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Research Letter |

Distribution of Opioids by Different Types of Medicare Prescribers

Jonathan H. Chen, MD, PhD1,2; Keith Humphreys, PhD1,2,3; Nigam H. Shah, MBBS, PhD4; Anna Lembke, MD3
[+] Author Affiliations
1Center for Innovation to Implementation (Ci2i), Veterans Affairs Palo Alto Health Care System, Palo Alto, California
2Center for Primary Care and Outcomes Research (PCOR), Stanford University, Stanford, California
3Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
4Stanford Center for Biomedical Informatics Research, Stanford University, Stanford, California
JAMA Intern Med. 2016;176(2):259-261. doi:10.1001/jamainternmed.2015.6662.
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This study shows that contrary to the California Worker’s Compensation data showing a small subset of prescribers accounting for a disproportionately large percentage of opioid prescribing, Medicare opioid prescribing is distributed across many different types of prescribers and specialities.

Researchers have suggested that the opioid overdose epidemic1 is primarily driven by small groups of prolific prescribers and “corrupt pill mills.”2,3 For example, the California Workers’ Compensation Institute found that 1% of prescribers accounted for one-third of schedule II opioid prescriptions and 10% accounted for 80% of prescriptions.4 This propagates a message that opioid overprescribing is a problem of a small group of high-volume prescribers, while general use is likely safe and effective. Medicare data provide the opportunity to address the question of whether such prescribing patterns occur across a national population.

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Figure 1.
Top 25 Prescriber Specialties by Total Medicare Part D Claims for Schedule II Opioids in 2013

Values are reported on logarithmic scale.

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Figure 2.
Cumulative Percentage Claims and Costs for the Top 10% of Prescribers for Different Populations

For example, 1% of California workers’ compensation (CA WC) Medicare prescribers incur 42% of their schedule II opioid costs. Note: The Medicare All Drug Claims curve overlaps and obscures the respective Costs curve.

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Medicare & Workers' Compensation Opioid Comparison
Posted on December 29, 2015
Alex Swedlow
Conflict of Interest: None Declared
Chen et al’s December 2015 research letter, “Distribution of Opioids by Different Types of Medicare Prescribers,” examined the National opioid prescribing patterns of Medicare physicians and compared them to those of California workers’ compensation physicians as documented in the California Workers’ Compensation Institute’s 2011 analysis (Swedlow, A., Ireland J. Johnson G. Prescribing patterns of schedule II opioids in California Workers’ Compensation. March 2011) . The research letter, however, failed to acknowledge the dissimilarities between the two systems that drive the observed differences, and thus produced a limited comparison of the experience across the two systems.

While Medicare accounts for approximately 20 percent of all California health care (California Healthcare Foundation 2015) , workers’ compensation accounts for less than 2 percent, and has a very different mix of patients, providers, injuries and treatments, as well as a different reimbursement model. Musculoskeletal injuries, the largest injury category utilizing opioids, are 3 to 4 times more prevalent in workers’ compensation than in Medicare ( Jones, S., David, R. Inpatient Utilization in the California Workers’ Compensation System. Research Update, CWCI, December 2014) . Workers’ compensation lacks Medicare’s supply and demand side controls (co-payments, deductibles, drug formularies) that have long been associated with curbing aberrant utilization and cost dynamics.

The authors are incorrect in their assertion that the CWCI study suggests that non-high volume prescribers’ reliance on Schedule II opioids is “likely safe and effective,” as the Institute study did not examine whether the actual prescriptions of the high-volume or low-volume prescribers were safe or unsafe. In a separate study we did highlight the use of Fentanyl for injured workers with minor strains (Prescribing Patterns of Schedule II Opioids Part 2: Fentanyl Prescriptions in California Workers’ Compensation. CWCI, April 2011) and we do agree that the national opioid epidemic is not the exclusive result of high-volume prescribers and must address all prescribers.

Alex Swedlow, MHSA
President, CWCI
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