A couple of years ago, while working as Chief Medical Officer of a Medicare Advantage health plan, our pharmacist called me to tell about a member who had filled prescriptions for a huge amount of pain medications, including oxycodone and Kadian, an oral morphine. She said she had never, in her entire career as a pharmacist, seen someone being prescribed so much of these powerful drugs (this was pre-Michael Jackson and propofol).
We set about investigating what was going on including talking to the prescribing physician who told me the patient was a legitimate chronic pain patient. He said he weighed over 300 pounds and is unable to walk because of his chronic knee pain. After failing to find that the doctor was known to overprescribe pain pills and the patient wasn’t an obvious drug dealer, we referred the case to the Plan’s Fraud, Waste, and Abuse Department. Before they could initiate an investigation, the member dropped our Plan and switched back to Traditional Medicare—where I have no doubt he continued to receive, subsidized by taxpayer’s dollars, bushels and bushels of expensive pain pills.
It turns out what we experienced has been occurring in lots of other places. According to an article in the New York Times, the Government Accountability Office has produced a report that shows “approximately 170,000 Medicare beneficiaries received prescriptions from five or more medical practitioners” for fourteen types of drugs that are frequently abused, including oxycodones, like OxyContin and Percocet, and hydrocodones, like Vicodin.
The doctor shoppers
All doctors know that there is a small subset of patients who go from doctor to doctor seeking pain medication prescriptions. When I was practicing Emergency Medicine, all of the ERs in San Francisco kept lists of drug-seeking patients that could be shared with other emergency departments. Early on in my career, I had a patient change the #10 I wrote on her prescription (for 10 tablets) to #100 before she arrived at the pharmacy. Luckily, the pharmacist caught it and gave me a call. After that, I always wrote the number and the words on the prescription for any drug with abuse potential (e.g., #10 (ten) or #25 (twenty-five)). ePrescribing should prevent this type of abuse, but will not make a big dent in the problem.
Drug-seeking patients may or may not have chronic pain and may or may not be addicted (they could also be selling). Unfortunately, some people have painful diseases, like sickle cell anemia or chronic low back pain, but they also become addicted to the medications used to treat their pain…therein lies the problem.
The NY times article describes several over-the-top examples of prescription pain medication abuse:
- A Georgia beneficiary received 3,655 oxycodone pills—a 1,679 day supply—during the course of a year. She had prescriptions from 58 different prescribers and filled them at 40 different pharmacies.
- A California man received prescriptions for 1,397 fentanyl patches from 21 different prescribers in a year.
- A Texas beneficiary received 4,574 hydrocodone pills from 25 different doctors.
These drugs were all paid for by the beneficiaries’ Part D plan—usually with a relatively small co-pay. That means that Medicare is paying the lion’s share of the costs and, therefore, is subsidizing the abuse.
Senator Thomas Carper (D, Delaware) was quoted in the article as saying “Federal dollars intended to address the health needs of the elderly and the poor are instead being used to feed addictions or to pad the wallets of drug dealers. This is clearly unacceptable.” That’s an understatement. It is fraud, waste, and abuse and it needs to be stopped. Senator Carper has called a hearing of the Homeland Security and Governmental Affairs subcommittee which he chairs.
The NYT article suggests that Medicare officials have been reluctant to limit suspected drug-seekers to only one prescriber or one pharmacy. Doctors who deal with this type of patient on a regular basis frequently recommend this type of intervention. The written response by Medicare states “High utilization of pain medications is not necessarily an indication of abuse, but could be an indication of poorly coordinated care in the treatment of pain symptoms.” That is flat out naïve on the part of whoever wrote the Medicare response.
It is a lot of work to be a drug-seeker—going from doctor to doctor, describing your symptoms over and over, and then making the rounds of pharmacies to get the drugs. I am sorry, but I don’t think getting oxycodone from 58 different prescribers or Fentanyl patches from 21 prescribers is just “poor care coordination.” The guys over at Medicare thinking about this issue need to get out into the field and talk to real practitioners more often.
Health plans often know about these types of patients. In two plans that I worked for, we designed reports that could show us patients who were prescribed pain medications by multiple prescribers. We shared these reports with the beneficiaries’ primary care physician(s) who found them valuable because they were often unaware that the patient was receiving so many drugs.
The bottom line
Getting costs under control is a part of Medicare’s Triple Aim. If we are going to do this, while maintaining or improving quality and the health of populations, we are going to have to get real about what goes on in the real world. People do abuse Medicare for a variety of reasons….getting subsidized pain meds is just one. There are no silver bullets when it comes to controlling costs, rather I like to say that there are instead thousands of golden BBs—eliminating the fraud, waste, and abuse related to drug-seeking behavior is one of them.