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Inspector General Faults Medicare for Not Tracking ‘Extreme’ Prescribers

Echoing a ProPublica investigation, a report finds hundreds of doctors with questionable and potentially dangerous prescribing patterns. In a response, Medicare says it will step up monitoring and review the list for fraud or abuse.

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A registered nurse discusses medication with a patient during a house call in Denver, Colo. (John Moore/Getty Images)

More than 700 doctors nationwide wrote prescriptions for elderly and disabled patients in highly questionable and potentially harmful ways, according to a critical report of Medicare's drug program released today.

The review by the inspector general of the U.S. Department of Health and Human Services flags those doctors as "very extreme" in their prescribing – and says that Medicare should do more to investigate or stop them.

The study mirrors a ProPublica investigation last month that found Medicare had failed to protect patients from doctors and other health professionals who prescribed large quantities of potentially harmful, disorienting or addictive drugs.

Medicare's prescription drug program was launched in 2006 and now accounts for about one of every four drugs dispensed nationwide. Last year, the government spent $62 billion subsidizing the drugs of 32 million people.

"Strong oversight of the Medicare prescription drug program is critical for protecting patients from harm," Sen. Tom Carper, D-Del., said in an email.

Carper chairs the Senate Homeland Security and Governmental Affairs Committee, which has scheduled a hearing Monday about prescription abuse in the Medicare program, known as Part D.

The inspector general's report focused on the prescribing of nearly 87,000 general-care physicians, such as family practitioners and internists, in urban and suburban areas in 2009. These doctors accounted for about half of all the prescribing in the program that year.

The review found more than 2,200 doctors whose records stood out in one of several areas: prescriptions per patient, brand name drugs, painkillers and other addictive drugs or the number of pharmacies that dispensed their orders.

Of those, 736 were flagged as "extreme outliers." Their patterns, the report says, raised questions about whether the prescriptions were "legitimate or necessary."

For instance, 24 doctors wrote more than 400 prescriptions for at least one patient, including refills dispensed. One Ohio physician did so more than a dozen times, according to the report. The average doctor wrote 13 per patient.

In another case, an Illinois doctor had prescriptions filled by 872 pharmacies in 47 states and Guam. General-care doctors, on average, had prescriptions for all their Medicare patients filled by 52 pharmacies.

The cost to the government was enormous in some instances. Medicare paid $9.7 million for the prescriptions of one California doctor alone – that is 151 times more than the cost of an average doctor's tally, the report says.

Most of this physician's drugs were supplied by just two pharmacies, both of which had previously been identified by the inspector general as having questionable billing practices.

All told, the drugs ordered by the doctors labeled "extreme outliers" cost Medicare $352 million, the report says.

While some of this may have been appropriate, the report says, "prescribing high amounts on any of these measures may indicate that a physician is prescribing drugs which are not medically necessary or that he or she has an inappropriate incentive, such as a kickback, to order certain drugs."

Sen. Tom Coburn of Oklahoma, the ranking Republican on Carper's committee, said no one wants Medicare to tell doctors which drugs to prescribe. But the government does have a responsibility in preventing fraud and abuse, he said.

Medicare officials "should be using their data to make sure those practicing medicine are practicing medicine and not practicing a sham," said Coburn, who is also an obstetrician.

The inspector general's report calls on the Centers for Medicare and Medicaid Services (CMS), which oversees the program, to step up scrutiny of doctors with questionable prescribing patterns. It urged CMS to direct its fraud contractor to expand its analysis of prescribers and train the private insurers that administer Part D on how to spot problem prescribers.

Medicare also should send doctors report cards comparing their prescribing to their peers, the report says.

In a response to the inspector general, the Medicare agency wrote that it agreed with the recommendations, has been working to reduce overuse of narcotics and plans to expand its use of data to flag questionable prescribing.

"We must balance these efforts with ensuring that beneficiaries have access to the medicines they need," a CMS spokesman said Wednesday in a statement.

For ProPublica's investigation, reporters analyzed four years of Medicare prescription drug data and examined the prescriptions of all health professionals across specialties. It examined all prescribers – 1.7 million in 2010 alone – not just those in general-care specialties or mostly urban areas.

The new report from the inspector general is the latest to find oversight problems in Part D. Previous reports found that insurers have paid for prescriptions from doctors who were barred by Medicare or whose identities were unknown to insurers or Medicare.

Coburn said Medicare has had repeated warnings that it was failing to properly oversee the program.

"This is incompetency and lack of somebody being held accountable," he said. "It's fixable."

Would it be too much to ask for to have the IG report turned over to the state medical licensing boards? These boards exist to protect patients from harm.

