Friday, October 19, 2012

Who do You Trust?


The news today includes two stories about physicians. Each is disturbing.

From California, we learn that as many as 201 doctors are accused of writing prescriptions for patients that they either did not evaluate or who did not need the medication. Allegedly, a California based company recruited these physicians and paid a commission to them for  prescribing certain topical analgesics to their patients. The company allegedly did the billing and collecting also. According to Workcompcentral.com
40 of the doctors named in the complaint matched physician names and addresses listed by California in their Qualified Medical Evaluator database, another 37 others matched  names only. The story reports that doctors in Florida, Arizona, and South Carolina are also implicated.

The Workcompcentral story reports that allegedly this pharmacy vendor and related companies control about 75,000 prescriptions, and billings of almost $20 million. For comparison, Melbourne, Florida has a census population of about 75,000 people. Those prescriptions may or may not be authentic, and each of those doctors deserves their day in court if they are eventually accused of wrongdoing.


In an unrelated story, a 61 year old Massachusetts surgeon named Kathaleen Porter will spend a year on house arrest, five years on probation, and has surrendered her medical licenses. Her offense? Prescribing an "alarming amount of Percocet to three patients between 2007 and 2009." Dr. Porter admitted she had not examined the patients for months, but that they would call her, tell her how many pills they wanted, and she would tape a prescription for them on her office door. One patient allegedly filled prescriptions at twelve different pharmacies, leading to some suspicion of a potential problem, and an investigation. This may be an example of where a mandatory prescription drug database would help; or this may be an example of how those who ignore laws will simply ignore the mandate to check the database.


The allegations in the first story may support various conclusions. It is possible that there is a massive misunderstanding, and no criminal  or otherwise inappropriate behavior has occurred. The plea in the second story may reflect a recognition of criminal liability, or perhaps the doctor elected to accept this outcome because defending against it was too costly in time and or money. It is also possible that everyone involved in each story is guilty and should be prosecuted to the full extent possible under the law. Between these two possible extremes, it may be that there is criminal agency at work here, but that there are also some people involved whose greatest flaw is their trust, laziness or stupidity, none of which is criminal.


It is curious that educated people would make a cost-benefit analysis and decide that their investment in education is worth risking on a few dollars. According to Yale University Medical School, the average Med School tuition in 2010 was about $40,000 per year, and the average school debt of graduates varied by schools, but ranged from about $80,000 to almost $200,000. For reference, in 2010 the median price of a new home in the United States was just over $200,000. Having invested the time and effort to get the best grades in high school, four years of college, medical school, and residency, the financial and other costs of becoming a doctor would seem as obvious as they seem steep. The risk of loss of such a privilege over prescriptions like Dr. Porter's boggle the mind.


Why do the news outlets continue to tell us about physicians involved with "pill mills?" Why would a physician prescribe Percocet in "alarming amounts" to a patient they have not examined in months. Why would a physician put their trust, their license, their livelihood in the hands of a third party who will bill on their behalf and in effect use their good name? There is a hue and cry regarding needs for government regulation on topics like physician dispensing, prescription medication databases, and pill mills. But might we solve some of our own problems if we more regularly enforced the laws we have?

Dr. Porter, for whatever reason, plead guilty to stepping outside the lines. She may no longer practice medicine. Her practice and her good name are no more. Good. The doctors involved in the prescription outsourcing story may be innocent of wrongdoing, guilty of trusting too easily, or guilty. Let the system work and let the penalty fit whichever outcome is reached. 

It is often repeated that we can learn as much from a bad example as we can learn from a good one. From Dr. Porter I hope many will take a lesson to heart. From the California investigation, perhaps time will teach us all lessons about who and how far we trust. 

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