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Medical Justice

Making healthcare safe for doctors

Healthcare Reform

Doctors Strive to Avoid Being Labeled Outliers – Except When it Comes to Schedule II Drugs

04/22/16 3:37 PM

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?


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.

Posted by Medical Justice | in Healthcare Reform | 6 Comments »
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Joseph Horton
Joseph Horton

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,… Read more »

Marc Darrow, MD

Hi Joseph:
Why high salt diet to increase volume?
Please email me
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?… Read more »


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… Read more »

bonjour ! riche chronique sur l’immobilier…
Je retrouve modérément des éditorials
de ce calibre