U.S. GOVERNMENT PUBLISHING OFFICE

33–794 WASHINGTON : 2019

THE OPIOID CRISIS: REMOVING BARRIERS 

TO PREVENT AND TREAT OPIOID ABUSE 

AND DEPENDENCE IN MEDICARE 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON WAYS AND MEANS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED FIFTEENTH CONGRESS 

SECOND SESSION 

FEBRUARY 6, 2018 

Serial No. 115–HL03 

Printed for the use of the Committee on Ways and Means 

( 

ii 

COMMITTEE ON WAYS AND MEANS 

KEVIN BRADY, Texas, Chairman 

SAM JOHNSON, Texas 

DEVIN NUNES, California 

DAVID G. REICHERT, Washington 

PETER J. ROSKAM, Illinois 

VERN BUCHANAN, Florida 

ADRIAN SMITH, Nebraska 

LYNN JENKINS, Kansas 

ERIK PAULSEN, Minnesota 

KENNY MARCHANT, Texas 

DIANE BLACK, Tennessee 

TOM REED, New York 

MIKE KELLY, Pennsylvania 

JIM RENACCI, Ohio 

PAT MEEHAN, Pennsylvania 

KRISTI NOEM, South Dakota 

GEORGE HOLDING, North Carolina 

JASON SMITH, Missouri 

TOM RICE, South Carolina 

DAVID SCHWEIKERT, Arizona 

JACKIE WALORSKI, Indiana 

CARLOS CURBELO, Florida 

MIKE BISHOP, Michigan 

DARIN LAHOOD, Illinois 

RICHARD E. NEAL, Massachusetts 

SANDER M. LEVIN, Michigan 

JOHN LEWIS, Georgia 

LLOYD DOGGETT, Texas 

MIKE THOMPSON, California 

JOHN B. LARSON, Connecticut 

EARL BLUMENAUER, Oregon 

RON KIND, Wisconsin 

BILL PASCRELL, JR., New Jersey 

JOSEPH CROWLEY, New York 

DANNY DAVIS, Illinois 

LINDA SA ́ NCHEZ, California 

BRIAN HIGGINS, New York 

TERRI SEWELL, Alabama 

SUZAN DELBENE, Washington 

JUDY CHU, California 

DAVID STEWART, Staff Director 

BRANDON CASEY, Minority Chief Counsel 

SUBCOMMITTEE ON HEALTH 

PETER J. ROSKAM, Illinois, Chairman 

SAM JOHNSON, Texas 

DEVIN NUNES, California 

VERN BUCHANAN, Florida 

ADRIAN SMITH, Nebraska 

LYNN JENKINS, Kansas 

KENNY MARCHANT, Texas 

DIANE BLACK, Tennessee 

ERIK PAULSEN, Minnesota 

TOM REED, New York 

MIKE KELLY, Pennsylvania 

SANDER M. LEVIN, Michigan 

MIKE THOMPSON, California 

RON KIND, Wisconsin 

EARL BLUMENAUER, Oregon 

BRIAN HIGGINS, New York 

TERRI SEWELL, Alabama 

JUDY CHU, California 

iii 

C O N T E N T S 

Page 

Advisory of February 6, 2018, announcing the hearing ....................................... 2 

WITNESSES 

Philip B. Scott, Governor, State of Vermont, accompanied by Al Gobeille, 

Secretary of Human Services .............................................................................. 7 

Ramsin M. Benyamin, M.D., President and Founder, Millennium Pain Center, 

and Board of Directors, American Board of Interventional Pain Physicians .. 30 

Jason Kletter, Ph.D., President, BayMark Health Services and Bay Area 

Addiction Research and Treatment (BAART) .................................................... 42 

Harold L. Paz, M.D., M.S., Executive Vice President and Chief Medical Officer, Aetna, Inc. ..................................................................................................... 51 

Laura Hungiville, PharmD, Chief Pharmacy Officer, WellCare Health Plans, 

Inc. ......................................................................................................................... 62 

QUESTIONS FOR THE RECORD 

Questions from the Majority Members of the Subcommittee on Health of 

the Committee on Ways and Means, to Ramsin M. Benyamin, M.D., President and Founder, Millennium Pain Center, and Board of Directors, American Board of Interventional Pain Physicians ................................................... 83 

Questions from Representative Adrian Smith, of Nebraska, to Harold L. Paz, 

M.D., M.S., Executive Vice President and Chief Medical Officer, Aetna, 

Inc. ......................................................................................................................... 84 

Questions from Representative Judy Chu, of California, to Harold L. Paz, 

M.D., M.S., Executive Vice President and Chief Medical Officer, Aetna, 

Inc. ......................................................................................................................... 85 

Questions from the Majority Members of the Subcommittee on Health of 

the Committee on Ways and Means, to Harold L. Paz, M.D., M.S., Executive Vice President and Chief Medical Officer, Aetna, Inc. .............................. 86 

SUBMISSIONS FOR THE RECORD 

Pharmaceutical Care Management Association (PCMA) ..................................... 88 

Philip B. Scott, Governor, State of Vermont ......................................................... 93 

(1) 

THE OPIOID CRISIS: REMOVING BARRIERS 

TO PREVENT AND TREAT OPIOID ABUSE 

AND DEPENDENCE IN MEDICARE 

TUESDAY, FEBRUARY 6, 2018 

U.S. HOUSE OF REPRESENTATIVES, COMMITTEE ON WAYS AND MEANS, SUBCOMMITTEE ON HEALTH, Washington, DC. 

The Subcommittee met, pursuant to call, at 3:07 p.m., in Room 

1100, Longworth House Office Building, Hon. Peter Roskam 

[Chairman of the Subcommittee] presiding. 

[The advisory announcing the hearing follows:] 

2 

ADVISORY 

FROM THE COMMITTEE ON WAYS AND MEANS 

SUBCOMMITTEE ON HEALTH 

FOR IMMEDIATE RELEASE CONTACT: (202) 225–1721 

Tuesday, February 6, 2018 

HL–03 

Chairman Roskam Announces Hearing on 

The Opioid Crisis: Removing Barriers 

to Prevent and Treat Opioid Abuse 

and Dependence in Medicare 

House Ways and Means Health Subcommittee Chairman Peter Roskam (R–IL), 

announced today that the Subcommittee will hold a hearing on ‘‘The Opioid Crisis: 

Removing Barriers to Prevent and Treat Opioid Abuse and Dependence in Medicare.’’ The hearing will discuss the ongoing opioid crisis, and the important role 

data, addiction prevention, and access to treatment play in addressing the crisis. 

The hearing will also examine possible legislative solutions to combat opioid abuse. 

The hearing will take place on Tuesday, February 6, 2018, in room 1100 of 

the Longworth House Office Building, beginning at 3:00 p.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 Tuesday, February 20, 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 Committee by a witness, any materials submitted for the printed record, and any written comments in response to a request for 

written comments must conform to the guidelines listed below. Any submission not in compliance with these guidelines will not be printed, but will be 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. 

3 

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

f 

/ 

Chairman ROSKAM. The Subcommittee will come to order. 

Welcome to the Ways and Means Health Subcommittee hearing 

on ‘‘The Opioid Crisis: Removing Barriers to Prevent and Treat 

Opioid Abuse and Dependence in Medicare.’’ I am pleased to take 

on this issue, along with Mr. Levin, as my first hearing as the new 

Subcommittee Chairman. 

This is the second hearing in a series held by the Ways and 

Means Committee on this crisis. And today we will explore opioid 

addiction and treatment in our Medicare population and ask the 

question how Congress can do more to improve detection, education, prevention, et cetera. 

Like many States, my home State of Illinois is experiencing an 

increase in opioid-related overdose deaths. According to the Illinois 

Department of Public Health, there has been a 44.3-percent increase in drug overdoses from 2013 to 2016. I know this figure is 

consistent with other States and other experiences. Approximately 

80 percent of drug overdose deaths in 2016 were opioid-related. Nationally, more than 42,000 Americans died from opioid-related drug 

overdoses in 2016, according to the Centers for Disease Control. 

That is over 115 people a day or the equivalent of over 14 people 

who would have lost their lives in the course of this upcoming 

hearing today. 

And while those are statistics and the statistics are compelling, 

we are talking about sons and daughters, brothers and sisters, 

mothers and fathers, and those who are dear to us who are struggling with this crisis in and around our communities. With 10,000 

baby boomers joining Medicare each day, we must harness innovation, technology, and data to get ahead of this problem. Unfortunately, there is a lack of available data regarding the Medicare 

population and the extent to which opioid abuse, overprescribing, 

and diversion is an issue for seniors and the disabled. Additionally, 

gaps in coverage for those that suffer from opioid addiction exist 

as well. 

To help us examine what States are doing to address the opioid 

epidemic, we have Governor Phil Scott to discuss the tremendous 

efforts that the State of Vermont has undertaken to battle the crisis through expanded treatment options and substance abuse disorder management. We have representatives from two health plans 

that serve Medicare beneficiaries to discuss how payers are managing care for those that suffer from substance abuse disorder and 

the hurdles they face in doing so. 

And, finally, to round out our witness panel, we have two representatives from the medical field to discuss both medicationassisted treatment and other intervention pain services. 

4 

I think all of us approach this issue with humility. All of us represent constituencies that are being overwhelmed by this crisis, 

and all of us are looking for solutions. And I think our constituents 

have sent us here with a disposition to get things done, and I look 

forward to working with both sides of the aisle to come up with 

commonsense solutions, to look at the things that work and celebrate them and pursue them, shun the things that don’t work, and 

to do everything that we can to relieve this crisis and bring hope 

and optimism in a field that is really quite overwhelming. 

I am pleased that Mr. Neal, the Ranking Member of the Ways 

and Means Committee, is here, and I would yield to him for the 

purposes of an opening statement. 

Mr. NEAL. Thank you, Mr. Chairman. Let me congratulate you 

on your first hearing here. I would remind all that you served with 

me on the Tax Subcommittee, and it was very clear that you decided your future would lie in the Health Subcommittee after that. 

Mr. Chairman, I am pleased that we are holding this hearing to 

identify solutions to address the opiate abuse and dependence specifically in the Medicare space. Although overdose rates are highest 

for people 25 to 54, this public health emergency also affects Medicare beneficiaries. Everyone in this room has a family member or 

knows someone directly impacted by the opiate epidemic. It could 

be somebody down the street. It could be somebody in the next 

room. In my home State of Massachusetts, last year, there were 

2,094 opiate-related deaths due to abuse. I thank my neighbor to 

the north, Governor Scott, and his Health Secretary, Al Gobeille, 

for joining us today. We share a border, and it also means that we 

share a common challenge in fighting the opiate crisis. Massachusetts Governor Charlie Baker, like Governor Scott, is working to 

employ all tools in this fight, ranging from expanding Medicaid coverage to provide treatment availability, data analytics, and treating 

addiction while stabilizing and supporting families. 

Opiate abuse and related deaths take a toll on all of our communities and on all of our families. There is no single cause and there 

certainly is no single solution. Expanding Medicaid under the Affordable Care Act to low-income working Americans who previously 

could not afford insurance has been the most significant step in recent years to stem the tide of the opiate crisis. Providing access to 

critical substance abuse and mental health services that previously 

were prohibitively costly has also worked. 

We need to look to Medicare beneficiaries’ ability to access treatment as ofttimes providers aren’t available to meet the needs. We 

know there are significant gaps in coverage and access under Medicare. 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 longer term addicts. I recently introduced legislation that would allow methadone to be covered for outpatient services under Medicare. 

We also need to work with our partners to identify best practices. 

Late last week, I sent a letter to the Energy and Commerce Ranking Member Pallone about 14 Medicare plans and asked them to 

help compile the best practices that they are aware of to address 

opiate-related disorders. Evidence-based tested activities that are 

5 

helping patients turn the corner will help us design sound policy. 

I look forward to these plans’ responses, and I hope Dr. Paz from 

Aetna today will share his knowledge about what they are doing 

as well. 

We also need to explore how substance abuse is affecting children and families. The epidemic is fueling rising caseloads for children and adult protective services, for foster care, and also for caregivers as they attempt to battle addiction. 

I am pleased that our Committee has worked together on this bipartisan basis on legislation to support families and to help them 

keep children safe who would otherwise be in foster care while they 

can now remain safely at home with proper monitoring. We hope 

we can continue this partnership because we have much work to 

do. 

I hope as we move into the following year that we will not endorse or embrace plans to cut efforts that would, in fact, undermine 

what we are attempting to do here today. For example, the Social 

Security—Services Block Grant is the largest source of Federal 

funding for child protective services and the only major source of 

Federal funding for adult protective services in most States. We 

have a lot of work to do, and Congress could play a positive role 

in partnering with the States to provide resources and help to 

eliminate Federal barriers to treatment and access and support 

families and law enforcement. 

And, Mr. Chairman, to you for holding this hearing, I appreciate 

it. I also point out something that you and I have talked about a 

number of times. There are now 2 million people on the sidelines 

who formerly were in the workplace battling this epidemic. When 

you look at labor participation rates, it has had a huge impact on 

what has happened. So this is a very important hearing. Thank 

you. 

Chairman ROSKAM. Thank you, Mr. Neal. 

I now recognize Mr. Levin for his opening statement. 

Mr. LEVIN. Thank you, Mr. Chairman, and congratulations. We 

all look forward to working with you. You are surely a very articulate, knowledgeable person. We look forward to it. And thank you 

for letting us, in essence, make two opening statements. Mr. Neal 

comes from a State, I think, where there has been a strong wrestling with this issue. The same in Michigan. 

Welcome to the witnesses. A son, Matthew, lives in Vermont and 

is active representing mainly education groups. In the halls, he 

may have bumped into you. 

Mr. Chairman, the opioid epidemic is an enormous societal problem that demands a concerted effort at every level of government. 

The death toll is astonishing. Ninety-one Americans die every day 

from an opioid overdose, with five dying every single day in my 

home State. We have to stop this killer. Despite the urgency of this 

crisis, it is clear that, although President Trump has declared a 

public health emergency, to date, the Administration has not taken 

significant steps to address it. 

Last year, President Trump proposed a budget that would radically alter the Medicaid program while slashing its funding by 

$1.3 trillion. Medicaid is the largest payer for behavioral health 

services. It funds detoxification, maintenance therapy, medicationVerDate Sep 11 2014 06:49 Mar 05, 2019 Jkt 033794 PO 00000 Frm 00009 Fmt 6633 Sfmt 6602 I:\WAYS\OUT\33794.XXX 33794
6 

assisted treatment, and other crucial services. We cannot claim we 

are serious about addressing this crisis on the one hand while gutting one of the country’s most important sources of treatment on 

the other. 

These efforts come on the heels of efforts within the Affordable 

Care Act that would have, I think, if repeal had occurred, undermined these efforts. I will look now to the future and leave those 

comments for the record. 

At this crucial time, the Administration has also undermined the 

Office of National Drug Control Policy, which for decades has 

helped fight drug abuse in this country. Last year, we fought 

against the Administration’s efforts to eliminate all funding for the 

Drug-Free Community Program, an effective multisector community-based drug prevention program that was really started by a 

fellow Member of this Committee, Rob Portman, when he served, 

and myself in 1996. There have been thousands of community antidrug coalitions that have received seed money because of this program. The appropriation level now is $90 million. 

This year, we heard once again that the Administration intends 

to propose undercutting this office by eliminating its oversight of 

drug control and prevention programs. And I must confess, I was 

really alarmed, like so many, when the Administration suggested 

placing a 24-year-old with no relevant experience in the second 

highest position. Through the Drug-Free Communities Act, we 

have had so much contact with this office. It needs the most talented personnel effort. 

A coordinated Federal response to this crisis is possible, but it 

will require a dramatic change of course. We must take immediate 

steps to ensure that we are effectively implementing programs that 

prevent flooding of our communities with unnecessary prescriptions. In Michigan, a State of less than 10 million, more than 11 

million opioid prescriptions are written annually, 11 million. This 

is more than enough to provide each resident of my home State 

with a bottle of opioids each year. 

Addressing the pervasiveness of this will require a broad-based 

effort to revise clinical guidelines with the goal of improving provider behavior, leadership at the State and Federal level to monitor 

for harmful prescriptions and marketing practices, and other immediate steps that will reduce the prevalence. 

I just close. We all, Mr. Chairman, encounter this problem every 

time we go home, do we not? Every time. And we hear of deaths. 

It is younger people, but also people not so young, people sometimes under immense stress. 

And I think with the leadership of this Subcommittee and the 

entire Ways and Means Committee, Energy and Commerce, and 

the Congress, we need to do everything to fulfill our obligation. All 

the answers aren’t in Washington, but some of them are. 

So we look forward to the testimony of you distinguished members of the public sector. Thank you, Mr. Chair. 

Chairman ROSKAM. Thank you, Mr. Levin. 

Let me describe how we will move the traffic today. We have two 

panels. The first panel will be the Governor. And we will have 5 

minutes from each of the witnesses. If you are getting a little 

7 

lengthy, I will tap my gavel gently. But I think most folks have had 

an opportunity to read all of the statements. 

To give us an introduction of the Governor is the distinguished 

gentleman and our friend from Vermont, Mr. Welch, who has this 

distinguishing gift of being able to tell someone to go jump in the 

lake but with such charm that you kind of look forward to the trip, 

actually. 

So, Mr. Welch, would you—— 

Mr. LEVIN. And there aren’t that many lakes in Vermont, either. 

Chairman ROSKAM. Could you introduce the Governor? 

Mr. WELCH. I thank the Chairman for that dubious introduction, but I am not here to tell you to jump in a lake. I am here 

to thank you for having a bipartisan hearing on an incredibly devastating problem. And, as Mr. Levin said, we here in the Federal 

Government can provide some help, but the hard work is done with 

first responders, with Mayors, and with Governors. 

One distinguishing thing about Vermont is we embraced the 

challenge on a bipartisan basis. The Democratic Governor, predecessor to Phil Scott, Peter Shumlin, spoke in his entire address in 

2014 about the opioid crisis. And I remember talking to some of my 

colleagues here, saying, ‘‘Peter, why would you be advertising that 

bad news,’’ but then, as we talked, acknowledging that that was a 

devastating issue in their own communities. 

Phil Scott was then Lieutenant Governor. He has taken up the 

leadership in Vermont now to follow through, and we have this bipartisan approach to try to address the tragic circumstances of 

opioid addiction. 

So I thank all of the Members of this Committee. 

Mr. Chairman, thank you for being here. 

Ranking Member Neal is here as well. It shows the urgency of 

this Committee. 

And all of us are ready to work with you. Thank you. 

And I give you the Governor of the State of Vermont, my friend, 

former Lieutenant Governor, now Governor Phil Scott, of Middlesex, Vermont. 

Chairman ROSKAM. Governor, you are recognized. Thank you 

for being here. 

STATEMENT OF PHILIP B. SCOTT, GOVERNOR, STATE OF 

VERMONT, ACCOMPANIED BY AL GOBEILLE, SECRETARY OF 

HUMAN SERVICES 

Governor SCOTT. Thank you very much. 

And thank you, Congressman Welch. We served together in the 

Senate not long ago. 

Chairman Roskam, Ranking Member Levin—I do know your son. 

I played hockey with him a few years ago. He is a very good hockey 

player—and Members of the Subcommittee, I want to thank you for 

the honor of appearing before you today. My Secretary of Human 

Services, Al Gobeille; Commissioner of Health, Dr. Mark Levine; 

and the Director of the Blueprint for Health, Beth Tanzman, are 

here with me as well. 

As was mentioned, in Vermont, the Governor and Lieutenant 

Governor are elected separately. So, in 2014, when then-Governor 

8 

Peter Shumlin, a Democrat, devoted his state of the State address 

to the opioid epidemic, I was sitting there listening as the Republican Lieutenant Governor. And I must admit, I was more than just 

a bit skeptical. I was concerned calling so much attention to this 

problem would damage our image and hurt our State. And sure 

enough, initially, many at the national level portrayed this as only 

a Vermont problem. We now know all too well this was and is a 

national problem. 

Governor Shumlin was right to focus our attention on this epidemic, and I have since learned the incredible devastation opioids 

have had on our State and our people. I have met countless 

Vermonters impacted by addiction, some in recovery, some still 

struggling, and some who have had their families torn apart, 

changing their lives forever. 

We have made a lot of progress in Vermont, much of it with support from you and our Federal partners, although, today, I approach you humbly because we have not yet solved this problem. 

Even with our small population, we see two Vermonters die from 

a drug overdose every week. And nearly every day a baby is born 

exposed to opioids, something I have highlighted as one of 

Vermont’s biggest challenges. 

We have some of the best access to treatment in the Nation, but 

too many Vermonters who need treatment have not sought it. And 

while Vermont’s rate of overdose deaths is the lowest in New England, we still lost 106 people in 2016. In 2017, it looks like it will 

be similar. Tragically, we also experienced high numbers of children under the age of five who come into State custody due to this 

crisis. And I think we all would agree these kids don’t deserve this. 

They need a better start. 

We have focused on what I refer to as the four legs of the stool: 

prevention, recovery, treatment, and enforcement. My first day in 

office I established by executive order the Opioid Coordination 

Council. This Council is made up of a wide range of perspectives, 

life experience, and different political philosophies. Importantly, 

this includes those who have suffered from the addiction themselves. I handpicked them and tasked them with providing recommendations to improve Vermont’s response to each of the four 

legs of the stool. 

We know that too many Vermonters become addicted through 

prescription pain medication. Therefore, the State implemented 

strict prescriber rules around pain management and a prescription 

monitoring system. So, for the first time, we are beginning to see 

a reduction in prescribed opioids. Unfortunately, we still prescribe 

three times as much as we did in 1999. 

Vermont has also made Narcan widely available to first responders, law enforcement, people with addiction, and family members 

of those suffering. We have aggressively used a screening, brief 

intervention, and referral to treatment model, also known as 

SBIRT, to prevent the progression of addiction. 

Enforcement is another important piece, but we are all in agreement: we can’t arrest our way out of this. Our courts, local police, 

and States attorneys have become important partners in addressing this epidemic, and we address it as a public health issue. 

9 

To treat opioid addiction, Vermont operates a medication-assisted 

treatment, or MAT system, called Hub and Spoke. With the support of our Federal partners, we established a help home for 

Vermonters with opioid addiction. Through well-coordinated and 

comprehensive services, we treat opioid addiction like we do any 

other chronic condition. Our Hubs provide all FDA-approved medications. They also provide critical nursing, counseling, and care 

management. In our Spokes, primary care offices prescribing buprenorphine are supported by nurses and counselors who offer 

more complete care. Finally, coordination between Hubs and 

Spokes assures the patients receive the appropriate level of care as 

they need it. 

Vermont and the Federal Government have been effective partners in tackling healthcare challenges for many years. It is in this 

collaborative spirit that I offer four areas where together we can 

improve our response: 

First, Medicare needs to treat this as the chronic condition that 

it is. I have sent a letter to the Secretary of Health and Human 

Services asking that CMS work with Vermont and engage Medicare in Vermont’s Hub and Spoke system. Working with our Federal partners, we hope to develop a path to make this a reality. 

Second, we need to make sure that SBIRT is fully supported 

within the billing system so Vermont can sustain and expand this 

important work. 

Third, we ask you to consider giving States relief from the IMD 

exclusion, which prohibits using Medicaid funds in mental health 

or treatment facilities of 16 or more beds. 

Finally, our small State could benefit tremendously from nationally supported research in the areas of alternative pain treatment 

and from expanded coverage for alternative chronic pain management. 

In closing, I would like to thank you for the opportunity to address this Committee. We have made great progress over the years, 

but we have much more to do if we are to improve the health of 

Vermonters and all Americans to truly end this crisis and this epidemic. 

Thank you. 

[The prepared statement of Governor Scott follows:] 

10 


33794A.001

Vermont Governor Scott Testimony to the House Ways & Means 

Subcommittee on Health 

February 6, 2018 

Vermont's Response to the Opioid Epidemic 

Chairman Roskam, Ranking Member Levin, Members of the Subcommittee, I want to thank you 

for the honor of appearing before you today. My Secretary of Human Services AI Gobeille, 

Commissioner of Health Dr. Mark Levine, and Director of the Blueprint for Health Beth Tanzman 

join me today. 

In 2014, then-Governor Peter Shumlin, a Democrat, devoted his entire State of the State 

address to the opioid epidemic. Sitting there listening as the then-lieutenant Governor (an 

independently-elected Republican), I must admit to being skeptical. I was concerned call ing so 

much attention to this problem would damage our image and hurt our state. And, at first, this 

was portrayed as a "Vermont Problem." We now know that this was, and is, a national 

problem. Governor Shumlin was right to focus our attention on this epidemic. Since then, I have 

learned all too well the impact of opioids on our state and our people. I have met countless 

Vermonters impacted by addiction. Some who are in recovery, some who are still struggling 

with addiction, and some who have had their families torn apart, changing their lives forever. 

We have made much progres.s in Vermont, much of it with the support of our federal partners, 

yet, today, I approach you humbly. We have not solved this problem. Every week, two 

Vermonters die from a drug overdose. Nearly every day, a baby is born exposed to opioids. 

Even though we have some of the best access to treatment in the nation, there are still many 

Vermonters who need treatment, but have not yet sought it. Vermont's rate of overdose 

deaths is the lowest in New England, but we still lost 106 people to drug overdoses in 2016. 

Unfortunately, 20171ooks to be similar. And, tragically, we continue to see high numbers of 

children under 5, who come into state custody due to opioids. These kids deserve a better 

start! 

What Vermont Has Done 

Continued Attention to the Issue 

We are focused on what I refer to as the four legs of the stool: Prevention, Recovery, 

Treatment, and Enforcement. On my first day in office I established, by executive order, the 

Opioid Coordination Council. This council is made up of a wide range of perspectives and 

different political philosophies. Importantly, that includes those who have suffered from 

addiction themselves. 

I handpicked them and tasked them with providing recommendations to improve Vermont's 

response in each of the four legs of the stool. 
11 


33794A.002

Prevention 

We know too many Vermonters became addicted through prescription pain medication. 

Therefore, the State implemented guidelines on safer prescribing for acute pain and using the 

CDC guidelines for chronic pain. We have enhanced our Prescription Monitoring System so that 

health care providers can see what controlled medications are being prescribed to their 

patients and avoid prescription drug abuse and dangerous drug-to-drug interactions. For the 

first time, we are beginning to see the amount of opioid prescriptions decline. It is discouraging 

to note, however, we still prescribe t hree times as much as w e did in 1999. 

Harm Reduction 

In Vermont, we make Narcan - the opioid overdose reversal drug - widely available to first 

responders, law enforcement, people with addiction and their family members. To date, we 

have successfully reversed over 1,000 overdoses. We also operate needle exchange programs, 

which not only help prevent the spread of diseases such as Hepatitis, but they also provide an 

important opportunity to engage people on treatment options. 

Early Intervention 

The screening, brief intervention, and referral-to-treatment protocol, also known as SBIRT, has 

been employed in emergency rooms, primary care offices and college health services. It helps 

people with risky substance use get education and support to prevent the progression to 

addiction and get them on a better path. The support of the federal Substance Abuse and 

Mental Health Agency (SAMHSA) has been critical to training and deploying SBIRT in Vermont, 

and we are now turning our attention to how we can not only sustain, but expand this practice 

to all emergency departments and primary care offices. 

Criminal Justice 

Enforcement is an important piece, but we know that we cannot arrest our way out of this 

epidemic. Our courts, local police, and State's attorneys have become important partners in 

treating the Opioid epidemic as a public health issue. We use the full force of the law to 

prosecute dealers, and the full force of our persuasion to divert individuals into treatment. 

Treatment 

To treat opioid addiction, we operate a medication-assisted treatment (MAT) system called the 

"Hub & Spoke," one of the most successful treatment systems in the nation. We follow the 

science, which clearly demonstrates that MAT is the gold standard for treating opioid addiction. 

Vermonters in treatment are less likely to overdose, have reduced use of acute health care 

services, and are much more likely to gain stable recovery. 

With the support of our federal partners at the Centers for Medicare and Medicaid Services, we 

amended our state plan to create a " Health Home" for Vermonters with opioid addition. The 

idea w as to treat opioid addiction like we would any other chronic condition with wellcoordinated and comprehensive services. 

2 
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33794A.003

We enhanced the services at our methadone treatment programs to include all the FDA 

approved medications for opioid addiction (Buprenorphine and Vivitrol), we added nursing, 

counselors and care management staff. We asked these programs, now called Hubs, to act as 

regional consulting resources on addiction care to general medical offices. 

We supported primary care by adding nurses and counselors to all the general medical offices 

where Buprenorphine is prescribed- the so-called "Spokes." The nurses and counselors at 

these sites work directly with prescribers to offer more complete substance use disorder care. 

The addition of these staff has allowed Vermont's primary care practices to provide 

comprehensive team-based care, and their relationship to the Hubs helps assure that the 

patients seen in primary care offices have access to higher levels of care when they need it. 

The services at both Hubs and Spokes are supported by payment reforms. At the Hubs, we have 

implemented a bundled payment that covers methadone and supportive services so important 

for successful treatment. In addition, the Hubs "buy and bill" for Buprenorphine and Vivitrol. At 

the Spokes, the nurse and counselor salaries are paid for by a per-member, per-month payment 

rather than reimbursement for each service they provide. 

The new investments we made were primarily in staffing to provide more comprehensive 

counseling and health services to people with addiction in both Hub and Spoke settings. This 

program has been incredibly successful, and we have provided advice and assistance to 

numerous other states who have expressed interest in applying it to their populations. Since its 

inception, we have tripled the people receiving treatment and almost doubled the number of 

providers working with these individuals. We also have data indicating that people receiving 

MAT have fewer visits to the emergency room and admissions to the hospital. We also have 

indications that this support is beginning to reduce opioid use and overdoses. 

Recovery 

I have had the privilege of speaking with Vermonters in recovery about what has helped them. 

They speak of the importance of fami ly, of the dignity of work, and of the support from peers. 

Vermont's recovery centers and peer recovery coaches help people regain their lives. My 

administration is very focused on the importance of building the workforce, and we will pursue 

opportunities to help people in recovery return to gainful employment. 

What Vermont Looks to Do Next 

Vermont and the federal government have been effective partners in tackling health care 

challenges for many years. It is in this collaborative spirit, that I offer four areas where, by 

working together, we can continue to improve our response. 

First, Medicare needs to treat addiction as the chronic health condition that it is. I have sent a 

letter to the Secretary of Health and Human Services asking that CMS work with Vermont and 

engage Medicare in Vermont's system of care, specifically the Hub & Spoke system. Working 

with our federal partners, we hope to develop a path to make this a reality. Medicare could also 

assure that the FDA-approved mediations for opioid addiction are available to beneficiaries. 
13 

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33794A.004

Second, we need to explore better ways to implement SBIRT so Vermont can sustain and 

expand this important work. The current billing practices do not seem to fully support this 

critical early intervention service. 

Third, we ask you to consider giving states relief from the IMD exclusion that prohibits the use 

of Medicaid funds in mental health or treatment facilities of 16 or more beds. 

Fourth, our small state could benefit tremendously from nationally-supported research in the 

areas of alternative treatments for pain and from expanded coverage options for alternatives to 

opioids to manage chronic pain. Such approaches can help prevent unnecessary and prolonged 

exposure to opioids and help reduce the rates of addiction. 

Closing 

In closing, I would like to thank you for the opportunity to address this committee. We have 

made great progress over the years, but recognize we have a lot more work to do, in 

partnership with you, to improve the health of Vermonters and all Americans, and to truly end 

this epidemic. 

4 
14 

Chairman ROSKAM. Thank you, Governor. We really appreciate 

your insight. Don’t go anywhere. I am now going to briefly introduce the other panelists for a little bit of a foreshadowing, and then 

we are going to come back for questions with you. 

