Prescribers With Questionable Patterns in Medicare Part D

WHY WE DID THIS STUDY

Under the Medicare Part D program, CMS contracts with private insurance companies, known as sponsors, to provide prescription drug coverage to beneficiaries who choose to enroll. In recent years, prescription drug abuse has emerged as a serious and growing problem. The Centers for Disease Control and Prevention has characterized prescription drug abuse as an epidemic. With the rise in prescription drug abuse, concerns about Medicare fraud, particularly prescriber fraud, have increased.

HOW WE DID THIS STUDY

We based this study on an analysis of Prescription Drug Event records. Sponsors submit these records to CMS for each drug dispensed to beneficiaries enrolled in their plans. Each record contains information about the pharmacy, prescriber, beneficiary, and drug. We analyzed all of the records for drugs billed in 2009. We developed five measures to describe Part D prescribing patterns and to identify general-care physicians with questionable patterns.

WHAT WE FOUND

Over 1 million individual prescribers ordered drugs paid by Part D in 2009. Prescribing patterns varied widely by specialty. Over 700 general-care physicians had questionable prescribing patterns. Each of these physicians prescribed extremely high amounts for at least one of the five measures we developed. For example, many of these physicians prescribed extremely high numbers of prescriptions per beneficiary, which may indicate that these prescriptions are medically unnecessary. Moreover, more than half of the 736 general-care physicians with questionable prescribing patterns ordered extremely high percentages of Schedule II or III drugs, which have potential for addiction and abuse. Although some of this prescribing may be appropriate, such questionable patterns warrant further scrutiny.

WHAT WE RECOMMEND

These findings show the need for increased oversight of Part D. We recommend that CMS (1) instruct the Medicare Drug Integrity Contractor to expand its analysis of prescribers, (2) provide sponsors with additional guidance on monitoring prescribing patterns, (3) provide education and training for prescribers, and (4) follow up on prescribers with questionable prescribing patterns. CMS concurred with all four recommendations.