Every month I receive a letter from my electric company. It shows how much power I am consuming relative to my peers – my neighbors. Studies have shown such data, when presented in a non-confrontational way – can impact behavior. In those studies, total energy consumption went down. In the letter I receive, no allowance is made for square footage of the house. I’m labeled an apparent outlier. A recalcitrant outlier. (I do drive high MPG hybrid, though.)
Doctors occasionally receive letters from insurance companies or healthcare systems highlighting compliance with targeted measures may be outside norms associated with their peers. One example include rates of vaccination for influenza. Such letters have boosted immunization rates among the less compliant.
A recent study looked at whether such non-confrontational letters might impact over-prescribing of Schedule II medications.
The answer is no.
The researchers identified about 1,500 “hyper-prescribers.” These doctors prescribed 400% more than their peers. These prescribers accounted for 10% of the Schedule II prescriptions in Medicare in 2012, but represented only 0.2% of the providers who wrote any prescriptions for Schedule II medications that year.
Half of these doctors (the experimental group) received a letter informing how much the doctor prescribed Schedule II medications compared to their peers.
Half of the doctors (the control group) received no such letter.
The letter said nothing of an impending audit. But, the letters might have served as a subtle reminder of potential consequences, given that anti-fraud investigators use prescribing patterns to identify those who will be audited.
So, what happened?
Nothing.
There was no statistically significant change in prescribing patterns between the two groups.
By mid-2014, 21% of these prescribers were already being investigated for fraud and abuse. They obviously triggered other database alarms.
The authors stated they plan to try again.
This time, they will send multiple letters over time to impress upon them they are being monitored. Further, they plan to alter the language of the letters to emphasize the negative consequences of inappropriate prescribing behavior.
It’s unclear why these letters had no effect. Perhaps they were never opened or, if they were, taken seriously. Further, if a doctor is running a lucrative pill mill, he may not respond to typical carrots and sticks.
Big Data is upon us. Hyper-prescribers of schedule II drugs are being labeled. If you do receive such a letter, it’s probably wise to not ignore it.
Most common drugs I prescribe are ibuprofen and methocarbamol. And Excedrin.
When patients come in with a history of “falling out” (fainting) and their blood pressure is 70/40, I look at the meds other docs have prescribed. It is invariably a smorgasbord of antihypertensives. I take them off of all of them, put the patients on a high potato chip diet for two weeks (to increase their salt and therefore circulating volume), and call their regular doc to tell him what I did and why. And suggest that he restart things a little more carefully. They always get better.
So, no schedule II’s–until Michael Bloomberg schedules potato chips (if sold in large bags). And patients think I hung the moon.
Hi Joseph:
Why high salt diet to increase volume?
Please email me lawdoc@marcdarrow.com
Thanks, Marc
” …if a doctor is running a lucrative pill mill, he may not respond to typical carrots and sticks.” is the correct answer.
Lucrative pill mills are terrific – cash only, short visits, no OCare, and eventual permanent orange jump suit for attire, and free food.
Unfortunately, the few doctors who run these types of clinics are likely addicted themselves, and one of the few things that may cause narcotic abusers to change their behavior is incarceration. Thank you.
There is an end result to the crackdown on pill mills to counteract over doses from Oxycontin (hillbilly heroin), with prescriptions filled under addicts Medicaid cards. Those end results are overdoses with real heroin, increased overdose deaths, increases in crime since real heroin cannot be paid for by Medicaid card (at least not yet), increases in HIV, increases in Hepatitis B and C, and increased health system costs and law enforcement costs.
Are we as a society better off? Did anyone in the government world anticipate the unintended consequences of the pill mill crackdown? Where do we go from here? More penalties for physicians? More physicians in jail? More crime statistics which calls for more law enforcement funding? Or do we start again to educate the young as to the dangers of drug addiction? Do we increase funding for drug treatment programs, drug courts? Do we legalize drugs that would take away the aura of attractiveness and the “pushers”? Early results from Colorado after legalization of marijuana, seem to indicate increased traffic fatalities (not all from the users of marijuana), increased DUI’s and an increased proportion of young people who are users. Perhaps the best approach is to stop offering welfare and assistance. Perhaps if people had to work for a living in order to eat they would be more inclined to use fewer recreational drugs because they would have less recreational time? Society already has enough medical information to make an informed decision about what direction it wants to take. Help in coming to a consensus and deciding the direction for our society to take is up to our political leadership, and the voters that put them in office.
RP – I enjoyed your thoughtful and well written response. I completely agree that sloth leads to drug usage and addiction. And Medicaid should have safeguards such that an EBT card cannot be used to buy a quart of malt beer. In the Northeast Corridor where we live, 1 in 4 residents receive food stamps and Medicaid after the expansion with OCare.
I believe the root cause of the current narcotic problem in America is multifactorial – dissolution of the traditional family, rising atheism, government indoctrination of our youth with common core, and an economy that’s good from afar, but far from good. Our smart college educated young adults are faced with staggering personal debt and high unemployment.
Our redistributive government encourages sloth, and OCare has made it nearly impossible for small businesses to expand and increase the workforce. Just the opposite happened – more people have been shifted to part time with no health insurance, and less stringent Medicaid eligibility requirements. If there are no jobs and high unemployment, people will want to get high.
The physician may be best advised to avoid overprescribing narcotics a trying to cure the
I hope the next administration will make policy to improve availability of unregulated small business growth. Let’s just get back to the 80s where tuition was cheap, jobs were plentiful, and people worked 40 or more hours a week – There seems to have been less addiction in the good old days. Thank you:)
bonjour ! riche chronique sur l’immobilier…
Je retrouve modérément des éditorials
de ce calibre