loss for you and i hope you know that is not only your son but everyone also we are trying to help in this regard, so that and we really appreciate yours, and it is my last question, what helped you develop a National Standard of care . Sure, is this on, and yes, yes, what i saw in the industry was literally about 45 Evidence Based Practice is that Treatment Programs should be following, each with multiple published articles, Clinical Trials showing that they worked, if you do x the patient does better, if you do abc the patient does better, but there are four to five of these approximately and they were not all in one place, they were all in pure viewed medical journals. There is not a business that has things, most businesses that are successful narrowed down to the less than ten core things that removed for success so i knew what we needed was less than ten Core Principles of care, number one of that could be readily understood, the general just mentioned many of those and lesson ten principles of, care number one i can be easily understood, number two most importantly, that can be measured, you can measure 45 things but you can measure less than ten, and we purposefully selected working with the leaner researchers, many that drafted the 2006 sergeant generals report that was followed up in the spotlight, working with them to draft eight principles of care that can be easily law measured, whether i was opioids, adolescents, or adults on. Thank you this has been an excellent panel and we thank you all for your commitment and compassion to the patients, let me tell you what is foremost on my mind this morning, every morning now we wake up to these news reports that there is this effort with this states and communities to work with the pharmaceutical companies and come up with a settlement that deals with the opioid drug addiction and the an epidemic that then Drug Companies contributed mightily to facing in this country, law it is almost turn that a significant portion of that money is going to go to Substance Use them treatment, it out to vote based on fraud and rip offs that you are already describing to us today, it seems to me that this lack of oversight could mean that with a potential influence of more money we are creating a perfect storm for more fraud. In through the colors we like you to do doctor, Going Forward what should the federal government working with these states and private sector due to make sure that if that settlement takes place and there are billions of dollars coming in for Substance Use on, what should they do to make sure they in dollars on go reputable operators and not more fraud. Its a good question, although our work will show that the certification, process the license process, the charter houses, have oversight so we would be good if we can ensure the funds can at least go to those homes that have some form what are the gaps in those areas . My understanding is that you already identified some gaps today in the oversights in those key areas. In the gaps are numerous, as i mentioned there is not one federal oversight to help us with this program, as you mentioned there were so he would you make the point person on the federal side . What is being the center of medicare, would it be the point person given the fact that there is nobody coordinating this. We did not look at that directly however we do know that samsung is providing grand money so that is one way to tie into what the states are doing. Would that be the most costeffective . Based on your work what would be the most Cost Effective ways turning on the federal side to fill the gaps so samsung would be better than . Unfortunately we havent looked for me to say which is better, however clearly seeing how us and others are involved. What are the other gaps . The other gaps is that we really dont have an understanding and the states are hearing very little theres not one program, this is a Grassroots Level some dont want to have federal regulations because theyre afraid that they would have loss of these recovery homes. What would be the two most serious gaps . In other words after this somewhere, and if you have a federal level reordering, and what are the two most serious gaps and if you dont deal with that more money will get ripped off . I wish i could answer that on. Who would be able to answer, that who can tell us with all this money coming in what the biggest gaps are . I think that is an excellent question because when you look at the number of individuals that we have interviewed just to get an understanding of the oversight of these homes. Lets go to mr. Mandel, you guys have already started us on the way to answering this because you found some problems with the accrediting organizations and the like, i gather you said that. I suspect many in this room would agree that it is difficult for the federal government to get down to regulating to the local level but with the federal government can do is condition all the grants it is coming to states on states doing Evidence Based Practices, so for example, sam said will be giving out billions of dollars to states, it could on condition that money if states did the following five or six things. My point is, number one the senator has been a leader in working on these kinds of behavioural issues right now, we are not talking about the federal government taking this over, we are talking about the fact that the federal government, ever talking about Substance Abuse, their significant amounts of dollars that the federal government has been involved with and the federal government being a partner with the accrediting organizations and with the states and the private sector and the light, will hold the record that durant has had, i would be very interested in hearing from each of you, what you think the biggest gaps are right now and you are ideas for helping to fill them and i also like to throw a bouquet to my seat made frittering good work on this and being part of the Bipartisan Coalition that is coming up with an actual plan to deal with it. Senator why did you ask for two things, 20 seconds, to big, things the hhs fillers is better data, i used to run his state health department, against the substance of your status book is a big deal because it will give states better information about what is going on where so that they can make better choices about who to lift up and who needs to be investigated. So better data is one, and number two i get anne as mr. Middle mentioned, we need to let consumers know what to look for and a good Treatment Center so please look at what shadow proof has put out and look at what we put out and use your positions to put that information out to people and dont have a checklist to tell good from bad, we have the checklist available and we need to help us push it out. We will keep the record opened, chairman wants to move quickly within the next ten days we would like to have recommendations