Suspicious Prescriptions for HIV Drugs Abound in Medicare
The inspector general of the U.S. 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.To check how your doctor prescribes drugs in the Medicare program and compares to peers, check outProPublica's Prescriber Checkup tool.ABOUT THE AUTHOR
Charles Ornstein is a senior reporter for ProPublica covering health care and the pharmaceutical industry.Credit: HIV
Report: Children of LGB Parents Functioning 'Quite Well'
The study also shows a high proportion of bisexual adults are parents.
Another study released this summer shows that lesbian, gay, and bisexual parents are as effective and nurturing as heterosexual parents, if not more so.The July report by the University of California, Los Angeles, School of Law's Williams Institute indicatesthat LGB families deal with extra pressures such as heterosexism in various societal settings, added legal implications in states that don’t allow same-sex marriage or adoption, and discrimination in medical settings. Despite these pressures, however, LGB families continue to prosper.“The findings are consistent in suggesting that despite confronting heterosexism in a variety of social contexts — including the health care system, the legal system, and the school system — LGB parents and their children are functioning quite well,” the report's authors write.The study mirrors others that cite the benefits of LGB-headed families, including one released in early July from the University of Melbourne, which said children raised by same-sex couples are healthier and happier than those raised by opposite-sex pairs.The report also points to the large portion of LGB parents — 64 percent — who are openly bisexual. The Williams Institute cited a 2013 Pew Research survey, which found that more than a third of all LGBT individuals report being a parent. An estimated 59 percent of bisexual women and 32 percent of bisexual men report having had children, while 31 percent of lesbians and 16 percent of gay men are parents.Although many LGB parents are bisexual, most of the research on LGB parenting has been has been limited to specific gender, racial, and economic demographics.“The research on LGB parenting is characterized by a variety of sampling- and methodological-related problems,” the authors of the Williams Institute report wrote. “The samples that are utilized in studies of LGB parents tend to be small, white, well-educated, and financially stable, and are often drawn from metropolitan areas.”Credit: Children
STUDY: Tivicay Surpresses HIV Even in Those Who are Drug Resistant
The recently approved HIV integrase inhibitor showed a high rate of suppressing the virus, even among those who are drug-resistant.
Tivicay, the recently approved HIV integrase inhibitor — a class of antiretroviral drug that is designed to block a virus from entering the DNA of a host cell — demonstrated high rates of viral suppression in a recent study. Significantly, Tivicay is also proven effective for people who are resistant to HIV antiretroviral drugs, according toNAM.The study concluded that among people starting treatment for the first time, there was no resistance detected during the 96 weeks of follow up, according to findings presented at the recent 20th International AIDS Conference in Melbourne, Australia.Modern antiretroviral treatments are highly effectively and are well-tolerated. However some people who have resistance to the existing drugs or may have difficulty tolerating specific side-effects.Jim Demarest of ViiV Healthcare lead a team that analyzed the outcomes among participants that were part of phase three trials with Tivicay. Three studies followed people who had not previously taken any HIV medications, while one trial focused on those who have received treatment before and had experienced resistance to two or more drug classes.In the studies that followed treatment-experienced participants, 71 percent of participants that took Tivicay saw viral suppression at 48 weeks, compared to the 64 percent of those who took Isentress, another drug used to treat HIV.Regulators in the U.S. are currently evaluating a fixed-dose medication containing Tivicay and Kivexa or Epzicom. If the drug is approved, it will be the first one-pill, once-daily regimen that does not contain tenofovir DF (brand name, Viread), which some people with HIV have avoided because of its risk of kidney and bone toxicity. This combination has already received approval by the European Medicines Agency and will be marketed as Triumeq in Europe.
