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The inspector general of the US Department of Health and Human Services finds Medicare spent tens of millions of dollars in 2012 for HIV drugs there’s little evidence patients needed. A 77-year-old woman with no record of HIV got $33,500 of medication
Medicare spent more than $30 million in 2012 on questionable HIV medication costs, the inspector general of the U.S. Department of Health and Human Services said in a report set for release Wednesday.
The report offers a litany of possible fraud schemes, all paid for by Medicare's prescription drug program known as Part D.
Among the most egregious:
In Detroit, a 77-year-old woman purportedly filled $33,500 worth of prescriptions for 10 different HIV medications. But there's no record she had HIV or that she had visited the doctors who wrote the scripts.
A 48-year-old in Miami went to 28 different pharmacies to pick up HIV drugs worth nearly $200,000, almost 10 times what average patients get in a year. The prescriptions were supposedly written by 16 health providers, an unusually high number.
And on a single day, a third patient received $17,500 of HIV drugs — and none the rest of the year. She got more than twice the recommended dose of five HIV drug ingredients.
The inspector general's report raise new questions about Medicare's stewardship of Part D. A ProPublica series last year showed that Medicare's lax oversight has enabled doctors to prescribe massive quantities of inappropriate medications, has wasted billions on needlessly expensive drugs and exposed the program to rampant fraud. Part D cost taxpayers about $65 billion in 2013.
Previous inspector general reports have criticized the way Medicare oversees doctors and pharmacies, but this one focuses on patients, who are not usually the focus of inquiries into fraud and abuse.
The inspector general flagged 1,578 Medicare beneficiaries who received HIV medications worth $32 million in 2012. (This figure does not include beneficiaries who, based on their records, appeared to be taking the drug Truvada for HIV prevention.)
More than half the patients identified by the inspector general had no diagnosis of HIV, had no records of laboratory tests to monitor the use of the drugs, and had not received any medical services from any of the prescribers.
Two pharmacies, both in Miami, dispensed drugs to 321 of these beneficiaries. Most of them were women with an average age of 74, two decades older than the typical patient who received HIV drugs in Medicare. These two pharmacies collected more than $350,000 for the drugs, the inspector general reported.
"While some of this utilization may be legitimate, all of these patterns warrant further scrutiny," the report says. "These patterns may indicate that a beneficiary is receiving inappropriate drugs and diverting them for sale on the black market. They may also indicate that a pharmacy is billing for drugs that a beneficiary never received or that a beneficiary's identification number was stolen."
The inspector general's analysis did not say if beneficiaries were complicit in the questionable activity or if their IDs had been used without their knowledge or permission.
Medicare places a premium on getting patients their medications in a timely way, particularly for conditions such as HIV.
HIV drugs pose a thorny problem for Medicare. Under the program's rules, the drugs are a "protected class." Insurance companies paid to administer Part D for the government must cover them without exception and cannot require prior approval for patients. Insurers are freer, however, to manage other drugs and can impose restrictions to control spending, prevent overuse and spot fraud.
The unscrupulous have tried to exploit the special status of HIV drugs, leading to a number of recent prosecutions against pharmacy owners and others. Sometimes pharmacies bill for the drugs, do not dispense them, and then bill Medicare or private insurers for them again. Beneficiaries may be misusing the HIV drugs, too; the inspector general noted that some medications have psychoactive effects or enhance the effects of painkillers.
The amount of suspicious activity involving HIV drugs is small relative to the overall usage of such medications. Medicare paid $2.8 billion to supply HIV drugs to 135,500 beneficiaries in 2012.
In addition to patients receiving HIV drugs without a history of HIV, other areas of possible fraud include patients receiving excessive doses of HIV drugs; patients receiving an excessive supply of an HIV drug; patients whose prescriptions were filled by a high number of pharmacies; patients receiving prescriptions from multiple prescribers; and patients taking HIV drugs that are not supposed to be taken together.
Fully 38 percent of beneficiaries with questionable utilization patterns lived in Miami or New York, a rate three times higher than the percent of patients receiving HIV drugs who live in those cities.
One 37-year-old in Miami received $146,160 in HIV drugs in 2012. He received 16 different HIV medications in a single month. "Several times during the year, he received these drugs from two different pharmacies on the same day," the report says.
The inspector general recommended that the Centers for Medicare and Medicaid Services take steps to rein in fraud and abuse of HIV drugs, including using prescription data to look for aberrant behavior among beneficiaries. The report says health plans should be required to conduct reviews looking for unusual patterns of HIV medication use. It also encourages Medicare to expand the ability of health insurers to put controls in place and restrict certain beneficiaries to a limited number of pharmacies or prescribers.
CMS generally agreed with the recommendations and said it would be open to Congress taking steps to limit the number of pharmacies or prescribers for beneficiaries who appear to be abusing drugs or engaging in fraud.
A travelogue going deep into the Himalayas, ending at Gaumukh
Uttarakhand is still recovering from last year’s disaster. It’ll be a while before the state returns to the way things were; but this is an ode not a eulogy. I made a trip to Uttarakhand the year before the floods. I am among those who last saw how it used to be. Thankfully, I chose the perfect time to travel. Most people travel during the peak season. But if you really want the best experience of any place, the trick is to go when ‘off-season’ is just about to end; the weather will be about to change; prices are down and tourists are scarce.
