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The American Journal of Managed Care March 2019
Fragmented Ambulatory Care and Subsequent Emergency Department Visits and Hospital Admissions Among Medicaid Beneficiaries
Lisa M. Kern, MD, MPH; Joanna K. Seirup, MPH; Mangala Rajan, MBA; Rachel Jawahar, PhD, MPH; and Susan S. Stuard, MBA
Incorrect and Missing Author Initials in Affiliations and Authorship Information
From the Editorial Board: Austin Frakt, PhD
Austin Frakt, PhD
Implications of Eligibility Category Churn for Pediatric Payment in Medicaid
Deena J. Chisolm, PhD; Sean P. Gleeson, MD, MBA; Kelly J. Kelleher, MD, MPH; Marisa E. Domino, PhD; Emily Alexy, MPH; Wendy Yi Xu, PhD; and Paula H. Song, PhD
Factors Influencing Primary Care Providers’ Decisions to Accept New Medicaid Patients Under Michigan’s Medicaid Expansion
Renuka Tipirneni, MD, MSc; Edith C. Kieffer, PhD, MPH; John Z. Ayanian, MD, MPP; Eric G. Campbell, PhD; Cengiz Salman, MA; Sarah J. Clark, MPH; Tammy Chang, MD, MPH, MS; Adrianne N. Haggins, MD, MSc; Erica Solway, PhD, MPH, MSW; Matthias A. Kirch, MS; and Susan D. Goold, MD, MHSA, MA
Did Medicaid Expansion Matter in States With Generous Medicaid?
Alina Denham, MS; and Peter J. Veazie, PhD
Access to Primary and Dental Care Among Adults Newly Enrolled in Medicaid
Krisda H. Chaiyachati, MD, MPH, MSHP; Jeffrey K. Hom, MD, MSHP; Charlene Wong, MD, MSHP; Kamyar Nasseh, PhD; Xinwei Chen, MS; Ashley Beggin, BS; Elisa Zygmunt, MSW; Marko Vujicic, PhD; and David Grande, MD, MPA
Medicare Annual Wellness Visit Association With Healthcare Quality and Costs
Adam L. Beckman, BS; Adan Z. Becerra, PhD; Anna Marcus, BS; C. Annette DuBard, MD, MPH; Kimberly Lynch, MPH; Emily Maxson, MD; Farzad Mostashari, MD, ScM; and Jennifer King, PhD
Currently Reading
Common Elements in Opioid Use Disorder Guidelines for Buprenorphine Prescribing
Timothy J. Atkinson, PharmD, BCPS, CPE; Andrew J.B. Pisansky, MD, MS; Katie L. Miller, PharmD, BCPS; and R. Jason Yong, MD, MBA
Gender Differences in Prescribing of Zolpidem in the Veterans Health Administration
Guneet K. Jasuja, PhD; Joel I. Reisman, AB; Renda Soylemez Wiener, MD, MPH; Melissa L. Christopher, PharmD; and Adam J. Rose, MD, MSc
Cost Differential of Immuno-Oncology Therapy Delivered at Community Versus Hospital Clinics
Lucio Gordan, MD; Marlo Blazer, PharmD, BCOP; Vishal Saundankar, MS; Denise Kazzaz; Susan Weidner, MS; and Michael Eaddy, PharmD, PhD
Health Insurance Literacy: Disparities by Race, Ethnicity, and Language Preference
Victor G. Villagra, MD; Bhumika Bhuva, MA; Emil Coman, PhD; Denise O. Smith, MBA; and Judith Fifield, PhD

Common Elements in Opioid Use Disorder Guidelines for Buprenorphine Prescribing

Timothy J. Atkinson, PharmD, BCPS, CPE; Andrew J.B. Pisansky, MD, MS; Katie L. Miller, PharmD, BCPS; and R. Jason Yong, MD, MBA
This article presents a synthesis of opioid use disorder guidelines and a framework to link them to claims data and recognize higher-quality practice, monitor outcomes, and individualize intervention.

Objectives: This study sought to formulate a consolidation of guidelines representing best practices related to office-based opioid treatment (OBOT) of opioid use disorder (OUD) using buprenorphine. It also demonstrates how a set of evidence-based guidelines may be linked with claims data to leverage analytic techniques that drive cost-effective, positive health outcomes.

Study Design: Literature review of US and international guidelines for OBOT using buprenorphine for OUD.

Methods: The study conducted a review of currently available US and several international guidelines from 2009 to 2018 published on OUD and the use of buprenorphine in OBOT. Guidelines were consolidated based on common elements. The process of correlating common elements with available commercial and state Medicaid claims data is described, including which elements are amenable to analysis along with relative complexity.

Results: Seven guidelines met inclusion criteria and are presented as 3 tables, organized by clinical themes and phase of care related to OBOT use of buprenorphine for OUD. Themes included establishing care, monitoring treatment stability and engagement, and nonpharmacologic treatment to improve outcomes. Areas of agreement and divergence between guidelines are highlighted. Specific components are identified as they relate to metrics of interest to public and private payers.

