Understanding your Department of Human Services (DHS) opioid prescribing report

• Index opioid prescription: The first opioid prescription after at least 90 days of opioid naiveté.
• Opioid naïve enrollee: A patient prescribed an opioid medication who does not have an active opioid prescription in the 90-day period before the index opioid prescription. The enrollee had to be continuously enrolled in Minnesota Medicaid or MinnesotaCare through the 90-day period before the index opioid prescription. 
• Post-acute pain period: This time period represents the date of the index opioid prescription plus 45 days. The time period captures opioid analgesia prescribed for acute and post-acute, or sub-acute, pain following an injury or procedure. 
• Morphine milligram equivalence (MME): The equianalgesic of a specific dose and formulation of opioids to parenteral morphine. Standard conversion ratios are used to calculate each opioid’s equianalgesic dose. 
  • Conversion formula for total morphine milligram equivalence (MME) of prescription (total MME of prescription): (Drug strength)*(Drug quantity)*(MME conversion factor)
  • Conversion formula for daily MME: (Drug strength)*(Drug quantity)*(MME conversion factor)/ (Days’ supply)
• Cumulative morphine milligram equivalence: The sum of the total morphine milligram equivalence of each opioid prescription received in a given timeframe. The DHS opioid prescribing reports provide data on the cumulative MME prescribed during the acute and post-acute pain period. 
• Chronic opioid analgesic therapy: greater than or equal to 60 consecutive days’ supply of opioids from any number of prescriptions. A gap less than or equal to three days is permissible between prescriptions.
• High dose chronic opioid analgesic therapy: Greater than or equal to 60 consecutive days’ supply of opioids and the daily dose is greater than or equal to 90 morphine milligram equivalence per day.
• Concomitant chronic opioid analgesic therapy and benzodiazepine prescriptions: Greater than or equal to 60 days’ supply of opioids and a benzodiazepine prescription that has greater than 7 days’ supply of overlap with the chronic opioid analgesic therapy during the measurement year.

The data in each report comes from Medicaid and MinnesotaCare pharmacy claims data (not the Minnesota Prescription Drug Monitoring Program). This means that only data on Medicaid and MinnesotaCare patients are included in the DHS prescribing reports. The following patients, settings or medications are excluded from the reports:

• Individuals who received a cancer diagnosis or treatment within the measurement period
• Individuals receiving hospice services (enrollees with a claim from a hospice place of service or hospice provider type)
• Procedural sedation or anesthesia
• Medications administered in an emergency department or from an inpatient pharmacy
• Medications prescribed to treat opioid use disorder
• All buprenorphine products

Enrollees excluded based on cancer or hospice have no data in the prescribing report. An enrollee who receives an excluded medication will just have that medication data excluded from the data. Any included opioid formulations prescribed to that enrollee in the measurement year are included.

The reports compare providers’ prescribing data to the average rate of their anonymized peers. Providers are included in one of 30 specialty groups based on their National Provider Identifier (NPI) primary taxonomy code, or based on direct confirmation with the provider about their practice type. 

DHS uses the following specialty groups for the opioid prescribing reports:

Addiction Medicine; Allergy and Immunology; Anesthesiology; Dental—General; Dermatology; Emergency Medicine; Family Medicine; Hospice; Hospitalist; Internal Medicine; Obstetrics and Gynecology; Oncology; Ophthalmology; Optometry; Oral and Dental Surgery; Orthopedic Surgery; Otolaryngology; Pain Medicine; Pathology; Pediatrics; Physical Medicine and Rehabilitation; Physician Assistant and Advance Practice Nurse; Podiatry-General; Podiatry-Surgical; Preventive Medicine; Psychiatry and Neurology; Radiology; Rheumatology; Specialty; Surgery; Urology

Your specialty information comes from the Centers for Medicare & Medicaid Services (CMS) National Plan and Provider Enumeration System. Your specialty group is based on your National Provider Identifier (NPI) primary taxonomy code. The taxonomy code uses a unique alphanumeric code, 10 characters in length. The code set is structured into three distinct levels: provider grouping, classification and area of specialization. (American Medical Association. Health Care Provider Taxonomy. Version 19.0 January 2019).

Providers self-select their taxonomy codes. The taxonomy codes are organized based on education and training and are used to define specialty, not specific services that are rendered.

Your unique National Provider Identifier number.

The report also provides your name on file with DHS. The address included in the report is the public address on file with the prescribers’ respective licensing board, with one exception. Podiatrists’ reports are mailed to the address on file with DHS.

The legend explains how to read the graphs in the report:

• The blue horizontal bar displays your specific data
• The orange horizontal bar displays the average data within your specialty
• The vertical red line indicates the quality improvement threshold for each given measure

Specialty comparison data for all seven measures is provided in the reports. If a provider’s specialty is not correctly designated on the report, the averages for each sentinel measure for all 30 specialties is available on the Sentinel Measures: averages by specialty webpage.

