In A Major Shift, Medicare Wants Power to Ban Harmful Prescribers

by Tracy Weber
and Charles Ornstein
plans to arm itself with broad new powers to better control — and
potentially ban — doctors engaged in fraudulent or harmful prescribing,
following a series of articles by ProPublica detailing lax oversight in its
drug program.
U.S. Centers for Medicare and Medicaid Services (CMS) described the effort late
Monday in what’s known as a proposed rule, the standard process by which
federal agencies make significant changes.
of the changes mark a dramatic departure for the agency, which historically has
given much higher priority to making medications easily accessible to seniors
and the disabled than to weeding out dangerous providers.
the first time, the agency would have the authority to kick out physicians and
other providers who engage in abusive prescribing. It could also take such
action if providers’ licenses have been suspended or revoked by state
regulators or if they were restricted from prescribing painkillers and other
controlled substances.
the agency will tighten a loophole that allowed doctors to prescribe to
Medicare patients even if they weren’t enrolled in the drug program, known as
Part D. Under the new rules, doctors and other providers must formally enroll
if they want to write prescriptions to the 36 million people in Part D. This requires
them to verify their credentials and disclose professional discipline and
criminal history.
Medicare and the private insurers that run Part D know little about those
writing the prescriptions — even those whose yearly tallies cost millions
of dollars or who prescribe high volumes of inappropriate drugs. ProPublica found that some of the
doctors had been criminally charged or convicted, had lost medical licenses or had
been terminated from state Medicaid programs serving the poor.
changes would take effect Jan. 1, 2015. As part of the process, CMS will accept
public comments until March 7 and could revise the proposals based on the
feedback. Undoubtedly, the new rules would require some patients to change
doctors — or force some doctors to apply to be part of Medicare.
of the proposed changes address failings detailed by ProPublica’s investigation
last year.
series showed that Medicare’s failure to keep watch over Part D has enabled
doctors to prescribe massive quantities of inappropriate medications, has wasted billions on needlessly expensive drugs and has exposed the program to rampant fraud. Part D
cost taxpayers $62 billion in 2012.
problems stem largely from Medicare’s failure to rigorously analyze what drugs,
and how many of them, physicians are prescribing to Part D patients.
the Freedom of Information Act, ProPublica requested and obtained data on the
drugs prescribed by every provider in the Part D program for five years —1.2
billion prescriptions in 2011 alone.
Reporters analyzed the data to spot doctors who prescribed in very different ways
than their peers — for example, by choosing drugs that were risky or
costly, or in ways that suggested fraud.
interviews, many of the doctors said they had never been contacted by Medicare
even though they agreed that their patterns were worthy of scrutiny.
part of its reporting, ProPublica sought the advice of experts on how to
tighten Medicare’s oversight of the program. Among Medicare’s planned changes
are several the experts suggested. But others were not addressed in the
for example, does not detail whether officials now plan to routinely scour
their data for providers with suspicious prescribing patterns and, when they
find them, what they’ll do.
proposed rule also does not include other suggestions such as requiring
diagnosis codes on prescriptions to assess their appropriateness or requiring
private insurers in Part D to report suspected fraud, waste and abuse to
Medicare’s fraud contractor. Such sharing is now voluntary.
the changes Medicare is proposing:

Giving its outside fraud contractor the ability to more easily investigate
suspicions of fraud. Currently, the contractor cannot directly access patient
medical charts to assess whether the patient actually saw the doctor or had a
condition that warranted the medication. The contractor must go back to
the insurers, which then request the records from doctors or pharmacies.
the rule change, the contractor would be given the power to access the records
directly. The inspector general of the U.S. Department of Health and Human
Services has repeatedly pressed Medicare to make this change.

Whittling down its list of “protected drug classes,” vital drugs for which
insurers cannot impose restrictions on use. The agency wants to remove
antidepressants and immunosuppressant drugs from this list, giving insurers
more latitude to require patients receive prior approval before receiving
certain brand-name medicines.

agency also said it may remove protection from antipsychotics, which can be
inappropriate for seniors with dementia, after 2015.
a blog post, Jon Blum, the principal deputy administrator for CMS, said his agency
is serious about fighting fraud and abuse in Part D. Since 2011, he wrote, the
agency has reduced the percentage of Part D patients who are potentially
overusing painkillers and acetaminophen, which can cause severe liver damage in
high doses.
strives to ensure that beneficiaries have the medications they need while at
the same time is being vigilant to safeguard the program from inappropriate use,”
Blum wrote.
when ProPublica looked at the highest prescribers of narcotics
in Part D, it found that many had faced criminal complaints, action by their
state medical boards or other accusations of misconduct.

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