Thursday, December 17, 2009

Feds Investigating High Prescribing Florida Docs


Associated Press

Feds investigating high prescribing Fla. docs

MIAMI (AP) -- The federal government has stopped reimbursing a Miami doctor who wrote nearly 97,000 prescriptions for mental health drugs to Medicaid patients over 18 months, in a case that prompted a key Senator to call for a nationwide investigation.

U.S. Sen. Sen. Charles Grassley of Iowa said Dr. Fernando Mendez Villamil wrote an average of 153 prescriptions a day for 18 months ending in March 2009. That's nearly twice the number of the second highest prescriber in Florida, who wrote a little more than 53,000 prescriptions, according to a list compiled by state officials.

Grassley, an Iowa Republican and ranking member of the Senate Finance Committee, which oversees Medicare and Medicaid, called the figures alarming and sent a letter Wednesday to the Department of Health and Human Services asking the agency to investigate top prescribers across the country. His inquiry comes as the government targets waste and fraud in the taxpayer funded programs.

HHS officials said they were aware of Florida's list of high prescribing doctors and were working closely with the state and federal agencies that investigate Medicaid fraud, according to a statement from Sec. Kathleen Sebelius' office.

Dr. Villamil hasn't been reimbursed by Medicare since May when HHS started investigating him.

An employee at Villamil's office declined to comment and a voicemail left at his office Thursday was not immediately returned.

"It's hard to believe that this dramatic level of activity could go unnoticed," Grassley told The Associated Press.

"It's a matter of program integrity, taxpayer protection and patient safety," added Grassley, who asked HHS officials to explain whether and how the agency tracks high-prescribing doctors.

The vast majority of the doctors near the top of Florida's list are in the Miami area, where Medicare fraud totals over $3 billion a year, higher than any place else in the country.

"The highest prescribers are always in Miami," said Karen Koch, vice president of the Florida Council for Community Mental Health. "They tend to use medication more maybe than in some others areas and then sometimes it's an anomaly in the data."

Koch said that some doctors on the list have multiple practices with other prescribers using their license, which is legal. The state also has a shortage of psychiatrists, meaning a smaller number of doctors are serving more patients each.

And sometimes patients doctor shop with the intention of selling the drugs, which also drives up prescription numbers.

The drugs that Villamil, a psychiatrist, prescribed most commonly included Seroquel, Zyprexia and Abilify.

Seroquel is the only drug that has street value in the United States. "When snorted, it acts like cocaine," said Koch. The other drugs "have high street value in South American countries because it is not available there so families in the U.S. are always trying to get it for their relatives there," she said.

The state's top prescriber list is part of the Medicaid Drug Therapy Management Program, which began monitoring mental and behavioral health medications when the program was created in 2006.

"The number of prescriptions recorded for Dr. Fernando Mendez-Villamil is high when compared to other Medicaid prescribers," state Agency for Health Care Administration spokesman Sue Conte said in an e-mail to The Associated Press.

However, she said "it does not indicate that there is anything improper regarding his prescribing," saying patients seeing a specialist like Villamil would need daily medications plus medications for acute episodes. Villamil's prescriptions also included refills, she said.

If a concern arises, AHCA's Office of Inspector General will more thoroughly investigate billing practices and prescribing patterns. If fraud is suspected, the case is sent to the Florida's Attorney General. About 123 cases were referred to the Medicaid Fraud unit in the past fiscal year, according to AHCA.

A spokesman for Florida's Attorney General said the office has a pending investigation into Villamil, stemming from a 2007 request from a private citizen. She declined to comment further.

A Florida doctor who prescribed several mental health medications to a 7-year-old foster care boy who killed himself in April is also on the list. The drugs carried a special FDA black box warning indicating they can cause suicidal thoughts and are not approved for young children, though some doctors still prescribe them to treat children.

Dr. Sohail Punjwani wrote 10,150 prescriptions during the same two year period, according to the report.

Dr. Punjwani, who has appeared on the high-prescriber list multiple times but has never been sanctioned, did not immediately return a phone call left by The Associated Press on Thursday.

Grassley's letter comes months after Gabriel Myers hung himself with a shower cord at his foster parents' home while under Punjwani's care. The boy's death prompted debate at the state's child welfare agency about stricter rules for prescribing powerful antidepressants and other drugs to foster children.


