Medicare Part D: Instances of Questionable Access to Prescription Drugs
Published: 2011-09-06T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: In 2009, GAO reported on doctor shopping in Medicaid, where individuals see several doctors and pharmacies, receiving more of a drug than was intended by any single physician. Questions have been raised about whether similar activity exists in Medicare Part D. GAO was asked to (1) determine the extent to which Medicare beneficiaries obtained frequently abused drugs from multiple prescribers, (2) identify examples of doctor shopping activity, and (3) determine the actions taken by the Centers for Medicare & Medicaid Services (CMS) to limit access to drugs for known abusers. To meet the objectives, GAO analyzed Medicare Part D claims for calendar year 2008 to identify potential doctor shoppers. To identify examples, GAO chose a nonrepresentative selection of 10 beneficiaries based on a number of factors, including the number of prescribers. GAO also interviewed policy officials from CMS and from prescription drug plans that administer the drug benefit program.
section_title: What GAO Found
paragraphs: GAO found indications of doctor shopping in the Medicare Part D program for 14 categories of frequently abused prescription drugs. About 170,000 beneficiaries (about 1.8 percent of beneficiaries receiving these 14 categories of drugs) acquired the same class of frequently abused drugs, primarily hydrocodone and oxycodone, from five or more medical practitioners during calendar year 2008 at a cost of about $148 million (about 5 percent of the total cost for these drugs). About 120,000 of these beneficiaries were eligible for Medicare Part D because of a disability. There may be justifiable reasons for receiving prescriptions from multiple medical practitioners, such as visiting specialists or several prescribers in the same medical group. However, one individual received prescriptions from 87 different medical practitioners in 2008. In such situations, there is heightened concern that Medicare beneficiaries are seeing several medical practitioners to support and disguise an addiction. GAO judgmentally selected 10 beneficiaries and found that they were doctor shopping for prescription drugs. These cases are among the more egregious and cannot be generalized beyond the examples presented. CMS has systems in place to identify individuals with doctor shopping behavior; however, according to CMS policy officials, federal law may not authorize them to restrict these individuals' access to drugs, including highly abused drugs, such as hydrocodone and oxycodone. One option to control doctor shopping used by Medicaid and some private sector plans is the restricted recipient program. It limits individuals identified as doctor shoppers to one prescriber, one pharmacy, or both for receiving prescriptions. There are issues to consider with a restricted recipient program, such as potentially denying legitimate drug needs and unknown administrative costs. These issues should be balanced against the potential protections such a program can provide. Doctor shopping for frequently abused drugs can increase the cost of the Part D program and jeopardize patient care. Controls proven to reduce doctor shopping could be considered by CMS.
section_title: What GAO Recommends
paragraphs: GAO recommends that CMS review its findings and consider steps such as a restricted recipient program for identified doctor shoppers and seek congressional authority, as appropriate. CMS agreed with the overall recommendation to improve its efforts to curb overutilization in Part D, but disagreed that a restricted recipient program is necessarily the appropriate control for the Part D program.

section_title: Letter
paragraphs: Prescription drug abuse is a serious and growing public health problem.  According to the Centers for Disease Control and Prevention, drug  overdoses, including those from prescription drugs, are the second  leading cause of deaths from unintentional injuries in the United States,  exceeded only by motor vehicle fatalities. Unlike addiction to heroin and  other drugs that have no accepted medical use, addiction to some  controlled substances can be unknowingly financed by insurance  companies and public programs, such as Medicare. There are reports  and allegations that criminals and drug abusers are able to illegitimately  acquire controlled substances by filing fraudulent claims, seeking  treatment from medical practitioners for feigned injuries and illnesses, and  perpetrating other fraudulent activities. The financial cost associated with  controlled substance fraud and abuse is more than the cost of drug  purchases since there are related medical services, such as doctor and  emergency room visits, that precede the dispensing of these medications.
