State Workgroup on Reducing Overuse
st
Wednesday, August 31 , 10:00AM-4:00PM
CalPERS Headquarters, 400 Q Street Sacramento, Lincoln Plaza North (room 1170/80)
Time
10 AM
10:15 AM
10:45 AM
11:15 AM
12:30 PM
1:00 PM
1:45 PM
2:30 PM
Topic
Welcome and Introductions
Overview of Statewide Workgroup: Role, Progress, Next Steps
Co-Chair Update – Progress, Related Activities
 Covered California
 CalPERS
 Department of Health Care Services
Opioid Overuse in California: Priorities for Action
 Health Plan Priorities: “Four-Part Prescription”
 Provider Priorities: Implementing Evidence-Based
Guidelines
 Purchaser Priorities: Covering Evidence-Based Benefits
Resources on Opioids by Target Audience: Overview
 Feedback: categories, examples, gaps
 How to use? How to spread?
 Participant exercise
Lunch
What can the Co-Chairs do to promote and support change?
 Current activities, potential directions
 Takeaways and next steps
Tracking Overuse of Opioids: CDPH Dashboard
3:45 PM
C-Section:
 Recognition awards for hospitals
 Consumer education resource on C-section in
development
Next Steps and Action Items
4:00 PM
Adjourn
Leads
Lance Lang, MD, Covered California
Jill Yegian, PhD, IHA
Lance Lang, MD, Covered California
Kathy Donneson, PhD, CalPERS
Neal Kohatsu,MD, DHCS
Kelly Pfeifer, MD, CHCF
Meeting Materials
Participant List
SWGRO Phase 2 Scope of Work (20162018)

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Karen Shore, PhD, Transform Health/IHA
Reactors:
 Jim Leo, MD, MemorialCare
 Julie Morath, RN MS, HQI
 Beccah Rothchild, Consumer
Reports
Lance Lang, MD, Covered California
Neal Kohatsu, MD, DHCS
Kathy Donneson, PhD, PERS
Jill Yegian/Ashley Kirk
John Pugliese, PhD, CDPH
Lance Lang, MD, Covered California
Stephanie Teleki, PhD, CHCF
Sarah Lally, IHA
Lance Lang, MD, Covered California
Jill Yegian, IHA
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
Health Plan Rx for the Opioid Epidemic
Clinical Guidelines/Recommendations
(excerpt: Appendix A, Table 2 and 3)
Minimum Insurance Benefits
Resources to Enable Action on Opioid
Overuse
Opioid Resources by Target Audience–
spreadsheet


Tracking Overuse of Opioids
CDPH Prescription Drug Overdose
Prevention Initiative
Awards for Performance on C-sections:
Recommended Approach
Next meeting: January 31 in SoCal
Statewide Workgroup on Reducing Overuse
Participant List
August 31, 2016
Parag Agnihotri, MD
Medical Director, Continuum of Care
Sharp Rees-Stealy Medical Group
Sarah Lally, MSc
Program Manager
Integrated Healthcare Association
William Cory, MD
Health Plan Physician Advisor
Kaiser Permanente
Lance Lang, MD, Co-Chair
Chief Medical Officer
Covered California
Catherine Dodd, RN,PhD
Director
San Francisco Health Service System
Darin Latimore, MD, FACP
Associate Dean
UC Davis School of Medicine
Kathy Donneson, PhD, Co-Chair
Chief, Health Plan Administration Division
CalPERS
James D. Leo, MD
Medical Director of Best Practice
and Clinical Outcomes
MemorialCare Health System
Ann Marie Giusto, RN
Director of Variation Reduction
Sutter Health
Shari Little
Chief Health Policy and Research
CalPERS
Evelyn Haddad, MD
Interim Medical Director of Specialty Care Services
San Mateo Medical Center
Julia Logan, MD, MPH
Quality Officer
CA Department of Healthcare Services
Katie Heidorn, MPA
Deputy Secretary
CA Health and Human Services Agency
David Lown, MD
Chief Medical Officer
CAPH/Safety Net Institute
Emma Hoo
Director of Value-Based Purchasing
Pacific Business Group on Health
Julie Morath, RN, MS
President/Chief Executive Officer
Hospital Quality Institute
Ashley Kirk, MHA
Program Associate
Integrated Healthcare Association
Lindsay Petersen, MS
Senior Quality Analyst
Covered California
Neal Kohatsu, MD, MPH, Co-Chair
Medical Director
CA Department of Health Care Services
Kelly Pfeifer, MD
Director, High-Value Care
California Health Care Foundation
Marshall Kubota, MD
Regional Medical Director
Partnership Health Plan
Patricia E. Powers, MPA
Executive Director
Center for Health Care Decisions
1
Beccah Rothschild, MPA
Senior Outreach Leader
Consumers Union
Karen Shore, PhD
Principal
Transform Health
Stephanie Spoerl, MPH
Senior Clinical Project Advisor
Cedars-Sinai Medical Center
Steven Steinberg, MD
Family Medicine Physician
Kaiser Permanente
Richard Sun, MD, Co-Chair
Chief Medical Officer
CalPERS
Stephanie Teleki,PhD
Senior Program Officer, High-Value Care
California Health Care Foundation
Michael van Duren, MD
Vice President, Variation Reduction
Sutter Health
Mike Witte, MD
Chief Medical Officer
California Primary Care Association
Salina Wong, PharmD
Director, Clinical Pharmacy Programs
Blue Shield of California
Jill Yegian, PhD
Senior Vice President, Programs & Policy
Integrated Healthcare Association
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Statewide Workgroup on Reducing Overuse – Phase 2 Scope of Work
May 2016
Project Objectives
The Statewide Workgroup on Reducing Overuse is a multi-stakeholder effort led by Covered California,
CalPERS, and the Department of Health Care Services to address overuse of selected medical conditions
in California. Specific objectives for Phase 2 of the Workgroup are to:



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Support co-chair efforts to meaningfully reduce the level of inappropriate care provided to
members in the three focus areas: low-risk C-section, opioids overuse, and imaging for low back
pain
Engage stakeholders, including purchasers, plans, providers, and consumer/patient
organizations, in a collaborative effort to improve quality and reduce costs through targeting
inappropriate and unnecessary care
Compile, curate, and disseminate resources for all three key audiences – plans, providers, and
members –that enable action in all three areas of focus:
Explore development of recognition awards for performance on C-section
Develop a dashboard of key measures in each of the three areas of focus to track and report on
progress
Project Background
According to the Institute of Medicine, waste accounted for 30% of the $2.5 trillion spent in the U.S. on
health care in 2009. Misuse and overuse of services accounted for 27% of the total waste, or $210
billion. In 2015, Covered California, DHCS, and CalPERS, which collectively purchase and/or manage
health care services for approximately 15 million Californians, came together to launch the Statewide
Workgroup to Reduce Overuse, targeting unnecessary and inappropriate medical services. IHA was
recruited to support three meetings of the Workgroup over a period of 11 months. All of the meetings
were well-attended by a diverse array of stakeholders that included the Co-Chairs (Covered California,
DHCS, and CalPERS), provider associations, provider systems, health plans, purchasers and consumer
representatives. Progress to date is outlined below:


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June meeting – laid the groundwork on the topic of overuse, including presentations from two
delivery systems and one health plan focused on reducing unnecessary variation and
inappropriate care.
August webinars – selected three priority focus areas for the Workgroup from a broader menu
created by IHA. Areas selected: 1) C-section for low-risk, first time birth; 2) Imaging for low back
pain without red flags; and 3) Opioid overuse.
October meeting – created a foundation for collective action on each of the three focus areas,
with presentations from the “champion” Co-chair and support from experts as needed. Covered
California led on C-section, CalPERS on imaging for low back pain, and DHCS on opioid overuse.
3

