Congressional Hearings
``THE OPIOID CRISIS: THE CURRENT LANDSCAPE AND CMS ACTIONS TO PREVENT OPIOID MISUSE''
Congressional Hearings
SuDoc ClassNumber: Y 4.W 36
Congress: House of Representatives
CHRG-115hhrg33659
| AUTHORITYID | CHAMBER | TYPE | COMMITTEENAME |
|---|---|---|---|
| hswm00 | H | S | Committee on Ways and Means |
[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
``THE OPIOID CRISIS:
THE CURRENT LANDSCAPE AND
CMS ACTIONS TO PREVENT OPIOID MISUSE''
=======================================================================
HEARING
before the
SUBCOMMITTEE ON OVERSIGHT
of the
COMMITTEE ON WAYS AND MEANS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
JANUARY 17, 2018
__________
Serial No. 115-OS10
__________
Printed for the use of the Committee on Ways and Means
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
______
U.S. GOVERNMENT PUBLISHING OFFICE
33-659 WASHINGTON : 2019
COMMITTEE ON WAYS AND MEANS
KEVIN BRADY, Texas, Chairman
SAM JOHNSON, Texas RICHARD E. NEAL, Massachusetts
DEVIN NUNES, California SANDER M. LEVIN, Michigan
DAVID G. REICHERT, Washington JOHN LEWIS, Georgia
PETER J. ROSKAM, Illinois LLOYD DOGGETT, Texas
VERN BUCHANAN, Florida MIKE THOMPSON, California
ADRIAN SMITH, Nebraska JOHN B. LARSON, Connecticut
LYNN JENKINS, Kansas EARL BLUMENAUER, Oregon
ERIK PAULSEN, Minnesota RON KIND, Wisconsin
KENNY MARCHANT, Texas BILL PASCRELL, JR., New Jersey
DIANE BLACK, Tennessee JOSEPH CROWLEY, New York
TOM REED, New York DANNY DAVIS, Illinois
MIKE KELLY, Pennsylvania LINDA SANCHEZ, California
JIM RENACCI, Ohio BRIAN HIGGINS, New York
PAT MEEHAN, Pennsylvania TERRI SEWELL, Alabama
KRISTI NOEM, South Dakota SUZAN DELBENE, Washington
GEORGE HOLDING, North Carolina JUDY CHU, California
JASON SMITH, Missouri
TOM RICE, South Carolina
DAVID SCHWEIKERT, Arizona
JACKIE WALORSKI, Indiana
CARLOS CURBELO, Florida
MIKE BISHOP, Michigan
DARIN LAHOOD, Illinois
David Stewart, Staff Director
Brandon Casey, Minority Chief Counsel
______
SUBCOMMITTEE ON OVERSIGHT
LYNN JENKINS, Kansas, Chairman
DAVID SCHWEIKERT, Arizona JOHN LEWIS, Georgia
JACKIE WALORSKI, Indiana JOSEPH CROWLEY, New York
CARLOS CURBELO, Florida SUZAN DELBENE, Washington
MIKE BISHOP, Michigan EARL BLUMENAUER, Oregon
DARIN LAHOOD, Illinois
TOM REED, New York
C O N T E N T S
__________
Page
Advisory of January 17, 2018, announcing the hearing............. 2
WITNESSES
Gary L. Cantrell, Deputy Inspector General for Investigations,
Office of the Inspector General, Department of Health and Human
Services (HHS)................................................. 6
Elizabeth H. Curda, Director, Health Care, Government
Accountability Office (GAO).................................... 18
Kimberly Brandt, Principal Deputy Administrator for Operations,
Centers for Medicare & Medicaid Services (CMS)................. 35
QUESTIONS FOR THE RECORD
Questions from the Hon. Lynn Jenkins, Chairman of the
Subcommittee on Oversight of the Committee on Ways and Means,
to Kimberly Brandt, Principal Deputy Administrator for
Operations, Centers for Medicare & Medicaid Services (CMS)..... 80
Questions from Representative Jackie Walorski, 2nd District of
Indiana, to Kimberly Brandt, Principal Deputy Administrator for
Operations, Centers for Medicare & Medicaid Services (CMS)..... 81
Questions from Representative Patrick Meehan, 7th District of
Pennsylvania, to Kimberly Brandt, Principal Deputy
Administrator for Operations, Centers for Medicare & Medicaid
Services (CMS)................................................. 87
Questions from Representative Joseph Crowley, 15th District of
New York, to Kimberly Brandt, Principal Deputy Administrator
for Operations, Centers for Medicare & Medicaid Services (CMS). 88
Questions from the Hon. Lynn Jenkins, Chairman of the
Subcommittee on Oversight of the Committee on Ways and Means,
to Elizabeth H. Curda, Director, Health Care, Government
Accountability Office (GAO).................................... 89
Questions from Representative Joseph Crowley, 15th District of
New York, to Elizabeth H. Curda, Director, Health Care,
Government Accountability Office (GAO)......................... 91
Questions from the Hon. Lynn Jenkins, Chairman of the
Subcommittee on Oversight of the Committee on Ways and Means,
to Gary L. Cantrell, Deputy Inspector General for
Investigations, Office of the Inspector General, Department of
Health and Human Services (HHS)................................ 92
Questions from Representative Patrick Meehan, 7th District of
Pennsylvania, to Gary L. Cantrell, Deputy Inspector General for
Investigations, Office of the Inspector General, Department of
Health and Human Services (HHS)................................ 94
Questions from Representative Joseph Crowley, 15th District of
New York, to Gary L. Cantrell, Deputy Inspector General for
Investigations, Office of the Inspector General, Department of
Health and Human Services (HHS)................................ 95
SUBMISSIONS FOR THE RECORD
American Association of Nurse Anesthetists (AANA)................ 97
Abuse Deterrent Coalition (ADC).................................. 103
Nola, a Concerned American Citizen............................... 109
Halyard Health................................................... 111
Premier healthcare alliance...................................... 115
Quest Diagnostics Incorporated................................... 118
``THE OPIOID CRISIS:
THE CURRENT LANDSCAPE AND
CMS ACTIONS TO PREVENT OPIOID MISUSE''
----------
WEDNESDAY, JANUARY 17, 2018
U.S. House of Representatives,
Committee on Ways and Means,
Subcommittee on Oversight,
Washington, DC.
The Subcommittee met, pursuant to call, at 10:00 a.m., in
Room 1100, Longworth House Office Building, Hon. Lynn Jenkins
[Chairman of the Subcommittee] presiding.
[The advisory announcing the hearing follows:]
ADVISORY
FROM THE
COMMITTEE
ON WAYS
AND
MEANS
SUBCOMMITTEE ON OVERSIGHT
CONTACT: (202) 225-1721
FOR IMMEDIATE RELEASE
Wednesday, January 17, 2018
OS-10
Chairman Brady Announces
Oversight Subcommittee Hearing on
``The Opioid Crisis: The Current Landscape and
CMS Actions to Prevent Opioid Misuse''
House Ways and Means Committee Chairman Kevin Brady (R-TX),
announced today that the Oversight Subcommittee will hold a hearing on
``The Opioid Crisis: The Current Landscape and CMS Actions to Prevent
Opioid Misuse.'' The hearing will focus on efforts by the Centers for
Medicare & Medicaid Services (CMS) to utilize data to identify
individuals in the Medicare Part D program who are at risk to abuse
opioids. The hearing also will examine the extent of the problem as
well as the tools CMS has available to prevent individuals from
receiving unnecessary opioids. The hearing will take place on
Wednesday, January 17, 2018, in room 1100 of the Longworth House Office
Building, beginning at 10:00 a.m.
In view of the limited time to hear witnesses, oral testimony at
this hearing will be from invited witnesses only. However, any
individual or organization may submit a written statement for
consideration by the Committee and for inclusion in the printed record
of the hearing.
DETAILS FOR SUBMISSION OF WRITTEN COMMENTS:
Please Note: Any person(s) and/or organization(s) wishing to submit
written comments for the hearing record must follow the appropriate
link on the hearing page of the Committee website and complete the
informational forms. From the Committee homepage, http://
waysandmeans.house.gov, select ``Hearings.'' Select the hearing for
which you would like to make a submission, and click on the link
entitled, ``Click here to provide a submission for the record.'' Once
you have followed the online instructions, submit all requested
information. ATTACH your submission as a Word document, in compliance
with the formatting requirements listed below, by the close of business
on Wednesday, January 31, 2018. For questions, or if you encounter
technical problems, please call (202) 225-3625.
FORMATTING REQUIREMENTS:
The Committee relies on electronic submissions for printing the
official hearing record. As always, submissions will be included in the
record according to the discretion of the Committee. The Committee will
not alter the content of your submission, but we reserve the right to
format it according to our guidelines. Any submission provided to the
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and any written comments in response to a request for written comments
must conform to the guidelines listed below. Any submission not in
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maintained in the Committee files for review and use by the Committee.
All submissions and supplementary materials must be submitted in a
single document via email, provided in Word format and must not exceed
a total of 10 pages. Witnesses and submitters are advised that the
Committee relies on electronic submissions for printing the official
hearing record.
All submissions must include a list of all clients, persons and/or
organizations on whose behalf the witness appears. The name, company,
address, telephone, and fax numbers of each witness must be included in
the body of the email. Please exclude any personal identifiable
information in the attached submission.
Failure to follow the formatting requirements may result in the
exclusion of a submission. All submissions for the record are final.
The Committee seeks to make its facilities accessible to persons
with disabilities. If you are in need of special accommodations, please
call 202-225-1721 or 202-226-3411 TDD/TTY in advance of the event (four
business days notice is requested). Questions with regard to special
accommodation needs in general (including availability of Committee
materials in alternative formats) may be directed to the Committee as
noted above.
Note: All Committee advisories and news releases are available at
http://www.waysandmeans.house.gov/
Chairman JENKINS. The Subcommittee will come to order.
Welcome to the Ways and Means Oversight Subcommittee Hearing on
the Opioid Crisis, the Current Landscape and CMS Actions to
Prevent Opioid Misuse.
Good morning. I want to thank the panel for coming and
welcome you all to today's hearing, the Opioid Crisis, the
Current Landscape and CMS Actions to Prevent Opioid Misuse.
Opioid abuse has devastated communities across America. In
2016, more than 42,000 Americans died due to opioids, a level
that is five times what it was in 1999.
My home State of Kansas is no exception. In 2000, 35
overdose deaths were attributed to opioids. In 2016, 159 people
died from opioid abuse in Kansas. Overdose deaths in America
are on the rise largely due to opioids, which account for three
out of every five overdose deaths. These numbers are startling,
and yet many experts believe they are too low. And,
unfortunately, this epidemic continues to get worse, which is
why finding ways to address the problem is a high priority for
this Committee.
No community is immune to the effects of opioid abuse.
Rural communities are hit particularly hard, as they often have
limited access to critical services and resources to support
those struggling with addiction. The immense cost opioids
impose on society as a whole cannot be overstated.
According to the Centers for Disease Control, opioids
imposed an economic burden of $78.5 billion in 2013. Much of
this is due to increased substance abuse treatment cost, lost
productivity, incarceration, and other burdens put on the
criminal justice system. Last year, the President's Council of
Economic Advisors estimated the cost to be even higher.
In order to address the opioid crisis, we need to
understand what the current state of the problem is. We also
need to understand what tools are in place to address this
problem and how they can be improved. Today we will examine how
the Centers for Medicare & Medicaid Services, or CMS, is
working to address opioid misuse in the Medicare Part D
program.
More than 42 million beneficiaries rely on the program for
prescription drugs, including opioids. It is critical that
Medicare and private Part D plan sponsors have the tools they
need to ensure that opioids are provided only when medically
necessary. We have a panel of experts that can talk about what
CMS and the plan sponsors are doing to identify those most at
risk so that appropriate interventions can be taken.
Our witnesses today should provide the Committee with
valuable insights into how things are currently working and
what can be done to improve them. The Committee plans to do
more oversight on this issue as we continue to examine other
ways to reduce opioid abuse.
Before closing, I want to recognize that a lot of what we
will be discussing today will be sanitized to some degree,
simply through the use of numbers and statistics. I would like
the record to reflect that the Members of this Committee know
that there are real people, real families, and real experiences
behind every number. That is why we are here today and we are
devoting time to such a critical issue.
With that, I want to thank our witnesses, and I look
forward to their testimony. I now yield to the distinguished
Member from Washington, Ms. DelBene, for the purposes of an
opening statement.
