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Johns Hopkins Health Plans

POD - Pharmacotherapy for Opioid Use Disorder

Product Lines:
Advantage MD, EHP, Priority Partners, and USFHP.

Measurement Period: January 1 - December 31

Description: 
The percentage of opioid use disorder (OUD) pharmacotherapy events that lasted at least 180 days among persons 16 years of age and older with a diagnosis of OUD and a new OUD pharmacotherapy event.

Stratifications: 
Ages as of the treatment period start date.

  • 16–64 years.
  • 65 years and older.

Report stratification by race and ethnicity.

Improvement Notation:
Increased score indicates improvement.

Data Collection:

  • Administrative.
  • Supplemental.

Initial Population:

  • Measure Item Count: Episode.
  • Age: 16 years of age and older as of the treatment period start date.
  • Benefits: Medical and pharmacy.
  • Continuous Enrollment: 31 days prior to the treatment period start date through 179 days after the treatment period start date (211 total days).
  • Allowable Gap: None.

Definition: 
Determining same or different medications: 

  • Same medications: Medication lists and value sets that are in the same row of the Opioid Use Disorder Treatment Medications table.
    • For example, a dispensing event from the Buprenorphine Oral Medications List and an encounter with a code from the Buprenorphine Oral Value Set are considered two dispensing events for the same medication. 
  • Different medications: Medication lists and value sets that are in different rows of the Opioid Use Disorder Treatment Medications table.
    • For example, a dispensing event from the Buprenorphine Oral Medications List and a dispensing event from the Buprenorphine Injection Medications List are considered two dispensing events for different medications.

Direct transfer: When the discharge date from the first inpatient setting precedes the admission date to a second inpatient setting by 1 calendar day or less.

Intake period: July 1 of the year prior to the measurement year to June 30 of the measurement period.

Negative medication history: To qualify for negative medication history, the following criteria must be met:

  • A period of 31 days prior to the OUD dispensing or medication administration event when the person had no OUD dispensing or medication administration events.
  • A period of 31 days prior to the OUD dispensing or medication administration event when the person was not already receiving OUD pharmacotherapy. 
  • For example, for an OUD dispensing event with a date of service of January 1, the 31 days prior includes December 1–31. If a person received a buprenorphine implant (180 days supply) any time during the 179 days prior to December 1, they are already receiving OUD pharmacotherapy on December 1 and do not have a negative medication history.

OUD dispensing event: OUD pharmacotherapy identified using pharmacy data (medication lists).

OUD medication administration event: OUD pharmacotherapy identified using medical claims data (value sets).

Treatment period: A period of 180 calendar days, beginning on the treatment period start date through 179 days after the treatment period start date.
Note: Persons can have multiple treatment period start dates and treatment periods during the measurement period. Treatment periods can overlap.

Treatment period start date: The date of an OUD dispensing or OUD medication administration event with a negative medication history during the intake period. 

Denominator:
Persons with any diagnosis of OUD (Opioid Abuse and Dependence Value Set) with a negative medication history for OUD dispensing or OUD medication administration events during the intake period. 

Note: The measure is based on episodes; therefore, it is possible for the denominator to include multiple events for the same person.

Numerator: Compliance
New OUD pharmacotherapy events with OUD pharmacotherapy for 180 or more days without a gap in treatment of 8 or more consecutive days.

Best Practice and Measure Tips

  • Refer to JH Priority Partners opioid policy.
  • The measure utilizes pharmacy claims data for opioid medications filled.
  • The measure can assist in identifying members with potential opioid use disorder.
    • Members are included in measure once a dispensing event for an opioid medication occurs during the Intake Period.
    • Review member records and outreach to members as appropriate.
    • All the medications list in the Opioid Medications table are used to identify opioid medication dispensing events.
    • To identify same or different drugs, use the medication lists specified for the measure in the Opioid Medications table. Drugs in different medication lists are considered different drugs. For example, a dispensing event from the Acetaminophen Codeine Medications List is considered a different drug than a dispensing event from the Codeine Sulfate Medications List.
  • Stay informed about the latest opioid research and guidelines by visiting:
  • Ways to help our member:
    •  The Johns Hopkins Health Plans Care Management team offers a variety of services to help members who are living with substance abuse and mental health issues may receive confidential care management support and coordination of care from a Licensed Clinical Social Worker. These behavioral health clinicians help members navigate their treatment needs for conditions such as depression, anxiety disorders, addictions, and autism spectrum disorders. For Priority Partners members, we work with Carelon Behavioral Health of Maryland to manage mental health needs.
      • Please send us your member referrals by contacting us at:
        Phone: 800-557-6916
        Monday through Friday: 8 a.m. to 5 p.m.
        Voicemail messages received after normal business hours will be addressed the following business day.
        EHP Behavioral Health: 410-424-4891
        EHP Behavioral Health- Secured: 410-424-4765
        USFHP Mental Health: 410-424-4839
        Advantage MD Behavioral Health, Inpatient & Outpatient: 844-340-2217
        Email: [email protected]
  •  When prescribing opioids:
    • Use the lowest dosage of opioids for the shortest length of time possible.
    • Refer to the CDC guidelines for prescribing Opioids for Pain
    • Establish and measure goals for pain and function.
    • Discuss benefits and risks of opioid and non-opioid treatments.
    • Engage family/significant others in the treatment plan. Advise them about the importance of treatment and attending appointments.
    • Schedule follow up appointments to reassess and adjust any medication regimens.
    • Provided a printed copy of treatment plan and ensure member adheres to the treatment plan.
    • Communications between the behavioral health provider and the Primary Care Physician (PCP) is encourage and care should be coordinated.

Measure Exclusions

Denominator Exclusions:

  • Persons in hospice or using hospice services any time during the measurement period.
  • Persons who died any time during the measurement period.

Measure Codes

Buprenorphine Implant 

  • HCPCS: G2070, G2072, J0570

Buprenorphine Injection 

  • HCPCS: G0533, G2069, Q9991, Q9992

Buprenorphine Naloxone 

  • HCPCS: J0572, J0573, J0574, J0575

Buprenorphine Oral 

  • HCPCS: H0033, J0571

Buprenorphine Oral Weekly HCPCS: G2068, G2079

Methadone Oral

  • HCPCS: H0020, S0109 
  • SNOMED CT US Edition: 310653000

Methadone Oral Weekly 

  • HCPCS: G2067, G2078

Naltrexone Injection 

  • HCPCS: G2073, J2315

Measure Medication

Opioid Use Disorder Treatment Medications

  • Buprenorphine 
  • Buprenorphine-naloxone
  • Naltrexone 

Note

  • Methadone is not included on the medication lists for this measure. Methadone for OUD administered or dispensed by federally certified opioid treatment programs (OTP) is billed on a medical claim. A pharmacy claim for methadone would be indicative of treatment for pain rather than OUD.
  • The allowable gaps in the measure numerator of 7 or fewer consecutive days are used to account for weekly billing and other variations in billing practices and do not necessarily indicate that OUD pharmacotherapy ended. For example, members receiving daily methadone treatment over their 180-day treatment period meet numerator criteria if their treatment is billed weekly.