Palm Beach Post
By Michael LaForgia

In Florida\’s juvenile jails, psychiatrists entrusted with diagnosing and prescribing drugs for wayward children have taken huge speaker fees from drug makers – companies that profit handsomely when doctors put kids on antipsychotic pills.

The psychiatrists were hired by a state juvenile justice system that has plied kids with heavy doses of the powerful medications, and the physicians have prescribed antipsychotics even before they were approved by federal regulators as safe for children.

One in three of the psychiatrists who have contracted with the state Department of Juvenile Justice in the past five years has taken speaker fees or gifts from companies that make antipsychotic medications, a Palm Beach Post investigation has found.

In two years, the four top paid doctors combined to accept more than $190,000 – all while working for DJJ. Three of the four psychiatrists still are seeing patients in state jails and residential programs.

In at least one case, the number of Medicaid prescriptions a psychiatrist wrote for children rose sharply around the time he was paid, The Post found.

\”That\’s very, very scary,\” said Jude Ann Prisco, a Palm Beach County mother whose child took psychiatric drugs while recently locked in a program. She said it never occurred to her that DJJ doctors might take money from drug companies. \”I\’m very upset by that, and I think they need to get some new guidelines.\”

Responding to The Post\’s findings, newly appointed DJJ Secretary Wansley Walters recently ordered a sweeping investigation into how antipsychotics are used in state jails and programs for kids. She declined to comment further, however, citing the probe.

DJJ doctors took payments as powerful antipsychotics flowed into state jails and homes. Child advocates say the widespread use of these drugs amounts to a policy of controlling children through \”chemical restraint.\”

\”This is a serious, legitimate and possibly life-threatening issue that requires investigation, reformation and possibly prosecution,\” said Circuit Judge Ronald Alvarez, who has sat on the juvenile court bench in Palm Beach County for 12 years.

DJJ relies heavily on the judgment of its contract doctors: In state juvenile jails and residential programs, the psychiatrists ultimately decide whether children should get medication – and which drugs kids should take.

Florida doesn\’t have disclosure laws

Doctors prescribed heavy doses of antipsychotic drugs for children in DJJ custody even before the drugs were deemed safe for kids.

Seroquel, for example, wasn\’t approved for kids until late 2009. Between mid-2006 and mid-2008, DJJ bought at least 217,563 tablets of Seroquel for children in the department\’s custody.

The state has no rules requiring drug companies to disclose payments to doctors. DJJ has no policy requiring contracted doctors to disclose conflicts of interest. In overhauling health care last year, Congress enacted a measure that requires all drug companies to disclose payments and gifts to doctors. However, that part of the law won\’t take effect until 2013.

DJJ doesn\’t track prescriptions going into its jails and programs. The rationale behind the department\’s system is that doctors, with help from nurses and other program staff, always prescribe drugs appropriately.

\”The idea was, if kids did not have a medical need for psychotropic medication, then there wouldn\’t be any purpose in giving (antipsychotics) to them,\” said DJJ spokeswoman Samadhi Jones.

Last Tuesday, six days before this story was published, DJJ\’s chief medical director, Lisa Johnson, took the unusual step of issuing a strongly worded memo to DJJ\’s contracted and state-employed doctors.

The note, among other things, cautioned psychiatrists against prescribing antipsychotics and other drugs for reasons that aren\’t approved by the federal government, except in extreme cases. It also reminded doctors that they aren\’t to use the drugs \”as a means of punishment, discipline, coercion, restraint or retaliation.\”

\’Quid pro quos\’ violate anti-kickback laws

The topic of doctors taking payments from pharmaceutical companies has become increasingly controversial in the past four years, after the federal government accused some companies of paying illegal kickbacks to physicians.

The subject takes on a new dimension when it involves doctors who care for children in state custody, said Eric Campbell, a professor at Harvard University who researches medical conflicts of interest.

\”In my eyes, the role of government is to ensure that people who are left in our care, who are vulnerable and need help, actually get that help,\” Campbell said. \”And potentially exposing them to inappropriate prescriptions, when the benefit of those goes to the individual physician, I see as especially problematic.\”

In general, if doctors prescribe drugs in exchange for payments from pharmaceutical companies, the quid-pro-quo arrangement violates state and federal anti-kickback laws, said Ryan Stumphauzer, a former federal prosecutor and founding member of South Florida\’s Medicare Fraud Strike Force.

Stumphauzer, who now is in private practice in Miami, added that The Post appears to have unearthed \”some truly stunning and troubling data.\”

Firms: Doctors provide valuable service

Drug companies\’ practice of compensating doctors is perfectly legal so long as it\’s not an effort to influence prescribing, said Bruce Reinhart, a former federal prosecutor now in private practice in West Palm Beach.

\”A drug company can give free samples, for example, or a doctor can go to a seminar, if the purpose of doing that is education,\” Reinhart said.

A spokeswoman for AstraZeneca, which makes Seroquel, said the company views payments as \”appropriate and ethical\” compensation for professionals who provide valuable services.

\”Physicians who speak about our products are compensated at a fair market value based on the physician\’s qualifications and the amount of time required to provide the service,\” Stephanie Andrzejewski said. \”Patients ultimately benefit when physicians are well informed and knowledgeable about our medicines, treatment options and standards of care.\”

Prescriptions rise with payments

AstraZeneca was one drug company that paid Dr. Umesh Mhatre after he started working for DJJ. Pfizer, maker of the antipsychotic Geodon, was another.

In 2010, Mhatre, who is board-certified in psychiatry and child psychiatry and based in Lake City, took $65,475 in payments and gifts, including $63,250 in speaker fees.

