Of the two doctors who ran Physicians Pain Specialists of Alabama (PPSA), U.S. District Court Judge Ginny Granade said there’s no doubt Xiulu Ruan was the more accomplished, though it was his pursuit of financial gain turned a legitimate practice into a criminal enterprise.

Granade made those comments just before sentencing Ruan to 21 years federal prison and just after hearing remarks his colleagues, former patients, friends and family. The sentence is one year longer than Ruan’s codefendant, John Patrick Couch, who was sentenced Thursday.

“It certainly appears Ruan was the better doctor. He was better educated and held more degrees and certifications,” Granade said. “However, it also appears he could not control his desire to make the most money he could off of these patients and insurance companies.”

In a seven-week trial earlier this year, a jury found Ruan and Couch guilty of 19 federal charges ranging from conspiracy to distribute controlled substances, health care fraud, violating anti-kickback statutes and violating the Racketeer Influenced and Corrupt Organizations (RICO) Act.

The case focused on the illegal prescribing of narcotic drugs, with an emphasis on opioid painkillers. Though many drugs were discussed at trial, the court focused on fentanyl, oxymorphone, oxycodone, hydromorphone and morphine when calculating a sentence.

Based on records kept by Alabama’s Prescription Drug Monitoring Program (PDMP), Ruan prescribed 306,213 kilograms of those drugs, an amount that was used to calculate his sentence based on formulas used in cases involving an equal quantity of marijuana.

In some instances, Couch wrote more prescriptions, but prosecutors say it was Ruan who orchestrated the schemes that allowed PPSA to defraud health insurers, collect kickbacks and leverage its in-house pharmacy through lucrative deals with pharmaceutical companies.

Assistant U.S. Attorney Christopher Bodnar led the prosecution of Ruan and Couch along with AUSA Deborah Griffin. (Jason Johnson)

“Certainly, for Dr. Ruan, money was absolutely the motive,” Assistant U.S. Attorney Christopher Bodnar said. “That was shown through numerous emails and witnesses’ testimony. It was the driving factor for a lot of the prescriptions written and the type of prescriptions that were written.”

Several of the doctors’ charges stemmed from “off-label” prescriptions for drugs intended to treat breakthrough pain in cancer patients that contain the powerful and addictive opiate fentanyl.

John Burns’s late wife was one of Ruan’s patients. In court, he told Granade Ruan falsified medical records in order to prescribe his wife fentanyl, saying he “somehow put on her medical files that she had cancer just so they could give her a higher dose of medicine.”

Burns said he’s been held liable for the cost of some of that treatment due to complications with his insurance that arose from that false cancer diagnosis on his wife’s medical record. However, he said living without his wife has been much harder.

“I can’t tell you the medicines he gave her killed her, but it certainly weakened her,” Burns told Granade. “The people they’ve hurt, the lives they’ve ruined — it came from a doctor being greedy, and it’s not right. Especially for someone that’s supposed to help people.”

Throughout the two-year legal ordeal, Ruan has frequently taken shots from prosecutors and in the media for his multi-million dollar collection of luxury automobiles the government is already in the process of liquidating.

On Friday, Mary Richardson, whose brother Tim Richardson died after being treated at PPSA, took one of those shots herself saying that her brother had “needed help and all he got was another prescription for profit, while Dr. Ruan got another car.”

However, several people also spoke on Ruan’s behalf, including physicians from across the country who submitted letters to Granade and one who traveled from Michigan. Several former patients and employees also described Ruan as “dedicated, educated, caring and intelligent.”

Sharon Nolan — a nurse practitioner at PPSA from 2011 through 2015 — was one, and despite the prosecution’s narrative, she said Ruan ran “a stringent practice,” while Couch and his staff “ran unchecked and prescribed whatever they wanted.”

“We’ve heard from patients today, but are thousands of others who were helped that were too scared to appear in court today because they’d be stigmatized by the media and the public for taking pain medication,” Nolan said. “Xiulu Ruan is one of the finest doctors I’ve ever worked with, and I wouldn’t hesitate to work with him again.”

Ruan himself spoke to Granade about his approach to caring for chronic pain patients, saying he’d always “pushed [himself] to the limit” in medical school and as a practitioner, so he could “have the most up-to-date skills for the betterment of [his] patients.”

He also rejected the idea that greed had been a motivation in any of the decisions he made.

Xiulu Ruan has been held at the Baldwin County jail since being convicted of multiple federal charges in February. (BCSO)

“I have never prescribed anything for money because money is not what I look for. I look for virtue and my patients’ best interest,” Ruan said. “I felt I had a moral obligation to use what I had learned to provide my patients with needed care to ease their pain and make life more livable.”

“I miss all my patients,” he added.

The 21-year sentence Grande handed down is a variance from guidelines established for his sentencing calculation and significantly less than the 40-year sentence prosecutors initially sought.

Ruan is also being ordered to pay millions of dollars in restitution for services fraudulently submitted by PPSA to insurers like Blue Cross and Blue Shield of Alabama, the U.S. Department of Defense health care system Tricare and Medicare.

Ruan will be liable for more than $12.5 million on his own, though he and Couch will be sharing the burden of reimbursing United Health Group and another arm of Tricare $2.7 million.

“Ruan, in particular, drove the fraud angle of this case,” Bodnar said. “The drug case in and of itself was huge, but had this been two separate cases, the fraud case would have been enormous.”

Acting United States Attorney Steve Butler was appointed by Attorney General Jeff Sessions earlier this year. (Jason Johnson)

Acting U.S. Attorney Steve Butler called the case “groundbreaking,” noting that it had already received some national attention.

He also said it could certainly have implications on other cases targeting “medical professionals who put greed and profit over legitimate patient care.”

“What happened with these two doctors could happen in any other situation,” Butler said. “However, their conduct in this case, which led to their conviction and these two long sentences, is not indicative of the vast majority medical professionals or their motivations, and we know that.”

Despite the victory in court, though, the government will no doubt have to validate the convictions of both doctors on appeal, as Couch and Ruan have already started the process to have the 11th Circuit Court of Appeals in Atlanta review their cases.

Though it’s unclear how that will take shape, part of Ruan’s could focus on the court’s decision to prevent patients who supported PPSA from testifying during their trial. On Friday, attorney Dennis Knizley said that was one reason so many spoke during Ruan’s sentencing.

“We were hampered at trial by not being able to put out what we call good medicine or the evidence of the good patients, and you heard one of the witnesses today say there would have been thousands of patients if the court had allowed us to do that,” Knizley said. “That’ll be a matter on appeal, and hopefully when the case is retired we will have those good patients.”

When asked about the 21-year prison sentence hanging over Ruan’s head, Knizley said no attorney is ever happy with that kind of result, but when guidelines include the possibility of a life sentence, “we’d rather take that.”

“We’re not happy with the conviction, we’re not happy with the sentence and we’re going to appeal it, but we’d much rather have 21 years than life,” Knizley added.