E-Prescribing and Medicaid CMS’ Perspective
Jessica Kahn
10/7/2008

Slide: 1
Okay, I’d like to introduce our next speaker who is Jessica Pollak Kahn. She is a Project Officer at CMS in the Family and Children’s Health Program Group, Division of Quality Evaluation and Health Outcomes, serving as specializing grants to states and nonprofit agency, she oversees the Medicaid Transformation, state high-risk Health Insurance Poll, and Emergency Room Diversion Grant Programs. Topic of focus areas includes health information technology, expanding access to primary care services and insurance coverage, and measuring and evaluating quality of care. She had her Masters in Public Health at Tulane and has worked in state and federal government for over 16 years both domestically and internationally. I think I heard a prelude to her presentation last week, a very interesting overview about what all the states are doing. Okay, I’ll pull this up. I’m one of those NEC speakers. So, I can’t stay in at the podium for long. I walk away from my mic and then everybody kiss me and there you luck, others can’t hear me, okay. Here we are, and show. Alright. So as Caroline said, my name is Jess and I have the pleasure of working with 35 states Puerto Rico and the District of Columbia on Medicaid Transformation Grants among other things. So, what I’m going to talk to you about today are the transformation grants that are including E-prescribing. This is

Slide: 2
one of the ways that CMS is trying to push the issue of health information technology by offering these grants that don’t require state match. And so they’ve really, they’ve been going since February of 2007, another round in September of 2007. So we have some time already to see what’s been happening and they have some lessons learned which I’ll share with you. You have all these in the hand-outs. There are two seats, three seats up here for those of you whose legs are getting tired, I sympathize. These are the states that are including E-prescribing in their Medicaid Transformation Grant. That doesn’t mean they’re exclusively just doing E-prescribing. As we heard this morning, there’s a lot, that it’s integrated into electronic health records as well but they had at least an E-prescribing component. As I said there’s no state matching fund. So this is really a way to be an impetus to get these states going and working on this. Sort of sad joke because they only have 24 to 36 months for our money to do it. We all know it probably takes longer than that which is why Rick’s point was well taken about getting federal matching funds. Maybe this would pilot it and get it started and then you could draw down the federal match if approved afterwards. And Congress asked that we have two primary evaluation requirements. They really were interested in much, much more than this. But they do need to measure any clinical improvements as a result of their projects and any cost savings. So a return on investment, caveat being that whole 24 or 36 months apart

Slide: 3
Okay. So where did most of them start? They started by looking at their environment for E-prescribing in their states. Who’s doing it and what geographic areas, or what kinds of providers, what software are they using, how often are they using it? They’re kind of needed to know where to start. And then they also do a lot of talking to the providers about what pieces of E-prescribing are the most attractive to them? What would they like to use?

Slide: 4
And this really does vary state to state as you all know. So, one of the ways that they got this information was through stakeholder involvement. Medicaid being a federal and state partnership, we encourage the states and they don’t really often need this encouragement to really include all of their stakeholders and so there’s a representative of the advocacy groups, of the consumer groups, the providers, the pharmacists, all of those, and I have some examples here. The Mexico Medicaid is working with the New Mexico Prescription Improvement Coalition which is this ad hoc state-wide organization, public and private, and they are trying to create a prescribing interface across all pairs and I’ll give you more examples about this model. But so they went to this organization that had all these different prescribers and payers involved and that’s one way they got stakeholder improvement. State Medical Directors and Medicaid Medical Directors have been real champions of these in some states, provide advisory groups. Some of them tell me they just have to get out in the car and drive around and talk to the providers face-to-face at various small groups, small settings. I think the governor mentioned from Rhode Island this morning, they’ve done focused groups and that’s one mechanisms for stakeholder involvement.

Slide: 5
I guess so what did they learn from all these stakeholder involvement and early needs assessment? And some of these are 20/20 hindsight so I can’t say that they all did this perfectly but they’re really great about being honest with us about their epiphanies looking back. So asking for input early. It is kind of hard with the federal grants because you’re going to write the applications and the proposals, you kind of sort to know what you want to do, and then you get funded, and then you go back to your stakeholder and say we got the grant but we sort of already put down the paper of what we wanted to do. So I understand there’s a little dilemma there. But asking for input early is very important. And we have been flexible with them and if they’ve had a sort of tweak their direction and maybe take a few steps east or west as a result of that input once they were able to get it. Showing them the demonstrations as you build. We have states, Alabama comes to mine that has their tech consultant, get in front of all of their clinical providers and literally goes screen by screen. This is what it’s going to look like. Oh, we don’t want to organize that way, that’s not how input it, we look at information, put that over there and that needs to be bolded and they come back three months later and they say, is this what you wanted, and I go yes, yes, yes that’s it, that’s better. Really, it’s not just what you wanted to be getting in here, six to nine months later, this is what you got, and it’s that constant demonstrations of what you’re talking about, what the elements need to be. Also, mentioned this morning, this piloting with the early adopters, the high volume prescribers. This has been very effective for them. Those people become the champions, they learned a lot from what works and doesn’t work for them and they get more bang from their back. Provider blitz at kick-off, this is interesting. You figure these grants started about 15 months ago. So, some of them are actually at the going live point, right around now, they started this summer. And they had all these stakeholder input like I told you, they had their providers help them build the darn thing, did you think that that man is that they had everybody immediately using it? Despite the fact, they’d all spent the past 15 months signing it together? Oh no! So now, there’ going hmmm…provider blitz. It’s still provider blitz. So, even after they have all these involvement, I’ve been talking to people ad nauseum they still need to go out and do a huge provider blitz with these same early adopters and high-volume folks that they thought they had been engaged with because people’s lives change and you need to really push it, push it, push it. So that was one of the things that some folks have to go back and add in. Monitoring usage by functionality. They’re looking at where are they logging in especially if it’s part of electronic health record system, not just E-prescribing, which functions are they using and how often. So really looking that within the first 90 days, the first 120 days and then going back and saying, how come you’re not using this piece and why aren’t you using that piece and then going back to the drawing for a little bit.

