LTC physician listed as 2010’s No. 1 Part D prescriber

May 13th, 2013 by Rod Baird

If you are a licensed prescriber and work in geriatrics or LTC, your 2010 Part D prescribing records are probably now public. 

This link takes you to a well researched, and largely balanced, ProPublica analysis of the complete Part D prescribing database for 2010. A well respected LTC physician, Daniel J. Hurley M.D., who works in Indianapolis, garnered the No. 1 position as Part D’s most frequent prescriber at 160,000.

This article raises a number of issues for those of us who work in geriatrics and LTC. Some of these issues are quite significant as we move into the “pay for performance” world.

I have a bit of insight into Dr. Hurley’s situation, resulting from a call by one of the article’s authors for background on LTC prescribing. As Dr. Hurley asserts, and I firmly believe, the LTC facilities he serves simply listed him as the prescriber when transmitting orders to the LTC pharmacy.

That assertion makes sense to those of us who work with LTC facilities and their largely paper order entry system. Over the past year, I’ve worked with dozens of LTC pharmacy professionals through the NCPDP (National Council for Prescription Drug Programs). This is the professional organization responsible for creating standards for the electronic messages that define an “electronic prescription.”

What is certain is that nearly 100 percent of LTC medication orders are managed by the nursing home.  The provider issues orders by telephone or written order sheet, and the facility takes responsibility for getting those orders to the pharmacy. None of the patient information is presented to the prescriber in digital or aggregate format. Reviews are conducted every 30 days using a paper list – a tool that relies exclusively on the physician/extender’s memory for drug-drug interactions, medication history, etc.

The prescriber has no reasonable way to verify which orders were actually attributed to him when a claim is submitted by the facility, pharmacy or other provider.

The article effectively highlights that there is no “oversight” on Part D prescribing patterns – this is an issue I’ve described repeatedly. The physicians I work with are eager for tools to better manage prescriptions in LTC – where the typical patient receives 12 or more medications. The obvious answer is using a LTC version of ePrescribing. This requires a different workflow than a typical ambulatory/outpatient visit, but is well within existing technological capabilities.

To me, it is amazing that CMS has ignored the opportunity to improve care for the LTPAC population by failing to promote ePrescribing’s use in nursing homes. CMS did propose in the 2012 draft of the Physician Fee Schedule that eRx message standards apply when prescriptions were electronically transmitted in LTPAC. However the rule was postponed until late 2014 based on vendor protests. As written, the use of eRx standards only applies if there is an electronic message; paper orders are unaffected.

Physicians working in LTC are exposed to a vicarious risk when they leave much of the recordkeeping to the facility and pharmacy – distorted performance measurements in “pay for performance” plans. Anyone paying attention to CMS reimbursement strategy recognizes that computerized claims analysis will drive future Medicare payment adjustments. Without manageable data (e.g. electronic copies of orders) the physician and their practice will be oblivious to what their alleged behavior appears to be. This ProPublica article proves that.

Rod Baird

About Rod Baird

Rod Baird is the Founder and President of Geriatric Practice Management (GPM). Since 1977, he’s led provider and management organizations that deliver care to Medicare/Medicaid beneficiaries. Past programs he’s overseen include home health, personal care, hospice, rehabilitation hospitals, adult and psych daycare, alcohol/drug rehabilitation, industrial medicine and primary care practices. The Centers for Medicare and Medicaid Services (CMS) selected Baird as one of only 73 individuals to serve with its InnovationProgram. His educational background includes a Master’s Degree in Physical Chemistry from the American University, Washington, D.C.

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