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Medicare proposes 'hard limit' on opioid prescriptions. Here's our take.


Read Advisory Board's take on the proposed opioid prescribing limits.

CMS on Thursday released an advance notice of proposed changes to Medicare Advantage and Medicare Part D payment policies that would set opioid prescribing limits for Medicare beneficiaries and increase MA plan payments in 2019.

CMS will accept comments on the proposals through March 5, 2018, with plans to publish a final rule on April 2, 2018.

CMS proposes opioid prescribing limits

In the proposal, CMS requested feedback on a slew of changes intended to limit opioid use among beneficiaries, MedPage Today reports.

For example, CMS proposed requiring Part D plans to implement "hard" point of sale opioid safety edits at pharmacies that could be overridden by the plan sponsor. CMS proposed setting the safety level at a 90 morphine-mg equivalent (MME) with a 7-day supply allowance. The agency said it also would expect Part D plans to set "soft" point of sale opioid safety edits that could be overridden by the pharmacist.

Demetrios Kouzoukas, CMS deputy administrator, said, "These are triggers ... [that] can prompt conversations between physicians, patients, and plans about appropriate opioid use and prescribing."

In addition, CMS proposed limiting the number of prescription opioids in an initial prescription for acute pain, "possibly with or without a daily dose maximum."

The agency also said it plans to enhance its existing opioid use monitoring system by adding alerts for high-risk beneficiaries who use certain drugs "in combination with prescription opioids"

Our coverage of the rest of CMS' proposed changes to MA and Part D payment and policy—including the agency's plan to redefine health-related supplemental benefits—continues below.

Advisory Board's take

By Rebecca Tyrrell, Pharmacy Executive Forum, and Gillian Michaelson, Health Care Advisory Board

CMS' proposal is a critical step toward curbing opioid prescription patterns and demonstrates the government's willingness to draw hard lines in how opioids are prescribed.

The new restrictions, if approved, could affect hundreds of thousands of patients. In 2016 alone, more than 500,000 Medicare Part D beneficiaries received an average morphine milligram equivalent (MME) of more than 120 mg a day for at least three months. Those prescriptions far exceeded the manufacturer's recommended dosage, increasing the chances of addiction and overdose. States have already started to see success with similar guidelines aimed at changing clinician behavior. Florida, for example, saw a 50% decrease in oxycodone death in 2012 as a result of 2010 regulations on pain clinics and the state's prescription drug monitoring program.

Government actors, however, cannot solve this crisis alone. Other members of the health care industry should learn from their example and provide clinicians and other clinical care team members with the tools and support they need to alter their pain management practices. This should include education on the crisis and its contributors, guidance on the availability and use of non-opioid and non-pharmacological pain treatment options, strategies for discussing and managing patient expectations around pain, and data and benchmarking tools to inform decision-making.

Physicians, for their part, should actively engage in hospital-level opioid safety committees and express their willingness to collaborate with policy leaders if they want a say in how prescribing regulations unfold.

For more on how providers should play a role in addressing the opioid epidemic, download our research report, which outlines three imperatives to guide hospitals and health systems in their efforts to reduce the impact of inappropriate opioid prescribing and misuse.

Download Now



Details on proposed changes to MA and Part D payment and policy

CMS in the advanced notice proposed increasing payments to MA insurers by an average of 1.84% in 2019, up from the 0.45% increase that plans received last year, Modern Healthcare reports. After adjusting for underlying MA coding trend codes, CMS said the average MA payment would increase by 3.1%, up from a 2.95% increase last year.

CMS said it would move forward with plans to increase the percentage of encounter data it uses to set payments for MA plans. CMS historically has relied on data from the Risk Adjustment Processing System (RAPS) to calculate payments for MA plans. In 2016, the agency began using a blend of encounter data from MA organizations and patient records submitted to RAPS

The percentage of encounter data for 2018 was set at 15%. For 2019, CMS proposed raising the percentage of encounter data to 25%. Industry stakeholders, including America's Health Insurance Plans (AHIP) and the American Hospital Association, have criticized CMS' increased use of encounter data, saying the data are often inaccurate.

CMS also proposed implementing a plan initially proposed in 2016 to change the funding formula for employer-based MA plans, which are also known as "employer group waiver plans." Under the proposal, CMS would replace the bidding process for employer-based MA plans with a lump-sum payment based on county-level bids.

In addition, CMS proposed expanding the health-related supplemental benefits MA insurers can cover to include products such as portable wheelchair ramps and non-skilled in-home supports. CMS said insurers could offer such coverage if the benefits compensate for physical impairments or reduce avoidable emergency department use.

CMS also proposed new star ratings for statin use among patients with diabetes or cardiovascular disease, as well as removing star ratings for beneficiary access and performance problems (Frieden, MedPage Today, 2/1; Dickson, Modern Healthcare, 2/1; Humer, Reuters, 2/1; CMS fact sheet, 2/1).

Medicare 101: Get the cheat sheet for Medicare Part D

book

Through the years Medicare has grown more complicated, including private supplemental insurance and prescription drug coverage. Download our Medicare Part D cheat sheet to learn how the Medicare prescription drug benefit works, and why it’s so important for provider organizations:

Download Now

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