Shaheen, Capito Call on Medicare to Address Policy that Favors Opioid-Based Drugs over Non-Opioid Alternatives

October 15, 2019

Bipartisan Letter Calls on Medicare to Ensure Payment Policies Don’t Incentivize Opioid-Based Pain Management Treatments Over Non-Opioid Alternatives

(Washington, DC) – U.S. Senators Jeanne Shaheen (D-NH) and Shelley Moore Capito (R-WV) sent a bipartisan letter last week urging Health and Human Services (HHS) Secretary Alex Azar and Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma to address Medicare’s payment policies to ensure that health care providers are not incentivized to use opioid-based pain management treatments over non-opioid alternatives. 

Under Medicare’s current reimbursement policy, the cost disparity between opioid-based pain medication and non-opioid drugs used to treat post-surgical pain creates a disincentive for providers to use the less addictive, non-opioid alternative. This issue is a significant concern in states including New Hampshire and West Virginia, which are on the frontlines of the substance misuse epidemic. In most cases, the Medicare program pays the same amount for outpatient surgeries, regardless of whether an opioid or a non-opioid alternative is used to treat post-surgical pain. In these instances, non-opioid drugs and devices used to treat pain after surgery are not separately reimbursed, which can create incentives for health care providers to prescribe low-cost but highly addictive opioids to treat the pain in order to keep the facility’s expenses for the procedure below the Medicare payment amount. 

In their letter, the Senators noted that under the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, CMS is required to review payments under Medicare’s Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System to ensure that there are not financial incentives to use opioids instead of non-opioid alternatives pain management.

“As our communities in New Hampshire and West Virginia work to turn the tide of the substance misuse epidemic, it’s critical that we tackle this crisis on all fronts. Prevention is a key role in our effort, which is why non-opioid alternatives are so important,” said Senator Shaheen. “If Medicare’s reimbursement system is fostering disincentives that discourage health care providers from using non-opioid alternatives then this policy must be reformed immediately to follow the law and to prevent more Americans from succumbing to this epidemic.”

“Addressing the opioid epidemic requires a multifaceted approach,” Senator Capito said. “A critical part of this is ensuring that the Medicare program does not create a perverse incentive for doctors to continue to prescribe opioids to patients. Instead, we should incentivize providers to utilize innovative non-opioid drugs and devices. In doing so, we can ultimately save much-needed dollars for our health care system while also addressing this issue.”

The Senators highlighted the dangers that the status quo poses to surgical patients, writing, “Without changes to current payment policy, health care providers may face financial disincentives that could undermine their ability to use non-opioid pain management treatments. In such cases, we are concerned that providers would continue to rely on addictive opioid pain medications, which expose patients to the risk of developing opioid use disorder.”

The Senators concluded, “We respectfully request that CMS provide details on its statutorily required review process, including the agency’s rationale and supporting data for its decision regarding each individual product that it evaluated. We urge CMS to examine the evidence to ensure that reimbursement policies are working in the best interests of patients. Thank you for your attention to this important issue.”

The letter can be read in full here.

Senator Shaheen has spearheaded the fight against the substance use disorder epidemic in the Senate. Shaheen helped negotiate the bipartisan agreement in 2018 that outlined the two years of opioid response spending – totaling $6 billion to respond to the opioid crisis. This included the set-aside funding for states with the highest mortality rates, like New Hampshire. This critical additional funding, which the Senator helped broker, has been included by Congress over the last two fiscal years. As a result of her efforts, New Hampshire received a more than ten-fold increase in opioid treatment funding through the State Opioid Response (SOR) grant program. Shaheen has also recently unveiled sweeping new substance use disorder legislation, the Turn the Tide Act, to help tackle the substance use epidemic and provide resources for Granite Staters struggling with substance misuse. The Turn the Tide Act provides $63 billion in funding over ten years to deliver flexible treatment funding to providers, establish proven prevention programs and address the substantial workforce challenges in the treatment field. The Turn the Tide Act also includes provisions to create two different Medicare payment rates for surgeries, which would vary depending on whether a non-opioid alternative is used, so that any Medicare payment disincentives are removed for the equation.