HealthJanuary 29, 2020

The strategic role of health plans and providers in the opioid battle

Is your organization equipped with the right code sets? The opioid crisis remains a critical public health issue. Every day more than 130 die from overdosing on opioids, and current industry estimates suggest that the total economic burden related to misuse alone in the United States is $78.5 billion a year, including the costs of healthcare, lost productivity, addiction treatment, and criminal justice involvement.

In recent years, healthcare stakeholders, government officials, and community groups have worked collaboratively to identify solutions that will holistically address the epidemic. Many industry leaders believe that both providers and health plans play a strategic role in improving the outlook. In fact, a growing number of healthcare industry stakeholders are taking a data-driven evidence-based approach to changing patient and physician behavior by leveraging data analytics.

While a national system for tracking prescriptions from state to state does not currently exist, health plans can track prescriptions via claims data to identify patterns of opioid use. Providers can limit the supply of opioids by improving prescribing practices as well as identifying and treating at-risk individuals in collaboration with community organizations. Equipped with the right data, healthcare organizations can work together to improve the outlook on the alarming statistics.

HEDIS and PQA quality measures: A starting point for health plans

In 2018 the National Committee for Quality Assurance (NCQA) added two new measures to the Healthcare Effectiveness Data and Information Set (HEDIS) in an effort to help combat and control addiction risks:

Use of Opioids at High Dosage: This measure assesses the rate of health plan members 18 years and older who are prescribed long-term opioid use at high dosages.

Use of Opioids from Multiple Providers: This measure assesses the rate of health plan members 18 years and older who receive opioid prescriptions from multiple providers and multiple pharmacies.

An additional opioid measure was added for 2019:

Risk of Continued Opioid Use: This measure assesses the percentage of members 18 years and older who have experienced a new episode of opioid use, putting them at risk for continued use. Two rates are assessed and reported:

  • The percentage of members whose new episode of opioid use lasted at least 15 days in a 30-day period.
  • The percentage of members whose new episode of opioid use lasted at least 31 days in a 62-day period.

Health plans can use these measures as a guide for improving oversight of safe and appropriate opioid prescribing practices. In addition, the Pharmacy Quality Alliance (PQA) Core Measure Set provides tools to evaluate patients with prescriptions for opioids in combination with benzodiazepines, a class of drug used for anxiety disorders. These prescribing patterns are associated with an increased risk of opioid use and abuse, overdose, and death.

The provider angle: Elevating MIPS scores

Within the Merit-Based Incentive Program (MIPS) of MACRA, opioid measures are defined as “high priority status.” Providers can submit six individual MIPS measures, of which at least one must be an outcome measure or high-priority measure.

In 2019, the Centers for Medicare and Medicaid Services (CMS) introduced the optional “Verify Opioid Treatment Agreement Measure,” which can result in a Bonus Score:

For at least one unique patient for whom a Schedule II opioid was electronically prescribed by the MIPS eligible clinician using CEHRT during the performance period, if the total duration of the patient’s Schedule II opioid prescriptions is at least 30 cumulative days within a 6-month look-back period, the MIPS eligible clinician seeks to identify the existence of a signed opioid treatment agreement and incorporates it into the patient’s electronic health record using CEHRT.

Because a higher MIPS score means higher Medicare Part B payments, potential bonuses, and increased revenue, providers will naturally strive to achieve this measure.

Positioning for opioid reporting success

Much of reporting today is built around patient cohorts that define value sets. Opioid measures present opportunities for both providers and payers, yet CMS has declined to release an opioid value set to support industry stakeholders in their analytics and reporting efforts. Consequently, healthcare organizations are left to their own devices to design systems that support complete, accurate data aggregation to fulfill reporting requirements.

The Health Language experts at Wolters Kluwer have worked with healthcare organizations to create a customized opioid value set to be used to prepare for adherence to measures or for analytics. Wolters Kluwer is a licensed distributor for CPT®, UB-04®, RxNorm, and hundreds of other standardized code sets, offering healthcare organizations the convenience and cost efficiencies of a single data provider.

Speak to an expert to learn more about to the Health Language opioid value set and other data offerings.

CPT® is a registered trademark of the American Medical Association (AMA)
UB-04® is a registered trademark of the American Hospital Association (AHA)

Speak To An Expert
Celeste Adams, Pharm.D.
Senior Medical Informaticist of Health Language, Wolters Kluwer, Health

As Senior Medical Informaticist, Celeste supports the company’s Health Language solutions by focusing on providing harmonization and normalization services related to RxNorm, Medi-Span, and other terminologies.

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