Senator Grassley Eyes Miami Psychiatrist


 U.S. Sen. Grassley


Miami Herald

Senator eyes Miami doctor

Sen. Charles Grassley pointed to a Miami doctor in an attempt to show that the government needs to do something about over-utilization of healthcare.

By John Dorschner

A Miami psychiatrist who writes prescriptions for Medicaid patients at a rate of 150 a day, seven days a week, has been targeted by a U.S. senator as an example of why the federal government should do more to investigate over-utilization of healthcare.

The biting letter, from Sen. Charles Grassley, R-Iowa, to federal Medicaid officials comes at a time when authorities are looking for ways to reduce what experts believe is massive overspending in areas like Miami, where healthcare costs can be more than twice the national average, as healthcare reform advocates look for ways to find the money to spread coverage to the uninsured.

The Grassley letter does not mention Fernando Mendez-Villamil by name, but noted ``with alarm'' documents from the Florida Agency for Healthcare Administration about a single prescriber who wrote 96,685 prescriptions from the last half of 2007 through the first quarter of 2009 for Medicaid patients.

AHCA records independently obtained by The Miami Herald show that the doctor is Mendez-Villamil, who wrote nearly twice as many prescriptions for mental health drugs as the No. 2 Medicaid prescriber in the state.

The huge number ``means that this physician wrote approximately 153 prescriptions each and every day, assuming he did not take vacations,'' Grassley wrote.

Mendez-Villamil told The Herald he works long hours and sees patients only for 10 minutes every two or three months. Medicaid pays him $45 per office visit. Each patient may require four or five prescriptions, he said, accounting for the large numbers he writes.

``When you know the patient, and the patient is stable, 10 minutes is long enough,'' said Mendez-Villamil, whose office is on Coral Way. He said he sometimes works 12-hour days during the week as well as Saturday mornings. He said he only prescribes what's medically necessary.

A reporter visiting his office at 8 a.m. on Saturdays has found a couple of dozen patients milling around out front, waiting to get in to see him.

Mendez-Villamil, 42, received his medical degree from the Universidad Central del Caribe in Puerto Rico. He did his residency in psychiatry at Jackson Memorial Hospital and has been licensed in the state since 1998.


The mental health drugs that Mendez-Villamil prescribes do not generally have a value as street drugs but they are expensive. He writes thousands of prescriptions a year for Zyprexa ($841.93 for 30-day supply at, Abilify ($634) and Seroquel ($430). All Medicaid drugs are paid for by Florida taxpayers.

David Katz, a Yale doctor specializing in public health issues, said it's tough to critique a doctor's work from afar, but he and others have abiding concerns about mental health treatment for underserved populations, such as poor Medicaid patients. Low reimbursement rates can lead to the ``knee-jerk use of prescription medications,'' which can ``translate into substandard care and preventable harm.''

Alfred Jonas, a Miami psychiatrist who's been practicing for more than a quarter-century, said he wondered about Mendez-Villamil's practice. ``There are psychiatric patients who can be seen every two months because they are so stable,'' Jonas said, ``but it's inconceivable to me that one's entire caseload would be like that, especially if they require four or five medications.

``And if they require that many prescriptions, it's unlikely that many wouldn't also need psychotherapy,'' which requires far more than a 10-minute session. ``It's all way too much for coincidence.''

In his letter to Kathleen Sebelius, secretary of Health and Human Services, Grassley demanded to know ``what systems'' federal agencies ``have in place to monitor utilization rates across the country?''


In an e-mail to The Herald Thursday afternoon, AHCA Press Secretary Tiffany Vause wrote that the state has a contract with the University of South Florida to monitor prescribing practices of doctors who write behavioral health prescriptions.

``The number of prescriptions recorded for Dr. Fernando Mendez-Villamil is high when compared to other Medicaid prescribers,'' Vause wrote, but the number does not ``indicate that there is anything improper regarding his prescribing. If a doctor is a specialist like Dr. Fernando Mendez-Villamil. . . it can be expected that he would have a high number of clients requiring the specialized treatment offered by psychiatric medications.''


Vause wrote many of the prescriptions the psychiatrist wrote could have been for refills. She said AHCA uses a warning system of ``edits'' that indicate causes for concern about a doctor's prescribing patterns. ``Mendez-Villamil has a small percentage of prescriptions that hit against these edits.''

