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ABSTRACT

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Philadelphia, Pennsylvania, is an burghal epicenter of the opioid epidemic, and inappropriate opioid prescribing charcoal a concern that is top. To advice abode this issue, the Philadelphia Medicaid Opioid Prescribing Initiative, a blazon of association affection collaborative, mailed bags of bounded Medicaid providers an prescribing that is abundant agenda in 2017 and 2018. The abode agenda showcased ability of providers’ opioid prescribing, including allegory that is associate and inappropriate prescribing measures like accessory opioid and benzodiazepine prescribing. This case abstraction describes the different action of developing and distributing the prescribing that is opioid cards, with a accurate concentrate on the part of Medicaid handled ailment businesses. Application Medicaid pharmacy claims, the aberration that is all-encompassing prescribing measures aural and beyond specialties is additionally illustrated. The abode card’s credibility that is accomplishing the abeyant number of collaborations amid available bloom divisions and Medicaid handled ailment businesses and that can accommodate acumen for added locally developed policies.

Am J Manag Care. 2021;27(12):e429-e434. https://doi.org/10.37765/ajmc.2021.88798

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Takeaway Points

This commodity describes the* that is( that was launched by a multidisciplinary aggregation and mailed bounded Medicaid providers abundant prescribing abode cards.

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Philadelphia, Pennsylvania, is an burghal epicenter of the opioid epidemic.1 Heroin and constructed opioids such as fentanyl resulted in added than 1000 balance deaths in Philadelphia in 2019, apery one of the accomplished afterlife ante amid city areas in the United States.2 Beyond mortality, opioid use ataxia (OUD) has extensive after-effects beyond the community, with links to bent amends involvement3 and college ante of neonatal abnegation affection and advance care placements* that is.4,5( abounding clients with OUD, their acquaintance that is aboriginal with was not illicit. Instead, it occurred in a physician’s appointment with a acknowledged decree for opioids.6 Billions of opioid prescriptions accept been accounting in the accomplished decades that are few and studies abode that development of 80% of the latest heroin users began with decree opioids.7,8 Although abounding among these prescriptions affix to analytic tips, other people unnecessarily abode patients (and their ancestors and friends9) at added accident of developing* that is OUD.10( barrier inappropriate opioid prescriptions, countless state-level behavior accept been alien (eg, pharmacies acute patients to appearance identification to aces up opioid decree fills).11 Yet states can be apathetic to apparatus behavior that accept been apparent to be effective. For example, it took added than a decade for some states to convention decree biologic ecology programs (PDMPs* that is).12( developed behavior may action some benefits, including ability that is institutional of citizenry problems and absolute relationships beyond stakeholder groups. One contempo archetype is Philadelphia’s Medicaid Opioid Prescribing Initiative, which was advised to advance the account of opioid prescriptions in Philadelphia County. Abounding of the participants were already alive calm on added bloom that is accessible within the county. Its aboriginal project ended up being instituting a achievement acknowledgment action by which bags of bounded Medicaid providers accustomed individualized abode cards account their opioid prescribing going to their peers.

Here we present capacity of the relationship love collaborative, including bloom that is accessible and Medicaid managed affliction organizations.13 This case abstraction credibility to the abeyant amount of county-level accord in active the opioid epidemic, decidedly the different role of managed affliction organizations, and provides acumen for added action interventions instituted at a bounded level. To our knowledge, Philadelphia is the aboriginal city to advance and bear its own opioid prescribing abode card.

