Federal Officials Listening to Medicare Set-Aside Group's Opioid Concerns
Elaine Goodman (medical/business reporter)
Wednesday, July 6, 2016
The National Alliance of Medicare Set Aside Professionals took a step forward in its campaign to place limits on opioid allocations in Medicare set-aside agreements when NAMSAP representatives visited Washington, D.C., last month.
The group says the Centers for Medicare and Medicaid Services tends to overestimate the amount of opioids that will be necessary when it reviews set-asides to cover future medical costs in workers' compensation settlements, unnecessarily driving up costs and sending the wrong message to the patient.
NAMSAP President Gary Patureau and attorney Amy Bilton, who are co-chairs of the organization’s Evidence-Based Medicine Committee, visited the Washington area June 20-21. They were joined by a third NAMSAP representative, Rasa Fumagalli of NuQuest.
Although no formal action is expected as a result of the meetings, follow-up sessions are planned, according to Patureau and Bilton. While workers’ comp Medicare set-asides may be just a small piece of nationwide efforts to combat the opioid crisis, Patureau said the visit was successful in bringing different branches of government together on the issue.
“We were very pleased with the outcome,” said Patureau, who is also executive director of the Louisiana Association of Self-Insured Employers.
In March, NAMSAP proposed evidence-based limits on opioids for workers’ compensation Medicare set-aside arrangements, which are intended to ensure that Medicare does not end up paying for an injured worker’s medical care. Workers’ comp settlement agreements may be sent to CMS contractors for review, a step that is often used by insurers and self-insured employers to avoid litigation with the agency. The Medicare Secondary Payer Act allows the government to sue if medical treatment allocations prove insufficient and Medicare ends up picking up the tab.
NAMSP says that including large allocations of opioids over the claimant’s life expectancy adds to the cost of the settlement and endangers the claimant. The organization has proposed limiting 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.
During their two-day visit, NAMSAP representatives met with Steve Forry, director of the Division of Medicare Secondary Payer Program Operations for the Centers of Medicare and Medicaid Services. They met with Deputy General Counsel Michael Passante and others in the Office of National Drug Control Policy.
Another meeting was with U.S. Sen. Bill Cassidy, R-Louisiana, and his staff. Cassidy is also a physician.
The NAMSAP representatives explained the perils of “institutionalizing” opioids in Medicare set-asides. Bilton said the officials seemed to be especially interested when the discussion turned from the dollars-and-cents of opioid prescribing to the human cost.
“I do think we are going to see a change,” Bilton said.
And NAMSAP appears to have gained one particular ally: Rear Adm. Pamela Schweitzer, who is the U.S. Assistant Surgeon General. In addition to meeting with the NAMSAP team, Schweitzer spoke to participants in a NAMSAP webinar during the visit.
“I’m quite honored to be able to be around a group of people that are just so passionate about trying to make a difference, and try to improve the lives and the quality of life for patients,” Schweitzer told webinar participants.
U.S. Surgeon General Dr. Vivek Murthy has launched an initiative called “Turn the Tide Rx,” aimed at better education for physicians on opioid prescribing. During the webinar, Schweitzer noted the association between increased opioid prescribing and the increase in overdose deaths.
“If we can decrease prescribing, we can make a big difference,” Schweitzer said.
Although it’s not yet clear how opioid limits might be set in Medicare set-asides, Patureau said one possibility would be to incorporate the provisions of legislation pending in Congress into Medicare set-aside reform legislation.
Rita Wilson, chief executive officer of Tower MSA Partners and a NAMSAP board member, wasn’t part of the Washington trip but also has concerns about excessive opioid allocations in Medicare set-asides.
“How can CMS allow that to be in a Medicare set-aside when their own Part D rules don’t allow that?” Wilson said.
Wilson said the average cost of a workers’ comp claim without opioids is about $13,000; when short-acting opioids are involved, the average cost increases to $39,000. The average cost of claims that include long-acting opioids rises to $177,000.
But it’s not just about the cost, Wilson said. Opioids also create issues with the patient’s quality of life, risk of addiction and possibility of overdose death.
Wilson advises clients to address the opioid issue throughout the life of a claim, not just when a settlement is being considered. That means sending injured workers to providers who have a reputation for responsibly prescribing pain medicine, she said, and looking for problematic prescribing throughout the claim.