The Medical Licensing Board of Indiana (MLB) at a March 28 meeting imposed several restrictions on the license of pain physician William Hedrick, M.D., of Fort Wayne. As a result of this and other recent cases, the legislature is now considering new rules for controlled substance prescribing that will impact Indiana physicians.
In December 2012, the state alleged Dr. Hedrick prescribed unsafe pharmacological mixes, unusually high pill counts, a preference for medication combinations highly valued for diversionary purposes, and unsafe interventional pain therapies – exceeding the appropriate amount of steroid per procedure and repeating procedures too frequently.
The state suggested some practices were more consistent with financial gain than patient benefit. The state also alleged numerous patients treated by Dr. Hedrick died from multiple drug toxicity while under care at the wholly owned multiple physician, multiple facility pain management practice where he was medical director.
Dr. Hedrick agreed to a suspension of his license until a full hearing could be held. At the February and March meetings of the MLB, hearings included about 10 witnesses over approximately 16 hours. After deliberating for an hour, the MLB narrowly found Dr. Hedrick in violation of three counts in the complaint:
- Overuse of steroid injections
- Inappropriate pain management treatment
- Failure to adequately supervise advanced practice nurses and physicians assistants (PAs)
Here are some relevant excerpts of the MLB findings in the case of Dr. Hedrick:
“Interventional procedures, specifically spinal injections, were clustered in an inappropriate manner intended to maximize the number of procedures to be performed at any given time with very little medical justification for performing them in this manner. Respondent lacked clear documentation of conditions or circumstances to support the use of such a treatment plan for any of the identified patients.”
“Respondent failed to utilize appropriate theories of practice regarding pain management and the delivery of healthcare services, in general. Respondent failed to recognize the complexities of quality control and supervision in the delivery of health care services, particularly where multiple providers and extenders are involved in the care of a patient. These failures were magnified in the context of a pain management clinic where controlled substance treatment and spinal procedures are heavily utilized.”
“[P]hysician extenders … disregard[ed] clear evidence of a patient’s substance abuse or psychiatric conditions in their clinical treatment decisions. In these instances, patients were still prescribed addictive controlled substances that have the potential to be misused or abused. Additionally, extenders failed to thoroughly review chart entries and patient notes before making clinical and prescribing decisions.”
The MLB did not find sufficient evidence to make a case against Dr. Hedrick on three allegations:
- As a board certified physical medicine and rehabilitation physician, he had insufficient education, training or experience in chronic opioid maintenance therapy.
- He recklessly prescribed highly addictive pain medications for non-medical purposes.
- He operated a pain clinic outside the legal bounds of legitimate medicine.
The resulting discipline
As a result, the MLB placed Dr. Hedrick’s medical license on probation for a minimum of two years. Within 90 days, he must successfully complete a competency assessment as well as ethics and documentation courses.
In his practice, Dr. Hedrick may not supervise or collaborate with more than one PA or nurse practitioner (NP). If he performs any interventional procedures, he and his extenders must adhere to specified WPS Local Coverage Determinations. He must have a MLB-approved independent physician review 15 percent of his charts on a monthly basis and report monthly on his compliance.
Dr. Hedrick and his extenders must review the INSPECT report for each patient at the time they prescribe controlled substances “and consider the information carefully for evidence of abuse or diversion of medications.”
Finally, Dr. Hedrick was ordered to pay a $3,000 fine, a $5 fee and state costs of $15,910.26 – in addition to his own significant legal expenses.
What this means to you
“The Indiana Attorney General and the MLB expect doctors to engage in safe and responsible clinical and administrative practices,” said Julie Reed, ISMA general counsel. “This absolutely includes oversight of PAs and NPs.”
And, as required by SEA 246, the MLB is required to adopt a set of emergency rules consistent with standard medical practice in pain management treatment and by Nov. 1, 2014, have in place permanent standards and protocols for prescribing controlled substances.
“These will be Indiana’s first comprehensive pain management rules,” added Reed. The Indiana General Assembly will study over the summer whether or not to mandate that a prescriber review an INSPECT report prior to issuing a controlled substance prescription. Other expanded uses for INSPECT also will be discussed.
Call the ISMA with questions or to register for a CME seminar on responsible opioid prescribing.