With little oversight and apparent carte blanche, a relative handful of Texas physicians wrote $47 million worth of Medicaid prescriptions for powerful antipsychotic and anti-anxiety drugs over the past two years, according to a Star-Telegram analysis.

The top five doctors alone wrote $18 million worth.

Most of the drugs have gone to children and adolescents, although prescribing the drugs to children, such as a toddler, is considered “off-label” — uses not approved by the federal Food and Drug Administration.

Now the state’s Medicaid program is among others under scrutiny, after Sen. Charles Grassley, R-Iowa, began investigating the use of mental-health drugs this year. Grassley, the ranking member of the Senate Finance Committee, told federal health officials to keep a better watch on top prescribers. His conclusion: Either some physicians have specialized expertise or the number of prescriptions suggests “overutilization or even health care fraud,” according to an October letter sent to the Health and Human Services Department.

Some advocates are concerned that the drugs are unsafe for children, who make up nearly 75 percent of Texas Medicaid’s 3.2 million recipients. In a 16-state study, Texas had the maximum rate of prescribing multiple mental-health drugs to youths in foster care. Although the number of prescriptions had dropped 19 percent by 2007, Texas was still tops, according to the June study.

And some doctors churn out prescriptions for children and others at an alarming rate. Antipsychotic drugs prescribed to children under 6 grew by 20 percent from 2007 to 2009, according to a November report by the Texas Health and Human Services Commission.

About 1.7 percent of children on Medicaid received antipsychotic drugs in fiscal 2009, state officials said.

Some children are overmedicated: One area doctor routinely prescribes five potent mental-health drugs simultaneously, said one of the state’s top prescribers. He said he tries to scale back the number of drugs the children are on.

Some experts believe that medication has pushed aside talk therapy, which might be effective and reduce medication needs.

The child, 31/2, suffers from shaken baby syndrome. When stressed, he pulls at his ventilator hoses and tracheotomy tube so much that his hands must be tied to the bed. He is prescribed antipsychotics because other sedatives could suppress the breathing centers of the brain.

Grassley asked Texas and other states for the top 10 prescribers who billed Medicaid for certain drugs. The Star-Telegram used prescriber numbers to identify the doctors, then sorted and tallied the drugs they were prescribing. Also reviewed was information on other mental-health drugs that have cost taxpayers about $1.3 billion during the past five years.

The analysis and research found:

In the past two years, 72 Medicaid providers wrote 186,992 prescriptions, an average of 2,597 each.

The state’s top prescriber, child psychiatrist G.K. Ravichandran of Houston’s Shamrock Psychiatric clinic wrote 27,000 scripts for the anti-anxiety drug Xanax in the past two years. The next-closest physician wrote 6,300.

Under his license, 44,138 prescriptions for antipsychotic drugs were written, at a cost to Medicaid of $6.4 million.

Dr. Fernando Siles, a child psychiatrist in Greenville, is the second most prolific Medicaid prescriber. He sees children from across North Texas, including Tarrant County.

In the past two years, Siles’ medical license was used to write 13,601 antipsychotic prescriptions at a cost of $4.6 million.

Siles, who treats solely Medicaid recipients, some as young as 3, has three nurse practitioners who also write prescriptions under his license, he said.

Many children referred to him are already on multiple antipsychotic drugs, and he tries to cut back, he said. “Fifty percent of the medications I prescribe, I did not start them on the medicine,” he said. “They came from other doctors.”

There may be other physicians who are also prescribing high volumes of antipsychotic drugs but aren’t as easily detected, state officials say.

Some physicians use a clinic to hide the volume of their prescribing, said Stephanie Goodman, spokeswoman for the Texas Health and Human Services Commission, which oversees Medicaid.

“To be quite honest, we feel like single doctors have started to bill under clinics to maybe hide that, to make it look like it’s not a single doctor prescribing all these,” she said.

The 13-year-old girl suffered depression and post traumatic stress disorder. She cut her arms and stomach. Her stepfather molested her, and then beat her when she refused to have sex. She cannot sleep at night for the nightmares of being locked in a closet. Prescribed an antipsychotic off label, she begins to have fewer flashbacks and nightmares.

Another top prescriber, Dr. Adolphus Lewis of Fort Worth, is a family physician who also treats the elderly. In one year ending in 1994, he wrote 61 prescriptions for one male patient, including enough Vicodin and Valium to pop seven pills a day.