GAO reported, in September 2009, on an investigation of Medicaid fraud  and abuse related to controlled substances in selected states. The  investigation found about 65,000 Medicaid beneficiaries and providers  involved in potential fraudulent or abusive purchases of controlled  substances in five selected states. These Medicaid beneficiaries in the  five selected states acquired the same class of controlled substance from  six or more different medical practitioners during fiscal years 2006 and  2007. Such activities, known as doctor shopping, resulted in about   $63 million in Medicaid payments. According to the Drug Enforcement  Administration (DEA), doctor shopping generally refers to visits by an  individual to several doctors, each of whom writes a prescription for a  controlled substance. The individual will visit several pharmacies,  receiving more of the drug than intended by any single physician, typically  for the purpose of abuse. Based on the findings from the Medicaid  investigation, you expressed concern about whether similar doctor  shopping was taking place in the Medicare Part D program.
Medicare Part D provides voluntary, outpatient prescription drug coverage  for eligible individuals 65 years and older and eligible individuals with  disabilities. The Medicare Part D program, which began in January 2006,  is administered by the Department of Health and Human Services’ (HHS)  Centers for Medicare & Medicaid Services (CMS). CMS contracts with  private companies—such as health insurance companies and pharmacy  benefit managers—to serve as Medicare Part D prescription drug plans.  Over 27 million individuals were enrolled in Medicare Part D in 2010 and  benefit expenditures were about $53 billion. Because of Medicare’s  vulnerability to fraud, waste, and abuse, GAO has designated Medicare  as a high-risk program. We and HHS’s Inspector General have  previously reported that the size, nature, and complexity of the Medicare  Part D program make it particularly at risk for fraud, waste, and abuse.  You asked us to (1) determine the extent to which Medicare beneficiaries  obtained frequently abused drugs from multiple medical prescribers,   (2) identify examples of doctor shopping activity, and (3) determine the  actions taken by CMS to limit access to prescription drugs for known  abusers.
To determine the extent to which Medicare beneficiaries obtained  frequently abused drugs through the prescriptions of multiple medical  prescribers, we extracted the claims for the 14 selected classes of drugs  from the approximately 1 billion Medicare Part D paid claims for calendar  year 2008. From this subset of claims we determined the number of  beneficiaries who saw at least five different medical practitioners for the  same class of drugs. We selected the 14 classes of drugs, 12 of which  are controlled substances, and the five or more prescribers threshold  based on our review of drug diversion literature and prior GAO work and  discussions with a criminal investigator whose recognized expertise is in  drug diversion and with an official representing state prescription drug  monitoring programs. To determine the total number of different  prescribers from which a beneficiary received a prescription, we identified  and totaled the number of different prescribers shown in each  beneficiary’s claims data by each class of drug. Some duplication may  have occurred in our estimate of doctor shoppers because the Medicare  Part D prescription claims identify prescribers using either their own  identifier or a group practice identifier. However, our analysis showed that  the extent of claims with group level identifiers was insignificant.
To identify examples of doctor shopping activity, we selected  beneficiaries from those identified as seeing at least five different medical  practitioners for the same class of drugs from a nonrepresentative  selection of five states: California, Georgia, Maryland, Massachusetts,  and Texas. These states were selected based on geographical location  and to provide a mixture of states that did and did not have programs for  monitoring prescriptions for controlled substances. We further narrowed  the number of individuals for our investigation primarily based on data  showing a high number of prescriptions filled within the 14 classes of  drugs, a high number of different prescribers involved, and the overlap of  prescriptions. To further develop these examples, we identified  overlapping prescriptions for the same class of drug from different  prescribers, and interviewed selected employees from pharmacies and  medical practitioners to confirm that these individuals were doctor  shopping. Although our 10 case studies allowed us to identify issues  related to the doctor shopping of Medicare Part D drugs, circumstances of  each case are unique and cannot be generalized.
