Transcripts For CSPAN3 Veterans Affairs Officials Testify On Opioid Theft 20170307

Veterans Affairs Department officials and the mayo clinic testified on efforts to curb opioid abuse by patients and Veterans Affairs health care facilities. And to stop the theft and sale of drugs by employees of the va and prevention efforts. A House Committee held last weeks hearing. Good afternoon. This hearing will come to order. I want to welcome everyone who has joined us today. Today we will address the lack of oversight in internal controls regarding controlled substances within the Veterans Health administration that leave facilities open to Drug Diversion and veteran harm. The diversion of drugs from v. A. Health care facilities is an incredible Patient Safety issue that puts veterans, v. A. Employees and the public at tremendous risk. Unfortunately the news has recently been filled with the story after story of Drug Diversions within v. A. In little rock, arkansas, v. A. Pharmacy technician reportedly used his access to medical supplies, websites to order and divert 4,000 oxycodone pills over 3,000 hydrocodone pills and more than 14,000 viagra and cialis pills at the cost of the v. A. Of more than 70,000. This technician was allegedly selling these drugs on the street where they had a value of more than 160,000. At a v. A. Facility in florida, a registered nurse was apparently stealing oxycodone and hydromorphone from the hospital to feed her addiction. Keep in mind, these are medications that should have been going to veterans for their care. These issues are in part a result of v. A. Having an adequate procedures in place to safeguard against theft and diversion of controlled substances. A recent Government Accountability office audit requested by this Committee Found that one v. A. Medical center missed 43 of the required monthly inspections, mostly in Critical Care areas such as the operating room and the intensive care unit. In addition, three other facilities did not follow all of vhas requirements for inspections of controlled substances. This is not the first instance where weaknesses were identified in v. A. s control substance Inspection Program. In 2009 and 2014, the v. A. Office of Inspector General found that some medical facilities were not conducting monthly inspections and some inspections were incomplete. V. A. Has been given multiple opportunities to address these concerns. This leaves me wondering what v. A. Is doing to repair the lax oversight and apparent abuse absence of accountability regarding these issues within vha. To make matters worse, there are also issues with drug testing employees to ensure they are suitable to provide care to our veterans. A 2015 office of Inspector General report found that v. A. Medical centers were not conducting preemployment and random drug tests for testing designated positions in many instances across vha which amounted to tens of thousands of employees not receiving drug tests required by the Drug Free Workplace Program. Most recently in january, 2017, the oig found high backlogs and background checks to include drug testing for high risk positions at the atlanta v. A. Medical center. It is precisely these tools that had been put into place to help protect patients and Health Care Organizations from Drug Diversions and harm. However, v. A. Does not seem to be taking them seriously as it should. Based on the oversight reports and numerous diversion incidents, we will discuss today, im concerned that v. A. s controlled substance Oversight Program is not working and that staff who fail to follow proper procedures are not being held accountable for violations. In case after case, what we see are examples of drugs being diverted for personal use or personal gain, yet there does not seem to be much progress made by the v. A. To correct the glaring problems that allow it to happen. By what is more concerning is that the programs to help deter diversion are not being implemented consistently within the v. A. Health system. We are in the midst of an Opioid Epidemic and its time for the v. A. To start making effective changes. To avoid putting veterans and the employees who serve them at risk. With that, i recognize Ranking Member custer for her opening statement. Thank you, mr. Chairman. And thank you for choosing this topic. Im particularly interested as the cochair, the founding cochair of our Congressional Task force to combat the heroin epidemic, and i appreciate this testimony. This afternoon, we are again examining v. A. s roll in ensuring that the Prescription Drugs are safely controlled in v. A. Medical facilities. Less than a year ago, former chairman kaufman and i held a hearing of the oni Sub Committee on this very issue in colorado, because the Drug Enforcement agency dea found several violations in the denver vamc. We continue to hear disturbing reports in hospitals and clinics in our communities that some Health Care Employees are stealing controlled substances for their own personal use or personal gain. We know that these cases are on the rise throughout the country. One Health Care Employee diverting controlled substances can be a Serious Public Health risk and can cause significant harm to many patients. We learned this lesson the hard way in New Hampshire with the technician who was injecting himself with fentanyl at a hospital in New Hampshire but it turned out this started at the baltimore v. A. Medical center and continued in more than a dozen hospitals in other states. Infecting up to 50 patients in our community with hepatitis c and some of these patients were veterans. Its clear the nationwide trend of opioid diversion also impacts our va. The v. A. Health system is one of the nations leading prescribers of opioid medication. Diversion in the v. A. Threatens the safety of veterans and hampers efforts to address the Opioid Epidemic in our communities, preventing diversions of these substances should be a paramount concern. Thats why i find the gao and gi finding particularly troublesome. Its unacceptable that some v. A. Medical facilities are not conducting routine inspections to prevent and identify Drug Diversion. Background investigations that could potentially identify finding employees who have diverted drugs or who may have a drug Substance Use problem were backlogged in atlanta. Health care were not subject to drug testing for six months, which could identify diversion of Prescription Drugs. We need to get to the bottom of why these safeguards and processes are not being followed. I want to know if the procedures when followed would work to prevent Drug Diversion and i want to know if v. A. Has the resources it needs to conduct the inspections, the background checks and to administer its drug fee workplace program. Im also concerned about the v. A. Hiring freeze thats currently in place and that v. A. Hr employees are not exempt. The gao and ig identified that staff need more personnel and more training to properly conduct these inspections. They also identified the need for more