So for our second panel, we are going to hear from Dr. Ramsin 

Benyamin, President and Founder of Millennium Pain Center, located in Bloomington, Illinois. We look forward to hearing from him. 

For our next few witnesses, I am going to yield to our colleagues. 

I will now yield to Mr. Thompson for the purpose of an introduction. 

Mr. THOMPSON. Thank you, Mr. Chairman, and congratulations on your new Chairmanship and thanks for having this hearing. 

Mr. Chairman, thanks for the opportunity to introduce and to 

welcome to the Committee Dr. Jason Kletter, the President of 

BayMark Health Services. Dr. Kletter has 20 years of experience 

in the addiction field and currently serves as President of the Bay 

Area Addiction Research and Treatment, headquartered in San 

Francisco in the bay area. His organization operates 20 opioid 

treatment programs in five States, serving 7,000 patients every 

day. Dr. Kletter also serves as the President of the California 

Opioid Maintenance Providers and as a board member of the American Association for the Treatment of Opioid Dependence. He has 

advised both Federal and State agencies, providing input on accreditation guidelines, physician training, and various State policies. 

As part of California’s Hub and Spoke program, modeled off the 

program Governor Scott described earlier, Dr. Kletter’s BAART 

program in Antioch, California, will serve as the Hub to a handful 

of Spokes that will provide treatment to constituents across my district. And I just learned today he is also a part-time resident of my 

hometown. 

So, Dr. Kletter, thank you for your testimony. I look forward to 

hearing about your experience in the field and understanding how 

this Committee can best support your work. Thank you for being 

here. 

Chairman ROSKAM. Thank you, Mr. Thompson. 

Mr. Larson. 

Mr. LARSON. Thank you, Mr. Chairman. And let me echo the 

sentiments of the Members of the Committee and congratulate you 

on your new Chairmanship. And I know how well you work with 

Mr. Levin, and we thank you for hosting this very important hearing today. 

It is my honor to introduce Dr. Harold Paz, who is the Executive 

Vice President and Chief Medical Officer for Aetna in my home 

State of Connecticut. 

Aetna is blessed that it has probably one of the leading thought 

leaders around healthcare in the world in Mark Bertolini, and Connecticut as a region is blessed to have an industry that is focused 

on this, including David Cordani from Cigna as well. But as head 

of the Aetna’s enterprisewide opiate task force, Dr. Paz is responsible for a companywide strategy to prevent the misuse and abuse 

of medications, something that is critical in this epidemic as it continues to wreck, savage this country of ours. 

15 

Under his leadership, we have been able to follow examples and 

hope that we are able to follow examples that the private sector is 

setting, find ways to help our public health system, especially 

Medicare and Medicaid, and effectively and humanely care for 

those suffering from addiction. Aetna has used its valuable data to 

help identify what they call super-prescribers and work with hardhit States to provide training and supplies of lifesaving treatments, 

like Narcan, as the Governor mentioned early on. 

So it is my high honor here today to introduce Dr. Paz. We look 

forward to your testimony, and we thank you for your leadership 

and acknowledge it is not just government but the private sector 

and, in fact, all of us that need to work in collaboration to solve 

this national epidemic. 

Thank you, Dr. Paz. 

Chairman ROSKAM. Thank you, Mr. Larson. 

And Mr. Buchanan. 

Mr. BUCHANAN. Thank you, Mr. Chairman, for holding this important hearing. I also want to congratulate you on your Chairmanship. I am excited about what you are going to be able to do 

with this Committee. 

I am pleased to welcome Laura Hungiville, Chief Pharmacy Officer of WellCare Health Plans based in Tampa, Florida, part of the 

region that I represent. They do a lot in our region, and throughout 

the State and the country. In this role, she helps implement programs to prevent opioid abuse, helps members living with chronic 

pain, and helps members battling addiction. 

WellCare insures 4.3 million members nationwide enrolled in 

Medicare Advantage, Medicare prescription drug plans, and Medicaid. Currently, this does not include mental health counseling, 

yet according to the HHS, approximately 13 percent of people age 

65 and older suffer from mental illness. 

And, with that, I yield back. 

Chairman ROSKAM. Thank you all. 

Now we will turn to make inquiries of the Governor and his 

team. We are going to break with our normal tradition and, by 

agreement, we are limiting our Members to 4 minutes. 

And, with that, I yield back to Mr. Buchanan to begin the inquiry. 

Mr. BUCHANAN. Thank you, Governor, for being here. We also 

have a Governor Scott in Florida, and I don’t know if you are related or not, but if you are nearly as talented as he is, you have 

to be a heck of a Governor. 

Governor SCOTT. If there is any controversy, I usually blame 

him. 

Mr. BUCHANAN. Let me just say, about 7 or 8 years ago, I had 

a lot of members from Kentucky and Tennessee and other places, 

and everybody would be coming to Florida. We had 1,300 pill mills 

that were here, and they had come here because we didn’t have a 

database. And it was a disaster. We were losing 10 people a day. 

We have shut down a lot of those pill mills, but they have moved 

over to heroin and fentanyl and other drugs in our community. In 

fact, my main county is the epicenter of Florida per capita with a 

lot of these drugs. 

16 

But I read something the other day. It just was a shocking statistic from the AARP on deaths from opioids. Of course, being in 

Florida, we have a lot of seniors. I think 60 percent of my constituents are 60 and older in my area. But deaths from opioids, they 

have increased seven times for a senior 65 to 74, because you always think sometimes about just younger people, over the past 15 

years. This is an absolute tragic thing. And I guess I would be interested in what you have learned from Vermont, in terms of a lot 

of your seniors. Let’s just take that initially, any thoughts that you 

have on that. 

Governor SCOTT. I will start off and then let my Secretary take 

over from there. But we are seeing—I think a lot of it is the prescription rate amongst seniors across the board that they store in 

their medicine cabinets and so forth. We have a drug take-back, a 

prescription drug take-back program, where in the first—what I 

thought was the first year they collected almost 6,000 pounds in 

our small State of Vermont. And I thought that was remarkable 

and that, for the first year, I would expect that with the pent-up 

reserves. And then they told me that was the third year, and they 

collected 5,000 the year before and 5,000 the year before that. So 

that tells me that the prescription rate is abusive and excessive. 

So I don’t believe we are seeing the deaths of our seniors as we 

do with our youth, but I will let our Secretary answer that. 

Mr. BUCHANAN. Just for time, let me get to another question. 

I think one of my colleagues had mentioned how everybody is impacted. My family has been impacted. But what are you doing on 

a little different score? What are you doing in terms of prevention? 

I had a mother come in the other day, four kids, homeschooled, two 

of them are addicted. 

So the thought to me is, what do we do to prevent this in the 

first place? Because once they go through that door—she told me, 

crying, that after 2 weeks of being on these pills, the older brother 

brought it home and got his sister hooked. In a matter of a couple 

of weeks, they got addicted. It has been over a year for both of 

them to be able to get off this stuff, and they might have to deal 

with this for the rest of their lives. 

So the impact and the power of these drugs is incredible, but I 

have a lot of stories like that. I have had three mothers come in 

where they have lost their children, and that is what got me initially involved in this effort. 

But what is your thought about prevention? Because once they 

go through that door, in my opinion, it is nice to have all these 

other things and it is important, but how do we prevent it in the 

first place? What more can we be doing on the prevention front? 

Mr. GOBEILLE. Thank you. My answer to that would be, we 

need to do a lot more in prevention. Some of the things that we 

have done is that we have worked with the goal of setting up a prescription monitoring system in our State. We passed a law in 2013. 

But we had done good work prior to that to try to get a database 

where we would know what specialties we are prescribing, at what 

levels, basically so that doctors would know who was prescribing 

what to their patients so that we could look inside our State, but 

also, because we are a small State, to our neighboring States and 

what was happening with our patients, basically, that could go 

17 

there for pills. So it is a game of, how do you reduce the impact 

of the pills, because this is a pill-driven crisis? And so anything 

that can aid that upstream has a big benefit. 

Mr. BUCHANAN. Let me just close out, because I want to yield 

back. 

Chairman ROSKAM. Thank you. Let me just give you a little 

housekeeping here. I think we as Members have a lot to say. We 

are going to be well-served if we allow our witnesses to give us 

input. And so keep the time on your question a little more limited 

so that they can come back. You know what I am saying? We are 

varying from our normal procedure. 

Mr. Thompson. 

Mr. THOMPSON. Thank you, Mr. Chairman. 

Governor, thank you for being here. According to the CDC, 42 

percent of workers with back injuries got an opioid prescription in 

the first year after their injury, and then a year later, nearly one 

in five of those patients are still taking the same drug, despite the 

fact that the FDA has not approved opioids for long-term use. So, 

clearly, these people are still suffering serious pain or they are addicted. 

So how do we make sure that folks, workers who have been injured on the job and are under the protection of the State workers’ 

comp system are getting appropriate treatment for their injury, 

and how can we ensure that they have access to treatment if they 

become addicted? 

Mr. GOBEILLE. Thank you. I think that the answer begins with 

taking a look at the way that pain clinics are formed, and I think 

you have a witness that will come up and describe it way better 

than I can. But, basically, there has to be a lot more avenues to 

treat the pain and to treat the rehabilitation for folks other than 

just opioids. 

So, while opioids may be an answer, there are a lot of other answers that need to—questions that need to be asked and potential 

remedies other than just simply prescribing long-term opioids. 

Mr. THOMPSON. Have you looked at the workers’ comp system 

in your State? I know in my State, I have constituents who become 

injured and it takes forever to get through the system, and they 

rely on the opioids to relieve the pain while they are waiting for 

treatment, sometimes treatment that never comes. And I am just 

concerned that this may exacerbate the entire program. 

Governor SCOTT. I have lived that life. I was three decades in 

the construction business, so I had numerous of my employees out 

with injuries and so forth. And we have to be very, very careful. 

Once we open the door and they are prescribed opioids and the prescription drugs, to just shut them off without proper treatment 

leads them to other methods of heroin, fentanyl, and so forth. So 

we are monitoring that. We are taking a look at that as we speak 

with interest as to what we can do to make sure that we have a 

pathway for them to recover because, again, we don’t want to just 

shut them off. We want to help them get through it so they can 

become more productive citizens back into the workforce, which is 

so important. 

And those are some of the opportunities that we see with our 

Opioid Coordination Council, to look for ways that we can break 

18 

down the stigma as well as to appreciate when someone has a 

problem so that we make sure—again, we want to make sure that 

we reintegrate them back into the workforce, because we desperately need them in Vermont. 

Mr. THOMPSON. Thank you. Some have said that Medicaid expansion is behind the opioid epidemic, but everything that I have 

read suggests that the expansion happened in 2014, and this has 

been going on since the nineties. 

So, Governor, can you tell us about the role Vermont’s Medicaid 

expansion is playing in your State’s efforts to address this epidemic, and just how critical will Medicaid be in the recovery process? 

Mr. GOBEILLE. Yes. So, to be clear, we don’t believe that Medicaid expansion caused this crisis. And, further, if we believe 

through fact that this is a chronic illness, then each payer should 

treat it like the chronic illness it is and be able to pay as a benefit 

for necessary treatment, counseling, et cetera. This really started 

in the late nineties, and I think that the evidence is clear. 

Mr. THOMPSON. Thank you very much. I yield back. 

Chairman ROSKAM. Mr. Smith. 

Mr. SMITH. Thank you, Mr. Chairman. Thank you to our witnesses for addressing what I think is a large problem across the 

country, both rural and urban. A lot of folks, as you know, are impacted. 

Governor, I am wondering if you think that the type of management and monitoring necessary to successfully guide patients 

through the process of medication-assisted treatment programs 

such as yours are possible under the Medicare program. Feel free 

to answer, either one of you. 

Mr. GOBEILLE. We do think they are possible, but the letter 

that we sent the HHS Secretary was basically a request not that 

Medicare just simply treat this like a chronic illness and begin to 

pay for the delivery of services, counseling, or medication-assisted 

treatment, for example, but to actually participate in Vermont’s 

system of care, which is partially Hub and Spoke but also other 

treatment modalities. 

So it is not enough to just sort of pay the bill. It is about the way 

in which the services are delivered and organized that we want 

Medicare to fully participate in like other payers. 

Mr. SMITH. Okay. I think you have answered my next question, 

so I appreciate that. And I think the approach—I would hope that 

there is the flexibility offered to States to address as they see fit 

that not often comes from the Federal Government, but hopefully 

that can be offered in the future, if you will. 

Mr. GOBEILLE. Yes, sir. And what I would add is that recovery 

and healing should be a part of a conversation with your healthcare provider. And Hub and Spoke might be one answer. There 

might be residential treatment. There might be, you know, other 

paths to sobriety and getting back to living the life you wanted to 

live. And so Medicare should participate in all of that, just like we 

do with other, you know, illnesses. 

Mr. SMITH. There are a lot of Nebraskans, especially in the agriculture community, who are buying their health insurance 

through the individual market. They are telling me that their outVerDate Sep 11 2014 06:49 Mar 05, 2019 Jkt 033794 PO 00000 Frm 00022 Fmt 6633 Sfmt 6602 I:\WAYS\OUT\33794.XXX 33794
19 

of-pocket expenses are $30,000 to $40,000 a year, with copays and 

deductibles contributing to that. That really puts a lot of access out 

of reach. 

And I am wondering if that will ultimately pose a barrier. Certainly, many of our hospitals are even getting stuck with those 

copays, unpaid copays and deductibles. And I am wondering how 

we might need to address that at the same time we are looking at 

these issues. 

Mr. GOBEILLE. So just an idea. The way that we treat colonoscopies, the way that we treat primary care services under the Affordable Care Act is that those are included, you know, as a benefit. Services like this could be included and not necessarily go 

against your deductible. 

And so it is a question of, you know, how you want to set up the 

insurance marketplace so that people actually participate, you 

know, in different types of prevention alternatives. And, you know, 

that would be, you know, for others denied, but I would think we 

would have to take a hard look at that. 

Mr. SMITH. Okay, very well. 

Thank you. I yield back. 

Chairman ROSKAM. Mr. Kind. 

Mr. KIND. Thank you, Mr. Chairman, and I welcome you and 

congratulate you on your new position. I look forward to working 

with you. 

Gentlemen, thank you for being here. And I, in particular, have 

been paying very close attention to the challenge you face in 

Vermont. I mean, you have a large rural State. I have a very large 

rural district in western Wisconsin. We face many of the same 

issues, and we appreciate your insight on this. 

And I also, Governor, appreciate your opening comments, as a 

former special prosecutor who dealt in the drug world for a long 

time. I have had a lot of forums, a lot of listening sessions back 

home, including with law enforcement, and I haven’t met anyone 

yet who thinks we are going to be able to deal with this through 

the criminal justice system. This has to be a public health approach 

ultimately to break the cycle of addiction for us to have any fighting chance to get out ahead of that. So I appreciate your insight 

on that. 

Governor, I was wondering if you have been following closely the 

Trump Administration’s Commission on Combating Drug Addiction 

and the Opioid Crisis, because last November, they did come out 

with a fairly detailed report and findings and recommendations 

that were submitted to us here in Congress for our consideration. 

Have you had a chance to look at that or review that at all? 

Governor SCOTT. Yes. Our team has taken a look at that. We, 

again, have set out on our own course that we think is working. 

Some of them were replicated within the report. But we are always 

looking for new information. 

And, again, one size doesn’t fit all, as we have found out. And 

there are always new opportunities to do something better. So we 

are still looking at the report, determining if there is anything that 

we can use to make better use of our system. 

Mr. KIND. Some of the recommendations are kind of commonsense principles that do apply across the board. I mean, increasing 

20 

access to substance abuse treatment programs. We are going to 

hear further testimony today on that. Also, under Federal law, insurers are already required to cover addiction treatment and mental health services. Many of them aren’t, and many of them aren’t 

including them within their networks. And it is especially difficult 

in rural areas, given what is available out there. They also recommended dedicating more money for treatment overall. They are 

encouraging greater use of alternative and complementary forms of 

medicine, rather than just a cocktail of prescription drugs that 

often lead to addiction and then contributing to the opioid epidemic. 

One of the recommendations—I am wondering if you had a 

chance to look at it or have an opinion—is recommending that we 

give the Department of Labor the authority to start penalizing insurance companies that aren’t including it in the network and are 

not adequately providing coverage for addiction treatment or other 

mental health services. 

Is that something we ought to be considering? 

Mr. GOBEILLE. So what I would say is that while they were 

holding their meetings and writing their report, our Opioid Coordination Council, which I chaired, we were writing a report as well. 

And we came out almost the same on so many issues. It, you know, 

really came out right at the same time. And the NGA also has a 

report. So there is a lot of common sense in all the documents. So 

I agree with your points. 

The last question that you asked, I think that we have to embrace this as a chronic condition. And then, if we do, we should 

make Medicare, Medicaid, and commercial insurers treat this as an 

essential health benefit, like we would kidney disease or diabetes 

or some other chronic condition. 

So yes, I would think that would be—— 

Mr. KIND. The other thing I think we ought to be considering 

is, since you guys are out front doing a lot of good work and trying 

to get out, and virtually every State is trying to do the same thing, 

is some type of national repository of best practices and best evidence medicine, what is working and what isn’t, so each State isn’t 

required to, you know, recreate the same wheel over again. 

Interesting. Even though we have been going through problems 

with VA reform lately, we have had some success in a bipartisan 

fashion implementing certain reforms with the VA Medical Center, 

especially when it comes to pain management and drug addiction. 

In fact, in my home area, Tomah, Wisconsin, the VA Center is developing a really interesting model with a tremendous track record 

of proven results that could become a model of care throughout the 

country if we do it right. So I would also take a closer look at what 

the VA has been doing on this front for some time. 

Thank you, Mr. Chairman. 

Chairman ROSKAM. Hold that thought and kind of weave your 

answer into an inquiry that is coming from Ms. Jenkins from Kansas. 

Ms. JENKINS. Thank you, Mr. Chairman. 

And thank you, Governor, for being with us on the Subcommittee. Like Vermont, my home State of Kansas is struggling 

with a nationwide opioid epidemic. In my view, it is particularly 

21 

difficult for rural States to expand access to opioid treatment services, just because of a lack of treatment facilities and trained medical personnel. So Vermont’s Hub and Spoke approach may very 

well be a model for our Nation. 

In your written testimony, you mentioned strategies for prevention, harm reduction, early intervention, criminal justice, treatment, and recovery. Your testimony brought to mind just a couple 

questions I would like to ask. 

The first is that it is my understanding that there is a low uptake in the electronic prescribing of controlled substances. Is the 

State of Vermont doing anything to encourage prescribers to utilize 

e-prescribing and, if so, can you just talk a little bit about any 

pushback the State may have received in implementing those proposals? 

Mr. GOBEILLE. I had to phone a friend. We use e-prescribing, 

and according to the smarter people than me behind me, we are 

good in that area even though we are rural and small. And so we 

could get you more information and submit that in writing, if that 

would be okay. 

Ms. JENKINS. I would be interested if you had any pushback. 

Yeah, if you could get back to me, that would be great. 

Mr. GOBEILLE. But about the pushback, I think what is interesting, the way the Congressman from Vermont was introduced as 

somebody who could, you know, politely tell somebody to jump in 

a snowbank, in Vermont, it is really hard to fight back common 

sense, because we are so small and we all know each other. And 

so we don’t run into that as much as you might think. 

Ms. JENKINS. Okay. I am told that substance abuse community 

clinics and residential treatment centers still use telephone, paper 

records, and faxes to communicate with each other and the larger 

medical systems. I have introduced H.R. 3331 with my friend, Congresswoman Doris Matsui, that would authorize a health IT demonstration for behavioral health providers. 

Do you think electronic health records can play a role in States’ 

efforts to combat the opioid crisis? And how is it the State of 

Vermont is using electronic health records? 

Governor SCOTT. The simple answer is yes. 

Mr. GOBEILLE. No, the simple answer is that is brilliant. So I 

am a restaurant owner, got into this, you know, sort of later in life. 

He was a construction company owner. And we thought we were 

behind the 8-ball in terms of being modern until we really got to 

work in healthcare. I mean, I haven’t seen a fax machine or a typewriter in a long time, but you can find them in some behavioral 

health clinics and some doctors’ offices. 

So the point you are making is right on target. There is not the 

electronic systems that are necessary to run our community mental 

health agencies and the like at the level that most people would 

think they would have, FQHCs as well, et cetera. 

Governor SCOTT. I would like to offer as well that when we talk 

about some of the treatment centers in our rural areas, it does put 

a burden on many who are seeking treatment. And when you think 

about in some of our rural sections, we had a waiting list in one 

area of 700 waiting for treatment. And that doesn’t lend itself well 

22 

for those seeking treatment when they have to be put on a waiting 

list. 

As well, those who were in treatment at that time, it was so far 

away that they would spend 2 hours driving to or taking a bus 

going to a treatment center to receive their treatment on a daily 

basis, 2 hours one way and then 2 hours back, an hour’s worth of 

treatment. So, for those who were expecting to reintegrate into the 

workforce and be part of society again, it doesn’t lend itself well 

when you are trying to take care of your family and to find a job 

where it is flexible enough so you can receive treatment. 

So it is something—we did put a Hub in that area. We reduced 

that level from 700 to zero. We don’t have a waiting list in that 

area anymore, and that is successful. I mean, that was a time 

when we took a moment to celebrate success because you don’t 

have much success in some months. But that was a time when we 

said we are doing something fruitful in a positive way. 

Chairman ROSKAM. Thank you. 

Ms. Sewell. 

Ms. SEWELL. I want to thank the Chairman and Ranking Member for hosting today’s forum. 

As many of us have seen, more Americans died from drug 

overdoses in 2016 than the number of those lost in the entirety of 

the Vietnam war. And preliminary data from CDC suggests that 

2017 was even worse than 2016. 

I want to thank you, Governor Scott, for your leadership on this 

topic as well as your testimony today. It is my hope that more 

States, including my own State of Alabama, will realize the successes achieved in Vermont and implement similar strategies to 

tackle this growing epidemic. 

You spoke a little to your administration’s focus on the importance of helping people in recovery return to gainful employment. 

I, like you, Governor Scott, have met with many people who are in 

recovery who tell me that it is the dignity of a job that keeps them 

going and that keeps their families going as well. So I think it is 

really important that we have models that stress the importance 

of getting gainful employment even when you are still in treatment, as you suggested earlier. 

The way we address this public health crisis will serve as a 

model for decades to come on addiction treatment. I believe we 

made a terrible mistake in the 1980s as a country in our response 

to the crack cocaine epidemic, where we are seeing that the response we gave was for more jails and not for more treatment centers. 

I am very happy that, with this epidemic, we are seeing that it 

truly is a public health crisis, and it is a crisis that requires intergovernmental help and lots of wraparound services, and so figuring 

out how we can get best practices I think is really important. 

An issue I worked a lot with in my rural areas is transportation. 

And so often getting access to treatments has been a big problem 

in the State of Alabama. In fact, I introduced a bill with Congressman Meehan. It is a bipartisan legislation that would allow Medicare Advantage plans to offer a wider array of supplemental benefits to chronically ill enrollees, such as transportation and nutrition 

23 

programs and mental health services. I believe we should implement this type of benefit expansion across Medicare programs. 

So I guess my question to you is, Governor Scott, would you recommend expanding coverage for treatment in Medicare, and can 

you explain why you believe improved Medicare coverage for treatment of opioid abuse is important in fighting this epidemic? 

Governor SCOTT. Absolutely. I am going to let our Secretary answer, fill in the gaps, but I did want to mention that is what the 

beauty is of this Hub and Spoke model, that we can have treatment 

facilities closer to those who need it. And when we see an area, 

such as we did, that needed more treatment, we set up another 

Hub. So it is essential that we react every time that we see an 

issue. 

I would also say, with the introduction and the use of Narcan in 

our State, I am afraid that the number of deaths that we are seeing, which is almost the same as the previous year, doesn’t tell the 

whole story, because we are preventing a lot of deaths from happening. So that doesn’t mean that—just because they are staying 

the same doesn’t mean that we are necessarily making a lot of 

ground up. So we have to fulfill that. 

Stigma is an important part of reintegrating, again, those into 

the workforce. And I think we have made some positive gains in 

that respect. A lot of employers we are speaking with, we are making a concerted effort through our Labor Department to try to determine—you know, give those folks a second chance or third 

chance or fourth chance, because sometimes it is not the first time 

or the second time; it is the third time. 

I had employees of mine that we all are aware, more aware now 

than we were then, that were addicted, and I didn’t know it. And 

they were great employees. And so we gave them that chance, that 

opportunity to succeed. 

Ms. SEWELL. Thank you. 

Chairman ROSKAM. Mr. Marchant. 

Mr. MARCHANT. Thank you, Mr. Chairman. 

Governor, you spent some time in the legislative branch. Do you 

think that your State has passed sufficient laws and statutes to 

give you the tools that you need to combat this? I have three questions. I will ask all three of them. 

Second, who in Vermont recognizes this dependency? Is it the 

State? Is it the doctor? Is it the person themself that recognizes 

that they are addicted, or is there a definition that the State has? 

And the last question is, is most of the acquisition of the opioid 

legal or illegal? 

Mr. GOBEILLE. Sorry, sir? 

Mr. MARCHANT. The acquisition of the pills. I mean, are they 

getting the pills legally, or are they buying them on the black market or from a dealer, as a percentage of the people that are—— 

Governor SCOTT. I will try to answer some of those and, again, 

I would ask my Secretary to fill in the gaps. But what we are seeing is a lot of the crime rate is due to obtaining some of the prescription drugs even and some of the unused prescription drugs in 

medicine cabinets. That is why the take-back program is so necessary. Those who have been utilizing opioids, their kids get inVerDate Sep 11 2014 06:49 Mar 05, 2019 Jkt 033794 PO 00000 Frm 00027 Fmt 6633 Sfmt 6602 I:\WAYS\OUT\33794.XXX 33794
24 

volved. They take the drugs. They sell them or utilize them themselves. That is an issue. 

I am trying to recall the rest of your question. 

Mr. MARCHANT. Has your legislature passed the statutes that 

you need? 

Governor SCOTT. Continually. I think we have a good working 

relationship. Again, I have served in the Minority, but we have always worked together, trying to do whatever we can, because we 

recognize this isn’t a partisan issue. This is an issue that faces 

each and every one of us. It doesn’t discriminate. Whether you are 

Republican or Democrat, it doesn’t discriminate. It doesn’t discriminate from a social standpoint either. So we recognize that, and we 

have been given many of the tools, and we continually seek resolutions to try to obtain more. 

Mr. GOBEILLE. And I think the last question you asked is, what 

door do you walk through to get treatment in Vermont? And we try 

to—— 

Mr. MARCHANT. Who declares that you need treatment? Is it 

usually self-declared or—— 

Mr. GOBEILLE. So what I would say is that, for treatment to 

work, it pretty much has to be self-declared, meaning on a base 

level, it has to be a recognition that the person has to make. 

But, also, through the screening tool that the Governor talked 

about in his opening remarks that we use in primary care offices, 

in emergency rooms, and in other healthcare delivery sites in our 

State, it allows for the conversation to happen with your healthcare 

provider or a healthcare provider where you may become aware of 

your behavior to help you get there. 

But, also, our Hub and Spoke model, the Hub is actually not just 

a Hub for treatment. It is a Hub of activity where you can go to 

receive counseling on your addiction and your options. We also 

have recovery centers in the State where you can go to basically 

reach out and get peer support for recovery. 

So we have a lot of different doors you can open. We are in the 

position now of how do we get more people into treatment, because 

now we can meet the needs of treatment. The Governor articulately 

went through our waiting list. We just recently in the last 6 

months have gotten to the point where we have eliminated the 

waiting list. So now we are trying to figure out how to get more 

people into treatment. 

Mr. MARCHANT. Thank you. 

Chairman ROSKAM. Mr. Blumenauer. 

Mr. BLUMENAUER. Thank you very much for joining us. I appreciate your efforts to kind of put a comprehensive picture on the 

table for us, and I think each and every one of us on an ongoing 

basis is struck by how complex and interdependent these elements 

are in our own community. 

We are troubled with addiction, homelessness, mental illness, 

nothing rising probably to the level in terms of the death and destruction of opioids, but there are a whole series of interrelated 

pieces. And there is lots of blame to go around: the Federal Government was asleep at the switch; problems with the pharmaceutical 

industry; with the medical profession. 

25 

And I appreciate your taking us through your outline of what we 

could be doing. I was particularly struck by your fourth point: Your 

small State could benefit tremendously from nationally supported 

research for areas of alternative treatment for pain. People are 

driven to opioids often when there are, in fact, cheaper and more 

effective alternatives, starting with therapy, but I would also point 

out one that my State has been a pioneer in, and that happens to 

be medical marijuana. 

There is pretty strong evidence that where medical marijuana is 

available, there are fewer opioid deaths. I think in the State of 

California, it is a third less than the national average. 

And I have had countless people, veterans, tell me what a difference it made for them to be able to have an alternative that was 

cheaper, less toxic, they played—they felt more comfortable with. 

NFL players are suspended routinely, maybe not the wife beaters, but the people who are caught self-medicating with pot because 

they don’t want to get shot up with painkillers, in some cases leading to tragic, tragic consequences. 

I am hopeful that this might be an area that we can explore. You 

just became the first State to have the legislature approve adult 

use of marijuana, something every other State in the Union, 30 

States, have done by a vote of the people who have been ahead of 

the politicians on this. 

And I wonder if you have some thoughts about opportunities to 

use medical marijuana as an area to expand these treatment options to be able to properly research it, to get rid of the Federal 

prohibition on robust medical marijuana research and be able to 

explore this as an alternative to this plague. 

Governor SCOTT. We passed medical marijuana when I was in 

the Senate, and I voted in favor and was one of the few Republicans that did. I was serving with Congressman Welch at the time. 

We recognize that one size doesn’t fit all, that that is why we 

need as much flexibility as possible, all different types of treatment 

on the table so to speak, so that we have everything at our—in our 

power to confront this. 

My wife is an RN. She lives this on a daily basis. She sees it in 

the office on a daily basis, all the abuse in terms of prescription 

drugs. But my wife is a runner as well, an athlete. And she has 

had a number of knee surgeries. She thought her running was 

over. 

And she started using this oil therapy about a year and a half 

ago, and she is back to running. She did a 10-miler about 2 months 

ago. So this works for her. My point is we just need everything on 

the table. We can’t allow ourselves to be—put blinders on in terms 

of what might work for one that might not work for another. 

Chairman ROSKAM. Mrs. Black, another RN. 

Mrs. BLACK. Yes, and thank you, Mr. Chairman. 

And thank you to your wife who is an RN and a runner. So I 

applaud you for tackling this issue that is a very large problem. 

And I want to go to the side, as you would expect an RN to do, 

and that is, how can we stop this from happening to begin with, 

because the cost of life, the cost of treatment, and the cost of the 

illegal activity is certainly very, very large? 

26 

And so I am very interested in what you said in your opening 

statement about the prevention piece of it and how your State is 

using the prescription monitoring system to help physicians. However, I do see in here, later on, you say that, for the first time, we 

are beginning to see the amount of opioid prescriptions decline. It 

is discouraging to note, however, that we still prescribe three times 

as much as we did in 1999. 

So there is a little bit of a contrast there about having a system 

where we can see what is going on, and yet there still seems to be 

more of this being prescribed. Can you help me out with that? 

Governor SCOTT. Well, again, in 1999, it went—it skyrocketed 

after that. There was just much more opioid prescription use. So 

we have seen, since we implemented that policy, we have seen it 

go down significantly. So—but still, compared to 1999, we are still 

using three times as much. 

Mrs. BLACK. So is this real time for your physicians that they 

can get into a computer and see whether someone has a prescription filled? And this is real time? 

