How one reporter accidentally stumbled on a state-wide prescribing investigation Date: 11/30/18
By Cheryl Clark
With “Death Certificate Project” and “opioids” in a headline, any story would — one would think — be a gold mine for page views.
But it surprised me that no media organization had published anything on this California effort when I found out about it on Aug. 1, though it had been going on for more than three years.
Designed to identify excessive opioid prescribers, the ongoing project involves the Medical Board of California’s review of nearly 2,700 death certificates for patients with confirmed fatal overdoses in 2012 and 2013. The board licenses some 137,000 medical doctors, 14.5 percent of the nation’s 951,000 physicians.*
The board’s reviewers pair the names of those deceased patients with the CURES prescription database to identify which clinicians prescribed any opioids for them within three years of their death — regardless of whether those prescriptions or even that same drug was the actual cause of death.
Though the project was launched around 2014, several high-level officials in organized medicine networks told me it was news to them or, if they had heard of the effort, they thought it had gone nowhere with a very low or non-existent yield for bad doctors who weren’t already under investigation for something else. The board had issued no press releases or public statements about it, except for a poorly publicized podcast posted May 30.
Even the 43,000-member California Medical Association, which one would think would be fighting back like crazy against what they might see as a horribly inappropriate over-reach, was uncharacteristically silent.
The San Francisco Marin Medical Society posted this advisory earlier this year, but that’s about it.
In fact, the first accusation stemming from the project wasn’t filed until Feb. 28 and didn’t even mention the “Death Certificate Project,” or that a patient under his care had died.
I learned of this effort because a physician neighbor casually told me one Saturday — while mowing his lawn — that in March, he’d received a worrisome letter from the Medical Board of California.
That letter asked him to send the medical records for one of his patients who, it said, fatally overdosed in 2012, six years earlier, and asked him to “respond to the allegations” because one of that patient’s opioid prescribers “was noted to have been you.”
It was particularly odd because another physician in his five-doctor practice had also received the same accusatory letter.
Those letters turned their practices upside down, requiring hours of work for them to document care delivered more than six years earlier and write detailed responses, not to mention worry about what the board might do.
He’d since received another letter saying his prescribing was determined to be appropriate and he was exonerated, but that he should be careful about opioids in the future. The other physician also was exonerated.
But a few weeks later, again while mowing his lawn, the same physician let another shoe drop. Three of his current, living patients had phoned his office in the past few days saying they had received alarming letters from the board.
The letters said the agency “is reviewing the quality of care provided to you by” him. The board asked those patients to authorize their physicians to turn over all their medical records to the agency, saying that by doing so, they’d be “providing a valuable service to all health care consumers in California.”
If the patients didn’t sign the releases, their letters said, “we intend to issue a subpoena” in order to get them. The implication was that those patients should be concerned about his quality of care. This, he said, was extreme, because those patients really needed pain relief for their conditions.
On July 31, I asked spokesman Carlos Villatoro if the board was “engaging in a broad search for inappropriate opioid prescribing by issuing subpoenas for the charts of patients” whose doctors prescribed them opioids.
He replied the next day. “Are you referring to our death certificate project? …”
See Episode 1 Medical Board Death Certificate Project.
Former board monitor and attorney Julianne Fellmeth of the Center for Public Interest Law was my next go-to source, since she attends all board meetings. She had vague recollections that director Kim Kirchmeyer had first discussed the results of the project in an enforcement meeting in July 2017, and sent me some links.
Kirchmeyer said that 450 allopathic physicians, another 72 osteopathic physicians, registered nurses and physician assistants were now under investigation because patients of theirs had died in 2012 or 2013, within three years of their care.
That screamed like a very big story to me, especially because the patients were treated so long ago.
My neighbor, Dr. Paul Speckart, and his internist partner, Dr. Brian Lenzkes, agreed to speak with me on the record about how much trouble this caused their practices and their emotions, since they cared very much about treating their patients’ well-documented and justified pain. They gave me all documents they’d received from the board, as well as their responses.
