Pain and gain: An Alabama clinic stands out amid data on Medicare payments

HUNTSVILLE, Ala. — Nearly 20 patients packed the waiting lobby of the Alabama Pain Center before 10 a.m. on a warm April day. Crosses and biblical passages adorned the walls. In a hallway, a painting titled “The Great Physician” depicted Jesus assisting a doctor in the operating room.

Afflicted by pain from spinal injuries, botched surgeries or rare nerve conditions, patients from Tennessee, Georgia and Florida have flocked across state lines to see K. Dean Willis, a tanned anesthesiologist with salt-and-pepper hair who says he is among the top 30 experts on the use of pain pumps.

Implanted under the skin, the pump looks like a titanium hockey puck. High-powered drugs are custom-mixed on site, injected into the pump and carried by catheter into the spinal fluid. When the pump runs low, the patient returns to have it refilled, like a gas tank.

Although some experts consider the implanted pain pump to be an unusual and controversial last resort of pain management, it has become a signature treatment at the Alabama Pain Center.

Willis is now garnering national attention and new scrutiny. For the first time, newly released Medicare data has identified the costs associated with specific doctors performing procedures or administering drugs. The data allows for the identification of “hotspots” for particular treatments. The Washington Post found that the Huntsville area ranked fourth in the nation in Medicare spending per enrollee for drugs administered by doctors in 2012, the only year for which data has been released.

Medical spending in Huntsville, Alabama

The procedures driving much of the cost were injections of “unclassified” drugs, a catchall category used by Medicare that includes drugs mixed at compounding operations, such as the one inside Willis’s clinic. Huntsville ranks No. 1 in that category.

“We see the worst of the worst,” Willis said in the hallway of his clinic. “It’s usually more expensive. Maybe that explains why our payments are so high.”

Nationwide, about $4 out of the $299 in total drug treatments by doctors per Medicare beneficiary is spent on unclassified drug injections. In Huntsville, the amount spent is $152 per enrollee — 38 times the national average — out of $766 in total drug treatments.

About 98 percent of the $11.4 million in Medicare’s payments for unclassified injections in Huntsville went to three doctors, all at the Alabama Pain Center: O. Jameson Stokes, Norman McCoomer and Willis were responsible for reimbursements in the amounts of $5.7 million, $3.3 million and $2.2 million, respectively, in 2012 and ranked first, second and third in the nation for Medicare payments for unclassified injections.

But the once-booming practice has hit hard times.

Stokes and McCoomer have left the Alabama Pain Center to open their own pain clinics. Over the past 16 months, Willis’s center has been under an audit by a contractor for the Centers for Medicare and Medicaid Services, which administers the government’s health insurance programs for the poor, elderly and disabled.

Last spring, Blue Cross and Blue Shield of Alabama, the largest private insurer in the state, accused the center of “fraudulent billing practices” in a court filing, claiming that among other things it charged $19,200 for one drug that should have cost $451. The center disputes the allegations.

In August, while the audit was ongoing, Medicare officials stopped the reimbursements altogether because of “issues” involving the unclassified injections, according to Howard Bogard, an attorney for the pain center. Medicare officials told The Post they are reviewing the center’s billing practices.

Roughly 42 percent of the clinic’s patients are on Medicare. As its cash reserves were running dry, the center rallied patients, who wrote letters to their politicians in Washington, including Sen. Richard C. Shelby (R), Sen. Jeff Sessions (R) and Rep. Mo Brooks (R), who then wrote letters to Medicare officials noting their interest in the issue. The funding was restored, although the audit continues.

The troubles with Medicare have forced a downsizing. The clinic has laid off more than 80 workers and is down to about 45 staffers.

“When we presented our side of the story to Medicare, we focused on the fact that if Medicare wants to audit us, audit us,” said Patrick Robbins, the practice administrator at the center. “We haven’t done anything wrong. But in the meantime, don’t put us out of business.”

At the center of the fight is the 59-year-old Willis, who is well known in Huntsville. Some patients speak of him with religious fervor, saying he is the best doctor they have ever seen. Others have taken to online message boards to complain about him and his unconventional treatments.

