Medicare Part D:
Instances of Questionable Access to Prescription Drugs
GAO-11-699: Published: Sep 6, 2011. Publicly Released: Oct 4, 2011.
Audio interview by GAO staff with Gregory Kutz, Director of Audit Services, Forensic Audits and Investigative Service
In 2009, GAO reported on doctor shopping in Medicaid, where individuals see several doctors and pharmacies, receiving more of a drug than was intended by any single physician. Questions have been raised about whether similar activity exists in Medicare Part D. GAO was asked to (1) determine the extent to which Medicare beneficiaries obtained frequently abused drugs from multiple prescribers, (2) identify examples of doctor shopping activity, and (3) determine the actions taken by the Centers for Medicare & Medicaid Services (CMS) to limit access to drugs for known abusers. To meet the objectives, GAO analyzed Medicare Part D claims for calendar year 2008 to identify potential doctor shoppers. To identify examples, GAO chose a nonrepresentative selection of 10 beneficiaries based on a number of factors, including the number of prescribers. GAO also interviewed policy officials from CMS and from prescription drug plans that administer the drug benefit program.
GAO found indications of doctor shopping in the Medicare Part D program for 14 categories of frequently abused prescription drugs. About 170,000 beneficiaries (about 1.8 percent of beneficiaries receiving these 14 categories of drugs) acquired the same class of frequently abused drugs, primarily hydrocodone and oxycodone, from five or more medical practitioners during calendar year 2008 at a cost of about $148 million (about 5 percent of the total cost for these drugs). About 120,000 of these beneficiaries were eligible for Medicare Part D because of a disability. There may be justifiable reasons for receiving prescriptions from multiple medical practitioners, such as visiting specialists or several prescribers in the same medical group. However, one individual received prescriptions from 87 different medical practitioners in 2008. In such situations, there is heightened concern that Medicare beneficiaries are seeing several medical practitioners to support and disguise an addiction. GAO judgmentally selected 10 beneficiaries and found that they were doctor shopping for prescription drugs. These cases are among the more egregious and cannot be generalized beyond the examples presented. CMS has systems in place to identify individuals with doctor shopping behavior; however, according to CMS policy officials, federal law may not authorize them to restrict these individuals' access to drugs, including highly abused drugs, such as hydrocodone and oxycodone. One option to control doctor shopping used by Medicaid and some private sector plans is the restricted recipient program. It limits individuals identified as doctor shoppers to one prescriber, one pharmacy, or both for receiving prescriptions. There are issues to consider with a restricted recipient program, such as potentially denying legitimate drug needs and unknown administrative costs. These issues should be balanced against the potential protections such a program can provide. Doctor shopping for frequently abused drugs can increase the cost of the Part D program and jeopardize patient care. Controls proven to reduce doctor shopping could be considered by CMS. GAO recommends that CMS review its findings and consider steps such as a restricted recipient program for identified doctor shoppers and seek congressional authority, as appropriate. CMS agreed with the overall recommendation to improve its efforts to curb overutilization in Part D, but disagreed that a restricted recipient program is necessarily the appropriate control for the Part D program.
Recommendation for Executive Action
Status: Closed - Implemented
Comments: Consistent with the intent of our recommendation, in September 2011, CMS began to solicit comments from Part D sponsors and other interested stakeholders on how the Medicare Part D program can more successfully exert control over payment for inappropriate overutilization of drugs. In particular, CMS sought comments regarding resource and timeline issues related to implementing a beneficiary-centric approach to managing overutilization. As of December 2011, CMS was reviewing the comments received from Part D plan sponsors and other stakeholders.
Recommendation: To improve efforts to address doctor shopping by beneficiaries of highly abused prescription drugs, the Administrator of CMS should review our findings, evaluate the existing drug utilization review (DUR) program, and consider additional steps such as a restricted recipient program for Medicare Part D that would limit these beneficiaries to one prescriber, one pharmacy, or both for receiving prescriptions. CMS should consider the experiences from Medicaid and private sector use of such restricted recipient programs, including weighing the potential costs and benefits of instituting the control. CMS could consider piloting such a program with a focus on hydrocodone and oxycodone, the two drug classes where we identified the largest potential doctor shopping activity. Along with a restricted recipient program, CMS should also consider facilitating the sharing of information on identified doctor shoppers among the Part D drug plan sponsors so that those beneficiaries cannot circumvent the program by switching prescription drug plans. In considering such controls, CMS should seek congressional authority as appropriate.
Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services