To determine the actions taken by CMS to limit access to prescription  drugs for known abusers, we obtained and reviewed agency documents,  including CMS regulations and program integrity requirements related to  Medicare Part D. We also interviewed policy officials from CMS, CMS’s  fraud contractor, and three Medicare Part D contractors. We selected the  Medicare Part D contractors based primarily on the number of  beneficiaries enrolled in their plans whom we identified as potential doctor  shoppers for these 14 classes of highly abusive drugs. These interviews  included a review of the various controls either in place or available for  use by prescription drug plans, along with their benefits and  implementation issues.
To determine the reliability of the Medicare claims data, we reviewed  related documentation and performed electronic testing to determine the  validity of specific data elements in the databases that we used to  perform our work. Based on the results of this work, we concluded that  the data elements used for this report were sufficiently reliable for our  purposes.
We conducted this forensic audit from May 2010 to May 2011 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives. We conducted our related  investigative work in accordance with standards prescribed by the Council  of the Inspectors General on Integrity and Efficiency.
subsections: section_title: Background
subsections: section_title: Medicare Part D Provides Prescription Drug Benefits
paragraphs: The Medicare Part D program, administered by CMS, provides a  voluntary, outpatient prescription drug benefit for eligible individuals 65  years and older and eligible individuals with disabilities. Beneficiaries may  pay for part of the drug benefit through monthly premiums, deductibles,  and co-pays. Low-income beneficiaries can receive substantial premium  and cost sharing assistance. CMS data indicate that about 19 percent of  the individuals who received Medicare Part D benefits in 2008 were  eligible because of their disabilities. CMS contracts with private  companies—such as health insurance companies and companies that  manage pharmacy benefits—to provide Part D prescription drug benefit  plans for Medicare beneficiaries. These companies are referred to as Part  D plan sponsors.
The Medicare Prescription Drug, Improvement, and Modernization Act of  2003 (MMA), which established the Part D program, requires all Part D  plan sponsors to have programs to safeguard Part D from fraud, waste,  and abuse. CMS regulations establish the requirements for  comprehensive compliance plans for Part D plan sponsors. To guide  Medicare Part D plan sponsors in designing a fraud and abuse program  that addressed Medicare Part D risks, in April 2006 CMS issued  recommendations for Medicare Part D plan sponsors’ fraud and abuse  programs based on input from various sources, including law  enforcement and industry representatives. The guidance, issued as  chapter 9 in the Prescription Drug Benefit Manual, contains further  interpretation and guidelines on the steps sponsors should take to detect,  correct, and prevent fraud, waste, and abuse in Part D. In the chapter 9  guidance, CMS identifies examples of potential fraud, waste, and abuse  by Medicare beneficiaries, such as beneficiaries engaging in doctor  shopping, where a patient seeks prescriptions from multiple physicians  with the intent to abuse or sell drugs, and directs the Part D plan  sponsors to report potential cases to the Medicare Drug Integrity  Contactor (MEDIC). The MEDIC contracts with CMS to support audit,  oversight, and antifraud and abuse efforts in Part D.
section_title: Controlled Substances Act Classifies Drugs Based on Their Potential for Abuse and Dependence
paragraphs: The Controlled Substances Act of 1970 (CSA) established a  classification structure for certain drugs and chemicals used in drug  manufacturing. Controlled substances are classified into five schedules  on the basis of their currently accepted medical use and potential for  abuse and dependence. Schedule I drugs—including heroin, marijuana,  and hallucinogens such as LSD—have a high potential for abuse, no  currently accepted medical use in treatment in the United States, and a  lack of accepted safety for use under medical supervision. Schedule II  drugs—including methylphenidate (Ritalin) and opiates such as  hydrocodone, morphine, and oxycodone—have a high potential for abuse  and may lead to severe physical or psychological dependence but have a  currently accepted medical use. Drugs on Schedules III through V have  medical uses and successively lower potentials for abuse and  dependence. Schedule III drugs include anabolic steroids, some  preparations of codeine, hydrocodone in combination with aspirin or  acetaminophen, and some barbiturates. Schedule IV contains such drugs  as the antianxiety medications diazepam (Valium) and alprazolam  (Xanax). Schedule V includes preparations such as cough syrups with  codeine. All drugs but those in Schedule I are legally available to the  public with a prescription.
