CMS tightens scrutiny of Medicaid opioid, antipsychotic prescribing
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.