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

Eligible Population:
Members 18 years and older as of November 1 of the year prior to the measurement year. This includes Population Health Incentive Program (PHIP) and the HealthChoice Performance Measure reporting for Priority Partners.

Definition:
The percentage of members 18 years of age and older who have a new episode of opioid use that puts them at risk for continued opioid use. New episodes of opioid use are captured from November 1 of the year prior to the measurement year through October 31 of the measurement year (Intake Period). A lower rate indicates better performance.

• Two rates are reported:
  • 15 days of prescription opioids in a 30-day period.
  • 31 days of prescription opioids in a 62-day period.
• Report two age stratifications and a total rate:
  • 18–64 years.
  • 65 years and older.
  • Total. The total is the sum of the age stratifications.

Continuous Enrollment:

• 180 days prior to 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:
  • Centers of  Disease Control and Prevention
    • CDC offers a number of materials and tools about opioid prescribing guidelines.
    • Permission is not needed to print, copy, or distribute any materials. Visit the CDC website.
• U.S. Department of Health and Human Services 
  • HHS (hhs.gov) offers a number of materials and tools about opioid prescribing guidelines:
    • Prevention
    • Treatment 
    • Recovery 
  • The Substance Abuse and Mental Health Services Administration (SAMHSA) guidance and resources for opioid-related treatment programs 
• Maryland Opioid Operational Command Center
  • Provides free resources regarding prevention, treatment and recovery.
• 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 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 Behavioral Health: 410-424-4839
      • Advantage MD Behavioral Health, Inpatient & Outpatient: 844-340-2217
      • Email: [email protected]
      • Website: https://www.hopkinsmedicine.org/johns-hopkins-health-plans/providers-physicians/division-of-health-services
• 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

Required Exclusion:

• Members in hospice or using hospice services anytime during the measurement year.
• Members who died any time during the measurement year.
• Palliative Care
• 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; 
    • Additional codes apply.
• 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

Measure Medications