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Drugging Juveniles - Doctors Hired to Evaluate Kids in State Custody have taken Huge Payments from Drug Companies


In Florida's juvenile jails, psychiatrists entrusted with diagnosing and  prescribing drugs for wayward children have taken huge speaker fees from  drug  makers - companies that profit handsomely when doctors put kids on  antipsychotic pills. The psychiatrists were hired by a state juvenile justice system that has
plied  kids with heavy doses of the powerful medications, and the physicians have  prescribed anti­psychotics even before they were approved by federal  regulators as safe for children. 

One in three of the psychiatrists who have contracted with the state Department of Juvenile Justice in the past five years has taken speaker fees  or gifts from companies that make antipsychotic medications, a Palm Beach  Post investigation has found. 

In two years, the four top paid doctors combined to accept more than $190,000   - all while working for DJJ. Three of the four psychiatrists still are  seeing patients in state jails and residential programs. 

In at least one case, the number of Medicaid prescriptions a psychiatrist  wrote for children rose sharply around the time he was paid, The Post found. 
 
"That's very, very scary," said Jude Ann Prisco, a Palm Beach County  mother  whose child took psychiatric drugs while recently locked in a  program. She said it never occurred to her that DJJ doctors might take money  from drug companies.
"I'm very upset by that, and I think they need to  get some new guidelines."

Responding to The Post's findings, newly appointed DJJ Secretary Wansley  Walters recently ordered a sweeping investigation into how antipsychotics  are  used in state jails and programs for kids. She declined to comment  further, however, citing the probe. 

DJJ doctors took payments as powerful antipsychotics flowed into state jails  and homes. Child advocates say the widespread use of these drugs amounts to  a policy of controlling children through "chemical restraint."

 "This is a serious, legitimate and possibly life-threatening issue that  requires investigation, reformation and possibly prosecution," said  Circuit Judge Ronald Alvarez, who has sat on the juvenile court bench in  Palm Beach  County for 12 years. 

DJJ relies heavily on the judgment of its contract doctors: In state juvenile jails and residential programs, the psychiatrists ultimately decide whether  children should get medication - and which drugs kids should take. 

Florida doesn't have disclosure laws

 Doctors prescribed heavy doses of antipsychotic drugs for children in DJJ  custody even before the drugs were deemed safe for kids. 
Seroquel, for example, wasn't approved for kids until late 2009. Between  mid-2006 and mid-2008, DJJ bought at least 217,563 tablets of Seroquel for  children in the department's custody. 

The state has no rules requiring drug companies to disclose payments to  doctors. DJJ has no policy requiring contracted doctors to disclose  conflicts of interest. In overhauling health care last year, Congress  enacted a measure  that requires all drug companies to disclose payments and  gifts to doctors. However, that part of the law won't take effect until  2013. 

DJJ doesn't track prescriptions going into its jails and programs. The  rationale behind the department's system is that doctors, with help from  nurses and other program staff, always prescribe drugs appropriately. 
"The idea was, if kids did not have a medical need for psychotropic  medication, then there wouldn't be any purpose in giving (antipsychotics) to them," said DJJ spokeswoman Samadhi Jones. 

Last Tuesday, six days before this story was published, DJJ's chief medical  director, Lisa Johnson, took the unusual step of issuing a strongly worded  memo to DJJ's contracted and state-employed doctors. 

The note, among other things, cautioned psychiatrists against prescribing anti­psychotics and other drugs for reasons that aren't approved by the  federal government, except in extreme cases. It also reminded doctors that  they aren't to use the drugs "as a means of punishment, discipline,  coercion, restraint or retaliation."

 'Quid pro quos' violate anti-kickback laws

 The topic of doctors taking payments from pharmaceutical companies has become  increasingly controversial in the past four years, after the federal  government accused some companies of paying illegal kickbacks to physicians. 
 
The subject takes on a new dimension when it involves doctors who care for  children in state custody, said Eric Campbell, a professor at Harvard  University who researches medical conflicts of interest. 

"In my eyes, the role of government is to ensure that people who are left  in our care, who are vulnerable and need help, actually get that help,"  Campbell said. "And potentially exposing them to inappropriate  prescriptions, when the benefit of those goes to the individual physician, I  see as especially problematic."