CSA mandates that DEA establish a closed system of control for  manufacturing, distribution, and dispensing of controlled substances.  Specifically, any person who manufactures, dispenses, imports, exports,  or conducts research with controlled substances must register with DEA  (unless exempt), keep track of all stocks of controlled substances, and  maintain records to account for all controlled substances received,  distributed, or otherwise disposed of. Although all registrants, including  pharmacies, are required to maintain records of controlled substance  transactions, only manufacturers, distributors, and pharmacies authorized  to dispense controlled substances by means of the Internet are required  to report certain controlled substance transactions, including sales to  the retail level, to DEA. The data provided to DEA are available for use in  investigations of illegal diversions at the manufacturer and distributor  levels. The act does not require pharmacies to report information on  dispensing to the patient level to DEA.
section_title: Prescription Drug Monitoring Programs Have Been Implemented by Most States
paragraphs: Most states have implemented prescription drug monitoring programs  (PDMP). These programs can help prevent and detect the diversion and  abuse of pharmaceutical controlled substances, particularly at the retail  level. States that have implemented PDMPs have the capability to collect  and analyze data on filled and paid prescriptions, including those from the  Medicare Part D program, more efficiently than those without such  programs, where the collection of prescription information can require a  time-consuming manual review of pharmacy files. If used properly,  PDMPs can detect diversion of the drugs by health care prescribers,  pharmacies, and patients. We have reported that states with PDMPs  have realized benefits in their efforts to reduce drug diversion.
Figure 1 shows that a total of 34 states had operational PDMPs as of  February 2011. These states vary in the extent to which schedules of  controlled substances are monitored. Some states also monitor certain  noncontrolled substances. According to the Department of Justice (DOJ),  in states that have implemented PDMPs, doctor shopping has decreased.  However, since determined doctor shoppers can travel to nearby states to  bypass a PDMP, DOJ has also reported an increased need for  information sharing between neighboring states to facilitate the interstate  exchange of PDMP data.
section_title: Some Medicare Beneficiaries Received Prescriptions from Five or More Medical Practitioners to Obtain the Same Class of Frequently Abused Drugs
paragraphs: Our analysis of Medicare Part D claims found that 170,000 Medicare  beneficiaries received prescriptions from five or more medical  practitioners for the 12 classes of frequently abused controlled  substances and 2 classes of frequently abused noncontrolled substances  in calendar year 2008. This represented about 1.8 percent of the  Medicare Part D beneficiaries who received prescriptions for these 14  classes of drugs during the same calendar year. These individuals  incurred approximately $148 million in prescription drug costs for these  drugs, much of which is paid by the Medicare program. Our analysis  also found the following:    Most of these 170,000 Medicare beneficiaries who were prescribed  prescriptions from five or more practitioners were eligible for Medicare  Part D benefits based on a disability. Specifically, approximately  120,000 Medicare beneficiaries (about 71 percent) were eligible for  Medicare Part D benefits based on a disability.    Of these 170,000 beneficiaries, approximately 122,000 beneficiaries  (72 percent) received a Medicare Low-Income Cost-Sharing (LICS)  subsidy.    Of the 14 classes of frequently abused drugs analyzed, hydrocodone  and oxycodone were the most prevalent. These drugs represented  over 80 percent of the instances of potential doctor shopping we  identified.
In some cases, beneficiaries may have a justifiable reason for receiving  prescriptions from multiple medical practitioners, such as visiting  specialists or several prescribers in the same medical group. However,  our analysis of Medicare Part D claims found that about 600 Medicare  beneficiaries received prescriptions from 21 to 87 medical practitioners in  the same year. In these situations, there is heightened concern that these  Medicare beneficiaries may be seeking several medical practitioners to  support and disguise an addiction. According to DEA, drug abusers use  diversion techniques such as doctor shopping to acquire controlled  prescription drugs. Further, DEA has also stated that diverted controlled  prescription drugs have been added to the supplies of some illicit drug  distributors. For example, according to DOJ, in 2008 hydrocodone  tablets and oxycodone tablets were illicitly sold in California, one of the  five states we selected for more detailed case investigations, for $5 and  $80 per tablet, respectively.
