Medicare Patients Abusing, Selling Rx Drugs, GAO Says

By Emily P. Walker, Washington Correspondent, MedPage Today
Published: October 04, 2011

WASHINGTON -- As many as 170,000 Medicare beneficiaries may be "doctor shopping" in order to get multiple prescriptions of commonly abused drugs for their own use or to sell to others, a Government Accountability Office (GAO) audit of Medicare's Part D program showed.

The audit found that 170,000 Medicare beneficiaries received prescriptions from five or more doctors for any of 14 types of commonly abused prescription drugs at a cost of about $148 million to the Medicare program, according to the report, written by GAO investigator Gregory Kutz.

Most of the doctor shoppers were not on Medicare because of their age -- 71% had Part D coverage because of a disability and 72% received a Medicare Low-Income Cost-Sharing subsidy.

In 600 cases revealed in the audit, Medicare beneficiaries received prescriptions from as many as 87 different doctors in the same year indicating, the report said, that the patients shopped around to find as many providers as possible to write prescriptions for drugs in those 14 categories -- mostly controlled substances and primarily hydrocodone and oxycodone.

"In these situations, there is heightened concern that these Medicare beneficiaries may be seeking several medical practitioners to support and disguise an addiction," Kutz told the Senate Homeland Security and Governmental Affairs Subcommittee on Federal Financial Managment, Government Information, Federal Services and International Security on Tuesday.

As subcommittee chairman Sen. Tom Carper (D-Del.) pointed out, what makes this situation unique is that unlike addictions to illegal drugs, these addictions are financed by the federal government.

"The difference between a 'street drug' like cocaine and a prescription pain pill is that in many cases, the federal government is often paying to feed this addiction with taxpayer money," Carper said.

Sen. Scott Brown (R-Mass.), the ranking member on the subcommittee, called it "taxpayer-funded drug dealing."

For its audit, the GAO reviewed prescriptions filled by Medicare Part D beneficiaries from May 2010 to October 2011 for a dozen controlled substances including oxycodone; amphetamine/dextroamphetamine (Adderall); benzodiazepines such as diazepam (Valium) and alprazolam (Xanax); acetaminophen with codeine; and for two frequently abused noncontrolled substances: the muscle relaxer carisoprodol (Soma) and non-narcotic painkiller tramadol (Ultram and Ultracet).

Homing in on 10 specific cases, the GAO determined the doctors writing the prescription were unaware that their patient was abusing drugs or trying to sell the drugs.

Some examples uncovered in the investigation:
•One beneficiary received prescriptions for 1,397 fentanyl patches and pills from 21 different doctors.
•Another received prescriptions for a total of 3,655 oxycodone pills from 58 different doctors, and filled the scripts at 45 different pharmacies.
•Another beneficiary received a 994-day supply of hydrocodone pills from 25 different prescribers.

One barrier to spotting fraud among Medicare beneficiaries with low incomes is that they are a special group that can switch Medicare plans monthly, making it difficult to spot excessive prescriptions or excessive visits to the doctor, Kutz noted. Traditional Medicare beneficiaries can only switch Medicare plans once a year.

CMS has a process in place to attempt to identify improper use of prescription drugs, but if Medicare beneficiaries get caught doctor shopping, there is no penalty, explained Kutz. They can continue to be enrolled in the Medicare Part D program and continue to doctor shop.

The GAO recommended limiting those who have been identified as doctor shoppers to one doctor and one pharmacy. It also recommended giving the names and information of known doctor shoppers to all insurance companies that administer Part D plans on behalf of Medicare.

CMS, however, doesn't agree that restricting the number of doctors and pharmacies Medicare Part D beneficiaries can use is a good idea, explained Jonathan Blum, MD, director of CMS' Center for Medicare.

"Some beneficiaries are seeing many doctors and might have complicated diseases," Blum told the panel. "We should review this before limiting how many doctors patients can see."

CMS recently issued a proposed rule that would require Part D sponsors to include a physician identifier on all prescription claims filed so insurers can confirm the script was written by an actual doctor.

In addition, CMS is hoping the 3,400 different Part D plan providers will follow the agency's new guidance on how to better detect misuse of controlled substances and to report suspected cases to the federal government.

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