U.S. GOVERNMENT PUBLISHING OFFICE

33–659 WASHINGTON : 2019

‘‘THE OPIOID CRISIS: 

THE CURRENT LANDSCAPE AND 

CMS ACTIONS TO PREVENT OPIOID MISUSE’’ 

HEARING 

BEFORE THE

SUBCOMMITTEE ON OVERSIGHT 

OF THE

COMMITTEE ON WAYS AND MEANS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED FIFTEENTH CONGRESS 

SECOND SESSION 

JANUARY 17, 2018 

Serial No. 115–OS10 

Printed for the use of the Committee on Ways and Means 

( 

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 OVERSIGHT 

LYNN JENKINS, Kansas, Chairman 

DAVID SCHWEIKERT, Arizona 

JACKIE WALORSKI, Indiana 

CARLOS CURBELO, Florida 

MIKE BISHOP, Michigan 

DARIN LAHOOD, Illinois 

TOM REED, New York 

JOHN LEWIS, Georgia 

JOSEPH CROWLEY, New York 

SUZAN DELBENE, Washington 

EARL BLUMENAUER, Oregon 

iii 

C O N T E N T S 

Page 

Advisory of January 17, 2018, announcing the hearing ....................................... 2 

WITNESSES 

Gary L. Cantrell, Deputy Inspector General for Investigations, Office of the 

Inspector General, Department of Health and Human Services (HHS) ......... 6 

Elizabeth H. Curda, Director, Health Care, Government Accountability Office 

(GAO) .................................................................................................................... 18 

Kimberly Brandt, Principal Deputy Administrator for Operations, Centers 

for Medicare & Medicaid Services (CMS) .......................................................... 35 

QUESTIONS FOR THE RECORD 

Questions from the Hon. Lynn Jenkins, Chairman of the Subcommittee on 

Oversight of the Committee on Ways and Means, to Kimberly Brandt, 

Principal Deputy Administrator for Operations, Centers for Medicare & 

Medicaid Services (CMS) ..................................................................................... 80 

Questions from Representative Jackie Walorski, 2nd District of Indiana, to 

Kimberly Brandt, Principal Deputy Administrator for Operations, Centers 

for Medicare & Medicaid Services (CMS) .......................................................... 81 

Questions from Representative Patrick Meehan, 7th District of Pennsylvania, 

to Kimberly Brandt, Principal Deputy Administrator for Operations, Centers for Medicare & Medicaid Services (CMS) ................................................... 87 

Questions from Representative Joseph Crowley, 15th District of New York, 

to Kimberly Brandt, Principal Deputy Administrator for Operations, Centers for Medicare & Medicaid Services (CMS) ................................................... 88 

Questions from the Hon. Lynn Jenkins, Chairman of the Subcommittee on 

Oversight of the Committee on Ways and Means, to Elizabeth H. Curda, 

Director, Health Care, Government Accountability Office (GAO) ................... 89 

Questions from Representative Joseph Crowley, 15th District of New York, 

to Elizabeth H. Curda, Director, Health Care, Government Accountability 

Office (GAO) ......................................................................................................... 91 

Questions from the Hon. Lynn Jenkins, Chairman of the Subcommittee on 

Oversight of the Committee on Ways and Means, to Gary L. Cantrell, 

Deputy Inspector General for Investigations, Office of the Inspector General, Department of Health and Human Services (HHS) ................................. 92 

Questions from Representative Patrick Meehan, 7th District of Pennsylvania, 

to Gary L. Cantrell, Deputy Inspector General for Investigations, Office 

of the Inspector General, Department of Health and Human Services 

(HHS) .................................................................................................................... 94 

Questions from Representative Joseph Crowley, 15th District of New York, 

to Gary L. Cantrell, Deputy Inspector General for Investigations, Office 

of the Inspector General, Department of Health and Human Services 

(HHS) .................................................................................................................... 95 

SUBMISSIONS FOR THE RECORD 

American Association of Nurse Anesthetists (AANA) .......................................... 97 

Abuse Deterrent Coalition (ADC) ........................................................................... 103 

Nola, a Concerned American Citizen ..................................................................... 109 

Halyard Health ........................................................................................................ 111 

Premier healthcare alliance .................................................................................... 115 

Quest Diagnostics Incorporated .............................................................................. 118 

(1) 

‘‘THE OPIOID CRISIS: 

THE CURRENT LANDSCAPE AND 

CMS ACTIONS TO PREVENT OPIOID MISUSE’’ 

WEDNESDAY, JANUARY 17, 2018 

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

The Subcommittee met, pursuant to call, at 10:00 a.m., in Room 

1100, Longworth House Office Building, Hon. Lynn Jenkins [Chairman of the Subcommittee] presiding. 

[The advisory announcing the hearing follows:] 

2 

ADVISORY 

FROM THE COMMITTEE ON WAYS AND MEANS 

SUBCOMMITTEE ON OVERSIGHT 

FOR IMMEDIATE RELEASE CONTACT: (202) 225–1721 

Wednesday, January 17, 2018 

OS–10 

Chairman Brady Announces 

Oversight Subcommittee Hearing on 

‘‘The Opioid Crisis: The Current Landscape and 

CMS Actions to Prevent Opioid Misuse’’ 

House Ways and Means Committee Chairman Kevin Brady (R–TX), announced 

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

The Current Landscape and CMS Actions to Prevent Opioid Misuse.’’ The hearing 

will focus on efforts by the Centers for Medicare & Medicaid Services (CMS) to utilize data to identify individuals in the Medicare Part D program who are at risk 

to abuse opioids. The hearing also will examine the extent of the problem as well 

as the tools CMS has available to prevent individuals from receiving unnecessary 

opioids. The hearing will take place on Wednesday, January 17, 2018, in 

room 1100 of the Longworth House Office Building, beginning at 10:00 a.m. 

In view of the limited time to hear witnesses, oral testimony at this hearing will 

be from invited witnesses only. However, any individual or organization may submit 

a written statement for consideration by the Committee and for inclusion in the 

printed record of the hearing. 

DETAILS FOR SUBMISSION OF WRITTEN COMMENTS: 

Please Note: Any person(s) and/or organization(s) wishing to submit written comments for the hearing record must follow the appropriate link on the hearing page 

of the Committee website and complete the informational forms. From the Committee homepage, http://waysandmeans.house.gov, select ‘‘Hearings.’’ Select the hearing for which you would like to make a submission, and click on the link entitled, 

‘‘Click here to provide a submission for the record.’’ Once you have followed the online instructions, submit all requested information. ATTACH your submission as a 

Word document, in compliance with the formatting requirements listed below, by 

the close of business on Wednesday, January 31, 2018. For questions, or if you 

encounter technical problems, please call (202) 225–3625. 

FORMATTING REQUIREMENTS: 

The Committee relies on electronic submissions for printing the official hearing record. As always, submissions will be included in the record according to the discretion of the Committee. 

The Committee will not alter the content of your submission, but we reserve the right to format 

it according to our guidelines. Any submission provided to the 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

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/ 

Chairman JENKINS. The Subcommittee will come to order. Welcome to the Ways and Means Oversight Subcommittee Hearing on 

the Opioid Crisis, the Current Landscape and CMS Actions to Prevent Opioid Misuse. 

Good morning. I want to thank the panel for coming and welcome you all to today’s hearing, the Opioid Crisis, the Current 

Landscape and CMS Actions to Prevent Opioid Misuse. Opioid 

abuse has devastated communities across America. In 2016, more 

than 42,000 Americans died due to opioids, a level that is five 

times what it was in 1999. 

My home State of Kansas is no exception. In 2000, 35 overdose 

deaths were attributed to opioids. In 2016, 159 people died from 

opioid abuse in Kansas. Overdose deaths in America are on the rise 

largely due to opioids, which account for three out of every five 

overdose deaths. These numbers are startling, and yet many experts believe they are too low. And, unfortunately, this epidemic 

continues to get worse, which is why finding ways to address the 

problem is a high priority for this Committee. 

No community is immune to the effects of opioid abuse. Rural 

communities are hit particularly hard, as they often have limited 

access to critical services and resources to support those struggling 

with addiction. The immense cost opioids impose on society as a 

whole cannot be overstated. 

According to the Centers for Disease Control, opioids imposed an economic burden of $78.5 billion in 2013. Much of this is due to increased substance abuse treatment cost, lost productivity, incarceration, and other burdens put on the criminal justice system. Last 

year, the President’s Council of Economic Advisors estimated the 

cost to be even higher. 

In order to address the opioid crisis, we need to understand what 

the current state of the problem is. We also need to understand 

what tools are in place to address this problem and how they can 

be improved. Today we will examine how the Centers for Medicare 

& Medicaid Services, or CMS, is working to address opioid misuse 

in the Medicare Part D program. 

More than 42 million beneficiaries rely on the program for prescription drugs, including opioids. It is critical that Medicare and 

private Part D plan sponsors have the tools they need to ensure 

that opioids are provided only when medically necessary. We have 

a panel of experts that can talk about what CMS and the plan 

sponsors are doing to identify those most at risk so that appropriate interventions can be taken. 

Our witnesses today should provide the Committee with valuable 

insights into how things are currently working and what can be 

done to improve them. The Committee plans to do more oversight 

4 

on this issue as we continue to examine other ways to reduce opioid 

abuse. 

Before closing, I want to recognize that a lot of what we will be 

discussing today will be sanitized to some degree, simply through 

the use of numbers and statistics. I would like the record to reflect 

that the Members of this Committee know that there are real people, real families, and real experiences behind every number. That 

is why we are here today and we are devoting time to such a critical issue. 

With that, I want to thank our witnesses, and I look forward to 

their testimony. I now yield to the distinguished Member from 

Washington, Ms. DelBene, for the purposes of an opening statement. 

Ms. DELBENE. Thank you, Madam Chair. And thank you for 

holding this important hearing. I would like to thank our witnesses 

also for taking the time to be with us here today. 

And I would like to acknowledge our Ranking Member, Neal, and 

thank him for being here today and joining us. But I want to start 

by congratulating our new Chair of the Subcommittee on Oversight. Clapping is appropriate. No, no, I said that is good. I know 

you are a certified public accountant, and were the 37th Kansas 

State Treasurer, both of which will be valuable for this Subcommittee in particular, as we look at IRS reforms. 

I look forward to working with you on this and other things that 

are under the Subcommittee’s jurisdiction, and I hope we’ll continue to work in a bipartisan fashion on issues that are important 

to all of us, just like today’s topics. So, thank you very much, and 

welcome to your new role. And I yield back. 

Chairman JENKINS. Thank you. I now yield to the distinguished Ranking Member of the Full Committee, Mr. Neal, for the 

purposes of a statement. 

Mr. NEAL. Thank you, Madam Chairperson. Everyone in this 

room has a family member or knows someone directly impacted by 

the opioid epidemic, somebody down the street, a neighbor, or we 

have all witnessed wrenching consequences of what this has done 

to families across the country. In Massachusetts, there were 2,094 

confirmed opioid-related overdose deaths in 2016. Although overdose rates are highest for people 25 to 54, this public health emergency also affects Medicare beneficiaries. 

According to a study recently from Altarum in November of 2017, 

the economic burden from opioids was estimated to be $95 billion 

in 2016, $21 billion of which was attributed to healthcare services, 

direct and indirect cost, and $55.6 billion lost to earnings and productivity. 

In 2016, one-third of Medicare Part D beneficiaries filled a prescription for opiates. For one-third of these beneficiaries, we know 

part of the consequence. This number is too high and we need to 

explore better ways to manage chronic pain. I hope that we can 

work in a bipartisan manner to urge the Centers for Medicare & 

Medicaid Services to move quickly to implement recommendations. 

Congress and the Administration need to do more to help Americans access necessary treatment for opioid use disorders. The Administration’s emergency declaration expires next week, but nothing at the moment has progressed. Yet, another missed opportunity 

5 

for positive action. The most significant step that has been taken 

in recent years to stem the tide of the opioid crisis has been to expand Medicaid under the ACA to low-income working Americans 

who previously could not afford insurance. 

