Statement of America’s Health Insurance Plans
America’s Health Insurance Plans (AHIP) is the national trade association representing the private sector in health care. Our nearly 1,300 member companies provide health, long-term care, dental, vision, disability, and supplemental coverage to more than 200 million Americans.
AHIP and our member companies applaud Congress for enacting legislation encouraging the development of uniform standards for electronic prescribing. We believe that the electronic prescribing initiative authorized by the Medicare Modernization Act of 2003 (MMA) is an important step toward developing an overall health information infrastructure.
The MMA mandated the development of standards for electronic prescribing for the new Medicare Part D prescription drug program. We believe these standards will have a significant impact on the application of electronic prescribing in physician offices, hospitals, and pharmacies. We appreciate this opportunity to provide our views and recommendations on electronic prescribing issues.
According to estimates from the Centers for Medicare and Medicaid Services (CMS), approximately 32.2 million Medicare beneficiaries will be enrolled in Part D beginning in 2006. The electronic prescribing standards will impact the relationship between these beneficiaries and their treating health care providers. It is vital, therefore, that the standards promote the delivery of efficient, safe, and high quality health care. The electronic prescribing standards adopted by the Department of Health and Human Services (HHS) will also strongly influence the development of similar standards for private sector health care.
This statement discusses the experience of some of AHIP’s member companies in encouraging the use of information technology for pharmacy benefit activities. It also includes recommendations for electronic prescribing standards that we are submitting to the National Committee on Vital and Health Statistics (NCVHS). The NCVHS is charged with advising HHS on the development of requirements for electronic prescribing standards.
Health Insurance Plan Pharmacy Initiatives
Health insurance plans have taken the lead in building the information infrastructure necessary for translating pharmacy data into better patient care. Many of AHIP’s member companies utilize web portals to allow individual members access to their pharmacy-related personal information, including pharmacy claims, benefits information, up-to-date formulary listings, and online search tools to find participating pharmacies by zip code or geographical area. Some health insurance plans also allow members to fill or refill prescriptions online, send questions electronically to a pharmacist about their medications, and purchase over-the-counter medications online at discounted prices.
A number of AHIP’s member health insurance plans are working with health care providers to incorporate everything from comprehensive electronic medical record and electronic prescribing programs to handheld devices and other software and hardware prescribing applications for use in provider offices. Health care providers are able to use this technology to view a patient’s medication history, diagnosis, formulary information, or allergies at the point of prescribing and can either print the prescription or send it directly to the pharmacy electronically.
These efforts demonstrate our members’ commitment to the development of electronic prescribing technologies at the point of patient care.
Practical Considerations for Electronic Prescribing Standards
We have urged the NCVHS to include the following considerations when developing its recommendations for electronic prescribing standards.
Standards Must Allow for Formulary and Benefits Information to be Made Available to the Prescribing Health Care Provider at the Point of Service
It is critical for health care providers and their patients to have all of the information needed to make decisions about health care – including information about cost and benefits coverage for prescription drugs and about potential drug interactions. The MMA specifically requires that the standards inform the prescribing health care professional and the pharmacy and pharmacist regarding “information on eligibility and benefits (including drugs included in the applicable formulary, any tiered formulary structure, and any requirements for prior authorization) . . .” In addition, the standards must provide information about “the availability of lower cost, therapeutically appropriate alternatives (if any) for the drug prescribed.”
Consumers need to be able to access information about their covered benefits and financial responsibility at the time a prescription is written. This information must include whether a prior authorization is required, applicable formulary information, any reasonably estimated co-payment or cost-sharing amounts that will be the patient’s responsibility, and whether less costly, therapeutic alternatives are available. Providing this information allows the prescribing health care provider and his or her patient to discuss the full range of prescription drug therapies available for treatment. In addition, electronic prescribing can improve the quality of care by giving providers information on potential drug interactions and other clinical decision-making support. The standards should allow for such functions.
AHIP recommends that electronic prescribing standards provide access to health benefits and formulary information, as well as appropriate decision support, at the point of patient care. This information should include whether a prior authorization is required, applicable formulary information, any reasonably estimated co-payment or cost-sharing amounts that will be the patient’s responsibility, and whether less costly, therapeutic alternatives are available. Standards should also allow information about drug-to-drug interactions and other clinical decision-making support.
