Low Opioid Fill Rates Continue Despite Termination of a Financial Incentive for Opioid-Free Vasectomies - Catherine Nam

May 30, 2023

In this conversation, Catherine Nam joins Ruchika Talwar in discussing her AUA 2023 award-winning poster, "Low Opioid Fill Rates Continue Despite Termination of a Financial Incentive for Opioid-Free Vasectomies." The research focuses on the aftermath of the termination of the Modifier-22 incentive that facilitated an additional 35% reimbursement for opioid-sparing recovery services in Michigan. Remarkably, the study finds a persistent low opioid fill rate, even after the incentive's discontinuation. This unexpected outcome suggests that temporary incentives might influence long-term behavioral change, having implications for more invasive procedures and broader health policy. Dr. Nam considers this a promising model for other states' insurance companies to implement, understanding it as an investment in long-term behavioral changes for physicians and a beneficial step for the community at large. The conversation also delves into the details of the study's analysis, the potential for similar models in different disease states, and the practicalities of pain control post-vasectomy.


Catherine Nam, MD, University of Michigan, Ann Arbor, MI

Ruchika Talwar, MD, Urologic Oncology Fellow, Department of Urology, Vanderbilt University Medical Center, Nashville, TN

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Ruchika Talwar: Hi everyone. My name's Ruchika Talwar and I'm excited to bring you more Health Policy content from the AUA 2023 annual meeting. Today I'm joined by Dr. Catherine Nam, who's a PGY-4 resident at the University of Michigan. She'll be discussing her poster award winner, Low Opioid Fill Rates Continue Despite Termination of a Financial Incentive for Opioid-Free Vasectomies. Dr. Nam, thanks so much for being here with us today.

Catherine Nam: Thank you so much for having me.

Ruchika Talwar: So tell me a little bit about the background of this study.

Catherine Nam: Yeah. So Michigan is a unique situation where we have the Michigan Opioid Initiative or M OPEN, and they put together an opioid sparing post-operative pathway for multiple procedures back in 2018. And Blue Cross Blue Shield of Michigan worked with the organization to incentivize this by allowing a Modifier-22, which allows for 35% additional reimbursement for the additional services that are needed to help guide the patients through an opioid sparing recovery process. And so this first started with a number of different procedures and then in July 1st of 2019 was expanded to include vasectomy, which is a perfect target because it's done so often in an office setting and it's seen as pretty minimally invasive. And in our prior work, what we found was that with the institution of the Modifier-22 incentive for vasectomy compared to the other office-based urologic procedures that didn't qualify for this quality incentive, there was an immediate decrease of opioids being prescribed and opioid fill rate for vasectomies.

The relative decrease was about two-thirds and the opioid size also decreased as well. But since then, the Modifier-22 incentive has actually been terminated at the end of 2021. And so we thought it would be really interesting to see how would the opioid prescribing patterns differ after this incentive is taken away? Would the changes be persistent beyond the incentive being in place or would prescribers revert back to their prior opioid prescribing where they're giving more with higher opioid fill rates? And what we found was that after the termination of the Modifier-22 incentive, there was actually a persistent low opioid fill rate and the size of the opioid prescriptions beyond the termination of Modifier-22.

And we thought that this was really interesting because this was an incentive that was in place for a time limited period, but the effects seemed to have persisted beyond that, which makes it really interesting in terms of applicability for other procedures that are also seen as pretty minimally invasive. And then it also makes it a little bit more palatable or approachable for other insurance companies such as Blue Cross Blue Shield or other insurance companies in other states to also use this incentive to have long-lasting effects in terms of decreasing the opioid prescribing and fill patterns.

Ruchika Talwar: Yeah, really interesting stuff. So before we get into the structure of the program, I want to spend a bit of time talking about your analysis. You told me a bit about your results, but why don't you tell me how you all calculated the opioid fill rates and what your control group was, what you found in that regard?