 In general, if doctors prescribe drugs in exchange for payments from  pharmaceutical companies, the quid-pro-quo arrangement violates state and  federal anti-kickback laws, said Ryan Stumphauzer, a former federal  prosecutor  and founding member of South Florida's Medicare Fraud Strike  Force. 

Stumphauzer, who now is in private practice in Miami, added that The Post  appears to have unearthed "some truly stunning and troubling data." 

Firms: Doctors provide valuable service

 Drug companies' practice of compensating doctors is perfectly legal so long as  it's not an effort to influence prescribing, said Bruce Reinhart, a former  federal prosecutor now in private practice in West Palm Beach. 

"A drug company can give free samples, for example, or a doctor can go to  a seminar, if the purpose of doing that is education," Reinhart said. 

A spokeswoman for AstraZeneca, which makes Seroquel, said the company views  payments as "appropriate and ethical" compensation for  professionals who provide valuable services. 

"Physicians who speak about our products are compensated at a fair market  value based on the physician's qualifications and the amount of time  required to provide the service," Stephanie Andrzejewski said. "Patients  ultimately  benefit when physicians are well informed and knowledgeable about  our medicines, treatment options and standards of care."


Prescriptions rise with payments

 AstraZeneca was one drug company that paid Dr. Umesh Mhatre after he started  working for DJJ. Pfizer, maker of the antipsychotic Geodon, was another. 

In 2010, Mhatre, who is board-certified in psychiatry and child psychiatry and  based in Lake City, took $65,475 in payments and gifts, including $63,250 in  speaker fees. 

Records show Mhatre billed Medicaid for more antipsychotics for children  during a period in which he was taking tens of thousands of dollars in  payments. 

The psychiatrist began working in St. Augustine in 2009 at the St. Johns  Juvenile Correctional Facility, a secured program where children aren't  eligible for Medicaid, and the St. Johns Youth Academy, a non-­secured  program where Medicaid can pay for kids' prescriptions. 

During his first 15 months seeing DJJ patients at the St. Augustine homes,  Mhatre billed Medicaid, on average, for about 254 prescriptions every three  months for antipsychotics that went to children. 

In the first six months of 2010, Mhatre took $39,000 in speaker fees from  AstraZeneca, and then, months later, accepted another $13,100, records show.  He also accepted more than $15,000 in speaker fees and to cover meals and  travel from Pfizer between mid-2009 and the end of 2010. 

Between April and June 2010, Mhatre wrote 328 children's prescriptions for antipsychotics  in three months, or 35 percent more of those scrips than he had billed  Medicaid for, on average, in three-month spans over the preceding 2½  years. 

Medical experts cautioned against drawing conclusions from Mhatre's  prescribing, saying a number of variables might have been at work. 

For instance, he might have seen more patients in the spring of 2010 than he  did in previous months: Mhatre's patient rolls weren't available. Speaking  through a receptionist at his office, Mhatre declined to comment for this  story. He continues to see patients for DJJ. 

Fat speaker fees, free meals and travel

 Mhatre is one of 17 current or former DJJ psychiatrists who, in two years,  took a total of $253,982 in speaker fees or free meals and travel. Many  doctors took payments or gifts valued at less than $300. A few, like Dr. Rex  Birkmire,  took much more. 

Birkmire, an Oviedo-based psychiatrist who is board-certified in psychiatry  and forensic psychiatry, has accepted nearly $129,000 from makers of  antipsychotics since mid-2009. He took at least $70,750 in payments for educational programs around the time he worked at the Orange Regional  Juvenile
Detention Center. 

After he started at DJJ, Birkmire billed Medicaid for dramatically fewer  children's prescriptions for antipsychotics than he had in previous months.  He evaluated patients in a secured juvenile jail, where DJJ, not Medicaid,  pays for drugs for children. 

Birkmire didn't respond to phone and e-mail messages seeking comment.


Taxpayers pay for prescriptions

 Many of the drugs prescribed to children in DJJ custody are paid for with  taxpayer dollars. 

DJJ buys drugs given to kids in its jails and state-operated residential  programs. But psychiatrists can bill Medicaid or private insurance for drugs  prescribed to children in non-secured homes operated by private contractors. 
 
Medicaid billing records don't identify patients who receive prescriptions,  making it impossible to tell how many, if any, of the scrips were written  for  children in DJJ custody. What the records do offer, however, is a window  into the prescribing habits of doctors who have worked for DJJ. 