The Medicaid expansion has provided millions of previously uninsured adults with access to health insurance, which includes coverage for substance abuse and mental health services. For Medicare, the specific topic of today’s hearing, we need to look to beneficiary’s ability to access treatment, as oftentimes providers aren’t 

available to meet the need. We know there are significant groups 

and gaps in the coverage and access under Medicare that need to 

be acknowledged. 

For example, Medicare does not cover outpatient treatment programs that provide comprehensive opiate addiction treatments, nor 

does Medicare cover methadone for addiction, which is often the 

treatment of choice for long term addicts. We clearly have our work 

to do this year, and we need to stop undermining the programs 

that provide coverage and treatment for those who need it, instead, 

strengthening and improving access to care and coverage. 

And another reflection, just off the talking points. What this has 

done to labor participation rates across the country is an underreported story. When the Department of Labor recently indicated 

that there are six million jobs in America every day that go unanswered, and when you consider that there are two million people 

with opiate addictions that are sitting on the sidelines who could 

be working, that is another consequence of what has happened. 

A number of people across America, who have opiate addictions, 

who are sitting home in the afternoon playing video games rather 

than in the workforce, ought to alarm all of us, and there ought 

to be something that we can all agree to in terms of the treatment 

needs of those very people. But this has a personal consequence for 

all of us as well, as I indicated in the first sentence. We all have 

a neighbor, friend, or a relative who is battling this addiction. And 

this ought to be well beyond the consequence of partisanship in 

this institution. We ought to be trying to find some remedies. And 

I yield back my time. 

Chairman JENKINS. Thank you, Mr. Neal. 

Without objection, other Members’ opening statements will be 

made part of the record. 

Today’s witness panel includes three experts: Gary L. Cantrell, 

Deputy Inspector General for Investigations at the Department of 

Health and Human Services Office of the Inspector General; Elizabeth H. Curda, Director of Health Care at the Government Accountability Office; and Kimberly Brandt, Principal Deputy Administrator for Operations at the Centers for Medicare & Medicaid 

Services. 

The Subcommittee has received your written testimonies, and 

they will be made part of the formal hearing record. You each have 

5 minutes to deliver your oral remarks. We will begin with you, 

Mr. Cantrell. You may begin when you are ready. 

6 

STATEMENT OF GARY L. CANTRELL, DEPUTY INSPECTOR 

GENERAL FOR INVESTIGATIONS, OFFICE OF THE INSPECTOR GENERAL, DEPARTMENT OF HEALTH AND HUMAN 

SERVICES (HHS) 

Mr. CANTRELL. Thank you. Good morning, Chairman Jenkins 

and Ranking Member Neal, and other distinguished Members of 

the Subcommittee. I am Gary Cantrell, Deputy Inspector General 

for Investigations at HHS OIG, and I am excited to be here today 

to discuss efforts by the HHS OIG to combat the opioid epidemic 

in Federal healthcare programs. 

Given a long history of healthcare fraud enforcement, program 

knowledge, and data analytics capabilities, OIG is uniquely positioned to help lead this fight against illegal opioid prescribing in 

Medicare and Medicaid. 

My testimony today will highlight our work to prevent opioid-related fraud and abuse, detect questionable prescribing and billing 

patterns, and enforce laws and regulations governing opioid prescribing. 

Opioid-related fraud encompasses a broad range of criminal activity, from prescription drug diversion to addiction treatment 

fraud. Many of these schemes involve kickbacks, medical identity 

theft, and criminal enterprises. Developing these investigations is 

complex, requiring the use of confidential informants, undercover 

operations, and surveillance to gather evidence of crimes often committed by corrupt doctors, pharmacists, and criminal networks. In 

the worst cases, our special agents uncover evidence of illegal prescribing leading to patient deaths. 

Given the complexity and high stakes of these investigations, 

OIG’s partnerships with DOJ, FBI, DEA, and State Medicare fraud 

control units is critical to the success of these efforts. OIG and our 

Medicare Fraud Strike Force partners led the 2017 national 

healthcare fraud take-down. This take-down was the largest ever 

healthcare fraud take-down, resulting in over 400 individuals 

charged; 120 of these defendants were charged for their roles in illegally prescribing and distributing opioids. 

The enforcement operation brought together more than 1,000 

Federal and State law enforcement personnel, including 350 OIG 

special agents. OIG has also shifted resources to support the Attorney General’s Opioid Fraud and Abuse Detection Unit, a multiagency effort capitalizing on data, with dedicated prosecutors and 

agents focused solely on prosecuting opioid fraud in the healthcare 

system. 

OIG uses advanced data analytics to put timely, actionable information about prescribing, billing, and utilization trends in the 

hands of investigators, auditors, evaluators, and our government 

partners. A recent report identifying Medicare beneficiaries receiving extremely high amounts of opioids and questionable prescribing 

patterns demonstrates the value of this approach. 

Of note, the report uncovered that half a million Medicare beneficiaries received opioids in excess of CDC guidelines. Further, 

nearly 90,000 beneficiaries are at serious risk of opioid misuse or 

overdose. Some of these received extreme amounts of opioids, over 

21⁄2 times the CDC recommended amounts, when others appear to 

be doctor shopping. 

7 

To get to the source of this extreme use, OIG identified about 400 

prescribers with questionable opioid prescribing patterns for these 

beneficiaries at serious risk. OIG is following up on these outlier 

prescribers, and we have also shared this data with our public and 

private sector partners. This is one example of how we leverage our 

relationships and empower our partners to help us tackle this problem. 

Recognizing the growing severity of the opioid epidemic, OIG has 

initiated work beyond Medicare. The work identifies opportunities 

to strengthen program integrity and protect at-risk beneficiaries 

across multiple HHS programs. For example, OIG audits and evaluations currently underway address the broad range of opioid-related funding and activity at HHS, including opioid prescribing in 

Medicaid, transfer prescription drug monitoring programs, FDA’s 

oversight of opioid risk management program and addiction treatment services. 

OIG’s work holds criminals accountable and results in impactful 

recommendations to improve program integrity, save tax dollars, 

and protect HHS beneficiaries from harm. Key recommendations to 

combat opioid-related fraud and abuse are outlined in my written 

testimony. 

In summary, OIG will continue to focus our multidisciplinary efforts on the opioid epidemic. We will identify opportunities to improve HHS prescription drug and treatment programs, share data 

and educate the public, and identify and hold accountable perpetrators of opioid-related fraud. 

I appreciate the opportunity to speak with you today, and I 

would be happy to answer any questions. 

[The prepared statement of Mr. Cantrell follows:] 

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Chairman JENKINS. Thank you, Mr. Cantrell. Ms. Curda, you 

are recognized for 5 minutes. 

STATEMENT OF ELIZABETH H. CURDA, DIRECTOR, HEALTH 

CARE, GOVERNMENT ACCOUNTABILITY OFFICE (GAO) 

Ms. CURDA. Good morning, Chairman Jenkins, Ranking Member Neal, and Members of the Subcommittee. I am pleased to be 

here to discuss our report on the Centers for Medicare & Medicaid 

Services oversight of opioid prescribing in the Medicare program. 

Overprescribing and misuse of prescription opioids has led to significant increases in opioid use disorder, overdoses, and deaths in 

the United States. 

Recognizing this, CMS developed an opioid misuse strategy with 

a goal to reduce harm from opioid misuse in its programs. Today 

I will discuss how CMS oversees opioid prescribing under Medicare 

Part D, both in terms of the beneficiaries who receive opioid prescriptions, as well as the providers who prescribe them. 

To oversee beneficiaries, CMS relies on private insurers, known 

as plan sponsors, to monitor and take appropriate action to address 

potential opioid overuse. CMS employs an overutilization monitoring system to alert plan sponsors about very high-risk beneficiaries. These are beneficiaries receiving high doses of opioids 

from four or more providers and pharmacies or from six or more 

providers regardless of the number of pharmacies. Excluding cancer and hospice care, about 33,000 beneficiaries met these criteria 

in 2015. Plan sponsors are expected to review a quarterly list of 

identified beneficiaries, determine appropriate action, and then respond to CMS with information on their actions within 30 days. 

The use of these criteria, along with plan sponsor actions, has 

helped to significantly reduce the number of these very high-risk 

cases. 

However, CMS oversight does not address the over 700,000 beneficiaries potentially at risk of harm, based on CDC guidelines. 

These guidelines note that long-term use of opioid doses over 90 

milligrams morphine equivalent per day are associated with significant risk of harm and should be avoided unless a provider determines that it is necessary. 

This is particularly the case for patients aged 65 and older, because the drugs can more easily accumulate in the body to toxic 

levels. We recommended that CMS gather information on the total 

number of these beneficiaries over time to help assess progress in 

reaching the agency’s goals related to reducing opioid harm and 

misuse. HHS concurred with our recommendation. 

CMS oversees Medicare Part D providers through its contractor, 

NBI MEDIC, as well as through the plan sponsors. NBI MEDIC 

provides oversight by analyzing Medicare prescriber data for 

outliers and determining potential fraud. NBI MEDIC conducts its 

own investigations of potential fraud, waste, and abuse by providers, and also refers cases to law enforcement or the Office of the 

Inspector General. 

CMS also requires plan sponsors to prevent, detect, and correct 

prescriber noncompliance, as well as fraud, waste, and abuse. However, NBI MEDICS analyses to identify outlier providers focused 

19 

broadly on all drugs at risk of abuse, rather than on opioids specifically. 

We recommended that CMS require NBI MEDIC to gather separate data on providers who prescribe high amounts of opioids. This 

would allow CMS to better identify those providers who are inappropriately and potentially fraudulently prescribing high doses of 

opioids. HHS concurred with this recommendation as well. 

CMS also lacks key information necessary for oversight of opioid 

prescribing because it does not require plan sponsors to report 

cases of fraud, waste, and abuse, cases of overprescribing, or any 

actions taken against providers. While CMS received some of this 

information from plan sponsors who voluntarily report their actions, it does not know the full extent to which plan sponsors have 

identified providers who prescribe high amounts of opioids or take 

an appropriate action. 

We recommended that CMS require plan sponsors to report on 

investigations and other actions taken related to providers who 

prescribe high amounts of opioids. HHS did not concur, noting that 

plan sponsors are responsible for detecting and preventing fraud, 

waste, and abuse, and that CMS reviews cases when it conducts 

audits. 

HHS also stated that it seeks to balance the requirements it 

places on plan sponsors. However, without complete reporting, 

CMS is missing key information that could help the agency achieve 

its goals. We continue to believe that CMS should require plan 

sponsors to report on the actions they take to reduce overprescribing. 

In conclusion, having information on the total number of beneficiaries receiving potentially harmful levels of opioid medication, 

as well as complete information on providers who may be inappropriately prescribing opioids, could help CMS as it works to decrease 

the risk of opioid use disorder, overdoses, and deaths. 

This concludes my prepared statement, and I am happy to answer the Committee’s questions. 

[The prepared statement of Ms. Curda follows:] 

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Chairman JENKINS. Thank you, Ms. Curda. Ms. Brandt, you 

are recognized for 5 minutes. 

STATEMENT OF KIMBERLY BRANDT, PRINCIPAL DEPUTY 

ADMINISTRATOR FOR OPERATIONS, CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) 

Ms. BRANDT. Thank you. Chairman Jenkins, Ranking Member 

Neal, and Members of the Subcommittee, thank you for inviting me 

to discuss CMS’s work to address the misuse of opioids in the 

Medicare Part D program. 

CMS understands the magnitude and impact the opioid misuse 

epidemic has had on our communities and is committed to a comprehensive and multipronged strategy to combat this public health 

emergency. 

As Principal Deputy for Operations at CMS, I am charged with 

directing cost-cutting issues that affect all of our programs, with 

the efforts to fight the opioid epidemic being one of our agency’s 

biggest priorities. We cover over 58 million Medicare beneficiaries, 

and the opioid epidemic affects every one of them as a patient, family member, caregiver, or community member. 

CMS recognizes that its primary role in the healthcare system is 

that of a payer. And as a payer, we are focused on the unique steps 

we can take to ensure that plans comply with requirements that 

protect beneficiaries. 

