Medicare Part D Overutilization Monitoring System (OMS) Summary

Home Health Care Policies: As part of a multifaceted response to address the growing problem of overuse and abuse of opioid analgesics (“opioids”) in the Part D program, the Centers for Medicare & Medicaid Services (CMS) adopted a policy in 2013 for Medicare Part D plan sponsors to implement enhanced drug utilization review. CMS is seeing real results from these efforts. From 2011 through 2014, there was a 26% decrease or 7,500 fewer Medicare Part D beneficiaries identified as potential opioid overutilizers. This represents a 39% decrease in the share of beneficiaries using opioids who are identified as potential opioid overutilizers.

In September 2011, the U.S. Government Accountability Office identified instances of questionable access to opioids in Medicare Part D and recommended that CMS improve its efforts to curb overutilization in the program. CMS immediately began working with Part D sponsors to improve drug utilization controls and better manage overutilization of opioids at the beneficiary level.

Effective January 1, 2013, CMS adopted an opioid overutilization policy that encompasses a medication safety approach by which sponsors are expected to reduce beneficiary overutilization of opioids and maintain access to needed medications using the following tools:

• Appropriate plan-level claim controls at point-of-sale (POS) for opioids, including safety edits and quantity limits.
• Improved retrospective drug utilization review to identify beneficiaries at high risk of an adverse event due to opioids (“high risk beneficiaries”).
• Case management with the identified beneficiaries’ prescribers followed by beneficiary-specific POS edits to prevent Part D coverage of opioid overutilization, if necessary.
• Data-sharing between Part D sponsors regarding identified beneficiary opioid overutilization.

Direct Oversight

CMS developed a comprehensive morphine equivalent dose (MED) approach to assist Part D sponsors in identifying high risk beneficiaries. Beneficiaries who are dispensed opioids that exceed 120 mg of cumulative MED for at least 90 consecutive days, and whose opioid prescriptions are associated with more than 3 prescribers and more than 3 pharmacies are identified as high-risk beneficiaries (i.e., potential opioid overutilizers). This approach was based on a promising method used in Washington State, as well as the opioid product list and MED conversion factors maintained by the Centers for Disease Control and Prevention. This cumulative MED approach to identify high risk use of opioids is now being widely adopted outside of Part D.

The Overutilization Monitoring System (OMS) is the tool designed and implemented by CMS in July 2013 to oversee sponsors’ compliance with CMS’ opioid overutilization policy. Through the OMS, Part D sponsors are provided quarterly reports on high risk beneficiaries and are required to provide CMS with the outcome of their review of each case.

CMS enhanced the Medicare Advantage Prescription System (MARx) in February 2014 to collect information from sponsors about their beneficiary-level opioid Point of Sale (POS) edits (i.e., messages from the payor that are transmitted to the pharmacy during adjudication of the prescription claim), which also alert a sponsor when a beneficiary identified by a prior sponsor as overutilizing opioids enrolls in the sponsor’s plan. As of June 29, 2015, sponsors submitted 1,699 beneficiary-level opioid POS edits to MARx.

Notable Impact

OMS Part D Potential Opioid Overutilization Rates, 2011 – 2014

The number of “first-time” opioid overutilizers also continues to drop. For Q4 2013, the OMS identified 13,393 new beneficiary opioid outliers; for Q4 2014, only 7,038 new beneficiary opioid outliers were identified, a reduction of 47%.