Centers for Medicare

1
Centers for Medicare Medicaid Services

• 2009 E-Prescribing Incentive Program
• 2008 MIPPA Legislation
• Michael T. Rapp, MD, JD, FACEP
• Director, Quality Measurement and Health
  Assessment Group
• Office of Clinical Standards and Quality
• Centers for Medicare Medicaid Services
• Baltimore, MD

2
Overview

• E-Prescribing
• Electronic Prescribing Incentive Program
• Earning an incentive payment
• ERx system selection
• Getting more Information

3
Background

• E-prescribing is 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
Background

• Many potential benefits to e-prescribing
  including safety, efficiency, formulary
  adherence, drug surveillance, cost savings.
• Limited adoption estimated only 5-18 of
  prescribers e-prescribe

5
Background

• The MMA and the creation of the Medicare
• Prescription Drug Benefit Program (Part D)
• promoted the use of electronic prescribing by
• requiring the adoption of interoperable Part D
• standards for Electronically prescribing Part
• D covered drugs prescribed to Part D
• eligible individuals.

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How eRx works

• An eligible professional decides to order a
  prescription for a patient.
• The prescription is entered into an eRx program
  and is transmitted to the desired pharmacy.
• Communication also occurs between the pharmacy
  benefit manager and the physician.

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eRx Communication
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MIPPA Legislation - PQRI

• MIPPA enacted July 2008
• PQRI 2 incentive for 2009 and 2010 program
  permanent
• Electronic Prescriber
• Added separate incentive for a successful
  electronic prescriber
• 2009 and 2010 2
• 2011 and 2012 1
• 2013 0.5
• 2014 0
• Provided parallel future fee reduction penalty
• 2012 1
• 2013 1.5
• 2014 and beyond 2

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Future Penalties for Not Electronically
Prescribing

• Fee reduction is prospective based on
  determination of successful electronic
  prescribing based on prior date to be determined
• This date will not be before 2010.
• Hardship exemption available for professionals

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MIPPA Legislation What is a Successful
Electronic Prescriber?

• MIPPA references 2008 PQRI electronic prescribing
  quality measure (i.e. e-prescribing measure
  125).
• MIPPA requires E-Prescribing measure to be
  removed from PQRI for 2009
• Measure 125 forms basis for 2009
• e-prescribing measure

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2009 PFS Rule What is a Successful Electronic
Prescriber for 2009?

• Eligible professional
• Physicians and other eligible professionals under
  PQRI
• Prescribing authority
• Successful reporting of electronic prescribing
  measure
• Successful reporting is defined as reporting
  measure in at least 50 of applicable cases
• PQRI and Electronic Prescriber Incentive Program
  implemented in 2009 PFS rule

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2008 PQRI E-Prescribing Measure

• 2008 PQRI Electronic Prescribing Structural
  Measure (measure 125) may be reported as one of
  quality measures
• 2008 PQRI Reportable at 80 of applicable cases
  
• 2008 No separate incentive

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Electronic Prescribing Measure

• Overall requirement to report measure that
  eligible professionals (EPs) has adopted
  qualified e-prescribing system.
• Professionals who have not adopted a qualified
  electronic prescribing system cannot report on
  this measure

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Electronic Prescriber Measure

• PQRI Claims Based Measure Reporting System
• Reporting Denominator
• Determines applicable case when Numerator Codes
  reportable
• HCPCS Billing Codes (Generally Office Visit
  Codes)
• Reporting Numerator
• G Codes
• Reportable in each case of denominator codes
  billed on claim
• The secretary may change the measure
  specifications until 12/31/08 (PFS Final Rule)

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Qualified Electronic Prescribing System