Catherine Nam: Yeah, I would be happy to elaborate on that a little bit more since I totally glazed over it. But in terms of the office control groups, we focused on the ones that we thought were comparable but weren't allowed to participate in the Modifier-22 groups. So this included prostate biopsies, cystoscopy and transurethral destruction of prostate tissue like RESUME or other procedures. And in terms of the analysis that we did, we did an interrupted time series where we looked at the comparable time period before the incentive was terminated and then the time period after. So we looked at six months before and six months after. We also did a two-month washout period before and after the incentive termination, given that the practice patterns might not be fully appreciated in the immediate before and after the policy change. And we use the administrative claims from Blue Cross Blue Shield of Michigan to identify the patients who have undergone these procedures across the state for both the before and after the termination of the Modifier-22.

Ruchika Talwar: Got it. Yeah, really interesting stuff. These financial incentive programs have existed in Michigan, as you said, for a little while now, they spanned vasectomy, but I know that they were also allowing for Modifier-22s for robotic prostatectomy, for example. So I really applaud your group for leading the way in this work and M OPEN has obviously set the standard for opioid free surgeries since, like you said, 2018. But I think this is an interesting application of looking at how even temporary incentives can change surgeon behavior. So tell me a bit about your thoughts on that.

Catherine Nam: Yeah. So I do think this is unique in that it's one of the only incentivizing policy changes that have been put in place for opioid sparing or decreasing opioid prescription because a lot of the other things have actually only added on work burden on the physicians more so than incentivizing and taking some of that burden away or acknowledging it. And so I think this is the first time that we're able to really appreciate the long-lasting effects of this incentive beyond the scope of the Modifier-22. But I think some of the interesting things would be looking at compared to robotic prostatectomy, which is a much bigger surgery, does robotic prostatectomy also have the significant persistent decrease? Or, because they're worried that it's a little bit more invasive, would physicians go back to prescribing more? So I think it would also be interesting to do a little bit of a comparison in terms of the invasiveness that's associated with these procedures or surgeries.

But that being said, I think this is the first example where we've had a temporary incentive that has been shown to have long-lasting effects, at least in the six-month period that we've looked at, and so could this potentially be a model to be used for other insurance companies in other states? I think absolutely. And for insurance companies, it would be a lot easier to implement for a shorter period of time, like two years or something, with this incentive understanding that it's a long-term behavior investment that they're making in physicians and for the community, I think it would be really worthwhile to explore.

Ruchika Talwar: Yeah, you bring up a good point. It is an investment so that you are reimbursing physicians more since they're able to use the Modifier-22. But if you look at healthcare costs on a larger scale, I think you bring up a good point where it may actually be a savings due to the fact that patients may have lower opioid exposures that would lead to presumably lower rates of overdose, addiction and pill diversion. So I agree there's a lot of buy-in. And looking at your model, I think it's a good model for other disease states as well, outside of just opioids. I think incentivizing high value care through perhaps forgoing low value testing. So the things that I think about are bone scans in low-risk prostate cancer or over utilization of certain imaging modalities. So it's interesting, I think we'll see a lot more of these behavioral incentive programs put into place as people like you are doing really innovative research in this world. So I look forward to that. I'm curious from a more practical standpoint, what protocol did your group use for pain control after vasectomy if they were not prescribing opioids?

Catherine Nam: Yeah. So for a vasectomy, we were just doing scheduled Tylenol and timed with ibuprofen maximum dose every six hours and icing scrotal elevation, which we were all doing anyway. And I do think part of the surprise for me when I was doing this study was how much opioids were being prescribed with a vasectomy. Because at Michigan Medicine, where I'm a resident, we don't ever prescribe opioids after vasectomies. And so I do think we're a bit of an anomaly where probably our practice patterns didn't change super significantly by this incentive, but just the generalized trend of decreased opioid prescription was already reflected in our practice patterns. But I don't think that was as reflective of the overall practice patterns of the state.

Ruchika Talwar: Yeah, I think that's a good point. I think in academic centers perhaps and especially in Michigan, you all have been leading the way in opioid free surgery in multiple realms, so it doesn't surprise me to hear that your patterns were consistent. But it's nice to think about the fact that even in the community when you're able to apply this incentive that the effects are long-lasting. So congratulations on a great study, very thought-provoking stuff and I'm sure that it's going to lead to policy changes in other disease states outside of urology as well. So great work and thank you so much for spending some time to chat with us today.

Catherine Nam: Great. Thank you so much for the opportunity.

Ruchika Talwar: Of course. And to our audience, we hope you'll continue to join us. We have a few more interesting Health Policy articles to spotlight and take care.