Prolific Prescribers Of Controlled Substances Face Medicare Scrutiny

Dec 15, 2014
Originally published on January 4, 2015 4:11 pm

Despite a national crackdown on prescription drug abuse, doctors churned out an ever-larger number of prescriptions for the most-potent controlled substances to Medicare patients, new data show.

In addition, ProPublica found, the most prolific prescribers of such drugs as oxycodone, fentanyl, morphine and Ritalin often have worrisome records.

In 2012, the most recent year for which data is available, Medicare covered nearly 27 million prescriptions for powerful narcotic painkillers and stimulants with the highest potential for abuse and dependence. That's up 9 percent over 2011, compared to a 5 percent increase in Medicare prescriptions overall. Even taking into account an increase in the number of Medicare enrollees, the prescribing rate rose slightly for these drugs, which are classified as Schedule 2 controlled substances by the Drug Enforcement Administration.

Twelve of Medicare's top 20 prescribers of Schedule 2 drugs in 2012 have faced disciplinary actions by their state medical boards or criminal charges related to their medical practices, and another had documents seized from his office by federal agents.

The No. 1 prescriber — Dr. Shelinder Aggarwal of Huntsville, Ala., with more than 14,000 Schedule 2 prescriptions in 2012 — had his controlled substances certificate suspended by the state medical board in March 2013. He surrendered his medical license four months later. (Aggarwal could not be reached for comment.)

Prescribing high volumes of Schedule 2 drugs can indicate a doctor is running a pill mill, said Dr. Andrew Kolodny, chief medical officer of Phoenix House, a New York-based drug treatment provider. Government regulators should do more to monitor prescribing patterns and intervene proactively if they appear aberrant, he said.

"We wait 'til these doctors kill people," said Kolodny, founder of Physicians for Responsible Opioid Prescribing, which advocates for tighter regulation of painkillers. "It doesn't make any sense."

Medicare's drug program, known as Part D, now covers about 38 million seniors and disabled people and pays for more than one of every four prescriptions dispensed in this country. Concerns about oversight of controlled substances date back to at least 2011, when the Government Accountability Office highlighted abuse of opioids in Part D and called on Medicare to take action.

Within the past year, Medicare has started to use prescribing data to identify potentially problematic doctors, as have some state medical boards. Beginning in mid-2015, Medicare will have the authority to kick doctors out of the program if they prescribe in abusive ways.

"It's a real area of concern for us," said Dr. Shantanu Agrawal, director of the Center for Program Integrity within the federal Centers for Medicare and Medicaid Services.

The 2012 data shows the upward trend line for prescriptions of controlled substances before these initiatives took hold.

The Drug Enforcement Administration classifies certain potent drugs based on their potential for abuse and sets limits on prescribing for each group. Drugs classified as Schedule 2 require written prescriptions and cannot be refilled.

ProPublica reported in 2013 that Medicare did not proactively analyze its prescribing data or take action against providers whose patterns were troubling, even if they had been charged with Medicare fraud or kicked out of state Medicaid programs.

Shelinder Aggarwal's Medicare prescribing history had plenty of red flags. The pain medicine specialist has consistently shown up in Medicare's data as a top prescriber of narcotics. By 2012, the year before he stopped practicing, more than 80 percent of his Medicare patients received at least one prescription for a Schedule 2 drug, in many cases oxycodone.

It took complaints from pharmacies near Aggarwal's office to alert the Alabama Board of Medical Examiners to his unusual prescribing habits, said Larry Dixon, the board's executive director. Board investigators subsequently made undercover visits to the doctor's office and videotaped him prescribing drugs without an exam.

"If you paid $1,200 in cash, they would put a VIP stamp on your medical records and you didn't ever have to have an appointment," Dixon said.

Medicare's Part D data draws a roadmap to the doctors who prescribe controlled substances most frequently.

In 2012, 269 providers wrote at least 3,000 prescriptions for Schedule 2 drugs, ProPublica's analysis shows. They were concentrated in a handful of states. Florida led the country with 52 providers, followed by Tennessee with 25. (Look up your doctor using our Prescriber Checkup tool.)

About one in five doctors who wrote at least 3,000 prescriptions for Schedule 2 drugs have faced some kind of sanction or investigation, ProPublica found.

In September, Medicare sent 760 letters to doctors who prescribed far more Schedule 2 drugs than others in their medical specialty and state. Officials hope the initiative will cause doctors to examine their prescribing and make changes.

"Simply being an outlier doesn't establish that you're doing something wrong," said CMS' Agrawal. "What we are trying to do is give physicians the ability to assess themselves, given their comparative data."

Medicare also has sent information on 71 prescribers for possible investigation to the inspector general of the U.S. Department of Health and Human Services, and on one doctor to a state medical board.

