Medicare and the Opioid Epidemic

Opioids are over prescribed in the U.S. Although they may provide effective pain relief when prescribed properly, increasing their dosage for chronic pain often results in a myriad of side effects as well as addiction, overdose and death. In response to the opioid epidemic, the Center for Medicare and Medicaid Services (CMS) developed an opioid overutilization policy designed to curb inappropriate prescribing of opioids.

Implemented in January of 2013, the policy relied upon an all-inclusive morphine equivalent dose (MED) approach to help Part D sponsors distinguish high risk beneficiaries. The use of more than 120 mg of MED for at least 90 days in a row, from more than three prescribers and three pharmacies, placed the beneficiary in the potential opioid over utilizer category. CMS required its Part D plans to provide quarterly reports identifying these high risk beneficiaries and the results of their review of each case.

Additional efforts to curb opioid abuse were outlined by U.S. Health and Human Services Secretary, Sylvia Burwell in a press release on March 26, 2015. She identified three key areas that would be targeted by the HHS department. The areas would focus on: “providing training and educational resources, including updated prescriber guidelines, to assist health professionals in making informed prescribing decisions,” “increasing the use of naloxone” and “expanding the use of Medication-Assisted Treatment (MAT)”to treat substance use disorders. These initiatives are evidence medicine based.

CMS has been moving forward with efforts to assist health care professionals in making informed prescribing decisions. Its September 28, 2015 press release announced its “Part D Enhanced Medication Therapy Management Model.” The goal of this model is “to test strategies to improve medication use among Medicare beneficiaries enrolled in Part D.” The test will begin on January 1, 2017, run for a five year period in five different regions with a focus on the coordination of medication management therapy between the beneficiary, prescribers and pharmacies.

CMS also announced the release of a Part D Opioid Drug Mapping tool on November 3, 2015. This interactive online tool allows the geographic comparison of the percentage of opioid claims within a local area to other communities nationwide. The data used in the mapping tool is based on the Medicare Part D claims filed in 2013. According to CMS Director Tom Frieden, M.D., M.P.H, “This mapping tool will help doctors, nurses, and other health care providers assess opioid-prescribing habits while continuing to ensure patients have access to the most effective pain treatment. Informing prescribers can help reduce opioid use disorder among patients.” (CMS News Release, November 3, 2015)

CMS’ focus on evidence based medicine guidelines in its Part D programs and its initiatives would be expected to result in less of a range in opioid use across the nation. Although the WCRC notes in its WCMSA Reference guide that it looks to evidence based medicine in reviewing the WCMSA proposals, its projections of opioids for life contradict this claim. Greater consistency between the CMS WCMSA determinations and CMS initiatives in non WC claims should be required.

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