Our analysis of Medicare Part D claims did not focus on all prescription  drugs, but instead targeted 12 classes of frequently abused controlled  substances and 2 classes of frequently abused noncontrolled substances,  as shown in table 1. Our analysis does have certain limitations based on  the data. Specifically, the data submitted to CMS did not identify the  prescriber for many Part D claims because of blank or invalid prescriber  identification values. At least 5.8 percent of the prescription claims for  these 14 categories of drugs contained blank or invalid prescriber  identification values. These claims were not included in our analysis.  Therefore, we potentially understated the total number of unique  prescribers for each beneficiary who received a prescription for all the  claims paid.
Table 2 shows the breakout by drug class for the approximately 170,000  Medicare Part D beneficiaries who were prescribed the same class of  drug by five or more medical practitioners. Because Medicare Part D  beneficiaries may be receiving multiple classes of prescription drugs from  five or more medical practitioners, certain beneficiaries may be counted in  more than one prescription drug class. As shown in table 2, hydrocodone  and oxycodone were the two prescription drug classes that were most  prescribed by multiple medical practitioners. Specifically, about 97,000  beneficiaries were prescribed hydrocodone by five or more medical  practitioners. In addition, our analysis found that about 57,000 Medicare  Part D beneficiaries received oxycodone drugs prescribed by five or more  practitioners. According to DOJ, doctor shopping is the primary method to  obtain highly addictive prescription opioids (e.g., hydrocodone and  oxycodone) for illegitimate use.
section_title: Examples of Doctor Shopping in Medicare Part D
paragraphs: We obtained additional information on 10 of the Medicare Part D  beneficiaries that showed indications of doctor shopping. In each of the  10 cases, we found evidence that the beneficiary was acquiring highly  abused drugs through doctor shopping. We also found that in each  example physicians were not aware that their patients were receiving  drugs prescribed by other prescribers. DEA’s definition of doctor shopping  specifies an individual receiving more of a drug than intended by any  single physician. In several examples physicians stated that they would  not have prescribed the drugs if they were aware that the patient was  receiving the same class of drugs from other sources. Table 3  summarizes the 10 examples of doctor shopping for prescription drugs,  including controlled substances, in the Medicare Part D program. The  total prescription cost of the drugs discussed in table 3 was about  $86,000 of which $2,200 was paid directly by the beneficiaries in co- payments or deductibles. We are referring these beneficiaries to the  Medicare Part D fraud contractor, as appropriate, for further  investigation.
section_title: Systems Are in Place to Identify Inappropriate Drug Use, but Measures to Stop the Activity Are Limited
paragraphs: CMS, through its Part D plan sponsors, does not limit access to  hydrocodone, oxycodone, and other highly abused drugs for beneficiaries  who are known doctor shoppers. Although systems are in place to identify  individuals with doctor shopping behavior, according to CMS Part D  program officials, federal law does not authorize Part D plans to restrict  the access of these individuals. CMS requires Part D plans to perform  retrospective drug utilization review (DUR) analysis to identify prior  inappropriate or unnecessary medication use. By analyzing historical  prescription claims data, the drug plans can identify individuals who are  likely obtaining excessive amounts of highly abused drugs or potentially  seeking such drugs from multiple medical practitioners. However, unless  restrictions are placed on these individuals, the current system will not  prevent these known abusers from continuing these practices.
If a beneficiary is found to be inappropriately obtaining abused drugs,  CMS guidance states that Part D plan sponsors would provide  practitioner and beneficiary education as appropriate. For instance, if a  potential doctor shopper is identified, intervention letters would be sent to  all prescribers who ordered the drug type for that individual. An  intervention might consist of an informational letter to the medical  practitioner; a response form for the medical practitioner to complete,  along with a preaddressed return envelope; and a patient drug profile.  However, the effectiveness of such a notification may be limited because  the physicians can overlook the intervention letters, or if a request for a  prescription is denied by one physician, the beneficiary can go to another  physician for the desired prescription.
