No easy definition for 'abusive' prescribing by doctors

As Medicare considers banning doctors who pose a "threat to the health or safety" of patients, it plans to consider an array of factors

When the agency that runs Medicare announced last week that it would take action against doctors who prescribe abusively in its massive drug program – perhaps banning them – it raised an interesting question.

What exactly constitutes “abusive” prescribing?

On this point, the Centers for Medicare and Medicare and Medicaid Services (CMS) is treading carefully, refusing to get pinned down by numerical thresholds for specific drugs. Instead Medicare will consider a variety of factors in deciding whether a physician’s drug choices pose a “threat to the health or safety” of seniors and the disabled.

“In our view, if a physician or eligible professional repeatedly and consistently fails to exercise reasonable judgment in his or her prescribing practices, we should have the ability to remove such individuals from the Medicare program,” officials wrote in the 678-page document proposing changes.

“Honest physicians and eligible professionals who engage in reasonable prescribing activities would not be impacted by our proposal,” they wrote.

In stories last year, ProPublica detailed lax oversight of the Medicare drug program, known as Part D. The series showed that federal regulators’ failure to keep watch over the program has enabled doctors to prescribe massive quantities of inappropriate medications, has wasted billions on needlessly expensive drugs and has exposed the program to rampant fraud. Part D cost taxpayers $62 billion in 2012.

In the “proposed rule,” CMS said it would weigh eight factors in determining whether a health professional poses a threat. These include:

Whether patients’ diagnoses support using the medications prescribed.

Whether providers wrote prescriptions to patients they could not have seen – such as those who are dead or were out of state at the time of billed office visits.

Whether providers prescribed excessive volumes of painkillers and other controlled substances linked to overdoses.

Whether disciplinary actions have been taken against providers by state regulators or Medicaid programs for the poor.

Whether providers have been sued for malpractice, including the number and type of such lawsuits, and whether those suits resulted in judgments or settlements.

Medicare said it would not base its decision on any single factor. “Nonetheless, there are certain criteria that, if met, would weigh heavily and perhaps decisively towards a finding that a revocation is justified,” the agency said.

Medicare’s case-by-case strategy is one ProPublica also determined was the best method when assessing Part D prescribing data it obtained from the program. The prescribing practices of doctors, reporters found, could not be judged by numbers alone – whether overall or concentrated on specific medications. Often what looked troubling in the data had a real-life explanation. For example, in some cases, when physicians’ annual tally of prescriptions topped 150,000 – an inconceivable amount – it turned out they specialized in nursing home care and their totals included prescriptions by others in their practices.

In order to identify physicians prescribing in unusual ways, ProPublica compared them to others in their specialty and state, looked at changes in their prescribing patterns from one year to the next, researched their backgrounds and disciplinary histories, and examined their preference for drugs with a high risk of abuse or misuse.

Reporters were able to spot the outliers. One Miami psychiatrist gave hundreds of elderly dementia patients antipsychotic drugs, despite a black-box warning against doing so. And an Oklahoma doctor gave an Alzheimer's medication to scores of autistic and developmentally disabled young adults, despite a lack of evidence that it would help them.

Neither doctor had ever been questioned by Medicare.

In submitting the proposed new rules, CMS said it lacked the legal authority to take action against physicians who prescribed improperly, unless they had been formally excluded from Medicare, a step typically taken only after a criminal conviction.

As a result, the document said, “This means, in many cases, that the prescriber can continue prescribing drugs that will be covered under Part D.”

Two senators pushing CMS to do more about abusive prescribing released statements praising the agency’s proposed new rules. Sen. Thomas Carper, D-Del., chairman of the Senate Homeland Security and Governmental Affairs Committee, called them “common sense reforms.”

Sen. Tom Coburn, R-Okla., the top Republican on the panel, said “the vast majority of physicians” want to help patients, but “where there is proof of abuse or fraud, CMS should take necessary actions to protect patients and taxpayers.”

Others greeted the proposals with more tempered reactions.

Dr. Ardis Dee Hoven, president of the American Medical Association, said the group is reviewing the proposal to ensure CMS “does not compromise appropriate prescribing or exceed its statutory authority.”

“Responsible prescribing of pharmaceutical drugs is a fundamental aspect of medical practice and the American Medical Association has zero tolerance for harming the health and safety of patients,” Hoven said in a statement.

Physicians who appropriately and safely prescribe medications “should not be targets of misguided government enforcement and driven out of practice,” she added

The agency will take comments on the proposed rules until March 7. They are slated to take effect on Jan. 1, 2015.



Sensex, Nifty may try to move up again

But Nifty’s resistance at 6,300-6,315 is quite strong

On Monday, we pointed out that as long as the NSE Nifty manages to keep itself above 6,250 on Tuesday, the upmove may continue, although it may be a very short rally. On Tuesday, the Nifty spent most of the day below 6,250. There is still a chance that the index may rally towards 6,300-6,315. However, it may be a short rally that may stall soon.