Ms. DELBENE. Thank you, Madam Chair. And thank you for
holding this important hearing. I would like to thank our
witnesses also for taking the time to be with us here today.
And I would like to acknowledge our Ranking Member, Neal,
and thank him for being here today and joining us. But I want
to start by congratulating our new Chair of the Subcommittee on
Oversight. Clapping is appropriate. No, no, I said that is
good. I know you are a certified public accountant, and were
the 37th Kansas State Treasurer, both of which will be valuable
for this Subcommittee in particular, as we look at IRS reforms.
I look forward to working with you on this and other things
that are under the Subcommittee's jurisdiction, and I hope
we'll continue to work in a bipartisan fashion on issues that
are important to all of us, just like today's topics. So, thank
you very much, and welcome to your new role. And I yield back.
Chairman JENKINS. Thank you. I now yield to the
distinguished Ranking Member of the Full Committee, Mr. Neal,
for the purposes of a statement.
Mr. NEAL. Thank you, Madam Chairperson. Everyone in this
room has a family member or knows someone directly impacted by
the opioid epidemic, somebody down the street, a neighbor, or
we have all witnessed wrenching consequences of what this has
done to families across the country. In Massachusetts, there
were 2,094 confirmed opioid-related overdose deaths in 2016.
Although overdose rates are highest for people 25 to 54, this
public health emergency also affects Medicare beneficiaries.
According to a study recently from Altarum in November of
2017, the economic burden from opioids was estimated to be $95
billion in 2016, $21 billion of which was attributed to
healthcare services, direct and indirect cost, and $55.6
billion lost to earnings and productivity.
In 2016, one-third of Medicare Part D beneficiaries filled
a prescription for opiates. For one-third of these
beneficiaries, we know part of the consequence. This number is
too high and we need to explore better ways to manage chronic
pain. I hope that we can work in a bipartisan manner to urge
the Centers for Medicare & Medicaid Services to move quickly to
implement recommendations.
Congress and the Administration need to do more to help
Americans access necessary treatment for opioid use disorders.
The Administration's emergency declaration expires next week,
but nothing at the moment has progressed. Yet, another missed
opportunity for positive action. The most significant step that
has been taken in recent years to stem the tide of the opioid
crisis has been to expand Medicaid under the ACA to low-income
working Americans who previously could not afford insurance.
The Medicaid expansion has provided millions of previously
uninsured adults with access to health insurance, which
includes coverage for substance abuse and mental health
services. For Medicare, the specific topic of today's hearing,
we need to look to beneficiary's ability to access treatment,
as oftentimes providers aren't available to meet the need. We
know there are significant groups and gaps in the coverage and
access under Medicare that need to be acknowledged.
For example, Medicare does not cover outpatient treatment
programs that provide comprehensive opiate addiction
treatments, nor does Medicare cover methadone for addiction,
which is often the treatment of choice for long term addicts.
We clearly have our work to do this year, and we need to stop
undermining the programs that provide coverage and treatment
for those who need it, instead, strengthening and improving
access to care and coverage.
And another reflection, just off the talking points. What
this has done to labor participation rates across the country
is an underreported story. When the Department of Labor
recently indicated that there are six million jobs in America
every day that go unanswered, and when you consider that there
are two million people with opiate addictions that are sitting
on the sidelines who could be working, that is another
consequence of what has happened.
A number of people across America, who have opiate
addictions, who are sitting home in the afternoon playing video
games rather than in the workforce, ought to alarm all of us,
and there ought to be something that we can all agree to in
terms of the treatment needs of those very people. But this has
a personal consequence for all of us as well, as I indicated in
the first sentence. We all have a neighbor, friend, or a
relative who is battling this addiction. And this ought to be
well beyond the consequence of partisanship in this
institution. We ought to be trying to find some remedies. And I
yield back my time.
Chairman JENKINS. Thank you, Mr. Neal.
Without objection, other Members' opening statements will
be made part of the record.
Today's witness panel includes three experts: Gary L.
Cantrell, Deputy Inspector General for Investigations at the
Department of Health and Human Services Office of the Inspector
General; Elizabeth H. Curda, Director of Health Care at the
Government Accountability Office; and Kimberly Brandt,
Principal Deputy Administrator for Operations at the Centers
for Medicare & Medicaid Services.
The Subcommittee has received your written testimonies, and
they will be made part of the formal hearing record. You each
have 5 minutes to deliver your oral remarks. We will begin with
you, Mr. Cantrell. You may begin when you are ready.
STATEMENT OF GARY L. CANTRELL, DEPUTY INSPECTOR GENERAL FOR
INVESTIGATIONS, OFFICE OF THE INSPECTOR GENERAL, DEPARTMENT OF
HEALTH AND HUMAN SERVICES (HHS)
Mr. CANTRELL. Thank you. Good morning, Chairman Jenkins and
Ranking Member Neal, and other distinguished Members of the
Subcommittee. I am Gary Cantrell, Deputy Inspector General for
Investigations at HHS OIG, and I am excited to be here today to
discuss efforts by the HHS OIG to combat the opioid epidemic in
Federal healthcare programs.
Given a long history of healthcare fraud enforcement,
program knowledge, and data analytics capabilities, OIG is
uniquely positioned to help lead this fight against illegal
opioid prescribing in Medicare and Medicaid.
My testimony today will highlight our work to prevent
opioid-related fraud and abuse, detect questionable prescribing
and billing patterns, and enforce laws and regulations
governing opioid prescribing.
Opioid-related fraud encompasses a broad range of criminal
activity, from prescription drug diversion to addiction
treatment fraud. Many of these schemes involve kickbacks,
medical identity theft, and criminal enterprises. Developing
these investigations is complex, requiring the use of
confidential informants, undercover operations, and
surveillance to gather evidence of crimes often committed by
corrupt doctors, pharmacists, and criminal networks. In the
worst cases, our special agents uncover evidence of illegal
prescribing leading to patient deaths.
Given the complexity and high stakes of these
investigations, OIG's partnerships with DOJ, FBI, DEA, and
State Medicare fraud control units is critical to the success
of these efforts. OIG and our Medicare Fraud Strike Force
partners led the 2017 national healthcare fraud take-down. This
take-down was the largest ever healthcare fraud take-down,
resulting in over 400 individuals charged; 120 of these
defendants were charged for their roles in illegally
prescribing and distributing opioids.
The enforcement operation brought together more than 1,000
Federal and State law enforcement personnel, including 350 OIG
special agents. OIG has also shifted resources to support the
Attorney General's Opioid Fraud and Abuse Detection Unit, a
multiagency effort capitalizing on data, with dedicated
prosecutors and agents focused solely on prosecuting opioid
fraud in the healthcare system.
OIG uses advanced data analytics to put timely, actionable
information about prescribing, billing, and utilization trends
in the hands of investigators, auditors, evaluators, and our
government partners. A recent report identifying Medicare
beneficiaries receiving extremely high amounts of opioids and
questionable prescribing patterns demonstrates the value of
this approach.
Of note, the report uncovered that half a million Medicare
beneficiaries received opioids in excess of CDC guidelines.
Further, nearly 90,000 beneficiaries are at serious risk of
opioid misuse or overdose. Some of these received extreme
amounts of opioids, over 2\1/2\ times the CDC recommended
amounts, when others appear to be doctor shopping.
To get to the source of this extreme use, OIG identified
about 400 prescribers with questionable opioid prescribing
patterns for these beneficiaries at serious risk. OIG is
following up on these outlier prescribers, and we have also
shared this data with our public and private sector partners.
This is one example of how we leverage our relationships and
empower our partners to help us tackle this problem.
Recognizing the growing severity of the opioid epidemic,
OIG has initiated work beyond Medicare. The work identifies
opportunities to strengthen program integrity and protect at-
risk beneficiaries across multiple HHS programs. For example,
OIG audits and evaluations currently underway address the broad
range of opioid-related funding and activity at HHS, including
opioid prescribing in Medicaid, transfer prescription drug
monitoring programs, FDA's oversight of opioid risk management
program and addiction treatment services.
OIG's work holds criminals accountable and results in
impactful recommendations to improve program integrity, save
tax dollars, and protect HHS beneficiaries from harm. Key
recommendations to combat opioid-related fraud and abuse are
outlined in my written testimony.
In summary, OIG will continue to focus our
multidisciplinary efforts on the opioid epidemic. We will
identify opportunities to improve HHS prescription drug and
treatment programs, share data and educate the public, and
identify and hold accountable perpetrators of opioid-related
fraud.
I appreciate the opportunity to speak with you today, and I
would be happy to answer any questions.
[The prepared statement of Mr. Cantrell follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman JENKINS. Thank you, Mr. Cantrell. Ms. Curda, you
are recognized for 5 minutes.
STATEMENT OF ELIZABETH H. CURDA, DIRECTOR, HEALTH CARE,
GOVERNMENT ACCOUNTABILITY OFFICE (GAO)
Ms. CURDA. Good morning, Chairman Jenkins, Ranking Member
Neal, and Members of the Subcommittee. I am pleased to be here
to discuss our report on the Centers for Medicare & Medicaid
Services oversight of opioid prescribing in the Medicare
program. Overprescribing and misuse of prescription opioids has
led to significant increases in opioid use disorder, overdoses,
and deaths in the United States.
Recognizing this, CMS developed an opioid misuse strategy
with a goal to reduce harm from opioid misuse in its programs.
Today I will discuss how CMS oversees opioid prescribing under
Medicare Part D, both in terms of the beneficiaries who receive
opioid prescriptions, as well as the providers who prescribe
them.
To oversee beneficiaries, CMS relies on private insurers,
known as plan sponsors, to monitor and take appropriate action
to address potential opioid overuse. CMS employs an
overutilization monitoring system to alert plan sponsors about
very high-risk beneficiaries. These are beneficiaries receiving
high doses of opioids from four or more providers and
pharmacies or from six or more providers regardless of the
number of pharmacies. Excluding cancer and hospice care, about
33,000 beneficiaries met these criteria in 2015. Plan sponsors
are expected to review a quarterly list of identified
beneficiaries, determine appropriate action, and then respond
to CMS with information on their actions within 30 days.
The use of these criteria, along with plan sponsor actions,
has helped to significantly reduce the number of these very
high-risk cases.
However, CMS oversight does not address the over 700,000
beneficiaries potentially at risk of harm, based on CDC
guidelines. These guidelines note that long-term use of opioid
doses over 90 milligrams morphine equivalent per day are
associated with significant risk of harm and should be avoided
unless a provider determines that it is necessary.
This is particularly the case for patients aged 65 and
older, because the drugs can more easily accumulate in the body
to toxic levels. We recommended that CMS gather information on
the total number of these beneficiaries over time to help
assess progress in reaching the agency's goals related to
reducing opioid harm and misuse. HHS concurred with our
recommendation.
CMS oversees Medicare Part D providers through its
contractor, NBI MEDIC, as well as through the plan sponsors.
NBI MEDIC provides oversight by analyzing Medicare prescriber
data for outliers and determining potential fraud. NBI MEDIC
conducts its own investigations of potential fraud, waste, and
abuse by providers, and also refers cases to law enforcement or
the Office of the Inspector General.
CMS also requires plan sponsors to prevent, detect, and
correct prescriber noncompliance, as well as fraud, waste, and
abuse. However, NBI MEDICS analyses to identify outlier
providers focused broadly on all drugs at risk of abuse, rather
than on opioids specifically.
We recommended that CMS require NBI MEDIC to gather
separate data on providers who prescribe high amounts of
opioids. This would allow CMS to better identify those
providers who are inappropriately and potentially fraudulently
prescribing high doses of opioids. HHS concurred with this
recommendation as well.
CMS also lacks key information necessary for oversight of
opioid prescribing because it does not require plan sponsors to
report cases of fraud, waste, and abuse, cases of
overprescribing, or any actions taken against providers. While
CMS received some of this information from plan sponsors who
voluntarily report their actions, it does not know the full
extent to which plan sponsors have identified providers who
prescribe high amounts of opioids or take an appropriate
action.
We recommended that CMS require plan sponsors to report on
investigations and other actions taken related to providers who
prescribe high amounts of opioids. HHS did not concur, noting
that plan sponsors are responsible for detecting and preventing
fraud, waste, and abuse, and that CMS reviews cases when it
conducts audits.
HHS also stated that it seeks to balance the requirements
it places on plan sponsors. However, without complete
reporting, CMS is missing key information that could help the
agency achieve its goals. We continue to believe that CMS
should require plan sponsors to report on the actions they take
to reduce overprescribing.
