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Medical Board Investigations: Criminal vs Civil Charles F. Cichon

Disclosure Information Consultant/Independent Contractor –Endo Pharmaceuticals

Learning Objectives Describe best practices in prescribing pain medications that correspond to state board requirements Identify requirements to maintain state licensure in relation to prescribing pain medications Recognize prescribing problems that are cause for concern with state boards

Headlines DEA raids doctor's offices in probe of improper prescriptions Doctor charged with 30 drug-related counts Doctors in Florida Booted from Medicaid Doctor ordered to stand trial for murder in overdose deaths Physician pleads guilty in drug-sex case

Federation of State Medical Boards  State medical boards are well-known in the health care community as the state entities which issue licenses to physicians or discipline those who step outside the law. But there is a third, equally important function that is less well known: investigating complaints received from patients and others about physicians who may be unethical or incompetent

Federation of State Medical Boards (cont’d)  State medical boards license physicians, investigate complaints, discipline those who violate the law, conduct physician evaluations and facilitate rehabilitation of physicians where appropriate.  By following up on complaints, medical boards give the public a way to enforce basic standards of competence and ethical behavior in their physicians, and physicians a way to protect the integrity of their profession. State medical boards also adopt policies and guidelines related to the practice of medicine  There are currently 70 state medical boards authorized to regulate allopathic and osteopathic physicians

Physician Information Vast Majority of physicians are legitimate healthcare professionals Less than 1% of licensed physicians are investigated by State Medical Boards for all complaints

Physician Sanctions for Prescribing Pain Medication  September, 2008 Study – FSMB, NAAG and the Center for Practical Bioethics  Data from 1998-2006  725 physicians identified -@0.1 percent of 700,000 practicing pain care physicians  Majority Primary Care – 25 pain specialists  2005-2006 DEA reported investigating an average of 4-5 doctors per state each year

Physician Discipline Medical boards also monitor licensed physicians’ competence and professional conduct. They review and investigate complaints and/or reports received from patients, health professionals, government agencies, health care organizations and other state medical boards about physicians who may be incompetent or acting unprofessionally and take appropriate action against a physician’s license if the person is found to have violated the law. State laws require that boards assure fairness and due process to any physician under investigation

What Medical Investigators Do  A medical board investigator’s role is to investigate — to dig for the facts of a situation by interviewing key players and gathering pertinent information  Occasionally, an investigator might collaborate with law enforcement on a field operation, such as making an undercover buy from a physician suspected of illegally selling narcotic prescriptions  Most of a typical investigator’s time is spent on more mundane tasks, such as placing phone calls, sending letters and taking affidavits. Such tasks might not sound as glamorous, but the painstaking care that goes into them is just as critical for protecting the public

Board Investigations What kind of complaints result in discipline? What happens when the board conducts an investigation? How long does the complaint process take?

Board Investigations (cont’d)  What kind of complaints result in discipline? –Misuse of alcohol or drugs –Sexual contact with patients –Conviction of a criminal act –Prescribing addictive drugs without a bona fide medical indication –Accepting money or other consideration in return for patient referrals –Practicing without a license or aiding others to do so –Providing substandard care

Board Investigations (cont’d)  What happens when the board conducts an investigation? – State law provides that the Board is required to show by evidence that a licensee has breached the Medical Practice Act. A thorough investigation of the facts must precede the Board making a charge against a physician or other health care provider

Board Investigations (cont’d)  How long does the complaint process take? – Usually, minor complaints are resolved within a few weeks in an informal manner. When a full investigation results in the Board bringing formal charges, the process takes longer. Cases involving standards of quality care go through a peer review in which other physicians examine the quality of care provided and issue an opinion. Because the Board provides due process to the licensees, the disciplinary process takes a long time

A Look Inside a Criminal Investigation Orlando – in a 3 month period, 1 physician prescribed more oxycodone than all doctors in California Clinic managers crushed and snorted pain meds in the office 3,200 oxycodone pills disappeared 1 day Security guard fired for reporting a drug deal on the parking lot

A Look Inside a Criminal Investigation (cont’d) 75 patients had 64 criminal records – 42 arrested for drug-related crimes Cash-insurance not accepted $160 - $300 per visit Signs - patients needed to bring empty pill bottles for a refund– price list for available pills posted on wall

“Red Flags” Physician has minimal to no training in pain management Patient volume (daily 100+) Patients from other states (carpool) Clinic run on cash only basis Similar prescription “cocktail” for each patient Drugs dispensed onsite

Criminal or Civil Typical Rx Drug Seeker Every bit as addicted as the heroin and cocaine addict Spends most of their waking hours planning on how to get their drugs Consumes much of their time deciding how to scam YOU!