The indices opened lower today, following a decline in the US markets Monday and major Asian markets today and continued to fall gradually through out the session. The BSE 30-share Sensex opened at 21,115 while the Nifty opened at 6,260. Soon after hitting the day’s high of 21,155 and 6,280 the indices started their downward journey. The indices hit a low of 21,009 and 6,234 late in the session from where they recovered a bit.  The Sensex closed at 21,033 (down 101 points or 0.48%) and the Nifty closed at 6,242 (down 31 points or 0.49%). Today’s fall was on a lower volume of 50.14 crore shares.


Among the other indices on the NSE, the top four gainers were Pharma (0.72%); Nifty Midcap 50 (0.31%); Midcap (0.04%) and Nifty Junior (0.02%) while the top five losers were Media (2.55%); Metal (1.57%); Realty (1.53%); PSE (0.89%) and Commodities (0.88%).


Of the 50 stocks on the Nifty, 14 ended in the green. The top five gainers were Cipla (2.05%); Lupin (1.86%); Cairn (1.82%); IndusInd Bank (1.67%); Dr Reddy (0.79%) and Infosys (0.73%). The top five losers were Tata Steel (3.03%); DLF (2.51%); NMDC (2.51%); Jindal Steel (2.34%) and Ranbaxy (2.14%).


Of the 1,505 companies on the NSE, 599 companies closed in the green, 825 closed in the red while 81 closed flat.


The rate of inflation based on the combined consumer price index (CPI) of urban and rural India slowed to 9.87% in December 2013, from 11.16% in November 2013, according to the data released by the government after trading hours on Monday. The moderation was largely driven by a fall in vegetable prices, which cooled nearly 19% from November on improved supplies. That helped slow down annual food inflation to 12.16% last month from 14.72% in November.


The Reserve Bank of India on Monday said that it had eased rules for hedging foreign exchange exposures, allowing greater flexibility for cancelling and rebooking forward contracts. RBI is now allowing domestically-held forward contracts for all current as well as capital account transactions with a residual maturity of one year or less to be freely cancelled and taken out again, called rebooking. Before the changes, domestic exporters could cancel and rebook up to 50% of the contracts booked in a financial year for hedging their contracted export exposures. Importers were allowed to cancel and rebook up to 25% of contracts booked in a financial year. These limits have been dropped. Foreign investors will be allowed to rebook 10% of the value of cancelled contracts, up from nothing previously.


US indices closed in the negative on Monday. The weakness persisted as a batch of weak earnings pre-announcements in the United States sparked concerns that the upcoming reporting season may disappoint.


Lawmakers in the United States staved off another possible shutdown by agreeing to series of measure to decide on US spending before the deadline. Lawmakers agreed to $1.1 trillion of spending that will run up to September 2014. This is part of the bi-partisan deal that the Republicans and Democrats agreed upon during the US Government shutdown, to agree to fund US spending subject to certain conditions. Earlier, the US shutdown majority of its government services as parties could not decide on spending levels to pay the bills.


Asian indices closed mostly in the red. Shanghai Composite the lone gainer was up 0.86%. Nikkei 225 was the top loser which fell 3.08%.


European indices were trading in the negative while US Future were trading marginally higher.


UK inflation unexpectedly slowed in December, reaching the Bank of England’s 2% target for the first time in more than four years. Consumer-price growth slowed from 2.1% in November, the Office for National Statistics said today in London.


In a separate report, the statistics office said factory-gate prices were unchanged in December from November and were up 1% compared with a year earlier. Input prices increased 0.1% on the month and fell 1.2% from a year earlier. That’s the biggest annual decline since September 2012.


Equity mutual funds report another round of net inflows in December as Sensex inched higher

While equity mutual funds registered a net inflow for two consecutive months, in CY13, equity funds suffered a net outflow of over Rs10,000 crore

Equity mutual funds received a net inflow of Rs857 crore in December 2013 compared to an inflow of Rs699 crore in November 2013. In CY13, equity mutual funds suffered an exodus of Rs10,427 crore. In the year, equity mutual funds reported a net inflow in just five months of the year. Massive outflows were witnessed in the months of January, May, September and October, working out to a total outflow of Rs11,820 crore. In a period when the Sensex rose by nearly 9% to 21,170 as on 31 December 2013 from 19,426 on 31 December 2012, equity assets under management declined by 5% to Rs1.83 lakh crore from Rs1.92 lakh crore over the same period.

As many as four new fund offers (NFOs) were launched in the month of December—Birla Sun Life Banking & Financial Services, Pramerica Midcap Opportunities, ICICI Prudential Value and Reliance Close Ended Equity—bringing in a total of Rs849 crore. Total sales of equity schemes in December 2013 increased to Rs5,508 crore compared to Rs5,414 crore in November. This is the highest sales recorded in two consecutive months. The previous best was reported in the months of February 2011 and March 2011, where the total sales amounted to Rs6,038 crore and Rs5,367 crore respectively.

In an earlier article we mentioned how investors and mutual fund houses rush in when the market is rising. (Read: Equity mutual funds register highest sales in November as market hovers near all-time high) In December, once again as the markets inched higher, inflows increased and new mutual funds were launched.

Despite the positive inflow in December, the total number of equity folios fell by 0.35 million to 29.89 million from 30.24 million in November. In CY13, equity fund folios fell by 12% to 29.89 million from 33.98 million, i.e. a loss of over 4 million folios.



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