February meeting – discussed and voted on proposed “action plan” for each of the three focus
areas, also received results of related (and CHCF-funded) Doing What Works project led by the
Center for Health Care Decisions.
The Statewide Workgroup on Overuse is gaining visibility: it was mentioned in the CHCF-authored
Health Affairs blog on Cesarean sections, and in a letter from CHHS and related agencies/departments
(including Covered California, DHCS, and CalPERS) to hospitals to encourage data submission to the
California Maternal Data Quality Collaborative. Most notably, Covered California’s 2017 contract with
Qualified Health Plans, which was approved by the board on April 7, requires participation in the
Statewide Workgroup. The last year has laid the groundwork for the next phase of the project –
creating and disseminating actionable resources (tools and information) that the Co-Chairs and other
Workgroup participants can use to meaningfully reduce overuse on C-section, low back pain, and
opioids over the next two years.
Scope of Work for Phase 2
Based on the groundwork laid in the first year, IHA proposes four key activities to support the ongoing
work of the Statewide Workgroup on Reducing Overuse over the next two years: convening meetings,
enabling action through curation and dissemination of tools and resources, developing performance
awards for hospitals reaching the statewide C-section target, and creating dashboards to track and
publicly report on key measures.
Task 1: Convene Workgroup for in-person meetings
The three in-person meetings that have been held to date have been engaging and productive, and have
made the case for ongoing in-person connections on these complex and multi-faceted topics. For the
next two years, it is anticipated that the Workgroup will meet three times each year, twice in Northern
California and once in Southern California.
Task 2: Enable Action – Curate and Disseminate Tools and Resources
In order to enable co-chairs and other Workgroup stakeholders to take action to address overuse, IHA
will identify actionable information from the vast body of work that has been done around each topic
area (C-section, low back pain, opioids) for three specific audiences (members, providers,
purchasers/plans); see Table 1 below. Information and tools will be shared through multiple channels
that reach the target audiences – leveraging the participants in the Statewide Workgroup, and going
beyond as needed.
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Table 1: Tools and Resources to Support Performance Improvement, by Focus Area and Audience
FOCUS AREA
AUDIENCE
Member Tools
(consumer/patientfacing)
Provider Tools
(clinician-facing)
Payer/plan Tools
C-section for low-risk, firsttime birth
Imaging for low back
pain
Opioid Overuse
New resources under
development specific to Csection, co-branded by
CMQCC and Consumer
Reports (CR)
Existing resources from
CR; commission new if
needed to fill gaps
Existing resources from
CR; commission new if
needed to fill gaps
CMQCC Toolkit available–
focus on dissemination;
Explore recognition awards
for performance (hospitals,
medical groups)
Tools drawn from Bree
Collaborative resources,
CERC, Choosing Wisely
(see Table 2);
differentiate acute vs.
chronic
Focus on payment principles,
purchaser contract language
(e.g. performance
expectations)
Focus on benefit design
best practices, e.g.
access to physical
therapy
Tools could include
scripting, CURES
database, CDC guidelines
(see Table 2);
differentiate existing vs.
new Rx, acute vs. chronic
Focus on plan levers,
including formulary,
utilization management;
CHCF issue brief
underway
Key activities:
 Scan of what others have done in California and across the country to support and enable
reduction of overuse. Examples of resources to tap include Q-Corp in Oregon, other NRHI
collaboratives, Bree Collaborative in Washington State, Stanford CERC, Choosing Wisely national
program and grantees.
 Create online resource to house the tools and content. For example, a “menu” of provider
resources could consist of several different types of resources including: clinical decision support
resources, specific measures and benchmarks, Choosing Wisely recommendations, clinical
pathways/guidelines, etc. An illustrative “menu” of resources is outlined in Table 2 below for
low back pain and opioids; C-section is not included because CMQCC has created a
comprehensive toolkit of provider resources. Similar compilations of resources would be
created for the other audiences across all three focus areas.
 Develop a “spread” plan that facilitates engagement of purchasers, plans, and providers beyond
those that have participated in Workgroup meetings to date. The plan would:
o leverage the Co-Chairs, other Statewide Workgroup participants and related efforts
ongoing statewide, such as Choosing Wisely projects, Transforming Clinical Practice
Initiative projects, IHA’s Medi-Cal work, and efforts led by CAPG, HQI, and others
o feature presentations at conferences, webinars, other forums convened by participants
to extend the Workgroup’s reach
5
o
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
incorporate resources into existing dissemination channels of participants, such as
newsletters (e.g. CalPERS newsletter to PPO members), websites, articles in publications
(e.g. CAPG’s publication)
o include outreach to specialty societies, and other key groups identified in the spread
plan
Execute the spread plan in partnership with Co-Chairs and participants
Track uptake; obtain feedback; assess interest in/demand for specific tools and information
from target audiences on the key topics
Assess gaps and consider development of new content and tools to fill. For example, clinical
decision support could be a powerful provider tool in addressing overuse, particularly for clinical
pathways that are amenable to rule-based alerts such as imaging for low back pain. However,
determining how best to incorporate CDS into clinical practices in a way that supports provider
workflow needs to be assessed. For example, options include: (1) using existing capabilities of
EMRs, such as Epic or Cerner; (2) using standalone (“bolt-on”) products that work with multiple
EMRs, such as Stanson (developed by Cedars Sinai); and (3) building tailored utilities. IHA could
commission an assessment of the options and tradeoffs, with recommendations for providers.
The Bree Collaborative in Washington State is interested in this topic as well, and could be a
partner. Depending on the scope of the gaps identified, funding may need to be pursued
separately.
Table 2: Provider Tools – illustrative “menu” of resources
Low Back Pain
Opioid Dependence
Guidance on
 AHRQ -- Confidential Physician Feedback Reports: Designing for Optimal Impact on
comparative
Performance.
performance
 CHCF – Working in Concert: A How-To Guide to Reducing Unwarranted Variations
feedback
in Care.
HEDIS measure on use of imaging
Extensive list of measures available, including
studies for low back pain is most
deaths, prescriptions, and number of people
Measures and
prevalent – see summary of data on
on high doses. CMS recently released a new
Benchmarks
p35 of from SWGRO October meeting core measure for Medicaid: use of opioids
materials
from multiple providers at high dosage in
persons without cancer.
 SWGRO October meeting
 SWGRO October meeting materials
materials compiled relevant CW
compiled relevant CW recommendations
recommendations – see p.7
– see p.8
Choosing Wisely
 Example: “don’t do imaging for
 Example: “don’t prescribe opiates in
Recommendations
low back pain within the first six
acute disabling low back pain before
weeks, unless red flags are
evaluation and a trial of other
present” from AAFP
alternatives is considered” from Amer
Acad Physical Med and Rehab
6
Examples of existing resources:
 Stanford CERC’s Spine Pain Care
“ICE” model
Clinical Pathways and
 Bree Collaborative report includes
Guidelines
array of resources
 Virginia Mason spine care model
Scripting for Patient
Conversations
Patient Materials

Minnesota project underway, will
provide publicly available
materials in about a year
Consumer Reports has developed an
array of materials for the Choosing
Wisely initiative. See, for example,
Imaging Tests for Back Pain:

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
CDC Guidelines on Opioids (JAMA, March
2016)
CDC educational resources
Physicians for Responsible Opioid
Prescribing
Health plans, including Partnership
Health Plan, Kaiser Permanente, Blue
Shield of California
None identified yet
Examples of available materials:
 Consumer Reports -Prescription
Painkillers: 5 Surprising Facts:
 Physicians for Responsible Opioid
Prescribing video
Task 3: Explore development of recognition awards for performance on C-section
Non-financial rewards can be a powerful motivator in changing provider behavior. The workgroup will
explore the development of awards for hospitals and physician organizations that achieve the Healthy
People 2020 national goal of reducing C-section births among low-risk mothers to 23.9 percent.
Key Activities:
 Reach out to CMQCC, ACOG, and other key stakeholders to obtain feedback on recognition
awards for performance on C-section
 Contingent on feedback, identify a lead organization for developing the methodology for
designating award winners and for branding the awards, and a governance structure to approve
the methodology and selection of award-winners
 Contingent on decision to move forward:
o collaborate with lead organizations to develop award timeline and structure
o create communications plan for awards that showcases award-winners
 Explore the feasibility of linking the medical groups and hospitals in order to create a joint award
that rewards collaborative efforts
Task 4: Dashboard – Measures, Data, Benchmarks, and Targets
Creating a dashboard for key measures across the three areas is a core component of the project. As is
always the case, data sources are challenging and it may not be possible to track and report at the
desired level of granularity. Nonetheless, even identifying the key measures and supporting a consistent
approach to measurement (where it doesn’t already exist) would add benefit through placing a clear
focus on the highest-priority measures, strengthening the signal to health care providers, and ideally
reducing the likelihood of duplicative and conflicting measurement efforts among the various initiatives.
7
Key Activities:
 For each of the three areas, reach agreement on up to five key measures to track
 Compile secondary data at the statewide level; more granular data would be compiled as well,
to the extent available
 Summarize the information on an online dashboard
 Update the information regularly -- at least annually
Partners/Audience/Stakeholders:
To date, the intended audience for this project has been is the co-chairs (DHCS, CalPERS, and Covered
California) and Workgroup participants, including provider associations, provider systems, health plans,
purchasers and consumer representatives. A complete list of participants in the Statewide Workgroup
on Reducing Overuse is included in Attachment A. In Phase 2, the Workgroup’s reach will extend
beyond the co-chair organizations and participants through development and execution of the spread
plan. As the Workgroup gains greater visibility, the resources produced are expected to be of interest to
a wide array of audiences in California and nationally, including health plans, providers, trade
associations, and policymakers.
8
Attachment A
Statewide Workgroup on Reducing Overuse
Participant List
All organizations listed have attended at least one meeting
Co-Chairs
Providers
Covered California
CA Department of Health Care Services
CalPERS
American College of Physicians, CA Chapter
CAPG
Safety Net Institute/CAPH
California Hospital Association
California Primary Care Association
Cedars-Sinai Health System
Hospital Association of Southern California
Hospital Quality Institute
Los Angeles County Department of Health Services
Sharp Rees-Stealy Medical Group
Southern California Permanente Medical Group
Sutter Health
UCLA Department of Medicine
Consumer Representatives
Center for Healthcare Decisions
Consumers Union
Western Center on Law & Poverty
Plans and Purchasers
Anthem Blue Cross
Blue Shield of California
Inland Empire Health Plan
Partnership Health Plan
San Francisco Health Service System
Collaborators
California Health and Human Services Agency
California HealthCare Foundation
Integrated Healthcare Association
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CHCF’s Changing Course: The Role of Health Plans in Curbing the Opioid Epidemic
June 2016
11
Appendix A. Common Components of Health Plan Clinical Guidelines
RECOMMENDATION
LITERATURE SUPPORT
EXAMPLES OF HEALTH PLAN APPROACHES
Avoid new starts for
patients with long life
expectancies
A large health plan study
showed that 67% of patients
taking opioids for 90 days
continued daily use two
years later.89
$$
Easy access to nonopioid therapies in acute pain
(behavioral health, physical therapy, complementary therapy)
$$
Prescriber education
$$
Member education
$$
Formulary controls
(limited number of tablets per fill, authorization review
for ongoing use after the first prescription)
$$
Pay for performance incentives
$$
Formulary dose limits
(with prompt authorization review to manage exceptions)
$$
Work with providers on individual tapering plans
$$
Case management and care coordination
$$
Access to nonopioid treatments
$$
Data analysis and work with outliers
$$
Specialist support through phone, email, or live video
consultation
$$
Increased access to buprenorphine for pain management
$$
Identification and investigation of fraud
$$
Removal of authorization barriers for buprenorphine
$$
Buprenorphine waiver trainings
$$
Incentive payments or grants for new programs
$$
Alternative payment models
$$
Outreach to waivered but non-prescribing clinicians
$$
Collaboration with local coalitions and counties
(e.g., whole person care and health home programs)
$$
Removal of authorization barriers for naloxone
$$
Prescriber education
$$
Member education
$$
Incentive programs
$$
Promotion of uptake in pharmacies
(dispense without prescription)
$$
Collaboration with local coalitions: distribution at community
events and needle exchanges, and with first responders
“avoid the 90-day cliff”
Taper patients onto
safer regimens
Offer medicationassisted addiction
treatment (MAT)
Promote use
of naloxone
Doses >100 MME a day
increase the death rate
almost ninefold 90 compared
to 1 to 20 mg daily; 30% of
opioid overdose deaths
include concurrent
benzodiazepine use.91
Buprenorphine and methadone
decrease rates of death, HIV,
and hepatitis rates and
increase retention in treatment
compared to social model
treatments.92
Communities with increased
naloxone availability have
lower death rates.93
California Health Care Foundation
12
30
California Society of Addiction Medicine
“The Voice for Treatment”
Minimum Insurance Benefits for Patients
with Opioid Use Disorder
By David Kan, MD and Tauheed Zaman, MD
Adopted by the California Society of Addiction Medicine Committee on Opioids and the
California Society of Addiction Medicine Executive Council on August 31, 2015.
LACK OF ACCESS TO MEDICATION-ASSISTED
TREATMENTS (MATS):
THE OPIOID USE DISORDER EPIDEMIC:
Opioid use disorder has emerged as a worsening, and often deadly,
epidemic in the United States. Recent surveys indicate that up to
1.9 million Americans met criteria for an opioid use disorder based
on their use of prescription opioid medications alone in 2013, and
that another 300,000 were regular users of heroin (SAMHSA 2013).
The burgeoning number of ER visits, hospitalizations, and overdoses related to opioids have led several parts of the country to declare
states of emergency in combating the epidemic through urgent
public health measures.
Despite the extensive evidence for their efficacy, less than 45% of
addiction treatment programs prescribe any single substance use
disorder (SUD) pharmacotherapy (Romana et al 2011). While a number of barriers contribute to low access to and utilization of medication-assisted treatments (MATs), insurance utilization management
policies remain a major obstacle to evidence-based treatment. A
recent New England Journal of Medicine article documents that,
“…several policy-related obstacles that warrant closer scrutiny.
These barriers include utilization-management techniques such as
limits on dosages prescribed, annual or lifetime medication limits,
initial authorization and reauthorization requirements, minimal
counseling coverage, and “fail first” criteria requiring that other therapies be attempted first. Although these policies may be intended
to ensure that MAT is the best course of treatment, they may hinder
access and appropriate care. For example, “Maintenance MAT has
been shown to prevent relapse and death but is strongly discouraged by lifetime limits.” (Volkow et al 2014)
THE EVIDENCE FOR OPIOID TREATMENT:
Robust studies have shown the effectiveness of methadone, buprenorphine, buprenorphine/naloxone (Suboxone®), and naltrexone in treating opioid use disorder when combined with the appropriate psychosocial approaches. Methadone is a full opioid
agonist, which reduces opioid withdrawal symptoms and cravings
(Amato et al, 2005), and buprenorphine/naloxone combination (Suboxone®) is a partial opioid agonist which acts similarly (Ling et al,
2005). Naltrexone, or its injected form, Vivitrol®, is an opioid antagonist, which blocks the reward from opioids and helps reduce the
reinforcing nature of the substance (Comer et al, 2006). All three
medications, when used in a long-term manner, can help a patient
to avoid relapse, and experience the health and functional benefits
of effective treatment for opioid use disorder.
At this time, MediCal recipients who choose to enroll in an opioid
treatment program (OTP) to receive methadone-buprenorphine
must pay out-of-pocket.
In 2015 the California Society of Addiction Medicine published its
survey of bronze-level plans offered by Covered California (CSAM
2015). CSAM’s report indicated that, while coverage varied, NONE of
the plans offered an acceptable level of coverage for the treatment
of patients with opioid use disorders.
The decision to start any of these medications, and the duration to
continue them, is highly individual and requires close collaboration
between patients and their providers (see appendix). Substance
use disorders, like all chronic medical illnesses, require treatments
that provide ongoing care throughout patients’ lifespans with
many having remissions and relapses. Outcomes from substance
abuse treatment is similar to that of chronic diseases such as diabetes, asthma and hypertension (McLellan, A.T., et.al., 2000).
EVIDENCE-BASED BEST PRACTICES:
1.Limits on opioid maintenance dosages: Individuals vary greatly
in their inborn capacity to metabolize opioid maintenance medications such as methadone. Arbitrary dosage limits are irrational
and daily doses need to be clinically determined.
13
www.csam-asam.org
2. Annual or lifetime medication limits: Such limits are based on the
ideology that all patients are best served by eventual detoxification and a drug-free lifestyle. However, research shows that the
gold standard for treatment of recurrent heroin addiction is long
term, often lifetime, maintenance on opioid agonist medications.
Premature termination of supportive medications massively increases risks of relapse.
3. Authorization/Re-authorization: Chronic illnesses with long-term
medication management should not be subject to overly frequent and burdensome re-authorizations.
4. Coverage for counseling: The scientific literature has established
that support services and counseling are essential for effective
treatment. Counseling services require insurance coverage for
these DSM-V disorders.
5.“Fail First” Criteria: These criteria violate precepts of “first do no
harm.” Many opioid relapses, particularly to street drugs such as
heroin, contain risks of infection with HIV or hepatitis C, overdoses, and overdose deaths. Eligibility for maintenance medications
is best established by a relapsing clinical history, not by regulations that demand a high-risk event as a pre-condition for coverage.
MINIMUM BENEFITS FOR PATIENTS WITH OPIOID
USE DISORDER:
Given the grave and increasing dangers related to opioid use disorders, patients should have full access to the effective treatments
available. Minimum insurance coverage should include full coverage for:
1. Regular physician visits for evaluation and follow up of opioid
use disorders.
2. Methadone at doses, frequency, and duration recommended
by the provider.
3. Buprenorphine at doses, frequency, and duration recommended
by the provider.
4. Naltrexone at doses, frequency, and duration recommended
by the provider.
5. Naloxone at doses, frequency, and duration recommended
by the provider.
6. Lab work and diagnostic tests necessary for safely and
effectively treating opioid use disorders.
7. Counseling or other substance use programming as
recommended for each patient.
8. All patients’ insurance plans should cover both methadone and
buprenorphine, including state funded and regulated opioid
treatment programs.
REFERENCES:
1. Substance Abuse and Mental Health Services Administration, Center for
Behavioral Health Statistics and Quality. (September 4, 2014). The NSDUH Report:
Substance Use and Mental Health Estimates from the 2013 National Survey on
Drug Use and Health: Overview of Findings. Rockville, MD.
2. Amato L, Davoli M, A Perucci C, et al. An overview of systematic reviews of the
effectiveness of opiate maintenance therapies: available evidence to inform
clinical practice and research. J Subst Abuse Treat. Jun 2005;28(4):321-9.
3. Ling W, Amass L, Shoptaw S, et al. A multi-center randomized trial of
buprenorphine-naloxone versus clonidine for opioid detoxification: findings
from the National Institute on Drug Abuse Clinical Trials Network. Addiction. Aug
2005;100(8):1090-100.
4. Comer SD, Sullivan MA, Yu E, et al. Injectable, sustained-release naltrexone for
the treatment of opioid dependence: a randomized, placebo-controlled trial.
Arch Gen Psychiatry. Feb 2006;63(2):210-8.
5. McLellan, A.T., et.al., Drug dependence, a chronic medical illness: implications
for treatment, insurance, and outcomes evaluation. JAMA. 2000;284:1689-1695.
6. Romana, P, Abrahama A, Knudsen H. Using medication-assisted treatment for
substance use disorders: Evidence of barriers and facilitators of implementation.
Addictive Behaviors, Volume 36, Issue 6, June 2011, Pages 584–589.
7. Volkow ND. Frieden TR, Hyde PS, Cha SS. Medication-Assisted Therapies —
Tackling the Opioid-Overdose Epidemic. N Engl J Med. May 29 2014 370:2063.
8. California Society of Addiction Medicine, Consumer Guide and Scorecard for
Health Insurance Coverage in California for Substance Use Disorders and Mental
Health. December 2014. http://csam-asam.org/sites/default/files/pdf/csam_
guide-scorecard-dec2014.pdf.
9. Substance Abuse and Mental Health Services Administration, MedicationAssisted Treatment for Opioid Addiction in Opioid Treatment Programs,
Treatment Improvement Protocol (TIP) Series, No. 43, 2005.
APPENDIX: EVIDENCE-BASED CONSENSUS
TREATMENT RECOMMENDATIONS
The following recommendations are from:
Medication-Assisted Treatment for Opioid Addiction in Opioid
Treatment Programs, Treatment Improvement Protocol (TIP) Series, No. 43, Center for Substance Abuse Treatment. Rockville (MD):
Substance Abuse and Mental Health Services Administration (US);
2005.
TIPS are best-practice guidelines for the treatment of substance use
disorders prepared by a large consensus panel sponsored by the
U.S. Department of Health and Human Services (HHS).
CHOICE OF MEDICATIONS
“The consensus panel recommends that OTPs offer a variety of treatment medications. Chapters 3 and 5 provide more details about the
pharmacology and appropriate use of methadone, levoalpha-acetyl methadol [no longer available], buprenorphine, and naltrexone.”
(p. 91)
“The consensus panel for this TIP expects that the availability of
buprenorphine in multiple settings will increase the number of patients in treatment and that its availability in physicians’ offices and
other medical and health care settings should help move medical
maintenance treatment of opioid addiction into mainstream medical practice.” (p. 26)
“In general, patient–treatment matching involves individualizing,
to the extent possible, the choice and application of treatment resources to each patient’s needs.” (p. 87)
14
www.csam-asam.org
TREATMENT DURATION
LAB WORK AND DIAGNOSTIC TESTS NECESSARY FOR
SAFELY AND EFFECTIVELY TREATING OPIATE USE
DISORDER
“Decisions concerning treatment duration (time spent in each
phase of treatment) should be made jointly by OTP physicians, other members of the treatment team, and patients. Decisions should
be based on accumulated data and medical experience, as well
as patient participation in treatment, rather than on regulatory or
general administrative policy.” (p. 106)
Since the inception of medication-assisted treatment for opioid addiction (MAT), drug testing has provided both an objective measure
of treatment efficacy and a tool to monitor patient progress. Important changes have occurred in current knowledge about and methods for drug testing in opioid treatment programs (OTPs) since the
publication of TIP 1, State Methadone Treatment Guidelines (CSAT
1993b). Testing now is performed extensively to detect substance
use and monitor treatment compliance. Analysis of test results provides guidance for OTP accreditation, as well as information for program planning and performance improvement. In addition, other
agencies concerned with patient progress (e.g., child welfare and
criminal justice agencies) routinely request and use drug test results
with patients’ informed consent (see CSAT 2004b). (p.143)
DOSAGE
“It is critical to successful patient management in MAT to determine
a medication dosage that will minimize withdrawal symptoms and
craving and decrease or eliminate opioid abuse. Dosage requirements for methadone, LAAM, and buprenorphine must be determined on an individual basis. There is no single recommended
dosage or even a fixed range of dosages for all patients. For many
patients, the therapeutic dosage range of methadone may be in
the neighborhood of 80 to 120 mg per day (Joseph et al. 2000), but
it can be much higher, and occasionally it is much lower.” (p. 70)
REGULAR PHYSICIAN VISITS FOR EVALUATION AND
FOLLOW UP OF OPIATE USE DISORDER
Patient–treatment matching begins with a thorough assessment to
determine each patient’s service needs (see chapter 4); then these
needs are matched to appropriate levels of care and types of services. Assessment should include the extent, nature, and duration
of patients’ opioid and other substance use and their treatment histories, as well as their medical, psychiatric, and psychosocial needs
and functional status. (p. 88)
[In the continuing care phase of treatment…] “the panel recommends that appointments with the OTP continue to be scheduled
every 1 to 3 months, although many programs prefer that patients
in continuing care maintain at least monthly contact.” (p. 119)
COUNSELING OR OTHER SUBSTANCE USE
PROGRAMMING AS RECOMMENDED FOR EACH PATIENT
A core group of basic- and extended-care services is essential to the
effectiveness of medication-assisted treatment for opioid addiction
(MAT) in opioid treatment programs (OTPs). Numerous studies support the belief that psychosocial interventions contribute to treatment retention and compliance by addressing the social and behavioral problems and co-occurring disorders affecting patients in
MAT (e.g., Brooner and Kidorf 2002; Joe et al. 2001). The consensus
panel agrees that a well-planned and well-supported comprehensive treatment program increases patient retention in MAT and the
likelihood of positive treatment outcomes. (p.121)
California Society of Addiction Medicine (CSAM)
575 Market Street, Suite 2125, San Francisco, CA 94105
415-764-4855 (phone) | 415-764-4915 (fax)
http://www.csam-asam.org
15
Resources to Enable Action on Opioid Overuse, August 2016
A key activity for the Statewide Workgroup on Reducing Overuse is identification of actionable
information from the vast body of work that has been done around each topic area, and to organize
selected resources online in a way that is easy to navigate and access. Focusing first on opioids, a
preliminary set of resources have been compiled for each target audience, with examples; selection
criteria are provided below. Following feedback, the categories will be revised and additional resources
compiled and made available online; a “spread plan” will then be developed to facilitate broad
engagement.
Table 1: Provider Resources on Opioids – Categories and Examples
Clinical Pathways and
Guidelines
Education and Training
Tools
Support for Patient
Conversations
Choosing Wisely
Recommendations


