Physician practice patterns and network design

Walid Gelad and many others have a recent article in the Journal  of General Internal Medicine** that looked at the different rate of emergency department physicians prescribing opioids in the Veterans Administration.  This is a replication of Barnett’s excellent work from 2017## that examined emergency department prescribing patterns to Medicare beneficiaries who were opioid naive.##

Walid highlights this graph as a key take-away.  There is huge variation in physician behavioral patterns when faced with similar patients.

I want to go in a slightly different direction than an opioid analysis with this graph. I want to go into network design. The Veterans Administration is a singular entity under, theoretically, singular management control. They have a good to excellent electronic medical record system. The opportunities for integrated care are fairly high. They have a much longer shadow of the future than most health financing entities. There are numerous opportunities present in the VA that most other systems in the United States don’t have. And they still have tremendous variation.

Insurers build narrow networks based on two primary objectives: price per unit control and total cost control. Some insurers will leverage reasonable competitive local clinician and hospital markets to get a dirt cheap rate per unit. The objective is to minimize price per unit without caring too much about how many units are paid for.

The other system is not as sensitive to the price per unit. Instead, the network is designed around variation in provider practice patterns on similar patients. The network if it was optimizing on minimizing opioid exposure in the ER would be built around the docs in the first quartile or at least built to avoid the docs in the most frequently prescribing quartile. This takes advantage of the fact that medicine for common conditions is still a folk art. There can be tremendous variation within the same office much less the same town on following evidence based recommendations. Building networks around providers who practice in a particular way that could conceivably lead to higher quality and lower total costs is a viable strategy.

Communicating the value proposition of a higher per unit cost but lower net cost is a challenge in the ACA domain given the subsidy structures. I think this type of network design choice could work far better in Medicare Advantage and large employer self-insured groups.
Variation in practice is widespread and common and it can be targeted.

** Barnett, M.L., Zhao, X., Fine, M.J. et al. J GEN INTERN MED (2019). https://doi.org/10.1007/s11606-019-05023-5

## N Engl J Med 2017; 376:663-673 DOI: 10.1056/NEJMsa1610524

 






29 replies
  1. 1
    Gin & Tonic says:

    Two questions, neither really addressing your main point. What is “opioid naive” and how can the physician know it’s true (if it’s based on self-reporting?) Have any studies been done on the accuracy or efficacy of those “0-10” or “1-10” pain rating scores? Having undergone a significant musculoskeletal trauma a couple of years ago, I was faced with this at nearly every surgical and PT encounter, and I found it really hard to give a meaningful answer. Maybe I have a high pain tolerance, or there is some inherent reticence in my background, but I just felt like I was always aiming low.

  2. 2
    Spanky says:

    A PAIN SCORE OF 1 ?!?!?!

    What the everloving fuck is any doctor doing prescibing opioids for that?

    Sorry if that sounds like derailing the thread, but I’d be curious how the VA numbers match up to physicians across the general population. (Not that different, I’d suspect, really.)

    (Full disclosure: A serious back spasm sent me to the ER last year where I was given opioid on-site and a prescription, but I rated my pain at “11”, seriously alarming my wife who knows I’m highly pain-tolerant.)

  3. 3
    Ruckus says:

    The opportunities for integrated care are fairly high. They have a much longer shadow of the future than most health financing entities. There are numerous opportunities present in the VA that most other systems in the United States don’t have. And they still have tremendous variation.

    As a VA patient I’d agree with this. My experience is that a lot of the variation is by specialty, not just individual doctors. Several specialties seem to be more prone to prescribe opioids than others as a general treatment, while some barely prescribe at all.

  4. 4
    Spanky says:

    @Gin & Tonic: A good question on what “opiod naive” means. I blithely assumed it meant people who didn’t know answers to basic questions about opioids. But that opens another whole can of worms, because who wants to be quizzed while they’re in pain? (Except … “1”?). I know I didn’t.

  5. 5
    Spanky says:

    @Ruckus:

    My experience is that a lot of the variation is by specialty, not just individual doctors. Several specialties seem to be more prone to prescribe opioids than others as a general treatment, while some barely prescribe at all.

