Medicare Planning to Adopt CDC Opioid Guidelines

By Pat Anson, Editor

The Centers for Medicare and Medicaid Services (CMS) has announced plans to fully implement the opioid prescribing guidelines released by the Centers for Disease Control and Prevention, which recommend that doctors not prescribe opioid medication for chronic non-cancer pain.

CMS is taking the CDC’s voluntary guidelines one step further, however, by mandating them as official Medicare policy and taking punitive action against doctors and patients who don’t follow them.

“When CDC released its guideline, I predicted that policymakers and payers would quickly move to convert CDC's voluntary recommendations into mandatory regulations, and my prediction appears to be coming true, both with CMS and with private payers,” said Bob Twillman, PhD, Executive Director of the Academy of Integrative Pain Management.

As Pain News Network has reported, CMS is adopting a “Big Brother” approach to fighting opioid abuse by developing a strategy that will encourage pharmacists to report doctors who may be overprescribing opioids and patients who may be abusing them. Information about thesepotential opioid overutilizers” would be shared with insurance companies, which would be empowered to “prevent opioid overuse at point of sale at the pharmacy.”

CMS contracts with dozens of private insurance companies – known as sponsors -- to provide health insurance to about 54 million Americans through Medicare and nearly 70 million in Medicaid.

“To address the opioid epidemic, CMS has implemented a medication safety approach by which sponsors are expected to reduce beneficiary overutilization of opioids and maintain access to needed medications,” the agency said in a statement.

Saying it wanted to “better align” its policies with the CDC guidelines, CMS is proposing a daily ceiling on prescribed opioids at 90 mg morphine equivalent dose (MED). Any dosage above that level would be considered excessive. Patients who receive opioids from more than 3 prescribers and more than 3 pharmacies during a 6 month period would also be red-flagged.

Insurers would be expected to police pharmacies, doctors and patients who do not follow CMS policies, potentially dropping them from Medicare coverage and their insurance networks.

“Under the Part D opioid overutilization policy, sponsors are expected to implement appropriate plan-level claim controls at POS (point of sale) for opioids, use improved retrospective drug utilization review to identify beneficiaries at high risk for an adverse event due to opioids, and perform case management with the identified beneficiaries’ prescribers followed by beneficiary-specific POS edits to prevent Part D coverage of opioid overutilization,” CMS said.

Such a policy change would have a sweeping impact throughout the U.S. healthcare system because so many insurers and patients are involved. The Veterans Administration is the only other federal agency to adopt the CDC guidelines – and many veterans have complained that they are no longer able to obtain adequate pain relief at VA facilities.

Critics of the CMS strategy say it is even more draconian than the CDC guidelines, which are intended only for primary care physicians.

“CDC's ‘soft limit’ of 90 MED in treating chronic pain was a recommendation aimed at treatment of some people with chronic pain by primary care specialists. CDC stated that all of its recommendations were voluntary, and in this case, further provided prescribers with the option to use a higher dose if indicated by a careful risk/benefit analysis,” Twillman said in an email to PNN.

“In light of these limitations, it seems inappropriate for CMS to ask Part D providers to institute opioid dosing limits for people with pain who don't have cancer or are receiving hospice care, and for all prescribers, both primary care and specialists. 

Strategy Developed by Insurance Industry

The agency’s proposed “Opioid Misuse Strategy” was released publicly in early January.  It closely follows a 62-page “white paper” prepared by the Healthcare Fraud Prevention Partnership (HFPP), a coalition of private insurers, law enforcement agencies, and federal and state regulators formed in 2013 to combat healthcare fraud. 

The white paper, however, goes far beyond fraud prevention by recommending policies that will determine how a patient is treated by their doctor, including what medications should be prescribed. 

The number of Medicare patients who “overutilize” opioids is relatively small – just 15,651 beneficiaries in 2015 – which represents just 0.13% of Part D opioid users.

CMS is seeking public comment on the proposal in its 2018 Advance Notice and Draft Call Letter, which outlines a number of other changes the agency is making to its Medicare Advantage and Part D prescription drug programs. Comments will be accepted through March 3rd, with final versions published on April 3, 2017.

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