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Top Medicare Official: ‘We Can and Should Do More’ to Oversee Drug Plan

Under pressure, Medicare’s director tells a Senate panel the agency will intensify the search for abusive prescribing patterns and undertake other reforms.

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Jonathan Blum, director of Medicare, testifies before the Senate Homeland Security and Governmental Affairs Committee on June 24, 2013. (Senate Homeland Security and Governmental Affairs Committee)

Stung by reports of risky and profligate prescribing by doctors and others, a federal health official promised Monday to revamp the way Medicare scrutinizes its massive prescription drug program for seniors and the disabled.

Jonathan Blum, director of Medicare, told a Senate panel that his agency needs to do more to search for fraud and abusive prescribing, problems flagged recently by ProPublica and by government analysts.

The Centers for Medicare and Medicaid Services (CMS) “takes very seriously the concerns being raised today,” Blum said before the Senate Homeland Security and Governmental Affairs Committee. “Not only does inappropriate prescribing weaken the fiscal integrity of the [prescription] program, but it places our beneficiaries in harm’s way.”

Among the steps Blum said his agency plans to take:

  • Require that all providers who write prescriptions to Medicare patients be enrolled in Medicare. That means they must verify their credentials and disclose if they’ve been disciplined or criminally convicted.
  • Push Medicare’s high-paid fraud contractor to ramp up searches for prescribers with troubling patterns and refer more cases to law enforcement.
  • Give private insurance plans that administer the drug program information about suspect pharmacies and providers, and, for the first time, allow them to limit or reject payments to them. Currently, the plans must pay for prescriptions written by all providers unless they’ve been kicked out of Medicare.
  • Work with Congress on legislation that would restrict patients who are suspected of “doctor shopping” to obtain painkillers. Medicare had previously opposed such a step.

Blum’s pledges were met with skepticism by Sen. Tom Coburn of Oklahoma, who noted that Medicare doesn’t have a good record of following through on promised reforms. Coburn, ranking Republican on the panel, said he wondered whether the committee would be sitting in the same place a year from now asking why officials had not acted.

“People are going to continue to die, right, under this program, and we’re going to put out rules in the fall?” he said at one point when Blum discussed making some changes later this year. “Why wouldn’t we put out rules now?”

Coburn, who is also an obstetrician, demanded that Blum submit written progress reports every three months and said they would be made public.

The hearing followed a ProPublica investigation published last month that found Medicare had failed to use its own records to flag doctors who prescribed thousands of dangerous, inappropriate or unnecessary medications.

One Miami psychiatrist, for example, wrote 8,900 prescriptions in 2010 for powerful antipsychotics to patients older than 65, including many with dementia. A black-box warning on the drugs says they should not be used in such patients because it increases their risk of death. The doctor said he’d never been contacted by Medicare.

ProPublica also found that many of the top prescribers of the most abused painkillers had been charged with crimes, convicted, disciplined by their state medical boards or terminated from Medicaid. Nearly all remained eligible to prescribe in Medicare.

At the time, Blum told reporters it was not Medicare’s responsibility to second-guess doctors and that any questions should come from the private insurance plans.

But facing the committee Monday, Blum stated, “Clearly we can and should do more.”

Sen. Tom Carper, D-Del., who chaired the hearing, cited two new government reports on the program, known as Part D, from the inspector general of the U.S. Department of Health and Human Services. The first, issued last week, found more than 700 general-care physicians with extremely questionable prescribing patterns, including some whose prescriptions were filled at hundreds of pharmacies across dozens of states.

On Monday, a second report said Medicare paid for more than 417,000 prescriptions that appeared to have been written by massage therapists, dieticians and other professionals who don’t have authority to prescribe drugs.

Blum said his department had already made changes to the popular prescription plan, such as requiring all prescribers to have a national health identification number to reduce fraud.

Coburn reserved his harshest criticism for Medicare’s oversight of its fraud contractor, Health Integrity LLC, saying the Maryland firm does little for the $14 million it receives each year. “I’m pretty disgusted,” he said. “My hope is that you’ll ride the contractors.”

Alanna Lavelle, the director of special investigations for WellPoint Inc., a large national insurer, also directed criticism at the fraud contractor. She said WellPoint had referred more cases of prescription fraud to the contractor than all but one insurer. But, she said, “We are never advised as to what type of action is ever taken.”

A Health Integrity representative referred a call for comment back to CMS. (UPDATE: Douglas Quave, senior vice president of Health Integrity replied after publication, noting in an email that since October 2011, the contractor had received more than 22,000 complaints from beneficiaries, insurers and others and had referred 1,100 cases to law enforcement.)

Coburn also sparred with Blum over what steps Medicare takes to check out the doctors and other health professionals who are prescribing to the 32 million elderly and disabled people in the program.

Blum acknowledged that Medicare does not always know about state medical board disciplinary actions and doesn’t always tell insurance plans when a provider has been kicked out of Medicare.

“That’s a vulnerability that I concede that we need to do a better job,” he said.

The hearing, which focused largely on the overprescribing of painkillers in Part D, also included testimony from representatives of the inspector general’s office and the Drug Enforcement Administration.

Blum said he expected resistance to some of the proposed changes because they will require more paperwork and oversight.

“It will create more friction that you will hear about from the physician community, from pharmacies, from beneficiaries themselves,” he said. “The program will need your support once that friction starts.”

It’s worth pointing out that this is largely an obvious result of confusing health care with health insurance.  Even Walmart finally figured out that it’s cheaper to provide the best health care than take out insurance.

nationaljournal.com/next-economy/solutions-bank/wal-mart-s-super-counterintuitive-health-care-plan-20130523

And to drive directly on the topic, doing it this way presumably requires less oversight.

There seems to be no Federal or State agency not riddled with fraud, so we are constantly using all our energy to create panels that yap about what needs to be done. Then, rather than curing the problem, more energy is directed toward finding ways around any new regulation that results. Coburn is right in asking if they’ll be back in a year asking why nothing has been done. New loopholes get done is the answer to that question.

Our GDP is fraud (greed). Cure that and prosperity will follow.

Dr. Henry Franceschi

June 26, 2013, 2:37 p.m.

If the political will is really finally here, a simple way exists to significantly reduce prescription drug overuse: mandate that physicians can only write script for medications that fall within their medically credentialed area of practice. Particularly, finally put a stop to primary care physicians dabbling in fields in which they are not demonstrably qualified.

Some teeth also have to be put into this, like loss of license for a year for first offenders then the usual 36-month Federal prison time for major or repeat violators.

Dr. A-F

The 800 lb. gorilla:  Medicare/Medicaid cannot shop or negotiate with big pharma, this being expressly forbidden in the “law”.
Example:  VALTREX, $9.29 in USA, 4.27 in Canada.  Prosecution rests.

Great that they have finally realized it. This problem has been going over and over again for years without being addressed. It led me to believe that there is nothing they can do or are just reluctant to do anything because they might have a cut in the anomalies.

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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