For us, all of our efforts are ultimately focused on protecting the 

health and safety of our Medicare beneficiaries. Due to the structure of the Medicare Part D program, Medicare Advantage organizations and Medicare Part D sponsors are well-positioned to identify and address improper opioid utilization by working with prescribing physicians. 

Our job at CMS is to oversee these efforts and to make sure that 

plan sponsors have the tools and information they need to be as effective as possible. We do this in a number of ways. First, as my 

colleague from GAO knows, we use the Overutilization Monitoring 

System, or OMS, to help ensure plan sponsors have established 

systems and programs to help prevent overutilization of prescription opioids. 

Through this system, CMS identifies high-risk beneficiaries who 

have visited multiple pharmacies or prescribers. We then report 

these high-risk beneficiaries to plans who conduct case management or implement real time alerts at a pharmacy. This effort has 

been very successful, with a 61 percent decline in the number of 

beneficiaries meeting the OMS criteria from 2011 to 2016, even 

while Part D enrollment was increasing at the same time. 

To improve on these outcomes and to better identify high-risk 

beneficiaries, we have improved the criteria used in OMS to reflect 

the Centers for Disease Control’s prescribing guidelines. This action will allow us to better identify potential opioid overutilizers 

and is just one of the many ways we are collaborating with our colleagues in HHS to tackle this epidemic and further protect beneficiaries at high risk of opioid overutilization. 

Thanks to recent action taken by Congress, CMS now has the authority to implement a new Medicare Part D lock-in policy. CMS 

has proposed to integrate this new authority with our OMS to exVerDate Sep 11 2014 07:39 Feb 25, 2019 Jkt 033659 PO 00000 Frm 00039 Fmt 6633 Sfmt 6602 I:\WAYS\OUT\33659.XXX 33659
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pand upon our existing innovative approach to reduce opioid overutilization in the Part D program. We believe this approach will 

improve quality of care through enhanced coordination while maintaining access to necessary pain medications. 

Second, all plan sponsors are using real-time alerts, referred to 

as safety edits, to flag potentially unsafe opioid prescriptions at the 

pharmacy. When these alerts are triggered, the pharmacist must 

take an action, depending on the type of safety edit, before the prescription can be dispensed. 

Through this process, prescribers can receive important information about their patients, such as a better picture of a patient’s 

total opioid dosage and prescription history. Ultimately, this helps 

prescribers make more informed decisions about the care that they 

are providing to their patients. 

Third, CMS tracks and monitors the number of Part D beneficiaries who receive high doses of opioid prescriptions regardless of 

the number of prescribers and pharmacies being used by the beneficiary. Using this information, CMS sends monthly patient safety 

reports to plan sponsors so they can conduct case management. Ensuring that Medicare beneficiaries with substance use disorder 

have access to the most effective treatment is a critical component 

of addressing the epidemic. 

We want to make sure that we cover the right treatment for the 

right beneficiaries in the right setting, and we are working to increase access to medication-assisted treatment by requiring that 

Part D formula include MAT drugs as well as Naloxone. 

In addition to these efforts to identify and protect beneficiaries 

who are at high risk for opioid overutilization, CMS also uses data 

to identify prescribers and pharmacies with questionable opioid 

prescribing and billing patterns. Plans receive quarterly reports on 

outlier prescribers and pharmacies they can use to initiate new investigations, conduct audits, and take administration actions like 

terminating a pharmacy from their network. 

Based on a recommendation by the GAO, these reports now separate outlier prescribers of opioids from other Schedule II prescribers. 

As we move forward with our efforts to curb this public health 

crisis, CMS plans to enact comprehensive strategies from all Medicare Part D sponsors on their activities aimed at combatting the 

opioid crisis. This will help CMS better understand the approaches 

sponsors are taking from both their Medicare and commercial alliance. Once we receive this information, we will conduct an analysis 

and provide best practice guidance to all plans. 

While CMS has taken numerous steps to improve our opioid 

overutilization and monitoring programs, we know there is much 

more we can do. We appreciate the work and recommendations 

from our colleagues at GAO and OIG, and we are continually assessing how we can best utilize our tools as a payer to build on 

their recommendations to tackle this crisis. 

Thank you for your interest in our efforts to protect Medicare 

beneficiaries, and I look forward to answering your questions. 

[The prepared statement of Ms. Brandt follows:] 

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Chairman JENKINS. Thank you. And I appreciate all three of 

you being here today with your excellent testimony. 

We will now proceed to the question and answer session. And I 

would like to direct my questions to Ms. Curda. 

Ms. Curda, in your testimony, you discussed how the OMS tracks 

only a small portion of the potentially at-risk beneficiary population. Can you talk more about what GAO found? 

Ms. CURDA. Sure. We found that the criteria that CMS is currently using in its OMS tracked the very high dose—beneficiaries 

who are getting very high doses, who are using multiple doctors, 

multiple pharmacies, but they aren’t tracking the larger number of 

beneficiaries that are at risk of harm because they are receiving 

higher doses of opioids. These are those that are receiving more 

than 90 milligrams morphine equivalent dose per day, which is indicated in CDC guidelines. 

According to a one-time analysis that CMS performed, this criterion covered about 700,000 beneficiaries in 2015. So, just relatively speaking, we are talking about 700,000 beneficiaries taking 

very, very high levels of opioids, versus the OMS criteria, which is 

in the sort of more tens of thousands range. And so, we recommended that they gather that data, not just for reporting back 

to the plan sponsors, but because it has this goal of reducing harm 

from opioid use, to track and monitor that information over time 

to see what is happening with that number of beneficiaries, to see 

is it going up, is it going down, and use it to inform its strategy. 

Chairman JENKINS. Right. One of the recommendations that 

GAO made was for CMS to track beneficiaries receiving large 

amounts of opioids, irrespective of the number of pharmacies and 

providers that they used to obtain them. Can you talk about why 

you believe this to be important? 

Ms. CURDA. Sure. CMS does track very useful information on— 

using its overutilization system, and also in its in-patient quality 

measures. But neither of those measures track the larger number 

of beneficiaries that are receiving harmful doses of—potentially 

harmful doses of opioid medication. And so we think that, in routinely collecting this information, they can better inform their 

strategy and track their goal achievements. 

Chairman JENKINS. What specific data do you believe is important for CMS to track? 

Ms. CURDA. This would be the patients receiving either 90 milligram morphine equivalent dose per day or greater through Medicare. 

Chairman JENKINS. Okay. How much of that data is currently 

being utilized for CMS for these purposes, and why do you believe 

the current data CMS is monitoring to be insufficient? 

Ms. CURDA. It is basically just a measurement issue. The CMS 

tracks data, but not at that level. And they don’t use it for the purposes of monitoring this harmful use of opioids over time. So we 

believe that by collecting this information and monitoring it, over 

time they can better track whether they are achieving their goals. 

Chairman JENKINS. Okay. Thank you. I would now like to recognize Ms. DelBene. 

Ms. DELBENE. Thank you, Madam Chair. The Administration 

recently released guidance indicating that it would allow States to 

51 

implement work requirements to access Medicaid. Ms. Brandt, in 

your testimony to the Committee, you state one of the points of the 

comprehensive evidence-based opioid strategy is to ‘‘improve access 

to treatment and recovery services, and to enable individuals to 

achieve long-term recovery.’’ 

In the guidance that was put out, the Administration requires 

exemptions for individuals with medical conditions, such as substance use disorders, and outlined that medical treatment for any— 

for their substance use may fulfill a work requirement. 

My question is, how does a work requirement improve access to 

treatment? And, second, how can an individual who is suffering 

from addiction access treatment to fulfill their work requirement if 

they are not allowed to get Medicaid and can’t have that to cover 

such a treatment? So, we end up in this circular situation where 

someone doesn’t have coverage, so they can’t get treatment, but 

they can’t fulfill the work requirement because they need to be in 

treatment to do that. Can you explain how we would address that? 

Ms. BRANDT. Thank you for your question. While the work requirements and the Medicaid requirements are not my day-to-day 

responsibility, I will do my best to sort of answer, to the best of 

my knowledge. 

As part of our issuance last week, as you mentioned, States are 

required to take steps to ensure access to appropriate treatment or 

services. And one of the things that they are supposed to do is 

make reasonable modifications to ensure that people who are receiving treatment for substance abuse disorders or opioid treatments are able to have reasonable accommodations. And so we 

have worked to provide guidance to the States to help them to ensure that balance, and the goal is to ensure that the beneficiary 

who is receiving those treatments can hopefully be able to have the 

appropriate accommodations made so they can continue to receive 

it. 

Ms. DELBENE. So, if a State doesn’t come up with a work—with 

the work-around, as you describe, how would someone access Medicaid so they can get treatment if they can’t fulfill their work requirement because they can’t fulfill—they aren’t allowed to access 

treatment? 

Ms. BRANDT. Well, our goal is to work with the States to ensure 

that they would be able to provide those types of accommodations 

as part of what they are supposed to do under the mandate of the 

work requirement. And we would work with them to ensure that 

the beneficiary, hopefully, would be able to continue to receive 

those types of services. 

Ms. DELBENE. Thank you. As CMS moves more providers to 

value-based payments in an effort to improve quality and lower 

healthcare costs, part of the challenge is to properly risk adjust for 

high-needs patients. And because substance use disorder is such a 

complicated condition that demands a tremendous amount of coordination of care, this may be one of the conditions that warrants 

a risk adjustment. And, in fact, this was done for a managed care 

demonstration in Massachusetts that focused on dual eligible enrollees under 65. 

Ms. Brandt, have you considered how we can better align payment to promote coordination and quality care for people with subVerDate Sep 11 2014 07:39 Feb 25, 2019 Jkt 033659 PO 00000 Frm 00055 Fmt 6633 Sfmt 6602 I:\WAYS\OUT\33659.XXX 33659
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stance use disorders in other value-based and managed care arrangements like ACOs and Medicare or Medicare Advantage Plans, 

and how is CMS promoting coordination of care between providers 

to mitigate the instances of high amounts of opioid prescribing? 

Ms. BRANDT. Thank you for your question. As I mentioned in 

my oral and written testimony, ensuring good access to beneficiaries across our payment lines is one of the goals at CMS. And 

one of the things that we have been doing is looking across all of 

our payment types, especially as we begin the new payment rules 

for this year and as we have discussions with providers to determine where we can do more and how we can have better coordination with them on just these types of issues. 

So it is something that we are currently engaged in as an agency, 

to try to figure out better ways to make sure that we are striking 

that balance and making sure, as I said in my testimony, that we 

have the right treatment, for the right people, in the right setting, 

at the right time. 

Ms. DELBENE. I understand that the—things like the managed 

care demonstration in Massachusetts have been looking at these 

scenarios. Is there something that you have learned from these 

that will better inform us on how best to address more complicated 

situations like substance use disorders? 

Ms. BRANDT. I can’t speak specifically to the Massachusetts 

demonstration project because I am not familiar with the outcomes 

of that, but I can tell you that we have been looking at all of our 

demonstration projects, the models we run, and our Centers for 

Medicare and Medicaid innovation, as well as across the CMS programs to look at lessons learned and best practices, and we are trying to bring all that to bear as we try to figure out good solutions 

for this crisis. 

Ms. DELBENE. Thank you very much. I yield back. 

Chairman JENKINS. Mrs. Walorski is now recognized for 5 minutes. 

Mrs. WALORSKI. Thank you, Madam Chair. Thank you to our 

witnesses for being here today. Like so many of the parts of the 

country, the opioid epidemic has affected my district in Indiana. It 

has destroyed lives, torn apart families, and put stress on first responders, hospitals, the foster care system, and other vital community institutions. Unfortunately, last year a dear friend of mine, a 

doctor in my district, was murdered for refusing to prescribe 

opioids. 

Opioids come in many forms: pills, heroin, the emerging threat 

of fentanyl, and others. Unfortunately, this means that there are 

too many fronts in the fight. 

Mr. Cantrell, I just want to ask you, identifying overprescribing 

by providers is incredibly important; however, examining at-risk 

beneficiaries can also help identify providers who are potentially 

overprescribing. The Inspector General identified in my State, Indiana, a prescriber who wrote an average of 24 opioid prescriptions 

each for 108 beneficiaries who received extreme amounts. 