In the 1980s, Willis completed his residency at Texas Tech University in anesthesiology. After a pain management fellowship, he returned to his native Huntsville to start practicing medicine. He also started two nightclubs, the Velvet Underground and the Stockyard Saloon, and a limousine company, along with several other businesses. He is no longer involved in those ventures, Bogard said.

In 2000, he formed the Alabama Pain Center. The center catered to patients who felt they were out of options, Willis said.

“They’re worn out,” he said. “We do something different here.”

The center treated many patients with more traditional methods, such as epidurals, spinal procedures and pain pills. But the practice increasingly became known for the pain pump, manufactured by Medtronic, and business took off. Willis added three satellite clinics and had planned to keep growing. He brought in a sleep doctor, a family practitioner, a physical therapist, four counselors and three psychologists.

“It’s not about the money,” he said. “God provides.”

‘A last resort’

The pain pump was pioneered in the 1980s, although then it was used mainly for cancer patients managing intense pain, according to Timothy Deer, a Charleston, W.Va., physician who has held leadership positions with several pain management societies.

Over the past two decades, its popularity has grown as doctors have expanded its use to non-cancer patients afflicted by other types of pain.

“Remember, this is a last resort,” Deer said. “They’ve already failed everything when they try this.”

There are around 2,500 physicians in the United States who treat patients with pain pumps, he said. Most pain-pump doctors are neurosurgeons, anesthesiologists or physiatrists, who are physicians specializing in rehabilitative medicine.

Karen Knight, a Colorado physiatrist who specializes in ­chronic-pain management, studied the use of the devices in 2007 while she was at a Veterans Affairs medical center in Cleveland.

At the time, the center was implanting them to treat patients with chronic, non-cancer pain. According to her research, the pumps were overused and the risks — including infections and inflammation — outweighed the benefits. As a result, the center curtailed the procedure for non-cancer patients, she said.

“There are better ways to manage pain,” said Knight, who does not use pain-pump implants in her private orthopedic practice.

Currently, the Alabama Pain Center treats about 325 out of 1,200 patients with the pump. Few of them are cancer patients.

When the Medicare data was released last month, Willis said he knew the millions in reimbursements would be negatively perceived. He said he wants the public to know that he has no control over how much insurance companies pay to reimburse a physician.

“Do I take it and use it? Or do I say, ‘No, you’re paying me too much’?” he said. “Who in the world would do that?”

Willis’s Christian convictions have become a hallmark of the clinic. A former employee successfully sued him in 2006 for more than $100,000 in damages for religious discrimination after she refused to attend his morning prayer meetings and was terminated. At the time, the center said she was fired for poor job performance.

The logo of the Alabama Pain Center, which is emblazoned on Willis’s scrubs, features a cross.

“We really care about people,” Willis said, bowing his head and wiping tears from his eyes. “We get a chance to be a part of miracles.”

His 10,000-square-foot house, known for a dazzling Christmas lights display, earned a write-up in the local newspaper. Last month, he was inducted into the regional sports hall of fame for his point-guard skills at the University of Alabama at Huntsville in the 1970s. He writes hefty checks to politicians of his choice. In March, he donated a total of $5,200 to Brooks.

“Dean Willis is one of those with steel in his spine,” the congressman said, adding that he considers the doctor a friend.

J3490

Inside the Alabama Pain Center one recent morning, a sole pharmacist quietly worked in a white-walled lab with an attached clean room used for mixing the pain injections.

The drug-compounding aspect of the center has allowed Willis to carve out his own niche. Robbins, the practice administrator, said Willis is the only physician in the nation to compound his own pain-pump medications on site rather than using an outside compounding pharmacy.

Compounding operations are subject to less-stringent federal regulations compared with drug manufacturers. Nationally, some compounded drugs have had problems with contamination and potency. Recent federal legislation has increased oversight.

Patients say there are clear benefits of on-site compounding. For instance, Willis can adjust the formulations of their injections to ensure that they do not build up a tolerance to the drugs.

