A lot has happened since our
investigation in May showed that Medicare wasn’t watching out for dangerous
or fraudulent prescribing by doctors and others in its popular prescription
drug program. In the past two weeks:
-
The inspector general of the U.S. Department of
Health and Human Services issued two critical reports about the drug program,
one on high-prescribing
doctors and the other on illegitimate
prescriptions. -
A U.S. Senate committee held a hearing on prescribing abuses in the
program, known as Part D. During the hearing, a top Medicare official promised
a host of reforms to improve oversight of the program, which cost taxpayers
$62 billion last year. -
A key U.S. senator wrote
letters to all 50 states asking whether their Medicaid programs for the
poor were alerting Medicare when they kicked doctors out. -
ProPublica published a story showing how top
Medicare prescribers of highly promoted drugs received
speaking fees from the companies that made them.
The inspector general has found fault with Part D’s
oversight almost since its inception. Below are summaries of its most recent
reports, as well as significant earlier ones.
Illegitimate
prescriptions
Last Monday, the inspector general reported that Medicare
paid for 417,000 prescriptions purportedly written by massage therapists,
athletic trainers, interpreters and others who aren’t allowed to prescribe
drugs. While just a small fraction of total drug
spending in the program, it raises questions about how closely Medicare
officials are tracking the validity of prescriptions or questioning those that
appear suspicious.
High-prescribing
doctors
On June 20, the inspector general cited more than 700
general-care physicians who wrote prescriptions for elderly and disabled
patients in highly questionable and potentially harmful ways. They were very
extreme outliers 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.
Scant Analysis
In January, the inspector general found that Medicare’s fraud
integrity contractor did little to proactively analyze prescribing data for
indications of fraud and abuse. Between April 2010 and March 2011, the
contractor only referred 19 cases to law enforcement based on its proactive
analysis of Part D data.
Questionable Pharmacy
Billing
In May 2012, the inspector general identified more than 2,600
pharmacies with questionable billing practices. “Little information is
currently available about Part D billing,” the report said. “There are no data
about how pharmacies typically bill Part D, or about questionable billing. Identifying
these data is an important first step in detecting potential fraud, waste, and
abuse.”
Banned Prescribers
In December 2011, the inspector general identified $15.1
million in drugs paid by Medicare Part D from 2006 to 2008 that apparently had
been prescribed by health professionals banned from the Medicare program. The
report cited “inadequate internal controls” at the Centers for Medicare and
Medicaid Services (CMS).
Inappropriate Drugs
In May 2011, the inspector general found that Medicare Part D had
paid for antipsychotic prescriptions for elderly nursing home residents for
uses not approved by the U.S. Food and Drug Administration. The drugs
specifically carry a warning that they can increase the risk of death in
patients with dementia. The inspector general recommended that Medicare require
prescriptions to carry a diagnosis code to help flag drugs given for
inappropriate reasons, but Medicare said no.
Invalid Prescribers
In June 2010, the inspector general found that $1.2
billion in drugs paid by Medicare in 2007 lacked valid identification for
those who prescribed the drugs. “Without
valid and accurate prescriber identifiers, CMS and its contractors have
difficulty performing oversight functions, such as verifying the prescriber’s
licensing information, determining whether the prescriber has been the subject
of disciplinary actions for inappropriate activities, or tracking potential
overprescribing issues,” an inspector general official
told Congress.
