The initiative to expand Florida’s GenRx e-prescribing program will enable physicians to dispense generic medication starter packs in the office using an e-prescribing tool.
After examining a patient and determining that a therapeutic drug is needed, the physician will enter the prescription on a handheld device or log in to a Web-based application using a laptop or desktop computer. The physician can then view a patient’s recent diagnoses, medication history, known drug allergies and any medications he or she is taking. Once the prescription is entered, the system provides feedback on potential drug interaction issues.
If there are no conflicts, the prescription is sent for authorization to the state’s claims-processing system, which approves or rejects the claim. If it’s approved, the prescription goes to the in-office pharmacy to be filled. Physicians can then electronically send the maintenance prescription to a commercial pharmacy.
“In our e-prescribing solution, the patient’s last pharmacy is the default pharmacy,” said Bruce McCall, pharmacy program manager at Florida’s Agency for Health Care Administration. “So in this physician/patient encounter, the provider can ask, ‘Do you still use Walgreens at the corner of 27th and Vine?’ If they say yes, then they can send the prescription and the person can pick it up several days later.”
— Heather B. Hayes
Florida has had an e-prescribing system since 2003, but fewer physicians have adopted the tool than state officials had hoped. That’s not because doctors aren’t impressed with the benefits, which include tighter security and confidentiality, fewer errors, and a potentially big decline in adverse drug events.
The deal-breaker is often a simple matter of logistics.
“What we hear from physicians all the time is that it takes longer to prescribe electronically than it does to use pen and paper,” said Bruce McCall, pharmacy program manager at Florida’s Agency for Health Care Administration, which oversees the state’s Medicaid program. “And time for a physician really is money.”
AHCA decided to essentially pay doctors to use e-prescribing — but in a way that was designed to help the agency save more money in the long term while expanding the use of the e-prescribing tool.
In early 2007, AHCA officials applied for and received a $1.74 million Medicaid Transformation Grant from the Centers for Medicare and Medicaid Services (CMS) to expand the state’s existing GenRx e-prescribing program.
They also proposed to address another costly challenge for Medicaid agencies: the tendency of physicians to send patients home with samples of expensive brand-name medications that often require pre-authorization to fill or are not on the state’s preferred drug list.
Those patients usually realize there’s a problem when they present prescriptions to a pharmacist. “The patient may end up being started on one medication and then we as the agency in charge have to come back to them through the pharmacist and say, ‘Well, now you have to switch to another medication,’” McCall said. “And that’s never as smooth a process as we would like it to be.”
When patients stay on brand-name medications, AHCA pays a high price. Although the agency has an overall 92 percent generic-use rate, brand-name medications represented 85 percent of prescription costs in the last quarter of the 2005-2006 fiscal year.
To tackle both issues, AHCA decided to combine technology with financial incentives. The agency will now pay physicians to dispense 10-day starter packs of generic medications to their Medicaid patients but only if they use the e-prescribing system.
Doctor’s office as pharmacy “The innovation here is that this is allowing the physician’s office to essentially function as the pharmacy,” said Will Saunders, chief operating officer of the Government Healthcare Solutions business at Affiliated Computer Services, which operates Florida’s Medicaid claims-processing system and is putting the GenRx expansion project in physician’s offices. “The concept of drawing physicians into the process of prescribing the cheapest and most efficacious drug is, I think, pretty visionary.”
The CMS grant money is being used to develop an in-office e-prescribing solution, McCall said. Physicians will enter their prescriptions on handheld computers, and back-office systems will capture the prescriptions for the starter medications, process the claims and print the labels.
The new system also links to the existing GenRx Web portal, which provides access to patients’ clinical and medication history, information on drug interactions, and clinical checks used to help ensure that a drug is warranted and effective.
Physicians will be able to keep tabs on whether the patient is complying with treatment because they can see if the patient has filled the initial prescription and is following through on refills. That could help improve the overall health of Medicaid patients, who often find it difficult to get to a pharmacy.
And patients who leave a doctor’s office with a handwritten prescription don’t always go to a pharmacy in a timely manner.
“The phy sician thinks they’ve done their job because the patient comes in with an existing condition that’s worsening and they write a prescription and they hand it to the patient,” said McCall, noting that the unfilled prescription rate nationally is 30 percent. “Unfortunately, the patient may or may not be able to go and get that prescription filled that day or that week, and they might not go at all.”
If patients take generic medications right away and begin feeling better, there’s a much better chance they will go to the pharmacy to fill maintenance prescriptions and comply with treatment, McCall said.
Targeting volume prescribers Florida is in the early stages of running a demonstration of the GenRx expansion. McCall said 35 doctors have enrolled in the program, which is already operational at three physician practices. AHCA officials hope to have as many as 600 physicians sign up, and they are especially interested in high-volume prescribers.
Initially, the generic starter medications will be limited to those that treat hyperlipidemia and diabetes, but the program will eventually expand to include treatments for other chronic diseases.
AHCA would like to see e-prescribing increase from 2 percent to 10 percent of overall prescriptions in six categories: medications for depression, drugs used to treat diabetes, cholesterol-lowering agents, third-generation cephalosporins, calcium channel blockers and alpha-beta blockers.
Getting the system fully operational, however, will take time, McCall said. Physicians must be certified as practitioner dispensers, and they and their employees must be trained on the software and processes involved.
Saunders said launching the GenRx expansion presented no technical difficulties, mainly because Florida had already developed and integrated the back-office systems. He said he believes that getting physicians to participate will be easy because the system is relatively simple to use. It also offers immediate and tangible benefits in terms of office operations and physicians’ interactions with patients.
“My thinking is that they’ll do this if it doesn’t cause them any administrative hassles and they can make a little bit of money at this,” he said. “As long as you have those two things, I think they’ll adopt this.”
McCall describes the approach as a win-win-win-win. The patient leaves the office with a drug remedy for his or her condition. The physician receives a little extra money for treating a Medicaid patient. Medicaid saves money by paying less for medications and expending fewer resources on prior authorizations. And the retail pharmacy that fills the patient’s maintenance prescription has a higher profit than it would on a brand-name medication.
The potential cost savings for Medicaid agencies in particular are compelling. AHCA analyzed claims data involving the six drug categories, which feature several popular brand-name drugs that have just become available or will soon be marketed as generics. If physicians persuaded half of the Medicaid patients on brand-name drugs in those categories to switch to generic equivalents, AHCA would save an estimated $7.75 million in one quarter.
Jessica Kahn, a project officer at CMS, said Florida’s solution is a good example of the type of innovative thinking the Medicaid Transformation Grants were designed to encourage.
“They’re getting all the regular benefits of e-prescribing, which could be flagging potential medication contraindications or reducing prescription errors, but they’re also effectively addressing the issue of how to encourage physicians to use more generic medications,” she said.
From the battlefield to the home front: Managing medical data
Government Health IT presents Col. Claude Hines Jr., program manager for the Defense Health Information Management System, in this recent InSight eSeminar. Col. Hines discusses the health information technology and tactical challenges faced by the military medical community in Iraq, Afghanistan and other areas of conflict. In doing so, he describes the current information technology solutions for transferring clinical data between battlefield care givers to health care personnel at military treatment facilities worldwide.
