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In this episode, we’re discussing the opioid epidemic and its impact on our society. Our guest is Gary Call, a family physician, who shares the emotional and financial cost on individuals and families caused by opioid addiction and overdoses is immense and impacts everyone. We’ll also be discussing the latest research on the opioid epidemic, including a study by Stanford researchers led by Dr. Tina Hernandez-Boussard, which aimed to develop a predictive model to identify risk factors for non-opioid users becoming chronic users. The study leveraged a unique research database of millions of de-identified Medicaid paid claims, and the results are both instructive and actionable. Dr. Call will also talk about the importance of translating research from leading academic institutions into real-world use cases that solve important health care problems and how it can help create a more equitable and effective system for all. Tune in to learn more about the opioid epidemic and what we can do to address it.

Gary Call is a family physician and health care executive.

He shares his story and discusses his KevinMD article, “Think twice before prescribing opioids as a first-line treatment for pain.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show, we have Gary Call. He’s a physician and health care executive. His KevinMD article is titled “Think twice before prescribing opioids as a first-line treatment for pain.” Gary, welcome to the show.

Gary Call: Thanks, Kevin. Happy to be here. Thanks for having me.

Kevin Pho: We’ll get to the article in a little bit. First off, briefly share your story and journey to where you are today.

Gary Call: Yeah, so I went to medical school at the University of Washington in Seattle, which is where I grew up, and I enjoyed that experience. I had an opportunity to do my family medicine residency at the University of Utah. I chose family medicine, and I’ve really enjoyed the career there. I really liked the interaction with people. I liked the opportunity to get to know people over time, and their families, so I’ve really enjoyed being a family physician.

Coming out of residency, I started working in a vertically integrated health care organization and joined the practice there. I had some opportunities to start doing some leadership-type activities, both at the clinic level and later in the family practice department at the hospital level, so I got into that a little bit and enjoyed some of the administrative and business side of things. After doing that for a few years, I decided to broaden my experience, and I really wanted to get into the private practice world. So I started a small group practice with a couple of friends. We had a three-person practice in family medicine, pretty much full spectrum. We didn’t do OB, but we did everything else, and I really enjoyed that a lot.

I did that for a few years, and as I was working there, I got an opportunity to get involved in managed care. I had a friend who was the head of a managed care organization, and they needed a medical director for just a couple of hours a week. This plan was just starting, so I started doing that and enjoyed it. I learned some new things that I didn’t know, and that expanded over time as the plan grew. Pretty soon I was working too much, and I had to make a decision: Do I continue in my practice, or do I go into managed care administration full time? I decided to go ahead and do the business side of things, which was interesting and, like I said, kind of a new experience.

I did that for a number of years. Gradually, I had a chance to work at both the state and the national level in managed care and learned all kinds of things about medical management, quality, and pharmacy. It was just a really great learning experience, and I had the opportunity to do a lot of things and learn a lot about the health care system. I did that for quite a long time, and then I had an opportunity to switch gears a little bit and get into health care technology.

So currently, I’m working as the chief medical officer for Gainwell Technologies, and that’s a company that provides health care technology that supports states as they administer their Medicaid programs. I’m in charge of all things clinical, but mostly focusing on identifying and recovering money from fraud, waste, and abuse, and also improving patient experiences and outcomes through a care management technology platform and some analytics that we also do. So I’ve really been blessed to have a career with a tremendous amount of different opportunities and a lot of experiences, which I think has helped my view of the health care system. It’s also been really rewarding. I really love learning new things and having opportunities to do some different types of stuff, so it’s been great.

Kevin Pho: Now, you’ve been on both sides of the spectrum, obviously. You’ve been on the clinical side, you’ve been on the administrative side, and now you’re on the health care tech side. So for those practicing clinicians who may not have your depth of experience, what are some misperceptions, would you say, about the administrative business side of medicine that you would want them to know about or clear up?

Gary Call: I think it’s interesting. When I first went into managed care, a lot of my colleagues and friends said, “Oh, I can’t believe you’re going to the dark side.” I thought about that, and my response really was, “I’m hoping I can make the dark side a little more light.” So I think, as I got into administrative medicine and the business side of things, it really helped to broaden my perspective and helped me understand more about the health care system, how it works, and how it functions. I don’t think we really teach people that.

And I think when you start out, when you’re in training and you’re just starting a practice and you’re really just head down trying to make it work, it’s unfortunate that you don’t have a bigger picture. Because I think if we understood how the system works, how to work with payers, how hospitals work, and how the physician’s role at hospitals works, if we understood all those things, it would really help us as physicians to have a more meaningful experience and really enjoy things. I think sometimes physicians feel like they’re victimized, or they just feel like they’re the captives of this overburdened system, and I think that leads to dissatisfaction and burnout, which is really too bad, because there are so many exciting things that you can do in medicine.

