Purpose

To determine if the Department of Health has taken sufficient steps to safeguard Medicaid recipients who are receiving opioids while also in a Treatment Program for opioid use disorder. This audit covered the period October 1, 2013 through September 30, 2017.

Background

The United States currently faces an opioid misuse epidemic, which began in the 1990s with the over-prescribing of opioid drugs for pain-related conditions. Opioid treatment programs (Treatment Programs) provide medication-assisted treatment, which includes certain opioid medications, coupled with counseling and behavioral therapies for people diagnosed with an opioid use disorder. New York State maintains a database to monitor prescription drug use, known as the Internet System for Tracking Over-Prescribing (I-STOP), which contains records of controlled substance prescriptions. I-STOP is a tool to assist prescribers in determining the most appropriate prescription(s) for an individual. To maximize safety of patient care, Treatment Programs should check I-STOP and, with a patient’s consent (as required by federal law), seek coordination of care with the patient’s other opioid prescriber(s). Per federal and State laws, opioid medications dispensed by Treatment Programs are not included in I-STOP for review by other practitioners. At the time of our audit, federal lawmakers were considering a series of bills aimed at addressing the opioid crisis, including a bill to modify federal law to allow Treatment Programs to contact other providers to coordinate patient care even without patient consent, and to remove the federal confidentiality restrictions that prevent Treatment Program opioid medications from being included in I-STOP. Although those modifications were not included in the opioids package recently passed by the U.S. Senate and the U.S. House of Representatives, the debate over the sharing of substance use disorder treatment information among different health care providers is expected to continue.

Key Findings

• During our audit period, 33 percent of Medicaid recipients in Treatment Programs also received prescription opioids outside of their Treatment Programs. Recipients may have received inappropriate, unnecessary, and/or dangerous opioid prescriptions if Treatment Programs did not check I-STOP and, where authorized, coordinate care with other prescribers to ensure the controlled substances prescribed to their patients were medically warranted.
• We identified 18,786 Medicaid recipients who received 208,198 opioid prescriptions through the Medicaid program while also in a Treatment Program for opioid use disorder. Of those recipients, 493 needed medical care as a result of 691 opioid or narcotic overdoses that occurred within a month of receiving a prescription opioid. Twelve of those individuals died during the time of their medical care involving the overdose.
• We reviewed medical records for a sample of 25 recipients who received 1,065 opioid prescriptions while in a Treatment Program for their opioid use disorder.
  • We determined Treatment Programs were not consistently checking I-STOP. We found that I-STOP was checked a total of 18 times for the 25 recipients. Further, we did not find that I-STOP was checked prior to every instance that a medication-assisted opioid was dispensed for take-home use, as required by State law.
  • We found that 13 of the 25 recipients were asked at least once during treatment to sign a consent form to coordinate care with the recipient’s opioid prescriber. However, 3 of the 13 recipients declined to sign a consent form. We found care coordination with regard to opioid prescriptions occurred for 59 of the 1,065 prescriptions (6 percent).

Key Recommendations

• Take steps to ensure Treatment Programs appropriately check I-STOP.
• Evaluate steps to improve scrutiny over opioid prescriptions for Medicaid recipients who are being treated for opioid use disorder, including determining whether managed care controls over opioid prescriptions for these recipients should be consistent with fee-for-service controls.

Other Related Audits/Reports of Interest

Department of Health: Medicaid Managed Care Premiums for Recipients With Comprehensive Third-Party Insurance (2016-S-60)
Department of Health: Maximizing Medicaid Drug Rebates for Health and Recovery Plans (2017-S-61)