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.