Written by Lisa Chedekel
In 2010 and 2011, Dr. Irene Abramovich of West Hartford was the state’s top prescriber of Invega, an antipsychotic medication marketed by Janssen Pharmaceuticals. She also was in the top five prescribers of Zyprexa, an antipsychotic marketed by Eli Lilly, in 2008 and 2009.
Drug company reports show Janssen paid Abramovich $11,900 in speaking fees and travel expenses in 2010. Eli Lilly paid her $26,000 as a speaker in 2009, and more than $47,000 for speaking and travel in 2010.
Similarly, in 2010 and 2011, Dr. Michael Brennan of Fairfield was the state’s No. 1 prescriber of Actiq, a narcotic pain medication with a high potential for abuse, manufactured by Cephalon. State records show he wrote out 105 prescriptions in 2011—more than double the number of the second-highest prescriber. From 2008-2011, he also was among the top four prescribers of the painkiller OxyContin, marketed by Purdue.
In 2010 and 2011, Brennan was a consultant and speaker for Cephalon, which paid him more than $31,000. He also is a consultant and speaker for Purdue.
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The dual role of doctors as heavy prescribers and drug company marketers has come under fire by patient advocates and some members of Congress, who secured a provision in the federal Affordable Care Act that requires pharmaceutical companies to publicly report all payments to physicians by September 2013. The disclosure rule was prompted by concerns that industry payments to doctors could influence their treatment decisions and fuel higher costs.
Earlier this year, one of the sponsors of the disclosure law, U.S. Sen. Charles Grassley, R-Iowa, wrote to officials in Connecticut and other states, requesting information on the top Medicaid prescribers of certain psychotropic and pain medications that he noted have a high potential for addiction, abuse and fraud.
In response, the Connecticut Department of Social Services (DSS) sent Grassley a list of the top-10 prescribers of 10 drugs, with an explanation of steps being taken to monitor and prevent overprescribing in the taxpayer-funded Medicaid program.
A C-HIT review of those lists for eight medications found that 43 of the 108 high-prescribers—or 40 percent—received income or benefits from the pharmaceutical companies that manufacture the drugs they dispensed in high quantities.
In some cases, the practitioners wrote out hundreds of thousands of dollars worth of prescriptions in years when they also were receiving thousands in compensation from the drug-makers. Others routinely accepted $25 or $50 business meals at lunch and dinner meetings where drug company reps pitched their products. The lists cover 2008-11.
Read: THE BOTTOM LINE ON HIGH-PRESCRIBERS HERE
The C-HIT review comes in the wake of a record, $3 billion fraud settlement by GlaxoSmithKline on charges that the company paid doctors to promote Paxil and other drugs for uses that had not been approved by the U.S. Food and Drug Administration. The government charged Glaxo with offering kickbacks to health professionals by dangling cash and trips as incentives and rewards for prescribing its drugs.
Many of the drugs on Grassley’s high-prescriber lists are expensive and have been marketed for non-approved, or “off-label,” uses. Eli Lilly, Cephalon and other drug-makers have paid millions in the last four years to settle government allegations of fraudulent marketing.
Abramovich and other high-prescribing physicians insisted that their pharmaceutical pay had no influence on their treatment decisions, saying their use of certain drugs was driven only by their patients’ needs.
“It’s a totally wrong representation” to connect the two, Abramovich said.
“The pharmaceutical companies are not villains. Our prescribing rate is not influenced by the pharmaceutical companies. We do what is best for the patients.”
Brennan said he is viewed as “the physician of last resort” for patients who suffer intolerable pain, and that he prescribes Actiq for only a small percentage of the 800 to 1,000 patients he sees a month. He said he does not see a conflict in being a promotional speaker for Cephalon or Purdue.
“It doesn’t look good, I know. I use these drugs a lot and I’m going around promoting them,” he said. “But the idea that I’ll go out three or four nights a week and spend time with other doctors who are trying to manage pain, does that mean I’m corrupted or corrupting? . . . No one gets a medication in my practice without a thorough, careful review.”
Drug companies for years have defended paying physicians for speaking engagements and meals as a means for productive, educational interactions. But critics say the practice raises potential conflicts and may influence prescribing habits.
“Doctors who take large amounts of money from Pharma and say it has no effect are deluding themselves,” said Dr. Carl Elliott, a professor in the Center for Bioethics and the Departments of Pediatrics and Philosophy at the University of Minnesota who has written extensively about physician ties to drug companies.