Take Mhatre, for example. In the run-up to his working for the department, he billed Medicaid for more mental health drugs than other doctors did. In 21  months, Mhatre wrote at least 24,771 prescriptions for mental health drugs,  including antipsychotics, for both children and adults. That breaks down to  42
scrips per day, seven days a week, for 84 weeks straight. 

In all, 52 psychiatrists who have worked for DJJ combined to bill Medicaid for  at least 175,247 prescriptions for psychiatric medications in 21 months, a  span that ended in March 2009. The doctors who took payments, a group that  numbered 17, accounted for more than half of all those prescriptions,  records  show. 

Big drug firms go to court

 Pharmaceutical companies began disclosing payments to doctors in 2009. The  move was related in part to lawsuits that alleged the drug makers were  paying illegal kickbacks to physicians who prescribed pills liberally. 

In April 2010, for example, AstraZeneca paid $520 million to settle the  federal government's allegations that the company paid kickbacks to doctors  who promoted Seroquel for off-label uses, among other claims. 

When it comes to money for DJJ doctors, AstraZeneca and other companies said  the payments weren't meant to influence prescribing. 

"AstraZeneca never pays physicians in exchange for prescribing our  medicines or as an incentive to promote our products," Andrzejewski,  the company spokeswoman, said in a statement. "Further, we have  policies in place to ensure that our payments to physicians do not create  conflicts of interest or otherwise influence the decisions these physicians  make in treating patients."

 Some doctors paid by drug companies work hard preparing talks and crafting  slides, and they can earn less than their hourly rate when delivering them,  said Dr. Robert Hendren, director of child and adolescent psychiatry at the  University of California, San Francisco. 

In other cases, Hendren said, companies seem to have sought out speakers based  on prescribing patterns. "I think that, in some of those ways, there  probably is undue influence," Hendren said. "I think people are  influenced by who pays them. I think there's no doubt about that."

 Needed transparency for payments

 Unlike other states, including California, Massachusetts and Minnesota,  Florida lacks rules requiring drug makers to disclose payments to doctors  licensed by the state. 

Such measures would create needed transparency, medical ethicists said. 
"I think it's because we worry that paying and marketing and advertising  and detailing can shape behavior," said Arthur Caplan, director of the  University of Pennsylvania's Center for Bioethics. "I don't think  that's a hypothetical, because we know that they do."

 Even better, said Campbell, the Harvard professor, would be if Florida  government medical contractors refused all offers of money from drug  companies. 
 
"Physicians who care for patients who are vulnerable populations need to  be particularly above reproach when it comes to this behavior,"  Campbell said. "I personally believe it's completely inappropriate for  physicians to moonlight as drug reps. You either sell drugs or you practice  medicine. But you can't do both."

 Staff researcher Niels Heimeriks contributed to this story. 

POST INVESTIGATION SPURS ACTION

 Responding to The Post’s findings, newly appointed Department of Juvenile  Justice Secretary Wansley Walters ordered a sweeping investigation into how  antipsychotics are used in state jails and programs for kids. She declined  to comment further, citing the probe.





ABOUT THIS SERIES


In charting the state Department of Juvenile Justice’s use of prescription  drugs, The Palm Beach Post analyzed department drug purchasing information  and state Medicaid billing data and reviewed thousands of pages of DJJ  inspection  reports, drug company disclosure records and court documents. The  Post also
conducted dozens of interviews with state officials, attorneys,  medical experts, advocates and child psychiatrists.


The task was complicated by DJJ’s inability to access its own records easily. Theoretically, the department can track prescriptions, but the system is  hampered by ‘functionality concerns,’ a spokeswoman said.


Asked about drugs dispensed to children, DJJ could provide information only  for a two-year period ending in mid-2008, and only for its 25 jails and a  fraction of its residential programs. The lock-ups represent only about  one-fifth of all juvenile jails and residential homes in Florida.


No information was available on the amounts of antipsychotic drugs dispensed  in the more than 100 remaining programs for juveniles, which are run by  private  contractors.


— Michael LaForgia

 ABOUT THE REPORTER

 Michael LaForgia has reported on Florida’s pill mill crisis, spurring arrests and reforms at the state and local levels, and exposed loopholes in Florida  law that put children at risk in summer camps. He joined The Palm Beach Post  in 2006.

Source The Palm Beach Post (May 2011)
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