to make sure that if we see this influx of money we are not gonna see it used for more fraud. We will get a senator daines and id like to recognize this is exactly why were having this hearing and it is a very constructive conversation. Thank you mister chairman Drug Overdose is now the leading cause of death through those under the age of 50 in the United States and let me let that sink in for a moment its a sobering fact. No doubt our country is in a major Opioid Crisis and we absolutely must do more into combat this drug epidemic, in fact in my home state of montana it is a matte that is destroying families and communities and in fact from she doesnt 11 to cheer dozens of teen there was a 415 increase in math cases in montana with matt related deaths rising 375 during that those years. Unfortunately in and my state of montana the matt graces is diverse proportionally impacting native american tribes, thats why it made up here included the mitigating matte act, and helped strengthen Indian Tribes ability to combat drug use and the support act that was signed by law last, year it was a good first step, but we solve a lot more to do. On the need to put an end to the tragic stories we are putting in the news, no more babies being born addicted to, know more stories of individuals taking advantage of who are seeking Substance Abuse treatment, i know i can speak on behalf of montana, we have enough. Doctor adams things were being, here first i like to invite you another hhs Administration Officials to come to montana to see this on matt crisis, its Mexican Cartel matte that is affecting it. Although the Opioid Crisis is in affecting it, matt is the biggest news, you can you speak to how matt is the big wave of the Opioid Crisis. Thank you for that and you are right and in montana the overdose rates have gone up 26 in the last year, we know that well we have seen a 5 decrease and opioid on, we have seen a 23 due to meth and stimulant, you are exactly right. I want to go back to the hhs strategy, better provision treatment and recovery, and number to Better Research on addiction. I want to say that a third of my officers work at the health facilities, we see this firsthand, i have visited tribes and reservations over the nation, and what i want you to know it is, this crisis is not a problem as much it is the failure to the system, to treat health is used, to build resilience into communities, its a failure to recognize that there is massive untreated pain in our country both emotional, mental, and physical. So we really need to lean and to truly better provision treatment and Recovery Services that include all those things, otherwise we are just going to keep playing whackamole over and over again and it will put out the opioid fire but the math fire will pop up again, in our country we are seeing this in montana in the west coast. If you look at the meth crisis in montana, the homegrown on meth that used to be the source, and purity levels of about 25 , today the Mexican Cartel anne meth have purity levels in north of 95 , so it is much more profit, into the prices have come down because theres so much more being produced, and the distribution has become much more sophisticated, we are literally takes a couple of days from the time across the southern border to reach a reservation in montana. We actually work to bring together Public Safety and Public Health, we need to work on the supply side and you talk a lot about the supply side, but i will tell you if we dont deal with demand, if we dont deal with people self medicating away their pain and mental Health Issues, there is always gonna be a supply, someone will find a way. I completely agree with you as well, lastly, i do believe we need this multifaceted approach, anne thats why ive been pressing the and i80 to treat meth an well it exists for opioids on, there is no mats for an are you familiar to do this for matt. Yes i had it too many conversation about this and i will tell you what i was told, the research is not an promising, they have spent millions of dollars and they will try to spend more to develop, it but our best solution right now is prevention, trying to get upstream trying to deal with these problems before they turn into the next wave of a meth, but we will devote research to try to find solutions for people who need recovery. Last statement would you commit to working with me to demands these reference to this montana overcoming the meth epidemic. Absolutely, certain parts of our country where native American Tribal folks reside are very, very personal to me and it is where i have tried to make a point of getting up to and visiting and i commit to you that we will not forget about those individuals their, citizens of our country and they should not be forgotten. Thank you dr. Adams. I ask you not to answer her letters from the federal Law Enforcement association and others into the record, these folks see the devastating effect on Substance Abuse of our local communities without objection, so senator stamina. So thank you so much for holding this hearing, to me on the panel, thank you very, much this is a very important topic that affects all of us in some way and im so sorry to hear about your son ryan, and im sure that he is part of the effort you put into moving this effort forward and making a meaningful difference for so many other families. I have heard like other people so many horrifying stories, individuals in the family struggling to get Substance Abuse help, as well as Mental Health, we know those are very much together, Mental Illness people are self medicating with alcohol and drugs when underneath there is Mental Illness as well so these are very much tied to the other, people are trying to do the right, thing get the best possible treatment, families, ultimately have as you have shown people can be taken advantage. Of unfortunately i believe this is happening in part because structurally on retreat Behavioural Health differently for reimbursement, its quality standards, its Evidence Based but its also, we predominantly do this through grants rather than reimbursement likely due for health care, so we have federally qualified health standards, we set high standards, and you get full reimbursement if youre physician or nurse at the health center, we dont have that on Behavioural Health which we are working very hard on right now. So we know on right now there is a right way to do things and we can spend federal dollars much more wisely with high standards, in fact a couple of years ago, im so grateful for the senator leadership on this as well, but on this table we have oklahoma, oregon, in pennsylvania, nevada, new jersey where we now have two years of data of what happens when you set quality standards, and Addiction Treatment and Mental Health and see how it plays out from people going to jail for people getting the treatment that they need and i want to thank the chairman and the