A Low-Cost, Rapid RCT to Reduce Overprescribing

Overprescribing of medications jeopardizes patients’ health and unnecessarily increases health care spending. Inappropriate prescribing by doctors may be a function of many behaviors, including outright fraud, inadequate patient monitoring, and misinformed prescription decisions.

In the United States, many are increasingly worried about the costs of overprescribing of drugs. To reduce fraud and improve patient safety, policymakers demand fixes to inappropriate prescribing and rigorous evidence that proposed solutions will produce the desired effects.

Could an inexpensive, informative letter sent to physicians notifying them that they are prescribing much more than their peers change behavior and reduce dangerous prescribing? And could a study address this policy question, costing little and taking short time, while maintaining the quality of a good evaluation?

In 2014, the White House Social and Behavioral Sciences Team (SBST) facilitated a research study with the Center for Medicare and Medicaid Services (CMS), the SBST, and academic researchers with support from J-PAL North America. Through a randomized evaluation, Adam Sacarny (Columbia), David Yokum (SBST), J-PAL affiliate Amy Finkelstein (MIT), and Shantanu Agrawal (CMS Center for Program Integrity) studied the effect of an informative letter on reducing the prescribing of Schedule II controlled substances in Medicare Part D by questionable prescribers. CMS has used such letters, targeted to potential oversubscribers, as one tool to potentially reduce fraud in the Medicare program.

The results of that study, published today in Health Affairs, were featured in the 2015 SBST Annual Report and are summarized in this J-PAL evaluation summary. In short, the evaluation found no measurable impact of the letter on Schedule II prescribing.

However, this study is a model example of a low-cost, rapid turn-around evaluation made possible by the use of high-frequency administrative data, a “light-touch” intervention, and an ongoing collaboration between CMS and researchers.

Indeed, in continued partnership with CMS, researchers are already testing a new letter to reduce questionable prescribing of Seroquel, a commonly prescribed antipsychotic. These letters will more strongly emphasize the negative consequences of inappropriate behavior, will use more recent data on mailing address to increase the likelihood that prescribers actually receive the letter, and will be sent multiple times in light of research on the effects of repeated letters.

Evidence from rigorous evaluations can help government agencies improve existing programs, decide which new programs to introduce, and allocate resources across programs. Sometimes studies will take years to complete so that we can understand the long-term effects of programs. Sometimes they will be expensive, but valuable investments for improving future spending. But the ongoing collaboration between CMS, SBST, and academic researchers show that it is also possible for studies to be leaner, costing relatively little and delivering results in short periods of time.

Author: Graham Simpson

Graham Simpson is a Policy Associate at J-PAL North America and manages the North America General Research Initiative. To share the results from randomized evaluations, he writes summaries, policy publications, and other materials. To encourage governments and organizations to use evidence to inform policy, he carries out training sessions and presentations, helps connect partners to academic researchers, and works to promote evaluation more broadly. Prior to joining J-PAL in 2014, Graham worked as an instructor at the Worcester County Jail and House of Correction where he taught high school equivalency classes, computer skills, and peer tutor training to inmates. Graham holds an A.B. in Economics from Harvard University.

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