Governor SCOTT. Yeah, I believe it is. Yes, go ahead. 

Mrs. BLACK. Okay. So that is very, very helpful. 

Mr. GOBEILLE. So it is real time, yeah. 

Mrs. BLACK. Okay. Let me go to the second piece, the early 

intervention and the prevention piece, the screening, the brief 

intervention referral to the treatment protocol, all of those things 

that are done in the emergency rooms and primary care. 

Is someone coming in that is self-referred, or is this happening 

when they come in for other kinds of treatment that the practitioner would say, ‘‘Maybe this is something I need to address,’’ and 

talk about how is that actually done? 

Governor SCOTT. I think it is all of the above, actually. It could 

be from many different situations to at least make others aware of 

the situation. 

Mr. GOBEILLE. Yes. So the way we did this was we received a 

grant and some Federal money to be able to do this in one hospital, 

and we started there and we have kind of spread out. And we don’t 

do it everywhere in the State yet, but we do it across a large part 

of—the majority of the State. 

And it isn’t just if you come in saying you think you have an 

issue with addiction or substance use disorder. It is literally if you 

come in for something else, we begin a screening process that sort 

of—that begins the conversation. And depending on how you answer questions and interactions, we go further and further and further. 

Mrs. BLACK. So you do the screening process on every patient 

that comes in; they answer a screen, and then, from there, you 

make a determination? 

Mr. GOBEILLE. Right. 

Mrs. BLACK. Okay. I had one additional question. In many other 

States, we see doctor shopping. Have you seen that in your State? 

Do you have pill mills? Do you see that doctor shopping? 

And do you also have those pain management facilities that are 

for cash only? Are you experiencing that in your State? 

27 

Governor SCOTT. I don’t think we see the pill mills in Vermont, 

but certainly we see the doctor shopping, and some of this electronic monitoring would help preclude that. 

Mr. GOBEILLE. Yeah. So what is interesting is we don’t have 

what you think of as the traditional pill mill, but we certainly had 

the issues you are describing. Doing the Spokes and having over 

200 primary care providers working together to try to basically 

deal with treatment, it has been really good for communication 

across the practice, and so it has cut down on doctor shopping. 

But also, our prescription monitoring system has improved every 

year, and it is at the point now where doctors can see that going 

on through software. 

Mrs. BLACK. Thank you. My time is expired. 

Thank you, Mr. Chairman. 

Governor SCOTT. Keep in mind as well, if I could add—just 

add—— 

Chairman ROSKAM. Wow, sliding into home. Nice. 

Governor SCOTT. Keep in mind that if you shut someone off 

from the prescription drug, the opioid, they find another method. 

They go to heroin or fentanyl. I mean, it is cheaper sometimes, so 

that is the problem. 

Chairman ROSKAM. Mr. Higgins. 

Mr. HIGGINS. Thank you, Mr. Chairman. And congratulations 

as well on your ascension to the Subcommittee Chair. 

My community, too, is devastated by the opioid deaths and overdoses. There were 316 in Erie County in New York State. Half of 

those were in the city of Buffalo. I just want to focus in on fentanyl. 

Fentanyl is a—it is a powerful artificial opioid, and it accounted for 

about 60 percent of the deaths in my community of Buffalo and 

Erie County. 

Mexico is a source of much of the illicit fentanyl that is for sale 

in the United States. Starting in 2015, Canada has seen a massive 

increase in fentanyl overdoses. You know, we are currently engaged 

in a renegotiation of the North American Free Trade Agreement. 

And I have always believed that the United States and Canada— 

the United States, a Nation of 323 million people, Canada, a nation 

of 36 million people—doesn’t effectively use its leverage in trade 

negotiations with a place like Mexico. 

You know, Mexico’s minimum wage is $4.70, not an hour, a day, 

which, if you assume it is an 8-hour day, is 57 cents an hour. In 

free trade, we should be using our leverage to stop this illicit transport, export of fentanyl to the United States and Canada. It is a 

new twist on a larger problem. I am just curious as to your 

thoughts about the viability of something like that. 

Governor SCOTT. Well, again, we watch with interest the 

NAFTA negotiation. We share as well a border with Canada, and 

they are our largest trading partner, essential to the vitality of 

Vermont’s economy. 

So we are hopeful that we can get through some of those, but I 

think that there should be an update to NAFTA, and I believe that 

we should be trying to do whatever we can to level the playing 

field, and that may be an area that we should look at. 

Mr. HIGGINS. Okay. The President in October declared that the 

opioid epidemic was a national health emergency. As you know, we 

28 

have been kind of stuck in terms of doing a series of continuing 

resolutions, which is really a failure to do fundamentally what Congress needs to do. 

But, obviously, money is a big issue here as it relates to treatment. Have you seen any change, at least in terms of your personal 

experiences, since that declaration was made in October, or is that 

something prospective that just hasn’t gained traction yet? 

Governor SCOTT. I don’t believe we have seen any difference 

since that declaration because we were—have been actively pursuing that. And we have been blessed with having good partners, 

again, with the Congress as well as with our—the Administration 

and this previous Administration as well in trying to confront this. 

So we have—they have given us some flexibility, and I think that 

has been essential. And if there is one thing that I can underscore 

and emphasize it is this: Allow us flexibility, and we will find the 

pathway forward. 

Mr. HIGGINS. I yield back, Mr. Chairman. Thank you. 

Chairman ROSKAM. Thank you. 

Well, Governor, thank you, and, Mr. Secretary, thank you. I just 

want to say thank you very much for your time today. We are 

being called in for votes. 

Let me ask you one wrapup question, if I could. Our Subcommittee, and this Committee in particular, is focused on Medicare. The first point that you made in your four points was in particular as it relates to Medicare. 

Let me just restate that part to refresh everybody’s recollection, 

and then I just want you to give us a little bit of commentary about 

what this means. So what you have proposed is Medicare needs to 

treat addiction as the chronic health condition that it is. 

And then you said you sent a letter to the Secretary of Health 

and Human Services asking that CMS work with Vermont to engage Medicare in Vermont’s system of care, specifically the Hub 

and Spoke system: Working with our Federal partners, we hope to 

develop a path to make this a reality; Medicare could also assure 

that the FDA-approved medications for opioid addiction are available for beneficiaries. 

I want to sort of go back to Mr. Marchant’s inquiry when he was 

asking about sort of the declaration of who is addicted. Can you 

just give us a little bit more insight? 

Is this a situation where, in order for this to be successful at all, 

someone has to self-identify as an addict, or does the Hub and 

Spoke system work for folks that are not acknowledging themselves 

as addicts but who are clearly addicts? Can you speak to that tension? Maybe it is a question for the Secretary or medical professionals. 

Governor SCOTT. Yeah, I am going to let him answer the rest 

of the question, so to speak. But I would, again, underscore that 

if they are not ready to admit they have an issue and to seek treatment, it is probably going to fail. And so to force someone into 

treatment is probably a recipe for failure as well. 

Secretary. 

Mr. GOBEILLE. Yeah. So what I would say is there is a definition of opioid use disorder, and, you know, they would have to meet 

29 

that clinical definition. And so, you know, that is sort of the blackand-white answer. 

But I think from a—you know, from a human perspective, when 

you think about caring for the whole patient or the whole population, to have something that is such a fundamental problem with 

someone’s health and not be able to treat it as basically the illness 

that it is with the payer that they have sort of distorts the healthcare system. 

And so what we are trying to do is work with CMMI and CMS 

to say we have an all-payer model that we have agreed to with the 

Federal Government to really take responsibility for what we spend 

on healthcare. And in order to do that, you have to treat the whole 

person and the whole population, and this needs to be an integral 

part of that. 

Governor SCOTT. And if you want to break down the stigma, 

this is one way to do it, to treat them the same. 

Chairman ROSKAM. Well, your insights have been really helpful 

today. And you didn’t clear the room, by the way. You didn’t clear 

the dais; it was the fact that we have been called for a vote. 

But I just want to let you know how much I appreciate—and I 

know I speak on behalf of the Ranking Member as well—your willingness to come and share your experience. We appreciate your 

forthrightness with the strengths and weaknesses, the things that 

you have learned, and the things that you have struggled with. 

And I know that we are going to continue to be interacting on 

this issue because this is a problem that is very dear to all of us, 

and I mean literally all of us. And it is an area where there is good 

work that can be done. And I think people of good will and tenacity 

willing to give others the benefit of the doubt as we move forward 

can be really, really significant. 

So I sense you have something else to say, Governor, so why 

don’t you respond? 

Governor SCOTT. Well, I only wanted to say that we extend an 

invitation to anyone on your Subcommittee who would like to come 

up and see it for themselves. We would happily show them what 

we have done so that they can see it. 

Chairman ROSKAM. Thank you. 

So the Committee stands in recess subject to the call of the 

Chair. We are going to go into recess and vote, and we will look 

forward to hearing from our next panel. 

So thank you very much. We will be back shortly. 

[Recess.] 

Chairman ROSKAM. The Committee will come to order. Thank 

you, all. I know I speak on behalf of everybody who is reassembling 

here and thank you for your patience. 

As I mentioned, your opening statements are a part of the 

record, and the Members have had an opportunity to review them. 

I think that in the interest of time, why don’t we begin to proceed. 

I will recognize each of you for 5 minutes, and we will give you a 

little bit of guidance in terms of the timing, and then we will open 

it up for questions from our Members. 

So, again, thank you for your patience. We really, really appreciate it. Dr. Benyamin, you are recognized for 5 minutes. 

30 

STATEMENT OF RAMSIN M. BENYAMIN, M.D., PRESIDENT AND 

FOUNDER, MILLENNIUM PAIN CENTER, AND BOARD OF DIRECTORS, AMERICAN BOARD OF INTERVENTIONAL PAIN 

PHYSICIANS 

Dr. BENYAMIN. Chairman Roskam, Ranking Member Levin, 

and distinguished Members of the Committee, thank you for the 

opportunity to provide my views on behalf of American Society of 

Interventional Pain Physicians, known as ASIPP. 

I am Dr. Ramsin Benyamin, and I am the Medical Director of 

Millennium Pain Center in Illinois. I have been practicing interventional pain management for over 20 years. My academic appointments are with the University of Illinois, Illinois Wesleyan 

University, and A.T. Still University of Missouri. 

I serve on the editorial board of several pain management peerreviewed journals and have over 150 publications, the most recent 

of which is our society’s 2017 guidelines for responsible, safe, and 

effective prescription of opioids. 

In the past, I have served as the President of ASIPP, and I am 

currently on the board of directors. I am also the President of Illinois’ Society of Interventional Pain Physicians. 

ASIPP is a not-for-profit professional organization founded in 

1998, now comprising over 4,500 members who are dedicated to ensuring safe and appropriate access to pain management services 

using interventional techniques in addition to medical management. 

As an organization, ASIPP has always been cognizant of prescription opioid dangers and began issuing warnings and offering 

preventive measures in early 2000 with its proposal of a national 

program known as NASPER, which eventually was signed into law 

as a State-run prescription drug monitoring program in 2005. 

Despite challenges in implementation of the national program, 

all 50 States now have prescription drug monitoring programs. 

Many of the common painful ailments, like spine degeneration, 

disk herniations, spinal stenosis, headache, pathologic fractures, 

and postsurgical chronic pain, if not managed timely by interventional pain techniques, would result in more invasive and costly 

procedures, raising the risk of dependency on more or higher doses 

of opioids. 

Currently, one in every three Medicare Part D recipients is on 

prescription opioids. Based on current data, despite reduction in 

opioid prescriptions since 2010, the majority of overdose deaths are 

mainly due to synthetic fentanyl and heroin abuse. 

Mr. Chairman, the pill-to-heroin shift has occurred, and that also 

involves lacing of marijuana with heroin or fentanyl. That is killing 

many of my fellow citizens in Illinois. 

As a result of this disturbing trend, on behalf of ASIPP, I am 

suggesting legislative reforms to curb opioid abuse and reduce 

opioid deaths while maintaining appropriate access and promoting 

nonopioid modalities like interventional techniques. 

Unfortunately, reductions and cuts continue to limit access to 

physical therapy, interventional techniques, and even nonopioid 

medical therapies while the opioid death rate continues to escalate. 

Our proposal includes a three-tier approach. Tier one: An aggressive public education campaign focused on the dangers of illicit 

31 

drugs, specifically heroin and fentanyl; a public education campaign relating to the adverse consequences of prescription opioid 

abuse, particularly in combination with benzodiazepines; and a 

mandatory 4 hours of continuing education for all prescribers of 

any amount of opioids or benzodiazepines. 

Tier two: Improved access to nonopioid techniques, including 

physical therapy and interventional techniques, by lowering or 

eliminating copayments; expanded low-threshold access to buprenorphine for opioid use disorder treatment; enhanced prescription 

drug monitoring program, including a national program like 

NASPER, which States having mandated capability to interact 

with the rest of the States or at least the neighboring States; and 

mandated review of prescription drug monitoring data by all prescribers prior to prescribing a controlled substance. 

Tier three: Buprenorphine must be available for chronic pain 

management with rescheduling it to a schedule two; and removing 

methadone from formulary. This medication, despite being only 1 

percent of total prescription opioids, results in more than 3,000 

deaths every year. 

Thank you, again, for allowing our organization the opportunity 

to testify. I will be glad to answer any questions. 

[The prepared statement of Dr. Benyamin follows:] 

32 


33794A.005

TESTIMONY OF RAMSIN BENYAMIN, MD, BLOOMINGTON, IL 

BEFORE WAYS AND MEANS COMMITTEE 

US HOUSE OF REPRESENTATIVES 

DATE: TUESDAY, FEBRUARY 6 

Chainnan Roskam, Ranking Member Levin, and distinguished Members of the Committee: 

Thank you for giving ASIPP this opportunity to provide our views on refonning 

approaches to curb drug overdose deaths and improve care of chronic pain with nonopioid 

treatments. 

I am Dr. Ramsin Benyamin and T am the Medical Director of Millenniwn Pain Center, a 

practice with other physicians in Bloomington, JL. T am also Clinical Assistant Professor of 

Surgery, College of Medicine, at University of Illinois, Urbana-Champaisn, IL, and Adjunct 

Research Professor, Department of Psychology, at Illinois Wesleyan University, Bloomington, IL. 

I have participated in mnltiplc clinical trials and published over 150 peer-reviewed articles. I also 

have clinics in Peoria, Decan1r, Pekin, Champaign, Libertyville, and Chicago, IL. I have been in 

the practice of interventional pain management for over 20 years. In the past, I have served as 

President of the American Society oflnterventional Pain Physicians (ASIPP) and I am currently 

on the Board of Directors of that society. I am the President of the Illinois Society oflnterventional 

Pain Physicians. 

The American Society of Jnterventional Pain Physicians is a not-for-profit professional 

organization founded in 1998 now comprising of over 4,500 interventional pain physicians and 

other practitioners who are dedicated to ensuring safe, appropriate and equal access to essential 

pain management services for patients across the country suftering with chronic and acute pain. 

There are approximately 8,500 appropriately trained and qualified physicians practicing 

interventional pain management in the United States. ASIPP is comprised of 50 affiliated state 

societies, and the Pue110 Rico Society of luterveutioual Pain Physicians. As an organization, 

ASIPP began issuing warnings and offering preventive measures in early 2000 with its proposal 

of a national program --- the National All Schedules Prescription Electronic Reporting Act 

(NASPER), which eventually was signed into law as a state-run prescription drug monitoring 

program in 2005. As you know, I am happy to state that all 50 states now have PDMPs. In fact, 

1 
33 


33794A.006

mandatory provider review of prescription drug monitoring programs and pain clinic laws have 

shown to reduce the amounts of opioids prescribed by 8% and prescription opioid overdose death 

rates by 12%. In addition, it has also been shown that relatively large reductions in heroin overdose 

death rates after implementation of mandatory prescription drug monitoring programs and pain 

clinic laws as of 2015.1 ASIPP also offers extensive educational efforts for pain physicians 

including a variety of review courses and competency examinations. 

lnterventional pain management is defined as the discipline of medicine devoted to the 

diagnosis and treatment of pain related disorders principally with the application of interventional 

techniques in managing sub acute, chronic, persistent, and intractable pain, independently or in 

conjunction with other modalities of treatment.2 

lnterventional pain management techniques are minimally invasive procedures including, 

percutaneous precision needle placement, with placement of drugs in targeted areas or ablation 

of targeted nerves; and some surgica l techniques such as laser or endoscopic discectomy, 

intrathecal infusion pumps and spinal cord stimulators, for the diagnosis and management of 

chronic, persistent or intractable pain.3 

Unfortunately, opioid deaths continue to increase at a dramatic pace despite reductions in 

opioid prescriptions since 20 I 0.4 No doubt opioid prescriptions are still explosive with the amount 

of opioids prescribed in the United States continuing to be 3 times higher than in 1999, the year 

AS!PP developed our idea of the National All Schedules Prescription Electronic Reporting Act 

(NASPER). Yet, in 2017, the national opioid epidemic continues to show escalation. Drug 

overdoses accounted for 64,000 deaths in 2016, with over 42,000 of opioid deaths, a 20% increase 

from 2015 from over 52,000. Increases are greatest lor overdoses related to the category including 

illicilly manufactured fentanyl, which more than doubled, accounting for more than 20,000 

overdose deaths in 2016 versus less than 10,000 deaths in 2015. This difference is enough to 

1 Dowell D, Zhang K, Noonan RK, Hockenberry JM. Mandatory provider review and pain clinic laws reduce the 

amounts of opioids prescribed and overdose death rates. Henlth Aff (Millwood) 20 16; 35: 1876-1883. 1TI1e National Unifonn Claims Commitlee. Specially Designation for huerventional Pain Managemenl- 09. 

www .cms.Wts.gov/n·ansmittals!Downloadslr l7 79b3 .pdf 3 Medicare Payment Advisory Commission. Report to the Congress: Paying for interventiooal pain services in 

ambulatory settings. Washington. DC: MedPAC. December. 2001. 

http:llwwv.•.medpac.gov/docmncntslreports/deccmber-200 1-report-to-the-congress-paying-for-intcrventional-paioservices·in·ambltJalory·senings.pdr?sfvrsn-9> 4 Guy GP, Zhang K, Botnn MK, ct al. Vital Signs: Changes in Opioid Prescribing in the United States, 2006-2015. 

MMWR Morb Mortal Jllkly Rep 2017: 66:697-704. 

2 
34 


33794A.007

account for nearly all increases in drug overdose deaths from 2015 to 20 16.5

·

6 Consequently, while 

fentanyl contributed to 20,000 deaths, heroin contributed to 15,000 deaths, whereas prescription 

drugs contributed to less than 15,000 deaths (Figs. 1-3).4

·

7 Deaths due to heroin were up nearly 

20% and deaths from other opioids such as hydrocodone and oxycodone were up 14%. Deaths due 

to methadone declined; however, they still constitute an extremely high percentage with over 3,000 

deaths, which is only I% of prescriptions. As we all realize, things might very well be worse than 

what is shown in the data. The present problem of overdose deaths is mainly due to illicit fentanyl 

and heroin use with contributions from prescription opioids. As you may know, Fentanyl is 

approximately 50 times as potent as heroin. This provides strong economic incentives for drug 

dealers to mix fentanyl with heroin and other drugs because smaller volumes can provide equally 

powerful effects at lower costs and easier transport.5 Ironically, the majority of people who use 

heroin are not seeking fentanyl and essentially try to avoid it.

8 However, technology bas improved 

so much that it is difficult to identify fentanyl, particuhtrly in white powder fonn, and heroin is 

typically sold more in states, east of Mississippi river.9 

s Dowell D. Noonan RJ<, Houry D. Underlying Factors in Dmg Overdose Deatlts. JAMA 20 17; 318:2295-2296. 6 US Ceurers for Disease Control and Prevention. Provisional cotmts of dmg overdose deaths as of Augusl6. 2017. 

bnps:J/www.cdc.gov/nchsldata/bealtll policy/montllly-dmg-overdose-death-estimates.pdf. 

' Ingraham C. CDC releases grim new opioid overdose figures: 'We're talking about more than an exponential 

inct·ease.' The Washington Post, December 2t, 2017. 

bUps://www. wasltittgtonpgst.com/news/wo•tk/wp/20 17/ 12/21 /cdc-releases-gri,u-ncw-opioid-overdosc-figureswere-talkiug-about-more-than-an-expoueutial-increasen utlll temt .f3ffi93ftbb8b 

8 CarroU JJ, Marshall BDL, Rich JD, Green TC. Exposure to fentanyl-()()ntaminated heroin and overdose risk among 

illicit opioid users in Rhode Island. Int J Drug Policy20 17: 46:136-145. 9 Gladden RM, Maninez P, Seth P. Fentanyl law enforcement submissions and increases in synthetic opioidinvolved overdose deaths. MMWR Morb Morta/IVkly Rep 2016:65:837-843. 

3 
35 


33794A.008

MI'IWi ptHCribingritQ Annual prescribing rate by no. ot 4aYS' supply ,., ,., e 80 -------- ! 80 - ol'lOCS.WS' wppty 

9 70 ~ 70 -- <lO~Wppfy R 

~ "" ~ "" 

a i so ----------------- so - Tour 

s s .0 

.... .0 -- High--dose (~90 MME Pt1 da7') 

~ lO i lO I ~ 

20 .. • 20 

i 10 

------------------ i 10 

20()6 2007 2008 2009 2010 2011 2012 2011 2014 201S 2006 2007 2008 2009 2010 2011 2012 2013 2014 201S 

AWfa9edaiyMMe pet JKescription Average no. of dayS' suppty p« lon 

70 20 

"" j 

-------

....____ ~ 16 .. ~so ~ 

i .0 i 12 

~ .., lO .. i i • 20 ! 4 10 i 

2006 2007 2008 2009 2010 '2011 2012 2013 201-4 2015 2006 2007 2008 2009 2010 201t 20'2 20l) 2014 2015 

Fig. 1. Annual opioid prescribing rates, by number of days' supply, average daily mo1phine 

milligram equivalent (MAtE) per prescriplion, and average number of days' supp~y per 

prescription - United States, 2006- 2015. 

Source: Guy Jr Gl', e1 al. Vilal Signs: Changes in opioid prescribing in tlle Uni!ed S!ales, 2006-2015. MMWR Morb 

Mortal Wkly Rep 2017;66:697-704' 

4 
36 


33794A.009

Opioid deaths surge in 2016 

Number of opioid overdose deaths, 1999 to 2016 

50k ...................... .................. . 

40k 

30k .................................................................................................... ·········· 

10k 

• 

0 -----------------------------------------------

42,249 

1999 2016 

WAPO.ST/WONKBl OG Source: CDC 

Fig. 2. Opioid deaths surge in 2016. Numberofopioid overdose deaths by catego1y, 1999/o 2016. 

Source: Ingraham C. CDC releases grim new opioid overdose figures: ' We're talking about more than an 

exponential increase.' The Washington Post, December 2 1, 2017.

1 

htms://www. washi•tgtonpost .comlnews/wonklwpl20 I 7/1212 1/cdc·releases-!!lint-new-opioid-overdose· figures-weretalking-abottt-more-than-mo-exponent ial-increasef?tttm tenn:. f3 f893febb8b 

5 
37 


33794A.010

20k Synthetic opiates, Including fentanyl 

15k ·· · ·· ··· ····· · ··· · ·· ·· · ··· ······ ··· ··· ··· ··· · · · · ·· ··· ·· · ··· ··· · · · ··· ··· ·· · ··· ······ ··· · · · ··· ······ ·· · ··· · · · ·· Natural & semi· 

synthetic opiates 

5k 

2016 

WAPO.ST/WONKBLOG Source: CDC 

Fig. 3. Opioid deaths surge in 2016. Number of opioid overdose deaths by categOJy, 1999to 

20/6. 

Source: Ingraham C. CDC releases grim new opioid overdose fi~lfes: 'We're talking abotll more than au 

exponential increase.' The Washingron Pos1, December 21 , 2017. 

bttps://www. washingtonpost.com/newsfwonk/wp/20 I 7/12/21/cdc-releases-grim-new-opioid-overdose-figures-wereta1ktng-about-more-tban-an-exponentia1-increasel'?utm tenn:.flf893febb8b 

In addition, recent data shows that the number of people presenting for opioid treatment 

with heroin abuse has increased from 8.7% in 2005 to 33.3% in 2015.'0 There also has been an 

increase in self-reported fentany l use among the population entering dmg treatment from 9% in 

2013 to 15% in 2016, referred to as "unlmown fentanyl" products. 11 Consequently, the number of 

prescription opioid admissions is declining and illicit fentanyl and heroin admissions are 

increasing. 

1

° Cicero TJ, Ellis MS. Kasper ZA. Increased use of heroin as an initiating opioid of abuse. Addict Behav 2017; 

74:63-66. 11 Cicero TJ, Ellis MS, Kasper ZA. Increases in self-repot1ed fentanyl use among a population entering drug 

treanneut: The need for systematic surveillance of illicitly manufactured opioids. Dmg Alcohol Depend 2017: 

177:101-103. 

6 
38 


33794A.011

TI1us far, the effectiveness of numerous interventions to curb opioid epidemic has been 

limited, including presctiption drug monitoring programs, pain clinic laws, treatment of opioid use 

disorder, guidelines, and numerous other policies. 

As a result of this disturbing trend, we, at ASIPP are suggesting more effective legislative 

efforts to curb opioid abuse and reduce opioid deaths, while maintaining appropriate access, and 

the promotion of nonopioid modalities including interventional techniques. 12 Consequently, we, 

at ASIPP propose a 3-tier approach to achieve these goals. 

Tier I includes the following: 

I. An aggressive public education campaign with explicit teaching on the 

dangers of the use of illicit drugs, specifically heroin and fentanyl. 

2. A public education campaign relating to the adverse consequences of opioid 

abuse in general with emphasis on the adverse consequences in combination 

with benzodiazepines. 

• A recent survey published in the New England Ja111·nal of Medicine 

shows that the public blame the opioid crisis on physicians, 

phannacists, and pharmaceutical companies without putting much 

responsibility on patients. Forty-six percent of the public puts the 

blame on doctors who inappropriately prescribe medication (33%) 

and 13% put the blame on pharmaceutical companies that sell 

prescription medication but only 28% blame people who sell 

prescription pain killers illegally and I 0% put the blame on people 

who take prescription pain killers. 13 

• In addition, the public believes that public education and awareness 

programs are effective in a large proportion of patients. 

3. Mandatory physician education for all prescribers of any amount of opioids 

or benzodiazepines with a mandated requirement of 4 hours of continuing 

education per year. 

"Manchilwlli L, Kaye AM, Knezevic NN, et al. Responsible, safe, and effective prescription of opioids for chronic 

non-cancer pain: American Society oflutervenlional Pain Physicians (ASIPP) guidelines. Pnin Physicinn 2017; 

20:S3-S92. 13 Blendon RJ, Benson JM. The public and the opioid-abuse epidemic. N Eng/ J Med2018; 378:407-411 . 

7 
39 


33794A.012

4. Mandatory patient education associated with the frrst prescription of any 

amount of opioid. 

Tier 2 includes the following: 

5. Easier access to, and low or no copayments for, nonopioid techniques 

including physical therapy and interventional techniques which could 

potentially reduce the medication use and improve patient's functions and 

outcomes. 12 

• Ironically, as reimbursement of interventional techniques has 

decreased with decreasing utilization since 2010, opioid deaths have 

been escalating.14 

• Evidence shows a direct relationship between the decline in 

utilization of interventional techniques and increase in the number 

of opioid deaths since 20 I 0 (Figs. 4 and 5) . 

• 2000-2016 • 2001).2009 • ~2016 

·-.., --·-- Fig 4. Comparative analysis of epidural and adhesiolysis procedures, facet joint inten,enrions 

and sacroiliac joint blocks, disc procedures and other types of nen1e blocks, and all 

interventionaltechniques. 

" Manchikanti L, Soiu A, Mann 01', et al. Reversal of growth of mitization of imervemional tcchuiques in 

managing chronic pain in Medicare population post Affordable Care Aci. Pain Physici(ln 2017: 20:55 1-567. 

8 
40 


33794A.013

2596 

• 200(}2009 

• 2()()9.2016 

2096 

1596 

1096 7.396 

596 I. 

-1.896 

-596 

-1096 

2.496 

•• -4.096 

LU#ibar intuliDurl 

c-bl ,.;.tw.4 

23.096 

0.396 

10.196 

.~ I - . 

-2.396 

Fig 5. Frequency of utilization of epidural injections episodes from 2000 to 2009 and 2009 to 

20/6, in Medicare recipients. 

6. Expand low-threshold access to buprenorphine for opioid use disorder5 ·

15

•

16 

It has been shown that a substantial proportion of patients who would 

benefit from buprenorphine treatment will receive this only if it becomes 

more attractive and more accessible than either prescription or illicit 

opioids. 15 

• Opioid overdose deaths have been shown to decrease 79% over a 

period of 6 years after widespread prescribing of buprenorphine in 

France.

16 This will also lead to ava ilability ofbuprenorphine and its 

products for chronic pain management. 

"Kolodny A. Ten steps the federal government should take now to reverse tl1e opioid addiction epidemic. JAMA 

2017; 318:1537-1538. 16 AIU'iacombe M. Fatseas M. Dubernet J, et a!. French field expet·ience with buprenorphine. Am J Addict 2004; 

13:S 17-S28. 

9 
41 

f 


33794A.014

7. Establishment of enhanced prescription drug monitoring program (POMP) 

with National All Schedules Prescription Electronic Reporting Act 

(NASPER) program, with each state with a mandated capacity to be able to 

interact with at least all bordering states. 

8. Mandated review of POMP data by all providers, prior to all prescriptions. 

Tier 3 includes the following: 

9. Bupreno1phine must be available for chronic pain management in addition 

to medication-assisted treatment, with a change of controlled substance 

scheduling to a Schedule II drug. 

10. Remove methadone from formulary, which is responsible for over 3,000 

deaths per year with only 1% of total prescriptions. 

Finally, it is essential to develop treatment paradigms for patients with tme somatic causes 

of pain. Nouopioid techniques have been recommended by !OM and attomey generals of many 

states. Yet, these have not been adequately considered. In fact, reductions and cuts continue to 

make difficulties to being able to utilize physical therapy, interventional techniques, and ironically 

even nonopioid medical therapy options. 17

·

18 

Thank you again for providing our organization with the opportunity to testifY before 

Congress and provide our views. 

It has been an honor to be here with you today. If you have any questions, I will be happy 

to answer. 

17 Naliooal Academies of Sciences, Engineering, and Medicine. 2017. Pain mmwgeme111 and the opioid epidemic: 

Balancing societal and individual benefits and risks af prescription opioid use. Wasbinglon, DC: 11te National 

Academies Press. 

doi: htlps:fldoi.org/10.17226/24781. 18 Letter to Marilyn Tavenner, from President and CEO, Ame1ica's Healllt lnsmance Plans from National 

Association of Attorneys General RE Prescription opioid epidemic. September 18. 2017. 

10 
42 

Chairman ROSKAM. Thank you. 

Mr. Kletter. 

STATEMENT OF JASON KLETTER, PH.D., PRESIDENT, 

BAYMARK HEALTH SERVICES AND BAY AREA ADDICTION 

RESEARCH AND TREATMENT (BAART) 

Mr. KLETTER. Chairman Roskam, Ranking Member Levin, and 

Members of the Subcommittee, I appreciate the opportunity to testify today about the opioid epidemic that is ravaging our country 

and important steps this Committee can take to help address this 

crisis. 

I am Dr. Jason Kletter, President of BayMark Health Services. 

BayMark provides treatment for opioid use disorder, or OUD, using 

medication-assisted treatment and outpatient detoxification services in 95 facilities across 26 States, including many of the States 

you represent. We are the largest organization in the country focused primarily on treatment services for opioid use disorder treating over 33,000 patients each day. 

