In the November 30 Sun Sentinel article "Many die as doctors exploit Medicaid," Fred Schulte raises concerns about the Medicaid prescribed drug program. The Agency for Health Care Administration, which administers the Florida Medicaid program, is fully aware of the issues raised in the article and continues to aggressively implement solutions to eliminate or minimize their effect. In the past four years, Florida Medicaid has implemented the most comprehensive prescribed drug cost control and fraud and abuse prevention program in the nation. Some of the major initiatives include:

• Beginning in 1998, the Agency implemented a comprehensive clinical prior authorization program targeting the drugs that have the potential for abuse, misuse, or overuse. In January 2002, Oxycontin was added to this special review process, utilizing clinical pharmacists to review the clinical appropriateness of the medication for each targeted prescription with the prescribing physician. Clinical prior authorizations have significantly reduced the inappropriate prescribing of the targeted medications and have saved the state over $150 million.
• Since 1998, Florida Medicaid has implemented the largest disease management program in the nation; through multiple contractors, beneficiary use of care is closely monitored for beneficiaries with a variety of diseases.
• The Legislature authorized a Prescribing Pattern Review Panel in 1999. Since 2002, the Agency increased the number of individuals referred to the panel as a result of increased monitoring of prescribing patterns. In the past 12 months, 150 individual physician prescribing records have been reviewed, resulting in 30 physicians being referred to the Agency for inclusion in the clinical prior authorization program that requires additional documentation and review of each prescription for those medications where the panel finds the prescribing patterns to be of concern.
• In 2001, the Agency implemented a monthly four-brand drug limit for adult beneficiaries; use beyond the limit requires prior authorization.
• In 2001, the Agency implemented a comprehensive drug benefit management program to analyze and manage drug benefit use by beneficiaries using certain categories of drugs or a high volume of drugs.
• Beginning in 2001, the Agency significantly expanded audits of Medicaid participating pharmacies to detect fraud and abuse.
• In 2001, Florida Medicaid imposed a 34-day limit on supplies and prohibited early refills.
• Early in 2002, the Agency hired five area pharmacists to meet with physicians in their offices. Area pharmacists discuss issues such as recipient doctor shopping, coordination of care, and appropriate utilization of pain medications. The Agency is currently adding four more area pharmacists.
• In FY 2002-03 (July 2002 - June 2003), the Agency implemented a Diverted Pharmaceuticals Pilot Project in Broward, Miami-Dade, Monroe and Palm Beach counties to prevent the fraudulent practice of reselling Medicaid prescribed drugs to wholesalers and pharmacies.
• In October 2002, the Agency implemented a recipient lock in program. This program requires that a recipient who has been identified as a high user and potential abuser of prescribed drugs, or who obtains prescriptions from multiple physicians, to obtain all of their medications from a single pharmacy. The program currently has 589 recipients enrolled, 200 of which were enrolled in the lock in program in just the last quarter. The majority of lock in recipients are using Oxycontin and other targeted medications. The intent is to ensure that at least one medical professional, the pharmacist, is aware of all the medications that the recipient is receiving.
• In February 2003, AHCA contracted with Heritage Information Systems to analyze and apply sophisticated drug algorithms used to detect unusual drug utilization patterns and assist the Agency in determining the cause. Prescription data are analyzed on a daily basis and summarized for the Agency on a weekly basis. Information is then disseminated to the appropriate drug utilization program for follow-up and action.
• In April 2003, the Agency began promoting the use of a website which allows the physician to view 90 days' history of all the Medicaid prescriptions filled for his/her patients. This allows the physician to check for abuse, compliance, and multiple prescribers.
• To further provide physicians with the necessary information to monitor their patients' drug use, in the spring of 2003, the Agency contracted with Gold Standard MultiMedia to provide 1000 handheld, wireless PDAs to the top prescribing Medicaid physicians. The PDAs provide the physician with 60 days' history of all the Medicaid prescriptions for their patients along with clinical information to assist in the appropriate prescribing of medications.
• The Agency uses all of these tools on a daily basis to detect and reduce inappropriate medication use.

While these efforts have dramatically decreased the rate of growth in Medicaid prescribed drug spending and have had a positive impact on prescription fraud and abuse, the Agency continues to develop initiatives that will further reduce the negative impact of improper drug use on Medicaid beneficiaries and eliminate loss due to fraud or abuse. The Agency is currently proposing legislation that will:

• Enable the Agency to take action against beneficiaries, including a suspension of benefits, who are abusing their Medicaid benefits. Beneficiary restrictions, however, are greatly limited by restrictions in federal law.
• Enable the Agency to deny a prescription claim that was written by a physician who is not enrolled to participate in the Medicaid program. Specifically, this proposal would allow the Agency to require that a health care professional be enrolled in the Medicaid program in order to pay for any drugs prescribed by the provider.
• Enable the Agency to mandate participation in the appropriate disease management program when the recipient is identified as an over-user or abuser of Medicaid services. This will enable the Agency to better monitor the care that is being provided to these recipients.
• Enable the Agency to sanction a provider who routinely submits claims with erroneous information (e.g., wrong physician identification number). This is in response to a study by the Agency that indicated that as much as 15% of pharmacy claims do not correctly identify the prescribing physician.
• Secure additional authority to limit the Medicaid provider network and prevent questionable providers from serving Medicaid beneficiaries.

The Agency is committed to reviewing all of the information highlighted in the articles. If any deficiencies are detected for which program controls have not already been implemented, the Agency will implement or seek legislation to provide additional controls.

In addition, the Agency for Health Care Administration continues to work closely with the Governor's Office of Drug Control and other state agencies to find solutions to address the abuse of pain-related medications. Recent efforts have included proposing legislation to require that all prescriptions written for a schedule II to IV controlled substance (e.g., Oxycontin and Methadone) for all patients regardless of payer be included in a single statewide database, accessible to all health care providers to guard against prescription drug abuse.

Dr. Rhonda M. Medows, FAAFP
Secretary, Agency for Health Care for Administration