Dana Lang said she ended up at the Alabama Pain Center seven years ago after a botched gastric-bypass procedure left her with severe abdominal pain. When she got the pain pump, she started with fentanyl, a man-made opioid. Later, Willis changed her medicine to sufentanil, which is at least five times as potent as fentanyl.

“He tweaks it whenever you need it,” said Lang, 38, of Arab, Ala. “You have to have the right combination of medication.”

Lang has two other drugs mixed in her pump: clonidine, which is used to treat high blood pressure and anxiety, and bupivacaine, which is a numbing agent.

Some of the drugs compounded at the Alabama Pain Center fall outside Medicare’s reimbursement codes, the more than 15,000 identifiers used to catalogue procedures and services. To bill for many of its compounded drugs, the center has relied on the J3490 code, which is used for unclassified injections and has more latitude in pricing.

Bogard, the center’s attorney, said that the regional Medicare guidelines for pricing were revised in 2013 to provide for the first time more specificity for the reimbursement of compounded pain-pump drugs. He said future payments to the center for pain-pump refills are likely to drop.

In January 2013, a Medicare contractor began an audit of the Alabama Pain Center, focusing on the unclassified injections.

The audit slowed reimbursements, hampered cash flow and caused a “significant administrative and legal burden” on the center, Bogard said. In August, Medicare went further, stopping all reimbursements to the center.

In October, local television crews covered the pain center’s saga. They brought their cameras into a town hall meeting packed with patients. Willis announced that the center would close on Nov. 15. But with time running out, he went on the offensive to keep it open.

The doctor wanted his patients to speak out, to write letters to their representatives in Congress and to stir outrage. Willis made a phone call to Tiffany Overby, a 20-year-old hairstylist who works at a mall salon in Buford, Ga., a suburb of Atlanta.

“He explained to me what was going on,” she told The Post in a recent interview. “He said I needed to write a letter. I broke down crying. I was scared.”

When Overby was in the sixth grade, she twisted her ankle during a game of kickball. Her ankle turned black and blue, she said, and it felt as though spiders were crawling on the sole of her foot. Then, it felt like her foot was being torched.

“It felt like someone was taking the sharpest knife and cutting through my muscles and tendons,” she said.

Overby was diagnosed with reflex sympathetic dystrophy syndrome, a rare and extremely painful nerve condition. Deeply depressed, she became suicidal. Another physician installed a pain pump, but Overby developed a tolerance to the morphine.

She traveled to Alabama to see Willis, who prescribed a mix of three drugs: fentanyl, clonidine and bupivacaine.

“As soon as the medicine went through the pump, I was in no pain at all,” she said.

Overby, who is covered under her father’s private insurance, makes the five-hour drive to Huntsville every three months for her pump refill. She told her story in a letter that she e-mailed to the governors of Georgia and Alabama.

“If something happens to the Alabama Pain Center I am very scared of what my life will be like,” she wrote.

In his Huntsville office, Mo Brooks has a file folder several inches thick of correspondence involving the pain center. The congressman said his office lobbied Medicare officials to speed up the audit process because it was unfairly forcing the clinic to close before a decision had been rendered.

At the end of October, Medicare lifted its payment suspension. The payments would resume and the center would remain open, but the audit continued.

“The patient letters put into context the harm that was being imposed by the suspension and allowed Medicare to make a more informed decision,” Bogard said. “While I cannot opine as to why Medicare lifted the suspension, patient harm can be considered when deciding whether to continue a suspension of Medicare payments.”

Early last year, Willis also engaged in a public fight with a private insurer, filing a lawsuit against Blue Cross and Blue Shield of Alabama over nearly $670,000 in disputed payments.

In a counterclaim to the suit, Blue Cross alleged that the center overbilled for its compounded drugs and “fraudulently or recklessly misrepresented material facts with the intent to deceive Blue Cross.” The insurer alleged that the center “randomly set $19,200 as the price” for sufentanil, despite the insurance company’s calculation that the proper payment was $451.

Blue Cross’s counterclaim also alleged that the center’s billing for clonidine resulted in a $5,571.64 payment when it should have cost $3.45.

Bogard said that he cannot comment on specifics of pending litigation but that the center “does strongly dispute the allegations” in the counterclaim. He also said the center developed its drug billings based on the amounts area hospitals charge for comparable medications.

On average, the clinic charged $2,701 per unclassified injection and received $2,158 per reimbursement, according to the 2012 Medicare data.

Willis is the only pain management physician left at the Alabama Pain Center. The names of the departed physicians, Stokes and McCoomer, have been scraped from the glass entrance to the building.

Bogard did not answer questions about why the physicians left the center.

At the end of 2012, Stokes said, he and Willis could not come to terms on a new contract. Willis said that Stokes was losing money for the center, Stokes recalled. He moved to the Atlanta area, where his parents live, to start his own pain clinic, the Innovative Pain Management Center in Roswell.

Stokes, 39, said he sees only a handful of the patients who knew of him from the Huntsville clinic. In his current practice, he said, he prefers not to deal with pain pumps.

On top of the list

Stokes said he was stunned last month when he saw he was the No. 1 pain-management doctor in the nation for Medicare reimbursements. He also ranked first for unclassified drug injections.

He said he made less than $300,000 working for Willis, with no bonuses or performance incentives.

Stokes said he did not provide pain-pump refills to any patients, despite the 1,864 injections billed under his name, and was unaware that the clinic had received $5.7 million in reimbursements for unclassified injections under his name in 2012.

Stokes said nurses at the center routinely injected the patients, who belonged to Willis.

“They irresponsibly placed a significant amount of money under my name,” he said. “I don’t know what their intent was. It puts me in danger. It brings me unwanted attention. The public is going to wonder, ‘Who is that physician making all of this money?’ ”

Bogard said that the 1,864 injections were “rendered by a qualified, non-physician provider” and that Stokes was a supervising physician in the office during the time of the treatments. The billing practice follows all Medicare guidelines, Bogard said.

It is not uncommon for procedures administered by nurses and other health-care providers to be billed under the names of their supervising physicians.

Stokes said assigning his name to the millions of dollars in injections was not “ethically or morally acceptable.”

“Why did I get all of these charges?” he said, pointing out that he drives a 2002 Isuzu Rodeo, the same car he had in medical school. “That’s not fair or right.”

McCoomer has started his own pain management clinic in Madison, a town on the outskirts of Huntsville. He deferred questions to his attorney, Andy Watson.

“Dr. McCoomer takes the Medicare billings issue very seriously,” Watson said. “We are making our own inquiries to the Alabama Pain Center about past practices while Dr. McCoomer was just an employee there.”

At the Alabama Pain Center, the audit drags on.

Although seven patients were waiting in line one recent morning, the toll of the past year can be easily seen. More than a third of the 45 staffers left are now devoted to billing. Willis is down to one location, his original clinic.

He had hoped to build his brand across the Deep South, preaching about the benefits of the pain pump and the miracles at the Alabama Pain Center.

Now, he likens the halls of his clinic to “a ghost town.”

The physical rehabilitation center, stocked with weights and therapy tools, stands vacant. In the back of the clinic, the procedure lab is empty.

A surplus of office furniture is stacked in the hallway. The center hopes it can resell some of the desks.

“You hunker down and survive,” he said.

Medicare payments
per beneficiary

Medicare spent $152 per member in the Huntsville, Ala., medical marketplace — 38 times the national average — for “unclassified” drug injections, including a type of injection used rarely around the country but used thousands of times a year at the Alabama Pain Clinic in Huntsville.

Amy Brittain is a reporter for The Post's investigative team.
David S. Fallis is a staff writer on the Washington Post’s investigations unit.
Dan Keating analyzes data for projects, stories, graphics and interactives. He was part of a team that won a Pulitzer at The Miami Herald for exposing vote fraud, and a team that was a Pulitzer finalist the year before for uncovering police fraud.
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