I-STOP Legislation “Hall Pass” Given to New York Health Care Community

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By Poojah Babbrah, Practice Lead, PBM Services

Providers, pharmacies and technology vendors in the state of New York are breathing a collective sigh of relief.  This afternoon, Governor Cuomo signed into law Bill S.2486 that delays, by one year, the implementation of the state’s I-STOP electronic prescribing mandate, which was adopted in 2012. The Governor has basically just given the collective New York health care community a “hall pass.”

I-STOP, which stands for Internet System for Tracking of Over Prescribing, was signed into law on August 27, 2012, by the New York State Legislature in order to help combat the rising issues around the misuse of prescription medication. The I-STOP legislation consists of five key components:

  1. Prescription Monitoring Program Registry
  2. Electronic Prescribing Mandate
  3. Controlled Substance Schedule Update
  4. Prescription Pain Medication Awareness Program
  5. Safe Disposal of Prescription Drugs

The one year delay specifically impacts the Electronic Prescribing Mandate requiring all providers in the state of New York to send all prescriptions (both controlled and non-controlled substances) electronically to the pharmacy; handwritten paper prescriptions will not be allowed. This mandate was supposed to go into effect on March 27, 2015, but it is now delayed by one year and will take effect on March 27, 2016.

For many, this “hall pass” has come just in time. Delays in vendor certifications, problems with identity proofing and even worse, delays in just purchasing a certified system, were all reasons given as to why the legislation should be delayed.  Those are all valid reasons, but what about those in the community who were able to meet the deadline? I liken it to spending hours and hours studying for an exam, just to come in the morning of the test to find out the teacher has delayed it because of a group of students who just weren’t ready. Frustrating?  Yes.  However, the other way to look at it is that you are all done and ready to go. No more prep needed!  Hat’s off to those of you who prepared and were ready for the deadline.  You are already making an impact on the real issue that the I-STOP legislation is meant to solve which is to reduce the abuse of controlled substances and improve patient safety as it relates to their prescription medications.

For providers and provider offices who are still not ready for electronic prescribing, you now have a pass valid for one year, but that does not mean you can relax. Choosing, implementing and enabling an EHR or stand-alone ePrescribing system takes time. If you prescribe controlled substances, there are added steps on top of the initial system implementation. One year may seem like a lot, but given the fact that this deadline was nearly 2.5 years after the initial approval of the legislation, the one year you now have to get up and running is comparatively short so get started now. 

Already have a certified system in place?  There is still plenty of work to do in your practice including making sure all providers have completed the identity-proofing process, obtained a two-factor authentication device that is compatible with the system and your providers are enabled to send EPCS prescriptions.  In addition, there are policies and procedures that must be followed by your practice to ensure you are meeting the DEA regulations outlined in the Interim Final Rule (IFR) for electronic prescribing of controlled substances. Many providers assume that they are all set once they have a certified system, however the regulations put much of the onus on the provider and the practice to ensure the system is being used and monitored correctly. 

IT Vendor Considerations

For the IT vendors who are in the midst of getting their systems ready for EPCS, I can’t stress enough the importance of getting through certification as quickly as possible.  Having been through it, I know that the auditing and certification process takes time and can be a challenge to navigate. Because there is no standard outline for the audit process, the DEA regulations are left to interpretation by the individual auditor and may vary widely from one auditing organization to another.  Also, ensuring that your system will meet all regulations outlined in the IFR can also be challenge for some vendors.

One year may seem like a lot of time, but keep in mind, it’s not just certification; you will also need time to ensure that 100% of your providers that use your system in the state of New York are enabled to sign and send EPCS prescriptions through your system.  This can also be a challenge as I mentioned above, primarily because the providers assume that the burden of implementation is on the IT vendor, when truly, the practice and the provider carry much of the burden themselves.

As Point-of Care Partners (POCP) recently wrote in HISTalk, “I-STOP may be the biggest health IT game changer of all.”  (You can read the blog here.)  This still holds true but keep in mind your 1-year hall pass WILL expire and when it does, you don’t want to be caught in the middle of the hallway with an expired pass and nowhere to turn. 