members and so many people here for giving us the opportunity to take the next step to more services, more states, to actually be able to put this in place. So we have seen in a short amount of time, this has been and samhsa has been a league in making sure that we set up these structures, so general atoms can you provide an update on the administrations work on an implementation for the excellence of mount health and Addiction Treatment act as well as the Certified Community for the transit are moving forward. Thank you for that question, and this is very personal to me, my brother as i mentioned sits in jail due to crimes he did to support his addiction, he hadnt recognized and untreated anxiety and depression. We know that many of these Substance Abuse disorders or coherent with behavioural issues and it is a priority for us to make sure that folks who are being treated for Substance Abuse disorder are having their behavioural Health Issues taken into account but we recognize that before they turn into Substance Abuse issues and self medication. You asked for an update, i know you spoke with the secretary and he shares with on your excitement about what is, happening i will tell you the 50 million in twenties even teen, Mental Health Substance Abuse disorder over 550 Million Dollars dissipated to 1200 Health Centers throughout our country and then the pilot granted you mentioned, so far there is also, good so i just want to say succinctly that we share your concerns, i want to thank you for your sapphire for this in michigan, youve all seen a 10 decrease and i think it is because you looked at this is both a mental and Behavioral Health issue and a Substance Abuse disorder is you are not separated out the two. I want to say quickly, i often tell folks a long time ago we caught off the head from the rest of the body, what i mean by that, we said everything that happens from here off, or a, welt vision, all Mental Health heres acquired go see someone and the block, anything happened from here down we will take care as your primary care, im telling you we need to encourage integrating Behavioural Health back into primary care. We know that its a brain disease, its a very important part of the body and we should treat it as we treat every other part of the body, i know my time is up so ill just indicate in the areas where we have Certified Community behavioural services, we actually have medication assistant treatment, we have specialists, real trained people with Evidence Based Treatment Options that are working with people and in each of these centers there is also a 24 hour, seven day a week access to crisis services, so folks arent going to jail or an emergency room, theyre actually able to talk to someone that is trained to help them. Thank you mister, chairman i think all of our panelists, a certainly agree with the points that have been made by a senator wyden and others, we need more information by consumers, more transparency in order to prevent fraud and i also agree that we have to get the matrix for that and that is not as easy, we have to narrow it to consumers can use that information most effectively and making decisions, i do think it does provide us some ability to look at a group that has a locked into these issues, i want to go on to a point that doctor items made when you talked about the five key messages we are addressing, Opioid Crisis, specifically messaging mentioning Recovery Support services, and maryland we found that support has worked well in our community, i included provisions in support at that dealt with on studying in the medicare pays support, and in gary county theyre working to increase the capacity for peer support in Emergency Rooms, in the county they are looking at nine traditional hours to make sure we have pierce support, programs in georgia Chester County there is one call peer support programs that are available, i would like to get youre here and how effective do you think the programs have been, and what we can do to try and encourage more opportunity for peer support, particularly in non conventional and non traditional hours and Emergency Rooms and things like that. Ive been all over the country, the communities i have seen that have turned around through overdose raids have done four key things, number one they saturated their communities, you cant get someone into treatment and recovery if theyre dead, number two they have had a warm handoff, usually through some sort of recovering time program, number three they provided mitigation assistant treatment because it is the Gold Standard, number four and a strong Public Safety and Public Health cooperation, so weak in that applies the, problem and you asked what we can do, i will tell you that i am very proud of the fact that during this administration we have increased a number of medicaid 11 15 waivers substantially, 22 have been approved during this administration, that has given states the flexibility to pay for things they feel are appropriate to improve success rates and treatment and recovery, including pierre uncovering, including housing, including childcare and transportation, we need to provide those Wraparound Services but you are right, peter recovery is one of the key tenants and making sure you can stop the overdose and making sure people can become productive again. Some states have implemented under the Medicaid Program peer, support you have any information about the effectiveness of the peer support programs under the Medicaid Program . Its good to see you mention the support act because theyre getting ready to begin a review that is going to look at medicaids use of the peer support in various states, i dont have an answer for you now but we do have work that is beginning that will provide those answers. Im pleased to see that, if you can keep us informed i would very much appreciate it. I would like to get to one other, issue in maryland we are looking at Stabilization Centers, to get that out of the emergency room, i certainly agree that we want them alive, so the medication is important, to the Emergency Services are important but Emergency Rooms are not in places for people in eating care. So the current Reimbursement Structure works against a stabilization, center with emergency room snowfall costs its usually, covered what can we do to encourage that type of care that a person who is stressed needs, . Usually non conventional hours or during the middle of the night and allow for the funding of programs such as Stabilization Centers and communities. Well again i would highlight giving states the flexibility to find these types of programs, such as we have done through the 11 15, waivers this is a good one to pick to mr. Amanda, you can speak from personal experience about the struggle about bringing your son in over and over and not having a place for him to go that would help him. Absolutely, and then you comes back to quality measures as far