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Medicaid abuse is rampant
A small group of Florida doctors are drugging the poor at taxpayer expense.
They are exploiting the Medicaid system by prescribing hundreds of millions of dollars worth of dangerous drugs that are feeding a booming black market and adding to a torrent of fatal overdoses.
The South Florida Sun-Sentinel found in an eight-month investigation that even as the state faces a budget crisis in which Medicaid costs figure prominently, abuse of the health care system for the poor by doctors -- and by willing pharmacists and patients -- has gone largely unpunished.
Regulators, for the most part, have failed to curb wild excesses in billing as pain-relief patches, sleeping pills, tranquilizers and other highly abused drugs have poured out over the past three years, frequently in staggering doses.
"This is a crime in plain sight," said David Moye, director of economic crimes and health care fraud for the Florida Attorney General's Office.
In a hand search of more than 2,000 reports of prescription drug deaths and a computer analysis of millions of pharmacy billing records the state has never made public before, the newspaper found that:
Medicaid, which serves about 2 million disabled and low-income Floridians, more than half of them children, paid pharmacies $346.6 million for narcotics and other potent drugs over the past three years. Frequently, the Medicaid prescriptions were for the maximum doses.
Less than 3 percent of the state's medical professionals issued the vast majority of these prescriptions. Sixteen doctors each ordered more than $1 million worth of dangerous drugs. By comparison, only 574 of the state's 56,926 medical professionals topped even $100,000 in pharmacy billings. Most prescribed less than a tenth that amount. Thousands of others wrote far less.
Many doctors who handed out the most prescriptions also are linked to multiple drug-related deaths. At least 40 doctors each had four or more patients die of overdoses in the past two years. Sixteen of the physicians had eight or more such deaths. How many of the dead also were Medicaid participants could not be determined from available records.
As doctors have switched patients from OxyContin, which has been linked to deaths and is highly addictive, three other painkillers have grown in popularity and are killing Floridians with alarming frequency.
Medicaid purchases of methadone, morphine and fentanyl have more than doubled since 2000, and deaths that can be linked to those narcotics have skyrocketed.
"We've got to get our hands around this and do everything we can," State Attorney General Charlie Crist said when shown the newspaper's findings. He promised immediate reforms and legislative proposals for tougher enforcement. "Unfortunately, too many lives have been lost."
James R. McDonough, director of the governor's advisory Office of Drug Control, agreed: "This is truly an epidemic with tragic consequences. There are many holes in the system."
Florida, state regulators admit, is paying dearly in human life and tax dollars for failing to set up a warning system that identifies abuse-prone medicines and monitors doctors who habitually prescribe them.
Doctors such as Freeland Williams II, a general practitioner in Vero Beach.
In 1993, Williams paid a $5,000 fine and accepted three years of probation to settle a Florida Board of Medicine civil complaint that he overprescribed pain pills for three patients, including one without "any objective evidence" of chronic pain, state records show.
Still, during the past three years, Williams prescribed $474,763 worth of controlled drugs for state-supported patients. Only 66 of all the medical professionals in the state had bigger billings, records show.
In 2002, a year when five of his patients fatally overdosed, Williams wrote prescriptions for $237,784 worth of these drugs, nearly triple what he had written two years earlier. That included pain patches for 73 Medicaid patients. Only 15 other doctors wrote more, according to the newspaper's analysis.
One of his patients was Bette L. Moody, a restaurant cook on Medicaid, who came to him in pain after she was burned in a kitchen fire.
Williams prescribed a bandage-like patch that oozed the super-strong narcotic fentanyl. On Nov. 23, 2002, the 39-year-old Fort Pierce mother died of poisoning from fentanyl and a muscle relaxant that Williams also had prescribed, her autopsy showed. She was found in bed, the patch stuck to her lower back.
Moody was the second of the doctor's pain-patch patients who died that month. On Nov. 7, 2002, one day after David Lovecchio took home a three-week supply of patches, his co-workers found the 36-year-old landscaper dead, curled up on a couch.
Family members said Lovecchio, who had battled painkiller addiction for several years, chewed the squishy patch to rush the release of narcotic into his bloodstream. He died, police and medical examiner reports show, of an overdose of fentanyl and two other drugs prescribed by Williams.