“At this point, there is over a decade’s worth of empirical data showing very clearly that money buys prescriptions—which is not to say that doctors actually realize this. The effects are often unconscious, and of course, we all think we are the exception. That is, we tell ourselves, ‘The money influences other people, but not me.”
He said the finding that 40 percent of Connecticut’s high prescribers had received some benefits from the companies marketing the drugs they prescribed was, unfortunately, “no surprise. This is very commonplace.”
Not all high prescribers who were paid by drug companies defend their dual role.
Dr. Velandy Manohar, a Middletown psychiatrist who was invited to be a paid speaker for AstraZeneca in 2010 after he began prescribing the company’s antipsychotic drug, Seroquel, said he is no longer promoting medications for the drug-maker.
“A lot of what the drug companies are doing is covert,” in terms of marketing drugs for uses not approved by the FDA, he said. “I see a problem with high prescribers being on a speakers’ list, if those two things are connected.”
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“The Numbers Are Shocking”
Grassley initially wrote to officials in all 50 states in 2010 to request details on top prescribers of antipsychotics and painkillers. In January of this year, he sent another round of letters to states, asking what steps they had taken to investigate doctors whose Medicaid prescribing habits had outstripped those of their peers.
In his follow-up letter to Connecticut DSS Commissioner Roderick Bremby, Grassley said he had concerns about “the oversight and enforcement of Medicaid abuse in your state.
“While I am sensitive to concerns about the potential for misinterpretation of the data you provided, the numbers themselves are quite shocking,” Grassley wrote. He cited the prescribing habits of Dr. Gerson Sternstein, a Berlin psychiatrist, who was the highest-volume prescriber of Actiq, Xanax, Oxycontin and Roxicodone in the Medicaid program in 2009. Records show Sternstein wrote out 1,822 prescriptions for Roxicodone alone—triple the number of the second-highest prescriber.
“These outliers are consistent with several of the antipsychotic drugs, as well,” Grassley said.
After Grassley’s initial inquiry, the Connecticut Medical Examining Board revoked Sternstein’s license in September 2011, after finding he had recklessly overmedicated 10 drug-addicted patients in 2009.
The state prescribing records show a relatively small group of physicians topping the lists of Medicaid high prescribers in the last four years. In some cases, like Sternstein’s, they stand out for writing far more prescriptions than other high prescribers. In other cases, they deal in multiple drugs: twenty physicians ranked in the top 10 for three or more of the potentially dangerous medications.
In 2011, for example, Dr. Stephen Zebrowski, a Plainville internist, was the highest prescriber of Oxycontin, dispensing 511 prescriptions—200 more than the next highest prescriber. He also was the second-highest prescriber of Roxicodone, the eighth-highest for Pfizer’s Xanax, and the fifth-highest for Janssen’s Duragesic. Oxycontin, Roxicodone and Duragesic are narcotic painkillers considered highly addictive and prone to abuse; Xanax is a benzodiazepine used to treat anxiety.
Similarly, in 2010 and 2011, Dr. Jose Camacho -Pantoja of Bridgeport was in the top five prescribers of four medications with potential for abuse—Xanax, and the antipsychotics Invega, Seroquel and Geodon. Both doctors received business meals from Pfizer and Janssen.
Zebrowski could not be reached for comment. Camacho-Pantoja, a psychiatrist at a community health clinic, said he was “very, very strict” about prescribing controlled substances, but had a large patient population with serious psychiatric disorders. He said he was aware that he was a top prescriber because drug company representatives, who track physician prescribing, had told him so.
He said that while he has attended dinner presentations paid for by Pfizer, he had turned down invitations to speak because “I simply don’t feel comfortable” promoting drugs he prescribes.
Some physicians emerged on a high-prescriber list at the same time as they received substantial payments as speakers for the drug’s manufacturer.
Dr. Kathleen Degen of Norwich was not among the top prescribers of Eli Lilly’s Zyprexa in 2008, but was the seventh-highest prescriber in 2009 (with 255 prescriptions), when Eli Lilly paid her $24,950 in speaking fees. Her prescribing fell off slightly in 2010, and she received $5,291 from Eli Lilly for speaking and travel. She disappeared from the high prescriber list in 2011 and received just $16 in meals from Eli Lilly, records show.
Degen did not return messages seeking comment.
Jill Gerber, a spokeswoman for Grassley’s office, said the senator understands that high- prescribing doctors “might not be problematic, and that they could just be in busy medical practices or settings.” But he wants to be sure there is “adequate oversight to weed out problems, especially with prescription drug abuse being so prevalent, of late.”