hr personnel to address the background check backlog in atlanta without adequate support staff in place, v. A. Medical facilities will continue to struggle to comply with the procedures and programs that they must follow to ensure that our veterans receive safe care. Finally, i look forward to learning about progress at the v. A. With regard to the Opioid Safety Initiative that we passed within cara just last year to bring down the rate of opioid prescriptions for all of our veterans. We must do everything we can to help veterans suffering from chronic pain and to help veterans struggling with Substance Abuse and addiction. The Opioid Epidemic is destroying the lives of veterans and their families in communities across New Hampshire and all across the country. And we need to Work Together to find Innovative Solutions to end this epidemic. As i say to my colleagues the heroin does not choose rs and ds. We can Work Together. We are proud champions of the comprehensive Addiction Recovery act that we passed last congress. I look forward to hearing about v. A. Compliance. Thank you, chairman, and i yield back. Thank you. Thank you, Ranking Member custer. I ask that all members waive their opening remarks as per this committees custom. With that, i welcome our first and only panel who is now seated at the witness table. On the panel, we have dr. Care clancy, deputy undersecretary for health, for organizational excellence. She is accompanied by dr. Michael valentino. Chief consultant for the Pharmacy Benefits Management Services of the Veterans Health administration. We also have mr. Nick dahl, Deputy Assistant Inspector General for audits and evaluations. Miss amy vocanos, Health System specialist for the office of Health Care Inspections in the office of the Inspector General. Finally, we have mr. Randall williamson, director of the Health Care Team for the Government Accountability office and dr. Keith berg, consultant and anesthesiology and chairman of the mayo clinic enterprise wide medication diversion prevention committee. I ask that the witnesses please stand and raise your right hand. Do you solemnly swear under penalty of perjury that the testimony you are about to provide is the truth, the whole truth and nothing but the truth . Please be seated. Let the record reflect that all witnesses have answered in the affirmative. Dr. Clancy, you are now recognized for five minutes. Good afternoon, chairman bergman. Ranking member custer and members of the Sub Committee. Thank you for the opportunity to discuss oversight of controlled substances in Drug Free Workplace Program at v. A. Facilities. I will address inspections to minimize diversion, drug testing for selected and employees and our commitment to accountability for employees who do not live up to our core values. Im accompanied today as you mentioned by Mike Valentino from pharmacy benefits. Report recently report prompted a swift response. We concurred with g. A. O. Six recommendations and expect them to be fully implemented by october of this year. We conducted a Conference Call last week with over 450 field base staff to launch the action plans and to provide tools that support that effort, followed by distribution of written instructions. Additional dissemination efforts are planned over the next two weeks. Although gao and v. A. Inspector general identified selected instances with these robust controlled, i believe the system is working as designed to make it difficult for v. A. Staff to divert drugs and most importantly to give us the tools to be able to detect diversion rapidly and take action when it does occur. Vha implemented robust controlled substance internal controls in the early 1980s. In many cases, these measures exceed those required by the controlled substances act and align with mayor clinics best practices. Data show that vas reported controlled substances loss rate is. 008 or 8 per 100,000. And it is v. A. s very own internal controls that lead to the vast majority of diversion cases being identified. The use of Illegal Drugs by v. A. Employees is inconsistent with the special trust placed in those who care for veterans. The Inspector General recently reviewed allegations at the atlanta v. A. Medical center of a backlog of background investigations and found that mandatory drug tests of must hires did not a occur over a six month period resulting in a backlog of about 200 background investigations. It was also found that the Drug Free Workplace Program was not administered from november of 2014 to may of 2015. Atlanta v. A. Leadership implemented a number of changes in 2016 in response to these recommendations, such as moving the Human Resources department under the direct supervision of the Medical Center director and developing a secondary data base for staffing and tracking all background investigations, we expect that that backlog will be cleared by the end of this march and if not well keep you informed. In addition, v. A. Has made Great Strides towards improving the Drug Free Workplace Program. In october of 2015, drug Program Coordinators began certifying on a monthly basis employees selected for random drug testing were tested when they were tested or why they were not tested. V. A. Also developing procedures to ensure the drug testing coding of employees in approximately 180,000 testing designated positions is accurate and complete. On march 1st of 2016, the assistant secretary for Human Resources and administration published a memorandum stating 100 of all applicants testing position be drug tested prior to appointment. V. A. Works closely with local, state and federal Law Enforcement entities to identify specific geographic areas with reported male losses and lost clusters has led to successful arrests, prosecutions and convictions. V. A. Has developed a culture of controlled substance and adopted a practice of over rather than underreported suspected cases of diversion. Mr. Chairman, im proud of the health care our facilities provide to our veterans, including Prescription Drug services. The issues were discussing here today are closely related to our nations overarching struggle with opioid use. As a whole, our nation needs to come up with a better alternative to Pain Management than opioids. V. A. Is at the forefront with our Opioid Safety Initiative which we pioneered in august of 2013. Were actively reducing the number of opioids we prescribe and the number of veterans receiving these prescriptions. Instead, were offering a variety of complimentary and treatment of chronic pain, chiropractic and acupuncture. Among many other options. Initiatives like these will reduce the number of controlled substances v. A. Prescribes making it easier to maintain their oversight. With support from congress, we look forward to continuing to improve our oversight of controlled substances and Drug Free Workplace Program which is further the improve the care of our veterans and the care they deserve. Thank you for the opportunity to testify and i look forward to your questions. Thank