Recent media coverage has revealed America’s pressing problem with opioid abuse and addiction, particularly within the Medicare population. A recent report released by the inspector general of the U.S. Department of Health and Human Services found that, annually, more than 500,000 Medicare beneficiaries received high doses of opioids for a period of at least 90 days, with almost 70,000 receiving an average daily dose more than 2.5 times recommended levels. Some 22,000 beneficiaries are believed to be engaged in a practice known as “doctor-shopping,” obtaining large amounts of opioids at more than one doctor or pharmacy. Beneficiaries living in rural areas appear to be most at risk, with Alabama and Mississippi having the highest proportion of patients taking prescription painkillers.
Policymakers in Washington began to address the opioid crisis with the passage last year of the Comprehensive Addiction and Recovery Act (CARA), which provides additional funding for education and treatment programs. But much more can be done, particularly for the Medicare population.
One strategy that would certainly help is for the Centers for Medicare and Medicaid Services (CMS) to more fully leverage Medicare’s value-based reimbursement programs — such as the new Merit-based Incentive Payment System (MIPS) — to address the crisis.
How does MIPS address opioids today?
Authorized by the Medicare Access and CHIP Reauthorization Act in 2015, MIPS changes reimbursement under Medicare Part B, basing clinician payment on their performance related to quality, cost, practice improvement activities, and use of certified health technology. Implemented in 2017, the original program design for MIPS incorporated some features aimed at curbing inappropriate use of opioids, but not in a manner to meaningfully address the problem.
For example, there are already three opioid-related measures within MIPS:
- Documentation of Signed Opioid Treatment Agreement
- Evaluation for Risk of Opioid Misuse
- Opioid Therapy Follow-up Evaluation
But these are among 271 total measures on which clinicians can choose to report. Clinicians must choose at least six measures on which to report, with no mandate or additional incentive to select one related to opioid use.
Similarly, MIPS contains two opioid-related practice improvement activities (i.e., consultation of a prescription drug monitoring program; completion of training to provide opioid medication-assisted treatment) out of more than 90 approved activities. Here, too, clinicians are not required to adopt the two opioid-related performance activities into their practice, nor are there incentives to voluntarily do so.
As for the MIPS technology use requirements known as Advancing Care Information (ACI), there are no functions specifically aimed at curbing opioid use. Although e-prescribing is a function included in the base ACI requirements, it currently has an extremely low annual performance threshold (i.e., at least one permissible prescription) to meet compliance. As for the Cost performance category, that is not scheduled to be brought online until 2019 at the earliest, and initial specifications focus almost exclusively on non-drug-related health expenses.
How could modifying MIPS help?
There are several modifications to MIPS that CMS could adopt within the next 12 months to more fully leverage the program in the fight against opioid abuse.
For example, additional opioid-related quality measures developed by the Pharmacy Quality Alliance and endorsed earlier this year by the National Quality Forum could be added to MIPS to track use of opioids in high dosage in persons without cancer and use of opioids from multiple providers. Among the six measures needed for a score on quality, MIPS-eligible clinicians should be required to report on at least one opioid-related measure (so long as it pertains to their specialty). As an alternative, CMS could boost the performance score (and presumably in turn, clinician reimbursement) for voluntary reporting on one or more opioid-related measures.
In its latest round of rule-making to update the MIPS program, CMS proposed adding two opioid-related practice improvement activities, including completion of the Centers for Disease Control and Prevention (CDC) modules for prescribing opioids and reviewing a patient’s history of controlled substance use via the state’s prescription drug monitoring program prior to prescribing a controlled substance for more than 3 days. Both should be approved and added to the list of permissible MIPS improvement activities. Moreover, CMS should either mandate that MIPS-eligible clinicians incorporate at least one of these opioid-related improvement activities into their practice (again, provided it is relevant to their practice), or increase their performance score for voluntary incorporation.
Focused use of specific health technologies could also be part of a more robust MIPS program design aimed at curbing opioid abuse. As mentioned earlier,e-prescribing is already required to achieve at least a base MIPS score for Advancing Care Information, and it is often cited as a method for enhanced tracking of controlled substance use. CMS could either modify MIPS to require that at least 25% of annual prescriptions for opioids be transmitted electronically or increase the performance score in the ACI category for those clinicians who do this voluntarily.
CMS should also reintroduce clinical decision support (CDS) reporting in the ACI category, adding either a mandate or performance bonus for clinicians who use CDS to consult with evidence-based best practices on opioid prescribing. Although it may require an act of Congress for authorization, CDS mechanisms could also deliver appropriate use criteria for safe prescribing of opioids, modeled after the pending mandate for ambulatory clinicians to consult appropriate use criteria via CDS prior to ordering an imaging test.
The opioid crisis is perhaps the gravest short-term challenge currently facing our healthcare system. Additional funding will help, but more fully engaging the clinicians who are prescribing opioids will likely be more impactful. By modifying the MIPS program as outlined above, CMS can more effectively address this dire public health crisis.
Christian Hartman, PharmD, MBA, FSMSO, is the Senior Director of Innovation and Strategy for Wolters Kluwer Health. He is the past president of the Massachusetts Society for Health Pharmacists (MSHP), founder and past president of the Medication Safety Officers Society (MSOS), and served as Commissioner of the Special Council on Compounding Pharmacies appointed by Governor Deval Patrick in response to the NECC crisis.