Figure. Interrupted time series of the initial opioid fill rate of patients who filled a periprocedural opioid prescription before and after termination of modifier 22 incentive for opioid-free vasectomy on December 31, 2021.

There has been increasing awareness of the opioid crisis over recent decades with one-third of opioid overdose deaths in 2018 accounted for by prescription opioids.¹ Given the multifaceted nature of the opioid epidemic, there have been multiple levels of interventions to limit prescription opioids. One example is the Michigan Opioid Prescribing Engagement Network that developed an opioid-sparing postoperative pathway for several surgeries in August 2018. To improve provider utilization of this intervention, Blue Cross Blue Shield of Michigan (BCBSM) incentivized this opioid-sparing pathway with a “modifier 22,” which allowed for up to 35% additional reimbursement for certain procedures that were performed with minimal or no postoperative opioids. This was the first instance of financially incentivizing a preventative opioid strategy for physicians. This opioid-sparing modifier 22 was expanded to include vasectomy on July 1, 2019. In our prior work, we examined the perioperative opioid fill rate before and after implementation of modifier 22 incentive mechanism for opioid-free vasectomy compared to urologic office control procedures that did not qualify for the modifier 22 incentive by using an interrupted time series.² We found that modifier 22 incentive was associated with a statistically significant decrease of 12.8% in the opioid fill rate in the vasectomy group compared to that of the urologic office control group that did not qualify for the modifier 22 incentive.² This meant that for every 3 opioid prescriptions that were filled prior to modifier 22, only 1 opioid prescription was being filled following institution of modifier 22.² These findings highlighted how the modifier 22 quality incentive could support judicious opioid prescribing.

Since our original study, the financial incentive using modifier 22 by BCBSM to encourage opioid-sparing vasectomy was terminated on December 31, 2021. Therefore, we sought to evaluate what happens to the physician opioid prescribing behavior and patient’s initial opioid fill rate after the modifier 22 financial incentive is terminated. Mirroring our prior methods, we performed an interrupted time series analysis before and after termination of modifier 22 for both the vasectomy and the urologic office control groups. We found that modifier 22 policy termination was not associated with a significant change in opioid fill rate in the vasectomy group (−0.6%, [95% confidence interval: −6.5%-5.3%]) nor urologic office control group (−0.6%, [95% confidence interval: −6.6%-5.5%]; see Figure). Not only did the initial opioid fill rate persist following termination of modifier 22 incentive, the size of the initial opioid fill was also sustained without a significant increase following termination of modifier 22 incentive with mean initial opioid size 59 oral morphine equivalents with the incentive in place and 36 oral morphine equivalents following incentive termination (P = .5) in the vasectomy group.

While our study has several limitations, our findings have important implications. First, for payors, we found that the physician practice pattern of decreased opioid prescribing associated with the modifier 22 incentive was sustained beyond the policy termination. This suggests that with a short-term investment up-front, lower opioid prescribing patterns could be maintained longer than the incentive duration. Other payors could potentially implement similar incentive programs as the BCBSM modifier 22 initiative. It is also possible that temporary financial incentives could be expanded to other high-value care initiatives and create lasting practice changes. For patients, the benefits are self-evident: fewer prescriptions will mean fewer opportunities for long-term opioid use or accidental overdoses. Moving forward, additional areas of study include doing a prolonged follow-up to ensure these practice patterns persist beyond the 6 months of our initial evaluation and comparing if these practice patterns are generalizable to other procedures that are seen as more invasive, such as robot-assisted radical prostatectomy.