Aetna targets dentist 'superprescribers' in latest opioid initiative

After a root canal or wisdom tooth removal, it's not unusual for a patient to walk away from the dentist's chair with a prescription for Vicodin or Percocet, even though ibuprofen would easily relieve the pain. Dentists are among the highest prescribers of highly-addictive prescription opioids—a driving factor in the worsening opioid epidemic.

National health insurer Aetna hopes to keep these opioids out of medicine cabinets and off the street by encouraging dentists and oral maxillofacial surgeons that prescribe abnormally large amounts of opioids to change their behavior.

Using claims data, Aetna pinpointed dentists and oral surgeons who prescribed a greater than seven-day supply of opioids at least four times over a two-year period. Earlier this year, Aetna sent personal letters to the 480 dentists and 249 oral and maxillofacial surgeons who fit the bill and warned them they are in the top 1% of high opioid prescribers among their peers. Aetna also sent prescribing guidelines to help those "superprescribers" right the course.

"That's very powerful," said Dr. Harold Paz, Aetna's chief medical officer. "When you get a letter like that, it causes you to stop and think."

Paz, along with Aetna's chief dental officer Dr. Mary Lee Conicella and Dr. Douglas Fain, president of the American Association of Oral and Maxillofacial Surgeons, signed the letters.

"There are some outliers out there that do prescribe a lot, and the focus of these efforts is to have them look at their prescribing practices and see if there's room for change," Fain said.

Aetna's got the right idea, said Dr. Andrew Kolodny, co-director of opioid policy research at Brandeis University. But he's skeptical the letters will have much of an effect on dentists' prescribing habits. "There's evidence that telling people where they stand compared to their peers doesn't do very much."

Aetna's latest initiative to combat the opioid epidemic builds on a similar one targeting mostly family physicians and internists. In August 2016, Aetna warned nearly 1,000 superprescribers who refilled opioid prescriptions an average of about four and a half times.

Since then, the Hartford, Conn.-based insurer has seen the rate of monthly opioid prescriptions among its 9.4 million commercial pharmacy membership drop by 7%. The rate of monthly opioid prescriptions among Aetna's Medicare Advantage pharmacy membership of about 1 million members fell by 5%.

In many cases, the doctors who received letters had no clue their prescribing patterns deviated from the norm, Dr. Paz said.

Aetna hopes to repeat those results among dentists, which prescribe about 18% of the opioid prescriptions to Aetna's members. Nationwide, about 12% of all opioids are prescribed by dentists, second only to family physicians, according to 2011 study in the Journal of the American Dental Association. Dentists are also the highest prescribers of opioids to patients ages 10 to 19, a 2011 JAMA study found.

The Centers for Disease Control and Prevention guidelines involve best practices for prescribing opioids to treat chronic pain. But oftentimes, dentists prescribe opioids after surgery, such as after a root canal, where the acute pain lasts just 72 hours at most, Conicella said.

"It's a different type of pain and really should require different type of management," she said. The CDC recommends dentists only prescribe the lowest effective dose of immediate-release opioids for acute pain, for three days or less. Several states, including New York, Pennsylvania and Massachusetts, have implemented laws limiting initial opioid prescriptions that doctors can write to 7 days.

There are times when a prescription for a powerful opioid is appropriate, Dr. Paz said. So Aetna excluded cases involving oncology patients or major injuries from its analysis of superprescribers. But, he said, "We have to ask the question about a young boy who has a root canal and receives a significant prescription of Vicodin. Does that make any sense at all?"

As pressure from the public, policymakers and law enforcement builds, Aetna is one of a small group of insurers that have stepped up efforts to fight the opioid epidemic leaving thousands dead every year. Opioids led to more than 33,000 overdose deaths in 2015, up more than 15% from 28,600 in 2014, according to the Centers for Disease Control and Prevention. In half the fatal cases, the overdose involved a prescription opioid.

Insurers are working to reduce the opioids dispensed by doctors in their network to keep patients from becoming addicted. A few are increasing access to treatment for those patients that become addicted to opioids. Aetna, along with national insurers Anthem, Cigna and UnitedHealth Group, recently lifted prior authorization policies for medication-assisted treatment, which often delays essential treatment when patients need it most.

Still, experts like Kolodny say health insurers aren't doing nearly enough to combat the growing epidemic.

While Paz and Conicella insisted that the cost of opioid-related claims wasn't a factor in Aetna's decision to send letters to physicians, it's clear that much of the cost of the opioid epidemic lands on private insurers. Private insurers paid out $445.7 million for treatment of opioid abuse and drug dependence disorders in 2015, up from $32.4 million in 2011, according to a report by not-for-profit Fair Health.

"This has to be a concerted effort of provider organizations, health insurers like Aetna, and everyone needs to participate, cooperate, to take the initiative to do something about (the epidemic)," Paz said. "We want to provide leadership on behalf of our members, our customers the physicians, the dentists that are in our provider networks, to do the right thing."