Medicare plan to stop drug abuse could hurt patients, AMA says

Insurers should not be given broad authority to deny payment for prescription medications just because they suspect misuse, an Association letter states.

By — Posted March 9, 2012

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The American Medical Association is calling on the Centers for Medicare & Medicaid Services to abandon a proposed plan that would greatly expand the use of drug utilization management to combat prescription medication abuse.

CMS proposed the plan based in large part on an October 2011 report by the Government Accountability Office that found significant doctor shopping by Medicare patients seeking frequently abused prescription drugs. The watchdog agency cited a lack of adequate levels of concurrent and retrospective drug utilization review by Medicare Part D sponsors, prompting CMS to propose a requirement that plans expand such reviews. In cases where the plans determine that prescribed drugs are not medically necessary, they will be directed to deny payment for the drugs at the point of sale, meaning patients would find out at the pharmacy counter that Medicare is not paying for their medications.

But the AMA notes that although the GAO report identified the opioids hydrocodone and oxycodone as the drugs involved in roughly 80% of the purported doctor shopping, the proposed CMS policies would extend more intensive drug utilization management across the board in the Medicare drug program. That could have unintended consequences for many patients who have justified medical needs for their prescription drugs.

"The AMA strongly agrees that combating potential prescription drug abuse and/or diversion is a pressing national priority," AMA Executive Vice President and CEO James L. Madara, MD, wrote in a March 2 letter to CMS Center for Medicare Director Jonathan Blum. "We, however, have serious concerns with the application of policies and programs that are designed to address prescription drug abuse/diversion to all prescription drugs and medications. This is especially troubling when the population of patients impacted will be elderly, more likely to be medically fragile, and less likely to be equipped to navigate the already bewildering array of Part D sponsor and pharmacy practices, policies and requirements."

Dr. Madara said CMS should focus instead on the primary issue of possible abuse or diversion of hydrocodone and oxycodone. Better communication with physicians of patients' medication dispensing and better integration of drug plans with state-based prescription drug monitoring programs are the best ways to fight the problem, he said. The AMA also disputes the CMS statement in the proposed rule that plan sponsors, who receive notice of all of a beneficiary's medication dispensing events, are in the best position to identify when certain drugs are not clinically necessary.

"As a threshold matter, we would urge CMS to acknowledge that physicians are best equipped to evaluate the medication needs of their patients, and CMS should not promote the adoption of policies that substitute physician clinical judgment with that of sponsors," Dr. Madara wrote.

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