CMS, Part D, and Opioids: A Familiar Approach

CMS has asked for additional public comment on its plan to improve drug utilization review for Medicare Part D participants.  I'd provide a link to the memo, but it was emailed to me and I can't seem to locate the file on the CMS web site (go figure).  If you really want to get your hands on it, let me know and I can email it to you. 

Turns out, CMS has found that approximately 0.7% of the total Part D population (or about 225,000 beneficiaries) received more than 120 mg MED daily for at least 90 consecutive days in 2011.  Kudos to CMS - not only for recognizing the clinical value of the 120 mg MED threshold, but also for citing the State of Washington's Department of Health as a source. 

The current CMS approach has a lot going for it. (Candidly, it looks a lot like our process for addressing these claims, so no surprise that we're supportive).  In summary, it calls for the following:

1) The Part D plan should have a documented policy for addressing overutilization of opioids.

2) There should be clinical triggers, defined by the plan, to flag certain beneficiaries for review. 

3) Protocols should be developed to eliminate from review those beneficiaries with legitimate need for high dose opioid therapy (i.e., cancer diagnoses).

4) The plan should be prepared to communicate directly with prescribers of the opioid medications, both in writing and telephonically, to address patient safety concerns, medical appropriateness, and medical necessity.  Further, the CMS approach calls for the conversation to be "clinician-to-clinician" (we would suggest a slightly more specific definition of "peer-to-peer", but CMS leaves that to the discretion of the individual plan). 

5) The results of the intervention should be incorporated into future claims management decisions, most obviously via a beneficiary-level claim edit (what we would think of as a PBM prior auth or block on a particular medication). 

6) Should a prescriber not cooperate, the CMS approach gives the plan the power to put such beneficiary-level claim edits in place to protect the patient's safety. 

7) Some sort of case management activity is necessary to ensure future compliance.

Solid start. 
How does this compare with your organization's approach?

Michael
On Twitter @PRIUM1