Falling in line with the House Energy & Commerce Committee’s 21st Century Cures draft, President Barack Obama’s fiscal 2016 budget for the first time includes a proposal to lock Medicare beneficiaries at a high risk of substance abuse into certain pharmacies or prescribers to cut down on drug abuse, and some following the issue say given the bipartisan and administrative support the issue is not expected to go away any time soon.
Beneficiary lock-in programs are used in commercial and Medicaid plans, and Cindy Reilly, director of PEW Charitable Trusts’ prescription drug abuse project, says the group is pleased there is interest in expanding these programs to Medicare Part D. Lock-in programs, or “safe pharmacy networks,” allow for plans to restrict beneficiaries deemed high risk to a certain pharmacy or pharmacies and to one or more prescribers for drugs that could be abused, like opioids.
HHS’ budget-in-brief says that while HHS already requires Part D sponsors to conduct drug utilization reviews and see which prescriptions are filled by certain beneficiaries, there isn’t much the agency can do on a preventative basis with that information.
“These efforts can identify overutilization that results from inappropriate or even illegal activity by an enrollee, prescriber, or pharmacy. HHS’s statutory authorities to take preventive measures in response to this information is limited,” HHS’ budget brief says.
HHS’ budget-in-brief says its proposal would be similar to many state Medicaid programs and would make sure beneficiaries have access to quality services.
Former CMS Medicare chief Jon Blum also expressed interest in a beneficiary lock-in policy a few years ago, but this is the first time such a policy has been included in the president’s budget, one beneficiary advocate noted. The proposal is not expected to cost anything over the next 10 years.
The president’s proposal follows the inclusion of a similar lock-in proposal in House Ways & Means health subcommittee Chair Kevin Brady’s (R-TX) Medicare program integrity bill introduced late last session. Ways & Means ranking Democrat Jim McDermott (WA), who sponsored the bill despite reservations, said the legislation would serve as a platform for further work this Congress.
Another beneficiary lock-in proposal was included in House Energy & Commerce Chair Fred Upton’s (R-MI) recently released 21st Century Cures draft (see related story).
The Pharmaceutical Care Management Association said last month that enacting these beneficiary lock-in programs in Medicare is a priority for pharmacy benefit managers in 2015, and the group says it is encouraging that support for a beneficiary lock-in policy is increasing.
Reilly said PEW, which recently asked Congress’ Medicare payment advisors to consider recommending such a policy, is also encouraged by the support in the president’s budget. She added that PEW is still evaluating Brady’s bill and the 21st Century Cures draft for the best way to balance reducing drug abuse by high-risk beneficiaries and beneficiaries access to these medications for legitimate purposes. But Stacy Sanders, federal policy director at the Medicare Rights Center, says Brady’s bill includes more developed beneficiary protections than the 21st Century Cures draft. She said Brady’s bill also gives clearer direction to the agency regarding stakeholder involvement.
Beneficiary advocates expressed some concerns over the draft of Brady’s bill, and the version introduced in December was a significant improvement over the draft bill, one beneficiary advocate said.
Sanders said lock-in policies are only one of many solutions around Medicare beneficiary abuse of prescription drugs that should be considered. The Medicare Drug Integrity Contractor should also be strengthened, and there needs to be more communication between the pharmacies and the MEDICs, Sanders said, as well as enhanced data sharing to help combat the problem. – Michelle M. Stein (firstname.lastname@example.org)