What is the purpose of a CBR on opioid prescribers?
CBR201801 was created to show providers how their prescribing patterns compare to their peers. Those whose prescribing patterns are significantly higher than their peers received CBRs. Such prescribing can be entirely medically appropriate, depending on the circumstances; however, we want to make sure providers are aware that inappropriate use and abuse of opioids is still a very serious problem. If you would like more information on CBRs, please select the following web link: Comparative Billing Reports.
Why were opioid prescribers selected as a topic for a comparative billing report (CBR)?
We selected opioid prescribers as a topic for a CBR because opioid abuse and opioid-related deaths are occurring at an alarming rate in the United States. According to an Office of Inspector General (OIG) report, one in three Medicare beneficiaries was given an opioid prescription in 2016. This means that out of 43.6 million enrollees, 14.4 million received opioids, costing Medicare nearly 4.1 billion in 2016. To read the entire OIG article, select the following link: Opioids in Medicare Part D: Concerns about Extreme Use and Questionable Prescribing.
What is the focus of CBR201801?
CBR201801 focuses on the following metrics:
- Percentage of beneficiaries prescribed opioids above 90 Morphine Equivalent Dose
(MED) for 3 months
- Average number of days prescribed per beneficiary
- Average charges per beneficiary for prescribed opioids
- Percentage of beneficiaries prescribed opioids by 4 or more providers
Does receiving a CBR mean that I am prescribing opioids incorrectly?
Receiving a CBR does not necessarily indicate incorrect prescribing. You received a CBR because your prescribing patterns for opioids are different than your peers. We hope this report assists you with identifying opportunities for improvement.
Where can I find the guidelines for opioid prescribing?
The Centers for Disease Control (CDC) has published guidelines to assist providers with prescribing opioids. These recommendations are geared toward patients over the age of 18 in the primary care setting. The focus is on chronic pain lasting over three months, but does not include beneficiaries being treated for active cancer, palliative care, and end of life care. To view these guidelines, please select the following link: CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016.
What is a Prescription Drug Monitoring Program (PDMP)?
PDMPs track, collect, monitor and analyze data transmitted electronically by pharmacies and dispensing physicians. The data is only available to entities authorized by state law. More information is available from the website of the PDMP Training and Technical Assistance Center at the following link: Prescription Drug Monitoring Frequently Asked Questions (FAQs).
What is the Morphine Equivalent Dose (MED)?
MED is the morphine equivalent dose in milligrams, and is used by the Centers for Medicare and Medicaid Services (CMS) to assist with identifying high risk beneficiaries. The CDC’s term, morphine milligram equivalents (MME), is equal to the MED created by CMS. To see the conversion factors for different types of opioids, please select the following link: Opioid Oral Morphine Equivalent Conversion Factors, 2017.
What is the Overutilization Monitoring System (OMS)?
In an effort to increase medication safety, the OMS reviews drug utilization and identifies beneficiaries who have duplicative opioid records, or who have been using opioids over long periods of time, and also those using multiple opioids in high doses. The goal is to ensure compliance with CMS guidelines and to prevent overutilization of certain prescribed medications. The following website may assist Part D sponsors with addressing issues related to unsafe use of opioid pain medications: Improving Drug Utilization Review Controls in Part D.
What is Turn the Tide Rx?
Turn the Tide Rx is a program that the U.S Surgeon General created based on the CDC guidelines. The goals are to educate clinicians to treat pain safely and effectively, to screen patients for opioid use disorder, and to treat addiction as a chronic illness, instead of a moral failure. The website has several fact sheets and a pocket card adapted from the CDC guidelines available for download. Turn the Tide Rx also offers free Continuing Medical Education (CME) units and trainings. This information can be found at the following web link: Turn the Tide Rx-The Surgeon General’s Call to End the Opioid Crisis.
Are any laws changing related to the opioid crisis?
The House Opioid Task Force’s 2018 legislative agenda has 17 bills that are advancing. Two of the bills have already passed. One of the bills focuses on requiring providers that apply for a Drug Enforcement Administration (DEA) license to certify that they will only prescribe controlled substances according to current best practice guidelines. Another bill proposes mandating all prescriptions for controlled substances received through Medicare Part D be transmitted electronically by 2020. For detailed information, please select this link: House Opioid Task Force has Big Plans for 2018.
How were providers selected to receive a CBR?
After analyzing the data for 823,000 prescribing providers nationwide, those providers who were Significantly Higher than their peers (specialty or nationwide) on at least two of the metrics calculated were chosen to receive the CBR. Additionally, each recipient prescribed opioids to at least 30 beneficiaries from July 1, 2016 to June 30, 2017.
How did you determine which specialty I would be compared with?
Metrics were calculated for each of the following peer groups:
- Specialty: Each individual prescriber was compared to all other prescribers of opioids with his/her specialty in the nation.
Prescriber specialty was derived from the taxonomy codes listed in National Plan and Provider Enumeration System (NPPES) files within the CMS Integrated Data Repository (IDR). We found that many of the opioid prescribers did not have “Medicare specialty codes”, and for that reason your “primary” taxonomy from the NPPES files was converted to specialty using the taxonomy classification from the National Uniform Claim Committee (NUCC) . The data from the NUCC allowed us to use the first four digits of the taxonomy code (found from NPPES) and find a specialty (NUCC Classification) for every prescriber.
- National: Each individual provider was compared to all other prescribers of opioids in the nation, regardless of specialty.
It looks like all of my metrics are much lower than the national averages and percentages, why did I receive this CRB?
