Tuesday, 22 November 2016 00:50

OPPS Pharmacy-Related Clinical Quality Measures Revised for 2017

Written by Courtney Boss, CPC and Robin Zweifel, BS, MT (ASCP)


In hopes of reducing Medicare prescription drug costs, the Centers for Medicare & Medicaid Services (CMS) is constantly analyzing trends associated with such costs under Part B and Part D. As one of the largest purchasers of prescription drugs in the United States, it is obvious that CMS must understand the underlying causes and proactively identify trends and develop methods for protection of program funds while remaining under scrutiny of the public to  in order to provide the nation’s aging population with high-quality, high-value, efficient care.

In March 2016, CMS proposed a Part B demonstration model to curtail sharp rises in Medicare prescription drug costs. The proposed rule was meet with strong opposition, resulting in a May 2016 announcement that the final rule would be delayed until March 2019 (go online to https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/costestimate/hr5122.pdf for more information).

Prescription opioids are part of the cause of a national epidemic of drug overdoses that now represents the leading cause of injury death in the United States due to overprescribing and misuse patterns. The concurrent use of opioids and benzodiazepines has been widely studied. Although this combination of drugs is known to cause an increased risk of death, the practice of prescribing the drugs together is still common.

According to statistics published by the Centers for Disease Control and Prevention (CDC), deaths due to overdoses involving prescription opioids quadrupled between 1999 and 2014. A proportional growth in sales of the associated prescription drugs has occurred over the same time period. Men between the ages of 25 to 54 accounted for the majority of 165,000 opioid-related deaths occurring between 1999 and 2014.

A few points to consider:

  • The almost 19,000 deaths occurring due to prescription opioid overdoses in 2014 is the equivalent of 52 deaths per day. Analyzing the statistics requires an understanding of the differentiation applied to the definition of “prescription opioid.” This number (19,000 deaths) includes overdoses due to synthetic opioid use (other than methadone). Synthetic opiates such as demerol, fentanyl, dilaudid, methadone, and buprenorphine are manufactured in laboratories and have the same chemical structures found in natural opium alkaloids. Synthetic varieties can be made even stronger than opium itself. 

Current statistics differentiate between natural opium alkaloids and synthetic opiates, but do not distinguish between pharmaceutical and non-pharmaceutical/illegally made fentanyl. The assumption is that the recent increase in deaths due to overdoses is due to illegally made fentanyl.

To better analyze the statistics related to opioid deaths, the CDC Injury Center is now separating the analysis of synthetic opioids (other than methadone) from other prescription opioids.

  • Based on the revised criteria for analysis, during 2014 there were over 14,000 overdose deaths linked to non-synthetic prescription opioids, or approximately 40 per day. 
  • Concern exists that this revised criteria appears to falsely decrease death stats and potentially undercounts the number of deaths associated with pharmaceutical fentanyl, tramadol, and other synthetic opioids that are used as pain relievers.

(For more information, go online to http://www.cdc.gov/drugoverdose/data/analysis.html).

Additional statistics reveal shockingly high numbers related to drug misuse, abuse, and opioid addiction.

  • In 2014, almost 2 million Americans abused or were dependent on prescription opioids.
  • As many as 1 in 4 people who receive prescription opioids for long-term, non-cancer pain treatment in primary care settings struggles with addiction.
  • Every day, over 1,000 people are treated in emergency departments for misusing prescription opioids.

(For more information, go online to http://www.cdc.gov/drugoverdose/data/overdose.html).

The opioid epidemic has been a major topic for discussion in healthcare circles. 

The discussion regarding controlling opioid use reached new levels of intensity when CMS requested public comment on a future electronic clinical quality measure concept for the hospital Outpatient Quality Reporting Program (OQRP), which addresses concerns associated with the prescribing of opioids or opioids and benzodiazepines. CMS will consider recommendations related to this measure, which is currently under development.