The state medical board accused Lewis of prescribing “medically excessive” numbers of pills to a woman who later died, court documents show. Her death, which was due to respiratory failure, implicated three drugs, including two that Lewis previously prescribed, according to the documents.

About 40 percent of the 72 top Medicaid prescribers among certain antipsychotic drugs have been disciplined by the state medical board. By comparison, last year the state disciplined less than 1 percent of the state’s 62,521 doctors.

In 2002, the Texas Medical Board restricted Ravichandran’s license for five years for “unprofessional or dishonorable conduct that is likely to deceive or defraud the public or injury the public.” The restriction, which was not related to prescriptions, was lifted within three years.

Siles’ license is spotless.

Lewis was restricted in 1998 for failure to practice medicine in an acceptable manner because of his prescribing. From 2008 to 2009, he wrote 3,696 prescriptions for antipsychotics — roughly 10 each day — that cost taxpayers $1,395,595. Lewis’ license is connected with 10,000 prescriptions of mental-health drugs to 1,864 clients from 2005 to 2009, fifth most in the state among Medicaid providers.

The state has automated checks, called edits, to catch overuse, incorrect dosage and misuse, Goodman said.

Identifying even one inappropriate prescription is difficult, Goodman said.

“To really prove up a case, you have to prove some of those prescriptions were inappropriate. And it’s not just the volume alone that does that,” she said. “It’s really going in and looking at the patient’s records and getting another doctor to say, ‘That prescription was not appropriate in that case.’”

“The conventional wisdom is that hospitals aggressively seek to shift costs from public insurance programs to private payers such as auto insurance companies,” said Elizabeth Sprinkel, Senior Vice President of the IRC. “With this study, we now have information on the magnitude of cost shifting and a better understanding of the need for supportive state laws and effective tools that will enable auto insurers to pay hospitals appropriately and help control auto injury claim costs,” said Sprinkel.

“Now this concept will be extended to Medicaid,” CQ reports. “Under the healthcare law (PL 111-148, PL 111-152), the curb on payments for preventable conditions must also apply to Medicaid.” In other words, “states won’t be allowed to pay providers including hospitals, doctors and other health care organizations if patients develop conditions that are deemed reasonably preventable.”

Kaiser Health News reported, “Currently, about 21 states have such a nonpayment policy,” but “the 2010 federal health law, in effect, expands the ban nationwide. The rule published [yesterday] gives states until July 2012 to implement it.” However, some medical groups have reservations about this policy. Kaiser Health News quoted written comments made by Michael Maves, MD, CEO of the American Medical Association, to the CMS three months ago. Maves wrote, “Simply not paying for complications or conditions, that, while extremely regrettable, are not entirely preventable, is a blunt approach that is not effective or wise for patients or the Medicare or Medicaid program.”

Writing in the Forbes “Health Dollars” blog, David Whelan focused on possible unintended consequences of the new rule proposed by the CMS that “would modify the Inpatient Prospective Payment System.” Whelan pointed out that “the new payment plan assumes that changing a whole industry is as simple as turning a few knobs and pushing a few buttons on the Medicare dashboard. Implementing such a scheme will be extremely difficult, possibly unfair and will most definitely increase the cost of health care rather than save money.” Whelan contended that Medicare currently does not have the necessary experience to make clinical judgments affecting patients. He also voiced concern that hospital systems would have to merge as a result of the proposed rule, thereby setting up “powerful health care oligarchies.”

From the American Association for Justice news release.

There is a handy site for Texas who want to know who represents them, and how to contact that person. Just visit http://www.fyi.legis.state.tx.us.

The Los Angeles Times reports, “The Obama administration announced a broad new initiative Tuesday to reduce medical errors, partnering with private insurers, business leaders, hospitals and patient advocates to tackle a problem that kills thousands of Americans every year.” This “campaign, funded by the healthcare overhaul the president signed last year, aims to cut by 40% over the next three years the number of harmful preventable conditions such as infections that patients acquire in the hospital.” HHS Secretary Kathleen Sebelius made the announcement about the Partnership for Patients initiative, and CMS Administrator Donald Berwick noted that the initiative has “big goals.”

The AP reports, “Sebelius said the new national Partnership for Patients will help other hospitals adopt those proven safety strategies.” The program “is funded by $1 billion from the new healthcare law, but has the potential to save Medicare up to $10 billion in that same time.”

