Home Forums Discussions General Discussion CMMS Ironies Part 2 ("ERx" requirement)

Ok guys, I want some feedback on this.

I am certain everyone is by now fully aware that if you submit certain procedure codes (indicating you ERx'd a patient's meds), they you can get up to a 2% increase in your overal Medicare reimbursement. This could add up to MAJOR dollars, and goes into effect Jan 1st.

Here's the irony, they said that a written or computer generated Rx which are printed and signed by the doctor are fine. They said that faxing a written or printed and signed Rx are fine. They said we can still call stuff in.

HOWEVER, they DENY us the right to do something AC is useful for: computer generated Rx that is faxed directly from the P.C., i.e. a PC-to-Fax.

Why are they singling out this one feature of many EMR's????

My theory is that the vendors of the ERx programs paid off the proper senators or congressmen or the proper CMMS administrators. No we have to subscribe to one of these.

AllScripts is free, but you have to manually input all the meds. Sure you can PAY MONEY to have them convert you current med lists to ERx format. But it ain't cheap.

This notion get me quite P.O.'d.

Here is my take. They can all GTH! I have no intention of paying for a service which would replace (poorly)a process I can now do for free and much more securely than ERX. My plan is to have all my Medicare patients who need refills to have their pharmacy call us. Then, when they call, they will be put on hold for, oh I don't know, 20 minutes, or told we are too busy right now to take their call and they will have to call back later. For new scripts, I will tell patients my staff will call it to their pharmacy when they have a free minute, which may not be until tomorrow or the next day(of course I will explain to the patients how easy this used to be for both us and them and the pharmacies when we could fax scripts directly from the room). I suspect that, after a few weeks of this the pharmacies will have had enough as will the patients who may now get off their buns and complain to their Congressnimrods that this new rule sucks and should be repealed. If any of you do otherwise, shame on you. We cannot hope to whip this beast if we continue to roll over and play dead.
In a similar vein, I continue to be a hard-long-eared equine to mail order pharmacies in other states which cannot accept stamped signatures (this also applies to any agency servicing Medicare which cannot accept stamped signatures). I refuse to manually sign and then fax them back as this is no longer an original signature. If they require an original, they have to mail me the form/script along with a SASE. Yea, me bad.

Leslie

Windmills are trembling all over the country! Good Luck Leslie, your an inspiration!

Well, I had an equine named Donkey Hote once. He was a bad assinus equinus also. I am just fed up with being pushed around like a rag doll.

Leslie

We should all have the mettle to fight back as Leslie has done!!

That's the problem, Adam. Just like prescribing antibiotics for a cold, it is easier for physicians to just do it rather than spend a few extra minutes explaining to the patient why we should not. It's the little battles that win the war.

Leslie

I'm grateful for more experienced physician colleagues like yourself who can help mentor us young-uns.

I agree with Leslie completely. I am fighting smaller battles, and maybe less stubbornly, (I've never owned a mule) but I am already seeing some progress. One of our reasons for an EMR was to try to cut down on the time it takes to manage pharmacy phone calls, (at the time we had NO CLUE about the real merits of an EMR). Now that we have a data base, and we have a paper trail that is more complete we are beginning to dig in our heals (pun intended, but not great) a bit. Did it ever seem to any of you that the pharmacy just doesn't seem to keep much track of refills? Does it seem that sometimes they just have a clerk call the office for a refill every month? We get an average of 30 calls/faxes per day currently and that is dropping dramatically, but I won't be happy until it is zero. (for three docs total)
Step One: Educate the patients, "I need to give you an Rx when you are here with me to be sure that you are getting the proper medication filled and at the right time" "Oh, don't worry, I'll just have them call you." "NO, THAT'S NOT A GOOD IDEA!" There are several reasons. First, it will delay your refill and you might run out of medications. I can't take time from patients who are here to be seen, while I review your chart to see if the refill is OK to fill. And I have to review your chart in detail to be sure that the medication being requested is the one you are supposed to be taking, and at the dose you are supposed to take. We find we could make a lot of errors if we are not very careful in this matter.
Step 2: The pharmacy Faxs a request for a refill of a medication that we gave a written Rx on in past few weeks. We deny the refill with the written message: "NO REFILL- Written Rx was given to the patient on XX/XX/XX with X refills and I DO NOT KNOW WHAT PHARMACY THE PATIENT HAS CHOSEN TO HAVE THIS FILLED AT. YOU MUST CONTACT THE PATIENT."
Step 3: Where appropriate and we have given a refill X 3 over the fax to the pharm and they did not keep track of the refills, simply faxing us for a refill again the next month, I answer, "NO REFILL, this was refilled x X on XX/XX/XXXX, PATIENT MUST BE SEEN". (And if appropriate we will Mail a written Rx to the patient for the patients convenience. We are not trying to punish or alienate our patients, just modify some behavior.)

Admittedly this is a small windmill, but my Donkey Hote has short legs!

Good points, Martin. Here is another issue. I am having more and more patients bypass me to go to an Urgent Care Center or, now in my market, Little Clinics in groceries or pharmacies, for their colds, sprains, etc. It is one thing if they go during off hours or weekends and their conditions are critical enough to mandate those visits (which is a whole other discussion). But, I had a patient with CRF come in yesterday who had gone to an Urgent Care Center the week before (during hours which I was open and could have seen them had they called or stopped by) for cellulitis of their leg. They were put on Levaquin and told to take NSAIDS for their pain. Mind you, everytime the patient comes in I specifically tell them to avoid all NSAIDS and other medications without first consulting me but, hey, this was a doctor at the Urgent Care and they figured he knew what he was talking about and, no, it did not occur to the patient to tell the doc they had CRF!! I about pooped my scrubs!! The meds were stopped immediately and I scolded the patient (in hindsight probably too strongly) but, MAYBE, I got it through to them that these kinds of venues are dangerous for them.
Another example and one which brings home again Martin's notion of the Medical Home. I have another patient with CRF and diabetes. She saw a podiatrist for her toenails (she needs help trimming them) and during his questioning she revealed to him she also has some mild neuropathy. When I saw her 3 months later I found she was on Lamisil (for mild onychomychosis) and Lyrica (full dose). I asked if he had done any labs since starting these and he had not. I asked her if he mentioned to her that these medications need to be adjusted for renal disease and need to be monitored with labs. She was completely astounded!!! She went back to the podiatrist and told him what I said. He said he assumed her primary doctor would do this!!! Again, I about fell off my stool!
On a side but similar topic, with all of the increasing medical liberties we are legislating for the para-professionals, have we also legislated the medical liability?? Are they paying the same high malpractice rates as I? And, how are they contributing to improved health care in this country? In my opinion, increasing access does not always justify the care delivered. I am sorry to those I may offend on this board but, I do not believe that the way to fix a shortage in primary care physicians is to expand the para-professional numbers. And this is coming from one who started out as a Physician Assistant. Lots of responsibility but little accountability (I know this varies from state to state). When I think back at how little I knew and how much I did I am amazed.

Leslie (who it seems always has an opinion on everything)

I completely agree about these para-professionals. I also don't like just anyone prescribing antidepressants and antianxiety medications. I have seen many a bad outcome because someone wasn't trained in the profession and "wants to help there patient out." I don't want to step on anybodies toes. If you are an OB-GYN then stick within your expertise. Don't try to handle every situation because your patient is too lazy to ask for a referral. I don't believe everybody can do everything. If you are in front of a lawyer, do you think he will cut you a break? I know if he wants my opinion you may not have the best outcome.