How To Write A Prescription

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1 Leveraging gfederal HIT Incentives to Maximize eprescribing Adoption & ROI: MIPAA, ARRA & Impact for Health Plans World Research Group s E-Prescribing Forum 2009 September 20, 2009 David S. Green Senior Consultant t Kurt Andrews, PhD Senior Consultant t

2 Agenda Understanding the landscape Understanding the benefits of eprescribing to stakeholders Key influences on the development of eprescribing The Federal Government's role in eprescribing Things to consider when assessing the impact of Federal incentives General Discussion 2

3 Is it time to change my strategy? So, what do you think we should do? 3 3

4 Why It May Be Time To Reconsider e-prescribing is undergoing a period of rapid growth and will soon be the predominant form of prescribing eprescribing % 2012 Recent federal financial support (incentives and penalties) radically alters the financial motivation for prescribers 4

5 It s on everyone s mind. EMR, EHR, PHR, HIPAA, MIPAA, ARRA, HIE, HIT, HIN 5

6 Terms and Definitions eprescribing (erx) The transmission, using electronic media, of prescription or prescription- related information Electronic Medical Record (EMR) a computerized legal medical record surrounding the delivery of healthcare in an out-patient (ambulatory) or in-patient setting. EMR = Ambulatory EMR for discussion purposes Electronic Health Record (EHR) EHR = EMR that can access healthcare related information stored elsewhere, an EMR with connectivity/interoperability Personal Health Record (PHR) A web-based set of tools enabling individuals to self-manage their health information, health, and health care 6

7 Terms and Definitions Continued Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) E-prescribing incentive e program which can provide up to 2% additional a payments to physicians who use qualifying e-prescribing technology. American Reinvestment and Recovery Act (ARRA) The broad economic stimulus law, passed in February 2009, which includes a significant spending portion ($36 billion) in the Health Information Technology for Economic and Clinical Health (HITECH) Act to promote adoption of electronic health records through incentive programs and promote health information exchange development. 7

8 eprescribing Has Evolved and So Have Definitions Early days - an electronically written then faxed to the pharmacy version of the paper prescription often typically referring to a handheld device CMS the transmission, using electronic media, of prescription or prescription-related t information between a prescriber, dispenser, pharmacy benefit manager, or health plan, either directly or through an intermediary, including an eprescribing network. E-prescribing includes, but is not limited to, two-way way transmissions between the point of care and the dispenser. HIMMS - eprescribing is the use of electronic tools to prescribe drug prescriptions. eprescribing tools can include both software programs, as well as hardware like personal computers, handheld and wireless devices, and touch screens. (HIMMS)

9 eprescribing Interoperability Physician Practice EMR or erx System A Request Eligibility, Drug History PBM or Plan A Rx Formulary Database B SureScripts Proprietary Response New Rx SureScripts RelayHealth erx Networks Refill Request Refill Auth/Denial Change Request C Claims Processing System benefit plan rules, formulary, history Retail or Mail Pharmacy Pharmacy Dispensing System Copyright 2007 Point-of-Care Partners, LLC 9

10 eprescribing Components and Value Cost & Efficiency Quality & Safety Generic substitution Formulary compliance Measu urable Va alue Renewal authorization Out-of-pocket costs Pharmacy connectivity Prior authorization eligibility Drug-drug interactions Drug adherence Fraud & abuse detection Prescription writer Drug reference guide Dispense drug history Prescribe drug history Drug-allergy interactions Drug-condition interactions Clinical guidelines Clinical contra-indications Drug/lab interactions Foundation Connectivity EMR/EHR Integration Complexity & Investment e t Copyright 2006 Point-of-Care Partners, LLC 10

11 eprescribing Is But One of Many EMR Functions John Doe s EMR Alerts Allergies & adverse reactions Clinical notes Clinical guidelines Diagnostic history Medication history PMS integration Patient disputed content Patient Education materials e-prescribing Test ordering Patient characteristics Task Management Quality reporting Wellness Identification *Based on CCHIT criteria Submit erx Copyright 2009 Point-of-Care Partners, LLC