(For more information, go online to https://www.federalregister.gov/public-inspection/2016/11/01).

CMS is taking many steps to reduce preventable deaths, reduce opioid-related emergency department (ED) visits and the costs associated with them, and identify patients who are at high risk for overdose, including those with a history of an opioid overdose and/or respiratory depression.

Additional measures are being taken at the state Medicaid level, where limitations are being set on the prescribing of opioid drugs. For example, in July 2016 the state of New York issued Public Health Law Section 3331, 5. (b), (c). This law limits practitioners to prescribing an initial seven-day supply of an opioid medication for acute pain. The law differentiates acute pain from chronic pain or extended care requiring pain management; acute pain is defined as pain that the practitioner reasonably expects to last only a short period of time. 

In many scenarios, the patient may have received their initial prescription after discharge from the hospital setting following emergency department treatment involving an accident, injury, or surgery, and then moved on to the clinic setting for the continued management of their conditions and pain management. 

The state of New York allows for follow-up consultation for the same pain by permitting practitioners to issue subsequent prescriptions and refills in accordance with existing rules and regulations.

Making changes to how physicians prescribe and dispense opioid or opiate-based drugs is one step Medicare and Medicaid plan to take in order to reduce abuse and to combat epidemics. The 2016 U.S. Department of Health and Human Services (HHS) budget focuses on prescription drug and opioid misuse, abuse, and overdose death prevention. Although much of this $99 million investment will be focused on reducing funds spent through the Medicaid program, there also will be an impact on Medicare spending through introduction of a Medicare Part D program that is intended to reduce or prevent prescription drug abuse by requiring high-risk beneficiaries to be directed to specified providers and pharmacies to obtain controlled substances.

A comprehensive solution will be needed to combat the opioid epidemic.

CMS has taken a look at policies that some have said played a role in contributing to and incentivizing prescribers to prescribe more opioids, such as the pain management dimension questions that were part of the hospital Value-Based Purchasing (VBP) program. Even though CMS is not aware of any studies that support this correlation, it has chosen to remove the pain management questions, stating that “the linkage of these particular questions to the Hospital VBP Program payment incentives creates pressure on hospital staff to prescribe more opioids in order to achieve higher scores on this dimension."

Stay tuned for survey question updates from CMS related to “provider communications and pain.”

The Joint Commission’s standards have also been cited by healthcare providers for contributing to physicians’ increasing tendency of prescribing opioids. The Joint Commission has responded with five related misconceptions, having noted that “the current standards do not push clinicians to prescribe opioids” and that their standards did not cause a sharp increase in opioid prescriptions.

The healthcare industry’s expectation of completely eliminating patient pain is also thought to contribute to aggressive treatment through pain medications. Instead, the patient’s quality of life should be considered before medications are prescribed, since these patients may be able to be treated with alternative methods. Every organization tasked with addressing the opioid epidemic should be concerned with how their organization’s expectations and standards may possibly have positive or negative effects. These organizations should work together to produce the comprehensive solution that is needed to lessen the impact of the opioid epidemic.

About the Authors

Courtney Boss is currently a healthcare consulting analyst for Panacea Healthcare Solutions, Inc. Courtney supports the Coding and Documentation and Revenue Capture departments, providing project assistance and auditing services. Prior to joining Panacea, Courtney performed E/M audits and worked extensively with ICD-10-CM education and implementation services for physician practices. She conducted ICD-10-CM chart reviews and served as product manager for an ICD-10-related software products.

Robin Zweifel is senior vice president of revenue capture services for Panacea Healthcare Solutions, Inc. Robin’s areas of expertise include clinical laboratory and chargemaster management as well as infusion and pharmacy regulatory compliance. She is the lead on the development of Panacea’s CDMAuditor’s CDM Coding & Compliance Module and contributes to a number of publications and Web-based products that help providers maintain regulatory compliance while ensuring positive revenue outcomes.

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Last modified on Tuesday, 22 November 2016 03:41