• As a qualified system, the program must be able
  to perform the following tasks
• Generate a complete active medication list
  incorporating electronic data received from
  applicable pharmacies and PBMs, if available
• Allow eligible professionals to select
  medications, print prescriptions, electronically
  transmit prescriptions, and conduct alerts
  (written or acoustic signals to warn the
  prescriber of possible undesirable or unsafe
  situations including potentially inappropriate
  dose or route of administration of a drug,
  drug-drug interactions, allergy concerns, or
  warnings and cautions)
• Provide information related to lower cost,
  therapeutically appropriate alternatives (if
  any). The ability of an electronic prescribing
  system to receive tiered formulary information,
  if available, would suffice for this requirement
  for 2009 and until this function is more widely
  available in the marketplace
• Provide information on formulary or tiered
  formulary medications, patient eligibility, and
  authorization requirements received
  electronically from the patients drug plan (if
  available)

16
Qualified eRx Systems and Part D Standards

• E-prescribing systems for 2009 are to be
  compliant with the Medicare Part D standards for
  required functionalities
• The standards refer to the version of messaging
  that the e-prescribing program uses to send the
  information over the prescription network

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Reporting Deminator

• Patient services billed using one or more of
  following encounter codes
• CPT Service Codes or HCPCS Codes for 2008
  measure 90801, 90802, 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, 99381, 99382, 99383,
  99384, 99385, 99386, 99387, 99391, 99392, 99393,
  99394, 99395, 99396, 99397, G0101, G0108, G0109
• Professional who does not at least once bill such
  a code has no
• occasion to report or qualify as successful
  electronic prescriber
• Measures codes may be updated for 2009
• PFS Rule indicates that will not be expanded
  outside professional office or
• outpatient setting for 2009
• Further limitation for incentive payment (but not
  reporting) that Part B
• allowed charges for the reporting denominator
  codes must make up at least 10 of
• professionals total Part B allowed charges
  (January 1-December 31, 2009)

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Reporting Numerator Codes

• G CODE OPTIONS
• All prescriptions in connection with the visit
  billed were electronically prescribed using a
  qualified e-prescribing system
• No prescriptions were generated during the visit
  but professional does have access to a qualified
  e-prescribing system
• Some or all prescriptions were written or phoned
  in due to patient request, State or Federal law,
  the pharmacys system being unable to receive the
  data electronically OR because the prescription
  was for a narcotic or other controlled substance.

19
Selection of a System

• Functionalities for Qualified System
• Compliance with Part D Standards for required
  functionalities
• EHR vs. Standalone Systems
• EHR systems with 2008 CCHIT Certification meeting
  qualifications
• CCHIT expects to review stand-alone systems for
  certification in 2009

20
Part D Standards

• As part of SureScripts-RxHubs vetting process,
  all vendors who are listed on the SureScripts
  website http//www.surescripts.com/get-connected
  .aspx?ptypephysician meet the 2009 Part D
  standards for the functions they provide.
• If an eRx system is not on the SureScripts
  network, a potential customer should look at the
  Part D standards on the CMS website and check
  with the products vendor.

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Additional Information

• CMS plans to have an eRx section on the PQRI
  website at www.cms.hhs.gov/pqri
• This section will contain information on
• The MIPPA legislation
• A Fact Sheet describing the MIPPA E-Prescribing
  Incentive Provisions
• Part D standards
• e-Prescribing Made Simple

22
Future Alternative to Determining Successful
Electronic Prescriber

• MIPPA authorizes Secretary to change future
  requirements for successful E-Prescriber
• May base limitation on number of Part D
  prescriptions rather than particular Part B
  services as in current measure
• Authorizes use of Part D data to determine
  successful e-prescribing

23
Implementation Schedule for 2009 PQRI and
e-Prescriber Incentive

• 2009 Electronic Prescribing Incentive
• 2009 PFS Rule placed on display October 30,
  2008
• Detailed information on Electronic Prescribing
  Incentive

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Additional PQRI Resources

• For more information on PQRI and eRxing please
  visit our website at http//www.cms.hhs.gov/pqri
  
• 2009 PFS Final Rule with Electronic Prescriber
  Incentive Implementation
• http//www.cms.hhs.gov/physicianfeesched/downloads
  /CMS-1403-FC.pdf?agreeyesnextAccept
• Thank you!
• Michael T. Rapp, MD, JD