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 last 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 last year.
New data from Medicare continues to show massive prescribing in 2012 by doctors who say they were victims of fraud schemes.
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, 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 (PDF) 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-Delaware) 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 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 (PDF) 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 three 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, 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 in 2012. 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.