October 11, 2019
Seema Verma, Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Re. Request for Information (RFI) for the Development of a CMS Action Plan to Prevent Opioid
Addiction and Enhance Access to Medication-Assisted Treatment
Dear Administrator Verma:
Thank you for the opportunity to respond to your RFI on ways to address the opioid crisis through the HHS Action Plan. The National Committee for Quality Assurance (NCQA) supports HHS efforts to review and enhance CMS payment and coverage policies related to both the provision of treatment for individuals with substance use disorders (SUDs) and acute and chronic pain. NCQA is dedicated to the continued development and strengthening of performance measures to assess the quality of care delivered to these populations, as well as continued contribution to the growing body of observational research related to disparities in current treatment of both pain and opioid use disorder (OUD) in the United States. Our work to date in this area has illuminated a number of challenges and barriers that CMS may be able to take action to address, described in more detail below.
We outline four areas that specifically target key questions posed in the RFI:
- Support access to non-opioid pain management by including additional non-opioid therapies in reimbursement policies, incentivizing care models that integrate multiple treatment modalities, and facilitating data-sharing across care teams.
- Optimize pain management for vulnerable beneficiaries by supporting data-driven activities that provide insight into disparities in opioid versus non-opioid prescription patterns and supporting the exemption of certain beneficiaries (e.g., those with Sickle Cell Disease (SCD)) from current opioid restrictions.
- Broaden SUD treatment coverage policies and use of data through increasing coverage of evidence-based SUD treatment, prioritizing transparency and harmonization in bundled payment structures, and playing a role in the dissemination of consensus-based definitions for important aspects of SUD treatment (e.g., treatment adherence, treatment discontinuation).
- Expand access to SUD care and care coordination by incentivizing models of care coordination and SUD treatment that reduce the impact of stigma and social determinants on access to SUD treatment (e.g., telehealth, office-based opioid treatment (OBOT).
Below, we provide more detailed comments on these suggestions.
- Support Access to Non-Opioid Pain Management
RFI Pain Question 3: What, if any, payment and coverage policies in Medicare and/or Medicaid have enhanced or impeded access to non-opioid treatment of acute and/or chronic pain?
NCQA Response: Through its quality measure efforts, NCQA has identified multiple challenges that have impeded access to, and measurement of, non-opioid treatment of acute and chronic pain. These challenges include variation in clinical practice guideline recommendations, inconsistency in coverage of non-opioid treatments, and lack of integration of complementary pain management options in the medical care system.
CMS could support beneficiaries’ access to pain management services by expanding and standardizing non-opioid therapies in reimbursement policies. Additionally, CMS could incentivize integrative pain management care models to encourage a multimodal and biopsychosocial approach to care, as supported by evidence. Ensuring that pain management services are accessible and organized in a way that facilitates team-based holistic care is foundational to quality pain management and a necessary step prior to evaluating more specific care processes for pain. Finally, to better inform policy and guideline development, CMS could support activities that provide insight into opioid versus non-opioid prescription patterns. Such activities could help policymakers and providers better understand the pain management landscape, identify problem areas or gaps in care or knowledge and target efforts to enhance evidence-based care or interventions.
- Optimize Pain Management for Vulnerable Beneficiaries
RFI Pain Question 1: What actions can CMS take to enhance access to appropriate care for acute and/or chronic pain in Medicare and Medicaid, including for special populations (for example, individuals with sickle cell anemia or individuals living in health professional shortage areas)?
NCQA Response: Currently, federal initiatives to regulate opioid prescribing, including among Medicare beneficiaries, may inadvertently increase treatment burden for vulnerable populations for whom opioids are an important treatment option for pain management. Recent work under a contract with the CMS Office of Minority Health, has illuminated potential opportunities to optimize pain management for vulnerable Medicare beneficiaries with SCD. The work demonstrated that Medicare beneficiaries with SCD have greater opioid prescribing needs (i.e., higher proportions with a prescription, higher dosages prescribed) but more access challenges (i.e., shorter duration prescriptions prompting multiple renewals) than beneficiaries with cancer or in hospice care.
