Grassley's Medicaid probe not turning up much in Iowa

Iowa Sen. Chuck Grassley is attracting widespread attention for his investigation into the nation's top Medicaid prescribers, but no smoking guns have turned up so far in his home state.

A look at the top prescribers in Iowa and the amounts paid for those drugs to pharmacies - the doctors aren't paid for prescriptions - didn't raise any red flags for the state agency overseeing Medicaid, either.

Ten doctors in Iowa wrote 23,220 prescriptions for eight painkillers, anti-anxiety and antipsychotic drugs in 2008, valued at nearly $4.7 million. Those numbers increased to 32,358 prescriptions and $6.1 million in 2009.

“There isn't any evidence that prescribers of those drugs were writing inappropriate prescriptions,” said Roger Munns, spokesman for the Iowa Department of Human Services, which administers Iowa's Medicaid system. “Generally speaking, the doctors with heavier Medicaid caseloads tended to make more overall prescriptions for those patients than doctors with fewer Medicaid patients. I don't know how they would benefit.”

In fact, reimbursement for Medicaid patients is lower than for other patients, so some offices set a limit on treating Medicaid patients. That means fewer doctors see the pool of Medicaid patients.

“It's easy to get on a list when you work 80 to 90 hours per week,” Waterloo psychiatrist Dr. Marvin Piburn Jr. said, noting that most doctors average 50 hours weekly. “I serve patients who are very poor, old or disabled. My patients would have nothing if they didn't have Medicare or Medicaid.”

Piburn, who works at the Black Hawk-Grundy Mental Health Center in Waterloo, the Independence Mental Health Institute and several other northeast Iowa clinics, was the top prescriber of Xanax in 2008 and 2009.

The 915 Xanax prescriptions he wrote last year pales in comparison to a Texas doctor who wrote 14,170 prescriptions for the same anti-anxiety drug that year.

A Miami doctor who wrote nearly 97,000 Medicaid prescriptions in 18 months for mental health drugs and an Ohio physician who wrote about 102,000 prescriptions in two years were the types of cases that precipitated Grassley's investigation.

“Senator Grassley is not investigating any specific type of fraud with this inquiry,” his staff wrote in an e-mail. “He is conducting oversight as to how the Department of Health and Human Services uses prescription drug data as one of a number of indicators in targeting possible program abuse.”

Grassley wrote in a letter to Iowa Medicaid Director Jennifer Vermeer that as the ranking member of the Senate Committee on Finance, he has an obligation to ensure taxpayers dollars are appropriately spent on programs such as Medicaid, which uses about $317 billion annually.

“The overutilization of prescription drugs, whether through drug abuse or outright fraud, plays a significant role in the rising cost of our healthcare system,” he wrote.

Staff members noted that Grassley did not find any “outliers” in Iowa who prescribe drugs at significantly higher rates than their peers.

The state monitors Medicaid through monthly claims reports and other means, Munns noted.

Antipsychotics on the list, such as Abilify, Risperdal and Seroquel, are used to treat schizophrenia, bipolar disease and other mental illnesses.

Child psychiatrist Dr. Larry Richards said without the medication, patients he sees at the Abbe Center for Community Mental Health in Cedar Rapids would not be able to function at home or in school, putting themselves and others at risk.

Richards was the top Abilify prescriber in 2009, with 844 prescriptions.

With a paid amount of more than $1.9 million for the top 10 prescribers in 2009, the drug led Iowa's list in cost.

Richards said Abilify has less severe side effects than other drugs, which enables patients to tolerate the medication and continue complying with their treatment.

He said he does not benefit from prescribing one drug over another.

“I'm just trying to prescribe what will help this person the most,” he said.

A check of seven drug companies that disclose payments showed just one of the number one prescribers in Iowa was paid.

Dr. Daniel Baldi, a Des Moines anesthesiologist, received about $7,500 in speaker fees from Johnson & Johnson.

Baldi, the top prescriber in 2009 of painkillers OxyContin and Roxicodone - neither of which is made by the company - could not be reached for comment Friday.

Accepting drug company payments is not illegal, but some are concerned about a potential influence. Federal rules in 2013 will require drug companies to report payments to physicians.

Cedar Rapids neurologist Dr. Winthrop Risk, the top prescriber of painkiller OxyContin in 2008, said he wasn't surprised his name was on the list, because he is willing to treat Medicaid patients.

Those patients “have a multitude of problems and they're time-consuming,” Risk said, making some doctors unwilling to treat them.

“Economics are secondary to taking care of patients,” he said. “You don't cherry-pick.”

Dr. Bhasker Dave, superintendent of the state's Mental Health Institute in Independence, said medications are needed to control the delusions, hallucinations and other conditions experienced by patients with severe mental illness. Some drugs may be expensive, but are less costly than hospitalization at MHI, which averages $600 to $900 daily.

“The doctors don't have any personal financial benefit” from prescribing certain drugs, said Dave, who was not on the list. He added that Iowa's shortage of psychiatrists means that fewer doctors see a larger number of patients compared to other states.

Piburn, the Waterloo psychiatrist with the high patient caseload, said he is too busy working to give lectures for drug companies. The only speaking engagement he has is about his mission trip to Haiti and he is paying to go to that conference, he said.

He is concerned that Grassley's investigation is comparing doctors who work long hours with a high number of Medicaid patients to those in private practice with shorter hours.

Still, Piburn is open to Grassley's inquiry.

“Chuck Grassley is fully entitled to look into anything he wants,” he said. “He just has to interpret the data correctly.”