Inappropriate Opioid use in Medicare Part D

In late 2014 MedPAC* published a critical analysis on the widespread prescribing of opioid (narcotic) drugs for Medicare beneficiaries. This analysis excluded the use of opioids for cancer and hospice patients (those with terminal illnesses). The findings of the MedPAC analysis, as well as the HHS Office of the Inspector General (2015) were striking:

  • More than 30% of Medicare Part D enrollees fill an opioid narcotic prescription each year for purposes other than relief of cancer pain or another terminal illness;
  • The highest prevalence of narcotic prescription use among Part D enrollees was concentrated in 12 states: Oklahoma, Arkansas, Louisiana, Alabama, Mississippi, Georgia, South Carolina, North Carolina, Tennessee, Kentucky, West Virginia, and Alaska;
  • In 2012 more than 700,000 hospitalizations could be traced to the improper abuse of opioids;
  • Between 2006 and 2014 spending for commonly abused opioids grew from $1.5 billion to $3.9 billion among Part D claimants, an increase of 156%.
  • Growth in spending for the opioids outpaced overall drug spending in this period by 156% to 136%. Critically, the growth in Part D opioid utilization doubled the growth rate of Part D beneficiaries (68%). This fact strongly points to a sharp increase in opioid utilization for the average beneficiary who may fill these prescriptions.
  • Approximately 1/3 of opioid users obtained prescriptions from 4 or more prescribers and the users filled opioid prescriptions at 3 or more pharmacies in a single year. These utilization patterns were strongly suggestive of abuse and/or diversion (misuse of drugs away from legal and medically necessary purposes to uses that are illegal and lack medical necessity).

In response to the above patterns of opioid abuse that have come to light, Congress sternly directed the Department of Health and Human Services to do much more. Congress specifically mandated an improvement in reporting opportunities to mitigate opioid prescription drug abuse and dependency.

Among the Congressionally-mandated measures were:

  • Strengthening of surveillance;
  • Improve prescription drug abuse prevention programs;
  • Enhance coordination among federal programs charged with addressing these issues;
  • Collaboration with insurers and pharmacy benefit managers to enhance surveillance, reporting, and mitigation efforts.

Pharmaceutical fraud results in substantial loss to the public fisc, and overutilization of opioid drugs has, and will continue to contribute to this loss.

*The Medicare Payment Advisory Commission (MedPAC) is an independent congressional agency established by the Balanced Budget Act of 1997 (P.L. 105-33) to advise the U.S. Congress on issues affecting the Medicare program.

REAL PEOPLE making real change Meet Some of our Heroes

Kathleen Hawkins

Dignity Health
$37 million

Kathleen Hawkins, RN MSN, had been employed by Defendant, Catholic Healthcare West (CHW) for approximately 6 years when she decided she had had enough of trying to change the hospital system from within.

CHW, a California not-for-profit corporation that operated hospitals in California, Arizona, and Nevada, was at the time the eighth largest hospital system in the nation and the largest not-for-profit hospital provider in California.

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Joe Strom

Johnson & Johnson
$184 Million

Joe Strom contacted us in 2005. We were very grateful that he did. We immediately formed an all-star legal team and a process to stop a very harmful pharmaceutical marketing strategy. It was this process we set into motion that ultimately returned hundreds of millions of dollars to the U.S. Treasury, and a portion of that, very well-deserved, into Joe’s bank account.

Joe told us a very troubling story about the off-label promotion of a pharmaceutical drug for patients who already suffered from chronic heart failure.

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Bruce A. Moilan Sr.

$27 Million

Bruce Moilan was a seasoned hospital systems expert by the time he contacted our Firm. At the time he decided to file his qui tam lawsuit, he was employed by South Texas Health System as a System Director for Materials Management. In this position, he oversaw $24 million in annual purchases of supplies and equipment and helped determine budget, reduction and cost analysis throughout the contract bidding and negotiations process. His job was to insure proper implementation for purchasing, receiving and management of inventory, for McAllen Hospitals, L.P.

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“I collaborated with Nolan, Auerbach and White on a broad variety of cases where whistleblowers stepped forward to disclose tactics employed by large companies to influence physicians' medical decision-making in patient care. They provide ample resources to not only optimize their client cases, but in doing so consistently leverage best medical evidence to further patient safety and resource utilization.”

— Fred Polsky M.D., Former Medical Director, CMS Zone 7 Integrity Contractor

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