Despite a national crackdown on prescription drug abuse, doctors churned out an ever-larger number of prescriptions for the most-potent controlled substances to Medicare patients, new data shows.
In addition, ProPublica found, the most prolific prescribers of such drugs as oxycodone, fentanyl, morphine and Ritalin often have worrisome records.
In 2012, the most recent year for which data is available, Medicare covered nearly 27 million prescriptions for powerful narcotic painkillers and stimulants with the highest potential for abuse and dependence. That’s up 9 percent over 2011, compared to a 5 percent increase in Medicare prescriptions overall. Even taking into account an increase in the number of Medicare enrollees, the prescribing rate rose slightly for these drugs, which are classified as Schedule 2 controlled substances by the Drug Enforcement Administration (DEA).
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Twelve of Medicare’s top 20 prescribers of Schedule 2 drugs in 2012 have faced disciplinary actions by their state medical boards or criminal charges related to their medical practices, and another had documents seized from his office by federal agents.
The No. 1 prescriber — Dr. Shelinder Aggarwal of Huntsville, Ala., with more than 14,000 Schedule 2 prescriptions in 2012 — had his controlled substances certificate suspended by the state medical board in March 2013. He surrendered his medical license four months later. (Aggarwal could not be reached for comment.)
Prescribing high volumes of Schedule 2 drugs can indicate a doctor is running a pill mill, said Dr. Andrew Kolodny, chief medical officer of Phoenix House, a New York-based drug treatment provider. Government regulators should do more to monitor prescribing patterns and intervene proactively if they appear aberrant, he said.
“We wait ’til these doctors kill people,” said Kolodny, founder of Physicians for Responsible Opioid Prescribing, which advocates for tighter regulation of painkillers. “It doesn’t make any sense.”
Medicare’s drug program, known as Part D, now covers about 38 million seniors and disabled people and pays for more than one of every four prescriptions dispensed in this country. Concerns about oversight of controlled substances date back to at least 2011,when the Government Accountability Office highlighted abuse of opioids in Part D and called on Medicare to take action.
Within the past year, Medicare has started to use prescribing data to identify potentially problematic doctors, as have some state medical boards. Beginning in mid-2015, Medicare will have the authority to kick doctors out of the program if they prescribe in abusive ways.
“It’s a real area of concern for us,” said Dr. Shantanu Agrawal, director of the Center for Program Integrity within the federal Centers for Medicare and Medicaid Services (CMS).
The 2012 data shows the upward trend line for prescriptions of controlled substances before these initiatives took hold.
The DEA classifies certain potent drugs based on their potential for abuse and sets limits on prescribing for each group. Drugs classified as Schedule 2 require written prescriptions and cannot be refilled. (Doctors may give patients up to a 90-day supply by writing additional prescriptions during a visit.) Prescriptions for Schedule 3 drugs, which are somewhat less addictive, can be phoned in and refilled up to five times.
The DEA says it does not have the resources to track physicians’ prescribing, and instead focuses on drug distribution. So it falls mostly to state medical boards, Medicare and law enforcement agencies to make sure doctors follow the rules for controlled substances. And they have typically relied on complaints, rather than data analysis, to trigger investigations.
ProPublica reported in 2013 that Medicare did not proactively analyze its prescribing data or take action against providers whose patterns were troubling, even if they had been charged with Medicare fraud or kicked out of state Medicaid programs. Most of Medicare’s top prescribers of Oxycontin in 2010 had legal or disciplinary actions filed against them; nonetheless, many retained the ability to prescribe in Part D, as of May 2013.
Shelinder Aggarwal’s Medicare prescribing history had plenty of red flags. The pain medicine specialist has consistently shown up in Medicare’s data as a top prescriber of narcotics. By 2012, the year before he stopped practicing, more than 80 percent of his Medicare patients received at least one prescription for a Schedule 2 drug, in many cases oxycodone. On average, all Alabama doctors in Aggarwal’s specialty issued prescriptions for Schedule 2 drugs to just 38 percent of their patients.
It took complaints from pharmacies near Aggarwal’s office to alert the Alabama Board ofMedical Examiners to his unusual prescribing habits, said Larry Dixon, the board’s executive director. Board investigators subsequently made undercover visits to the doctor’s office and videotaped him prescribing drugs without an exam.