Theft and sale of drugs by agency workers. The House Veterans AffairsCommittee Held this hearing late last month. 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 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 controlled 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 drugfree 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 kuster 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 role 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 subcommittee 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 and 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. From this example, it is clear that the nationwide trend of opioid diversion also impacts our v. A. 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 igs findings 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 employees at the Atlanta Health care center 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 lean. 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 bergman, and i yield back. Thank you. Thank you, Ranking Member kuster. I ask 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. Carolyn 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 AssistantInspector General for audits and evaluations. He is accompanied by miss amy valcanos, Health Care Systems for the office of Health Care Inspections in the office of Inspector General. Finally, we have mr. Randall williamson, director of the Health Care Team for the Government Accountability office and dr. Keith berg, consultant in 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 kuster and members of the subcommittee. 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 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. Gaos recently released report on facility controlled Inspection Programs in four of our facilities has prompted a swift response. We concurred with gaos six recommendations and are now implementing them. 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 provide tools that support the effort, followed by distribution of written instructions. Additional dissemination efforts are planned over the next two weeks. Other gao and v. A. Inspector general identified selected instances of noncompliance with these robust controls. 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 we believe they align closely with mayo clinics recommended best practices. Data from january 2nd of 2014 through march 11th of 2016 show that v. A. s 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 mandatory drug testing of new hires did not occur over a sixmonth period, resulting in a backlog of about 200 background investigations. It was also found that the drugfree 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 inspection of 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. Is 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 tentatively scheduled for appointment to a drug tested 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 loss reporting and has adopted a practice of over rather than underreporting 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 complementary and integrative treatments for chronic pain such as chiropractic and acupuncture among many others. 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 Programs which will further 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 kuster and members of the subcommittee, 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 prior to appointment. They selected three out of ten applicants 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 had compliance rates 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 sufficient oversight practices to monitor whether facilities referred all employees with a positive drug test result 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 v. A. s 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 in testing designated positions for at least six months in 2014 and 2015. Despite the lack of drug testing for six months we found no indications v. A. Management at either the local or the National Level was aware of the lapse. Because no drug testing occurred, the atlanta v. A. 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 v. A. Reportedly have taken action on these recommendations. V. A. Also requires that managers at vha facilities ensure that a controlled substances Inspection Program is implemented and maintained. The oig has reviewed v. A. s management of controlled substances during our combined Assessment Program reviews. We rolled out the results of our work in june of 2014 and they reference that work in their recent report. The oig also has a vigorous Investigative Program related to Drug Diversion. We primarily focus on three categories. First, 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 pursues. Next, controlled and noncontrolled substances for illegal distribution, which involve cases where v. A. Pharmaceuticals are stolen for the purpose of illegal sale. Also the diversion of controlled substances by a theft of pharmaceuticals. Our investigations have revealed mailed 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 has provided costcutting oversight of the Drug Free Workplace Program and controlled inspections through our audits and inspections. This is necessary to take steps to reduce risks to the safety of employees and veterans by having and following active program controls. We investigate Drug Diversion and seek prosecution for those engaged in Drug Diversion. Based on our work in recent years, we have concluded v. A. Lacked reasonable assurance that it is achieving a drug free workplace and adequately securing controlled substances. This concludes my statement and we would be happy to answer any questions that you or subcommittee members may have. Thank you. Mr. Williamson, you are now 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 opioids and other controlled 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 its controlled substance Inspection Programs. All v. A. Medical facilities that store and dispense controlled substances are required to undertake monthly inspections of all areas within the facilities that are authorized to have controlled substances. Each facility director is responsible for overseeing the Inspection Program and appointing a coordinator to manage the inspectors who conduct the inspections. Usually both the coordinators and inspectors have other responsibilities within each facility and work parttime 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 any 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 vha policy requirements as was the case for three of the four facilities we visited. 