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Wilson: What Do Medicare Part D, Medicare Set-Asides and Parenting Have in Common?

  • National

For those who have raised children or are in the process of doing so, one of our biggest challenges is to instill in our children some sort of positive decision-making paradigm. 

Rita Wilson

Rita Wilson

You can call it religious values, moral absolutes, grounding or just plain common sense, but as parents, we set boundaries (rules) from the earliest age and try to be consistent in our enforcement. 

Our children may think we’re just mean, but this is a price we’re willing to pay if it helps establish an internal barometer to use when approached by people, thoughts and ideas that challenge them.

In raising my three children, one of the techniques I used was a simple, banded bracelet with the acronym, “WWJD” that is, "what would Jesus do? This was a popular phrase in the Bible Belt where we lived.

I asked that they look at the bracelet each time they were faced with an obstacle or asked to do something that didn’t quite feel right. One afternoon, my son was telling a story about something that happened at his elementary school that caused him to look at his bracelet. I was so pleased when he said he actually looked at it! 

He then responded, “Mom, I tried to decide what Jesus would do, but had a little bit of a tough time, so I switched it in my head to 'WWMD,' and I knew exactly what Mom would do!” 

I couldn’t help laughing, but based on his response to the situation, my simple reinforcement worked. At the same time, this also reminded me that our actions speak much louder than our words. Children will do as we do long before they will do as we say.

How does this relate to Medicare Part D and Medicare set-asides?

Each day, one of my first activities is to review my Google Alerts to look for news about non-group health plans, Medicare secondary payer issues and opioids. On a recent morning, the article that drew my attention was from MedPageToday.com entitled “CMS Proposes Opioid Prescribing Limits for Medicare Enrollees.” My first thought in reading the article was that this was great news.

“We are proposing important new actions to reduce seniors’ risk of being addicted to or overdoing it on opioids while still having access to important treatment options,” said Demetrios Kouzoukas, Centers for Medicare and Medicaid Services deputy administrator and director of the Center for Medicare. “We believe these actions will reduce the oversupply of opioids in our communities.”

Key components of the proposal include:

  • Hard formulary levels at pharmacies to would restrict the amount of opioids beneficiaries could receive.
  • Establishment of a safety level of 90 morphine mg equivalent (MME).
  • Limiting the number of pills and days supply in an initial prescription for acute pain.

According to Kouzoukas, “these are triggers … [that] can prompt conversations among physicians, patients and plans about appropriate opioid use and prescribing.”

I then realized what CMS was doing. It was setting boundaries to help physicians, patients and plans make better decisions about opioid use — the same type of boundaries I set for my children so they would make better decisions as adults. 

What a great idea! If physicians, patients and plans (both Medicare and workers’ compensation) can dialogue before prescriptions are filled, better decisions about opioids are inevitable, and the frequency of opioid addiction will diminish.

So what’s the problem?

Unfortunately, there remains a problem in the world of workers’ compensation and the workers' compensation Medicare set-aside arrangement review process. While I applaud CMS’ effort, there remains a strong disconnect between CMS’ proactive stance on opioid limitations with Medicare Part D and its opioid-friendly review process for WCMSAs.

At the same time, I must also admit to a similar disconnect between what happens with prescription opioids during the life of a workers’ compensation claim and what we are asking CMS to do when reviewing the MSA at settlement time. Are we asking CMS to “do as I say,” instead of providing the example of  “do as I do?”

Can we connect the dots?

After reading the article, I realized that as an MSP compliance company that has integrated opioid triggers into its Pre-MSA Triage and review process since Day 1, Tower now has a new weapon in its arsenal to assist clients to identify pharmacy obstacles as early possible, and to address issues of inappropriate drug use.

By advising clients to establish and enforce “CMS-like” boundaries at Rx fill time, we have the potential to reduce opioid use in workers’ compensation, just as CMS seeks to accomplish with Medicare Part D.

Through such efforts, we can reinforce dialogue among physicians, claimants and workers’ compensation plans before the Rx is filled, and hopefully facilitate better decisions about the first opioid Rx.

And as for the disconnect between Medicare Part D and the WCMSA review process, we cannot force CMS to change its drug review process. We can, however, leverage CMS’ expertise to support better outcomes with Medicare beneficiaries, MSAs and settlements by mirroring its Medicare Part D policies and processes within the workers’ compensation pharmacy benefit manager model.

In doing so, we provide CMS with a positive example of its own recommendations implemented successfully, and can hopefully encourage it to “do as we do.”


So how do we affect change in opioid prescribing habits in workers’ compensation? It’s as simple as the bracelet I gave my children. From Day 1 of a claim involving an active or soon-to-be active Medicare beneficiary, we continually ask the question, “What would Medicare do?” and we execute.

Rita Wilson is CEO of Tower MSA Partners LLC.

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