Although not currently used in the Medicare Part D program, officials from  the Part D plan sponsors we interviewed stated that additional controls  already in place in the Medicaid program and in some private sector plans  could be used to better restrict the dispensing of abused drugs, such as  hydrocodone and oxycodone, to individuals identified as doctor shoppers  through detecting a pattern of abuse during retrospective analysis. Such  programs employ a restricted recipient program, where prescription drug  plans restrict beneficiaries who have been identified as drug abusers to  one prescriber, one pharmacy, or both for receiving prescriptions.  However, according to CMS policy officials, the restricted recipient  program cannot be utilized in the Medicare Part D program because MMA  did not authorize CMS to establish such restrictions on beneficiaries. As  such, Part D plan sponsors are prevented from implementing these  controls on specific individuals to prevent doctor shopping. There are  issues to consider with a restricted recipient program, such as potentially  denying legitimate drug needs and unknown costs for administration.
These costs include developing and implementing criteria and procedures  for placing individuals in the program, allowing them to change providers  as appropriate, and ultimately releasing them from the program.
Effective retrospective DURs require prescription drug plans to be able to  share information about individuals identified as doctor shoppers with  other Part D plans, as appropriate. Even if a restricted recipient program  were implemented, according to CMS officials, Medicare Part D plan  sponsors are not allowed to share beneficiary information with other  plans. As a result, a Medicare Part D plan sponsor cannot forewarn  another Medicare Part D plan sponsor when an identified doctor shopper  has left its plan and enrolled in another. Because Medicare Part D  beneficiaries can change prescription drug plans on at least a yearly  basis, beneficiaries may be able to switch plans and continue their  doctor shopping activity. Thus, to prevent known doctor shoppers from  circumventing a restricted recipient program, a mechanism would also  need to be established that allows CMS or its fraud contractor to inform  the new plan of the doctor shopping activities of the beneficiary. Without  such notification, beneficiaries will be able to bypass a restricted recipient  program merely by switching prescription drug plans.
section_title: Conclusion
paragraphs: Prescription drug abuse is a national problem and appears to exist in the  Medicare Part D program. In addition to the costs to society of addiction,  overdose, death, and related criminal activities, taxpayers and Medicare  beneficiaries bear the additional costs for excessive prescriptions  obtained to supply an addiction or for diversion to illicit drug distributors.  Protecting patient health and combating the illegal diversion or abusive  usage of prescription drugs, while ensuring that the pharmaceuticals  remain available for those with legitimate medical needs, involves the  efforts of both the prescription drug plans and the federal government.
Although systems are in place to identify inappropriate drug use,  measures to stop the activity are limited. The restricted recipient program  is one tool that could be used to prevent doctor shopping in the Medicare  Part D program. If such a tool were implemented for Medicare Part D,  CMS would also need a mechanism to share information about restricted  recipients between plans. This would allow a new plan to be informed  about the beneficiary’s prescription use and to take appropriate action. In  considering a restricted recipient program, CMS could utilize the  experience of Medicaid and private sector programs to facilitate  implementation issues and address the costs and benefits of such a  program. CMS could also consider piloting a restricted recipient program  focusing on hydrocodone and oxycodone, the two drug classes where we  identified the largest potential doctor shopping activity. Increased controls  over dispensing highly abusive drugs can help reduce the risk that  individuals will use Medicare to facilitate their dangerous drug activities,  which increases the cost of the program and jeopardizes patient care. As  part of any evaluation, additional controls, such as the restricted recipient  program, may require additional legal review and based on that review  may require congressional authority to implement.