I also serve on the Board of the American Association for the 

Treatment of Opioid Dependence, and I am also here today on behalf of the OTP consortium, a trade association comprised of more 

than 300 opioid treatment programs across 37 States. I have 25 

years of experience in OUD treatment. 

I want to start by highlighting two data points: First, according 

to the CDC, opioids killed more than 42,000 people in 2016. That 

is about 115 people every day in our country. These are our friends, 

our family, our neighbors, our coworkers. 

Second, the White House Council of Economic Advisers estimates 

the economic cost of the opioid crisis was $504 billion in 2015 

alone. Of course, these statistics do nothing to describe the devastating effects on our families and communities. 

OUD is regarded by experts to be a disease of the brain, not a 

moral downfall. This concept of OUD as a chronic disease is essential to understanding successful treatment solutions, the most effective of which is medication-assisted treatment. 

MAT is the integration of medication and psychosocial services to 

provide individualized care that will have the greatest likelihood of 

helping people with OUD transition to recovery and lead healthy, 

socially productive lives. 

There are three federally approved medications for use as part 

of MAT, methadone, buprenorphine, and naltrexone, all of which 

must be used in conjunction with psychosocial services to have the 

greatest likelihood of success. 

The benefits of MAT are substantial and have been proven repeatedly through rigorous scientific studies. MAT has been shown 

to improve patient survival, increase retention in treatment, decrease opioid use and criminal activity, increase patient’s ability to 

gain and maintain employment, and lower person’s risk of contracting HIV or hepatitis C. 

Those who receive MAT are 75 percent less likely to have an 

addiction-related death than those who don’t. There are roughly 

1,500 opioid treatment programs, or OTPs, across the United States 

providing treatment to approximately 400,000 patients. OTPs are 

43 

highly regulated, comprehensive treatment programs that are required by law to provide MAT. 

OTPs provide medication, individual and group counseling, random drug testing, and other supportive services, such as case management, primary care, mental health services, HIV, and hepatitis 

C testing. 

Methadone, which is most commonly administered as part of 

MAT, has been used in OTPs for more than 50 years. It has been 

rigorously researched and considered to be the gold standard in 

treatment of opioid dependence. MAT with methadone is highly 

regulated and can only be dispensed for OUD by clinics that have 

been certified by SAMHSA, the DEA, and other agencies. It is an 

excellent medication when used as part of MAT with patients having very high retention and success rates. 

Retention in treatment over an extended period of time is essential for positive outcomes. At BayMark, about 61 percent of our patients are retained in treatment for at least 90 days. Furthermore, 

while 100 percent of our patients are using opioids multiple times 

each day upon admission, about 50 percent of those folks in treatment less than 30 days are free from illicit opioids. That number 

jumps to 82 percent for patients in treatment more than 1 year. 

This is proof that MAT delivered in OTPs is saving hundreds of 

thousands of lives. 

According to CMS, 30 percent of Part D enrollees used prescription opioids in 2015. So we should not be surprised that more than 

300,000 Medicare beneficiaries have been diagnosed with opioid 

use disorder. Moreover, Medicare beneficiaries have the highest 

and fastest growing rate of OUD. 

Unfortunately, Medicare does not cover comprehensive treatment 

services in OTPs. Instead, Medicare pays for more expensive treatments in less effective settings. This must change. 

We respectfully request that Congress pass legislation to provide Medicare beneficiaries with coverage for MAT with all FDAapproved medications to help treat OUD in the OTP setting. We 

recommend that Medicare adopt a bundled payment methodology 

where MAT-related services provided in the OTP setting are reimbursed under a capitated rate. This model has proven to be successful in Medicaid and TRICARE and could be quickly implemented by the 1,500 OTPs across the country, rapidly increasing 

access to lifesaving treatment for Medicare beneficiaries. 

While our country is in the throes of a tragic epidemic, the silver 

lining here is that we have a very effective treatment and a dedicated and compassionate workforce ready and able to save lives 

and build communities. 

Thank you for the opportunity to testify today. I am happy to answer any questions that you have. 

[The prepared statement of Mr. Kletter follows:] 

44 


33794A.015

~BayMark ~ HEALTH SERVICES 

The Opioid Crisis: Removing Barriers to Prevent and Treat Opioid 

Abuse and Dependence in Medicare 

Testimony of 

Jason Kletter, Ph.D 

President 

BayMark Health Services 

Prepared for the 

U.S. House of Representatives 

Committee on Ways and Means 

Subcommittee on Health 

1100 Longworth House Office Building 

February 6, 2018 
45 


33794A.016

Chairman Roskam, Ranking Member Levin, and members of the subcommittee, I 

appreciate the opportunity to testify today about the opioid epidemic that is ravaging 

our country and important steps this committee can take to help address this crisis. I want 

start by thanking all of you for your interest and attention to this important issue. 

I am doctor Jason Kletter, President of Baymark Health Services. BayMark, which is 

headquartered in Lewisville, TX, currently provides treatment for opioid use disorder 

(OUD) usine medication-assisted treatment (MAT) and outpatient detoxification services 

in 95 facilities across 26 states-including Alabama, California, Florida, Illinois, Minnesota, 

Nebraska, Pennsylvania, and Texas. We are the largest organization in the country 

focused primarily on treatment services for opioid use disorder. We provide treatment 

services across three modlaities: licensed opioid treatment programs, less-structured 

office-based services and outpatient detoxification combined with extended recovery 

support services. Each day, we treat over 33,000 patients in their recovery from opiate 

dependence and addiction. Our nation faces an unprecedented epidemic of opiate use, 

and BayMark works hard every day to expand accesst to high-quality, evidence-based 

services to those who need them. 

I currently serve on the board of the American Association for the Treatment of Opioid 

Dependence (AATOD). I am also the President of the California Opioid Maintenance 

Providers group, have served as advisor to the California Department of Health Care 

Services on many committees including the Narcotic Treatment Program Advisory 

Committee, the California Outcome Management System Workgroup, the Counselor 

Certification Advisory Committee and the Continuum of Services System Redesign. I have 

also participated in Federal Center for Substance Abuse Treatment initiatives, advising on 

accreditation guidelines and evaluating training curricula for opioid treatment program 

(OTP) physicians. All told, I have 25 years of experience in OUD treatment, including frontline positions such as health worker and counselor and many administrative roles 

including corrections contract manager and Human Resource Director. I am also here 

today on behalf of the OTP Consortium, a trade association comprised of more than 300 

OTPs across 37 states. 

Given that it is impossible to open a newspaper, turn on a TV or check social media and 

not be overwhelmed with news about our nation's opioid epidemic, I won't spend a lot 

of time reciting the grim statistics; I know everyone on this Committee is familiar with the 

scale and scope of this crisis. I will, however, highlight just two data points that I think 

are among the most shocking: First, according to the Centers for Disease Control and 

Prevention, opioids (including prescription opioids, heroin, and fentanyl) killed more than 

42,000 people in 2016, more than any year on record. That's about 115 people each day 

in our country-these people are our family, friends, neighbors, and coworkers. 

2 
46 


33794A.017

The second data point that warrants special attention is, according to a report from the 

White House Council of Economic Advisors, in 2015, the economic cost of the opioid crisis 

was $504.0 billion, or 2.8% of the gross domestic product that year.1 

So, the data tells us that not only are massive numbers of people being killed by this 

epidemic, but it is diminishing our nation's resources and costing us very real dollars. 

Of course, these shocking statistics do nothing to describe the devastating effects on our 

families, neighborhoods and communities across the nation. 

Opioid Use Disorder is a Disease 

I want to be sure that you all are familiar with the current, state-of-the-art science about 

opioid use disorder. QUO is regarded by experts to be a disease of the brain, not a lack 

of will power or a moral downfall. Advances in technology over the past several decades 

have allowed scientists a better understanding of the impacts of drug use and the root 

cause of the behaviors that manifest from people with OUD. Alan Leshner, a former 

Director at the National Institute of Drug Abuse (NIDA) wrote in 2001: 

''J\ core concept thot has been evolving with scientific advances over the past 

decade is that drug addiction is a brain disease that develops over time as a result 

af the initially voluntary behavior of using drugs. The consequence is virtually 

uncontrollable compulsive drug craving, seeking, and use that interferes with, if 

not destroys, an individual's functioning in the family and in society. "2 

In addition, NIDA noted, "addiction affects multiple brain circuits, including those 

involved in reward and motivation, learning and memory, and inhibitory control over 

behavior."3 

This concept of OUD as a chronic, relapsing disease is essential to understanding 

successful treatment solutions. 

Medication-Assisted Treatment 

The most effective solution we have for treating OUD is medication-assisted treatment 

(MAT). MAT is the integration of medication and psychosocial services to provide 

individualized, care that will have the greatest likelihood of helping people with OUD 

transition to recovery and lead healthy, socially-productive lives. There are three 

federally-approved medications to treat opioid use disorder, all of which should be used 

in conjunction with psychosocial services: methadone, buprenorphine, and extended 

release injectable naltrexone. 

1 The Underestimated Cost of the Opioid Crisis, Council of Economic Advisors, November 2017. 

2 Leshner, A. I. (2001). Addiction is a brain disease.lssues in Science and Technology, XVII, 3. Dallas, TX. 

' NIOA. (2009). Drug facts: Treatment approaches for drug addiction. Retrieved from 

http://www.drugabuse.gov/publications/drugfacts/treatment-approaches-drug-addiction 

3 
47 


33794A.018

Agonist medications like methadone and buprenorphine help to stabilize the patient so 

that they can effectively participat e in counseling, case management and other services 

that lead to recovery. Naltrexone is an antagonist that blocks the effects of opioids. 

However, buprenorphine, methadone, and naltrexone are not proverbial "silver bullets." 

Despite the claims by some, medication alone generally does not lead to recovery. The 

medication simply assists the treatment. These patients need counseling and other 

surrortive sP.rvic:P.s to <~~~ure ~uc:ces~ful outc:omes. 

The benefits of MAT are substantial and have been proven repeatedly through rigorous 

scientific studies for more than SO years: MAT has been shown to improve patient 

survival, increase retention in treatment, decrease opioid use and criminal activity; 

increase patients' ability to gain and maintain employment, improve birth outcomes 

among women who have substance use disorders and are pregnant, and lower a person's 

risk of contracting HIV or hepatitis C by reducing the potential for relapse.4 Those who 

receive MAT are 75% less likely to have an addiction-related death than those who do not 

receive MAT.s 

Opioid Treatment Programs 

There are roughly 1,500 Opioid Treatment Programs or "OTPs" across the United States 

providing treatment to approximately 400,000 patients. OTPS are highly-regulated, 

highly-structured, comprehensive treatment programs that provide MAT. More 

specifically, OTPs provide medication, individual and group counseling, random drug 

testing and other supportive services such as case management, primary care, mental 

health services, HIV and Hepatitis C testing and more. 

Much of the OTP regulations are intended to prevent diversion of the powerful 

medications used as part of MAT. For example, our skilled nurses administer the 

medication to patients each day until patients are able to demonstrate stability and 

progress in treatment, as measured in part by random drug tests. In this way, we can be 

certain that the medication is not being sold on the street, unlike other sites of care, 

where a physician may write a prescription for 30 days and have no ability to ensure the 

intended person is using the medication as directed. As a result of this highly-regulated 

structure, diversion from OTPs is very limited. Daily medication administration also has 

therapeutic value, allowing compassionate, trained medical staff to briefly assess patients 

daily and provide information and words of encouragement to retain them in treatment. 

4 https://www.samhsa.ggy/medication-assisted-treatment!treatroent 

5 Miller, T. and Hendrie, D. Substance Abuse Prevention Dollars and Cents: A Cost-Benefit Analysis. DHHS Pub. No. 

(SMA) 07-4298. Rockville, MD: Center for Substance Abuse Prevention, SAMHSA, 2008. 

4 
48 


33794A.019

At Bay Mark, about 8S% of our 33,000 patients are administered methadone, another 14% 

are provided buprenorphine, and the remaining 1% receive extended release naltrexone. 

Which medication each patient receives as part of MAT on their path to recovery is 

determined on an individual basis as part of the assessment and history of drug use 

identified during a collaborative process between the patient and his/her physician. 

Methadone for Treatment Purposes 

Methadone has been used for more than SO years, has been rigorously researched and is 

considered to be the "gold standard" in the treatment of opiate dependence. In fact, the 

American Society of Addiction Medicine states that the efficacy and safety profile of MAT 

with methadone in the OTP setting "has been solidly and repeatedly established in the 

clinical outcomes literature since 196S."6 

Methadone is highly regulated, as it should be, and can only be dispensed for OUD by 

clinics that have been certified to treat OUD by the Substance Abuse and Mental Health 

Services Administration, the Drug Enforcement Adminsitration and others. Methadone 

blocks the effects of heroin and prescription drugs containing opioids while eliminating 

withdrawal symptoms and relieving drug cravings. It is an excellent medication when 

used as part of MAT, with patients having very high retention and success rates. 

Proven Track Record 

As discussed in SAMHSA's TIP 43, research has shown that retention in treatment over an 

extended period of time is essential for positive outcomes with OUD, just as it is with 

other chronic diseases such as diabetes, hypertension and asthma.7 

At BayMark, about 61% of our patients are retained in treatment for at least 90 days. 

Furthermore, while 100% of our patients are using opioids multiple times each day at 

admission, about SO% of our patients in treatment less than 30 days are free of opioids. 

That number jumps to 60% for patients in treatment 3·6 months, 68% for patients in 

treatment 6·9 months, and 82% for patients in treatment more than one year. This is 

proofthat MAT delivered in an OTP is saving hundreds of thousands of lives. 

6 https://www.asam.org/docs/default·source/public· policy·statements/lobot·treatment·Z· 04.pdf?slvrsn•O 7 Mclellan, A.T.; Lewis, D.C.; O'Brien, C.P.; and Kleber, H. D. Drug dependence, a chronic medical illness: Implications 

for treatment, insurance, and outcomes evaluation. JAMA 284(13):1689-1695, 2000. 

5 
49 


33794A.020

Medicare Coverage Policy is a Barrier to Access 

According to CMS, 30% of Part D enrollees used prescription opioids in 2015.8 So we 

should not be surprised that more than 300,000 Medicare beneficiaries have been 

diagnosed with opioid use disorder.

9 Moreover, Medicare beneficiaries have the highest 

and fastest growing rate of OUD.10 Alarmingly, Medicare hospitalizations due to 

complications caused by opioid abuse or misuse increased 10% every year from 1993 to 

2012.11 

While Medicare pays for the pain medications that are contributing to the OUD epidemic, 

it does not pay for the full range of treatment options necessary to treat beneficiaries' 

addiction. Specifically, Medicare does not cover comprehensive treatment services in 

OTP specialty care settings. This would be equivalent to covering insulin for diabetics 

without covering glucose monitoring or educational services intended to improve diet 

and other behaviors. Furthermore, no single medication works for all people so having a 

range of proven treatment options is essential for mitigating the vast harms caused by 

the current opioid epidemic. 

Instead, Medicare will pay for "treatment" with more expensive medications in what are 

often times less-effective settings. The average reimbursement for MAT in an OTP is 

roughly $500 per month while average reimbursement for similar treatment in an officebased environment is roughly $800-$1,000 per month, largely because buprenorphine is 

more expensive than methadone. 

Medicaid beneficiaries have OTP coverage. TRICARE beneficiaries have access to 

treatment in the OTP setting. Yet, Medicare beneficiaries do not, unless they are willing 

to pay out-of-pocket for treatment. At BayMark, we estimate that between five and 

seven percent of our patients are Medicare beneficiaries, which is consistent with the rest 

of the industry. 

• CMS Announcement of Calendar Year 2017 Medicare Advantage Capitation Rates and Medicare Advantage and Part 

D Payment Policies and Final Call letter, page 216 

9 1bid. 

10 https:l/jamanetwork.comliournals/jamapsychiatrvlfullarticle/2s3S238 11 1bid. 

6 
50 

f 


33794A.021

What Can Congress Do? 

In the 2017 Medicare Advantage and Part D Advance Notice and Call Letter, CMS sought 

comments about whether Medicare's methadone coverage policy "is a barrier to 

treatment."12 In the final rate notice, CMS said "absent a change in law, Medicare is 

unable to cover methadone for MAT under Medicare Part B or Part D. However, under 

Part C, [Medicare Advantage] organizations may cover methadone for MAT as a 

supplemental benefit." 13 More recently, President Trump's Commission on Combating 

Drug Addiction and the Opioid Crisis recommended that HHS and CMS "remove 

reimbursement and policy barriers to SUD treatment, including those ... that limit access 

to any forms of FDA-approved medication-assisted treatment." 14 

Given the current public health emergency stemming from opioid addiction, and the 

rapidly rising number of Medicare beneficiaries suffering from OUD, we respectfully 

request that Congress pass legislation to provide Medicare beneficiaries with coverage 

for MAT with all FDA-approved medications to help treat OUD in the OTP setting. 

Recommended Medicare Benefit Structure 

Congress can look to Medicaid and TRICARE when designing a Medicare OTP benefit. 

Specifically, BayMark, AATOD, and the OTP Consortium recommend that Medicare adopt 

a bundled payment methodology where all MAT-related services provided in the OTP 

setting, in addition to any medications provided, are reimbursed under a unified, fairly 

reimbursed capitated rate. The bundled model has proven to be successful in Medicaid 

and TRICARE and could be quickly implemented by the 1,500 OTPs across the country -

ensuring timely access to life-saving treatment for Medicare beneficiaries. BayMark, 

AATOD and the OTP Consortium stand ready to work with this committee and your 

colleagues in Congress to design, advocate for, and implement this long-overdue 

coverage option. 

Conclusion 

In closing, I want to thank you for your concern and your attention to this matter. While 

our country is in the throes of a tragic epidemic, the silver lining here is that we have very 

effective treatment and a dedicated and compassionate workforce ready and able to save 

lives and rebuild communities. 

12 CMS Advance Notice of Methodological Changes for 0f 2017 for Medicare Advantage Capitation Rates, Part C and 

Part 0 Payment Policies and 2017 Call letter, page 205. 

u CMS Announcement of Calendar Year 2017 Medicare Advantage Capitation Rates and Medicare Advantage and 

Part 0 Payment Policies and Final Call letter, page 208 

14 https:Uwww.whitehouse.gov/sites/whitehouse.gov/files/lmages/Final Report Draft 11-1-2017.pdf 

7 
51 

Chairman ROSKAM. Thank you very much. 

Dr. Paz. 

STATEMENT OF HAROLD L. PAZ, M.D., M.S., EXECUTIVE VICE 

PRESIDENT AND CHIEF MEDICAL OFFICER, AETNA, INC. 

Dr. PAZ. Thank you, Chairman Roskam, Ranking Member Levin, 

and Members of the Subcommittee, for holding today’s hearing on 

the opioid abuse epidemic. I appreciate the opportunity to share 

Aetna’s perspective on this critical public health issue. 

Aetna is a leading diversified health company that serves over 38 

million individuals in the United States and around the world. I 

currently serve as the company’s Executive Vice President and 

Chief Medical Officer, a role I have held since 2014. 

In my capacity as CMO, I lead clinical strategy and policy across 

Aetna’s lines of business and am responsible for driving clinical innovation to improve member experience, quality, and cost. I am 

also a practicing physician. 

The opioid epidemic is the leading public health issue facing our 

Nation. We have already lost far too many of our friends, family, 

and neighbors to this unprecedented health crisis. Aetna is taking 

a holistic approach to addressing the opioid epidemic. 

The various segments of Aetna’s businesses are all working to 

help our members struggling with addiction and to prevent future 

opioid dependency. To that end, Aetna has created an enterprisewide opioid task force, which I chair, to drive a multifaceted strategy to help stem the tide of overuse. 

We have developed a strategy focused on preventing misuse and 

abuse, intervening when we identify at-risk provider and member 

behavior, and supporting members by providing access to evidencebased treatments. 

I am pleased to share with this Subcommittee three examples of 

Aetna’s efforts to fight the opioid epidemic as well as recommendations for Congress and the Administration. We believe important 

efforts in our commercial lines of business can inform how CMS 

regulates Medicare Advantage and Part D plans to allow for similar programs in the Medicare space. 

First, within our commercial business, Aetna is leveraging formulary and plan design tools, such as quantity limits and prior authorization, to reduce opioid misuse and encourage evidence-based 

treatments. 

For example, as of January 1, Aetna is limiting initial opioid prescriptions for acute pain to a 7-day supply. These stricter daily and 

dosage limits are in alignment with CDC guidelines and will help 

to reduce the potential for abuse and addiction. 

Second, effective January 1, Aetna became the first and only national payer to waive copays for Narcan, a lifesaving, highly effective opioid overdose reversal agent, for our fully insured commercial members once their deductible is met. We hope this copay 

waiver will increase access to remove possible financial barriers to 

the use of naloxone. 

Third, within Aetna’s Medicare business, we are striving to be 

part of the solution. Aetna has taken steps to promote appropriate 

prescribing and coordination of care for our Medicare members who 

utilize opiate drug therapies. 

52 

Aetna has instituted interventions in its Medicare formularies to 

assist members in receiving appropriate opioid medication when 

necessary while preventing inappropriate use and addiction. We 

also support pharmacists in utilizing opioid controls as well. 

Aetna is committed to continuing to work with CMS to highlight 

areas of opportunity for change to better combat the opioid epidemic. We believe there are three specific areas where Congress 

and CMS can take additional steps to help remove barriers currently limiting the ability of plans to combat the epidemic itself. 

First, while Aetna now limits initial fills of acute opioid prescriptions to a 7-day supply in our commercial business, Medicare Advantage and Part D plans are precluded from unilaterally limiting 

the duration of a prescription. We are encouraged that CMS in its 

recently released call letter is proposing significant steps to allow 

Medicare and Part D plans to take more action to preventing over 

prescribing. 

We strongly encourage CMS to finalize provisions that allow additional point-of-sale edits and supply limits of prescription opioids 

that limit initial prescribing to a 7-day supply. 

Second, we also support CMS’ continued efforts to address the 

opioid epidemic and believe the implementation of CARA and the 

adoption in Part D of a lock-in mechanism will prevent sponsors 

with a critical tool to help—will provide sponsors—excuse me— 

with a critical tool to help curtail the abuse of opioids. 

Still, we believe there are several changes CMS should make in 

implementing the lock-in program to ensure its success, such as allowing Part D sponsors to retain the ability to use point-of-sale 

claim edits to address other frequently abused drugs and allowing 

plans to maintain the lock-in status of a member until notified by 

the applicable provider that the member is no longer at risk. 

And, finally, we strongly support modernizing privacy regulations to provide access to a patient’s entire medical record, including substance use disorder records, and to ensure that providers 

and organizations have all the necessary information to provide 

safe, effective, high-quality treatment and care. 

We urge Congress to expeditiously pass the bipartisan legislation 

introduced in the Senate and here in the House by Representatives 

Mullin and Blumenauer to align this outdated regulation with already strict HIPAA standards. 

In conclusion, Aetna is deeply committed to doing its part to turn 

the tide on the epidemic. We look forward to continuing to play a 

productive role in the dialogue with the Subcommittee and with 

other policymakers to help find solutions to this epidemic. 

Thank you, again, for your leadership on this issue and for inviting Aetna to be here today. 

[The prepared statement of Dr. Paz follows:] 

53 


33794A.022

Statement of 

Dt·. Hal Paz, M.D., M.S., Executive Vice President and Chief Medical Officer 

Aetna, Inc. 

United States House Ways and Means Committee 

The Opioid Crisis: 

Removing Buriers to Prevent and Treat Opioid Abuse and Dependence in Medicare 

Februat·y 6, 2018 

Page 1 of9 
54 


33794A.023

Thank you Chairman Roskam, Ranking Member Levin and members of the Health 

Subcommittee for holding today's hearing on the opioid abuse epidemic. l appreciate your 

leadership in bringing a diverse group of stakeholders together to discuss ways we can further 

our efforts to address the challenges posed by the opioid abuse epidemic facing our nation. 

appreciate the opportunity to share Aetna's perspective on this critical public health issue. 

Aetna is a leading diversified health company that provides individuals, employers, health 

care professionals, and others with innovative benefits, products, and services. We serve over 38 

million individuals in the United States and around the world. 

I currently serve as the company's Executive Vice President and Chief Medical Officer 

(CMO), a role I have held since 2014. In my capacity as CMO, I lead clinical strategy and 

policy across Aetna's lines of business and am responsible for driving clinical innovation to 

improve member experience, quality, and cost in all areas of the health care delivery system. 

Prior to my role at the company, I served as Chief Executive Officer and Dean of Penn State 

Hershey Medical Center and Health System. Prior to this, I served as Chief Executive Officer 

and Dean of the Robert Wood Johnson Medical School. I am an active licensed physician and 

pulmonologist who still cares for patients at the West Haven VA Hospital. 

The opioid epidemic is the leading public health issue facing our nation, negatively 

impacting the lives of thousands of American families. The Centers for Disease Control and 

Prevention (CDC) has estimated that in 2016, 64,000 Americans died of dnag overdoses- three 

times the rate in 1999 and up 21% from 2015. Furthermore, America's addiction crisis has Jed to 

a two-year consecutive decline in our country's life expectancy, an alanning demographic trend 

we haven't witnessed since the 1960s. t 

Aetna understands the importance of fighting the opioid epidemic. Aetna's goal is to help its 

members who are stnaggling with addiction rentm to a productive life free of opioids. Aetna's 

various business segments are working to support this goal and to prevent future opioid 

dependency, wlule alig,tung with the evolving legal and regulatory guidance surrounding the 

opioid epidemic. Aetna is also committed to working with state and federal officials to advocate 

for legislative and regulatory solutions to enable greater public-private partnerships in addressing 

1 Samgaban. Lam·a. ' 'The opioid crisis is driving down U.S. life expectancy. new data shows." PBS. December 21 , 

2017. 

Page 2 of9 
55 


33794A.024

this epidemic. Furthermore, the Aetna Foundation is, where possible, supporting state and local 

programs that are aimed at combatting this national crisis. 

Aetna is taking a holistic approach to addressing the opioid epidemic. The various 

segments of Aetna's business- including our Commercial, Medicaid and Medicare product 

lines- are aU striving to help our members struggling with addiction and to prevent future opioid 

dependency. To that end, Aetna has established an "Enterprise-Wide Opioid Taskforce"-which 

I chair- with the objective of driving a multi-faceted strategy to help stem the tide of over-use. 

We have developed a strategy focused on: preventing misuse and abuse; intervening when we 

identify at-risk provider and member behavior; and supporting members by providing access to 

evidence-based treatments. 

Aetna is focused on helping its members avoid unnecessary opioid use and effectively 

manage opioid use when needed. In doing so, Aetna is striving-where possible and 

appropriate- to iJlcrease. tbe use of altemative therapies for members' pain relief, such as 

physica l therapy, chiropractic/osteopathic manipulative treatment, massage (in conjunction with 

physical therapy), cognitive behavioral therapy, and other effective alternative moda lities. For 

members who are dealing with chronic pain, Aetna supports a multi-disciplinary treatment 

approach, including both outpatient and inpatient treatment programs that consider physical, 

social, and behavioral factors. 

I am pleased to share with the Committee highlights of Aetna's efforts to fight the opioid 

epidemic. Specifically, we believe our important efforts io our Commercial lines of business, for 

example, can inform how the Centers for Medicare and Medicaid Services (CMS) regulates 

Medicare Advantage (MA) and Part D plans to allow for similar programs in the Medicare space. 

At Aetna, we are taking a number of steps to address the opioid epidemic. For example, we 

are leveraging fonnulary and plan design as tools to reduce opioid misuse and encourage 

evidenc.e-based treatment. While regulatory and contractual requirements affect the specifics of 

Aetna's approach by state and product line, Aetna is using these tools to ensure that appropriate 

prior authorization and quantity limits support tbe proper use of opioids for pain management 

and that alternative non-opioid treatments are available. As of January I, 2018 in our 

commercial business, Aetna is limiting initial opioid prescriptions for acute pain to a seven day 

Page 3 of9 
56 


33794A.025

supply, as well as a limit of90 milligrams of morphine e.quivalency per day. These stricter daily 

and length of coverage limits will help reduce the potential for abuse and risk of addiction. 

In our commercial business, Aetna requires prior authorization for all opioids for acute pain 

beyond the seven day initial fill, and also requires prior authorization for all opioids used for the 

treatment of chronic pain. These guardrails ensure that additional opioids are used for the 

shortest possible duration and only when the benefits of use outweigh the risks, aligning with 

CDC guidelines. The prior authorization requirement ensures that for longer tenn use in treating 

chronic pain, the physician and member have a treatment and monitoring plan in place to help 

prevent excessive side effects and possible future addiction. 

Furthermore, Aetna understands the important role that Medication-Assisted Treatment 

(MA1) plays in treating opioid use disorder. Aetna seeks to support its members who are 

recovering fi:om opioid dependency and/or are at risk of an opioid overdose. To that end, in its 

conunercial business, Aetna has removed prior authorization requirements on generic dmgs that 

treat opioid addiction, including oral buprenorphine/naloxone and generic dosages of Suboxone 

and Subutex. 

Aetna continues to look for ways to intervene when it identifies at-risk behavior with 

members. Per CDC, the Substance Abuse and Mental Health Services Administration 

(SAMHSA), the World Health Organization, and the American Medical Association (AMA) 

Opioid Task Force recommendations, physicians should consider co-prescribing naloxone-a 

lifesaving, highly effective opioid overdose reversal agent - to patients who are at an increased 

risk of an overdose. In light of these recommendations, effective January 1, 2018, Aetna became 

the first and only national payer to waive copays for Narcan for its fully-insured commercial 

members once their deductible is met. We hope that this copay waiver will increase access and 

remove possible financial barriers to the use of naloxone. In order to further increase access in 

regions particularly hard-hit by the opioid epidemic, Aetna donated 720 doses ofNarcan to first 

responders in the Nortbem Kentucky and Appalachia regions in August 2017 in support of 

community efforts to prevent deadly opioid overdoses. Aetna employees also led an educational 

training event for first responders and community members. And last December, Aetna donated 

408 Narcan kits to Howard County, Maryland. 

Page 4 of9 
57 


33794A.026

In order to promote prescriber education and prevent potential overprescribing, in 2016, 

Aetna sent letters to the top l% of opioid prescribers within their respective specialties, to make 

them aware of their outlier prescribing pattems. These approximately I ,000 opioid "superprescribers" were also provided the 2016 CDC guidelines for the use of opioids for the 

management of chronic pain. Last year, Aetna also sent 480 individualized letters to "superprescriber" dentists and, in collaboration with the American Association of Oral and 

Maxillofacial Surgeons, sent 249 letters to "super-prescriber" oral surgeons. 

Also, in our commercial business, Aetna is in the process of implementing a pilot program to 

provide coverage of Exparel- a non-narcotic pain injection used in patients following wisdom 

teeth extraction (or other dental surgery)- to its fully insured plans in lieu of opioid pills. By 

providing safer alternatives for pain control, fewer opioids are prescribed, and we can avoid the 

risk of misuse and diversion of unused pills. 

Within Aetna's Medicare business, we have also been taking strides to be part of the 

opioid solution. Before I tum to specific examples, it's important to consider the structural 

framework of the Medicare program itself. The Medicare population, including seniors and the 

qualified disabled, receives their benefits in multiple ways. For example: 

I. Some are enrolled in fee-for-service (FFS) Medicare, stand-alone Part D, and have a 

supplemental policy through an employer or a purchased Medigap plan; 

2. Others are enrolled in a Medicare Advantage-Prescription Drug Plan (referred to as an 

"MA-PD") which combines a Medicare Advantage health plan with an integrated 

prescription drug plan; 

3. Others who are lower income or dual-eligible have both Medicare and Medicaid, and still 

get their dmg benefit through Medicare Part D; 

4. Furthermore, certain Medicare retirees obtain coverage through a Medicare employer 

group waiver plans (EGWP), but often the employers choose another entity to provide the 

dmg benefit. 

