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 Value Based Purchasing (VBP) 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 JH opioid prescribing guidelines.
• 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 inform 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. https://www.cdc.gov/opioids/providers/prescribing/index.html
• U.S. Department of Health and Human Services 
  • HHS (hhs.org) 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. Visit the website: https://beforeitstoolate.maryland.gov/resources/
• 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).

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