So again, having that perspective has really helped me see the broader picture, and it has really helped me understand that if we all understood the perspectives of the different players, whether it’s the government, because I’ve worked a lot in Medicaid, so I understand, I think, to some degree, what the government’s trying to accomplish with health care, or payers, hospitals, patients, or advocacy groups. I’ve worked with all those groups, and I think having that experience and that view has helped me really have a more positive experience in health care and a really enjoyable career, and maybe not feel that burnout and victimization that I think so many physicians feel right now.

Kevin Pho: So give us an example, a brief story or example of something that a clinician who is perhaps burned out, you wish they could better understand, something from the other side that can help their burnout. Give us an example of some of those misperceptions that may arise.

Gary Call: Yeah, so I’ve had an opportunity to do a lot of work in medical management, which includes prior authorization, and that’s probably one of the biggest thorns in the side of physicians everywhere. I think everybody hates prior authorization. But I’ve seen it from the other side. I know when I first went to the managed care organization, I thought, “Oh, man, the physicians in our community are so awesome. This is going to be a breeze.” And some of the things I saw, quite frankly, shocked me: people requesting services that had no medical justification and that weren’t following any practice guidelines or best practices at all.

So I think what I learned as a physician was to take the things that you typically do in your practice, especially those services that might require an authorization, and learn about them. Really learn what the best practices are, and line yourself up to be data-driven. I think that helps. Again, it’s always going to be a burden, but I think if you know what it is the managed care companies expect, and again, from that side of the fence, we’re really just expecting people to follow data-driven practices and best practices that are published out there, then I think it’s an opportunity for people to maybe make that less burdensome, because they’re prepared and they know what the expectation is, and I think it would just be a lot easier. I think people will feel less burdened by that process if it doesn’t feel like an enemy, but like you’re both just working together on data-driven practice.

Kevin Pho: All right, let’s move on to your KevinMD article, titled “Think twice before prescribing opioids as a first-line treatment for pain.” Now, tell us, how did this article come together?

Gary Call: Yeah, so one of the things I do at Gainwell, as we talked about, is the work we do with state Medicaid programs. We have a ton of Medicaid claims data, and so we were trying to think: How can we take that data and make it useful to improve and tackle some of health care’s most challenging problems? So we went to some of our clients and we said, “If we de-identify the data, would you allow us to use this database for research purposes?” And we’re grateful that some of our clients agreed to let us do that.

So then we took that database, and we reached out to some academic partners and said, “Hey, we’ve got this research database. We’d love to work with you on some academic research that’s geared toward things that the industry can use to get better and solve some of these big problems.” One of the problems I was really interested in at the time, and still am, is the opioid problem we have in the country, and how we tackle that and get ahead of it. How do we identify at-risk people? We’ve seen how hard it is, once people start to have a problem with opioids, to treat that and to solve that problem. So how do we get ahead of that and identify people at risk? That was something I was particularly interested in at the time, and luckily, it resonated with one of our academic partners. Dr. Tina Hernandez-Boussard, who’s at the Stanford University School of Medicine, she and her research team have been doing a number of studies on opioids using Gainwell’s database, so it’s been really interesting to see some of the fruits of their research.

The article that I wrote for your blog was really based on one of the published articles that they had, and there was some really interesting stuff there. I would have thought that the main risk factor for opioids was continuing to prescribe over a period of time. But what they really found, when they did their predictive analytics and built the risk model, was that it was actually the initial prescription that seemed to have the most influence on whether somebody developed chronic opioid use. And it was characteristics, things like the number of pills that they were given, the duration of treatment, and the choice of the drug. Not surprisingly, long-acting oxycodone was a high risk factor, but I think something that was very surprising, and would surprise a lot of physicians, was that tramadol was also a high risk factor. That was interesting to me, because I think in the industry a lot of people are using tramadol almost as an alternative to opioids, thinking that it’s lower risk. So that was kind of a surprising finding from the study.

To me, one of the goals that we had in doing this research is to find things that are not just academic, because so much academic research just sits on a shelf somewhere. We were really hoping to influence practice and provide solutions. So I think this all offers an opportunity for physicians to really consider their initial prescribing of opioids and really think about that. I think when we come out of training, in our early years of practice, we develop these prescribing habits, and I think people kind of just follow those. So as you consider what you should do differently, I think this is an opportunity to think about that first prescription: “Do I really need it? And if so, what duration, what dosage, what drugs am I going to choose?” I think this study really offered that opportunity.

And I also think it gave us an opportunity in the industry to use this research. I mean, at Gainwell, we’re using this in some of our analytics products and some of our patient outreach and care management products. So again, that tie-in between academics and industry is so critical, and we really feel fortunate to have started doing research with the data that we have.

Kevin Pho: Now, when you talk about that initial prescription, what were some typical doses, number of pills, or lengths of treatment that would be associated with that patient perhaps having a problem with opioids in the future?

