Medicare drug plans need tools to combat drug abuse

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  • 08/21/2022

This article originally appeared on

In August, House Ways and Means Subcommittee on Health Chairman Kevin Brady (R-TX) introduced a bill, Protecting Integrity in Medicare Act of 2014, designed to help Medicare drug plans reduce fraud. More than 16,000 people die annually from abusing pain relievers, according to the Centers for Disease Control and Prevention, double the number that die abusing cocaine and heroin combined. Drug diversion costs insurers nearly $75 billion per year ??? about two-thirds of it from public programs such as Medicare and Medicaid.

Under current law, Medicare drug plans are not allowed to restrict the benefits of beneficiaries thought to be abusing or reselling prescription painkillers. The bill introduced by Brady would change this, allowing the drug plans to ???lock-in??? suspected abusers to a single doctor and pharmacy for pain medications.

"Every senior in America is affected by Medicare fraud, waste, and abuse,??? Rep. Brady said when he released a draft of his bill. ???It is devastating for those personally harmed, drives up premiums and hastens insolvency for others??? [W]e must do more to protect the Medicare program and our nation???s seniors."

Abuse of pain medicines a growing problem

Abuse of opioid pain relievers is a growing problem for Medicare drug plans. The most common way enrollees obtain large numbers of addictive pain relievers is by ???doctor shopping.??? This involves seeing multiple doctors with complaints about chronic pain, having redundant medical tests performed and asking each physician seen to prescribe pain medication.

To avoid detection, beneficiaries generally fill their prescriptions at multiple pharmacies ??? hoping that no doctor or pharmacy will question them. Although doctors and pharmacies may not realize a given patient is abusing prescription pain relievers, drug plans can detect it ??? but Medicare drug plans lack the authority to prevent this abuse.

Express Scripts is the largest pharmacy benefit manager (PBM) in the country. It has studied prescription drug abuse extensively in the plans it manages. According to Express Scripts, for every $1 worth of narcotic pain relievers lost to fraud, $41 more dollars are wasted due to unnecessary physician visits, unnecessary tests and unnecessary emergency room visits to obtain the drugs.

On September 29th the Alliance for Health Reform and the Pharmaceutical Care Management Association cosponsored a Capitol Hill briefing to highlight the problem caused by prescription opioid drug abuse and to discuss ways to reduce fraud. One of the speakers was Jo-Ellen Abou Nader, Senior Director, Fraud, Waste & Abuse Services at Express Scripts.

Abou Nader explained to attendees: ???PBMs??? are uniquely positioned to not only identify but to investigate these cases for fraud, waste, abuse and to collaborate with our payers.??? She indicated that a program to restrict the activities of drug-seeking enrollees would help Medicare drug plans reduce waste, fraud and abuse. ???We would love to see one in the Medicare world because our payers are really struggling. They are struggling because they do not have a way to control the behavior and the tools to be able to do that.???

???Lock-in??? cuts abuse

The restriction program that Abou Nader was talking about is a Safe Pharmacy ???lock-in??? ??? a program that virtually every state Medicaid program has implemented to protect public health and reduce fraud. The program would require a change in federal law to allow Medicare drug plans to ???lock-in??? enrollees suspected of abusing narcotic pain relievers.

Under a ???lock-in??? program, drug plans identify enrollees with suspicious claim patterns. Suspicious claims would likely involve Medicare enrollees shopping for narcotic pain relievers at multiple doctors, and filling prescriptions at multiple pharmacies. Once identified, suspected enrollees would be ???locked-in??? to a specific doctor for pain management, and a specific pharmacy to fill pain medications. No other physician or pharmacy could prescribe or dispense pain medications ??? but all other Medicare benefits would remain unaffected.

In August 2014 the Department of Health and Human Services, Office of Inspector General issued recommendations to reduce questionable usage of narcotic pain relievers by Medicare beneficiaries. One of the recommendations was to establish a lock-in program.

Devon M. Herrick, PhD is a health economist and senior fellow at the National Center for Policy Analysis.


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