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Florida Sanctions Top Medicaid Prescribers — But Only After A Shove

Medicaid programs have long had evidence that a few physicians prescribed risky drugs in excess, but it wasn’t until Sen. Charles Grassley, R-Iowa, demanded to know the top prescribers that states began to investigate.

At Dr. Huberto Merayo’s bustling psychiatry practice in Coral Gables, Fla., hundreds of poor patients on Medicaid walked away each year with prescriptions for powerful antipsychotic drugs.

Merayo’s prescriptions for the drugs totaled nearly $2 million in 2009 alone, state records show.

The 59-year-old psychiatrist is also in demand by the makers of these drugs. He’s earned more than $111,000 since 2009 delivering promotional talks for AstraZeneca, Eli Lilly & Co. and Pfizer, according to ProPublica’s database of drug-company payments to doctors.

This year, Florida regulators finally challenged Merayo’s enthusiasm for the pricey drugs, which are used to treat schizophrenia and bipolar disorder. A state review found he hadn't documented why patients were prescribed the pills and had given them to patients with heart ailments or diabetes despite label warnings.

In May, Florida summarily ended his contract with Medicaid. But the action, though decisive, followed years of high prescribing by Merayo, according Florida’s own statistics. And he was booted only after public questioning by U.S. Sen. Charles Grassley, R-Iowa, who had asked states to investigate such cases.

Merayo’s situation is one of at least three in which Florida allowed physicians to keep treating and prescribing drugs to the poor amid clear signs of possible misconduct.

The state’s responses were marked by head-scratching errors, including the misspelling of Merayo’s name on official documents, and lengthy delays.

In another example, Florida allowed Dr. Joseph M. Hernandez of Lake City to continue prescribing narcotic pain pills to Medicaid patients for more than a year after he was arrested and charged in 2010 for trafficking in them.

States pushed to act

Medicaid programs across the country have long had evidence that physicians have been prescribing risky drugs in excess and perhaps to the wrong patients. These prescriptions also racked up huge bills for the programs.

But like Florida, many states did not act on that evidence. Last year, Grassley demanded data from each state about its highest prescribers of pain pills and antipsychotics, and he asked state and federal officials to determine whether the prescriptions written by these doctors were legitimate.

Since then, states including Louisiana, Arizona, Oklahoma and New York have kicked some high-prescribing physicians out of Medicaid. California has temporarily suspended or placed restrictions on 15 to 20 doctors in the past two years for prescribing disproportionately high volumes of painkillers and antipsychotics to Medicaid patients.

Florida has been in sight lines of law enforcement, politicians and government officials because it is widely viewed as a hotspot for health-care fraud. Until recently, the state's lax rules allowed pill mills to proliferate, serving as a hub for painkiller distribution in Florida and beyond.

In April 2008, after much debate over the high number of children being prescribed antipsychotics, Florida began requiring doctors to get preapproval before giving the drugs to kids under age 6 in the Medicaid program. Since then, the number of such prescriptions written for kids has plummeted.

But the same level of scrutiny has not extended to prescriptions written for older Medicaid patients.

Florida health officials declined to discuss specific cases or answer detailed questions about why it has taken so long to investigate and sanction some physicians. State officials also would not detail the systems in place to alert them to troubling prescription patterns. The Florida Medicaid program serves about 3.2 million poor children, pregnant women and the disabled.

In a statement, the Florida Agency for Health Care Administration said it “employs a variety of detection tools to determine possible overutilization and other departures from peer group or utilization norms.”

One prescriber, $4.7 million

When psychiatrist Fernando Mendez-Villamil’s role as Florida’s top prescriber of antipsychotics became public in 2009, it made the local news. But documents show Florida had known since at least 2004 that Mendez-Villamil, who also heavily prescribed other drugs, was a problem.

It did not bar him from billing Medicaid until last year after Grassley made his prescribing record public.

Mendez-Villamil wrote more than 96,000 Medicaid prescriptions for mental-health drugs from July 2007 to March 2009, more than any other physician in Florida, according to a list compiled by Florida in June 2009 for Grassley.

Mental-health-drugs typically include antipsychotics, antidepressants and those to reduce anxiety.

In 2009 alone, Mendez-Villamil prescribed about $4.7 million in antipsychotics to Medicaid patients, according to state records.

Florida had been trying to get Mendez-Villamil to cut back his prescribing for years, according to a March 2010 letter from U.S. Health and Human Services Secretary Kathleen Sebelius to Grassley. The total Medicaid paid for all his prescriptions dropped by more than half from 2004 to 2008, she wrote, “Nonetheless the level of activity remains concerning.”

Yet, just months prior to Sebelius’ letter, a Florida Medicaid spokeswoman told The Miami Herald that Mendez-Villamil’s prescriptions didn’t “indicate that there is anything improper.”

Mendez-Villamil, who was officially terminated “without cause,” sued the state last year to have his Medicaid contract reinstated; the case is pending. His lawyer, Robert Pelier, said Mendez-Villamil was “collateral damage” in Grassley’s campaign.

“Dr. Mendez-Villamil doesn’t benefit by prescribing. He doesn’t get paid by the prescription. He doesn’t have any interest in generating [prescriptions] other than medication to keep the patient stable,” Pelier said.

