JOHN HOPKINS' RESEARCH SHOWS MANY PRIMARY CARE PHYSICIANS DO NOT UNDERSTAND BASIC FACTS ABOUT HOW PEOPLE MAY ABUSE DRUGS OR HOW ADDICTIVE MEDICATIONS MAY BE

Many primary care physicians – the top prescribers of prescription pain pills in the United States – don’t understand basic facts about how people may abuse the drugs or how addictive different formulations of the medications can be, new Johns Hopkins Bloomberg School of Public Health research suggests.

This lack of understanding may be contributing to the ongoing epidemic of prescription opioid abuse and addiction in the U.S.

Since Vicodin was the largest prescribed drug in the United States last year, primary care physicians need to rethink their views on these issues. All it takes is one patient who may suffer from undiagnosed depression or have a hidden addiction issue to change that physicians' professional and personaL life. That includes civil lawsuit, Medical Board problems, and even potential criminal exposure.

Reporting online June 23 in the Clinical Journal of Pain, the researchers found that nearly half of the internists, family physicians and general practitioners surveyed incorrectly thought that abuse-deterrent pills – such as those formulated with physical barriers to prevent their being crushed and snorted or injected – were actually less addictive than their standard counterparts. In fact, the pills are equally addictive.

“Physicians and patients may mistakenly view these medicines as safe in one form and dangerous in another, but these products are addictive no matter how you take them,” says study leader G. Caleb Alexander, MD, MS, an associate professor in the Bloomberg School’s Department of Epidemiology and co-director of the school’s Center for Drug Safety and Effectiveness. “If doctors and patients fail to understand this, they may believe opioids are safer than is actually the case and prescribe them more readily than they should.”

He adds: “Opioids serve an important role in the treatment of some patients. However, our findings highlight the importance of patient and provider education regarding what abuse-deterrent products can and cannot do. When it comes to the opioid epidemic, we must be cautious about overreliance on technological fixes for what is first and foremost a problem of overprescribing.”

Another finding from the new research: One-third of the doctors erroneously said they believed that most prescription drug abuse is by means other than swallowing the pills as intended. Numerous studies have shown that the most common route by which drugs of abuse are administered is ingestion, followed by snorting and injection, with the percentage of those ingesting the drugs ranging from 64 percent to 97 percent, depending on the population studied. Certain medications are more likely than others to be snorted or injected.

Prescription drug abuse is the nation’s fastest growing drug problem, according to a report released by the White House in 2011. According to the U.S. Centers for Disease Control and Prevention, prescription drug overdose death rates in the United States have more than tripled since 1990 and have never been higher. The clinical use of prescription opioids nearly doubled between 2000 and 2010. By 2009, prescription drugs surpassed motor vehicle crashes as a leading cause of unintentional death, with more people dying from prescription opioids than cocaine and heroin combined.

“Doctors continue to overestimate the effectiveness of prescription pain medications and underestimate their risks, and that’s why we are facing such a public health crisis,” Alexander says.

For the study, Alexander and his colleagues conducted a nationally representative survey of 1,000 primary care physicians between February and May 2014 examining their knowledge, attitudes and beliefs regarding prescription drug abuse. 

They focused not only on opioid abuse and diversion (the use of prescription drugs for recreational purposes), but also their support for clinical and regulatory interventions that may reduce opioid-related injuries and deaths.

The researchers found that all respondents believed that prescription drug abuse was at least a small problem in their communities, with more than half reporting it was a “big problem.” While there was disconnect in physicians’ understanding of some elements of abuse and addiction, the researchers found large support for a variety of measures that could reduce prescription opioid abuse.

Nearly nine out of 10 physicians said they “strongly supported” requiring patients to get opioids from a single prescriber and/or pharmacy, something that would cut down on the number of patients who go from doctor to doctor to get more pain pills than one doctor would prescribe.

Two-thirds of doctors strongly supported the use of patient contracts, where patients agree to properly use their pain medication and not give or sell it to others. 

More than one-half strongly supported the use of urine testing for chronic opioid users to make sure patients are taking their medication and not diverting it and are not taking drugs they are not prescribed.

Alexander says he is heartened by the numbers, but believes some physicians may be overstating their support for such measures, as they would be time-consuming to implement and, in the case of urine testing, are already recommended by some guidelines yet typically underused.

“Despite the high levels of support, there are many barriers to implementation and there may be reluctance to translate these changes into real-world practice,” he says. “But for the sake of making a dent in an epidemic of injuries and deaths, we have to find ways to make changes. Too many lives are at stake to stick with the status quo."

Attorney Commentary: Compliance, training and new procedures are key. The world of prescribing has changed. Have someone outside your practice evaluate your prescribing, documentation and efforts to confirm prior diagnoses, prior prescriptions to patients, screen for drug abuse and minimize risk. It is good for patients and for your own professional practice. This is healthy risk management. Have patient contracts and create new procedures for anyone receiving pain medications - even if just for a short term problem.

