New data on drug and device company payments to doctors largely excludes nurse practitioners and physician assistants, though they play an ever-larger role in health care. One advanced-practice nurse pleaded guilty last month to taking drug company kickbacks
This story was co-published with NPR's Shots blog.
A nurse practitioner in Connecticut pleaded guilty in June to taking $83,000 in kickbacks
from a drug company in exchange for prescribing its high-priced drug to treat cancer pain. In some cases, she delivered promotional talks attended only by herself and a company sales representative.
But when the federal government released data Tuesday on payments
by drug and device companies to doctors and teaching hospitals, the payments to nurse practitioner Heather Alfonso, 42, were nowhere to be found.
That’s because the federal Physician Payment Sunshine Act doesn’t require companies to publicly report payments to nurse practitioners or physician assistants, even though they are allowed to write prescriptions in most states.
Nurse practitioners and physician assistants are playing an ever-larger role in the health care system. While registered and licensed practice nurses are not authorized to write prescriptions, those with additional training and advanced degrees often can.
A ProPublica analysis of prescribing patterns in Medicare’s prescription drug program, known as Part D, shows that these two groups of providers wrote about 10 percent of the nearly 1.4 billion prescriptions in the program in 2013. They wrote 15 percent of all prescriptions nationwide (not only Medicare) in the first five months of the year, according to IMS Health, a health information company.
For some drugs, including narcotic controlled substances, nurse practitioners and physician assistants are among the top prescribers.
“Nurse practitioners see patients, order tests, recommend procedures and prescribe medications,” Dr. Walid Gellad, an associate professor of medicine at the University of Pittsburgh and co-director of its Center for Pharmaceutical Policy and Prescribing, wrote in an email. “It seems straightforward to think that their relationships with the pharmaceutical and device industries are of as much relevance as physicians, dentists, chiropractors, etc.”
He added, “If the purpose of the act is to shine a light on the relationship between industry and the health care sector, then you’ve left out an important component of that sector.”
When the Sunshine Act was drafted, those involved say, nurse practitioners weren’t part of the discussion. “Physician groups were among the stakeholders who were very engaged,” said Allan Coukell, senior director for health programs at the Pew Charitable Trusts. “Nursing groups weren’t part of the policy discussions and weren’t ultimately covered by the law.”
Still, Coukell said, “To the extent that a lot of prescribing now is done by health professionals who aren’t physicians, and a lot of marketing is directed at them, they ideally should also be part of the disclosure.”
Asked whether payments to these providers should be reported, a spokesman for the Centers for Medicare and Medicaid Services, which manages the disclosure system, said: “Nurse practitioners and physician assistants are currently not covered recipients under the statute for Open Payments.”
A representative of the Pharmaceutical Research and Manufacturers of America, the industry trade group, declined comment.
Although payments to nurse practitioners are not required to be reported under the law, a handful of companies did so anyway. Of the 606,000 providers who received payments in 2014, several hundred self-identified as nurse practitioners or physician assistants. The rest were doctors, dentists, optometrists, podiatrists and chiropractors. (Some of the self-identified nurse practitioners and physician assistants actually appear to be doctors, but have misclassified themselves.)
Alfonso was employed as an advanced-practice nurse at Comprehensive Pain and Headache Treatment Center in Derby, Connecticut. An investigation revealed that she was a heavy prescriber of Subsys, an expensive drug used to treat cancer pain, the U.S. Attorney’s Office for Connecticut said. Between January 2013 and March 2015, she wrote more than $1 million in Subsys prescriptions to Medicare patients alone, more than any other prescriber in Connecticut, prosecutors alleged.
“Interviews with several of Alfonso’s patients, who are Medicare Part D beneficiaries and who were prescribed the drug, revealed that most of them did not have cancer, but were taking the drug to treat their chronic pain,” the U.S. attorney’s
Prosecutors said Alfonso was paid as a promotional speaker by Subsys’ maker, Insys Therapeutics Inc., for more than 70 dinner programs at a rate of about $1,000 per event. “In many instances, the dinner programs were only attended by Alfonso and a sales representative for the drug manufacturer,” the U.S. attorney said in the release. “In other instances, the programs were attended by individuals, including office staff and friends, who did not have licenses to prescribe controlled substances. For the majority of these dinner programs, Alfonso did not give any kind of presentation about the drug at all.”
The charge against Alfonso carries a maximum sentence of five years in prison and a fine of up to $250,000. Sentencing is scheduled… Continue Reading…