Records show Mhatre billed Medicaid for more antipsychotics for children during a period in which he was taking tens of thousands of dollars in payments.

The psychiatrist began working in St. Augustine in 2009 at the St. Johns Juvenile Correctional Facility, a secured program where children aren\’t eligible for Medicaid, and the St. Johns Youth Academy, a non-secured program where Medicaid can pay for kids\’ prescriptions.

During his first 15 months seeing DJJ patients at the St. Augustine homes, Mhatre billed Medicaid, on average, for about 254 prescriptions every three months for antipsychotics that went to children.

In the first six months of 2010, Mhatre took $39,000 in speaker fees from AstraZeneca, and then, months later, accepted another $13,100, records show. He also accepted more than $15,000 in speaker fees and to cover meals and travel from Pfizer between mid-2009 and the end of 2010.

Between April and June 2010, Mhatre wrote 328 children\’s prescriptions for antipsychotics in three months, or 35 percent more of those scrips than he had billed Medicaid for, on average, in three-month spans over the preceding 2½ years.

Medical experts cautioned against drawing conclusions from Mhatre\’s prescribing, saying a number of variables might have been at work.

For instance, he might have seen more patients in the spring of 2010 than he did in previous months: Mhatre\’s patient rolls weren\’t available. Speaking through a receptionist at his office, Mhatre declined to comment for this story. He continues to see patients for DJJ.

Fat speaker fees, free meals and travel

Mhatre is one of 17 current or former DJJ psychiatrists who, in two years, took a total of $253,982 in speaker fees or free meals and travel. Many doctors took payments or gifts valued at less than $300. A few, like Dr. Rex Birkmire, took much more.

Birkmire, an Oviedo-based psychiatrist who is board-certified in psychiatry and forensic psychiatry, has accepted nearly $129,000 from makers of antipsychotics since mid-2009. He took at least $70,750 in payments for educational programs around the time he worked at the Orange Regional Juvenile Detention Center.

After he started at DJJ, Birkmire billed Medicaid for dramatically fewer children\’s prescriptions for antipsychotics than he had in previous months. He evaluated patients in a secured juvenile jail, where DJJ, not Medicaid, pays for drugs for children.

Birkmire didn\’t respond to phone and e-mail messages seeking comment.

Taxpayers pay for prescriptions

Many of the drugs prescribed to children in DJJ custody are paid for with taxpayer dollars.

DJJ buys drugs given to kids in its jails and state-operated residential programs. But psychiatrists can bill Medicaid or private insurance for drugs prescribed to children in non-secured homes operated by private contractors.

Medicaid billing records don\’t identify patients who receive prescriptions, making it impossible to tell how many, if any, of the scrips were written for children in DJJ custody. What the records do offer, however, is a window into the prescribing habits of doctors who have worked for DJJ.

Take Mhatre, for example. In the run-up to his working for the department, he billed Medicaid for more mental health drugs than other doctors did. In 21 months, Mhatre wrote at least 24,771 prescriptions for mental health drugs, including antipsychotics, for both children and adults. That breaks down to 42 scrips per day, seven days a week, for 84 weeks straight.

In all, 52 psychiatrists who have worked for DJJ combined to bill Medicaid for at least 175,247 prescriptions for psychiatric medications in 21 months, a span that ended in March 2009. The doctors who took payments, a group that numbered 17, accounted for more than half of all those prescriptions, records show.

Big drug firms go to court

Pharmaceutical companies began disclosing payments to doctors in 2009. The move was related in part to lawsuits that alleged the drug makers were paying illegal kickbacks to physicians who prescribed pills liberally.

In April 2010, for example, AstraZeneca paid $520 million to settle the federal government\’s allegations that the company paid kickbacks to doctors who promoted Seroquel for off-label uses, among other claims.

When it comes to money for DJJ doctors, AstraZeneca and other companies said the payments weren\’t meant to influence prescribing.

\”AstraZeneca never pays physicians in exchange for prescribing our medicines or as an incentive to promote our products,\” Andrzejewski, the company spokeswoman, said in a statement. \”Further, we have policies in place to ensure that our payments to physicians do not create conflicts of interest or otherwise influence the decisions these physicians make in treating patients.\”

Some doctors paid by drug companies work hard preparing talks and crafting slides, and they can earn less than their hourly rate when delivering them, said Dr. Robert Hendren, director of child and adolescent psychiatry at the University of California, San Francisco.

In other cases, Hendren said, companies seem to have sought out speakers based on prescribing patterns. \”I think that, in some of those ways, there probably is undue influence,\” Hendren said. \”I think people are influenced by who pays them. I think there\’s no doubt about that.\”

Needed transparency for payments

Unlike other states, including California, Massachusetts and Minnesota, Florida lacks rules requiring drug makers to disclose payments to doctors licensed by the state.

Such measures would create needed transparency, medical ethicists said.

\”I think it\’s because we worry that paying and marketing and advertising and detailing can shape behavior,\” said Arthur Caplan, director of the University of Pennsylvania\’s Center for Bioethics. \”I don\’t think that\’s a hypothetical, because we know that they do.\”

Even better, said Campbell, the Harvard professor, would be if Florida government medical contractors refused all offers of money from drug companies.

\”Physicians who care for patients who are vulnerable populations need to be particularly above reproach when it comes to this behavior,\” Campbell said. \”I personally believe it\’s completely inappropriate for physicians to moonlight as drug reps. You either sell drugs or you practice medicine. But you can\’t do both.\”