Point-of-Care Partners (POCP) has long been active in ePrescribing and EPCS. If you are an IT Vendor, POCP can help you efficiently transition your prescribers to EPCS in New York and in states that are expected to enact legislation similar to I-STOP.  Our ePrescribing State Law Review is the most succinct yet comprehensive analysis of federal and state rules, regulations and statutes governing electronic prescriptions, including EPCS. To learn more about the Law Review or subscribe to our complimentary ePrescribing State Law Capsule, visit our Regulatory Resource Center.

Pooja Babbrah is a health care information technology consultant with Point-of-Care Partners, a leading Health IT Management consulting firm. Pooja has spent more than 20 years in the health care industry and launched DrFirst’s EPCS Gold product, the health care industry’s first certified platform for e-prescribing of controlled substances. 

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12 years and Counting

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By Tony Schueth, CEO & Managing Partner

Last week, LinkedIn announced my 12th year at Point-of-Care Partners (POCP). Since I started the company, that makes POCP 12 years old.  

Having been in business the same number of years it takes to graduate high school, I thought others might be interested in how we got started and what has provided the foundation for our success.

Eight months before I started POCP,  I had been part of a “right-sizing” to position my previous employer for an IPO.  A tenured employee in good standing with a solid company in that era, I received a very generous package and outplacement services that enabled me to step back and evaluate where I wanted to go next.     

During that transition period, I started consulting with a small, entrepreneurial technology company in the ePrescribing space. I started to market their product to pharmaceutical manufacturers and helped the tech company with a health plan under contract with a PBM. That experience was eye-opening! It reinforced the fact that I really liked working with different types of companies.

That tech company was “left at the Altar” by a prospective buyer that decided not to purchase them at the last minute.  At the time, they didn’t have the funds to pay me, as my consulting fees were supposed to come from the buyer but my contract was with the “dissed” company.  When they eventually found another buyer, I was offered $.50 on the dollar of what I was owed. I was told that because it was a stock buy-out, there wasn’t likely to be enough to pay off all debtors, and I was low on the priority list. Nonetheless, I decided to see what happened to the purchasing company’s stock; after all, I had earned those fees! What happened was that their stock went from the $1-$2 range – where it had hovered for years – to $13, and they were able to pay me in full.  It reinforced something I already knew – that ePrescribing is “sexy.” 

One of the things the outplacement firm helps you to understand is the realities of starting your own business. An indicator of a likelihood of success is doing something you had been doing in your previous employment. While my functions were different, I worked in the same subject matter – ePrescribing – as I had for my previous employer. 

Our first engagement as POCP was with the PBM. When that concluded, the health plan engaged us. After that, a pharmaceutical manufacturer engaged us. Then I got involved in government-sponsored testimony and pilots with academic institutions, a Blues plan and an electronic health record. All of this was around ePrescribing, and the notion of focusing on a subject matter and working across stakeholders was born. I truly believe that the fact that we have clients from different stakeholder categories makes us more effective.

We sometimes get pigeonholed as being experts in just one subject matter, which isn’t the case. Our job, therefore, is to make the case that we have other areas of expertise. One of the tools we use to do that is our newsletter, which we write ourselves and have published since day 1. Rather than compete against news agencies and outlets, we use it to demonstrate our expertise and remind people we’re here.  It has been effective and well-received, and we still publish it, along with blogs, tweets, whitepapers, etc.

Today we do work in clinical decision support, health information exchange, analytics/outcomes, patient engagement and electronic prior authorization, and we’re still involved in ePrescribing, currently around controlled substances, specialty products, formulary, REMS and data quality.

To be sure, it’s been a fun 12 years!  On a personal note, we have a first-grader who we still have to get through college. Therefore, it’s going to be at least another 12 years!  I’m looking forward to the ride!!

 

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Proposed Changes in MU’s Attestation Periods: Will They Drive Meaningful Change?

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By Michael Burger, Senior Consultant

How do you spell relief? The Centers for Medicare and Medicaid Services (CMS) apparently hopes that proposed changes in Meaningful Use (MU) attestation periods will give providers some of the breaks they have been seeking and drive up plummeting physician attestation rates.  Is this too little, too late, or will it drive meaningful change?

CMS recently announced it is considering several proposals to help providers garner MU incentive payments and avoid Medicare payment penalties. The proposals suggest that CMS is trying to address providers’ concerns that the 2014 criteria were basically unreachable and unworkable, not to mention the perception that MU itself is too unwieldy and burdensome.  