12 Checkpoint and Questions Understanding discussed definitions and terms Other terms that t may need to be defined d Further clarification/discussion 12

13 eprescribing Stakeholders Health Plan/PBM Prescriber Patient Pharmacy 13

14 Benefits: Prescribers Reduce cost Reduce phone calls Reduce chart pulls Streamline prior authorization ti process More time for patient care Low impact to existing workflow Improve quality of care Increased quality of care by enabling easy access to computerized medication history Decreases potential medication errors due to illegible prescriptions Avoid potential adverse drug events Improve patient satisfaction Reduced waiting time at pharmacy Aura of high tech 14

15 Research: Practice Efficiency Study Results Health Alliance Plan / 57% of physicians believe there is a reduction in time Henry Ford Medical Group (2006) spent by support staff. Rand/NJEPAC (2006) 80% reduction in callbacks related to coverage issues; majority of eprescribers found the system to be easy to use (79% strongly agreed or agreed). Surescripts/Brown Univ/ 90% of physicians noted improved care efficiency; Midwestern Univ (2006) 50% reduction in time consumed to manage refill requests and pharmacy callbacks. Health Management Technology $48,000 saved per year with automated refills. (2003) Medco (2003) Tufts Healthplan (2002) 42% reduction in pharmacy calls to practice; 84% reduction in calls related to formulary. 2 hours per day saved per physician; 30% reduction in phone calls. 15

16 Research: Practice Quality & Safety Study Surescripts/Brown Univ/ Midwestern Univ (2006) Rand/NJEPAC (2006) Health Alliance Plan / Henry Ford Medical Group (2006) Results 75% of physicians believed patient safety & quality of care improved; 50% of physicians perceived communication with patients improved. Medication history perceived as very useful & worth the effort; eprescribers were more likely to perceive that they have enough clinically i ll relevant information to make a decision than non-eprescribers. 85% of physicians believe eprescribing has improved the practice of medicine at their clinic; 77% of physicians believe eprescribing improves the safety of patient care; 70% of physicians believe eprescribing improves patient satisfaction. 16

17 Research: Miscellaneous Study Results SEMI (2006) Mail service claims increased 5.8% Surescripts/Walgreens (2006) 11% improvement in new prescriptions filled by patients 3 months after eprescribing implemented Rand/NJEPAC (2006) Successful installs had appropriate expectations: ti anything you start new (is going) to cause problems up-front (but) within two weeks that will be sorted out. Rand/NJEPAC (2006) Discontinuation of eprescribing: poor communication between the physician and staff office disorganization lack of time physician time to learn new process 17

18 Benefits: Pharmacy Reduce cost* Reduces potential medication errors due to illegible prescriptions Allows for more patient consultation Less delay in getting prescription approved/adjudicated dj di d * Pharmacies currently incur cost of ~$0.22 per new or renewal erx (no fee for refill) Improve quality of care Less clarification phone calls to the prescriber More efficient use of time Less reversals cleaner scripts from the prescriber Potential to handle more scripts/day Improve patient satisfaction Reduces pharmacy wait times More predictable co-payment Improved sense of quality & modernity in getting prescriptions from their pharmacists 18

19 Benefits: Patients Reduce cost Reduces potential medication errors due to illegible prescriptions Facilitates improved medication compliance Contributes to improved self-management performance Improve quality of care Reduced out of pocket costs Better utilization of cost-effective alternatives Improve patient satisfaction Reduces pharmacy wait times More predictable co-payment Improved sense of quality & modernity in getting prescriptions from their physicians 19

20 Research: Patient Perceptions Study Journal of the American Geriatric Society (August 2007) Brigham & Women s MMA erx Pilot (2006) Results Patients who had been eprescribed a drug said they preferred e-prescriptions over paper prescriptions. Patients who had been eprescribed drugs were also more likely to say they talked to their doctors about medication use most of the time or often. Physicians reported that eprescribing is generally wellperceived by patients Kokomo Family Care (2000) Awareness of eprescribing was high (86%) Majority of the patients agreed that eprescribing was helpful in: Facilitating MD and pharmacist working together Assisting their physician in drug interaction ID Allowing the pharmacist to read the prescription Alerting their physician as to what s on formulary 20

