By MICHAEL C. PATTERSON
According to a new state draft report on Medical Marijuana (MMJ), Florida had 168,810 patient "certifications" for MMJ between October 1, 2018 and March 31, 2019. More than half of the certifications came from 89 Physicians. The report has alarmed members of a special panel of MDs setup by the State of Florida charged with keeping tabs on the ordering patterns of physicians who can authorize patients to take MMJ. Sarvam TerKonda, MD, of Jacksonville and member of the joint panel, said after reviewing the report, "To me, I look at this data and say this is just another form of a pill mill."
The panel, created in state law, is responsible for reviewing the data for patterns and annually submitting a report with recommendations to the legislature. The concern stems from 89 Physicians (7 percent of the physicians who are eligible to write MMJ certifications) are writing 56 percent - 94,850 - of the certifications. Chronic non-malignant pain was the number one qualifying condition (34 percent) followed by "medical conditions of the same kind or class," and PTSD (26 percent).
There are some people, including physicians, who are not familiar with the MMJ industry that will immediately assume fraud or "pill mill" activity is going on by reviewing this data. However, as someone who studies the United States and global medical cannabis industries, there are legitimate reasons why a few Florida physicians are certifying a large number of patients.
Marijuana is still illegal federally. Physicians are worried about the legality of cannabis and potentially losing their DEA license to prescribe FDA approved medications. Those concerns were real a few years ago, but with medical cannabis legal now in 34 states, there has not been one reported case of a United States Physician losing their DEA license to prescribe FDA medications due to recommending or "certifying" a patient for MMJ. Furthermore, medical practices receive the bulk of their funding from federal insurance programs (Medicare and Medicaid). Therefore, most medical practices refuse to allow their physicians to write MMJ certifications for fear of losing their federal insurance funds.
Physicians are extremely risk averse. As a professional who has spent many years and hundreds of thousands of dollars to complete their medical education, physicians typically do not "jump" to start a new medical service without a tremendous amount of research and validation that their medical license or medical practice will not be negatively affected in some way. As of August 30, 2019, there were 2,466 Qualified Physicians in the state of Florida who can certify MMJ patients. The Florida statute for "Qualified Physician" is below:
"A physician must have an active, unrestricted license as a physician under Chapter 458, F.S., or osteopathic physician under Chapter 459, F.S., and complete a 2-hour course and exam before being qualified to order medical marijuana and low-THC cannabis for qualified patients."
If every MMJ certification was evenly distributed between all of the Qualified Physicians, there would be approximately 38 MMJ certifications per Qualified Physician during the period in question. So, the state has plenty of Qualified Physicians to certify MMJ patients, but very few who are willing to actually write the certifications.
"Early Adopter" Physicians are not pill mills. Ten years ago, Florida was ravaged by physicians who were writing prescriptions for highly addictive narcotics and selling the same narcotics in their offices. This practice was made illegal by the Florida legislature and Florida physicians are now unable to sell narcotics in their offices. Based on the previous problems with pill mills, the state of Florida placed safeguards in the Florida MMJ law (F.S.381.986), which does not allow a conflict of interest by writing MMJ certifications and selling MMJ. Furthermore, each physician must check the prescription history of controlled substances prior to issuing an MMJ certification and patients are only allowed to have an MMJ certification from one Florida physician, which prevents "doctor shopping," attempting to get multiple certifications from multiple doctors. Excerpts from F.S. 381.986 are below:
"b)?A qualified physician may not be employed by, or have any direct or indirect economic interest in, a medical marijuana treatment center or marijuana testing laboratory."
"5.?Reviewed the patient's controlled drug prescription history in the prescription drug monitoring program database established pursuant to s. 893.055."
"6.?Reviews the medical marijuana use registry and confirmed that the patient does not have an active physician certification from another qualified physician."
MMJ certifications have become another medical specialty. Due to few physicians willing to write MMJ certifications, specialty physician practices have been created in Florida which focus primarily on writing physician MMJ certifications. These companies provide a public service by allowing physicians, who do not want to write MMJ certifications, a place to send their patients to receive a certification. These specialty practices have become well versed in understanding the Florida law regarding MMJ certifications, qualifying diagnoses, contraindications, and delivery methods of MMJ. Medical Marijuana Physician practices are becoming a medical specialty no different than referring a patient to a cardiologist, oncologist, radiologist, orthopedic surgeon, infectious disease physician, or other physician specialty practice.
Many Physicians are now employees. With consolidation of healthcare across the United States and the increase of ACOs, more and more physicians do not own their own practices. Physicians are becoming employees of major healthcare providers, just like other traditional healthcare specialists such as nurses, ARNPs, PAs, physical and occupational therapists. With fewer physicians able to own their own businesses, their employer determines whether they can participate in writing MMJ certifications. So far, none of the major Florida healthcare providers have publicly announced that they will allow their physicians to write MMJ certifications.
As the Florida MMJ system progresses, we must continue to evaluate the program and ensure there is balance between the 3 pillars of the industry - public safety, patient access, commerce. However, we must also recognize potential factors contributing to any data procured through this new industry and not jump to conclusions that are invalid or not accurate based on individual bias of medical cannabis or past experiences with other health programs.
Michael C. Patterson, founder and CEO of U.S. Cannabis Pharmaceutical Research & Development of Melbourne, is a consultant for the development of the medical marijuana industry nationwide and in Florida. He serves as a consultant to Gerson Lehrman Group, New York and helps educate GLG partners on specific investment strategies and public policy regarding Medical Marijuana in the U.S. and Internationally. He can be reached at email@example.com