In conclusion, having information on the total number of
beneficiaries receiving potentially harmful levels of opioid
medication, as well as complete information on providers who
may be inappropriately prescribing opioids, could help CMS as
it works to decrease the risk of opioid use disorder,
overdoses, and deaths.
This concludes my prepared statement, and I am happy to
answer the Committee's questions.
[The prepared statement of Ms. Curda follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman JENKINS. Thank you, Ms. Curda. Ms. Brandt, you are
recognized for 5 minutes.
STATEMENT OF KIMBERLY BRANDT, PRINCIPAL DEPUTY ADMINISTRATOR
FOR OPERATIONS, CENTERS FOR MEDI-
CARE & MEDICAID SERVICES (CMS)
Ms. BRANDT. Thank you. Chairman Jenkins, Ranking Member
Neal, and Members of the Subcommittee, thank you for inviting
me to discuss CMS's work to address the misuse of opioids in
the Medicare Part D program.
CMS understands the magnitude and impact the opioid misuse
epidemic has had on our communities and is committed to a
comprehensive and multipronged strategy to combat this public
health emergency.
As Principal Deputy for Operations at CMS, I am charged
with directing cost-cutting issues that affect all of our
programs, with the efforts to fight the opioid epidemic being
one of our agency's biggest priorities. We cover over 58
million Medicare beneficiaries, and the opioid epidemic affects
every one of them as a patient, family member, caregiver, or
community member.
CMS recognizes that its primary role in the healthcare
system is that of a payer. And as a payer, we are focused on
the unique steps we can take to ensure that plans comply with
requirements that protect beneficiaries.
For us, all of our efforts are ultimately focused on
protecting the health and safety of our Medicare beneficiaries.
Due to the structure of the Medicare Part D program, Medicare
Advantage organizations and Medicare Part D sponsors are well-
positioned to identify and address improper opioid utilization
by working with prescribing physicians.
Our job at CMS is to oversee these efforts and to make sure
that plan sponsors have the tools and information they need to
be as effective as possible. We do this in a number of ways.
First, as my colleague from GAO knows, we use the
Overutilization Monitoring System, or OMS, to help ensure plan
sponsors have established systems and programs to help prevent
overutilization of prescription opioids.
Through this system, CMS identifies high-risk beneficiaries
who have visited multiple pharmacies or prescribers. We then
report these high-risk beneficiaries to plans who conduct case
management or implement real time alerts at a pharmacy. This
effort has been very successful, with a 61 percent decline in
the number of beneficiaries meeting the OMS criteria from 2011
to 2016, even while Part D enrollment was increasing at the
same time.
To improve on these outcomes and to better identify high-
risk beneficiaries, we have improved the criteria used in OMS
to reflect the Centers for Disease Control's prescribing
guidelines. This action will allow us to better identify
potential opioid overutilizers and is just one of the many ways
we are collaborating with our colleagues in HHS to tackle this
epidemic and further protect beneficiaries at high risk of
opioid overutilization.
Thanks to recent action taken by Congress, CMS now has the
authority to implement a new Medicare Part D lock-in policy.
CMS has proposed to integrate this new authority with our OMS
to expand upon our existing innovative approach to reduce
opioid overutilization in the Part D program. We believe this
approach will improve quality of care through enhanced
coordination while maintaining access to necessary pain
medications.
Second, all plan sponsors are using real-time alerts,
referred to as safety edits, to flag potentially unsafe opioid
prescriptions at the pharmacy. When these alerts are triggered,
the pharmacist must take an action, depending on the type of
safety edit, before the prescription can be dispensed.
Through this process, prescribers can receive important
information about their patients, such as a better picture of a
patient's total opioid dosage and prescription history.
Ultimately, this helps prescribers make more informed decisions
about the care that they are providing to their patients.
Third, CMS tracks and monitors the number of Part D
beneficiaries who receive high doses of opioid prescriptions
regardless of the number of prescribers and pharmacies being
used by the beneficiary. Using this information, CMS sends
monthly patient safety reports to plan sponsors so they can
conduct case management. Ensuring that Medicare beneficiaries
with substance use disorder have access to the most effective
treatment is a critical component of addressing the epidemic.
We want to make sure that we cover the right treatment for
the right beneficiaries in the right setting, and we are
working to increase access to medication-assisted treatment by
requiring that Part D formula include MAT drugs as well as
Naloxone.
In addition to these efforts to identify and protect
beneficiaries who are at high risk for opioid overutilization,
CMS also uses data to identify prescribers and pharmacies with
questionable opioid prescribing and billing patterns. Plans
receive quarterly reports on outlier prescribers and pharmacies
they can use to initiate new investigations, conduct audits,
and take administration actions like terminating a pharmacy
from their network.
Based on a recommendation by the GAO, these reports now
separate outlier prescribers of opioids from other Schedule II
prescribers.
As we move forward with our efforts to curb this public
health crisis, CMS plans to enact comprehensive strategies from
all Medicare Part D sponsors on their activities aimed at
combatting the opioid crisis. This will help CMS better
understand the approaches sponsors are taking from both their
Medicare and commercial alliance. Once we receive this
information, we will conduct an analysis and provide best
practice guidance to all plans.
While CMS has taken numerous steps to improve our opioid
overutilization and monitoring programs, we know there is much
more we can do. We appreciate the work and recommendations from
our colleagues at GAO and OIG, and we are continually assessing
how we can best utilize our tools as a payer to build on their
recommendations to tackle this crisis.
Thank you for your interest in our efforts to protect
Medicare beneficiaries, and I look forward to answering your
questions.
[The prepared statement of Ms. Brandt follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman JENKINS. Thank you. And I appreciate all three of
you being here today with your excellent testimony.
We will now proceed to the question and answer session. And
I would like to direct my questions to Ms. Curda.
Ms. Curda, in your testimony, you discussed how the OMS
tracks only a small portion of the potentially at-risk
beneficiary population. Can you talk more about what GAO found?
Ms. CURDA. Sure. We found that the criteria that CMS is
currently using in its OMS tracked the very high dose--
beneficiaries who are getting very high doses, who are using
multiple doctors, multiple pharmacies, but they aren't tracking
the larger number of beneficiaries that are at risk of harm
because they are receiving higher doses of opioids. These are
those that are receiving more than 90 milligrams morphine
equivalent dose per day, which is indicated in CDC guidelines.
According to a one-time analysis that CMS performed, this
criterion covered about 700,000 beneficiaries in 2015. So, just
relatively speaking, we are talking about 700,000 beneficiaries
taking very, very high levels of opioids, versus the OMS
criteria, which is in the sort of more tens of thousands range.
And so, we recommended that they gather that data, not just for
reporting back to the plan sponsors, but because it has this
goal of reducing harm from opioid use, to track and monitor
that information over time to see what is happening with that
number of beneficiaries, to see is it going up, is it going
down, and use it to inform its strategy.
Chairman JENKINS. Right. One of the recommendations that
GAO made was for CMS to track beneficiaries receiving large
amounts of opioids, irrespective of the number of pharmacies
and providers that they used to obtain them. Can you talk about
why you believe this to be important?
Ms. CURDA. Sure. CMS does track very useful information
on--using its overutilization system, and also in its in-
patient quality measures. But neither of those measures track
the larger number of beneficiaries that are receiving harmful
doses of--potentially harmful doses of opioid medication. And
so we think that, in routinely collecting this information,
they can better inform their strategy and track their goal
achievements.
Chairman JENKINS. What specific data do you believe is
important for CMS to track?
Ms. CURDA. This would be the patients receiving either 90
milligram morphine equivalent dose per day or greater through
Medicare.
Chairman JENKINS. Okay. How much of that data is currently
being utilized for CMS for these purposes, and why do you
believe the current data CMS is monitoring to be insufficient?
Ms. CURDA. It is basically just a measurement issue. The
CMS tracks data, but not at that level. And they don't use it
for the purposes of monitoring this harmful use of opioids over
time. So we believe that by collecting this information and
monitoring it, over time they can better track whether they are
achieving their goals.
Chairman JENKINS. Okay. Thank you. I would now like to
recognize Ms. DelBene.
Ms. DELBENE. Thank you, Madam Chair. The Administration
recently released guidance indicating that it would allow
States to implement work requirements to access Medicaid. Ms.
Brandt, in your testimony to the Committee, you state one of
the points of the comprehensive evidence-based opioid strategy
is to ``improve access to treatment and recovery services, and
to enable individuals to achieve long-term recovery.''
In the guidance that was put out, the Administration
requires exemptions for individuals with medical conditions,
such as substance use disorders, and outlined that medical
treatment for any--for their substance use may fulfill a work
requirement.
My question is, how does a work requirement improve access
to treatment? And, second, how can an individual who is
suffering from addiction access treatment to fulfill their work
requirement if they are not allowed to get Medicaid and can't
have that to cover such a treatment? So, we end up in this
circular situation where someone doesn't have coverage, so they
can't get treatment, but they can't fulfill the work
requirement because they need to be in treatment to do that.
Can you explain how we would address that?
Ms. BRANDT. Thank you for your question. While the work
requirements and the Medicaid requirements are not my day-to-
day responsibility, I will do my best to sort of answer, to the
best of my knowledge.
As part of our issuance last week, as you mentioned, States
are required to take steps to ensure access to appropriate
treatment or services. And one of the things that they are
supposed to do is make reasonable modifications to ensure that
people who are receiving treatment for substance abuse
disorders or opioid treatments are able to have reasonable
accommodations. And so we have worked to provide guidance to
the States to help them to ensure that balance, and the goal is
to ensure that the beneficiary who is receiving those
treatments can hopefully be able to have the appropriate
accommodations made so they can continue to receive it.
Ms. DELBENE. So, if a State doesn't come up with a work--
with the work-around, as you describe, how would someone access
Medicaid so they can get treatment if they can't fulfill their
work requirement because they can't fulfill--they aren't
allowed to access treatment?
Ms. BRANDT. Well, our goal is to work with the States to
ensure that they would be able to provide those types of
accommodations as part of what they are supposed to do under
the mandate of the work requirement. And we would work with
them to ensure that the beneficiary, hopefully, would be able
to continue to receive those types of services.
Ms. DELBENE. Thank you. As CMS moves more providers to
value-based payments in an effort to improve quality and lower
healthcare costs, part of the challenge is to properly risk
adjust for high-needs patients. And because substance use
disorder is such a complicated condition that demands a
tremendous amount of coordination of care, this may be one of
the conditions that warrants a risk adjustment. And, in fact,
this was done for a managed care demonstration in Massachusetts
that focused on dual eligible enrollees under 65.
Ms. Brandt, have you considered how we can better align
payment to promote coordination and quality care for people
with substance use disorders in other value-based and managed
care arrangements like ACOs and Medicare or Medicare Advantage
Plans, and how is CMS promoting coordination of care between
providers to mitigate the instances of high amounts of opioid
prescribing?
Ms. BRANDT. Thank you for your question. As I mentioned in
my oral and written testimony, ensuring good access to
beneficiaries across our payment lines is one of the goals at
CMS. And one of the things that we have been doing is looking
across all of our payment types, especially as we begin the new
payment rules for this year and as we have discussions with
providers to determine where we can do more and how we can have
better coordination with them on just these types of issues.
So it is something that we are currently engaged in as an
agency, to try to figure out better ways to make sure that we
are striking that balance and making sure, as I said in my
testimony, that we have the right treatment, for the right
people, in the right setting, at the right time.
Ms. DELBENE. I understand that the--things like the managed
care demonstration in Massachusetts have been looking at these
scenarios. Is there something that you have learned from these
that will better inform us on how best to address more
complicated situations like substance use disorders?
Ms. BRANDT. I can't speak specifically to the Massachusetts
demonstration project because I am not familiar with the
outcomes of that, but I can tell you that we have been looking
at all of our demonstration projects, the models we run, and
our Centers for Medicare and Medicaid innovation, as well as
across the CMS programs to look at lessons learned and best
practices, and we are trying to bring all that to bear as we
try to figure out good solutions for this crisis.
Ms. DELBENE. Thank you very much. I yield back.
Chairman JENKINS. Mrs. Walorski is now recognized for 5
minutes.
Mrs. WALORSKI. Thank you, Madam Chair. Thank you to our
witnesses for being here today. Like so many of the parts of
the country, the opioid epidemic has affected my district in
Indiana. It has destroyed lives, torn apart families, and put
stress on first responders, hospitals, the foster care system,
and other vital community institutions. Unfortunately, last
year a dear friend of mine, a doctor in my district, was
murdered for refusing to prescribe opioids.
Opioids come in many forms: pills, heroin, the emerging
threat of fentanyl, and others. Unfortunately, this means that
there are too many fronts in the fight.
