CMS’ opioid overutilization criteria

Performance of CMS’ opioid overutilization criteria for classifying OUD or overdose – Feb 2019

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. 

Here CMS is finally looking at outcomes of their policy. Meanwhile, the CDC, which even included a requirement to evaluate outcomes in its own guideline, has refused to do so.

I’m almost certain they fear that any outcome measurements will show how ineffective their guideline has been at stemming overdoses and how perversely effective it has been in harming pain patients.

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


  • 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.

How can a person be an “overutilizer” if they haven’t received any prescriptions for a year and a half? This makes no sense at all – just like most of such measurements and the resulting ineffective and cruel policies.

According to the team from the University of Florida College of Pharmacy, however, these criteria demonstrated low sensitivity in identifying high-risk populations.

I think that in ordinary English, this means the criteria they were trying to use don’t work.

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.

I’m impressed that someone is actually looking at outcomes, but the *only* outcome they were looking at is whether the patient was later diagnosed with OUD.

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.

Yet I’d be willing to bet this didn’t stop them from using it anyway, as they do with all tools that claim to be “helping stem the opioid crisis”, whether they actually work or not.

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

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