Boston Sunday Globe: Fed-up doctor sidesteps insurance company limits

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Dr. A. Hoffmann of Framingham says he has written about 10 bogus

prescriptions. (Janet Knott/ Globe Staff)

(http://www.boston.com/news/globe/)

Fed-up doctor sidesteps insurance company limits

He breaks rules, citing patient care

By Rowland, Globe Staff | June 11, 2006

FRAMINGHAM -- When Tufts Health Plan cut a patient's prescription for the

sleep aid Lunesta from 30 pills to 10 pills a month, her physician, Dr.

A. Hoffmann, decided to circumvent state regulations by writing a second

prescription in the name of her husband so she could get 10 more pills per

month

..

Hoffmann is aware that by publicly acknowledging the prescription ploy, he

could be subject to disciplinary action and even criminal charges. But he

considers himself a ``medical conscientious objector, " and says a patient's

welfare comes before what he believes are unreasonable insurance restrictions.

``I'm willing to do something that may put me at risk, " he said. ``I feel I

have no alternative. "

Hoffmann, 50, has been practicing since 1981, and has run a busy solo

practice in Framingham since 2002. He said he has broken prescribing

regulations

about 10 times in the last six or seven years to avoid insurance company

restrictions on various drugs.

His actions are an extreme example of widespread dissatisfaction among

primary - care physicians, who say they are frustrated by increasingly

restrictive

rules imposed by health insurance companies in an effort to reduce

healthcare costs.

``This is doctor resistance through guerrilla tactics, " said Arthur Caplan,

chairman of the Department of Medical Ethics at the University of

Pennsylvania. If insurers ``are really putting the screws to your patients, you

do have

an advocacy responsibility, and that may mean cutting corners, or doing

something deliberately wrong to get them what they need. Who wouldn't want that

person as their doctor? "

But the head of the Massachusetts Board of Registration in Medicine , the

licensing authority for the state's physicians, said writing a prescription for

someone other than a patient constitutes insurance fraud and violates the

board's prescribing rules. Hoffmann could face a range of sanctions, from

warnings to fines to license revocation.

``Although his intentions may be very honorable, he should really think

through the potential harm to the patient and those family members, " said

Achin Audesse, the board's executive director. By prescribing drugs for a

patient's spouse, she said, Hoffmann is purposely creating inaccurate medical

records, which could put a person at risk if that information was used by a

doctor to make a medical decision. He could also be breaking several state

laws,

including writing a false prescription, insurance fraud, and larceny.

Attorney General F. Reilly's office declined to comment because the

Boston Globe did not disclose Hoffmann's name in advance of this story's

publication.

The gray-haired, Harvard-trained Hoffmann hardly fits the stereotype of a

renegade. He is an author and a member of the Massachusetts Medical Society's

ethics and discipline committee.

With regard to insurance company restrictions, he said, ``It's becoming

increasingly clear to me that the system is badly broken. A lot of my

colleagues

are demoralized, angry, and frustrated. Rather than . . . moan over

late-night coffee in the corridors of the hospital, it's time to convert our

dedication to our patients into a more constructive stance. "

In the Lunesta case, Hoffmann said, the patient is a recovering alcoholic

and her family's primary wage earner. Her inability to sleep could cause her to

start drinking again, he said, so he prescribed the sleeping pills. In the

past, he has lost appeals with insurance companies over their caps on Lunesta

usage , Hoffmann said, and he worried that the woman's health could decline

while he navigated the bureaucracy. The patient decided not to fill the

prescription in her husband's name after learning that it might cause problems

for

her doctor, Hoffmann said.

Tufts Health Plan said that in this case and others like it, the company

would consider referring doctors to the board of registration and prosecutors,

but that it would probably not terminate a patient's coverage.

Tufts believes such actions are clearly wrong, said Dr. J. Hinkle,

chief medical officer . ``We have certain standards we have to follow that are

there for good safety reasons, " he said. ``This is not a practice that would

be supported by any physician. "

The 10-pill monthly limit on Lunesta prescriptions is based on the judgment

of the company's prescribing committee, which determined that most patients

take it on an occasional basis and therefore would not need more than 10 pills

a month, Hinkle said.