21 Benefits: Health Plans/PBMs Reduce cost Decreases potential medication errors due to illegible prescriptions Facilitates improved care management (e.g. detection of adherence issues) Improve quality of care Reduced phone calls & administrative costs Better utilization of cost-effective alternatives Increased generic prescribing Reduced d medication errors Improve patient satisfaction Employers: lower premium growth due to reduced drug spend Prescribers: Fewer hassles over coverage and prior authorization Consumer: Reduced d wait time at pharmacy 21

22 Formulary and Safety Benefits 33% to 50% Formulary compliance warnings resulting in a change or cancellation 33%+ Drug/drug interaction alerts resulting in a change or cancellation 33% to 50% Drug/allergy interaction alerts resulting in a change or cancellation 99%+ Generic substitutions allowed 1% 5% Improvement in generic dispensing rate 22

23 Research: Financial Benefits Study Brigham and Women s (2008) SEMI (2006) Affinity Health (2005) Results eprescribing claim costs $0.70 PMPM; implementation costs offset with 355 patients Avg costs $7.44 for mail eprescribing, $2.11 for retail eprescribing; Generic dispensing rate 2.6% Avg costs $4.12 for new Rx; PMPM 57 vs control; target drugs were 17.5% lower Univ. of VA. (2003) Annual drug cost savings in a PCP academic group = 2%; Estimated ADE cost reduction of 62% Tufts Healthplan (2002) Wide-spread deployment of eprescribing could mitigate rising gpharma costs by 2% or more Allscripts (2000) Aggregate impact by plan varied, ranging from 75 to $3.20/Rx 23

24 Research: Medicare More than 70% of potential drug spend is controlled by PCPs eprescribing has the potential to: Reduce drug spend trend by 1% Decrease customer service issues up to 32% for highly hl restrictive ti formularies eprescribing can lower patient drug spend Up to 15% on minimally restrictive formulary Up to 8% on moderately restrictive formulary Source: Potential Impact of Electronic Prescribing on Medicare Prescription Drug Spend, October 25, 2005, Milliman, courtesy of RxHub 24

25 Checkpoint and Questions Importance of eprescribing Has eprescribing impacted your organization? How? Will it in the future? Why? 25

26 eprescribing Key Influences

27 eprescribing and Major Influences 90% 80% % of Total Prescription Transmitted Electronically 70% 60% 50% 40% 30% 20% Early adopter era Initiatives era Federal incentives era??? Initiative continuation 10% 0% MMA MIPAA Surescripts/RxHub HL-7 ARRA 27

28 Who Were The First Adopters? Propeller heads Technology 1 st generation Standards not established Marked by high initial adoption but low continuation of use rate No integration with PMS Some programs sponsored by PBMs 28

29 Initiatives? What is an eprescribing Initiative? eprescribing Initiative Definition: Health plans, PBMs, employers and other stakeholders cover the costs of e-prescribing systems for key physicians in a defined market. Where are eprescribing Initiatives? Demographics of initiatives: All over the country in almost every state. 29

30 Initiatives Have Driven Early Adoption #1 Massachusetts, #2 Rhode Island, #3 Michigan, #4Nevada, 30

31 Initiative survey: It s about patient safety Patient safety 2:1 choice What are your top 3 Expected Results? Results Area Ranked 1 Ranked 2 Ranked 3Weighted Total Increase patient safety Save money for stakeholders Decrease Medical Costs Decrease patient cost Comply with Federal or state law Monetary Savings Source: POCP e-prescribing Initiative survey (2009) 31

32 How Initiatives Measure Patient Safety How does an eprescribing initiative measure patient safety? Drug Utilization Review alerts: For Drug-Drug, Drug-Allergy (others) Examine Rx s changed as a result of alerts Available from the vendor only Likely not available outside an initiative Pharmacy DUR alerts: Other: Compare DUR rates pre/post eprescribing ER admission rates Physician reporting Source: POCP e-prescribing Initiative survey (2009) 32

33 Incentives Drive erx Usage 200 Monthly erxs per physician Initiatives with incentives Initiatives without incentives Source: POCP eprescribing Initiative survey (2009) 33