CDC Guidelines on Opioids (JAMA, March 2016)
CDPH guide for provides with patients using opioids








Clinician action guide (ICER)
Commonly used opioids (NIDA)
Considerations for prescribing opioids (NIDA)
Patient Interview Simulation (NIDA)
Scripting for patient conversations about opioid prescribing
Patient agreement (contract)
SWGRO October meeting materials compiled relevant CW recommendations ( p.8)
Example: “don’t prescribe opiates in acute disabling low back pain before
evaluation and a trial of other alternatives is considered” from Amer Acad Physical
Med and Rehab
ICER study on managing patients with opioid dependence
Research and Evidence

Guidance on
comparative
performance feedback
(not opioid-specific)


AHRQ -- Confidential Physician Feedback Reports: Designing for Optimal Impact on
Performance.
CHCF – Working in Concert: A How-To Guide to Reducing Unwarranted Variations
in Care.
Clinical Decision Support  CURES patient alerts for prescribers and pharmacists
 Any specific modules or tools in EMRs?
Extensive list of indicators available, including deaths, prescriptions, and number of
people on high doses; CDPH leading dashboard effort. Various performance measures
Measures and
also available, including recently-released CMS core measure for Medicaid: use of
Benchmarks
opioids from multiple providers at high dosage in persons without cancer. See related
discussion document and matrix on measures.
16
Table 2: Purchaser/Plan Resources on Opioids – Categories and Examples
Contract language re
reimbursement
requirements, quality


Utilization management,
e.g. prior authorization


Benefit design, including
formulary for Rx


None identified yet
CHCF Issue Brief Changing Course: The Role of Health Plans in Curbing the Opioid
Epidemic and summary infographic Health Plan Rx
CHCF case studies: Case Studies: Three California Health Plans Take Action
Against Opioid Overdose
Minimum Insurance Benefits for Patients with Opioid Use Disorder, CA Society of
Addiction Medicine
CHCF Issue Brief: Changing Course: The Role of Health Plans in Curbing the Opioid
Epidemic
CHCF case studies: Case Studies: Three California Health Plans Take Action
Against Opioid Overdose
Table 3: Consumer/Patient Resources on Opioids – Categories and Examples
Fact Sheet


Consumer Reports -Prescription Painkillers: 5 Surprising Facts
Pregnancy and opioid pain medications
Patient Guidelines


CDC Guideline Information for Patients
Patient Agreement


Sample patient agreement for opioid usage

Video “Best Advice for People Taking Opioid Medication” available at Physicians
for Responsible Opioid Prescribing
Patient Action Guide (ICER)
Patient Support