Drug makers recommend that doctors monitor closely patients taking atypical antipsychotics, because users are prone to obesity and diabetes. In 2007, Mendez-Villamil prescribed this class of drugs 6,000 times, state records show. He told The Herald that he leaves possible side effects, such as diabetes, to the patients' general practitioners.



Monday, December 14, 2009

NYTimes - Poor Children Likelier to Get Antipsychotics


Poor Children Likelier to Get Antipsychotics

New York Times


Published: December 11, 2009

New federally financed drug research reveals a stark disparity: children covered by Medicaid are given powerful antipsychotic medicines at a rate four times higher than children whose parents have private insurance. And the Medicaid children are more likely to receive the drugs for less severe conditions than their middle-class counterparts, the data shows.

Suzanne DeChillo/The New York Times

Dr. Derek H. Suite, a psychiatrist in the Bronx, says he sees many children on antipsychotic drugs who do not need them.


Children and Antipsychotic DrugsGraphic

Children and Antipsychotic Drugs

Those findings, by a team from Rutgers and Columbia, are almost certain to add fuel to a long-running debate. Do too many children from poor families receive powerful psychiatric drugs not because they actually need them — but because it is deemed the most efficient and cost-effective way to control problems that may be handled much differently for middle-class children?

The questions go beyond the psychological impact on Medicaid children, serious as that may be. Antipsychotic drugs can also have severe physical side effects, causing drastic weight gain and metabolic changes resulting in lifelong physical problems.

On Tuesday, a pediatric advisory committee to the Food and Drug Administration met to discuss the health risks for all children who take antipsychotics. The panel will consider recommending new label warnings for the drugs, which are now used by an estimated 300,000 people under age 18 in this country, counting both Medicaid patients and those with private insurance.

Meanwhile, a group of Medicaid medical directors from 16 states, under a project they call Too Many, Too Much, Too Young, has been experimenting with ways to reduce prescriptions of antipsychotic drugs among Medicaid children.

They plan to publish a report early next year.

The Rutgers-Columbia study will also be published early next year, in the peer-reviewed journal Health Affairs. But the findings have already been posted on the Web, setting off discussion among experts who treat and study troubled young people.

Some experts say they are stunned by the disparity in prescribing patterns. But others say it reinforces previous indications, and their own experience, that children with diagnoses of mental or emotional problems in low-income families are more likely to be given drugs than receive family counseling or psychotherapy.

Part of the reason is insurance reimbursements, as Medicaid often pays much less for counseling and therapy than private insurers do. Part of it may have to do with the challenges that families in poverty may have in consistently attending counseling or therapy sessions, even when such help is available.

"It's easier for patients, and it's easier for docs," said Dr. Derek H. Suite, a psychiatrist in the Bronx whose pediatric cases include children and adolescents covered by Medicaid and who sometimes prescribes antipsychotics. "But the question is, 'What are you prescribing it for?' That's where it gets a little fuzzy."

Too often, Dr. Suite said, he sees young Medicaid patients to whom other doctors have given antipsychotics that the patients do not seem to need. Recently, for example, he met with a 15-year-old girl. She had stopped taking the antipsychotic medication that had been prescribed for her after a single examination, paid for by Medicaid, at a clinic where she received a diagnosis of bipolar disorder.

Why did she stop? Dr. Suite asked. "I can control my moods," the girl said softly.

After evaluating her, Dr. Suite decided she was right. The girl had arguments with her mother and stepfather and some insomnia. But she was a good student and certainly not bipolar, in Dr. Suite's opinion.

"Normal teenager," Dr. Suite said, nodding. "No scrips for you."

Because there can be long waits to see the psychiatrists accepting Medicaid, it is often a pediatrician or family doctor who prescribes an antipsychotic to a Medicaid patient — whether because the parent wants it or the doctor believes there are few other options.

Some experts even say Medicaid may provide better care for children than many covered by private insurance because the drugs — which can cost $400 a month — are provided free to patients, and families do not have to worry about the co-payments and other insurance restrictions.

"Maybe Medicaid kids are getting better treatment," said Dr. Gabrielle Carlson, a child psychiatrist and professor at the Stony Brook School of Medicine. "If it helps keep them in school, maybe it's not so bad."

In any case, as Congress works on health care legislation that could expand the nation's Medicaid rolls by 15 million people — a 43 percent increase — the scope of the antipsychotics problem, and the expense, could grow in coming years.