Aetna believes the best way to manage Medicare beneficiaries' health is through a fully 

integrated model, such as MA-PD, that coordinates Medicare, Medicaid (if applicable), and drug 

Page 5 of9 
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33794A.027

benefits. Evidence shows that integrated medical and drug plans are better for the consumer and 

provide quality service at lower cost.2 However, structural barriers exist even within MA-PDs 

that limit Aetna's ability to impose opioid utilization management restrictions (such as requiring 

non-opioid pain management prior to the use of opioids). And with added flexibility, even more 

can be done to address beneficiaries' overall healthcare needs, including health, wellness, pain 

management, addiction, and drug utilization. 

As a Medicare Managed Care Organization (MCO), Aetna's Individual Medicare fonnularies 

are governed by regulations and guidance from the CMS. CMS's regulatory framework is 

designed to protect Medicare members' access to prescription drugs, to ensure timely delivery, 

and to minimize disruption of members' drug therapies. Accordingly, MCOs like Aetna are 

limited in their ability to make fonnulary and utilization management changes to limit the use of 

opioids. 

Despite these constraints, Aetna has taken steps to promote appropriate prescribing and 

coordination of care for its Medicare members who utilize opioid drug therapies. As a general 

matter, Aetna has instituted, with CMS approval, utilization management tools in its Medicare 

formularies to assist Aetna's members in receiving appropriate opioid medication when 

necessary, while preventing inappropriate use and/or addiction. Aetna's Medicare plan system 

implementation also contains point of sale pharmacy messages to pham1acists in support of 

opioid use controls, as well as retrospective utilization programs to support physician appropriate 

prescribing and coordination of care. 

As an example, under the point of sale messaging, a dispensing pharmacist will receive an 

alert when a member has a product like Suboxone in their recent drug history fills and is 

attempting to fi ll an opioid prescription. The alert is meant to infonu the pharmacist that he or 

she should assess whether a different non-opioid pain medication would be a more appropriate 

treatment before filling the prescription. 

In addition, Aetna has aligned its targeting criteria- by which it identifies high dose opioid 

users for potential intervention- in Medicare more closely with CDC guidance on high dose, 

high risk utilization of opioids. Beginning this year Aetna Medicare's targeting criteria 

' Smith·Mclallen, Aaron. "Effects of Pharmacy Benefit Carve·ln on Utilization and Medical Costs: A Three Year 

Study." Benefits Magazine. February 2012. 

Page 6 of9 
59 


33794A.028

decreased from a 120 milligram morphine equivalent dose threshold to 90 milligrams. This 

change will help target a greater number of at-risk members for potential intervention. 

Aetna is committed to continuing to work with Congress and CMS to highlight areas of 

opportunity for change to better combat opioid abuse. There are a few specific areas where we 

believe Congress and CMS can make changes: 

Limit Initial Opioid Prescriptions to 7-Day Supply 

While Aetna now limits initial fills of acute opioid prescriptions to a 7-day supply in our 

Commercial business, current Medicare rules preclude Part D plans from unilaterally limiting the 

duration of a prescription (though patients or prescribers may request a shorter fill than 

prescribed). In other words, in most states that do not have pharmacy-specific rules to tlus 

effect, standalone Part D and MA-PD plans cannot limit a prescription fill to only seven days 

because of safety or potential abuse concerns, without a member or prescriber's request. 

We are encouraged that CMS- in its recently released 2019 MA and Part D Advanced 

Notice and Call Letter- is proposing significant steps to allow MA and Part D plans to take 

more action to prevent over prescribing of prescription opioids. Specifically, we strongly 

encourage CMS to finalize provisions that allow additional point-of-sale edits and supply limits 

of prescription opioids that limit initial prescribing to a 7-day supply, in a lignment with CDC 

guidelines. 

Ensure Success of Medicare Part D Lock-in 

We support CMS' continued efforts to address the opioid epidemic and believe the 

implementation of CARA, and the adoption in Part D of a lock-in mechanism (by which a 

member can be "locked in" to one pharmacy to prevent "pharmacy shopping"), will provide Part 

D sponsors with a critical tool to help curtail inappropriate abuse of opioids and other 

medications. However, there are several critical changes CMS should make in implementing the 

Medicare Jock-in program to ensure its success. First, we believe Part D sponsors must retain the 

ability to usc point of sale claims edits to address other frequently abused drugs, including those 

often used concurrently with opioids. Second, sponsors must also be allowed to continue to 

apply point of sale edits when a member is identified by their prescriber as potentially at-risk, 

even iftl1ey do not meet the CMS criteria. Third, we also believe plans should be allowed to 

Page 7 of9 
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33794A.029

maintain the locked-in stams of a member until notified by the applicable provider that the 

member is no longer at risk. Arbitrarily terminating these important limitations after one year 

without a clinical reason, we believe, unnecessarily puts members at risk of relapsing. 

Modernize Privacy Regulations 

As a practicing physician, I understand and respect the importance of privacy as it relates to 

health care. However, I also believe that certain privacy regulations limit the ability for MCOs, 

like Aetna, and health providers to securely exchange relevant information about a patient's 

history with substance abuse, addiction, or mental health. We at Aetna believe these barriers 

warrant further review and updating. 

We strongly support modernizing privacy regulations, 42 CFR Part 2, to provide access 

to a patient's entire medical record, including substance use disorder records and to ensure that 

providers and organizations have all the infom1ation necessary to provide safe, effective, high 

quality care. 

Care coordination for members with a substance use disorder is of utmost importance. 

The current outdated rule poses a serious safety threat to those with substance use disorders due 

to risks from drug interactions and co-existing medical problems. In addition, these outdated 

regulations mn counter to new, innovative delivery care models where providers must use patient 

data and analytics to manage the health of a population and identify patients for targeted 

outreach. 

To this end, Congress should expeditiously pass bipartisan legislation introduced in both 

chambers by Representatives Mullin and Blumenauer in the House (H.R. 3545) and Senators 

Manchin and Capito in the Senate (S. 1850) to align this outdated regulation with already strict 

HIPP A standards. 

In conclusion, Aetna is deeply committed to doing its part to reverse the trend of opioid 

misuse, abuse, and overdoses across the nation. We have already lost far too many of our 

friends, family, and community members to this unprecedented health crisis. We will continue 

to enhance our programs to reduce inappropriate opioid prescribing, encourage the use of nonopioid pain treatment modalities, and promote evidence-based recovery for our members 

struggling with opioid use disorder. We look forward to continuing to play a productive role in 

Page 8 of9 
61 

f 


33794A.030

the dialogue with the Committee and with other policymakers to help fmd solutions to this 

epidemic. Thank you again for your leadership on. this issue and for inviting Aetna to be here 

today. 

Page 9 of9 
62 

Chairman ROSKAM. Thank you very much. 

Ms. Hungiville. 

STATEMENT OF LAURA HUNGIVILLE, PHARMD, CHIEF 

PHARMACY OFFICER, WELLCARE HEALTH PLANS, INC. 

Ms. HUNGIVILLE. Mr. Chairman, Ranking Member Levin, 

Members of the Committee, I am Laura Hungiville, Chief Pharmacy Officer for WellCare Health Plans. I want to thank you for 

your invitation to appear today to share with you our experiences 

regarding the opioid epidemic and the variety of practices we have 

employed aimed at curbing the overuse and misuse of prescription 

opiates. 

It is important that the Committee is addressing this vital issue, 

and managed healthcare companies are equally committed to finding solutions. First, though, let me tell you a little bit about 

WellCare. Headquartered in Tampa, Florida, WellCare focuses exclusively on provider government-sponsored managed healthcare 

services through Medicaid, Medicare Advantage, and Medicare prescription drug plans. 

WellCare prides itself on managing healthcare services for the 

underserved and most vulnerable populations. We serve 4.3 million 

members nationwide with roughly 1 million members relying on 

WellCare for prescription drug services. 

In any given State our beneficiary population ranges from 40 to 

50 percent dual eligible. While certainly not the only population at 

high risk of controlled substance misuse, mental illness and poverty often go hand in hand with substance abuse disorders. 

We have spent the last several years investing resources and 

time into innovative methods for decreasing the misuse of controlled substances among our beneficiaries, culminating most recently in the launch of an opioid task force. 

This task force was created to ensure that we are taking an integrated approach to helping our members. Our company has insourced medical, pharmacy, and behavioral departments, a rarity 

among managed care plans, to ensure that we are looking at the 

member in a holistic manner. 

First and foremost, our goal is to prevent abuse and addiction. 

Our second goal is to help our members who are battling addiction 

and often chronic pain to help them manage both conditions. Those 

members who are at the greatest risk of overdose and death receive 

the highest attention. 

One of our key programs involves monitoring doctor and pharmacy shopping so we can flag high utilizers. WellCare works with 

patients to enter into medical service agreements, which patients 

benefit from having a single doctor focused on prolonged pain management therapies to deter opioid misuse. 

For several years, WellCare’s pharmacy-run opioid overutilization case management program has been using predictive modeling 

to identify at-risk individuals. As a result, WellCare proactively 

identified over 200 at-risk members nationally in 2017 based on 

specific criteria, including prescription dispensing, provider, and 

emergency department utilization. 

We placed these individuals into a lock-in program connected to 

one pharmacy, one healthcare provider, and a care manager who 

63 

helps connect members to needed physical, behavioral, pharmacy, 

and social services. 

In regard to the CMS standard for morphine-equivalent dosage, 

we have also identified 2,100 additional members who have received prescriptions over the previous CMS standard of 120 milligrams of opioids per day. We intervene with these members 

through member education on alternative medications, outreach to 

prescribers, and have begun including integration point with our 

behavioral health case management team. For our noncancer members, this translated into utilization reduction of over 43 percent 

between 2015 and 2017. 

Since the transition to the lower daily ceiling of 90 milligrams of 

morphine-equivalent doses, WellCare continues to see increased 

numbers of members captured through our overutilization case 

management program. 

We also recognize that we must look beyond the treatment of 

pain to address opioid overuse. Our multifaceted set of interventions includes the creation of the CDC-compliant task force and engaging policy groups at the State level to include prescription drug 

monitoring program training, and CME for physicians on the training of using opiates. 

Some of these partnerships also include working with the YMCA 

to educate teens on the risk of opioid use, especially in the foster 

care system. At the organizational level, we are rolling out 

telehealth programs for use in emergency rooms to help increase 

medication-assisted treatment. 

And, finally, we are also developing incentive programs for physicians to become SAMHSA certified, given the increased demand for 

addiction specialists. 

Much of which I have outlined has been possible because of 

States like Kentucky where Medicaid regulations allowed us to be 

aggressive in targeting opioid misuse. In Kentucky, we are able to 

see a decrease of nearly 50 percent. 

We would also like to recommend CMS incentivize other providers to become SAMHSA certified, allow health plans to be empowered to have more restrictive lock-in programs, mandate electronic prescribing of opioids, and address the gaps that create barriers for plans by providing PDP plans with access to medical 

claims, and allow health plans access to PDMPs as well. 

Lastly, Congress, CMS, and the FDA should create educational 

campaigns similar to the one deployed for tobacco cessation to educate consumers about the dangers of the opioids and remove the 

stigmatization and encourage people to seek help. 

In conclusion, ending this opioid crisis will require a partnership 

with all stakeholders, and WellCare looks forward to being an active participant as the Committee and Congress work to combat 

this epidemic. Thank you. 

[The prepared statement of Ms. Hungiville follows:] 

64 


33794A.031

Comments for the Record 

U.S. House Committee on Ways and Means, Subcommittee on Health 

Hearing on 

The Opioid Crisis: Removing Barriers to Prevent and Treat Opioid Abuse and Dependence in 

Medicare 

Tuesday, February 6, 2018 

By Laura Hungiville 

ChiefPhannacy Officer 

WeiJCare Health Plans, Inc. 

Mr. Chairman, Ranking Member Neal, members of the Committee - I am Laura Hungiville, Chief 

Pharmacy Officer for WeliCare Health Plans. I want to thank you for your invitation to appear 

today to share with you our experiences regarding the opioid epidemic and the variety of practices 

we have employed aimed at curbing the overuse and misuse of prescription opiates. 

It is important that the Committee is addressing this vital issue, and managed healthcare companies 

are eqtk111y committed to finding solutions. We understand the severity of the epidemic, and 

applaud the Committee's continued commitment to bringing an end to this crisis, which is exacting 

a toll on individuals and families across the country. 
65 


33794A.032

We would like to use this opportunity to detail some of the key protocols we have implemented to 

successfully reduce the number of overdoses due to opioid abuse as well as introduce new pain 

alleviation alternatives. 

First though, let me tell you a little bit about WeliCare. Headquartered in Tampa, Florida, 

WellCare focuses exclusively on providing government-sponsored managed bealthcare services, 

primarily through Medicaid, Medicare Advantage, and Medicare Prescription Drug Plans, to 

members with complex medical needs. WeliCare prides itself on managing heahhcare services 

for the underserved and most vulnerable populations. We serve 4.3 million members nationwide, 

with roughly one million members re lying on Well Care for prescription drug coverage. 

In any given state, our beneficiary population ranges from 40-50% dual eligible - those 

beneficiaries that qualify for both Medicare and Medicaid. While certainly not the only population 

at a high risk of controlled substance misuse, mental illness and poverty often go hand in hand 

with substance abuse disorders. We have spent the last several years investing resources and time 

into innovative methods for decreasing misuse of controlled substances among our beneficiaries, 

culminating most recently in the launch of an Opioid Task Force. 

The task force was created to ensure that we are taking an integrated approach to helping our 

members. Our company has insourced our medical, phannacy, and behavioral departments - a 

rarity among managed care plans - to ensure that we are looking at the member in a holistic 

manner. First and foremost, our goal is to prevent abuse and addiction. Our second goal is to help 

our members who are battling addiction, and often chronic pain, and to also help them manage 
66 


33794A.033

both conditions. Those members who are at the greatest risk of overdose and death receive the 

highest attention. 

One of our key programs involves instituting metrics to monitor doctor and phannacy shopping so 

we can flag high utilizers and working with patients to enter into medical service agreements. 

Under a medical service agreement, at-risk patients benefit from having a single doctor focused 

on prolonged pain management therapies to deter opioid misuse. 

Identifying At-Risk Populations 

For several years, WeiiCarc's phannacy-mn opioid ovemtilization case management program has 

been using predictive modeling to identify at-risk individuals. As a result, WeiiCare proactively 

identified over 200 at-risk members nationally, based on specific criteria including prescription 

dispensing, prescription refills, and provider and emergency department utilization. We placed 

these individuals in a "lock-in" program connected to one phannacy, one healthcare provider, and 

a care manager with specialized training and experience in substance use disorder treatment. Care 

managers also help connect members to needed physical, behavioral, pbannacy, and social 

services. 

In regard to the CMS standard for morphine equivalent dosage (or MED), we have also identified 

over 2,100 additional members who have received prescriptions over the previous CMS standard 

of 120 mg of opioids per day. We intervened with these members through member education on 

alternative medications, outreach to prescribers, and have beg1m including an integration point 

with our behavioral health case management team. For our non-cancer members, this translated 

into a utilization reduction of over 43% between 2015 and 2017. Since the transition to the lower 
67 


33794A.034

daily ceiling of90 mg M£0, WeliCare continues to see improvement in the numbers of members 

captured through our overutilization case management program. 

Looking Bevond Na•·cotic T1·eatment of Pain 

Well Care recognizes that we must look beyond the treatment of pain to address opioid overuse. 

Our multifaceted set of interventions include the creation of the CDC-compliant task force and 

engaging policy groups at the state level to include Prescription Drug Monitoring Program 

(POMP) training and physician Continuing Medical Education (CME) training on opiates. Some 

of these pannerships include working with the YMCA to educate teens on the risk of opioid use, 

especially in the foster care system. At the organizational level, we are rolling out a telehealth 

program for use in emergency rooms and to help increase access to Medication Assistance 

Treatment (MAT). And finally, we arc also developing an incentive program for physicians to 

become Substance Abuse and Mental Health Services Administration (SAMHSA) certified, given 

the increased demand for addiction specialists. 

Row CMS and Cong•·ess Can Take Action 

Much of what I outlined above has been possible because of states like Kentucky, whose Medicaid 

regulations allowed us to be aggressive in targeting opioid misuse. For example, at the conclusion 

of a recent six-month pilot project, opioid prescription fills by our Kentucky members had 

decreased by nearly 50%. As a managed care plan that provides services to members in a variety 

of states, WeliCare recognizes the geographic variation in opioid use and resources and believes 

that federal policymakers would be well-served by applying protocols that have proven successful 

at the state level to Medicare in light ofthc current public health emergency. 
68 

f 


33794A.035

We would also recommend the following: 

• CMS could incentivize other providers to become certified and start treating members with 

substance use disorders by providing reimbursement to support the additional activities 

offered under a comprehensive treatment plan, such as counseling, medication assisted 

treatment, social services, drug screening, and PDMP integration. 

• Health plans need to be empowered to have more restrictive lock in programs, with the key 

being limiting patients to one provider and one pharmacy. 

• Congress should mandate electronic prescribing of opioids to prevent prescription 

tampering, improve security, reduce fraud and limit opioids getting in the wrong hands. 

• CMS needs to address data gaps that create barriers for plans by providing PDP plans with 

access to medical claims data to identify members most at risk for abuse. Additionally, 

health plans do not have access to PDMPs in most states, and therefore do not have a 

complete view of the member's utilization of opioids. 

• Lastly, Congress, CMS, and FDA should create an educational campaign similar to the one 

deployed for tobacco cessation, to educate consumers about the dangers of opioids, remove 

stigmatization and encourage people to seek appropriate help. 

In conclusion, ending the current opioid crisis will require a partnership between all stakeholders 

- Congress and relevant Federal agencies, healthcare payers and providers, as well as patients and 

their families - in order to continue the successes we have already seen from efforts such as those 

I outlined today. WeliCare looks forward to being an active participant as the Committee and 

Congress work to combat this epidemic. Thank you again for the opportunity to testify today. I 

welcome any questions you may have. 
69 

Chairman ROSKAM. Thank you very much. You have given us 

great insight and very valuable perspectives. 

We are in a very uncertain time right now in terms of scheduling 

and the chatter that we are getting about being called back in. 

Since this has been a two-panel hearing today, I would ask unanimous consent to limit the Members’ questions to 3 minutes. 

And, without objection, so ordered. 

And, with that, we will yield to recognize Mr. Kelly. 

Mr. KELLY. Thank you, Mr. Chairman. 

Thank you all for being here. 

Dr. Benyamin, I was fascinated by your testimony. And I think 

last year when President Trump talked about this war on drugs, 

he had talked about nonaddictive painkillers because we are a Nation now of dependence or codependence. I don’t think there is any 

doubt about that. 

If you could just go a little bit further into that. I marvel at the 

fact that we have 50 laboratories around this country that are collecting all this type of data. But your testimony, more than anything, appealed to me because I have been so close to this issue. 

Would you expand a little bit more on the fact that we do have 

a way of keeping pain down? But I think the development of those 

drugs also had to do with reimbursements, right? If we can keep 

the pain down and the patient says, ‘‘I am not feeling the pain,’’ 

it is a better result. But it involves an addiction. So please hit the 

nonaddictive ways of killing pain. 

Dr. BENYAMIN. Thank you, Congressman. That’s a very good 

question. 

We can divide that into two sections, the medication part and 

the interventional part. So, on the medication front, we have had 

challenges as far as funding and research funding for nonaddictive medication, as you know. And we do not have many choices. 

Our choices are between scheduled prescription drugs and antiinflammatories. And we all know that anti-inflammatories have 

their own side effects. 

One of the issues is access. Many of the health plans do not cover 

nonopioid medications. Like, I will give you a good example of a 

patch that is anti-inflammatory. If you call for a preauthorization, 

unanimously, they all will deny the patch. They will say to you: 

Well, we do not cover the anti-inflammatory patch, but we do cover 

the fentanyl patch. That is the answer that you get. So that tells 

you part of the problem that we face. 

On the nonmedication front, I think we are a young specialty. 

Interventional pain management is a young specialty. And we have 

been adding to our tools to treat, as I mentioned, the spinal disorders, like spinal stenosis, and fractures in the spine. These are 

conditions that, in the past, we did not have any solution for between surgery and opioids. And now we are providing solutions 

that are minimally invasive techniques that can prevent these patients from getting to the point of becoming dependent on opioids 

or having all these invasive surgeries and, as a result, becoming 

dependent on opioids. 

Mr. KELLY. Sir, I want to thank you. I am running out of time. 

I want to thank you all for being here. We have run out of options 

as a country. We have to get this fixed. So thank you so much for 

70 

what you are doing. Please continue your work. We really appreciate you being here. Thanks so much. 

I yield back, Mr. Chairman. 

Chairman ROSKAM. Mr. Levin. 

Mr. LEVIN. Well, I join in our appreciation for all of your efforts. 

Just quickly—and then I wanted to ask you another question— 

why do you think it took us so long to recognize this epidemic? 

Anybody want to venture? It did take us a long time. 

Dr. BENYAMIN. Can I take a shot at that? 

Mr. LEVIN. Please. 

Dr. BENYAMIN. So I think part of it is a lack of awareness and 

a lack of knowledge, a lack of public information, and usually we 

react. You know, we always react, we go from one extreme to the 

other. 

As I said before, this is not just a pill problem anymore. The shift 

has occurred from the pill to heroin and synthetic fentanyl. And I 

will be glad if we take some precautionary legislation that will prevent that from happening and reduce the supply of these drugs in 

our country. 

In my community, the rate of death from opioid overdose had tripled in 3 years. And, you know, I would like you to understand 

that it is very hard for the coroner to determine the exact cause 

of death. You know, all these data are based on coroners’ reports, 

which is based on what pathologists find in the system. 

Now, if you have five, six, seven medications or drugs in the system, who is to say which one of these is the real cause of death? 

That is why they mark them all as opioid overdose. 

Mr. LEVIN. So let me ask you then, in terms of awareness, expanding Medicare treatment, isn’t that a very good idea, Doctor? 

Mr. KLETTER. So, if I could add to that, I think, to your first 

question, the reason it has taken so long to recognize is less about 

not recognizing it and more about the stigma associated with the 

disease. 

People with the disease of addiction are sort of shunned and kept 

in the shadows and embarrassed and shamed, and treatment has 

been sort of similarly treated. There hasn’t been a lot of attention 

or focus on treatment services. In fact, physicians are not taught 

how to treat addiction in medical school generally. They are not 

taught a lot about opioids and/or addiction. 

Mr. LEVIN. So expanding Medicare—— 

Mr. KLETTER. So how can expanding Medicare help? Well, first 

of all, making it part of mainstream medicine, helping to sort of acknowledge the disease as just that, as a disease. 

We heard Governor Scott of Vermont earlier say we need to do 

a better job of making—of acknowledging the disease and thinking 

of it as a disease rather than thinking of it as a lack of will power 

or a moral downfall. 

Mr. LEVIN. Okay. So—— 

Mr. KLETTER. And so Medicare contributes to that by, you 

know, legitimizing the treatment that we have as a medical treatment. 

Mr. LEVIN. Thank you. 

Chairman ROSKAM. Mr. Paulsen. 

Mr. PAULSEN. Thank you, Mr. Chairman. 

71 

I want to follow up a little bit on some of the perspectives that 

were offered on the minimally invasive procedures. And, look, I 

mean, historically, the practice of providers has been to prescribe 

opioids to patients for years, and it is hard to stray away from that 

course and then to try new different therapies for pain management. 

Now, I also understand that there are about 200 FDA-approved 

devices for which CMS does reimburse, but it seems that not 

enough providers or Medicare Advantage plans, for instance, are 

alerting patients to some very effective and efficient ways to manage pain outside of the risk of addiction. 

One example is a spinal cord stimulator that involves a minimally invasive procedure and uses electrical signals to block pain 

signals from reaching the person’s brain. It has about a 50 percent 

or greater opportunity for reduction in pain, and more than half of 

the patients don’t need to have any pain medication for that management. And it is FDA-approved. It is Medicare reimbursed. It 

has helped about 500,000 patients. 

So I am just curious, maybe Dr. Paz and Ms. Hungiville first, 

what are your health plans doing in general to ensure that providers are aware and that patients have access to some of these 

covered nonopioid treatments? 

Dr. PAZ. So thank you very much for the question. 

So we, as you indicated, cover these types of devices for patients 

that appropriately fit the criteria. And where we spend a great deal 

of our emphasis at our opioid-wide task force is really looking at 

patients with acute pain because that becomes the entry point for 

them being exposed to opioids in the first place. And that is where 

alternative types of—my colleagues mentioned, alternative types of 

treatment come into play, physical therapy, chiropractic, osteopathic, manipulative therapy, different types of approaches, the use 

of nonsteroidals, SSRIs, for example. These are things that we can 

do for acute pain. And, frankly, there is data that shows that some 

of the over-the-counter treatments of pain, acetaminophen even, 

nonsteroidals, can be equally effective, if not more so, for the treatment of those situations. 

When a patient has long-term chronic pain, that is a different 

matter altogether. And, quite frankly, in those situations, if we 

think it is appropriate, we will cover opioids because that may be 

the only treatment that is effective. But, certainly, also if a physician is recommending or prescribing a device, that is something 

that would be covered as well. 

Mr. PAULSEN. Ms. Hungiville, are there any barriers to nonpharmaceutical therapies for chronic pain that currently exist, or 

can you expand on—— 

Ms. HUNGIVILLE. It is awareness, and through our case management, we are trying to educate providers as well as our beneficiaries that there are alternatives to the opioid treatment. And so 

that is one of the interventions that we employ: to make them 

aware of other alternatives. 

Mr. PAULSEN. Good. I mean, this seems to absolutely make 

sense based on the testimony we are hearing. So I appreciate your 

perspectives and yield back, Mr. Chairman. 

Chairman ROSKAM. Mr. Reed. 

72 

Mr. REED. Well, thank you, Mr. Chairman. 

And the question I have is for Dr. Benyamin. I am sorry. Is that 

it? 

Dr. BENYAMIN. Benyamin. 

Mr. REED. Oh, okay. Thank you. I appreciate that, Doctor. 

The question I have for you is, pain, in and of itself, is that a 

bad thing, from a physician’s perspective? 

Dr. BENYAMIN. It depends on the condition. If it is acute, it is 

always an alarming sign that there is something happening. 

Mr. REED. So as a physician—and I see two doctors up there— 

what is a successful outcome of pain management? Is it zero pain? 

Or is there some level of pain that to me is a natural response of 

the body telling a doctor, ‘‘Hey, there is an issue here’’? And are 

doctors and physicians trained to overmedicate in order to get to 

an unlikely outcome of zero pain, which is probably not, in my 

humble opinion, the best outcome that we can anticipate from physicians? 

Dr. BENYAMIN. Absolutely, Congressman. 

Mr. REED. So could you explain that a little bit? 

Dr. BENYAMIN. Yeah. This is how we—part of the reason why 

we got into this crisis is in all these regulations that we had by 

the hospitals. If you remember, there was a time they used to call 

pain the fifth vital sign. 

Mr. REED. Uh-huh. 

Dr. BENYAMIN. I mean, it cannot be ignored. 

Mr. REED. Where do those regulations come from? Government, 

right? 

Dr. BENYAMIN. From government, right. 

Mr. REED. We directed you to get to zero pain, did we not? 

Dr. BENYAMIN. Right. So that was enforced in the hospitals. All 

the accredited institutions, health institutions, needed to address— 

assess and address pain to a point that the pain level will go down 

to anywhere below four. 

Now, as you know, that is a very subjective number. And if you 

look at Medicare actually, they never talk about regulations. They 

usually talk about—they never talk about the numbers. They talk 

about quality and function of the patient. 

So I think we need to shift this emphasis toward quality of life 

and function, and those are the tools that we use in our practice. 

And we rely much less on that number unless it is required by a 

lot of insurance companies. 

I will give you an example. The Congressman mentioned the spinal cord stimulator. We have this arbitrary number of 50 percent. 

If the patient’s pain didn’t go from 8 to 4, well, then, his implant 

will not be approved, right? 

Mr. REED. So, as we learn from that experience going forward 

and setting policies going forward, could you provide me some insight as to how we would do the new regulations to encourage a 

better outcome than what we may have, by unintended consequences, made in good faith to limit pain but had an unintended 

consequence of exacerbating this problem? 

Dr. BENYAMIN. Absolutely, unintended consequences. That is 

what we are facing. And that is why I was mentioning to the 

Chairman that we need to—if we are looking for a solution, there 

73 

is no one magic wand that we are going to wave here and solve this 

problem. This has many aspects to it. 

As the Governor mentioned, I like that four pillars of the treatment on—how to address this issue. And you have to work at the 

prevention. You have to work on recognizing, what is the disease? 

Is the patient having a substance use disorder? Treat that, treat 

the consequences, prevent disasters, and limit the supply. If you 

look—or, you know, the studies have shown that when you limit 

the supply, we have less of a prescription writing and less deaths. 

Mr. REED. Thank you very much for the input. 

Chairman ROSKAM. Mr. Renacci. 

Mr. RENACCI. Thank you, Mr. Chairman. 

It is interesting what my colleague, Mr. Reed, mentioned, because I was 18 years old in a horrible motorcycle accident and went 

to school the next day with a bottle of aspirin. It is amazing how 

government has changed things. 

But, anyway, I have introduced legislation with Congressman 

Mark Meadows that would enact a 7-day limit on opioid prescriptions for acute pain with some exceptions. It was crafted in consultation with over 30 stakeholders to address what studies and researchers have proven time and time again: risk of addiction increases with the length of your opioid prescription. 

Dr. Paz, in your testimony, you state that Aetna limits opioid 

prescribing for acute pain to a 7-day supply. CMS has recently proposed limiting initial limit fills to 7 days. This would apply for all 

new opioid users in Medicare as well as require plans to implement 

a hard edit for beneficiaries prescribed more than a 7-day supply 

of opioids. 

Dr. Paz, what research led to Aetna’s decision to adopt a stricter 

threshold before Medicare proposed it? 

Dr. PAZ. So this is in our commercial plans, and we base that 

on the CDC recommendations. Those are the same recommendations that we share with physician and dental superprescribers, 

who are prescribing large quantities of opioids to our members as 

well. 

We think that is very important guidance. It is something that 

should be used by the provider community, by physicians and dentists who have prescribing privileges. And we felt the first place to 

put that in place was in our commercial plans where we could, in 

fact, do that. 

Mr. RENACCI. So do you believe limiting opioid prescriptions for 

populations other than Medicare beneficiaries—I think you have 

said this—would have an effect similar to what CMS is hoping to 

achieve with Medicare beneficiaries? 

Dr. PAZ. So I would say that there is one exception to that, Congressman, and that is in individuals that are not suffering from 

acute pain but in individuals that are terminally ill with cancer, for 

example, in hospice. There are circumstances where there are very 

good reasons to have long-term use of opioids. But we are focused 

here, and most of the situations we are looking at are, in fact, really 35 percent of the population are coming to us with acute pain 

situations. 

74 

Mr. RENACCI. Well, it is interesting. My bill provides exceptions 

for cancer treatment, hospice care, palliative care, and chronic 

pain. 

The next question is for any of the witnesses: What exceptions 

would you all recommend for CMS as well as what should Congress 

consider as a nationwide prescription limit other than those four? 

You mentioned those. Are there any other exceptions that anyone 

on the panel thinks we should have? 

Okay. I yield back. 

Chairman ROSKAM. Mr. Thompson. 

