Policy and Industry Experts Push for Coordinated Solutions to Reduce Prescription Drug Fraud, Waste and Abuse

December 08, 2011
  • Fraud, Waste and Abuse Cost the U.S. Health Care System Billions of Dollars Annually

A multidisciplinary roundtable discussion convened on Capitol Hill today to explore ways to fight the growing issue of prescription drug fraud, waste and abuse. While estimates vary on the scope of the problem, experts agree that the cost to the U.S. health care system is substantial, amounting to billions of dollars lost annually on fraud alone, putting an added strain on the country’s limited health care resources.

The roundtable, moderated by Julian Pecquet, lead author of The Hill’s Healthwatch blog, featured commentary and discussion among an expert panel representing policymakers, law enforcement, prescription drug payers and addiction specialists.

Roundtable panelists included Louis Saccoccio, executive director, National Health Care Anti-Fraud Association (NHCAA); John Spiegel, Director, Medicare Program Integrity Group, Centers for Medicare and Medicaid; Joshua Stein, senior vice president and principal counsel, OptumRx, and a former federal prosecutor with the U.S. Attorney’s Office in Colorado; Michael C. Theis, partner, Hogan Lovells (Denver, Colo.) and former criminal health care fraud coordinator for the District of Colorado; and David Shurtleff, Ph.D., acting deputy director, National Institute on Drug Abuse.

U.S. Representative Hal Rogers (R-KY), Chairman of the House Appropriations Committee and Co-Chair of the Congressional Caucus on Prescription Drug Abuse, gave opening remarks.

Prescription drug fraud, waste and abuse have serious consequences for the nation’s health and health care system. Improper payments for prescription drugs and other services in the Medicare and Medicaid programs totaled $54 billion in 2009.1 Additionally, it is estimated that about 200 million pounds of prescription drugs dispensed outside of hospitals are wasted, or go unused, annually,2 raising the risk that these drugs will be shared or sold illegally. According to the Centers for Disease Control, 12 million Americans said they were using opioid pain relievers without a prescription in 2010, and prescription narcotics now kill more people than heroin and cocaine combined.

During the discussion, participants explored practical solutions for how government and private industry could work together in new ways – including using sophisticated technologies – to stem the abuse of prescription drugs and prevent further misuse of our nation’s health care resources. Consensus emerged from the diverse group of panelists around the need for increased access to and sharing of data among public and private stakeholders to simultaneously reduce fraud, waste and abuse and ensure better health outcomes for patients.

“We’ve already seen how cost-effective, technology-based programs like Kentucky’s well-regarded prescription drug monitoring program can help states combat fraud and reduce the abuse and diversion of powerful pain drugs,” said Rep. Rogers. “As we work to get our country’s fiscal house in order, the collaboration of states, the federal government, law enforcement and the private sector in using technology to fight prescription drug fraud is a win-win: we can reduce costs in our overburdened health care system while simultaneously protecting the lives of Americans suffering the consequences of an epidemic touching every corner of our nation.”

Other solutions discussed included restricting high utilizers of narcotics to a particular pharmacy; the use of real-time auditing to prevent fraudulent or wasteful prescriptions from being filled; the need for additional training and education for physicians and consumers; and partnerships between industry and law enforcement to uncover fraudulent or abusive pharmacies and prescribers.

“Pharmacy benefit managers can – and do – play an important role fighting prescription drug fraud, waste and abuse by creating their own programs and tools that can quickly identify irregularities and potential issues,” said Joshua Stein of OptumRx. “By working with law enforcement, we are able to help ensure that the dollars allocated by the federal government and employers are actually used to help Americans live healthier lives.”

The roundtable was sponsored by OptumRx, a leading pharmacy benefits management organization and an Optum company.

About OptumRx
OptumRx is an innovative pharmacy benefit management organization managing the prescription drug benefits of commercial, Medicare and other governmental health plans, as well as those of employers and unions through a national network of 64,000 community pharmacies and state-of-the-art mail service pharmacies in California and Kansas, both of which have earned the prestigious Verified Internet Pharmacy Practice Sites™ (VIPPS®) accreditation by the National Association of Boards of Pharmacy®. Visit www.optum.com for more information.

About Optum
Optum is a leading information and technology-enabled health services business dedicated to making the health system work better for everyone. Optum comprises three companies – OptumHealth, OptumInsight and OptumRx – representing over 30,000 employees worldwide who collaborate to deliver integrated, intelligent solutions that work to modernize the health system, improve overall population health and build Sustainable Health Communities. Visit www.optum.com for more information.

1White House Office of Management and Budget, 2010
2National Community Pharmacists Association, 2010 


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