By Elaine Goodman (medical/business reporter)
Thursday, April 21, 2016
Amid a growing number of U.S. government initiatives to address what’s being called a national crisis of opioid abuse, some say that one federal agency seems to be out of step.
The Centers for Medicare and Medicaid Services continues to demand payment for large amounts of opioids as a condition for approving proposed future-medical settlements in workers' compensation and other insurance cases, Medicare set-aside consultants say.
But efforts are intensifying to reduce CMS’ opioid allocations.
The National Alliance of Medicare Set-Aside Professionals has proposed what it calls evidence-based limits on opioids in workers’ comp Medicare set-asides.
Limiting costs earmarked for future opioid expenditures would help “reduce ongoing usage of these dangerous medications,” NAMSAP said in a press release last month.
And Franco Signor, a provider of Medicare secondary payer services, plans to send a letter to the White House this week asking for limits on opioid allocations in Medicare set-aside agreements, according to Heather Schwartz Sanderson, chief legal officer with Franco Signor. Sanderson said Franco Signor also supports NAMSAP’s proposal.
Evidence is growing that long-term use of opioids may be ineffective, and harmful to the patient, in treating chronic pain.
Even though CMS mentions evidence-based medicine in its reference guide for workers’ compensation Medicare set-asides, the arrangements CMS creates often don’t reflect that philosophy, Sanderson said. As an example, she cited a recent case in which a claimant in a workers’ comp settlement was allocated four different opioid prescriptions to be used simultaneously, for the claimant’s 27-year remaining life expectancy.
“In reality, they allocate based on the claimant’s prescription usage,” Sanderson said. “Across the board, they’re not using evidence-based medicine.”
NAMSAP has called for caps on opioid usage in settlement cases based on opioid guidelines the federal Centers for Disease Control published last month.
Specifically, the NAMSAP proposal asks to limit opioid prescribing to morphine equivalent doses of 90 milligrams for no more than a month when the MSA includes expectations of surgery, or a limit of 40 milligram MED for up to a month followed by a tapering plan. Morphine equivalent dose is a way of standardizing dosage among different opioid drugs.
CMS’ own policy recommends that sponsors of Medicare prescription drug plans set red flags for beneficiaries taking a morphine equivalent dose of 120 milligram a day for more than 90 days and who receive prescriptions from more than three prescribers or pharmacies, according to NAMSAP.
“So why do (workers' comp Medicare set-aside) approvals often include future prescription allocations with morphine equivalent dosages in excess of 120, 200 or even 500 (milligram) per day, over the beneficiary’s full life expectancy?” NAMSAP said. “And what message does a WCMSA supporting these high opioid dosages over a patient’s entire life expectancy send to the addicted patient?”
In a blog post about NAMSAP’s press release, Prium President Michael Gavin noted the conflicting opioid policies between the two federal agencies, CDC and CMS. Prium provides workers’ comp medical-cost management services.
“When the federal government’s public health agency says one thing, but that same government’s health care payment policy agency says another, they ought to be called to account for it,” Gavin wrote.
While he commended NAMSAP’s proposal, Gavin said he was doubtful that CMS would implement it. The agency has traditionally accepted what treating physicians want to do, he said, even when the treatment plans go against evidence-based medicine.
NAMSAP’s opioid proposal for Medicare set-aside arrangements is a continuation of the work of NAMSAP’s evidence-based medicine committee.
The group has been working with federal officials, not only at CMS, but also in the Surgeon General’s office and the National Guideline Clearinghouse, said NAMSAP President Gary Patureau.
CMS updated its Medicare set-aside reference guide to include references to evidence-based medicine in response to input from stakeholders including NAMSAP, Patureau said. The hope is that the next edition of the guide will address opioid usage, he added.
Patureau said use of high-dose opioids is harmful to the patient and also drives up costs beyond just the cost of the painkillers. The patient is soon taking a long list of additional drugs to counteract the side effects of the opioids. The solution, Patureau said, is to provide “appropriate care” to the injured worker.
“If you provide appropriate care, everything else takes care of itself,” said Patureau, who is also executive director of the Louisiana Association of Self Insured Employers.
Keith Rosenblum, a senior strategist for workers’ compensation risk control for Lockton Cos., said an injured workers’ opioid use should be addressed before a case heads to settlement, even if that means a prolonged delay. Lockton is an insurance brokerage that provides risk management services.
That might involve a health and behavioral assessment to find underlying causes for the opioid usage, including psychosocial issues, he said.
“Get them treated effectively before attempting to settle the case,” Rosenblum said.
Rosenblum called NAMSAP’s proposal “outstanding.” He said it may take a concerted effort of NAMSAP and other proponents to make the proposals a reality.