you, dr. Clancy. Mr. Dahl, you are now recognized for five minutes. Mr. Chairman, Ranking Member custer and members of the Sub Committee, thank you for the opportunity to testify today on the office of Inspector Generals work related to Drug Free Workplace Programs and the oversight of controlled substances at v. A. Facilities. I am accompanied by a member of the oig health care inspection staff in manchester, New Hampshire, and is also a former v. A. Pharmacist. The federal Drug Free Workplace Program was initiated with the goal of establishing a drug free federal workplace. The program made it a condition of employment for all federal employees to refrain from using Illegal Drugs on or off duty. V. A. Has designated safety sensitive occupational series as testing designated positions including positions such as physicians, nurses, Police Officers and Motor Vehicle operators. In recent years, the oig has completed two projects that assessed aspects of the Drug Free Workplace Program. In march, 2015, the oig issued a report detailing the results of an audit of v. A. s program. We identified Program Weaknesses in three areas. First, preemployment applicant drug testing. If a drug if a tested applicant has a verified positive test result, v. A. Should decline extending a final offer of employment, however we reported that v. A. Did not ensure compliance with policy to drug test all applicants selected for a testing designated position. They selected three out of ten for testing. Second, employee random drug testing. We estimated v. A. Achieved a National Drug testing rate of 68 of employees selected for random drug testing in fiscal year 2013. In our review of 22 randomly selected facilities, we found four facilities did not test any randomly selected employees. Ten ranging from 31 to 89 while the remaining eight facilities tested at least 90 of the randomly selected employees. We also estimated at least 9 of about 206,000 employees in testing designated positions were not subject to the possibility of random drug testing because they were not properly coded with the drug test code in v. A. s personnel system. Those not subjected to random drug testing included physicians, nurses and addiction therapists. Finally, reasonable suspicion drug testing we reported that v. A. Lacked monitor whether facilities all employees with the positive drug results to the Employee Assistance program. Based on our work, we determined v. A. s program was not accomplishing its primary goal of ensuring illegal drug use was eliminated and vas workplace was safe. We made five recommendations and as of today one remains open. A more recent report focussed on Human Resources issues at the atlanta v. A. Medical center. During this review, we substantiated an allegation that there was no drug testing of employees and testing designated positions for at least six months in 2014 and 2015. We found no indications that va management at the local or the National Level was aware of the lapse. Because in drug testing occurred, the atlanta va Medical Center lacked assurance that employees who should have been subject to drug testing during this period remained suitable for employment. We made two recommendations focused on the Drug Free Workplace Program and va reported they have taken action on the recommendations. Va also requires that managers at vha facilities ensure that a controlled Inspection Program is implemented and maintained. The oig has reviewed vas management of controlled substances during our combined Assessment Program reviews, we rolled up the results of our work in june 2014, and gao references that work in their recent report. It the diversion of controlled and noncontrolled substances by vha employees. The diversion of drugs by Health Care Providers for personnel use is a serious issue that the oig diligently purr sue ll lly purs. Cases where va pharmaceuticals are diverted or stolen for the purpose of illegal sale. Also, the diversion of controlled substances by a theft of male pharmaceuticals. Our investigations revealed male pharmaceuticals are vulnerable to theft at any point in the process with the most common occurrence being theft by employees of the mail carrier. In conclusion, the oig provided cross cutting oversight of the program and controlled substances inspections through our audits and inspections. This is necessary to ensure va takes the steps necessary to reduce risks to the safety and wellbeing of veterans and va employees by having and following Proper Program controls. We also actively investigate Drug Diversion and seek prosecution for those engaged in Drug Diversion. Based on our work in recent years, we have concluded va lacked reasonable assurance that it is achieving a drug free workplace and adequately securing controlled substances. Mr. Chairman, this concludes my statement. We would be happy to answer any questions you or other somebody Committee Members may have. Thank you. Mr. Williams, you are recognized for five minutes. Thank you. The increase in the prescribing and use of opioids over the last two decades sometimes referred to as the opioid explosion has brought with it the need for medical facilities to undertake efforts to prevent diversion of substances by facility employees for their own personal use. Diversion of controlled substances can compromise patient treatment, can be costly to the facility and can cause harm in our communities for those that are recipients of illegally obtained controlled substances. I am here to discuss our report on vhas efforts to prevent diversion of opioids and other controlled substances through the controlled Inspection Programs. All v. A. Medical programs that store and dispense substances are required to undertake inspections of all areas in the facilities that are authorized to have controlled substances. Each facility director is is responsible for overseeing the Inspection Program and appointing a coordinator to manage the inspectors to conduct the inspections. Usually both the coordinators and inspectors have other responsibilities within each facility and work part time on the Inspection Program. The coordinator is responsible for ensuring that monthly inspections are conducted and for submitting reports to the facility director, summarizing inspections and trends. We found that the program is not being managed according to vha policy and needed improvement in certain areas. First, monthly inspections are not always being conducted as required. We visited four v. A. Medical facilities across the country and found that over a 14month period one facility missed 43 of the required inspections, while another missed 17 . The operating rooms in one facility, for example, were not inspected at all because we were told that the inspectors needed to arrive before or after normal operating room hours and could not do so because of their conflicting work schedules. Second, when conducting the inspections, facility inspectors did not always follow policy requirements, as was the case for three of the