Anatomy of a DEA Investigation

It always starts with a phone call.

An unassuming but authoritative presence on the phone, normally an investigating officer from a local police station requesting to speak with a healthcare provider regarding a particular patient.

The receptionist instantly grasps the magnitude of it, quietly walking over to the provider and blankly indicating that a law enforcement agent is on the line – prompting the provider to stop whatever he or she is doing and take the phone call.

It is never a good idea to keep law enforcement waiting on the line.

The conversation is terse. The officer on the line quickly mentions the patient in question and begins to inquire about the care received. The questions center around specific actions that transpired during the patient encounter:

“Did you even see the patient?”

“Did you conduct a physical exam?”

“Do you have the medical records?”

“When was the last time you ordered a drug screen?”

Becoming ever more focused on the main question in the mind of the officer – what was the controlled substance prescribed?

“Do you know how many pills you prescribed?”

“How many did you prescribe last time?”

For many in the healthcare world, the word choice and the overt emphasis on the number of prescription medications seems odd. Most are not used to referring to medications as pills, or focusing on the total number of medications prescribed as opposed to the daily use of medications.

But the difference in jargon highlights a growing difference in perspective between investigating officers and healthcare providers. Previously, law enforcement looked at the clinical encounter as the location for a potential drug exchange – medications for something. And they correlate specific acts or behaviors with criminal behavior.

Now, if a provider does not perform a specific act, such as order enough urine drug screens, then that provider is a suspect. With the underlying assumption being the lack of oversight constitutes potentially criminal behavior warranting an investigation.

This is where the different perspectives grow into something quite concerning. It makes sense to investigate a provider for exchanging medications for additional cash, sexual favors, or any other illicit gains. But to investigate a provider for not doing something is an entirely different proposition.

It would be akin to pulling someone over for speeding just for driving a sports car. You can make the assumption that if someone drives a sports car, then they may likely speed in the future. But that is largely hypothetical and purely speculative.

Yet this is how many DEA investigations begin. A local officer reaches out to the provider, usually based upon a tip from a pharmacist, and initiates a phone call based upon that tip. Ostensibly to ask about a patient that was seen, but really to identify incongruencies between what the provider says and what information the officer has received.

If the provider cannot recall the number of prescription pills given to the patient in question, the officer may assume that the provider is being careless with the prescriptions and notify the DEA.

If the provider acknowledges that a urine drug screen was not performed at the last visit, the officer may assume the provider is not implementing the necessary oversight to prevent diversion.

Inquiries which allude to the shift in investigational tactics among law enforcement agents, both locally and federally.

Law enforcement has prioritized the risk of diversion over the clinical care of a patient, or the potential risk over the actual risk. This means what does not happen in the clinical encounter is now as important as what does happen during the clinical encounter.

And when the investigating officer calls a provider, that officer is speculating not only if the provider did something to warrant an investigation, but also if the provider did not do something to warrant an investigation.

Ultimately the goal is to identify specific acts, or the absence of specific acts that can then be used to justify the need for further investigation. A justification that is subject to wide-ranging, inconsistent interpretations.

Which make these initial phone calls even more critical. The decision to formally investigate a provider, conduct a raid of his or her clinic, and seize medical records largely come from these initial interactions – turning speculation into criminal investigation.

After these phone calls, the investigating officer reaches out to the DEA office and indicates whether the provider warrants further examination. Most DEA branches are understaffed and rely heavily on local law enforcement. So if the local officer believes a provider should be investigated, then the DEA usually follows that lead.

DEA agents will then find a patient, pharmacist, or even a neighboring tenant to serve as an informant against the provider. Anything that at the very least insinuates improper behavior.

This usually entails having the informant document a set of claims in an affidavit, a written statement confirmed by oath or affirmation, for use as evidence in court to secure a search warrant from the federal courts. The affidavit is normally given to a local magistrate judge, a federal judge who is appointed by the court to assist the publicly elected district judges. Magistrate judges generally oversee first appearances of criminal defendants, set bail, and conduct other administrative duties. Their role is largely procedural.

And once they receive an affidavit, they usually authorize a search warrant with little to no oversight on the authenticity of the affidavit or why a particular informant was chosen to speak against a given provider. The decision to provide a search warrant is primarily reflexive.

Once the search warrant is received, the DEA then prepare for their famed drug raids. Tactics originating for investigations on drug dealers or gang activity, that the DEA now uses on suspected providers.

These raids consist of local law enforcement and DEA agents bursting into provider offices with guns drawn and bulletproof vests festooned as though they are entering into active battle. The act is largely ceremonial, intended to intimidate and humiliate providers.

Most of the time the DEA agents scour about, as the actual investigative work consists of little more than uploading or photocopying a few medical records, including records of the patient whose line of questioning led to the whole sequence of events.

But then again, the effect of the investigation is the most important aspect of the whole investigation to begin with. What evidence produced matters less than the act of investigating itself.

If law enforcement believe the risk of diversion outweighs the quality of care, then it makes sense to investigate what did not happen as much as what did happen – and to judge a provider as much on what transpired during the clinic as what did not transpire.

If you follow that line of thinking to its logical conclusion, then it quickly becomes apparent that the perception of enforcement is more important than the actual findings themselves. And the fear of prescribing is more important than the need to prescribe – even medically necessary medications.

This is what happens when you place the speculative risk of drug diversion over the actual risk of poor patient care.

It all comes down to that initial phone call.

The anatomy of a DEA investigation.

