Opioid Act Aims to ID,Help Patients at Risk
When Congress passed the SUPPORT for Patients and Communities Act as its response to the opioid epidemic, it included provisions to expand capacity in Medicare and preventive measures for a population that is vulnerable to opioid-use disorder.
An analysis of Medicare Part D data by the Health and Human Services (HHS) Office of the Inspector General revealed that more than 500,000 Medicare Part D beneficiaries received high amounts of opioids in 2016, with the dose far exceeding the manufacturer’s recommended amount. Beyond the treatment of addiction, opioid use can also pose health risks such as breathing complications, confusion, drug-interaction problems, and increased falls, which can in itself pose significant health problems for elderly patients.
In 2014, the Agency for Healthcare Research and Quality published a report demonstrating that elderly females had a higher rate of opioid-related inpatient stays than elderly males and the rate of opioid-related inpatient stays was highest among those age 65 and older in 13 states. The report highlighted a need to expand capacity for treatment and increase ways to identify at-risk Medicare patients.
To expand capacity, the legislation expands Medicare coverage to include opioid treatment programs (OTPs) for the purposes of medication-assisted treatment. Opioid treatment programs were not previously recognized as Medicare providers, forcing beneficiaries to pay out of pocket for their services. This provision allows Medicare to pay the outpatient OTP through bundled payments made for holistic services including medications, counseling, and testing.
Another significant provision addresses opioid misuse in the elderly population by allowing for comprehensive screenings for Medicare beneficiaries for opioid-use disorder and other substance disorders. The screenings will be included in the initial preventive physical examination (the ‘welcome to Medicare’ visit) and annual wellness visits thereafter. The physician may include a review of the beneficiary’s current opioid prescriptions and screen for potential substance-abuse disorders. The comprehensive screening is an important tool to assess patients and allows the physician to create care plans to both address pain and ensure a patient receives appropriate treatment for substance-use disorder.
Other provisions addressing the Medicare program and the opioid epidemic build upon Center for Medicare and Medicaid Services (CMS) efforts that began this past April, when CMS finalized the 2019 Medicare Part D prescription-drug program requirements and included a ceiling for opioid doses. Any prescription at or above the ceiling would trigger a ‘hard safety edit’ requiring the pharmacist to talk with the prescribing doctor about the dose. CMS also adopted a new policy that requires all new opioid prescriptions for short-term acute pain to be limited to no more than seven days’ supply.
The legislation accelerates the development and use of drug-management programs for at-risk beneficiaries by mandating that all prescription-drug plans use such a program by 2022. The legislation also requires CMS to identify beneficiaries enrolled in Medicare Part D with a history of opioid-related overdose and include them in the definition of beneficiaries potentially at risk for prescription drug abuse under the Part D drug-management program.
Given the vulnerability of the elderly population, it was important to address both capacity for treatment and the identification of at-risk Medicare patients in the SUPPORT for Patients and Communities Act. The legislation takes important steps toward addressing opioid and other substance-abuse disorders in the Medicare program.