Criteria for Selection of Resources






Reputable source with credibility/involvement in this space – e.g., government,
nonprofit/research/think tank, university, professional societies, consumer advocacy
organizations
2014 or later
References research or other sources of content
Type of material included: website with additional resources, fact sheet, infographic, policy
brief, journal article, video vs. excluded: anecdotes/materials developed by individuals
Publicly available for free
Relevant to target audience
17
Engagement Strategy and Spread Plan – Idea Generation
A key goal of the SWGRO is to enable action on reducing overuse through one of many “levers” (see
diagram) of change. What are the most promising pathways for spreading the Workgroup’s message
and resources? Questions to consider include:
1. How could your organization use the resources?
2. What ideas do you have about how to engage others?
3. What tools or resources do you need that are not on this list?
Some ideas on how your organization could USE the resources – consider all “levers:”
Purchasers
• Influence plans through contract requirements
• Educate consumers through member channels
• Influence consumers through benefit design
Plans
• Influence providers through contracts (requirements or reimbursement)
• Share data with providers to support clinical decision-making
• Educate consumers through member channels
Providers
• Influence clinician behavior through information, incentives
• Educate patients (and families) seeking inappropriate care
Consumers
• Ask questions! Do I really need this? What are the risks? What if I do nothing?
Some ideas on how we might ENGAGE OTHERS
 leverage the Co-Chairs, other Statewide Workgroup participants and related efforts ongoing
statewide, such as Choosing Wisely projects, efforts led by CAPG, HQI, and others
 present at conferences, webinars, other forums convened by participants
 incorporate resources into existing dissemination channels of participants, such as newsletters,
websites, articles in publications
 partner with specialty societies
 stories of success –highlight what’s working
Data/
Transparency
Purchaser
Requirements
Workforce
Reduce
Overuse
Payment
Public
Policy
Quality
Improvement
Patient
Engagement
18
Sample Opioid Resources
#
Category
Title
Organization
Organization
Type
1
Fact sheet
Avoid Opioids for Most Long-Term Pain
Consumer Reports
nonprofit
2
Fact sheet
Know the Risks
CDC
federal govt
3
Fact sheet
Medicines to relieve chronic pain
ConsumerReportsHealth
nonprofit
4
Fact sheet
Pamphlets for Pregnant Women Who Use
Buprenorphine or Methadone
ACOG
professional
society
5
Fact sheet
Pregnancy and Opioid Pain Medications
CDC
federal govt
6
Fact sheet
Prescription Opioids: What You Need to Know
CDC and American
Hospital Association
federal govt
and
professional
society
Target
Audience
Brief Description
Choosing Wisely: Information on
side effects of opioids, alternative
drug and non-drug treatments for
patients, patient
Print fact sheet
chronic pain, considerations for
advocates
pregnant women, and safe use of
opioids.
Information about opioid
dependency risks and alternative
patients
Print poster
pain management approaches.
Describes the risks of opioid use
and alternative pain management
patients, patient
Print fact sheet approaches. Also lists
advocates
circumstances when opioid use may
be appropriate.
One fact sheet describes how to get
started on buprenorphine or
methadone during pregnancy and
pregnant
Print fact sheets how to safely use them. The other
women
fact sheet addresses childbirth,
ability to breastfeed, and infant care
when using these drugs.
Date
Citations
Provided
URL
2016
No
https://www.case.edu/wellness/medi
a/caseedu/wellness/documents/Cho
osing-Wisely-Opioids-Brochure.pdf
??
No
http://www.cdc.gov/drugoverdose/pd
f/guidelines_patients_poster-a.pdf
2014
No
http://consumerhealthchoices.org/wpcontent/uploads/2014/12/Choosing
WiselyOpioidsASA-ER.pdf
No
http://www.acog.org/AboutACOG/ACOGDepartments/Tobacco--Alcohol--andSubstance-Abuse/SubstanceAbuse/Pamphlets-for-PregnantWomen
Yes
http://www.cdc.gov/drugoverdose/pd
f/pregnancy_opioid_pain_factsheeta.pdf
No
https://www.cdc.gov/drugoverdose/p
df/aha-patient-opioid-factsheet-a.pdf
No
http://consumerhealthchoices.org/wpcontent/uploads/2014/05/BBDPrescription-Painkillers-Pkg.pdf
No
https://www.acgov.org/health/docum
ents/PatientsGuideTakingPainMedsSafelyBrochure.pdf
No
https://www.drugabuse.gov/sites/def
ault/files/files/SamplePatientAgreem
entForms.pdf
Yes
cdc.gov/drugoverdose/prescribing/p
atients.html
No
https://icer-review.org/wpcontent/uploads/2016/01/FINALPatient-Action-Guide.pdf
10/2015
pregnant
women
??
Print fact sheet Lists the risks for pregnant women of
using opioid medications.
Lists opioid risks and side effects,
information on alternative ways to
patients, patient
05/09/2016
Print fact sheet
manage pain, and how to safely use
advocates
opioids.
Lists five common misconceptions
about opioid medications, as well as
tips about how to safely use opioids
patients, patient
2014
Print fact sheet
and alternative ways to manage
advocates
pain. Lists opioid prices including
best buys, and addresses treatment
for migraines.
Information on opioids, as well as
risks, alternative treatments,
3/22/2016
patients
Print fact sheet
overdose, storage and disposal, and
addiction resources.
7
Fact sheet
Prescription Painkillers: 5 surprising facts
ConsumerReportsHealth
nonprofit
8
Fact sheet
Taking Your Pain Medications Safely: A
Patient’s Guide to Using Opioids Safely to
Manage Pain
Alameda County Health
Care Services Agency
local govt
9
Patient
agreement
Sample Patient Agreement Forms
NIDA
federal govt
patients, health
care providers
#
Patient
guidelines
Guideline Information for Patients
CDC
federal govt
patients
#
Patient support
An Action Guide for Management of Opioid
Dependence: Next Steps for Patients and
Families
ICER
nonprofit
patients, patient
advocates
Patients
Type of
Material
19
Two sample agreements for patients
receiving 1) pain treatment with
??
opioids, and 2) long term controlled
substance prescriptions.
Information on how to manage pain
with opioids and risks involved. Also
has links to the new Guideline for
Prescribing Opioids for Chronic
03/15/2016
Online fact sheet Pain, what to do if prescribed
opioids, non-opioid pain
management options, and other
resources including treatment
locator.
Sample
agreement
Action guide
Information on how to identify and
address opioid dependence. Also
includes information on and links to
various treatments and resources,
including treatment locator.
09/2014
Sample Opioid Resources
#
Category
Title
Organization
Organization
Type
Target
Audience
Type of
Material
#
Patient support
Best Advice for People Taking Opioid
Medication
Physicians for
Responsible Opioid
Prescribing
nonprofit
patients,
clinicians
Video
patients, patient
advocates
Descriptions
plus links to
additional info
#
Patient support
Drug & Pain Medication Facts
HHS
federal govt
#
Patient support
Easy to read drug facts
NIDA
federal govt
patients
Descriptions
plus links to
additional info
#
Patient support
Family and Friends
Overdose Free PA
university
patients,
families
Descriptions
plus links to
additional info
#
Patient support
Fighting the Opioid Epidemic on Jessie’s
Behalf
HHS
federal govt
patients
Patient/family
testimonial
#
Patient support
Hydrocodone Combination Products
MedlinePlus
federal govt
#
Patient support
Opioid Medications
FDA
federal govt
#
Patient support
Patient Education Guidelines for Opioid
Medications
Neighborhood Health
Center
nonprofit
Patients
Brief Description
Advice for people on, or about to
start taking, opioid medications,
related to chronic non-cancer pain.
Date
Citations
Provided
URL
3/1/2013
No
http://www.supportprop.org/resource
/video/
Yes
hhs.gov/opioids/drug-and-painmedication-facts/index.html
No
https://easyread.drugabuse.gov/
No
http://www.overdosefreepa.pitt.edu/e
ducation-toolbox/family-andfriends/#help
No
http://www.hhs.gov/blog/2016/07/14/
fighting-the-opioid-epidemic-onjessies-behalf.html
No
medlineplus.gov/druginfo/meds/a60
1006.html
No
www.fda.gov/Drugs/DrugSafety/Infor
mationbyDrugClass/ucm337066.htm
No
nhcoregon.org/wpcontent/uploads/sites/554/2015/08/P
atient_Education_Guidelines_for_O
pioid_Medications_2_53651.pdf
Extensive list of opioid medications
and their uses, along with benefits
and risks. Includes information on
12/10/2015
Opioid Facts for Kids & Teens. Page
includes links to other resources
including prevention, treatment and
recovery, and overdose response.
Describes how various drugs
including pain medicines can be
abused and their effects on the
body. Includes resources for family
??
members, patient testimonials and
videos, and phone # for treatment
locator. Provides links to prevention,
as well as recovery and treatment.
Information on addiction, including
how to talk about it and where to get
??
help, as well as information on
overdosing.
Describes Senator David Grubb's
daughter's addiction to opioids and
07/14/2016
the need to address the opioid
epidemic.
Extensive information about
hydrocodone combination products,
patients, patient
08/15/2016
Online fact sheet
including instructions for use, side
advocates
effects, storage and disposal, and
what to do in case of overdose.
Descriptions Consumer information including
patients, patient
links to resources on how to avoid
08/19/2016
plus links to
advocates
additional info misuse of prescription painkillers.
patients
20
Patient
education
material
Describes the expectations for
patients related to opioid medication
for the treatment of chronic pain.
2/4/2014
Sample Opioid Resources
#
Category
Title
Organization
Organizatio
n Type
Target Audience
Type of
Material
1
Clinical decision
support
CURES 2.0 Patient Safety Alerts
California Department
of Justice
state govt
clinicians
Online tool
2
Clinical decision
support
Opioid Risk Tool (ORT) for Narcotic
Abuse
MD+CALC
for profit
company
clinicians
Online tool
3
Clinical
pathways and
guidelines
CDC Guideline for Prescribing Opioids
for Chronic Pain — United States,
2016
CDC
federal govt
4
Clinical
pathways and
guidelines
Guideline Resources
CDC
federal govt
5
Clinical
pathways and
guidelines
Clinical Guidelines Flowchart for
Evaluation and Treatment of Chronic
Non-Cancer Pain
Alameda County
Health Care Services
Agency
local govt
6
Clinical
pathways and
guidelines
Guidelines for Prescribing Controlled
Substances for Pain
Medical Board of
California
state govt
Providers
Brief Description
The CA Medical Board’s Guidelines for
Prescribing Controlled Substances for
Pain state that physicians should use the
CURES PDMP to identify patients who
obtain drugs from multiple sources and
document in their records that they
requested a Patient Activity Report
(PAR) from CURES and the outcome of
such report. CURES messages can alert
clinicians when their patient’s
prescription level exceeds the following:
1) currently prescribed more than 100
morphine milligram equivalents per day,
2) obtained prescriptions from 6 or more
prescribers or 6 or more pharmacies
during last 6 months, 3) currently
prescribed more than 40 morphine
milligram equivalents of methadone
daily, 4) currently prescribed opioids
more than 90 consecutive days, and 5)
currently prescribed both
benzodiazepines and opioids.
Tool to help identify patients at high risk
for opioid misuse who might benefit
more from other modalities of pain
control. User inputs information on
individual and family health history and a
risk score is produced.
Date
Citations
Provided
??
No
https://oag.ca.gov/cures/faqs
??
No
mdcalc.com/opioid-risk-tool-ortfor-narcotic-abuse
Yes
https://www.cdc.gov/mmwr/vol
umes/65/rr/rr6501e1.htm
No
http://www.cdc.gov/drugoverdo
se/prescribing/resources.html
No
https://www.acgov.org/health/d
ocuments/ClinicalGuidelinesFl
owchart.pdf
Yes
http://www.mbc.ca.gov/License
es/Prescribing/Pain_Guideline
s.pdf
Recommendations for primary care
clinicians who are prescribing opioids for
chronic pain including: 1) when to start
Clinical
clinicians
########
guidelines or continue opioids for chronic pain; 2)
opioid selection, dosage, duration, followup, and discontinuation; and 3) risk
assessment and harms of opioid use.
Resources to help improve
communication between providers and
patients about the risks and benefits of
opioid therapy for chronic pain, improve
Descriptions the safety and effectiveness of pain
clinicians
8/19/2016
plus links to treatment, and reduce the risks
additional info associated with long-term opioid therapy,
including opioid use disorder, overdose,
and death. Includes a variety of tools,
fact sheets, checklists, and a webinar
series.
Brief summary that includes review of