Can you talk about your approach to identifying potentially problematic prescribers, and then also, once these prescribers are identified, what happens? 

53 

Mr. CANTRELL. Yes, thank you. First of all, in our data brief, 

we used an analysis approach that we hadn’t previously utilized. 

We wanted to first focus on the beneficiaries who are at greatest 

risk of harm because of the volume of opioids they were receiving. 

And, instead of just looking at the universe of claims, we look then 

at the individuals, the prescribers who were prescribing specifically 

to a high number of those at-risk beneficiaries. 

So, that led us to, in our report, 400 different prescribers who 

were prescribing either to a large number of doctor-shopping Medicare beneficiaries, or to a large number of patients receiving high 

amounts of opioids. 

So, when we have this analysis, we use this data—first, we report on these results, so that we can inform the public. We share 

this information with CMS, so they can begin engaging in administrative or other review to monitor these prescribers, and we refer 

many of these out to our field offices, to our partners at the Department of Justice for criminal investigation. 

Now, with 400 different prescribers identified, it isn’t necessarily 

the case that all are committing fraud, so we sift through the data 

to identify those that appear most likely to be committing fraud, 

send them out to the field, and then, ultimately, it takes boots on 

the ground to investigate these matters and bring individuals to 

justice who have committed this fraud. 

And so it is very intensive work, and we work closely with DEA, 

FBI, State agencies, and local law enforcement, and this is a huge 

priority for us to bring individuals who are prescribing in the Medicare and Medicaid space these opioids illegally. 

Mrs. WALORSKI. And just as a followup, I have heard from doctors in my district. They would like to have access to more data so 

they know, and they are a little bit less at risk on, you know, falling into some kind of a doctor-shopping kind of a network. 

Can you talk about ways you believe we can improve data sharing to combat opioid abuse? And then, are there ways to improve 

data sharing really just while working within State privacy laws as 

well? 

Mr. CANTRELL. Well, first of all, we certainly encourage the 

utilization of prescription drug monitoring programs in every State. 

We believe these are an important tool. For us, we see Medicare 

claims data, we have great visibility there. We have a little less, 

slightly less, but some visibility in the Medicaid, but we don’t see 

cash-based transactions and other transactions like that, which the 

PDMPs would include. 

And so, we think it is vitally important for prescribers and pharmacies to check these PDMPs to make sure that they are not dispensing to doctor-shopping patients. And we look for other ways to 

share this information across both the Federal Government and 

with the States and the private sector. 

One of the things I think is most important that we have done 

is share their approach to this analysis, but also the underlying 

data with our private sector program integrity partners who we 

work with, through the Healthcare Fraud Prevention Partnership 

and the National Healthcare Antifraud Association. So they are 

empowered to conduct their own analysis, monitor these individuals, and hopefully have a broader impact. 

54 

Mrs. WALORSKI. I appreciate it. And, Ms. Brandt, just quickly, 

is—one of the things I have continued to work on here is access to 

non-opioid alternatives. Is CMS developing a plan to use more nonopioid alternatives for patients with chronic pain? 

Ms. BRANDT. Yes. As I mentioned in my oral testimony, we are 

working to increase access to medication-assisted treatments and 

are looking and working with the CDC and other partners to determine—— 

Mrs. WALORSKI. On a scale of one to ten, where are we, in looking? What have we found? What are we doing? 

Ms. BRANDT. We have done a number of stakeholder listening 

sessions over the past while, where we got a lot of valuable input, 

and we have been having meetings with NIH, CDC, and others. So 

I would say we are probably at about a six; we have more to do, 

but we are definitely moving in the right direction. 

Mrs. WALORSKI. Thank you. Madam Chairman, I yield back. 

Chairman JENKINS. Mr. Neal is recognized for 5 minutes. 

Mr. NEAL. Thank you, Madam Chairperson. 

Massachusetts, as I noted in my opening statement, is really— 

we are reeling from the addiction crisis, and your testimony was 

really well done this morning, the three of you. The number of 

opioid-related deaths in Massachusetts is now four times higher 

than it was 15 years ago, and it continues to get worse. We certainly owe it to our communities and to our families who have been 

hit by the epidemic to prevent addiction; that means earlier intervention and treating those afterward as well. 

There is a compelling argument as to the most effective way to 

treat opiate addiction for all of us. Medication-assisted treatment, 

MAT, is the evidence-based standard for treating opioid addiction. 

Medical and substance use disorder experts in the President’s own 

Commission point to MAT as a vital tool to attack the epidemic. 

Medicare is usually the standard bearer when it comes to 

healthcare coverage, but Medicare does not cover a key MAT option, methadone for outpatient service. Ms. Brandt, Ms. Curda, you 

both testified about the importance of MAT in your opening statements. 

What is the Administration doing, and what would you recommend that it continue to do or should do to expand access to 

medication-assisted treatment? 

Ms. BRANDT. Well, as I mentioned, Congressman, we are continuing to look at the wide range of alternate treatments, such as 

Naloxone and others. We are well aware of methadone and the 

statutory impediments to that, but we are open to working—I know 

you have legislation on that—we are open to working with Congress to provide technical assistance on those issues. But we can 

continue committed at CMS to determine what all we can do to increase the access to medication-assisted treatments. 

Ms. CURDA. We prepared a couple of reports on the issues surrounding access to medication-assisted treatment, not specifically 

in Medicare, but in general. The first report we did looked at the 

sort of regulatory and legal framework for access to these drugs, 

and also looked at some of the barriers to access. And there were 

things like not having enough doctors who have the appropriate 

waivers in order to prescribe this medication, and also in some 

55 

cases, simply attitudinal issues where this is viewed as perhaps a 

substitute for another kind of addiction. 

So taking these issues into account, Congress passed legislation 

last year to enhance access to medication-assisted treatment, and 

we did a further report looking at HHS’s roll-out of the grant programs intended to enhance access to medication-assisted treatment, and we found that they had a strategy for accomplishing 

this. They were getting the programs going. It was a little too early 

to assess their effectiveness, but we did note that they did not have 

any sort of measures in place for their goals for expanding access 

to MATs, so not knowing sort of what the ultimate goal is for that, 

and that they did not have sort of firm timeframes. They had 

planned an evaluation of their efforts, but they did not have any 

firm timeframes for when that would be done. 

Mr. NEAL. Thank you. I hope the Administration and my colleagues on the other side, who I know are all sincere in their efforts on this, would also be supportive of another piece of legislation that I have offered, and that would be to hold harmless first 

responders who administer Naloxone. When they show up, oftentimes there is violent reaction as the high comes down, and they 

sometimes have to subdue the individual who has just been treated; save their lives, and then are attacked for saving their lives. 

So I think holding those individuals harmless would make a good 

deal of sense, and I hope that the—in a bipartisan manner we 

might be able to address that part of this complicated issue as well. 

Thank you for your testimony, and thank you Madam Chairperson; I yield back. 

Chairman JENKINS. Mr. Schweikert is recognized for 5 minutes. 

Mr. SCHWEIKERT. Thank you, Madam Chairman. 

My assumption is that everyone in this room has been affected 

by addiction in a family member, a friend, or a neighbor. Growing 

up in a household where my mother was actually an addiction 

counselor, after years of fighting through her own demons, you actually just understand how complicated this is. 

This is actually an interesting opportunity, as the Ranking Member was talking about some of the different pieces of legislation he 

has, and I agree, we should actually start to step up and do a package, because there is no golden bullet here, no magic bullet. 

But I do want to also touch on—we have a piece of legislation, 

and it is bipartisan, we have Republicans, Democrats, and this 

Committee from E&C, and that is a mechanism to standardize the 

prior authorization process, so the electronic mechanism is underneath. 

And Ms. Brandt, I am going to ask you to sort of walk us 

through right now for Part D, how prior authorization actually is 

working today, and then I want to sort of pitch everyone on the 

Committee, the concept of, let’s actually put together a package of 

bills, hopefully our prior authorization standardization will be one 

of those. But how does it work today for Part D? 

Ms. BRANDT. Well, let me caveat by saying, I am not a Part D 

expert, so I will give you the best of my understanding—— 

Mr. SCHWEIKERT. Okay. 

Ms. BRANDT [continuing]. As to how it works. But currently the 

way it works is that the Part D sponsors have formularies which 

56 

have approved drugs on them, and as patients present, they see if 

the drugs that they are looking to receive, that are being prescribed 

to them, are off of that formulary. And then they determine whether or not, based on CDC prescribing guidelines, they meet the appropriate dosage amounts. 

Some of what the GAO was saying, we have been working to incorporate into our Overutilization Monitoring System to determine 

that beneficiaries are not prescribed beyond what are acceptable 

levels in the program. 

And so, using those types of criteria and screening, it is then determined what is appropriate to be able to authorize to be paid 

under the person’s plan. 

Mr. SCHWEIKERT. For our other witnesses—and thank you for 

that. Any other thoughts, that if I came to you—in reading the testimony, it looks like we are doing a much better job in our data 

collection and data modeling and finding bad actors. 

Okay, now that we have the data, how do you move to a solution? Is it alternative pharmaceuticals? Is it a standardization of 

the red flashing light for the pharmacy or the doctor, saying, this 

doesn’t need to be filled? You have the data; what is the next solution, what is the next layer? 

Mr. CANTRELL. One of the things that we are recommending 

and continue to monitor is the beneficiary lock-in program that has 

now been authorized and CMS is working to implement. With the 

number of beneficiaries at risk because of the volumes of prescriptions they are receiving, I think this data analysis leads us to patients that maybe should be considered for this type of lock-in, at 

least gets us started as to where to focus these efforts, and that 

will help manage the care of these individuals who need services. 

Mr. SCHWEIKERT. All right. 

Ms. CURDA. We didn’t acknowledge that issue specifically, but 

I think you can sort of take an all of the above approach, you can— 

all of these things working together can help. One thing we looked 

at, a couple of years ago, was more of a prevention focus. It gets 

very costly when it gets to the point where someone is addicted to 

opioids and requires therapy and treatment. It is much better to 

prevent the addiction in the first place; to the extent that we can 

have controls in place to flag these individuals who are getting very 

high doses, it is very helpful. 

But we did a—the Comptroller General held a forum that talked 

about prevention and talked about educational healthcare and sort 

of a legal kind of strategy. 

Mr. SCHWEIKERT. That is actually a very rational approach. In 

my last couple of moments, I will pitch our new Chairman, which 

I am elated to have you—I feel so tall next to you. There is an opportunity here for us to take a number of the pieces of legislation, 

because we know there are some alternative pharmaceuticals out 

there that actually have less addictive effects or more stabilizing 

effects. 

There is my fixation on taking the data that has been collected, 

building that standardization on the preauthorization so we stop— 

it becomes almost a preventative because you don’t write the prescription. And the uniqueness of this Oversight Committee, and its 

charter, we have the ability to do legislation. Maybe it is time we 

57 

all get together, figure out if we have solutions, bundle them together, and move forward. 

And with that, I yield back. 

Chairman JENKINS. Excellent. I yield to Ms. Chu for 5 minutes. 

Ms. CHU. Thank you. Mr. Cantrell, in your testimony you mentioned an example of drug testing or treatment fraud in which 

sober living homeowners were bribed to direct their residents to a 

specific lab for their year-end sample screenings. As you noted, this 

resulted in fraudulent earnings at the expense of sober living 

homeowners and those residents who are in recovery. 

I truly appreciate the OIG’s attention to this issue, as I have 

heard directly from constituents about the fraud and abuse that 

can occur in sober living facilities. And, in fact, the bottom line is 

we need better oversight, because not only are these bad actors 

preying on vulnerable individuals who have just left treatment, but 

institutions like the OIG are playing catch-up to find these nefarious actors, and in the meantime, more individuals can be hurt. 

So I believe we should be assisting those who have entered and 

completed treatment and who need support to make a full recovery. 

That is why I introduced the bipartisan H.R. 4684, the Ensuring 

Access to Quality Sober Living Act, and it would direct a Substance 

Abuse and Mental Health Services Administration, or SAMHSA, to 

develop a set of best practices for sober living facilities so that individuals and families with loved ones just leaving treatment can 

better identify the good actors from the bad. 

