Prescription Drug Abuse: A Growing Compliance Risk for Medicare Advantage Plans

The GAO recently released a report on fraud and prescription drug abuse in Medicare Part D. Prescription drug abuse is a serious and growing public health problem. According to the CDC, drug overdoses, including those from prescription drugs, are the second leading cause of deaths from unintentional injuries in the United States, exceeded only by motor vehicle fatalities. Unlike addiction to heroin and other drugs that have no accepted medical use, addiction to some controlled substances can be unknowingly financed by insurance companies and public programs, such as Medicare Part D.
The report released by the GAO describes beneficiary doctor shopping in the Medicare Part D program for 14 categories of frequently abused prescription drugs. The objectives were: 

(1) To determine the extent to which Medicare beneficiaries obtained frequently abused drugs from multiple prescribers;

(2) To identify examples of doctor shopping activity; 

(3) To determine the actions taken by (CMS) to limit access to drugs for known abusers.

The analysis found that about 170,000 Medicare beneficiaries received prescriptions from five or more medical practitioners for the 12 classes of frequently abused controlled substances and 2 classes of frequently abused non-controlled substances in calendar year 2008. These individuals incurred approximately $148 million in prescription drug costs for these drugs, much of which is paid by the Medicare program. Most of these 170,000 Medicare beneficiaries who were prescribed prescriptions from five or more practitioners were eligible for Medicare Part D benefits based on a disability. Specifically, approximately 120,000 Medicare beneficiaries (about 71 percent) were eligible for Medicare Part D benefits based on a disability. Of these 170,000 beneficiaries, approximately 122,000 beneficiaries (72 percent) received a Medicare Low-Income Cost-Sharing (LICS) subsidy.
The Government Accountability Office (GAO) is a key driver for identifying issues of accountability in government agencies that translate into Congressional initiatives resulting in CMS auditing activity for Medicare Advantage Plans. CMS currently requires Part D plans to perform retrospective drug utilization review (DUR) analysis to identify prior inappropriate or unnecessary medication use and provide education, such as alert letters, to the prescribers involved. By analyzing historical prescription claims data, the drug plans can identify individuals who are likely obtaining excessive amounts of highly abused drugs or potentially seeking such drugs from multiple medical practitioners. However, according to CMS Part D program officials, federal law does not authorize Part D plans to restrict the access of these individuals, leaving little recourse for preventing known doctor shoppers from obtaining hydrocodone, oxycodone, and other highly abused drugs.
The GAO recommends for CMS to review the findings, evaluate the existing DUR program, and consider additional steps, such as a restricted recipient program for Medicare Part D that would limit identified doctor shoppers to one prescriber, one pharmacy, or both for receiving prescriptions. CMS should consider the experiences from Medicaid and private sector use of such restricted recipient programs, including weighing the potential costs and benefits of instituting the control. In addition to a restricted recipient program, CMS should consider facilitating the sharing of information on identified doctor shoppers among the Part D drug plan sponsors so that those beneficiaries cannot circumvent the program by switching prescription drug plans. Finally, in considering such controls, CMS should seek congressional authority, as appropriate.
Medicare Advantage often employs weak, ineffective DUR programs that fail to identify fraud and abuse in the Part D drug benefit or, once fraudulent or abusive patterns are identified, lack any systematic follow-up of the information. Plans can expect this to become a CMS Audit Hot Button. A relatively small percentage of the Medicare population impacts a significant financial impact. Clearly, there is a favorable ROI for plans to develop strong DUR programs. The Gorman Health Group can help in developing effective, proactive utilization management programs for your Medicare Advantage Plan.