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 vha 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 corrective actions if missed inspections or other 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 that did review the quarterly trend reports took no action to ensure that one of the facilities in the review and had not prepared quarterly trend reports had a correct tich 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 coordinator or inspectors could not carry out their responsibilities because of pressing job duties or unforeseen circumstances. We recommended that v. A. Adopt this type of practice systemwide 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. Berge, 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, health care employers, coworkers and even endangers the diverters themselves. While we have long known of these hazards of patients being deprived of pain medication, only fairly recently has the grave risk to extremely vulnerable patients been revealed by the outbreaks of disease such as blood poisoning or viruses that have been transmitted by drug diverters in the commission of their crimes. Many patients have been infected with potentially fatal illnesses. I have attached for your review a paper outlining six such outbreaks over a tenyear period that resulted in illness and death in patients. One of these diversion infection scenarios included Veterans Affairs patients being exposed to a diverter that communicated his hepatitis c infection to approximately 50 patients. This individual was referred to earlier in the introduction comments. This diverter was a radiation technologist who traveled the country. He had been fired for multiple jobs for diverting fentanyl for his own use but by lying on job applications he had no trouble finding employment. In the darkened invasive radiology suites he would swap fentanyl syringes for ones he had previously used to inject himself. He would then excuse himself to a restroom, inject himself with the stolen fentanyl, draw tap water and repeat the process with the next patients fentanyl. In this manner he conveyed his potentially lethal illness to many innocent victims. The patients described in these outbreaks were all extremely vulnerable positions either undergoing an invasive procedure while under anesthesia or while in an intensive care unit. 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 controlled substances from attack across 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 robust surveillance, detection, investigation, intervention programs in place to minimize the risk to all involved. While it be impossible to eliminate Drug Diversion from the health care workplace, its imperative that robust systems rapidly detect and halt such activity. I have attached for your review an article from the mayo clinic. It outlines our program from its inception to its very successful implementation. While we continue to try to improve our system, it has proven effective in identifying a host of drug diverters since implementation seven years ago. Diverters come from a diverse background. These stories are incredible, but they point to the powerful draw these drugs have over addicts. As such its not good enough to have effective policies and procedures on the books. They must be rigorously 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 to have a reputation for being effective at rapidly identifying, terminating and prosecuting Drug Diversion and diverters. Only by doing so can we protect the most vulnerable of our patients from preventible harm. This problem will never go away so we must become very good at rapid intervention. Only by instituting and following effective antidiversion policies and procedures will this be possible. I thank 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 oral testimony will be entered into the hearing record. We will now proceed to questioning. Dr. Clancy, in your testimony 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. Berge 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 see is 91. 4 of these losses occur outside our facility in the mail 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. Berge, v. A. s office of Human Resources management reported to the oig that they interpreted language in the v. A. s drug free workplace handbook to require only some job finalists for testing designated 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 kuster, you are recognized for five minutes. Thank you. Thank you to our panel. 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 DiversionDeterrence Program would look like and yet we continue to have this problem at various locations. My question is currently the v. A. Gives authority to the individual facilities to implement these inspection procedures, but is there any reason i guess this is for dr. Clancy is why could v. A. Not streamline this process and apply one standard to all facilities and in fact, have an Inspection Team based out of the Central Office that would go out . 