Medicare Should Consider Pharmacy Lock-Ins

Sep 29, 2014
Pharmacy lock-ins are an effective tool to address drug-seeking behavior. However, current CMS rules prevent Medicare plans from implementing a pharmacy lock-in.
  • Commercial
  • Medicare
  • Pain

People who are addicted to prescription drugs often go to multiple doctors and pharmacies to obtain narcotics. But by requiring certain members to fill narcotic prescriptions at a single designated pharmacy – a “pharmacy lock-in” – commercial health plans are helping prevent such drug-seeking behavior, while still ensuring that patients can continue to access the medications they need.

A pharmacy lock-in also allows pharmacy benefit managers like Express Scripts to leverage our unique position to identify and investigate potential cases of fraud, waste and abuse.

Medicare plans are prevented from implementing this safety mechanism that could cut down on billions of dollars of abuse and fraud in our healthcare system. Current CMS rules prevent Medicare plans from implementing a pharmacy lock-in.

America’s Other Drug Problem

Each year, prescription drug abuse kills nearly 17,000 people – more than heroin and cocaine combined.

This puts patients, their families and communities at risk. It also takes a financial toll on employers, government programs and other payers. The high costs associated with drug abuse are unsustainable.

Prescription painkiller abuse leads to:

Case Study: Abuse Intervention

In one case, Express Scripts' Fraud, Waste & Abuse team investigated a patient who had filled 43 controlled-substance prescriptions from 17 prescribers and five pharmacies in 2011. Over a period of 425 days, she received 2,588 dosage units – or 825 days’ worth of medication.

By implementing pharmacy lock-in, the payer was able to cut off her avenues for getting improper prescriptions (doctor shopping) and for getting them filled (pharmacy shopping). Just as important, the solution also provided the patient the care and treatment she needed to address her addiction.

Today, this patient is using only one pain management physician, and she continues to use only one pharmacy to fill her narcotic prescriptions. The intervention led to a greater quality of care and safety for the patient. Also, the health plan has avoided unnecessary pharmacy costs of $1,088, as well as an estimated $40,000 that would have been wasted on medical spending attributed to related doctor shopping.

Maintaining Access

Lock-ins require patients to see a single physician and use a single pharmacy only for pain medications. These patients can continue seeing other physicians and using other pharmacies for non-narcotic prescriptions.

Lock-ins are an effective, sensible tool in addressing drug-seeking behavior, but unfortunately this type of solution isn’t available under current Medicare regulations. That needs to change.

Today, Jo-Ellen Abou Nader will join a group of industry experts to discuss prescription drug abuse at a Congressional Briefing in Washington, D.C.

Author Bio

Lab Staff
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