    True, and the study was limited to emergency room doctors. So pardon my ignorance here, but do ER doctors in a VA hospital only see vets? Or do they receive ambulances if they’re the nearest hospital, and therefore see patients from the general population?

  6. 6
    lahke says:

    Is any of this variation a function of patient race? Sorry, can’t read the info now to check for myself.

  7. 7
    Ruckus says:

    @Gin & Tonic:
    The scoring system is useful for one time incidents but requires the patient to understand the concept and it’s definitions. Which trying to learn when your pain level is off your personal chart is not easy. At the VA you get asked your pain score every time you get seen and it seems like a waste of time and quite possibly is misleading for your continuing health. But come up with a better system. BTW my system goes to 12, not ten. Docs are amused or terrified by 11 and 12, especially if they don’t know you. But untreated and untreatable pain can be a serious symptom all on it’s own, no matter it’s level. And my experience is that treatment with opioids is a fools game, It’s OK for short term intense pain, not so much for constant lower levels.
    @Spanky:
    I think you hit on a problem with the pain score system. We all perceive pain but levels are not the same across the board for the same injury or disease. Your 1 could be someone else’s 5 or 6. My score goes to 12 because I have on and off long term issues that varies by attack and what the medical system is willing/able to do to help. Also one can get used to a level of pain and the perception can cause one to either lower or raise the number, depending on their perception/length of pain.
    Like I said above though, design a better one as a treatment system.

  8. 8

    medicine for common conditions is still a folk art

    This is a massively underrated facet of our medical system. A huge amount of what doctors do is based on personal experience and some lectures from medical school, rather than the latest research. They’re supposed to take regular continuing medical education, but it’s still a scattershot way of keeping up to date, even assuming they’re paying attention and not blowing it off. The net result is that medical practice lags far behind the best medical research, even in organizations like VA and Kaiser that are in position to push their physicians to follow protocols. It’s a huge problem, and I don’t know that anyone even knows where to start in dealing with it.

  9. 9
    Ruckus says:

    @Spanky:
    Vets. But one has to be registered in the VA system to be treated. And a vet not registered doesn’t get treated as far as I can tell. It is a voluntary system, you aren’t registered unless you want to be. Not sure if you are registered at one time and don’t use the system for a period of time if you might have to reregister. VA.gov explains the system decently if one is interested.

  10. 10
    TomatoQueen says:

    Agree with Ruckus, my way of conveying the pain info on the 1-10 scale is 1= nothing 10=active labor, so what I have right now is close to labor or 7 to 8. Say this enough times to enough staff (how much is enough) over the course of a 3 to 5 day stay and they will show understanding and a more realistic expectation of what a pain medication can accomplish. The big change has been in-hospital & at-home pain management instructions: we used to be told to Stay Ahead of pain, so that if your dose is every four hours, you should be taking your next dose at the 3rd hour–you don’t hear this any more. I can’t believe however that humans suddenly don’t need to stay ahead of pain. Also a shout-out to whoever designed VA medical records–I see this stuff all day long and it is a top-quality easy to read product, as opposed to a lot of fancy-pants illegibility.

  11. 11
    Ruckus says:

    @Roger Moore:
    The VA follows protocols better than the general medical system in my experience but there is still a wide variation by doctor. I think that one of the controls is that the VA prescribes and supplies meds and that gives a level of control and followup that is missing in the general field.
    @lahke:
    I’d bet there is some variation just because individual docs have a lot of leeway in how they treat any particular problem and person. My experience at the VA is that some feel there is racism involved but I don’t see it in the system, only in individual docs. The system does a lot to make equality a major issue but individual docs are individuals and come with all the problems that all of us have to one degree or another. ETA I should add that I’m a white guy so directly I don’t see things the same way as a person of color might. That said the problems that a lot of vets face can be a lot different than the general population and that can make a huge difference in treatments and perceptions.

