all evidence in sustainability is supported by these increases .
Potential drivers for the positive financial changes are seen in the lower no-show rate and the higher level of coding per visit . There was a -12.14 % decline in overall noshow rate , in part driven by a -72.75 % decline in no-show rate for specific ISOMP days . These visits , which have a substantially negative impact on patient care and financial costs to healthcare providers , 13-14 are a common issue in primary care with rates as high as 50 %. 15 Even more impactful were the higher levels of coding per visit , evidenced by the + 0.212 ( 1.295 to 1.507 ) average work RVU per visit increase in global practice . This effect is seen most clearly when considering the ISOMP days ( Table 2 ), in which the work RVU level was sustained by the high frequency use of the 99215 EM code which increased by + 3,366.67 % over baseline . This higher level of coding was entirely related to the timebased counseling and care coordination necessary to complete guideline concordant care of NMCP . 16-20 This billing augmentation was primarily driven by Group A , the subjects who continued opioids ( Table 4 ). This cohort spent the longest time exposed to the ISOMP and accounted for an increase in total work RVUs of + 42.95 %. That result was dependent on a + 0.86 increase ( 1.14 to 2.00 ) in average opioid encounter work RVU , leading to a + 0.57 increase ( 1.08 to 1.65 ) in overall average encounter work RVU . The take home message is that patients maintaining their opioids for NMCP sustain this model .
GLOBAL FINANCIAL IMPACT
Although the primary goal was to evaluate the financial sustainability of the ISOMP for a physician practice , it is important to analyze the impact of the 38 % discontinuation rate on healthcare savings . Data from Group B , or the patients choosing to wean off of all opioids , show potential thirdparty payer savings were found ( Table 5 ). Not only were there 24.04 % fewer visits , but the work RVU billed also decreased by 17.56 %. A closer look into this group ’ s data reveals potentially sustainable savings . Table 5 separates the 19-month ISOMP time period into pre-wean and post-wean components . On average , it took 5.58 months of the 19-month protocol period to wean a patient in Group B . Once weaned , this group required significantly less frequent visits per month ( -44.99 %: 3.35 vs 6.01 ) and generated fewer RVU per month ( -47.39 %: 4.44 vs 8.44 ). It can be projected that the longer duration of time the patient is off opioids for NMCP , the greater the savings to the medical community . It should be noted that these results reflect the primary care savings , as the global cost was not able to be calculated .
The potential implications of using an ISOMP can be viewed from the perspective of the patient , the provider , the payer , and society . Patients can benefit by engaging in a program that has been shown to encourage cessation of opioids through careful assessment and education , reducing the excess risk associated with this class of medication . Primary care physicians benefit from fewer patients at risk for opioid complications , the reassurance they are following an evidence-based template guiding their complex care , and the ability to do this in a fiscally sustainable manner with less strain on workload . Payers have the advantage of fewer enrollees using opioids , resulting in a lower number of healthcare visits and cost . For society , the costs related to opioids extends to loss of productivity , absenteeism , and morbidity and mortality in citizens who misuse opioids . 4 The savings to the healthcare system and pharmaceutical savings of decreasing the opioid burden were not able to be calculated .
There are several limitations to this study , as follows : small sample size , retrospective nature , single physician practice involved , and single geographic region . Reproducing this study at multiple primary care sites , in different geographic regions , and with populations with differing opioid penetrance could help determine whether these results are generalizable . Should the ISOMP prove to be widely applicable , it could help address issues identified in the National Institutes of Health Pathways to Prevention Workshop regarding the role of opioids in the treatment of chronic pain . 1 In addition , this structured program provides a template to provide a multidimensional approach to these high-risk patients .
CONCLUSIONS
Beyond the obvious clinical benefit of a 38 % decrease in practice population using opioids for NMCP , 8 the ISOMP diminishes the scheduling burden for the provider and improves visit compliance . Furthermore , the program can be constructed in a financially responsible manner , as we have shown that revenue is maintained with the increased coding of the timebased opioid visits . Overall health cost savings are found in the weaned cohort . When this group is split and the post wean RVU are analyzed , the true work / cost benefit can be seen . The benefits garnered should only continue to grow as patients continue to remain opioid-free .
REFERENCES
1 . Reuben DB , Alvanzo AA , Ashikaga T , et al . National Institutes of Health Pathways to Prevention Workshop : the role of opioids in the treatment of chronic pain . Ann Intern Med . 2015 ; 162 ( 4 ): 295-300 . doi : 10.7326 / M14-2775 .
2 . Ray WA , Chung CP , Murray KT , Hall K , Stein CM . Prescription of Long-Acting
Opioids and Mortality in Patients With Chronic Noncancer Pain . JAMA . 2016 ; 315 ( 22 ): 2415-2423 . doi : 10.1001 / jama . 2016.7789 .
3 . Birnbaum HG , White AG , Schiller M , Waldman T , Cleveland JM , Roland CL . Societal costs of prescription opioid abuse , dependence , and misuse in the United States . Pain Med . 2011 ; 12 ( 4 ):
657-667 . doi : 10.1111 / j . 1526-4637 . 2011.01075 . x .
4 . Reinhart M , Scarpati LM , Kirson NY , Patton C , Shak N , Erensen JG . The Economic Burden of Abuse of Prescription Opioids : A Systematic Literature Review from 2012 to 2017 . Appl Health Econ Health Policy . 2018 ; 16 ( 5 ): 609-632 . doi : 10.1007 / s40258-018-0402-x .
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