HEDIS® 2020: How health plans can impact the opioid epidemic through preventive measures

Wednesday, September 4, 2019 | By Theresa Lane, Pharm.D.

HEDIS® 2020: How health plans can impact the opioid epidemic through preventive measures

Continuing this blog series on the HEDIS 2020 guidelines, I will follow up on Amy Salls’ discussion on Opioid use with some preventive measures plans can take under the pharmacy benefit.

In the United States, the total economic burden of opioid overdose, abuse and dependence is estimated at $78.5 billion (2013 data year).1 Seventy-five percent of the people who misused these drugs developed an opioid use disorder by taking prescription medications.2  There are some risk factors for prescription opioid abuse and overdose, including overlapping prescriptions from multiple prescribers/pharmacies and taking high daily dosages of prescription opioid pain relievers.3 Health plans can take steps to address these risk factors and decrease opioid abuse and misuse through simple restrictions to the drug formulary and benefit design and by using an MTM program.  Here are some recommendations:

For short-acting opioid use for acute pain, the health plan can implement the following measures to prevent opioid abuse and misuse:

  • A maximum daily limit of 49 morphine milligram equivalents (MME) for opioid-naïve members
  • A maximum daily limit of 90 MME for experienced members
  • A days supply limit of 7 days for treating acute pain in naïve adult members
  • A days supply limit of 3 days for treating acute pain in naïve pediatric members

SS&C Health clients that implement restrictions on opioid use through days supply limits and dosing quantity have seen a measurable decrease in the past two years:

  • The number of opioid claims dropped from 4 to 2 per 100 total claims
  • The number of members receiving ≤7 days supply (adults >20 years) increased from 58% to 66%

In comparison, similar plans that did not implement restrictions saw minimal change in opioid use during the same period:

  • The number of opioid claims dropped from 5 to 4 per 100 total claims
  • The number of members receiving ≤7 days supply (adults >20 years) increased from 46% to 47%

Our opioid management program incorporates these preventive measures along with prescriber and pharmacy education. Exceptions to allow access to opioids for chronic pain therapy are built into the design, while data analytics and continued monitoring help identify opportunities to maximize the appropriate use of opioids by members. To learn more about our utilization management solution, download our brochure.

Another factor for opioid dependence is coordination of care to evaluate inappropriate dosing, which could be a driver for that population. Using a medication therapy management program (MTM) can increase medication appropriateness and adherence, while showing a savings for the health plan. An MTM program can address misuse of opioids and inappropriate use with benzodiazepines and other drugs.  The clinician performing the medication therapy management can assess the patient for misuse and offer non-pharmaceutical alternatives for chronic pain management. Download our infographic to see potential savings

While restrictions are fine to limit use, the health plan must also provide access to these opioid drugs when clinically appropriate.  A prior authorization program and exceptions for specific populations (cancer, hospice) ensure members who would benefit from opioid use for chronic pain receive treatment.   

If you are looking for HEDIS solutions under the pharmacy benefit, contact me at TMLane1@dsthealth.com to see how we can help you make the most of the resources you have for the best possible outcomes with your opioid program.

Watch for the final blog in this series, where Amy will complete the HEDIS 2020 discussion with insights on regulations around using supplemental data.


  1. Florence, Curtis S., PhD; Zhou, Chao, PhD; Luo, Feijun, PhD; Xu, Likang, MD. The Economic Burden of Prescription Opioid overdose, Abuse, and Dependence in the United States, 2013. Medical Care: October 2016. 54(10): 901-906.
  2. Cicero, Theodore J., PhD; Ellis, Matthew S., MPE; Surratt, Hilary L. PhD; Kurtz,
  3. Steven P., PhD. The Changing Face of Heroin Use in the United States; A Retrospective Analysis of the Past 50 Years. JAMA Psychiatry. 2014. 71(7): 821-826.
  4. White, Alan G., PhD; Birnbaum, Howard G., PhD; Schiller, Matt BA; Tang, Jackson BSc; Katz, Nathaniel P. MD. Analytic Models to Identify Patients at Risk for Prescription Opioid Abuse. American J. Managed Care: 2009. 15(12): 897-906.


HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).



Theme picker