Electronic prescribingusing computer technology to write and transmit prescriptions between physicians and pharmacies as well as to view medication histories, costs and formularieshas the potential to revolutionize medicine by reducing errors and improving the monitoring of patients responses to treatment. It also has the potential to save insurers big money by boosting adherence to formularies, and steering patients and their physicians to generic alternatives.
The money-saving possibilities of e-prescribing have been proven through insurer-sponsored pilot projects around the country over the past five years. Today, insurers, and especially Blue Cross and Blue Shield plans, are pushing e-prescribing to the next levelwidespread use, acceptance and federal mandates.
On Jan. 31, representatives from major Blues insurers met in Washington to discuss, among other things, e-prescribing. In consultation with Capitol Hill staffers, the purpose of the meeting was to accelerate lobbying efforts to push for wider adoption of the prescribing technology. Namely, Blues plans are urging Congress and the Bush administration to mandate e-prescribing for Medicare providers this year, and to support lifting a ban on e-prescribing of controlled substances such as pain medications and antidepressants.
The week prior, the national Blue Cross and Blue Shield Association unveiled its five-point plan for universal healthcare. Among the recommendations to reform healthcare is e-prescribing. Scott Serota, president and chief executive officer of the Blues, said at a news conference that a Medicare mandate on e-prescribing is a key step in getting universal coverage. The association declined to comment further.
Many of the 39 Blues plans around the nation, which collectively cover roughly 99 million Americans, have bankrolled e-prescribing initiatives over the past five years with varying success.
Highmark Blue Cross and Blue Shield, based in Pittsburgh, ran afoul of the Internal Revenue Service in 2006 after the agency objected to the insurers plan to give $26.5 million to participating physicians because some of them work in for-profit practices. And a $43 million WellPoint technology program launched in 2003 resulted in fewer than 1,000 physicians agreeing to try e-prescribingout of 20,000 participants.
Theres still no consensus on the best way to implement e-prescribing among the Blues, but results of regional Blues projects have shown that e-prescribing can reduce medical errors, increase attachment to formularies, boost generic use among patients and overall lower costs, both for insurers and providers. One health system in Michigan saved some $3 million annually through its initiative. Some 7,000 deaths nationally are attributed to illegible prescriptions and drug interactions.
Were trying to get more-consistent approaches among the Blues on e-prescribing, said Catherine Peper, vice president of health information technology at Blue Cross and Blue Shield of Florida, who attended the Blues Washington meeting.
Between 2% and 25% of physicians use either a Web-based portal or personal digital assistant to write and order prescriptions for their patients electronically, depending on their state of residence and practice size. Typical barriers include cost, resistance to new technology, concerns about security and data protection, and poor system support, studies have shown.
This could be a killer app, but it has to be supported by those who are paying the claims, said Jonah Frohlich, a senior program officer at the California HealthCare Foundation, which monitors healthcare information technology efforts. A killer application is a technology that drives widespread adoption. So, just as e-mail was a killer app that drove the masses to the Internet and home PCs, many are hoping that e-prescribing will be the application that drives physicians to embrace electronic health records, Frohlich said.
If e-prescribing were to be widely adopted, payers, including the Blues, could see major savings, analysts said. The Southeast Michigan e-Prescribing Initiative, under way since February 2005, has shown this. Launched in a collaboration between the Henry Ford Health System in Detroit, Blue Cross and Blue Shield of Michigan, General Motors Corp., Ford Motor Co., Chrysler and the United Auto Workers, the program has cost about $1 million, with about half of that going to fund technology.
The project today involves about 2,700 physicians who write more than 282,000 combined prescriptions per month using several different e-prescribing tools, including DrFirst and RelayHealth, both commercial products. Physicians receive $1,000 to participate, with half upfront and half six months later as an incentive.
Since the program started, the rate of generic-drug prescribing has risen from 56% to 71%, said Matt Walsh, associate vice president of purchaser initiatives at Health Alliance Plan, a not-for-profit health plan affiliated with the Henry Ford Health System. The system has saved $3 million a year through the program, Walsh said, primarily through the increased use of generics and more adherence to the plans formulary.
The alliance has been so successful that it expanded to the inpatient side late last year at 736-bed Henry Ford Hospital in Detroit. So far, 10 physicians at the hospital are participating. They can access patients medication histories upon admission and see their insurers drug formulary. When the patient is discharged, his or her medical list is sent to the physicians outpatient e-prescribing system so drugs can be reconciled, continued or changed. It closes the loop, Walsh said.
Other Blues plans have experienced similar initial successes but are re-evaluating their strategies. CareFirst Blue Cross and Blue Shield of Maryland achieved a threefold return on its e-prescribing investment through lower drug costs since launching its pilot program in 2004, though the insurer would not disclose a dollar figure. CareFirst lent access for about 300 physicians to DrFirsts Web-based e-prescribing tool or a PDA. Formulary compliance increased by 4%, which the health plan considered significant, said Pete Stoessel, director of administration, medical systems and business development at CareFirst.
But CareFirst is phasing out the program and integrating e-prescribing into its existing pay-for-performance incentives, Stoessel said. We got a lot of attention, which meant that vendors started calling, he said. We wanted to get out of managing the sponsorship piece. Participating physicians will continue to use the technology, but physicians new to e-prescribing will choose their own vendor.