medical and medication history,
Clinical
incorporation of non-opioid interventions,
clinicians
??
guidelines
and opioid management and reassessment.
Guideline for prescribing controlled
substances for pain, including
providers/provider
Clinical
information on types of pain,
11/2014
groups
guidelines
considerations for special patient
populations, and treatment strategies.
21
URL
Sample Opioid Resources
#
Category
Title
Organization
Organizatio
n Type
Target Audience
Type of
Material
7
Clinical
pathways and
guidelines
Primary Care Guidelines for Chronic
Opioid Prescribing
Oregon Medical
Group
state govt
providers/provider
groups
Clinical
guidelines
8
Clinical
pathways and
guidelines
Reducing Opioid Overdose, Misuse
and Dependency: A Guide For CCOs
Oregon Health
Authority
9
Clinical
pathways and
guidelines
The ASAM National Practice Guideline
for the Use of Medications in the
Treatment of Addiction Involving
Opioid Use
American Society of
Addiction Medicine
professional
association
providers/provider
groups
Clinical
guidelines
10
Education and
Training Tools
A Proactive Response to Prescription
Opioid Abuse
NEJM
journal article
clinicians
Journal article
11
Education and
Training Tools
Alameda County Safety Net Working
Group on Opioid Prescribing
Alameda County
Health Care Services
Agency
local govt
clinicians
Descriptions
plus links to
additional info
12
Education and
Training Tools
An Action Guide for Management of
Opioid Dependence: Next Steps for
Clinicians
ICER
nonprofit
clinicians
Action guide
13
Education and
Training Tools
Cautious, Evidence-Based Opioid
Prescribing
Physicians for
Responsible Opioid
Prescribing
nonprofit
clinicians
Fact sheet
14
Education and
Training Tools
Commonly Used Long-Acting Opioids
Chart
NIDA
federal govt
clinicians
Fact sheet
15
Education and
Training Tools
Providers
Emergency Care for the Opioid
Epidemic: Leaders Discuss MedicationAssisted Treatment in the ED
CHCF
state govt
nonprofit
clinicians
Guidelines
Meeting
summary
clinicians
22
Brief Description
Brief information for primary care
physicians on how to assess and treat
chronic pain.
Resource to help CCOs develop a
comprehensive approach to reducing
opioid overdose, misuse, and opioid use
disorder. Includes information on
prescribing guidelines in office settings
and the ED, Prescription Drug
Monitoring Program (PDMP), as well as
treatment strategies.
Date
Citations
Provided
04/2014
No
URL
oregon.gov/omb/Topics-ofInterest/Documents/OMG%20
Opioid%20Rx%20Guidelines.p
df
Yes
http://www.oregon.gov/oha/hea
lthplan/ContractorWorkgroups
MeetingMaterials/Reducing%2
0Opioid%20Overdose_A%20G
uide%20for%20CCOs.pdf
Yes
http://www.asam.org/docs/defa
ult-source/practicesupport/guidelines-andconsensus-docs/asam-nationalpractice-guidelinesupplement.pdf?sfvrsn=16
Yes
http://www.nejm.org/doi/pdf/10.
1056/NEJMsr1601307
Yes
https://www.acgov.org/health/i
ndigent/coalition.htm
No
https://icer-review.org/wpcontent/uploads/2016/01/FINA
L-Physician-Action-Guide.pdf
Yes
http://66.147.244.123/~suppos
s3/wpcontent/uploads/2014/01/PRO
P_OpioidPrescribing.pdf
No
https://www.drugabuse.gov/sit
es/default/files/files/Commonly
UsedLAOpioids.pdf
Yes
http://www.chcf.org/resources/
download.aspx?id={2D429EA37C5F-42F9-B864E77DAAC2EB04}
10/6/2015
Information on evidence-based
treatment of opioid use disorder.
Includes information on assessment and
diagnosis; withdrawal; alternative
########
treatments; and special populations
including pregnant women, adolescents,
individuals with pain, and individuals with
co-occurring psychiatric disorders.
Summary of FDA Opioids Action Plan,
including prioritizing abuse-deterrent
formulations and
overdose treatments, addressing the
########
lack of nonopioid alternatives for
pain management, and developing a
better evidence base.
Links to a variety of safe prescribing
tools as well as presentations,
2016
resources, and articles.
Includes resources, guidelines, and
training for clinicians on how to evaluate
09/2014
patients, screen for addiction, and
formulate treatment plans.
Lists common myths and facts about
chronic opioid therapy. Includes lists of
Do's and Don'ts for 1) acute pain
01/2014
management and 2) chronic pain
management.
Chart of commonly used long-acting
opioids, including eight opioid
compounds, their brand names,
??
available strengths, typical starting
doses, and dosing intervals for initiation
of opioid therapy.
Convening of emergency physicians,
addiction specialists, behavioral health
providers, and policy experts who
examined current models of ED
addiction treatment and discussed what
it would take to spread these models in
California. The meeting focused mostly
on the use of buprenorphine in opioid
use disorder and injectable naltrexone
for alcoholism.
07/2016
Sample Opioid Resources
#
Category
Title
Organization
Organizatio
n Type
Target Audience
Type of
Material
16
Education and
Training Tools
Guideline for Prescribing Opioids for
Chronic Pain
CDC
federal govt
clinicians
Fact sheet
17
Education and
Training Tools
Health Professionals Resources
HHS
federal govt
clinicians
Descriptions
plus links to
additional info
18
Education and
Training Tools
Healthcare Professionals
Overdose Free PA
university
clinicians
descriptions
plus links to
additional info
19
Education and
Training Tools
Managing Pain Safely (MPS) Toolkit
Partnership
HealthPlan of
California
nonprofit
clinicians
Descriptions
plus links to
additional info
20
Education and
Training Tools
Opioid Abuse in Chronic Pain —
Misconceptions and Mitigation
Strategies
NEJM
journal article
clinicians
Journal article
21
Education and
Training Tools
Opioid Prescribing: Safe Practice,
Changing Lives
American Society of
Addiction Medicine
professional
association
clinicians
Online course
22
Education and
Training Tools
Pain Care on a New Track:
Complementary Therapies in the
Safety Net
CHCF
nonprofit
clinics/community
health centers
Report
23
Education and
Training Tools
Pathways to Safer Opioid Use
Office of Disease
Prevention and
Health Promotion,
HHS
federal govt
clinicians
Online course
24
Education and
Training Tools
Prescribing Opioids: Care amid
Controversy
CMA
professional
association
clinicians
Report
Providers
23
Brief Description
Date
Brief summary intended to improve
communication between providers and
patients about the risks and benefits of
opioid therapy for chronic pain, improve
the safety and effectiveness of pain
treatment, and reduce the risks
associated with long-term opioid therapy,
??
including opioid use disorder and
overdose. Topics include determining
when to initiate or continue opioids for
chronic pain; opioid selection, dosage,
duration, follow-up, and discontinuation;
and assessing risk and addressing
harms of opioid use.
Links to resources for safe opioid
prescribing, recognizing opioid abuse,
########
treating opioid abuse, and medicationassisted treatment prescribing.
Information on addiction, including how
to help patients prevent overdose and
??
deal with emergencies. Also has
professional development resources.
Links to a variety of tools and critical
documents related to managing pain
??
including risk calculators, guidelines,
and prescribing in the ED.
Addresses common misconceptions
regarding the abuse-related risks of
########
opioids and risk mitigation strategies.
Online course for all prescribers of
extended-release and long-acting
opioids. Topics include patient
??
assessment, applying and managing
therapy, patient counseling, and drug
knowledge.
Presents strategies that health centers
can use to provide multidisciplinary,
comprehensive treatment for chronic
pain as an alternative to treatment with
opioids; such programs combine
medical therapy, behavioral therapy,
07/2016
physical reconditioning, complementary
and alternative medicine, and selfmanagement education. Includes
examples of innovative chronic pain
programs.
Uses the principles of health literacy and
a multimodal, team-based approach to
promote the appropriate, safe, and
effective use of opioids to manage
########
chronic pain. Simulates choices with the
goal of avoiding opioid-related adverse
drug events.
Information on options for pain
management, evaluating patients for
opioid therapy, opioid treatment plans
2014
and agreements, monitoring and
ongoing assessment, and special patient
populations.
Citations
Provided
URL
No
http://www.cdc.gov/drugoverdo
se/pdf/guidelines_factsheeta.pdf
No
hhs.gov/opioids/healthprofessionals-resources
Yes
http://www.overdosefreepa.pitt.
edu/educationtoolbox/healthcareprofessionals/
No
http://www.partnershiphp.org/P
roviders/HealthServices/Pages
/MPSToolKit.aspx
Yes
http://www.nejm.org/doi/full/10.
1056/NEJMra1507771#t=articl
e
No
asam.org/education/resources/
Opioid-Prescribing
Yes
http://www.chcf.org/~/media/M
EDIA%20LIBRARY%20Files/P
DF/PDF%20P/PDF%20PainTh
erapiesSafetyNet.pdf
No
http://health.gov/hcq/trainingpathways.asp
Yes
http://californiaacep.org/wpcontent/uploads/PrescribingOpioids-Care-AmidControversy-CMA-2014.pdf
Sample Opioid Resources
#
25
Category
Education and
Training Tools
Title
Prescription Opioid Abuse
26
Recovery Within Reach: MedicationEducation and
Assisted Treatment of Opioid Addiction
Training Tools
Comes to Primary Care
27
Education and
Training Tools
Summary of 2015 Interagency
Guideline on Prescribing Opioids for
Pain
28
Education and
Training Tools
SUMMIT: Procedures for MedicationAssisted Treatment of Alcohol or
Opioid Dependence in Primary Care
29
Education and
Training Tools
The Prescription Opioid Epidemic: An
Evidence-Based Approach
30
Guidance on
comparative
performance
feedback
Working in Concert: A How-To Guide
to Reducing Unwarranted Variations in
Care
31
Research and
Evidence
Management of Patients with Opioid
Dependence: A Review of Clinical,
Delivery System, and Policy Options
32
Research and
Evidence
Safe Opioid Prescribing for Adults by
Nurse Practitioners: Part 1. Patient
History and Assessment Standards
and Techniques
33
Support for
patient
conversations
Opioid Prescribing Patient Education
34
Support for
patient
conversations
Sample Patient Agreement Forms
Providers
Organization
American Dental
Association
Organizatio
n Type
professional
association
Target Audience
clinicians
CHCF
nonprofit
clinicians
Washington State
state govt
clinicians
RAND
Johns Hopkins
Bloomberg School of
Public Health
CHCF
nonprofit
university
nonprofit
Type of
Material
Brief Description
Links to educational tools for dentists on
Descriptions
opioid pain medications, including free
plus links to
webinars and some members-only
additional info
content.
Explores options for expanding access
to MAT (specifically, buprenorphine) for
individuals addicted to opioids, provides
recommendations for California clinics
Report
and primary care practices, identifies key
elements to successful primary care
buprenorphine programs, and describes
model programs and approaches.
Information on how to treat the different
phases of pain, including when and how
Fact sheet
to discontinue, addressing special
populations, and recognizing misuse.
Tool for identifying and treating patients
with substance use disorders in primary
care settings, including 1) discussing
alcohol‐or opiate dependence with
patients 2)
‐ guide to treating
How-to guide
alcohol dependent patients with
extended release, injectable naltrexone;
and 3) a guide for administering
buprenorphine/naloxone to patients with
opioid dependence.
Convening at which participants
identified opportunities for intervention
including prescribing guidelines,
prescription drug monitoring programs,
Meeting
pharmacy benefit managers and
summary
pharmacies, overdose education and
naloxone distribution programs,
addiction treatment, and communitybased prevention.
clinicians
clinicians
Information for organizations on how to
providers/provider
How-to guide reduce unwarranted variation in care and
groups
improve efficiency, quality, and patient
experience.
Report on
clinical
Clinical effectiveness review and
effectiveness
economic analysis related to managing
and cost
patients with opioid dependence.
Discusses national standards for safe
opioid prescribing, including the
The Journal for Nurse professional
clinicians
Journal article
importance of patient history and
Practitioners
journal
assessment prior to opioid prescribing.
Tips for how to educate patients on
opioid therapy, including what directions
Ohio State Medical professional
clinicians
Fact sheet
to give to the patient and accompanying
Association
association
explanations.
Two sample agreements for patients
receiving 1) pain treatment with opioids,
health care
Sample
NIDA
federal govt
providers, patients agreement and 2) long term controlled substance
prescriptions.
ICER
nonprofit
