In November, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule intended to protect Medicare beneficiaries who are at risk from opioid misuse. The rule sets expectations for insurers developing drug management programs known as patient review and restriction (PRR) programs, which are used to identify at-risk patients and assign them to designated prescribers and/or pharmacies for their controlled substance needs. While welcome, this rule as proposed fails to adequately protect these patients, and must be improved.
PRRs are widely used in Medicaid and commercial insurance because they can improve care coordination, reduce opioid prescriptions and visits to multiple doctors and emergency rooms, and bring down health care costs.
These programs would also be valuable in Medicare. The U.S. Department of Health & Human Services’ Office of Inspector General found that almost 90,000 beneficiaries were at serious risk of opioid misuse or overdose in 2016, either because they were receiving high doses of opioids for extended periods of time, or were visiting multiple prescribers and pharmacies to obtain these medications.
Unfortunately, the proposed rule has significant shortcomings, as Pew noted in a recent letter. Specifically:
The proposed rule also has strengths, including strong patient protections. For example, it requires that beneficiaries enrolled in PRR programs have reasonable access to their prescribed medications, which means that patients can provide input on selected prescribers and pharmacies. Furthermore, enrollees with special circumstances—such as those who have multiple residences—can select providers in each location. And individuals who wish to appeal their enrollment in the PRR program can use Medicare’s existing appeals process.
CARA provided the CMS with new tools to protect Medicare beneficiaries from opioid-related harms. Unfortunately, without major changes, the proposed regulations would not fully achieve this goal.
Cynthia Reilly directs Pew’s substance use prevention and treatment initiative.
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