Government Accountability Office Investigates Doctor Shopping

Oct 20, 2011

At the request of the US Senate Subcommittee on Federal Financial Management, Government Information, Federal Services, and International Security, the Government Accountability Office (GAO) conducted an investigation into doctor shopping in Medicare Part D. Doctor shopping is the practice in which individuals solicit prescriptions for drugs of abuse from multiple doctors and fill them at multiple pharmacies. The report is a follow-up to a 2009 report on doctor shopping within the Medicaid program, in which GAO found that doctor shopping resulted in costs of $63 million to the Medicaid program. Because of its size and complexity, Medicare Part D is vulnerable to fraud and abuse. GAO was asked to determine the extent to which Medicare beneficiaries obtained frequently abused drugs from multiple prescribers, identify examples of doctor shopping activity, and determine the actions taken by the Centers for Medicare and Medicaid Services (CMS) to limit access to drugs for known abusers.

GAO looked at claims for 14 commonly abused classes of drugs from the approximately 1 billion Medicare Part D paid claims for the 2008 calendar year. From this subset of claims they determined the number of beneficiaries who saw at least five different doctors for the same class of drugs. They found that 170,000 individuals, or around 1.8% of Medicare Part D beneficiaries that received prescriptions for those classes of drugs saw at least five different doctors. GAO estimates the cost of this activity to be about $148 million (about 5% of the total cost for these drugs).

In its analysis, GAO found that most of the Medicare beneficiaries that obtained drugs from five or more doctors were eligible for Medicare Part D because of a disability. They also found that, of the 14 classes of drug examined, oxycodone and hydrocodone were by far the most frequently obtained drugs, making up 80% of the instances of potential doctor shopping. The report also contains specific examples of individuals engaging in doctor shopping; for instance, over the course of a year, one beneficiary received prescriptions for a total of 3,655 oxycodone pills from 58 practicioners, and filled prescriptions at 45 pharmacies.

According to the report, 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. To curb the practice, GAO recommended a restricted recipient program, a practice already in place within Medicaid and some private sector plans. Under such a program, suspected doctor shoppers would be limited to one prescriber, one pharmacy, or both for receiving prescriptions. GAO also recommended that CMS 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.

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