Ten
years after Medicare’s vaunted prescription drug program was signed into law, the
Obama administration and Congress are re-evaluating whether it does enough to
stop inappropriate prescribing and fraud by physicians.
Until
now, the program’s top priority has been getting drugs into the hands of its elderly
and disabled enrollees, earning it high praise from consumers and politicians.
But after a series of critical articles this year by ProPublica, Medicare is now putting in place changes that would
give greater priority to targeting fraud and curbing waste.
In
particular, Medicare has told senators that it plans to begin referring
physicians with troubling prescribing patterns in the program, known as Part D,
to their states’ medical boards for possible disciplinary action. That was one
of the solutions proposed by a group of experts consulted by ProPublica earlier
this year.
Medicare’s
failure to keep watch over Part D has enabled doctors to prescribe massive quantities of harmful medications, has wasted billions on needlessly expensive drugs and has exposed the program to rampant fraud, ProPublica found. More than 36 million people have
drug coverage from Medicare at a cost to taxpayers of $62 billion last year.
Medicare’s
problems largely stem from the fact that it hasn’t rigorously analyzed data on
physician prescribing.
Using
the Freedom of Information Act, ProPublica requested and obtained data on the
drugs prescribed by every provider in the Part D program for five years —
billions of prescriptions in total. Reporters analyzed the data to spot doctors who prescribed in very different ways
than their peers — for example, by choosing drugs that were risky or
costly or in ways that suggested fraud.
Scores
of doctors stood out for unusual patterns, but in interviews, many of them said
Medicare had never asked them about their drug choices. One Oklahoma psychiatrist, for example, prescribed the Alzheimer’s drug Namenda
to hundreds of patients with autism and other developmental disabilities who do
not have dementia.
Unlike
other parts of Medicare, Part D is entirely run by private insurance companies,
which are paid by the government to process the bills. These insurers, however,
have access solely to the prescriptions for their members – not
to a provider’s prescriptions across multiple health plans. Only Medicare can
see everything a provider orders.
During a Congressional hearing in June, and again in a memo to senators last month, a top Medicare official detailed steps the program
has taken, or plans to take, to improve its oversight of Part D. Among the efforts:
- It sent insurers a
list of pharmacies whose statistics place them at high risk of fraud and
intends to do the same for questionable prescribers. - It made 31
referrals to law enforcement from July to November based on its own data
analysis and initiated 82 new investigations. That’s more than the 19 referrals
made in the full year between April 2010 and March 2011, according to a January 2013 report from the inspector general of the U.S. Department of
Health and Human Services. - It is considering
whether to require that all physicians who prescribe under Part D also be
enrolled in Medicare. Currently, any licensed doctor can have their
prescriptions filled by the program, even if they aren’t a certified Medicare
provider. Such a requirement would allow Medicare to terminate doctors engaged
in abusive prescribing.
Senators
Tom Carper, D-Del., and Charles Grassley, R-Iowa, have been pushing Medicare for answers about these efforts. Carper is chairman of the Senate Homeland Security
and Governmental Affairs Committee, which monitors government fraud, and
Grassley is ranking Republican on the Senate Judiciary Committee.
Separately,
the HHS inspector general this month said ensuring
that drugs are appropriately prescribed in Medicare and Medicaid is a top
priority. The inspector general in June said that Medicare has not done enough to look for questionable prescribing among doctors
and cited ProPublica’s analysis in its report.
The
inspector general is currently researching how vigorously insurers are flagging
and referring Part D fraud to Medicare.
Elsewhere,
disciplinary actions have been taken against two of the doctors mentioned in ProPublica’s articles.
Dr.
Adolphus Lewis,
credited with more than 100,000 prescriptions in the program in 2011, was disciplined by Texas’ medical board in October
2013 for failing to keep adequate
records of his examinations of a patient who had skin ulcers and pneumonia. He
was ordered to have his practice monitored by another physician and to take a
recordkeeping course.
The
board noted that its action did not reflect poor care provided by Lewis, who
has declined previous requests for comment by ProPublica. Lewis could not be reached
for this article.
ProPublica
had reported that Lewis had been sued repeatedly for malpractice and that his
license had been temporarily restricted in 1998
for improper prescribing of painkillers.
Also
in October, the Florida medical board reprimanded and fined Dr. Fernando Mendez-Villamil,
who had been accused of giving patients as young as 3 a variety of mental
health drugs without properly diagnosing or monitoring them.
ProPublica
had reported how in April 2010, Florida Medicaid expelled Mendez-Villamil without publicly revealing its reasons. An internal
memo cited concerns about “the volume of patients being seen, and the
medications being prescribed.”
In
2011, Mendez-Villamil remained one of Medicare’s top prescribers of mental
health drugs. His lawyer, Michael Gennett, said in an
email that “after review of the Board of Medicine’s allegation by an
independent expert, the parties amicably resolved their differences without any
admission of wrongdoing by Dr. Mendez.”
Beyond
that, new data from Medicare continues to show massive prescribing in 2012 by doctors
who say they were victims of fraud schemes. Earlier this month, ProPublica
reported how Medicare was slow to stop or even question doctors whose
prescription patterns within the program bore the hallmarks of fraud.
One
of those was Florida Dr. Carmen Ortiz-Butcher, whose prescribing costs in Part D jumped from
$282,000 in 2010 to $4 million the following year. The doctor’s lawyer said Ortiz-Butcher
stumbled upon the fraud a couple months ago when her brother received a package
of prescriptions ostensibly written by her.
Data
released by Medicare after ProPublica’s story shows
that an additional $4.9 million in prescriptions were attributed to Ortiz-Butcher
in 2012.
Another
doctor’s prescribing in Part D plummeted in 2012 after drawing the scrutiny of
fraud investigators in 2010 and 2011. California psychiatrist Ernest Bagner was credited with only $38,000 in prescriptions last
year. In the two prior years, his prescription tally totaled more than $7
million. In an interview, Bagner said none of this
prescribing was his and that his identity had been stolen.
Finally,
despite arrests on health care fraud charges in 2011, two providers in Michigan
still racked up hundreds of thousands of dollars in new prescriptions in 2012.
Anmy Tran, a
Michigan podiatrist found guilty this year of health care fraud, was credited
with $158,000 worth of drugs, and Mark Greenbain, a Michigan psychiatrist who pleaded guilty to health
care fraud this year, wrote prescriptions worth $517,000, Medicare data show.
Both
physicians were cited in the ProPublica article published earlier this month about fraud in the program.
Jennifer LaFleur, ProPublica’s
former director of computer-assisted reporting, contributed to this report.
