- The Government Accountability Office (GAO) has recommended that CMS should collect additional data on Medicare beneficiary opioid risks, including the number of beneficiaries with high-dose opioid prescriptions, the number of providers that overprescribe opioids, and available health plan data on overprescribing indicators.
CMS effectively identified over 33,000 beneficiaries at risk for opioid overutilization, but the current criteria CMS uses to detect possible opioid abuse may miss risk indicators described within CDC guidelines, GAO asserts.
“We found that CMS does not identify providers who may be inappropriately prescribing large amounts of opioids separately from other drugs, and does not require plan sponsors to report actions they take when they identify such providers,” GAO said.
“As a result, 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.”
Currently, CMS uses limited information to identify at-risk beneficiaries through its Overutilization Management System (OMS). In 2016, CMS started to gather information through the OMS about its patient safety measures and the number of beneficiaries that use high-dose opioids for 90 days or longer.
However, GAO argues that this method inadequately captures Medicare populations at risk for opioid abuse because it doesn’t include all potential abuse risk factors.
“Because neither the OMS criteria nor the patient safety measures include all beneficiaries potentially at risk of harm from high opioid doses, 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 said.
GAO additionally recommended that CMS should collect more data on providers, which includes the number of providers that prescribe high-dose opioid prescriptions.
CMS uses a third-party contractor, NBI MEDIC, to monitor providers who prescribe large amounts of Schedule II substances. NBI MEDIC also participates in other projects that collect data analytics on opioid prescribing behaviors and Medicare abuse investigation referrals.
But GAO found that NBI MEDIC lacks information on the specific opioids that are overprescribed.
“According to CMS officials, they direct NBI MEDIC to focus on Schedule II drugs, because these drugs have a high potential for abuse, whether they are opioids or other drugs,” GAO said.
“However, without specifically identifying opioids in these analyses—or an alternate source of data—CMS lacks data on providers who prescribe high amounts of opioids, and therefore cannot assess progress toward meeting its goals related to reducing opioid use.”
GAO suggested that CMS should require NBI MEDIC to gather separate data on providers that overprescribe opioids. Focusing on provider data would allow CMS to determine the individuals participating in high-risk behaviors, GAO said.
CMS should also require plan sponsors to report on actions related to providers who inappropriately prescribe opioids, the report said.
CMS delegates individual opioid use monitoring to plan sponsors, but CMS may not not receive the data in order to effectively identify risk, GAO argued.
CMS requires plan sponsors to have methods to identify beneficiaries who are potentially overusing specific drugs or groups of drugs. Health plans may take actions such as case management, point-of-sale limits for members, formulary point-of-sale adjustments, and referrals for fraud or abuse investigations.
However, GAO found that CMS does not require plan sponsors to report cases of fraud, abuse, or overprescribing to CMS or NBI MEDIC.
GAO believes that CMS needs this data from payers to effectively address overprescribing in the future.
“Without complete reporting—such as reporting from all plan sponsors on the actions they take to reduce overprescribing—we believe that CMS is missing key information that could help assess progress in this area,” the agency added.
HHS concurred with two of the three recommendations but argued that health plans are doing enough to manage and monitor opioid abuse.
“HHS did not concur with this recommendation,” GAO said. “HHS noted that plan sponsors have the responsibility to detect and prevent fraud, waste, and abuse, and that CMS reviews cases when it conducts audits.”
GAO summarized its findings by encouraging CMS to use its recommendations as part of a larger effort to improve beneficiary care quality.
“A large number of Medicare Part D beneficiaries use potentially harmful levels of prescription opioids, and reducing the inappropriate prescribing of these drugs is a key part of CMS’s strategy to decrease the risk of opioid use disorder, overdoses, and deaths,” GAO concluded.
“Despite working to identify and decrease egregious opioid use behavior—such as doctor shopping—among Medicare Part D beneficiaries, CMS lacks the necessary information to effectively determine the full number of beneficiaries at risk of harm, as well as other information that could help CMS assess whether its efforts to reduce opioid overprescribing are effective.”