The Department of Health and Human Services (HHS) Office of the Inspector General (OIG) recently posted its findings following a review of opioid prescribing in Medicaid using the Transformed Medicaid Statistical Information System (T-MSIS). While the OIG noted that the data reviewed is critical for nationally quantifying the opioid crisis’s impact on Medicaid and for monitoring the crisis, a national review is not possible at this time due to gaps and inconsistencies in the data that individual states submit through T-MSIS.
The review follows the August 2018 announcement by the Centers for Medicare & Medicaid Services (CMS) that all states would be submitting T-MSIS data and that CMS would have research-ready files available in 2019. Since then, CMS has been working with states to improve the quality of their data submissions. Most recently, in May 2019, CMS added three of the variables OIG reviewed—diagnosis code, drug quantity, and pharmacy NPI—to its priorities for data quality.
In summary, after analyzing the T-MSIS data, HHS-OIG wrote that until T-MSIS data are complete in all states and limitations across states are addressed, it will not be possible to conduct a national evaluation of Medicaid beneficiaries at risk of opioid misuse or overdose. OIG also noted that without a unique beneficiary ID, it is not possible to identify all at-risk beneficiaries in need of opioid-related treatment and to take appropriate action, or to monitor utilization of services to protect beneficiaries from poorly coordinated care. Further, without a diagnosis code, HHS-OIG noted that it is not possible to identify patients’ medical conditions to determine medical necessity for services, including excluding all patients with cancer diagnoses for whom higher doses of opioids may be appropriate.
OIG also made several recommendations for CMS to ensure the identification of at-risk beneficiaries and providers who may be overprescribing. The recommendations include:
- CMS should work to ensure that individual beneficiaries can be uniquely identified at a national level using T-MSIS. CMS should work with states to address instances in which a single beneficiary has more than one Medicaid ID within a state as well as work to ensure that in cases in which a beneficiary was enrolled in more than one state over time, claims for individual beneficiaries can be linked across states. CMS agreed with the OIG and noted that the agency plans to: implement a process to enable IDs to be linked, issue guidance to states on assignment and coding of unique IDs, and issue guidance to data users on identification of individual beneficiaries at the national level.
- While CMS recently prioritized completeness of pharmacy NPIs, CMS should now prioritize correct and complete state reporting of prescriber NPIs. CMS agreed on this point and will prioritize completeness of prescriber NPIs.
- CMS should issue guidance to clarify which services require a diagnosis code. CMS recently prioritized completeness of diagnosis codes, but some states are unsure whether a diagnosis code is required for all services. In response, CMS notified the OIG of plans to clarify these requirements.
CMS has been working with state agencies for several years to launch and improve the quality of T-MSIS data. As the OIG’s review was focused on such a high profile topic, it is likely that further pressure on CMS and individual states may have an impact on the quality of data submitted via T-MSIS.