From Analytics to ActionA Law Enforcement Perspective on the Use of Data

Analytics to Combat Rx Drug Diversion

Gary CantrellDeputy Inspector General

Mike CohenInspector

U.S. Department of Health and Human Services Office of Inspector General/Office of Investigations

Overview

• HHS-OIG Overview

• Use of Data Analytics

• Prioritizing Enforcement through Data

• Rx Data Analytics

• Rx Drug Fraud Trends in Medicare/Medicaid

• Case Example – Pharmacy Scheme

• Measuring Impact

Program Scope

• CMS is the largest purchaser of health care in the world – approximately $802 billion

• Medicare, Medicaid, and Children’s Health Insurance Program provide care for approximately 1 in 4 Americans (roughly 107 million beneficiaries)

• CMS processes more than 1 billion Medicare claims annually

HHS Office of Inspector General

• Mission: Protect the integrity of HHS programs as well as the health and welfare of program beneficiaries

• Fight fraud, waste, abuse in Medicare & Medicaid, plus 100 other HHS programs

• Largest Inspector General’s office in Federal Government

• Office of Investigations performs criminal, civil and administrative enforcement

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OIG Statistics

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Office of Inspector General Statistics

OIG Action FY10 FY11 FY12 FY13 FY14 Total

Criminal Actions 647 723 778 960 971 4,079

Civil Actions 378 382 367 472 533 2,132

Exclusions 3,340 2,662 3,131 3,214 4,017 16,364

HHS Investigative Receivables $3.2 Billion $3.6 Billion $4.3 Billion $4.0 Billion 2.9 Billion $ 18.2 Billion

Non-HHS Investigative Receivables $576.9 Million $952.8 Million $1.7 Billion $1.02 Billion 1.1 Billion $5.3 Billion

Total Investigative Receivables $3.8 Billion $4.6 Billion $6.0 Billion $5.0 Billion 4.1 Billion $ 23.6 Billion

How do you prioritize enforcement in a program so large?

Data Analytics

• Data analytics plays a significant role in OIG’s oversight and enforcement strategy

– Allocate Resources

– Triage Allegations

– Investigations are more efficient

– Measure Impact

IMPACT

Rx Drug Analytics

Medicare Prescription Drug Spending

Medicare Payment Trends:Miami FL CBSA, 2006-2014 (Q3)

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Pharmacy model

Metro area distribution of the 1,000 pharmacies with the highest risk scores

0 50 100 150 200 250 300 350 400 450

Miami

New York

Los Angeles

Detroit

Houston

Tampa

McAllen

Dallas

Number of pharmacies

Prescriber model

Metro area distribution of the 1,000 prescribers with the highest risk scores

0 50 100 150 200 250 300 350 400 450

Miami

New York

Detroit

Los Angeles

Atlanta

Tampa

Phoenix

Houston

Number of prescribers

Prescriber “pill-mill” model

Metro area distribution of the 1,000 prescribers with the highest risk scores

0 10 20 30 40 50 60

Nashville

DC/Baltimore

Atlanta

Philadelphia

New York

Phoenix

Detroit

Seattle

Number of prescribers

Proactive Analysis

Recent OIG Drug Reports

• Inappropriate Medicare Part D Payments for Schedule II Drugs Billed as Refills– Inappropriately paid $25M for schedule II refills

– Pharmacists putting “dummy numbers” or pharmacy number rather than prescriber number: “AB0000000”

• Prescribers with Questionable Patterns in Medicare Part D – 736 general care physicians

– Medicare paid $352M for part D drugs from these physicians

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Recent OIG Drug Reports

• Retail Pharmacies with Questionable Part D Billing– Over 2600 pharmacies identified

– Found 873M prescriptions written for 24M benes

• Medicare Inappropriately Paid for Drugs Ordered by Individuals Without Prescribing Authority– Massage Therapists, Athletic Trainers, Home Repair Contractors,

etc.

