There's growing attention and support for the inclusion of a patient review and restriction program in Medicare to help prevent opioid overuse and addiction.
In a congressional hearing last week on a separate topic, CMS acting Administrator Andy Slavitt lauded such programs. In July, Sen. Pat Toomey (R-Pa.) introduced a bipartisan bill to include the program in Medicare. President Barack Obama also included the program in his 2016 HHS budget request.
Patient review and restriction programs, which require patients at risk of prescription drug abuse to receive controlled substances from only designated prescribers and pharmacies, are already used in many state Medicaid programs. Patients in hospice care or those who receive treatment for some cancers are excluded.
Cynthia Reilly, director of the Pew Charitable Trust prescription drug abuse project, said there have been previous efforts to include the program in Medicare, but the idea has been “definitely gaining traction” recently.
About 28% of Medicare Part D beneficiaries not in hospice or cancer treatment were prescribed opioids in 2011, and more than 1.7 million of those patients received a dosage that put them at increased risk of an overdose, according to the CMS.
The program can help prevent overuse by curbing “doctor shopping,” or the practice of visiting several doctors to get prescriptions from each. Patients in the program who go to a nondesignated pharmacy or provider for certain prescriptions will have their claim rejected unless it's an emergency.
Current programs allow medical professionals to review individual classes and use varying criteria to identify which patients will be flagged for abuse. Most criteria involve receiving frequent prescriptions from a variety of doctors. The patients are flagged from one to three years. Their designation can be appealed.
Studies of some of the Medicaid programs show they are successful in reducing the use of certain prescriptions and can offer substantial cost savings, according to an expert panel convened by the Centers for Disease Control.
Reilly said the main concern in implementing the program would be ensuring that patients with a legitimate need for medication aren't refused. Observations of the existing programs have shown the clinical reviews and appeals process keeps this from happening.
To ensure convenience, patients should have a say in which pharmacies they are required to use, she said.
The program would also need to be reviewed for patient satisfaction and well as prescription drug overuse statistics, Reilly added.
In another effort to fight prescription drug abuse, the CMS has issued a proposed rule that would require providers to consult their state's prescription-drug monitoring program to check for a patient history that could indicate overuse. The rule received many negative comments this month. Providers said it would be an administrative hassle and could have inaccurate information.
