published Tuesday, November 30th, 2010

Scrutinizing scripts


by Emily Bregel

TennCare officials declined to provide the names of the state's top prescribers for eight powerful drugs when responding earlier this year to a request from a U.S. senator wanting to crack down on unscrupulous prescribing.

In April, Sen. Charles Grassley, R-Iowa, requested all state Medicaid programs to provide the names and number of prescriptions for the top-10 prescribers of eight drugs, including Xanax, OxyContin and antipsychotics like Seroquel.

TennCare Director Darin Gordon responded in May with a full list of the total prescriptions and amount billed to the state from both 2008 and 2009 records for those drugs. But the bureau declined to identify the prescribers, instead using pseudonyms like "Prescriber 1," according to the documents.

Nine other states also used generic titles, instead of identifying the doctors by name or by prescription identification number, according to Grassley's office. That's out of the 45 states that have responded to Grassley's request so far. Alabama is the only state that has declined to respond to the request.

TennCare officials explained they "de-identified" the top doctors because the listing implied that the doctors were doing something wrong or fraudulent when the situation is far more complex.

Since most of the drugs included in Grassley's query were psychiatric drugs, psychiatrists were most commonly listed as the highest-ranking prescribers, which does not necessarily suggest wrongdoing, said Dr. Wendy Long, TennCare's chief medical officer.

"We didn't want to see a provider unjustly accused of poor quality care," she said. "We have a shortage of psychiatrists in Tennessee and we don't want to drive them out of the TennCare program by contributing to the spread of misinformation."

Statewide, Tennessee has one of the nation's highest prescription drug utilization rates, a habit that was costing the TennCare program $2.5 billion a year, before limits to the program's pharmacy benefit were implemented in 2005.

Long agreed that scrutiny of doctors' role in high drug use is justified.

"We absolutely agree that this is a very important issue and we spend an awful lot of time monitoring the pharmacy drug program," Long said. "We just believe it is a complicated process. ... You just have to look a little deeper than simply who wrote the most prescriptions."

In some cases, doctors with high prescription rates can be guilty of fraud.

Long said program officials "didn't see anything that clearly indicated a problem" in TennCare's listing of top prescribers.

"We didn't see implausibly large numbers of patients ... or numbers of prescriptions per patient that would be outside the realm of reason," she said.

But she acknowledged that the list did include some doctors who already were on TennCare's radar for their prescribing habits, Long said.

When TennCare identifies doctors who might be overprescribing, "we dig deeper. We look at who are the patients, we conduct medical records reviews," she said.

If TennCare officials suspect flaws in prescribing habits, they refer the doctor to the Tennessee Bureau of Investigation. The unit can require the doctor to undergo training if it's just an issue of poor education, or press charges, Long said.

Grassley has asked the U.S. Department of Health and Human Services for a federal investigation into the high prescribing rates among doctors for powerful narcotics following news reports of a Miami physician who wrote more than 96,000 prescriptions for mental health drugs in a 21-month period, all billed to the Florida Medicaid program.

None of Tennessee's Medicaid providers were anywhere close to the prescribing level of the Miami physician, and all prescribers listed wrote fewer than 2,000 prescriptions in a year for each drug.

The senator has requested a response from the federal officials by Dec. 3, said Jill Gerber, spokeswoman for Grassley's office.

"It's a matter of seeing where taxpayer money is going for this medicine," Gerber said. "Maybe it's all 100 percent legitimate, maybe it's 95 percent legitimate. It's just a matter of doing a little due diligence on behalf of the taxpayers and the patients themselves."

The responses Grassley's office has received so far from state Medicaid programs include some large disparities between the top prescribers and the 10th-highest in the same category. Among the results:

* In Tennessee, the top prescriber for Risperdal in 2008 wrote 1,670 scripts, compared to 663 scripts written by the 10th-highest prescriber.

* In Ohio, one provider topped the list in most drug categories, with 13,461 Abilify prescriptions in 2008 and 13,825 in 2009; 4,958 Geodon prescriptions in 2008 and 4,426 in 2009; and 20,433 Seroquel prescriptions in 2008 and 18,890 in 2009.

* In Texas, one doctor authorized 13,596 filled prescriptions for Xanax in 2008, which increased to 14,170 filled in 2009. Comparatively, the lowest of the top 10 doctors who prescribed Xanax wrote 1,444 prescriptions in 2008 and 1,696 in 2009.

HIGH PRESCRIPTION USE

Nationwide, Tennessee ranks at the top of the list of the states with the highest per-capita prescription drug use. With 18 prescriptions per capita in 2008, Tennessee had the third-highest level of prescription drug use, behind West Virginia at No. 1 and Kentucky at No. 2, according to the most recent Novartis Pharmacy Benefit Report. The national average is 12.7 prescriptions per capita.

Although that's an improvement in ranking from 2005, when Tennessee ranked No. 1 for prescription use, Tennessee's usage rate has increased from 17.3 prescriptions per capita in 2005, according to the report.

Prescription drug use is increasing nationally, in part because of an aging population as well as a growing incidence of chronic conditions such as diabetes -- often fueled by high obesity rates -- which require regular medications, said Dr. Terry Shea, director of pharmacy management for BlueCross BlueShield of Tennessee.

"Sometimes increased utilization is not a bad thing," Shea said. "When we look at diabetics, we look to see that they're on the appropriate medications that will help prevent long-term kidney damage."

In recent years, BlueCross has implemented a program to encourage its commercially insured patients to use over-the-counter medicines when appropriate and to avoid unnecessary prescriptions, he said.

Doctors face pressure from patients who are increasingly coming to appointments expecting to walk out with a prescription in hand, and their demands are fueled by direct-to-consumer marketing instructing patients to "ask their doctor" about a certain pill, Shea said.

"Direct-to-consumer advertising is one of the things that has been acknowledged that increases utilization," he said. "It's a double-edged sword in that it makes patients aware that there may be potential therapies for their problems, but it also does encourage the behavior of" requesting drugs by name.

TENNCARE LIMITS TO DRUG BENEFIT

The TennCare program has taken steps to rein in an out-of-control prescription drug benefit.

TennCare underwent major reforms in 2005 to control ballooning expenses, including cutting more than 150,000 people from the TennCare rolls and limiting the program's pharmacy benefit, which was costing the state $2.5 billion annually.

"Pharmacy was our single largest cost driver in the program," Long said.

Reforms limited most TennCare enrollees to five prescriptions per month, excluding certain drugs such as chemotherapy.

Pharmacy drugs now cost the state less than $1 billion a year, Long said.

Safety, in addition to cutting costs, was a major reason for the changes, Long said.

"Contrary to popular belief, more isn't always better in medicine," she said. "We've seen a fairly dramatic decrease in emergency room visits related to drug use and abuse" since prescription limits were implemented.

Long also emphasized the flaws in comparing one state Medicaid program's top prescription numbers to another. TennCare patients can only get prescriptions filled for one month at a time, meaning TennCare doctors must write three prescriptions for patients who need a three-month supply of a drug.

In another state, a doctor might simply write a single 90-day prescription, Long said.

Contact staff writer Emily Bregel at ebregel@timesfree press.com or 423-757-6467.

about Emily Bregel...

Health care reporter Emily Bregel has worked at the Chattanooga Times Free Press since July 2006. She previously covered banking and wrote for the Life section. Emily, a native of Baltimore, Md., earned a bachelor’s degree in American Studies from Columbia University. She received a first-place award for feature writing from the East Tennessee Society of Professional Journalists’ Golden Press Card Contest for a 2009 article about a boy with a congenital heart defect. She ...

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