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 just an addon. It doesnt seem as though were taking it sufficiently seriously and wouldnt it make more sense if we had an office of inspection that would then go out, perhaps as you did yourself, without advance warning and do these checks . Thank you, congresswoman. Thats exactly what we are 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 user of opiates. Thats whats feeding this epidemic. Can you talk to me more about both the Program Within cara, encouraging va. To reduce the use of opiate medication or any other examples you might have in the system . Of course. Thank you for the question. Im happy to report that we are on track for all the provisions in cara. Incredibly enough, 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 i have 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 beginning in august of 2013, weve seen a 31 reduction in the number of patients receiving opioids. 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 that youre actually taking the medications that you received. Were seeing the overall dosage of 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. 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 was doing, but what about the visn and the faculty level, what are we doing there . So every one of our net works thats a Veterans Integrated Service network, has a pharmacy lead there. I will say its my understanding theres 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 to some extent, i believe mr. Williamson referred to the fact 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 from pharmacy, whos here today, not mr. Valentino, one of his top lieutenants, came with me and noted there was a problem with not randomly conducting inspections throughout the month. If you let it go to the end of the month, but if stuff happens that week that means you will have slipped a month and so forth. That is the kind of thing that i think we can and will improve on. Okay. My next question is for mr. Dahl. In your investigation related to the 2015 and 2017 reports, how many positions identified as no background check completed were the high risk, the testing designated positions . Do you know that . Well, the 2015 report did not get into the background investigations. Our 2017 report, which was focused only on the atlanta v. A. Medical center, i wouldnt have that information at hand, but id be happy to look into that. Can we get a copy of that to try to figure that out because we want everyone tested because as you described and somebody at the panel did that everyone is at risk with this, anyone we hire. That being said if were going to drop them into those highrisk positions, we definitely have to do some backing up and making sure. Im kind of short on time here, but dr. Berge, this is a question that im sure my constituents and people throughout this nation are going to ask, would your Health Care Organization hire a clinic professional prior to completing a background check . No. Thats what i thought. Okay. What risks are associated with hiring a clinical staff prior to a background check . Well, one source of frustration is like when we are interviewing an applicant for say our nurse anesthesia school, Employment Law forbids us from asking if you have been treated for chemical dependence before. We have had such people that have developed a fentanyl addiction and they have gone through treatment for cocaine in the past. We are barred for asking those questions, but we would complete the post offer of employment drug testing. If i can add. Let me say this and i know im short on time. This is an issue ive dealt with on the state level and then here at this level as well. We want to remember 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 to us, he gave us information. It wasnt correct and he came back and said to us what part of im an addict, i lie, dont you understand. Thats why its so important to not only do the question, but make sure that we do the follow up checks and the concerns i see is the holes that are existing in the system. We cant have it we want to do everything we can to empower you to try to stop this epidemic that is affecting, and it has it doesnt matter whether youre what your race is, gender, socioeconomic status is, weve got to continue to work on this. Thank you very much, mr. Chairman. I yield back. Thank you. Mr. Walsh, you are recognized for five minutes. Thank you all for being here. Dr. Clancy, we have a long history in this too,. I just for the committees sake for the new members, the first piece of legislation that we authored in 2008 was the pain directive that went to the v. A. To set up the step Pain Management. That was with a lot of work from the folks from the mayo clinic, Boston Scientific and all the best practices working in conjunction with the v. A. There is one of those issues that the seamlessness between the private sector and the 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 here is Pain Management. Its in the beginning. Our nation goes through these issues of issuing opioid and pulling them back which creates its own problem. The diligence on the control side, we can always do better on that. I think theres been some great suggestions there. But i would suggest to all of us that program, am i right, dr. Clancy, was never fully implemented . We had this discussion here about 18 months ago. Did we ever fully implement it before it expired . Im not sure, but i could get back to you on that. What i do know is that thanks to the new legislation that representative kuster was asking about, the cara bill, we are now making sure there is Pain Management expertise and teams accessible by all our facilities. For some of our facilities thats going to be partly virtual. But as arkansas as an integrated system it builds on that same principal. Absolutely. It fully implemented the same thing thats happening in the private sector. As many of us know as the v. A. Goes, so goes the rest of the world. How much collaboration do you have with experts out there . Im just meeting dr. Berge today, although we have mutual