Mr. Cantrell, I just want to ask you, identifying
overprescribing by providers is incredibly important; however,
examining at-risk beneficiaries can also help identify
providers who are potentially overprescribing. The Inspector
General identified in my State, Indiana, a prescriber who wrote
an average of 24 opioid prescriptions each for 108
beneficiaries who received extreme amounts.
Can you talk about your approach to identifying potentially
problematic prescribers, and then also, once these prescribers
are identified, what happens?
Mr. CANTRELL. Yes, thank you. First of all, in our data
brief, we used an analysis approach that we hadn't previously
utilized. We wanted to first focus on the beneficiaries who are
at greatest risk of harm because of the volume of opioids they
were receiving. And, instead of just looking at the universe of
claims, we look then at the individuals, the prescribers who
were prescribing specifically to a high number of those at-risk
beneficiaries.
So, that led us to, in our report, 400 different
prescribers who were prescribing either to a large number of
doctor-shopping Medicare beneficiaries, or to a large number of
patients receiving high amounts of opioids.
So, when we have this analysis, we use this data--first, we
report on these results, so that we can inform the public. We
share this information with CMS, so they can begin engaging in
administrative or other review to monitor these prescribers,
and we refer many of these out to our field offices, to our
partners at the Department of Justice for criminal
investigation.
Now, with 400 different prescribers identified, it isn't
necessarily the case that all are committing fraud, so we sift
through the data to identify those that appear most likely to
be committing fraud, send them out to the field, and then,
ultimately, it takes boots on the ground to investigate these
matters and bring individuals to justice who have committed
this fraud.
And so it is very intensive work, and we work closely with
DEA, FBI, State agencies, and local law enforcement, and this
is a huge priority for us to bring individuals who are
prescribing in the Medicare and Medicaid space these opioids
illegally.
Mrs. WALORSKI. And just as a followup, I have heard from
doctors in my district. They would like to have access to more
data so they know, and they are a little bit less at risk on,
you know, falling into some kind of a doctor-shopping kind of a
network.
Can you talk about ways you believe we can improve data
sharing to combat opioid abuse? And then, are there ways to
improve data sharing really just while working within State
privacy laws as well?
Mr. CANTRELL. Well, first of all, we certainly encourage
the utilization of prescription drug monitoring programs in
every State. We believe these are an important tool. For us, we
see Medicare claims data, we have great visibility there. We
have a little less, slightly less, but some visibility in the
Medicaid, but we don't see cash-based transactions and other
transactions like that, which the PDMPs would include.
And so, we think it is vitally important for prescribers
and pharmacies to check these PDMPs to make sure that they are
not dispensing to doctor-shopping patients. And we look for
other ways to share this information across both the Federal
Government and with the States and the private sector.
One of the things I think is most important that we have
done is share their approach to this analysis, but also the
underlying data with our private sector program integrity
partners who we work with, through the Healthcare Fraud
Prevention Partnership and the National Healthcare Antifraud
Association. So they are empowered to conduct their own
analysis, monitor these individuals, and hopefully have a
broader impact.
Mrs. WALORSKI. I appreciate it. And, Ms. Brandt, just
quickly, is--one of the things I have continued to work on here
is access to non-opioid alternatives. Is CMS developing a plan
to use more non-opioid alternatives for patients with chronic
pain?
Ms. BRANDT. Yes. As I mentioned in my oral testimony, we
are working to increase access to medication-assisted
treatments and are looking and working with the CDC and other
partners to determine----
Mrs. WALORSKI. On a scale of one to ten, where are we, in
looking? What have we found? What are we doing?
Ms. BRANDT. We have done a number of stakeholder listening
sessions over the past while, where we got a lot of valuable
input, and we have been having meetings with NIH, CDC, and
others. So I would say we are probably at about a six; we have
more to do, but we are definitely moving in the right
direction.
Mrs. WALORSKI. Thank you. Madam Chairman, I yield back.
Chairman JENKINS. Mr. Neal is recognized for 5 minutes.
Mr. NEAL. Thank you, Madam Chairperson.
Massachusetts, as I noted in my opening statement, is
really--we are reeling from the addiction crisis, and your
testimony was really well done this morning, the three of you.
The number of opioid-related deaths in Massachusetts is now
four times higher than it was 15 years ago, and it continues to
get worse. We certainly owe it to our communities and to our
families who have been hit by the epidemic to prevent
addiction; that means earlier intervention and treating those
afterward as well.
There is a compelling argument as to the most effective way
to treat opiate addiction for all of us. Medication-assisted
treatment, MAT, is the evidence-based standard for treating
opioid addiction. Medical and substance use disorder experts in
the President's own Commission point to MAT as a vital tool to
attack the epidemic.
Medicare is usually the standard bearer when it comes to
healthcare coverage, but Medicare does not cover a key MAT
option, methadone for outpatient service. Ms. Brandt, Ms.
Curda, you both testified about the importance of MAT in your
opening statements.
What is the Administration doing, and what would you
recommend that it continue to do or should do to expand access
to medication-assisted treatment?
Ms. BRANDT. Well, as I mentioned, Congressman, we are
continuing to look at the wide range of alternate treatments,
such as Naloxone and others. We are well aware of methadone and
the statutory impediments to that, but we are open to working--
I know you have legislation on that--we are open to working
with Congress to provide technical assistance on those issues.
But we can continue committed at CMS to determine what all we
can do to increase the access to medication-assisted
treatments.
Ms. CURDA. We prepared a couple of reports on the issues
surrounding access to medication-assisted treatment, not
specifically in Medicare, but in general. The first report we
did looked at the sort of regulatory and legal framework for
access to these drugs, and also looked at some of the barriers
to access. And there were things like not having enough doctors
who have the appropriate waivers in order to prescribe this
medication, and also in some cases, simply attitudinal issues
where this is viewed as perhaps a substitute for another kind
of addiction.
So taking these issues into account, Congress passed
legislation last year to enhance access to medication-assisted
treatment, and we did a further report looking at HHS's roll-
out of the grant programs intended to enhance access to
medication-assisted treatment, and we found that they had a
strategy for accomplishing this. They were getting the programs
going. It was a little too early to assess their effectiveness,
but we did note that they did not have any sort of measures in
place for their goals for expanding access to MATs, so not
knowing sort of what the ultimate goal is for that, and that
they did not have sort of firm timeframes. They had planned an
evaluation of their efforts, but they did not have any firm
timeframes for when that would be done.
Mr. NEAL. Thank you. I hope the Administration and my
colleagues on the other side, who I know are all sincere in
their efforts on this, would also be supportive of another
piece of legislation that I have offered, and that would be to
hold harmless first responders who administer Naloxone. When
they show up, oftentimes there is violent reaction as the high
comes down, and they sometimes have to subdue the individual
who has just been treated; save their lives, and then are
attacked for saving their lives.
So I think holding those individuals harmless would make a
good deal of sense, and I hope that the--in a bipartisan manner
we might be able to address that part of this complicated issue
as well.
Thank you for your testimony, and thank you Madam
Chairperson; I yield back.
Chairman JENKINS. Mr. Schweikert is recognized for 5
minutes.
Mr. SCHWEIKERT. Thank you, Madam Chairman.
My assumption is that everyone in this room has been
affected by addiction in a family member, a friend, or a
neighbor. Growing up in a household where my mother was
actually an addiction counselor, after years of fighting
through her own demons, you actually just understand how
complicated this is.
This is actually an interesting opportunity, as the Ranking
Member was talking about some of the different pieces of
legislation he has, and I agree, we should actually start to
step up and do a package, because there is no golden bullet
here, no magic bullet.
But I do want to also touch on--we have a piece of
legislation, and it is bipartisan, we have Republicans,
Democrats, and this Committee from E&C, and that is a mechanism
to standardize the prior authorization process, so the
electronic mechanism is underneath.
And Ms. Brandt, I am going to ask you to sort of walk us
through right now for Part D, how prior authorization actually
is working today, and then I want to sort of pitch everyone on
the Committee, the concept of, let's actually put together a
package of bills, hopefully our prior authorization
standardization will be one of those. But how does it work
today for Part D?
Ms. BRANDT. Well, let me caveat by saying, I am not a Part
D expert, so I will give you the best of my understanding----
Mr. SCHWEIKERT. Okay.
Ms. BRANDT [continuing]. As to how it works. But currently
the way it works is that the Part D sponsors have formularies
which have approved drugs on them, and as patients present,
they see if the drugs that they are looking to receive, that
are being prescribed to them, are off of that formulary. And
then they determine whether or not, based on CDC prescribing
guidelines, they meet the appropriate dosage amounts.
Some of what the GAO was saying, we have been working to
incorporate into our Overutilization Monitoring System to
determine that beneficiaries are not prescribed beyond what are
acceptable levels in the program.
And so, using those types of criteria and screening, it is
then determined what is appropriate to be able to authorize to
be paid under the person's plan.
Mr. SCHWEIKERT. For our other witnesses--and thank you for
that. Any other thoughts, that if I came to you--in reading the
testimony, it looks like we are doing a much better job in our
data collection and data modeling and finding bad actors.
Okay, now that we have the data, how do you move to a
solution? Is it alternative pharmaceuticals? Is it a
standardization of the red flashing light for the pharmacy or
the doctor, saying, this doesn't need to be filled? You have
the data; what is the next solution, what is the next layer?
Mr. CANTRELL. One of the things that we are recommending
and continue to monitor is the beneficiary lock-in program that
has now been authorized and CMS is working to implement. With
the number of beneficiaries at risk because of the volumes of
prescriptions they are receiving, I think this data analysis
leads us to patients that maybe should be considered for this
type of lock-in, at least gets us started as to where to focus
these efforts, and that will help manage the care of these
individuals who need services.
Mr. SCHWEIKERT. All right.
Ms. CURDA. We didn't acknowledge that issue specifically,
but I think you can sort of take an all of the above approach,
you can--all of these things working together can help. One
thing we looked at, a couple of years ago, was more of a
prevention focus. It gets very costly when it gets to the point
where someone is addicted to opioids and requires therapy and
treatment. It is much better to prevent the addiction in the
first place; to the extent that we can have controls in place
to flag these individuals who are getting very high doses, it
is very helpful.
But we did a--the Comptroller General held a forum that
talked about prevention and talked about educational healthcare
and sort of a legal kind of strategy.
Mr. SCHWEIKERT. That is actually a very rational approach.
In my last couple of moments, I will pitch our new Chairman,
which I am elated to have you--I feel so tall next to you.
There is an opportunity here for us to take a number of the
pieces of legislation, because we know there are some
alternative pharmaceuticals out there that actually have less
addictive effects or more stabilizing effects.
There is my fixation on taking the data that has been
collected, building that standardization on the
preauthorization so we stop--it becomes almost a preventative
because you don't write the prescription. And the uniqueness of
this Oversight Committee, and its charter, we have the ability
to do legislation. Maybe it is time we all get together, figure
out if we have solutions, bundle them together, and move
forward.
And with that, I yield back.
Chairman JENKINS. Excellent. I yield to Ms. Chu for 5
minutes.
Ms. CHU. Thank you. Mr. Cantrell, in your testimony you
mentioned an example of drug testing or treatment fraud in
which sober living homeowners were bribed to direct their
residents to a specific lab for their year-end sample
screenings. As you noted, this resulted in fraudulent earnings
at the expense of sober living homeowners and those residents
who are in recovery.
I truly appreciate the OIG's attention to this issue, as I
have heard directly from constituents about the fraud and abuse
that can occur in sober living facilities. And, in fact, the
bottom line is we need better oversight, because not only are
these bad actors preying on vulnerable individuals who have
just left treatment, but institutions like the OIG are playing
catch-up to find these nefarious actors, and in the meantime,
more individuals can be hurt.
So I believe we should be assisting those who have entered
and completed treatment and who need support to make a full
recovery. That is why I introduced the bipartisan H.R. 4684,
the Ensuring Access to Quality Sober Living Act, and it would
direct a Substance Abuse and Mental Health Services
Administration, or SAMHSA, to develop a set of best practices
for sober living facilities so that individuals and families
with loved ones just leaving treatment can better identify the
good actors from the bad.
So, Mr. Cantrell, can you expand upon the OIG's efforts to
address fraud and abuse in the sober home industry?
Mr. CANTRELL. Yes. Thank you. Sober homes have become--we
used to talk a lot about pill mills, now we have sober homes
becoming fraud mills. These aren't services that are
necessarily covered by Medicare or Medicaid, but they are ways
to attract people at great risk because they are likely
addicted--have a substance abuse disorder, need treatment, need
services, but instead corrupt sober home owners are basically
farming them out for either medically unnecessary services,
treatment, or testing, or services and treatment that are just
never provided.
