Delaware Division of Medicaid and Medical Assistance: E-Prescribing Initiative
Stephen Groff
10/7/2008

Slide: 1
Okay, very quickly, I’d like to introduce our next speaker Stephen Groff, the Social Service Chief Administrator with the Delaware Division of Medicaid and Medical Assistance. Mr. Groff is the Chief of Planning and Policy Development for the Division of Medicaid and Medical Assistance in Delaware. In this capacity, he manages the planning and policy activities for the Delaware Medicaid and SCHIP Programs as well as state-administered programs, providing prescription assistance, services for individuals with chronic renal disease, and the healthcare coverage for non-citizens. He has over 21 years of experience in planning, policy, and budget with the development of Department of Health and Social Services. Prior to moving the Medicaid, Mr. Groff worked in the Administration Division of DHSS, focusing on budget and policy analysis, which is a great preparation for Medicaid I’m sure. And he also has a degree on Psychology, also a good preparation. Mr. Groff. Actually, I hit the phone. Who’s this? Excuse me? Thank you very much and good morning. I am Steph Groff from the Delaware Division of Medicaid and Medical Assistance and as mentioned, I’m the Chief of Planning and Policy Development so I do not have a strong IT background. So, please don’t direct too many IT questions on my way. What I would like to talk about today is a little bit about what Delaware is doing, how we got there, and why we wanted to move in this direction.

Slide: 2
As I’m sure you are aware, Delaware is a very small state. We have a total population of only about 800,000 people. They are located in three counties. The northernmost County is on the 95 quarter between Baltimore and Philadelphia, so it’s relatively urban. Our two lower counties are quite rural. Our southernmost county is seen large growth in population due to the desire to retire there because of the beaches. So, we’re rather diverse within that very small area. As far as the programs that we administer that offer prescription coverage, we have the Medicaid Program, obviously, and we have about 154,000 enrollees currently. Of those 21,000 are dual eligibles and of those 21,000, about 9,500 are full duals. We also have an SCHIP Program which we called the Delaware Healthy Children Program and we have about 5,500 children enrolled in that program currently. We have a state funded prescription assistance program for individuals, 65 and over, or those with disabilities and incomes below 200% of the poverty level. In addition to regular prescription coverage, that program now provides premium assistance and wraparound coverage for Part D beneficiaries; and we have about 7,000 enrollees in that program. And finally, we have a program for individuals with end-stage renal disease, with incomes below 300% of the Federal Poverty Level; and we have about 450 enrollees in that program. The reason that I mentioned all of these is because, as you might imagine, people can move from one program to another, so our eligibility are claims processing and a lot of our policy really are integrated and so when we roll out our e-prescribing, it won’t be solely for Medicaid. These are the programs with benefit as well. This is what I call our readiness for e-prescribing, so to speak, where we were in Delaware and how we moved forward with this.

Slide: 3
Several years ago, our Medicaid pharmacy team identified e-prescribing as a need. And this was based primarily on the request that they were receiving from providers or inquiries where they really wanted greater access to medication history and then prescription policy after we implemented PDL several years ago. And they wanted that at the point of care so that they could use that in their decision making and of course that wasn't available. At that time, I had not moved to this division; I was still in the secretary's office, but we were very supportive. We understood, you know, how this could be of benefit. Unfortunately, we are limited by our budgets and we could not proceed at that time because we simply didn't have state funding to initiate such a project. But after that, our State Employee Health Program partnered with Blue Cross/ Blue Shield to introduce pilot in 2006. And what they did was, they went out and they recruited 100 providers, and in Delaware, 100 providers was really a relatively large number, and offered them PDAs and software to get them started with e- prescribing. And we are relatively fortunate that we have a fairly high e-prescribing already going on in the state. The annual SafeRx Awards showed Delaware to be fourth in the nation. In 2007, that represented about 12% of prescribers, only 6% of prescriptions, and 87% of community pharmacists. So, this was not something that we were necessarily trying to roll out to a group that wasn't already moving in that direction, which I think is very helpful for us. We also have a Health Information Exchange, a state-wide health information exchange that is, moving very strongly towards implementation. But this is a public-private partnership. It shares strong support from all of our hospitals. It’s called the Delaware Health Information Network and they are planning to roll out e-prescribing functionality within the next year; and we look forward to integrating with that effort and that is one of our plans for sustainability of this project. So, shortly after I moved to the Division of Medicaid and Medical Assistance, the DRA was passed and this wonderful Transformation Grants were announced, and we saw this is a true opportunity for us where funding limited us before. We were very fortunate to secure a grant in the second round of awards and we’re very appreciative of that opportunity to allow us to move forward with our e-prescribing initiative.