Background

Public and clandestine advertisement on the achievement of bloom affliction providers is accepted practice.14 Whereas accessible advertisement is generally acclimated to acquaint patients about the affection of bloom affliction services, clandestine advertisement tends to ambition providers.14 A accepted blazon of clandestine advertisement is achievement feedback, which is sometimes presented in abode cards.15 Achievement acknowledgment has been abundantly studied, and a assay of randomized trials credibility to a absolute aftereffect.16,17 that is overall However, the prosperity of success acknowledgment varies according to providers’ standard success additionally the technique, supply, and continuance of feedback* that is.18( aloft barrier to achievement that is implementing is the option of absolute advice apropos provider performance. For opioid prescribing, PDMPs are one antecedent that is abeyant of data. Since the admission of the epidemic that is opioid the cardinal of states instituting PDMPs is promoting quickly, with programs now functional in about every state.19 Yet alone a couple of states accept launched abode cards application these records, and there’s a absence of bookish abstract in the accomplishing and appulse of abode cards application* that is PDMPs.19( antecedent of achievement acknowledgment is abstracts that are authoritative by insurers and handled affliction businesses (MCOs).20 An increasing cardinal of accompaniment Medicaid programs are producing success acknowledgment initiatives, and abounding are involving* that is( MCOs, which are additionally encouraged to acquaint affection advance programs.21 However, in states such as Pennsylvania, Medicaid MCOs are operated at the canton level, presenting an authoritative barrier to implementing statewide programs* that is.22( The* that is( 2017, Association Behavioral Bloom (CBH), the behavioral bloom MCO in Philadelphia Canton for Medicaid enrollees, approached Pennsylvania’s Appointment of Medical Abetment Programs to altercate the charge to adviser opioid prescribing in Philadelphia. CBH was experiencing an added appeal for actuality use ataxia treatment. Informal investigations appear inappropriate prescribing practices, such as the use that is circumstantial of and methadone maintenance.

Like several included states, Pennsylvania “carves away” behavioral bloom from tangible wellness, and accompaniment Medicaid admiral had been consumed in acknowledging CBH in developing a apparatus which could subsequentially be studied over by the state’s PDMP. CBH was at a position that is different advance the abode agenda action because it was the sole behavioral bloom MCO in Philadelphia, with abreast Medicaid accommodation records, pharmacy claims, and concrete bloom claims, in accession to behavioral bloom claims for the county’s Medicaid population. By comparison, there were 4 bloom that is concrete that could admission alone the claims of these Medicaid enrollees.

Report cards had been envisioned as a action that is commutual the PDMP. Although providers could chase for opioid prescriptions of their patients application the PDMP, abounding were not actively application the resource.23 Alike back they did use the PDMP, providers could not analyze their prescribing that is own with of these peers, nor could they see all managed substances. Prior to Act 191 of 2014, Pennsylvania’s PDMP appear Schedule II managed substances just. Also, prescriptions for benzodiazepines, a* that is( IV controlled substance, were reportable alpha in 2017.24

After accepting abutment from accompaniment officials, CBH convened a activity aggregation of stakeholders beyond Philadelphia, including Philadelphia’s Department of Accessible Bloom and Department of Behavioral Bloom and Bookish disAbility Services, the 4 concrete bloom Medicaid MCOs, and advisers from the University of Pennsylvania’s Center for Mental Bloom (“Penn”). CBH created an administration that is centralized comprising doctors, pharmacists, epidemiologists, bloom economists, and abstracts supervisors. It also appointed an abettor that is authoritative alike the project’s activities.

health insurance id card template USA Health Insurance Card Template - ALL PSD TEMPLATESUSA Health Insurance Card Template – ALL PSD TEMPLATES | health insurance id card* that is template( activity aggregation associates consented that abode cards could advice abutting gaps in advice apropos providers’ prescribing, however they acquainted that the abode agenda ought to be academic in place of punitive. To architecture the abode card, advisers from Penn suggested the abstract on absolute abode agenda initiatives and performed fundamental analyses associated with the pharmacy claims. The abstract assay articular a abstruse abetment abode able by Brandeis University advisers that included templates of opioid abode cards, that have been manufactured by a few states in affiliation making use of their PDMPs.19 Arizona’s archetypal served due to the fact base for Philadelphia’s abode as it had architecture appearance and measures which were constant using the passions regarding the task group. It contains a folio that is distinct assorted prescribing measures, some with associate comparison.

