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Lawmakers Look for Ways to Identify and Prevent Opioid Abuse in Medicare Program

January 17, 2018

Today, the Oversight Subcommittee, chaired by Rep. Lynn Jenkins (R-KS), held a hearing on the opioid crisis and what the Centers for Medicare and Medicaid Services (CMS) can do – as one of the nation’s largest payers of prescription drugs – to better identify and prevent opioid abuse.

At the start of the hearing, Chairman Jenkins explained how the opioid crisis has affected families in her home state and across the country:

“In 2016, more than 42,000 Americans died due to opioids – a level that is five times what it was in 1999. My home state of Kansas is no exception. In 2000, 35 overdose deaths were attributed to opioids. In 2016, 159 people died from opioid overdose in Kansas. … No community is immune to the effects of opioid abuse.”

Looking specifically at the Medicare Part D program – a voluntary prescription drug program for Medicare beneficiaries – Chairman Jenkins added:

“More than 42 million beneficiaries rely on the program for prescription drugs, including opioids. It is critical that Medicare, and private Part D plan sponsors have the tools they need to ensure that opioids are provided only when medically necessary.”

Elizabeth H. Curda, Health Care Director at the Government Accountability Office (GAO), discussed a recently released report on how opioids are prescribed and paid for in the Medicare program. She explained that CMS has developed certain criteria for identifying beneficiaries who over-utilize opioids, as well as the providers who prescribe them. However, she made clear that these criteria have helped CMS identify only very high-risk patients who receive high dosages of opioids from multiple providers or pharmacies. Ms. Curda added:

CMS oversight does not address the over 700,000 beneficiaries potentially at risk of harm based on [Center for Disease Control] guidelines. … CMS also lacks key information necessary for oversight of opioid prescribing because it does not require plan sponsors to report cases of fraud, waste, and abuse, cases of over prescribing, or any actions taken against providers. … Without complete reporting, CMS is missing key information that could help the agency achieve its goals.”

Members of the Oversight Subcommittee asked witnesses what steps CMS must take to improve their oversight process and protect Medicare beneficiaries from opioid misuse, addiction, and overdose. Here are some of the solutions Members and witnesses discussed:

1. Alternative Treatment Options for Patients with Chronic Pain

Rep. Jackie Walorski (R-IN): “One of the things I’ve continued to work on here is access to non-opioid alternatives. Is CMS developing a plan to use more non-opioid alternatives for patients with chronic pain?”

CMS Principal Deputy Administrator for Operations Kimberly Brandt: “We are working to increase access to medication, assisted treatments, and are looking and working with the CDC and other partners to determine the best approach.”

2. Limiting the Number of Pharmacies Beneficiaries Can Use (Known as “Medicare Lock-In”)

Rep. Pat Meehan (R-PA)“We have worked on some programs here in the Congress … and one of those is the Medicare lock-in [as a part of the Comprehensive Addiction and Recovery Act (CARA)]. And I have listened to each of the panelists describe in various ways how individuals have been able to utilize the system either by going to multiple pharmacists or multiple doctors or multiple plans to get the drugs. … Where do you think lock-in may be utilized?”

Kimberly Brandt: “We really appreciate this additional tool from Congress. We agree with OIG. We think this is going to be a very powerful tool. We are currently in the notice and comment period for this. We have to promulgate regulations to implement it. … Beginning in 2019 we will be able to begin using this tool.”

Rep. Meehan“How do you think it’s going to make a difference?”

Kimberly Brandt: “It will allow us to limit a beneficiary to a pharmacy. … Right now they can go to multiple pharmacies, multiple prescribers. This limits the scope of that much more narrowly.”

3. Partnering with the Private Sector & Law Enforcement

Rep. Mike Bishop (R-MI)“I was astounded to see that in Michigan where I’m from, my home state, the cost of opioid addiction is over 4% of our GDP. … I’m interested to know what the private sector is doing to partner with you?”

Office of Inspector General Deputy Inspector General for Investigations Gary Cantrell: “We talk – and CMS is an integral part of the healthcare fraud partnership, prevention partnership – but it provides a community of private-sector payers, state agencies, as well as federal payers and law enforcement to share, first of all, information about trends and schemes. But also, it’s a forum where they can safely share data from different resources, analyze that data, and come up with answers or identify issues across multiple data sources that weren’t previously available to be searched across. … For me, it’s certainly of great value in learning about these schemes.”

As Chairman Jenkins concluded:

“The Committee plans to do more oversight on this issue as we continue to examine other ways to reduce opioid abuse.”

The Ways and Means Committee will continue working to prevent the opioid crisis from devastating more lives and causing more harm to our communities across America. In the weeks ahead, the Health Subcommittee will hold another hearing on CMS and the opioid crisis to discuss legislative solutions to help Americans at risk of opioid abuse.

CLICK HERE to learn more about the hearing.