'Doctor-Shoppers' Get Pain Meds at Medicare's Expense

October 26, 2011

October 26, 2011 — The ongoing federal crackdown on pain-pill scams that drain the coffers of Medicare and Medicaid is now focusing on "doctor-shoppers" in the Medicare Part D program for prescription drugs.

Such patients visit multiple physicians in a short period of time to amass a horde of pain medications, sedatives, stimulants, or muscle relaxants to either feed their own addiction or sell on the street. Typically, the physicians do not know that colleagues are writing duplicate prescriptions for these patients.

In a study submitted to a Senate subcommittee earlier this month, the Government Accountability Office (GAO) reported that some 170,000 Medicare Part D patients received prescriptions from 5 or more clinicians — a pattern that suggests doctor-shopping — in 2008 for 14 classes of frequently abused controlled and noncontrolled substances. These patients represented 1.8% of all Part D beneficiaries who received such medications that year.

The prescriptions for these 170,000 patients were worth $148 million — not counting the cost of associated office visits — and Medicare Part D picked up much of the tab, according to the GAO. Medicare Part D, created in 2006, provides beneficiaries with drug coverage through private plans.

The pain relievers hydrocodone and oxycodone accounted for most of the suspicious prescriptions. The GAO noted that doctor-shopping is the prime method for obtaining these prescription opioids for illicit use.

The GAO report should not be construed as necessarily describing a drug problem among seniors. Of the 170,000 patients who might have been doctor-shopping, 71% qualified for Medicare Part D not because of their age but because they were disabled. In addition, roughly the same percentage received a low-income cost-sharing subsidy.

How to Spot a Doctor-Shopper

The GAO dug deeper into 10 cases of prescriptions from multiple clinicians that left little doubt that a scam was under way. A Medicare Part D patient in Georgia, for example, obtained almost a 5-year supply of oxycodone pills in 2008 from dozens of pharmacies with prescriptions from 58 different prescribers. The patient exhibited hallmarks of a doctor-shopper by:

  • Repeatedly asking for early refills of prescriptions

  • Refusing to see a specialist despite repeated recommendations to do so

  • Asking specifically for oxycodone because of an allergy to other drugs

More guidance on how to spot a doctor-shopper emerged during a Senate hearing earlier this month on the problem of prescription drug abuse in Medicare Part D. Louis Saccoccio, executive director of the National Health Care Anti-Fraud Association, told a subcommittee of the Committee on Homeland Security and Governmental Affairs that drug fraudsters:

  • Often claim that their medications were lost, spilled, or stolen

  • Request brand-name medications as opposed to generics because they have a higher street value

  • Escalate doses on their own without a documented change in medical condition

  • May visit hospital emergency departments to obtain drugs when they know their doctor-shopping behavior is being monitored

"We Have to Strike a Careful Balance"

Testifying before the Homeland Security and Governmental Affairs subcommittee, GAO Director of Forensic Audits and Special Investigations Gregory Kutz said private drug plans in the Medicare Part D program can spot probable doctor-shoppers in their claims data, but by law can do little to stop them in their tracks other than send a letter to physicians alerting them to suspicious behavior. Kutz recommended that the Centers for Medicare and Medicaid Services (CMS) consider a control measure deployed by Medicaid and some private insurers: restricting likely doctor-shoppers to 1 prescriber, 1 pharmacy, or both.

For such a "restricted recipient program" to work, Kutz said, Part D plans need the ability to warn one another when a doctor-shopper is switching plans to evade corrective action. Part D beneficiaries can change plans at least once a year, and those who receive a low-income subsidy can do so once a month.

Jonathan Blum, the deputy administrator and director of CMS, told the subcommittee that his agency would consider the proposal for Part D plans to share information about doctor-shoppers. However, limiting doctor-shoppers to a single prescriber or pharmacy is not possible under current Medicare Part D regulations, Blum said, nor would it be appropriate. A restricted recipient program would be hard to enforce when low-income Medicare Part D beneficiaries can switch plans so easily. Furthermore, CMS does not want to erect a barrier between a beneficiary and needed care, he said.

"We have to strike a careful balance," Blum told the subcommittee. "Clear fraud — that needs to be stopped. But there are legitimate beneficiaries who have legitimate pain needs." They include patients with complicated medical problems who see as many as 4 or 5 physicians, he added.

That said, Blum assured lawmakers that CMS is taking action to reduce doctor-shopping by Medicare Part D beneficiaries, which he acknowledged is a growing problem. Among other things, he said, the agency is:

  • Helping Part D drug plans become more adept at spotting and preventing drug fraud

  • Encouraging the use of electronic prescribing, which can give physicians a patient's medication history across all prescribers

  • Attempting to use state prescription drug monitoring programs to detect diversion and abuse of controlled substances in Medicare Part D

  • Centralizing claims data across federal healthcare programs such as Medicare, Medicaid, and the Veterans Health Administration so that law enforcement agencies can better battle fraud on a systemwide basis

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