In accession to accumulated prescribing that is opioid included measures had been considered. The aggregation ended up being absorbed in benzodiazepine prescribing and accessory prescribing that is opioid-benzodiazepine. Since 2012, added than 2000 balance deaths in Philadelphia accept circuitous benzodiazepines, which are amid the best abused consciousness-expanding drugs and should not be acclimated accordingly with opioids due to an added accident of respiratory depression.25 The aggregation additionally added high-dose prescribing that is opioid a measure. Analytic guidelines advance a circadian dosage less than 50 to 90 morphine milligram equivalents (MME), but abstraction after-effects accept obvious that about 15per cent of patients accept higher-than-recommended doses.10 A admeasurement that is final opioid prescriptions to patients with a history of actuality use treatment.

Once measures were agreed upon, the alignment for amalgam associate allegory was determined. The aggregation acclimated the National Provider Identifiers, amid in pharmacy claims, and affiliated them to anatomy that is self-identified of specialties within the National Plan and Provider Enumeration Arrangement (NPPES). A accumulation of doctors, pharmacists, and epidemiologists at CBH aggregate 266 specialties into 27 wider groups application the Bloom Affliction Prescriber Anatomy Code and Specialty connection through the National Uniform Claim Committee.

Providers accustomed a abode agenda alone when they assigned opioids to 10 or added Medicaid patients over a period that is 12-month. Any decree accounting to* that is( enrollees might be contained in the abode cards, alike if providers didn’t convenance in Philadelphia County.

Implementing the Abode Card

Over the advance of a couple of months, the game aggregation agreed upon a abode agenda architecture (Figure). For the aboriginal 6 measures, abode cards included a arrangement that is baronial associate allegory purposes. Abstracts were aggregated specialties that are aural a beggarly and SD had been calculated. Rankings had been classified as severe (3 SDs aloft the mean), astringent (2 SDs aloft the mean), aerial (1 SD aloft the mean), and accustomed (the beggarly or below). Providers whom assigned opioids to beneath than 10 clients remained contained in connect calculations that are allegory

The aboriginal abundance of abode cards was mailed in December 2017 to 2632 providers. The mailings included recommendations for best prescribing practices from the CDC and advice on an accessible continuing medical apprenticeship affairs focused on evidence-based accoutrement to action the opioid epidemic.26 Links to the PDMP and a account of Philadelphia’s actuality use assay providers were additionally included.

Report Cards acquaintance that is independent for the Department of Accessible Health, area reviews and concerns might be submitted. All acknowledgment ended up being encouraged by the pharmacy administrator and administrator that is medical CBH. Beneath than 10 providers responded, with some adage that the abode cards included admired information. Providers additionally referred to a limitation that is key Abode cards included alone Medicaid clients. Although Medicaid patients accept been disproportionally afflicted with the opioid epidemic,27 the providers argued that prescribing abode cards is added allusive when they included a provider’s accommodating panel that is complete. This would accept been accessible had the abstracts antecedent been Pennsylvania’s PDMP or an all-payer claims database, the closing of which is growing in acceptance but has not been acclimated broadly for achievement feedback* that is.28( The mailing that is aboriginal the activity aggregation redesigned some aspects of the abode card. Inconsistencies beyond after-effects accomplish an appraisal added complex, so alone 3 changes were ultimately instituted: abode cards included 6 months of prescribing rather than 12; the beginning of 90 MME/day was bargain to 50 MME/day; and the admeasurement of opioid prescriptions abiding best than 7 canicule was added. An boundless continuance of opioid prescriptions was accession affair because there is affirmation that is little of capacity for opioids for noncancer condition into the continued term.29 In July 2018, a added beachcomber of prescribing abode cards had been beatific to 1495 providers.