The quality improvement thresholds were set based on careful analysis of Medicaid and MinnesotaCare administrative prescribing data (claims data). In general, the thresholds were set at a rate that represented an inflection point between high volume and low volume prescribers in the data analysis. The threshold will remain at their current numbers, unless DHS is advised to change the thresholds by a clinical advisory body. 

The quality improvement thresholds do not differ among specialties. The quality improvement threshold are listed below:

• Measure 1: Greater than 8 percent of enrollees seen in the measurement year were prescribed an index opioid prescription (non-surgical specialties only
• Measure 2: Greater than 50 percent of all index opioid prescriptions exceeded the recommended dose (100 total MME for non-surgical specialties; 200 total MME for surgical specialties)
• Measure 3: Greater than 15 percent of opioid prescriptions prescribed during the initial index opioid prescribing episode met or exceeded 700 cumulative MME
• Measure 4: No quality improvement threshold
• Measure 5: Greater than 10 percent of enrollees prescribed chronic opioid analgesic therapy (COAT) had a daily dosage that met or exceeded 90 MME per day
• Measure 6: Greater than 10 percent of enrollees prescribed COAT with a daily dosage of at least 50 MME per day had an overlapping benzodiazepine prescription
• Measure 7: No quality improvement threshold

This measure shows the percent of enrollees prescribed one or more index opioid prescriptions between January and December of the measurement year:

• The numerator: the number of opioid naïve enrollees prescribed a new opioid prescriptions in the measurement year.
• The denominator: the number of enrollees seen in the measurement year.

The graph shows:

• Blue bar: the number of enrollees you prescribed one or more index opioid prescriptions to in the measurement year divided by the number of enrollees you saw in the measurement year.
• Orange bar: the number of enrollees your peers prescribed one or more index opioid prescriptions to in the measurement year divided by the number of enrollees they saw in the measurement year.
• The quality improvement threshold: greater than 8 percent. Note: the quality improvement threshold only applies to providers in nonsurgical specialties. There is no threshold for surgical specialties, including Obstetricians & Gynecologists.

In the sample report: Dr. Fake Prescriber prescribed an index opioid prescription to 2.1 percent of the 281 Minnesota Medicaid and MinnesotaCare enrollees she saw in the measurement year (denominator = 281 enrollees). Her peers in her specialty group prescribed an index opioid prescription to 2.5 percent of the Minnesota Medicaid and MinnesotaCare enrollees they saw. Dr. Prescriber’s prescribing rate is under the quality improvement threshold of greater than 8 percent.

This measure shows the percent of index opioid prescriptions that exceeded the recommended dose in the measurement year. The recommended dose is less than 100 morphine milligram equivalence (MME) for medical specialties and less than 200 MME for surgical specialties.

• The numerator: the number of index opioid prescriptions prescribed that exceeded the recommended dose in the measurement year.
• The denominator: the number of index opioid prescriptions prescribed in the measurement year.

The graph shows:

• Blue bar: the number of index opioid prescriptions you prescribed that exceeded the recommended dose in the measurement year divided by the number of index opioid prescriptions you prescribed in the measurement year.
• Orange bar: the number of index opioid prescriptions your peers prescribed that exceeded the recommended dose in the measurement year divided by the number of index opioid prescriptions they prescribed in the measurement year.
• The quality improvement threshold: greater than 50 percent for both medical and surgical specialties.

In the sample report: Of the six index opioid prescriptions Dr. Fake Prescriber prescribed in the measurement year, 16.7 percent exceeded 100 MME (denominator = 6 prescriptions). Her peers in family medicine prescribed index opioid prescriptions greater than 100 MME 28.5 percent of the time. Dr. Prescriber’s prescribing rate is under the quality improvement threshold of 50 percent.

This measure shows the percent of opioid prescriptions prescribed that met or exceeded 700 cumulative MME in the post-acute pain phase (up to 45 days following an acute event). This includes the index opioid prescription and any other opioids prescribed within a 45-day window of the date of the index opioid prescription.

• The numerator: the number of prescriptions prescribed during the post-acute pain period that met or exceeded the 700 cumulative MME threshold in the measurement year.
• The denominator: the number of opioid prescriptions prescribed during the post-acute pain period in the measurement year.

The graph shows:

• Blue bar: the number of prescriptions you prescribed during the post-acute pain period that met or exceeded the 700 cumulative MME threshold in the measurement year divided by the number of opioid prescriptions you prescribed during the post-acute pain period in the measurement year.
• Orange bar: the number of prescriptions your peers prescribed during the post-acute pain period that met or exceeded the 700 cumulative MME threshold in the measurement year divided by the number of opioid prescriptions they prescribed during the post-acute pain period in the measurement year.
• The quality improvement threshold: 15 percent for medical and surgical specialties.

