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Johns Hopkins Health Plans

COU - Risk of Continued Opioid Use

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

Measurement Period: January 1 - December 31
 
Description:
The percentage of persons 18 years of age and older who have a new episode of opioid use that puts them at risk for continued opioid use. Two rates are reported:

  1.  The percentage of persons with at least 15 days of prescription opioids in a 30-day period.
  2. The percentage of persons with at least 31 days of prescription opioids in a 62-day period.

Stratifications: 
Age as of November 1 of the year prior to the measurement period.

  • 18–64 years.
  • 65 years and older.

Measure Reporting:
Population Health Incentive Program (PHIP).
HealthChoice Performance Measure reporting for Priority Partners. 

Improvement Notation:
Decreased score indicates improvement.

Data Collection:

  • Administrative.

Note: Supplemental data may not be used for this measure, except for denominator exclusions.

Initial Population:

  • Measure Item Count: Person.
  • Age: 18 years of age and older as of November 1 of the year prior to the measurement period.
  • Benefits: Medical and pharmacy.
  • Continuous Enrollment: 180 days prior to the IPSD through 61 days after the IPSD.
  • Allowable Gap: None.

Definition: 
Identifying same or different drugs: Use the medication lists specified 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.

Intake period: November 1 of the year prior to the measurement period to October 31 of the measurement period.

IPSD - Index prescription start date: Earliest prescription dispensing date for opioid medication during the intake period.

Negative medication history: A period of 180 days prior to the IPSD when the person had no pharmacy claims for either new or refill prescriptions for an opioid medication.

Denominator:
New episode of opioid use.

Numerator:
Numerator 1: ≥15 days covered.
Persons with 15 or more calendar days covered by an opioid medication during the 30-day period beginning on the IPSD through 29 days after the IPSD.

Numerator 2: ≥31 days covered.
Persons with 31 or more calendar days covered by an opioid medication during the 62-day period beginning on the IPSD through 61 days after the IPSD.

Best Practice and Measure Tips

  • Refer to Priority Partners opioid policy.
  • The measure utilizes pharmacy claims data for opioid medications filled.
  • Since measure is an inverse measure, a lower rate is desirable. 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. 
    • Once members are compliant for 30 days rate, take steps to prevent member from becoming compliant for the 62 days rate.
    • All of the medications lists 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:
  • The following opioid medications are excluded from this measure:
    • Injectables.
    • Opioid-containing cough and cold products.
    • Single-agent and combination buprenorphine products used as part of medication-assisted treatment of opioid use disorder (buprenorphine sublingual tablets, buprenorphine subcutaneous implant and all buprenorphine/naloxone combination products).
    • Methadone for the treatment of opioid use disorder
    • Ionsys® (fentanyl transdermal patch).
  • Ways to help our member:
    • Refer the member to a care manager:
      • 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 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 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.
  • Persons receiving Palliative Care or had an encounter for Palliative Care any time during the intake period through the last day of the measurement period. 
  • Any of the following during the 12 months prior to the earliest prescription dispensing date through 61 days after the IPSD:
    • Cancer 
    • Sickle Cell Disease

Exclusion Codes

  • Cancer*      
    • Malignant Neoplasms ICD-10-CM: C00.0-C00.6, C00.8, C00.9, C01, C02.0-C02.4, C02.8, C02.9, C03.0, C03.1, C03.9, C04.0, C04.1, C04.8, C04.9, C05.0, C05.1, C05.2, C05.8, C05.9, C06.0, C06.1, C06.2, C06.80, C06.89, C06.9, C07, C08.0, C08.1, C08.9, C09.0, C09.1, C09.8, C09.9, C10.0, C10.1-C10.4, C10.8, C10.9, C11.0-C11.3, C11.8, C11.9, C12, C13.0, C13.1, C13.2, C13.8, C13.9, C14.0, C14.2, C14.8, C15.3, C15.4, C15.5, C15.8, C15.9, C16.0- C16.6, C16.8, C16.9, C17.0- C17.3, C17.8, C17.9, C18.0- C18.9, C19, C20, C21.0; C92.60, C93.92, C93.Z0, C93.Z1, C93.Z2, C94.00, C94.01, C94.02, C94.20, C94.21, C94.22, C94.30, C94.31, C94.32, C94.40, C94.41, C94.42, C94.6, C94.80, C94.81, C94.82, C95.00, C95.01, C95.02, C95.10, C95.11, C95.12, C95.90, C95.91, C95.92, C96.0, C96.2, C96.20, C96.21, C96.22, C96.29, C96.4, C96.5, C96.6, C96.9, C96.A, C96.Z; 
    Sickle Cell Diseases*
    • ICD-10-CM:  D57.00- D57.03, D57.09, D57.1, D57.20, D57.211- D57.213, D57.218, D57.219, D57.40, D57.411- D57.413, D57.418, D57.419, D57.42, D57.431- D57.433, D57.438, D57.439, D57.44, D57.451-D57.453, D57.458, D57.459, D57.80, D57.811- D57.813, D57.818, D57.819

*Please note that not all ICD-10-CM and SNOMED CT US Edition codes are listed here. For access to the complete set of codes related to COU measure, contact your Provider Engagement Liaison or email [email protected].

Measure Medications

Opioid Medications

  • Acetaminophen-benzhydrocodone
  • Acetaminophen-butalbital-caffeine-codeine
  • Acetaminophen-caffeine-dihydrocodeine
  • acetaminophen-codeine
  • acetaminophen-hydrocodone
  • acetaminophen-oxycodone
  • acetaminophen-tramadol
  • aspirin-butalbital-caffeine-codeine
  • aspirin-carisoprodol-codeine
  • aspirin-oxycodone
  • belladonna alkaloids-opium
  • buprenorphine
  • butorphanol
  • codeine sulfate
  • fentanyl
  • hydrocodone
  • hydrocodone-ibuprofen
  • hydromorphone
  • ibuprofen-oxycodone
  • levorphanol
  • meperidine
  • methadone
  • morphine
  • naloxone-pentazocine
  • opium
  • oxycodone
  • oxymorphone
  • tapentadol
  • tramadol