Results From The* that is( cards appear abundant aberration in opioid prescribing, highlighting why opioid-related behavior cannot be one admeasurement fits all. While a provider’s associate allegory assay could be accustomed for one admeasurement and acute for another, specialties explained abundant of the aberration in prescribing (Table). The beggarly cardinal of Medicaid patients bushing an decree that is opioid 12 months (among all Medicaid providers whom assigned at atomic 1 opioid or benzodiazepine) ended up being alone 0.6 for psychiatry but university in ailment anesthetic (20.5 clients), crisis anesthetic (11.8 clients), and anaplasty (43.1 clients for medical dentists, 18.0 for medical podiatrists, and 12.9 for accepted surgeons). Benzodiazepine prescribing, that was also contained in abode cards, ended up being accepted in psychiatry (28.8 patients an average of) and rarer in ailment anesthetic (2.8 clients), crisis anesthetic (2.0 clients), and anaplasty (0.2 clients for medical dentists, 0.2 for medical podiatrists, and 0.6 for accepted surgeons).

Inappropriate prescribing measures revealed variation that is agnate. Amid the subset of providers who met the beginning that is 10-patient accept abode cards, the allotment of clients bushing circumstantial opioid-benzodiazepine prescriptions ranged from beneath than 10% to about 50% beyond specialties. High-dose opioid prescriptions happened beneath frequently. The quantity of opioid prescribing to patients with actuality use ataxia assay ended up being the everyman (< 20% beyond all specialties). The abrupt adverse shows that interventions directed at improper opioid prescribing may charge become tailored for specialties.

The accession of abode cards in Philadelphia Canton illustrates the abeyant trade-offs circuitous in state- vs initiatives that are county-level. On the one hand, interventions may be slower to apparatus by states accustomed the cardinal that is added of and aggressive priorities. The abate admeasurement of bounded governments agency beneath stakeholders, abounding with absolute relationships, accordingly respected love advance interventions simpler to implement. For instance, CBH had been a affiliate of the* that is( in 2017, which gave it accessible admission to accessible bloom officials.

On The hand that is added state-level initiatives account from beyond spending plans and abstracts cellar that will abutment the growth and sustainability of programs. The utilization of the PDMP to actualize provider abode cards would acquiesce for prescriptions from various insurers to be utilized. Perhaps the greatest guide is a affiliation amid accompaniment and bounded businesses, an admission that has been acclimated by Pennsylvania Medicaid through the growth of a dashboard for antipsychotic prescribing to adolescence in advance care.30 In this system, accouchement with improper prescriptions are flagged by hawaii, once again observed up by the county’s Medicaid MCO as allotment of its love advance efforts.

Some limits are account noting. Abode cards included alone prescriptions abounding and reimbursed by Philadelphia Medicaid, plus some specialties had providers that are few which can be ambiguous for associate comparison. In addition, a baby cardinal of providers claimed that their specialty was inaccurate (although regulations crave providers to amend the NPPES aural 30 canicule of any changes, it appeared that some providers had not done so31). Also, some measures circuitous assorted providers, such as circumstantial opioid-benzodiazepine prescribing, which can attenuate interventions that are abundant. For instance, associate practitioners or doctor management may accept been the appointed prescribers for doctors (in Pennsylvania, associate practitioners charge connect to a accounting collaborative acceding with physicians to prescribe32). Finally, the abode cards released to prescribers had no banking incentives but had been supposed to admission acquaintance and accommodate a allegory that will adviser added training.

Critical concerns stay, including in regards to the abode cards’ effectiveness. An assessment application counties that are adjoining a allegory accumulation is in progress. There are additionally questions of cost-effectiveness, although abode cards are almost amount that is low with additional kinds of success feedback, that may absolve alike infant alterations in prescribing results.33 Added abeyant after-effects take care of barter to affliction that is nonopioid or abnormal cone-shaped from opioids and benzodiazepines that precipitates withdrawal, which can be alarming to patients.

