Medicare’s lack of federal control feeds opioid crisis, senators say

Medicare spending on opioids is skyrocketing, but the agency’s investigations into misuse have plummeted in the last couple of years, congressional investigators revealed Monday, suggesting that a lack of federal controls could inadvertently be feeding the prescription drug abuse epidemic.

Sens. Rob Portman, Ohio Republican, and Claire McCaskill, Missouri Democrat, said Medicare’s drug-benefit program spent $4.1 billion on commonly abused painkillers in 2015, up from $1.5 billion in 2006. Nearly one in three enrollees used a painkiller, with generic Vicodin being the most common.

But Medicare’s checks on abuse haven’t kept up with the ballooning use, the senators said, meaning that more people could be bilking the system and fueling the epidemic with drugs subsidized by U.S. taxpayers.

The two senators, who run the Senate’s permanent investigative panel, said the contractor charged with policing Medicare’s prescription drug program, known as Part D, investigated only 7 percent of the complaints it received in 2015 from insurers.

Those insurers use sophisticated data tools to flag beneficiaries who obtain more drugs than they need or submit claims to multiple pharmacies in a pattern that signals possible misuse.

The insurers themselves, meanwhile, need to start making use of a database created to flag prescribers or pharmacies that commit fraud across multiple plans, the senators said.

“The abuse of opioid drugs is a national health crisis. The subcommittee’s investigation found that the federal government can, and must, do more to combat opioid fraud and abuse,” said Mr. Portman and Mrs. McCaskill. “Private health insurance companies on the front lines of this crisis also must boost their efforts to use every available tool and piece of data to identify and care for beneficiaries in need of help.”

Their report faulted the administration and its contractor for not digging deep enough into prescribing patterns. It cited a doctor who was prescribing an unusual amount of narcotic oxycodone, but was cleared after a cursory search for licensing problems, suspended payments from Medicare or additional complaints about him in their system.

The contractor later received more complaints about the doctor, who was ultimately convicted of running a multimillion-dollar pill mill leading to an overdose death of at least one of his patients.

The Senate report is part of congressional efforts to catch up with the opioids epidemic that is ravaging U.S. communities and, in some places, killing more people than car crashes do.

About 19,000 of the record 47,000 drug overdose deaths in 2014 were attributed to prescription opioids. Nearly 2 million Americans were addicted to painkillers that year, while 586,000 were abusing heroin, according to the Senate report.

The Centers for Medicare and Medicaid Services works with the Medicare Drug Integrity Contractor, or MEDIC, to process complaints about fraud and abuse in prescription drug program.

Senate investigators said the contractor’s instructions to private insurers for reporting fraud, waste or abuse weren’t specific enough, and that there were no guidelines at all for opioids.

The upshot is an “ad hoc, case-by-case approach” to reporting that’s borne out in the volume of reports to the MEDIC by large insurers under Medicare, the report said.

For instance, UnitedHealth Group and Humana had a similar number of enrollees — 9.5 million versus 8.2 million — in 2015, yet UnitedHealth submitted 15 times more reports on fraud and abuse to the MEDIC than Humana, according to the report.

Also, some insurers in Medicaid were more likely than others to restrict patients with a track record of opioid abuse to a single provider or pharmacy, a technique known as a “lock-in.”

Investigators said that suggests some insures are under-using the technique as they administer plans under the federal-state program for the poor.

President Obama recently signed a comprehensive opioids bill pushed by Mr. Portman and Sen. Sheldon Whitehouse, Rhode Island Democrat, that will allow insurers in the Part D program to begin using lock-ins in 2019.