34 Initiative Survey: Were you satisfied? Had the least negative ratings Highest rated Satisfaction Rating Not Somewhat Very Highly Weighted Area Satisfied Satisfied Satisfied Satisfied Satisfied Total Project Management Initiative flexibility Initiative as a whole Stakeholder participation Public perception of the initiative ROI to stakeholders Dr. participation i Vendors Funding Dr. adoption and usage Lowest rated Source: A 2009 survey of 23 eprescribing initiative executives by POCP. 34

35 Open Discussion of Health Plan/Initiative Experiences p What was your eprescribing initiative experience? How did, funding, vendor selection, reporting work? Are there things you d have done differently? What?

36 15 Minute Break

37 The Federal Government as a Stakeholder 37

38 MMA (Medicare Part D) Federally funded prescription drug benefit for Medicare recipients and some Medicaid recipients. Relaxed Stark and Safe Harbor laws to permit hospitals to provide MDs with software. Funded pilot studies on e-prescribing components: medication history, formulary and benefit, fill status, patient instructions, drug name standardization, electronic prior authorization Landmark legislation required health plans to accommodate erx, if the clinician was e-prescribing. In that case, had to use standards. April 1, 2009 all Medicare Part D health plans must provide medication history, formulary and benefit information in standardized electronic format to those physicians prescribing electronically Didn t require physicians to prescribe electronically 38

39 eprescribing Controlled Substances eprescribing of controlled substances not legal ~12% of all prescribed drugs are controlled substances In October 2008, DEA accepted responses to a notice of proposed rule-making (NPRM) regarding e-prescribing of controlled substances Significant and considerable groups voiced that several provisions that were unacceptable Since then, CMS has been negotiating with the DEA. A final rule with more favorable terms likely l to be released 4Q09. 39

40 Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) MIPPA provides both carrots and e-prescribing Forecast Model (2009, 2010) sticks to prescribers around e- Prescribing. Patients per day % of Practice Medicare 24 33% Physicians qualify by having e- Prescribing functionality and writing Medicare Patient Per Day 8 50% of their Rxs electronically Revenue per Medicare Patient t $85 Criteria is self-reported to CMS. Days per year 250 Incentive* Year Penalty* +2% 2009 None +2% 2010 None +1% 2011 None +1% % +.5% % None Beyond -2% * Increase or decrease in Medicare Part B revenue Medicare Revenue Per Year $168,30 0 Potential % Increase 2% Incremental Revenue per MD per Year $3,366 Source: Allscripts

41 HIT Advocate-in-Chief In January, 2009, signed into law the American Reinvestment and Recovery Act of 2009 (ARRA). The HITECH component: Set aside a potential ~$36 billion in funds to encourage adoption and use of electronic health records (EHRs) Formed the HIT Policy and HIT Standards committees Modified the HIPPA standards and security laws Strongly and firmly believes that HIT is critical to health care reform. Included in voluminous house draft : Administrative simplification, which includes increasing electronic exchange of clinical data and standardized quality reporting; Patient-Centered t t Medical Home pilot, which h has electronic prescribing as a key ingredient A new Bureau of Health Information, which would be responsible for collecting and reporting health information across agencies. 41

42 ARRA Funding Appropriations for Health IT $2 billion for loans, grants & technical assistance for: National Resource Center and Regional Extension Centers EHR State Loan Fund Workforce Training Research and Demonstrations Appropriations for HIE At least $300 million of the total at HHS Secretary s discretion for HIE development Funneled largely through States or qualified State-designated entities For planning and/or implementation Source: Colorado Regional Health Information Organization, May 2009 New Incentives for Adoption New Medicare and Medicaid payment incentives for HIT adoption $20 billion in expected payments through Medicare to hospitals & physicians $14 billion in expected payments through Medicaid ~$34 billion expected outlays, Community Health Centers $1.5 billion in grants through HRSA for construction, renovation and equipment, including acquisition of HIT systems Broadband and Telehealth $4.3 billion for broadband & $2.5 billion for distance learning/ telehealth grants 42

