A Pharmacoepidemiological Approach to Investigating Inappropriate Physician Prescribing in a Managed Care Setting in Israel

Objective: To identify cases of inappropriate physician prescribing in a managed care setting in Israel that may have resulted from misuse of magnetic-stripe membership cards.

Study Design: Retrospective drug utilization analysis of electronic patient prescription data.

Methods: In a managed care setting involving approximately 1000 physicians who issue approximately 1.4 million prescriptions annually, the rate of prescription of sex-specific drugs to patients of the opposite sex for which the drugs are indicated was evaluated for 2003. The categories of drugs included in the analysis were drugs for the treatment of benign prostatic hyperplasia or erectile dysfunction that were prescribed to women, as well as oral contraceptives, vaginal pessaries, hormone therapy, or raloxifene hydrochloride prescribed to men.

Results: Throughout the study year, 193 different physicians wrote 341 prescriptions that matched the drug inclusion criteria for 210 different patients. The most frequently observed scenario involved the prescription for women of selective á-blockers, including alfuzosin hydrochloride, tamsulosin hydrochloride, and terazosin hydrochloride, that are indicated exclusively for the treatment of benign prostatic hyperplasia.

Conclusions: The electronic patient record system used in the health maintenance organization studied was programmed to block the prescription of sex-specific drugs for patients of the opposite sex for which they are intended unless proper authorization has been obtained. Furthermore, periodic investigation into prescription impropriety may be easily accomplished through the implementation of pharmacoepidemiological methods commonly used in drug utilization studies.

(Am J Manag Care. 2005;11:89-90)

Health insurance fraud involving inappropriate physician prescribing of drugs has become an issue of significant concern in the managed care setting internationally. In Israel, one aspect of this matter involves the misuse of member identification cards for the illegitimate acquisition of prescription drugs. Under the Israeli National Health Law, all Israeli citizens are enrolled in 1 of 4 health maintenance organizations (HMOs) that deliver a uniform, government-defined benefits package. This study was conducted in the Leumit Health Fund (an HMO), which serves approximately 700 000 members throughout the state of Israel (approximately 10% of the population) and involves approximately 1000 physicians who issue approximately 1.4 million prescriptions annually. Leumit Health Fund has implemented a computerized electronic patient record (EPR) system that requires patients to present a magnetic-stripe membership card to be electronically registered by the physician before receiving treatment. In addition to recording the medicines prescribed during the session, Leumit Health Fund's EPR system generates prescriptions on HMO prescription forms that entitle members to purchase drugs for a copayment, which generally provides a significant savings to the patient. Leumit Health Fund employees who receive coverage from this HMO also benefit from a 60% discount on the copayment. Because HMO membership is acquired on an individual basis and not on a family basis, situations occur in which only one member of a family is covered by Leumit Health Fund, with the remainder of the family being covered by 1 or more of the other 3 HMOs. There is concern that Leumit Health Fund employee members may be requesting physicians to prescribe drugs for next of kin who are not covered by Leumit Health Fund, to receive the employee discount or to avoid paying a replacement fee for a family member's lost membership card. Such behavior results in fraudulent data entries into the true cardholder's EPR of diseases diagnosed, drugs prescribed, and other information. Furthermore, because this information will not be documented in the patient's file, future practitioners will be denied what is potentially essential information concerning the patient's history. The objective of this study was to evaluate the prevalence of illegitimate prescriptions for patients involving physician complicity, while exploring the feasibility of implementing pharmacoepidemiological methods of drug utilization analyses as managerial tools.

METHODS

This analysis evaluated the rate of prescription of sexspecific drugs to patients of the opposite sex for which the drugs are intended. The categories of drugs included in the analysis appear in the Table. Using a prescription database generated by EPR data, all prescriptions written throughout 2003 for patients of the opposite sex for which the target drugs are intended were identified and analyzed.

RESULTS

The results of the study are presented in the Table. Throughout the study, 193 different physicians wrote 341 prescriptions that matched the drug inclusion criteria for 210 different patients. The most frequently observed scenario involved the prescription for women of selective á-blockers, including alfozosin hydrochloride, tamsulosin hydrochloride, and terazosin hydrochloride, that are indicated exclusively for the treatment of benign prostatic hyperplasia (BPH). All cases observed involved women diagnosed as having a lower urinary tract dysfunction during the visit in which these drugs were prescribed. Other cases included prescriptions for oral contraceptives written by a male physician for himself whose wife is not covered by the HMO, as well as oral contraceptives for a male regional manager. In view of these findings, the EPR system used in the HMO was programmed to block the prescription of sex-specific drugs for patients of the opposite sex for which they are intended.

DISCUSSION

This study in a nationwide HMO demonstrates that the suspicion concerning illegitimate prescriptions for patients involving physician complicity was not unwarranted. The 141 cases involving men being prescribed vaginal preparations or oral contraceptives are sufficient to adequately substantiate this suspicion. The cases in which women with lower urinary tract conditions were prescribed drugs licensed exclusively for the treatment of BPH raise a significant policy issue for the HMO. Although there have been reports in the literature on the use of these drugs in women for these conditions,^1,2 these drugs have not been approved by the Israel Ministry of Health for indications other than BPH. Consequently, should a physician wish to prescribe these drugs for conditions other than BPH, special authorization must be requested on an individual basis justifying this off-label use. Accordingly, the HMO bears no obligation to cover treatment with these drugs in these women. Although the HMO faces dilemmas of this type on a daily basis, our experience has been generally limited to requests for off-label use of antineoplastic drugs for types of cancers for which they are not indicated. However, because cancer drugs are ordered and approved on an individual basis, no possibility exists that they will be dispensed for an off-label use without the proper authorization. This is not the case with the drugs for the treatment of BPH. Because these drugs can be freely prescribed and dispensed without gatekeeper intervention, off-label prescribing can go undetected. This issue is particularly pertinent because the selective á- blockers observed include expensive drugs that would not have been authorized unless the less expensive alternatives available were found to be ineffective or contraindicated in the specific patient. Although the observed incidence of inappropriate prescribing was low, the findings of this study should serve as a warning signal to the HMO that increased vigilance is warranted in monitoring the use of drugs with potential off-label abuses.

CONCLUSIONS

Routine prescription monitoring using pharmacoepidemiological methods should be implemented in the HMO studied. Furthermore, the HMO medical division must formulate an official pharmacy policy that addresses the therapeutic and reimbursement issues raised by this study.

Acknowledgments

We thank Raphael Cayyam, MD, for reviewing the manuscript before submission and for his helpful comments.

From the Leumit Health Fund, Tel Aviv, Israel.

Address correspondence to: Natan R. Kahan, RPh, MHA, Kupat Cholim Leumit, PO Box 3512, Petach Tikva, Israel 49134. E-mail: nkahan@leumit.co.il

Neurourol Urodyn.

1. Serels S, Stein M. Prospective study comparing hyoscyamine, doxazosin, and combination therapy for the treatment of urgency and frequency in women. 1998;16:31-36.

Int J Urol.

2. Kakizaki H, Ameda K, Kobayashi S, Tanaka H, Shibata T, Koyanagi T. Urodynamic effects of á-blocker tamsulosin on voiding dysfunction in patients with neurogenic bladder. 2003;10:576-581.

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