Posted by Tracy Green, Esq.

Green and Associates, Attorneys at Law

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California Podiatrist Pleads Guilty To Federal Health Care Fraud For Upcoding, Providing Services Not Medically Necessary, Using Unlicensed Staff, Improper Billing, and Altering Records

For over ten (10) years, podiatry has been a red flag for Medicare auditors. The rules for podiatry services are strict and a podiatrist recently agreed to plead guilty to Medicare fraud based solely on podiatry services.  

On October 23, 2015, a podiatrist, Neil A. Van Dyck DPM, who operated a podiatry practice in Roseville, California called Placer Podiatry pleaded guilty to health care fraud in the Eastern District of Caifornia. This was under a plea agreement and was negotiated between the government and Dr. Van Dyck’s attorney.

According to court documents, Dr. Van Dyck was a California-licensed podiatrist. Van Dyck offered “spa”-like treatments and performed routine foot care at his practice.

Between 2009 and 2014, however, the government alleges that Dr. Van Dyck submitted over $2.8 million in fraudulent claims for reimbursement to Medicare, Medi-Cal, Tricare and private insurers (where about $1 million was paid) by doing the following:

1.  Dr. Van Dyck allegedly falsely claimed that he performed more expensive procedures than he actually performed and that some of these procedures were “spa-like” rather than medical procedures;

2.  Dr. Van Dyck allegedly falsely claimed that the routine foot care that was provided was justified  because of illness or symptoms that were not present; 

3.  The treatments were allegedly performed by unlicensed staff sometimes when Dr. Van Dyck was not present at his practice; 

4.   Dr. Van Dyck allegedly altered a single-use skincare patch by cutting it into pieces and billed Medicare for multiple applications; and

5.  In response to a request for documents from an investigator for Medicare, Dr. Van Dyck allegedly altered patients’ medical records to justify his fraudulent bills.

Dr. Van Dyck is scheduled to be sentenced by Judge Garland E. Burrell Jr. on January 15, 2016. The plea agreement is sealed and thus the sentence that he faces is not know.  Dr. Van Dyck faces a maximum statutory penalty of 10 years in prison and a fine of $250,000 or twice the loss or gain but with a plea agreement it would be highly unlikely that the maximum sentence would be imposed. The actual sentence, however, will be determined at the discretion of the court after consideration of any applicable statutory factors and the Federal Sentencing Guidelines, which take into account a number of variables.

Attorney Commentary: As I have seen in many cases over the years, the alteration of patient records in request to an audit or subpoena for records is being used to show fraudulent intent. While physicians may see issues in records and seek to correct them, they do not understand that changing records (unless those changes are noted in the charts on the date performed) can be used against the physician.

Moreover, physicians who bill services need a compliance plan and method for evaluating billing and procedures. Billing mistakes will happen but when it goes on for over 5 years, the billings add up. In fraud cases, it is the amount “billed” that is used for sentencing on loss amounts and not the amount “collected.” While the amount collected is relevant for sentencing, it is better for providers to catch mistakes themselves. Physicians will bill and be paid for years and assume that they must be doing it right.

Medicare is a “good faith” billing system. Medicare and Tricare pay and reserve the right to audit and challenge all billing for the prior 6 years. Do not assume that simply because you are being paid that the billing and documentation is correct. Get a compliance plan to keep your billing out of the claims that there is any “fraud,” “lack of medical necessity,” or “lack of documentation.”

Posted by Tracy Green, Esq.

Green and Associates

Email: tgreen@greenassoc.com

Office: 213-233-2260

Obama Says US Will Tackle Prescription Drug Abuse

The New York Times reporting on President Obama’s visit on Wednesday October 21, 2015 to West Virginia is in this article entitled “US Will Tackle PrescriptionDrug Abuse.” In the article, it notes that: “Experts say few prescription drug health care providers are properly trained to safely prescribe painkillers, while access to medication-assisted treatment for addicts is too difficult.”

President Obama's visit to West Virginia comes as politicians are grasping for a policy response, including presidential candidates in both parties. Former Secretary of State Hillary Rodham Clinton has laid out a $10 billion plan that promotes treatment over incarceration. New Jersey Gov. Chris Christie has visited drug rehabilitation centers and talked up his work to create drug courts at home that mandate treatment over jail time for non-violent offenders.

Before leaving the White House, Obama ordered federal agencies that employ health care providers to offer training on prescribing painkillers. They also must review their health insurance plans and address policies that might prevent patients from receiving medication as part of their treatment.

A Centers for Disease Control and Prevention (CDC) report released in July 2015 found the number of people who reported using heroin within the past year had nearly doubled from 2002 to 2013. Heroin use was up among nearly all demographic groups, but showed particular spikes among women and non-Latino whites. Researchers say two factors are driving the trend: the rise in abuse of opioid painkillers — drugs that are often a precursor to heroin — and the increasing availability of cheap heroin.