So, Mr. Cantrell, can you expand upon the OIG’s efforts to address fraud and abuse in the sober home industry? 

Mr. CANTRELL. Yes. Thank you. Sober homes have become—we 

used to talk a lot about pill mills, now we have sober homes becoming fraud mills. These aren’t services that are necessarily covered 

by Medicare or Medicaid, but they are ways to attract people at 

great risk because they are likely addicted—have a substance 

abuse disorder, need treatment, need services, but instead corrupt 

sober home owners are basically farming them out for either medically unnecessary services, treatment, or testing, or services and 

treatment that are just never provided. 

Sometimes these homes are places where individuals can continue to get drugs. And so we have all read about the horror stories 

of individuals going to these homes trying to get treatment and ultimately overdosing. So this is a problem that is of great concern 

to us. Largely, it affects us on the ancillary services side as they 

farm them out, pay kickbacks to doctors and drug testing labs. 

But it is also through the Healthcare Fraud Provisions Partnership, we know it has had an enormous impact on the private sector 

payers as well. So this is definitely a problem that we are noticing 

and we are tackling as it affects Medicare and Medicaid. 

Ms. CHU. Well, I thank you for pursuing it. 

And now I would like to address a question to Ms. Curda. We 

know that there is, of course, obviously, an unprecedented crisis, 

and we are going to have to find solutions that work for everyone, 

and that is why I believe we should be expanding our treatment 

options for a vulnerable population to include alternative medicines 

like acupuncture. 

58 

Acupuncture has been the subject of numerous studies by the 

National Center for Complementary and Integrated Health and the 

National Institutes of Health, and it has been found to be nonadditive, noninvasive, and can be good for conditions like migraines, hypertension, chronic pain, or arthritis. 

And, in fact, no less than 13 independent studies on the effectiveness of acupuncture are referenced in NCCIH’s web page on acupuncture. At a time when there is an over prescription of opioids, 

I believe that we should be opening our doors to alternative treatments like acupuncture. And that is why I introduced H.R. 2839, 

the Acupuncture for Heroes and Seniors Act, which would ensure 

that qualified acupuncturist services are covered through Medicare. 

It is currently available for individuals who receive their health 

insurance through the Affordable Care Act in States like California, as well as in some Medicaid plans, but seniors should not 

lose out. 

So, Ms. Curda, has the GAO ever studied the impact of making 

acupuncture available through traditional Medicare plans? 

Ms. CURDA. No, I don’t believe that GAO has done that work. 

Ms. CHU. Is it possible for GAO to evaluate the effectiveness of 

offering integrative health alternatives like acupuncture to opioid 

prescribing practices and government healthcare programs? Do you 

foresee any hurdles in such an examination? 

Ms. CURDA. Yes. I think GAO could look at that question. The 

hurdle would be the sort of status of the literature and evidence 

in that area. We would probably want to first do a review of the 

literature to see, you know, what does the peer-reviewed literature 

say about the effectiveness of that treatment. And we could certainly describe, you know, what that evidence lays out. 

Ms. CHU. Thank you. 

Chairman JENKINS. Mr. LaHood is now recognized for 5 minutes. 

Mr. LAHOOD. Thank you, Chairman Jenkins. And it is an honor 

to be part of this Subcommittee and Full Committee, and I appreciate the opportunity to have this subject matter before us today. 

And I want to thank the witnesses for your valuable testimony 

here today. 

I represent a district in central and west central Illinois that is 

a rural district, 19 counties. And this is an epidemic that continues 

to rage in a district like mine. And it really transcends socioeconomic—all socioeconomic categories, rural, urban, and all sectors of society. And over the last 2 years, I have held a number of 

roundtables in my district with first responders, law enforcement, 

judges, treatment center providers, and physicians, to try to understand the issue better, but also look at how we, from a public policy 

standpoint, what we can do to fix this problem. 

And as I look at the numbers in Illinois, data from 2016 shows 

that, in a 3-year period, deaths from overdose increased by 44 percent from 2013 to 2016, and over 80 percent of those deaths were 

attributed to opioids. Of those 80 percent of opioid-attributed 

deaths, there was a 70 percent increase from those attributed from 

opioids in that same 3-year period. 

In Adams County, in my district, they have seen a 360 percent 

increase in emergency department visits related to opioid and herVerDate Sep 11 2014 07:39 Feb 25, 2019 Jkt 033659 PO 00000 Frm 00062 Fmt 6633 Sfmt 6602 I:\WAYS\OUT\33659.XXX 33659
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oin overdoses over that 5-year period from 2010 to 2015. Additionally, the county saw a 300 percent increase in overdose mortality 

rates due to opioids and heroin in the same period. 

And looking at what is the solution, obviously, we have looked 

at—from a law enforcement perspective, what do we need to do on 

the criminal justice side? Also looking at how you hold doctors accountable, and what we do in that space. We have talked a lot 

about, you know, how we have more resources and money for treatment centers. 

And in some ways, when we look at this epidemic and the direction we are going, I equate it in some ways to what drunk driving 

was in this country 25 years ago. It was raging out of control, so 

what did we do? We allocated resources, we raised awareness, we 

had a public campaign, and we also had something called Mothers 

Against Drunk Driving that was organic that started. 

So I don’t necessarily think this is a Federal solution, this is 

going to be solved in Washington, DC, and that we have to work 

with our local stakeholders in our different States and local areas 

that are doing a lot of good work on this. And so when I think 

about the testimony here today, Mr. Cantrell, I wanted to ask you, 

you talked a little bit about prescription drug monitoring systems. 

In terms of States that have done a pretty good job on that, can 

you talk about examples of that, which have kind of been a model 

for how to do it, and what they have done to be successful? 

Mr. CANTRELL. The OIG hasn’t completed any work on evaluating PDMPs across the country. But in just talking to our staff 

across the country, our special agents, and hearing from individuals who work in different States, there are a couple of things that 

need to happen, I think, to make a PDMP successful. 

One, it has to be—there needs to be some sort of requirement 

that data be entered in a timely fashion. I think that, for those 

that are successful, there is timely data entry, there is timely review of that data. Sometimes there needs to be interoperability. 

Some of these PDMP systems don’t talk from State to State, and 

we see many fraud schemes, of course, that cross State lines. 

So the States that have interoperability with their neighboring 

States, that is a plus. And then we have seen, in terms of data access, for us in law enforcement, some States restrict access for law 

enforcement, and other States allow that sort of access. From my 

perspective, of course, I believe in that law enforcement access to 

help identify those individuals who may be prescribing or doctor 

shopping in seeking to divert drugs. So those are some of the components of what I think can make up a successful PDMP. 

Mr. LAHOOD. And is there an example or a model you can point 

to that has done a pretty good job around the country? 

Mr. CANTRELL. I just heard anecdotally that, as Kentucky got 

started, they were doing a pretty good job; they are one of the earlier ones that I was hearing about. I have heard that the State of 

New York, from our agents, is doing a pretty good job, but I don’t 

have any data or any statistics to point to their success or favor. 

That is just anecdotally what I have heard from some of our 

agents. 

Mr. LAHOOD. Thank you. 

Chairman JENKINS. Mr. Crowley is recognized for 5 minutes. 

60 

Mr. CROWLEY. I thank the Chair, I thank the Ranking Member 

for holding this hearing today on what has become a devastating 

epidemic for our Nation. My district, like many other districts 

across the country, has been ravaged by the opioid epidemic. More 

Bronx residents die of drug overdoses—more Bronx residents died 

of drug overdoses in 2016 than any other New York City borough. 

Out of the 308 overdose-related deaths, 85 percent involved 

opioids generally, and 76 percent involved heroin or fentanyl. This 

devastation is unaccepted anywhere. But there is an aspect in my 

district that is notable, part of the opioid epidemic when compounded with other parts of the country. 

The increase in prescription opioids across the country has led to 

a spike in heroin use, which people turn to for a more potent high 

as they run out of their prescription medications. Heroin has become even more accessible and cheaply available to communities 

across the country. 

In a community like mine, which is still recovering from the 

aftermath of the failed tough on crime tactics of the 1980s and 

1990s, residents have not properly dealt with their addictions and 

are more likely to use and abuse newly available heroin. That 

makes opioid-related overdoses a side effect of the race-based drug 

enforcement policies of the past. 

As we work to address the opioid epidemic, I encourage this Administration and my colleagues in Congress to work toward a more 

holistic approach that focuses on treatment rather than punishment. And I challenge all of us to strive for a better understanding 

of the entirety of the epidemic, which impacts different communities on different levels. 

Urban communities, particularly communities of color, must be a 

part of this conversation, and they must be a part of the solution 

to this terrible and growing problem. 

Mr. Cantrell, in the OIG report, Opioids and Medicare Part D, 

there are concerns about extreme use and questionable prescribing, 

and it suggests that prescribers are not checking the State prescription drug monitoring databases, or these databases do not 

have current data. 

Can you explain how prescribers are trained or are supposed to 

be trained on how to use their State prescription drug monitoring 

database? 

Mr. CANTRELL. I am sorry, but I don’t actually know the training requirements for the use of these prescription drug monitoring 

programs. And I would suspect it might vary from State to State. 

Mr. CROWLEY. Do you have State-based data on where there 

are vulnerabilities of prescriber use of prescription drug monitoring 

databases? 

Mr. CANTRELL. We do not at this time. 

Mr. CROWLEY. Thank you. What are HHS–OIG’s recommendations for improving prescriber use of these databases? 

Mr. CANTRELL. Education is certainly one strong component. 

And we, along with the DEA, who goes around the country talking 

to pharmacists and prescribers, participated in these events to 

train and educate individuals in the community about the importance of this tool and the fraud schemes that they should be lookVerDate Sep 11 2014 07:39 Feb 25, 2019 Jkt 033659 PO 00000 Frm 00064 Fmt 6633 Sfmt 6602 I:\WAYS\OUT\33659.XXX 33659
61 

ing out for when utilizing these tools. So I think education is critical. 

And I, once again, this is not based on any analysis that we have 

done, but I have just heard there are some barriers to utilization 

because it can take a long time to access these PDMPs as they are 

providing patient care. 

I have heard from individuals in the community that sometimes 

just the nature of the system can, maybe it is slow, and it can deter 

you. So I think that obviously any improvements that can be made 

to increase the timeliness of these sorts of data checks would be 

critical to ensuring adoption and use. 

Mr. CROWLEY. I think there is one critical area in terms of government that can be involved in helping to get a handle on what 

is happening in each of the States. And I would hope that we 

would have a more robust addressing of the monitoring databases. 

Mr. Cantrell and Ms. Curda, does the OIG or GAO look at race 

as a factor in collecting data regarding the opioid epidemic? 

Mr. CANTRELL. We do not. 

Ms. CURDA. We have not looked at that. 

Mr. CROWLEY. Well, thank you. And I appreciate your time 

here today. 

Thank you very much. I yield back. 

Chairman JENKINS. Mr. Bishop, you are recognized for 5 minutes. 

Mr. BISHOP. Thank you, Madam Chairman. Thank you to the 

panel for being here today and providing your valuable testimony. 

I appreciate the information that you shared and your expertise. 

I am from the State of Michigan. I share all the same concerns 

that the rest of the Committee has on this subject. Each of us has 

our own stories to tell. Over and beyond the direct impact on families and individuals who are impacted by this scourge of opioid 

abuse, there is another statistic that I find alarming. 

The American Enterprise Institute recently published a study 

looking at the cost of the opioid epidemic. And it did it by State. 

And I was astounded to see that in Michigan, where I am from, my 

home State, the cost of opioid addiction is over 4 percent of our 

State’s GDP. And yet I look at other States on this table that we 

have been provided, and it shows other States that have also been 

impacted, but not to the extent that other States have. 

There is a huge disparity in how much other States have been 

impacted. For example, the White House Council of Economic Advisors, it estimates the societal burden to fight the fatalities from 

opioid overdoses, and also estimated the nonfatal cost of the opioid 

epidemic in 2015 to be $72.3 billion, and the fatal cost to be $431.7 

billion. And then you look at the State by State, and you see the 

huge disparity. 