New Regulation Further Restricts Legal Abortions
Jakarta. Experts have lashed out a new government regulation that they warn will severely restrict one of the few circumstances in which a woman can legally get an abortion in Indonesia.The regulation on reproductive health, signed with little media attention last Friday by President Susilo Bambang Yudhoyono, stipulates that women who get pregnant as a result of rape may apply for a legal abortion, but only within 40 days of their last period.An existing article in the 2009 Health Law, however, places no such restriction on when a rape victim may get an abortion.The new rule, critics say, will give rape victims virtually no time to make a clear and informed decision about whether they want to abort the fetus.“There shouldn’t be this 40-day restriction,” Masruchah, a member of the National Commission on Violence Against Women, or Komnas HAM, told the Jakarta Globe on Tuesday.“Rape victims in rural areas, for instance, often never find out that they’re pregnant” until two or three months later, she added.Suryono Slamet Iman Santoso, a gynecologist at Jakarta’s Abdi Waluyo Hospital and former reproductive health lecturer at the University of Indonesia, notes that most women don’t even think about testing for pregnancy until after 40 days from their last period.“That’s when their expected period is typically about two weeks late. So it’s only after 40 days that you can make a reasonably accurate determination of whether a woman is pregnant or not,” he told the Globe.“I believe there shouldn’t be this restriction. It will be hard to implement,” he added.The new regulation also fleshes out the process for determining what constitutes a life-threatening health condition for the mother or fetus, which is another circumstance in which a woman may get an abortion — but restricts this too by requiring that the woman obtain approval from her husband.No such condition is listed in the 2009 Health Law.Government officials, however, are crowing over what they call a progressive regulation, saying that it places women’s health at the fore.“It takes into consideration every aspect of the health, safety and comfort of the woman, her family and the fetus,” Anung Sugihantono, the Health Ministry’s director general for maternal and child health, said in Jakarta on Tuesday.“It should also be understood that this regulation does not legalize abortion,” he added.The government regulation will be shored up with a Health Ministry regulation that details the processes and mechanisms for a legal abortion, Anung said.Credit: Legal abortions
How many men are paedophiles?
The Pope was recently reported to have said that about 2% of Catholic clergy are paedophiles. But how does this compare with society as a whole - is it more or less than average?As soon as you give this question a moment's thought, you realise that it's not going to be an easy one to answer. Paedophiles are not easy to identify."Because paedophilia is so secretive and so few people are willing to admit it, there is no meaningful way to get a reliable estimate," says Dr James Cantor, a psychologist and sexual behaviour scientist at the University of Toronto."There's no meaningfully ethical way of taking 200 men, hooking them up to detectors, showing them pictures of adults and children and seeing how many respond most to children."One person who has attempted an estimate is Dr Michael Seto, a clinical and forensic psychologist at the Royal Ottawa Healthcare group.In 2008 he wrote a book in which he put the prevalence of paedophilia in the general population at 5%.The figure was based on surveys conducted in Germany, Norway and Finland in which men were asked whether they had ever had sexual thoughts or fantasies about children or engaged in sexual activity with children.But Seto stresses that 5% was an upper estimate, and that the studies were limited in what they revealed."What those surveys don't include are questions on the intensity of those thoughts and fantasies, whether they were repeated or not. Someone might say 'Yes' because they once had a fantasy but our understanding of paedophilia would be that that person recurringly had sexual thoughts and fantasies about children."Now, with more data and better methodology, he has revised his figure down to about 1% of the population, though he makes clear this is still only an educated guess.One problem is that the term "paedophile" means different things to different people."It's very common for regular men to be attracted to 18-year-olds or 20-year-olds. It's not unusual for a typical 16-year-old to be attractive to many men and the younger we go the fewer and fewer men are attracted to that age group," says Cantor.He thinks that if we say that a paedophile is someone attracted to children aged 14 or less, then he estimates that you could reach the 2% figure."If we use a very strict definition and say paedophilia refers only to the attraction to pre-pubescent children [then it] is probably much lower than 1%," he says.The term is often applied to a person who sexually abuses someone below the age of 16, but given that in some countries - and even some US states - you can marry below the age of 16 this definition would clearly not be universally accepted.There is consensus on the clinical definition. Michael Seto and his colleagues agree that a paedophile is someone who has a sexual interest in pre-pubescent children, so typically those under the ages of 11 or 12.But whether the prevalence using this definition