four facilities we visited. For example, inspectors dont always verify that controlled substances had been properly transferred from pharmacies to automated dispensing machines in patient care areas or inspectors didnt always count all of the controlled substances stored in patient care areas. Third, we found that local written inspection procedures were not fully consistent with policy requirements. We found this problem at three of the four hospitals we visited. These three weaknesses increase the risk of diversion at v. A. Facilities. We found that many of these problems were allowed to happen in part due to poor oversight at the facility and network levels. Facility directors at two of the four facilities we visited did not consistently perform their oversight responsibilities for the Inspection Program, which include reviewing monthly inspection reports and implementing actions if problems are identified. Also, we found that two of the four Network Managers who had oversight responsibilities for the Medical Centers we visited did not review facilities trend reports as required. The control substance inspection coordinator is required to prepare and submit these quarterly reports based on trends identified in the monthly inspections. Further, one of the two networks did review the quarterly trend reports took no action to ensure that one of the facilities in the review that had not prepared quarterly trend reports had a corrective action plan to do so in the future. Aside from the oversight weaknesses, we found there is limited training for coordinators to better ensure they have a complete and detailed understanding of vha inspection procedures. Finally, two of the facilities we visited had backup coordinators to help manage the inspection process and complete inspections when the primary coordinators could not carry out their responsibilities because of pressing job duties or unforeseen circumstances. We recommended that v. A. Adopt this type of practice and v. A. Concurred. V. A. Concurred with our five other recommendations to improve the process and provide better oversight. This concludes my opening remarks. Thank you, mr. Williamson. Dr. Berg, you are now recognized for five minutes. Thank you for the opportunity to speak with you today about Drug Diversion from the health care workplace. Such diversion is a crime that endangers all patients, employer, coworkers and the diverters themselves. While we have long known of these hazards of patients being deprived of pain medication, by diversion, only recently has it been revealed by outbreaks of disease such as blood poisoning or viruses that have been transmitted in the commission of their crimes. Many patients have been infected with potentially fatal illnesses. I have attached for your review verter. This individual was referred to earlier in the introduction comments. This diverter was a radiologist technologies who traveled the country working for multiple employment agencies. Country. He had been fired for multiple jobs for diverting fentanyl for his own use and by lying on job applications he had no trouble finding employment. In the darkened invasive radiology suits he would swap fentanyl syringes for ones he had used on himself and he would then excuse himself to a rest room, draw tap water and repeat the process. In this manner he conveyed his potentially lethal illness to many innocent victims. The patients described in these o eight outbreaks were vulnerable. Clearly such behavior is unacceptable and the recognition of these dangers posed by diversion, the Drug Enforcement administration requires stringent drug control policies and procedures to be put in place to protect drug controlled substances to protect all points from manufacturing and distribution, dispensing and disposal. The drugs used in the Health Care Setting are highly sought after drugs of abuse both by addicts and those that would profit from the sale of the drugs. Experience has shown the necessity of having surveillance, detection, investigation, intervention programs in place. While it be impossible to eliminate Drug Diversion from the health care workplace, its imperative that systems halt such activity. I have attached for your review an article from the mayo clinic. While we continue to try to improve our system, it has proven effective in identifying drug diverters. Diverters come from a whole host of places. These stories are incredible, but they point to the powerful draw these drugs have over addicts. Its not enough to have effective policies on the books. They must be followed. Diverters are clever and desperate and they will gravitate into an area where they perceive the drugs to be most vulnerable to attack. It behooves any Health Care Facility for being able to identify drug diverters. Only by doing so can we protect patients from harm. This problem will never go away so we must become very good at rapid intervention. Only by following policies and procedures will this be possible. I think that the committee for its attention to this issue and stand ready to answer any questions you may have. Thank you. Thank you. The written statements of those who have just provided testimony will be entered into the hearing record. We will now proceed to questioning. Dr. Clancy in your form you state that the v. A. Performs an actual count of all controlled substances every 72 hours. Who performs these counts and who oversees that these counts actually occur at each facility . Sir, what i saw when i made a more or less unannounced visit to the d. C. V. A. Last week is that pharmacy techs who are working in the vault are doing that and they are double counting as theyre doing it. So in other words, there are two assistants who are each verifying because counting a lot of pills is prone to missing one and so forth. That is further verified by a supervisor. Given the weaknesses identified by the oig and more recently by gao, how can v. A. Central office be sure that these counts are taking place and that they are accurate . You observed one. Yes. I think dr. Berg just said it well. We have very good policies in place, but its very important that theyre rigorously followed so we are exploring right now how we might do some backup audit to make sure that those policies are followed. As i mentioned in my opening, we actually have already disseminated written statements to the field. Wed be happy to make a copy of that memo available for the record or for your interest, but again its very important to know that this actually happens, that our aspirations are as good as were delivering on. Thank you. Dr. Clancy how many cases of Drug Diversion has the Program Identified in the last two years . What i have here is a poster, which we could make available to the committee. Mike, if you could just turn that around, of controlled substance losses by type. The data that we looked at specifically goes from january 2nd of 2014 to march 11th, i believe of 2016. What you saw is that 91. 4 of these losses occur outside our facility in the mayo system. That leaves about 1. 5 , i believe, from employees internally. But, again, this is something that were checking all the time. If theres any question whatsoever, v. A. Police are engaged as well as the Inspector Generals office and theyve been most helpful. And of those losses that occurred at v. A. Facilities, outside of the loss in the postal, will you be able to provide the subcommittee a list of those facilities where the drugs have been reported missing or stolen in the last two years . We would be happy to do that. Okay. Mr. Williamson, what is the role of the Medical Center directors in terms of ensuring inspections and proper oversight . Well, they are the key at the facility level to looking at the monthly inspection reports, picking off any issues that come to pass there from misinspections, inspections that are not done correctly, things the coordinator report to them and they are responsible for holding somebody accountable for correcting that. I see i have about a minute left here. Dr. Berg, v. A. s office of Human Resources of management reported to the iog that they interpreted language in the v. A. s drug free workplace handbook to require only some positions to be drug tested before being appointed. Would this be an acceptable practice in your Health Care Organization . I believe in our Health Care Organization we do pre post offer of employment testing on all applicants. What are the consequences for hiring Health Care Workers prior to drug testing or completing background checks . Well, you might be letting the fox in the henhouse. You might be letting somebody who would test positive and is, in fact, an addict into an area where they can get their hands on drugs. Theres an example of that in the denver area within about three years ago Kristen Parker is now spending 30 years in federal prison for infecting about 36 patients with hepatitis c. She was a heroine addict that took a job in a facility and started diverting fentanyl. Thank you. Ranking member custer, you are recognized for 5 minutes. Thank you. I want to thank the gao and ig for their helpful reports. I want to focus in on evidence demonstrating we know what a successful Drug Diversion deterns program would look like and yet we continue to have this problem at various locations. Apply one standard to all facilities, and, in fact, have an Inspection Team based out of the Central Office that would go out to the visits. It seems what im hearing is that this is often just an added task. In fact, in one case somebody was a Food Services worker that this was an add on. It doesnt seem as though were taking it seriously and wouldnt it make more sense if we had an office of inspection that would go out, as you did yourself, without advanced warning and do these checks . Thank you, congresswoman. Thats what were going to be looking into. I think what we need to look at is how much of this could be done remotely. How much of it requires on site presence and frankly how much can we identify ahead of time, which facilities are likely to have the most challenges. I suspect that in some instances, but we need to test this, we will know which facilities are more likely to be compliant i guess correctly which one was the facility in the gao report based on many other things i knew about that particular facility and i wasnt incredibly surprised by the distribution of the others, but we need to actually up our game and make sure that great policies are implemented consistently. Theres no question about that. At least have consistency. What im curious about is having a system that would be consistent throughout. So i have got a couple of minutes. I want to return to the issue of reducing the amount of opiate medication generally in the v. A. Population. We had testimony from a medical researcher that out of the 60,000 surgeries a year, 99 of people get opiate medication and one in 15 will become a chronic. Epidemic. Can you talk to me more about both the Program Within encouraging v. A. s to reduce the use of opiate medication or any other examplesha have in this system . Of course. Thank you for the question. Im happy to report that we are on track for all the provisions in cara. V. A. s portion of that is named for a veteran who died under our care and i was literally speaking with his father yesterday and ive been most impressed by the family honoring the experience of their son by working with us to make sure that we provide better care. V. A. Has really been on the forefront of reducing the use of opioids. So begng ruction in the number of patients receiving weve seen a 56 reduction in the number of veterans who are receiving an opioid and another type of drug that has a particularly high risk for adverse reactions. We are doing much more frequent urine testing because were trying to minimize diversion from patients, veterans actually selling the drugs they got at v. A. To elsewhere. So the right answer on a urine drug screen is positive opioids has decreased quite significantly and weve also seen these results at a time when weve seen an overall growth in the number of veterans we are serving. I want to be clear. Were not done and we will continue to monitor this and im very proud of the work that we are doing to offer veterans alternatives to chronic Pain Management. So my time is up, but i would just say to the chair that as we continue, id love to have further testimony about the chronic pain programs and how we can bring down the use of opiate medication. Thank you. Thank you. Mr. Bost, youre recognized for five minutes. Id like to continue down that the Ranking Member asked the first part of the question i was going to ask, and that was the report from 2009 and then again in 2014 on the weakness that the v. A. Controlled substance program had, you kind of explained what the v. A. Central office what is doing, but what about the visn and the faculty level, what are we doing there . So every one of our networks thats a Veterans Integrated Network has a pharmacy lead there. I will say it is my understanding that there is some variability in terms of how many other members of the team that they have. Many are quite strong in terms of reviewing facility reports and providing that oversight. Others, its my understanding are less so. Id be happy to provide more detail for the record. I think that we need a very consistent approach. Heres the facilitys responsibility. Here is the second line which should be the network and then Central Office providing what is sometimes referred to as the third line of defense. Im quoting from sort of accepted practices and internal audit, which is an area that we have just started up within my group. Okay. I see that i know that youve been trying to do that since the 2014 report, but why do you suppose that when all of a sudden the gao came back many of those same weaknesses showed up again, what are we not doing correctly to move quick enough to try to deal with it . Its getting the epidemic were dealing with is nationwide, but we have to