PSR Director's Update for June 2018
In June 2018, one final determination became effective.
A. Director’s Section 92 agreements effective in June 2018
No agreements entered into by the Director and persons under review (in accordance with s 92 of the Act) were ratified in June 2018.
B. PSR Committees' final determinations effective in June 2018
PSRC No. 1021
On 21 June 2018, a final determination came into effect concerning Dr Martyn Arnold Green, formerly of Salisbury Surgery, 34 Ainsworth Street, Salisbury Queensland 4107. Dr Green was directed to be reprimanded and counselled by the Director. He was disqualified from the PBS scheme for 12 months and directed to repay $96,397.78 to the Commonwealth. These directions followed from a final report of a PSR Committee, which concluded that Dr Green engaged in inappropriate practice for services that he rendered as MBS items 197 and 2713. The Committee also found that he engaged in inappropriate practice in connection with prescribing PBS items 1647Q (morphine sulfate pentahydrate 30 mg/mL injection, 5 x 1 mL ampoules) and 8582Q (tramadol hydrochloride 100 mg/2mL injection, 5 x 2 mL ampoules).
The Committee’s findings regarding Dr Green’s prescribing of morphine and tramadol
The Committee’s findings in relation to Dr Green’s prescribing of morphine and tramadol were serious. Dr Green was assigned to the 99th percentile (compared to other active general practitioners) for the volume of tramadol and morphine ampoules that he prescribed during the review period. He prescribed 118 scripts for parenteral morphine (590 30mg ampoules) and 93 scripts for parenteral tramadol (465 100mg ampoules) during the review period. These figures did not include morphine and tramadol ampoules Dr Green may have obtained through doctor's bag arrangements. Dr Green administered these ampoules parenterally to patients. Dr Green’s prescription and administration of parenteral morphine and tramadol carried a risk of causing harm to patients secondary to adverse effects and dependency. Dr Green also prescribed and administered parenteral morphine and tramadol with other medications, including benzodiazepines and other opioid medications.
Dr Green’s usage of parenteral morphine and tramadol as an adjunct to spinal mobilisation and manipulation and acupuncture
The Committee found that Dr Green had a ‘grossly inadequate’ understanding of morphine and tramadol. Dr Green’s evidence was that his patient population mostly comprised patients with chronic pain. He explained that he had a special interest in pain management. He provided spinal mobilisation and manipulation under parenteral analgesia, principally to patients with chronic musculoskeletal pain. Dr Green said that he had administered parenteral opioids in this manner for approximately fifteen to twenty years.
Dr Green would administer either morphine or tramadol to patients with chronic pain and then provide acupuncture or a combination of acupuncture and vertebral mobilisation and manipulation. On occasion, Dr Green would administer a combination of cortisone, a local anaesthetic and parenteral tramadol or morphine along with acupuncture and spinal mobilisation and manipulation. The Committee found that Dr Green's provision of parenteral tramadol and morphine as an adjunct to acupuncture and/or spinal mobilisation and manipulation was inappropriate. The provision of opioids in these circumstances was not clinically justified given that there was no apparent therapeutic benefit to Dr Green's patients or any clinical evidence to support this practice.
The Committee found that on some occasions Dr Green administered parenteral morphine and tramadol in circumstances where he would not ordinarily do so. He did this to make it easier for him, or simply to enable him, to render spinal mobilisation and manipulation due to his own health circumstances and/or due to the size or build of his patients. The Committee found this constituted inappropriate practice. Dr Green's administration of these medications was, in those instances, not based on any clinical indication or medical necessity.
In some cases, the Committee found that Dr Green administered morphine and provided spinal mobilisation and manipulation where doing so was strongly contraindicated by the patient's presentation and history. In such cases, Dr Green risked exacerbating patients’ musculoskeletal pathology for no clinical benefit. For example, spinal mobilisation and manipulation with opioid analgesia was provided to a patient who had very recently had spinal surgery.
The Committee noted Dr Green's oral evidence and clinical records indicated that he used parenteral tramadol and morphine in certain cases of chronic pain and for ‘severe headaches’. The Committee concluded that it was not appropriate to prescribe and administer parenteral tramadol and morphine in the particular circumstances of these cases. This is especially in view of parenteral tramadol and morphine being short acting analgesics that provide inadequate pain control for management of long-term conditions such as chronic pain.