Slide: 4
Our project goals are first and foremost to improve overall health quality. Clearly, e-prescribing offers opportunity to reduce medication errors, to identify drug-drug interactions, duplicate therapies, and to increase client compliance with their prescription regimens. We also have to improve adherence to our Medicaid PDL guidelines and to reduce requests for exception prior our authorizations. We hope to achieve that by making the PDL information available at the point of care, and we hope that people will be more inclined to follow these guidelines because now it will be much easier, much simpler to do so. In this environment, we have to always pay attention to fraud and abuse and program integrity, and we feel that e-prescribing offers opportunities here to reduce “doctor shopping” and medication diversion. And in those areas, we found support from our Managed Care Organizations while the prescription benefit is a ... in Delaware is to pay free for service. Our Managed Care Organizations still see this as something to be very beneficial to them and it also receives support from our Office of Narcotics and Dangerous Drugs.

Slide: 5
We have to improve client and provider satisfaction because problems will be resolved at the Point of Care now and this will reduce the need for callbacks, for consultation between pharmacists, prescribers, and our Medicaid pharmacy staff. Clients hopefully will not be running back and forth between doctors and pharmacies. So we’re hopeful that everyone will be happier once they’ve adopted. And for all of those reasons mentioned above, we feel that we will also benefit from a reduction in overall program costs. And I forgot. I don't believe I mentioned from the beginning. I apologize. If anyone is trying to follow along in a handout, you do not have my handout because I didn't get in here on time. So it will be available later, but I apologize for that.

Slide: 6
Our E-prescribing proposal- the approach that we took in Delaware was we collaborated with EDS, who is our fiscal agent and also provides PBM services for our state. DrFirst and SureScriptsRxHub to develop a full e-prescribing solution and by that, I mean it has both benefit coverage and medication history, as well as the actual transmission of the prescription to the pharmacy. To universal program, meaning that providers can integrate real-time MMIS information through a HUBS, regardless of what third party Point of Contact Vendor they may currently have, if they have one. And we did that because we felt that, that would facilitate participation of providers who already had the prescribing capability.

Slide: 8
But we have a small pilot component that’s targeted specifically a practitioner who would be new to e-prescribing to encourage them to adopt e-prescribing.

Slide: 7
Our system features will include real-time medication history, benefit plans, our preferred drug list, prior authorization requirements, and there will be a URL which will lead prescribers to our PA forms, and the descriptions of the prior authorization requirements, clinical decisions support, warnings and alerts that include drug-drug interactions, duplicate therapy, dosage limits, early/late refill, quantity limits, and allergy alerts.

Slide: 6
I mentioned that we had a small pilot incentive

Slide: 8
program and what we are doing there is we are providing PDAs, or as we found that everybody wants a PDA, so this is all application we made, and we are offering other devices such as laptops, or I'm not exactly sure what they’re called there like a mini laptop or a notebook or whatever, if that's really more in line with what the prescriber wants. We're providing the software and training and these will be provided for a year to 50 practitioners in the state. And the way we went about targeting those practitioners, was first, we went after those who have the highest number of Medicaid claims. And I think I mentioned before that in earlier pilot 100 providers is a lot in Delaware. Well, our 50 highest volume prescribing physicians actually represent about 20% of our total prescription claims. So, that could be a pretty big hit for us. We also wanted to target providers with the highest number of prior authorization request, hoping that having access to this system will cut down on the need for that manual request and target providers with the highest number of denied claims for prior authorization, or for those who are trying to request drugs that are non-PDL. We wanted geographical distribution across the three counties and our one big urban area which is the City of Wilmington. And as just I was saying, getting your stakeholders, we had consultation with our Medical Society of Delaware which has been extremely supportive, our Medical Care Advisory Committee, our DUR board, and our P&T Committee.

Slide: 9
Five minutes? I thought I was going fast. We did exclude certain people- those providers who already have interactive e-prescribing capability from the pilot program, of course they can already access the system once it will be up and running. And we excluded providers that are predominantly affiliated with hospital because we felt that they are already moving in this arena, so they didn't really need our incentives.

Slide: 10
Our evaluation measures are broken into three areas, first of all, the improvement of the quality of care. We will be monitoring a number of prescription changes and/or cancellations due to warnings and alerts, the number of interactions and formulary warnings and alerts, and the number of duplication therapy prescriptions. In looking at administrative burden of providers, we'll be monitoring the number of percent of Medicaid physicians who are using e-prescribing, the number of prescriptions that are filled via e-prescribing, and the number of requests for prior authorization. And then finally, in looking at cost reduction, we want to see whether there’s improvement in the proportion of PDL usage, and we’ll be looking at drug expense for Medicaid beneficiary.

Slide: 11
The current status of our project which has not been implemented yet, design and analysis is completed; construction is completed. We are about halfway through our testing, and we’ll be doing certification testing through the month of October. We have completed our physician recruitment. We got all 50 providers that we were looking for and we are scheduled to go live on November 3rd of this year and we’re very excited about that.

Slide: 12
And if you would like additional information, I'll also give you my contact information here. If you have questions that I can't answer, I can certainly put you in touch with the people on our team who could. So thank you very much.