Improper monitoring of the prescribing patterns of health professionals who participate in Medicare’s Part D prescription drug program put seniors and the disabled at serious risk, claim the authors of a joint report issued by ProPublica and The Washington Post.
Analyzing hundreds of millions of Part D claims submitted between 2007 and 2010, they argue that an intentional lack of federal oversight has made it extremely difficult to identify prescribers with questionable practices, including those (1) operating “prescription mills,” from which cash-paying patients can get prescriptions on request; (2) prescribing drugs for unapproved uses that may be harmful, disorienting, or addictive; or (3) overprescribing antipsychotics and strong pain medication to seniors.
Since the federal Centers for Medicare and Medicaid Services (CMS) oversees both Medicare and Medicaid, it has already collected data about all Medicare participants, including their diagnoses, the services they received, and prescription drugs they are taking. The report’s authors argue that this puts the center in the best position to determine if Part D patients are being prescribed appropriate drugs for their conditions. But CMS maintains that this is a function Congress intentionally withheld from it to ensure that it did not second guess doctors’ treatment decisions. Instead, this function belongs to the stand-alone drug plans with whom CMS contracts for Part D services.
The unique separation of functions is a significant hurdle for those looking to increase CMS’ oversight activity. Although Medicare scrutinizes and makes payment decisions for participants’ medical and hospital service claims, Part D claims are paid directly by stand-alone drug plans that are also assigned to detect prescription irregularities. But, with rare exceptions, Medicare does not allow plans to reject drug claims or have access to patients’ medical diagnoses, making it nearly impossible for them to determine if patients have been given the wrong drug for their conditions. Program rules also require Part D insurers to pay for prescriptions from all providers – even those they believe are acting improperly – unless the provider has been formally excluded from the program.
ProPublica has used information gathered from its Medicare claims data to create an online tool, Prescriber Check Up. The tool allows people to search for individual providers to see what drugs they prescribe. At the moment, the public database is limited to claims activities for 2010.