The Committee found that some patients received an alarming volume of tramadol and/or morphine injections over the review period. For example, the records indicated that Dr Green administered about 80 injections of morphine to one patient during the 12-month review period. As another example, Dr Green provided some patients with morphine injections on a weekly or twice-weekly basis. In some cases, Dr Green prescribed these medications to patients who had a history of drug dependency. The Committee also found that Dr Green prescribed an alarming combination of medications in addition to prescribing and administering tramadol and morphine. For example, in the 12-month review period:
- Dr Green provided morphine injections with prescriptions for Valium, Serapex, Mogadon, Endone and Targin to one patient.
- Another patient was provided morphine injections with prescriptions for Valium and Endone.
- Another patient was provided morphine injections with prescriptions for Valium, Mogadon, Lyrica and OxyContin.
- Another patient was provided morphine injections with authority prescriptions for Prodeine Forte and prescriptions for OxyContin.
- Another patient was provided morphine injections with prescriptions for OxyContin, OxyNorm, Prodeine Forte and Norgesic.
The Committee found that Dr Green fostered patient dependency on parenteral tramadol and morphine injections. There was limited evidence that Dr Green's frequent provision of parenteral analgesia, acupuncture, and/or spinal mobilisation and manipulation were of clinical benefit. Further, the Committee found that Dr Green did not use any system (such as objective pain scoring) that could have helped measure the effectiveness (or otherwise) of morphine and/or tramadol treatment.
Some examples of specific cases where the Committee found that Dr Green inappropriately prescribed and/or administered morphine or tramadol included:
- A patient who had serious lumbar spine pathology and a history of spinal surgery and who received 26 morphine injections and a combination of Valium, Serapex, Mogadon, Endone and Targin. The patient also had a history of substance abuse. In addition to other clinical concerns, Dr Green did not document all occasions that he administered morphine to this patient.
- For another patient, Dr Green administered morphine on 53 occasions during the review period. He also prescribed OxyContin, OxyNorm, Prodeine Forte and Norgesic to the patient. The entries relating to those injections were barely legible and affected by other recordkeeping inadequacies. Each entry included only a cursory reason for contact (such as ‘chronic pain’) and limited detail in relation to the management of that pain. The Committee found that Dr Green exposed this patient to the adverse effects of parenteral morphine without there being any medical reason that would justify its administration.
- Dr Green administered morphine on six occasions to an elderly patient who had been prescribed Fentanyl patches. Reasons for finding inappropriate practice included that the purpose of administering morphine was said to be for ulcers or foot pain, which in the circumstances of this case was not clinically appropriate. The medications were also prescribed in circumstances where there was no one to monitor the patient for the full duration of his elevated serum morphine levels.
- In another case, Dr Green risked exacerbating a patient’s lumbar pathology by providing spinal mobilisation and manipulation in conjunction with administering morphine.
Dr Green’s administration of morphine and tramadol ampoules prescribed for one patient to other patients
The Committee found that Dr Green prescribed parenteral tramadol and morphine for specific patients, and, following supply of those medications by a pharmacist, administered those medications to other patients. The Committee found this to constitute inappropriate stewardship of opioid ampoules. The Committee found that this meant that Dr Green's patients would appear to have received more or less morphine and tramadol than was actually administered to them. It would not be apparent to anybody except Dr Green who the true recipients of the dispensed ampoules were. This practice also appeared to be noncompliant with several regulatory requirements.
Dr Green’s recordkeeping relating to his prescribing and administration of morphine and tramadol and regulatory notifications regarding morphine
Dr Green was required to keep a controlled drugs register recording, among other things, information relating to any morphine that he administered during the review period. The Committee found that the controlled drugs registers that Dr Green kept to record his administration of morphine were inadequate. He used two small handwritten notebooks that were written in an unusual manner and were difficult to comprehend. He used an idiosyncratic recordkeeping system. This involved an array of symbols relating to the administration of morphine and the number of ampoules that he had at his practice. The Committee found this recordkeeping system was very difficult to comprehend. The various symbols used by Dr Green were not comprehensible on the face of his record books alone. It would be almost impossible for another medical practitioner to comprehend important information such as how much morphine was administered to patients or the quantity of morphine ampoules at his practice. In no case did he record the quantity of morphine ampoules that he administered.
Dr Green also did not adopt a standard left-to-right page orientation when completing the books. Rather, he wrote chronological entries on the right side of the book, and after reaching the end, worked backwards by completing chronological entries on the left side of the book. Dr Green’s handwriting was also often hard to decipher.