Typical Rx Drug Seeker Compliments physician Deliberately mispronounces drug name Agitated when cut off drugs of choice Threatens lawsuit Leaves abruptly when scam does not work

Physician/Patient Education Patients receiving medicines need education Instructions on how to take the drugs Instructions on potential abuse/misuse by friends, family members, visitors Educational written instructions to patient

Physician/Patient Education (cont’d) Do not keep medicines that can be abused/misused in medicine cabinet or bathroom closet Keep medicines in inconspicuous location known by the Patient or care giver Understand that your alcoholic cousin may also be interested in your prescription medicines

Physician/Patient Education (cont’d) Understand that patient’s teenager or teen’s friend may use or distribute these drugs to classmates or at parties Understand that laborers coming into your home may be interested in your medicines (carpet layers, painters, furniture movers, installers, etc.)

Physician/Patient Education (cont’d) Understand that the drugs prescribed to patients, are for personal use only! Understand that providing your drugs to others may cause catastrophic results in other persons of which you may become liable

Physician/Patient Education (cont’d) Report any problems with the diversion of your CS prescriptions to your prescriber Dispose of unused medication promptly Patient needs to do their part to reduce Rx abuse/addiction

Dealing With The Suspected Diverter  PERIODIC URINE SCREENS – (Include hydrocodone/oxycodone)

 PILL COUNTS  Consider Caregivers, friends, family as potential suspects  Medication agreement with patient  Gross or repeated violations are grounds for termination of DrPatient relationship

Prescription Monitoring Programs (PMP’s)  Enacted by individual states to track the prescribing/dispensing of Rx drugs  Most involve only controlled substances  All involve access to health professionals  Varied availability for law enforcement  Valuable tool for investigators especially if easily accessible  Electronic databases  Can identify diversion and reduce health care fraud

Pharmacist Collaboration Communicate regularly with local pharmacists Understand and discuss their concerns Understand they have a corresponding responsibility Encourage them to be a part of your pain management team

Why Get Involved?  Drug seekers keep you from legitimate patients  Lack of addressing the issue will increase the problem  Perpetuates patient’s addiction or trafficking by ignoring the problem

Prescribing Practices Legitimate patients with pain should not suffer because practitioners are fearful of law enforcement Law enforcement is not interested in investigating appropriate prescribers Its important that none of us allow those who divert prescription drugs to influence the legitimate prescribing and dispensing of controlled substances

Test Your Knowledge: Criminal vs. Civil Scenario: you are experiencing back pain after a weekend spent moving into a new home. You know the appropriate dose of oxycodone to relieve your pain. Instead of requesting an appointment with your primary care physician you call in a prescription to the pharmacy for yourself. Are your actions appropriate? (sample question from the Arizona Medical Board’s new test for physicians, which is based on that state’s medical practice act)

Test Your Knowledge: Criminal vs. Civil A. No. Regardless of how seemingly obvious the cause of the pain and type of controlled substance needed, it is never appropriate for a physician to self prescribe a controlled substance B. No. There are alternative over the counter drugs that can provide the same effect C. Yes. You had the same back pain in the past and you were previously prescribed the same medication D. Yes. You are a licensed physician. You know exactly what medications you need to feel better

Test Your Knowledge: Criminal vs. Civil Answer: A. No. Regardless of how seemingly obvious the illness and type of controlled substance needed, it is never appropriate for a physician to self-prescribe a controlled substance –A.R.S. 32-1401(27)(g) states that it is unprofessional conduct to use controlled substances except if prescribed by another physician for use during a prescribed course of treatment


Thank You!

Medical Board Investigations: Criminal vs Civil  

Charles F. Cichon