Researchers found that most users reported using at least one other drug in combination with heroin, which contributes to high overdose rates. Between 2002 and 2013, the rate of heroin-related overdose deaths nearly quadrupled, and more than 8,200 people — by some estimates, one in every 50 addicts — died in 2013, according to the CDC.

Commentary: It is curious that now that the demographic of drug abusers is non-Latino whites, there is more emphasis on treatment than incarceration. Heroin use was never seen as a drug for whites but now that it is - the attention is properly focused on it. Better late than never. Substance abuse it turns out does not respect anyone and it does not discriminate against race or economic status. However, it takes the mainstream to get affected before our policies change. 

Perhaps our nation has learned something from criminalizing drug possession – including the shameful past of mandatory minimums for crack cocaine and other drugs that sent many people of color or of low socioeconomic status to prison for many years for the crime of being an addict. If this is what it takes, then it is still the right thing to do. It reminds me of the times when AIDS was regarding as an issue affecting gay men but when it began to effect others, the country took action. This is a national health issue and highlights the issues with addiction that have been around for years.

Now the insurance companies need to treat addiction as a disease and provide health insurance coverage. One of the issues that arises is that once an addict is detoxed, the health insurance companies claim “no medical necessity” and refuse to provide coverage for residential programs that last over 30 days.

Physicians also need to be trained to spot those who are not simply “dependent” on painkillers but have become addicted. Since once those prescription drugs will not be prescribed, it seems that patients are then going to seek heroin or other drugs from non-medical sources and this is how heroin and prescription drugs get intertwined.

Practice point: Physicians and pharmacists need to take as much continuing education in these areas. Simply refusing to write prescriptions is not the answer. Yet this is now what is being reported. Post-surgery patients are being denied more than a couple of days of painkillers and physicians and pharmacists are running scared. 

Part of the answer is creating new systems, new type of consent forms and patient education which is also in writing, and perhaps having pain patients watch videos which detail that the warning labels are NOT advisory or suggestive but that mixing other drugs, exceeding dosage or mixing alcohol is a life or death issue. If one overdose death can be prevented - it is worth it. Pharmacists need to increase the warnings even for those who have taken the medications before - with the Internet some people think they are their own physicians and know better than the physicians or pharmacists.

All this takes time and of course insurance companies do not pay for "counseling" patients but this can be systemized for the health of patients and so that physicians and pharmacists are not blamed if the patient abuses or misuses the prescribed drugs. If we could put "black box" labels on any medications that could cause death when not taken as prescribed, it should be done. This is part of the FDA's domain and all the regulatory and licensing agencies need to work together in order to address this crisis.

Posted by Tracy Green, Esq.
Green and Associates, Attorneys at Law

Lancaster Man Sentenced to Nearly 7 Years in Prison for Unemployment Insurance Fraud and Tax Fraud

The federal and state governments are putting priority on fraud against government programs. One case highlights a more extreme example. 

On September 28, 2015, Carl Artis, 55 from Lancaster, California, was sentenced by United States District Judge George Wu to 80 months in federal prison on fraud charges related to a scheme to defraud the state’s unemployment insurance program and a related scheme to obtain fraudulent federal tax refunds.  Judge Wu also ordered the defendant to pay $598,000 in restitution.

Mr. Artis pleaded guilty in February to one count of mail fraud and one count of making false claims against the United States government. According to the plea agreement filed in the case, from at least August 2010 through August 2014, Artis operated a scheme to defraud the California Employment Development Department (EDD) of unemployment insurance benefits. 

To execute this, Mr. Artis allegedly registered fictitious companies with the EDD, submitted false wage information for individuals whom he falsely claimed worked for these companies, and then fraudulently applied for and obtained unemployment insurance benefits in the names of these individuals.

In addition, from at least April 2011 until July 2013, according to the plea agreement Mr. Artis engaged in a scheme to defraud the Internal Revenue Service by submitting fraudulent tax returns that sought tax refunds. In the tax fraud scheme, Mr. Artis allegedly used the identities of many of the same individuals and businesses used in the EDD scheme.

This case shows that given the economy, that the governments (federal and state) are putting priority on unemployment insurance fraud.  

Even individuals who are entitled to benefits must remember that they are signing documents under penalty of perjury and that there is a significant risk if statements made on forms submitted to the state are false or misleading. If there is any issue of whether a statement is false or misleading, seek legal advice before it is submitted.

Posted by Tracy Green

Green and Associates, Attorneys at Law

Pharmacy Owners Indicted In U.S. District Court in California For Using Pharmacy to Illegally Distribute Vicodin and OxyContin

The Los Angeles Times reports that two owners of a pharmacy Global Compounding in West Los Angeles have been indicted in federal court on counts of using a front for drug trafficking. The Los Angeles Times has a link to the Indictment. The men are presumed innocent and the allegations are that the men used their ability to buy controlled substances (Vicodin and OxyContin) wholesale and sold them for nonmedical reasons.

Posted by Green and Associates