The New York Times “Prescriptions” blog quotes Sebelius as saying, “Americans go the hospital to get well, but millions of patients are injured because of preventable complications and accidents. … Working closely with hospitals, doctors, nurses, patients, families and employers, we will support efforts to help keep patients safe, improve care, and reduce costs. Working together, we can help eliminate preventable harm to patients.”

According to the CNN “The Chart” blog, the initiative “will save 60,000 lives over the next three years by reducing millions of preventable hospital-related complications and injuries. Sebelius says the new partnership will also save about $35 billion in healthcare costs including $10 billion in Medicare savings.” Meanwhile, American Medical Association president Cecil Wilson, MD, said that the group’s “physicians will be encouraged to do everything they can to reduce adverse events and hospital readmissions.” Wilson added, “We know that if we ensure that a patient’s primary care physician receives their discharge papers within 24 hours of their release from the hospital, the likelihood of hospital readmission will be reduced.”

The Hill reports in its “Healthwatch” blog that HHS aims to accomplish the initiative’s goals “by disseminating best practices that have already allowed the nation’s best hospital systems to cut preventable errors significantly.” Berwick noted, “Blame and accusation are not the answers; teamwork, improvement are the answers.” The AMA’s Wilson is also quoted as saying, “We all need to do everything we can to avoid preventable patient illness and injuries while also working to ensure that patients are able to heal without complications.”

Reuters reports that another goal of the initiative is to cut hospital readmissions by at least 20 percent. Sebelius noted that 500 hospitals are already part of the effort.

CQ reports, “Because the program is voluntary, making good on the projections is initially going to require a disciplined effort by hospital and other healthcare CEOs to devote time and resources to the project — in addition to their efforts to comply with the many requirements of the healthcare law.” Berwick explained that “the changes needed in healthcare delivery to meet the goals of the project will help hospitals qualify in a few years for incentive payments under the health law to improve patient safety.”

The PBS NewsHour “The Rundown” blog reports, “The partnership will begin by asking hospitals to focus on nine types of medical mistakes where there is potential for dramatic reductions in harm. These include pressure ulcers, drug reactions, childbirth complications and surgical site infections.” Notably, Berwick will “oversee the new partnership.” He stated, “Through strong partnerships at national, regional, state and local levels … we are supporting the hospital community to significantly reduce harm to patients.

From the American Association for Justice news release.

The Houston Chronicle ran an article about proposed cuts to the Texas Medicaid system, and the effect those cuts might have. Here are excerpts from the article:

If we played drinking games during editorial-board meetings, the phrase “penny-wise and pound-foolish” would be the death of our livers. In these dark days, in our endless discussions of the terrifying state budget proposed for Texas, it is the Cliché That Cannot Be Avoided.

It comes up in meeting after meeting, e-mail after e-mail, from group after group, from outfits representing senior citizens, the middle class, children, the court system, hospitals, doctors, universities, the mentally ill and public schools. The budget-slashed, rainy-day-fund-untouched Texas that our Legislature is contemplating wouldn’t be just a mean, hard place for our families to live. It would be an inefficient one, too — and one whose problems this budget will only make worse.

The proposal to cut reimbursements paid to Medicaid providers by 10 percent is pure pound-foolishness. And its horrifying long-term costs will hit us all.

For most of us, Medicaid seems far from our everyday lives; we think of it as a program that covers people who’ve been poor, or will be poor, all their lives.

But actually, Medicaid generally winds up helping people who spend most of their days in the middle class. According to the Texas Hospital Association, 50 percent – half! – of all the babies delivered in Texas are billed to the program. And according to the AARP, Medicaid covers two-thirds of the elderly in nursing homes.

“The older you get, the more likely you are to be poor,” Bob Jackson, AARP Texas state director, explained to us recently. “And nursing home care is expensive. People who’ve been good middle-class taxpayers all their lives, who never expected to be poor, end up on Medicaid.”

The 10 percent cuts would be plenty awful if they only meant that those babies and grandmas would receive 10 percent less of the medical care they need: 10 percent fewer vaccinations, 10 percent less help avoiding bedsores. But the actual effects would be even more painful — and more widespread.

Texas already runs one of the leanest Medicaid reimbursement programs – one so lean that it doesn’t cover the actual cost of treating Medicaid patients. Doctors already lose money on those patients; many simply can’t afford to accept them. And further cuts could mean that far more would have to stop accepting Medicaid.