as, defining through science where the most effective methods to treat people and having a transparent set of quality measures where the information is published on a regular basis, where we talked about consumers seeing the information where they can learn where to send their family members but its also prepares, for paris to understand which providers are most appropriate in their networks and which ones are not. Its also four state regulators and its also information that providers can learn from each other. We have talked about the unscrupulous providers out there but there is a lot of good things in the Provider Community that are not unscrupulous they dont have the information about what programs are most effective in which tactics are most effectives and if we had transparent quality information they can learn from each other and all the information they need to improve, so its not just ratings, its quality measurement, its Quality Improvement to find the resources to do so. Senator you brought up dr. Adams my way, so here is what i found out, you are wife sat beside my wife at the International Club, we had lunch at the Indian Museum and she was not hostess at the International Club meeting, the childrens and, is your wife really that active . My wife is and she shared her story, she just finished treatment for melanoma at the National Institute for health and we are cancer free based on her last pet scan, a your wife was so incredibly kind, you can tell im pretty nervous talking in public but my wife to degrade job and appreciated the support. My wife is a 33 or survivor of breast cancer, she sure that. Dr. Hanson, thank you i just got a promotion, thank you chairman grassley and Ranking Member wyden, i want to thank all our witnesses for being here today, but dr. Adams and mr. Mandela i want to thank you guys for sharing your family stories, enduring that you combat the stigma that is such a part of this disease and undermines our capacity to treat, it so thank you, as many have mentioned today, they are again today the support for our patients and Community Act was signed into, law on the passing of this legislation was a critical step in addressing the Opioid Crisis, but the crisis didnt happen overnight and we know it will take a continuous and sustained investment at the federal level to curb and reverse the tide of what is truly a horrible epidemic, i look forward to working on a bipartisan basis to find the support act, to build on the support act to prevent treatment and Recovery Services, i want to start with the question to dr. Adams about services and access to women in particular, the hhs office on Womens Health estimates that 70 who enters Substance Abuse treatment of children and many dont allow children it to be president when their mother is receiving treatment, this is obviously a real barrier. So we have one set offer services for britain postpartum moms, so they have true proven to be really effective and when pregnant women and moms have access to Evidence Based treatment outcomes improve for the entire family, on unfortunately recovery homes like this are few and far between, its one of only a handful available to him in New Hampshire. Moreover reporting from news lets more discussing today have shown in that some recovery homes are scanning patients are not using the documents we are asking them to, use one of the best means to recovery is residency an oxford house, which isnt Evidence Based recovery that addresses addiction, according to this report only 29 provide Recovery Housing for women, so doctor adams what is hhs doing to expand access to long term evidence pastry manage for moms and allows them to remain with their children in a safe environment and how can congress support those efforts, that is a question i want you to answer and to the doctor after doctor adams how do we ensure that we provide access to the increasing number of women in need of treatment and Recovery Services especially given the relative limited number of high quality recovering homes and serve women. I visited New Hampshire many times, few places have suffered as much from the operate epidemic but also few places have had as much success in overcoming the, epidemic and owner that has been tear focused on this, i have been to the hospital there and focus on the work, there what are we doing. . Well we have a National Training initiative for the best practices, including keeping moment baby together ive partnered with the doctor to write an article calling on more ob gyn to become strange so that we are in playing hopping potato with a mom and that we can can take care of our. Two others and i will mention quickly on the misuse model will increase treatment and improving the quality of care for pregnant and postpartum patients and the integrated care for kids model through this is a child center in service that emphasizes providing those support, and so can agree with you more and we are trying to do all we can to provide the flexibility and we also have an 11 15 weyburn that provides more flexibility. Thank you. Thank you gao, we have looked at neonatal absent syndrome and we also have ongoing work on mortality, courtroom virtually doesnt relate to the Opioid Crisis, we have on the reports coming out on medicaid and postpartum women as part of the support, i think its actually being released today so that there will be more information there. Thank you i know were running out of time, i will follow up with you doctor adams, and i have a bill to help remove the waiver innocence airy for physicians to do medication assistant treatment, i am concerned that people dont understand that it is a Gold Standard and how important is, im concerned about the stigma attached to him 18 still 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. Absolutely, happy to follow up. Senator bob menendez i apologize for a passing over you, i apologize. Thank you for holding this hearing, doctor adams i spoke with a constituent your son is grappling with substance based problem, she mentioned that there is a disconnect between what she has been told by experts is the appropriate time for a reason to be in a Treatment Center, and what her insurance will cover so now he has cycled through treatment a couple of, times this is not the first time ive heard this what drives me to the question and, do you think there is a disconnect between what we know our Evidence Based best practices for Substance Abuse treatment and courage for such programs . Yes i cant get any plane earned, that we think we should point someone in a Treatment Program and that in four to six weeks they are going to be magically care and we know that recovery is a lifetime and its one of the reasons that hhs is focusing on trying to emphasize treatment and recovery and provide that flexibility for states to provide that transition and recovery moving forward. What would you recommend to close the gap between