clinicians
24
Date
Citations
Provided
URL
??
No
www.ada.org/en/advocacy/adv
ocacy-issues/prescription-drugabuse
03/2016
Yes
http://www.chcf.org/resources/
download.aspx?id={16C05C60758D-42E6-AFE0D0ED72CDB840}
01/2016
No
http://www.agencymeddirector
s.wa.gov/Files/FY16288SummaryAMDGOpioidGui
deline_FINAL.pdf
No
http://nebula.wsimg.com/1735
e46ce18607113746f30247f3fa
ad?AccessKeyId=5647EEC70
4480FB09069&disposition=0&
alloworigin=1
Yes
http://www.jhsph.edu/research/
centers-and-institutes/centerfor-drug-safety-andeffectiveness/opioid-epidemictown-hall-2015/2015prescription-opioid-epidemicreport.pdf
2016
11/2015
http://www.chcf.org/~/media/M
EDIA%20LIBRARY%20Files/P
DF/PDF%20W/PDF%20Worki
ngInConcertReducingVariation
s.pdf
https://icer-review.org/wpcontent/uploads/2016/01/CEP
AC-Opioid-Dependence-FinalReport-For-Posting-July211.pdf
09/2014
Yes
07/2014
Yes
03/2016
Yes
http://www.npjournal.org/article
/S1555-4155(15)010429/fulltext
??
No
osma.org/Documents/Resourc
es/Smart-Rx/Smart-Rx-PatientEducation.pdf
??
No
https://www.drugabuse.gov/sit
es/default/files/files/SamplePat
ientAgreementForms.pdf
Sample Opioid Resources
#
Category
Title
Utilization
management
An Action Guide for Management of
Opioid Dependence: Next Steps for
Payers and Policymakers
2
Utilization
management
Ensuring Safe and Appropriate
Prescription Painkiller Use:
The Important Role of Community
Health Plans
3
Utilization
management
Health Plan Rx for the Opioid Epidemic
CHCF
4
Utilization
management
Opioid Management Program
Implementation 2012-2013
BCBS MA
1
5
Utilization
management
Stemming The Tide Of Prescription
Opioid Overuse, Misuse, And Abuse
Organization
ICER
Alliance of
Community
Health Plans
Health Affairs
Blog
Organization
Target Audience
Type
Type of
Material
Brief Description
Date
Citations
Provided
Action
guide
Information on managing opioid dependence,
including how to improve and expand
treatment to various populations such as
individuals in the criminal justice system, and
implementing medical policies that support
efficient, effective clinical practice.
09/2014
No
plans
Information on initiatives developed by
community-based, not-for-profit health plans
Report with and provider groups to ensure that their
case
members have appropriate access to safe
studies and effective pain management, while
working to limit the risk of opioid misuse or
dependence.
2012
Yes
nonprofit
plans
Identifies 4-part prescription to address the
opioid epidemic: promote judicious
Infographic prescribing practices; focus on improved
member outcomes; identify overuse, misuse,
and fraud; and support safe communities.
06/2016
No
nonprofit
plans
Case study
Describes management program for shortacting and long-acting opioids. Program
includes prescriber opioid reports and
suboxone/buprenorphine case management.
6/20/2014
Yes
Journal
article
Information on Kaiser Permanente's system
approach to the opioid epidemic, including
development of up-to-date evidence-based
treatment guidelines, and prescriber
education and training. Efforts led to a decline
in use of opioids across most of KP’s service
area, (8 states and DC).
9/22/2015
No
06/2016
Yes
06/2016
Yes
1/28/2016
Yes
nonprofit
professional
association
journal article
plans,
policymakers
plans
6
Utilization
management;
Benefit design
Case Studies: Three California Health
Plans Take Action Against Opioid
Overuse
CHCF
nonprofit
plans
Case
studies
Highlights three health plans (Partnership
Health Plan of CA, Blue Shield of CA, Kaiser
Permanente Southern CA) that adopted multipronged approaches to address the opioid
epidemic and reduced opioid prescribing
rates by up to 50%.
7
Utilization
management;
Benefit design
Changing Course: The Role of Health
Plans in Curbing the Opioid Epidemic
CHCF
nonprofit
plans
Issue brief
Explores tools that plans have to decrease
opioid overprescribing: engaging providers,
working with high-risk members, addressing
misuse, and supporting healthy communities.
8
Utilization
management;
Benefit design
CMCS Informational Bulletin: Best
Practices for Addressing Prescription
Opioid Overdoses, Misuse and
Addiction
Payers
CMS
federal govt
Medicaid
programs
Describes several Medicaid pharmacy benefit
management strategies for mitigating
prescription drug abuse and discusses
Guidance
strategies to increase the provision of
naloxone to reverse opioid overdose, thereby
reducing opioid-related overdose deaths.
25
URL
https://icer-review.org/wpcontent/uploads/2016/01/FINALPayer-Action-Guide.pdf
http://www.achp.org/wpcontent/uploads/ACHP-BriefEnsuring-Safe-and-AppropriatePrescription-Painkiller-Use1.pdf
http://www.chcf.org/~/media/MEDIA
%20LIBRARY%20Files/PDF/PDF%
20H/PDF%20HealthPlansOpioidInfo
graphic.pdf
https://www.nhpf.org/uploads/Hando
uts/Kowalski-slides_06-20-14.pdf
http://healthaffairs.org/blog/2015/09/
22/stemming-the-tide-of-prescriptionopioid-overuse-misuse-and-abuse/
http://www.chcf.org/~/media/MEDIA
%20LIBRARY%20Files/PDF/PDF%
20C/PDF%20CaseStudiesHealthPla
nsOpioid.pdf
http://www.chcf.org/~/media/MEDIA
%20LIBRARY%20Files/PDF/PDF%
20C/PDF%20ChangingHealthPlans
Opioid.pdf
https://www.medicaid.gov/federalpolicy-guidance/downloads/cib-02-0216.pdf
Sample Opioid Resources
#
9
10
11
Category
Utilization
management;
Benefit design
Utilization
management;
Benefit design
Utilization
management;
Benefit design
Payers
Title
Managing Pain Safely: Multiple
Interventions to Dramatically Reduce
Opioid Overuse
Minimum Insurance Benefits for
Patients with Opioid Use Disorder
Organization
Partnership
Health Plan of
CA
Organization
Target Audience
Type
non-profit
public health
plan
plans
Type of
Material
Brief Description
Describes plan's initiative re: opioid
prescribing including internal workgroups
focused on pharmacy, provider network,
community initiatives, member services/care
coordination/ utilization management, policy
Case study and communication, and data management.
Efforts led to a 48% decrease in total opioid
prescriptions per 100 members per month.
Includes a variety of risk assessment tools
and identifies key factors for outcomes
achieved.
California Society
Describes evidence-based best practices and
professional plans, employers,
of Addiction
Fact sheet minimum benefits for patients with opioid use
association
policymakers
Medicine
disorder.
National Center
Prescription Opioid Abuse: Challenges
for Biotechnology federal govt
and Opportunities for Payers
Information
plans
Meeting
summary
26
Identifies strategies to mitigate financial risks
associated with opioid abuse. Includes
internal strategies such as formulary controls,
claims data surveillance, and claims
matching; as well as external policies and
procedures that support and educate
physicians on reducing opioid risks among
patients with chronic pain.
Date
2015?
Citations
Provided
URL
Yes
https://www.cdph.ca.gov/Documents/
PHP_MultipleInterventionstoDramati
callyReduceOpioidOveruse.pdf
8/31/2015
2013
Yes
http://www.csamasam.org/sites/default/files/pdf/misc/
csam-insurance_benefits_opioids2016-approved.pdf
Yes
ncbi.nlm.nih.gov/pmc/articles/PMC3
680126
Tracking Overuse of Opioids – August 2016
Objective: To inform the tracking and monitoring component of the Statewide Workgroup on Reducing
Overuse’s work on opioids, this document provides a brief overview of data sources, performance
measures, and monitoring efforts underway related to use of opioids in California.
Background: The opioid epidemic has gained increasing attention due to the increased number of opioid
overdose related deaths, the billions of dollars spent annually on medical and drug abuse treatments,
and the increase in prescription drug use – all of which have significantly impacted patient, providers,
and health plans. Tackling overuse of opioids requires the ability to measure current status and
progress over time – and activity in this area is proliferating in response to the problem. This document
covers:
 CDPH Dashboard, resulting from the efforts of the Prescription Opioid Misuse and Overdose
Prevention Workgroup’s Data Task Force
 California’s CURES database
 Performance measures currently in use, including by the IHA’s Value Based P4P program
CDPH Dashboard
The California Department of Public Health (CDPH) and its state partners convened a Prescription Opioid
and Overdose Prevention Workgroup in Spring 2014. This workgroup is exploring opportunities to
improve collaboration and expand joint efforts among state departments working to address this
epidemic. It has identified two priorities: expansion and strengthening of prevention strategies and
improvement of monitoring and surveillance. Toward the second priority, the Workgroup’s Data Task
Force is charged with promoting and increasing access and sharing of high-quality data on prescription
drug (opioid) use and misuse for the purpose of reducing prescription drug overdoses and deaths
throughout California. The Task Force is leading development of a dashboard that will provide online
access to wide variety of indicators related to use of opioids in California, scheduled for public release in
fall 2016.
California’s CURES Database (Controlled Substance Utilization Review and Evaluation System)
CURES is an online system through which prescribers and pharmacists must submit weekly data on
Schedule II through IV controlled substances to the Department of Justice. All California prescribers
authorized to prescribe scheduled drugs and licensed pharmacists are required to register for access to
CURES 2.0 by July 1, 2016. Only prescribers and pharmacists are able to access CURES data for patient
care purposes. CURES receives about 1 million prescriptions per week, and the uniform submission
requirement allows for aggregation of data across prescribers and pharmacists. Based on the data,
CURES makes several patient alerts available to support patient care:
1. Patient is currently prescribed more than 100 morphine milligram equivalents per day
2. Patient has obtained prescriptions from 6 or more prescribers or 6 or more pharmacies during last 6
months
3. Patient is currently prescribed more than 40 morphine milligram equivalents of methadone daily
27
4. Patient is currently prescribed opioids more than 90 consecutive days
5. Patient is currently prescribed both benzodiazepines and opioids
The CURES database is the California version of the national Prescription Drug Monitoring Program
(PDMP). Data from California and other states is analyzed by the PDMP Center of Excellence (COE) at
Brandeis University, and publicly reported, with funding from the DOJ. The resulting Prescription
Behavior Surveillance Systems (PBSS) provides epidemiological analyses of de-identified data to help
target and evaluate interventions aimed at reducing prescription drug abuse and diversion.
Performance measures currently in use, including by the IHA’s Value Based P4P program
IHA developed a matrix that provides an overview of the existing clinical quality measures used to track
and improve the effective use of opioid medications (see exhibit). An array of measures are currently in
use, with involvement from the following state and national performance measure sets and measure
stewards: Pharmacy Quality Alliance (PQA), AHRQ’s National Quality Measures Clearinghouse (NQMC),
PQRS, PRIME, QRS, CMS Medicaid Adult Core Sets, HEDIS, and NCQA.
In July 2016, the Value Based Pay for Performance program (managed by IHA) adopted PQA’s three
opioid measures as testing measures for Measurement Year 2017.
28
OPIOID PERFORMANCE MEASURES – AUGUST 2016
Alignment
Measure
Opioid High Dosage: The
proportion (XX out of 1,000) of
individuals without cancer
receiving a daily dosage of opioids
greater than 120mg morphine
equivalent dose (MED) for 90
consecutive days or longer
Multiple Prescribers and Multiple
Pharmacies: The proportion (XX
out of 1,000) of individuals
without cancer receiving
prescriptions for opioids from four
(4) or more prescribers AND four
(4) or more pharmacies
Multi-Provider, High Dosage: The
proportion (XX out of 1,000) of
individuals without cancer
receiving prescriptions for opioids
greater than 120mg morphine
equivalent dose (MED) for 90
consecutive days or longer, AND
who received opioid prescriptions
from four (4) or more prescribers
AND four (4) or more pharmacies
Substance use disorders:
Percentage of patients aged 18
years and older with a diagnosis of
current opioid addiction who were
counseled regarding psychosocial
AND pharmacological treatment
options for opioid addiction within
the 12 month reporting period
Steward
PRIME1
QRS2
CMS Medicaid
Adult Core Sets
PQA
X
added 2016
PQA
X
added 2016
3
X
added 2016
PQA
4
NQMC :
004208
Measure description
Assessment and management of
chronic pain: percentage of
