Death Certificate Project Accuses 64 Calif. Doctors

https://www.medpagetoday.com/painmanagement/opioids/81954

The so-called Death Certificate Project initiated by the Medical Board of California that began in 2015 has now resulted in formal accusals of wrongdoing filed against 64 physicians related to their drug prescribing, primarily involving opioids, newly updated records show.

Five of the 64 have surrendered their licenses; six others were put on probation, and eight received public reprimands.

These are out of a total of 469 physicians investigated for excessive prescribing because of patients’ overdose deaths in 2012 or 2013.

Two of the 64 accusations were withdrawn, according to statistics released by the board last week.

The remaining 43 physicans of the 64 accused still await final decisions; half of these have been hanging more than 7 months and five for nearly a year.

Beyond the 64 doctors against whom an accusation had been filed, another 11 of the 469 are still under investigation. It remains to be seen whether a round orange gavel signifying a disciplinary action will mark any of their profile pages.

The agency’s investigators continue to prowl the state Department of Justice’s prescription drug database to identify doctors who prescribed opioids to a patient who, according to a death certificate, fatally overdosed in 2012 or 2013, even as long as three years after that doctor wrote that script, and not necessarily from the same drug the doctor prescribed.

Separate investigations were conducted of 72 nurse practitioners, physician assistants, and osteopathic physicians — who are governed by different state boards — but the results of those were not immediately available.

In the next leg of the investigation, the medical board, which licenses some 140,000 physicians, will scrutinize practices of doctors whose patients fatally overdosed in 2016 and 2017, when presumably far more conservative opioid prescribing had replaced more liberal practices and as the extent of addiction potential and lethality of these drugs was better understood.

‘Witch-hunt’

The project is intended to stop overdoses and save lives. But it has been harshly lambasted by some doctors as a “witch hunt.” It also has disrupted practices by many physicians who — prior to 2014 — were abiding by the now outdated mantra that patients’ pain complaints should be aggressively treated with whatever it takes.

Many representatives of organized physician groups said the project is now hurting patients in pain trying to get relief. Pain specialists’ waiting lists have backed up and increasing numbers of primary care providers refuse to prescribe opioids in fear that years later, a patient death — even by suicide — may put their licenses under public scrutiny as well.

But Kimberly Kirchmeyer, the medical board’s executive director, defended the project. In an e-mailed statement, she said it “is helping the board meet its mission of consumer protection in a proactive way.” She added that her agency “will continue to find ways to improve this process.”

In remarks to the board during its January meeting, Kirchmeyer gave more detail. She said expert reviewers looked for high-dose opioid prescribing patterns that included morphine equivalencies greater than 90 mg, opioids in combination with sedating drugs like benzodiazepines, Soma, sleeping pills, and other unsafe combinations of medications. Additionally, the reviewers zeroed in on doctors who prescribed dangerous drugs frequently, “and other red flags.”

A welcome change?

Perhaps not surprisingly, consumer advocates have applauded the Death Certificate Project for calling out doctors with reckless prescribing habits.

Carmen Balber, executive director of Consumer Watchdog, spoke from “the injured patient’s perspective,” saying, “Doctors in this state are accustomed to weak or non-existent regulatory oversight. For patient safety, it’s about time that the medical board started acting to proactively investigate the opioid crisis.”

In many accusations she’s read, dangerous prescribing practices are obvious. “Patients are not getting medical exams. Doctors are not confirming the injuries the patients came forward with. Doctors are prescribing wildly excessive doses of medications. Even to a lay person it seems blatantly obvious that action should have been taken,” Balber said.

Patient safety activist Eric Andrist of Los Angeles, who started the newer Patient Safety League which posts stories about medical harm and patient experiences, travels around the state to every medical board meeting to complain that the agency is too soft, allowing hundreds of dangerous doctors to get off with no more than a slap on the wrist. He said he’s pleasantly surprised the board tackled the opioid issue in the first place.

“They’ve always said that they don’t and won’t look for cases themselves … and only act on complaints brought to them,” he said. Without this initiative, these doctors would never have been punished or called out. He also praised the yield of 19 accusations resulting in disciplinary action to date — even with 43 more to go — because by his count the agency’s average is much lower.

