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 received prescription opioids at a high dosage (average morphine milligram equivalent dose [MME] ≥90) for ≥15 days during the measurement period.

Measure Reporting:
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 the first day of the measurement period.
• Benefits: Medical and pharmacy.
• Continuous Enrollment: The measurement period.
• Allowable Gap: None.

Denominator:
Persons who had two or more opioid dispensing events on different dates of service and had ≥15 total days covered by opioids. 

Numerator:
Persons whose average MME was ≥90 during the treatment period.

Best Practice and Measure Tips

• The measure utilizes pharmacy claims data for opioid medications filled.
• Members are included in measure once a dispensing event for an opioid medication occurs during the Intake Period.
• 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.
• Schedule follow-up visits to ensure members are not showing opioid use disorder.
• Safely discontinue the opioid therapy when dosage exceeds 120 morphine milligram equivalents daily.
• Utilize non-narcotic and non-pharmacologic measures to control pain as part of a comprehensive pain management plan.
• Provide educational materials and resources that include information on treatments and process and options.
• Stay informed about the latest opioid research and guidelines by visiting:
  • Centers for Disease Control and Prevention (CDC)
    • CDC offers a number of materials and tools about opioid prescribing guidelines.
    • Permission is not needed to print, copy, or distribute any materials.
  • The Substance Abuse and Mental Health Services Administration (SAMHSA) 
    • Provides free resources regarding prevention, treatment and recovery.
  • 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 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 Behavioral Health: 410-424-4839
    • AMD 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 adhere 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.
• Cancer any time during the measurement period.
• Sickle Cell Disease any time during the measurement period.

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, D57.01, D57.02, D57.03, D57.04, D57.09, D57.1, D57.20, D57.211, D57.212, D57.213, D57.214, D57.218, D57.219, D57.40, D57.411, D57.412, D57.413, D57.414, D57.418, D57.419, D57.42, D57.431, D57.432, D57.433, D57.434, D57.438, D57.439, D57.44, D57.451, D57.452, D57.453, D57.454, D57.458, D57.459, D57.80, D57.811, D57.812, D57.813, D57.814, D57.818, D57.819D57.00- 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 HSO measure, contact your Provider Engagement Liaison or email [email protected].[

Measure Medications 

Opioid Medications