In a 2010 letter to Grassley, Mendez-Villamil wrote that his prescriptions were justified by his busy practice. He worked at least 60 hours a week and saw patients every 10 to 15 minutes, he said. Most required prescriptions for two or three different drugs, he said, and refills made the numbers add up quickly.

Even though doctors aren't typically paid for prescribing a drug, there are other ways it can be lucrative.

Some doctors require patients to return often for refills, allowing them to bill for office visits. Others dispense drugs in lieu of spending more time with patients, allowing them to squeeze in more appointments. Still others have been arrested or convicted of selling access to their prescription pads.

Top prescriber despite sanctions

Hernandez was Florida’s top Medicaid prescriber for the painkiller oxycodone in 2009. In February 2010, he was charged with trafficking in the pills. He kept his license, however, and continued to rank among the state’s top Medicaid prescribers.

In July, Hernandez’s license was suspended. State officials found that 34 of his Medicaid patients had died — some from drug toxicity — since 2008, according to the state’s suspension order.

Moreover, Hernandez previously had been cited for medical lapses. In 2007, the Florida Department of Health barred him from performing surgery, saying he was legally blind in his left eye. The agency also fined him $5,000 for leaving a hollow needle or a portion of a catheter in a patient’s chest and not telling the patient or the medical staff at the hospital where the patient was transferred. And in 2009, he was fined $1,000 for failing to take a medical recordkeeping course.

Based on Florida’s action, the District of Columbia and Illinois revoked his licenses in 2007 and 2008. Florida then fined Hernandez $10,000 for failing to notify the state about the D.C. revocation.

Shelisha Coleman, a Florida Medicaid spokeswoman, said her agency was not told of Hernandez’s 2010 arrest until this year — even though state investigators were involved in the case. She could not explain why.

Hernandez’s attorney, Gilbert Schaffnit, did not return three calls seeking comment. He told The Miami Herald last summer that his client “is very diligent about the way he practices and prescribes, despite what the state would have you believe.”

Hernandez could not be reached. His criminal court case is pending.

Dumped from speakers’ circuit

In the case of Merayo, ranked second on Grassley’s list of Florida's high prescribers of mental-health drugs, the state found a variety of problems with his practice.

Some of Merayo’s patients told a reviewer they stopped taking the drugs he prescribed after being granted an exemption from taking the U.S. citizenship test. Immigrants can qualify for citizenship without taking the test if they can prove they are physically or mentally disabled.

A memo from a chief investigator for the Florida Agency for Health Care Administration does not say whether authorities suspect Merayo prescribed the drugs to create evidence of such a disability.

Yet, even when terminating Merayo, Florida had trouble getting it right. The state first informed him that he was being dropped as a Medicaid provider because his license had been suspended — even though it hadn’t been. Merayo’s license remains clean.

The letter also referred to him as "Humberto" Merayo instead of Huberto.

Medicaid subsequently gave a different reason. Merayo was told his Medicaid contract was being terminated “without cause,” something the state can do unilaterally, said his lawyer, Sean Ellsworth.

In a statement provided by Ellsworth, Merayo said he had not been “advised of any allegations involving billing irregularities” by Medicaid. He declined to comment on the allegations in the memo.

Among the companies that paid Merayo as a speaker, Eli Lilly said in an email message that it no longer uses him. AstraZeneca said it doesn’t plan to renew his contract for 2012, and Pfizer did not respond to questions.

ProPublica learned about the terminations of Mendez-Villamil and Merayo from Ken Kramer, a Florida Scientologist who runs a website devoted to exposing what he considers abusive practices by psychiatrists. Scientologists believe that the drugs used by psychiatrists “have no basis in science” and create “lifelong drug addicts,” according to the Church of Scientology website.

Feds walk a “fine line”

Officials at the U.S. Centers for Medicare and Medicaid Services, which works with state Medicaid programs and provides part of their funding, said they don’t keep track of high prescribers terminated by states. Each state administers its own program.

A partnership between states and the federal government, Medicaid provides health care to millions of low-income patients. Some doctors cater almost exclusively to Medicaid patients.

Angela Brice-Smith, director of the agency’s Medicaid integrity program, said her staff is working with some states to ensure the highest prescribers of antipsychotics are using the drugs appropriately, and to educate them if they are not.

“It’s sort of a fine line we’re treading,” she said. “We’re not trying to imply that we’re practicing medicine, but at the same time trying to share our observations.”

High rates of prescriptions do not always mean that physicians are doing something wrong. Some physicians, such as those working in busy urban mental-health centers, may indeed be prescribing properly. Each case needs to be reviewed separately, she said.

Medicaid programs spent more than $27 billion on prescription drugs in 2010, before rebates, according to federal statistics. As state budgets shrink, the pressure on states to “get the bad actors out” is growing, said Matt Salo, executive director of the National Association of Medicaid Directors. “There’s only so much you can do with a slap on the wrist.”

In an email message, Grassley said states need to use their own records to search for trouble.

“High numbers of prescriptions can indicate a busy medical practice with complicated patient needs, or they can indicate a problem,” he said. The government has an obligation to “get to the bottom of anything that looks questionable.”

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