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Regulatory Issues

Social Security Disability Fraud Revealed

Senator Tom Coburn of Oklahoma chaired a hearing of the Homeland Security & Governmental Affairs Committee on the topic of Disability Fraud. The hearing was revealing, as are these articles (CBS News/60 Minutes, ABAJournal, C-Span). Coburn, a physician himself, detailed one fraud scheme.

As he details the boilerplate employed by those named in the current scheme, including attorneys and physicians, one can’t help but wonder if those involved in the system were not aware of the abuse as it took place, only to ignore the sham claims that were being approved by the thousands.

Perhaps the tide is shifting against the tolerance for misuse of the system. Unclear in this matter is what will take place with the claimants who have received millions if not billions of dollars as a result of fraud.

These Deaths Are Not Statistics…

In medical school and residencies the teaching is that narcotics have no place in the treatment of most chronic pain, especially musculoskeletal pain. But these teachings have been ignored and people are dying as a result. This article cites findings on significant death rates among women due to opiate overdoses, including from Oxycontin. These are prescription drugs, either received directly or drugs diverted to the street. These deaths are disproportionately the poor, single mothers, and the defeated. Federal data shows a quintupling of deaths among women due to prescription pain killers since 1999, climbing at a rate higher than men, with the gender gap narrowing.

More women die from these drugs than from homicide or cervical cancer. These deaths are not statistics. They are men and women who did not need to die and most likely did not need the narcotics.

Physicians who prescribe them casually and the companies that create and promote them aggressively should rethink their motives and their practices. It is easy to say yes to drugs. It is harder to listen with one’s heart and mind to the real pain that underlies many of these lost lives. Collectively we must find a different path. Read more…

(Don’t) Forget to Take Your Vitamins

This Opinion piece in The New York Times earlier this month makes some interesting – and disturbing – points on the vitamin industry.

Several studies over the past two decades indicate that some consumers have suffered adverse health effects from the over-consumption of vitamins: In a study published in The New England Journal of Medicine in 1994, 29,000 Finnish men, all smokers, had been given daily vitamin E, beta carotene, both or a placebo. The study found that those who had taken beta carotene for five to eight years were more likely to die from lung cancer or heart disease.

Two years later the same journal published another study: 18,000 people who were at an increased risk of lung cancer because of asbestos exposure or smoking received a combination of vitamin A and beta carotene, or a placebo. Investigators stopped the study when they found that the risk of death from lung cancer for those who took the vitamins was 46 percent higher.

If over-consumption of vitamins is as dangerous as these and other referenced studies suggests, what’s the Food and Drug Administration’s stance on regulating intake? Well, in December 1972,  the F.D.A. announced a plan to regulate vitamin supplements containing more than 150 percent of the recommended daily allowance. Vitamin makers would have to prove that these “megavitamins” were safe before selling them. However, legislation was introduced preventing the FDA from regulating megavitamins; it became law in 1976. Read more…

Sentencing in the Long Island Railroad Disability Fraud Scheme

What is missing in this New York Times article is any reference to the consequences for those many claimants who engaged in the fraud, and the management and employees of the Long Island Rail Road, who clearly were aware that such fraudulent claims were the norm. Perhaps they were only counting the days until their own disability retirements. How many of those who Dr. Ajemian helped obtain benefits have been criminally charged for fraud and how much of the millions of dollars of ill-begotten compensation has been returned to the public from which it came?

What this doctor did, based upon the article, was reprehensible, but let’s not kid ourselves. The culture of disability is alive and well in the public and private sector. Well intended efforts to addresses excesses and distortions in the system may lead to personal attacks on those who try.

HIPAA Compliance in the Cloud

This short article in Forbes on-line summarizes concerns with compliance to — and related costs — updates in HIPAA (Health Insurance Portability and Accountability Act). As noted, security and privacy are getting more serious with each iteration.

This is no small concern:

The Department of Health and Human Services estimates that the cost of compliance with the final rule will be somewhere between $114 and $225 million (first year) and about $14 million for each year thereafter… the rule qualifies as an “economically significant” one under Executive Order 12866.

The reason for this new level of security is pretty fundamental. Healthcare has had some serious deficiencies through the years and it’s a prime target for identity theft. Not so much for the actual healthcare information but for financial fraud – which is a companion problem in healthcare (to the tune of about $70 billion a year in Medicare fraud alone).

Read more…

Should the head of the NRA be restricted from owning guns?

By Brian L. Grant MD
If a sign of mental illness is delusional thinking and being out of touch with reality, Wayne LaPierre may qualify. His ongoing rants suggesting that there exists some sort of mental health database that if consulted, would screen out murderers, is absurd.

Mr. LaPierre, please show us what you refer to. Also, please demonstrate how many — if any— of those thousands of killers who used firearms were in this non-existent database?

I hope you are not suggesting that an individual who seeks counseling or psychotherapy from a psychiatrist or psychologist, or antidepressants from their primary care doctor should be entered in a registry restricting their current firearm rights?

