HHS wary of proposal to reduce Medicare drug fraud

Federal officials are inadequately policing fraud by painkiller addicts and drug dealers who illicitly obtain prescription drugs through the Medicare Part D program, the Government Accountability Office reported on Tuesday.

One proposed remedy -- to improve monitoring for abuse through restricting beneficiaries to a single doctor and pharmacy -- is opposed by the Health and Human Services Department for fear of denying legitimate patients their needed medications.

Some 170,000 Medicare Part D beneficiaries acquired one of 14 classes of frequently abused drugs from five or more doctors during 2008, at a cost of about $148 million, GAO said in a report and testimony to the Senate Homeland Security and Governmental Affairs federal financial management subcommittee.

The 14 include such common drugs as hydrocodone and oxycodone.

"In some cases, beneficiaries may have a justifiable reason for receiving prescriptions from multiple medical practitioners, such as visiting specialists or several prescribers in the same medical group," said Gregory Kutz, GAO's director of forensic audits and investigative services.

"However, our analysis of Medicare Part D claims found that about 600 Medicare beneficiaries received prescriptions from 21 to 87 medical practitioners in the same year," he said. "In these situations, there is heightened concern that these Medicare beneficiaries may be seeking several medical practitioners to support and disguise an addiction."

More than 70 percent of the abusers, GAO estimates, are low-income or disabled eligible beneficiaries, not those in the over-65 age group who make up the majority of the optional Part D subscribers.

Sen. Tom Carper, D-Del., who called the hearing with Sen. Scott Brown, R-Mass., said a failure to counter the problem of "doctor shopping," particularly at a time of fiscal austerity, both harms taxpayers and contributes to a public health crisis. He stated that 7 million Americans, many of them teens, abuse prescription drugs -- that's more than the combined users of heroin, cocaine, hallucinogens, ecstasy and inhalants.

"According to GAO, the controls that Centers for Medicare and Medicaid Services has put into place to stop this sort of abuse haven't done the trick," he said. "If a Part D plan sponsor suspects a beneficiary is doctor shopping, they send a letter to the doctors who've been visited. The letter is sent along with a self-addressed envelope in which the doctors can send a response to the sponsor's concerns. In some cases, the doctors will stop giving the doctor-shopping patients prescriptions. In other cases, they won't. Sometimes, the letters go unanswered."

Carper has joined with Brown and Sen. Tom Coburn, R-Okla., in sponsoring the Medicare and Medicaid Fighting Fraud and Abuse to Save Taxpayer Dollars Act (S.1251), which "contains a set of important steps that will help rein in those trying to defraud our federal health care programs," he said.

GAO recommended applying a restricted recipient program, or "lock-in," used by many states in their Medicaid program to confine each prescription drug beneficiary to a single doctor and pharmacy to ease monitoring.

But such an approach might violate the 2003 statute creating the prescription drug benefit and risks denying legitimate patients their medication, according to Jonathan Blum, director of the Center for Medicare at CMS.

"We have to strike a careful balance in stopping egregious behavior that makes no clinical sense, but to also see to legitimate healthcare needs," he said. Unlike the state programs that allow a comprehensive view of prescription use, the federal program includes 3,400 different plan sponsors, some of which are stand-alone drug benefit providers with no connection to larger healthcare services.

Medicare Part D "has been a great success in that costs have risen more slowly than the Congressional Budget Office originally projected," he said. Since the law took effect, CMS compliance efforts have been focusing on "underutilization," disciplining drug plans that fail to deliver as promised, he said. "Now it has reached a new stage of maturity, and it is time to focus on overutilization."

He agreed with GAO that the system for combatting fraud and abuse needs improving, citing CMS moves to encourage wider use of electronic health records, "proactive" data monitoring, and use of patient I.D. numbers on prescription claims. "But we can't have undue restrictions on delivery" under what he referred to as "our dysfunctional healthcare system, which the Affordable Care Act is trying to reform."

Blum noted that a Sept. 28 letter CMS sent to plan sponsors is part of an effort to solicit their cooperation in tackling the problem. Brown and Carper said the letter was insufficient because it left out key stakeholders such as pharmacies and law enforcement organizations. "With millions of dollars at stake, you've got to do more than send a letter," Brown said. "Take the gloves off -- dictate, don't suggest." He also criticized the quality of information sharing between CMS and the Drug Enforcement Administration.

Blum said his agency does refer evidence of abuse to the HHS inspector general and CMS' auditor, "but CMS does not carry guns," he said. "Some of the cases GAO cites are true fraud, but some are cases of legitimate health care needs."