Slide: 6
From the Medicaid perspective, and you all know these probably as well as we do. But this is probably non-exhaustive list of all the things that we see being included under this huge rubric prescribing. And the reason I think it’s important to have a list like this is because there is as many clinical things as there are administrative and vice versa. It can or should have as much utility to the providers as possible and order them, some advise them to use it. And from a Medicaid Agency’s perspective, this last one is really important because they still have quality oversight. Those of you who can’t read it, it says tracking drug over and under-utilization. So, yes, this is about making this available at the point of care, and it’s about cost savings but they’re supposed to be also using this as a trend just to see overall how are we treating certain conditions and what’s our prescribing pattern so that their medical directors or whoever is looking at this should be taking a few steps back in using this data over time also.

Slide: 7
So, I’m going to give you some very broad examples and we have two states here to go in much more detail, of what are the most common models we’re seeing Medicaid using under these grants for E-prescribing. And Rick did a nice schematic of that also. So, these web-based tools. The idea is that the providers can log in securely than in any other software, sorry vendors, and they just have internet access. Now, the states may have developed this on their own or they may have actually paid for a product and then adapted it; but nonetheless, the providers don’t need to buy a product, they just need internet access. The advantages, remember that slide before, they can have all the various bells and whistles that they want on this tool. It can link to their electronic claims payment, it can link to pre-authorizations, any of the other things they want to add into their, to increase the convenience of the provider. And we see it accessible to various different means – PDAs, desktops, laptops, and it’s linked as Rick mentioned to MMIS or Medicaid Management Information System claims data warehouse, that’s where they’re polling that medical history and it’s routing back and forth.

Slide: 8
Schematic how a provider submits a query

Okay, so I really don’t, this is a very, very, very overly generalized step 1, step 2 of what recommend should, with providers using this web-based tool which sends the query to their data hub which sometimes or something they have developed, sometimes or something they’ve contracted for, which transmits the query to the Pharmacy Benefit Manager to verify eligibility in the formulary and then on the next step,

Slide: 9
How the query gets routed to the pharmacy

the provider looks the results and then using that tool against amidst the prescription to the switch vendor such as SureScripts, now SureScripts/RxHub, you can tell my slide needs to be updated, and they transfer the prescription, the pharmacy which then can fill it and bill the PBM. So it’s a rough visual of what that model looks like.

Slide: 10
So, the question is that, are they doing this just for Medicaid? Because as someone mentioned, the writers don’t like to have to use one system for Medicaid and other system for their Blue Cross and other system for Humana Inc., it’s a little old. So not necessarily, we have some that are just building it for Medicaid and that’s because in their state they’ve decided Medicaid needs to drive E-prescribing. If they get it done, then maybe the others will come on board. But Alabama’s for example, includes Alabama Blue Cross/Blue Shield. Providers log in; they can see either Medicaid or their Blue Cross’s electronic health records and do E-prescribing for both. So the advantage of that joint provider outreach, all these provider blitz is done together, it’s one website between Medicaid and Blue Cross/Blue Shield in Alabama. I think they said they have about 60% of all Alabama residents’ data in that warehouse. So that’s a phenomenal possibility for all the things they could do with then and they’re adding in clinical decision support and many other pieces. As I said, given the time, I just don’t have time to tell you all of the great things that they are doing with this but E-prescribing is one piece of it.

Slide: 11
How the data hub works

So again, this is sort of the idea that the data hub which is Medicaid governed in this case is also getting data from Blue Cross/Blue Shield. But they do, it is a Medicaid data hub.

Slide: 12
The other model that Rick had mentioned is where the joint data warehouse such as a ... where most of the different agencies are all putting their data into it but it’s not owned and controlled by Medicaid. Okay then another model; is this the idea of building an interface for a variety of off-the-shelf products. So, if you have a state where people are using E-prescribing fairly well, you’re getting some adoption up there but they’re using a variety of different products, how does he make a lot of money to build a whole new E-prescribing utility for a Medicaid because then again they have to do that duplication of efforts? So, in New Mexico, for example, they are working with their organization which is also linked to the Part D staffs, again, that makes the providers happy, and this is what they’re doing.

