Some Medicare Beneficiaries Received Prescriptions from Five or More Medical Practitioners to Obtain the Same Class of Frequently Abused Drugs

Our analysis of Medicare Part D claims found that 170,000 Medicare  beneficiaries received prescriptions from five or more medical  practitioners for the 12 classes of frequently abused controlled  substances and 2 classes of frequently abused noncontrolled substances  in calendar year 2008. This represented about 1.8 percent of the  Medicare Part D beneficiaries who received prescriptions for these 14  classes of drugs during the same calendar year. Specifically, approximately  120,000 Medicare beneficiaries (about 71 percent) were eligible for  Medicare Part D benefits based on a disability. These drugs represented  over 80 percent of the instances of potential doctor shopping we  identified. In some cases, beneficiaries may have a justifiable reason for receiving  prescriptions from multiple medical practitioners, such as visiting  specialists or several prescribers in the same medical group. In these situations, there is heightened concern that these  Medicare beneficiaries may be seeking several medical practitioners to  support and disguise an addiction. DEA’s definition of doctor shopping  specifies an individual receiving more of a drug than intended by any  single physician. Table 3  summarizes the 10 examples of doctor shopping for prescription drugs,  including controlled substances, in the Medicare Part D program. Although systems are in place to identify  individuals with doctor shopping behavior, according to CMS Part D  program officials, federal law does not authorize Part D plans to restrict  the access of these individuals. Although not currently used in the Medicare Part D program, officials from  the Part D plan sponsors we interviewed stated that additional controls  already in place in the Medicaid program and in some private sector plans  could be used to better restrict the dispensing of abused drugs, such as  hydrocodone and oxycodone, to individuals identified as doctor shoppers  through detecting a pattern of abuse during retrospective analysis. There are  issues to consider with a restricted recipient program, such as potentially  denying legitimate drug needs and unknown costs for administration. Increased controls  over dispensing highly abusive drugs can help reduce the risk that  individuals will use Medicare to facilitate their dangerous drug activities,  which increases the cost of the program and jeopardizes patient care. Recommendation for Executive Action

To improve efforts to address doctor shopping by beneficiaries of highly  abused prescription drugs, we recommend that the Administrator of CMS  review our findings, evaluate the existing DUR program, and consider  additional steps such as a restricted recipient program for Medicare Part  D that would limit these beneficiaries to one prescriber, one pharmacy, or  both for receiving prescriptions. CMS could consider piloting such a program with a focus on  hydrocodone and oxycodone, the two drug classes where we identified  the largest potential doctor shopping activity. In considering such controls, CMS  should seek congressional authority as appropriate. CMS agreed with our overall recommendation to improve efforts to curb  overutilization in Part D, but disagreed that a restricted recipient program  is necessarily the appropriate control for the Part D program. To reflect the issues raised by  CMS, we revised our recommendation to include other actions that may  be taken by CMS to address overutilization of prescription drugs.
Why GAO Did This Study

In 2009, GAO reported on doctor shopping in Medicaid, where individuals see several doctors and pharmacies, receiving more of a drug than was intended by any single physician. Questions have been raised about whether similar activity exists in Medicare Part D. GAO was asked to (1) determine the extent to which Medicare beneficiaries obtained frequently abused drugs from multiple prescribers, (2) identify examples of doctor shopping activity, and (3) determine the actions taken by the Centers for Medicare & Medicaid Services (CMS) to limit access to drugs for known abusers. To meet the objectives, GAO analyzed Medicare Part D claims for calendar year 2008 to identify potential doctor shoppers. To identify examples, GAO chose a nonrepresentative selection of 10 beneficiaries based on a number of factors, including the number of prescribers. GAO also interviewed policy officials from CMS and from prescription drug plans that administer the drug benefit program.

What GAO Found

GAO found indications of doctor shopping in the Medicare Part D program for 14 categories of frequently abused prescription drugs. About 170,000 beneficiaries (about 1.8 percent of beneficiaries receiving these 14 categories of drugs) acquired the same class of frequently abused drugs, primarily hydrocodone and oxycodone, from five or more medical practitioners during calendar year 2008 at a cost of about $148 million (about 5 percent of the total cost for these drugs). About 120,000 of these beneficiaries were eligible for Medicare Part D because of a disability. There may be justifiable reasons for receiving prescriptions from multiple medical practitioners, such as visiting specialists or several prescribers in the same medical group. However, one individual received prescriptions from 87 different medical practitioners in 2008. In such situations, there is heightened concern that Medicare beneficiaries are seeing several medical practitioners to support and disguise an addiction. GAO judgmentally selected 10 beneficiaries and found that they were doctor shopping for prescription drugs. These cases are among the more egregious and cannot be generalized beyond the examples presented. CMS has systems in place to identify individuals with doctor shopping behavior; however, according to CMS policy officials, federal law may not authorize them to restrict these individuals' access to drugs, including highly abused drugs, such as hydrocodone and oxycodone. One option to control doctor shopping used by Medicaid and some private sector plans is the restricted recipient program. It limits individuals identified as doctor shoppers to one prescriber, one pharmacy, or both for receiving prescriptions. There are issues to consider with a restricted recipient program, such as potentially denying legitimate drug needs and unknown administrative costs. These issues should be balanced against the potential protections such a program can provide. Doctor shopping for frequently abused drugs can increase the cost of the Part D program and jeopardize patient care. Controls proven to reduce doctor shopping could be considered by CMS.

What GAO Recommends

GAO recommends that CMS review its findings and consider steps such as a restricted recipient program for identified doctor shoppers and seek congressional authority, as appropriate. CMS agreed with the overall recommendation to improve its efforts to curb overutilization in Part D, but disagreed that a restricted recipient program is necessarily the appropriate control for the Part D program.