what is paid for and what is recommended. I can only speak on vexed practices not on regulation legislation, i will say that it is important that folks look at the fact that youre not going to solve this problem with a short four week or six weeks treatment, we need to fund that spectrum and again we are trying to use the flexibility we have to give states the ability to do that. And seems that is more consequential the way it is operating now, the more its consecrated to the left an individual and when we wrote people in the campaign for difference agents in services, what an outcomebased Payment System form remit Treatment Services insuring best practices involved. It is something we are pushing towards, the whole Service World i think needs to be looked at very closely, we need to make sure that we are paying people to actually create health and wellness and not paying people to do procedures or to keep someone on their until their funding runs, and we are committed to providing that flexibility but also to incentivizing new payment models, if you look at what we are doing we are trying to help states and local entities figure out what works for them, we like to show proof of concept so he can get out. First of all, you have my deepest sympathies foreign youre lost, none of this is easy, you previously stated that you do not support federal regulation but an approach to how highway funds are talked about in speed limit changes, should the federal government tie funds to addiction space, when should all states have in the books and what if any laws should the federal government lead on to to ensure uniformity and protection . Sure can i add there is one federal law then i think is very important which many members are working on right now which is to require as part of their dna license all doctors in the field and psychiatrists, as part of their data license for prescribing controlled substances to tie into education, if that is done there will be a huge improvement in the system because doctors right now can prescribe oxycontin, mike it in, person its, all open wades without having any training, and to be able to be trained and basic prevention and treatment in addiction, it will be a huge lift to this country. So thats number one of the federal government can do, then to answer to your question, as far as what leverage the government can do for your example, the 55 mile speed limit, number one, state medical societies conforming to the cdc prescription would be a huge lift. Requiring states to follow a quality measuring system, like ours, ours is the only one out there but there could be others, its not specific to us, tying it to states, state funding that is coming from the government, only going to Evidence Based, to Treatment Programs following Evidence Based Practices, again that relates to quality measurement, so you can determine which treatments are following Evidence Based Practices, were crying better cool schools in their state two of the sikh training to prevent and treatment of addiction, there is three right there that will be significantly, significant improvements to the system, if i can add one more federal to illuminate that at 2000 which requires any doctor who wants to prescribe to go through a significant process with the dea, licensing hours of training, oversight on, doctors can prescribe without any additional training, why do they have to go through this whole process to prescribe the results in less than 5 can prescribe this, lesson 50 of the counties in the United States have even one doctor who can prescribe this. There is legislation now in congress to eliminate that in 2000, i would highly recommend that. Thank you very much. Doctor adams and other witnesses, welcome, doctor adams we are really proud of you in the state of indiana and we think they were doing in the country found in your current capacity, i was really glad to see you highlight velvet industries in your testimony, they are really making a difference as well, doctor todd graham ive physician with three decades of service was killed on july 26 2017 for refusing to prescribe an opioid to a patient, tragic, it is memory i worked with then senator to pass a provision in the support act then aims to reduce the over prescribing of opioids by expanding the use of not opioids alternatives within the Medicaid Program, how is it working on increasing the utilization of these not opioid management approaches . Well i have to tell you, this is a major point of emphasis for us, as part of our five point strategy, and it cant happen fast, enough when folks dont realize is 25 years ago when i was in medical school and they told me that paid it was the fifth title signed they came from a good place, we didnt still do have an epidemic of untreated pain in this country, we threw opioids at the problem foolishly, now we are pulling them back, we had a significant it agrees in a bright prescribing when i say to folks is that if we are also measuring what we are substituting to treat pain and folks are going to continue to self medicate they are going to continue to be angry when they dont get their pain treated and we are going to continue to trace our tails, so they order 945 million across 41 states to increase research and practices in terms of pain and addiction, we have also gone around the country and lift it up these different mechanism, cms has done a lot to make sure we are paying for the right things and ive actually worked with businesses because we put a lot on them and we have to remember that the other guerrilla or the employer based insurance and we have to make sure they are being paid for alternatives, many of them will pay for a 16 blanket in but wont pay for one of the alternatives for their covered lives. Well thank you i think thats really important and there is a lot of evidence appropriately so on the increasing access to treatment, we also need, i know you agree with, this to make sure that people are in Treatment Services that are working, this is something i place great emphasis on it during the hearings pertaining to the Opioid Crisis lasts congress in the testimony doctor items you say that we have massive evidence on prevention, Early Intervention treatment, and recovery strategies, can you elaborate on the evidence you are referring, to especially in terms of treatment because as i travel around the great state of indiana and talk to Different Service providers, doctors and others, i have to say there is harrow canadian. There is often varying perspectives on what works and what doesnt work. You mentioned a couple of, things i will work backwards, so we need to make sure that when someone is done with treatment they can be reintegrated back into society, stigma is killing more people than overdose is and it is causing people to relapse when they cant find a job, when they cant be reintegrated into society, so work is a very important part of, this post