Some medical licensing boards are also expanding their efforts to use data to spot problematic prescribing. North Carolina's medical board has proposed new regulations allowing the agency that runs the state's prescription drug monitoring program to share data with the board. The board currently can only access the data when it is pursuing an active investigation into a particular physician.

Similarly, Alabama's legislature recently authorized its medical board to regulate pain medicine clinics and proactively access data from its prescription monitoring database.

Dixon, the Alabama board's executive director, and Henderson said their states' changes are not meant to impede legitimate care by doctors.

"Most of these people are just as genuine as you could possibly hope," Dixon said.

Data, alone, can be misleading. Dr. Mark Ellis, a pain specialist in Athens, Ga., was the third-highest prescriber of Schedule 2 drugs in the country in 2012, with more than 10,000 prescriptions. But unlike many states, Georgia does not allow nurse practitioners and physician assistants to write prescriptions for these controlled substances on their own, requiring them to be signed by a physician. As a result, Ellis said he was credited with the prescribing of four other professionals in his practice. (Ellis was fined by Georgia's medical board in July 2005 for working with a physician assistant without consent from the board.)

With scrutiny of painkiller prescribing on the rise, Ellis said he attempts to ensure that patients are taking, not selling, their pills by requiring frequent drug testing.

Rules put in place by several states have reduced prescribing of narcotics, experts say. New York, Kentucky and Tennessee now require that doctors check databases that track every controlled substance prescription in their states before prescribing such drugs to patients for the first time and at certain intervals afterward. Other states are considering or are in the process of implementing similar rules.

Mandatory checks are "the most-effective single tool we've found yet to address this problem," said John Eadie, director of the Prescription Drug Monitoring Program Center of Excellence at Brandeis University.

ProPublica is a nonprofit investigative reporting newsroom based in New York.

Copyright 2017 ProPublica. To see more, visit ProPublica.

RENEE MONTAGNE, HOST:

Prescriptions for narcotic painkillers and stimulants are rising quickly in the Medicare program. In just one year from 2011 to 2012 prescriptions of very strong painkillers, like OxyContin and morphine, plus stimulants, like Ritalin and Adderall, grew by almost 10 percent. That's the finding of a new analysis by the nonprofit investigative journalism organization ProPublica. The rise is happening despite a widening crackdown on prescription drug abuse. David Greene spoke with ProPublica senior reporter Charles Ornstein.

CHARLES ORNSTEIN: The alarms have been sounding now for several years about the use of powerful painkillers and the overuse of them, in fact, and how they've been linked to overdose deaths. And so the fact that we're seeing this go up at all is a sign that some of these efforts to crack down have not yet really taken hold - at least in 2012, which is the year covered by this number.

DAVID GREENE, BYLINE: And who were the doctors? That seems to be a part of this that is the most troubling. The top 20 prescribers here, you found many were under investigation by law enforcement or faced discipline in the past? Give me some more details about that.

ORNSTEIN: Sure. Well, some of these doctors have subsequently surrendered their licenses. They have been terminated from their state's Medicaid programs. They've faced actions from the DEA. They're under investigation or indictment for both issues involving drugs, but also in some cases sexual conduct with patients. So it appears that some of these were under investigation or had already been disciplined in 2012 - so the time covered by this data. Medicare, though, has historically been pretty slow to respond to such information.

GREENE: And what might that suggest to us if we have, you know, a dozen or so doctors who have faced disciplinary action or are under investigation who are prescribing these types of painkillers at a pretty high rate?

ORNSTEIN: What I think it means is that the tide is beginning to turn. I think that if a doctor is out there and is prescribing a whole lot of pain medication, it's very likely that this is going to catch the eye of Medicare, which has subsequently changed its practices. They're looking for this sort of thing. State medical boards are now on the lookout for this. So I think there's less cover for doctors to prescribe anything they want without fear of any consequences.

GREENE: Sounds pretty bad on its face to have doctors who, you know, have faced legal action, who are prescribing painkillers and narcotics. I wonder if there's been a response from the doctors who you've named here.

ORNSTEIN: Well, some doctors that we talked to said, you know, that data in itself can be misleading. And what I mean by that is they say that their numbers may include numbers from nurse practitioners or physician assistants who work under them, and so it's not just a single doctor prescribing all of this medication. Most doctors, though, did not return our phone calls or attempts for comment.

And I think that what we heard from other experts is that, you know, most doctors want to do the right thing. Pain is a very real problem, and if you're in pain, you just want relief from that. And so doctors are trying to help provide that relief. But I think what we're learning more and more is that pain and treating pain can also lead to abuse. It can lead to addiction, and it can lead to dependence. And there's a lot of questions about whether or not these narcotic painkillers actually relieve the pain.

GREENE: Charles Ornstein, thanks very much.

ORNSTEIN: Thanks, David.

MONTAGNE: Charles Ornstein is a senior reporter at ProPublica. You can go to propublica.org to look up how much your doctor prescribed within Medicare in 2012. Transcript provided by NPR, Copyright NPR.