Recently, our membership has been receiving letters from payers (primarily Medicare Advantage) discouraging the use of medications considered to be “high-risk” for patients over age 65. The letters include quoted information from the Beers Criteria list.
The 2012 Beers Criteria were developed by the American Geriatric Association (AGA) as a guide to assist physicians in making clinical decisions about appropriate medications for geriatric patients. However, we now know that Medicare Advantage payers are limiting access to medications based on the Beers Criteria to prevent a low star rating. CMS currently labels the quality of Medicare Advantage plans using a star rating system, which includes the rating of “patient safety and accuracy of drug pricing.” This particular rating corresponds to whether Medicare advantage plans’ in-network providers prescribe medications on the Beers Criteria list. For example, a sleep physician prescribing zolpidem for chronic use to a 70 year new patient deviates from Beers Criteria recommendations and would potentially result in the Medicare Advantage plan receiving a lower star rating. Therefore, Medicare Advantage plans are motivated to discourage their in-network providers from prescribing off the Beers Criteria list. This challenges our members’ ability to make prescription decisions based on clinical judgment and can delay patient care.
The AASM is seeking information from members about the impact of the Beers Criteria on sleep medicine. If you have received a letter from your payer recommending that you discontinue prescribing “high-risk” medications for your sleep patients, please share a de-identified copy of the letter via email (coding@aasm.org) or via fax (630-737-9790 attn: Carolyn).