set the example. I would agree, we think of it as setting an example. I think some of these coordinators have collateral duties. I do note that for many of our facilities anesthesia and the operating rooms tend to be areas probably because of the hours where there have been problems conducting inspections. Every facility has been in our system has been directed, redirected quite recently to have a backup coordinator. My colleague, not mr. Valentino, one of his top lieutenants, came with me the other day and he noticed that maybe there was a problem with not randomly conducting the inspections throughout the month. If you let it go until the end of the month which is understandable, but nonetheless, if you know, stuff happens that week that means you will have slipped a month and so forth. That is the kind of thing i think he we can and will improve on. My next question is for mr. Dahl. In your investigation related to 2015 and 2017 reports, how many positions identified as no background check completed were the high risk or testing designated positions, do you know that . Well the 2015 report did not get into the investigation. The 2017 focused on the atlanta v. A. Medical center. I wouldnt have that information at hand but i would be happy to could you get a copy of that to figure it out . We want everyone tested. As you described, echb is at risk with this. That being said, if we drop them into the highrisk positions we definitely got to do some backing up and making sure. Im short on time but dr. Burj, and this is a question that im sure my constituents and people throughout the nation will ask, would your Health Care Organizations hire a clinic professional prior to completing a background check . No. Thats what i thought. What risk is associated with a clinical hire prior to background check some. One source of frustration is like we we are interviewing an applicant for say our nursage esthesia school that Employment Law for bids us to ask if youve been through treatment for chemical dependency before. While weve had such people come in that develop fentanyl addiction and in retrospect, well theyve gone through treatment for cocaine abuse in the past. In some ways we are barred from asking questions but we would like preemployment drug testing information. I know im running short on time mr. Chairman but this is an issue that ive dealt with on the state level and here at this level as well. One thing we want to remember is how vitally important those tests are. Because this disease, and it is a disease, to be an addict. I had a friend that one time when we begged him to talk us to, we gave us an information and it wasnt correct and it came back and said to us, what part of, im an addict, i lie, dont you understand . Thats why it is so vitally important to not only do the question but make sure that we do the followup checks and the concerns i see are the holes in the system. We want to do everything we can to help stop this epidemic affecting and it doesnt matter whether what your race is, gender is, Socio Economic status is, weve got to continue to work on this. Thank you, mr. Chairman, i yield back. Thank you. Mr. Wall yas, youre recognized for five minutes. Thank you, chairman. Thank you all for being here. Dr. Clancy, you and i have a long history. Just for the committees sake for new members, the first piece of legislation we authored in 2008 was the pain director to the v. A. To set up Pain Management. That came with all of the best practices working in conjunction with the v. A. This is the seamness the seamlessness between the private sector and v. A. Is pretty strong. We all have the same issues. But my colleagues were getting at it and the Ranking Member knows this. The fundamental issue is Pain Management. Our nation goes through cyclical issues of issuing opioids and pulling them back. The diligence on the control side, we can always do better on that and i think theres great suggestions there but i would suggest that through all of us, that program and, aim right, dr. Clancy, was never fully implemented. We had that discussion about 18 months ago. Did we ever fully employment it before it fully expired . Im not sure but i could get back to you on that. I know the legislation that representative custer was asking about, we are now making sure that there is Pain Management expert tees and teams accessible by all our facilities. For some of our facilities that is partly virtual but as an integrated system we can but it is the same principle. As most of us know, if the v. A. Goes so does a lot of the other system because of the sheer volume of this. How much collaboration do have you with experts out there . Im just meeting dr. Berge today although we have a mutual colleague friend. We consult with others pretty broadly. They drew on expertise from a number of folks in the v. A. , including from your district. As you said this is a Common Health challenge shared bit country. Dr. Berge, thank you for being here. You and your colleagues over the years, i think the thing to this about this is that everything isnt reactive and this recent Opioid Epidemic and overdoses that come with it, that is not a surprise to folks your like selves. But when you said mayo clinic saw holes you decided to turn around, and known as one of the best, how long did you expect that to be implemented and see change . We were probably about a year and a half at creating our system that was in response to a tampering a diversion that ended up on the front page of the newspaper and embarrassed us. We tried to work through every spot in the supply chain and tried to address that and it takes time to go through that process. You have facility, how many facilities . We have the midwest, minnesota facility and surrounding area. We also have jacksonville, florida and some small surrounding area in scottsdale, arizona and some so 50,000 plus employees roughly . About 70,000. For the entire system . So this a Big Health Care system. I think maybe one of the frustrations is sometimes the slowness of the reacting to these situations as the bureaucracy takes time. Youre feeling comfortable now there is with the new legislation and with the emphasis on this and with the situations that come up that are unacceptable. The thing is as i think for many of us we know thats what happened in these situations have been brought to light are happening in the private sector. Our responsibility is the v. A. Our responsibility from an ethical and legal responsibility is to the veterans. Do you feel like its moving quickly enough for you . Im excited by how enthusiastic our employees are by this. This a national problem. We will tracking this very very closely. I get it too. Theyre embarrassed by this. We recognize when its not done right the issue and the areas impacted. This is a tragic situation. We can do something about it because we have that ability in the v. A. And im looking to see we have these things implemented as quickly as we can and i know you are all too. Thank you for your