The upshot? If pregnant women can’t find a doctor who’ll see them, they’re likely to skip prenatal care — and thus, more likely to suffer serious problems with their pregnancies or give birth to a premature baby. Those intensive-care outcomes aren’t just tragic; they’re far more expensive than prevention. And we taxpayers will end up paying for them.

Even babies and mothers-to-be lucky enough to have insurance would be affected. Medicaid cuts, the hospital association says, would cause some OB/GYN wards to close entirely. Those closures would hit rural places hardest, leaving towns without a hospital ready to deliver babies. One likely closing in the Panhandle, for instance, would mean that a woman could go into labor more than a hundred miles from a maternity ward.

The cutbacks would hit the elderly just as cruelly — and with equally little in likely cost savings. Consider Medicaid’s Primary Home Care program, which pays for an attendant to do the stuff that allows a fragile person to continue living at home: help with things like shopping, tracking medicines or bathing.

Cutting the Medicaid reimbursement makes it likely that agencies wouldn’t be able to pay those home health care workers even minimum wage, the AARP points out; and since it’s illegal to pay less, agencies would have to stop providing the service. Without home help, a semi-self-sufficient senior would likely be propelled into a nursing home — which would cost Medicaid three times as much.

Of course, that’s assuming that a nursing home could be found. Slashed reimbursements, the AARP says, means that many long-term care facilities would also stop accepting Medicaid patients. The elderly who outlive their assets – the blind, the Alzheimer’s-addled, the wheelchair-bound — would be left to shift for themselves.

Texas can’t afford to treat its babies and its elderly so badly. It’s time to tap that rainy-day fund. Spending those pennies will save us pounds. And lives.

Hundreds of nursing homes, including dozens in Dallas-Fort Worth, may close if lawmakers cut Medicaid as leaders propose.

GOP leaders have introduced budgets in both chambers that would reduce by one-third the state’s budget for its 56,000 nursing home residents on Medicaid. Two-year spending would sink to $2.8 billion, from $4.2 billion.

“We are not crying wolf. Pieces of the sky are falling,” said Tim Graves, head of the Texas Health Care Association, a trade group that represents 500 nursing homes, most of them for-profit operations. He said the cuts would jeopardize about half of the state’s 1,100 nursing homes: those with 70 percent or more of patients on the Medicaid rolls.

In 2009, the elderly and disabled made up only 30 percent of the enrollment in Texas Medicaid, a state-federal health program for the poor. But they consumed nearly 60 percent of the $24.5 billion spent that year.

Some advocates say Texas spends too much on institutional care of enfeebled Medicaid recipients, and should do more to keep them at home. Graves responded that Texas’ Medicaid payment levels for skilled nursing homes rank 49th in the nation.

He said 551 Texas nursing homes, 85 of them in Dallas and surrounding counties, are at serious risk. That’s because Medicaid covers 70 percent or more of their residents, he said.

Graves said the cuts could trigger a wave of bankruptcies and closures, especially combined with coming cuts in Medicare to help pay for the federal health care overhaul.

Mike Gavin, president of Plano-based Preferred Care Partners Management Group, which owns nine North Texas nursing homes and 26 others across the state, agreed the outlook is scary for the industry.

Currently, Texas Medicaid pays the company about $130 per patient per day, he said. Under the leaders’ budget, that would drop to $88.

Gavin said Preferred Care would have to lay off nurses and assistants, especially at its two Dallas County homes, DeSoto Nursing and Rehabilitation and Lancaster Nursing and Rehabilitation. At each, 80 percent of patients are on Medicaid.

Layoffs jeopardize the quality of care, which Gavin said can set off “a death spiral” of citations from the state, damage to a home’s reputation and relatives’ removing their loved ones.

Perhaps no group of nursing home residents is more vulnerable than those with advanced dementia: unable to speak for themselves, suffering the physical as well as the cognitive effects of their terminal disease, prone to confusion or fear when subjected to blood tests or trips in screaming ambulances.

Yet dementia patients are often subjected to aggressive treatments and transfers even though studies show little benefit, as researchers at Hebrew Senior Life Institute for Aging Research in Boston keep pointing out.

This time, Dr. Susan Mitchell and her colleagues looked at Medicare spending for more than 300 patients with advanced dementia in Boston-area nursing homes over a period of 18 months. One of the largest expenditures, about 30 percent of the total, was for hospitalizations; skilled nursing care after those hospital stays accounted for another 10 percent. (Hospice was a big factor as well, though only 22 percent of the patients with advanced dementia were receiving hospice care, a dispiriting number in itself.)