Sometimes these homes are places where individuals can
continue to get drugs. And so we have all read about the horror
stories of individuals going to these homes trying to get
treatment and ultimately overdosing. So this is a problem that
is of great concern to us. Largely, it affects us on the
ancillary services side as they farm them out, pay kickbacks to
doctors and drug testing labs.
But it is also through the Healthcare Fraud Provisions
Partnership, we know it has had an enormous impact on the
private sector payers as well. So this is definitely a problem
that we are noticing and we are tackling as it affects Medicare
and Medicaid.
Ms. CHU. Well, I thank you for pursuing it.
And now I would like to address a question to Ms. Curda. We
know that there is, of course, obviously, an unprecedented
crisis, and we are going to have to find solutions that work
for everyone, and that is why I believe we should be expanding
our treatment options for a vulnerable population to include
alternative medicines like acupuncture.
Acupuncture has been the subject of numerous studies by the
National Center for Complementary and Integrated Health and the
National Institutes of Health, and it has been found to be
nonadditive, noninvasive, and can be good for conditions like
migraines, hypertension, chronic pain, or arthritis.
And, in fact, no less than 13 independent studies on the
effectiveness of acupuncture are referenced in NCCIH's web page
on acupuncture. At a time when there is an over prescription of
opioids, I believe that we should be opening our doors to
alternative treatments like acupuncture. And that is why I
introduced H.R. 2839, the Acupuncture for Heroes and Seniors
Act, which would ensure that qualified acupuncturist services
are covered through Medicare.
It is currently available for individuals who receive their
health insurance through the Affordable Care Act in States like
California, as well as in some Medicaid plans, but seniors
should not lose out.
So, Ms. Curda, has the GAO ever studied the impact of
making acupuncture available through traditional Medicare
plans?
Ms. CURDA. No, I don't believe that GAO has done that work.
Ms. CHU. Is it possible for GAO to evaluate the
effectiveness of offering integrative health alternatives like
acupuncture to opioid prescribing practices and government
healthcare programs? Do you foresee any hurdles in such an
examination?
Ms. CURDA. Yes. I think GAO could look at that question.
The hurdle would be the sort of status of the literature and
evidence in that area. We would probably want to first do a
review of the literature to see, you know, what does the peer-
reviewed literature say about the effectiveness of that
treatment. And we could certainly describe, you know, what that
evidence lays out.
Ms. CHU. Thank you.
Chairman JENKINS. Mr. LaHood is now recognized for 5
minutes.
Mr. LAHOOD. Thank you, Chairman Jenkins. And it is an honor
to be part of this Subcommittee and Full Committee, and I
appreciate the opportunity to have this subject matter before
us today. And I want to thank the witnesses for your valuable
testimony here today.
I represent a district in central and west central Illinois
that is a rural district, 19 counties. And this is an epidemic
that continues to rage in a district like mine. And it really
transcends socioeconomic--all socioeconomic categories, rural,
urban, and all sectors of society. And over the last 2 years, I
have held a number of roundtables in my district with first
responders, law enforcement, judges, treatment center
providers, and physicians, to try to understand the issue
better, but also look at how we, from a public policy
standpoint, what we can do to fix this problem.
And as I look at the numbers in Illinois, data from 2016
shows that, in a 3-year period, deaths from overdose increased
by 44 percent from 2013 to 2016, and over 80 percent of those
deaths were attributed to opioids. Of those 80 percent of
opioid-attributed deaths, there was a 70 percent increase from
those attributed from opioids in that same 3-year period.
In Adams County, in my district, they have seen a 360
percent increase in emergency department visits related to
opioid and heroin overdoses over that 5-year period from 2010
to 2015. Additionally, the county saw a 300 percent increase in
overdose mortality rates due to opioids and heroin in the same
period.
And looking at what is the solution, obviously, we have
looked at--from a law enforcement perspective, what do we need
to do on the criminal justice side? Also looking at how you
hold doctors accountable, and what we do in that space. We have
talked a lot about, you know, how we have more resources and
money for treatment centers.
And in some ways, when we look at this epidemic and the
direction we are going, I equate it in some ways to what drunk
driving was in this country 25 years ago. It was raging out of
control, so what did we do? We allocated resources, we raised
awareness, we had a public campaign, and we also had something
called Mothers Against Drunk Driving that was organic that
started.
So I don't necessarily think this is a Federal solution,
this is going to be solved in Washington, DC, and that we have
to work with our local stakeholders in our different States and
local areas that are doing a lot of good work on this. And so
when I think about the testimony here today, Mr. Cantrell, I
wanted to ask you, you talked a little bit about prescription
drug monitoring systems.
In terms of States that have done a pretty good job on
that, can you talk about examples of that, which have kind of
been a model for how to do it, and what they have done to be
successful?
Mr. CANTRELL. The OIG hasn't completed any work on
evaluating PDMPs across the country. But in just talking to our
staff across the country, our special agents, and hearing from
individuals who work in different States, there are a couple of
things that need to happen, I think, to make a PDMP successful.
One, it has to be--there needs to be some sort of
requirement that data be entered in a timely fashion. I think
that, for those that are successful, there is timely data
entry, there is timely review of that data. Sometimes there
needs to be interoperability. Some of these PDMP systems don't
talk from State to State, and we see many fraud schemes, of
course, that cross State lines.
So the States that have interoperability with their
neighboring States, that is a plus. And then we have seen, in
terms of data access, for us in law enforcement, some States
restrict access for law enforcement, and other States allow
that sort of access. From my perspective, of course, I believe
in that law enforcement access to help identify those
individuals who may be prescribing or doctor shopping in
seeking to divert drugs. So those are some of the components of
what I think can make up a successful PDMP.
Mr. LAHOOD. And is there an example or a model you can
point to that has done a pretty good job around the country?
Mr. CANTRELL. I just heard anecdotally that, as Kentucky
got started, they were doing a pretty good job; they are one of
the earlier ones that I was hearing about. I have heard that
the State of New York, from our agents, is doing a pretty good
job, but I don't have any data or any statistics to point to
their success or favor. That is just anecdotally what I have
heard from some of our agents.
Mr. LAHOOD. Thank you.
Chairman JENKINS. Mr. Crowley is recognized for 5 minutes.
Mr. CROWLEY. I thank the Chair, I thank the Ranking Member
for holding this hearing today on what has become a devastating
epidemic for our Nation. My district, like many other districts
across the country, has been ravaged by the opioid epidemic.
More Bronx residents die of drug overdoses--more Bronx
residents died of drug overdoses in 2016 than any other New
York City borough.
Out of the 308 overdose-related deaths, 85 percent involved
opioids generally, and 76 percent involved heroin or fentanyl.
This devastation is unaccepted anywhere. But there is an aspect
in my district that is notable, part of the opioid epidemic
when compounded with other parts of the country.
The increase in prescription opioids across the country has
led to a spike in heroin use, which people turn to for a more
potent high as they run out of their prescription medications.
Heroin has become even more accessible and cheaply available to
communities across the country.
In a community like mine, which is still recovering from
the aftermath of the failed tough on crime tactics of the 1980s
and 1990s, residents have not properly dealt with their
addictions and are more likely to use and abuse newly available
heroin. That makes opioid-related overdoses a side effect of
the race-based drug enforcement policies of the past.
As we work to address the opioid epidemic, I encourage this
Administration and my colleagues in Congress to work toward a
more holistic approach that focuses on treatment rather than
punishment. And I challenge all of us to strive for a better
understanding of the entirety of the epidemic, which impacts
different communities on different levels.
Urban communities, particularly communities of color, must
be a part of this conversation, and they must be a part of the
solution to this terrible and growing problem.
Mr. Cantrell, in the OIG report, Opioids and Medicare Part
D, there are concerns about extreme use and questionable
prescribing, and it suggests that prescribers are not checking
the State prescription drug monitoring databases, or these
databases do not have current data.
Can you explain how prescribers are trained or are supposed
to be trained on how to use their State prescription drug
monitoring database?
Mr. CANTRELL. I am sorry, but I don't actually know the
training requirements for the use of these prescription drug
monitoring programs. And I would suspect it might vary from
State to State.
Mr. CROWLEY. Do you have State-based data on where there
are vulnerabilities of prescriber use of prescription drug
monitoring databases?
Mr. CANTRELL. We do not at this time.
Mr. CROWLEY. Thank you. What are HHS-OIG's recommendations
for improving prescriber use of these databases?
Mr. CANTRELL. Education is certainly one strong component.
And we, along with the DEA, who goes around the country talking
to pharmacists and prescribers, participated in these events to
train and educate individuals in the community about the
importance of this tool and the fraud schemes that they should
be looking out for when utilizing these tools. So I think
education is critical.
And I, once again, this is not based on any analysis that
we have done, but I have just heard there are some barriers to
utilization because it can take a long time to access these
PDMPs as they are providing patient care.
I have heard from individuals in the community that
sometimes just the nature of the system can, maybe it is slow,
and it can deter you. So I think that obviously any
improvements that can be made to increase the timeliness of
these sorts of data checks would be critical to ensuring
adoption and use.
Mr. CROWLEY. I think there is one critical area in terms of
government that can be involved in helping to get a handle on
what is happening in each of the States. And I would hope that
we would have a more robust addressing of the monitoring
databases.
Mr. Cantrell and Ms. Curda, does the OIG or GAO look at
race as a factor in collecting data regarding the opioid
epidemic?
Mr. CANTRELL. We do not.
Ms. CURDA. We have not looked at that.
Mr. CROWLEY. Well, thank you. And I appreciate your time
here today.
Thank you very much. I yield back.
Chairman JENKINS. Mr. Bishop, you are recognized for 5
minutes.
Mr. BISHOP. Thank you, Madam Chairman. Thank you to the
panel for being here today and providing your valuable
testimony. I appreciate the information that you shared and
your expertise.
I am from the State of Michigan. I share all the same
concerns that the rest of the Committee has on this subject.
Each of us has our own stories to tell. Over and beyond the
direct impact on families and individuals who are impacted by
this scourge of opioid abuse, there is another statistic that I
find alarming.
The American Enterprise Institute recently published a
study looking at the cost of the opioid epidemic. And it did it
by State. And I was astounded to see that in Michigan, where I
am from, my home State, the cost of opioid addiction is over 4
percent of our State's GDP. And yet I look at other States on
this table that we have been provided, and it shows other
States that have also been impacted, but not to the extent that
other States have.
There is a huge disparity in how much other States have
been impacted. For example, the White House Council of Economic
Advisors, it estimates the societal burden to fight the
fatalities from opioid overdoses, and also estimated the
nonfatal cost of the opioid epidemic in 2015 to be $72.3
billion, and the fatal cost to be $431.7 billion. And then you
look at the State by State, and you see the huge disparity.
And I am wondering, why does it cost West Virginia, which
has the highest per capita burden at $4,793 per resident? And
then you look at Nebraska, which is $465 dollars per resident.
Why is that? Are there more resources there? Is there some kind
of demographic there that is more susceptible to this? What
causes this kind of data?
Can someone tell me that? Mr. Cantrell.
Mr. CANTRELL. Just in terms of what we see, what we focus
on, fraud trends, you know, there is a variety of factors, but
we definitely see that once a fraud scheme takes root, it
becomes viral in communities. And that is no different, I
think, than in the opioid epidemic. And our agents,
unfortunately, in the Detroit area, see numerous fraud
investigations related to illegal opioid distribution. And
sometimes we are told that it is an export area. So that those
drug schemes are meant to often export those drugs to other
States where they can get higher reimbursement.
So this is the intelligence, you know, we hear from the
ground. Once again, I don't have any analytics available to
point to reasons why one State is different than the other,
but, you know, we have continued throughout my career, my 20-
year career, certainly to see South Florida as a hotspot or an
epicenter of healthcare fraud in general. It has also been a
point where we have seen lots of fraud related to opioids.
Certain communities where this has taken root, it is hard to
get rid of it once it has taken root.
Mr. BISHOP. But you can identify those areas, those
demographics where this kind of abuse and fraud happens. You
have indicated that you have an opioid abuse and fraud program
that you administer. Can you tell us how that works and what
the resources are? Who is in charge of it? What is your mission
in that organization?
Mr. CANTRELL. So, that is a new unit, established by the
Attorney General just last year. As it was initiated, they
rolled out 12 prosecutors in 12 districts around the country to
focus specifically on this epidemic. And as a partnership, FBI,
OIG, DEA, we all dedicated agent resources to those
prosecutors.
