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To Fight Opioid Abuse, Report Says CMS Will Need More Data


"CMS is lacking information that it could use to assess how opioid prescribing patterns are changing over time."

For the CMS to effectively fight prescription opioid abuse, the Government Accountability Office (GAO) recommends that it collect more data about doctors that prescribe high volumes of the drugs and patients who may be on the path to addiction.

“CMS is lacking information that it could use to assess how opioid prescribing patterns are changing over time, and whether its efforts to reduce harm are effective,” authors of the new report from GAO wrote.

The agency already collects data on doctors who prescribe large volumes of any Schedule 2 drug, through the external National Benefit Integrity Medicare Drug Integrity Contractor (NBI MEDIC) program. That data can be turned over to law enforcement if illegality is suspected, but the report suggests that the system should allow for high-volume prescribers of opiates to be viewed separately to better target the problem.

Additionally, while NBI MEDIC is required to identify and investigate allegations of fraud, waste, and abuse, plan sponsors are not explicitly obligated to report suspected cases. “Without complete reporting—such as reporting from all plan sponsors on the actions they take to reduce overprescribing—we believe that CMS is missing key information that could help assess progress in this area,” the report concludes.

Similarly, the report notes that CMS tracks Medicare beneficiaries who receive opioid prescriptions, but it “lacks information on most beneficiaries at risk of harm from opioid use.”

Since the creation of the Overutilization Monitoring System (OMS) in 2013, CMS has flagged beneficiaries for certain criteria, like those receiving morphine-equivalent dose (MED) of 120mg per day for 90 consecutive days or receiving opioid prescriptions from 4 or more providers (or filling opioid prescriptions at 4 or more pharmacies) over the course of 12 months.

It has instituted measures—like notifying pharmacists when a beneficiary is trying to fill a prescription that exceeds an allotted limit—that it says have reduced the number of potentially problematic prescriptions filled.

However, patients who receive a MED of 90mg or more long-term may be susceptible to serious health risks. A previous estimate from CMS estimated that there were over 727,000 of those beneficiaries during a 6-month measurement in 2015, but the GAO says that “CMS officials told us that the agency does not keep track of the total number of these beneficiaries, and does not have plans to do so.”

The report credits the agency for working effectively to inhibit the most egregious cases of “opioid use behavior,” but continues that “CMS lacks the necessary information to effectively determine the full number of beneficiaries at risk of harm,” and to monitor whether its efforts are effective.

“Access to information on the risks that Medicare patients face from inappropriate or poorly monitored prescriptions, as well as information on providers who may be inappropriately prescribing opioids, could help CMS as it works to improve care,” the new GAO report concludes.

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Craig Newman
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