Medicare is coming for your pain meds

Last year, the Pharmacy Quality Alliance (PQA) identified opioid abuse as a high priority area for measure development…

The PQA opioid measures are intended for health plans to “examine the quality of use related to the dose of the medications over time, access to the medications, and the combination of both of these criteria.” The denominator for all three measures includes individuals with two or more prescription claims for opioids filled on at least two separate days in a twelve month period with a total equal to or greater than a fifteen day supply. The numerators of these measures correlate to inappropriate medication use, poor care-coordination, or doctor shopping.

Two or more prescriptions for opioids in a 12-month period — my god, how many millions of pain patients would that include?

According to the 2016 Centers for Medicare and Medicaid Services (CMS) Call Letter released in April, these PQA measures may be adopted as future display measures in the Medicare Star Rating System or used in the Overutilization Monitoring System (OMS)…

Each PQA member organization will have the opportunity to vote on the endorsement of three new performance measures on May 14th at the PQA Annual Meeting.

1. Use of Opioids at High Dosage in Persons Without Cancer
2. Use of Opioids from Multiple Providers in Persons Without Cancer
3. Use of Opioids at High Dosage and from Multiple Providers in Persons Without Cancer

It appears that no matter what painful medical condition you suffer from, if it’s not cancer, it doesn’t count.

PQA Member Organizations (partial list):

University of New Mexico College of Pharmacy

Cardinal Health
CVS Health
Publix Super Markets, Inc
Rite Aid
Safeway, Inc.
The Kroger Co.
United Drugs
Walgreen Co.

Blue Cross and Blue Shield of North Carolina
Florida Blue
UnitedHealth Group

Kaiser Permanente

AstraZeneca LP
Bristol-Myers Squibb
Johnson & Johnson
Lilly USA
Merck & Co.
Novartis Pharmaceuticals Corporation
Pfizer, Inc.
Purdue Pharma, L.P.

Express Scripts, Inc. 

American Pharmacists Association (APhA)

Brookings Institution

Centers for Medicare and Medicaid Services (CMS)

U.S. Food & Drug Administration (FDA)

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