I also heard that the California Health Care Foundation, which had funded some research in this area with the San Diego County Medical Examiner’s office, was concerned about the medical board’s effort, and a CHCF source put me in touch with a San Francisco doctor who had been caught up in an investigation that started last December.
Physicians raise numerous concerns
Physicians, some of whom spoke with me off the record, were concerned for a variety of reasons.
The death certificates under review were all from 2012 and 2013, long before the opioid epidemic’s extent was as well known or understood as it is today, and way before aggressive efforts to limit or avoid narcotic dosages.
Clinicians were being asked to produce patients’ medical records to justify their prescribing for patients from as early as 2009. It would be far more reasonable to review death certificates and prescribing practices in later years, at least since fatalities and hospitalizations from opioid use has been a target of new guidance and recommendations from state and federal agencies which weren’t published until 2014 and 2016.
Since 2002, California physicians – by law – must take a course that stressed their need to treat a complaint of pain, and regard it as a fourth vital sign. Additionally, quality measures ask patients to score their doctors on whether their doctor addressed their pain on a score from one to five, and tied it sometimes to payment.
To date, Villatoro has identified 23 physicians who faced accusations because of the Death Certificate Project, nearly 25 percent of them from San Diego County, which has only 11 percent of the state’s physicians.
Some clinicians have expressed concern that the death certificates reviewed were weighted toward San Diego County, whose medical examiner has been said to be more diligent about performing toxicology on suspected overdose deaths compared with other counties, especially smaller ones whose deaths are investigated by law enforcement rather than medical professionals.
It could be that San Diego doctors were disproportionately affected, but Villatoro and Kirchmeyer responded by saying that all counties were represented in their review.
Some of the documents, including one that is an exceptional 63-pages long, allege prescribing practices that arguably should have come to the board’s attention long before the discovery that someone’s patient fatally overdosed.
Board officials insist they plan to obtain and review opioid-related death certificates for 2014 to date, but as of last month had not yet begun those investigations.
I’ve loaded the 23 accusations filed so far to Document Cloud. Here are the links, so you can see the types of physician behavior the Medical Board of California is tackling.
Here are five stories that have run to date
Nov. 6, 2018 • Calif.'s 'Death Certificate Project' Nabs 11 More Physicians: State medical association wants study to evaluate agency's fairness
Nov. 2, 2018 • 'I Had Not Kept Up': A Physician Re-Education Story: Patient's overdose made Jeoffry Gordon, MD, recognize he didn't know everything
Sept. 12, 2018 • Provider Groups Hit Back at California’s Death Certificate Project: “Witch hunt” said to be sowing fear in medical community
Sept. 5, 2018 • The 10 Calif. Docs Accused of Overprescribing Opioids: Complaints cite “gross negligence,” “incredibly high” doses — and bad penmanship
Aug. 30, 2018 • ‘Death Certificate Project’ Terrifies California Doctors: Hundreds threatened with disciplinary action for opioid scripts to patients who overdosed
Story ideas and questions to ask
Would the medical board find more doctors overprescribing opioids by reviewing CURES first, rather than wait until a patient ends up dead?
Would letters from the county medical examiner or coroner directly to the doctor promptly, after a patient has died of an overdose, be more effective in reducing opioid prescribing. Dr. Roneet Lev and Jason Doctor, who published this report detailing results from a project in San Diego County, in the journal Science, believe that it could. More research is underway to see if doctors are lowering opioid prescriptions or their dosages after receiving those letters.
How have prescribing practices changed in the wake of the Death Certificate Project? As several physicians mentioned, they may be referring patients more frequently to pain management specialists for treatment. Are they getting overloaded, as Dr. Jim Hay suggested in the Sept. 12 story?
Are other states engaging in similar efforts to track opioid overprescribing by looking at death certificates? I know of a similar program in North Carolina, but it was much more restrictive in focusing its investigations.
How much has the board spent on this investigation to date? The board refused to say.
More to come.
Cheryl Clark is a senior health care reporter for MedPage Today.