Conclusions: Among US and international guidelines for treatment of OUD, common themes are readily identified and may indicate agreement in regard to interventions. Linking pharmacy and medical billing claims data to evidence-supported best practices provides public and private payers the ability to track individual patients, facilitate high-quality care, and monitor outcomes.

Am J Manag Care. 2019;25(3):e88-e97
Takeaway Points
  • Opioid use disorder (OUD) continues to be a widespread and expensive health problem, with illicit use currently driving increased adverse events and costs disproportionately directed to public and private managed care organizations and health plans.
  • We propose a consensus of elements common to US and several international guidelines as the basis for an analytic approach to identifying patients in need of targeted intervention and providers demonstrating exemplary clinical practice.
  • An analytic approach to using data already available to public and private health plans and managed care organizations has the potential to effectively target interventions and resources to the time and place they are needed in order to make a cost-effective, high-value impact on the care of individuals with OUD.
Despite widespread efforts by private- and public-sector healthcare providers, organizations, and policy makers, the opioid epidemic in the United States has shown few signs of abating. Widespread opioid prescribing has resulted in many patients developing opioid use disorder (OUD), which is described by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, as “a problematic pattern of opioid use leading to clinically significant impairment or distress” with at least 2 specific criteria within a 12-month period.1 Based on cross-sectional data from between 2006 and 2011 from the National Survey on Drug Use and Health (NSDUH), the number of individuals in the United States with OUD was estimated to be 2.1 million.2 Furthermore, 2016 NSDUH results showed that approximately 3.3 million Americans engaged in nonmedical use of prescription opioids within the past month, suggesting that the number of additional individuals at risk for developing OUD is substantial.3

The CDC reported 2016 data showing 42,249 opioid-related drug overdose deaths, driven primarily by an increase in deaths involving heroin and synthetic opioids believed to be fentanyl derivatives.4 This marks a continuing trend of a rising death toll from opioid-related deaths over the preceding decade, with growing focus on illicit drug use and less on opioid prescribing alone.5 Even with the ongoing emphasis on healthcare provider education, increased regulations limiting prescription opioids, and expansion of prescribing limits for buprenorphine, OUD remains undertreated and prevalence continues to climb, secondary to illicit opioid use.

OUD and opioid-related adverse events including overdose are associated with significant societal costs, morbidity, and mortality. The economic burden of opioid overdose, abuse, and dependence includes medical and OUD treatment costs, lost work productivity, and the societal costs of those who enter the criminal justice system. Using 2013 data, this total economic burden was estimated at $78.5 billion annually, with $28.9 billion associated with healthcare and substance abuse treatment costs.6 However, a 2017 report by the US Council of Economic Advisors states that previous figures underestimated the total healthcare burden of OUD by not including the economic costs of overdose deaths and illicit use, and their analysis reflects a cost of $504 billion in 2015.7 Results of analyses using commercial insurance databases have shown that opioid abuse results in excess healthcare costs per patient of between $10,627 and $14,810 annually.8,9 A 2015 review of the available literature using data from 2009 to 2014 regarding increased healthcare costs for opioid users suggested that the average cost to a payer for a patient with OUD is $23,000 to $25,000 per year, of which increased costs attributable to OUD are approximately $15,000 per patient annually.10

OUD is fundamentally a public health problem, and its high economic burden makes it a source of financial incentive for both commercial and public (ie, Medicare or state Medicaid) health plans and accountable care organizations—all hereafter referred to as payers—to facilitate adequate treatment of patients with OUD. In early 2017, the chief executive officers of several prominent payer organizations approached this study’s sponsor specifically requesting assistance to monitor OUD treatment and identify providers of high-quality care using claims data. The comprehensive review presented herein represents the initial analysis critical to the creation of a surveillance solution for OUD using data analytics. High-quality care guidance must begin with a consolidation of available evidence to identify and implement best practices, yet multiple national and international stakeholder organizations publish OUD treatment guidelines. Practice pattern variation is inevitable when each organization promotes the recommendations of its own subject matter experts. Nevertheless, harmonious definitions can be leveraged to identify and track individuals with OUD to provide them with appropriate treatment resources, prioritize early intervention, and promote sustained recovery. Effectively achieving this aim requires completing several crucial tasks: (1) tracking members who are at risk for OUD or currently diagnosed with OUD, (2) coordinating care and facilitating access to high-quality providers, and (3) measuring treatment outcomes for these patients as well as determining the impact of providers.

Proposed Solutions

Our proposed solution for these problems employs a summary of widely recognized treatment guidelines and clinically validated best practices. We present a review of the major US, and several international, OUD treatment guidelines where consensus among common elements leads to best practice and areas of discrepancy may account for practice pattern variation. By culling the shared elements across a number of guidelines, we are able to focus on aspects that are measurable and actionable for a payer that desires an evidence-based, consistent approach to managing OUD. Tracking actionable aspects of the consolidated common elements among these guidelines requires linking them to relevant medical billing and pharmacy claims data. This framework provides a foundation for defining the criteria by which at-risk patients are identified and the quality of treatment outcomes is assessed. Payers can utilize this data management and solutions approach to identify high-value providers and subsequently create a network of higher-quality and accessible recovery centers to which patients with OUD may be directed; this would thus drive high-quality outcomes and lower healthcare costs among individuals with OUD.

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