training and taking a look at the Scarlet Letter we attach to people when they come out of a Treatment Center that prevents them from getting a job, as far as Substance Abuse Treatment Centers, you are right there is way more heterogeneity, and i would turn to for hiding key aspects of what we should look for in a Treatment Center. Absolutely, we have identified several principles that they should have. Number one a full and complete assessment, not just of addiction issues, but also mental Health Issues, any physical issues need to be complete with all three when Evidence Base that is rival and valid that is delivered by someone who has the credentials to ask questions in the right way and understand it. Number two when you have that assessment to continue to reassess in your care, if i have chest pains today and going to the hospital they will not tell you based on the first 15 minutes of question, here is what your treatment is going to be like for the next 20 days, they dont tell me what my treatments when it relates to the next two days or one day, then they will test me again and readjustment all along the way. Many Treatment Programs dont do, that so continue to reassessed and carriages, to number three Evidence Based medication not just for opioids but alcohol, number for, access to behavioral therapies that are gabriel based, there are only seven that were in the Surgeon Generals report both in 2016 and highlighted in the spotlight and have randomly controlled trials tested and proven to work, they have to have those, i can go on and on, but its all on our website, they exist and they are easily measured. So i also noted that it takes 17 years on average for evidence to actually reach the fields, and that is gonna be unacceptable, so i would welcome the future dialog about things we might be able to do at the federal level to compress that timeframe sir. I will highlight use this to share the lists four steps and gradient to look for and evaluating a Treatment Center, but we need you all to how share that. Senator capacity will be the last one, and will you close the meeting because i have to go to a meeting in my office, so i think all in the panels and chairman for this very fruitful meeting, senator cascade. Thank you, and he can grant himself as much time is needed. Thank you for being here, first let me to highlight something doctor adams that hhs has done, you have a task force on Pain Management which is really good because youre statement earlier said that there is still untreated pain and yet we have people who are dying from addiction, that is attention and as you know anne they differentiate between they present from chronic pain never escalating working and society from the person who is breaking into a car to steal a promise to fight drugs, so that it is just distinction we need to make as a physician, and lets not turn our backs on the person who has that stable dose it is contributing to society, which includes people in this room anne and differentiate that person from, those secondly, to my to folks in the middle, youve been ignoring, but ive been focusing on you as well. I hear that private Insurance Companies are very capable out looking at Pain Management, looking launch internally at the outcomes, okay, who is released, then immediately goes back to a situation that requires more careful addiction, versus those that have a sustained response. Yeah we continue to hear that medicaid as a poor job of, that now it seems like this would be something that could be done with a supercomputer. In terms of, if you look at diagnostic codes, okay if someone has billing for Pain Management center and then they have readmission for something that is possibly related to drugs, overdose within a period of time and you compare everybody against everybody and you sort out whos doing a good job and who can improve their work, and he should just be kicked out, now one it is the obstacle for doing so, either of you . All stirred from oigs perspective, we do a lot of analysis similar to what you described in the medicare space. We have great access to medicare claims, but on the same side we dont have the same level of. So we do have the transform medicaid statistical information center, is not ready for primetime . Not quite many, proving, but not quite ready. It is rapidly improving, it makes me think that some states are ahead of the curve where some are still coming out, so can we take those as proof of concept that are already submitting data and then create a system that scales as other states come on board . That is something we could explore. Now why not something we need to . I worked for the investigations offices, but i dont want to come into anything and we can take it back and follow up with you. Maam. So similarly the work that we have done that im familiar with would be related to medicare because the data is there and we have previously reported. By the way can i answer one. Ding i have spoken to people that work for clearing houses, so when someone changes of medicare plan and they have to do data, these clearing houses are actually better because they havent all and it has to be with an identifier because it is transferring data from planning to, so these folks actually have a just appointed out as appointed information. So we actually work for you and we would welcome a conversation about work we can do in this area. Let me ask you one more time, because gao usually does a good, job of roughly in the time that it takes you to complete a study, an elephant is born, so it takes a while but doctor adams is it possible for a change as can stand up and maybe getting a system from one of these two folks but that what you can employ so that we dont have to wait a year and a half or an excellent study but by that time situation on the ground has perhaps changed . It is something i will take back, you know sir that i will follow up with, you i appreciate your leadership and one of the few physicians and i think you bring up a very important question and issue. Let me ask you one more thing, i have done a lot of work in jails, you mentioned your brother, thank you for your openness about that, i think the statistics is that 15 of males entering a jail have a Mental Health issue, 30 of females, if you add addiction to that you are going to be at higher. Current law is that, if you were jailed, even before you are adjudicated you lose your va and medicaid benefits, okay so i have been arrested but i am, i have three months and sometimes you spent six months in jail before you go to court, and i mentally ill but ive lost my benefits even though subsequently ive clear to me not guilty, this is a fairly common scenario, im not making things up. There is a Score Associated with this, but as a physician i know that if the formally area and then jail does not include the psychotropic said of stabilized me out of the free word free world, to then why care