In the sample report: Dr. Fake Prescriber did not prescribe an opioid prescription that crossed the 700 cumulative MME threshold during the post-acute pain period (denominator = 9). The average her Family Practice specialty was 5.5 percent. Dr. Prescriber’s percentage is under the quality improvement threshold of 15 percent.

This measure shows the number of patients prescribed an opioid prescription during a period of chronic opioid analgesic therapy (COAT) in the measurement year:

• The numerator: the number of patients prescribed an opioid in the measurement year during a span of COAT (greater than or equal to 60 consecutive days’ supply of opioids).
• The denominator: the total number of patients with at least one opioid prescription prescribed in the measurement year.

The graph shows:

• Blue bar: the number of patients you prescribed at least one opioid prescription to during a period of 60 consecutive days’ supply of opioids divided by the number of patients you prescribed at least one opioid prescription to in the measurement year 
• Orange bar: the number of patients your peers prescribed at least one opioid prescription to during a period of 60 consecutive days’ supply of opioids divided by the number of patients your peers prescribed at least one opioid prescription to in the measurement year 
• The quality improvement threshold: none.

In the sample report: Dr. Fake Prescriber prescribed an opioid prescription to a patient with COAT 10 percent of the time. The average her Family Practice specialty was 23.6 percent. There is no quality improvement threshold for this measure.

This measure shows the percent of patients prescribed COAT with the daily dose exceeding 90 MME per day in the measurement year:

• The numerator: the number of patients prescribed at least a 28 days’ supply of opioids within a COAT span in the measurement year with the daily dose exceeding 90 MME per day.
• The denominator: the number of patients with an opioid prescription during a COAT period in the measurement year. 

The graph shows:

• Blue bar: the number of patients you prescribed at least a 28 days’ supply of opioids within a COAT span in the measurement year with the daily dose exceeding 90 MME per day divided by the number of patients you saw on COAT in the measurement year.
• Orange bar: the number of patients your peers prescribed at least a 28 days’ supply of opioids within a COAT span in the measurement year with the daily dose exceeding 90 MME per day divided by the number of patients they saw on COAT in the measurement year.
• The quality improvement threshold: greater than 10 percent.

In the sample report: Dr. Fake Prescriber did not prescribe opioids exceeding 90 MME per day to any patients receiving COAT in the measurement year. Her peers within her specialty group prescribed opioids exceeding 90 MME/day to patients receiving COAT 2.2 percent of the time.

This measure shows the percent of patients receiving elevated doses of COAT who received a concomitant benzodiazepine prescription:

• The numerator: the number of patients prescribed at least a 28 days’ supply of opioids within a COAT span greater than 50 MME per day and an overlapping benzodiazepine prescription greater than 7 days in the measurement year.
• The denominator: the number of patients prescribed an opioid prescription during a COAT period in the measurement year.

The graph shows:

• Blue bar: the number of patients you prescribed at least a 28 days’ supply of opioids within a COAT span greater than 50 MME per day and an overlapping benzodiazepine prescription greater than 7 days in the measurement year divided by the number of patients you prescribed COAT in the measurement year.
• Orange bar: the number of patients your peers prescribed at least a 28 days’ supply of opioids within a COAT span greater than 50 MME/day and an overlapping benzodiazepine prescription greater than 7 days to in the measurement year divided by the number of patients they prescribed COAT in the measurement year.
• The quality improvement threshold: greater than 10 percent.

In the sample report: Dr. Fake Prescriber did not prescribe elevated dose COAT and concomitant benzodiazepines. Her peers prescribed elevated dose COAT and concomitant benzodiazepines 1.7 percent of the time they prescribed COAT.

This measure shows the percent of COAT patients receiving opioids from multiple prescribers:

• The numerator: the number of patients prescribed COAT who received opioids from more than two other providers while on COAT in the measurement year.
• The denominator: the number of patients prescribed COAT in the measurement year.

The graph shows:

• Blue bar: the number of patients you prescribed COAT to who received opioids from two or more additional providers divided by the number of patients you prescribed COAT in the measurement year.
• Orange bar: the number of patients your peers prescribed COAT to who received opioids from two or more additional providers divided by the number of patients your peers prescribed COAT to in the measurement year
• The quality improvement threshold: none.

In the sample report: Dr. Fake Prescriber did not prescribe COAT to any patients who received opioids from more than two other providers during the COAT span in the measurement year. She prescribed COAT to one patient in the measurement year (denominator = 1).

Submit questions or feedback about your report to the Opioid Prescribing Improvement Program (OPIP) Inquiry.