This piece is about one leg of a longer trip. It ends at Gaumukh, the mouth of the Gaumukh Glacier from where the Bhagirathi starts flowing, gushing past Gangotri, Uttarkashi and into the plains where it becomes the Ganga after its confluence with Alaknanda River at Devprayag. A large part of Indian history begins from the Himalayas. The Indus and the Ganga, the two major sources of our civilisation, originate here. The unimpeded Bhagirathi flows only up to Uttarkashi, getting bound up in the Tehri Dam a little after.
Following the River from Uttarkashi is one of the most complete trips for the faithful, the trekker, the naturalist, the storyteller and taxed city-dwellers looking for a place to rest. The temple at Gangotri opens on akshaya tritiyaa. If you’re lucky, you may go in a year when this festival falls towards the end of April instead of the usual month of May. Like most hill towns in India, it is built around a market street, with hotels overlooking the River and a government lodge situated a little away from the hustle and bustle. Government lodges are usually at the best locations, unless you plan to live in luxury. These are characterised by mediocre service but their food is reasonably priced.
On the day of the temple’s opening, a procession brings Lord Narsimha’s idol from a village in Harsil, the winter resting place of the idol, when Gangotri is covered by metres of snow. The procession snakes up to the temple and a grand aarti performed by the chief priest prepares the shrine for the coming year. Every evening, there is an aarti in obeisance to the River. The flaming plates of incense and burning ghee cast a religious glow upon the clear River.
When it’s over, look around. For a town situated at 3,100 metres in the Himalayas, it feels unnervingly spacious. When you’ve travelled a lot in the mountains, you realise that unlike the expected feeling of freedom, mountains could engulf you with a creeping claustrophobia, because they block out the horizon. From the town, you can see the Bhagirathi winding down from Gaumukh, which is hidden behind overlapping mountain valleys. In the background, lie the imposing Meru, Shivling and Bhagirathi peaks. Most of those are in the upper Himalayas and snow-capped throughout the year.
Gangotri is the place to which the faithful come, gain a pardon and return home. Some walk further into the Gangotri National Park, for which you will need a permit. They ask you cursory questions about your health and warn you about the oncoming weather. On most days, you’ll find young Nepali and pahadi boys hawking porter services to those who want to trek ahead. Once the permit is obtained, you must walk half a kilometre to the check-post where the trail begins. Your bags are turned inside out, every synthetic and non-biodegradable material counted, you pay a deposit and sign a receipt agreeing to bring each piece back. A middle-aged couple was returning as I stood signing the receipt and, a few minutes later, I could hear excited arguments about their deposit getting impounded because they were ‘just two plastic bags’ short.
For the next 14km, there will be those who find a greater estimation of themselves, those who curse the deadening walk and those who click a hundred pictures from horseback, led by a guide. The road hugs the mountains on the left, next to the pristine waters flowing below to the right, sandwiched by another mountain line on the right bank. At these heights, the air is rare and crisp, unpolluted by lorries ferrying construction material. Which brings us to the most important caveat when travelling to such places: altitude sickness can be fatal. If your health is not good, don’t trek. If you feel your chest constricting or any dizziness, return immediately to lower altitudes. Those in good health can enjoy the vegetation as this is among the most beautiful alpine forestation in the world. In autumn, the trees turn golden and the land becomes stark white.
Once the road turns a few times, you pass small settlements (habitable only in summer), or stock houses, and an understandably tired traveller is treated to the white crown of the Shivling peak. When the snow on the peak is falling at just the right angle, the wind is blowing just right and clouds are far enough from the mountain, legend has it that you can see an ‘OM’ at the top of the peak. A few more miles ahead and a final mound stands between you and the base camp. Because the Bhagirathi peaks holding the glacier are so huge and far away, their size seems to barely change and from the top of the hilly mound, you see a flat patch with three sets of buildings. One is a government rest house, another an aashram for travellers to spend the night, run by a baba, and the third an administrative accomodation. If you’re the adventurous type, go for the aashram; most foreigners stay there. The government rest house is excellent, too. This is Bhojbasa, the base camp for the final trek to Gaumukh.
It’s best to get some rest before you head for the glacier. If you leave early in the morning for the 4km walk up to the glacier, you’ll find the river frozen under your feet, cutting many short routes through the boulders and landslides. The best part of this walk is when the sun rises embracing the mountains around and you see the white snow-caps above turn golden and the slowly descending border between shadow and sunlight. When the sun hits the frozen waters below your feet, the ice slowly starts cracking. Beautiful though it is, it’s best to walk along the banks thereafter.
The glacier itself is preceded by a small shrine which was originally at the site of the Gangotri Temple; but two centuries of global warming has pushed it to its current location. Gaumukh is two storeys high, a regal vault of ice weighing tonnes. Somewhere in its gut, the water unfreezes and, through a spout not higher than a few feet, the river flows out. There isn’t too much ambient noise; but on rare occasions, a block of ice breaks off and falls into the water. Those expecting a site to match the 7,000-metre tall mountains behind, may be a little disappointed. But, for the faithful, filling their bottles with gangajal is enough. Anyone who knows Indian history can trace thousands of years of civilisation to this spot. Some say these are the best places to meditate, if you’re the type. I agree.
I gather that a lot of this is in a shambles after the floods. The tourist trade always becomes the bane of the tourist place. But, as William Blake said, “Great things are done when mountains and men meet.” Jesus preached on ‘The Mount’; the commandments were given on Mount Sinai; Krishna was titled ‘Lord’ when he lifted mount Govardhan; Lord Shiva roamed somewhere above Kedarnath; Jupiter lived on the Capitoline Hill; and Zeus on Olympus. A trip to the Himalayan reaches is among the best experiences in an increasingly plastic world.