To do so would fly in the face of logic, privacy, and have zero impact on the problem of gun deaths. There is no linkage between seeking mental health care and dangerousness, and any such registration would only serve to deter individuals from addressing issues that might then go untreated.

Any mental health professional possessing appropriate humility knows that their record of predicting dangerousness is little better than the general public.

The public depiction of some of the recent mass killers certainly describe strange individuals, who before their act are not unlike those that one might find in large numbers in any high school class, software, Star Trek, or dare I say, Psychiatry convention. Hindsight bias, where something suddenly becomes obvious after the fact, is simple but misguided.

The proximate cause of gun deaths are guns and bullets. Killers armed with less lethality may be less dangerous toward others and themselves.

Do we collectively as a society have the political will and common sense to at least confine our arguments to reality?

Read More at:  The Economist: “Why the NRA keeps Talking about Mental Illness, Rather than Guns.”

Connecticut Shooting Differs in Newsworthiness and Degree, Not Substance

By Brian L. Grant MD

Many of us were in a sad mood on December 14, the day of the Connecticut shootings. But further reflection lead me to the unfortunate conclusion that beyond the fact that the carnage in one spot was mainly children and the number in this single incident was high, this was a typical day in America.

According to the Center for Disease Control and Prevention (CDC), we had 31,347 (10.2 per 100,000) deaths by firearm in the U.S. in 2009. That is an average of 86 per day. Of these about 64% are actually suicide, and a small number are accidental.

In the same year, motor vehicle accidents took the lives of 34,485 (11.2 per 100,000 or about 94 per day). Only a few more than were killed with guns. Cars serve a vital purpose and there is unfortunately collateral damage when they collide. Guns are for killing.

Related statistics from Wikipedia describe firearm deaths across many countries in the world.

Our rate per population of gun deaths in the U.S. is roughly 40 times that of the UK and twice that of Canada. Both countries, along with much of Europe, have significant limits on guns. We can’t identify who might engage in slaughter ahead of time without locking up all of us. What we can do is make those predisposed to harm others less lethal by making it a lot tougher to get a gun and limit the types of guns available. This might include limiting access to military and police only on guns capable of shooting many shots rapidly.

As a non-expert on the technical aspects of firearms, I would defer details to those better informed regarding guns and ammunition that ought not be in civilian hands. No hunter or person protecting their home will be meaningfully limited in their purpose by such restrictions. But it might change our landscape regarding gun violence.

We have attempted in this blog to address irrational behavior in a number of areas including the obesity epidemic and our dysfunctional health care system. The recent tragedy may have the positive outcome of shocking society and political leaders into a careful review of the status quo, based upon data and not rhetoric, and hopefully without “shooting” the messengers, as is the habit by those who don’t like what they see or hear.

In the aftermath of the shooting, outspoken gun opponents such as Mayor Bloomberg of New York are being attacked for their opinions, at least as much as their opinions are being challenged.

The political force represented by gun proponents, embodied by the National Rifle Association (NRA), is formidable. Politicians are scared of being on their bad side. Perhaps now more than a few of us, including politicians, will finally say enough and make rational decisions based upon careful analysis. This should include reviewing laws and gun cultures of other countries where freedom seems to coexist with safety and more restrictive gun laws. How many might have the courage to publicly take on the extreme positions of the NRA? Could their political dominance come to an end? Can caring and decent gun owners take it upon themselves to move beyond rhetoric to consider that change may be in order?

It is truly hoped that responsible gun owners will separate themselves from the extremists who see limits on guns at virtually any level as impingement on their freedom and our nation’s values.

One person’s freedom is another person’s burden, or even death, when an innocent is shot with a gun that should not have been available. Competing interests deserve to be heard. We should not be proud of our national record of gun deaths.

For every person who defends themself with firearms reasonably, how many have abused their power and taken a life that could have been preserved? How many murders are the result of open and basically unrestricted commerce in guns? How many suicides would have not taken place if limits were in place? How many people would be served in a positive way by a change, including lives saved?

Indeed, how many actual additional deaths of innocent victims of criminals with guns, as claimed by proponents, would take place? Do international comparisons have relevance, or are we Americans so special and unique that we have nothing to learn from countries like Australia, France, Canada, and Chile, among others? Should we instead emulate Brazil and El Salvador? Even the Mexican drug cartels get their weapons to commit mayhem from north of the border.

We require cars to have all sorts of safety features that have reduced mortality. We license drivers and cars. We have police watching our driving and enforcing driving laws daily. What reasonable limits on access and types of guns and ammunition would balance safety with ownership?

Our constitution has been amended many times including establishing the right to bear arms, allow women to vote, and  abolish slavery. What would our founding fathers say about modern weaponry including semi-automatic rifles and their place in the hands of ordinary citizens? Can the constitution stand as it is with respect to guns while allowing meaningful laws to be imposed? The constitution is silent on types of weapons and the government should be allowed to regulate as they already do, and are hired by us to do.