  12. 12
    Spanky says:

    @Ruckus: Hmmmm. So a vet’s “just a flesh wound” 1 may not correspond well to the general population’s concept of a 1. Just to add to the somewhat random scoring.

    But like you said, come up with a better one.

  13. 13
    Ruckus says:

    @TomatoQueen:
    Not being able to experience labor I can’t use that system, my 11 and 12 scale is based upon consideration of do I want to die, how and how soon, not because I know it would be better, but just because I know how bad it is. But like all pain levels, most of it is temporary to one degree or another.
    For example I have intense pains all the time but they are short lived and not localized. And no one seems to be able to affect any cure. I think it’s all in my head but what can be done about it besides doping one up so that nothing is felt or removing the cause, the brain, which is IMO, not allowed. Pain is necessary to life, not to make us suffer but to tell us when something is wrong. That our knowledge as a species is limited in how to reasonably deal with constant or intermittent pain is an ongoing problem. Often we can’t fix the source and have a human being remain.

  14. 14

    @Gin & Tonic: Opioid Naive = Not having consumed an opioid in a long while

  15. 15
    Ruckus says:

    @David Anderson:
    Opioid Non Naive ?= someone who never wants to consume one ever again?

  16. 16
    Walker says:

    For pain scales, I always try to calibrate my answer to the doctor. I say “I had (well understood) condition X 20 years ago that I rate an 8. This rates a score of…”

  17. 17
    Fair Economist says:

    The high-intensity prescription ED aren’t as bad as I expected. I figured they’d be pushing (so to speak) 100% for 9 and 10 intensity.

    Edit: also, yay replication!

  18. 18
    Another Scott says:

    @TomatoQueen:

    my way of conveying the pain info on the 1-10 scale is 1= nothing 10=active labor,

    This reminds me of a recent news story. Science:

    Athletes who can run the equivalent of 117 marathons in just months might seem unstoppable. The biggest obstacle, it turns out, is their own bodies. A new study quantifies for the first time an unsurpassable “ceiling” for endurance activities such as long-distance running and biking—and it also finds that pregnancy’s metabolic toll resembles that of an ultramarathon.

    “It’s very cool data,” says Harvard University evolutionary biologist Daniel Lieberman, who wasn’t involved with work. “It makes a very convincing case that at the extremes of human endurance, there’s a hard limit.”

    Physiologists and athletes alike have long been interested in just how far the human body can push itself. When exercising over a few hours, a wealth of evidence suggests most people—and mammals—max out at about five times their basal metabolic rate (BMR), or the amount of energy they expend while they’re at rest. How humans use energy during longer endurance activities is another question entirely, says Herman Pontzer, an evolutionary anthropologist at Duke University in Durham, North Carolina.

    […]

    In a second finding, the authors report that human pregnancy—the energy expenditure of which has been measured in earlier studies—demands about the same level of energy as long athletic endurance events. It is also governed by the same metabolic constraints. “To think about pregnancy in the same terms that we think about Tour de France cyclists and triathletes makes you realize how incredibly demanding pregnancy is on the body,” Pontzer says.

    Some researchers, including Lieberman, have hypothesized that humans evolved bodies that can run long distances in order to hunt down large, calorie-rich animals, and that those same metabolic adaptations could have allowed human mothers to birth larger babies with bigger brains. Given that pregnancy and endurance activities operate under the same metabolic rules, it could have been the other way around, Pontzer argues: Perhaps humans evolved to have bigger-brained babies, which then afforded our species more endurance.

    On that point, Lieberman isn’t convinced. “That’s a pretty big leap to make and would need a lot more evidence to support it,” he says. “Let’s take it one step at a time—just like a marathon.”

    It kinda makes sense. If there were some benefit or some way to expend more energy during pregnancy (either to have a larger (more likely to survive) child, or to have it grow quicker, then that probably would have been selected for. So, there must be some limit (that changes only very slowly).

    Women are amazing. ;-)

    Cheers,
    Scott.

  19. 19
    Another Scott says:

    @Another Scott: Moderation?!? Really?

