SS&C Blog

HEDIS® Guide 2019: opioid measures

Wednesday, August 1, 2018 | By Lisa Kabasakalian

HEDIS® Guide 2019: opioid measures

The Opioid Epidemic - Measures Reflect a Unique Role for Health Plans

The opioid epidemic is an urgent public health issue. Approximately 11.5 million people misuse prescription opioids each year,1 and the most recent data from the Centers for Disease Control and Prevention (CDC) indicates opioids were involved in 42,249 deaths in 2016.2 An analysis from CDC shows the overdose epidemic is spreading geographically and increasing across demographic groups.3

In response, clinicians, federal and state officials, and healthcare organizations are working together to identify and adopt strategies to increase safety in opioid prescribing. NCQA is joining the effort to define the critical decision points in the use of opioids for pain management and identify meaningful metrics to evaluate quality performance.

Unique Role for Health Plans

Health plans are in a unique position to join the fight against the opioid epidemic. A national system for tracking prescriptions filled from one state to another does not exist. However, through claims data, health plans can track opioid prescriptions across state lines and from more than one provider. Plans can help assess patterns of opioid use, identify individuals who are at risk of abuse, and help clinicians and members find alternatives for pain management.

Three opioid HEDIS measures adapted from the Pharmacy Quality Alliance give health plans targets to evaluate performance in opioid prescribing and track improvements from year to year. These opioid measures are among several new behavioral health measures NCQA has and is developing to promote awareness and assessment. The opioid measures are designed to help health plans identify those at risk for opioid overuse and misuse who may benefit from additional monitoring, services, or support.

Opioid Measures Introduced in the 2018 HEDIS Season

The measures introduced during the HEDIS 2018 season center on high dosages, as well as multiple prescribers and pharmacies, which are risk factors for dangerous overdose and death.

Use of Opioids at High Dosage captures the rate per 1,000 members 18 years and older who received prescription opioids for 15 days or more at an average morphine equivalent dose >120mg.

Use of Opioids from Multiple Providers captures the rate per 1,000 members 18 years and older who received prescription opioids for 15 days or more from multiple prescribers. Three multiple prescriber rates are reported: four or more prescribers, four or more different pharmacies, four or more different prescribers, and four or more different pharmacies.

New Opioid Measure for the 2019 HEDIS Season

The measure added for the HEDIS 2019 season – Risk of Chronic Opioid Use – will assess 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. Two rates will be calculated, evaluating members prescribed opioids for at least 15 days in a 30-day period and those prescribed opioids for at least 31 days in a 62-day period. Chronic opioid use often begins with the management of acute pain. This measure guides health plans to focus on members receiving opioid therapy for acute pain who are at risk of becoming long-term users.

Assessing the Opioid Use Measures

Analytics and reports for these HEDIS opioid use measures can guide health plans in assessing safe and appropriate opioid prescribing. A combination of reports from a health solutions provider on HEDIS measures and other metrics can help health plans monitor the use of opioids and identify members who may be susceptible to or dealing with opioid addiction. These include:

  • HEDIS measure reports:
    • HEDIS opioid use measures (Risk of Chronic Opioid Use; Use of Opioids at High Dosage; Use of Opioids From Multiple Providers).
    • Other HEDIS measures with breakout information on opioids (Identification of Alcohol and Other Drugs Services; Initiation and Engagement of Alcohol and Other Drugs).
  • Member risk report – Member stratification to create a holistic view of members for quick review and intervention.

In conclusion, with a broad view of opioid use through claims data, health plans have an essential role to play in overcoming the US opioid crisis. Opioid use measures are evolving as the industry continues to learn which steps can be taken to improve outcomes. The current HEDIS measures can help health plans assess current performance and track their improvement over time in identifying members at risk from chronic opioid use. This will help health plans appropriately target resources and interventions to reduce this risk

1 U.S. Department of Health and Human Resources. What is the U.S. Opioid Epidemic? Accessed June 5, 2018.

2 Centers for Disease Control and Prevention. Drug Overdose Death Data.  Accessed June 5, 2018.

3 Centers for Disease Control and Prevention. U.S. Drug Overdose Deaths Continue to Rise; Increase Fueled by Synthetic Opioids Published March 29, 2018. Accessed June 5, 2018.

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