Performance of CMS' opioid overutilization criteria for classifying OUD or overdose

Researchers investigated whether the criteria underpinning CMS' opioid Overutilization Monitoring System could effectively pinpoint Medicare subscribers with opioid use disorder (OUD) or at high risk for overdose.

Researchers investigated whether the criteria underpinning CMS' opioid Overutilization Monitoring System could effectively pinpoint Medicare subscribers with opioid use disorder (OUD) or at high risk for overdose. The program, launched in 2013, asks that plan sponsors take action—such as utilization review, case management, and dose-dependent safety alerts or reimbursement denials—when they do identify high-risk beneficiaries. To meet the definition, patients must have received opioids with a mean daily morphine equivalent dose of 90 mg from more than three prescribers and three pharmacists or received prescription opioids of the same dose from more than four prescribers. For OUD, high-risk patients were classified as overutilizers if they had a diagnosis of OUD or an overdose within 6–18 months of receiving an opioid prescription. According to the team from the University of Florida College of Pharmacy, however, these criteria demonstrated low sensitivity in identifying high-risk populations. They reached this conclusion after applying the criteria to between 142,036 and 190,320 Medicare beneficiaries who were prescribed opioids from 2011–14 and tracking their outcomes over three overlapping 6-month cycles for each calendar year. The investigators found that the criteria employed by CMS failed to capture most patients with OUD or overdose. Moreover, they wrongly labeled more than one-half of patients as high risk who were not subsequently diagnosed with OUD or overdose. Based on the results, the study authors emphasize the need for different strategies for flagging high-risk patients for the prevention or treatment of OUD.