testimony. Thank you. Thank you. Mr. Dahl, youre with the Inspector Generals office, correct, sir . Sfrs yes, sir. Mr. Williamson youre with the government accountable office. Yes. You two gentlemen have reported theres a problem with keeping practice of the drugs at the v. A. Facilities, is that correct . Would you both conclude we still have a problem . Im sorry. I missed that. Would you conclude we still have a problem . I would think that based on the recent work that there is still an issue. Thank you. Dr. Clancy youre the director for Organizational Health excellence . What does that mean . Does that mean making sure who has these harmful drugs . What it means is providing oversight for quality, for safety of care and for integrity and integrity is about compliance. What person at the v. A. , what one person is responsible for this problem . Whos the head banana. That would be the undersecretary for health. Who is that. That is someone in an acting position. You know that our undersecretary was recently confirmed as secretary. Could you spell that name. Alaigh. Okay. You report to that individual . Huh . You report to that individual. Yes. When someone is caught, dr. Clancy, stealing drugs or selling them and making them available to folks that shouldnt have them like our veterans that were working so hard to help, what action is taken . It depends on the specifics of the circumstances. Do you call the cops . Yes. Good, okay. And what sort of actions recently have taken place in the system that you can share with us about people being held responsible for this abuse . I think you have probably seen from newspaper articles that a fair number of people that we have brought to the attention of Law Enforcement have in fact been convicted and are serving time. Theyre paying their debt to society. We would be happy to get you a whole list for the record. That would be great. Well make sure we get that list. Thank you very much. Integrated services networks. Who are they, what do they do, and how are they involved in this . We have facilities that are hospitals, clinics and so forth all over the country including alaska, hawaii, manila and gaum and so forth. A big span reach. This is a sub management what does the integrated network do . They manage and provide oversight. They would be responsible also for making sure that we have a good head count on where the drugs are and where theyre being disbursed. Yes. Who is the head person over there. There are 18 of these networks. So in your area is dr. Mayo well make sure we get a list of these people also. Mr. Williamson have you found in traveling around the country in dealing with separate v. A. Facilities that there is inconsistency and i think congressman mccuster asked this question earlier. Theres inconsistency in which organizations, which medical facilities actually do a better job than not in following these protocols. Absolutely. How do you fix that problem . There was one facility that we looked at that did everything right. What was going on there was commitment and leadership from the medical director right down to the inspectors. Thats what you need. There is an example at the v. A. That this can be done correctly . Yes. What would you guess, what percentage of the v. A. Facilities around the country are doing this well . 10 , 15 . So there are 85 of the v. A. Facilities around the country who are dispensing drugs illegally or at least in a hurtful way, correct. I wouldnt say dispensing drugs illegally. Theyre not following the tenants of the inspection. As a result, these drugs get in the wrong hands . Correct. Okay. Dr. Berge, youre in the private sector at mayo, correct. Correct. Youre in the private sector. Correct. Have you found that with an effective Drug Control Program you can save money . I believe we can. I believe if you were to ask the executives of the New Hampshire hospital thats being sued multiple lawsuits that they wish they had a more effective system. Besides avoiding litigation, is there a way to save money when you have an Effective Program like this . Thats extremely hard to quantify. I think to have an effective system in place is not an inexpensive endeavor in itself. But it allows you to we have heard that the word on the street is dont go to work for mayo because if youre going to steal drugs theyll catch you. Thank you very much for being here. Dr. Dunn, youre recognized for five minutes. Thank you. Dr. Clancy i severe at the lake city facility and theres testimony here that we did not read a loud, but i think youre familiar with that they had a problem in the lake city facility recently with a nurse miss appropriating drugs. Can you discuss the corrective actions and protocols that have been established at that lake city facility in the wake of this incident to restore the quality of care and the level of Workplace Safety for the community and also tell me if your current controlled substance coordinator in that facility is properly certified and educated on the management of controlled substances and the supply chain and the management policies. I would happy to take that for the record. Our first focus was on protecting patients and then holding the individual accountable so ill get the rest of the information. Youre not familiar with that particular incident. I am familiar with the incident. I am not familiar with all the details of the followup. Dr. Berge, youre an expert in Substance Abuse and how it comes to pass. Im a surgeon, and ive managed operating rooms and directed hospitals and large clinics and this is a problem we all have to address. Its part of the job that we have to do when we do health care. Ive seen this studied at the state level as well. Im looking at this particular pie chart here that suggests that 90 of the problem with diversion, with controlled substances is occurring not in the health care facilities, but in the United States Postal Service and in ups. Ive looked at a lot of Drug Diversion, a lot of problems with this in my 35 year career as a surgeon. Year career as a surgeon. Year career as a surgeon. I have never seen anything like this reported. This is perless perilously close to, the dog ate my homework. Iloe dog ate my homework. Do you believe that 90 of the drug problem in this country occurs in the United States Postal Service. Im not qualified to comment on that because thats not where we see it. Im basically assigned to within the walls of our health care facilities. So what happens with out, i dont know. Thats not what we see at mayo. We see other forms of diversion. Perhaps i should redirect that question and say do you mean by this that the 90 of the problem occurs in the Veterans Administration facility mail rooms or are you actually saying that employees of the United States Postal Service and United Parcel service or people who victimize them are getting 90 of the diverted drugs. What i am saying and ill ask my colleague to elaborate, is that between the time the prescriptions are put in an envelope understand we have a