Medicare and “lock-in” programs (one doctor, one pharmacy)

Highlighting two recent reports by the Office of Inspector General (OIG) that reveal missed fraud prevention opportunities by the Centers for Medicare & Medicaid Services (CMS), members of the Subcommittee on Oversight and Investigations grilled leaders of the OIG and CMS at a hearing Tuesday, looking for ways to detect and prevent Part D fraud, waste and abuse.

Members of the subcommittee harped on the high volume of opioid prescribing through Medicare Part D that has led to an increase in opioid addiction throughout the country. OIG reports show that spending on commonly abused opioids has grown 156 percent within the last nine years, reaching $3.9 billion in 2014. The total number of beneficiaries receiving those drugs grew 98 percent, compared to 68 percent for all other drugs. In the recent national fraud takedown, 44 of the 243 individuals arrested were involved in Part D fraud schemes, many of which involved opioid prescriptions…

During the hearing, Maxwell also pointed to three specific oversight tools that would improve Part D oversight… A “lock-in” program that restricts certain beneficiaries that are identified as overusing opioids to a limited number of pharmacies and prescribers in order to prevent drug diversion…

Officials from the Office of the Inspector General reported that 43 percent of Medicare Part D beneficiaries in Alabama received prescription opioids last year, compared to 32 percent nationwide. About 41 percent of beneficiaries in Tennessee and Oklahoma received opioids, followed by 40 percent in Alaska…

Part D spending on the most addictive prescription opioids increased from $1.5 billion to $3.9 billion a year between 2006 and 2014, according to the report. Spending was highest for OxyContin, hydrocodone-acetaminophen, fentanyl and morphine-sulfate. Officials are concerned about the prevalence of the drugs because of the high potential for addiction and abuse.

There is also longstanding concern about fraud in Medicare Part D, and officials worry that some prescription opioids could be funneled from pharmacies to street-level drug dealers. Fraud could account for as much as 10 percent of federal healthcare spending, according to estimates from the Office of the Inspector General.

In a recent data brief released by the Office of the Inspector General, 1,432 retail pharmacies showed questionable activity, including 468 that had triple the average percentage of prescriptions for commonly abused opioids. Many of the pharmacies were located in Miami, New York, Los Angeles and Detroit, all areas that were targeted last week by the Medicare Fraud Strike Force…

The agency could also require a “lock-in” for patients suspected of doctor shopping, Anderson said.  “That’s where you restrict certain beneficiaries to a certain number of prescribers or pharmacies,” she added. The practice is already common in state Medicaid programs, including Alabama’s…

There is currently bipartisan legislation in Congress authorizing Patient Review and Restriction (PRR) programs in Medicare, and the president’s 2016 fiscal year budget request proposes authorization to establish PRR programs in Medicare as well. These are programs that are currently used by state Medicaid and private insurance plans…

Click to access Pew_MedPAC__Comments.pdf

Pew encourages MedPAC to recommend that Congress provide Part D plan sponsors the authority to implement patient review and restriction (PRR) programs to address potentially inappropriate opioid use… PRRs, also known as “lock-in” programs, are designed to identify and intervene in instances when patients over-utilize narcotics and other prescription drugs that are subject to abuse…

(10/29/2014) Medicare Should Adopt A ‘Lock In’ Policy

Herrick cites evidence that some Medicare beneficiaries either traffic in opioids or abuse them themselves. Medicare facilitates this because there are no limits to the doctors or pharmacies that beneficiaries can use. For the addicted or criminal Medicare beneficiary, this leads to “doctor shopping” and “pharmacy shopping.” Medicaid programs in some states have succeeded in reducing this abuse by making dependents chose one doctor and one pharmacy…

“It’s also good idea is consider expanding lock-in to include more drugs than just narcotic pain relievers if diversion of other types of drugs becomes a problem. A recent government investigation found Medicare spent $32 million for AIDS drugs in 2012 for 1,600 people with questionable drug utilization — more than half of which did not appear to actually have HIV. Many of these visited multiple doctors for prescriptions and/or filled their drugs at multiple pharmacies to obtain excessively-large quantities of costly HIV drugs. Some of these drugs were likely resold on the illicit market due to their high resale value. Another possibility is unscrupulous (possibly bogus) pharmacies stole Medicare enrollees’ identities and billed Medicare for drugs never dispensed.”

Herrick proposes that Medicare adopt what the industry calls “lock in” of a beneficiary’s pharmacy benefits to one doctor and one pharmacy. (The industry could have thought up a better term than “lock in.” How about “exclusive provider”?) The reforms Herrick proposes could save billions of dollars every year.

2 thoughts on “Medicare and “lock-in” programs (one doctor, one pharmacy)

  1. of course medicare has higher rates of people using opiates! medicare provides coverage ONLY to the DISABLED and ELDERLY, all of whom have more medical and behavioural health issues, especially those with chronic pain. Private insurers only cover that population, AND all healthy workers. There are MORE healthy workers covered privately than elderly/disabled…so of course the number of people receiving long term opiate therapy for chronic pain is less. Duh! so, in short, the number discrepancy reveals the demographics of those covered by private or medicare coverage, and are entirely accurate, and there is no issue with addiction and abuse in the elderly and disbaled population covered by medicare.

    Liked by 2 people

    • It’s funny how these big-data statistics on opioids are always used against us. But when you break them down, as Pharmacist Steve has done, they can actually show how pain is being under-treated. Nobody’s interested in looking past the surface of statistics that look alarming, especially with the CDC yelling “epidemic” everywhere.

      Liked by 1 person

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