43 ARRA Appropriated Funds $2 billion in gross outlays Program HIE Planning and Development EHR Adoption Loan Program Health IT Extension Program Distribution Agency ONC ONC ONC Use of Funds Planning Grants Implementation Grants Loan Funds Health IT Research Center Regional Extension Centers State-designed Entity States Loans Recipients Health Care Providers Indian Tribes Workforce Training Grants HHS, NSF Medical Health Informatics EHR in Medical School Curricula Nonprofits Least-advantaged Providers New Technology Research and Development Grants NIST, NSF Health Care Information Enterprise Integration Research Centers Higher Education Medical/Graduate Schools Adapted from California HealthCare Foundation 2009 Federal Government Labs 43

44 ARRA Entitlement Funding $34 billion in gross outlays Recipients Program Medicare Payment Incentives Distribution Agency CMS Use of Funds Incentive Payments through Carriers Acute Care and Children s Hospitals Medicaid Payment Incentives CMS and states Incentive Payments through State Agencies For providers 1) using certified electronic health records and 2) that are meaningful users Adapted from California HealthCare Foundation 2009 Physicians and Dentists Nurse Practitioners and dmidwivesi FQHC 44

45 Meaningful Use CMS proposed a matrix that provides considerable information i about priorities, i i goals & objectives, expressed as capabilities and measures. Matrix and criteria for meaningful use are in development. December 2009 release expected for 2011 criteria. Source: Health IT News 2009 The goal of meaningful use of an EHR is to enable significant and measurable improvements in population health through a transformed health care delivery system. 45

46 Meaningful Use & eprescribing eprescribing figures heavily in the objectives and measures to address the policy goals of Improving the quality, safety, efficiency and reduce health disparities and of improving i care coordination. Objectives for 2011 and 2013 include a range of eprescribing functionalities, such as implementing drug-drug allergy checks and drug-formulary checks, maintaining i i an active medication list, and having the ability to generate and transmit prescriptions electronically. Measures for 2011 and 2013 include the 2015 % of Rxs entered directly by physicians Improved Outcomes through CPOE and act on erx fill data Data Capture & Sharing 2013 Advanced Clinical Processes 46

47 Certification for meaningful use Certification Commission of Health Information Technology (CCHIT) has been named as a certifying i entity for EHRs Additional certifying organizations are probable In June, CCHIT announced three new paths to certification to address some concerns. To get to smaller MDs but also to meet broader goals, need multiple pathways. Cost: ambulatory EHR $37K + $9K annual renewal for comprehensive certification, less expensive for other options Allows path for stand-alone eprescribing systems to be certified and remain relevant 1.) rigorous 2.) modular 3.) low-cost, site -level Adapted from Circle Square

48 CCHIT Certification Programs Concepts Preliminary ARRA 2011 Certification Comprehensive Certification of EHR Systems for Functionality, Security, Privacy, and Interoperability Meets or exceeds Federal standards For providers wanting maximal assurance of integrated EHR capabilities as well as ARRA qualification Modular certification of EHR Technology limited to Security, Privacy, and Interoperability Meets Federal standards For providers who prefer to combine technologies from multiple sources or selfdevelop an EHR to qualify for ARRA Source: CCHIT (2009) 48

49 CCHIT Certification: Other Information "We are concerned that providers could not achieve meaningful EHR use in 2011 if they wait until spring the expected date of (the Department of Health and Human Services')' final approval of requirements - to begin adopting this technology," said Mark Leavitt, "CCHIT has analyzed the recommendations of the federal HIT advisory committees and is preparing p to offer new paths to certification beginning g this October (2009). CCHIT and ARRA 2011 Certifications anticipated to expire December 31, 2012 If Final HHS rule does not introduce more stringent requirements, Final ARRA 2011 Certification will be granted immediately to those with Preliminary certification Currently CCHIT certified EHRs will only need to undergo certification of missing components Source: CCHIT (2009) 49