    (sigh)

    Help? Thanks.

    Cheers,
    Scott.

  20. 20
    MoxieM says:

    I’m neither a vet, nor a medical person (although, NB, I did significant longitudinal research on injection drug use and tx modalities, so I’m, not ignorant of the literature…)

    I’m also a person who lives with chronic intense pain. I do all the applicable non-surgical stuff (PT, yoga, etc etc) to relieve. I’m developing ulcers from NSAID use.

    I’ve been managing all this for years. And, I live utterly on my own–I’m what they call an “elder orphan” (weird term), and also highly socially isolated for : reasons. So I have to be able to take care of myself.

    The only, and I mean only, time I have had any relief from constant excruciating pain–like labor, is when I had 2 months of very low-dose Oxycontin prescribed because I was moving and (see: ulcers). This is the only relief over a period of at least five years… (I had a home birth with back labor, so I know about that pain.) Living with long term acute pain is psychologically and emotionally worse, way worse than labor. And you don’t get a baby, either.

    So, a couple of points and/or questions:
    –How applicable is a sample of VA patients to the general population? (I realize the sample here is the docs, but by default we’ve got the Vets.)
    –VA docs generally don’t practice elsewhere, am I right? (at least, the ones I’ve known)
    –Are the patients not primarily male?
    –I believe–could be wrong–that chronic pain is undertreated among women, especially older women, therefore a sample of (older men?) has ?? utility?
    –the preponderance of deaths from “opioids” has become deaths from street drugs, specifically fentanyl, not Rx drugs, yes?
    –how well defined is the pathway from Rx to street drug, and for whom? how does that population break down?
    –there are differences in the population in likelihood of addiction to Rx opioids–e.g., older women are more likely to be responsible users; younger males not, etc. I think this is an important point to raise every time “opioid scare” comes up.

    The point is, that people like me are daily being withheld relief that we rather desperately need, and responsibly use, due to inflammatory discussions of “opioid use” or prescription or whatever, without including all the caveats. I’ve only pointed at a few.

  21. 21
    Kent says:

    Somewhat related.

    My wife is a primary care physician who is frequently in the position to prescribe or deny opioids.

    We recently moved from Texas to Washington. She says that her new clinic in WA is remarkably more liberal about opioids than was the case in Texas and she things the state medical boards play a role. She says in TX it was easy to get crosswise and investigated by the state medical board if one was suspected of over-prescribing. Whereas in OR and WA the tilt has been in the other direction.

    I don’t know if anyone has explored this, and whether addiction rates are different in TX compared to elsewere. It is just one anecdote I happen to remember.

  22. 22

    @Another Scott:

    Some researchers, including Lieberman, have hypothesized that humans evolved bodies that can run long distances in order to hunt down large, calorie-rich animals, and that those same metabolic adaptations could have allowed human mothers to birth larger babies with bigger brains.

    Count me as very skeptical of this whole side of things. What I got from the article was that the long-term constraint on metabolism was the ability to digest enough calories to maintain that level of activity. That’s very different from our adaptations that make us good long distance runners, which are primarily built around what kind of muscle fiber we have and our ability to sweat like crazy. I would certainly want to actually study other animals to see if the ratio of humans’ long-term metabolic maximum to our basal metabolism is drastically different from other animals’ before drawing those kinds of conclusions.

  23. 23
    Patient Subzero says:

    @Spanky: Prescribing opioids for pain rated 1 seems to leave no room for pain that is, you know, painful but tolerable. When I went to the ER with that turned out to be a kidney stone, I gave it an 8. I figured 9 would be something that leaves me screaming (though maybe I would have been if the pain had come all at once rather than increasing gradually), and 10 would be reserved for something like catching on fire. I got an opioid rx from the ER. Another at my second ER visit a month later, and a third rx when I had surgery to remove the stone. Have plenty left over from all three, sitting in a kitchen cupboard in non-childproof bottles.