The Standards Process Must Be Flexible
Health care providers and health insurance plans have invested significant resources over the past few years in implementing standards for electronic health care transactions and code sets required by the Health Insurance Portability and Accountability Act (HIPAA). This process has provided a number of important “lessons learned” that are applicable to the development of electronic prescribing standards.
One of the criticisms of the HIPAA standards process is that it applies formal agency rule-making to standards that may need to be modified to meet a changing business environment. The HIPAA process requires any new standards or modifications to first be approved by a Designated Standards Maintenance Organization (DSMO), then submitted for review by all other DSMOs, then reviewed and approved by the NCVHS. At that point, the standard is recommended to HHS, which must publish a proposed rule, accept public comment, and after consideration of those comments, release a final rule.
This process requires a significant amount of time before a new HIPAA standard can be introduced or an existing standard is modified. Imposing a similar process for adopting electronic prescribing standards could lead to a number of administrative and operational difficulties because the standards would not keep pace with changing business needs.
AHIP believes that a flexible, streamlined process must be implemented for adoption and modification of the electronic prescribing standards.
Pilot Testing of the Standards is Critical
Another important lesson from the HIPAA experience is the need to submit any standards to rigorous testing before proceeding to implementation. Testing standards under “real world” conditions will help determine if any changes are needed before the standards are implemented system-wide.
The MMA includes a requirement that the new electronic prescribing standards be pilot tested under HHS direction unless there is adequate industry experience with such standards. We believe that pilot testing is critical to the success of electronic prescribing standards and should be required for all proposed standards, including those currently in use by some health insurance plans, health care providers, and pharmacies.
The Medicare Part D program establishes a unique set of cost-sharing and other requirements which are not applicable to private sector business. A standard that has been successfully used for the private sector may not satisfy the Medicare Part D requirements. Pilot-testing is necessary to determine whether any proposed standard, regardless of its prior industry experience, will meet the Medicare Part D requirements.
AHIP believes that any electronic prescribing standards must be pilot tested before final adoption by HHS.
Initial Stages: Evaluation of Standards
Incorporating new technology into physician practices requires a significant amount of preparation, administrative resources, and training. In order to encourage adoption, electronic prescribing standards must be kept simple and easy to understand. When possible, existing standards, such as those developed by the National Council on Prescription Drug Progress (NCPDP) or by the American National Standards Institute Accredited Standards Committee X12 (ANSI ASC X12), should be used rather than creating an entirely new standard. In addition, the standards should outline minimum functionally requirements, instead of mandating proprietary formats.
The NCVHS “Work Plan” includes a number of standards requirements for consideration that go beyond those set out in the MMA. While it may be appropriate in the future to include this additional information in the electronic prescribing process (for example, information about prescription drug-to-lab test cross checks), the initial standards should be limited to the MMA’s specific requirements. It is more important to get the basic components of electronic prescribing right at this early stage than to impose additional information requirements.
AHIP recommends that the initial electronic prescribing standards developed by the Secretary be limited to the specific information requirements set out in the MMA.
Standards Must be Compatible with Other E-Health Requirements
Health insurance plans and health care providers are subject to the HIPAA transaction standards which set out requirements for basic health care transactions such as claims, enrollment, and payment. Other HIPAA administrative simplification rules govern the security and privacy of information exchanged between health care providers, health plans and insurers, and health care clearinghouses.
The health care community is also engaged in a wide range of initiatives related to the development of electronic health records, interoperability standards, and increasing use of information technology in the delivery of health care. The electronic prescribing standards that the Secretary will eventually adopt should not be considered in a vacuum; they must fully complement these other regulatory requirements and health information initiatives.
AHIP recommends that the electronic prescribing standards be consistent with existing regulatory requirements imposed on health care providers and health insurance plans by the HIPAA standards for electronic health care transactions, health information privacy and security. To the greatest extent possible, the electronic prescribing standards adopted by the Secretary should use, or be based on, existing standards that are widely accepted in the health care industry. In addition, we believe the Secretary must make sure that the standards that are adopted are compatible with ongoing efforts by the health care community to develop and implement electronic health records and interoperable health information systems.
Conclusion
AHIP and its member health plans and insurers strongly support the development of a uniform set of standards for electronic prescribing for the Medicare Part D program. We believe these new standards will improve the quality and efficiency of health care provided to Medicare beneficiaries and will encourage the development of electronic prescribing processes in physician offices, hospitals, and pharmacies.