Improving Drug Utilization Review Controls

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-02-01.html

It looks like CMS (Center for Medicare & Medicaid Services) is trying to implement CDC opiate dosing guidelines on all Part D/Medicare Advantage pts. More “bureaucratic creep” on the guidelines… that – per the CDC – did not bear the weight of law.

While not stated in this information, there has been other “rumors” that CMS via their Part D providers to restrict pts to a single provider and pharmacy.  This statement really concerns me ….“sponsors are expected to reduce beneficiary overutilization of opioids and maintain access to needed medications“...  and if a particular pharmacy that a pt is locked into… has a pharmacist on staff that “is not comfortable” filling opiates… the pharmacy is out of stock for a number of reasons… how much influence or FORCE to get the Part D program and the pharmacy to “maintain access to needed medications”… how long will a pt have to suffer thru cold turkey withdrawal… while the “wheels of the bureaucracy” gets corrective action in place ?  After all the “pharmacy crawl” will not be a option.. since the pt is locked-in to a particular pharmacy… which may or may not be a singular store and not all the stores in an entire chain.

Medicare/Medicaid has a “freedom of choice of providers” by pts from day one… now they are going to take that freedom away at their opinion of a pt’s MAY be getting excessive opiates. Once again, there is seemingly no consideration for the pt’s severity/intensity of pain, CYP-450 enzyme metabolism defect of opiates. Like everything else with a “cookie cutter” type of medical care… those 5%-10%  at each end of the “bell curve”..  those “out-liers” are just SCREWED in regards to getting adequate therapy.

Maybe we should be on the lookout for increased passage of “assisted suicide” laws…to help those out-liers with access to a “final solution” to resolve their chronic pain issues ?

To address the opioid epidemic, CMS has implemented a medication safety approach by which sponsors are expected to reduce beneficiary overutilization of opioids and maintain access to needed medications. CMS also implemented the Overutilization Monitoring System (OMS) to help oversee sponsors’ compliance with this CMS overutilization guidance. Building upon these successes, CMS is proposing a number of updates to these policies intended to address drug utilization concerns within the Part D program for 2018, including:

• Proposing revisions to the retrospective drug utilization review criteria used to identify potential opioid over utilizers through the OMS to better align with the CDC guideline on opioid prescribing, reduce false positives, and maintain a policy that is still manageable for sponsors; and
• Proposing establishing the expectation for sponsors to, at a minimum, implement hard formulary-level safety edits based on a cumulative morphine equivalent dose (MED) approach to prospectively prevent opioid overuse at point of sale at the pharmacy.   

Process
Comments on the proposed Advance Notice and Draft Call Letter are invited from the industry, seniors, consumer advocates, and the public, and must be submitted by March 3, 2017. The final 2018 Rate Announcement and Call Letter, including the final Medicare Advantage and FFS growth percentage and final benchmarks will be published by Monday, April 3, 2017. 

Comments can be emailed to: AdvanceNotice2018@cms.hhs.gov. 

The Advance Notice and Draft Call Letter may be viewed through: http://www.cms.hhs.gov/MedicareAdvtgSpecRateStats/ and selecting “Announcements and Documents.”

Filed under: General Problems