February 3, 2017
By Anna Whites*
The Centers for Medicare & Medicaid Services (CMS) published on its website a White Paper, Healthcare Payer Strategies to Reduce the Harms of Opioids, prepared by the Healthcare Fraud Prevention Partnership (HFPP).1 The White Paper provides insight into the way payers look at opioid prescribing and addiction treatment.
HFPP is a voluntary, public-private partnership between the federal government, state agencies, law enforcement, private health insurance plans, employer organizations, and health care anti-fraud associations to identify and reduce fraud, waste, and abuse across the health care sector.
According to the White Paper “Healthcare payers (herein, payers), employer organizations, and law enforcement all have strong motivations to combat the inappropriate prescribing of opioids to improve patient health and reduce expenditures for medically unnecessary services and therapies.”2 The White Paper notes “Payers collect and administer a large amount of healthcare information that can be used to identify and intervene on behalf of patients at risk of opioid-related harm, as well as to target fraud, waste, and abuse in opioid prescribing.”3
The White Paper references five specific actions that payers are encouraged to engage in as soon as possible: (1) Train providers on the Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain and require adherence to these; (2) Promote access to and usage of Medication-Assisted Treatment (MAT), recognizing that MAT in conjunction with behavioral therapy is more effective than therapy alone; (3) Promote the availability of naloxone; (4) Encourage the use of data to identify fraudulent, wasteful, or abusive practices associated with opioids in order to target corrective actions by having payers share data about providers and practices, as cross payer data has proven effective in identifying problem areas or providers; (5) Identify and disseminate effective practices across the health care sector, particularly with regard to identifying patients at risk of opioid misuse and providers whose opioid prescribing patterns fail to comply with quality indicators (such as the CDC Guideline for Prescribing Opioids for Chronic Pain).
Payers are in a unique position to hold and share large quantities of data about opioid use and treatment. This is collected through Prescription Drug Monitoring Programs and Drug Utilization Reviews. Payers can also affect utilization or prevent abuse by prioritizing reimbursement for overdose prevention products such as naloxone, using formularies to promote abuse deterrent formulations, and requiring prior authorization or denying reimbursement for prescriptions or prescription combinations that could result in patient harm. Payers are even assessing whether certain high risk patients or high risk diagnoses should be “locked in” to particular approved providers.4
The report urges payers to distribute the CDC Guidelines to practitioners and to require provider education on those guidelines as a top priority.5 Payers are encouraged to use in person visits to providers “to balance pharmaceutical representative office visits and help to increase knowledge, improve adherence to the new CDC guideline, and ultimately change opioid prescribing behavior.”6 Patient education recommendations include mass media advertising on prescribing fraud and patient addiction dangers, and partnership with behavioral health vendors to disseminate materials.7
The White Paper realistically addresses access issues with regard to MAT, noting “In many areas there is an insufficient quantity of behavioral health and treatment services, as well as physicians with MAT experience.” This problem is particularly severe in rural areas. Recent efforts have been made to address this access issue. For example, the Substance Abuse and Mental Health Services Administration recently increased the number of patients that a physician can treat with buprenorphine to 275; and the Controlled Substances Act was amended by the Comprehensive Addiction and Recovery Act of 2016 (CARA) to allow additional provider types to prescribe.8 Telehealth as a means of providing both patient education and counseling is also recommended to increase access.9
*We would like to thank Anna Whites (Anna Whites Law Office PSC, Frankfort, KY) for authoring this email alert. We also would like to thank Kathy S. Ghiladi (Feldman Tucker Leifer Fidell LLP, Washington, DC) and Suzette E. Gordon (Bronx Partners for Healthy Communities, New York, NY) for reviewing this email alert.
1 https://downloads.cms.gov/files/hfpp/hfpp-opioid-white-paper.pdf (hereinafter, White Paper).
2 White Paper at p. 2.
3 White Paper at p. 4.
4 White Paper at p. 28.
5 White Paper at pp. 16, 28.
6 White Paper at p. 17.
7 White Paper at p. 19.
8 White Paper at p. 21.
9 White Paper at p. 22.