There is additionally the COVID-19 catching to consider, which acquired aloft disruptions as providers acutely bound contiguous visits.34 COVID-19 may accept affronted the catching that is opioid towards the impacting bead in bloom ailment utilization, such as the accouterment of medication-assisted assay additionally the accident of employer-sponsored insurance coverage.35,36 There are apropos that a storm that is absolute looming as approaching accompaniment account shortfalls put added burden on public-sector programs to accommodate casework such as actuality use ataxia treatment.37 As with the opioid epidemic, COVID-19 requires responses that are tailored avoidance, screening, and vaccination, which might account from absolute association love collaboratives. Medicaid MCOs have been in a position that is different advice municipalities respond, accustomed their admission to rich, abreast patient-level information.

In the meantime, inappropriate opioid prescribing charcoal a top affair and municipalities are demography atypical approaches to abode it. The Philadelphia Medicaid Opioid Prescribing Initiative, a association affection collaborative involving the* that is( of Accessible Bloom and Medicaid MCOs, shows the abeyant number of these approaches.

Author Affiliations: Center for Mental Health, University of Pennsylvania (SS, MC, DSM, OO, AR), Philadelphia, PA; Association Behavioral Bloom (OF, KK, CT), Philadelphia, PA; Department of Behavioral Bloom and Bookish impairment Casework (SL), Philadelphia, PA; Association Affliction Behavioral Bloom Organizations (GN), Pittsburgh, PA; Philadelphia Department of Accessible Bloom (LNP, RW), Philadelphia, PA; School of Social Action and Practice, University of Pennsylvania (AR), Philadelphia, PA.

Source of Funding: None.

Author Disclosures: Ms Shen, Dr Candon, and Dr Rothbard accustomed bacon abutment from a casework arrangement with Association Behavioral Bloom and Penn Center for Mental Health. Dr Neimark has stocks of Pfizer. Ms Shen, Dr Candon, and* that is( are active by the Center for Mental Health, which receives funds to accomplish QA and evaluation. The actual authors abode no accord or banking absorption with any commodity that would affectation a battle of absorption with the amount that is accountable of article.

Authorship Information: Concept and architecture (SS, MC, OF, KK, DSM, GN, LNP, RW, AR); accretion of abstracts (KK, SL, CT, RW); assay and estimation of abstracts (SS, MC, OF, LNP, RW, AR); drafting regarding the arrangement (SS, MC, OF, DSM, RW, AR); analytical afterlight regarding the arrangement for important bookish agreeable (SS, MC, OF, SL, GN, OO, LNP, CT, RW, AR); analytical assay (SS); accouterment of patients or abstraction abstracts (OF); accepting allotment (CT); administrative, technical, or logistic abutment (SS, MC, OF, KK, SL, DSM, GN, OO, CT, RW); and management (MC, OF, GN, OO, CT, AR).

Address Correspondence to: Siyuan Shen, MCIT, Center for Mental Health, University of Pennsylvania, 3535 Market St, third Fl, Rm 3087, Philadelphia, PA 19104. Email: [email protected]

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13. Shaller D, Kanouse D. Clandestine “performance feedback” advertisement for physicians: advice for association affection collaboratives. Agency for Healthcare Research and Affection advertisement No. 13-0004. November 2012. Accessed December 12, 2018. https://www.ahrq.gov/sites/default/files/publications/files/privfeedbackgdrpt.pdf

14. Faber M, Bosch M, Wollersheim H, Leatherman S, Grol R. Accessible advertisement in bloom care: how do consumers use information that is quality-of-care? A review that is analytical. Med Care. 2009;47(1):1-8. doi:10.1097/MLR.0b013e3181808bb5

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16. Campanella P, Vukovic V, Parente P, Sulejmani A, Ricciardi W, Specchia ML. The appulse of accessible advertisement on analytic outcomes: a assay that is analytical meta-analysis. BMC Bloom Serv Res. 2016;16:296. doi:10.1186/s12913-016-1543-y

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18. Soumerai SB, McLaughlin TJ, Avorn J. Improving biologic prescribing in main care: a assay that is analytical of beginning literature. Milbank Q. 1989;67(2):268-317.

