- CMS should gather more comprehensive data on Medicare patients and providers to sufficiently monitor and prevent opioid overprescribing, according to a report from the US Government Accountability Office (GAO).
Misuse of opioids has become a serious public health issue in the US, including for Medicare and Medicaid beneficiaries.
GAO stated that in 2016, about one-third of individuals participating in Medicare Part D received at least one opioid prescription at a cost of nearly $4.1 billion.
These prescriptions are often associated with inappropriate activities, such as questionable prescribing practices and “doctor shopping” to receive multiple opioid prescriptions from different providers.
To evaluate CMS’s efforts to oversee opioid prescribing for Medicare Part D patients, GAO reviewed CMS opioid utilization and prescriber data, as well as CMS’s strategy to prevent opioid misuse.
In 2013, CMS created the Overutilization Monitoring System (OMS), which identifies patients with high-risk use of opioids, and monitors plan sponsor compliance with CMS’s opioid overutilization policy.
Until the end of 2017, the OMS identified beneficiaries as having a high risk of opioid misuse when they met three criteria: if they received a total daily morphine-equivalent dose (MED) greater than 120 mg for 90 consecutive days; received opioid prescriptions from four or more providers in the prior 12 months; and received opioids from four or more pharmacies in the prior 12 months.
Between 2011 and 2016, the OMS reduced the number of high risk beneficiaries by 61 percent.
However, GAO noted that these criteria may not have been enough to identify all high-risk beneficiaries.
“The agency did not have comparable information on most beneficiaries who receive high doses of opioids—regardless of the number of providers and pharmacies used—and who therefore may be at risk for harm, according to the Center for Disease Control and Prevention’s (CDC) 2016 guidelines,” GAO wrote.
“These guidelines noted that long-term use of high doses of opioids—those above a MED of 90 mg per day—are associated with significant risk of harm and should be avoided if possible.”
At the beginning of 2018, CMS revised its OMS criteria to adhere to CDC guidelines and include more at-risk beneficiaries.
The new OMS criteria identify beneficiaries as high-risk individuals if they have an average MED of 90 mg or more for any duration, and if they received opioids from four or more providers and pharmacies (or from six or more providers regardless of the number of pharmacies) in the last six months.
Using the revised criteria, CMS conducted a one-time analysis of Medicare beneficiaries and estimated that there were 727,016 individuals who fell into the high-risk category.
“We recommended that CMS should gather information over time on the total number of beneficiaries who receive high opioid morphine equivalent doses regardless of the number of pharmacies or providers, as part of assessing progress over time in reaching the agency’s goals related to reducing opioid use,” GAO wrote.
Despite the benefits that could come from tracking these beneficiaries over time, CMS officials told GAO that the agency does not plan to track the total number of these individuals as part of the revised OMS criteria.
In addition to monitoring opioid use, CMS oversees opioid prescribing habits through its contractor, NBI MEDIC, as well as Part D plan sponsors.
CMS requires NBI MEDIC to identify providers who prescribe high amounts of Schedule II drugs, which include opioids, and report these providers to CMS.
Additionally, CMS requires plan sponsors to implement an effective compliance program, which must include measures to prevent fraud, waste and abuse in all drug prescribing.
However, GAO stated that these initiatives did not deliver enough data for CMS to successfully evaluate opioid use in Medicare.
“Our report concluded that although these efforts provided valuable information, CMS lacked information necessary to adequately oversee opioid prescribing. CMS’s oversight actions focused broadly on Schedule II drugs rather than specifically on opioids,” GAO said.
“Without specifically identifying opioids in these analyses—or an alternate source of data—CMS lacked data on providers who prescribe high amounts of opioids, and therefore cannot assess progress toward meeting its goals related to reducing opioid use, which would be consistent with federal internal control standards.”
GAO recommended that CMS require NBI MEDIC to gather separate data on providers who prescribe high amounts of opioids.
GAO also advised CMS to require plan sponsors to report providers who prescribe high amounts of opioids, rather than allowing plan sponsors to choose whether to report this information.
Although HHS did not agree with this recommendation, GAO maintains that this information is key to successfully monitoring opioid prescribing rates in Medicare.
GAO expects that more data will allow CMS to reach its goals of reducing opioid misuse and enhancing care for beneficiaries.
“It is important that health care providers help patients to receive appropriate pain treatment, including opioids, based on the consideration of benefits and risks,” GAO concluded.
“Access to information on the risks that Medicare patients face from inappropriate or poorly monitored prescriptions, as well as information on providers who may be inappropriately prescribing opioids, could help CMS as it works to improve care.”