The Health and Human Services Office of Inspector General (“OIG”) remains concerned with potential prescription drug abuse. The Centers for Disease Control and Prevention estimates that approximately seven million people in the U.S. misused prescription drugs in 20101 and has characterized prescription drug abuse as an epidemic. Due to concerns of prescription drug abuse and the recent number of convictions involving prescriber fraud, the OIG has conducted several studies concerning controlled substances and pharmacies’ dispensing practices. One such recent study, Prescribers with Questionable Patterns in Medicare Part D (“OIG Study”)2, expands upon previous studies and evaluates the prescribing habits of certain practitioners with questionable prescriptive practices.
Background and OIG’s Findings
The Centers for Medicare & Medicaid Services (“CMS”) contracts with private insurance companies (“Sponsors”) to provide drug coverage to Medicare Part D beneficiaries. The OIG Study analyzed Sponsors’ Prescription Drug Events (“PDE”) billed to Part D in 2009, which included over one billion records. Each PDE record contains information about the beneficiary, pharmacy, prescriber and drug dispensed.
The OIG used five metrics to evaluate Part D prescribing patterns for each individual prescriber, including (1) the average number of prescriptions per beneficiary; (2) the total number of pharmacies associated with each prescriber; (3) the percentage of prescriptions for Schedule II drugs; (4) the percentage of prescriptions for Schedule III drugs; and (5) the percentage of prescriptions for brand-name drugs. The OIG suggested that prescribers found to be at or above the 90th percentile for each of these categories had questionable prescribing practices. However, the OIG was clear that there could be legitimate reasons for a prescriber to appear in the 90th percentile, thus additional follow-up was needed to determine whether the prescribing habits were illegitimate. Of note, the OIG Study looked specifically at Schedule II and III drugs, which have significant potential for abuse and may lead to severe psychological or physician addiction. On average, Schedule II drugs were 4 percent and Schedule III drugs were 7 percent of prescriptions from each prescriber, while the 90th percentile for these schedules started at 10 percent and 23 percent respectively.
The OIG Study also analyzed prescribing patterns based on provider specialty. Notably, a few specialties, such as physical medicine and rehabilitation specialists, were more likely than others to order high percentages of Schedule II drugs. The specialties more likely to prescribe Schedule III drugs included surgeons, emergency medicine specialists and dentists. For general-care physicians, the OIG identified 736 with questionable prescribing patterns based on what the OIG characterized as having extremely high amounts for at least one of the five measures developed. For these five measures, the OIG provided the national average or percentage as well as what the OIG believes is an extremely high threshold for general-care physicians. On a national level, general-care physicians’ total prescriptions are typically 2 percent for Schedule II drugs, 3 percent for Schedule III drugs and 28 percent for brand-name drugs. The OIG set the high threshold amounts for these same categories at 14 percent for Schedule II drugs, 14 percent for Schedule III drugs and 68 percent for brand-name drugs. General-care physicians whose prescriptive practices are at or over the OIG’s extremely high threshold potentially could have questionable prescribing patterns. Another metric the OIG reviewed was the number of prescriptions per beneficiary. The OIG explained that ordering a high average number of prescriptions per beneficiary could indicate that a physician is prescribing drugs that are not medically necessary.
Potential Effect on Pharmacies
In light of this study, pharmacies should be aware of factors that may be used to “flag” prescribers as having questionable prescribing habits. As pharmacists focus efforts on satisfying their corresponding duty to fill only legitimate prescriptions, they may wish to add the review of their prescribers’ prescriptive practices mentioned in the OIG Study to their compliance program audit plans. For example, they may want to evaluate whether a certain prescriber writes an abnormally high percentage of Schedule II drugs.
Pharmacies that identify prescribers with questionable prescriptive practices (for example, a prescriber writes an abnormally high percentage of prescriptions of Schedule II drugs) will need to consider how to address such issues through their compliance programs.
This article is educational in nature. If you have any questions or would like additional information on this topic, please contact Susan Bizzell at 317.977.1453 or email@example.com, Brian Jent at 317.977.1402 or firstname.lastname@example.org, Nicholas Gonzales at 414.721.0486 or email@example.com or your regular Hall Render attorney.
Special thanks to Janice Pascuzzi, Law Clerk, for her assistance with the preparation of this article.