patient’s diagnoses with chronic
pain who are prescribed an opioid
who have an opioid agreement
form and urine toxicology screen
documented in the medical record
Measure description
1
NQMC:
009368
X
Public Hospital Redesign and Incentives in Medi-Cal (DSRIP 2.0) = PRIME
Quality Ratings System = QRS
1
3
Pharmacy Quality Alliance = PQA
4
National Quality Measures Clearinghouse = NQMC
29
2
IHA VBP4P
X
Testing
measures
for MY
2017
X
Testing
measures
for MY
2017
X
Testing
measures
for MY
2017
Comments
Endorsements: Going
through NQF endorsement
over the next 6-9 months
Changes in morphine
milligrams equivalents
(MME) levels is on the radar
due to input from other
specialty societies;
Note: CDC – suggests max
of 90 mg MED;
CMA – suggests max of 100
mg MED
IHA Update: Measures will
be available for public
comment in September
Alignment
Measure
Assessment and Management of
chronic pain: Percentage of
patients diagnosed with chronic
pain with a diagnosis of
neuropathic pain who are
prescribed an anti-neuropathic
non-opioid medication prior to
use of opioids
Measure description
Assessment and management of
chronic pain: percentage of
patients diagnosed with chronic
pain who are prescribed an opioid
at a dose less than 100 mg per day
of morphine
Measure description
AOD Dependence: The percentage
of adolescent and adult patients
with a new episode of alcohol or
other drug (AOD) dependence
who received Initiation of AOD
Treatment; Engagement of AOD
Treatment
Measure description - HEDIS
Measure description - QRS
Opioid Therapy Evaluation:
Chronic opioid therapy follow-up
evaluation
Measure description
Documentation of Opioid
Treatment: Documentation of
signed opioid treatment
agreement Measure description
Opioid Evaluation of Misuse:
Evaluation or interview for risk of
opioid misuse
Measure description
Steward
PRIME1
QRS2
CMS Medicaid
Adult Core Sets
IHA VBP4P
Comments
NQMC:
009366
NQMC:
009370
**NQF #1799
HEDIS;
NCQA
004
X
Initiation Benchmarks
(2015)
CA HMO/POS Avg.: 32.97%
National HMO Avg.: 31.85%
Engagement Benchmarks
(2015) CA HMO/POS Avg.:
10.63%
National HMO Avg.: 10.35%
PQRS
#408
Registry based measures –
eligible professionals
report 9 measures covering
3 domains
PQRS
#412
Registry based measures –
eligible professionals
report 9 measures covering
3 domains
PQRS
#414
Registry based measures –
eligible professionals
report 9 measures covering
3 domains
Glossary
• Morphine Equivalent Dosage (MED) – numerical standard against which most opioids can be compared, yielding an apples-toapples comparison of each medication’s potency
• Morphine Milligram Equivalents (MME) – numerical threshold total daily dose of opioids
• Methadone - an opioid medication that is used to reduce withdrawal symptoms in people addicted to heroin or other narcotic
drugs without causing the ”high” associated with the drug addiction
• Buprenorphine–a medication proven to be effective in lowering death rates from opioid addiction, and increasing retention in
2
treatment.
30
May 2016
California Department of Public Health (CDPH)
California Prescription Drug Overdose Prevention Initiative
Background:
The Centers for Disease Control and Prevention (CDC) awarded the California Department
of Public Health (CDPH) a four year, $3.7 million federal grant for the California
Prescription Drug Overdose Prevention Initiative on September 1, 2015. The purpose
of the grant is to advance and evaluate comprehensive interventions for preventing
prescription drug overuse, misuse, abuse, and overdose, particularly the misuse and
inappropriate prescribing of opioid pain relievers.
Current Grant Activities:
The California Prescription Drug Overdose Prevention Initiative is expanding public
health efforts started in 2014 by the CDPH Director’s state-level Prescription Opioid Misuse
and Overdose Prevention Workgroup, currently working on the following:
1. Promoting registration and use of the Department of Justice’s new Controlled
Substance Utilization Review and Evaluation System (CURES 2.0) prescription drug
monitoring program by prescribers and dispensers of Drug Enforcement Agency
scheduled drugs;
2. Developing policy and practice opportunities for health care systems and health
insurance plans to promote safe prescribing, access to medically assisted treatment
and naloxone;
3. Developing a one-to-one educational outreach program (known as academic detailing)
for prescribers and dispensers in high burden areas of the state to promote safe
prescribing, access to medically assisted treatment and naloxone;
4. Providing data, technical assistance and support to local health departments,
coalitions and community members in translating overdose and related data into
actionable information to address the opioid prescription/illicit drug problem
locally;
5. Providing support to the CDPH Director’s Prescription Opioid Misuse and Overdose
Prevention Workgroup which is convening four task force groups on communications
and outreach, data gathering and sharing, integrated health care and policy, and
treatment; and,
6. Conducting process and outcome evaluation of the interventions to improve practice
and identify effective strategies for expansion and replication.
CDPH is also partnering with the California Healthcare Foundation (CHCF) to fund 17 local
coalitions (representing 24 counties) to promote safe prescribing, use of Naloxone, and
expansion of medically assisted treatment options. CHCF awarded grants to organizations
covering the following counties: Alameda-Contra Costa, Humboldt, Lake, Los Angeles,
Mendocino, Napa, Northern Sierra (Lassen, Plumas, Sierra), Orange, Placer-Nevada, San
Luis Obispo, Santa Clara, Santa Cruz, Shasta, Tuolumne and Yolo-Napa-Marin-Sonoma.
CDPH is providing funding to the local health departments in Plumas and Tuolumne
Counties.
31
Awards for Performance on C-sections: Recommended Approach
Today’s Objective: To present a recommendation to the Overuse Workgroup for a hospital-level recognition
award for performance on C-sections to be awarded in October.
BACKGROUND
Cesarean deliveries can be life-saving procedures. However, increasing numbers of healthy women are
undergoing these surgical procedures when they may not be medically indicated. These practices result in a
higher rate of complications for mothers and babies. Furthermore, approximately 90% of women with a prior
cesarean have subsequent deliveries by cesarean, leading to higher risks of major complications. With more
than 500,000 births every year in California, there is a compelling need to reduce unnecessary cesarean
deliveries and to provide appropriate, evidence-based care.
While much attention is given to incentives that focus on payment, non-financial rewards can also be very
powerful motivators in changing provider behavior. As a part of the second phase of the project, the Statewide
Workgroup on Reducing Overuse (“Overuse Workgroup”) is exploring the development of awards for hospitals
that achieve the Healthy People 2020 national goal of reducing C-section births among low-risk, first time
mothers1 to 23.9 percent. To support this work, IHA led a call with California leaders in maternity care (see
Appendix A for a participant list) to discuss different approaches for the recognition awards and, based on their
feedback, developed the following proposal and next steps as outlined below.
RECOGNITION AWARDS OVERVIEW
Award Level
Developing a recognition award at the hospital level is the most actionable pathway for the Workgroup to
pursue at this time. Hospital NTSV C-section rates across the state vary dramatically, ranging from 12% to 70%.
Reducing the rates for low-risk, first time birth represents a real opportunity for improvement. Furthermore,
hospital C-section rates are publicly reported in California (via CalQualityCare.org). IHA is actively exploring ways
to effectively and meaningfully measure the quality of maternity care at the physician organization (PO) level,
but this data is not yet available.
Awards Methodology
For the first year of the recognition program, the recommendation is to focus on a “Keep it Simple” approach for
the awards. The awards will focus only on highlighting hospitals that meet or exceed the Healthy People 2020
target of reducing C-section births among low-risk mothers to 23.9 percent. This approach leads to a
straightforward methodology that can easily identify the award winners from publicly reported rates, using a
widely accepted data source (CMQCC) and measure (NQF endorsed). Additionally, the “Keep it Simple” approach
will be easy to implement this year.
The Healthy People 2020 target is a modest threshold for hospitals to work towards and the goal of this
recognition program will be to have 100% of California hospitals below this target. In subsequent years, the
1
Otherwise known as NTSV (Nulliparous, Term, Singleton, Vertex) C-Section
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Overuse Workgroup could explore the development of a tiered recognition program, one that recognizes
hospitals that achieve the basic 23.9% threshold, another that rewards hospitals for top performance on
reducing low-risk, first time C-sections, and/or another that could reward the most improved hospitals.
Awarding Body
The Overuse Workgroup, co-chaired by Covered California, DHCS and CalPERS, will act as the awarding body for
the public recognition awards program. As the three largest purchasers of health care in California, the
organizations cover well over half of the births in the State, and will be influential in creating change.
Timeline
Currently California hospitals’ C-section rates are publicly reported annually on CalQualityCare.org. Transition
planning is underway to transfer ownership from CHCF to CHART. In order to garner as much press as possible
for the recognition awards, the Overuse Workgroup will work with CHART to coincide an annual press
conference announcing the award winners with their public reporting timeline.
The Office of Statewide Health Planning and Development (OSPHD) will be releasing data for the second half of
2015 shortly. CMQCC and CHART will calculate the NTSV rate for public reporting once the data is available.
Once calculated, hospitals will be allowed a review period before rates are publicly reported by CHART. Based
on this timeline, a press conference to announce recognition award winners will be planned for mid-October.
Public Recognition Event
The Overuse Workgroup co-chairs, together with the California Health and Human Services Agency (CHHS), will
work together to hold a press conference to showcase hospitals that meet the 2020 target. The prime audience
for the event will be the media in order to garner significant press and influence hospital leadership. The plan
will be to engage Secretary Dooley, who is supportive of public recognition awards, to announce hospitals that
meet the 2020 threshold on behalf of the Overuse Workgroup co-chairs.
Next steps will include organizing a subgroup, led by Covered California and CHHS, to organize the October press
conference and to investigate the possibility of an event for hospitals at a later date. The subgroup will develop
a communications plan in order to enhance media coverage. Additionally, while the recognition is at the hospital
level, the subgroup will also coordinate efforts with ACOG on the communications strategy to ensure providers
are also engaged since they are key partners in this work.
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Appendix A: Maternity Leaders Consulted on Recognition Awards Proposal
Organization
American Congress of Obstetricians and
Gynecologists (ACOG), District 9
Participants
John Wachtel, Chair
Stephanie Teleki, Senior Program Officer, High-Value Care
California HealthCare Foundation (CHCF)
Eric Antebi, Communications Officer
California Health & Human Services Agency
(CHHS)
Katie Heidorn, Deputy Secretary
California Hospital Assessment and
Reporting Taskforce (CHART)
Bruce Spurlock, Chair
Claire Manneh, CHPSO, Director of Programs
Hospital Quality Institute (HQI)
Julie Morath, President/CEO
Elliot Main, Medical Director
California Maternal Quality Care
Collaborative (CMQCC)
Cathie Markow, Administrative Director
Ann Castles, Project Manager, Maternal Data Center
Lance Lang, Chief Medical Officer
Covered California
Ahmed Al-Dulaimi, Research Specialist
Department of Health Care Services (DHCS)
Julia Logan, Chief Quality Officer
Sarah Lally, Project Manager
Integrated Healthcare Association (IHA)
Jill Yegian, Senior Vice President, Programs and Policy
Diane Stewart, Senior Director
Pacific Business Group on Health (PBGH)
Brynn Rubenstein, Senior Manager
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