Medicare e-Prescribing Incentive Begins . . . but DEA Restrictions Could Cause Problems

The Medicare bill Congress passed last summer underlines the importance of a move to electronic prescribing by physicians. But now the Drug Enforcement Administration (DEA) may complicate that conversion, especially for psychiatrists who prescribe significant amounts of Schedule II stimulants and Schedule IV benzodiazepines.

The DEA is now considering allowing physicians to prescribe Schedule II through V controlled substances electronically. This would be a big incentive for psychiatrists to make the financial and time investments needed to convert computer systems to e-prescribing. Psychiatrists have been slow to move to such a system: many do not see the sense in maintaining 2 prescribing systems-paper for controlled substances and electronic for other drugs.

While conversion to e-prescribing will have its costs, it will also have its benefits starting on January 1, 2009. Under the Medicare Improvements for Patients and Providers Act of 2008, physicians who meet certain e-prescribing reporting standards qualify for Medicare incentive payments starting in calendar year 2009. Those payments are set at 2% for 2009 and 2010; 1% for 2011 and 2012; and 0.5% for 2013. Beginning in 2012, physicians who have not made the leap to e-prescribing will be subject to a percentage reduction in their Medicare physician fee schedule payment.

The Centers for Medicare and Medicaid Services published on October 30, standards that physicians will have to meet to qualify for those incentives. These include the e-prescribing systems they will have to use and the way billings must be coded. For example, to qualify for an incentive payment under the 2009 E-Prescribing Incentive Program, a "successful electronic prescriber" is an eligible professional who reports the e-prescribing measure in at least 50% of the applicable cases.

Along comes the DEA with a totally unrelated proposal-one that will have an impact on the ability of psychiatrists to qualify first for those incentive payments and then to stay out of “harm’s way” and not be kicked into the disincentive category starting in 2012.

Psychiatrists write a significant number of prescriptions for controlled substances, although estimates are unavailable. Child psychiatrists, of course, prescribe stimulants such as methylphenidate for children with attention-deficit/hyperactivity disorder. Adam G. Lowe, communications coordinator for the American Academy of Child & Adolescent Psychiatry, says his group does not keep statistics on what percentage stimulants account for out of all prescriptions. Now, though, prescriptions for stimulants have to be written. So the DEA’s proposal to allow psychiatrists to write e-prescriptions will bear on how easy (or hard) it will be to meet Medicare’s 50% requirement.

The proposal’s shortcomings appear numerous, and not just to physicians. “We are concerned with several provisions in the proposed rule that would create undue burdens on prescribers and pharmacists that, if left unaddressed, may have the unintended consequence of limiting prescriber and pharmacist uptake of e-prescribing of controlled substances,” says John A. Gans, PharmD, executive vice president and CEO of the American Pharmacists Association.

Physicians are unhappy that the DEA would require them to present themselves at a “DEA-registered hospital,” a “law enforcement agency,” or the state licensing board to prove their identity and qualification for prescribing controlled substances. This obviously would take significant time out of a busy day. Some states now require physicians to register with their state boards of pharmacy. But no in-person "proofing" is required.

There are a number of complicated software and authentication requirements, which may baffle most physicians. These have to do with “two factor authentication,” among other things. A psychiatrist would be required to use a computer system that locked him or her out after the system was idle for more than 2 minutes. “While it is understandable that a lock out is necessary to prevent unauthorized personnel from getting access to the system, it also is a rigid requirement that does not meet the needs of a physician,” said Scully.

Practically, a physician could start to tap out an e-prescription, stop to look up some information about the drug or check the patient’s medical record, and in the process spend enough time away from the e-prescription that he is locked out. He would then have to log in again. “APA believes that these requirements would result in confusion and delays in health care offices since physicians would be unable to adapt the system to suit their working needs,” Scully added. He suggested that the DEA consider allowing physicians to modify the software programs to permit longer times before lockouts and to allow physicians to prepare prescriptions in advance and sign them when they are ready. This flexibility would encourage physicians to adopt e-prescribing systems since they would be able to modify the program to suit their needs, while maintaining a secure environment.