Five licenses surrendered

Among the most egregious cases, those that prompted five physicians to surrender their licenses, departure from the standard of care was especially well documented.

In the longest accusation, a 63-page petition to revoke the license of Frank D. Gilman, MD, of San Diego, the board listed hundreds of prescriptions written for four patients. He prescribed 370 prescriptions for one of them, and of those more than 200 were for oxycodone. Two of his patients died from overdoses. Gilman was accused of gross negligence, repeated negligent acts, incompetence, repeated acts of clearly excessive prescribing, and failure to maintain adequate and accurate medical records.

John Winthrop Pierce, MD, of San Francisco, surrendered his license after one of his patients died of an overdose of hydrocodone. The board’s 28-page accusation said that he had prescribed a long-acting combination of fentanyl and morphine for another patient who had exhibited suicide ideation, and overall prescribing behavior that constituted gross negligence and repeated negligent acts.

Robert M. Littman, MD, of San Diego, also surrendered his license after the board’s accusation said that his treatment of a patient, who was found dead at her home from “carisoprodol, lorazepam, oxycodone, zolpidem and trazodone toxicity” with traces of amphetamines and clonazepam, constituted “gross negligence.” The patient had received prescriptions from multiple doctors, and “doctor shopped,” but Littman had failed to conduct toxicology screenings and had not checked the prescription database to see what other prescriptions she had been getting.

Philipp Leo Bannwart, MD, of Zermatt, Switzerland, surrendered his license after the board found fault with his treatment of a patient in Concord, near San Francisco. She died of “acute methadone intoxication.” The board accusation says that Bannwart wrote combination prescriptions for her, including methadone, Percocet, Norco, and promethazine-codeine syrup, constituting what the board called “gross negligence, repeated negligent acts/incompetence/improper prescribing without an appropriate prior examination and medical indication.”

Daniel George Clark, MD, of Auburn, surrendered his license after the agency found that a patient died after Clark increased dosages of fentanyl, which it labeled “gross negligence.”

Probation and public reprimand

Six accused physicians were placed on probation for periods of 3-7 years: Ashmead Ali, MD, of California City; Jay Milton Beams, MD, of Susanville; Harold Budhram, MD, of Shasta Lake; William Lee Matzner, MD, of Simi Valley; Michelle Anne Orengo-McFarlane, MD, of Martinez; and Ilona Sylvester, MD, of Thousand Oaks.

Another eight physicians were formally reprimanded and ordered to take courses on prescribing practices and, in most cases, medical record-keeping: Alyn Gary Anderson, MD, of Huntington Beach; Michael S. Basch, MD, of Temecula; Jose Rosendo Cesena, MD, of El Cajon; Vorakiat Charuvastra, MD, of Los Angeles; Moshe Miller Lewis, MD, of San Francisco; Diana Maria Prince, MD, of Rohnert Park; Charles Yang, MD, of Huntington Beach; and Tahir Yaqub, MD, of Atwater.

Still-pending accusations against the remaining 43 physicians can be read here.

The California Medical Association did not respond to a request for comment about the current status of the Death Certificate Project. But in an interview late last year, David Aizuss, MD, CMA president and an ophthalmologist from Encino, criticized the board for going after doctors because of how they prescribed controlled substances before 2014. “I don’t think it’s appropriate to apply our current clinical guidelines to what was going on six or seven years ago,” he said then.

Asked why the investigations take so long, medical board spokesman Carlos Villatoro replied that for the latest fiscal year ending June 30, 2018, it took an average of 322 days after an accusation was filed for the case to conclude without compromising due process. He added that the process involves the Attorney General’s office and the office of administrative hearings, both of which are outside the board’s control, he said.

Other MedPage Today stories about the California Medical Board’s Death Certificate Project:

‘Death Certificate Project’ Terrifies California Doctors

Provider Groups Hit Back at California’s Death Certificate Project

Calif.’s ‘Death Certificate Project’ Nabs 11 More Physicians

Foundation Wants Revamp in Calif.’s Death Certificate Project

Methodology Fixes Coming for Calif. Death Certificate Project

Filed under: General Problems