is 0.5%, as James Cantor says or 1%, as Michael Seto says, you can be assured than in any large group of people - whether they be politicians, entertainers, or Catholic clergy - you are likely to find some paedophiles.Paedophilia is not restricted to men - some women also sexually abuse children, although research suggests this is much less common.But back to the Pope. How would he define "paedophile"? We don't know, but there is a clue.There is one well-known study of paedophilia among Catholic clergy, carried out by John Jay College of Criminal Justice in New York. Its researchers went to each diocese in the US and found all the plausible accounts of abuse involving clergy who served between 1950 and 2002 - and they found that 4.2% of had been plausibly accused of abuse.That included allegations of abuse of adolescents as well as pre-pubescent children.But if you use the stricter, clinical definition of paedophilia the figure drops to between 1-2% according to Prof Philip Jenkins from the Institute of Studies of Religion at Baylor University in Texas. This corresponds, more or less, with the figure attributed to the Pope."If he was using a different word like 'abusive clergy' then I think he would be going for a higher figure," says Jenkins.The John Jay College study is not perfect, though. For some reason, 40% of the allegations referred to abuse said to have been carried out in a six-year period between 1975-1980.It seems unlikely that cases of paedophilia in the clergy would have been so heavily concentrated in one period. Furthermore, even if there was a peak in the 1970s, a lot of the perpetrators are probably no longer active in the church.All we can confidently say is that, firstly, the figures are imperfect - both for Catholic clergy and the general population. And secondly, that these imperfect figures are in the same ballpark.Credit: How many
China activists fight gay 'conversion therapy'
Gay rights activists in China are preparing for what they say could be a legal milestone in their fight to stop homosexuality being treated as an illness.Later this month, a Chinese court will hear the first case of its kind brought against a clinic that offers so-called "gay conversion therapy".A long campaign in Europe and America has been successful in shifting the medical consensus against such treatment, and now campaigners want Chinese doctors to follow suit.In an office block in the eastern city of Nanjing, down a gloomy corridor, I find the Nanjing Urban Psychiatric Consultancy Centre.It's a small office with a sparsely-furnished treatment room upstairs, from which - seemingly prompted by our arrival - a young male patient hurriedly leaves.China declassified homosexuality as a mental illness well over a decade ago, but clinics like this one are still easy to find.Dr Zhou Zhengyou shows me some of the books he's written on the subject over the course of his career.One of them is a guide for parents who suspect their son or daughter might be gay.The overriding message appears to be that it is their own parenting methods that are somehow to "blame".Dr Zhou now claims to cure up to 70% of his gay patients, although he says it is a long and difficult process.And, his critics point out, at $120 (£70) a session - a lot of money on an average Chinese wage - long and difficult can mean lucrative.Dr Zhou tells me that today he uses counselling alone and does not treat his patients with so-called aversion-therapy offered elsewhere in China. But he is happy to describe how it works."One common method is electric shock. When the patient has a gay thought, we electrocute them or inject them with drugs that make them sick," he said.
Legal challengeChina's gay community has begun to fight back. They've organised a number of protests - small in number but nonetheless brave in China.Video footage of one demonstration shows activists holding up a protest banner at a Beijing medical conference. "Being gay is not an illness," it reads.The delegates do not seem convinced. "We cannot support homosexuality," a doctor said. "Although we try to understand it," his colleague adds.In addition to such direct action, the campaigners have been given another avenue to pursue.For the first time, China has allowed them to challenge gay conversion therapy in the courts."I had electric shock therapy only once," the man bringing the case, who calls himself Xiao Zhen, told the BBC. "Imagine those who've had it many times."He put himself through the treatment in order to gather the evidence and he's now hoping that a successful court ruling in his favour will effectively ban the practice.It's a battle that has been fought elsewhere, of course.Aversion therapy has been the target of campaigners in Europe and America for decades and today, the notion of the gay conversion has not completely gone away.But the modern medical consensus in the West is that there's no good evidence that sexual orientation can be changed.Some people suggest that attitudes in China have been slower to evolve because of the one-child-policy as well as heavy Confucian pressure on young people to get married and produce a family heir.Attitudes in China, though, are changing fast - that Shanghai now holds an annual gay pride event is proof of that. It includes gay film screenings, discussion groups and a fun-run.Being China, participants are not allowed to march.Now the court case, it's hoped, will be another step forward, sending a message that the enduring medical prejudice needs to stop.Credit: China activists