High Prescribers

Houston psychiatrist G.K. Ravichandran practices a “bio-psycho-social-spiritual” approach to mental health treatment, relying heavily on clinically controversial brain scans to detect everything from anxiety to marital discord. He also has a strong penchant for prescribing heavy drugs.  

Ravichandran wrote Texas Medicaid patients more than 54,000 prescriptions for costly, potent antipsychotics between 2005 and 2009 — more than any other doctor in the state, and a figure other practicing physicians call borderline impossible. The next highest prescribers of antipsychotics include a North Texas music therapist who believes his Peruvian pan flute tunes have therapeutic benefits, and a Beaumont child psychologist reprimanded for continuing to prescribe to a proven drug abuser. Between them, they doled out more than 89,000 prescriptions for antipsychotics in that time period, according to a Texas Tribune review of state Medicaid data.

Their prescriptions make up just a fraction of the total: Over the last five years, Texas physicians wrote Medicaid patients nearly 3.4 million prescriptions for antipsychotics — mind-altering drugs designed to treat schizophrenia, bipolar disorder and severe psychological distress, but proven to have serious side effects in kids. While a small portion of the state’s 3 million Medicaid patients received the drugs, many of the highest-prescribing doctors predominantly treat children, a strong indication that’s where the bulk of these antipsychotics are going.

Officials with the state Health and Human Services Commission say psychotropic drugs represent just 2 percent of the 30 million Medicaid prescriptions filled every year. But they acknowledge the drugs are powerful and need close monitoring, particularly in children. Agency spokeswoman Stephanie Goodman wouldn’t say whether Health and Human Services is investigating any particular doctors for overprescribing antipsychotics but warned that “any doctor prescribing far more drugs than his counterparts should expect to be on our radar.”

It’s unclear why certain psychiatrists have such high prescription numbers; there’s no evidence they have relationships with drug vendors that incentivize high prescribing. Whether it’s a psychiatric trend, a professional preference or an easy out, lawmakers and child welfare experts say it’s worrisome, because more than 70 percent of Medicaid patients are under 19. Drugs like Seroquel and Risperdal, designed to quell schizophrenia in adults, are often prescribed to curb attention deficit disorder and depression in kids, they say — and can lead to severe weight gain, diabetes, movement problems and even some heightened suicide risks.

“You don’t want your kids to become victims of a health care system where you’re putting profit over safety,” said Rep. Sylvester Turner, D-Houston, who tried unsuccessfully to pass legislation last session that would have set higher standards for prescribing certain drugs to kids on Medicaid. “You don’t want a situation where doctors are cavalierly prescribing a medication that is powerful and potent, but not safe or appropriate.”

But other mental health advocates argue that medical professionals know best, and that Medicaid fraud investigators and prescribing privileges are enough to govern these psychiatrists. Last session, they helped derail Turner’s bill, which instead evolved into a study of prescription habits among doctors treating kids on Medicaid. “In all branches of medicine, there are some people who over-prescribe medications … but I’d think that’s a minority,” said John Bush, executive director of the Federation of Texas Psychiatry. “There are all kinds of mechanisms in place to identify those outliers and to discipline them when necessary.”

Practicing physicians say the numbers of prescriptions being written by the three doctors who show up most in state Medicaid records — especially Ravichandran — are unheard of, particularly for child and adolescent psychiatrists, and for drugs as potent as antipsychotics.

Dr. Marty Barrash, a veteran Houston neurosurgeon, said that even in the years where he saw more than 1,000 new patients and performed more than 300 surgeries, he never wrote more than 15 or 20 prescriptions a week for anything, including painkillers. “And I was operating on people's brains,” he said. 

The state spends roughly $2 billion a year on prescription drugs for the one in eight Texans on Medicaid. More than 10 percent of that money is spent on powerful antipsychotic drugs — many of which have no generic alternative and are expensive. And the doctors who see these Medicaid patients are sometimes paid royally for treating them. 

North Texas psychiatrist Fernando Siles, the second-highest prescriber, wrote nearly 22,000 antipsychotic prescriptions to Texas Medicaid patients between 2005 and 2009, and was paid $1.9 million from the state for treating them. Siles, who attended medical school in South America, is a recording artist who plays the Peruvian pan flute. His website emphasizes his “Flute Doctor” music therapy practice, and attributes “major psychiatric breakthroughs” to “listening to his original music.” Messages left with Siles’ office were returned by his music manager. Siles, a child and adolescent psychiatrist who has treated foster children, could not be reached for comment.

Meanwhile, Beaumont child and adolescent psychiatrist Kanneganti Ravikumar wrote 13,000 antipsychotic prescriptions while being paid $3 million for caring for Medicaid patients, according to state records. Ravikumar was cited by the Texas Medical Board in 2008 for continuing to prescribe serious psychotropic drugs to a patient who was abusing them. He could not be reached for comment.

The state paid the Shamrock Psychiatric Clinic, Houston psychiatrist and top anti-psychotic prescriber Ravichandran's personal practice, roughly $3 million in the last four years for treating Medicaid patients, according to state records. The woman who answered the phone at Ravichandran's $3.4 million, 9,000-square-foot home in Houston’s exclusive Piney Point Village demanded a reporter call the doctor at work. Ravichandran, who went to medical school in India, did not return phone messages left on his clinic answering machine. 

Ravichandran’s website prominently advertises his use of “SPECT” brain scans in his diagnoses. But many neurologists say there’s zero evidence that SPECT scans — the top-dollar procedures Ravichandran uses to measure blood flow in the brain — can shed any light on mental illness; it’s only FDA-approved for a couple of specific uses, and insurance rarely covers it. Some go as far as calling it a scam, equating it to reading palms. “Parents come in and get convinced they need a high-tech snake oil picture of their child’s brain, and they pay $2,000 out of pocket,” said Michael Greicius, the principal investigator at Stanford University’s Functional Imaging in Neuropsychiatric Disorders Lab. “It preys on parents whose kids have behavioral disorders.”

Medicaid Prescriptions For Antipsychotics By County: 2009

Source: Texas Health and Human Services Commission

Hattie McGill felt like one of these parents. From the time her toddler son was sexually abused at his Waco day care, he began exhibiting behavioral problems — severe moodiness, anxiety, reclusion. One psychiatrist after the other diagnosed McGill’s son, who was on Medicaid, with attention deficit disorder, with bipolar disorder, with autism. They prescribed Ritalin, then Concerta, then Seroquel. McGill, desperate for a solution, filled the prescriptions — and watched as her son’s weight ballooned and he struggled with exhaustion and seizures.

By the time her son was 14, McGill said, she realized these doctors were prescribing through trial and error — not because they knew how to help her son. She weaned him off of all of his antipsychotics six months ago and said every day is an improvement. “We’re still dealing with the withdrawal, with coming down from all of these medications,” McGill said. “But I had to fight for him, to fight the doctors who just fall back on those drugs because they don’t know what else to do.”

State health officials say antipsychotic drugs have dramatically improved mental health treatment for many patients; the drugs available before these top-dollar medications came onto the scene had even stronger, more debilitating side effects.

And they say they’ve got several measures in place to ensure the drugs aren’t abused or over-prescribed. The Health and Human Services Office of the Inspector General analyzes Medicaid data to look for anomalies in prescribing, Goodman said. The Medicaid Vendor Drug Program performs spot checks on prescribing patterns for high-cost drugs at pharmacies across the state. And the state instituted new guidelines in 2005 to guard against over-prescribing of psychotropic drugs among foster children in state care — an effort Goodman said has dramatically reduced use.

The antipsychotic prescribing study commissioned in 2009 is due in November, Turner said, and depending on the results, lawmakers could revisit legislation on it next session. “There are antipsychotic drugs that have been given to children under the age of two, and in some cases under the age of 1,” Turner said. “The goal is not to micromanage, or to delay needed treatment. But there should be at least some minimum level of authorization to check the safety and appropriateness of these drugs in children under 16.”