Williams helped Lovecchio get the patches for free under a "patient assistance program" that its manufacturer, Janssen Pharmaceutica Products, sponsors for low-income patients. He saved $514.99, according to a receipt from the Vero Beach Walgreens that filled the order.
Carol Goodrich, a spokeswoman for Janssen, would not talk about individual patients, but said: "Misuse and diversion are issues we are concerned about. We are in the business of educating patients about the appropriate use of products."
Lovecchio's brother Mark, a lawyer in Williamsport, Pa., said the system makes "it even easier for you to stay addicted and to kill yourself."
"It's legal and it's free and all of the safeguards against abuse aren't there," he said.
Moody's mother, Mary Richmond of Vero Beach, concedes that her daughter abused medications, but blames the doctor, too.
Williams said that he started writing more prescriptions for Duragesic because of "so many problems" with OxyContin. He declined to discuss patients who died, except to say: "If people take them as directed, these drugs are safe."
Nobody keeps track of doctors who are drugging the poor.
Drug companies do keep careful records on controlled drugs that doctors order for Medicaid and for the privately insured, but they don't share that information with state regulators, law enforcement or the public.
The Sun-Sentinel identified Florida's top Medicaid drug prescribers by analyzing 8.8 million pharmacy billings from the state. Medicaid officials have never done this type of analysis because the records are used mainly to ensure accurate payment to doctors and pharmacies that participate in the program.
The Medicaid bills offer rare insight into the prescribing habits of doctors when it comes to painkillers, tranquilizers, sleeping pills, steroids that build body mass in people wasting away from AIDS, and medicines that calm hyperactive children.
Between 2000 and the end of last year, Medicaid in Florida, a program larger than all other states except New York, California, Texas and Pennsylvania, purchased about 800 types of controlled drugs. Some were brands such as OxyContin 80 mg, which costs more than $7 a pill, and some were generics that cost less than one-hundredth that amount.
Aside from the sheer size of the health program, abuse is easy, according to state fraud officials, because any doctor can order controlled drugs. There are no requirements that they have training in managing pain or in specialties such as AIDS care that require costly drugs.
Also, Florida law demands that doctors treat pain aggressively, in the belief that a patient should not suffer because of a doctor's fear of retribution from regulators, or that a patient might become addicted.
State officials concede they are struggling to differentiate legitimate patients from drug-seekers who have learned to tap Medicaid to score narcotics, to get high or sell. They also are having a tough time distinguishing bona fide pain practitioners from unscrupulous doctors who cater to pill freaks.
"Some of these doctors get deceived. Word gets out on the street that they are easy touches and they (Medicaid patients) take advantage of them," said Jerry Wells, Medicaid pharmacy manager for the Florida Agency for Health Care Administration. "As soon as we clamp down on one of these doctors, there is another one."
Medical groups long have argued that the vast majority of doctors order these drugs sparingly. The billing data support that, showing that about 3 percent of the state's doctors prescribed roughly two-thirds of all Medicaid controlled drugs. Many of those doctors are generalists, whose need for high doses of such medicine as painkillers for hundreds of patients is dubious.
There is little doubt they are making money from the practice. Medicaid pays for both doctor visits and prescriptions. Two doctors in 2000 and 2001, for example, each got more than $1 million for seeing patients. Then Medicaid also paid better than $3 million more for narcotics prescriptions the two prescribed.
The abuses may be even more widespread. Some doctors take hardly any money from Medicaid, or drop out of the bureaucratic health program -- though their patients continue to run up huge narcotics bills. These doctors opt to get paid directly from their state-supported patients, sometimes $100 or more per office visit, which the doctors require before handing out new narcotics prescriptions.
State officials say they want the Florida Legislature to require that prescriptions come only from doctors enrolled in Medicaid.
Pharmacists, too, get a transaction fee from Medicaid for every prescription they handle for the program. They also make money on drug markups.
Medicaid paid out far more for OxyContin than for any other narcotic.
The state spent $82 million in the past three years on that painkiller alone. The pills can cost $600 to $800 a month per patient, and the newspaper has linked them to scores of overdose deaths.
Seven doctors in Florida each prescribed more than $1 million worth of OxyContin in three years. Only two have formal training in pain management, and state officials suspect that many of these prescriptions were excessive.
