Medicaid's top doctor repudiates state opioid accusations
Michigan's top Medicaid doctor is defending himself from a state regulatory complaint accusing him of over-prescribing painkillers, arguing state regulators have ignored the complexities of treating patients with severe chronic pain and misapplied federal guidelines on prescribing opioid medications.
The state Department of Licensing and Regulatory Affairs filed a complaint with the Michigan Board of Osteopathic Medicine and Surgery on May 1. It accused Dr. David Neff of failing to exercise due care, conform to minimal standards of practice or use the Michigan Automated Prescription Monitoring System (MAPS) when prescribing opioids to some patients in his part-time private practice.
Neff was immediately placed on leave from his $194,184-a-year position as Michigan's chief medical director for Medicaid, the health program mostly targeted at low-income residents. His attorney, Tim Dardas of East Lansing-based Hackney Grover law firm, said he and Neff are limiting comments to a response submitted to the state.
The complaint alleges that Neff prescribed higher doses of opioids to some patients than recommended by the U.S. Centers for Disease Control and Prevention. But the CDC's dosing recommendations don't apply to patients with severe chronic pain, Neff noted in his May 31 response.
"(T)he CDC, since 2016, published at least twice that the guideline does not apply to patients who are taking opioids, perhaps at high doses, for chronic, persistent, unrelenting pain," he stated in his response.
Neff, whose private practice once totaled about 13,000 patients, continues to treat about 85 complex patients while working full time for the state Medicaid program. He provides chronic pain treatment and palliative care to about 25% of his patients, many of whom he's taken care of for decades.
LARA based its complaint on a review of 10 patient's charts, as well MAPS, which tracks every controlled substance written in the state.
Seven of the 10 patients whose charts were reviewed by investigators were not covered by the CDC guidelines because they suffer from severe, intractable pain, Neff said.
Neff was also accused of failing to check the MAPS system before writing opioid prescriptions, a requirement in Michigan since June 1, 2018. The doctor's response said the system doesn't always work and is sometimes inaccurate, while the wording of the statute is vague on details.
The Michigan law doesn't specify how often the system must be checked, or how long before the prescription is written, Neff said. CDC guidelines, meanwhile, recommend checking automated prescription monitoring systems when opioid therapy starts or every three months.
While Neff said he does run MAPS reports on his patients, he argued he didn't feel it necessary to run a report before every prescription written for patients he'd been treating monthly for decades.
"(T)he misapplication of 'rules' creates an atmosphere of confusion and hostility for prescribers which has led to unfortunate consequence of intimidating healthcare providers who are trying their best to care for this vulnerable population of patients," Neff wrote in his response. "The state wields a mighty hammer indeed when it can sanction a licensee (or threaten to sanction a licensee) regarding the medical care and treatment of licensee's patients.
"The hammer must be swung with discretion and precision," the response continued. "When it isn't, prescribers with a reasonable expectation of self-preservation may spend more time trying to avoid 'the hammer' by discharging, abandoning or recommending unrealistic and medically unreasonable choices to their patients than they do trying to do what they have spent their professional lives doing; competently and compassionately caring for patients."
Neff's response reflects sentiments widely held in the medical community as legislatures, law enforcement and regulatory agencies nationwide have stepped up efforts to combat the opioid crisis, sometimes with unforeseen consequences.
Some doctors have stopped prescribing opioids, leaving patients without prescriptions they legitimately need. Others too quickly wean patients from drugs they've been taking for years.
Farmington Hills Dr. J.A. McErlean said he has never met Neff, but was outraged to hear of the complaint against the highly regarded doctor, a well-published researcher and practitioner who has lectured on opioid prescriptions.
"I want there to be somebody out there monitoring physicians, but it’s gotten to the point where if your only tool is a hammer everything is a nail," McErlean said in a recent call to The Detroit News.
"There is no strong single voice to say prosecute the bad guys, leave the good guys alone."