As I go to more and more conferences and I work with more and more people at my company, I have come to notice that all along I’ve been assuming that everyone around me knows everything about ePrescribing. And that’s just not true. Not that I know it all, but I was inspired at a recent pharma conference to write this section explaining the basics of ePrescribing after I had a group of brilliant physicians, pharmacists and researchers ask me to explain the ePrescribing ecosystem and all of the politics and ins and outs, etc. Needless to say, it was a great conversation and I love sharing what I’ve learned over the years from lots of brilliant colleagues who have been doing this a lot longer than I have.
So here it goes.
Let’s step back for a second and play the part of the patient going in for their regular annual checkup with their primary care doctor. Normally, you’ve scheduled this office visit at least a few days in advance. The night before your visit, the doctor’s EMR has probably gone out to Surescripts with what is called a “270 Request” and said the following:
“I have Dave Scaglione in my office, and here’s all of his demographics. Can you please tell me which formulary he has and can you also send me his unique PBM member ID so that when I send an ePrescription to his mail order pharmacy, it will be easily routed and handled more quickly? Oh and can you tell me which mail order pharmacy he has coverage with? Thanks.”
Surescripts sits on what is called a “Master Patient Index” or an MPI file. This is a database that contains 300+ million covered lives, populated by all of us PBMs and payers. So Surescripts does a HIPAA-compliant match (about 75% success rate) and then passes that request on to my PBM. My PBM then responds with a corresponding “271 Response” that contains the requested information and confirms that I do in fact have coverage with my PBM as of that point in time.
Fast forward a few hours when I am in the exam room with my doctor and she is discussing prescribing a new drug or even re-prescribing an existing drug therapy, her EMR has that information standing by during her search process.
But let’s back up a few weeks, because in theory, her EMR has gone out to the Surescripts network on a monthly basis and downloaded all of the formulary, co-pay and coverage files for the payers and PBMs that represent her patient population. I live in Minneapolis, so her EMR system has probably downloaded BCBS Minnesota, United Health Care, Aetna, Cigna, Humana, Medica, Health Partners and a few others. These are what we call “F&B” files or “Formulary & Benefits” files. They are governed by the NCPDP (National Council for Prescription Drug Programs) Formulary & Benefits standard so all payers and PBMs publish the same file structure which makes it easy for the EMR systems to consume the data (there’s some devil in those details which I will discuss in detail later).
So we’re on the happy path and my doctor’s EMR has all of the latest F&B files and Surescripts has returned a positive eligibility match. As she searches for the drug she wants to prescribe, her EMR is now bouncing that drug name and NDC off of the F&B files for BCBS Minnesota because remember that 271 response? It contained a filename that tells the EMR which F&B set to look at when I am being prescribed for. In this case, BCBS Minnesota Commercial Generic Rx formulary.
With me so far? I know, it’s a lot.
So as my doctor is searching for, say, Byetta 5mcg, she should, in theory (remember I told you about the devil in those details) see the following information about Byetta:
It is on formulary, but it is not a preferred drug and there is a Step Therapy edit on this drug. If approved, the co-pay is $150 for a 30 day supply at retail, and $225 for a 90 day supply at my mail order pharmacy.
Here’s where the devil in the details pops up: All of this formulary information is ballpark, 30K foot information, and that’s assuming my doctor’s EMR (and really it’s their IT department) has downloaded the latest F&B information. What it doesn’t tell you are patient-specifics such as, and here’s an example, that I actually don’t need that Step Therapy because I’ve already tried the 2 drugs that are required as steps and it also doesn’t tell the doctor that I’ve already met my HSA deductible for this year so when I go to my local pharmacy, I’m actually not going to get a rejection for Step Therapy and my co-pay will be $0. That’s not bad, right? That’s good news! However, it rarely works out like this.
Here’s What Usually Happens:
The EMR vendors have had almost no good guidance on how to interpret and display the F&B data that PBMs and payers send to them (Surescripts should step up and provide this service but they refuse to do so). So one very large vendor will display smiley faces, another check boxes, and a lot, unfortunately display nothing. In fact, they gave up on the F&B data years ago when they turned it off because they learned to not trust the info. The said thing is, we PBMs are sending out the best info we can these days and it is in fact correct, but we have a lot of trust to regain with physicians and their IT departments around this issue. Now the EMR vendors are not without blame. There are roughly 600 different EMR vendors out there in the marketplace and to be quite honest, ePrescribing is one of the last things on their priority list as they tend to not make any money on ePrescribing (always follow the money trail) and on top of that, they have rolling industry updates to make year over year which are costly.
Ok, ok, but it’s not all gloom and doom because there’s actually some really positive things going on that I didn’t mention. It’s called Medication History. So let’s step back into the role of me when I moved here to Minneapolis from South Carolina and what took place in my doctor’s EMR.
Remember that “270 request” and the “271 response?” Well those are the eligibility requests and with that, the doctor can then send what we call a medication history request in the same manner. So when I moved to Minneapolis and had a whole new doctor who had no medical records for me since my doctor in SC was all paper-based, she went ahead and was able to ask my PBM for the last 2 years’ worth of my medication history. This is great from the fact that there is no interpretation taking place here because I either filled a drug at a pharmacy or I didn’t. So my doctor was able to see that as a diabetic I was on Novolog insulin, metformin, etc. She also saw where I filled those (CVS Pharmacy) and the times I had filled those scripts and also who prescribed them (my former doctor in SC). This not only allowed her to make light work of building out my medication list as a new patient (no data entry, she just confirmed that I was on them and clicked 2 buttons), but she was also able to let her EMR do a full drug utilization review (DUR) for safety just to make sure she didn’t prescribe anything that contraindicated my current regimen. So that’s a very powerful transaction for doctors and patients because at the end of the day, we want doctors to use EMRs for safety.