central mail order pharmacy which for most prescriptions works extraordinarily well and does high order of business, somewhere between there and the Veterans Home is where it is diverted. On occasion weve heard from veterans thats diverted by a Family Member. It could be any one of those points. Thats where working with the Inspector General, v. A. Police and outside Law Enforcement has been helpful. Okay, lets drill down on this further. It looked like we were lying it down opt Postal Service. Whats happening is the v. A. Is getting receipt of the drugs who who they purchased it from and then theyre distributing it in their system. They may be using ups or usps and where between once the v. A. Has a drug and they pass it off to another part of the v. A. , the drugs are being diverted . Is that the system . No, this is outside the system. I have to tell you, 35 years ive never heard this kind of accusation, 90 of the problem is in the postal system. Im flabbergasted. Let the record reflect that. Dr. Dunn, we looked at this and one of the first things we tried to obtain was good data. Id be very suspicious of those too because losses are not always synonymous with diversion. We have to be careful of that, but the reporting system v. A. Doesnt have a very good reporting system for Drug Diversion cases so i would be very suspicious of any data. I am too. Thank you. Dr. Row, your recognized for five minutes. Thank you. Im going to go along with a little bit of what dr. Dunn was doing. We know theres a drug epidemic and in the state of tennessee it is. Is there any data on how many veterans die of Drug Overdose deaths both by die as peen and op opioids . Do you have any information on that . How many of our veterans died . We do track that very closely and wed be happy to get that for you for the record. As i look a the this graph more, i couldnt figure out how you determined 90 . If somebody is home and just said i didnt get my drugs, the one good thing, if there is any good thing about an Electronic Health record, what used to happen to us when we would close our office at 5 00, people would call in and ask about i just had surgery we had a big practice two weeks ago and doctor so and so didnt leave me enough medicine. I would pull up the record and say you dont seem to be a patient at our practice. People are clever at getting drugs. When you say 90 , how could you figure that number out because you say here that the post office doesnt deliver it. How do you know that . I can help with that. This is based on a sample of reports from january 2014 through march of 2016. So whenever we have a loss, we have a template that the individual facility fills out. What happened, who did you report it to, d. E. A. , v. A. Police and so on and so forth. If those reports were able to glean information and identify if it was a situation where a v. A. Staff member diverted a drug or whether it was a patient calling and saying i didnt get my package. Our packages are sent with tracking information. So we can tell where it is in the delivery stream and at some point if we if the patient says they dont get it, we have one of two situations. Either they did get it or a Family Member got it or it went missing somewhere. These are i agree. These may not be diversions, but these are indeed loss reports that are generated by our facility. I need to interrupt because my time is short. It looked to me like if we know how many died, if theres a real problem, it looks like there may be a better way to deliver these medications to people than sending them out in the mail. If thats where nine out of ten of these problems are and were losing a lot of people, it looks to me like thats a sloppy system in thats the case. Dr. Clancy, in your written testimony you said 92 loss by mail and you answered about how you got out at that information. In reviewing the forms 106 submitted to the committee, we learned of instances where the va mailed substance to see the wrong address and worse to the wrong veteran. How many cases of 92 were delivered to the wrong address or the wrong person. Thats really sloppy. We would be happy to get that for the record. We appreciate that and please take that for the record and bring those numbers to the committee. For now whats the v. A. Doing to ensure they get the right prescription . Thats sloppy work when you mail it to the wrong address or to the wrong person for goodness sakes. There is a big part of the effort initiated by secretary mcdonald that includes making sure that Veterans Data is integrated from multiple sources because many veterans get multiple services from us. So when they move we have accurate information. Everything that is mailed out is bar coded so it can be tracked. So if a veteran calls up a facility and says my medications didnt come, they can actually track it. Theres a tracking number whether its Postal Service or ups. Ultimately thats helpful to Law Enforcement in figuring out what happened. Is that a system we want to continue at the v. A. . The v. A. Is a huge system treating millions of people. Not thousands, but millions. Youre right that this is an area where its not working as well as it should. If we required every veteran to come in to pick up their controlled substances, we could certainly do that. I think it could create some unintended consequences. Some of our veterans live very far away so we may have to look at some other options. I agree with that. It would do that. Im not saying that you should do that. Im saying we have a situation now where 30,000 people these are all deaths that are preventible. Thats disturbing to me that you have as many people die from Drug Overdoses as car wrecks. Thats a huge problem for the entire country. Mr. Poloquin has one followup question. Id like to follow up what chairman roe was talking about. Its clear to me, and i think everybody in this room, that the va, theyre doing a horrible job when it comes to this issue. Why in the heck do we have to dispense the pills from the va . How many pharmacies do we have in this country . I dont know. We have a bunch of them, right . Why in the heck cant we have pharmacies around the country closer to where our population is where our veterans are, why dont they dispense the pills if youre doing such a horrible job . Dr. Clancy . Im sure as my colleague noted, first of all, be mail order works extraordinarily well for other types of medications and as we work through how to reduce this area of vulnerability, there may be a lot of other options we could consider. Good. What youre saying if youre getting an aspirin or Something Like it probably makes sense, but a controlled substance, maybe its better if its close at home where folks come in and theyre known by the folks at the pharmacy. We will leave this meeting now. We are going to where ukraine and five other Eastern European nations are testifying before the subcommittee about russian influence around the former soviet block. The hearing should get under way momentarily. Live coverage on cspan 3