Few Penalties For Prescribing
Only Sternstein and two others on the high-prescriber lists have been subject to disciplinary action by the state Medical Examining Board, according to a database maintained by the state public health department.
Sternstein’s license originally was suspended in August 2010—despite his status in 2008 and 2009 as an outlier prescriber of Actiq, Oxycontin and Roxicidone.
A number of other states have taken strong action in the last two years to crack down on over-prescribers. South Carolina officials have investigated 34 of the 83 providers who appeared on their lists for possible Medicaid abuses, and have recouped nearly $1.9 million that was inappropriately billed to the state Medicaid program, correspondence with Grassley’s office shows. Texas has opened investigations into more than three-dozen prescribers identified on its lists, making several referrals to the attorney general for criminal prosecutions. Delaware has initiated investigations into its high prescribers and has taken some form of administrative action against 12 percent of those practitioners.
In his March 2012 response to Grassley, DSS commissioner Bremby highlighted the action against Sternstein and said his office was tracking Medicaid prescribing closely. He said two companies hired by DSS to manage behavioral health and medical services in the Medicaid program were overseeing the prescribing of psychotropic drugs and pain medications, with a special effort to monitor pediatric psychiatric prescribing.
Responding to questions last week, DSS spokesman David Dearborn said the agency’s behavioral health contractor would be conducting “an analysis of psychotropic medication prescribing patterns for all Medicaid members.”
Prescribers identified as outliers “will receive notification alerting them of their prescribing patterns as a first intervention to raise awareness of their behavior. ” If prescribing patterns don’t change, further steps would be taken, with the state reserving the right to “disenroll the prescriber from the Medicaid network,” Dearborn said.
Licensing records show that two high prescribers besides Sternstein have faced state discipline for drug-related violations in the past. One of them, Dr. Naimetulla Syed of Glastonbury, had his license suspended for two years in 1998 by the state medical board for improper prescribing of controlled substances.
Prescribing records from 2010 and 2011 show Syed was the second-highest prescriber of Xanax, and received $628 in meals and items from Pfizer those two years. He now faces new state charges of improper dispensing of methylphenidate, a psycho-stimulant. He could not be reached for comment.
Many of the drugs targeted by Grassley’s office as being overprescribed have been the subject of government crackdowns on fraudulent marketing.
AstraZeneca and Eli Lilly both paid large federal fines in the last three years to resolve allegations of marketing the antipsychotics Seroquel and Zyprexa for off-label uses, in part by paying physicians to promote the drugs. In 2009, Connecticut was one of several states that successfully sued Eli Lilly for marketing Zyprexa for off-label uses and for concealing its risks.
Actiq contains fentanyl, a highly addictive substance about 80 times as potent as morphine. It is approved only for the management of breakthrough pain in cancer patients, but is widely prescribed “off label” for non-approved uses such as headaches or back pain. In 2008, Cephalon paid a $425 million federal fine, and a separate $6 million settlement to Connecticut, to resolve charges that it improperly marketed three drugs, including Actiq.
Most of the Connecticut physicians who were prolific prescribers of Actiq in the last four years are not oncologists, or cancer doctors. Off-label prescribing isn’t illegal, but marketing or promoting drugs for unapproved purposes is.
The lists of prescribers show wide variation in the dollar amounts that are billed to Medicaid for the 10 targeted drugs. For example, Dr. Randolph Trowbridge of Danbury, the top-billing prescriber of Actiq in 2009-11, wrote 58 prescriptions for Actiq in 2010, billing Medicaid $788,674—or $13,597 per prescription. That was more than four times what Brennan billed for 113 prescriptions.
Trowbridge, who specializes in physical rehabilitation, said he has only three patients who are prescribed Actiq, one of whom takes 300 pills “every single week” because of debilitating pain.
“I’m just giving patients what is helpful,” he said. “I’m very much aware that these are very expensive drugs, but what am I supposed to do? Not give him the medication?”
Dearborn said billing amounts fluctuate because of the quantity of pills per prescription, and because some doctors may prescribe brand-name drugs, while others use generics.
Elliott, the University of Minnesota expert, said he is skeptical that new federal rules requiring drug-company payment disclosures will end the ties between physicians and Pharma.
“They are a band-aid. They don’t really help patients,” he said. “Sunshine laws are predicated on the notion that if you make the payments public, doctors will be shamed into turning down the money. But it doesn’t really turn out that way.”