colleague friends. We consult with others pretty broadly. When the cdc published guidelines last year, they drew on a number of folks from the v. A. , including from your district. As you said, this is all about a Common Health challenge shared by the country. Thank you for being here. You and your colleagues over the years, the thing about this is not to think everything is reactive. This recent opioid especialpide the overdoses and everything that come with it, this was not a surprise to many folks like yourself but when you said mayo clinic saw you had maybe some holes in there and you decided to turn around and are now recognized as one of the best. How long did it take you to implement that before you saw or expected to see change . We were probably about a year and a half in creating our system and that was in response to a tampering 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 where we were vulnerable and figure out a plan to address that. And it takes some time to go through that process. You have facilities how many facilities . We have we have the minnesota facility and the surrounding area. We also have jacksonville, florida and some small surrounding area and scottsdale, arizona. And some surrounding area. You have 50,000 plus employees roughly. About 70,000. For the entire system on that. This is 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 oversight and legal responsibility but also from an ethical responsibility is to those veterans. Do you feel like its moving quickly enough for you . Im excited by how enthusiastic our employees are about this. This is a national problem. Im excited by the progress we have made. We will be tracking this very very closely. I get it too. Theyre embarrassed by this. We recognize when its not done right, the issue and surrounding areas impacted. This is a tragic situation. We can do something about it and do something quickly because we have that ability in the v. A. And i guess im just looking for to see these things maybe be implemented as quickly as we can. I know you are, too. Thank you for your testimony. Thank you. Mrshgs poliquin, you are recognized for five minutes. Thank you. Youre with the Inspector Generals office, correct, sir . Yes, sir. Mr. Williamson youre with the Government Accountability office . Yes. You two gentlemen have reported theres a problem with keeping track of the drugs at the v. A. Facilities, making sure theyre not stolen and so on, 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 gaos recent work that there is still an issue. Thank you. Dr. Clancy, you are the deputy undersecretary for health for organizational excellence. What does that mean . Does that mean keeping track of whos got these harmful drugs, making sure theyre not put in the wrong hands . 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 . Hm . 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. You do. 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. Big, big span of reach. The system is organized into these networks. This is sort of a submanagement problem. What does the integrated Services Networks do . They manage and provide oversight for the facilities and clinics 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. Correct . Yes. Who is the head person over there . There are 18 of these networks. In your area, that would be dr. Michael mayosmith for new england. Well make sure we get a list of these people also. Mr. Williamson, have you found in traveling around the country dealing with separate v. A. Facilities that there is inconsistency and i think congresswoman kuster asked this question earlier, i want to get this straight, theres inconsistency which medical facilities 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 tenets of the inspections. As a result, these drugs get in the wrong hands . Correct. Okay. Good. Dr. Berge, you are in the private sector at mayo, correct . 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. Mr. Chairman, thank you very much. Dr. Dunn, you are recognized for five minutes. Thank you. Dr. Clancy, i serve on a constituency that actually has a veterans hospital, the lake city facility, and theres testimony here that we did not read aloud but i think you are familiar with that they had a problem in the lake city facility recently with a nurse misappropriating the 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. Iwould be happy to take that for the record. Our first focus was on protecting patients and then holding the individual accountable but i will 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 follow up. We will find that for you. All right. Let me depart for a second. Dr. Berge, you are 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 StatesPostal Service and in u. P. S. Ive looked at a lot of Drug Diversion, a lot of problems with this in my 35 year career as a surgeon. I have never seen anything like this reported. This is perilously close to the old excuse, the dog ate my home work. Do you believe that 90 of the problem with Drug Diversion in this country occurs in the United StatesPostal 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 without 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 StatesPostal 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 a high order of business. Very large volumes. Somewhere between there and the Veterans Home where it was supposed to go 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. Lets drill down on this farther. That looked like we were lying it off on the Postal Service. Whats happening is the v. A. Is getting receipt of the drugs from who they purchased it from and then theyre distributing it in their system. They may be using u. P. S. Or usps and somewhere 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 vha 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. Roe, you are 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 by with diazapenes and 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. The other thing i have, as i looked at 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 need you to call me a prescription in. Emr, i pull it up 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, dea, oig, va police and so on and so forth. In those reports we are 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. 