Last year, 29 doctors in the state each had 100 or more low-income patients on the drug. Only eight of them listed expertise in pain management on statements of medical training they filed with the state Department of Health. Many worked at high-volume clinics in South Florida.
State records also show that a small number of AIDS clinics have handed out OxyContin to a suspiciously large percentage of their patient load, leading some regulators to worry that the drug is being used, in part, to keep people coming back for the costly therapies the clinics then can bill Medicaid for.
"That's reprehensible," said Attorney General Crist. "The notion that you would try to generate additional business and revenue by luring people into an addiction to a very powerful drug. It's inhumane at best. That's a horrific notion."
The top Medicaid prescriber of dangerous drugs in the state from 2000 through 2002 was Miami-Dade ophthalmologist Ronald Lubetsky, who wrote orders worth $2,527,453. Medicaid paid more than $2.3 million of that for OxyContin, for which Lubetsky was also Florida's top Medicaid prescriber, the billing analysis showed.
The doctor said in an interview that he has drastically cut back, mainly because he realized that some patients were selling or abusing the drug.
"I was naïve. I didn't see where there could be anything wrong," Lubetsky said. "When I started to see what was going on I didn't want to be part of this equation."
Not far behind Lubetsky was Dr. Armando Angulo, a Hialeah general practitioner with $2,282,268 in controlled drugs, almost all paid to pharmacies for OxyContin.
Angulo could not be reached for comment. Phone lines to his offices have been disconnected, his former lawyer was out of the country, employees at the clinic where he used to practice said they did not know his whereabouts and a local lawyer trying to have him served documents in a court case could not find a valid address.
Angulo and four other Miami-Dade doctors accounted for about $4 million of the $31 million Medicaid spent statewide on the drug last year, according to the Sun-Sentinel's analysis.
"Boy, that's a lot of drugs," said Dr. Stephen Nelson, chairman of the Florida Medical Examiners Commission. "That's very suspicious."
Florida health care fraud chief Moye said: "That's just drug dealing. That's all it is."
Eighteen of the top 25 Medicaid OxyContin doctors whom the newspaper investigated have lost patients to overdoses in the past two years.
Two of Angulo's patients died, including Richard Thompson, 56, a longtime drug abuser disabled from a railroad job injury. The doctor gave him OxyContin and the sedative alprazolam, records show. Thompson died in Miami on Sept. 9, 2001, of an accidental overdose of both, an autopsy found.
Patient deaths are not concrete evidence of poor care, though regulators acknowledge that when there is a pattern of these deaths over years, questions should be raised about a doctor's competence or ethics.
The Sun-Sentinel uncovered this pattern last year in a review of hundreds of death records on file at morgues in South Florida. It tied 16 patient deaths over about four years to Plantation osteopath Mitchell Wick.
In response, state officials barred Wick and three other doctors with multiple patient deaths from writing narcotics prescriptions. All four face penalties that could include revocation of their medical licenses.
All four were major Medicaid participants.
In each area of the state, the newspaper tracked overdoses to a small number of doctors -- many the same ones who are prescribing narcotics liberally for Medicaid clients.
Around Jacksonville, where more than 3,500 physicians practice, 67 could be identified as prescribers of drugs that contributed to an overdose death in the past two years.
The bulk of these deaths were linked to an even smaller number of physicians, including two whom the state has disciplined for allegedly practicing substandard medicine, and most were large Medicaid pharmacy billers.
Dr. Gary Barnard of Orange Park had four overdose deaths, three involving methadone and other drugs. In a fifth case, a man prescribed methadone and Valium by Barnard died unexpectedly, but the medical examiner could not determine a cause.
Four other doctors in the Jacksonville area each had four overdose deaths among patients.
Barnard could not be reached despite calls to his office and a letter seeking comment.
In Pasco County, near St. Petersburg, eight of 11 doctors who had each prescribed more than $100,000 of narcotics lost patients to overdoses. Three of those doctors experienced five or more patient deaths.
In the Space Coast area, where the newspaper examined 138 overdose deaths, two doctors stood out. Nine patients of Dr. David Wang, who practices at the Cocoa Walk-In Clinic, died of overdoses in 2001 and 2002, four of them within a month last year.
At least four had mixed medications with cocaine or heroin, autopsy reports show. Wang declined to comment.
