E-Prescribing Profits, Pitfalls, and Perils
Agenda • Medicare’s E-Prescribing Program • Frequently-Asked Questions About Medicare’s E-Prescribing • Possible Problems/ Perils • Discussion
E-Prescribing Definition of E-Prescribing: The transmission, using electronic media, of prescription or prescription-related information between a prescriber, dispenser, pharmacy benefit manager (PBM), or health plan, either directly or through an intermediary, including an e-prescribing network. E-prescribing includes, but is not limited to, two-way transmissions between the point of care and the dispenser.
E-Prescribing Benefits: • Improving patient safety and quality of care • Reducing Illegibility • Reducing oral miscommunications • Providing warnings and alert systems • Provide access to patient’s medication history • Reducing time spent on pharmacy phone calls and faxing • Automation of renewals and authorization • Improving formulary adherence • Improving drug surveillance/recall The e-prescribing initiative has been predicted to save Medicare $156 million by avoiding adverse drug events.
Prior studies – E-Rx and safety • Most alerts over-ridden by prescribers • Weingart et al. Arch Int Med, 2003 • Reviews suggest reduced ADEs, but inadequate studies in outpatient setting • Ammenwerth et al. JAMIA, 2008 Michael A. Fischer MD, MS: E-prescribing in community-based practices: successes and barriers
E-prescribing positives • Prescription security • Financial gain • Office efficiency • Medication safety • Insurance issues • Communication with pharmacy Michael A. Fischer MD, MS: E-prescribing in community-based practices: successes and barriers
E-prescribing positives • Prescription security • Less people touch the actual prescription • Patients cannot lose the prescription • Patients cannot tamper with prescription Michael A. Fischer MD, MS: E-prescribing in community-based practices: successes and barriers
E-prescribing positives • Financial gain • Direct incentives a major factor • Initial adoption subsidized • Later incentives for ongoing use • Potential gains in patient satisfaction • “if we can reduce wait times, we’ve succeeded” • Unclear of ROI in terms of practice billing • Can pick up script faster with fewer lags for questions or authorization Michael A. Fischer MD, MS: E-prescribing in community-based practices: successes and barriers
E-prescribing positives • Office efficiency • Major changes in practice workflow • Less calls for front-end staff • Refills and other non-critical medication issues can be batched for MD review • Frees staff time and attention • Less interruption of work • Pharmacy information is updated and accurate • Perceived ROI, but hard to quantify • Need for a pharmacy phone triage? Michael A. Fischer MD, MS: E-prescribing in community-based practices: successes and barriers
E-prescribing positives • Office efficiency • Major changes in practice workflow • Less calls for front-end staff • Refills and other non-critical medication issues can be batched for MD review • Frees staff time and attention • Less interruption of work • Pharmacy information is updated and accurate • Perceived ROI, but hard to quantify Michael A. Fischer MD, MS: E-prescribing in community-based practices: successes and barriers
Ongoing challenges/barriers • Learning curve • Usability • Reliability • Safety concerns • Patient resistance • Data security Michael A. Fischer MD, MS: E-prescribing in community-based practices: successes and barriers
Ongoing challenges/barriers • Learning curve • New skill: “not covered in medical school” • Difficult for older prescribers • High burden on champions/superusers • New tasks for some personnel – source of resistance • Lack of support at the point of service Michael A. Fischer MD, MS: E-prescribing in community-based practices: successes and barriers
Ongoing challenges/barriers • Usability • Types of devices/interfaces • Problems with some pharmacies • Inability to transmit to PBMs • Controlled substances • Reliability • Connectivity/network problems, loss of productivity • Resistance for sick patients or weekends
Ongoing challenges/barriers • Safety concerns • Selecting wrong patient • Selecting wrong drug (Cipro/Cialis) • Some doses/formulations not in system • Drug alerts not perceived as helpful: “ignore almost all” • Some alerts may be handled by non-prescribers in the process of queuing Michael A. Fischer MD, MS: E-prescribing in community-based practices: successes and barriers
Ongoing challenges/barriers • Patient resistance • Wanting something in hand (older pts) • Bad experiences with failed transmissions • Inability to transmit to PBMs • Data security • Concern about whether transmitting patient data creates liability exposure • Concern about prescribing data and tracking/profiling • Who owns the data??? Michael A. Fischer MD, MS: E-prescribing in community-based practices: successes and barriers
The Medicare Incentive Scheduleand Penalties In 2009 and 2010, physicians who successfully e-prescribe may receive a bonus payment of 2 percent of their overall Medicare reimbursement in addition to a potential 2 percent incentive related to PQRI for a potential bonus of 4 percent in Medicare reimbursement.