This also comes in super handy for helping doctors identify potential drug-seekers. One caveat though: this is only claims-based so if a person goes to a pharmacy and doesn’t run their insurance, this won’t be reported unless the pharmacy chain agrees to do so (Walmart is closing this gap already) and most major chains currently won’t run cash-based claims.
Ok, so that was what I like to call the “front of the house” for ePrescribing. Now that the doctor has identified which medications they want to prescribe, it’s time to do what we call the “prescription routing” side of the house, or more simply put, send an ePrescription to the pharmacy.
At this point the physician only has to confirm what they’re about to send, pick a pharmacy (retail, mail or specialty) and hit send. Once the send button is hit, the ePrescription (sometimes called a NewRx) goes from the doctor’s EMR, up to the corporate EMR site (an Allscripts user for example will have their script go to Allscripts HQ in Chicago) and then get routed to Surescripts. In this ePrescription there is a unique pharmacy identifier known as an NCPDP ID. This tells Surescripts where to send the script. The next step is to go to the corporate pharmacy site where the chain then routes to the appropriate store. 99.99% of the time, that transaction takes less than 5 seconds to get from the doctor to the individual pharmacy. The doctor then gets a confirmation status that the script arrived at its final destination, or it failed, is delayed, etc.
Now this second part of this is not without its own issues. NDCs have their own host of issues that I won’t even begin to get into here (repackaging, etc) and there is still a lack of codification around the sig portion of an ePrescription so some of the common issues we see are when a doctor has a sig that says one thing and then a notes section that contradicts that sig. That then requires a callback to the physician from the pharmacy, which defeats the entire purpose of ePrescribing.
The next transaction is the refill request, sometimes referred to as “REFREQ”. This is when a pharmacy has run out of refills on an existing script and they send a request to have the doctor approve more fills for the patient. This, if implemented correctly, has the potential to highly reduce faxes, phone calls and paper processes in a primary care practice around refill authorizations. The problem though has been that over the years some chain pharmacies have done a poor job of sending duplicate requests if they don’t get a doctor’s response within 24 hours (most docs take 48-72 to respond) or even sending refills for scripts that were never written or have been discontinued due to adverse drug events or inefficacy.
So long story short, we as an industry have a lot of work to do. I have high hopes that there are other companies out there building out the next generation of ePrescribing and clinical networks so that we can get some competition in this space and drive up quality. At this point, the technology is not the barrier, it’s unfortunately competition where there doesn’t need to be competition. We can all work together for the betterment of health care and still make lots of money.
But that, as they say, is a story for a different day.
I’m very excited to be able to finally post this press release. The past year of my life has been spent building out a comprehensive ePA product for Prime’s prescribers and network pharmacies.
ST. PAUL, MINN. – Dec. 20, 2013 –Obtaining prior authorization for prescription medications can be a time-consuming and frustrating process for health care professionals and their patients. The process has traditionally required paper forms, faxes and follow-up phone calls, having the potential to take time away from patient care. To speed up the process, Prime Therapeutics (Prime), a leading pharmacy benefit manager, has contracted with CoverMyMeds.com, a health care technology leader, to launch an electronic prior authorization solution that has the ability to process prior authorization approval, often before the patient leaves the office.
Fast access to medications is a necessity for health care professionals today as they help their patients start or continue their journey of feeling better and living well. A recent Prime pilot study of more than 4,000 electronic prior authorizations found Prime’s automated system reduced prior authorization turn-around time by as much as 90 percent. In addition, duplicate submissions were reduced by 10 percent, and the study showed a 100 percent reduction in missing required information.
“Prior authorizations can be time consuming for doctors and their office teams,” said Michael Showalter, senior vice president and chief marketing officer at Prime. “By reducing the time it takes to process prior authorizations, we are making it easier for doctors to help our members. It also means members are less likely to be turned away at the pharmacy due to prior authorization delays. When we help members get the medicine they need when they need it, we improve both medication adherence and the member experience.”
Through the new program, health care professionals and pharmacists can submit the prior authorization directly to Prime online free of charge. Health care professionals and pharmacies receive real-time notifications of the prior authorization outcome. This automated process helps obtain better, more complete prior authorization information and reduces the need for follow up phone calls.
Health care professionals using Prime’s electronic prior authorization capabilities have said the online system, including the status dashboard, is easy to use. “We are helping doctors spend more time on patient care instead of paper work. The efficiencies electronic prior authorization brings are a win for our health plan clients, for doctors and our members,” said Showalter.
About Prime Therapeutics
Prime Therapeutics LLC (Prime) helps people get the medicine they need to feel better and live well. Prime manages pharmacy benefits for health plans, employers, and government programs including Medicare and Medicaid. The company processes claims and delivers medicine to members, offering clinical services for people with complex medical conditions. Headquartered in St. Paul, Minn., Prime serves nearly 23 million people. It is collectively owned by 13 Blue Cross and Blue Shield Plans, subsidiaries or affiliates of those plans. Prime has been recognized by Modern Healthcare as
one of “healthcare’s hottest companies for 2013.”
For more information, visit www.primetherapeutics.com or follow @Prime_PBM on Twitter.
CoverMyMeds is the leader in automating Prior Authorizations (PAs), and the first step in patient adherence. Prescribers and pharmacies have submitted over 7 million prior authorizations, and other coverage determination forms through our automated system. CoverMyMeds was recently named the 8th fastest growing healthcare company (Inc 500|5000) in 2013.
Organizations that wish to benefit from electronic prior authorization for prescription drugs can contact us at 866.452.5017 or visit www.covermymeds.com.
Original Press Release: