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Idaho Statesman
Idaho’s Medicaid payments for prescription drugs questioned
But the state says Medicaid records don’t prove doctors are overprescribing
November 11, 2012
By AUDREY DUTTON

Idaho Medicaid Dick Armstrong addresses the State Legislature

U.S. Sen. Chuck Grassley, an Iowa Republican who has assumed a role as a taxpayer watchdog, says some Idaho physicians have overprescribed antipsychotic drugs and addictive narcotics such as OxyContin to Medicaid patients.

“After an extensive review of prescribing habits of the serial prescribers of pain and mental health drugs in your state, I have concerns about the oversight and enforcement of Medicaid abuse in your state,” Grassley wrote in a Jan. 23 letter to Idaho Department of Health and Welfare Director Dick Armstrong.

Grassley asked for a list of the state’s top prescribers of certain drugs that have a high potential for addiction or that have been scrutinized for misuse in certain patient groups, such as in nursing homes.

“Mental health drugs continue to be prescribed at astounding rates, and pain management clinics are turning into a hotbed for black market painkillers,” he wrote.

The state sent Grassley records of prescribing activity by Medicaid providers for 2008 and 2009. Grassley called the numbers “shocking.” The state then sent him records for 2010 and 2011.

– One doctor wrote about 4,870 prescriptions in 2010 and 2011 for four of the antipsychotics, with Medicaid payments for them totaling $1.7 million.

– A nurse practitioner in 2008 wrote 106 OxyContin prescriptions totaling $42,768, and the following year a doctor wrote 102 OxyContin prescriptions for $56,737.

– Four Medicaid providers wrote more than 300 prescriptions each for the sedative Xanax in 2011.

– For one kind of drug, the atypical antipsychotic Abilify, Medicaid paid about $2.5 million for prescriptions written by 10 health care providers in 2011.

– Medicaid paid about $269,000 for the painkiller oxycodone prescribed by the most frequent providers in 2011.

The top prescribers represented only a fraction of the 11,000 to 18,000 medical providers who served Medicaid patients in those years.

The payments for their prescriptions made up a sizable share of the total spending in those years. The Medicaid program spent $61 million to $83 million per year on prescribed drugs between 2008 and 2011. The total billed to Medicaid for Abilify in 2008 by the top 10 prescribers was more than $1 million.

The most frequent prescribers for the eight drugs in question include two doctors who have been disciplined by the Idaho Board of Medicine for reasons unrelated to Grassley’s concerns. They also include doctors, nurse practitioners and physician assistants who have taken payments or gifts from drug companies since 2009. A few collected more than $10,000 for speaking and consulting work.

Grassley has sent similar letters to many other states. His office said it had no record of a response from Idaho as of last week, but the Idaho Department of Health and Welfare provided the Statesman a copy of its response sent in March.

“The number of prescriptions written by these prescribers … does not necessarily indicate overprescribing or inappropriate prescribing,” wrote Medicaid Administrator Paul Leary. Mental health or pain specialists will, by nature of their jobs, have more patients who need those drugs, he wrote.

Indeed, the top physician prescribers for the drugs were, in most cases, psychiatrists, pain specialists or cancer specialists.

Grassley asked the state to explain whether it monitors its Medicaid-billing doctors to make sure they don’t have black marks on their records. Leary said Medicaid does that only if it finds that a provider isn’t appropriately prescribing drugs.

Medicaid has no system to spot excessive prescription writing, but the Idaho Board of Pharmacy has a prescription-monitoring program and would be responsible for flagging overprescribers, Leary said.

A NARCOTIC PROBLEM

Though the Idaho Medicaid program does not oversee the people writing the prescriptions, it has identified a problem with drug-seeking patients and is working on ways to curb it.

If a patient is on Medicaid, he or she is restricted to a certain number of doses per day and prescriptions per month. More than 100 drugs require an authorization from Medicaid before they can be filled, Leary said.

The use of psychotropic drugs in certain Medicaid populations has prompted federal studies.

According to a report by the Government Accountability Office late last year, children in the foster care system were much more likely to be on at least one psychotropic drug — sometimes more than five at once. The office said federal guidance could help with state-run oversight of prescriptions for children.

That is something Idaho’s Medicaid program might be addressing.

“The Medicaid Pharmacy Program is … participating in a project with other areas of the Idaho Department of Health and Welfare and various community organizations to improve the use of psychotropic drugs in foster kids,” Leary wrote.

He added that he expects to set up a system for red-flagging possible misuse, making sure there is consent for treatment and getting prior authorization when necessary.

According to Medicaid data, about 24 percent of foster children were prescribed psychotropic drugs in 2008, compared with 7 percent of children not in foster care.

However, as the GAO noted, higher rates could be partly due to mental-health needs, traumatic life events and fragmented medical care of foster children compared with nonfoster children.

A federally mandated board in Idaho is looking at abuse-prone prescription drugs among the state’s Medicaid patients.

An October report profiled 150 patients who received the most narcotics through Medicaid in an eight-month period.

The average patient was on three opioid drugs — painkillers such as OxyContin — prescribed by four health care providers. They had been on the drugs for several years. The most common diagnoses were back pain, chronic pain and vertebrae disc problems. About 39 percent of them also had diagnosed problems with drug abuse.

When the board cross-referenced Idaho Board of Pharmacy information, it found that 30 percent of the high-narcotic Medicaid patients were also paying cash for separate prescriptions. The extra number of doses ranged from two to 4,275 in the eight-month span.

Idaho Medicaid is putting some new rules in place for certain narcotics to cut down on the potential for abuse, the report said. They include making sure that three less problematic drugs have failed to help a patient before the patient is switched to a narcotic such as OxyContin or Vicodin.

A panel appointed by Gov. Butch Otter recommended Friday that the Legislature broaden Idaho’s Medicaid program to cover more than 100,000 additional low-income residents.