E-Prescribing Incentive Program MIPPA authorized a new incentive program, separate from PQRI, for EPs who are successful e-prescribers For 2009, successful e-prescribers are eligible for a incentive payment equal to 2% of estimated allowed charges submitted by 2/28/2010 2009 E-Prescribing Incentive Reporting Period: January 1, 2009 – December 31, 2009 MIPPA also requires that names of eligible professionals who are successful e-prescribers be posted on the CMS web site
2009 Successful E-Prescribers “Successful E-Prescriber” is defined as an EP who reports the e-prescribing measure established for PQRI (i.e., Measure #125) for at least 50% of applicable Medicare Part B FFS patients using a qualified system E-prescribing measure is reportable only through claims Limitation to applicability of incentive payment Denominator codes for the e-prescribing measure must comprise at least 10% of an EP’s total allowed charges for all covered services furnished by the EP during the reporting period
2009 E-Prescribing Process Encounter Form Coding & Billing National Claims History File NCH Confidential Report Critical Step PBM Visit Documented in Medical Record & Rx Generated Rx Trans-mitted to Pharmacy N-365 Carrier/MAC Analysis Contractor Incentive Payment
Reporting ScenariosE-Prescribing All of these scenarios represent successful 2009 reporting A 70 year old male patient presents to the clinician’s office for medical care. Scenario 1: The clinician discusses current medications and prescribes new medication, updates active medication list in eRx system, transmits prescription electronically to pharmacy Reports G8443 Scenario 2: The clinician documents there is no change in meds, no prescription generated. Reports G8445 Scenario 3: Pt has mail order pharmacy that cannot accept eRx & asks for hard copy. Physician updates meds in eRx system, eRx system provides hard copy of prescription to patient. Reports G8446
What is Not E-Prescribing Intravenous drugs given in the office Calling in a prescription for NH patient Patient seen in ED and is sent home with a prescription Faxing a prescription to a pharmacy Sending a prescription via PDA (exception: depends on software used – must meet e-prescribing system qualifications, plus you must have seen the patient) Knowingly sending a computer-generated fax initiated at the doctor’s office to a pharmacy (exception: if sent via qualified e prescribing system and pharmacy system generates message as a fax, it is e-prescribing) Office visits provided as part of a global surgical package Medicare Advantage patients (exception: some private fee-for-service plans - can e-prescribe, but this does not count toward incentive payment calculation)
Coding for E-Prescribing 2009 • You must use a QUALIFIED E-prescribing system AND • Have an encounter with one of these codes • 90801, 90802, 90803, 90804, 90805, 90806, 90807, 90808, 90809, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, G101, G0108, G0109. • Notice some from original guidelines were removed.
Coding for E-prescribing 2009 Report on all eligible patients: G8443--All prescriptions created during the encounter were generated using an e-prescribing system. G8445--No prescriptions were generated during the encounter. Provider does have access to a qualified e-prescribing system. G8446--Provider does have access to a qualified e-prescribing system. Some or all prescriptions generated were printed or phoned in as required by state regulation, patient request, or pharmacy being able to receive electronic transmission.
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Future Penalties for Not Electronically Prescribing Eligible professionals who are not successfully using electronic prescribing by 2012 will be penalized 1% of their covered Medicare Part B charges. This means that these providers will be paid at 99% for their covered Medicare Part B fee schedule services. Limitation applies as for incentives Fee reduction is prospective, providers will have to electronically prescribe by a date to be determined to be sure their fees are not reduced in 2012. This date will not be before 2010. Hardship exemption on a case-by-case basis for small practices.