Even though the drugs are typically cheaper than long-term therapy, they are the single biggest drug expenditure for Medicaid, costing the program $7.9 billion in 2006, the most recent year for which the data is available.

The Rutgers-Columbia research, based on millions of Medicaid and private insurance claims, is the most extensive analysis of its type yet on children's antipsychotic drug use. It examined records for children in seven big states — including New York, Texas and California — selected to be representative of the nation's Medicaid population, for the years 2001 and 2004.



The data indicated that more than 4 percent of patients ages 6 to 17 in Medicaid fee-for-service programs received antipsychotic drugs, compared with less than 1 percent of privately insured children and adolescents. More recent data through 2007 indicates that the disparity has remained, said Stephen Crystal, a Rutgers professor who led the study. Experts generally agree that some characteristics of the Medicaid population may contribute to psychological problems or psychiatric disorders. They include the stresses of poverty, single-parent homes, poorer schools, lack of access to preventive care and the fact that the Medicaid rolls include many adults who are themselves mentally ill.


Children and Antipsychotic DrugsGraphic

Children and Antipsychotic Drugs

As a result, studies have found that children in low-income families may have a higher rate of mental health problems — perhaps two to one — compared with children in better-off families. But that still does not explain the four-to-one disparity in prescribing antipsychotics.

Professor Crystal, who is the director of the Center for Pharmacotherapy at Rutgers, says his team's data also indicates that poorer children are more likely to receive antipsychotics for less serious conditions than would typically prompt a prescription for a middle-class child.

But Professor Crystal said he did not have clear evidence to form an opinion on whether or not children on Medicaid were being overtreated.

"Medicaid kids are subject to a lot of stresses that lead to behavior issues which can be hard to distinguish from more serious psychiatric conditions," he said. "It's very hard to pin down."

And yet Dr. Mark Olfson, a psychiatry professor at Columbia and a co-author of the study, said at least one thing was clear: "A lot of these kids are not getting other mental health services."

The F.D.A. has approved antipsychotic drugs for children specifically to treat schizophrenia, autism and bipolar disorder. But they are more frequently prescribed to children for other, less extreme conditions, including attention deficit hyperactivity disorder, aggression, persistent defiance or other so-called conduct disorders — especially when the children are covered by Medicaid, the new study shows.

Although doctors may legally prescribe the drugs for these "off label" uses, there have been no long-term studies of their effects when used for such conditions.

The Rutgers-Columbia study found that Medicaid children were more likely than those with private insurance to be given the drugs for off-label uses like A.D.H.D. and conduct disorders. The privately insured children, in turn, were more likely than their Medicaid counterparts to receive the drugs for F.D.A.-approved uses like bipolar disorder.

Even if parents enrolled in Medicaid may be reluctant to put their children on drugs, some come to rely on them as the only thing that helps.

"They say it's impossible to stop now," Evelyn Torres, 48, of the Bronx, said of her son's use of antipsychotics since he received a diagnosis of bipolar disorder at age 3. Seven years later, the boy is now also afflicted with weight and heart problems. But Ms. Torres credits Medicaid for making the boy's mental and physical conditions manageable. "They're helping with everything," she said.


Friday, December 11, 2009

Green Mental Health Care

Genita Petralli

Green Mental Health Care —
Reclaiming Lives From
Psychiatric Drugs

by Genita Petralli, Nutritional Biochemist

"My life is dedicated to reclaiming lives from psychiatric drugs and exposing psychiatry for what it is; a gang of white collar drug pushers robbing our society of every resource that supports it right down to our future; the children.

"As a scientist and licensed practitioner I want to educate all those interested in what is causing the epidemic mental health crisis of today, how to avoid it, how to get off of psych drugs if you are on them now, and why toxic drugs should not ever be called medicine."

Click here to read more.


Friday, December 04, 2009

Ever see a psychiatrist get his license revoked?

Today, the Florida Board of Medicine voted unanimously to revoke Emanuel John Falcone’s medical license.

He had sex with a patient.


See video here:




Psychiatrist Emanuel Falcone


More stories and TV footage will be coming forth but the below links show what has been reported today.  


A few excerpts:

Florida Times Union

Florida State Prison psychiatrist's license stripped over past patient-sex relationship

In today’s hearing, Falcone’s effort to get his revocation reduced to probation and a fine, among other penalties, was rebuffed by the panel. He declined to be interviewed as he left the hearing and walked away with his head down and hands in his pockets.

