1. E-Prescribing Profits, Pitfalls, and Perils

2. Agenda Medicare’s E-Prescribing Program Frequently-Asked Questions About Medicare’s E-Prescribing Possible Problems/ Perils Discussion

3. 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.

4. 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.

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. The Medicare Incentive Schedule and Penalties YearSuccessfulNot 20092%0% 20102%0% 20111%0% 20121%-1% 20130.5%-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.

17. 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

18. 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

19. 2009 E-Prescribing Process Visit Documented in Medical Record & Rx Generated Encounter Form Coding & Billing Carrier/MAC Analysis Contractor NCH National Claims History File Incentive Payment Confidential Report Critical Step Rx Trans- mitted to Pharmacy N-365 PBM

20. Reporting Scenarios E-Prescribing All of these scenarios represent successful 2009 reporting 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 A 70 year old male patient presents to the clinician’s office for medical care.

21. 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)

22. 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.

23. 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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25. 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.

26. 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.

27. 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.

28. 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.

29. 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.

30. 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

31. 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.

32. 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.

33. Medicare FAQs Do I get more money if I report on 100% of our patients? –No. –You’re kidding me, right?

34. 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.

35. 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%.

36. Medicare FAQs Do you get penalized for over- reporting? –No, you do not.

37. 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.

38. 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.

39. Medicare FAQs Is Medicare looking at Part D data now? –They have not made a statement one way or the other.

40. 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.

41. 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.

42. 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.

43. 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.