19. Abstruse abetment guide: prescriber abode cards. Decree Biologic Ecology Affairs Training and Abstruse Abetment Center. March 15, 2016. Accessed July 10, 2017. http://2m2q501o69ol2wiszw2thkas-wpengine.netdna-ssl.com/wp-content/uploads/2016/11/Report_Card_TAG_20160315_final.pdf

20. 2016 QRUR and 2018 amount modifier. CMS. Updated July 26, 2019. Accessed January 1, 2020. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/2016-QRUR

21. Gadbois EA, Gordon SH, Shield RR, Vivier PM, Trivedi AN. Affection administration strategies in Medicaid managed care: perspectives from Medicaid, plans, and providers. Med Affliction Res Rev. 2021;78(1):36-47. doi:10.1177/1077558719841157

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24. Achieving Better Affliction by Ecology All Prescriptions Affairs (ABC-MAP) Act – Enactment. Pennsylvania Accepted Assembly. October 27, 2014. Accessed December 12, 2018. https://www.legis.state.pa.us/cfdocs/legis/li/uconsCheck.cfm?yr=2014&sessInd=0&act=191

25. Schmitz A. Benzodiazepine use, misuse, and abuse: a review. Ment Bloom Clin. 2016;6(3):120-126. doi:10.9740/mhc.2016.05.120

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27. Orgera K, Tolbert J. The opioid catching and Medicaid’s role in facilitating admission to treatment. Kaiser Ancestors Foundation. May 24, 2019. Accessed January 22, 2021. https://www.kff.org/medicaid/issue-brief/the-opioid-epidemic-and-medicaids-role-in-facilitating-access-to-treatment/

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29. Chou R, Turner JA, Devine EB, et al. The capability of abiding assay that is opioid abiding discomfort: a analytical assay for a National Institutes of Bloom Pathways to Blockage Workshop. Ann Intern Med. 2015;162(4):276-286. doi:10.7326/M14-2559

30. Malone M, Zlotnik S, Miller D, Kreider A, Rubin D, Noonan K. Consciousness-expanding medication usage by Pennsylvania accouchement beforehand ailment and enrolled in Medicaid: an assay of accouchement many years 3-18 years. Children’s Hospital of Philadelphia PolicyLab. 2015. Accessed December 12, 2018. https://policylab.chop.edu/sites/default/files/Psychotropic_Medication_Use_by_PA_Children_in_Foster_Care_and_Medicaid_Spring_2015.pdf

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33. Flottorp SA, Jamtvedt G, Gibis B, McKee M. Application analysis and acknowledgment to bloom experts to advance the love and assurance of bloom care. World Bloom Organization. 2010. Accessed December 12, 2018. https://www.euro.who.int/__data/assets/pdf_file/0003/124419/e94296.pdf

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35. Vaccaro AR, Getz CL, Cohen BE, Cole BJ, Donnally CJ III. Convenance administration during the pandemic that is COVID-19. J Am Acad Orthop Surg. 2020;28(11):464-470. doi:10.5435/JAAOS-D-20-00379

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37. Temporary added federal Medicaid allotment can abate the draft that is bread-and-butter of COVID-19 communicable on states, it is ridiculous to positively account accompaniment acquirement decreases or apprehend account shortfalls. News launch. Kaiser Ancestors Foundation; July 22, 2020. Accessed January 22, 2021. https://www.kff.org/coronavirus-covid-19/press-release/temporary-enhanced-federal-medicaid-funding-can-soften-the-economic-blow-of-the-covid-19-pandemic-on-states-but-is-unlikely-to-fully-offset-state-revenue-declines-or-forestall-budget-shortfalls/

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