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 if thats the case. Dr. Clancy, in your written testimony you said 92 of loss by mail, you sort of answered about how you got at that information. In reviewing the forms 106 submitted to the committee, we learned of instances where the va mailed controlled substances to the wrong address and worse, to the wrong veteran. How many cases of 92 were missing in the mail were those delivered to the wrong address or to 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 note that the numbers, 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 so when they move, change phone numbers or whatever, 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 va . The va 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 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. For them to get their controlled substances. 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. Its a huge problem for the entire country. I yield back. Mr. Poliquin is recognized for one followon question. Id like to follow up what chairman roe was just 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 v. A. . 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, 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 to home where folks come in and theyre known by the folks at the pharmacy. We have a problem here and so forth and so on. Why not . I think we ought to consider that. I dont know what the protocol is, mr. Chairman, but i bet these nice folks can come back and report back to us. Id like to follow up along the same vein, mr. Dahl and mr. Williamson, you two fellows said roughly 10 or 15 of the medical facilities in the v. A. Are doing this right. That means 80 , 85 no, thats what i would we only looked at four and the ig looked at 58, but thats based on there are a bunch of them that are doing it wrong. Whats that . There are a bunch of them that are doing it wrong . Correct. I have an idea. Why dont we get you nice folks to talk to our great staff here and find out whos doing it right and well have our staff, mr. Chairman, call up the folks that are doing it right and lets find out why theyre doing it right and then maybe we can have this nice person, mr. Alaigh, who i believe, dr. Clancy, you report to, the undersecretary for organization excellence, come before the committee and then we can see okay, weve had these folks that are doing it right, now were having a problem at the va doing it wrong, maybe you can tell us why 80 are doing it wrong. Just an idea. What do you think about that . Do you think that would work . I missed that last part, sir. You think that would work . Would that give us a little bit of help . With the poex that are doing it wrong . Best practices, it wouldnt hurt to share them. There you go. Were all trying to get this right because we have a lot of veterans who are in pain and we have a lot of folks that are having problems with opioids and heroine, including the Second District of maine that im very concerned about. Anything that we can do to help you folks, we will do that. I know our great staffer kate will be in touch with you folks to get the names we talked about. Yes, doctor. We often do do sharing of best practices and have a Big Initiative on that now and i think its a splendid idea. Have you been doing that for the last eight years . Not in this particular area. How have you been doing it in this area . We have focused on reducing opioid use. Last couple of years. Yes. You still have 80 that are not doing it right . I am not quite as confident. I think that may be a slightly pessimistic projection, but i will tell you when we look i will let you know. Thank you. More reason for us to get the folks who are doing it right to come and report to us and maybe have the person who is in charge of everybody tell us why the other folks arent doing it right. And if i might, the doctor is a woman. Wonderful. Thank you very much. Appreciate it. Thank you. Yield back my time. Thank you. Thanks to everyone. Thanks to the witnesses. This has been a great next first step as we move forward with a very serious issue here. You are now excused. It is clear from the testimony that has been provided today, as well as the numerous cases we hear about in the news that Drug Diversion is a major problem in va facilities. The lack of yeefr sight and accountability, storage and destruction is is troubling. We hope by bringing this ib to light, it will encourage the va to take steps necessary to impose better oversight and control. The progress and changes the va is making. I ask unanimous consent that members have five days to revise and extend their remarks and include material. I would like the thank the audience members for joining in todays conversation. With this, this hearing is adjourned. Your documentary b has been selected as this years grand prize winner. What, oh, my gosh. 7th and 9th grade sisters in blacksburg, virginia. This years grand prize wirn of our video documentary. Its titled the tempest toss, which explores refugees and immigration policies. One whos been forced to flee his or her country because of persecution, war or violence and cannot return safely. With so many fleeing their countries desperate without a home, politicses and institutes today are arguing over one urgent question. Should the United States let more into the country . They win the 5,000 prize. We asked students to tell us what is the most urgent issue for the new president and congress address in 2017. 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