Caplan said Hoffmann's actions are not unusual in the medical community. For

instance, he said, doctors sometimes engage in ``upcoding " -- documenting a

diagnosis that is more serious than the patient's actual condition -- if they

believe a hospital stay should be extended.

But another ethicist, s, said Hoffmann has an obligation to work

within the boundaries of the law. ``He's not the only frustrated doctor in

Massachusetts, " said s, who is chairman of the department of health law,

bioethics, and human rights at the Boston University School of Public Health .

Educated at Princeton University and a 1981 graduate of Harvard Medical

School, Hoffmann worked as an emergency room physician at Brigham and Women's

Hospital , Massachusetts General Hospital , and MetroWest Medical Center in

Framingham before becoming a primary care doctor in 1992 .

He said that in the last two years he has increasingly had doubts about his

profession because of insurance company interference and other economic

pressures. ``It's like constantly walking through quicksand to get anything

done, "

he said.

Similar dissatisfaction among primary - care doctors nationally is beginning

to have an effect on the medical profession, according to professional

societies. Older primary care doctors are retiring earlier than ever, while

physicians fresh out of medical school are opting for more lucrative specialty

practices . A survey by the American College of Physicians found that the

percentage of third-year medical school students in the United States who

intended

to enter primary-care practice declined from 54 percent in 1998 to 20 percent

in 2005.

The organization does not condone violating prescription rules under any

circumstances, said its president, Dr. Lynne Kirk.

``It's not within my realm of ethics, " she said. Kirk added that she

recognizes that ``there is a lot of frustration, both on the part of the

physician

and the part of the patient. "

Results of a Massachusetts Medical Society survey of doctors earlier this

year showed they believe there are critical physician shortages in family

practice and internal medicine. There is anecdotal evidence to support that

opinion. For example, MetroWest Medical Center in Framingham estimated that the

12

communities in the western suburbs it serves need 47 additional primary care

doctors to supplement the 100 affiliated with the area's four hospitals.

Hoffmann, who has a roster of 2,500 patients, said he is forced to turn away

five prospective new patients daily. He has been looking for a partner for a

year, but hasn't found one because of the shortage of doctors.

His office is on the ground floor of a medical office building near

MetroWest Medical Center. He bounces between exam rooms , seeing an average of

26

patients during a day that sometimes stretches beyond 12 hours.

Many doctors in Massachusetts, particularly specialists, earn several

hundred thousand dollars or more annually, but Hoffmann said his income falls

on

the lower end of the scale for a primary care physician -- he estimated his

household income after expenses at $110,000, including his wife's salary as

office manager.

Hoffmann said that he understands that insurance companies and hospitals are

trying to rein in a healthcare system bloated by runaway costs, but that he

is responsible for providing the best care he can, not helping to restrain

spending by insurance companies.

On Monday, he found two reports when he arrived at his office at 7:30 a.m.

One, from Blue Cross and Blue Shield of Massachusetts, said he is prescribing

too many expensive, brand-name drugs and too few generics. The other, an

``excess day report " from MetroWest Medical Center, showed his patients stay in

the hospital too long.

``Big Brother is looking over our shoulders, " he said. Blue Cross and other

insurers say they are trying to contain prescription drug costs by promoting

the use of less expensive generics.

Later in the day, Hoffmann treated a retired Boston firefighter suffering

from a chronic sinus inflammation that antibiotics failed to control. The

insurance company refused to cover a possible alternative treatment , an

anti-fungus medication called Sporanox. Hoffmann is appealing the decision. In

the

meantime, he gave the patient samples of a powerful antibiotic to temporarily

relieve his symptoms.

``If they won't give you the Sporanox, " he told the patient , ``we'll put

you in the hospital. "

Rowland can be reached at _crowland@..._

(mailto:crowland@...) .

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