Now, that is just a small, at this point in time, kind of
effort in comparison to the total effort nationwide in this
area, but it is an important focus in areas that were not
necessarily the bigger markets that had the greater resources.
We focused on smaller markets in these first 12 districts to
bring resources to various communities that hadn't necessarily
seen the amount of resources in the past.
Mr. BISHOP. Thank you for that. You also mentioned there
were private sector partners as well. I am interested to know
what the private sector is doing to partner with you.
Mr. CANTRELL. So we talked, and CMS is an integral part of
the healthcare fraud prevention partnership, but it provides a
community of private sector payers, State agencies, as well as
Federal payers and law enforcement to share, first of all,
information about trends and schemes, but, also, it is a forum
where they can safely share data from different resources,
analyze that data, and come up with answers or identify issues
across multiple data sources that were previously available to
be searched across.
So I think, for me, it is certainly of great value in
learning about these schemes, because some of these schemes,
like the sober home scheme that was discussed earlier, I was
hearing about it from our private sector partners before we
were seeing it impacting Medicaid or Medicare. And so it is a
great intelligence tool.
Mr. BISHOP. Okay. Thank you so much. And I yield back.
Chairman JENKINS. Mr. Meehan is recognized for 5 minutes.
Mr. MEEHAN. Thank you, Madam Chairman. I am grateful for
you allowing us to sit in on this very, very important issue.
And I want to thank you for the work that you are doing, each
of the panelists, engaged in what is a remarkable challenge for
all of us, and particularly back in our communities.
I want to ask specific questions about the Medicare
relationship to this, but in my own region of southeastern
Pennsylvania, we have seen a staggering 83 percent increase in
drug deaths. That is overwhelming. And when you look at what is
driving that, the distinguishing issue appears to be fentanyl,
but it is fentanyl which is tied to its use with, oftentimes,
opioids. And I know we are dealing with a poly-drug
environment, and there is no simple solution.
But if we are going to have an impact on this, we want to
start by dealing with the opioid abuse in the first place. We
have worked on some programs here in Congress with things that
we have done already that have come from recommendations from
people like you. One of those is the Medicare lock-in. And I
have listened to each of the panelists describe in various ways
how individuals have been able to utilize the system, either by
going to multiple pharmacists, or multiple doctors, or multiple
plans to get the drugs. And still staggering, that even with
Medicare, we are talking about people who are later in life--
often, not all the time--but later in life, and we are still
talking about dependency in that group.
So the lock-in program, as I understand right now, Mr.
Cantrell, would allow us to have a designated distributor and a
much better control over that individual's relationship. Now,
there have been recommendations and utilization by numbers of
plans, but CMS itself, or at least the government, hasn't
created it. Can you tell me where we are on that, where you
think lock-in may be utilized?
Mr. CANTRELL. Well, first, I will say we are very
supportive of lock-in, but I think I would like to defer to my
colleague from CMS to talk about where it stands.
Mr. MEEHAN. Is this Ms. Brandt?
Ms. BRANDT. Yes.
Mr. MEEHAN. Because I was going to go to you next because
you----
Ms. BRANDT. No problem.
Mr. MEEHAN [continuing]. Mentioned that in your testimony.
Ms. BRANDT. I am happy to. As I mentioned in my testimony,
we really appreciate this, this additional tool from Congress.
We agree with the OIG. We think this is going to be a very
powerful tool. We are currently in the notice and comment
period for this. We have to promulgate regulations to implement
it. In fact, the comment period closed yesterday, so that's
good timing with the hearing today.
But we are looking forward to reviewing those comments and
then implementing those comments as we do the final rule. And
then, beginning in 2019, we will be able to begin using this
tool. And we are very excited at the potential that it is going
to add to our suite of tools to help us address these types of
issues.
Mr. MEEHAN. How do you think it is going to make a
difference?
Ms. BRANDT. Well, it will make a difference because it will
allow us, as you said, to limit. We will be able to limit a
beneficiary to a pharmacy and be able to have them at one
pharmacy. And that is the only place, or however it works out
for implementation--we are still working all that out--but
essentially, they could be limited to one pharmacy, which would
allow us then to be able to see their billings just related to
that pharmacy. Right now, they can go to multiple pharmacies,
multiple prescribers. This limits the scope of that much more
narrowly.
Mr. MEEHAN. Okay. If you know, because I am sure the
comments have come from a variety of places, but I am assuming
you have been monitoring this as we have been going through the
comments. Have there been any observations which have
influenced your thinking on this or any kind of a perspective
that was shared in the comment period that either opens up a
new place for us to consider the program or a concern that we
may not have been thinking about?
Ms. BRANDT. Well, as the comment period did just close
yesterday and because it is open rulemaking, I am afraid I
can't speak to that, sir.
Mr. MEEHAN. Okay.
Ms. BRANDT. But as we move forward and have things that we
can share, we will be happy to do so.
Mr. MEEHAN. Okay. Well, I appreciate that. May I just ask
if anybody has a thought on one other problem that I am hearing
quite a bit about, and it does relate to opioid abuse, but it
is the abuse of treatment programs in certain States in
particular, in which people appear to get treatment for a
period of time, they go off, and there are almost finder's fees
to get them in, and they walk out.
And people are targeting them to get them readdicted,
getting them back into treatment so long as there is a payer,
they are in, then they pull them out. And some of these things
appear almost to be scams. Is anybody looking at this issue, or
does anybody have any thoughts? The OIG.
Mr. CANTRELL. Unfortunately, we are seeing a great deal of
fraud relating to the treatment side of this epidemic, where we
need legitimate services the most.
We discussed the sober homes where addicted residents are
sometimes farmed out for lab testing that is either never
provided or isn't appropriate, and they are billing thousands
of dollars for these residents, for these tests. They are
offered counseling, which once again is never provided or isn't
the quality of counseling that actually these individuals need.
And unfortunately, we are also seeing, in terms of some of
the medication-assisted treatment, which, I think, many have
discussed the importance of increasing access to that, we are
seeing fraud schemes relating to this, the availability of
these drugs that are intended to treat this crisis.
So the fraud has followed this epidemic from source all the
way to treatment. And that is the unfortunate thing that we are
seeing around the country right now.
Mr. MEEHAN. I would love to follow up more with you on
that, but, Madam Chairman, I yield back.
Chairman JENKINS. Mr. Blumenauer is recognized.
Mr. BLUMENAUER. Thank you very much, Madam Chair. And I do
appreciate our Subcommittee having this hearing. I think this
is the first time Ways and Means has really dealt with this
opioid crisis and the impact it has on the things that we are
responsible for.
I hope it is not the last. I hope that there is an
opportunity--I think this is one thing that touches us all that
we feel strongly about. It certainly impacts our community. It
makes a difference in terms of employment. What is it, for one-
quarter of the women who are ineligible of being in the
workforce, there is an opioid problem, I am told.
I am concerned that, as we are looking at different
therapies, different options, there is a way to focus on
something that some of our States have done, the State of
Washington, the State of Oregon, dealing with medical
marijuana. And I have some material, Madam Chair, that I would
like to place in the record that makes it clear that States
that have worked with medical marijuana prescribe fewer pills.
[The submission for the Record of
Hon. Earl Blumenauer follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. BLUMENAUER. There is, on average, a 25 percent lower
rate in terms of overdose deaths. The State that has had it the
longest, medical marijuana, California, it is a third less. It
is a cheaper alternative. It is not addictive, the way that we
see with many of the opioids that have been handed out like Tic
Tacs.
It is an area where the public has demanded change.
Politicians haven't brought medical marijuana to 29 States. It
has been the public that has voted for--at least--excuse me, I
guess Vermont is in the process of being the first State that
does it legislatively. But this has been driven by individual
voters. It is supported by strong majorities of the American
public. Florida approved, in 2016, a medical marijuana program
with 71 percent of the population.
I would hope, Madam Chair, that we would have an
opportunity to explore what the impacts are in terms of how
Cannabis can prevent dose escalation and the development of
opioid tolerance, which happens with people who are taking
oxycodone or something like that.
We have the opportunity to be a viable first-line
analgesic. We have an opportunity to make a big difference with
our veteran populations, who, sadly, we have policies in the
Federal Government now that prevent VA doctors from even
talking to veterans about the implications of medical Cannabis,
even in States where it is legal.
And I think we are missing a huge opportunity to help a
troubled population, to cut down on the overdose deaths and
save substantial amounts of money and, while we are at it,
squeeze the black market, which is fueling a lot of other
illegal activities.
I hope, Madam Chair, that my colleagues will have a chance
to look at the materials. It just happens to be from a
physician, a researcher from Oregon. I hope you won't hold that
against it, but the whole second page is documented in terms of
justifying the points that I am making.
This is something that we are no longer going to be able to
avoid. The public is demanding it; 95 percent of the population
has access to some form of legal marijuana. We have the so-
called Charlotte's Web Law, where it is a low CBD dose that is
available for children with severe seizure disorders. But when
you put all that together, it is 95 percent of the population.
The American Legion has come forward saying let's research
this, let's look at it. We are hearing from veterans that it
makes a difference.
Last month I was at our VA hospital, and we were dealing
with this precise subject of opioid addiction. And I happened
to raise, in the course of the meeting, I said we ought to be
looking at medical marijuana and the impact it has. When I
walked out of the room, I was followed by a veteran who was on
the staff, who took my hands and said, ``I am glad you raised
that. I couldn't survive without medical marijuana.''
I think we are missing the boat if we don't dive into this.
And I would commend this to my colleagues for their attention.
Thank you very much.
Chairman JENKINS. Mr. Reed is recognized for 5 minutes.
Mr. REED. Thank you, Madam Chair. And as I was listening to
some of the exchanges, I wanted to take a moment before I got
into my prepared questions. My colleague from Washington asked
about the work requirements for Medicaid, potential issues, and
somehow that impacts substance abuse providers. And one of the
things that it reminded me of is often Medicaid, and I know it
is not the jurisdiction of this Committee, but Medicaid's--I
seem to get the impression--goal of providing insurance
coverage is the only metric that a lot of folks here in DC
gauge its success by.
By that I mean getting people into Medicare programs,
therefore, they have health insurance and, therefore, our job
is done. But I think we can do better than that.
And, Ms. Brandt, I think your response to that question
illustrated CMS' point of view that we can go beyond just
insurance coverage and actually get to making people healthier.
And so one of the questions I have for you when I want to
understand the work requirements that are being proposed is: if
someone is in treatment for drug addiction, I look at drug
addiction as a disease. It is a medical-related situation. That
individual, to me, is not an able-bodied individual as those
work requirements I have advocated for over the years would
envision.
If someone is seriously addicted and in in-patient-type
treatment, is it CMS' position that that individual is able
bodied as we are trying to define it under the proposed work
requirements that are being discussed across the country today?
Ms. BRANDT. Thank you for your question. I am not sure I
can specifically answer our definition of able bodied because,
again, the work requirements are outside of the realm of what I
deal with day-to-day, but I can tell you, as I mentioned
before, that our goal is to make sure that States have steps
that they are taking to ensure access to appropriate treatment
services, particularly for those who have substance use
disorders or opioid disorders.
So if there are people with addiction issues, our goal is
to work with the States to ensure that they are providing
access to those services and that they are giving appropriate--
--
Mr. REED. If that addiction is a disease and that prevents
them from being able bodied, I would hope that our official
policy position would be that that is not who we are addressing
with our work requirement.
The other issue that I would raise on this that I am so
passionate about, is one of the things that I hear from our
employers across the country. One of the barriers to
reemployment--which is empowering to individuals, employment, a
job, an opportunity, does a lot for, not just earning their
paychecks, but for their soul and their dignity and mental
health and their physical health--is being addicted to drugs;
not being able to pass a drug test.
So we have a program under Medicaid or Medicare that is
trying to address opioid addiction; does that not help us to
try to solve the overall issue, when it comes to the example
for Medicaid, in regards to getting people empowered to be put
back into the workforce by getting their addiction under
control and having the goal of, not just insurance coverage for
those individuals, but also the services and the treatments
necessary to get them into a healthy position, which removes
that barrier to reemployment that I am discussing here today.
Would you agree with that?
Ms. BRANDT. Well, as I mentioned, our number one goal is
the beneficiary. Our goal is to make sure we are getting the
right treatment for the right people at the right time, to help
get them to be as able bodied and productive as possible.
Mr. REED. I appreciate that. And I share that commitment.
And I hope our policies here at the Federal level achieve that,
as we set them into a potential future course.
Now to my more prepared remarks. You know, one of the
things that I have seen, as all of my colleagues have seen
across this country, is that opioid addiction is something that
knows no barriers. It impacts everyone. It doesn't delineate,
you know, how much money you have, what kind of family you were
raised in, what race you are, whether you are a man or a woman.
Addiction is that demon that knows no boundaries, in my humble
opinion.
And I am reminded of Vanessa, who we were able to assist
through our office in the district, who was pretty much written
off. Her parents pretty much adopted the tough love approach.
And Vanessa came to us just recently after going through some
very difficult times. And working with her parents, we were
able to get her into a rehab situation. And her parents and her
reunited, and at a town hall they were able to declare that she
was opioid-free. That is a success story.
And so when I see the new programs that are coming out of
CMS--I know I only have 24 seconds left--the Overutilization
Monitoring System shows that we went from 29,000 in 2011 down
to 11,000 in 2016, for at-risk beneficiaries. That is a
significant improvement. How are we going to enhance and
promote that type of program even further and get that into the
system?
Ms. BRANDT. Well, we are continuing to constantly update
that Overutilization Monitoring System. Most currently, we
updated it to reflect the newest CDC guidelines. We have been
very much focused on first-time opioid over-utilizers. And in
fact, we have seen a 77 percent reduction in those since 2013,
and we are continuing to use the work of our colleagues at GAO
and the OIG and their recommendations to further refine our
approach.
Mr. REED. I appreciate that. And to all the Vanessas out
there, I just say we stand ready across both aisles to join
hands to serve their needs and address their addiction to get
them into that healthy life.
With that, I yield back.
Chairman JENKINS. Mr. Curbelo is recognized for 5 minutes.
Mr. CURBELO. Thank you, Madam Chairman, for this
opportunity. And I thank all the witnesses. I am from South
Florida, so regrettably, I have to raise the issue of
healthcare fraud in this context, given that, unfortunately, we
are known throughout the country for that issue.
Mr. Cantrell, can you describe some of the types of fraud
schemes that you see out there related to opioids? And if you
have any examples that are specific or relevant to South
Florida, I would appreciate those as well.
Mr. CANTRELL. The fraud schemes, unfortunately, in many
cases, we see them migrate from South Florida to other parts of
the country. We found it to be a place where fraud schemes are
born, in some instances. I know you know this, but that
continues to be an important area for our work in healthcare
fraud. But in terms of opioid-related fraud, it runs the gamut.
We have seen situations where we have bad prescribers who
are receiving kickbacks, who would write opioid prescriptions
and also write prescriptions for other noncontrolled, high-
expense drugs and get paid a kickback by a pharmacy. The
pharmacy will dispense the opioid and never dispense the
expensive drug, keeping all the profit that is paid by Medicare
for that drug that was never even dispensed or medically
necessary. That is one very egregious scheme.
We have seen examples of physicians who have gone into
business with known criminal networks, outlaw motorcycle gangs,
for the sole purpose of illegally distributing Oxy's and
pairing up with known drug dealers. Sometimes we call them
marketers or patient recruiters. In this case, in this area of
fraud, they are simply pairing up someone who wants the drug
with a pharmacy who is willing to get the drug for a kickback
in most of these situations.
In some of these cases, this overprescribing leads to
overdoses, and, unfortunately, sometimes an overdosed death for
those who have been overprescribed. And so these schemes are
not unique to South Florida. These are par for the course, and
we are seeing these types of schemes around the country.
Some of the things that we have seen in places like South
Florida and New York are schemes related to HIV medications,
which are very expensive. And so we have individuals who have
HIV, need the medication, but are willing to, in essence, sell
it back to a pharmacy for a kickback or sell it on the black
market for a profit.
So schemes like this, whether they are related to opioids
or other expensive noncontrolled drugs, are certainly present
in South Florida, but also in other areas of the country.
Mr. CURBELO. And do you think that government is doing
enough to mitigate this, to address this? Do you think that law
enforcement has the resources to pursue these types of cases?
Mr. CANTRELL. I will say that I don't think we have the law
enforcement resources to address all the complaints that we
have coming through our system. So there is more fraud out
there than we are certainly able to address, given our
resources. So what we do is utilize the data that we have
available to us to maximize the use and the impact of the
resources that we have.
So we focus our efforts in places like South Florida,
whether it is South Florida or somewhere in Indiana, wherever
the highest impact or the most impactful fraud schemes are,
where there are potentially patients at risk or where there is
certainly lots of money being stolen, we will focus those
resources, utilizing data and also intel from the street, if
you will, allowing traditional law enforcement methods to focus
on the right areas.
There is, I think, more that we can certainly all do. And
we have discussed some recommendations for CMS and identified
many areas where they are going to improve their monitoring in
this area, but it is a huge, enormous issue that requires
resources and focus from a lot of different agencies.
Mr. CURBELO. Thank you very much for that response. And I
would just encourage all of my colleagues--we focus on the
victims of opioid abuse, and we should because they are the
ones suffering, but I think we also have to shine the light on
the criminals and find a way to put a dent in all of these
fraudulent schemes and operations that really open the door for
so many vulnerable Americans to this type of addiction.
So I thank you, and I hope that we can begin in South
Florida, just a place where a lot of these schemes begin, that
perhaps we can begin solving the problem there.
I appreciate it.
Chairman JENKINS. Mr. Paulsen is recognized for 5 minutes.
Mr. PAULSEN. Thank you, Madam Chair, for putting this
hearing together and for our witnesses today.
We have all heard the stories of tragedies of opioids that
are impacting real people. These are real families and very
heartbreaking stories of addiction and death. It is no
different in Minnesota. I mean, in 2016, the most recent year
of data that we have, we have seen a 12 percent rise in opioid
deaths over 2015. So Minnesotans are suffering through this
epidemic as well, like so many other States.
And one of the challenges that we have seen and had is that
the theft of opioids from either pharmacies or even from
people's trash has been occurring, where it is a problem due to
outdated disposal techniques or information about how to
properly dispose of opioids. So many people are now simply
throwing them away and thinking nothing of it. Safe home
disposal of unused and unwanted medications is one of the ways
or tools to prevent theft and abuse from inappropriate access
to these painkillers or prescription painkillers.
We know that many people, including younger people, in
particular, start on this path to addiction and overdose by
stealing medications that are prescribed to others. So we have
a company in Minnesota that I toured not long ago, Vertitech,
that makes a very low-cost, easy-to-use, safe disposal bag that
properly and completely disposes of opioids, patches and pills.
It is a little different than going to a senior fair that I
have hosted where maybe the Hennepin County sheriff comes in
and they have a proper disposal technique or facility that is
filled immediately with seniors who come in and dispose of
their medications.
So Ms. Brandt, let me just ask you, is CMS considering ways
to help encourage Medicare and Medicaid beneficiaries to
dispose of unused and unwanted medications as part of a more
comprehensive strategy to confront this epidemic that we have?
Or are you aware of the role that these drug deactivation bags
can have in this space?
Ms. BRANDT. Well, one of the interesting aspects of my job
is that I get to meet with and talk to a lot of people. And as
I mentioned earlier, one of the things we did last fall was
have a number of stakeholder meetings. And as part of one of
those stakeholder meetings, this topic came up, and there was
actually quite an active discussion about the disposal of
drugs. And one of the things that we talked about was the types
of bags that you are describing and how effective those can be
in environments.
We also have heard from CVS, Walgreens, and several of the
other pharmacies about ways that they have been doing things
within their pharmacy networks to encourage that. So at CMS,
one of the things we have been looking at is how we can partner
with our partners at CDC, the Drug Enforcement Agency, and
others to really work to educate beneficiaries about the safe
disposal of opioids and other types of drugs and the full range
of tools available to them to dispose of them.
Mr. PAULSEN. That is great. I would encourage you to stay
in touch with us or Members of Congress, obviously, to support
this work that you are doing now around the safe medication
disposal strategies that you are looking at, and certainly to
partner with you. If there are any opportunities to do that,
please let us know.
Ms. BRANDT. Absolutely. It is always helpful for us to hear
about the strategies that you all are seeing in your
communities and then have that dialogue. And we will definitely
keep in touch.
Mr. PAULSEN. Thank you, Madam Chairman. I yield back.
Chairman JENKINS. I recognize Mr. Kelly for 5 minutes.
Mr. KELLY. Thank you, Madam Chair. And thank you all for
being here.
I think Mr. Reed hit on a lot of different aspects about
the personal involvement that we all have. And knowing too much
about it because of going through things personally. And the
quote that is out there or the saying that says ``where we are
all involved, we are either dependents or codependents.'' But
what I wonder about is, I mean, this started, this war on drugs
actually started back in 1970 with the opium wars, with
President Nixon. And I think in the early 1970s, with President
Reagan. Mrs. Reagan said to ``just say no'' and Mr. T said
``just say no.''
So I don't think it has been for a lack of concern, and it
certainly hasn't been for lack of dollars that we have spent. I
am in the automobile business. I don't want people to confuse
what I am saying here. I am just saying that we do have the
ability to track so many things.
I mean, if you were to come into the dealership today and
ask me about a car, I can tell you the complete warranty
history on that car, everything that has been done to it. The
question then becomes, if we have this ability, why aren't we
able to incorporate it with people who prescribe drugs? And
maybe it is because of the HIPPA Act, I don't know, but we have
so much technology out there today that allows us to really get
an in-depth look at who it is that we are talking about, what
they are prescribing, and who is getting the benefits of this.
So, Mr. Cantrell, I have heard from many healthcare
providers who were frustrated with the HIPPA law that prevents
their ability to coordinate care for substance disorder
patients that are frequent fliers of their emergency
departments.
If the law were amended to allow care coordination, does
HHS have a sense of how much Medicare, Medicaid, and private
plans, that cost would go down? There is a tremendous--the
totality of this is just overwhelming. And I think sometimes we
get confused. If we could just throw more money at it, we could
get it fixed. We have thrown so much money away and seen
nothing but an increase. Is there a better way to use this data
and to coordinate it?
Mr. CANTRELL. We don't have any estimates of the impact of
that sort of change, but I absolutely agree that there are more
opportunities to utilize this data to more effectively manage
this issue, this crisis. And for Medicare, we have fairly good,
strong data related to opioid prescribing.
In Medicaid, it is an area where we still lack visibility
across the country, and it inhibits, we think, CMS' ability to
oversee the Federal dollars that go out to Medicaid that relate
to this opioid crisis, and it doesn't allow us to get a handle
on the scope of the problem in Medicaid without going, in
essence, State to State.
There is a system that CMS is working on to improve the
access to that Medicaid data, and we think, as they continue to
improve that data and get timely, full, complete data from all
50 States, we will have--I don't know what we will see, but it
will be enlightening as we do the same kind of analytics that
we are doing in Medicare against the Medicaid.
Mr. KELLY. I guess that is where I am coming from. Because
I mean, and I really, I look at the private sector. I mean, if
you wanted to--again, I am going to go back to what I do. If
you wanted to find out if a car that you were looking to buy
was ever involved in an accident, you go to the Carfax, and we
have all seen this on TV. Why can't we go and find out exactly
where the problem is? It just has to be there.
These are prescriptions. And I see the numbers, and we have
all this tracking of everything we have done, yet we can't
coordinate it. We can't put the two together to help the people
that really need it the most. And look, I know it is about the
money. There is no question. What a huge economic model this
is. And again, because I am too personally attached to it, it
is not spending more money. We keep thinking that the idea is
to spend more money. I think if we are spending more money, it
is probably going to have to do with personnel, people like you
that handle these things, that never quit on this. This is not
a nine-to-five job. This is 24 hours a day that we all worry
about it.
I think the frustrating part, when we can separate
ourselves from this, first of all, there is a huge loss for
human beings. There is a huge loss in dollars that are being
wasted because we can't connect the dots. We can't combine the
information. I just don't know why we can do it so easily in
the private sector with things that are just inanimate, but we
can't do it where we are, when we are talking about human
beings, being able to touch them, get them together and
actually getting to know how we could serve them. And I don't
know how much more it would cost because I think we don't have
enough boots on the ground to see it.
The other thing is this waste, fraud, and abuse; it is
incredible what is happening on our watch right now. I wouldn't
care what the cost was if it was actually going to help a
patient or a person. I just think it is so sad that we are in a
situation right now. And the President has declared it a
national emergency. Pennsylvania has declared it a national
emergency. We started in the 1800s knowing what the problem
was. We have gone through this whole process. We are no closer
to the answer today than we were way back in the opium wars.
