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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.
Benefits:
E-Prescribing
 Improving patient safety and quality of care
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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
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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
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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
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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
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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
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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
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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 Schedule
and Penalties
Year
Successful
Not
2009
2%
0%
2010
2%
0%
2011
1%
0%
2012
1%
-1%
2013
0.5%
-1.5%
2014+
0%
-2%
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
PBM
Visit Documented in Rx TransMedical Record & Rx mitted to
Generated
Pharmacy
Encounter
Form
Critical
Step
Coding & Billing
N-365
NCH
Analysis Contractor
Confidential
Report
National Claims
History File
Carrier/MAC
Incentive Payment
Reporting Scenarios
E-Prescribing
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
All of these scenarios represent successful 2009 reporting
What is Not E-Prescribing
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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 feefor-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 eprescribing system.
– G8446--Provider does have access to a qualified eprescribing 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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• For more
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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 overreporting?
– 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 eprescribing 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 eprescribing 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.