Saturday, May 17, 2008

Incentives for e-Prescribing

Recently, and around the time of a hastily-called meeting by the Brookings Institution on e-prescribing, I was asked about incentives.

I have been following this only peripherally, so I made a lot of calls and sent a lot of emails. I drew some conclusions that may be my own bias filtered through what I want to hear, but I present them nonetheless.

The Southeast Michigan e-prescribing initiative is one of the most impressive success stories. Incentives to prescribers were $500 - $1000 with recurring incentives with P4P. Some up-front funds were used for infrastructure.

This writer believes the most important determinant of success was the involvement of every significant organization involved in the effort. Rather than just focusing on the prescriber, this project was initiated by employers (the auto makers) and involved actively retail pharmacies, plans, PBMs, SureScripts/RxHub, vendors, and prescribers. I believe it was the strength of this guiding community coalition that made this project an ongoing success.

Details can be found through a Powerpoint Presentation or through a search engine.

A similar experience was found in Horizon BCBS of New Jersey – one of the groups involved in the CMS e-prescribing trials last year. In this case, a commitment had been made over time.

One could therefore argue that a similar, broad-based cultural shift had taken place by the time the trials were initiated.

There are many examples in which plans provided significant financial incentives to practitioners but where results were wanting. In most of these efforts, physicians were provided with some combination of hardware, eRx software, mobile phones, telecommunications subsidies, and P4P approaches. In one effort, the program increase total reimbursement 1% (not just eRx-associated) if one met certain simple adoption milestones. Practitioners received another 1% if used a more extensive EMR system. Additional funding of another 5% or more could be attained if one met other P4P milestones. Interest in the program was low. The incentives (particularly the 1% of total increase in plan payments, did not seem to foster change. No pharmacy participation was mentioned.

Prematics seems to have a different approach. This vendor focuses on the high prescribers. Payment is through plans or other intermediaries to the vendor, and not to the practitioner. Payments are based on transaction fees in the range of $1-2. These fees are correlated with the estimated savings of $55 for every brand-to-generic shift. This model assumes and works towards linkages with pharmacies and other involved stakeholders. It focuses “incentives” to the prescriber on ease of use, flexibility, and convenience. These payer-to-vendor models do not preclude additional provider compensation for pay-for-performance, outcomes, or more effective and efficient medication management programs. Such incentives just aren't used to capitalized the infrastructure (and one wonders what happens to the self-pay patients; are they "free riders"?)

In my view, the e-prescribing pilots suggest the following:
  • Adoption is low but increasing rapidly as critical masses are achieved in communities.
  • It is a system-level issue involving pharmacies, providers, intermediaries and other critical programs.
  • Training and expertise may come from national or state-level expertise, but the real change happens locally.
  • Systematic, community-based approaches like SE Michigan take the most effort, but the guiding coalition and the critical mass focusing on the cultural and organizational issues suggests a far higher likelihood of success.
  • Incentives for a single provider have to be significant (at a minimum of 5% increase), but the Prematics model suggests that simply providing better systems more responsive to workflow might foster adoption. (Were I in practice, I am not sure I'd want to have my infrastructure costs assumed by a payer or intermediary, since, this is money that could be paid directly to providers for services.)

From the intermediary or employer side, brand-to-generic shifts so offset many of the costs; the question is: can the same shifts be assured without e-prescribing? I think perhaps so; certainly PBMs push drug trend before eRX (through tiered co-payments), and the differential profits realized by retail pharmacists influenced a lot of pharmacy generic shift behavior.

This brief posting is not particularly comprehensive or rigorous. But the simple question is:
  • To what extent does X incentive to one party in a transaction lead to Y results independent of the incentives to other parties in the transaction? (i.e. can you just give money to physicians and expect results if the system in which they practice is not ready for change?)
  • To what extent - and how - do system-wide or community-based initiatives involving more parties influence adoption and use? what are the overall costs and benefits of these?

To me, community-based approaches involving pharmacy, prescribers, intermediaries, employers, and government are the best way to go.


Post a Comment

<< Home