Part D prescription opioid policies and drug management programs exempt beneficiaries who are prescribed opioids for the management of cancer-related pain or who are receiving hospice care, but not beneficiaries with SCD. To optimize pain management for special populations, CMS can support the exclusion of vulnerable beneficiaries with SCD from current opioid prescribing restrictions. Other vulnerable populations with chronic conditions with pain-related needs may also warrant special consideration.
- Broaden SUD Treatment Coverage Policies and Use of Data
NCQA currently maintains multiple measures to assess treatment of SUD at the health plan and provider level of accountability (Appendix A). As the policy landscape around SUD treatment coverage continues to evolve over time, NCQA recognizes that it is important to update and refine existing measures while continuing to fill gaps in measurement with new and meaningful measures. To develop and maintain valid and reliable quality measures, it is critical that underlying administrative data be sufficiently granular to understand, with specificity, whether individuals are accessing appropriate treatments and attaining meaningful outcomes. Quality measures that can illuminate care gaps across health plans and payers could help CMS provide actionable guidelines/policies.
RFI SUD Question 2: What, if any, payment and coverage policies in Medicare and/or Medicaid have enhanced or impeded the identification of, and access to the treatment by, beneficiaries with SUDs, including OUD?
NCQA Response: NCQA supports CMS policies aimed at broadening coverage of and reimbursement for evidence-based SUD treatment and the concept of service bundling, if such a model can help to improve access and coverage of treatment. However, valid and reliable quality measurement is contingent on payment and coverage policies that result in administrative claims data that can be leveraged to understand how individuals access services and meet outcomes of interest. Bundled payment structures create a challenging environment for quality measurement, as bundle structures vary across payers and states with regard
During the development of the new HEDIS® measure, Pharmacotherapy for Opioid Use Disorder, NCQA was exposed to differences in SUD service bundles across payers and the challenges these differences present for assessing care quality. Through public comment feedback, expert panel input, and qualitative interview findings from health plans and states, we learned that there is significant variation in the OUD treatments (both pharmacotherapy and non-pharmacotherapy options) included in service bundles. Variability in reimbursement intervals (e.g. weekly, monthly) and lack of granularity in bundled payments obscure the ability to assess the intensity and type of treatments individuals receive, and whether individuals are truly accessing and receiving evidence-based care.
RFI SUD Question 7: What recommendations do you have for data collection in Medicare and/or Medicaid
- On the treatment of SUDs, including OUD, to better support coverage, payment, treatment, access policies, and ongoing monitoring, and/or
- To facilitate research, policy development, and inform coverage and payment policies to prevent OUD?
NCQA Response: As CMS continues to revise Medicare and Medicaid payment and coverage policies to support the improved access to evidence-based SUD treatment, we urge that importance be placed on how administrative claims data resulting from these payment policies can be leveraged for quality measurement and ongoing monitoring of adequate treatment access. We urge CMS to prioritize transparency and, where possible, harmonization, in bundled payments for SUD treatment to promote the development and use of valid and reliable quality measures across all payers and plans. Transparency in bundled payment would require that treatment and service claims continue to be collected and available for quality measurement, regardless of how payment is ultimately disbursed. NCQA recommends that, in addition to treatment and service claims, CMS also prioritize the collection and standardization of patient-reported outcome
For many diseases or conditions, there is consensus in the literature and the field around how to identify treatment and outcomes using administrative claims data. For example, in the measurement of diabetes, which, like SUD, is a chronic relapsing condition, thresholds for identifying new diagnoses, measuring Hemoglobin A1c control and identifying appropriate specialty care (e.g., eye exam, foot exam) exist and are widely used across the field. For SUD, many important aspects of overall treatment are not yet operationalized in a standardized way. For example, definitions of “treatment adherence,” “treatment discontinuation,” and “new episodes of treatment” vary among quality measures, payers, and health systems research. We urge CMS to work collaboratively with federal partners and key stakeholders to develop and disseminate SUD definitions for use in health services research, quality measurement, quality improvement initiatives and Medicare and Medicaid data resources.
