Ten Connecticut prescribers, including a Derby nurse practitioner who is under investigation by the state, were responsible for more than 22 percent of the state’s Medicare spending on potent narcotics in 2013, new federal data show.
More than 4,300 Connecticut clinicians, mostly physicians, wrote Medicare prescriptions for oxycodone, morphine and other Schedule II drugs, which have a high potential for abuse and addiction, at a total cost of $40 million. But a handful of those providers accounted for the largest share of those prescriptions, an analysis of the data show.
Topping the list, in both the number of prescriptions and cost, was Heather Alfonso, an advanced practice registered nurse (APRN) at the Comprehensive Pain & Headache Treatment Centers, LLC, in Derby, who wrote out 8,523 prescriptions, at a cost of $2.7 million. Statewide, the average number of prescriptions per clinician was 104, and no other prescriber had more than 5,000 Schedule II claims. The average cost per prescriber was $9,138; the next closest individual cost was $1.8 million.
Alfonso could not be reached for comment. She is no longer employed at the pain center, a person who answered the phone there said this week.
A February story by C-HIT had identified Alfonso as among the top 10 Medicare prescribers – nationally — of Schedule II drugs in 2012. Her prescribing habits in 2012 and 2013 did not appear to attract scrutiny until earlier this year, when a probe by the Drug Control Division of the Department of Consumer Protection led her to surrender her state and federal licenses to prescribe controlled substances.
The state health department has an ongoing investigation into Alfonso’s APRN license, an agency spokesman said this week.
The 2013 data, released recently by Medicare officials, shows that Alfonso and nine other high-volume prescribers — including Dr. Mark Thimineur, an anesthesiologist who is medical director of the Derby pain center – accounted for more than $9 million of the $40 million spent on Schedule II drugs. Of the nine, five are physicians, three are APRNs, and one is a physician assistant.
In numbers of prescriptions, only three other providers besides Alfonso had more than 4,000 claims – Maryann Chomiak, a physician assistant at Pain and Spine Specialists of Connecticut, LLC, of Trumbull; Dr. Michael Brennan, a Fairfield pain specialist; and Dr. Pardeep Sood of Pain and Spine Specialists of Connecticut. Dr. Robert Boolbol, Sood’s partner in the pain practice, was the fifth highest prescriber, with more than 3,100 claims.
Alfonso was the state’s highest prescriber of a number of narcotics: Oxycodone (4,086 claims); morphine (1,385); fentanyl (782); hydromorphone (970); and methadone (508). Chomiak was the second-highest prescriber of oxycodone (2,981), morphine (752) and methadone (288). Brennan and Sood were the third and fourth highest prescribers of oxycodone, respectively. Sood also was among the top five prescribers of morphine and fentanyl.
Sood said he and Chomiak, who works with Boolbol, deal with a “very difficult patient population” suffering from chronic pain, and use interventional treatments, such as spinal injections, whenever possible. While Sood acknowledged that their numbers of narcotics prescriptions were high, he attributed that to a high patient volume, and said most prescriptions were for “low-dose” narcotics.
“We limit the dose, we limit the quantity,” he said. “We live by the book . . . We try to monitor these patients to the best of our ability,” including random urine testing and counseling for patients receiving opioids. “We are interventional pain doctors . . . totally different from some of the doctors who run a ‘pill mill.’”
Brennan said he was not surprised by the data, which shows him as the third highest prescriber of Schedule II drugs, at the second highest cost to Medicare. The dispensing of pain medications is increasingly concentrated in the hands of a few specialists, he said, as “fewer and fewer doctors” are willing to write such prescriptions.
“I’m the doctor of last resort” for people in chronic pain, Brennan said, adding that he only accepts patients who are referred by other physicians. “We put people through (scrutiny) before we accept them as patients . . . We really ferret out the people who should not be here.”
Brennan said his prescribing volume is high, compared to non-specialty practitioners, because “this is all I do.” He teaches safe opioid prescribing for Pri-Med and the state’s medical society and has authored a number of journal articles on pain management.
State agencies and the federal Centers for Medicare & Medicaid Services (CMS), which oversees Medicare, have rarely taken action against high prescribers. CMS adopted regulations that will allow it to begin removing providers from the program this year if it finds a pattern of prescribing that is “abusive,” or if a state suspends or revokes a provider’s ability to prescribe.
In Connecticut, the Department of Consumer Protection’s drug control division maintains a statewide prescription database and is empowered to notify law enforcement or regulatory agencies of any improper prescribing activity.
A bill proposed by Gov. Dannel Malloy and approved by the legislature last month tightens controls over prescribing by, among other things: requiring practitioners, before prescribing more than a 72-hour supply of any controlled substance, to check the patient’s record in the prescription database, and to review the patient’s record at least every 90 days; and requiring physicians, APRNs, physician assistants and dentists to take continuing education in pain management and prescribing controlled substances.
In hailing passage of the bill, Malloy said in a statement, “By ensuring that health care professionals prescribing treatment are utilizing patient history data to help them make smart decisions, we’ll curb potential abuse.”
Other states have taken stronger action to crack down on opioid prescribing, including imposing special regulations on pain management clinics; requiring pharmacies to record prescriptions for controlled substances immediately in a database, rather than weekly, as in Connecticut; and directing health agencies and medical boards to review prescription data to spot problem prescribing.
Alfonso was reprimanded last July by the state Board of Examiners for Nursing for providing narcotic pain medications to a patient seven times without personally examining the patient, instead “inappropriately” relying on an unlicensed assistant, state records say. She paid a $2,000 fine and took courses in safe prescribing and delegating work duties, but was allowed to continuing practicing without restrictions.
In recent years, several physicians have been charged with illegal dispensing of controlled substances, after investigations by the Drug Enforcement Administration and other agencies. Last month, Dr. John Katsetos of Fairfield pleaded guilty to narcotics distribution and fraud offenses, admitting that he failed to perform basic examinations of patients and that he saw multiple patients at once and billed Medicare and Medicaid for individual visits.
In 2014, Connecticut emergency departments had nearly 1,900 visits related to opioid overdose – a 50 percent increase over 2011. Close to 500 state residents died from accidental drug overdoses in 2013, a 38 percent increase from 2012, a state report shows.
C-HIT data specialist Grant Smith contributed to this report.