Addiction is a complex disease. To beat this epidemic, a diverse group of stakeholders will need to develop cohesive strategies, coordinate their approaches, and establish a funding model that rewards performance, and incentivizes investment, in line with payment model transition.
The “opioid epidemic” continues to make headlines across the United States due to the sharp increase in opioid-related drug overdoses. A quick Google Trends search reveals that in April 2017, the term opioid epidemic generated more online searches than it ever had before. But for all this newfound attention, the opioid epidemic is still producing countless tragic stories that are being felt by individuals in very personal ways—leaving lives ruined or lost, as well as a nation grappling with policy and funding decisions, in its wake.
First, some background.
In 2015, there were more than 33,000 deaths from drug overdoses involving opioids in the United States, that’s about a 16% increase from 2014 according to the Centers for Disease Control and Prevention. Death rates from synthetic opioids (excluding Methadone), in particular, have grown by a staggering 70%-plus.1 Frequently prescribed by physicians, synthetic opioids include common painkillers that have been created in labs (e.g. codeine, fentanyl, oxycodone). These highly addictive and potent medications have effectively flooded the market—there are now more than 650,000 opioid prescriptions dispensed each day in the U.S.1 The inevitable bi-product of an increase in availability and consumption, overdoses—about 80 people die every day from an opioid-related overdose.2
The social and economic impact of this crisis is difficult to comprehend. We are spending nearly $55 billion each year to combat prescription opioid abuse.2 That equates to more than $2,600 for every individual struggling with a substance abuse disorder. And considering how many of these individuals go undiagnosed or untreated, we are probably seeing just the tip of the iceberg.
Recently, The Department of Health and Human Services announced they would be raising their stake by providing another $485 million in grant funding to help fight the opioid epidemic. But money alone cannot solve this problem. Without clear policy and accompanying objectives, it becomes extremely difficult to determine what, if anything, is helping to move the needle in the fight against addiction.
Establishing objectives, why is it so hard?
Clinical Quality Measures (CQMs) are defined by the Centers for Medicare and Medicaid Services (CMS) as “tools that help measure and track the quality of health care services provided by eligible professionals, eligible hospitals and critical access hospitals within our health care system.”3 As payment models shift from pay-for-service to pay-for-value, CQMs are proving to be the new unit of exchange, the currency of tomorrow’s healthcare delivery system. Increasingly, providers will be (and are) incentivized, judged, and paid based upon how they perform relative to clinical quality targets.
The National Quality Forum (NQF) is a non-profit organization that helps promote CQMs based upon a rigorous vetting system. Most clinical bodies, associations, and organizations that develop CQMs (i.e. NCQA, The Joint Commission, American Society of Addiction Medicine) seek endorsement from the NQF for the measures they put forth. CMS, for its part, has identified NQF as the experts in CQMs. Clinical quality measures receiving NQF endorsement are more likely to be used as a proxy for performance by both private and public payers because they have been subject to rigorous evaluation by large committees and are correlated with evidence-based care. The NQF has indexed more than 600 endorsed measures, but up until now only a limited number of measures have targeted substance abuse and addiction.
The Patient Safety Standing Committee oversees the NQF patient safety measure portfolio. This body evaluates newly submitted and previously endorsed measures against NQF's measure evaluation criteria. They also identify gaps in the portfolio, provide feedback on gaps, and conduct ad hoc reviews. On December 13, 2016, the NQF’s Consensus Standards Approval Committee (CSAC) reviewed the Standing Committee’s recommendations and endorsed 11 new measures, three of which were developed by the Pharmacy Quality Alliance (PQA) and designed to specifically address the use of opioids.4 They draw attention to use of high dosages or prescriptions from multiple providers, with appropriate exclusions, including cancer patients. These are the first NQF-endorsed measures which confront the nation’s devastating and increasing opioid epidemic.
Now come the next set of challenges, including data capture, which up to this time, has not been mandated or normalized from site to site. Once standardized, benchmarking and systemic performance improvement efforts may follow more easily.
Why CQMs are important within the context of combating addiction.
Guidelines have been created to help administer appropriate treatment for opioid addicts, such as the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Behavioral Health Quality Framework. Also, the American Society of Addiction Medicine’s (ASAM) board approved a set of performance measures for addiction specialist physicians in 2015.5 The adoption of addiction-specific CQMs will offer providers, insurers, and pharmacists the ability to measure progress and commit resources—for both individuals and populations. Building a universal database of standard addiction-related CQMs that can be tracked, analyzed, and used to improve interventions—that’s the next series of steps for us to take.
Addiction is a complex disease. To beat this epidemic, a diverse group of stakeholders will need to develop cohesive strategies, coordinate their approaches, and establish a funding model that rewards performance, and incentivizes investment, in line with payment model transition. It is often said that you can’t improve what you are unable to measure. We currently track a critically important outcome measure, overdose deaths. But our improvement efforts will be well served by the development of process measures which offer quick turnaround in response to interventions. It is through this lens that CQMs become an important barometer in combating opioid addiction.
Joseph Siemienczuk, MD, Chief Medical Officer, Enli Health Intelligence
Ginger Pape, PharmD, Senior Clinical Advisor, Enli Health Intelligence
1. CDC. National Vital Statistics System, Mortality. CDC WONDER. Atlanta, GA: US Department of Health and Human Services, CDC; 2016. https://wonder.cdc.gov/
2. Birnbaum, H. G., White, A. G., Schiller, M., Waldman, T., Cleveland, J. M., & Roland, C. L. (2011). Societal Costs of Prescription Opioid Abuse, Dependence, and Misuse in the United States. Pain Medicine,12(4), 657-667. doi:10.1111/j.1526-4637.2011.01075.x
3. Center for Medicare & Medicaid Services. Clinical Quality Measures. (2015, September 04). Retrieved May 12, 2017, from https://www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/clinicalqualitymeasures.html
4. Department of Health and Human Services. Patient Safety 2016 Final Report. (2017, March 15). Retrieved June 19, 2017, from https://www.qualityforum.org/Publications/2017/03/Patient_Safety_Final_Report.aspx
5. Behavioral Healthcare Summer 2015. (n.d.). Retrieved May 12, 2017, from http://mydigimag.rrd.com/publication/frame.php?i=262557&p=&pn=&ver=html5&view=articleBrowser&article_id=2032750