becomes disrupted, and my condition may decline, so im banging the question, but can you give your thoughts and maybe ill take it over to you sir as to the, whenever the school or, the wisdom of allowing medicaid nba benefits to continue someone whos incarcerated with the jail at least prior to the point of being declared guilty or not guilty. So you bring up two important points, number one our jails and prisons have become our into facto Substance Abuse disorder institutions, we have to flip that script if were gonna figure a way out of, this and its got county we have to law at working closely with the jails to solve the hiv outbreak that was related to prescription opioid issues because we know that so many folks will cycle on and off, it is a significant problem. So what youre telling me, is that they would be admitted for hiv and there were instrumental be disrupted and they will develop resistance and get off of whatever controlled it. It certainly not optimal for care and we need to look at how we can transition of that system, but i will also say just very plainly and frankly to you sir that i learned in indiana that we dont have a lot of flexibility at the state level, some of that is because the way the law is running curling, we need to take a look at, that we need to take care of the person and the patient because it has implications beyond that individual and on to society. And senator brown is here from ohio, i will need a bipartisan colleague, i think the score is ten billion over ten years to allow those medicaid benefits to continue and as i have described will be put in jail before their adjudicated, sir. Thank you, i like to add something, throughout the last hour we have talked about different components of the Opioid Epidemic and solutions, as we talked about the age we talked about how to remedy each of these individually but i think it would be really helpful if we can go back, Surgeon General adams has mentioned three times in the last hour or something else, i dont think it has got any area time which is stigma, Surgeon General has called the biggest killer out, there he hasnt talked about any of the specific issues being the biggest killer, its stigma, why has he said . That he sent that because sting arm regions everything weve been talking about for the last hour, if there is policies in jails where people lose their insurance why is that, that is because most people in america think that it is bad people doing bad things you cant make good decisions, when science shows that is not the case. Its why isnt our payment policies equal to other physical diseases, because we have grown up and a Health Care Industry that believes it is their fault, we shouldnt pay for treatment, 20 of doctors in this country and the state of massachusetts in a recent study that we did, which i suspect is anne relative to the rest of the country dont want people who are addicted in their waiting rooms, and might affect their practice, 80 of americans in a recent poll, 80 of americans say i am uncomfortable associating with someone addicted to prescription opioids as my friend, coworker or neighbor. So lets say we get through all the hurdles weve been talking about in the last hour and someone gets the treatment even though 20 have reported one of the key reasons they dont go is because they dont want anyone to know, that say they gave past that hurdle and they get the treatment, and then they find a provider even though there is very few providers and get treated for the reasons we are talking about. Then they get to a provider that delivers quality care through all the hurdles that we spoke about today, they are successfully treated, but then they enter a society where 80 of americans dont want you working next to, them dont want you living in their neighborhood, dont want you to be their friend, dont want you dating or marrying their daughter, im sure my son didnt see the statistics, nor the 20 million americans, this is not just opioids, they feel it every day. So i think you and doctor adams for being so honest with your experience, and helps fight the stigma. Senator brown. Thank you all for being here and thank you mr. Mindelo for coming to my office several months ago and i know there is a lot of pain on this panel and among a lot of us who have had deaths in our family that we think should have happened more incarcerations or just difficult time so things for you making innovation of our lives to step up and help others so they dont have to experience the pain that some of you and many of us in this room have had, i want to start with doctor macaulay, in the course of the work on this report, how many instances, i will ask a couple of questions, how many incidences of Substance Abuse disorder and Medicare Fraud did you investigate across these five states and of that total, what percent were a patient, where the patient was the perpetrator of fraud. Thank you for the question, we are a little, different we dont do the investigation of the, case that would be a better question perhaps for mr. Cantrell, whoever we did take a Sample Selection of five states and he found that all five states have reported fraud and then we went in and spoke with various after is involved in that, including the medicaid fraud unit, to our knowledge, again we dont go into the case but for example in florida they were lured there and on knowingly brokered and sent to other players is without their knowledge. I want to ask you when you can respond to that, today some of your work is it your opinion that individuals with Substance Use disorder is seeking treatment generally the culprits in this case of fraud or more likely the victims . In the cases we see they are the victims. Overwhelmingly . Overwhelmingly. We have certainly in our fraud schemes, participating patients who are off in, maybe there are patient but theyre also a patient broker where theyre trying to elicit other individuals to come into a fraud scheme, but generally speaking they are the victims of these crimes. Do you both believe that states are doing a good job addressing fraud when they say they maintain the tools they have at the forefront, that they have the tools to police this kind of fraudulent behavior committed much less often by the victim than the perpetrator . I think certainly on the Health Care Fraud space when we had the Fraud Control units theyre very active in this space, our office is very active but where i think there have been navy and need for additional oversight, its not in the Law Enforcement space but treatment and quality standards that weve discussed here today, and to be sure there are quality Treatment Services that are receiving federal funding and getting the product and treatment that we all expect. Similarly we also found that interstates, florida, massachusetts and utah had all started certification or licensed or programs in texas and ohio while they did have this program set