The Manipulation Proclamation

At my office, these letters get a cursory look and are then dropped directly into the shredder. This study assessed the impact of “behavioral nudges” to stem over-prescribing of quetiapine in the Medicare Part D program.

Issuing peer comparison letters led to “substantial and durable reductions” in prescriptions for the antipsychotic drug quetiapine, with no evidence of negative impacts on patients, researchers reported.

Determination of patient impact was made by reviewing the 9-month mortality and hospital utilization claims data.

The study by Adam Sacarny, PhD, of Columbia University’s Mailman School of Public Health in New York City, and colleagues assessed the impact of “behavioral nudges” to stem over-prescribing of quetiapine in the Medicare Part D program.

A letter was sent to 5% of the high-volume primary prescribers of quetiapine based on Medicare Part D claims history. The letter noted that the prescriber’s number of quetiapine prescriptions was high relative to their peers and was under review by the CMS. It also included an ominous statement that the prescriber may be contacted regarding further actions. 

The study’s primary outcome was to determine the total quetiapine days supplied by prescribers for the first 9 months of the experiment. The letter resulted in a 11.1% fewer days of quetiapine prescribed. The reduction persisted for 2 years then trended back toward baseline.

The researchers suggested that primary care physicians “may be able to target ‘guideline concordant’ patients for whom stopping quetiapine may be clinically justifiable while maintaining access for patients who experience clinical benefits (by continuing to prescribe to these patients or by shifting them to psychiatrists).”

Amol Navathe, MD, PhD, of the Leonard Davis Institute for Health Economics at the University of Pennsylvania in Philadelphia, praised the study as a “low-cost, scaleable intervention”, but did caution:

  • that finding and seeing a psychiatrist may be difficult for patients with dementia or other cognitive deficits. (No shit)
  • “So the actual impact on the patient, beyond what we’re seeing in claims, may actually potentially be more … I think we need to just be thoughtful about that,” he stated.
  • Beth McGlynn, PhD, vice president for Kaiser Permanente Research, said during a panel discussion Tuesday that one valuable aspect of the study is that the researchers worked upfront with the CMS, which could mean the results will have greater influence going forward.
  • However, that potential influence could also have drawbacks — if Congress decides this intervention is good, it could become “the law of the land,” McGlynn said. “Keep an eye out for that because … talk about blunt instruments.”
  • Another concern is that such letters might scare prescribers into simply opting out. 

When I initially read this, I said out loud, ‘Oh Lord’ and immediately wanted to smack my head against the wall. The most frustrating thing about this little experiment is that the authors won the Academy Health Publication-of-the-Year Award for 2019. Really? This type of peer comparison letter is not a novel concept. I have shredded hundreds of them over the past 15 years. 

I can’t help wondering if the attempts at manipulating a doctor’s practice of medicine can get any more ridiculous? Don’t answer that… we all know it can.

Cynthia R Stuart DO

Dr. Stuart is Board Certified in Family Medicine. Originally from Georgia, she spent most of her youth in Miami, Florida and has been a Texas resident since the early 1990s. She attended UNTHSC-Fort Worth and completed her residency at UTSW/Methodist Hospital System where she was Chief Resident in her senior year. She is an Associate Professor at UTSW and UNTHSC, participating as a preceptor for medical students and residents. She completed a two-year course at SMU Cox School of Business in Advanced Leadership that enables her to advocate for quality health care providers and local public health programs in her community. She is the head of the Credentials Committee, sits on the Medical Executive Committee and the Ethics Committee at Baylor Scott and White Hospital of Carrollton. She has appeared on numerous news and radio programs to educate the public about various health topics. Dr. Stuart has managed her private practice in Carrollton since 2005 and is now a Direct Primary Care Physician. 

  1 comment for “The Manipulation Proclamation

  1. Randy
    June 13, 2019 at 10:01 am

    We used to call these nasty-grams and they work, at least on me. If the CMS sends me a letter saying I’m doing something way more than other doctors and they are watching me, I’m going to do less of it.

    And of course it will lead to under-prescribing and under-treatment. The nursing homes in my area are scared to death of anti-psychotics because it might be a red flag on an audit. I’m encouraged to treat everything with trazadone, which seems to have been placed on a pedestal despite only having FDA approval for treatment of depression.

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