The Centers for Medicare & Medicaid Services (CMS) is proposing that beginning in 2019, initial opioid prescriptions for acute pain be limited to 7 days.
The agency is also suggesting in the 2018 Draft Call Letter that Medicare Part D prescription drug plans monitor patients who take medications considered to be “potentiators” of opioid misuse and opioid-related adverse events — specifically, gabapentin and pregabalin.
Noting an alarming increase in gabapentin use to treat pain and concurrent opioid and gabapentin use, CMS is asking for comment on whether it is useful to more closely monitor beneficiaries receiving these prescriptions.
The CMS proposal came as a US House committee took a closer look at Medicare’s oversight of opioid use. At the February 6 hearing, members of the Ways and Means Health Subcommittee said there are few data on opioid use among older Americans and that Medicare has done a poor job of encouraging prevention and treatment.
“With 10,000 baby boomers joining Medicare each day, we must harness innovation, technology and data to get ahead of this problem,” said Subcommittee Chairman Peter Roskam (R-IL). “Unfortunately, there is a lack of available data regarding the Medicare population and the extent to which opioid abuse, overprescribing, and diversion is an issue for seniors and the disabled,” he said.
That echoed an October 2017 Government Accountability Office (GAO) report, which found that Part D plans are not sufficiently identifying and helping beneficiaries at high risk for opioid misuse. CMS established its overutilization monitoring system (OMS) in 2013, but opioid misuse continues, and thousands of baby boomers are being added to the Medicare rolls daily.
Drugs of Concern
The agency said in its latest announcement that the system has reduced “very high risk overutilization of prescription opioids in the Part D program,” but “given the urgency and scope of the continuing national prescription opioid epidemic, we will propose new strategies to more effectively address this issue for patients in Part D.”
CMS proposes the following:
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To have the OMS identify high-risk beneficiaries who use “potentiator” drugs (such as gabapentin and pregabalin) in combination with prescription opioids to ensure that plans provide appropriate case management. The agency noted in its proposal that in just 2 years (2015 to 2017), the rate of gabapentin users in Part D plans increased by 14%: from 93 to 108 users per 1000 enrollees. Opioid users had even higher gabapentin use.
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To create a new quality measure that would track how well Part D plans flag concurrent use of opioids and benzodiazepines. The OMS already flags concurrent benzodiazepine use, but there is no follow-up mechanism. According to CMS, in late 2016, when the OMS began tracking concurrent use, 64% of beneficiaries flagged as potential opioid overusers had a benzodiazepine prescription. In 2017, after monitoring, the number had dropped to 62%.
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That Part D plans to have a pharmacy point-of-sale edit that prohibits dispensing of any prescription that is more than a 90 morphine milligram equivalent, or a 7-day supply.
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That all sponsors implement soft point-of-sale edits that alert when there is duplicative therapy of multiple long-acting opioids.
CMS is taking comments on the proposal until March 5 and will publish the final requirements on April 2.
The Part D proposal builds on another CMS proposed rule, issued in December 2017. The agency was required by the Comprehensive Addiction and Recovery Act of 2016 to beef up opioid oversight.
As with that previous regulation, the newest proposal would exempt patients with cancer, in hospice, or in long-term care facilities from much of the strict oversight.
Methadone Treatment Not Covered
Even as enrollees who misuse opioids are flagged, Medicare is not fully prepared to help. The federal health program does not pay for outpatient methadone treatment, for instance.
“We know there are significant gaps in access and coverage under Medicare,” said the top Democrat on the Ways and Means Health Subcommittee, Richard Neal (MA), at the hearing.
Neal introduced a bill in October 2017 — the Medicare Beneficiary Opioid Addiction Treatment Act — that would require Medicare to pay for outpatient methadone therapy.
Neal and Democratic colleague Frank Pallone (NJ) also have written to 14 Medicare Advantage and Part D drug plans asking them to share their evidence-based best practices.
“The growth of Medicare Part D spending on opioids far outpaces the growth in enrollment, having increased 165 percent from 2006 to 2015,” said Neal and Pallone. They said that among the 12 million Medicare enrollees who were prescribed opioids in 2015, “the average beneficiary received five prescriptions for commonly abused opioids.”
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