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Vaccine Passports: what we need to know

The COVID-19 pandemic has killed more than half a million people in the US and has seriously impacted our daily lives. The granting of Emergency Use Authorizations for COVID-19 vaccines has been a game changer in helping to reverse the pandemic onslaught. Demand for the vaccines currently far exceeds supply nationwide. They have become the golden ticket that can transport us back to a time when routine activities, such as attending school or taking vacations, didn’t seem fraught with danger. What’s the best way to go about re-establishing these activities? One idea that’s getting discussed seriously is giving those who have been immunized a vaccination passport (VP).

What is a vaccination passport?

Let’s start by clarifying some terminology. VPs are documents that show that someone has been given a vaccine(s) and is therefore presumed to be immune from getting and sharing that disease. These are distinct from diagnostic tests to determine if a person is or is not infected with a particular virus (PCR and viral antigen tests) or has been exposed to a virus (antibody tests). VPs are the modern day equivalents of the “letters of transit” that played a key role in the film Casablanca. They’ll enable you to travel freely.

Why give vaccine passports?

Vaccinated people are unlikely to transmit the virus that causes COVID-19 with others, though this has yet to be definitely proven. So, what’s the primary rationale for giving vaccination passports? It seems the goal is to incentivize people to get vaccinated. Folks might be more likely to seek out the vaccine if it bestows upon them certain privileges, such as being able to travel freely. While the idea might sound appealing at one level, the road to vaccine passports is pockmarked with political potholes and littered with logistical land mines.

Administrative issues

There are a lot of important questions that need to be answered before VPs can become widespread; it’s unlikely there will be a “one size fits all” solution. What might VPs look like? Pieces of paper (that could easily be lost or counterfeited), or a digital key or document you store on your smartphone (that many older folks still don’t have)? If you lost one, how would you get it replaced? Would your vaccination records be tied to your other medical records, and if so, what kind of privacy and security protections would be needed to safeguard your data? How would the passport administrator verify that you got vaccinated in the first place? Who is responsible for correcting any errors that crop up? Given how much we’ve struggled as a nation to simply solve the scheduling of vaccinations, VPs might be significantly more difficult to manage.

Who’s going to run the program?

A coalition of health tech leaders (including Epic, the Mayo Clinic, Microsoft and Salesforce) has started the Vaccination Credential Initiative to create an internationally accepted digital health card. Its vision – as stated on its website – is “to empower individuals to obtain an encrypted digital copy of their immunization credentials to store in a digital wallet of their choice. Those without smartphones could receive paper printed with QR codes containing World Wide Web Consortium (W3C) verifiable credentials.” Some European countries (e.g. Denmark) are working on developing their own immunization passports, and the President of the European Union Commission has voiced support for them.

We already have a hodgepodge system designed to keep folks with COVID-19 from traveling. Many airlines are requiring proof of non-infectivity to board a plane – these are distinct from VPs. The methods adopted vary from airline to airline: United uses Travel Ready Center, American uses VeriFly while others use Common Pass. Saga cruises are the first in the UK to demand proof of vaccination, but not everyone is on board with the concept. The World Travel and Tourism Council stated its opposition to allowing travel only by those who have been vaccinated, on the grounds that it is discriminatory.

Discrimination concerns

The concept of gaining advantage from one’s immunological status is not a new one. In New Orleans in the mid 19th century, great economic value was attached to those who survived the onslaught of epidemic waves of yellow fever. A mix of structural racism and a system valuing “immunocapital” ranked men and women highly if they were yellow fever survivors. Those that had not had the disease yet found it difficult to obtain work or obtain credit and women could not marry. Slaves were similarly revalued, with larger assessments attached to survivors. This legacy of viral discrimination casts a long shadow over current discussions surrounding vaccination passports.

Also problematic is the fact that not everyone will be eligible for VPs. Some people can’t be vaccinated for medical reasons but would still like to participate in whatever activities the passports enable (such as travel opportunities). These individuals will likely file complaints if they are denied VPs, arguing that they’re discriminatory in nature. Vaccine opponents will no doubt also file lawsuits seeking to block the use of VPs, claiming they represent an attack on their freedoms and personal choice.

Others may be shut out of VP programs because they don’t have the computer skills to register online, a problem that’s turned out to be widespread with the vaccinations. Don’t have any ID? In some places this prevents the most vulnerable from getting the COVID-19 vaccine, and therefore VPs as well. Many Black and marginalized communities are already deeply suspicious of the medical establishment, and wary of receiving a COVID-19 vaccine. Restrictions that prevent these groups from participating in various societal activities because they don’t have VPs will echo the Jim Crow days of poll taxes and literacy tests that were required to vote.

Enforcement issues

VPs bring up a similar issue as mask mandates: who is going to enforce them? It is one thing for a cruise line to do so, since reservations are required and extensive paperwork needs to be filled out in advance. Who is going to keep non-vaccinated people out of restaurants or concerts that require proof of vaccination? We’ve already seen anti-maskers storm department stores, ignore requirements to wear masks on planes and even kill a security guard who confronted them.

Black market for vaccine passports

Many airlines are now requiring proof of a negative COVID-19 test before they will let their customers fly. This has led to a black market for fake negative COVID-19 test results for those who are looking to game the system. Similarly, bogus cards claiming that the cardholder was exempt– for medical reasons – from having to wear a mask, have been manufactured and distributed. It’s not hard to imagine that a similar market will emerge for VPs.

Overcoming vaccine hesitancy

Given the multitude of issues and concerns listed above, moving forward with issuing vaccination passports seems highly problematic. If the primary purpose of having VPs is to drive up immunization rates, that can be better accomplished by running public service announcements and ads illustrating how liberating it is to start doing normal activities once vaccinated. A nationwide campaign to do just that is already in the works. I personally can think of a better use for the time and money that will be spent on establishing VPs: use them to focus efforts on overcoming vaccine hesitancy in concert with combatting the high tide of online vaccine misinformation and disinformation.

Source: Technology Networks

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