How States Try to Prevent Prescription Drug Abuse Among Medicaid Patients

Patient review and registration program increases oversight of opioid prescription trends.

Prescription drug abuse is a growing problem in the United States that is oftentimes not talked about or even known about until it is too late to help someone. With growing rates of drug overdoses, private and public insurance companies are trying to prevent this problem from becoming even more widespread through a practice called patient review and registration (PRR), according to a recent study by The Pew Charitable Trusts.

Insurers believe that PRRs could potentially save the lives of patients. A PRR is when insurers believe a patient to be at-risk for drug abuse, they will assign them to predetermined physicians and pharmacies. According to the study, 49 states currently operate PRRs, some even dating back to the 1970s.

Because everything is predetermined, the insurance companies will be able to ensure that at-risk patients will not be able to access any prescription drugs unless they are prescribed by a trusted physician. Additionally, patients will not be able to obtain fraudulent prescriptions or inappropriate access to these drugs.

With PRRs, there will be no guess work or having to wonder if a patient truly needs the medication they are taking.

A majority of states use at least 5 criteria. The 3 most common criteriaare: using a certain number of pharmacies to obtain prescription drugs within a predetermined period of time, using a certain number of prescribers to obtain prescription drugs within a predetermined period of time, and obtaining and/or filling a certain number of controlled substance prescriptions within a predetermined period of time. There are some states that use up to 7 criteria.

Any person who meets their state’s criteria for an at-risk patient, must have their past claims and prescriptions evaluated. Most states have nurse practitioners or pharmacists review these claims to ensure that there was no abuse.

If these medical professionals deem the at-risk patient’s use was appropriate, they will not be placed in a PRR program.

An identified at-risk patient has the right to appeal the decision. If they do not, most states will allow the patients to choose from a list of approved physicians, pharmacies, and hospitals.

Most programs have a certain time frame in which a person can be enrolled. Once the patient has been enrolled for their specified amount of time, their case will be reviewed for re-enrollment in the PRR.

While there is certainly a great need for this program, it is not without faults. A large gap that needs to be examined more closely is the use of cash to pay for prescriptions.

Forty-one percent of states who responded to this study say that this is its biggest downfall. Because the physician or pharmacy does not submit a claim for reimbursement, the state’s Medicaid department cannot know what kind of care or drug the patient received.

There is a system called prescription drug monitoring programs which allows some states to see cash transactions. However, most states cannot access this.

It is clear that for these programs to achieve their full potential, it should be able to monitor all transactions, even cash, the study concluded. This improvement will allow patients to receive proper care and there to be no question about their intent with any physician’s appointment or filled prescription.