I presume American doctors ( I’m in the UK ) don’t go by the Hipocratic Oath ?

Whoa, whoa.  “Investigate or stop them”?

Like, make sure what they’re doing is medically sound, but if nobody feels like making sure, just run with the assumption?

I’m no supporter of the pharmaceutical companies, by any means, but I do still believe that drugs can help people in the proper circumstances.  How about “investigate them, then stop them, if they’re doing something wrong”?

Or maybe not half-assing medical care would make it too expensive or something.

My wife and I are coincidentally going to a pain mgmt clinic.
We do not take any Rx pain killers other than non Rx type.  We’ve gotten epidural shots for chronic back pain.
Point I wanted to make is that our dr has extreme controls on those patients who do get Rx pain killers. They get only a 30-day supply, cannot refill more often than those 30 days, have to see him before any refills etc.

It’s dangerous to apply a blanket policy under the ambiguous title of “overprescribers”  Chronic Pain sufferers and the Terminally Ill will see their lives deteriorate significantly when their doctors are at risk of censure from regulators.  The plain truth is that there are no options for some patients other than higher than normal doses of certain drugs deemed to be highly addictive - even though their condition often prevents them from becoming addicted and addiction would certainly be moot anyway given their state of health.  One way or the other this one is sure to be filed under “road to hell paved with good intentions…”

Dear ProPublica,

FYI. 

Australia’s Pharmacutical Benefit Scheme ( PBS) tacks doctors who over perscribe and have done so for years and with hugh success, I might add.  Why not take a look at how they accomplish the task of identifying these doctors?  So it CAN be done!

Much good luck to you all in your continuing investigation.

Danella Morgan

June 20, 2013, 2:50 p.m.

Dear ProPublica,

FYI. 

Australia’s Pharmacutical Benefit Scheme (PBS) tacks doctors who are, in any way, over perscribes and have done so for years with a high success rate, I might add.  Why not take a look at how they accomplish the task of identifying these doctors?  Yes, it CAN be done!

Much good luck to you all in your continuing investigation.

Congratulations on such a powerful investigative report. Making an impact that directly improves people’s lives demonstrates the positive influence serious journalists can bring to bear on society. Thank you!

Daniel Robert Snodgrass

June 20, 2013, 4:20 p.m.

The report says, “Medicare paid $9.7 million for the prescriptions of one California doctor alone…”

That’s a bunch of bells and whistles, which should have sounded an alarm somewhere.

Stephanie Palmer

June 20, 2013, 4:49 p.m.

After an operation, I was prescribed Oxycontin. The script was for 30 of which I took 3. Several months later, I had to go back to the doctor and was offered another prescription of the same medicine. I declined because I already had 27 of them.  I’m not interested in going to the doctor for pain meds, I want to know what’s causing the pain. I think prescriptions are handed out much too easily.  Incidentally, the remaining 27 pills were given for a dog which had been prescribed the same medication.  The entire incident was too weird for me. And I still wonder why anyone would want to feel the way these narcotics make you feel.

justeline petel

June 20, 2013, 8:21 p.m.

Interviews with patients indicate that narcotics are the most effective relief. AND, prescribed pain meds are relatively cheap and safer than over the counter NSAIDs, which wreak havoc on internal organs. Price-fixing and gouging by big pharma are the villain in this situation. Fear of addiction is laughable to elders facing chronic and debilitating pain.

@justeline petel, who emoted Fear of addiction is laughable to elders facing chronic and debilitating pain.

Indeed.  And the not-so-elderly who suffer from bone cancer…and, as I’ve seen, suffer from such pain that death becomes their last hope.

And is laughable to people like me, who tried to “get by” with NSAIDs as recommended by my then doctor’s office…only to blow a blood vessel in my nasal passages whose bleeding could not be staunched, resulting in the loss of six units of blood, emergency surgery, and seven days in CCU.

But at least my physician didn’t have to put up with the suspicion of or being hassled by this state’s quite proactive prescription police.

Justeline Petel I couldn’t agree more.  You said it best.  To be able to function a little on narcotics so you can enjoy your family instead of taking something that will do more harm is all those in pain want.  They know their quality of life is over. But the current paradigm is to maim and kill with newer patented pharmaceuticals that they can charge hundreds of dollars a month to fill. 

Health insurance companies and Medicare ought to fight this to save their insured from further harm which will cost them more money.

As always, well done propub, the pattern of abuse on a wide scale is evident. Long over due to see regular perp walks with handcuffs on the mainstream news. The deafening silence of mainstream media clearly points to its own article. “Why the silence NBC/CBS/FOX?” etc.

Just forcing the question would make for interesting responses.

