Health-Care Watchdog Report May Increase Focus on Opioid Abuse

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By James Swann

A health-care watchdog’s report on the risks of opioid abuse among Medicare Part D beneficiaries may signify a shift in resources, both in terms of investigators as well as data analytics.

There’s likely to be a lot more action involving cases associated with opioids, based on both the July 13 Health and Human Services Office of Inspector General report and the nationwide health-care fraud “takedown” announced the same day, Gejaa Gobena, a health-care attorney with Hogan Lovells in Washington, told Bloomberg BNA.

“The focus will not just be providers, as seen in the takedown, but also on whether manufacturers and pharmacy benefit managers are paying close enough attention to prescribing patterns,” Gobena, a former deputy chief of the fraud section in the Department of Justice’s Criminal Division, said.

The OIG report identified roughly 500,000 Medicare Part D beneficiaries who received high doses of opioids in 2016, and 90,000 who were at a serious risk of overdose. The fraud takedown led to charges against 412 individuals, and 120 of the cases involved opioids.

The report is likely the precursor to more enforcement action against opioid abuse, Laura Cordova, a health-care attorney with Crowell & Moring LLP in Washington, told Bloomberg BNA.

Cordova said the damage from the epidemic is affecting entire families and communities, not just individuals.

“Because of that, I believe law enforcement and prosecutors will continue to prioritize cases involving alleged violations related to opioid abuse,” Cordova said.

Opioid Crisis

Opioids have a proper place within medical treatment, but the overprescription of them has fueled the current crisis, which has been heightened by the illicit distribution of heroin and fentanyl, Kerry Harvey, a health-care attorney with Dickinson Wright in Lexington, Ky., told Bloomberg BNA.

Harvey was appointed the U.S. attorney for the Eastern District of Kentucky in 2010, and at that time there were very few heroin prosecutions and almost no cases involving fentanyl, Harvey said.

“By the time I left earlier this year, we were fully engaged in a burgeoning crisis involving these deadly drugs, and unquestionably, this crisis is directly related to the overuse of prescription opioids,” Harvey said. Harvey said 80 percent of heroin users in the U.S. first abused prescription pain pills.

With the opioid problem reaching crisis levels, Harvey said, he expects there will be increasingly aggressive enforcement because there is no other choice.

“The OIG data brief sounds a needed warning, and providers should be on notice that scrutiny of prescribing practices is increasing and enforcement action will follow,” he said.

Harvey said it’s likely the OIG will devote more resources to the opioid crisis, following a trend started at the Department of Justice several years ago.

There have been some encouraging signs on the prescription opioid front, Harvey said, noting that providers are better educated about the drug risks, regulators are more aggressive, and patients are more alert.

Harvey also said the Centers for Medicare & Medicaid Services can play a pivotal role in fighting opioid abuse. The CMS sets the conditions of participation for Medicare and Medicaid, which pay for a large portion of the opioids prescribed across the country, Harvey said.

“This gives CMS a highly effective tool to drive good, common sense prescribing practices, which is a necessary component to solving the opioid crisis,” Harvey said.

Enforcement Focus

Enforcement involving opioid abuse will continue to be a top priority for the government, Judy Waltz, a health-care attorney with Foley & Lardner LLP in San Francisco, told Bloomberg BNA. The opioid epidemic hits a population (Part D beneficiaries) that’s not traditional drug users, so more people can relate to it, Waltz said.

The OIG’s report is an impressive example of data mining and shows the potential for using Medicare data to assess current concerns and trends in health care, Waltz said.

Waltz said she was especially interested in the report’s finding that nurse practitioners and physician assistants made up one-third of the 401 providers the OIG identified who had questionable prescribing patterns for Part D beneficiaries at serious risk of opioid abuse.

“We’ve seen something of a focus on those groups here in California, although primarily at the state level,” Waltz said.

Waltz said the report should be a wake-up call for all practitioners to think about what their data footprint will show as data mining becomes more prevalent and efficient.

The high number of at-risk beneficiaries is very concerning, Waltz said, illustrating how extensive the opioid problem is and raising the question of how to respond without depriving patients who need pain control of some good options.

Next Steps

The OIG report didn’t contain any specific recommendations for reducing the risks of opioid abuse, but did offer some best practices for providers, including full use of state prescription drug monitoring programs.

The program databases include information on a patient’s prescription history, and providers can see if patients have been receiving high levels of opioids or have engaged in doctor-shopping—a practice where patients visit multiple doctors to collect more opioids.

Other OIG suggestions included strengthening public health surveillance, providing better access to treatment and recovery services, and improving the availability of drugs that can reverse opioid overdoses.

To contact the reporter on this story: James Swann in Washington at

To contact the editor responsible for this story: Kendra Casey Plank at

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