Your data was compared to both the national averages/percentages and the averages/percentages for your specialty. In many cases, even though prescribers are below the national statistics, they are above the values calculated for their specialty. This comparison is provided to allow you to see how you compare to others in the specialty, as well as nationwide.
What do the comparisons mean?
There are four possible outcomes for the comparisons between the provider and the peer groups:
- Significantly Higher – Provider’s value is higher than the peer value and the statistical test confirms significance
- Higher – Provider’s value is higher than the peer value, but the statistical test does not confirm significance
- Does Not Exceed – Provider’s value is not higher than the peer value
- N/A (not applicable) – Provider did not have sufficient data for comparison
I am higher than my peers on the percentage of beneficiaries with four or more prescribers of opioids. How can I monitor what others are prescribing to my patients?
Prescription drug monitoring programs (PDMPs) are state-level programs to improve opioid prescribing, inform clinical practice, and protect patients at risk. States have implemented a range of ways to make PDMPs easier to use and access. For more information on other prescriptions that your beneficiaries are receiving, please consult the information on PDMPs and OMS on our website at the following link: CBR201801 Recommended Links.
What does Table 1 mean?
Table 1 is the provider’s data Summary of Opioid Prescriptions to Medicare Part D Beneficiaries for services between July 1, 2016 and June 30, 2017. The example in the sample CBR shows that this mock provider has a total of 2,048 opioid prescriptions that were written for 327 beneficiaries, for total charges of $132,832. To view this example, select the following web link: CBR201801 Sample CBR.
What is shown in Table 2?
Table 2 is the Percentage of Beneficiaries Prescribed Opioids above 90 MED for 3 Months. It is calculated as the Number of Beneficiaries Prescribed at Least 90 MED for 3 Months or More divided by the Total Number of Beneficiaries, and then multiplied by 100. The example in the sample CBR shows that the mock provider has 61 beneficiaries identified as prescribed 90 MED or more for three months, out of a total of 327 beneficiaries. Dividing 61 by 327, and multiplying by 100, you should get 19 percent after rounding. The specialty’s percentage (in this example, Anesthesiology) is 13 percent, and the national percentage is 4 percent. The statistical test used in this analysis, chi-square test, shows that this provider’s percentage is Significantly Higher than both of his peer groups. To view the sample of Table 2, select the following web link: CBR201801 Sample CBR.
How did you determine if a beneficiary was “above 90 MED for 3 months?”
The Morphine Equivalent Dose (MED) was first calculated for each prescription. The percentage was calculated as the number of beneficiaries identified for receiving at least 90 MED for at least 3 months, divided by the total number of beneficiaries prescribed opioids by this provider, multiplied by 100.
The prescription data was then expanded to include daily records for each provider/beneficiary by adding together all drugs prescribed for each day, combining MEDs if the beneficiary had any overlapping prescriptions. Ninety-day rolling averages were calculated on the daily MEDs for each prescribing provider and beneficiary combination. All beneficiaries with a rolling 90-day average MED of 90 or above were identified. The percentage was calculated as the Number of Beneficiaries Above 90 MED for 3 Months, divided by the Total Number of Beneficiaries prescribed opioids by this provider, multiplied by 100.
How did you calculate the “Percentage of Beneficiaries Prescribed Opioids by Four or More Providers” statistic?
All beneficiaries prescribed opioids by four or more different prescribing providers were identified using data from the IDR. The percentage was calculated for each individual provider as the Total Number of Beneficiaries with Four or More Prescribers during the time period July 1, 2016 to June 30, 2017, divided by the Total Number of Beneficiaries prescribed opioids by this provider in the same time period, multiplied by 100. For more information on other prescriptions that your beneficiaries are receiving, please consult the information on PDMPs and OMS on our CBR201801 Recommended Links page.
What is shown in Table 3?
Table 3 provides the Average Number of Days Prescribed per Beneficiary. It is calculated as the Sum of Days Prescribed divided by the Total Number of Beneficiaries. In the example in the sample CBR, the mock provider has a total of 44,447 beneficiary-days when an opioid was prescribed, for a total of 327 beneficiaries. Dividing the 44,447 by 327, you should get an average of 135.92 days. In this case, the provider is Significantly Higher than both the specialty and the national averages based on the results of the t-test. To view the sample of Table 3, select the following web link: CBR201801 Sample CBR.
What is shown in Table 4?
Table 4 provides an analysis of the Average Charges per Beneficiary. To calculate this metric, the Sum of Charges for Opioids is divided by the Total Number of Beneficiaries. The mock provider in the CBR sample has total allowed charges of $132,832 for all opioids prescribed to Medicare Part D beneficiaries. This covers 327 beneficiaries. Dividing $132,832 by 327 beneficiaries will give you the average of $406.21 for this provider. This provider’s average Does Not Exceed the specialty’s average, but is Significantly Higher than the national average. To view the sample of Table 4, select the following web link: CBR201801 Sample CBR.
What is shown in Table 5?
Table 5 gives an analysis of the Percentage of Beneficiaries Prescribed Opioids by Four or More Providers. It is calculated as the Total Number of Beneficiaries with Four or More Prescribers divided by the Total Number of Beneficiaries, and then multiplied by 100. The mock provider in the CBR sample has 135 beneficiaries identified as having four or more providers that have prescribed opioids during the one year time period of analysis, out of 327, his total number of beneficiaries. Dividing 135 by 327 will give you this provider’s percentage of 41 percent. This provider’s percentage is Significantly Higher than the national average. His percentage is Higher than his specialty’s percentage of 36 percent; however, the chi-square test cannot confirm that this difference is significant, so that is why Higher is shown in this table for the comparison with his specialty. To view the sample of Table 5, select the following web link: CBR201801 Sample CBR.