section_title: Recommendation for Executive Action
paragraphs: To improve efforts to address doctor shopping by beneficiaries of highly  abused prescription drugs, we recommend that the Administrator of CMS  review our findings, evaluate the existing DUR program, and consider  additional steps such as a restricted recipient program for Medicare Part  D that would limit these beneficiaries to one prescriber, one pharmacy, or  both for receiving prescriptions. CMS should consider the experiences  from Medicaid and private sector use of such restricted recipient  programs, including weighing the potential costs and benefits of instituting  the control. CMS could consider piloting such a program with a focus on  hydrocodone and oxycodone, the two drug classes where we identified  the largest potential doctor shopping activity. Along with a restricted  recipient program, CMS should also consider facilitating the sharing of  information on identified doctor shoppers among the Part D drug plan  sponsors so that those beneficiaries cannot circumvent the program by  switching prescription drug plans. In considering such controls, CMS  should seek congressional authority as appropriate.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to CMS and DOJ for comment. DOJ  stated that it did not have comments on the report. CMS’s comments are  reprinted in appendix I, and its technical comments were incorporated in  the report as appropriate.
CMS agreed with our overall recommendation to improve efforts to curb  overutilization in Part D, but disagreed that a restricted recipient program  is necessarily the appropriate control for the Part D program. CMS stated  that GAO provided no evidence that a restricted recipient program would  be more effective than existing DUR requirements. CMS also requested  the data from the report to consider whether these data indicate a failure  of Part D plan sponsors to effectively implement concurrent or point-of- sale DURs or whether there are additional approaches to supplement  DURs while not jeopardizing patient access to care. It also stated that  CMS officials are undertaking additional evaluation of MEDIC data on  potential overutilization to identify potential solutions and that they will  issue program guidance to Part D sponsors on any best practices and  develop an internal monitoring strategy.
We appreciate that CMS agrees with us that more efforts could be  undertaken to curb overutilization in the Part D program, and we  recognize its challenge in balancing the need to combat fraud, waste, and  abuse with the program’s goal of providing beneficiaries sufficient access  to medically necessary prescription drugs. To reflect the issues raised by  CMS, we revised our recommendation to include other actions that may  be taken by CMS to address overutilization of prescription drugs. CMS  guidance states that Part D plans must perform retrospective DUR  analysis to identify inappropriate prescriptions and provide education,  such as alert letters, to the prescribers involved. However, our case study  examples showed that the receipt of such letters by prior prescribers did  not prevent inappropriate prescriptions from being obtained from other  prescribers. We support CMS looking into both enhanced point-of-sale  and retrospective controls and related actions to address overutilization  and questionable access to specific drugs.
CMS said that GAO provided no evidence that a restricted recipient  program would be more effective than existing DUR requirements.  However, our intent is not to prescribe a restricted recipient program as  the only solution, but instead for CMS to consider utilizing it along with  existing controls. The Part D plan sponsor officials we interviewed stated  that a restricted recipient program, already in place in Medicaid and the  private sector, could better restrict the dispensing of abused drugs. A  restricted recipient program is an additional control that can be used for  known abusers identified by retrospective DUR while not jeopardizing  legitimate patient access to care. Thus, a restricted recipient program  warrants further consideration by CMS.
We used CMS’s own prescription drug paid claims data for our analysis.  We are referring the examples in table 1 to the MEDIC as appropriate.  We are also referring to the MEDIC the identities of other more egregious  potential cases we identified through our analysis. According to CMS paid  claims data, these individuals visited 40 or more prescribers in 2008 for a  single class of drug and had overlapping prescriptions for the same drug  class from different prescribers.
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section_title: Appendix I: Comments from the Centers for Medicare & Medicaid Services
section_title: Appendix II: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, the following individuals made  major contributions to this report: Erika Axelson, Assistant Director;  Matthew Harris, Assistant Director; Matthew Valenta, Assistant Director;  John Ahern; Gary Bianchi; Scott Clayton; Eric Eskew; Maria Kabiling;  James Murphy; Jonathon Oldmixon; Philip Reiff; Barry Shillito; and April  Van Cleef.