Ultimately, CareFirst decided it shouldnt be purchasing a certain technology and pressing it onto providers, he said. You open up the portal to e-prescribing and let the provider decide which vendor will be the winner and the loser, Stoessel said.
Thats the approach the Florida Blues is taking as well, with ePrescribe Florida. Launched last year, the initiative involves the Blues; other major insurers, including Humana and UnitedHealthcare; and the Florida Hospital Association and Florida Medical Association. The collaborative aims to educate providers about e-prescribing and provide some minimal criteria for vendor participation while remaining vendor-neutral. The Florida Blues will give physician incentives to use e-prescribing through pay-for-performance. The insurer is hoping to boost e-prescribing among Florida providers from 2% in 2007 to at least 8% this year, Peper said.
We are hoping it will be replicated around the country, Peper said. She said that although the Florida Blues was a little nervous about working with competitors like UnitedHealth Group, there was little resistance to the idea of working together to get physicians around the state to adopt e-prescribing. Florida is the first such state to have this collaboration.
Staying the course
Insurance giant WellPoint, however, is continuing to move forward with sponsorship-based e-prescribing, with pilot projects in Ohio and New Hampshire, along with participating in RxHub, a repository of formulary, eligibility and benefit information that is owned by the top pharmacy benefit managers. Unless you have the health plans pushing this, it will take a mandate from Congress or decades for e-prescribing to be adopted widely, said Charles Kennedy, vice president of health information technology at Indianapolis-based WellPoint. He said the uptake in generic prescribing and resulting reduced pharmacy costs paid by WellPoint, is funding the e-prescribing initiatives.
Getting critical mass around e-prescribing could happen if it is required by Medicare, many experts agree. Medicare is going to be the only thing that leads the way, said Kristin Begley, pharmacy practice leader with human resources consulting firm Hewitt Associates.
In another move to advance e-prescribing, U.S. Sen. John Kerry (D-Mass.) and U.S. Rep. Allyson Schwartz (D-Pa.) in December 2007 introduced the Medicare Electronic Medication and Safety Protection Act. The bill provides a one-time bonus to physicians of between $1,000 and $2,000 toward startup costs of e-prescribing as well as bonus payments for each script written electronically. Physicians not e-prescribing by January 2011 would see a 10% reduction in Medicare fee schedules, according to the legislation. Physicians could get one- to two-year hardship exemptions.
As of Jan. 8, healthcare organizations representing hospitals and nursing homes, HMOs, insurers, health professionals and other health services have donated a total of $148,700 to Schwartzs 2008 re-election campaign, out of $1.5 million total donations. Kerry has received a total of $111,664 from the same healthcare sectors for his 2008 re-election campaign out of a total of $14.7 million raised, according to the Center for Responsive Politics.
Schwartz announced last month that she was forming a task force on healthcare with fellow Democratic representatives Rep. Lois Capps of California and Rep. Jason Altmire of Pennsylvaniaall former health professionalsto push e-prescribing and disease-management bills. Capps has received $55,750 from healthcare industry groups, out of a total $476,754 raised for her 2008 campaign, and Altmire received $52,900 from healthcare industry groups, out of a total $1.1 million raised this election cycle, according to the Center for Responsive Politics.
In a separate effort, the Senate Judiciary Committee held a hearing in December 2007 to speed up a long-awaited Drug Enforcement Administration decision on whether to permit e-prescribing of controlled substances, which make up about 10% of prescriptions written nationwide. Pharmacy benefit managers and some physicians testified that allowing these drugs to be e-prescribed would reduce fraud and abuse and boost e-prescribing adoption, particularly among specialists who routinely prescribe controlled medications such as opioid painkillers. Earlier this month, the DEA announced it drafted a rule to lift the ban and sent it to the Justice Department and the Office of Management and Budget for review. The American Medical Association opposes a federal e-prescribing mandate, but agrees that controlled substances should be allowed to be e-prescribed.
An imperfect tool
Joseph Heyman, M.D., who has a solo gynecological practice in Amesbury, Mass., and is chairman-elect of the AMA board of trustees, has been e-prescribing for about five years and pays $40 a month for his Web-based e-prescribing program.
He said that while it is a great tool, the technology is too imperfect for it to be mandated. These programs have to be good enough for everyone to use them, Heyman said. Its also important that physicians not become prisoners of whoever is supplying the technology.
Another concern is that employers or insurers could use e-prescribing data for other purposes, such as targeted drug marketing, he said.
These worries are common among physicians, said Joy Grossman, a senior researcher at the Center for Studying Health System Change and author of a study published in Health Affairs last April titled Physicians experiences using commercial e-prescribing systems. Physicians reported incomplete medical histories for patients; overzealous alerts and reminders; problems communicating with pharmacy benefit managers and pharmacies themselves. Given all the barriers, mandates alone wont address them, she said.
Still, Heyman sees the benefits of e-prescribing in his practice every day. Recently, he was able to access the pharmacy history of one of his patients to whom he had been prescribing 50 to 60 Percocet pills a year to lessen premenstrual syndrome symptoms. Looking at her medication history provided by her insurer, he learned that a physician four towns away was each month prescribing her 120 Vicodin, another powerful pain medication with potential for abuse. Heyman called the patient and confronted her. She hasnt come back, he said.
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