And I am wondering, why does it cost West Virginia, which has 

the highest per capita burden at $4,793 per resident? And then you 

look at Nebraska, which is $465 dollars per resident. Why is that? 

Are there more resources there? Is there some kind of demographic 

there that is more susceptible to this? What causes this kind of 

data? 

Can someone tell me that? Mr. Cantrell. 

62 

Mr. CANTRELL. Just in terms of what we see, what we focus 

on, fraud trends, you know, there is a variety of factors, but we 

definitely see that once a fraud scheme takes root, it becomes viral 

in communities. And that is no different, I think, than in the opioid 

epidemic. And our agents, unfortunately, in the Detroit area, see 

numerous fraud investigations related to illegal opioid distribution. 

And sometimes we are told that it is an export area. So that those 

drug schemes are meant to often export those drugs to other States 

where they can get higher reimbursement. 

So this is the intelligence, you know, we hear from the ground. 

Once again, I don’t have any analytics available to point to reasons 

why one State is different than the other, but, you know, we have 

continued throughout my career, my 20-year career, certainly to 

see South Florida as a hotspot or an epicenter of healthcare fraud 

in general. It has also been a point where we have seen lots of 

fraud related to opioids. Certain communities where this has taken 

root, it is hard to get rid of it once it has taken root. 

Mr. BISHOP. But you can identify those areas, those demographics where this kind of abuse and fraud happens. You have indicated that you have an opioid abuse and fraud program that you 

administer. Can you tell us how that works and what the resources 

are? Who is in charge of it? What is your mission in that organization? 

Mr. CANTRELL. So, that is a new unit, established by the Attorney General just last year. As it was initiated, they rolled out 12 

prosecutors in 12 districts around the country to focus specifically 

on this epidemic. And as a partnership, FBI, OIG, DEA, we all 

dedicated agent resources to those prosecutors. 

Now, that is just a small, at this point in time, kind of effort in 

comparison to the total effort nationwide in this area, but it is an 

important focus in areas that were not necessarily the bigger markets that had the greater resources. We focused on smaller markets 

in these first 12 districts to bring resources to various communities 

that hadn’t necessarily seen the amount of resources in the past. 

Mr. BISHOP. Thank you for that. You also mentioned there were 

private sector partners as well. I am interested to know what the 

private sector is doing to partner with you. 

Mr. CANTRELL. So we talked, and CMS is an integral part of 

the healthcare fraud prevention partnership, but it provides a community of private sector payers, State agencies, as well as Federal 

payers and law enforcement to share, first of all, information about 

trends and schemes, but, also, it is a forum where they can safely 

share data from different resources, analyze that data, and come 

up with answers or identify issues across multiple data sources 

that were previously available to be searched across. 

So I think, for me, it is certainly of great value in learning about 

these schemes, because some of these schemes, like the sober home 

scheme that was discussed earlier, I was hearing about it from our 

private sector partners before we were seeing it impacting Medicaid or Medicare. And so it is a great intelligence tool. 

Mr. BISHOP. Okay. Thank you so much. And I yield back. 

Chairman JENKINS. Mr. Meehan is recognized for 5 minutes. 

Mr. MEEHAN. Thank you, Madam Chairman. I am grateful for 

you allowing us to sit in on this very, very important issue. And 

63 

I want to thank you for the work that you are doing, each of the 

panelists, engaged in what is a remarkable challenge for all of us, 

and particularly back in our communities. 

I want to ask specific questions about the Medicare relationship 

to this, but in my own region of southeastern Pennsylvania, we 

have seen a staggering 83 percent increase in drug deaths. That is 

overwhelming. And when you look at what is driving that, the distinguishing issue appears to be fentanyl, but it is fentanyl which 

is tied to its use with, oftentimes, opioids. And I know we are dealing with a poly-drug environment, and there is no simple solution. 

But if we are going to have an impact on this, we want to start 

by dealing with the opioid abuse in the first place. We have worked 

on some programs here in Congress with things that we have done 

already that have come from recommendations from people like 

you. One of those is the Medicare lock-in. And I have listened to 

each of the panelists describe in various ways how individuals have 

been able to utilize the system, either by going to multiple pharmacists, or multiple doctors, or multiple plans to get the drugs. 

And still staggering, that even with Medicare, we are talking about 

people who are later in life—often, not all the time—but later in 

life, and we are still talking about dependency in that group. 

So the lock-in program, as I understand right now, Mr. Cantrell, 

would allow us to have a designated distributor and a much better 

control over that individual’s relationship. Now, there have been 

recommendations and utilization by numbers of plans, but CMS 

itself, or at least the government, hasn’t created it. Can you tell me 

where we are on that, where you think lock-in may be utilized? 

Mr. CANTRELL. Well, first, I will say we are very supportive of 

lock-in, but I think I would like to defer to my colleague from CMS 

to talk about where it stands. 

Mr. MEEHAN. Is this Ms. Brandt? 

Ms. BRANDT. Yes. 

Mr. MEEHAN. Because I was going to go to you next because 

you—— 

Ms. BRANDT. No problem. 

Mr. MEEHAN [continuing]. Mentioned that in your testimony. 

Ms. BRANDT. I am happy to. As I mentioned in my testimony, 

we really appreciate this, this additional tool from Congress. We 

agree with the OIG. We think this is going to be a very powerful 

tool. We are currently in the notice and comment period for this. 

We have to promulgate regulations to implement it. In fact, the 

comment period closed yesterday, so that’s good timing with the 

hearing today. 

But we are looking forward to reviewing those comments and 

then implementing those comments as we do the final rule. And 

then, beginning in 2019, we will be able to begin using this tool. 

And we are very excited at the potential that it is going to add to 

our suite of tools to help us address these types of issues. 

Mr. MEEHAN. How do you think it is going to make a difference? 

Ms. BRANDT. Well, it will make a difference because it will 

allow us, as you said, to limit. We will be able to limit a beneficiary 

to a pharmacy and be able to have them at one pharmacy. And 

that is the only place, or however it works out for implementaVerDate Sep 11 2014 07:39 Feb 25, 2019 Jkt 033659 PO 00000 Frm 00067 Fmt 6633 Sfmt 6602 I:\WAYS\OUT\33659.XXX 33659
64 

tion—we are still working all that out—but essentially, they could 

be limited to one pharmacy, which would allow us then to be able 

to see their billings just related to that pharmacy. Right now, they 

can go to multiple pharmacies, multiple prescribers. This limits the 

scope of that much more narrowly. 

Mr. MEEHAN. Okay. If you know, because I am sure the comments have come from a variety of places, but I am assuming you 

have been monitoring this as we have been going through the comments. Have there been any observations which have influenced 

your thinking on this or any kind of a perspective that was shared 

in the comment period that either opens up a new place for us to 

consider the program or a concern that we may not have been 

thinking about? 

Ms. BRANDT. Well, as the comment period did just close yesterday and because it is open rulemaking, I am afraid I can’t speak 

to that, sir. 

Mr. MEEHAN. Okay. 

Ms. BRANDT. But as we move forward and have things that we 

can share, we will be happy to do so. 

Mr. MEEHAN. Okay. Well, I appreciate that. May I just ask if 

anybody has a thought on one other problem that I am hearing 

quite a bit about, and it does relate to opioid abuse, but it is the 

abuse of treatment programs in certain States in particular, in 

which people appear to get treatment for a period of time, they go 

off, and there are almost finder’s fees to get them in, and they walk 

out. 

And people are targeting them to get them readdicted, getting 

them back into treatment so long as there is a payer, they are in, 

then they pull them out. And some of these things appear almost 

to be scams. Is anybody looking at this issue, or does anybody have 

any thoughts? The OIG. 

Mr. CANTRELL. Unfortunately, we are seeing a great deal of 

fraud relating to the treatment side of this epidemic, where we 

need legitimate services the most. 

We discussed the sober homes where addicted residents are 

sometimes farmed out for lab testing that is either never provided 

or isn’t appropriate, and they are billing thousands of dollars for 

these residents, for these tests. They are offered counseling, which 

once again is never provided or isn’t the quality of counseling that 

actually these individuals need. 

And unfortunately, we are also seeing, in terms of some of the 

medication-assisted treatment, which, I think, many have discussed the importance of increasing access to that, we are seeing 

fraud schemes relating to this, the availability of these drugs that 

are intended to treat this crisis. 

So the fraud has followed this epidemic from source all the way 

to treatment. And that is the unfortunate thing that we are seeing 

around the country right now. 

Mr. MEEHAN. I would love to follow up more with you on that, 

but, Madam Chairman, I yield back. 

Chairman JENKINS. Mr. Blumenauer is recognized. 

Mr. BLUMENAUER. Thank you very much, Madam Chair. And 

I do appreciate our Subcommittee having this hearing. I think this 

is the first time Ways and Means has really dealt with this opioid 

65 

crisis and the impact it has on the things that we are responsible 

for. 

I hope it is not the last. I hope that there is an opportunity— 

I think this is one thing that touches us all that we feel strongly 

about. It certainly impacts our community. It makes a difference in 

terms of employment. What is it, for one-quarter of the women who 

are ineligible of being in the workforce, there is an opioid problem, 

I am told. 

I am concerned that, as we are looking at different therapies, different options, there is a way to focus on something that some of 

our States have done, the State of Washington, the State of Oregon, dealing with medical marijuana. And I have some material, 

Madam Chair, that I would like to place in the record that makes 

it clear that States that have worked with medical marijuana prescribe fewer pills. 

[The submission for the Record of Hon. Earl Blumenauer follows:] 

66 


33659A.039
67 

f 


33659A.040
68 

Mr. BLUMENAUER. There is, on average, a 25 percent lower 

rate in terms of overdose deaths. The State that has had it the 

longest, medical marijuana, California, it is a third less. It is a 

cheaper alternative. It is not addictive, the way that we see with 

many of the opioids that have been handed out like Tic Tacs. 

It is an area where the public has demanded change. Politicians 

haven’t brought medical marijuana to 29 States. It has been the 

public that has voted for—at least—excuse me, I guess Vermont is 

in the process of being the first State that does it legislatively. But 

this has been driven by individual voters. It is supported by strong 

majorities of the American public. Florida approved, in 2016, a 

medical marijuana program with 71 percent of the population. 

I would hope, Madam Chair, that we would have an opportunity 

to explore what the impacts are in terms of how Cannabis can prevent dose escalation and the development of opioid tolerance, which 

happens with people who are taking oxycodone or something like 

that. 

We have the opportunity to be a viable first-line analgesic. We 

have an opportunity to make a big difference with our veteran populations, who, sadly, we have policies in the Federal Government 

now that prevent VA doctors from even talking to veterans about 

the implications of medical Cannabis, even in States where it is 

legal. 

And I think we are missing a huge opportunity to help a troubled 

population, to cut down on the overdose deaths and save substantial amounts of money and, while we are at it, squeeze the black 

market, which is fueling a lot of other illegal activities. 

I hope, Madam Chair, that my colleagues will have a chance to 

look at the materials. It just happens to be from a physician, a researcher from Oregon. I hope you won’t hold that against it, but 

the whole second page is documented in terms of justifying the 

points that I am making. 

This is something that we are no longer going to be able to avoid. 

The public is demanding it; 95 percent of the population has access 

to some form of legal marijuana. We have the so-called Charlotte’s 

Web Law, where it is a low CBD dose that is available for children 

with severe seizure disorders. But when you put all that together, 

it is 95 percent of the population. The American Legion has come 

forward saying let’s research this, let’s look at it. We are hearing 

from veterans that it makes a difference. 

Last month I was at our VA hospital, and we were dealing with 

this precise subject of opioid addiction. And I happened to raise, in 

the course of the meeting, I said we ought to be looking at medical 

marijuana and the impact it has. When I walked out of the room, 

I was followed by a veteran who was on the staff, who took my 

hands and said, ‘‘I am glad you raised that. I couldn’t survive without medical marijuana.’’ 

I think we are missing the boat if we don’t dive into this. And 

I would commend this to my colleagues for their attention. Thank 

you very much. 

Chairman JENKINS. Mr. Reed is recognized for 5 minutes. 