There are three suggested changes on the table:

  • Realignment of hospital reporting periods for MU stage 2 electronic health record (EHR) use to the calendar year. 
  • Modification of other aspects of the program to match long-term goals, reduce complexity, and lessen providers’ reporting burdens.
  • Shorten the reporting period for ambulatory physician use of stage 2-certified EHRs in 2015 to 90 days, down from 365 days.

If adopted, what, if anything, will these changes accomplish?

Hospitals. The new calendar-year attestation period will help give eligible hospitals more time to install  2014 Edition software, incorporate it into their workflows, and get trained on how to use it. This obviously is helpful. However, the new attestation period is unlikely to drive significant changes in how hospitals purchase and use MU-certified EHRs.  That is because most hospitals have already made EHR- and MU-related decisions, and a change to the attestation period at this point isn’t likely to alter those decisions.

According to recently released CMS attestation data, 9 in 10 eligible hospitals had attested to MU use and were using MU-certified EHRs through December 2014.  Very few of those (10%) who had attested between 2011– 2013 dropped out of the MU program. CMS believes that some 4,000 hospitals are scheduled to attest to Meaningful Use Stage 2 in FY 2015 and of those, the vast majority were using 2014 certified technology in FY 2014.

While there is always room for improvement, hospitals seem to be pretty much set for MU adoption and use in 2015.

Ambulatory physicians.  Ambulatory physicians are a whole different story. About three-quarters of eligible professionals (EPs) were unable to attest for 2014. Moreover, roughly 257,000 professionals–about half of those eligible–will have their Medicare payments dinged in 2015 because they didn’t meet MU criteria.  CMS apparently is anticipating that the easy money of MU incentive payments for a year–based on only three months of usage–will draw noncompliant providers back into the fold. And once they start using their EHRs, CMS hopes they will learn to love them. But are those incentive payments enough to make a difference?

We believe they are not enough, because many physicians see the incentive payments as insufficient to cover new EHR or upgrades.  According to one calculation, individual physicians who start MU in 2014 may receive a maximum of $24,000 in cumulative payments through 2016–with $12,000 in 2014, $8,000 in 2015 and $4,000 in 2016. This isn’t enough to cover the acquisition of an EHR, not to mention implementation and training. Such low numbers can be a shock to many physicians, who are disappointed in the small return on what they viewed as semi-heroic efforts to qualify for stage 1. It is such a turnoff that many are concluding that the juice is not worth the squeeze for continued MU participation.

If this paltry carrot isn’t enough to change behavior, neither is the “stick” of payment penalties. CMS estimates that more than half of those facing penalties (142,000 EPs) will see a payment adjustment of between $1 and $1,000. Consider the situation of a three-physician practice with $1.425 million total annual revenue and a 20% Medicare payer mix.  Each physician would earn $95,000 annually for Medicare patients.  A 1% reduction for not meeting MU requirements would translate into a $950 annual penalty per physician, or roughly $4/day.

This isn’t enough of a financial impact to drive a meaningful number of noncompliant docs back to the MU path. Even doubling the financial penalty for noncompliance next year to 2% doesn’t seem like much of a threat in real numbers to many doctors. They are willing to absorb the loss rather than continue in the MU program. Many simply are concluding that the efficiency gained by not focusing on MU-required record-keeping will more than offset the penalties.

Market forces outside of MU also might be impacting attestation numbers. Because many physician practices are being acquired, they are deferring major purchases like EHR upgrades in an effort to keep their balance sheet polished to look good to prospective buyers. 

Finally, the new attestation window may not be long enough for recalcitrant providers to learn to love their EHRs. If doctors need only use their EHRS for three months to qualify for MU attestation, they don’t have sufficient time to be trained and to become proficient enough to integrate new processes into their workflows.

The bottom line.  We applaud CMS for listening to its provider customers and continuing to make improvements to the MU program.  MU’s parameters were set forth in legislation. This didn’t leave CMS much wiggle room on the regulatory side to make implementation improvements. They are playing the hand they’ve been dealt, which, unfortunately, may not be good enough to drive provider behavior toward MU’s requirements. 

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