Eleven of Melbourne pain specialist Sarfraz "Sam" Mirza's patients died of overdoses, most of them last year, according to autopsy reports.
Mirza was arrested earlier this year on drug trafficking charges for allegedly writing excessive numbers of OxyContin prescriptions. He was not charged in connection with any deaths.
Old, new drugs
Florida's drug-death epidemic is not fading as use of OxyContin diminishes.
The newspaper traced abuse of fentanyl to 127 deaths, most since the second half of last year. Many of the victims died with fentanyl-laced pain patches called Duragesic affixed to their bodies.
More than 530 more fatal overdoses have resulted from misuse of methadone and morphine pills -- painkillers many doctors had hoped would be cheaper and less likely to be abused than OxyContin.
Methadone since the late 1960s has been a favored treatment for heroin addiction and in many cities addicts line up to receive oral doses. In recent years, many pain clinics have been dispensing large numbers of methadone pills, partly because of growing concern over the safety of OxyContin.
Florida Medicaid paid for just over 1million doses of 10 mg methadone pills in 2000; in 2002 that figure swelled to 2.8 million doses, according to the newspaper's analysis.
Abuse of the drug, which costs Medicaid about 15 cents a pill, has swelled, too.
Methadone was present in 82 of 170 drug overdose cases from the past two years examined in the Jacksonville area, for instance. Overall, the newspaper found that methadone played some role in 444 deaths in Florida, including several in which the patient started taking the drug only a few days earlier in a vain attempt to shake off OxyContin addiction.
Morphine, a drug long associated with war injuries and high addiction rates, also is making a comeback.
Morphine pills are sold under several names and dose strengths. Medicaid paid for about 366,000 doses of 30 mg morphine pills in 2000 and two years later, for about 476,000, billing records show.
Morphine also is turning up as a killer, notably around St. Petersburg, where several of the top Medicaid prescribers of the drug practice.
A 21-year-old transient collapsed and died of morphine toxicity on the lawn of a Clearwater home in October of last year.
In his pants, police found a bottle of morphine pills that had been prescribed for him a day earlier.
In May of last year, a 52-year-old woman arrived at her St. Petersburg doctor's office in a wheelchair seeking pain relief after falling off a horse. She was dead within hours of receiving a morphine injection.
Four months later, morphine killed a 24-year-old woman with depression in a St. Petersburg area care center.
She apparently had gotten the pills from a fellow resident with a legitimate prescription for them.
Morphine deaths also stand out in the Tallahassee area, where the Sun-Sentinel found nine of 48 people who died of prescription overdoses since the start of 2001 had been taking morphine pills, including two nurses.
No drug, however, has been abused in as many bizarre manners as fentanyl.
The drug is marketed in several forms and dosages, including raspberry-flavored lozenges on sticks that patients suck like lollipops to ease cancer pain, and the Duragesic pain patches, which are sold in four strengths.
A 26-year-old waiter in Sarasota was found dead on his couch in December of last year of what turned out to be an accidental overdose. Three fentanyl pops were in his mouth, an autopsy report said.
But many fentanyl-related deaths resulted from abuse of the patch marketed by Janssen, a division of Johnson & Johnson.
One patch is supposed to be placed on the skin every three days. The people who died across Florida frequently were found with two or more on their bodies, autopsy reports show. Six were stuck on a woman who died in Miami; a man from Winter Park had applied two to his right arm.
A 28-year-old timeshare salesman overdosed in his Orlando apartment in July 2001 after friends saw him licking the patches. A 38-year-old woman in Largo went into a coma and died on April 23 after she boiled a patch and drank the resulting brew.
Duragesic is becoming a big-ticket drug for Medicaid, as well.
The plan paid for 298,000 patches in 2000, and for 532,000 two years later. Costs are beginning to eclipse spending on high-dose OxyContin.
In about a dozen largely rural counties of North Florida, Medicaid spent $182,818 on the drug in September, compared to about $117,000 for OxyContin.
Drug czar McDonough said he was dismayed to hear a new round of drugs is killing Floridians.
"Every time you think that you've got your arms around this problem of drug abuse, we always see a new wave," he said.
"We're now entering into the most fatal era in history with medically approved drugs being abused."
Fred Schulte can be reached at email@example.com or 954-356-4591.