Mr. REED. Thank you, Madam Chair. And as I was listening to 

some of the exchanges, I wanted to take a moment before I got into 

my prepared questions. My colleague from Washington asked about 

69 

the work requirements for Medicaid, potential issues, and somehow 

that impacts substance abuse providers. And one of the things that 

it reminded me of is often Medicaid, and I know it is not the jurisdiction of this Committee, but Medicaid’s—I seem to get the impression—goal of providing insurance coverage is the only metric 

that a lot of folks here in DC gauge its success by. 

By that I mean getting people into Medicare programs, therefore, 

they have health insurance and, therefore, our job is done. But I 

think we can do better than that. 

And, Ms. Brandt, I think your response to that question illustrated CMS’ point of view that we can go beyond just insurance 

coverage and actually get to making people healthier. And so one 

of the questions I have for you when I want to understand the 

work requirements that are being proposed is: if someone is in 

treatment for drug addiction, I look at drug addiction as a disease. 

It is a medical-related situation. That individual, to me, is not an 

able-bodied individual as those work requirements I have advocated for over the years would envision. 

If someone is seriously addicted and in in-patient-type treatment, 

is it CMS’ position that that individual is able bodied as we are trying to define it under the proposed work requirements that are 

being discussed across the country today? 

Ms. BRANDT. Thank you for your question. I am not sure I can 

specifically answer our definition of able bodied because, again, the 

work requirements are outside of the realm of what I deal with 

day-to-day, but I can tell you, as I mentioned before, that our goal 

is to make sure that States have steps that they are taking to ensure access to appropriate treatment services, particularly for those 

who have substance use disorders or opioid disorders. 

So if there are people with addiction issues, our goal is to work 

with the States to ensure that they are providing access to those 

services and that they are giving appropriate—— 

Mr. REED. If that addiction is a disease and that prevents them 

from being able bodied, I would hope that our official policy position would be that that is not who we are addressing with our work 

requirement. 

The other issue that I would raise on this that I am so passionate about, is one of the things that I hear from our employers 

across the country. One of the barriers to reemployment—which is 

empowering to individuals, employment, a job, an opportunity, does 

a lot for, not just earning their paychecks, but for their soul and 

their dignity and mental health and their physical health—is being 

addicted to drugs; not being able to pass a drug test. 

So we have a program under Medicaid or Medicare that is trying 

to address opioid addiction; does that not help us to try to solve the 

overall issue, when it comes to the example for Medicaid, in regards to getting people empowered to be put back into the workforce by getting their addiction under control and having the goal 

of, not just insurance coverage for those individuals, but also the 

services and the treatments necessary to get them into a healthy 

position, which removes that barrier to reemployment that I am 

discussing here today. 

Would you agree with that? 

70 

Ms. BRANDT. Well, as I mentioned, our number one goal is the 

beneficiary. Our goal is to make sure we are getting the right treatment for the right people at the right time, to help get them to be 

as able bodied and productive as possible. 

Mr. REED. I appreciate that. And I share that commitment. And 

I hope our policies here at the Federal level achieve that, as we set 

them into a potential future course. 

Now to my more prepared remarks. You know, one of the things 

that I have seen, as all of my colleagues have seen across this 

country, is that opioid addiction is something that knows no barriers. It impacts everyone. It doesn’t delineate, you know, how 

much money you have, what kind of family you were raised in, 

what race you are, whether you are a man or a woman. Addiction 

is that demon that knows no boundaries, in my humble opinion. 

And I am reminded of Vanessa, who we were able to assist 

through our office in the district, who was pretty much written off. 

Her parents pretty much adopted the tough love approach. And 

Vanessa came to us just recently after going through some very difficult times. And working with her parents, we were able to get her 

into a rehab situation. And her parents and her reunited, and at 

a town hall they were able to declare that she was opioid-free. That 

is a success story. 

And so when I see the new programs that are coming out of 

CMS—I know I only have 24 seconds left—the Overutilization 

Monitoring System shows that we went from 29,000 in 2011 down 

to 11,000 in 2016, for at-risk beneficiaries. That is a significant improvement. How are we going to enhance and promote that type of 

program even further and get that into the system? 

Ms. BRANDT. Well, we are continuing to constantly update that 

Overutilization Monitoring System. Most currently, we updated it 

to reflect the newest CDC guidelines. We have been very much focused on first-time opioid over-utilizers. And in fact, we have seen 

a 77 percent reduction in those since 2013, and we are continuing 

to use the work of our colleagues at GAO and the OIG and their 

recommendations to further refine our approach. 

Mr. REED. I appreciate that. And to all the Vanessas out there, 

I just say we stand ready across both aisles to join hands to serve 

their needs and address their addiction to get them into that 

healthy life. 

With that, I yield back. 

Chairman JENKINS. Mr. Curbelo is recognized for 5 minutes. 

Mr. CURBELO. Thank you, Madam Chairman, for this opportunity. And I thank all the witnesses. I am from South Florida, so 

regrettably, I have to raise the issue of healthcare fraud in this 

context, given that, unfortunately, we are known throughout the 

country for that issue. 

Mr. Cantrell, can you describe some of the types of fraud 

schemes that you see out there related to opioids? And if you have 

any examples that are specific or relevant to South Florida, I would 

appreciate those as well. 

Mr. CANTRELL. The fraud schemes, unfortunately, in many 

cases, we see them migrate from South Florida to other parts of the 

country. We found it to be a place where fraud schemes are born, 

in some instances. I know you know this, but that continues to be 

71 

an important area for our work in healthcare fraud. But in terms 

of opioid-related fraud, it runs the gamut. 

We have seen situations where we have bad prescribers who are 

receiving kickbacks, who would write opioid prescriptions and also 

write prescriptions for other noncontrolled, high-expense drugs and 

get paid a kickback by a pharmacy. The pharmacy will dispense 

the opioid and never dispense the expensive drug, keeping all the 

profit that is paid by Medicare for that drug that was never even 

dispensed or medically necessary. That is one very egregious 

scheme. 

We have seen examples of physicians who have gone into business with known criminal networks, outlaw motorcycle gangs, for 

the sole purpose of illegally distributing Oxy’s and pairing up with 

known drug dealers. Sometimes we call them marketers or patient 

recruiters. In this case, in this area of fraud, they are simply pairing up someone who wants the drug with a pharmacy who is willing to get the drug for a kickback in most of these situations. 

In some of these cases, this overprescribing leads to overdoses, 

and, unfortunately, sometimes an overdosed death for those who 

have been overprescribed. And so these schemes are not unique to 

South Florida. These are par for the course, and we are seeing 

these types of schemes around the country. 

Some of the things that we have seen in places like South Florida and New York are schemes related to HIV medications, which 

are very expensive. And so we have individuals who have HIV, 

need the medication, but are willing to, in essence, sell it back to 

a pharmacy for a kickback or sell it on the black market for a profit. 

So schemes like this, whether they are related to opioids or other 

expensive noncontrolled drugs, are certainly present in South Florida, but also in other areas of the country. 

Mr. CURBELO. And do you think that government is doing 

enough to mitigate this, to address this? Do you think that law enforcement has the resources to pursue these types of cases? 

Mr. CANTRELL. I will say that I don’t think we have the law 

enforcement resources to address all the complaints that we have 

coming through our system. So there is more fraud out there than 

we are certainly able to address, given our resources. So what we 

do is utilize the data that we have available to us to maximize the 

use and the impact of the resources that we have. 

So we focus our efforts in places like South Florida, whether it 

is South Florida or somewhere in Indiana, wherever the highest 

impact or the most impactful fraud schemes are, where there are 

potentially patients at risk or where there is certainly lots of 

money being stolen, we will focus those resources, utilizing data 

and also intel from the street, if you will, allowing traditional law 

enforcement methods to focus on the right areas. 

There is, I think, more that we can certainly all do. And we have 

discussed some recommendations for CMS and identified many 

areas where they are going to improve their monitoring in this 

area, but it is a huge, enormous issue that requires resources and 

focus from a lot of different agencies. 

Mr. CURBELO. Thank you very much for that response. And I 

would just encourage all of my colleagues—we focus on the victims 

72 

of opioid abuse, and we should because they are the ones suffering, 

but I think we also have to shine the light on the criminals and 

find a way to put a dent in all of these fraudulent schemes and operations that really open the door for so many vulnerable Americans to this type of addiction. 

So I thank you, and I hope that we can begin in South Florida, 

just a place where a lot of these schemes begin, that perhaps we 

can begin solving the problem there. 

I appreciate it. 

Chairman JENKINS. Mr. Paulsen is recognized for 5 minutes. 

Mr. PAULSEN. Thank you, Madam Chair, for putting this hearing together and for our witnesses today. 

We have all heard the stories of tragedies of opioids that are impacting real people. These are real families and very heartbreaking 

stories of addiction and death. It is no different in Minnesota. I 

mean, in 2016, the most recent year of data that we have, we have 

seen a 12 percent rise in opioid deaths over 2015. So Minnesotans 

are suffering through this epidemic as well, like so many other 

States. 

And one of the challenges that we have seen and had is that the 

theft of opioids from either pharmacies or even from people’s trash 

has been occurring, where it is a problem due to outdated disposal 

techniques or information about how to properly dispose of opioids. 

So many people are now simply throwing them away and thinking 

nothing of it. Safe home disposal of unused and unwanted medications is one of the ways or tools to prevent theft and abuse from 

inappropriate access to these painkillers or prescription painkillers. 

We know that many people, including younger people, in particular, start on this path to addiction and overdose by stealing 

medications that are prescribed to others. So we have a company 

in Minnesota that I toured not long ago, Vertitech, that makes a 

very low-cost, easy-to-use, safe disposal bag that properly and completely disposes of opioids, patches and pills. It is a little different 

than going to a senior fair that I have hosted where maybe the 

Hennepin County sheriff comes in and they have a proper disposal 

technique or facility that is filled immediately with seniors who 

come in and dispose of their medications. 

So Ms. Brandt, let me just ask you, is CMS considering ways to 

help encourage Medicare and Medicaid beneficiaries to dispose of 

unused and unwanted medications as part of a more comprehensive strategy to confront this epidemic that we have? Or are you 

aware of the role that these drug deactivation bags can have in this 

space? 

Ms. BRANDT. Well, one of the interesting aspects of my job is 

that I get to meet with and talk to a lot of people. And as I mentioned earlier, one of the things we did last fall was have a number 

of stakeholder meetings. And as part of one of those stakeholder 

meetings, this topic came up, and there was actually quite an active discussion about the disposal of drugs. And one of the things 

that we talked about was the types of bags that you are describing 

and how effective those can be in environments. 

We also have heard from CVS, Walgreens, and several of the 

other pharmacies about ways that they have been doing things 

within their pharmacy networks to encourage that. So at CMS, one 

73 

of the things we have been looking at is how we can partner with 

our partners at CDC, the Drug Enforcement Agency, and others to 

really work to educate beneficiaries about the safe disposal of 

opioids and other types of drugs and the full range of tools available to them to dispose of them. 

Mr. PAULSEN. That is great. I would encourage you to stay in 

touch with us or Members of Congress, obviously, to support this 

work that you are doing now around the safe medication disposal 

strategies that you are looking at, and certainly to partner with 

you. If there are any opportunities to do that, please let us know. 

Ms. BRANDT. Absolutely. It is always helpful for us to hear 

about the strategies that you all are seeing in your communities 

and then have that dialogue. And we will definitely keep in touch. 

Mr. PAULSEN. Thank you, Madam Chairman. I yield back. 

Chairman JENKINS. I recognize Mr. Kelly for 5 minutes. 

Mr. KELLY. Thank you, Madam Chair. And thank you all for 

being here. 

I think Mr. Reed hit on a lot of different aspects about the personal involvement that we all have. And knowing too much about 

it because of going through things personally. And the quote that 

is out there or the saying that says ‘‘where we are all involved, we 

are either dependents or codependents.’’ But what I wonder about 

is, I mean, this started, this war on drugs actually started back in 

1970 with the opium wars, with President Nixon. And I think in 

the early 1970s, with President Reagan. Mrs. Reagan said to ‘‘just 

say no’’ and Mr. T said ‘‘just say no.’’ 

