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Medicare Part D: Instances of Questionable Access to Prescription Drugs

GAO-11-699 Published: Sep 06, 2011. Publicly Released: Oct 04, 2011.
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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.


Recommendations for Executive Action

Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services 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.
Closed – Implemented
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.

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Access to health careBeneficiariesClaimsComparative analysisControlled substancesSubstance abuseDrugsFraudHealth care programsMedicaidMedicareNarcoticsPatient care servicesPharmaceutical industryPhysiciansPrescription drugsPrivate sectorProgram abusesProgram evaluationSubstance abuse