Ms Jean Whiting

June 21, 2013, 11:38 a.m.

Based upon what I have read, there seems to be patterns of abuse in government programs that have inadequate supervision—which seems to be most of them.  Big Pharma wrote Part D—they must be llicking their chops over this abuse. You can give anyone a discount off drrugs—and raise prices. Yes, many elders (like me) may need prescription drugs, but my doctor watches my scrips carefully and any restricted drugs are for a month with no refill.  My insurance (Tufts Medicare Pfd) also checks periodically.
I agree with Justeline re pain meds—I tried everything in the book, but NSAIDS wrecked my stomach and acetaminophen just doesn’t fit the bill.  And fear of addiction for me and for other seniors is indeed laughable.

I’m sure I am on the list since I am a Hospice doctor.If there’s to be an investigation I hope the investigators will include practicing physicians.

Medicare Part D is nothing more than corporate welfare.  The article says, “Last year, the government spent $62 billion subsidizing the drugs of 32 million people.”  It is good news to hear that so few physicians are scamming the system so greatly.  I refuse to take many of the medications physicians try to prescribe because they often cause more harm than good.  Improper medication interaction caused a dear elderly friend of mine to lose her bearings a few years ago and she went from an active, brilliant 80+ year old woman to a woman in a wheelchair who could not think straight.  People should talk to their pharmacist about drug interactions before starting a new one.

justeline petel

June 23, 2013, 3:20 a.m.

An examination of ProPublica’s numbers indicates extreme bias. What or who is behind this “expose?” If 736 out of 7,870 MDs are “extreme prescribers,” they amount to LESS THAN 1% of the doctors examined. If 2,200 out of 87,000 docs have a loose hand with the prescription pad, we are STILL looking at a “tiny” percent - two or three.

Ergo, something is rotten I think in Denmark - or in this case at ProPublica! The harm these “outliers” are wreaking financially or personally cannot come close to the harm that awaits the 49,000,000 uninsured Americans, many, of whom will NOT be covered by a beaurocratic healthcare program. ProPublica would do us a favor by examining the extreme amounts being paid to big pharma, and the suffering that their price-gouging causes to millions of Americans (49 million, remember?) who cannot afford drugs that cost pennies to make. MD-bashing is misplaced anger in this arena. ProPublica has the nerve to critiicize a doctor who made a million dollars over 4 years! Ha, ProPublica’s editors reportedly are paid twice that amount. Why don’t you pick on someone your own size? Or are you sharing the agenda of one of your big business donors?

This is just one more reason that healthcare itself is the third or second leading cause of death.

“Obamacare: Making a bad situation worse”
http://relevantmatters.wordpress.com/2012/05/21/obamacare-will-make-a-bad-situation-worse/

clarence swinney

June 24, 2013, 4:42 p.m.

HYPOCRISY
Congressmen called for repeal of Obamacare then plead for its dollars for their
constituents. Senator Chambliss—Rep. Paul Ryan—the Nation magazine has identified 22 other Obamacare-bashing GOP lawmakers who have pleaded for money from Obamacare.

clarence swinney

June 24, 2013, 4:45 p.m.

IG should get on hospital charges.
Wife in ER for hi blood pressure.
Gave her a handheld breathalyzer
She one in her purse.
Paid $32
Hospital charge $500.
We did not will not pay.

Glad I didn’t listen to them and take all those poisons they prescribed. Dangerous drugs, calcium channel blockers , drugs with warning labels “Do not take if kidney disease” ,  drugs that prolong the QT interval: Albuterol, cipro, levaquin,  see azcert.org for full listing and other drugs with black box warnings and the most important but not documented comment a physician said to me, ” NO MORE RADIATION” but failed to tell me what GADOLINIUM metal contrast used for the magnets in the MRI does to you! fkrs and you think this is funny, too.
Rx’d drugs for known intentional misdiagnosis, too. LIED to me and MEDICARE about it. their drug testing /dosing destroyed my life, lungs, kidneys, skin, immune system and health. When NIH and Do D stops funding these horrific human experiments on healthy adults and children maybe costs will go down, but trust will not be restored. You’ve failed the American people. Liars. If you want to get better, STOP TAKING THESE POISONs that are killing you and stop all the x rays and MRI scans esp those with contrasts aka dyes.  READ the labels, warnings and contra indications. 
I hate every one of you.

This article is part of an ongoing investigation:
The Prescribers

The Prescribers: Inside the Government's Drug Data

Medicare’s failure to monitor what doctors are prescribing has wasted billions of taxpayer dollars on excessive use of brand-name medication and exposed the elderly and disabled to drugs they should avoid.

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