So I don’t think it has been for a lack of concern, and it certainly 

hasn’t been for lack of dollars that we have spent. I am in the automobile business. I don’t want people to confuse what I am saying 

here. I am just saying that we do have the ability to track so many 

things. 

I mean, if you were to come into the dealership today and ask 

me about a car, I can tell you the complete warranty history on 

that car, everything that has been done to it. The question then becomes, if we have this ability, why aren’t we able to incorporate it 

with people who prescribe drugs? And maybe it is because of the 

HIPPA Act, I don’t know, but we have so much technology out 

there today that allows us to really get an in-depth look at who it 

is that we are talking about, what they are prescribing, and who 

is getting the benefits of this. 

So, Mr. Cantrell, I have heard from many healthcare providers 

who were frustrated with the HIPPA law that prevents their ability to coordinate care for substance disorder patients that are frequent fliers of their emergency departments. 

If the law were amended to allow care coordination, does HHS 

have a sense of how much Medicare, Medicaid, and private plans, 

that cost would go down? There is a tremendous—the totality of 

this is just overwhelming. And I think sometimes we get confused. 

If we could just throw more money at it, we could get it fixed. We 

have thrown so much money away and seen nothing but an increase. Is there a better way to use this data and to coordinate it? 

Mr. CANTRELL. We don’t have any estimates of the impact of 

that sort of change, but I absolutely agree that there are more opportunities to utilize this data to more effectively manage this 

74 

issue, this crisis. And for Medicare, we have fairly good, strong 

data related to opioid prescribing. 

In Medicaid, it is an area where we still lack visibility across the 

country, and it inhibits, we think, CMS’ ability to oversee the Federal dollars that go out to Medicaid that relate to this opioid crisis, 

and it doesn’t allow us to get a handle on the scope of the problem 

in Medicaid without going, in essence, State to State. 

There is a system that CMS is working on to improve the access 

to that Medicaid data, and we think, as they continue to improve 

that data and get timely, full, complete data from all 50 States, we 

will have—I don’t know what we will see, but it will be enlightening as we do the same kind of analytics that we are doing in 

Medicare against the Medicaid. 

Mr. KELLY. I guess that is where I am coming from. Because 

I mean, and I really, I look at the private sector. I mean, if you 

wanted to—again, I am going to go back to what I do. If you wanted to find out if a car that you were looking to buy was ever involved in an accident, you go to the Carfax, and we have all seen 

this on TV. Why can’t we go and find out exactly where the problem is? It just has to be there. 

These are prescriptions. And I see the numbers, and we have all 

this tracking of everything we have done, yet we can’t coordinate 

it. We can’t put the two together to help the people that really need 

it the most. And look, I know it is about the money. There is no 

question. What a huge economic model this is. And again, because 

I am too personally attached to it, it is not spending more money. 

We keep thinking that the idea is to spend more money. I think 

if we are spending more money, it is probably going to have to do 

with personnel, people like you that handle these things, that 

never quit on this. This is not a nine-to-five job. This is 24 hours 

a day that we all worry about it. 

I think the frustrating part, when we can separate ourselves 

from this, first of all, there is a huge loss for human beings. There 

is a huge loss in dollars that are being wasted because we can’t 

connect the dots. We can’t combine the information. I just don’t 

know why we can do it so easily in the private sector with things 

that are just inanimate, but we can’t do it where we are, when we 

are talking about human beings, being able to touch them, get 

them together and actually getting to know how we could serve 

them. And I don’t know how much more it would cost because I 

think we don’t have enough boots on the ground to see it. 

The other thing is this waste, fraud, and abuse; it is incredible 

what is happening on our watch right now. I wouldn’t care what 

the cost was if it was actually going to help a patient or a person. 

I just think it is so sad that we are in a situation right now. And 

the President has declared it a national emergency. Pennsylvania 

has declared it a national emergency. We started in the 1800s 

knowing what the problem was. We have gone through this whole 

process. We are no closer to the answer today than we were way 

back in the opium wars. 

And I think that is the saddest part of it all. Where has it led? 

It is not because of the lack of investment or the lack of concern. 

How do we get to the point where we can actually connect this stuff 

so we don’t have to worry about Vanessas or Jims or Bills or Marys 

75 

that are out there today? It is just a tremendous loss in human potential and taxpayer cost. 

I thank you so much. Madam Chair, I thank you so much. And 

listen, what you are doing is incredible. I can tell you, I coached 

children’s sports a lot in my life. I can’t tell you the number of 

times I have been in a funeral home looking at some young person 

in a coffin, and around the room were pictures of them when they 

played for me at the Penn Street Cardinals or they played for me 

at our Little Marlins team. And I look at that, and I think, ‘‘what 

happened to that little boy, what happened to that little girl, that 

they reached this point in their life.’’ I think it is just so tragic. And 

it is not about the money. It is about the results. 

Please let’s find a way to put this together so we can track it the 

right way. Thank you so much. I know I am way over my time, but 

I will tell you what, this is overtime. This goes back to the 1870s. 

And if we are no closer to a cure today than we were then, what 

was the whole purpose and the exercise? Thank you for staying on 

this and not giving up. 

Chairman JENKINS. Mr. Rice is recognized for 5 minutes. 

Mr. RICE. Thank you, Madam Chairman. 

I got a call from a friend of mine a couple of weeks ago about 

his daughter who had been arrested, and she had drugs on her person and is probably going to jail. I knew this young lady growing 

up. She grew up with my children. She played with my children. 

She is a fantastic, bright young lady who has just, her life is spiraling downward. 

And I read these statistics on South Carolina. Do you know the 

number of deaths from opioid abuse have doubled in the last 3 

years? They surpassed traffic deaths a couple of years ago. The national statistics say opioid deaths killed 60,000 people last year, 

which is significantly more than if you combine homicides and traffic deaths nationally. 

So, and if you look at the graph, I mean, it goes from flat to 

straight up. It is not leveling off. We haven’t peaked. It is just accelerating. So whatever we are doing, clearly it is failing. We are 

not doing enough. 

I look at how you, you know, what you guys do is try to track 

where there are problem users and attack that, or problem prescribers and attack that, but that is not working. I look at your 

definitions just from this hearing summary today that you consider 

a beneficiary at risk if they receive a daily dose of greater than 120 

milligrams, get prescriptions from four or more providers, and fill 

prescriptions from four or more providers. Good grief. Good grief. 

I mean, clearly, if you have those three conditions combined, that 

is obviously a huge problem. In 2016, despite your efforts, despite 

these programs that you have put in place, you tell us a beneficiary 

in New Hampshire received 134 prescriptions for opioids from one 

prescriber, including 13 months of OxyContin, that is 80 milligrams; 13 months of OxyContin, 60 milligrams; 13 months of 

OxyContin, 40 milligrams; 14 months of oxycodone, 30 milligrams; 

and 13 months of fentanyl patches. You guys didn’t catch that? 

Good grief. Whatever you are doing is not working. 

A beneficiary in Washington, DC received prescriptions for 

opioids from 42 different prescribers and filled them at 37 different 

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pharmacies in a year. In a single month, this beneficiary received 

2,330 pills from prescriptions written by just one prescriber. And 

we didn’t catch that? You know, it is just overwhelming and depressing that we are so bad at this. 

One problem I see is what Mr. Kelly was referring to a minute 

ago, is the inability of the Federal Government to bring itself into 

the modern age of technology. I know, talking with folks on the IRS 

in this Subcommittee, talking with folks in Social Security, that 

they are still using Cobol and Fortran in a lot of their stuff, and 

they are using computers that have magnetic tape and all that, 

where everybody else left that behind, you know, decades ago. 

The IRS has 52 points of failure where only one person knows 

how to program these old computers. And if this person dies or retires, they don’t know what they are going to do. Is CMS in that 

condition? Is CMS in such a bad shape, such a bad shape that it 

is impossible for them to accumulate and interpret the data that 

we are talking about? 

Ms. BRANDT. Well, we made numerous strides at CMS over the 

past several years, and particularly in the past 2 years, to really 

try to become more modern with our data. 

As Mr. Cantrell mentioned, one of the big developments that we 

have, which is going to go a long way toward helping us with having more of a full picture, is that we were seeing comprehensive 

Medicaid data from all of our States. 

One of the challenges we have—— 

Mr. RICE. What does that mean when you say—— 

Ms. BRANDT. That means—— 

Mr. RICE. You said you will soon have comprehensive Medicaid 

data from all of our States. That is a fascinating statement right 

there. What does that mean? 

Ms. BRANDT. Let me demystify it for you. That means at the 

current point in time we have over 46 States and our goal is to 

have all 50 States—— 

Mr. RICE. We have 50 States. 

Ms. BRANDT. Yes. We have 46 out of the 50 States that are currently reporting in their Medicaid data. We are working with the 

other four States to get all of that data in. And once we are able 

to have all of the States reporting in data in a consistent format, 

then we will be able to use that data to do more of the data analysis—— 

Mr. RICE. Okay. Can you do that by regulatory requirement, or 

would that require some legal, some legislation? 

Ms. BRANDT. This is all within our authority. We are using our 

regulatory authority to do that. 

Mr. RICE. And basically, you are going to say ‘‘if you don’t meet 

these benchmarks by this date, we are not going to pay for the prescriptions anymore,’’ I hope? 

Ms. BRANDT. Well, that’s true with part of this on the Medicaid 

side. And then on the Part D side of the house, Medicare Part D 

side, we work with the plan sponsors, who are the ones who actually receive the data. 

Mr. RICE. So have you given them benchmarks and set forth the 

timelines by which they have to meet those benchmarks? 

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Ms. BRANDT. On the Medicaid side, we have. We have been 

working with them. They have deadlines they have to meet. And 

we are working with them to ensure that they are meeting those 

reporting deadlines. 

And on the Medicare Part D side, we consistently work with the 

plans to issue updated guidelines to make sure that they are reporting to us with as accurate information as possible. 

Mr. RICE. So what does that mean? That you haven’t given them 

the guidelines? 

Ms. BRANDT. No, we have, but we update the guidelines on an 

ongoing basis. So, for instance, we just issued—— 

Mr. RICE. Are you getting the Medicare Part D information from 

all 50 States now? 

Ms. BRANDT. Well, that comes from the plan sponsors, not from 

the States. So the States provide us with Medicaid data, which is 

for drugs that are covered under Medicaid—— 

Mr. RICE. Okay. So from the plan sponsors, are you getting information—— 

Ms. BRANDT. Yeah. 

Mr. RICE [continuing]. From all 50 States? 

Ms. BRANDT. Well, the plan sponsors operate in all 50 States, 

but they, themselves, are the frontline. They are the ones who provide the point-of-sale data. 

Chairman JENKINS. The gentleman’s time has expired. 

Mr. RICE. All right. I just want to ask one quick question. I 

know I am over time. Just one quick question. 

Mr. Cantrell, is there any legal impediment to you gathering this 

information from all 50 States? Because if there is, we need to fix 

that. What is that legal impediment, if there is one, and how do 

we fix it? 

Mr. CANTRELL. There is no legal impediment. Given the 

progress that has been made at CMS for doing this, it might not 

make sense for us to independently do it separately. 

So we are hoping to leverage CMS’ effort to collect this data in 

all 50 States, but in order to do our work and do it independently, 

we have and continue to get data directly from the States—— 

Chairman JENKINS. Thank you, Mr. Cantrell. Thank you, Mr. 

Rice. The gentleman’s time is expired. 

I would like to recognize the distinguished Member from Washington, Ms. DelBene, for a request. 

Ms. DELBENE. Thank you, Madam Chair. Congressman Lewis, 

the Ranking Member of this Subcommittee, was unable to join us 

today. And I would just like to ask unanimous consent to enter his 

opening statement into the record. 

Chairman JENKINS. Without objection, so ordered. 

[The submission for the Record of Hon. Suzan DelBene follows:] 

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Chairman JENKINS. I would like to thank our witnesses for appearing before us today. Please be advised that Members have 2 

weeks to submit written questions to be answered later in writing. 

Those questions and answers will be part of the formal hearing 

record. 

With that, the Subcommittee stands adjourned. 

[Whereupon, at 11:46 a.m., the Subcommittee was adjourned.] 

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