So what’s wrong with this picture? “I’d estimate 75 percent of those hospitalizations are avoidable,” Dr. Mitchell told me in an interview. “By and large, research shows they can be treated with equal effectiveness in the nursing home. And it’s less traumatic for a nursing home resident with dementia to remain in place.”

Most of those hospital trips occurred when patients developed respiratory infections, particularly pneumonia, a common and recurring problem when dementia progresses to its final stages.

Ideally, patients’ relatives would be discussing, among one another and with doctors, whether to use aggressive treatments like intravenous antibiotics at this stage of the disease. These elderly patients, most in their 80s, could no longer recognize family members, speak more than a few words, leave their beds or feed themselves. The question of quality of life versus quantity comes into play.

But even when families decide to pursue every possible treatment, or when their ailing relatives have specified that course in advance directives, rushing demented old people to hospitals is unnecessary, Dr. Mitchell cautioned. “Being in an emergency room where people are taking blood and putting in IVs in this crazy, noisy setting — it’s been described as an ‘assault,’ and I concur,” she said. Intravenous antibiotics, if that’s the treatment agreed on, can be administered in nursing homes.

Part of the motive for hospitalization, Dr. Mitchell added, might be “cost-shifting” by nursing homes. Patients returning after a hospital stint will be covered for up to 100 days by Medicare, at higher rates than the Medicaid payments that may have covered them before. The billions of dollars saved by reducing repeated hospitalizations, she suggested, might better be spent improving nursing home care.

But families have a role to play, too. If they understand that dementia is a terminal disease, that treating recurring infections may prolong life but won’t restore health or bring comfort, that such treatments, if desired, can be usually administered in nursing homes themselves — they may be less willing to have the staff dial 911.

Mylan has been sued by several other states, and last year pharmaceutical companies Mylan, AstraZeneca, and Johnson & Johnson agreed to pay $124 million in settlement of claims that the companies violated the U.S. False Claims Act by underpaying Medicaid rebates.

Bloomberg News (12/8, Blum, Voreacos) reports, “Abbott Laboratories and two other drugmakers agreed to pay $421.2 million to settle claims they overcharged the US for medicines, the Justice Department said.” Specifically, “Boehringer Ingelheim GmbH’s Roxane Inc. will pay $280 million, Abbott will pay $126.5 million and B. Braun Melsungen AG will pay $14.7 million.” The “settlements resolve civil claims that the companies inflated the average wholesale prices for drugs reported to the federal health programs Medicare and Medicaid.”

AFP (12/8) reports, West “said the companies were guilty of ‘offering their customers one price and then falsely reporting a greatly inflated price to the lists the government uses when determining how much to pay for the drugs.’” According to officials, “the fraud led to the government overpaying reimbursements by hundreds of millions of dollars.”

West said in the Los Angeles Times (12/8, Zajac) the price differences “amounted to kickbacks to the companies’ customers.” He called the inflation practice “so widespread that its acronym, AWP, was said by industry insiders to mean ‘Ain’t What’s Paid,’” adding “the only purchasers who paid the inflated, reported drug price were you, the American taxpayers.” All three companies maintained compliance with laws and regulations.

Integrity of patient-care threatened. The Wall Street Journal (12/8, Catan) adds that West said, “Not only did this practice cost our public health-care programs millions of dollars, it also threatened to undermine the integrity of the choices health care providers made for their patients.” The Journal goes on to add the cases were originally filed as whistleblower suits by Ven-a-Care. Under the False Claims Act, the government joined the suit, allowing the Florida-based company to partake in any recovered profits.

The Boston Herald (12/8, Kronenberg) reports, “Prosecutors say the three firms overcharged the government by providing false information to the ‘Average Wholesale Price’ list, a database of drug costs that Medicare and Medicaid used to use when reimbursing doctors and pharmacies.” West said “the alleged scam not only cost the government money, but also gave doctors and pharmacies incentives to prescribe certain drugs whether appropriate or not. Authorities also say the higher prices stuck poor and elderly patients with inflated drug co-pays.”

Abbott subsidiary settles kickback suit. In related coverage, the AP (12/7) reported Kos Pharmaceuticals, “a subsidiary of Abbott Laboratories has agreed to pay more than $41 million to settle allegations that it paid illegal kickbacks to get doctors, physician groups and managed care organizations to prescribe or recommend two of the company’s drugs, Advicor and Niaspan.”

From the American Association for Justice news release.