50 Incentives for Meaningful Use of Certified EHR Technology Starting 2011 EHR Technology Starting 2011 Medicare Incentives Incentives for non hospital based professionals $44k over 5 years Penalties starting % bonus for health professional shortage areas Incentives to hospitals $2m base x transition factor Plus $200 per discharge between 1,150 and 23,000 Medicaid Incentives not hospital based professionals with at least 30% Medicaid patients Other criteria for children hospitals; pediatricians; FQHCs; rural clinics 85% of net average costs Capped at $63,750 No penalties

51 $25.0 $20.0 Medicare/Medicaid Incentives per Professional $ in thousands Medicare: total $44k Medicaid (@85%): total $63.75k $21.3 $18.0 $ in thou usands $15.0 $10.0 $12.0 $8.5 $8.5 $8.5 $8.5 $8.5 $8.0 $5.0 $4.0 $2.0 $ $0.0 Source: American Recovery and Reinvestment Act as enacted by House and Senate (GPO) 51

52 Physician Net Out-of-Pocket with ARRA Incentives Medicare Medicaid Physician Net Medicare Physician Net Medicaid Source: American Recovery and Reinvestment Act as enacted by House and Senate (GPO) System cost estimate source: Case Western Reserve Based on single physician costs for purchase price (2011, 35k) and ongoing (2012+, 10k).

53 A Strong Federal Incentives Program Should Increase eprescribing Dramatically 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Prescriptions transmitted electronically POCP PCMA CBO pre- MIPAA/ARRA 2,500,000,000 2,000,000,000 1,500,000,000 1,000,000, ,000,000 0 Copyright 2009 Point-of-Care Partners, LLC

54 Checkpoint and Questions Clarification of previous slides Do you think that t federal incentive programs will increase adoption. And if so, how much? 54

55 Leveraging Federal Incentives 55

56 Would a Health Plan Even Want to Invest in stand alone eprescribing Now? stand alone eprescribing Now? Issues to consider in formulating your strategy: MIPPA still provides incentives es until 2013 An eprescribing program could be a low cost/ high return way to get EHR resistant physicians to be more Tech friendly. Still allows significant value back to the health plan. Compliments ARRA: creates technology bridge Only with HHS Certified modularized and interoperable systems Will physicians adopt stand-alone eprescribing in this environment?

57 Would a Health Plan Even Want to Invest in eprescribing within an EMR/EHR? More Issues to consider: ARRA incentive results (EHR adoption rates) won t be known until at the earliest Federal Incentive program issues and shortcomings will be identified Timing of incentive payments may be a significant issue, especially for Medicare Small office physicians may reject EHRs even with Federal incentives.not enough value for them

58 Other ARRA Notes Physicians must declare which incentive program (Medicare or Medicaid) that they will participate in No double dipping Physicians can participate in MIPPA incentive program and migrate to ARRA Can t receive incentives from both MIPPA and ARRA concurrently 58

59 Value of erx vs. EMR/EHR erx Stand-Alone EHR Low - ~$3k High ~$35k Cost Low erx only High Many Functionality Medium Lower Rx High Lower Rx, Lower other Health Plan medical Value Medium Good value Medium Functionality doesn t offset cost Physician Value Source: Case Western Reserve 2009; POCP

60 Implications of EHR Meaningful Use & ARRA Incentives Strategy Component Passive Aggressive Able to target key Drs No Yes Ride coattails of ARRA HIT Yes No adoption Show market leadership No Yes Access key erx data Funding needed for health plan incentives i above ARRA Risk of non-preferred EHRs adopted by key Drs A combo erx/ehr program w/incentives No - Data from SureScripts/Internal No Yes no way to influence market adoption No not necessary Yes Data from vendors and SureScripts/Internal Yes Yes Drs have free will however additional incentives will drive choice Yes allows most all offices an HIT option Build on HIT momentum, for No rising i tide Yes - take advantage of coordination of care, med rec, & technology for information other care efficiencies. distribution (care profiles, etc.)

61 Leveraging the Federal Incentives Health Plans should evaluate their markets: physician relations physician demographics market position existing EMR/EHR adoption Finalize their own assessments of erx Initiatives including ROI Could an EMR/EHR/eRx program help achieve company objectives in this environment? Different scenarios different strategies one size may not fit all 61

62 David S. Green and Kurt Andrews