State cuts doctors from Medicaid [The Honolulu Star-Advertiser]

March 27--The state terminated three Medicaid physicians who were prescribing relatively high amounts of potent psychiatric and pain drugs, while two other providers are under investigation by federal agencies, according to information provided to a U.S. senator.

The actions against the five physicians came to light in a Feb. 23 letter that Dr. Kenneth Fink of the state Department of Human Services sent to U.S. Sen. Charles Grassley, who has been focusing on Medicaid abuses across the country.

Fink oversees Hawaii'sMedicaid program, a state and federally funded health insurance program for low-income residents.

After getting 2008 data showing the top 10 Hawaii prescribers for six antipsychotic medications, a painkiller and an antidepressant, Grassley, a member of the Senate Judiciary Committee, said in a Jan. 23 letter to state Health Director Loretta Fuddy that he had concerns about oversight and enforcement of Medicaid abuse here.

"While I am sensitive to the concerns of misinterpretation of the data you provided, the numbers themselves are quite shocking," Grassley wrote.

Grassley noted, for instance, that the top prescriber of OxyContin, an addictive painkiller, wrote nearly double the prescriptions prescribed by the second provider on the list and more than four times the 10th prescriber. He also noted that the top prescribers of powerful antipsychotic drugs wrote double or triple the number of prescriptions as others on the lists.

None of the physicians on the lists were identified by name, only by their prescriber identification numbers.

Kayla Rosenfeld, a DHS spokeswoman, declined to provide any information on the investigations or to even confirm their existence. She also declined to provide information about the three physicians who were cut off from treating patients in the Medicaid program, their identities and the circumstances leading to their terminations.

In a written statement to the Star-Advertiser, Rosenfeld said the department monitors its programs, including provider prescription rates, to ensure against fraud, waste and abuse.

"We are mindful that while many prescriptions are therapeutically useful, they also are potentially dangerous and addictive," she wrote. "DHS will continue to be vigilant to protect against fraud and abuse."

Sen. Suzanne Chun Oakland, chairwoman of the Senate's Human Services Committee, said she has been in Medicaid-related meetings with Fink during which the overprescription issue was discussed. "It's not a very extensive problem here in Hawaii," she said.

Hawaii has had managed care in the Medicaid market longer than most other states, according to industry officials, and managed care incorporates strict monitoring that is designed to help control costs and shape more efficient treatments.

Daryl Huff, a spokesman for AlohaCare, which has about a third of Hawaii's regular Medicaid market (excluding the aged, blind and disabled segment), said his organization for years has used an automated claims-review system run by an outside vendor to flag any prescription and usage patterns outside of the norms.

"We're very aggressive in investigating when these things are flagged," Huff said.

In the nine months he has been with AlohaCare, Huff said he was aware of only one or two cases involving controlled substances that led to internal investigations. If AlohaCare officials find that laws or regulations have been broken, the cases are reported to authorities, he said.

Hawaii Medical Service Association, the state's largest health insurer, likewise said it refers cases to the appropriate government agency if it has sufficient evidence of abuse.

"We take every precaution to guard against abuse and have staff responsible for monitoring all lines of business for potential abuse or fraud," HMSA spokeswoman Elisa Yadao said in a statement to the Star-Advertiser.

Grassley, an Iowa Republican, has been investigating whether doctors nationally have been bilking the Medicaid system by writing excessive prescriptions for drugs he describes as having high potential for abuse and fraud by providers and patients. He asked each of the 50 states to provide him with lists of their top prescribers for a variety of drugs, including Seroquel and Zyprexa (antipsychotics), Roxicodone (painkiller) and Xanax (anti-anxiety medication).

Because of their addictive properties, the painkillers often are abused by patients or are sought for resell on the black market. Some of the antipsychotics have been the focus of investigations in which pharmaceutical companies were accused of illegally promoting the drugs for unapproved uses.

Among other things, the data provided to Grassley showed that the top 10 Hawaii prescribers of Seroquel collectively wrote more than 5,000 prescriptions in 2008 -- the latest year for which statistics were available -- at a cost of nearly $1.4 billion to Medicaid. The top prescriber accounted for 810 prescriptions, while the 10th-highest one wrote 310, according to the data.

The top prescriber for Zyprexa wrote 581 prescriptions, billing Medicaid more than $330,000 -- the highest amount among the individual physicians on the seven lists. The 10th prescriber for Zyprexa wrote 140 prescriptions.

Some of the doctors showed up on multiple lists. The top Zyprexa prescriber, for instance, also was the top one for Geodon, another antipsychotic, and the second highest for Seroquel.

In his letter last month to Grassley, DHS' Fink wrote that some of the providers on the lists worked in the state Adult Mental Health Division or at one of Hawaii's private inpatient mental health facilities. Those providers, he said, deal with the most severely mentally disabled and would be expected to be outliers for psychotropic medications. Outliers are those who prescribe amounts outside the norm.

In response to Grassley's question about whether providers have been reported to the state medical board, Fink said some -- he didn't specify a number -- have been referred to the Department of Commerce and Consumer Affairs, which licenses physicians.

He also noted that 98 percent of prescriptions are processed by managed care organizations and that the state Narcotics Enforcement Division of the Department of Public Safety monitors prescriptions for controlled substances.

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