- Expand access to SUD care and care coordination
RFI SUD Question 5: What actions could CMS take to improve access to evidence-based, FDA-approved MAT or other therapies in Medicare and Medicaid, including for special populations (for example individuals living in health professional shortage areas)?
NCQA Response: Through NCQA’s work on the development and maintenance of SUD quality measures and engagement with SUD learning collaboratives, we have identified a few significant barriers to evidence-based treatment. First, health care providers, including primary care practitioners and specialists, are constrained and reluctant to exchange SUD-related patient data with other providers, health plans, or state health information exchanges (HIEs). This lack of data sharing creates a system where high-quality SUD treatment and care coordination is stymied and is a known barrier to provider and health plan level quality measure reporting. NCQA recommends that CMS support SAMHSA’s proposed revisions to 42 CFR Part 2. Further, NCQA proposes that CMS work with other government agencies to reduce barriers to secure and purposeful SUD data exchange among health care organizations, promote and disseminate best practices for data sharing, and identify methods to systematically measure health plan structural supports and practices related to data sharing.
Finally, to improve access to evidence-based treatment, CMS could incentivize SUD treatment services and models that reduce the impact of stigma and social determinants on access to treatment. These services and models could include the use of telehealth in the management of patients with SUD, OBOT, and wrap-around services with grounding in social determinants of health to support beneficiary adherence to treatment plans.
Thank you again for the opportunity to comment on the RFI. If you have any questions, please contact NCQA Director of Federal Affairs, Paul Cotton, at (202) 955-5162 or at firstname.lastname@example.org.
Margaret E. O’Kane
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
Appendix A: HEDIS® Measures for Assessment of SUD Treatment
|Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment (IET)
|Percentage of beneficiaries age 13 and older with a new episode of AOD abuse or dependence who received:
Engagement of AOD treatment, defined as initiation plus two or more additional services with an AOD diagnosis, within 34 days of initiation visit.
|Health plan and provider
|Pharmacotherapy for OUD (POD)
|The percentage of new opioid use disorder pharmacotherapy events with OUD pharmacotherapy for 180 or more days among members age 16 and older with a diagnosis of OUD. Note: “new opioid event” requires a clean negative lookback period of 31 days where the member did not have a dispensing event for OUD pharmacotherapy or receive OUD pharmacotherapy (e.g., implant, injection).
|Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence (FUA)
|Percentage of ED visits for beneficiaries age 18 and older who had a principal diagnosis of substance use disorder, and who had a follow-up visit with a corresponding principal diagnosis. Two rates are reported: 1. A follow-up visit for substance use disorder within 7 days of visit. 2. A follow-up visit for substance use disorder within 30 days of visit.
|Follow-Up After High Intensity Care for Substance Use Disorder (FUI)
|Percentage of acute inpatient hospitalizations, residential treatment or detoxification visits for a diagnosis of substance use disorder among members age 13 and older that result in a follow-up visit or service for substance use disorder. Two rates are reported: 1. A follow-up visit for substance use disorder within 7 days of visit/discharge. 2. A follow-up visit for substance use disorder within 30 days of visit/discharge.
|Unhealthy Alcohol Use Screening and Follow-Up (ASF)
|The percentage of members 18 years of age and older who were screened for unhealthy alcohol use using a standardized tool and received appropriate follow-up care if they screened positive. Two rates are reported. 1. Unhealthy Alcohol Use Screening. The percentage of members who had systematic screening for unhealthy alcohol use. 2. Counseling or Other Follow-up. The percentage of members who screened positive for unhealthy alcohol use and received brief counseling or other follow-up care within two months of a positive screening.
|Unhealthy Alcohol Use Screening and Follow-Up (ASF)
The percentage of members 18 years of age and older who were screened for unhealthy alcohol use using a standardized tool and received appropriate follow-up care if they screened positive. Two rates are reported.