IHA Daily Briefing: Aug. 8

Thursday, August 8, 2019
CMS Announces New Medicaid DUR Program Standards
IL AG: Remove Federal Opioid Treatment Barriers
CDC: Naloxone Prescriptions Lag in Rural Areas
Briefly Noted

CMS Announces New Medicaid DUR Program Standards
On Monday, the Centers for Medicare & Medicaid Services (CMS) released new prescription opioid guidance to states by updating standard requirements for the Medicaid Drug Utilization Review (DUR) program.  The Medicaid DUR program is a two-phase process that screens drug claims to help identify clinical misuse or abuse and examines claims data to identify patterns of abuse.

CMS says the guidance will help states implement drug use review procedures newly required under the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (the SUPPORT Act), so state Medicaid programs can better monitor opioid prescribing and dispensing patterns, including new requirements for states to implement electronic notifications, also known as safety edits. These notifications alert healthcare professionals, such as pharmacists, of potential concerns with a medication prescribed for the patient that has to be resolved before it can be dispensed and safely taken by the patient.

Implementation of new Medicaid DUR standards carries out another part of the SUPPORT for Patients and Communities Act that will boost oversight of prescribing and dispensing opioids in state Medicaid programs. These reviews target:

  • Requirements for refilling opioid prescriptions;
  • Prescription monitoring for opioids and other drugs when prescribed at the same time, such as benzodiazepines;
  • Antipsychotic prescription monitoring for children; and
  • Fraud and abuse detection.

While many states already have safety edits and other procedures in place to monitor the use of opioids, CMS says that the guidance assists states in implementing the SUPPORT for Patients and Communities Act requirement that state Medicaid programs apply opioid-specific safety edits. All states will be required to send alerts to pharmacists to identify Medicaid beneficiaries who may be refilling an opioid prescription too soon and may be in need of better pain management assistance.  

Last week, CMS issued two informational bulletins: Caring Recovery for Infants and Babies and Help for Moms and Babies. These bulletins provide information on certain provisions of the SUPPORT Act that give new coverage options to state Medicaid programs to assist some of the most vulnerable beneficiaries – babies, pregnant women, and mothers – with substance use disorder, including opioid use disorder.

Last year, IHA, in collaboration with the Illinois College of Emergency Physicians, developed and released Opioid Prescribing Guidelines for treating patients with acute and chronic pain in the emergency department and immediate care centers.


IL AG: Remove Federal Opioid Treatment Barriers
Illinois Attorney General (AG) Kwame Raoul joined a coalition of 35 attorneys general on Monday, urging U.S. Senate and House of Representatives leadership to remove federal barriers that are currently preventing healthcare providers from offering treatment for opioid use disorder.

In the letter, Raoul and the coalition asked members of Congress to take three steps to help remedy the opioid crisis by removing barriers to treatment, including:

  • Replacing cumbersome, out-of-date, privacy rules with the effective and more familiar privacy rules contained in the Health Insurance Portability and Accountability Act (HIPAA).
  • Passing HR 2482, the Mainstreaming Addiction Treatment Act, to eliminate burdens on prescribing buprenorphine – one of three drugs used as part of medication-assisted treatment, the most effective treatment for opioid use disorder. Outdated and unnecessary federal requirements imposed by the Drug Addiction Treatment Act are discouraging doctors from prescribing this life-saving drug to patients who need it.
  • Fully repealing the Medicaid Institutions for Mental Diseases (IMD) exclusion. The IMD exclusion prohibits state Medicaid programs from receiving federal reimbursement for the cost of treatment for adults between the ages of 21 and 65 receiving mental health or substance use disorder treatment in a residential treatment facility with more than 16 beds and where more than half of the patients are receiving such treatment.

In August 2018, the Centers for Medicare & Medicaid Services approved Illinois’ 1115 Waiver, permitting federal matching dollars for residential and inpatient psychiatric hospital treatment for individuals with substance use disorders. This five-year pilot does not create new hospital reimbursement or extended length of stay; instead it is intended as a funding mechanism for the state to receive the federal match dollars. An October 2018 Provider Notice details the Illinois Dept. of Healthcare and Family Services’ intention to move forward with the pilot.


CDC: Naloxone Prescriptions Lag in Rural Areas
The Centers for Disease Control and Prevention (CDC) is reporting in its latest issue of Vital Signs that the overdose-reversing drug naloxone is not being dispensed in many areas of the country that need it the most. In 2018, rural counties had the lowest dispensing rate—1.5 naloxone prescriptions per 100 high-dose opioid prescriptions—and half of those required a prescription copay. Nationwide, the average dispensing rate was one naloxone prescription per 70 high-dose opioid prescriptions. The number of naloxone prescriptions dispensed doubled from 2017 to 2018.

From 2012 to 2018, the estimated annual rate of naloxone dispensed from retail pharmacies in the Midwest states, including Illinois, jumped from 0.5 to 139.9 per 100,000 persons, on average. For a visualization of naloxone prescriptions by county, click here.


Briefly Noted
Yesterday, IHA made available to its member hospital CEOs, CFOs, and other finance staff, via the IHA C-Suite, preliminary federal fiscal year 2021 wage index and occupational mix survey reports. Members are asked to review their reports and submit any corrections with the corresponding support documentation to their Medicare Administrator Contractor no later than Tues., Sept. 3, 2019.