Mr. THOMPSON. Thank you, Mr. Chairman. 

Dr. Kletter, you heard about the Hub and Spoke program, a program with the Spokes. What can we do or do better at the Federal 

level to enable the success of this program rather than to impede 

it? 

And I have a county that I represent, Lake County, which is contiguous to your second home, that has a high opioid—a terribly 

high opioid problem. And what can we do to make sure that they 

have long-term access to these services, and can you talk a little 

bit about the barriers in the Medicare program that would prevent 

treating those patients? 

Mr. KLETTER. Sure. So we heard quite a bit about the Hub and 

Spoke program from Governor Scott. It is a fantastic program. 

BayMark happens to operate three of the six Hubs in the State of 

Vermont, so we are very fond of it. And we are developing 4 of the 

19 in California. 

While Vermont is a very small State, they have created what 

seems to be a no-brainer. This is one of the most effective approaches to treating the opioid epidemic we have seen in the treatment community. 

So what can Congress do? Well, as I said in my testimony, Congress can pass legislation that would allow Medicare to cover treatment services at OTPs. OTPs are the Hubs within this Hub and 

Spoke program. And the concept is that you get a Hub where all 

three federally approved medications can be provided and wraparound services, including counseling and drug testing, and other 

supportive services are provided. 

And then patients are admitted at the Hub, they are stabilized 

there, and then once they are stabilized, they are stepped down to 

a less-restrictive model of care, level of care, and those are the 

spokes. Those are primary care physicians generally. 

And the reason that the model was created was because, as we 

know, many primary care physicians have been reticent to prescribe medications to folks with opioid use disorder because it is a 

complicated disease and requires a lot of attention. 

The beauty of the Hub and Spoke system is that the Hub provides services in the form of a MAT team, a nurse, and a counselor, 

to the Spoke so that the physician has additional resources in dealing with the patients, in helping the patients manage their medications, making sure they are not being diverted, making sure they 

are taking them on time, making sure they are participating in all 

the services, like counseling, that are required for effective outcomes. 

75 

So coverage in Medicare is important, and we work quite a bit 

with SAMHSA, who has been helpful in developing more OTPs 

around the country. The CURES funding that came out of Congress 

last year or this year has been used in California primarily for developing this Hub and Spoke model. It is being used in other States 

to develop the Hub and Spoke model. 

So we would encourage you to look very closely at how States are 

using their CURES funding and make sure that they are using it 

in ways that are evidence-based and are, in fact, intervening in 

this epidemic and reducing overdose deaths. 

Mr. THOMPSON. Thank you. I yield back. 

Chairman ROSKAM. Ms. Jenkins. 

Ms. JENKINS. Thank you, Mr. Chairman. 

And thank you all for being here today. 

I have introduced a piece of bipartisan legislation called the Furthering Access to Coordinated Treatment for Seniors Act, or the 

FACTS Act, which helps to bridge the gap in communication between the clinical setting, where patients are diagnosed and prescribed medication, and the pharmacy setting, where patients receive their medications. In particular, for opioids, having information about hospitalizations due to medication mismanagement can 

add in another layer of support from the Part D and pharmacy 

community. This coordination is something that is desperately 

needed in fee-for-service Medicare, and I really look forward to advancing it here in the House. 

With that said, Ms. Hungiville, as I understand, standalone Part 

D plans cannot review Part A and B claims data. Is that correct? 

Ms. HUNGIVILLE. That is correct. 

Ms. JENKINS. And Medicare Advantage prescription drug plans 

can review A and B data plans. What type of challenge does this 

lack of data present for standalone Part D plans in managing the 

benefit of a potential opioid abuser, and what could plans do to assist beneficiaries in claims if data were made available? 

Ms. HUNGIVILLE. Well, we are limited to identifying those 

members that are at the greatest risk. For the members in our 

Medicare Advantage plan, we are looking at their prescription utilization. We are looking at their hospitalizations. We are looking at 

their ER visits. And we are predicting, sometimes with their first 

opioid prescription, whether they are at risk for developing into addiction, and we are putting them into our treatment algorithms. 

In our standalone Part D plan, we don’t have that visibility. So 

we have to rely on the traditional multiple prescriptions from multiple pharmacies and multiple providers. So we are not able to intervene as quickly as what we would like and hopefully prevent addiction rather than treating addiction. 

Ms. JENKINS. Okay. 

Thank you, Mr. Chairman. I yield back. 

Chairman ROSKAM. Mr. Blumenauer. 

Mr. BLUMENAUER. Thank you very much for being with us 

this afternoon. 

There are lots of things to chew on, but, Dr. Paz, I really appreciate your reference to the legislation we have to try to make sure 

that we take care of this disconnect between people who, in terms 

of unnecessarily restrictive information, for prescribing physicians 

76 

to actually know that somebody has an opioid addiction problem. 

I think the legislation that we have would help remedy that. 

Do you have any sense why this is so hard to remedy? Is this 

just because any time we are dealing with patient privacy we are 

in kind of a never-never land, that it hasn’t received a high enough 

priority? Are there examples that you or any of the panelists can 

help us with to show the disastrous consequences of a physician 

not having this information? 

Dr. PAZ. So, Congressman, thank you for the question. I think 

there are two parts to the answer. First is the general backdrop of 

the lack of interoperability of health information in general. We 

have real challenges in healthcare in terms of connecting data that 

sits in different places between providers with the patient and 

often having patient information that is patient-centric that is usable by a patient to make important health decisions. That is a challenge that is historical, longstanding, and, in fact, has become even 

more complicated with the use of electronic records to record and 

retain that information. So that is one issue. It is the backdrop for 

the challenges we have in really improving care in general in terms 

of wastefulness. 

But the other part of it is the part two reform that I mentioned 

in my testimony. HIPAA was written for many, many good reasons, 

and, obviously, we are in support of it, as I am sure everybody is, 

to protect patient health information. But at the same time, we 

have to have modernization of federalization around health information privacy so that, in certain circumstances like the one we 

are talking about today, providers, physicians have access to information to know if their patient is abusing or addicted to opioids so 

that they can make the important decisions they need to make to 

assist and help their patient. Absent that, they are operating without the useful information they need. And, in fact, that is to the 

detriment of their patient. 

Mr. BLUMENAUER. Mr. Chairman, I think this is just one area, 

but it speaks to a larger set of challenges. But I am hopeful that, 

shining a spotlight here, we can help avoid potentially disastrous 

consequences, but maybe it will guide us toward a broader conversation about some adjustments we can make to protect the confidentiality we all care about but not make it unduly restrictive in 

terms of people being able to do the job for their patients. 

Dr. BENYAMIN. Mr. Chairman, may I interject? Very briefly, 

this is one of the problems, Congressman, with the prescription 

monitoring program, in which we have limitations in accessing the 

private data from addiction management facilities. And those are 

not reflected in prescription monitoring programs. And a lot of 

small mom-and-pop types of pharmacies, they are not reporting to 

the data center. 

And, again, this is a State-run program. And, you know, as I 

mentioned in my testimony, we would like to see a national program so that the States can interact with each other. People who 

live in, you know, border cities, they can easily cross over and get 

prescriptions from two different providers and the providers not 

even know what is going on. 

Chairman ROSKAM. Thank you. Mr. Marchant. 

77 

Mr. MARCHANT. Dr. Kletter, I see that your company is 

headquartered in Lewisville, Texas. 

Mr. KLETTER. That is correct. 

Mr. MARCHANT. That area is the entire northern border of my 

district. Can you tell me a little bit about the program that you 

provide to my constituents in Texas? And tell me a little bit about 

the opioid situation in Texas, specifically north Texas, if you could. 

Mr. KLETTER. Sure. I can tell you that the program that we operate in Lewisville in particular is under our AppleGate line of 

business. And AppleGate is an office-based practice that provides 

medication-assisted treatment, which is buprenorphine, along with 

counseling and drug testing. So it is sort of a hybrid between an 

opiate treatment program, which is a very highly structured program, and a typical office-based practice, which is a primary care 

physician prescribing medications. 

So what we do there is we prescribe medications and counseling 

and we do counseling and do drug testing to—it is a small number 

of folks so far. We have been open in Lewisville for just a short 

time. We have 12 sites in Texas in total. Most of those sites are 

opiate treatment programs. And, again, opiate treatment programs 

are the more structured, more regulated programs where we have 

more intensive services and we provide daily medication administration. 

The daily medication administration is part of the Federal regulations that help to prevent diversion of these very powerful medications. So what that means is a patient will come into treatment. 

They will get a history and physical with a physician. They will be 

provided a clinical assessment, generally an ASAM assessment, 

American Society of Addiction Medicine assessment, or an Addiction Severity Index assessment. They will be determined or diagnosed with opioid use disorder, and they will be provided with the 

appropriate dose—the appropriate type of medication and the appropriate dose of medication, based on a physician’s order. And 

based on that physician’s order, they will then participate—they 

will develop a treatment plan with a counselor, and every 90 days, 

that treatment plan will be updated so that we can make sure that 

they are doing well, they are progressing in treatment. 

We will do a monthly random drug test to make sure that they 

are not only taking the medication that we are giving them but 

that they are also not taking other illicit or prescribed opiates. And 

they will get their medication from a nurse every day who does sort 

of a very brief assessment to make sure that the dose is the right 

dose and that they are progressing well in treatment and getting 

some words of encouragement to follow their treatment plan. 

Mr. MARCHANT. Does Texas have an effective opioid policy, as 

far as assistance from the State? 

Mr. KLETTER. The Medicaid rates for reimbursement for the 

services that we provide are not good in and of themselves, but 

they have done a great job in using the STR money out of the 

CURES grant to supplement that program this year and next, 

hopefully. So, generally, the regulatory environment in Texas is 

good. Funding could be improved, but they are working on that, 

and they are doing better, and we are encouraged that they have 

been a good partner. 

78 

Mr. MARCHANT. Thank you. 

Chairman ROSKAM. Mrs. Black. 

Mrs. BLACK. Thank you, Mr. Chairman. 

And I appreciate you all being here today. As a nurse for over 

45 years, I have watched this scourge on our society occur. And I 

know we talk about chronic pain. We certainly want to take care 

of people that have chronic pain; there is no doubt about that. They 

suffer. You can see that by their blood pressures, by their anxiety, 

by their pulses. But what we did with this, ‘‘how bad is your pain,’’ 

the smiley face system, was not a very good thing for us to do, and 

I am glad that we have finally stopped doing that. 

Thank you, Dr. Benyamin, for what you are doing with the interventional pain management. And I would like at some point in 

time, and I know we don’t have enough time here, to talk with you 

more about the results that you are getting from that. What percentage of your patients going through that kind of treatment have 

found success? Is there a number that you could give me on that 

of the—— 

Dr. BENYAMIN. I would be glad to provide you with all the 

data. 

Mrs. BLACK. I would really like that. 

Dr. Kletter, I want to go to you and talk to you a little bit 

about—or excuse me, Mr. Kletter—or is it Dr. Paz? Which one of 

you is doing the program where you are using the medicationassisted treatment? 

Mr. KLETTER. We are. 

Mrs. BLACK. Dr. Kletter, okay. What percentage of your clients 

have eventually become drug-free with your medication-assisted 

treatment? How do you move them to a drug-free situation? 

Mr. KLETTER. So, as I said in my testimony, it is important 

to understand that medication—as we think about medicationassisted treatment, it is important to understand the concept of 

opioid use as a chronic disease. And so, like any other chronic disease, we know that patients who suffer from opioid use disorder 

struggle with it in some cases for their entire life. We have very 

effective treatment, but we don’t have a cure for the treatment. 

And so, generally, our approach is not to encourage people to get 

off of treatment immediately. We do encourage folks to stay in 

treatment at least a year, and in that way, we know that— 

although science tells us that you must stay in treatment for at 

least a year to sort of help heal the brain from the changes that 

have occurred, we know from science that there are changes that 

have occurred in the brain from overuse of opioids. So we encourage folks to stay in treatment at least a year. I can tell you that 

60 percent of our patients are in treatment—— 

Mrs. BLACK. I know my time is going to run out here in just 

a second. If I could get more information from you on looking further out and what all the results are, that would be great. 

And then, Ms. Hungiville, I would like to ask you about how you 

are using telehealth, since that is something that I am very interested in. 

Ms. HUNGIVILLE. Well, we are piloting a program where, in 

the ER, we are trying to get patients when they are in crisis, in 

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79 

able to them to immediately start with medication-assisted treatment and then get them into counseling and into a program. 

Mrs. BLACK. I would love to hear more from you as well. 

And, Mr. Chairman, I am asking for a lot of information I guess 

will be sent back to your office so that you could share with us 

some of the results of what you are doing. Thank you so much. 

Chairman ROSKAM. Thank you. Just a couple questions in kind 

of summary. 

Dr. Kletter, in your testimony and in your statement, you used 

the phrase ‘‘opioid use disorder.’’ Is that a term of art? Is that 

somehow distinguishing between the word ‘‘addiction,’’ and are you 

communicating something else? I have a brother who is an emergency physician, and I noticed that at one point, the emergency 

physicians began to speak about the emergency department. 

So what is the story behind that phrase, and is there a subtlety 

that you are communicating there that we need to know about, or 

are these phrases interchangeable with addiction? 

Mr. KLETTER. So opioid use disorder is the term that is used 

in the Diagnostic and Statistical Manual of Mental Disorders, the 

DSM, which is sort of the tool that physicians use to diagnose disease, psychological disease generally. 

So there is a distinction between addiction and dependence. That 

is really critical to understand. The difference is, of course, addiction, which is—so opioid use disorder is what you might call an addiction, and it is characterized in the DSM by there being 11 criteria in order to meet the diagnosis of opioid use disorder. 

Two of those are physiological; they are tolerance and withdrawal. The other nine are behavioral, things like engaging in behaviors despite negative consequences, compulsive use, using increasing amounts over time even though you don’t intend to. So 

there is an important distinction between opioid use disorder and 

tolerance—or, sorry, dependence, dependence being simply using a 

medication consistently—you could be dependent on a medication. 

For example, I take a statin. I am dependent on that medication 

to prevent my cholesterol from getting too high and having a heart 

attack. So I don’t know if that answers your question. 

Chairman ROSKAM. Yes, it does. But there are some subtleties 

there that I need to learn more about. So, if you have any insight 

on the tutorial, I would be grateful. 

Mr. KLETTER. Sure. We are happy to tell you more and invite 

you or Mrs. Black or any of the Members of the Subcommittee to 

any of our facilities. We are happy to show you around, show you 

what we do, and how effective our services are. 

Chairman ROSKAM. Okay. That would be helpful. 

Dr. Paz, in your testimony, you spoke about intervening for those 

who are at risk. How are at risk individuals, patients or overprescribers identified, and what is the threshold, you know, based on 

Mr. Blumenauer’s observations about the sensitivity around privacy and all that sort of stuff? How do you navigate through identifying someone who is at risk, and how do you walk through that 

carefully? 

Dr. PAZ. Thank you for the question, Mr. Chairman. 

So there are several different ways we do this, and one is we 

have access to our members’ claims history, in terms of prescripVerDate Sep 11 2014 06:49 Mar 05, 2019 Jkt 033794 PO 00000 Frm 00083 Fmt 6633 Sfmt 6602 I:\WAYS\OUT\33794.XXX 33794
80 

tions of opioids. And we will find evidence of pharmacy shopping, 

physician shopping. Right there, that would be a risk factor. We 

have records of his prior history—— 

Chairman ROSKAM. So you basically have predictive modeling. 

I mean, you have that access to those algorithms that say, ‘‘Hey, 

there is a problem here.’’ 

Dr. PAZ. And then we would intervene if there are circumstances 

where that occurs, again, within the boundaries of HIPAA requirements, certainly. 

Chairman ROSKAM. What does that intervention look like? 

Dr. PAZ. We have case managers, care managers that we actually have that intervene with our member, for example. 

Chairman ROSKAM. Is it explicit? I mean, is it a call from a 

case manager that says, ‘‘I think you have a problem’’? 

Dr. PAZ. Yeah. 

Chairman ROSKAM. Okay. 

Dr. PAZ. Yeah. We would certainly—our case managers would 

interface or interact with a member that has a set of conditions 

that requires some kind of an intervention that we can offer, not 

as a provider, though, which is key. 

We work with providers, and, again, being mindful of HIPAA requirements. 

Chairman ROSKAM. Say that again. You were just making an 

important point, and I didn’t quite pick up on it. So the important 

point that you are making is a distinction between providers and 

carriers, based on what? 

Dr. PAZ. So, in terms of prescribing, a provider would prescribe. 

Chairman ROSKAM. Right. 

Dr. PAZ. We have access to information that would suggest overprescribing. And I gave a few examples earlier that putting in limits on how many days a prescription can be written for for acute 

pain, putting in a dosing limit as well. So these are things that we 

can do. 

We have done other things like partnered with a company, 

Pacira, which has produced a nonopioid pain reliever for oral surgery, post-oral surgery. We have created a partnership with them. 

It is a value-based contract that we have with them, so it is emphasizing quality outcomes for our members that receive that drug. 

But they are now going to receive a nonnarcotic after oral surgery as opposed to a 30-day supply of a narcotic post-oral surgery, 

which, interestingly, in our review of data and analytics, we find 

does, sadly, occur. It occurs even after a routine dental visit, unfortunately. So for a wisdom tooth extraction. 

So there are a number of different things that we can do including, for example, we have two programs that are noteworthy. One 

is the work that we are doing with mothers who have neonatal abstinence syndrome. We launched this program in several States. 

Again, our care managers intervene with mothers who have been 

identified as being neonatal abstinence, at risk for having children 

born with neonatal abstinence syndrome, and we put a program in 

place with ICUs, neonatal ICUs in their communities to address 

that. 

And, certainly, our program where we distribute naloxone and 

make sure that we are working to train first responders in commuVerDate Sep 11 2014 06:49 Mar 05, 2019 Jkt 033794 PO 00000 Frm 00084 Fmt 6633 Sfmt 6602 I:\WAYS\OUT\33794.XXX 33794
81 

nities to help members avoid death associated with overdose and 

addiction. 

Chairman ROSKAM. That is helpful. Thank you. 

What is the duration? And this is for the physicians on the panel. 

What is the duration that somebody can be taking an opioid and 

they become addicted? We have talked about a 7-day threshold. I 

have heard that referred to several times. 

You know, Doctor, you are shaking your head. There is not a 

magic number. What is a threshold? What is a range? What is a 

reasonable expectation? 

Dr. BENYAMIN. You know, again, it all depends on who is the 

patient, what is the pathology behind it, the reason. What is the 

reason that the patient is taking the medication? Is it a patient 

who just feels aches and pains all over their body, or is it a patient 

who has had five low back surgeries and three neck surgeries and 

two knee replacements? You know, these are all different patients. 

And, you know, we are human beings at the end of the day. We 

are not robots. So we react differently to disease, and we react differently to medications for the disease. So we have to allow for individualization of these treatments. 

Chairman ROSKAM. In your study and evaluation of this for any 

of the four of you, is there a spectrum in terms of addiction, or does 

somebody cross a line and they are addicted? 

Dr. PAZ. So, in general, that 7-day number that is in the CDC 

recommendations is there for a reason, because roughly—and this 

is, again, depending on the study you look at—about 14 percent of 

individuals who are exposed to a week of a narcotic will become addicted. 

Chairman ROSKAM. Fourteen percent. So, in other words, 14 

percent of people who are on it 7 days or more, they are addicted. 

Dr. BENYAMIN. And, Mr. Chairman, the psychiatrists will 

argue that addiction is a disease in the person; it is not in the substance. So this is a continuous saga between one side of this equation and the other. 

Chairman ROSKAM. The medical spectrum. Yes, I understand. 

Ms. HUNGIVILLE. The dosage is also important, and the CDC 

guidelines also say that more than 50 morphine-equivalent dosages 

per day puts you at a higher risk of developing addiction. 

Dr. BENYAMIN. Mr. Chairman, if I have to point to one thing 

that is missing in a lot of medical specialties, we are good at writing prescriptions, at prescribing treatments, but we are not good at 

monitoring the treatment as far as effect and side effect. 

That is why it is very important that when we prescribe, that is 

what our guidelines say—how you need to monitor the effect and 

the side effects of medications, that is going to be the key. 

Chairman ROSKAM. That is a good summary. So let me ask 

each of you, in closing, if you had to communicate one thing, not 

four things, not a handful of things, one thing to this group today, 

what would it be? Doctor. 

Dr. BENYAMIN. Cut the supply of heroin and synthetic 

fentanyl. That is like a weapon of mass destruction affecting our 

communities. 

Chairman ROSKAM. Got it. Dr. Kletter. 

82 

Mr. KLETTER. Increase access to evidence-based treatment services. 

Chairman ROSKAM. Dr. Paz. 

Dr. PAZ. Ensure education around use of nonopioid pain treatments. 

Chairman ROSKAM. Okay. Ms. Hungiville. 

Ms. HUNGIVILLE. And I would also add limiting dosages of 

opioids for acute conditions. 

Chairman ROSKAM. Okay. Mr. Thompson. 

Mr. THOMPSON. Thank you for indulging me. 

I mentioned to the Governor my concern about the treatment 

delay in the workers’ compensation programs leading to opioid 

problems, and it is something I am very, very interested in. 

I have seen a lot of anecdotal evidence that this is true. In my 

State of California, there is just a long waiting period. Everybody 

is denied—a lot of people are denied the procedures that the medical profession recommends, so it stretches out the time that they 

are on painkillers. And I have just seen too many people who, because of this, become addicted. 

And I am looking at some different things to try to deal with 

this. So, if any of you have any information that would help me out 

in that, would you please send it to me? 

Chairman ROSKAM. We have been joined by our former colleague, Ed Whitfield, a great American from Kentucky and former 

Chairman of our partner Committee, the Energy and Commerce 

Committee, which has a lot to do with the solutions here. So it is 

good to have him back. 

For the record, Members are advised that they have 2 weeks to 

submit written questions that can be answered later in writing, 

and those questions and your answers will be made part of the formal hearing record. 

Finally, two things: Number one, thank you for your time. You 

have been very generous with your time today, and I know it is an 

adventure to schlepp out here and all that, so thank you for doing 

that and for the time that you put into your testimony. It was very 

helpful. 

Second, if you think of things subsequent to this, whether you 

are flying home, driving around, whatever you are doing, in the 

next several weeks or months, and you think, I wish I had said 

that or I have this article, and I think those people would benefit 

from it, send it to us. And I will make sure that it is distributed. 

You get the sense of the caliber of these people. These are serious, thoughtful people that are solution-oriented. We are not looking for pen pals, if you know what I am saying. But, things that 

you think we should be reading, would be very, very helpful. 

So, on behalf of the whole Subcommittee, I want to thank you for 

your time today and look forward to continuing to interact with you 

in the future. Thank you. 

The Committee stands adjourned. 

[Whereupon, at 6:31 p.m., the Subcommittee was adjourned.] 

[Questions for the Record follow:] 

83 

f 


33794A.036

Questions for the Record for Dr. Rams in Benyamin 

Ways and Means Subcommittee Hearing on the Opioid Crisis: Removing Barriers to Prevent 

and Treat Opioid Abuse and Dependence in Medicare 

February 6, 2018 

Subcommittee on Health (Majority) 

Question: Diversion and misuse are critical issues with these drugs- what do you think about 

long-acting treatments, such as injections, that are administered by healthcare professionals 

and thus are never in the hands of the patient? Could that help alleviate this problem? 

Answer: Eliminating the handling process of pills and patches by patients will 

definitely reduce the risk of diversion and misuse. Injectable long acting opioids in the 

form of intra-thecal pumps have been used for many years and are currently available 

to Part D recipients. More recently, clinical trials are ongoing to evaluate safety and 

efficacy of once weekly or monthly subcutaneous injection of a long acting opioid. 

Once approved by FDA, it may prove to be a great tool to reduce diversion and 

misuse. 

Question: We know that often medication combined with behavioral therapy is a critical part of 

a successful treatment and recovery for individuals with substance use disorders. For this 

therapy to be successful, manyofthose will probably be on some formofdaily medication. Do 

you see thatactofhaving to take medication everyday as a barrier? Do you think the patients 

do? And then, do you think that practitioner-administered treatments that last a week or a 

month could benefit certain patient populations? 

Answer: As a matter of principle, the more frequent the treatment, the higher the risk 

of non-compliance. Having a weekly or monthly opioid administered by practitioners will 

definitely reduce the risk of non-compliance and maintain a more stable dose of 

medication in the body, cost permitting. 

Question: We know that patients who overdose are most vulnerable to having a relapse within 

a week ofthatoverdose. While behavioral therapyis a critical partoflong term treatment and 

recovery, often times, these individuals are not stable enough to appreciateorreadyto enter 

into therapy right afteran overdose. What do you think about medications that last a week and 

can be administered by a practitioner immediately after an overdose, thus giving those patients 

more time to become stable and seek permanent treatment? 

Answer: Currently there is an opioid maintenance therapy in the approval process 

that's injected once weekly. Once approved by FDA, it will provide a good option to 

bridge the acute stage into long term treatment plan. 
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33794A.037

Questions for the Record for Dr. Harold L. Paz 

Ways and Means Subcommittee Hearing on the Opioid Crisis: Removing Barriers to 

Prevent and Treat Opioid Abuse and Dependence in Medicare 

February 6, 2018 

Representative A. Smith (R-NEl: 

Question: Dr. Paz, can you talk about what Aetna is doing to educate their prescriber 

network on appropriate prescribing of opioids and other treatment options for chronic pain 

currently? Is there a difference in how you educate small, independent pharmacies in places 

rural Nebraska versus some of the larger chain pharmacies? What are some of the 

challenges you are seeing to providing this type of education to our rural communities? 

Aetna Answer: 

Aetna has taken a proactive approach to working with providers to reduce opioid 

prescribing, misuse, and abuse. We are using our data resources to encourage prescribers 

to reduce misuse and prevent the diversion of unused pills. Specifically, starting in 2016, 

Aetna began sending letters to the top 1% of opioid prescribers within their respective 

specialties to make them aware of their outlier prescribing patterns. These approximately 

1,000 opioid "super-prescribers" were also provided the 2016 Centers for Disease Control 

("CDC") guidelines for the use of opioids for the management of chronic pain. This program is 

growing and in 2017, Aetna, in collaboration with the American Association of Oral and 

Maxillofacial Surgeons, sent separate letters to 480 "super-prescribing" dentists and 249 

"super-prescribing" oral surgeons. As part of the "super-prescriber" initiative, Aetna set up a 

dedicated email address to which prescribers can respond to Aetna's letters and request 

more information on their own prescribing patterns. The "super-prescriber" initiative is 

evolving as Aetna continues to explore additional ways to curtail inappropriate opioid 

prescribing to its members. 

In addition to the stigma of opioid use disorder, rural communities in particular face 

challenges in the availability of multi-disciplinary care teams for chronic pain management and 

opioid use disorder treatment using medication-assisted treatment ("MAT") and cognitive 

behavioral therapy. As one example of Aetna's efforts to help combat these challenges, 

Aetna is exploring ways to increase access to behavioral health telemedicine services, 

including by supporting research at the University of Alabama Birmingham to study the use of 

telemedicine to provide MAT to pregnant mothers. Furthermore, the Aetna Foundation 

recently announced that it will provide grants totaling $6 million over the next two years to 

fund select projects that state and local leaders have identified as promising, or particularly 

well-suited to tackle the most critical opioid-related challenges. The Aetna Foundation's initial 

$1 million grant was recently awarded to the North Carolina Harm Reduction Coalition for its 

Rural Opioid Overdose Prevention Project. 
85 


33794A.038

Representative Chu (0-CA): 

Question: Dr. Paz and Ms. Hungiville, I'd like to ask if either of Aetna or Wei/care offer plans 

that cover acupuncture as an alternative to treat pain, and If so, what is the rationale for 

including such coverage? 

Aetna Answer: 

Aetna supports a multi-modal approach to treating pain that includes pharmacologic 

and non-pharmacologic treatment options. Such options may include acupuncture when 

medically appropriate, although it varies by plan. 

In our Medicare business, in 2018, ten of Aetna's regional MA-PD plans have added a 

supplemental acupuncture benefit that provides as a covered service between six to twelve 

visits per year and a member cost share range of $0 to $20. These kinds of added benefits, 

known as "mandatory supplemental benefits," are part of the product offered in this market and 

are included in the premium. 
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33794A.039

Subcommittee on Health (Majority) 

Question: Diversion and misuse are critical issues with these drugs - what do you think 

about long-acting treatments, such as injections, that are administered by healthcare 

professionals and thus are never in the hands of the patient? Could that help alleviate this 

problem? 

Aetna Answer: 

Aetna is continually evolving its management of opioids in the face of the ongoing 

health crisis and in line with federal and state guidance. Aetna's clinical strategy is generally 

supportive of long-acting injectable MAT products, which have the potential to address two 

clinical issues related to proper treatment of addiction: improved treatment adherence and 

reduced diversion of MAT products. Aetna will determine the appropriate coverage of such 

products when they are FDA-approved and available on the market. . 

Question: We know that often medication combined with behavioral therapy is a critical part of 

a successful treatment and recovery for individuals with substance use disorders. For this 

therapy to be successful, many of those will probably be on some form of daily medication. Do 

you see that act of having to take medication everyday as a barrier? Do you think the patients 

do? And then, do you think that practitioner-administered treatments that last a week or a 

month could benefit certain patient populations? 

Aetna Answer: 

Aetna is continually evolving its management of opioids in the face of the ongoing health 

crisis and in line with federal and state guidance. Aetna is committed to enhancing access to 

evidence-based addiction treatment options for its members. One important treatment option 

available to those with opioid use disorder is medication-assisted treatment ("MAT"), which 

includes medications such as methadone or buprenorphine. The World Health Organization 

found the most effective treatment for opioid dependence is a combination of psychosocial 

support and an opioid agonist (such as methadone or buprenorphine).' These medications 

have shown positive results in interrupting the intoxication withdrawal cycle, significantly 

reducing drug use, and improving retention in treatment plans. 

Aetna continues to evaluate ways to expand its members' access to this treatment 

option when appropriate. In its commercial business, Aetna has removed prior authorization 

requirements on generic drugs that treat opioid addiction, including oral buprenorphine/naloxone 

and generic dosages of Suboxone and Subutex. In addition, these products are now on the 

Aetna Preventive Medicine List, which helps reduce member cost-sharing. In 2017, and 

continuing in 2018, Aetna's Medicare formularies offer access to MAT for opioid addiction 

therapy, as well as reversal agents such as Narcan. 

Aetna's clinical strategy is generally supportive of long-acting injectable MAT 

products, which have the potential to address two clinical issues related to proper treatment 

of addiction: improved treatment adherence and reduced diversion of MAT products. Aetna 

1 See, for exomple, http:// www. who.int/substonce_ obuse/octivities/treotment_ opioid _dependence/en/ 
87 

[Submissions for the Record follow:] 


33794A.040

will determine the appropriate coverage of such products when they are FDA-approved and 

available on the market. 

Question: We know that patients who overdose are most vulnerable to having a relapse within 

a week of that overdose. While behavioral therapy is a critical part of long term treatment and 

recovery, often times, these individuals are not stable enough to appreciate or ready to enter 

into therapy right after an overdose. What do you think about medications that last a week and 

can be administered by a practitioner immediately after an overdose, thus giving those patients 

more time to become stable and seek permanent treatment? 

