Medicare Part D Plans to Take Active Role in Reducing Prescription Abuse

As prescription drug abuse and misuse continues to increase, CMS is asking Medicare Part D sponsors (private insurance companies that provide drug coverage to beneficiaries) to step up efforts to help physicians, pharmacists, and patients identify problems. 

In April, CMS released its annual capitation rates and payment policies letter. It includes a section focusing on “Improving Drug Utilization Review Controls in Part D,” which outlines additional steps sponsors must take when they suspect overutilization of medication is occurring.

According to the CMS announcement, the additional steps required stem from a recent Government Accountability Office report, which summarizes findings of “egregious overutilization” of medications by Part D beneficiaries obtaining medications from a minimum of five different prescribers and a maximum of 50 prescribers.

“The medications most often identified as being potentially overprescribed were those opioid products containing hydrocodone followed distantly by oxycodone containing products,” the announcement states. “Therefore, we are focusing on addressing overutilization of opioids beginning [in calendar year] 2013.”

Those efforts include a requirement that Part D sponsors create and monitor Part D utilization reports to identify patterns of duplicative drug use over sustained periods of time and/or across multiple drug products that relate to opioid prescriptions. If sponsors do identify a possible problem, clinicians employed by the health plans are to discuss the problem with the physician who prescribed the medication.

If for some reason medical necessity for the medication cannot be established, the sponsor may implement beneficiary-level edits at point of sale at all network pharmacies. That will result in the rejection of claims or quantities of medication, according to CMS.

Though some physicians may dislike increased involvement on behalf of Part D sponsors, it may be necessary at times, Barbara Sullivan, associate director at the Utah Addiction Center at the University of Utah in Salt Lake City, said in an e-mail to Physicians Practice.

“Recently docs in Florida have come under scrutiny because people from all over the country have gone to Florida to get multiple opiate prescriptions filled,” she pointed out. “Then these folks have returned to their home states and sold the drugs on the streets.”

In fact, according to NPR, physicians in Florida prescribe 10 times more oxycodone pills than doctors in every other state in the country combined.

In addition, while many states have prescription drug registries, sometimes physicians fail to check them prior to prescribing medication to patients, said Sullivan. “The additional steps of proving medical necessity and clinical case management [written into the April announcement] may make it more difficult for people to 'doctor shop,'” she said.

In February, when CMS announced its initial outlook for calendar year 2013, there was no requirement written into it that Part D sponsors contact the prescribing physician prior to denying or making changes to Medicare coverage for prescriptions that the sponsor thought indicated overuse.

This drew concern from many physicians and physicians organizations. “Part D sponsors are not in a position to evaluate medication overutilization,” academic pathologist James Madara, CEO and executive vice president of the AMA wrote in a letter to CMS in response to the notice. “The only information they have is the various claims that are submitted for prescription coverage. Sponsors do not know diagnoses and they do not know about any other services the patient is receiving that do not involve Part D coverage.”

In a statement e-mailed to Physicians Practice, pediatric neurosurgeon Peter W. Carmel, president of the AMA, said the organization is pleased that CMS responded to its concerns in the April announcement.

“The AMA has made it clear that physicians, not health insurers, have the clinical knowledge and expertise to make decisions about which medications a patient should receive,” Carmel said. “The revised CMS policy will require health plan staff to communicate with physicians and resolve questions about potential overuse of medications before contemplating any changes to a patient’s prescription drug coverage."