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Federal Report Calls for Expanded Oversight of Opioid Use by Medicare Part D Beneficiaries

November 07, 2017

During 2016, more than 14 million Medicare Part D beneficiaries received opioid prescriptions, and spending for opioids was almost $4.1 billion. Medicare Part D is the federal government program to subsidize the cost of prescription drugs and prescription drug insurance premiums for Medicare beneficiaries.

The U.S. Government Accountability Office (GAO) was asked to describe what is known about the Centers for Medicare & Medicaid Services’ (CMS) oversight of Medicare Part D opioid use and prescribing. The report examines:

  • CMS oversight of beneficiaries who receive opioid prescriptions under Part D
  • CMS oversight of providers who prescribe opioids to Medicare Part D beneficiaries

The GAO released a report recommending greater monitoring of opioid use among Medicare beneficiaries to reduce harm.

Private insurance plans that implement Medicare Part D are expected to use CMS criteria to monitor opioid overuse by Medicare beneficiaries. The CMS criteria identify beneficiaries at the greatest risk of harm from opioid use, but the GAO found that it does not capture data on an even larger population of beneficiaries potentially at risk of harm from high doses of opioids.

CMS' criteria focus on beneficiaries who:

  • Receive prescriptions of high doses of opioids
  • Receive prescriptions from four or more providers
  • Fill the prescriptions at four or more pharmacies

The criteria allows plan sponsors to focus their attention on those beneficiaries determined to have the highest risk of harm from opioid use. However, the GAO report says that CMS' criteria do not provide enough information about the larger population of potentially at-risk beneficiaries. CMS estimates that, while 33,223 beneficiaries would have met revised criteria in 2015, 727,016 would have received high doses of opioids regardless of the number of providers or pharmacies.

The GAO believes that CMS is lacking information that it could use to assess how opioid prescribing patterns are changing over time, and whether its efforts to reduce harm are effective. The GAO recommends that CMS:

  • Gather information about the full number of at-risk beneficiaries receiving high doses of opioids
  • Identify providers who prescribe high amounts of opioids
  • Require plan sponsors to report to CMS about actions related to providers who inappropriately prescribe opioids

The U.S. Department of Health and Human Services concurred with the first two recommendations, but not with the third.

Earlier this year, the Office of Inspector General issued a brief expressing concern about fraud, abuse, and misuse of opioids, including those obtained under Medicare Part D. Key takeaways from the brief:

  • One in three Medicare Part D beneficiaries received a prescription opioid during 2016
  • About 500,000 beneficiaries received high amounts of opioids
  • Almost 90,000 beneficiaries are at serious risk; some received extreme amounts of opioids, while others appeared to be doctor shopping
  • About 400 prescribers had questionable opioid prescribing patterns for beneficiaries at serious risk

HAP will continue to monitor activity related to this issue. For information about HAP’s engagement in addressing the opioid crisis, contact Rob Shipp, HAP’s vice president, population health strategies.

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