Aetna Answer: 

Aetna's clinical strategy is generally supportive of long-acting injectable MAT 

products, which have the potential to address two clinical issues related to proper treatment 

of addiction: improved treatment adherence and reduced diversion of MAT products. Aetna 

will determine the appropriate coverage of such products when they are FDA-approved and 

available on the market. 
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33794A.041

A PCMA 

Statement for the Record 

Pharmaceutical Care Management Association 

for the 

UNITED STATES HOUSE OF REPRESENTATIVES 

COMMITTEE ON WAYS AND MEANS 

HEALTH SUBCOMMITTEE 

" The Opioid Crisis: Removing Barriers to Prevent and Treat Opioid Abuse and 

Dependence in Medicare" 

February 6, 2018 
89 


33794A.042

A PCMA 

Introduction 

Thank you for the opportunity to submit this statement for the record for the hearing, 

"The Opioid Crisis: Removing Barriers to Prevent and Treat Opioid Abuse and 

Dependence in Medicare: PCMA thanks the Subcommittee for its important work to 

remove policy barriers that may stand in the way of needed changes to help the millions 

of American families torn apart by the nation's opioid crisis. 

PCMA is the national association representing America's pharmacy benefit managers 

(PBMs), Which administer prescription drug plans for more than 266 million1 Americans 

with health ooverage provided through self-insured employers, health insurers, labor 

unions, Medicare, Medicaid, SCHIP, and the Federal Employees Health Benefits 

Program (FEHBP). 

Make E-Prescribing of Mandatory for Controlled Substance,;: Support H.R. 3528, 

the Every Prescription Conveyed Securely Act 

E-prescribing dramatically reduces medication errors and fraud and PBMs can use 

claims data to identify at-risk patients and providers with highly unusual prescribing or 

dispensing patterns. After the DEA allowed a-prescribing for controlled substances in 

2010, states followed. Currently all states permit it and a few states actually require its 

use for controlled substances. By directing a prescription electronically from a specific 

prescriber to a specific pharmacy, a-prescribing makes it difficult to pharmacy shop and 

commit. E-prescribing platforms can provide physicians with a patient's medication 

history among numerous providers. This can be especially important with controlled 

substances, where patients may engage in doctor shopping to find one or more doctors 

to write a prescription for a dangerously addictive drug. Congress should require aprescribing for all controlled substances. H.R. 3528, the Every Prescription Conveyed 

Securely Act, would require the use of E-prescribing of controlled substances in 

Medicare. We are appreciative of Congressman Kelly and Higgins for cosponsoring this 

important legislation. 

How PBMs Can Help 

PBMs can be an important part of the solution to curbing the nation's opioid crisis. Given 

their role administering prescription drug benefits in realtime, PBMs, through the 

software systems they use to assess eligibility, determine cost sharing, and adjudicate 

claims, can see whether patients are using multiple prescribers and pharmacies, are 

getting a morphine-equivalent dosage well beyond that recommended by the Centers 

2 
90 


33794A.043

A PCMA 

for Disease Control and Prevention (CDC), and are getting a longer days' supply than 

necessary. 

Increasingly, as health information networks improve and physicians move toeprescribing controlled substances, PBMs and prescribers will have better information on 

how, where, and when prescriptions for controlled substances are obtained. Where the 

law will allow it, PBMs will also be able to reduce coverage for prescriptions exceeding 

an appropriate days' supply or a morphine-equivalent dosage, and will be able to direct 

patients at risk to an appropriate pharmacy or pharmacy chain for their controlled 

substances. 

There are significant steps policymakers can take to help private sector efforts to reduce 

opioid abuse. 

Other Common-Sense Policy Solutions to Curb the Opioid Crisis 

While the factors driving America's opioid crisis are complex and do not lend 

themselves to easy solutions, targeted policy changes can help curb prescription opioid 

abuse and diversion. 

Implement Seven-day Fill for Acute-Pain Opioid Users: As recommended by the 

Centers for Disease Control, prescriptions for acute pain should be limited to prevent 

patients from getting addicted to pain medication. The CDC specifically mentions that a 

first fill for acute pain should rarely need to exceed a seven days' supply. The limit 

would not apply to treatment of cancer or chronic pain, or the use of opioids in treating 

addiction or for patients in palliative or end-of-life care. Limiting prescriptions to treat 

acute pain to seven days strikes an appropriate balance between meeting patients' 

needs for pain relief and helping protect them from potential addiction, and also lessens 

the danger of diversion. 

The Centers for Medicare and Medicaid Services (CMS), in the current Advance Notice 

of Methodological Changes for Medicare Advantage Capitation Rates and Part D 

Payment Policies and Draft Call Letter, states that it expects Part D plans to implement 

a hard safety edit that limits coverage of an initial opioid prescription fill exceeding seven 

days for the treatment of acute pain. PCMA supports this modification. The Food and 

Drug Administration (FDA) could also change the labeling for opioids to distinguish 

appropriate duration of prescriptions for acute users and long-term users of these drugs. 

Finally, the Drug Enforcement Agency (DEA) should modify its rules to allow 

pharmacies to dispense less than the full prescription written by a prescriber. 

3 
91 


33794A.044

A PCMA 

Use Lowest Effective Dose: According to the CDC, "when opioids are started, 

clinicians should prescribe the lowest effective dosage.";; Specifically, the CDC 

recommends that clinicians "should carefully reassess evidence of individual benefits 

and risks when increasing dosage to 50 morphine milligram equivalents (MME) or more 

per day, and should avoid increasing dosage to 90 MME or more per day or carefully 

justify a decision to move a dosage to 90 MME or more per day:• In addition to 

considering changes in labeling for the seven-day policy mentioned above, the FDA 

should add to the label for opioids the information in the CDC guidelines for use of the 

minimum effective dose. 

Improve and Integrate State Prescription Drug Monitoring Program (PDMPs) and 

Require Prescriber Check: Prescription drug monitoring programs, or PDMPs, are an 

important tool to help identify and prevent prescription drug abuse. POMP data should 

be updated in a timely manner. should be interoperable across state lines, and easily 

accessible to prescribers and pharmacies. Additionally, prescribers should he reC]uired 

to check state POMP databases when prescribing opioids, at least until a-prescribing is 

widely adopted and supplies similar information. 

Align Substance Abuse Treatment Privacy Laws with HIPAA to Encourage Better 

Care Coordination: To help facilitate care coordination for those suffering from 

substance abuse. the law on substance abuse records should be harmonized with the 

Health Insurance Portability and Accountability Act (HIPAA). Under current substance 

abuse treatment privacy laws at 42 CFR Part 2, addiction treatment providers must 

obtain individual, written consent from patients in order to share any information with 

non-addiction clinicians- the only exception being for "true emergencies." Obtaining 

multiple consents from a patient, as required under current law, is challenging and 

creates barriers to integrated approaches to care that produce the best outcomes for 

patients. The separate and different treatment in the law of substance abuse disorder 

patient history creates virtual care silos, hinders good medical care, and perpetuates the 

unnecessary division between physical and behavioral health and may serve to 

perpetuate stigma in the contemporary era of electronic health records (EHRs), 

integrated health care, and HIPAA privacy protections. 

Implement Thoughtfully the Comprehensive Addiction and Recovery Act of 2016: 

PCMA supported the passage of the lock-in provisions in CARA and appreciates CMS 

for undertaking the process to get the lock-in implemented under Part D. We also 

support the flexibility to lock a beneficiary into a specific prescriber(s) or specific 

pharmacy or both, based on the beneficiary's utilization. However, we are very 

concerned that CMS's proposal in the proposed Part D rule promulgated November 28, 

2017, to require a Pan D plan sponsor to wait six months from the date the beneficiary 

4 
92 

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33794A.045

A PCMA 

is first identified as potentially at-risk before limiting that beneficiary to a given pharmacy 

or prescriber for frequently abused drugs is counterproductive. Indeed, a six-month 

delay works against the goal of CARA and defeats the purpose of the lock-in program, 

which is to take steps quickly to protect beneficiaries and reduce fraud. Without timely 

intervention, these beneficiaries will continue to abuse and potentially divert opioids. 

Furthermore, CMS should preserve the flexibil ity of the current Drug Utilization Review 

(OUR) and Overutilization Monitoring System (OMS) programs while also providing 

flexibility for Part D plan sponsors and their PBMs to develop and implement their lockin programs. 

Conclusion 

We thank the Subcommittee for this opportunity to share our views on how commonsense policy proposals can help curb America's opioid crisis. PCMA stands ready to 

work with the Subcommittee and all Members of Congress to artcress the rampant 

overuse of opioids. Should there be any questions, please contact Jonathan Heafitz at 

jheafitz@pcmanet.org. 

• PFt Ncwswite. "P9Ms Provide Policy Sofotions to Increase Competition. Roc:ruce Rx Costs, ~ Fob 04, 2016. 

', Dowell, Op. Cit 

• Cowell. Op. Cic. 

5 
93 


33794A.046

PHILIP B. SCOTI Go,.c!Tt(W' 

January 12, 2018 

The Honorable Eric Hargan 

State ofVcm10nt 

OFFICE OF HIE GOVERNOR 

Acting Secretary of U.S. Department of Health & Human Services 

Hubert H. Humphrey Building 

200 fndependence Avenue, S.W. 

Washington, DC 20201 

Dear Mr. Secretary: 

Opioid addiction is devastating communities across our country and in our state of Vermont. As 

the President's Commission on Combating Drug Addiction and the Opioid Crisis stated in its 

final report, drug overdoses are now the leading cause of unintentional deaths. In response, the 

President has declared the opioid crisis a public hca.lth emergency. An important step in 

addressing this crisis, and one supported by the President's Conunission, is increasing access to 

treatment, including medication-assisted treatment (MA 1). In that spirit, I am writing you today 

to ask that we expand our existing state and federal partnership by including Medicare as a 

participating payer in Vermont's nationally-recognized "Hub and Spoke" opioid addiction 

system of treatment, as well as for Vermont providers offering complementary prevention, 

diagnosis, and recovery activities. 

The state of V cnnont and federal government have been effective pa1tners in health care reform 

for many years. Vermont has been provided the nexibility and tools to improve Lhe delivery of 

health care and by extension the health and well-being ofVcnnonters. Vermont's Global 

Commitment to Health Medicaid 1115 waiver and the Vermont All-Payer Accountable Care 

Organization Model Agreement arc examples of how the federal govcmment and a state can 

design a program that furthers federal goals while being customized for the strengths and needs 

of an individual State. 

Given the urgency of opioid abuse, the state ofVennont would like to further our pannership 

with CMS by requesting that CMS consider Medicare's participation in Vem1ont's Hub and 

Spoke program. This highly praised opioid addiction treatment progrdfll has since its launch in 

2013 increased access to MAT for thousands of Vermonters. Through coordinated team-based 

care, it seeks to provide the necessary level of care in the most appropriate settings. Furthermore, 

MAT is viewed as a gold standard in opioid use disorder treatment and has been associated with 

reduced medical expenditures in a Medicaid population. Early analysis indicates this pattern 

could be repeated with Medicare beneficiaries. While Hub and Spoke services to date have been 

primarily supported by Medicaid, this epidemic does not discriminate against age or 

socioeconomic status, and Medicare beneficiaries are a growing cohort of Americans overcome 

by tlus crisis. Medicare participation in Hub and Spoke would improve VenJJOot's ability to 

provide necessary care to the Medicare beneficiaries who need it. 

109 STATE STREET • THe PAVH.JON • MONTPELIER, VT05609-0lOI • www.VE&\IIONT.GOV 

TELEPHONE: 802.828.3333 + FAX: 802.828.3339 + TOO: 802.828.3345 
94 


33794A.047

The llonorable Eric Hargan 

January 12,2018 

Page Two 

The Vermont All-Payer Accountable Care Organization Model Agreement could serve as a 

platform for the state and CMS to involve Medicare. This novel and forward-thinking model 

grants Vermont significant flexibility to integrate care across the health care and social services 

system and across payers. It also holds Vermont accountable to statewide perfom1ance targets 

such as reducing deaths attributed to substance abuse, expanding access to treatment, and 

improving early intervention. 

Vermont is also exploring all-payer approaches to prevention, non-opioid management of 

chronic pain, and identification of individuals with risky substance use behavior, as well as 

treatment for opioid use disorder. Many of these efforts are reflected in the recent 

recommendations by the Opioid Coordination Council I established at the beginning of my 

administration. As this work matures, additional opportunities for partnership between Vermont 

and the federal government are likely to arise. Vermont has made great strides in increasing 

prevention and access to care with Medicaid and state funds; but to truly tackle the opioid crisis, 

we need an "all hands on deck" approach coordinated across local, state, and federal partners. 

Together, I believe that we can demonstrate how an effective state and federal collaboration can 

serve communities tom apart by the opioid crisis. 

Thank you in advance for your consideration. Please do not hesitate to contact me or my stafT 

with questions or concerns. 

Sincerely, 

PBS/kp 

c: Administrator Seema Verma, Centers for Medicare 1111d Medicaid Services 
95 


33794A.048

Contents lists evaltabie at ScienceDirect 

journal of Substance Abuse Treatment 

Impact of Medication-Assisted Treatment for Opioid Addiction on 

Medicaid Expenditures and Health Services Utilization Rates in Vermont 

Mary Kate Mohlman, Ph.D ..... Beth Tanzman. M.S.W. •. Karl Finison. MA b. 

Melanie Pinette, M.E.M. b. Craig jones. M.D. • 

'" vtonnonc 6hltp/fllt/or Htdr/J.IlOB I So11Jt 280 Sl't.llt Driw. Wotnt.ll)'. VTOS61J. USA 

• o,po61r Hf'Ofllll DGRJ.154 ContmttdoiSuttt ~frt 2S7.1'<1r00nd. M£04JOI.l/So\ 

ARTIClE I NFO ABST RA CT 

NridtllliStory: 

itt-ctN«! 20 NOI>'embtr 20 IS 

Reuh-«1 in rtVistd fonD 1 May 2016 

A«('l)trd _.., .. t.1.ly2016 

Mfod icado~H:Ssisll'd trC'~tmttX 

MAT 

Op;oid 

Add~ioo 

Mtdie.Jid 

In 1he t:ace of incre.u.ing r.:nt"S of overdQSt de~ hs. tseCtlaring heo.llth c•e rosu.~nd che r~ndous $Ocl.tl costs 

of opioid .-:ldiction. policy m.,lktrs ~re .J:sted to .Jddress rhe questions ol whel her .:~nd how to exp.:)nd .lC'Cm to 

rre.nment sttvictS.In respon!lt to.Jn upy.•.1rcl tttnd in opioid .Jbust .:and <~dvtrst Ol.ltCOmei. Vmnont is invtSrif\S 

lnmtewideex~nslonof .J medlc.-ion•.uslsttd theQP)' pro&r.tmdelivertd in a nt(\\'01'\: d community ,..-~icts 

.1nd SJ)('C"i.Jiit«t trtatmtnt ctntm {Hub & Spoke Progr.am). This study w.u conduettd fO test met .Jdont~St (or 

thtst h\\'tStmem <tnd to e.s:t;~bli.sh<~ prto-Hlb& Spoke baSthnt fortv.aluating tht .lddirivt impa<t oru~ progt;)n\. 

Using <1 seri.JI croSS·St<1ional design from 2008 to 2013 to tv.Jiuate m«tk<tl daims lbr Vtrmont Mtditaid 

bmt'fid.vleswith opioid deptndern or addiction (61 ss in tht" imervrntiongroup. 2494 in the COfllrol group). 

this Study ~ssesses the HNtmem .lnd mtdtQI service expeonditurts (Of th05t rtctivlns mtdlc~ ion...assiSltd 

ut.lfmtm ro P~rNI 10 th05e t«tlving s\b:sttlnct ~bust rt't.Jtmti'U wlthoul mtdic.1tion. Rt$-ulrs SUggtSf fhat 

medk.ltion-.lssisted t:her.Jpyis.usodattd wid\ rtdu<t"d gtntta! he<~lth<.ll't t.xpendilurtS .)nd uriliz.ation. such 

as inp.atient hOspilcll :tdmissiOns and outp.ltitnt emergency d~.artmtnt visirs. for Mtdkaid bt~ ki.lrits 11.ith 

opioid addiction. For state Medicaid lt.adtrs (.King similar dociiion.s on appto.ldlts to Ol)ioid .1dcSiction. these 

results provi<k ~.uty suppon fwtxpanding medication-assisted ~:re-atmtot ~ ratht r th.1n rel)i.ng only on 

psydlosodal. abstinc-nre. or detoxification intetVrntions. 

0 2016 Thr Authors. Published by Else-vi« Inc. This is an open access anic:lt under the CC BY-NC-ND license 

(hnp://m>ariwrommons.org/licmStS/by-nNld/4.0/). 

1.lntroduction 

1.1. Opioid Epidnnic 

Opioid addictioncontinUH ro grow as a public: health problem with 

signific;mt impacts on morbidity t~nd mortality. health care expendi· 

tures, crime. and health ourcornes. In 2013. 1.9 million Americans 

¥Jere dependent on pa_in relievers. and S 17 .OOOwere dependent on heroin (Substance Abuse and Ment<tl Health Services Administration 

(SAMHSA). 2014.1) Kolodny eta/. estima1ed 1ha1 this figure WilS d=r 

ro S million when including indivklu.1ls with acrive opiold prescriptions 

who may also have been addicted (Kolodny, Courtwright, Hwang. et dL 

201 S ). While use of prescription opioids has held steady or declined 

since 2002. heroin use has increased (Substance Abuse and Mental 

Health Services Administration (SAMHSA). 2014a). The growth in 

heroin use has carried ovet to pattenls in monality. which is increasing 

n..ltionally (Department ofHe.llthand Human Serv ~. 201S). In 2010. 

3036de.aths resulted from heroin overdoses and 16,651 deaths from 

• C«f'tSPOI.'Idlte~~ Vft'ITIOl'll8t.itprlnlfotttild\.N08 1 Soudt.280SUtt DrNt, 

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£-mrJil' ~m; nwrylc.MI!.mohliN""'-'tflTIOfll.p {M.k. MohiiNn~ 

hetp://dlt.doi.ol'3fiQ101&'jJt;at2016.05Jl02 

opioid pain reliever overdoses. In 2013. heroin overdose dedths more 

than doubled to 8257 while opioid pain reliever overdose deaths 

dropped slighliy 10 16.235 (Nalional lnslilule on Drug Abuse. 2015). 

Furthermore evideoce associates nonmedical use or p.1in relievers 

with subsequent heroin use (Muhuri. Gfroerer. & Davies. 2013). 

highlighting the link between lidt and illicit drug use and the need to 

address both as a continuum of the same epidemic. 

Vermont's experience miiTors the national trend. Nonmedical use or 

prescription pain relievers among Vermonters 01ge 12 ye.1rs and older 

dedined beiWeen 2012 .JJld 2013 (from 4.6%10 3.71:: p-v>lue <0.01 ). 

(Substance Abuse and MeiHal He<tlth Services AdmlnisrratiOI\ 

(SAMHSA). 2014b) even as opiale-altribuled dedlhs (from 39 10 68 

per year) and oveldoses (from I A 10 2.2 discharges per I 0.000 people) 

incre.lSed from 201010 2013 (Vermall Depanmem of Heallh. 2014.1). 

Berween 2008 and 2012. the average number of infants exposed to 

opiates at birth mote than doubled, increasing from 17.8 binhs per 

1000 hospit<tl deliveries to 39.8 (Vennom Department of He<thh, 

2014b). One possible expla11.11ion for the inc-teaSt h1 adverse opioid· 

related outcomes is an increase in heroin u.se.The addictions treatment 

system inMkeexperience .Jppears to suppon this conclusion. From 20 11 

co 2013. the numberorvermonters receiving tre.ument for prescripr:ion 

opiates and heroin increased rrom2864 (654 for heroin and 2210 for 

07*"S472/CI2016 11w Aulh«s. Publlst~td by EtsM« Inc...,... Is M~optn.l«~tSS ~rddt unci« m~ccsv~r<-NDI~m.st (hctp://mi!lNeoonwncw'ls.«tJ1ic~nc·Dd/"-O/.l. 
96 


33794A.049

10 lrtX. Mohhon rr ot 1 }Outnd oJSubs.fdM'Abl« »Nmtnr 61 ( 2016) 9-1• 

prescription opiates) co 3971 ( 13?5 for heroin ;tJ'Id 2596 for prescription 

opiatts) - .t 38.6t ovcrall incttase, with a 110.2t inc~"Nse fo r heroin 

and a 17.5t in<rc.ase for prtScrlption op at~ (Vermont Dt1>.1nmfflt 

of He• II h. 2014b). 

The combination of increasing overdose deachs.. opia ~ex.posed 

newborns, and demand for treatment services constituted a public 

he"Jilh emergency, .:u1d Vtmlont policym.lkers determined that 

a systemic rtsponse w.1s ncedcct Howevtr. in a small. rural St.ltt':, 

po1icymaktrs must consider I he cost of expanding acce-ss to trtcument 

foropioid addiction and the impact on overall health CMe and medical 

service expenditures. 

1.2. Tttatmtnt for Opiold Abl.l$t or Dtptncknc~ 

Medication·assist«< treatment (MAT) is defined by the U.S. 

Oepart"lnenl of Health ind Human 5ervices' Center for Substance 

Abuse Treatment as •the use of medications, in combination with 

counseling and be e~vio al ther.Jpies to provide .1 whole patient 

appro.Kh to the treatment or substance use disorders .. (Substance 

Abuse and Mental Health Services AdministTation (SAMHSA). 2016). 

The approach involves long·tmn useofmedicationsand isak.in to insulin use among people with diabetes. Evidence hils demonstrated the~t 

MAT. the combination or medice~tion and counseling. is more effective 

dt treatment retention Clnd reduction or heroin and prescription opiate 

abuse th<tn using time-limited medication (i.e .. opioid detox.ification or 

tapering) or psychosocial and abstinen<e interventions: the latter approaches are associated with higher r .. ttes of relapse (Fullerton. Kim. 

Thomas. et .V .. 2014: Thomas. f1J11erton. Kim, et al. 2014). Funhennore, 

maintenance MAT is associated with improved birlh outcomes when 

given to opioid...-.ddicted pregnant women. e~Jthough neonatal absti· 

nence syndrome remilhl$ a concern (Fullerton el al .. 2014: Thomas 

et al.2014). Both Fullerton etalandThomaset al.found mixed results 

on whether MAT affected the use of other illicit drugs. criminal be:h.avior, and risk factors for human immunodefkiencyvirus (HJV) orhepa.ti· 

tis C virus (HCV). Other Sludies. however. do indic.ue .1n association 

between MAT and reduced overaJI monality and specifkaiJy while in 

prison. recidivism, and treatment eng.agement ilmong those reamtly released from prison (Degenhardt.I..Cirney. Kimber. et al .. 2014: F.1rrell· 

MacDonald, MacSwain. Cheverie. Tiesmaki. & fischer. 2014: I..Cirney, 

Cisev. Farrell. et al. 2014: Zaller ec al.. 2013). 

1.1 Cost ofMtdlcadon-AssisredTroormmr forOpioid Abuse or O.,.ndtna! 

While the effectiveness or maintenance MAT in redudng opioid use 

has been demonstrated, the t.re.nment itself comes with higher dire<t 

costs than t<tpering. abstineoce. or psychosocial inte1ventions. ln 2009, 

$866 million was spem across all payers on substance abuse prescription medicine. 931; of which wem towards prenorph . one of the 

drugs used to treat opioid addiction (Substance Abuse e~nd Mental 

Health Services Administr.1tion (SAMHSA). 2013). While 1he costs or 

me he~do e are negligible. Lhe deljly dosing and other services provided 

In opioid ue.umem programs (O'Ws) where methadone is dispensed 

are re.Jatively high. 

However. the question rem<ehls as to whether MAT cosu c.tn be 

offset by reductions in other health care expenditures. Relatively few 

studies have ex.tmined the tot.ll cost or health care services for opioid 

.lddicts. Two studies h<ave looked elt data from commercial hec1hh 

insurance claims on the overall heaJth care COS1S .tnd utilil.ltion rates 

for tho~ using MAT comp.lred to those rreared without MAT (Basel', 

Chalk, Fiellin.&Cclstfriend., 2011: McC.arryet al .• 2010). McCany ct al. 

round th.tl over .t five--year period. members on MAT h.ld 50% lower 

total e~n.nu.tl he.1lt:h plan costs thclJl those who held two or more visilS 

to an Addiction treatment department and no meth.ldone and 6~ 

lowe!' th.lll those with zero Ol' one visit for .lddicrion tre.nment .1nd no 

rMthadone (Mc'C.al'ty et al., 2010). B.tsel' et al found l\.l u~r a sixmonth period, those whh MAT had significantly tower overall annual 

health plan costs compared to those with no medication ($10,1 92 vs. 

$14,353: p-value <0.0001) (Baser ecal .. 2011). The diiTerenco w.u 

driven largety by lower inp.1tient servictS and non-opioid--related outp.uient services for the group n.'(civing medic.u-ion (Baser et at. 201 1). 

M<Adam-Marx et al reported in 2010 that Medicaid benefidilriCS 

with opioid ilbuse. dependence. or poisoning hitd nearly triple the 

tot.tl medical cosu adjusted fol' b.\seline sample char.tCieristics comp.ved robrncficiarits matched byagto.gtnder,and state with noo1>ioid 

abt>se diag o~s ($23.556 vs. S8436: p-value <0.001 ). The opioid depen· 

dence/abuse group also had higher prev.1Jence or comorbidities. SU(h as psychiatric disordm. pain re ed diagnoses. and other substance 

abuse conditions (McAdcun·Marx. Role~ cl. Cleveland. & Oderda 2010). 

While this srudy cons der~!<~ overall cost, it did 0(1( addrtss MAi coscs 

in particular or any impact treatment may have had on overall COSl 

Focusing spedfically on a Medicaid population is import{l:nt for two 

reasons. First Medicaid beneficiaries as a population remain at greater 

risk for subsc.ance abuse. including opioid .t<ldiction and overdose. 

Approximatety 12% of Medic.tid be:neftci.tries between a,ges 18 .Jnd 64 

years has e1 substance use disorder (Melnn. Frieden. Hyde. Volkow, & 

Koob. 2014). 1n Washington State. the U.S. Centers for Disease Control 

• nd Prevention (CDC) found that between 2004 •nd 2007. 4S.S% or 

fat.ll prescription opioid painkiller overdoses involved people enrolled 

in Med ce~id (Coolen. Best. Uma, Sabel, & Paulozzi. 2009). Second. 

Medic.Jid's share of c1U substance Jbuse expenditures h.tS increased 

from 9% to 21% between 1986 .t!¥12009 (Substance Abuse and Mental 

Health Services Administr•tion (SAMHSA). 201 3~ This equates co Me<l· 

icaid spending o1pproximately SS billion in 2009 on substance itbuse 

treatment. c1n amount that includes federal. state. e~ d k:Kal funds. This 

dollar amount and the findings by McAdam· Marx et al. (2010) indicelte 

thelt state Medicaid programs have an interest in understclnding the 

potential im e~a or expanding MAT services on tOlal expendirures and 

milization of medical services. 

This study examines Vermont's Medic.tid expenditures for opioid 

addiction trecltment and other medic:al.tnd non-medic.ll services, in· 

cludings-peci.liMedicclid services (SMS). which are services uniquely re-o 

imbursed by Medic.tid that t.trget social. e<onomic • .tnd rehabilitadve 

needs (e.g., transportation. home and community·based servicn. case 

management dental. residential tre.a~nt. day treatment. mental 

he.tlth f.xilit:ies.and school· based setvices). More explicitly, it compares 

the heellth care expenditures between two groups with opioid e~dd c .. 

tion: those receiving MAT rMAT group"). spedficelJiy methadone or 

bupre110rphine. elnd those receiving non-foedic.ulon treatment .lP· 

proaches. such as behavior.tltherapies alone ( .. non-M.AT group"). with 

the goal of assessing the cos:t effectiveness of MAT and establishing 

baseline delta ..tgainst which expanded and enh..tnced treatment .l(('ffi 

c.1n be evatwted. 

2. M•teri.ll and Methods 

2.J. Data Source and SampJ~ A>pularion 

This study revic-.ved a1111ua.l medic.ll expenditures .tl\d utilization 

r.ttes (pel' person) for Vermont Medicaid enrollees from 2008 to 2013 

who were identified c1s e~ving an opioid addiction or dependency. The 

dat.J source for this study was Vennont's all·payer claims database. 

the Vermont He.thh Care Uniform Reponing and Ev.tluation System 

(VHCURES). Due to limjra.tions .trlsing from the starutorily-mandated 

de-identified status or VHOJRES. this Study could not use a cohort 

dtSign. but ins1ead relied on .1nnual cross-section.ll data fore.K'h year 

in the study period. 

The srudy population included members with Medicaid coverage. 

ages 18-64 ye.trs. who had cl.tims In VHCURES indic.lting treatment 

foropioid add!Ci onbe w~n thccellend.lr years2008and 2013. Within 

each year. members participating in MAT v.-ert romp.1rtd to members 

with opiokladdiccion receiving non-MAT therapit$. ExpenditurtS .1nd 
97 


33794A.050

lrtX.MohhonttOl ~o{~bsnwtAbi«Tmumtnc67(2016)9-l.f II 

T.ablt l 

~hco~lth &~JPI*:s bcht stucty ~Don.unicpJt(Q.ItltofM«<iald ~Dtnts fortht Yt"<li'S 2008 to20ll. 

t>tmosrolpi\1</Heatlhdl.wact«IMk tMT Noa-MAT 'i' 

~~HOOOI MtmbC'f(\)l)fll • P•V.tll.ll' 

N 6158 71.l% 2~ 2US 

,.,. (in ~¥S).. ftnWits 

I 8-34, fnn:dot 2450 79DS 7 11 .. .,. <0.001 

)s.-.44.~.1Lt 634 lOA% 222 20.11 

45-Gt.ftrnalot 29< 9SS lOS 18.6S 

Ag.f'(iD)ItatS}. mOO" 

18-34.m.ak 2259 n.ss 898 64.6S <O.O(U 

3S-44.m.tlt 724 n."' 271 19.$1 

--~.m.l.lt 330 IO.SS 256 18AS 

3 M"" Oi.WUI Ri$t Gloup{CRG)" 

OpWd-.ddicttd only (CRG <<Mf'SOIY 1)

1 ... !O.Sl ... 19.8S <0.001 

ACI.Itc itnm or minor <tu"onic di~~ (C'Itt$ '2-4) 275 4SS )).0 13.4% 

Single' domin.mt or mcNkrnt dlronkdisotnt (CRC 5) $)51) $6.9S 1Sl2 61DS 

scnilk.lnt <'hronl< diSt.lst', muil«pn sysum (atG 6) 1637 26.1iS 605 243S 

C..ntn/C.Moi:Strophie C«<dition (CRCi 7· 9) 56 .... 4S I.SS 

Womm with prot· and ptrin,uaJc.vt (denomNillf is ftfiUifS) 962 )I .OS 142 12.9S <0.001 

~drisCV'irus (HC'V) db_gnosis 12$7 20.1iS 249 IO.OS <0.001 

M~iciidintbrprioJ)'('o~r S4'7) ..... ms 81.6S <0.001 

SnitM.I.1 mcnt~l ht'o~lth dit<Wdu ms 21.6S $09 lOA% 0.2;)4 

Chronl<dise~ 

Astlwtu 13$4 22SS ... IS.OS <0.001 

AUtntioo 6tfioc:k hyptr «tivk)' disordtr {AOHO) 80) l ).ol 20) &IS <0.001 

COIOn.lryhC\Iirtdisto~se )) .,. 19 .... 0.218 

('hronit ob$1NtliYC pu~ di$orckr (COPD) 137 2.l% 69 2.SS 0.134 Dt"presslon 3125 so."' 1072 43.0S <0.001 

J-typtnft'lsloft 425 .... 21S . .... 0.006 

O~es 161 2.6X 92 '·"' 0.007 

• Si~individ~bCoU'I ~in 1'1\ullipt .1$t .lind diok.lll rist groups Oil~ the Sp;ll'll)(tM study prriOd, the sum dtbr pti'~.\p'S rutt'dSIOOl. 1 Mmtltrs >Mibou1addltloNI <Oit'IOtbiditltsorcomptbm!dW..noses. 

selected utiUt.C:ion nw.asureswereevatwted for the MAT and non·MAT 

groups over the si.x·yt>ar period. 

