In the recent newspaper series "Drug- ging the Poor," I tried to expose not only the human tragedy of prescription drug abuse, but also the huge financial cost. The series revealed that a small group of Florida doctors have pre- scribed large quantities of narcotic painkillers and other addictive drugs to low-income people on Medicaid, costing taxpayers hundreds of mil- lions of dollars and adding to a tor- rent of overdose deaths in the state.
The project linked some of the state's top prescribing Medicaid doctors to overdose deaths or histories of pro- fessional misconduct. It also uncov- ered millions of dollars in suspect bill- ings for drugs, including claims gen- erated using the license numbers of doctors who were dead or otherwise ineligible to write prescriptions. Several databases, some created from paper. records readily available to the public and others from data made public for the first time, provided key information for the reporting.
First, the paper records. I obtained nearly 3,000 drug over- dose autopsy case files, most of them from 2001 and 2002, from Florida's 24 medical examiner dis- tricts. I examined each file, looking for the name of the treating physician of the deceased. Some files con- tained "medication inventory" sheets, which logged all of the pills found at the death scene with the name of the doctor, drug, the pharmacy that filled the prescription and the date filled, but others didn't.
I typed the names of victims, doctors and drugs into a Microsoft Access da- tabase on my laptop. It was often as frustrating as it was time consuming. In many cases, pills were found at the death scene in bottles, but no- body recorded the name of the doc- tor who had prescribed them, for in- stance. After visiting morgues for several months my death file grew and a pat- tern emerged: each examiner's dis- trict had a handful of doctors with ab- normally high numbers of deaths that had gone unnoticed.
I wound up with more than 40 doc- tors with four or more patient deaths for 2001 and 2002. Sixteen doctors had prescribed pills found at the scenes of eight deaths or more, mostly in that same two-year period. Some had deaths spanning several medical examiner districts. Nobody had done this type of re- search before, even though state medical licensing officials believe a pattern of overdose deaths in a doctor's medical practice warrants investigation.
Nor had anyone matched doctors with high numbers of patient deaths against Medicaid prescription drug billing data. I got the chance to do that after Florida At- torney General Charlie Crist agreed to make the billing records public at no cost. After some negotiation, Medicaid fraud unit investigators sent me a Microsoft Access database on CD- ROM. It contained data for 8.8 mil- lion Medicaid pharmacy claims, which amounted to more than $346 million in drug billings for 2000-2002.
The database contains two tables, one that was 1.49 GB, the other slightly smaller. The data included sales of all "controlled" drugs - 844 varieties of narcotics and other medications. Each drug has a five-character code that serves as a unique identifier. The drugs range from brand name painkillers like OxyContin that cost Medicaid more than $7 a pill to generic tranquilizers and sleeping pills that cost just pen- nies per dose.
I spent many hours rummaging through this huge data set. The database contains fields for the name of the prescribing doctor, license number of doctor, year of the prescrip- tion, county of the doctor, amount paid, number of Medicaid recipients treated and the pharmacy that billed for the drugs. Initial queries using Access showed fewer than 3 percent of the state's doctors were prescribing two- thirds of the narcotics dispensed to people on Medicaid.
Five doctors had prescribed $2 million or more worth of narcotics over three years, much of it OxyContin. I spent many hours rummaging through this huge data set, doing queries and sorting results to find other patterns. Scrolling through, I spotted the name of a doctor I knew had died years ago and that gave me the idea to see if others who were deceased or had their licenses re- voked were still generating phar- macy bills.
They were. When I matched the top billing phar- macies with prescribing doctors, I no- ticed that a small group of pharma- cies had derived most of its Medic- aid billings from prescriptions written by one or two doctors, a situation state officials later said raised the possibility of kickback schemes. But the most significant finding came from checking the top prescribing doctors against the overdose data- base I created from autopsy and po- lice reports.
It turned out that many, though not all, of the highest Medicaid prescribing doc- tors were the same ones with abnormally high numbers of patient deaths. For ex- ample, 16 of the top prescribers had a combined 61 patient overdoses result- ing in death in two years. Many of these doctors also had been disciplined previously by the state for offenses that included drug traffick- ing and trading drugs for sex.
I used the Florida Department of Health's online physician profiles and old binders with documents summa- rizing disciplinary actions taken against doctors. The profiles include a cat- egory for "deceased," and helped to identify dead doctors who were still generating bills. The profiles and the CD order form can be found on the Web at www.doh.fl.us/MQA. I also used the Internet-based Medi- care and Medicaid exclusion list and compared by hand every Florida doc- tor who had been kicked out of Med- icaid but still generated billings.
(See http://exclusions.oig.hhs.gov/ search.html.) Another data set that proved invalu- able came from the Florida Agency for Health Care Administration, which oversees Florida's $12 billion- a-year program. I e-mailed a list of the codes for all of the controlled drugs to the agency's Medicaid pharmacy man- ager, and he had the state's Medicaid contractor provide at no cost a Microsoft Excel spreadsheet with the drug, doses purchased, cost of drug and number of units for 2000 through September 2003.
This data showed that dosage levels of certain drugs, in- cluding Xanax bars and methadone, had soared. A project like this can be done in states that grant access to autopsy reports, though getting the Medicaid data might take some tough negoti- ating and even a lawsuit. It's worth the expense and effort. Pre- scription drug overdose deaths are soaring nationwide and in many states authorities believe Medicaid helps fuel the illegal street market in these pills.
States facing huge cost increases in Medicaid simply can't afford to allow fraud schemes to go unchecked. Here are some tips for taking the re- porting beyond the data analysis: Contact the families of people who die. While many won't welcome a call from a reporter, others will help you get documentation such as pharmacy receipts showing the dates victims were prescribed pills and the amounts. Seek the advice of legitimate pain management doctors and pharma- cists at their offices or stores.
Many will be helpful. Whenever possible, review the complete file from a medical examiner's death investigation. Many times an investigator's notes will have the phone number or comments from the doctor who prescribed the drugs. Phone numbers also are criti- cal in making sure you have the right physician. Fred Schulte can be contacted by e- mail at fschulte@sun-sentinel.com.