Slide: 13
They are going to do two things. One is they’re focusing on the small provider, the rural safety net providers but this is Medicaid. And we really want to make sure that the people who are way out there in the rural areas get the same quality of care as people in the urban areas who have more access to services. So they’re going to help those private providers, I mean, sorry, those Medicaid providers pay for their choice of a state-approved list of softwares. So they have a menu. Still, they could have some competition, but the state has bedded CCHIT and whatever other standards for E-prescribing software. And then they’re working with RxHub with other private payers to develop this multi-vendor approach, this interface that would be able to accomplish what I described to you before but with multiple different off-the-shelf products. And in terms of incentives, Medicaid and these other providers in this collaborative are going to help pay the transaction fees for the first year; so, to get those early adopters. And in the second year maybe they’ll pay half the fees. And on third year, they won’t pay any. So this idea that in addition to those who are targeted the 50 providers who are targeted to help them actually pay for the software. For everybody else who joins in the state regardless of payer if they’re participating, they can have some incentive in offsetting the transaction fees early on. So the advantages, it brings together multiple payers, it’s targeting key provider groups and then it’s addressing the provider incentives up front. The next also has an electronic health record

Slide: 14
How the provider uses Sure Scripts

projects. So again these things are very linked. Not necessarily needing to walk you through the same thing again but the idea is that is that it’s an off-the-shelf product, and their data hub in this case is RxHub, SureScript/RxHub, I have to get used to saying that.

Slide: 15
Okay. Two minutes. I thought I was talking too fast. Okay, so sort of second approach to this using off-the-shelf is to use existing hubs and to integrate their software into the data warehouse. So, New Hampshire and Mississippi are doing this, Nevada has proposed to do this if approved by CMS. The idea is that the providers practice management softwares, interacts with the MMIS system that Rick described which had they have integrated some Rx/SureScripts software. So the providers get back all the things that they want and they have all of the advantages that they want. And in Nevada, they estimated that 70% if their pharmacies are ready for this change. So, it’s just trying to figure out whether you want to design something yourself, do you want to work with products that other people have designed, you want to work with integrating some other software into your software, there’s a variety of choices and so what we’re learning from these grants is what’s working for which environment.

Slide: 16
So some of the reasons, the rationales and questions they asked themselves in trying to figure out which of these approaches have to do with cost and sustainability. Tennessee, for example, is paying all the fees, no transaction fees for their Medicaid providers. All they need is internet connectivity. That’s for electronic health records and E-prescribing. Okay, I don’t know if they could do that forever. We don’t know. And New Mexico, as I said, they are doing it in just for a year. Delaware is offering PDAs for their initial pilot adopters. So looking at this issue of incentives and how long are you going to sustain them. And then, what is the incentive for small, independent pharmacies? We’ve been having some discussions with many states though Connecticut is one of the more vocal about having some resistance from pharmacies over the transaction fees and for a big chain perhaps they can see over the long term where they can have that work force efficiency, they will offset those transaction fees. But if you’re a small and independent pharmacy, maybe you don’t have the profit margin for that initially. So how do we figure out what the incentive should be and some states need to be perhaps looking at dispensing fees and what they’re reimbursing for that.

Slide: 17
Okay, quickly, provider incentives. Again if you have low adoption of E-prescribing maybe you want to do what Tennessee is doing - offer something with no fees just to get it out there. Come on, you’ll just use it, use it, use it, and then we’ll figure out how we’re going to sustain this over time. If they got medium to high adoption, either picking a utility that has multiple functionality such as the pre-authorization or any other steps that might make it very sexy for providers to use it beyond the E-prescribing or offering an interface to what they already using if they’ve already invested in the off-the-shelf products. And then the other irrational thing to consider on is focusing on your target populations. Are you going to look at all prescribers, just high volume, rural/safety net, who are you looking at? These are all these issues that the Medicaid agencies

Slide: 18
have had to grapple with and talk to their stakeholders about and there’s politics involved on this. These are early lessons learned. I kind of put this on the whole slide a hundred times, you know, provider adoption is slow. I know, we’ve talked about what’s going to accelerate adoption. These projects have gone out there. They’ve done many assessments, they’ve done the stakeholder involvement, and they think they have great technical designs but they still tell you that it takes a while to ramp up adoption. Incentives matter. Not always the same incentives matter to the same people whether they be financial, or workflow or efficiency but they really do matter. And so far from the Medicaid model, we’re seeing that this one-stop shop is the most attractive. So can we get electronic health record and our clinical decision support and our E-prescribing and some of the administrative functions all in one place? And the answer is yes, they’re more likely to use that.

Slide: 19
Okay, because I’m out of time, if you go to our website, you can download the narratives for every funded transformation grants and see in detail what they’re doing by state and how much money they got, what they’re trying to achieve. I encourage you to reach out to those states specifically because I can’t speak for them as well as they can speak for themselves. But if you really, really want to ask me something and you don’t have chance today, there’s my email that I bravely gave out. So, okay. That’s it.