The inclusion criteria for the MAT group were based on claims data 

fort be two primary drugs used in MAT: methadone .\nd buprenorphine 

Methadone is dispensed only at designated trt.auncnt fadllties (Opioid 

Treatment Progr.unsorOTPs). Priorto2013 in Vermont. buprenorphine 

was prescribed only in general medic.11 offices by authorized physicians 

(Office Based Opioid Treatment or OBOT). Members receiving metha· 

done treatment were seie<ted using the Healthc.are Common Procedure 

CodingS)'Siel'n(HcYCS) programcodeH0020 in thccl..limsdata. Mem· 

bers receiving buprenorphine treiHment were setected U$ing a list of 

National Orug Codes (NDCs}. with the exclusion of ~ny fo rm of 

buprenorphine when prescribed specifkaJiy for pain management. In 

addition. patients under any treatment for chronic pain were excluded. 

Tht non-MAT comparison group was also identified ushlg claims data. 

These induded membtrs who ne .. •er r«eiv«< MAT .tnd had at lr.asltwo 

opioid •ddiction diognoses (ie. ICD-9 codes 304.00. 304.ol. 304.02. 

30<l70.304.71, 304.72) on diWerentd.Jtes o( .,IVice • .._sting ongoing ad· 

diction. Theopioid .xldiction treatment forthe non-MAT population includ· 

ed individual mdgroup outpatient seMces. i~ensiveoutpatient programs. 

panial hospitalization. detoxification. and I'C$klential treatment $eiViCCS 

idl'ntitied from the dai1ns dat~ using HCPCS olnd revenue codes.' As in the 

MAT group. patients under any U'eatment for chronic pain were e.xdt.Jded. 

for each calendar ye.ar. MAT .and non· MAT members were evaluated 

using demographics and health status (Table I). Demographic mea· 

sures induded age, gender . .trd county of residence. HeaJth status indi· 

cators included nwjor mental health disorders (i.e .. schizophrenia. 

I HCPCS oVId Rtv~IV.It Codts: G0176. G0177. H0001.HOC>0'2. HCJOO.\. HOOOS. H0006. U0014, U0016. H0020, U0022, H0028, HOI)) I, HOO)l. U00)6,110037, H0046, U0047, 

H2:017, H20 I&. t-Q019. H2020. H2!n7, H20).). H20JS. H20l6. S947$, T1000. Tl007, 

TIOI I. TIOil. 0907,90.801.90,802, 90.804. 90,805, 90,306. 90,807, 90.808. 90,809, 

90.810. 90.81 1. 90.812. 90.813. 90.814..90.815. 90.845. 90.846. 90.841. 90.$49. 90..853. 

90..857. 90.861. 90.87S. 90.8'16. 90.880. HOOIS. $9480. TIOOS. 090S. 0906. HOOIO. 

HOOII, ltOOil. ll0013, UOOIS. 110019, T2048, 1002.90.316.90,817, 90,818, 90,819, 

90.821.90,822. 90.823. 90.$)4. 90.826. 90.827. 90.82&. 90.829.110017,112013,. t10008, 

110009, H003S. 9)2()1, li20l4. I 004 

major depression. bipolar and other psychoses). sdected chronic di$-

ease diagnoses (i.e .. asthma. att·ention deficit hyperactivity disorder 

(ADHD). duonjcobstructive pulmonary disorder (COPO). congestive 

htan f.:tilu!'t'. corollltry hearc disease. depression, diabetes. and hyper· 

tens-ion), and 3 MJM Clinical Risk Croup (C C) t.ncgorics.. which were 

used to identify differences in healt:h status for other conditions 

{e.g.. cancer} among the MAT and non·MAT populations. For purposes 

of ensuring a large enough subsample, theCRG categories were grouped 

into five c.negories: opioid-.addicted only {which included those 

addicted or dependent on opioids whh no comorbklities or complk'<tt· 

ing diagnoses): having a his'lory of significant acute disease, <l single 

minor chronic disease. or minor chronic dise.1se in multiple org.1n sys.-

ten\S: having a single dominant or moderate chronic dise•se: having 

significant chronic se~se in multiple organ systems; and having dom~ 

in<tnt chronic disease in three or more organ systems. metastatic and 

complicated malign.tncies. or catastrophic conditions. Members with 

daims indicating pre- and perinatal (are or HCV positivity were also 

identified A meuure of (OOtinuity of enrollment in Medic .aid ("'Medicaid 

in the Plior Ve.ll') was assigned ror amemberW!ow., enrolled in Medic.OO 

during both the srudy period year and the prior year. 

12. Staristit;al Analysis 

To reduce the effect or extreme outlier cases. total expendHures 

were capped at the gg:h percentile fore<~.chgroup (Centers for Medic.v-e 

and MedicAid Services. 2014). 

Dcmogrilphic data fore.lch groupwasc.omp.Jred with a x2 goodness 

of til test with the signifk.mce level set fit 0.05 (Table t ). MuJtivariable 

linear regression models were used to evaluate the expenditure and ut ~ 

ljzation dependent variables that were derived from claims d.lta. Expen· 

diture and utitiz.uion measures induded those listed in Table 2. 

The '1'otal Expenditw..- model included lhocostsor.n mo<li<al ser· 

vices and the (OSts .1ssodated with opioid 01ddic:tion treatments for both 

the MATgroupalld the non·MATgroop.asdescribed .above. The '1'otal 

Expenditures without Treaonent" model excluded c1U opioid dddiction 

tre<~.tmem costs to determine the impact of MAT on medicAl 
98 


33794A.051

12 

T.lblt l 

Mju:slt'd .W«<\3t .mi'II.NI ~t'UrtS .11nd utiHution r.11tt.s1

• 

MAT Non·MAT Olfkrm«1 P-v.tklot 

Toulotxptndlrut,es 

ExptOOittlfts -· $14.468 ........ - S411 O.o7 

TOt.llt~tumwithoot tre.nment $8'194 $ 11.203 - Sl409 <0.01 

Bu.prtootphiMf'Xpnlditvrt.S 12?08 - $47 $27SS <0.01 

TOtaiPft'~t?(ptmtilures $4461 $2166 $2295 <0.01 

tnp~K-re coxpcnditures Sl132 $37$7 - S16:lS <0.01 

OU !JhM.enf ot)CJ)MdilurfS $345 1604 - S259 <0.0 1 

Ptokssiorul ot.x~diturts $674 $961 -1307 <0.01 

SMS txpcndil.wts $2872 $4160 - SI288 <0.01 

Utllutloo r~t ptrson) 

lrt~~R-ne d~s 1.54 1.00 - 1.46 <0.01 

tnp~irerc diS<hars:tS 0.30 OS2 - 0.22 <0.01 

ED visits 1.+1 2A8 - 1.04 <0.01 

Prinwy<.nphysic:~nvisiu 15.2? 9.81 SA& <0.01 

Mva.IK«i ~ o.29 0..$4 - 0.25 <0.01 

SC:.lndird kn.agina 0.76 IAJ - 0.67 <0.01 

Ct.>lon0SC09'1 0.01 om - 0.01 <O.o1 

£di0Jf~ 0.46 O.SJ - 0.07 0.002 

Mordic.11 ~1fsctAs.u. 0.<49 0.82 - 0.33 <0.0 1 

SIJ~Jiulsl)('(i.llistvisit.s 3.04 1.89 l,IS <0.01 

• SMSrdft110SPf'd,IIMrdie.lid~.lnd~llktr~I'IOMta'ld«l~ 

blstd stMcts.cast nwasf'I'Yltnldootal rcsidendal CTt.JUnM. day ur.llrner.. ~health 

bdll!its..llrdschod-bastdS<'I'Vbs. 

1 Mulliv¥Yb&er~no11l~si:s..-dj...s~ rors~ .•. c.JI<n~ryc-~uUnic-.liri:sk 

lfOUPS. Mcdbid in tht prior~--. Mp..Otis C viM {HCV) St.ltu:s.¥1d PR-- And pcri-rwt01l ..,. 

I Oilkrtrn • MAT-no!WM.T, 

expenditures .alone. All expenditure outcomes ,md ut11iuttion rates 

listed in Table 2 were fldjusted £or parti.ll enrollment within the caJen· 

dar year and the independent variables included MAT status. gender. 

.1ge group. pre- and ptrinatal status. HCV St.ltus, "Medicaid in prior 

year"' status. and health status as nwasurcd by CKCs. Chronic di~ases 

and mental health disorders \oWre excluded from the regression because 

they were encompassed by the CRGs. The independent variab~ or MAT 

v. non· MAT was created as a binary (Oil) variable, as were -women 

with pre- and perinataJ care", HCV. and "Medicaid in the prior year". 

1bc remaining were multi-level indicator varidbles -the model adjusted 

ror age and gender groups using males 18-34 as the rererence group. 

and he.alth status based on CRG groups using '"opioid-addicted only" 

as the reference group. 

AU statistic.al.1na1ysjs was done 'o'lith SAS version 93. 

3. I. Sample Population and Demographics 

Over the period rrom 2008 to 2013. we identified 6158 unique 

Mediuid benefldaries with a diagnosis for opioid misuse and health 

care daims for MAT. and 2494 unique Medicaid patients with a diagnosisoropioid misuse but nocklimsforMAT.Table 1 compares the health 

status J nd demogrJphics for Medicajd members who re<eived MAT and 

non·MAT tre.ument between 2008 and 2013. The MAT group was 

slightly younger with higher proportion or 18-34 year old$ in both 

genders (79.0% ... 64.3% ror relThlles •nd 73.8% v~ 64.6'li ror m•les). 

Over ill the MAT group was more likely to be female (50.3% vs. 44.3%: 

value O.OOI ). In line with this trend, MAT members had a hJgher 

rate or pre. and perinatal care compared to non· MAT ( 16% vs 6%). 

MAT members Jlso hJd J higher prevalence of known positive tests 

ror HCV (21% vs 10%) and were more likely than non-MAT to have 

continuity of coverage in Medicaid as indicated by hiVing Medicaid in 

the prior year (88.9% vs. 8 t.6X). The prevatence or members with 

serioos ment.JI health disorders (e.g_ schizophrenia, major depression. 

bipolar o1.nd other psychoses) in MAT was slightly higher than non· 

1\fi\T (22% vs. .but the difference was 11ot st.uiscic-ally signifte.lnt 

(p.v•lue = 0.23). 

Table 1 also compares risks gtoups and prtV.llenct of select conditions between the two groups. Bds«l on the x2 goodness of tlt test·. 

there was signitlcanl difference in the disHibution oft he risk groups 

among the MAT .1nd non-MAT groups. The non-MAT group had higher 

proponionsc-Ategottt«< as opioid-addicted only (I.e .• those wilh opioid 

addicrion or dependency but without comorbidititSor complicating diagnoscs) or as h.aving CICU1.e illnes:s or a minor chronK: disf.ue. The MAT 

group had higher proportions with a single domin.1nt or moderate 

chronic disease or i significant chronic disease in multiple organ systerns. 8oth groups h.ad low rAresof c-clncer And C.ltastrophicc-oncUtions. 

Of the St"~ ed c-hronic condilions with gn if~eant differences betwi'en 

tht two groups, MAT had higher prevaltnce or ADHO. depression. and 

asthma and a lower prevaJencc or hypertension and dia~ces.. 

32. Mulcivarlablt Rtgreffion Rtsulcs 

Table 2 shows the adjusted expenditure .11\d utiliution rates per 

person for the MAT and the non-MAT groups and the differences between the two sludy populAtions. In all categories or expenditures except prescriptions. membel'$ or the MAT group had IOV\•er costs. For 

101.11 medical expendhutes.lnduding treannent COStS. the MAT group's 

annual e~ dit l'd \oWrt S4121us than ~ non-MATgroup'StJQ>Cndilt•res. although this difference was not signilkant (p-value: 0.07). 

When opioid .1ddiction treatment costs for both groups were excluded . 

the dirference in annuaJ expenditures or the MAT group relative to the 

non-MAT group grew to - $2409 (p-value: <0.01 ). In each of the four 

exptnditure subc:.uegories {inp;atil!nl. outpalient. professional services. 

and special Medic-aid services exptnditt•res) the TI.V.T group's medical 

ex.penditures were significantly lower. with the largest difference seen in inpatient expenditures (-$1625). For lhe utilization categories 

(Table 2). the 1\iAT group has signifkintly lower utllization rJtes per 

person Mross .111 Cfltegories except for primary care physici-o1n visits 

and surgical sp«iJiist viSits. 

The expenditure models also found lh.U. independent o(MAT Status. 

a positive di~ os s of HCV was associated with si,gnifiCflntly higher 

costs ror both models: S35 18 (P·Vfllue: <0.01) in the 1'ol'a1 Expendi· 

cures" model and S2679 (p .. value: <0.01 ) in the -'Total Expenditures 

Wlchout Treatment Costs"' model. Conversely, being enrolled in 

Medicaid in the previous ye:arwas assodated with )Ower costs: - Sl 169 

(P'vdlue: <0,01 ) in the 'Total ExJ)<I1ditures"mcxlel and - $630 (p.value: 

0.01) in the "Tol:ill Expenditures without Treatment Costs" modeL 

4. Discussion 

4.1. 1lndings 

The results indicJted that the overo~ll difference in annu.1J average 

expenditures was lower ror the MAT group. even with the cost or 

MAT. but not signitlc,antly lower. However. wh01 opioid addiCtion treatment costs were removed. the MAT grot•P had substantial and statistically significant lower health care costs overall compared to the non· 

MAT group. This WfiS especially noteworthy given the MAT group's 

higher r.1tes of pre .. and perin.ttal care. HCV positivity, o1.nd more severe 

health status acrord ~ to risk groupings (higher proportions or young 

(emales clnd higher rates of pre- .:and perinatal Cilre were expected be· 

cause pregnant women were prioritized ror MAT treatment. especially 

in On>s). Evaluation of the utilization rates suggests th.tt reduction in 

cost was due. in pan. to lower inpatient admissions.Jnd ouQ>.tr.ient hos· 

pitalemergency department visits. The higher rJte of primary care visils 

for the MAT group was exJ>«C,ed since buprenorphine is prescribed in 

general medical offkes.lt may also indiGtle that MAT may be succmfuJIy linking patients with preventive care services. The increased utiliza· 

tion oft he surgical specialists and the decreased utilization of imaging 

seiVices will require Jddition.ll analysis lo identlfy the reasons for 
99 


33794A.052

these trends. OYeraU. however, drlss1udy, in COiljunaion wfth the many 

studies supporting MAl treatment efficacy, suggests that exp.11lding 

Vennont's MAT S~JVictS for itS Medic-aid-enrolled populal'ion has the 

~entia! to produce better opioid Jddiction trtatmenl rest.~lrs and 

lower ~rail health care costs compa.red to other approaches to opioid 

~ddittio ltre.ument 

The findings Also indic-.ue that mott continuous enrollment in Medicaid was associated wilh reduced expenditure$ independent of the 

MAT program. One interpretaliOn of this rtsult is that newly iMurtd 

members tended to have higher initial health care utilization if they 

had been without it bdnehand. and their continued enrollment led to 

a reduction in heallhcareexpenditures-. Further study is netded to cvalll.ltc this conclusion<tnd itsimplic.uionson expalldingMATservices. 

Another point addressed in the results is the prevalence or HCV 

among the opioid-addicted population. As noted in Table 1. 20.6% or 

MAT members and I D.O% of non-MAT members were diagnosed with 

HC.V between 2008 ttnd 2013. By comp;Jrisoo. chronic HCV prevalen<e 

In I he US is approxhn.artly 0.8% (Centers for Oist.l.Se Control .and Prevention (CDC). 2'016). Further inquiry into the reasons behind this difference should be pursued. st.~ch as whether there is ilxreased HCV 

scree-ning for MAT Pildents. a possibility supported by another study 

(Lamey. Grebely. Falster. et ttL. 2015}. or greater referral among Medicdid benefidaries with HCV to MAT services. Additionally, further Mlaly. 

sis Should evalu.a1e the racrors conl'ributing to cost such as severity or 

HC.V-nsociateddisease and treatment-seeking patterns. HCV treatment 

is expensive. especially I he combination therapies involving the relatively new sofosbuvir and edis~USVir approved ttfter the time frame 

for thts study: however. these drugs have significantly reduced side 

efTeasand t~atmenttil'lltS (6-t2 wet.ks vs. 24-48 \vet:ks) and product 

higher cure rat·es (85%-95% vs. 50%-80%) than the traditional 

pegylttted-intefleron with riboviron 1herapy (Centers for Disease COntrol•nd Prevention CDC~ 2016). Shoukl MAT provide • me•ns (or im- proved HCV detection through increased screening. MAT may have the 

.tdded benefit of reducing HCVtranslrission (Tsui. Ev.1ns.lum. Hahn. & 

Page. 2014; White. Oort. Uoyd. Rawlinson. & Maher. 2014) and the 

medical complications that arise from chronic HC.V infection. 

4.2.Umitotions 

White VHCURES data h.ave been validatod as a reliable dar a sour« 

(Hof'fer & Stein. 2014). they do have some limitations relevan• to this 

study. First. as mentioned above. the de-identified status ofVHCURES 

makes cohorr studies difficult: therefore we used annual crosssectional for each year in the study period. 

~cond, the dataset did not allow fort he eStimation or methadone 

costs in isolation. The HCPCS program code. which is used to identify 

MAT members receiving methttdone a.n<l their treatment costs. com· 

bines medication ttnd health home services. Furthermore, methadone 

is not present in pharmacy clttims,limiting the abiliry to find tre.ned 

members .1nd isolttte methadone medk.1tion costs. 

Third. the dat<J m.ay ill(hKie some bias due to the influence or 

outliers. While outliers were capped .lt the 99Ch percentile. they 

could still potentially influen« the results given the small sample size. 

However. since the yearly dollar ttmounts were consistent {data not 

shown). this influence is likely minimaL 

Mnally.a fewunrne.lSUrable confoundcrs could also have introduced 

biiS to this study such il$ unaccounted ditTerencn in the seve-rity of opioid addiction between the MAT and non· MAT groups and access to 

treatment. Additional studies on these factors would improve further 

evaluations of MAT. 

s. conclusion 

Given that total heallh c.1re expenditures djd not differ significantly 

(p-value:0.07) even with the highercostsofMATservicesand medicr 

lions. the outlook for .1 stJtewide program focused on providing 

" maintenance r-v..T is favor.-.ble. While the total .-.ddlctiOI\S uea.tment 

cous wete highet for the MAT group, these we~ offset by much k>wer 

health rare utilil.ltion and ~xpen<liturf!S. indicAting .1n insignific.anl 

Qverall cos• differer.:e between the MAT and non-MA.T groups. Whilt 

causation cannot be determined in this study. the results. aJon.g with 

SU01tg evidence 1h.u malnte11.t.nce MAT is more effective at .:tehieving 

t~atment ttttntion and ttdudng opioid use (fullettOil et at. 2014: 

Thomas tt al, 2014), present<~ persu.-.siv~ argument fot expanding a 

MAT .o(entered opiau~ addiction treatment program throughout the 

state of Vermont. 

Towttrd the end of this study's time frame (mid-2013). Vermont. 

through Its health c~ delivery reform program. the vermont Blueprint 

for Health, btgan to roll out a comprehensive stJVices design buflt on 

MAT and the opponunity for H~alth Homes offered under the Afford-

•ble Care""'-The gool ofthis program. olso known as Hub ( 011'>) •nd 

Sp:~ke (OBOT or buprenorphine-prescribing providers). was to expand 

access to methadone, enhance methi~done treatment programs by 

linking Health Home Services with prlnla.ry and community servi~s. 

and providing dinic:.1l starr to suppOrt and complement prirn..1ry care 

providm waivered to prescribe buprenorphine. 

The results ohhis study serve as .1 strong baseline by which to evaluate Vermont's Hub and Spoke program and to assess whether thereduction in medic.1l costs have continued under the progro1m's service 

enhancemtnt.S. Additionally, the methodology employed in this study 

will be expanded to aualyzc the impact or MAT beyond heaJth c.are, 

such as on incarceration rtttes. employment rat·es. ttnd rat·es or child 

and family services. These subsequent studies will provide a fuller 

understanding o( the sociNill costs ttnd savings or opioid addiction 

and trr.ltmcnt. 

Ad<nowt<dgments 

The authors gratefully •cknowledge jeff Stodddrd (Onpoint) for 

manuscript review. The .1uthors would like to highlight the extraordi· 

nary leadership of the Honotablc Covtmor Peter Shumlin orvem1ont 

(or highlighting the issues of opioid addktion in his 2014 ·State of the 

State" speech and dedicttting the resources of his administration to developing it systemic policy response in VermonL The authors also recognize the distinguished leadership of the Vermont ()epil.nment of Health 

by Commissioner HanyChen and Deputy Barbara Gmaglio for develop· 

ing the addictions treatment system and for their commitment to integratjon and collaboration with the Blueprint for Heo~lch. The ttuthors 

wish to express their deep gro1titude for the .tdministratiw and clinical 

leadership provided by Mark Larsen, Victoria Loner, an<l carrie 

Hathaway in supporting concrete. actionable changes in the health delivery system to dr~maticaJiy improve .!Cctss to MAT treatment for 

Vermonters. Finally. the ttuthors would like to particularly thank the 

program partners across the state whose dedicated effons are 

trMisforn'ling our health ttnd addictions c.ve delivery systems.. These in· 

elude the program directors .u Vennont"s opioid treatment programs. 

the medical care providers who offer MAT. the Blueprint projea. m.a_n. 

oJ8('fS and practice fadlitators who guide and support the treatment system, the Dartmouth team supporting practice improvement in MAT 

programs, and Stolte legislators. Together they are ch.tnging the face of 

heahh and .-.ddictionsc.lfe for all rlus. 

Funding: All fundingforthisstudyc .• lme fromannu.1l st.ueappropriated budget ror the Vermont Blueprint for He<lhh. 

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IS66-2009. baps:J~ort..S.~m~ov/Shil\k'Onlftlf/SMA 3-4740~MA 3-4740.pW 

SubSI~ AbuSe .lnd Mtt'IUd Ht.lllh Se'vbsAdmitllsr¥ion (SAMHSA) (20145). Rt~ 

ftomtlr»JJNIO:n1~0101gUi!atfltdl'rh!l'I)'I'/Ndiftrd~ Rodevillt,MD 

(htlp://WWW.$.1m.f'4~.l(N/d.U.a/'$ii~$/<Jt.(.wiVNts/NSDUllrt$uiUPDfWHTML201l/ 

WC'biNSOUHm.ule$20 l.pd( A~dNovtmbtf IO,l015), 

Sub$\t•nc~ Abu~ o~nd Mtnl41 Htallh StrviCr$ Adminbtr.Jtion (SAMHSA) (2014.$). 

Compoll'ison of l01 l ·l012 vs. l012·l013 HSOOH Sc.n &tinults. l'bpur 

D<IUI, Narl $uno en., ()$~ Htol http: /WWW~h$l.IOY d~4/Si.f~S/dd.nfrJI'i tS/ 

NSOUHSUttE.sQOl 2-201 ).p1JCb UIItT~NSDUHs.tSIIo"TtrmCHC2013Jum. 

~~0.20 5). 

Subsl .. nce Abuse 01nd MtnUI "C'.afth Strviet$ MminiUntiOn (SAMHSA), ~t 

m('dicacion-.11~sted r"'.tt~nt. Mtdit'•t TI\'.M SWSt Uk Oisotd. 2016. (http;:/fwww. 

dpi,.Wmhw.govhNtir~,.aspx. Acmscd MJy 11. 2016). 

Thom.s. C. P .. FuU<"fGOn. C. A.. Kim. M .. Monc:tj..no. L. LYJNn. O. R. DovJhmy. R. H. -

Octphin-Rittmon. M. t (2014).. Mil'dkol(ioo~ ed tr\••cmnu with bupfenorptil'l('; 

..\sstsskli rflt tYidtnC(', Ps.)'chiolric' $tMcn;, 65(2). 158-170, http;Jjdx.doi.«JIIQ. 

117$(•ppi.ps.201)00lS6. 

fsl.i,.j.l. Ev•s.J. L.lum. P.j.. H.lbn.j.A.& P .. K. (2014).Assoditloo o( opiokl.lf')nlst 

thet•PY with lOW« iOOdmct ofb~klsC vfi\IS lnfecdon in )'CUf'II~Uit lnjcctlcCit 

dtuJ ust s.}AM.\JIII'~mlll Mtdrdnt', 174. 1974-1981. bttp://dx.dolofl/10.1001/ 

~lnttmmt>d20 4.5416. 

V«mon 0tp.uttnMtoiHe.Jith(20 14.l).Wutbritf·~ndnlgmfAdtinWrmolllt. 

11 ( hltp://tlt.lllhWm'!Oni.&OI//acl.lp/<IO('t.lmeni:SISBJW. RXIS.SueBrit(Junt20 1._000.. 

pdi':A«<t$$ed~l1'1btr 10, 2015). 

VM'n(l'l ~nto1Ht.lll h()014b).'l"hrdu'JII(ftg~O/Ofit;lidc.fdicrion.,2http- fwww. 

ht.althwrmont.sov/~d..p{trt01trntnt/opioids/dotumtnt$J'OpioicKNllc'ngt8ritL 

j\ln('2014.pclr(A«mc:d Nc)I.W!Ixf 10.l01S) 

Whitt.l.l)rcn. G.J,.. Lloyd A Jt..R.JwliMon. W.O.& ~ht'f. L (2014).0pidd wbQitutiOIII 

ther•py proc«Uapiost htp.Jdris Cvwus o~equisition in I)('Op!('who illjtn d~Tlv:­

UITS-c study. Tht.WI!dlml)ow'ndi({AuumJd.201,l2S.l29. 

blltr. H.. McKtnlit. M. rritd~NM, P. D .. CR"m. T. C.. M<Gow.lin. S. & Rkh.j. 0. ( 2013).. 

ln.ii_VtiOn olbup-('tl()t'phine dwins inc~.MiGn.and rtttneiCWI in lrt.ll~ upon rt--

k.~St.}IJumol Q(Subs~ Atlu:sc r,_,..,.., 4S. 22Z..2l6. havJ/dx.!Joi.Ot'lfl0.10164. 

P.,t.2013.02.005.. 
101 


33794A.054

With SBIRT, the system is the 

solution. 

The SBIRT suategy oilers cllric:al tOOlS 

tor eHectM!911d efficient riSk Sltatitieatlon. 

brief mocM!tlonal interventiOnS. and warm rerwats to IOIOw·uP treatment. 

SBIRT P<O'oli<leS a systematized approach 

tnat rern<:MlS subjectivity ana inconsiStency. 

9l1d introduces preactatllity ancJ effiCienCy. 

SBIRT in action: 

• C<ml'<Jrit)l Health centers ot 13<rilgtoo 

• The Heann center - Ptainf<!ld 

.o. The NOTCH -M-ankin County 

• central vr Mect c.r women'S Health 

.o. Btaltlebo!O FamJy Medlcino 

SBIRT has applications across 

a wide range of preventable 

risks, including: 

+ SUBSTANCE MISUSE 

+ DEPRESSION 

+ ANXIETY 

+ OBESITY 

+ MEDICATION ADHERENCE 

• Rvtland Regional Meet center ED 

• NorthweStern Mecl center ED 

" SouthweStern vr MecliCal Ctr eo 

• UVM Stu<len1 Heal1h & W<lllness 

• Pooples Health & wetness 

• Mt. Ascutney Healtlt Ctr.. • Rvtland Free Cllnid 

Northem Counties Heann Ctwe Inc·• • Bennington Free Cl1lc 

• Conm Health SeMces ol L.amoiiiG V8ley' • Good N<lig~ Healtlt Cl1lc 

" central vr Mecl center ED 

SBIRT OUTCOMES 

SBIRT strategy involves: 

+ UNIVERSAL SCREENING 

+ INITIAL AND SECONDARY 

SCREENING 

+ BRIEF INTERVENTION 

+ BRIEF TREATMENT 

+ REFERRAL TO SPECIALTY 

TREATMENT 

1 of every 5 tnd1viduaJs ~ rooeived Ell navenoon fO' ~ 

dn1J use were absttn&nt from drugs or had stgntftcantly 

reducod thetr manJuana use at the 6 month follow up. 

Researeh on the cost ettec:tiveless of SBIRT 1'\,'\S fot.n::l that 

IOr"""'Y $1 spent on brief.---,, cost saw19S r.r1go 

from S3 80 to $5.80: 

Based on the runber of tntevenbons conduCted 11 vr SBIRT 

and the estimated cost of those servtces, tho estunated 

cost sa.V1ngs range from $547 to S806 par pefSOn ... 

• AltMIIng ..... 2000, 2(1(0. GMIMio .. ~ 2006 

***** 1 of every 2 .ndtvtduals v.no recatved an tntervenuoo lor rts:ky alCOhol use were erthef abStinent or wrthtn 

recommended dnnktng ltmtts at the 6 month follow up. 

** .....chewt 

-~~ ..... ~~ 

... COII~OIWIT.,.~,....,_.,,_.~

....... lti~~~*IO~,.......cwo.. 

~/S81A'f.Aidl.oee('_..I)CII 

..... _,~(IO!rl .... ~ 
102 

Æ 


33794A.055

Snapshots of SBIRT success in Vermont. 

SBIRT Cultural Broker Program 

S8IRT C<At..aJ Bro~<er Program IS run ~ SpecoMn You1n ano Family seMoes ano inc:*JOOS s;x ~nCM:~.Ja~S 1r0m the 

Elllvtanes&'Nepii, COOg<:Aeoo, ana SOmali ~ugee ~whO~ screening. llrief inteMlOtiOO. and ref<lrraJs •o uootment ror aiOOI10f ano Clr\Jg use and men1a1 heaiiJ1 within tllei' comn>.l1i1ieS 10r ages 18 ano Older. The cutt ... aiBrol<ers 

are able to <lefM!r S8IRT In a Wtuafly sensi\Ml mamer, often 1n in<livfavafS' prererrea ranguages. 

Asking me SBIRT "-'esoons comp!elely changed my 

drlrnting and drug use lllaVe leSS stress. am sa..,.;ng more money and l'lave a much happkJr Wo 

-------------------

Rcfugcclitnmlgrant screened fOf SBIRT 

Patients' Rating of Initial Discussion at Six Month Follow-Up lntEli'Jiew 

I know more Jboul how my ~loohol .ancJJor drug u::.e .J!ftcb my pl'rysio.al GS% 

hulth btcJu:.. of tht decu:.:s.!on 

The dl:.(-tr"...t.lon with ~tJ~H m.Jck m• lhlnk dlHe-rently Jbout my 62,_.. 

alcohol .and/or drug u:.e 

"" .. .,. ...,. ~-............. .,....,.tlrofloh , ............. .._""' 

Decrease in Risky Behavior 

~.-. Ri::l:kv AJc::ohol Use lloc<_ln_Orug ........ 

.. ...,. 

h 14 a 

. - " ;J .. .,. 10 

p :1 _ f .. .,. 61 • 

iJ U·..,. • ~ .,, t .. - VISIC sblrt.v9rmonlgov to seatn l1lOI8 abOut SOIAT and moot three 

health care pr<Mders v..no are suc:oessllAy uSing SBIRT 

-

,..,. 

Doc<.-. In"'*' Drug Use 

Ji• 

s! 

1I I 

... I 2.6 

I -.... 

/ SAMHSA 

,..,.