Dr Green’s practice of administering injections of morphine or tramadol from ampoules prescribed to other patients also adversely affected the comprehensibility of his records. The number of ampoules that were actually administered from dispensed PBS item 1647Q or 8582Q scripts was not able to be readily discerned. This was so because it was rarely the case that Dr Green would document in the patient record that he had administered morphine or any other information relating to the administration of morphine. He did not document that not all ampoules were administered to the patients for whom they had been prescribed.
Examples of this conduct include:
- A patient who was prescribed 25 ampoules. The morphine books record only one instance of morphine being administered to this patient, whereas the patient’s clinical record indicates that morphine was administered on ten occasions.
- Another patient was prescribed ten ampoules. The morphine books record only one instance of morphine administration, whereas the patient’s clinical record indicates that morphine was administered on six occasions.
In relation to tramadol, the Committee found that in only four instances in the 104 unique records examined by the Committee did Dr Green record his administration of tramadol. It was not possible for the Committee to discern whom tramadol ampoules that Dr Green prescribed were administered to, especially considering Dr Green's practice of administering tramadol ampoules for patients other than for whom prescriptions were written.
Accordingly, the Committee found that Dr Green’s recordkeeping of essential information relating to morphine and tramadol was manifestly inadequate. Further, the Committee found that there were numerous issues apparent in relation to Dr Green’s compliance with regulatory requirements attaching to morphine. These included that Dr Green may not have appropriately notified regulatory authorities in connection with his administration of morphine to patients for lengthy periods of time and to drug dependent patients.
The Committee’s findings regarding Dr Green’s provision of acupuncture and mental health consultations (MBS items 197 and 2713)
For both MBS item 197 and 2713, the Committee found that cases where Dr Green provided spinal mobilisation and manipulation under analgesia involved inappropriate practice. Patients attended on many occasions and were provided with acupuncture in conjunction with opioid analgesia as well as other pharmacological treatment, with no evidence that their conditions had improved. The Committee also found that Dr Green prescribed opioids, benzodiazepines and other medications without adequate clinical justification.
For example, one patient attended Dr Green for acupuncture 48 times during the review period. On many of those occasions, Dr Green administered parenteral morphine and other medications including Lipitor, Lyrica, oxycodone and Celestone. There was no evidence that the patient’s condition improved as a result of this polypharmacy and frequent acupuncture.
In some cases, the Committee found that Dr Green failed to appropriately manage serious medical conditions or otherwise provided inadequate clinical input, or did not adequately document his clinical input. For example, the Committee found that:
- Dr Green failed to do anything to manage a number of different patients who presented on different occasions with very significant hypertension. This included a patient who had a history of regular elevated blood pressure readings and chronic renal failure.
- In another case, a 70-year-old patient presented with a potentially malignant breast lesion that was not investigated properly.
- In another case, Dr Green failed to adequately examine, investigate, and take a history from a patient who presented with chest pain that may have been myocardial in origin
In several cases, the Committee found that Dr Green provided services when he was not able to appropriately provide those services due to his own health circumstances.
Specifically in relation to MBS item 197 (acupuncture consultation lasting at least 20 minutes), there were additional reasons why the Committee found that Dr Green engaged in inappropriate clinical practice in rendering this item. These included that substantial clinical input that Dr Green asserted he provided was not documented in the records. For all services reviewed, limited detail was recorded in relation to acupuncture services.
The records for MBS item 197 also did not support that he provided consultations that were of an appropriate clinical complexity attributable to a Level C consultation and that would have involved at least 20 minutes of personal clinical input. The Committee found that important clinical details were not recorded in the records. For example, in some cases there was no evidence that Dr Green took a history of or examined patients’ presenting complaints nor formulated or documented a plan for management.
For MBS item 2713 (mental health consultations lasting at least 20 minutes), the Committee found that Dr Green failed to keep adequate and contemporaneous records. The Committee found that Dr Green over relied on tickboxes in his recordkeeping software, without elaborating on what those tickbox findings meant. For example, a tickbox relating to a particular behaviour or condition was often ticked by Dr Green, without any elaboration on what that meant for the patient.
The Committee found that on occasion, adequate information in relation to abnormal clinical findings or history was not recorded. For example, in one case, a patient had suicidal thoughts but the record did not provide any insight into the patient’s suicidality.
In some cases, the Committee found that Dr Green did not address a mental health disorder in connection with an MBS item 2713 service.
C. Federal Court
The decision in the judicial review application first mentioned in September 2017 remains reserved.
D. Referrals to the major non-compliance (fraud) division
No matters were referred to the major non-compliance (fraud) division in June 2018.
E. Referrals to AHPRA
No matters were referred to AHPRA in June 2018.