• Part D Beneficiaries With Questionable Utilization Patterns for HIV Drugs– Almost 1,600 Part D beneficiaries had questionable utilization

patterns for HIV drugs.

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DHHS/OIG

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Rx Drug Fraud Trends

OIG Purview

• All drugs billed to Medicare, Medicaid

• This includes Controlled and Non-Controlled medications

• Non-Controlled very expensive

• Used as bargaining chips

SubSys

• Fentanyl approved for cancer pain

• 2014 Medicare spent $98M for 13K prescriptions

Others

• Oxycodone, hydrocodone products (Zohydro)

• ADHD medications

• Sedatives/Anxiolytics (Ativan)

• Ketamine (compounding)

Why Worry About Non-Controlled?

• Used illicitly by themselves

– Antipsychotics (“jailhouse heroin”)

– HIV medications side effects (e.g. Sustiva)

• Used as “potentiators” for opiates

Polypharmacy Cocktails Potentiators

• Abilify + Seroquel Snort (“jailhouse heroin”)

• Soma + Codeine (“Soma Coma”)

• Seroquel + Zyprexa + Ativan + ETOH + Cocaine

• HIV Protease Inhibitors + Percocet

• Caffeine + ETOH + Eyeball

• Promethazine/Codeine + Tampon

• ETOH + Albuterol Inhaler

• Adderall + Albuterol + Sleep deprivation

• Adderall + Lexapro + Cannabis

• Meth/Ecstasy/Viagra (Rectally)=“Royal Flush”

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Erowid Recipe Blog

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DHHS/OIG

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Case Example

• Detroit pharmacist (Babubhai “Bob” Patel) owned 26 pharmacies

• Provided kickbacks to induce physicians to write prescriptions and present them to his pharmacies

• Pharmacist/owner arrested and sentenced to 17 years

• 26 Defendants Originally Charged– 20 Convicted or Pled Guilty, including

• 11 of 12 Pharmacists

• 2 of 4 Doctors

• 13 Additional Defendants Charged– Including 5 doctors, 4 Pharmacists, and a Home Health Agency

owner

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One of Patel’s “Apartments”

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Boxes Confiscated from Search Warrant

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Measuring Impact

Outcomes: DME Payment Trends

• Medicare payments for DME in Miami peaked at more than $60 million per quarter in 2006

• In 2007, numerous federal oversight and administrative initiatives were launched by CMS, OIG and others, including the Medicare Fraud Strike Force in May 2007

• Miami-area DME payments decreased from over $40 million per quarter in 2007 -before the Strike Force’s first takedown-to $15 million per quarter in 2011 (e.g., approximately $100 million in annual savings thereafter)

Sustained declines in Medicare payments have followed Federal enforcement and oversight action.

Outcomes: HHA Payment Trends

• Medicare payments for Home Health care increased from 2006 until 2010

• In 2009, federal enforcement actions (initiated by the HEAT Strike Force case U.S. v. Zambrana in Miami), followed by the OEI HHA Outlier Payments report, influenced CMS to change Medicare’s HHA outlier coverage policy

• Since 2010, Medicare payments for home health care nationally decreased by more than $300 million per quarter (e.g., more than $1 billion annually)

– In Miami, payments for HHAs decreased by $100 million per quarter since peak in 2009

– In Dallas and McAllen, TX, payments for HHAs are down by $30 million per quarter

– In Detroit, payments for HHAs decreased by $25 million per quarter since peak in 2009

Sustained declines in Medicare payments have followed Federal enforcement and oversight action.

What To Do if you Suspect Medicare Fraud or Diversion Activity?

If you suspect a Medicare provider or beneficiary is diverting, contact

• 800-HHS-TIPS or at

• oig.hhs.gov/report-fraud

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Questions?

Gary.Cantrell@oig.hhs.gov

Michael.Cohen@oig.hhs.gov