And I think that is the saddest part of it all. Where has
it led? It is not because of the lack of investment or the lack
of concern. How do we get to the point where we can actually
connect this stuff so we don't have to worry about Vanessas or
Jims or Bills or Marys that are out there today? It is just a
tremendous loss in human potential and taxpayer cost.
I thank you so much. Madam Chair, I thank you so much. And
listen, what you are doing is incredible. I can tell you, I
coached children's sports a lot in my life. I can't tell you
the number of times I have been in a funeral home looking at
some young person in a coffin, and around the room were
pictures of them when they played for me at the Penn Street
Cardinals or they played for me at our Little Marlins team. And
I look at that, and I think, ``what happened to that little
boy, what happened to that little girl, that they reached this
point in their life.'' I think it is just so tragic. And it is
not about the money. It is about the results.
Please let's find a way to put this together so we can
track it the right way. Thank you so much. I know I am way over
my time, but I will tell you what, this is overtime. This goes
back to the 1870s. And if we are no closer to a cure today than
we were then, what was the whole purpose and the exercise?
Thank you for staying on this and not giving up.
Chairman JENKINS. Mr. Rice is recognized for 5 minutes.
Mr. RICE. Thank you, Madam Chairman.
I got a call from a friend of mine a couple of weeks ago
about his daughter who had been arrested, and she had drugs on
her person and is probably going to jail. I knew this young
lady growing up. She grew up with my children. She played with
my children. She is a fantastic, bright young lady who has
just, her life is spiraling downward.
And I read these statistics on South Carolina. Do you know
the number of deaths from opioid abuse have doubled in the last
3 years? They surpassed traffic deaths a couple of years ago.
The national statistics say opioid deaths killed 60,000 people
last year, which is significantly more than if you combine
homicides and traffic deaths nationally.
So, and if you look at the graph, I mean, it goes from flat
to straight up. It is not leveling off. We haven't peaked. It
is just accelerating. So whatever we are doing, clearly it is
failing. We are not doing enough.
I look at how you, you know, what you guys do is try to
track where there are problem users and attack that, or problem
prescribers and attack that, but that is not working. I look at
your definitions just from this hearing summary today that you
consider a beneficiary at risk if they receive a daily dose of
greater than 120 milligrams, get prescriptions from four or
more providers, and fill prescriptions from four or more
providers. Good grief. Good grief.
I mean, clearly, if you have those three conditions
combined, that is obviously a huge problem. In 2016, despite
your efforts, despite these programs that you have put in
place, you tell us a beneficiary in New Hampshire received 134
prescriptions for opioids from one prescriber, including 13
months of OxyContin, that is 80 milligrams; 13 months of
OxyContin, 60 milligrams; 13 months of OxyContin, 40
milligrams; 14 months of oxycodone, 30 milligrams; and 13
months of fentanyl patches. You guys didn't catch that? Good
grief. Whatever you are doing is not working.
A beneficiary in Washington, DC received prescriptions for
opioids from 42 different prescribers and filled them at 37
different pharmacies in a year. In a single month, this
beneficiary received 2,330 pills from prescriptions written by
just one prescriber. And we didn't catch that? You know, it is
just overwhelming and depressing that we are so bad at this.
One problem I see is what Mr. Kelly was referring to a
minute ago, is the inability of the Federal Government to bring
itself into the modern age of technology. I know, talking with
folks on the IRS in this Subcommittee, talking with folks in
Social Security, that they are still using Cobol and Fortran in
a lot of their stuff, and they are using computers that have
magnetic tape and all that, where everybody else left that
behind, you know, decades ago.
The IRS has 52 points of failure where only one person
knows how to program these old computers. And if this person
dies or retires, they don't know what they are going to do. Is
CMS in that condition? Is CMS in such a bad shape, such a bad
shape that it is impossible for them to accumulate and
interpret the data that we are talking about?
Ms. BRANDT. Well, we made numerous strides at CMS over the
past several years, and particularly in the past 2 years, to
really try to become more modern with our data.
As Mr. Cantrell mentioned, one of the big developments that
we have, which is going to go a long way toward helping us with
having more of a full picture, is that we were seeing
comprehensive Medicaid data from all of our States.
One of the challenges we have----
Mr. RICE. What does that mean when you say----
Ms. BRANDT. That means----
Mr. RICE. You said you will soon have comprehensive
Medicaid data from all of our States. That is a fascinating
statement right there. What does that mean?
Ms. BRANDT. Let me demystify it for you. That means at the
current point in time we have over 46 States and our goal is to
have all 50 States----
Mr. RICE. We have 50 States.
Ms. BRANDT. Yes. We have 46 out of the 50 States that are
currently reporting in their Medicaid data. We are working with
the other four States to get all of that data in. And once we
are able to have all of the States reporting in data in a
consistent format, then we will be able to use that data to do
more of the data analysis----
Mr. RICE. Okay. Can you do that by regulatory requirement,
or would that require some legal, some legislation?
Ms. BRANDT. This is all within our authority. We are using
our regulatory authority to do that.
Mr. RICE. And basically, you are going to say ``if you
don't meet these benchmarks by this date, we are not going to
pay for the prescriptions anymore,'' I hope?
Ms. BRANDT. Well, that's true with part of this on the
Medicaid side. And then on the Part D side of the house,
Medicare Part D side, we work with the plan sponsors, who are
the ones who actually receive the data.
Mr. RICE. So have you given them benchmarks and set forth
the timelines by which they have to meet those benchmarks?
Ms. BRANDT. On the Medicaid side, we have. We have been
working with them. They have deadlines they have to meet. And
we are working with them to ensure that they are meeting those
reporting deadlines.
And on the Medicare Part D side, we consistently work with
the plans to issue updated guidelines to make sure that they
are reporting to us with as accurate information as possible.
Mr. RICE. So what does that mean? That you haven't given
them the guidelines?
Ms. BRANDT. No, we have, but we update the guidelines on an
ongoing basis. So, for instance, we just issued----
Mr. RICE. Are you getting the Medicare Part D information
from all 50 States now?
Ms. BRANDT. Well, that comes from the plan sponsors, not
from the States. So the States provide us with Medicaid data,
which is for drugs that are covered under Medicaid----
Mr. RICE. Okay. So from the plan sponsors, are you getting
information----
Ms. BRANDT. Yeah.
Mr. RICE [continuing]. From all 50 States?
Ms. BRANDT. Well, the plan sponsors operate in all 50
States, but they, themselves, are the frontline. They are the
ones who provide the point-of-sale data.
Chairman JENKINS. The gentleman's time has expired.
Mr. RICE. All right. I just want to ask one quick question.
I know I am over time. Just one quick question.
Mr. Cantrell, is there any legal impediment to you
gathering this information from all 50 States? Because if there
is, we need to fix that. What is that legal impediment, if
there is one, and how do we fix it?
Mr. CANTRELL. There is no legal impediment. Given the
progress that has been made at CMS for doing this, it might not
make sense for us to independently do it separately.
So we are hoping to leverage CMS' effort to collect this
data in all 50 States, but in order to do our work and do it
independently, we have and continue to get data directly from
the States----
Chairman JENKINS. Thank you, Mr. Cantrell. Thank you, Mr.
Rice. The gentleman's time is expired.
I would like to recognize the distinguished Member from
Washington, Ms. DelBene, for a request.
Ms. DELBENE. Thank you, Madam Chair. Congressman Lewis, the
Ranking Member of this Subcommittee, was unable to join us
today. And I would just like to ask unanimous consent to enter
his opening statement into the record.
Chairman JENKINS. Without objection, so ordered.
[The submission for the Record of Hon. Suzan DelBene
follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman JENKINS. I would like to thank our witnesses for
appearing before us today. Please be advised that Members have
2 weeks to submit written questions to be answered later in
writing. Those questions and answers will be part of the formal
hearing record.
With that, the Subcommittee stands adjourned.
[Whereupon, at 11:46 a.m., the Subcommittee was adjourned.]
[Questions for the Record follow:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
[all]
| MEMBERNAME | BIOGUIDEID | GPOID | CHAMBER | PARTY | ROLE | STATE | CONGRESS | AUTHORITYID |
|---|---|---|---|---|---|---|---|---|
| Brady, Kevin | B000755 | 8164 | H | R | COMMMEMBER | TX | 115 | 1468 |
| Davis, Danny K. | D000096 | 7927 | H | D | COMMMEMBER | IL | 115 | 1477 |
| Kind, Ron | K000188 | 8216 | H | D | COMMMEMBER | WI | 115 | 1498 |
| Larson, John B. | L000557 | 7866 | H | D | COMMMEMBER | CT | 115 | 1583 |
| Thompson, Mike | T000460 | 7806 | H | D | COMMMEMBER | CA | 115 | 1593 |
| Crowley, Joseph | C001038 | 8068 | H | D | COMMMEMBER | NY | 115 | 1604 |
| Nunes, Devin | N000181 | 7826 | H | R | COMMMEMBER | CA | 115 | 1710 |
| Sanchez, Linda T. | S001156 | 7844 | H | D | COMMMEMBER | CA | 115 | 1757 |
| Higgins, Brian | H001038 | 8088 | H | D | COMMMEMBER | NY | 115 | 1794 |
| Marchant, Kenny | M001158 | 8766 | H | R | COMMMEMBER | TX | 115 | 1806 |
| Reichert, David G. | R000578 | 8212 | H | R | COMMMEMBER | WA | 115 | 1810 |
| Buchanan, Vern | B001260 | 7885 | H | R | COMMMEMBER | FL | 115 | 1840 |
| Roskam, Peter J. | R000580 | 7926 | H | R | COMMMEMBER | IL | 115 | 1848 |
| Smith, Adrian | S001172 | 8040 | H | R | COMMMEMBER | NE | 115 | 1860 |
| Jenkins, Lynn | J000290 | 7950 | H | R | COMMMEMBER | KS | 115 | 1921 |
| Paulsen, Erik | P000594 | 8003 | H | R | COMMMEMBER | MN | 115 | 1930 |
| Chu, Judy | C001080 | 7837 | H | D | COMMMEMBER | CA | 115 | 1970 |
| Reed, Tom | R000585 | 8090 | H | R | COMMMEMBER | NY | 115 | 1982 |
| Sewell, Terri A. | S001185 | 7792 | H | D | COMMMEMBER | AL | 115 | 1988 |
| Schweikert, David | S001183 | 7802 | H | R | COMMMEMBER | AZ | 115 | 1994 |
| Renacci, James B. | R000586 | 8106 | H | R | COMMMEMBER | OH | 115 | 2048 |
| Kelly, Mike | K000376 | 8708 | H | R | COMMMEMBER | PA | 115 | 2051 |
| Meehan, Patrick | M001181 | 8125 | H | R | COMMMEMBER | PA | 115 | 2052 |
| Noem, Kristi L. | N000184 | 8147 | H | R | COMMMEMBER | SD | 115 | 2060 |
| Black, Diane | B001273 | 8153 | H | R | COMMMEMBER | TN | 115 | 2063 |
| DelBene, Suzan K. | D000617 | 8374 | H | D | COMMMEMBER | WA | 115 | 2096 |
| Walorski, Jackie | W000813 | H | R | COMMMEMBER | IN | 115 | 2128 | |
| Holding, George | H001065 | H | R | COMMMEMBER | NC | 115 | 2143 | |
| Rice, Tom | R000597 | H | R | COMMMEMBER | SC | 115 | 2160 | |
| Smith, Jason | S001195 | H | R | COMMMEMBER | MO | 115 | 2191 | |
| Curbelo, Carlos | C001107 | H | R | COMMMEMBER | FL | 115 | 2235 | |
| Bishop, Mike | B001293 | H | R | COMMMEMBER | MI | 115 | 2249 | |
| LaHood, Darin | L000585 | H | R | COMMMEMBER | IL | 115 | 2295 | |
| Doggett, Lloyd | D000399 | 8181 | H | D | COMMMEMBER | TX | 115 | 303 |
| Johnson, Sam | J000174 | 8159 | H | R | COMMMEMBER | TX | 115 | 603 |
| Levin, Sander M. | L000263 | 7997 | H | D | COMMMEMBER | MI | 115 | 683 |
| Lewis, John | L000287 | 7902 | H | D | COMMMEMBER | GA | 115 | 688 |
| Neal, Richard E. | N000015 | 7967 | H | D | COMMMEMBER | MA | 115 | 854 |
| Blumenauer, Earl | B000574 | 8116 | H | D | COMMMEMBER | OR | 115 | 99 |
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