The perpetration of fraud negatively impacts every sector of healthcare, including (and perhaps especially) the abuse of prescription drugs. So it makes sense that parties with different agendas and priorities across a variety of industries would throw their weight together in trying to stamp out fraud and abuse when it comes to a category of drug that is highly susceptible to being abused.
The Healthcare Fraud Prevention Partnership (HFPP) is a collaborative undertaking between public and private entities such as healthcare anti-fraud organizations, the Centers for Medicare & Medicaid Services (CMS), state agencies, law enforcement, private healthcare insurers, and employer groups. The HFPP’s goal is to uncover fraudulent practices within the healthcare industry and to ultimately “reduce fraud, waste, and abuse.”
A white paper released by the HFPP earlier this year focuses on furnishing payers with new resources for reducing harm to patients from opioid abuse. “Healthcare Payer Strategies to Reduce the Harms of Opioids” is a 62-page report that adds to the opioid abuse canon by zeroing in on how payers are impacted, and how they can work to alleviate fraud.
“Unparalleled public health crisis”
The HFPP’s report describes the nation’s opioid epidemic this way:
“The effects of opioid misuse and OUD [opioid use disorder] have conspired to create an unparalleled public health crisis in the U.S., affecting millions of citizens and challenging a healthcare system that is committed to turning the tide of opioid misuse and OUD while ensuring that patients receive the treatments they need.”
And of course the crisis doesn’t only take a human toll on the country, but a financial one as well. In the words of the white paper:
“The CDC [The Centers for Disease Control] estimates that prescription opioid misuse, OUD, and opioid overdose cost the U.S. economy over $78 billion in 2013 in the form of higher healthcare and substance use disorder treatment costs, excess criminal justice costs, and productivity losses borne by employers.”
The CMS’s Opioid Misuse Strategy
Playing a major role in the HFPP is of course not CMS’s first involvement in an anti-opioid abuse endeavor.
Ever since the Department of Health and Human Services (HHS) launched its Opioid Initiative in spring of 2015, the CMS has been active in developing and implementing methods to fight opioid abuse, including a 2017 update to its “Opioid Misuse Strategy.”
CMS does have a particular interest in this issue: Medicare and Medicaid beneficiaries are hit particularly hard by prescription opioid use disorder, at a rate of 6 out of every 1,000 for the former and 8.7 out of every 1,000 for the latter, which experts place as more than 10 times greater than the privately-insured population.
Some of CMS’s ongoing efforts mentioned in its updated strategy guide include:
- Implementing “more effective person-centered and population-based strategies” that decrease the risk for opioid use disorders;
- Expanding access to and the use of the prescription drug naloxone (a medication-assisted treatment for opioid use disorder);
- Broadening patient availability to screening, diagnosis, and treatment of opioid use disorder;
- Increasing “evidence-based practices” for severe and chronic pain management.
However, this latest HFPP white paper centers around challenges to payers in particular, rather than to providers or patients.
HFPP’s suggestions for payers: prevent, educate, mitigate
There are several strategies that the report suggests payers implement in the effort to reduce fraud in the area of opioid use through prevention, education, and mitigation.
For starters, the HFPP recommends strengthening provider-patient communication from the payer perspective so that patients will have reliable access to policies, practices and resources that are appropriate for their individual circumstances. The HFPP suggests that payers bolster their opioid-risk resources with the goal of offering providers an increased level of education on the subject of opioid use.
Additionally, the HFPP discusses the concept of categorizing at-risk populations into “patient audiences” for whom certain educational resources would be appropriate. Telehealth is also mentioned as a means of delivering patient care and promoting patient awareness.
Prescription drug monitoring programs (PDMPs) are another measure that the HFPP lauds as important for payers to consider when seeking ways to standardize data and therefore ferret out potential fraud. PDMPs are protocols that mesh electronic health records (EHRs) with provider and prescriber monitoring. Access to EHR data and the use of electronic prescribing can help physicians spot patterns of abuse, including non-medical use or over-prescribing.
The HFPP encourages independent research followed by sharing of ideas
The HFPP white paper concludes with an urging for payers themselves to become active innovators in the fight against opioid abuse. The report asks payers to take advantage of the partnership’s resources in order to undertake their own studies or create their own strategies that they can share with others. The logic here is that all healthcare stakeholders are negatively impacted by fraud and waste, and therefore it would behoove them to share research results or successful tactics for ameliorating abuse.
“The HFPP supports the creation and dissemination of new information related to best practices in combating opioid misuse and OUD. The HFPP data resources are unparalleled in the U.S., as no comparable cross-payer collection of timely healthcare payment data exists elsewhere,” the report states. “At the same time, knowledge gaps continue to exist regarding the most effective strategies to reduce inappropriate opioid prescriptions, promote recovery from OUD, and increase the use of opioid alternative therapies for pain management.”
This blog post is provided for educational purposes only and is not offered as, and should not be relied on as, legal advice. Any individual or entity reading this information should consult an attorney for their particular situation. For more information/questions regarding any legal matters, please email [email protected] or call 310.203.2800.