Florida Department of Corrections Admits Poor Judgement in Hiring

The Florida Department of Corrections admits its medical staff used poor judgment when they hired a psychiatrist at Florida State Prison, even though they knew his medical license had been revoked in New York for having sex with a mentally ill patient he was treating.

Medical license revoked for prison psychiatrist

The Associated Press


RAIFORD, Fla. -- A senior psychiatrist at Florida State Prison at Raiford will have his medical license revoked.

The Florida Board of Medicine voted unanimously Friday to revoke the license of Emanuel Falcone.

Florida Health News

Psychiatrist's license revoked

By Carol Gentry


Falcone, 52, resigned when top officials at the Department of Corrections found out from a reporter for the Florida Times Union that his New York license was revoked last year. Authorities there had charged him with taking sexual advantage of a patient who had multiple personality disorder, an adult woman who had numerous childlike "alters."


Weekley said it was unfortunate that corrections officials reacted to "a high-profile media circus." Indeed, television cameras recorded the proceedings, an unusual event for an administrative board.

Thursday, December 03, 2009

Prison Psychiatrist Resigns


Florida Times Union

Raiford prison psychiatrist quits over sex with patient

By Paul Pinkham

Thursday, Dec. 3, 2009


A senior psychiatrist at Florida State Prison in Raiford quit Wednesday  after corrections officials were asked why he was hired even though New York revoked his medical license last year for  having sex with a mentally ill patient.


Emanuel John Falcone was hired for the $188,000-a-year position in September,  even after revealing his past to the person who interviewed him, prison officials said. Falcone, 52, also faces a pending recommendation, scheduled to be heard Friday, that his Florida license be revoked or suspended.


Department of Corrections Secretary Walter McNeil was unaware of any of that until the Times-Union called Tuesday with questions about why Falcone was hired, a department spokeswoman said.


“Once he learned about it, we started questioning Dr. Falcone, and he chose to resign,” said Gretl Plessinger.


She said she was unaware who else in the department knew of Falcone’s past.


A woman answering Falcone’s phone number in Fort Myers said, “I don’t think he’s going to be interested in talking to you,” before hanging up Wednesday afternoon. In his formal response to the New York Bureau of Professional Medical Conduct last year,  he admitted the sexual relationship but denied ever treating the woman, who suffers from multiple personality disorder.


He was not charged with a crime.


Jennifer Druitt,  executive director of the Florida Council Against Sexual Violence, said she was surprised the prison system would hire Falcone after he lost his license in New York and faces losing it in Florida. At best, she said, he exhibited serious problems with judgment.


According to the New York bureau, the woman began seeing Falcone’s girlfriend, a licensed clinical social worker, in her Manhattan office in 2003. The patient-relationship continued after the couple married and moved to Florida in 2005. Falcone’s wife would share the patient’s information with him, the New York bureau found. The woman and Falcone began communicating by phone, and he gradually took over her treatment.


In a case summary, a panel of New York physicians wrote that Falcone was “fascinated” by her alternative identities, some of which were children. Her actual age wasn’t in any of the reports.


Their sexual relationship began in 2006 when they got together in New York, the summary said. It continued with a weekend trip that year to swanky Captiva Island, near Fort Myers.


Falcone told the bureau he never considered his interactions with the woman to be treatment or therapy. But the panel rejected that argument in permanently revoking his license in September 2008 for professional misconduct, gross and repeated incompetence and negligence and failing to maintain medical records.


“He was too selfishly motivated and lost sight of his oath,” the panel said. “... We saw no remorse, no humility, no sign that he understood the great harm that he caused despite his attempt to present a speech that was supposed to convince us otherwise.”


The bureau found his actions toward the patient “predatory” and said he knew her illness left her vulnerable.


“He eventually exploited that vulnerability for his own purpose and satisfaction,” the panel wrote.


Florida’s Health Department began investigating last December,  including allegations that he didn’t notify Florida authorities about the New York revocation.


The department petitioned the Board of Medicine in April  for revocation or suspension of his Florida license. State law says having a license revoked by another jurisdiction is grounds for disciplinary action by the Board of Medicine.


In October, Falcone requested a hearing at the board’s Friday meeting in Orlando. The board could take any action it chooses, from a reprimand to revocation.