Future Penalties for Not Electronically Prescribing In 2013 - 1.5% deducted from their covered Medicare Part B services. Professionals will be paid at 98.5% of the physician fee schedule for covered services. In 2014 and beyond penalty will increase to 2%. Professionals will receive 98% of the physician fee schedule for the covered services they provide.
Part D Information The Secretary has the authority to change the requirements for successful E-Prescribing in the future. The MIPPA legislation allows for future use of Part D data in lieu of claims-based reporting by eligible professionals.
FAQs On The Medicare Program • What is a qualified e-prescribing system? • As a qualified system, the program must be able to perform the following tasks: • Generate a medication list • Selecting medications, transmitting prescriptions electronically and conducting safety checks* • Providing information on lower cost alternatives • Providing information on formulary or tiered formulary medications, patient eligibility and authorization requirements received electronically from the patient’s drug plan • *Safety checks include: automated prompts that offer information on the drug being prescribed, potential inappropriate dose or route of administration of the drug, drug-drug interactions, allergy concerns, and warnings/cautions.
FAQs: Medicare • Can we just report and not have an e-prescribing system? • No, the measures incentive requires that you have an e-prescribing system. • Reporting the measure without the system would be fraudulent billing.
FAQs: Medicare • Run that by me again---how much can we make? • Medicare will ultimately decide based on your reporting frequency. • But here’s how you calculate this: • Take all of your allowed Medicare billings for 2008 for one NPI provider--take out drugs, DMERC, and labs. • Multiply it by .02 (2%) • Add up all participating providers
Medicare FAQs • Who is qualified? • If 10% of your PFS revenue(all services---not labs and drugs) is from the visits that you report on, you are qualified. • Most MEDICAL Oncologists are qualified; most Radiation Oncologists are not…but it is good to test your assumptions.
Medicare FAQs • Is it too late to get in now? • No, it is not. You will have to report on 75% of your patients starting April 1, but that is less reporting than PQRI is. Theoretically, you could start as late as July.
Medicare FAQs • Do I get more money if I report on 100% of our patients? • No. • You’re kidding me, right?
Medicare FAQs • Do I have to report the e-prescribing measures on the same claim with the visit in the measure? • It is not SPECIFICALLY required but it will help you get the incentive. Providers were not paid in 2007 due to “widowed” codes. This is supposed to be corrected, but it is a good idea to leave nothing to chance.
Medicare FAQs • What if one of our providers does not e-prescribe and it is for one of the reasons not in the codes? • If you started reporting already, just do not report the measure that day. You want to make sure you stick to the code descriptors. The threshold is 50%.
Medicare FAQs • Do you get penalized for over-reporting? • No, you do not.
Medicare FAQs • Can we use e-prescribing as one of our PQRI measures? • No, e-prescribing has been removed from PQRI for 2009. • You can only get paid for it once.
Medicare FAQs • Will we have to report these codes every year of the incentive? • At some point, Medicare will start using Part D data to evaluate your e-prescribing behavior. They have not announced when this will happen.
Medicare FAQs • Is Medicare looking at Part D data now? • They have not made a statement one way or the other.
Medicare FAQs • Should the physician document that the e-prescribed in the chart or not? • As far as Medicare auditors are concerned, “if it wasn’t written it was not done”…so, something about e-prescribing or not should be in the chart, check off sheet, or EMR. • If they e-prescribe a narcotic, your state law probably prohibits e-prescribing and that would obviate that G-code.
Technical FAQs • Can we use our EMR to e-prescribe? • Maybe, maybe not…there is not a CCHIT-certified EMR solution in Oncology. • The system must meet the Medicare specifications for e-prescribing.
Technical FAQs • If we look at a stand-alone solution, like Oncology ERx, how do we get our existing patients in there? • Oncology ERx has a feature where you can upload your patients using a comma-delimited file or spread sheet. • Interfaces can be built for a small charge.
Technical FAQs • Can we e-prescribe to our own pharmacy? • Yes, you can…the doctor can transmit from the treatment room to the pharmacy and it counts.