they were providing training and other services to the operators of the hottest, they were very concerned and wanting to take steps. And these questions i will start with doctor adams, but you can answer and i preface it by, there i think, every one of us on this committee, in both parties think that we simply are doing enough with prevention education, upscaling treatment and all that, i applaud the doctor for his interest in a no working with others on the pretrial incarcerated to keep them on medicaid, its just, its upside down thinking that you take away their medicaid when they mostly needed at that point. We are clearly not doing enough to provide the kind of Treatment Options for everyone who needs them, we know the overall numbers of not only adults with of Substance Abuse disorder that receive treatment is low but we know those on medicaid are significantly more likely to receive treatment than those with private coverage for instance, thousands of ohioans are receiving treatment because of medicaid, i was at a Substance Abuse clinic in cincinnati and amanda put a hand on his adult daughters arm and sort of gently said my daughter will not be alive if it wasnt for medicaid, we know those stories, the statistics and my question for each of you, if you could answer as close as you can to a yes or no. Is putting additional burdens on beneficiaries make it harder for them to access and maintain coverage, that could compromise efforts to address the Addiction Treatment and limit access to substance disorders, those burdens helpful or are they not . Well are you talking about medicaid . Okay, well i would say that we want to make medicaid as effective and as easy to see this as we possibly can, you frame as a burden, i dont know which particular provisions you are referring to, i do leave that we should make medicaid more available and we have tried to give states the flexibility through a Record Number to craft there Medicaid Programs in a way that works for their citizens and constituents. And so we currently have were looking at beneficiaries of medicaid and their access to assist in treatment, for example. We have work that looks into Medicaid Eligibility but i am not the expert on that so i would have to get back to you on that. I would completely agree with the comments earlier, these are in general specifically, at any barriers for those who dont have insurance to get medicaid would absolutely create a lot more loss of life and cost to our system, so people going through pr, rooms to prisons, etc, etc, we need to keep as few barriers as possible so more people can be on medicaid that needed, that are qualified for medicaid without the barriers, absolutely, 100 thank you and i appreciate the response, and i will close with this, the imposition of work requirements and state Medicaid Programs will have a Chilling Effect on access to treatment anne, this hearing underscores the ludicrous and it is and the hard heartedness of anne far too many people in this party and the Trump Administration who are trying to repeal the Affordable Care, act they couldnt do it, here they tried very hard, they couldnt do it, here they want to do it through the courts and its hard hearted, its stupid, it means a lot more people die on this assaults, and many have insurance i didnt have it for the Affordable Care act and we know what it means to young people when their parents plan and we know what it means for the expansion, we had a republican governor who showed more courage than most of his Party Members around the country and expanded medicaid and saved thousands of lives, is just absolutely cruel and stupid to think repealing the Affordable Care act could be good for our country, thank you. Senator cassidy, can i make one more comment . I would just very quickly say that i ran state in indiana when we expand in coverage to several thousand citizens, as Surgeon General i want everyone to hear me say that access to Quality Affordable Health Care is critically important, this administration believes that we should give states the flexibility and the opportunity to do it the way that were expressed for them anne, again in the Record Number of 11 15 waiver it shows a commitment to that flexibility in giving states that flexibility and in my Opening Statement i talked about anne developing industry and, the bakery in indiana and i think it is important when we talk about work and i understand if one of the predictors will be successful is whether they can get back to work and so i will be the first that it is a hawk but requirement but i dont use in the strong data where we think about ways how people reintegrate deciding get a job. Thats what im how can we bring people together so folks can recover . Thank you for allowing me to testify indiscreetly important hearing. I went to give a shout out to the work you are doing in ohio. You have been able to drive down your overdose rates by 10 and it is because of partnerships you have brought. That is because we had medicaid and the president of the United States wants to take it away. I appreciate who appointed you. I dont know, your political philosophy doesnt matter but i appreciate your comments on work requirements but the president of the United States wants to wipe off the books the portable care act with no replacement on medicaid and the fact that we have driven down the death rate in ohio and addiction rate in ohio is because we have that very very important Public Health tool. That will be the final rule. The chair will thank you all for your testimony. We will be the record open for two weeks for submission of questions for the record. The hearing is now adjourned, thank you. [inaudible conversations] booktv has live coverage of the texas book festival from austin starting today 11 00 eastern with other discussions on the Trump Administrations immigration policies with washington correspondent julie davis and michael share. The life and career of former un ambassador Samantha Power and the impact of disinformation with the under secretary of state richard stangl. Live coverage from the texas book festival continues sunday at noon eastern with surgeon and Johns Hopkins University Professor doctor marty offering his thoughts on healthcare. And fox recounts her time as a cia operative and american University Professor e from ken dion race in america. Be sure to watch our live weekends coverage of the texas book festival starting at 11 00 am eastern today and at noon not sunday, on booktv and be sure to catch the Miami Book Fair next month on booktv on cspan2. Tuesday the Senate Commerce science and Transportation Committee hearing examining the boeing 737 max following two international accidents last year. Testifying before the committee is bowings president and ceo Dennis Mullen bergen Vice President and chief engineer john hamilton. Watch live tuesday at 10 00 eastern on cspan 3, online on cspan. Org or listen wherever