Gary Call: I think the biggest thing was, I mean, I don’t remember off the top of my head, unfortunately, the morphine milligram equivalents of the dosages, but we did find that a prescription that went for more than 10 days was a significant risk factor on that initial prescription. And I also think that, as we looked at it, drug choice was really critical. Like I said, it seemed like long-acting opioids and, as I mentioned, surprisingly, tramadol were two of the risk-factor drugs that we saw in that prescribing. So again, I think it’s about just being judicious and thinking about it, and not being the surgeon who just always gives people 30 oxycodone or whatever after a procedure. Think about what you’re doing and get out of some of those habits that maybe we’ve developed. I think that’s the opportunity that I see.

Kevin Pho: Now, did the study differentiate between the settings where the opioids were prescribed? You did mention a postoperative setting versus a primary care setting.

Gary Call: It didn’t really differentiate there, but it did look at people who were opioid-naive, meaning they hadn’t had any opioid prescriptions in the previous six months, and then identified people who had opioid prescriptions still ongoing six to nine months after the initial prescription. That was about 30 percent of the population that we looked at, and that’s out of a study population of about 180,000 people. So it was really a much higher percentage than I would have thought that went on to have chronic opioid use, and like I said, it seems to be that initial prescription.

Kevin Pho: So you mentioned opioids like OxyContin and oxycodone, as well as tramadol. You didn’t look at any other opioid-type or habit-forming medications, something like gabapentin or benzodiazepines, for instance?

Gary Call: Yeah, this study did not look at those types of medications. It was really focused on opioids, so we didn’t look at those, and maybe that’s a step for other research. I know we continue to work with the Stanford team, and we’re hoping to do more research along these lines, again trying to focus on the idea that it’s so much easier to prevent people from having a problem than to address the problem afterward. I think we’ve all been touched in some way by the opioid crisis and the overdose deaths, and so we’re really trying to look for ways to have an impact and make a difference ahead of time.

Kevin Pho: Any other risk factors that particularly struck you, other than that initial prescription?

Gary Call: I think those were the main things that really struck me as meaningful. And again, I think it’s counterintuitive, and that’s why I think it’s so important. Because, again, as a prescribing physician, I would have thought it’s maybe the second or the third time you go to the opioids that really develops that habituation and the problem, and that’s not what the study found. So it was a super interesting study, I thought, and very applicable to our practices.

Kevin Pho: So what are the next steps in terms of studying the opioid crisis using Gainwell’s data?

Gary Call: Yeah, I think we’ll continue to look at things. We have some ongoing studies about adherence to treatment. We’re doing a study with a university that talks about how the movement of Medicaid patients affects their ability to adhere to opioid treatment, for example. So I think we’re looking at a broad range of things, but again, mostly focused on how we prevent it, so we’re looking at some other aspects of that.

And we’re also using our research for other things too. We’re looking at our data. We’re doing some studies with Southern Methodist University on hospital readmissions, for example, and what some of the risk factors are that would help us predict those. We’re doing some studies with some Australian universities who have expertise in geospatial mapping, looking at social determinants of health. For example, one thing that we’ve looked at is diabetics, mapping good food sources versus fast-food outlets in certain areas where the underserved populations live, and it’s quite striking. We had one study that we did in a state where, within the areas with the highest concentration of Medicaid patients with diabetes, there were 100 fast-food outlets and zero grocery stores. So it just gives us an opportunity to address some of those kinds of things.

So I think Gainwell’s data is really an opportunity to understand the Medicaid population on a much bigger scale than we’ve had before, and most of the academics say it’s kind of a one-of-a-kind database opportunity. So we’re excited to be able to continue that research work.

Kevin Pho: We’re talking to Gary Call. He’s a family physician and health care executive. His KevinMD article is titled “Think twice before prescribing opioids as a first-line treatment for pain.” So, Gary, I just want you to reiterate the clinical repercussions of the study. Just tell us some of those, as well as the take-home messages from your article.

Gary Call: Yeah, I think the take-home message from the article is that in everything that we do, be thoughtful. Don’t be habit-driven. Because as I look at some of the data and some of the ways that the opioids were prescribed, it just looks like people are doing things out of habit. So I think, be thoughtful and be conscious of that first prescription. A, do you really need opioids? B, if you do, what’s the minimum I can do? And again, we all walk that fine line with controlling patients’ pain. So we’re not saying don’t prescribe opioids, obviously, and that actually has been a little bit of a problem with the opioid crisis, as people are afraid to even prescribe them at all. But just be thoughtful, be data-driven, use best practices, and think about that first prescription. I think that is really critical.

And I think that probably applies, Kevin, to pretty much everything we do in medicine. It’s so easy to get into a habit, “This is the way I do stuff,” and I think we just always need to take an opportunity to evaluate and rethink our practices and make sure that, again, we’re following the data, we’re following best practices, and we’re really seeking those out.

Kevin Pho: Gary, thank you so much for sharing your time and insight. Thanks again for being on the show.

Gary Call: Yeah, thanks again. I really appreciate the opportunity. Thank you.