Let me briefly put to rest the concept that we can prevent many firearm deaths by better mental health assessment. The majority of mentally ill are not violent and unless one chooses to define violence as mental illness, the majority of those who shoot others are not mentally ill. The proximate cause of gun deaths are bullets and guns, not mental illness. Other countries with their share of troubled people and criminals have fewer deaths because violence is enacted in less lethal ways, such as with knives or fists.

We had a sad day. Let us hope that we will honor the memory of all victims of violence in the U.S. with meaningful change consistent with both our respect for liberty and for human life.

Drug Distributors Pressured to Reduce Narcotic Painkiller Shipments

Over the past few months, the DEA has tried a variety of different tactics to battle our painkiller epidemic.

From arresting hundreds of doctors, cracking down on pill mills, and investigating pharmacies, it’s most recent attempt has large drug distributors rattled.

The New York Times reports that after honing in on Florida and Ohio, the DEA is now putting pressure on other pharmaceutical distributors nationwide.

Earlier this year, the agency charged drug distributor Cardinal Health for violating it license to sell controlled drugs. Since then, Cardinal no longer does business with a dozen pharmacies in Arizona, California, Nevada, and Oklahoma and the number is growing.

The article notes that the pressure has pushed distributors to create a nationwide shipment reduction to pharmacies and doctors who order a high volume of narcotic pain killers.

“We had a strong anti-diversion system in place, but no system is perfect,” Cardinal Chairman and Chief Executive told the Times.

Since then, they have strengthened their criteria and  have also  created a committee that evaluates pharmacies that order large amounts of narcotic drugs.

Another major distributor, AmerisourceBergen, recently disclosed that it also faces a federal criminal inquiry into its oversight of painkiller sales.

The DEA’s crackdown on pharmacies and big distributors like Cardinal and AmericsourceBergen have shown that the agency is taking a much more aggressive approach to ending our nations painkiller issue.

However, doctors and pharmacies are critical of the way distributors have abruptly cut them off from their supply. One California pharmacist argued that his pharmacy specializes in pain patients which would explain his high volume orders.

“The drug distribution system is a sprawling one that involves about 800 companies, which range in size from a few giants like Cardinal to hundreds of small firms. For wholesalers, the markup on medications can be small, sometimes a few pennies a pill. But with billions of pills sold annually, the profits can be big. Narcotic painkillers are now the most widely prescribed drugs in the United States, with sales last year of $8.5 billion.”

There is also added incentive to sell Oxycontin and other narcotic painkiller because of their addictive properties and because street value on the black market is as much as $80 per 80-milligram dose.

However, while the DEA is implementing new tactics against distributors for failing to notify the agency of a “suspicious order” from a pharmacy or other customer, it does not share those reports with officials in the state where the pharmacy is based.

After the New York Times had asked for the agency to disclose the number of such reports it received annually, they declined saying, the agency considered such statistics “law enforcement sensitive” information.

In response, the Times has filed a Freedom of Information Act request seeking that data. Read More…

 

DEA Investigates Walgreens for Oxycodone Distribution

In an effort to battle the prescription drug abuse epidemic, the U.S. Drug Enforcement Agency (DEA) is turning it’s focus to drug wholesalers and retail pharmacies. Last Friday, the DEA issued warrants to inspect six Walgreens Florida pharmacies on suspicion that Oxycodone is being diverted to the black market.
The Reuters article “Crackdown on Prescription Painkillers Widens to Walgreens,” provides a breakdown of the DEA’s investigation and why increased sales volume of highly addictive painkillers sparked some red flags. The article stated:

“The purchase of large amounts of Oxycodone by a retail pharmacy is indicative of a pharmacy that fills prescription issued by physicians at pain clinics and/or a pharmacy which services primarily drug seeking individuals that abuse the medication.” Read More…

The death toll from narcotic painkillers now exceeds those of heroin and cocaine combined and DEA agents are determined to stop the illegal distribution of Oxycodone. They have already suspended  CVS Caremark Corp and Cardinal Health Inc’s license to distribute because they believe they “failed to conduct due diligence to insure that all prescription drugs are sent only to legitimate channels.”

All DEA Registrants have an obligation to ensure that medications are getting into the hands of legitimate patients, and when they choose to look the other way, patients suffer and drug dealers prosper,” DEA Special Agent in Charge Mark Trouville said in the email. Read More…

American Pain: The Largest U.S. Pill Mill’s Rise and Fall

This article in Bloomberg Businessweek puts a human face on the opioid crisis – an interview with one of the owners of the largest Florida “pill mill” provider of prescription versions of Oxycontin. Now in jail, Christopher George provides some insight into how pill mills work and just how DEA regulations work and don’t work.

It’s a horrendous problem for society (according to the Centers for Disease Control and Prevention, 14,800 Americans died from overdosing on opioids in 2008, the most recent year data is available—more than the number of deaths from heroin or cocaine), as we’ve frequently noted at MCNtalk in the past. There were 335 million prescriptions for painkillers written in 2011. Is it any wonder some of them were from criminals? Read more…