Medicare Part D

In 2009, GAO reported on doctor shopping in Medicaid, where individuals see several doctors and pharmacies, receiving more of a drug than was intended by any single physician. Questions have been raised about whether similar activity exists in Medicare Part D. GAO was asked to (1) determine the extent to which Medicare beneficiaries obtained frequently abused drugs from multiple prescribers, (2) identify examples of doctor shopping activity, and (3) determine the actions taken by the Centers for Medicare & Medicaid Services (CMS) to limit access to drugs for known abusers. To meet the objectives, GAO analyzed Medicare Part D claims for calendar year 2008 to identify potential doctor shoppers. To identify examples, GAO chose a nonrepresentative selection of 10 beneficiaries based on a number of factors, including the number of prescribers. GAO also interviewed policy officials from CMS and from prescription drug plans that administer the drug benefit program.

GAO found indications of doctor shopping in the Medicare Part D program for 14 categories of frequently abused prescription drugs. About 170,000 beneficiaries (about 1.8 percent of beneficiaries receiving these 14 categories of drugs) acquired the same class of frequently abused drugs, primarily hydrocodone and oxycodone, from five or more medical practitioners during calendar year 2008 at a cost of about $148 million (about 5 percent of the total cost for these drugs). About 120,000 of these beneficiaries were eligible for Medicare Part D because of a disability. There may be justifiable reasons for receiving prescriptions from multiple medical practitioners, such as visiting specialists or several prescribers in the same medical group. However, one individual received prescriptions from 87 different medical practitioners in 2008. In such situations, there is heightened concern that Medicare beneficiaries are seeing several medical practitioners to support and disguise an addiction. GAO judgmentally selected 10 beneficiaries and found that they were doctor shopping for prescription drugs. These cases are among the more egregious and cannot be generalized beyond the examples presented. CMS has systems in place to identify individuals with doctor shopping behavior; however, according to CMS policy officials, federal law may not authorize them to restrict these individuals' access to drugs, including highly abused drugs, such as hydrocodone and oxycodone. One option to control doctor shopping used by Medicaid and some private sector plans is the restricted recipient program. It limits individuals identified as doctor shoppers to one prescriber, one pharmacy, or both for receiving prescriptions. There are issues to consider with a restricted recipient program, such as potentially denying legitimate drug needs and unknown administrative costs. These issues should be balanced against the potential protections such a program can provide. Doctor shopping for frequently abused drugs can increase the cost of the Part D program and jeopardize patient care. Controls proven to reduce doctor shopping could be considered by CMS. GAO recommends that CMS review its findings and consider steps such as a restricted recipient program for identified doctor shoppers and seek congressional authority, as appropriate. CMS agreed with the overall recommendation to improve its efforts to curb overutilization in Part D, but disagreed that a restricted recipient program is necessarily the appropriate control for the Part D program.

Recommendations

Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.

Director: Gregory D. Kutz Team: Government Accountability Office: Forensic Audits and Investigative Service Phone: (202) 512-9505