CMS tight­ens scru­tiny of Med­i­caid opi­oid, an­tipsy­chotic pre­scrib­ing

Modern Healthcare - - NEWS - By Vir­gil Dick­son

The CMS is tak­ing steps to com­bat the grow­ing prob­lem of opi­oid ad­dic­tion by plan­ning to more closely track adult use of the drugs, as well as an­tipsy­chotic drug use among chil­dren and ado­les­cents. The ef­forts are part of new qual­ity mea­sures for Med­i­caid and the Chil­dren’s Health In­sur­ance Pro­gram (CHIP).

The agency is­sued a no­tice out­lin­ing its plan, which comes amid ris­ing un­ease about the high rates of an­tipsy­chotic med­i­ca­tions pre­scribed to mi­nors for off-la­bel uses.

The CMS will re­quire Med­i­caid pro­grams, be­gin­ning no later than De­cem­ber 2016, to track the use of high-dosage opi­oids ac­quired from four or more providers and phar­ma­cies by ben­e­fi­cia­ries who don’t have can­cer.

That mea­sure is in­tended to sig­nal in­ap­pro­pri­ate pre­scrib­ing or frag­mented care, ac­cord­ing to the Phar­macy Qual­ity Al­liance, which en­dorsed the move this year. The Amer­i­can Phar­ma­cists As­so­ci­a­tion said the new Med­i­caid mea­sure could help iden­tify pat­terns of opi­oid mis­use.

The Cen­ters for Dis­ease Con­trol and Preven­tion re­ported this month that the num­ber of peo­ple who died from over­doses in 2014 was the high­est on record and has tripled since 2000. Med­i­caid re­cip­i­ents are twice as likely as peo­ple in com­mer­cial in­sur­ance plans to re­ceive a prescription for an opi­oid painkiller, and six times more likely to over­dose on the drugs, ac­cord­ing to a 2014 study by the Na­tional As­so­ci­a­tion of Med­i­caid Direc­tors. They’re also more likely to visit an emer­gency depart­ment for treat­ment, where opi­oids are of­ten pre­scribed, the as­so­ci­a­tion found.

“Many of th­ese doc­tor shop­pers need ad­dic­tion treat­ment for them­selves, or they are di­vert­ing med­i­ca­tion to oth­ers,” said Dr. Jeanmarie Per­rone, a drug safety re­searcher at the Univer­sity of Penn­syl­va­nia. “Ei­ther way, we need to help iden­tify and con­trol this ex­cess source of opi­oids.”

The CHIP mea­sure, mean­while, would track the per­cent­age of chil­dren and ado­les­cents who have been pre­scribed two or more an­tipsy­chotic med­i­ca­tions at the same time. The mea­sure is sup­ported by the Na­tional Col­lab­o­ra­tive for In­no­va­tion in Qual­ity Mea­sure­ment (NCINQ), a mul­ti­state and mul­ti­stake­holder col­lab­o­ra­tive fo­cused on pe­di­atric care.

An­tipsy­chotic pre­scrib­ing for chil­dren has in­creased rapidly in re­cent decades, driven by new med­i­ca­tions and by the longer du­ra­tion of the drugs’ use, ac­cord­ing to the NCINQ. Be­tween 1996 and 2002, the num­ber of an­tipsy­chotic drugs pre­scribed for chil­dren in­creased five­fold, from 8.6 pre­scrip­tions per 1,000 pe­di­atric pa­tients to 39.4. Chil­dren and ado­les­cents who take the drugs are at higher risk of se­ri­ous health con­di­tions, in­clud­ing weight gain, tremors and diabetes.

In 2008, the most re­cent year for which com­plete data are avail­able, Med­i­caid and CHIP spent $3.6 bil­lion on an­tipsy­chotic med­i­ca­tions, up from $1.65 bil­lion in 1999, ac­cord­ing to Math­e­mat­ica Pol­icy Re­search.

In March 2015, an anal­y­sis by HHS’ Of­fice of In­spec­tor Gen­eral found that 92% of an­tipsy­chotics taken by pe­di­atric Med­i­caid ben­e­fi­cia­ries in five states were pre­scribed for off-la­bel uses.

Based on that find­ing, the OIG rec­om­mended that the CMS work with state Med­i­caid pro­grams to re­view the use of an­tipsy­chotics by chil­dren en­rolled in Med­i­caid.

The use of mul­ti­ple an­tipsy­chotic med­i­ca­tions “is sel­dom jus­ti­fied and is an ap­pro­pri­ate fo­cus for a qual­ity mea­sure,” said Stephen Crys­tal, a pro­fes­sor of health pol­icy at Rut­gers Univer­sity. Crys­tal’s re­search sug­gests that chil­dren on Med­i­caid are pre­scribed an­tipsy­chotics at much higher rates than pri­vately in­sured chil­dren.

Dr. Mark Olf­son, a pro­fes­sor of psy­chi­a­try at Columbia Univer­sity, said the new mea­sure was wise “in light of the wide­spread prescription of com­plex psy­chotropic med­i­ca­tion reg­i­mens to young peo­ple and the risks of an­tipsy­chotic med­i­ca­tions.” Ac­cord­ing to re­search Olf­son pub­lished in JAMA Psy­chi­a­try in Septem­ber, drugs in­tended to treat bipo­lar dis­or­der and schizophre­nia are of­ten used to treat chil­dren and teenagers for at­ten­tion deficit hy­per­ac­tiv­ity dis­or­der, even though safer treat­ments are avail­able.

Other ex­perts, how­ever, ex­pressed con­cern that the new mea­sure could dis­suade providers from pre­scrib­ing mul­ti­ple an­tipsy­chotics even when the sever­ity of a pa­tient’s con­di­tion calls for them.

“I’m hop­ing they don’t get dinged be­cause they are pre­scrib­ing what might be nec­es­sary for care,” said Dr. Michael Nay­lor, a for­mer pres­i­dent of the Amer­i­can Acad­emy of Child and Ado­les­cent Psy­chi­a­try.

Be­tween 1996 and 2002, the num­ber of an­tipsy­chotic drugs pre­scribed for chil­dren in­creased five­fold, from 8.6 pre­scrip­tions per 1,000 pe­di­atric pa­tients to 39.4.

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