  24. 24
    Kevin the Hen says:

    Obligatory pain scale reference:
    http://hyperboleandahalf.blogs.....bably.html

  25. 25
    David says:

    Interesting, but I’d like to see some current data on this. The study goes back to 2012 and is only in 2012. The VA has really tightened down on opioid prescribing in the past few years and I suspect that there is much less opioid prescribing overall than before in the ER as well as in the less urgent outpatient setting. VA docs (at least in my state) are now required to look up in a statewide registry controlled substance prescribing for the individual patient before deciding to prescribe a controlled substance.

    Yes, there might be individual variants in prescribing practices, but the overall amount of opioids Rx’d is down significantly. This prescribing in also monitored much more tightly than in the past by the pharmacist and by the pain clinic docs.

  26. 26
    Ruckus says:

    @MoxieM:
    Interesting questions.
    I’m just getting back from a long day at the VA hospital and can answer some of your questions, if not completely accurately, close enough for government work.
    There are more women vets than might be imagined and there are women’s clinics specifically for their different needs.
    But yes the overwhelming population is men. And they age from probably 25 ish to over 90. One of the differences is that often there are results of injuries sustained that are not nearly as often noticed outside the VA. Amputations/prosthetics being a biggie. One sees a lot of this at the hospital. After that it seem to be mostly physiological damage and after that normal stuff that is seen in most any system.
    Most of the docs are federal employees, I understand they do use contracted docs sometimes. That may not be correct, it’s just my understanding when they have an extreme shortage in an area. So I would doubt that they can work elsewhere. The other thing is that most of the clinics in the hospital use residents or med school students to do initial intakes, who are then overseen by an attending. So an attending might have 3 or 4 intake folks working for them at a time. Today for example I was seen by a medical school student. I asked where she went but not her year, but from her knowledge I’d bet 4th year. After they do their exam they discuss you with the attending and the attending and intake person come back and may do further exams and discuss with you the outcome, make an prescriptions necessary and tell you when they want you back.
    After that I don’t have any more answers for you. Other than for me I’ve been prescribed a few different opioids for my issues and every one of them has varied from not good to very, very, not good. I was given Oxy once after an operation and it was worse than the pain. Not my cup of tea. At all.

  27. 27
    Ruckus says:

    @Patient Subzero:
    As the pain scale is subjective I can see this. I almost cut off my thumb, once ( a boy can learn, damnit ) 80% of the tendon severed, nerve bundle and artery 100% severed. There was no pain what so ever. Zero. The sewing it back together, that was about an 8 1/2. Maybe 9. I’ve been hit by a truck and that didn’t hurt as bad, but then adrenaline is a wonderful thing.
    I’ve had migraines that are worse, my personal pain scale goes to 12. The normal 10 is you need be put to sleep to endure the pain. 11 on my scale is I wish someone would just shoot me. 12 is I’d shoot my self if it didn’t hurt so fucking bad to move or even if I could move, and had a gun to get.

  28. 28
    Inspectrix says:

    If this isn’t a dead thread…
    The VA DoD has a decent pain scale with colors, faces, numbers, and anchoring words that are more useful:
    https://www.va.gov/PAINMANAGEMENT/docs/DVPRS_2slides_and_references.pdf

  29. 29
    David says:

    @Ruckus:

    Depends on the clinic. in some clinics patients are seen directly with an attending and no residents are in the clinic. Other clinics patients are seen with physician extenders, e.g. PA or NP. Depending on the state, physician extenders can be independent practitioners or have to discuss cases with attendings. Some clinics have patients seen with residents and then with the attendings. It’s a function of availability of residents (who often have other duties than seeing outpatients) and physician extenders. None of the attendings I work with only have resident clinics (called teaching clinics). All see patients individually as well.

    Worth remembering that medical students have absolutely no standing in the clinic in terms of history and that the attending is expected to verify key portions of the history and exam. Med students can’t prescribe anything and their notes are for the purpose of reviewing how the student writes the note and formulates the situation, not for the purposes of patient care.

    Residents have medical licenses and can prescribe medications, but the attending is still considered responsible for the history, exam, plan and orders as well as the outcome.

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