GAO: Medicare’s Opioid Use Monitoring Lets At-Risk Patients Fall Through the Cracks

January 22, 2018

The federal government’s guidance for monitoring opioid use among Medicare beneficiaries does not go far enough in identifying which beneficiaries are most at risk and the Centers for Medicare & Medicaid Services should collect data on exactly how many at-risk beneficiaries receive high doses, according to a new GAO report.

The CMS provides guidances to Medicare Part D plan sponsors on how to monitor opioid overuse among beneficiaries and requires them to use review systems based on CMS’ own criteria. These criteria target patients with high-dose prescriptions, prescriptions from four or more providers and who fill prescriptions with at least four pharmacies.

However, according to the GAO, CMS criteria are still overly broad. While 33,223 beneficiaries would have met the criteria in 2015, more than 727,000 would have received high doses of opioids independent of how many providers of pharmacies they used.

CMS took steps to address these blind spots in 2016, collecting information on some beneficiaries using a higher opioid use threshold, but this approach still does not include all at-risk beneficiaries, because the threshold is more lenient than CDC guidelines, the GAO said. In November 2017, CMS proposed a rule to require high-risk beneficiaries to only fill prescriptions at certain pharmacies.

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