Electronic Prescribing, Automated Refills, and Obamacare.
Mr. Tullman, who left Allscripts late, last year . . . characterized his activities in Washington as an attempt to educate lawmakers and the administration. “We really haven’t done any lobbying,” Mr. Tullman said in an interview. (See reverence in section 4 above)
Between 2008 and 2012, a time of intense lobbying in the area around the passage of the legislation and how the rules for government incentives would be shaped, Mr. Tullman personally made $225,000 in political contributions Mr. Tullman said his recent personal contributions to various politicians had largely been driven by his interest in supporting President Obama and in seeing his re-election. . .
Industry executives say that big digital records companies like Cerner, Allscripts and Epic Systems of Verona, Wis., have reaped enormous rewards because of the legislation they pushed for. “Nothing that these companies did in my eyes was spectacular,” said John Gomez, the former head of technology at Allscripts. “They grew as a result of government incentives.” . . .
“We called it the Sunny von Bülow bill. These companies that should have been dead were being put on machines and kept alive for another few years,” said Jonathan Bush, co-founder of the cloud-based firm Athena health and a first cousin to former President George W. Bush. “The biggest players drew this incredible huddle around the rule-makers and the rules are ridiculously favorable to these companies and ridiculously unfavorable to society.”
The major push for electronic prescriptions was to capture the refill market, usurp the doctor’s responsibility for prescribing by making all prescription essentially freewheeling over riding the doctor’s refill limit which is geared to the needs for re-evaluation of the patient. In other words when a physician evaluates and exams a patient, reviews the lab work, x-rays and other procedures, the physician proceeds to the treatment plans and determines a safe interval after which the patient needs further face-to-face reevaluation. Hence, there should never be a need for the pharmacist to request a refill. For physician to respond to a fax refill request, without reviewing the chart when at the previous office visit the physician has decided on the appropriate interval, would lower the quality of care. To superficially review a chart to see if a premature renewal would jeopardize care would a clerical nightmare, time consuming of about one-half of a follow up unscheduled office visit. If the patient or insurance company paid for that like other professions get paid for the time spent, whether in conference, on phone, or email, this harassment wouldn’t be near as painful or costly.
I was at a health care meeting when the electronic prescribers held forth and bragged about being able to gender refill requests by sending a fax request for refills when the doctors considered opinion was to limit the refill requests to remind the patient that further re-evaluation was needed before the prescription was renewed.
The Allscripts reps couldn’t understand why any doctor would want to eliminated the fax reminders that the prescription had run its course. Doesn’t this just make things run smoother?
The prescription drug executives do not understand the basic nature of health care. To interfere without understanding can be very hazardous in medicine.
I tried to explain that they were sending fax refill requests when the last prescription was picked up and sometimes several times a week adnauseam. What they should be doing is reminding the patient that this was their last refill and they needed to see their doctor for reassessment as to the continuing need of this prescription, a possible change in medications, or a renewal for a safe period of time before the further assessment would be required. If it was a 30 day refill, the patient might be reminded that they have 30 days to see their doctor. If it was a 90 day refill, they would have 90 days to see their doctor.
Recently I was only seeing male patients for three days while my wife and office manager/assistant was visiting her sick father in Florida, I read the faxes that were dropped into my computer each day at 7 PM when I finished my patients. I counted more than a hundred refill requests each day when there should have been none. In the past I would have shredded 100 sheets of paper per day and destroyed at least one tree per day. Now they come into our computer and I could read them and deleted them electronically without such a waste of paper.
In California, controlled substances such as a hypnotic or tranquillizer required a doctor’s re-assessment after four refills. For narcotic controlled substances, a patient reassessment is required after five refills. For a pharmacist to try entice further refills by fax, without the face-to-face reassessment, can precipitate Quality of Care as well as legal issues. There are a few frequently abuse controlled drugs that can’t be refilled at all. These patients require monthly exams to obtain these drugs. To give these patients two prescriptions with different dates so they could come in every other month, instead of monthly, could be interpreted as a major violation and make the physician liable for a felony conviction. These may not be medical limits in some patients, but they are legal limits and thus equally hazardous for the physician if not followed.
In California the medical practice act prohibits treatment without a current medical examination. A current medical examination has generally been interpreted as being examined within a year. If the patient has stable disease, whether arthritis or heart disease, we would generally give refills for the entire year. A faxed refill request may run afoul of the medical practice act which is policed by the California Medical Board (CMB) which monitors our license to practice medicine. To jeopardize our license to practice medicine is a serious threat to our future as well as our family’s future.
A physician who is diligent in writing hypnotic prescription with 4 refills, narcotics with 5 refills, and routine medications with 11 refills, should never hear from the pharmacist to vary this. The pharmacist’s job after the prescription has run its course is to remind the patient to make an appointment to acquire a new prescription from his/her physician.
So with a 100 fax refill request in a single day it would require an extra 300 minutes after hours to review the charts to make sure no medical jeopardy in Quality of Care (QOC) issues were present or legal jeopardy was incurred. If my office manager was present, she would have the same 300 minutes of work with no reimbursement.
Notis Brevis: Before you feel the above is an exaggeration, we have just completed a six-month request to see Medicaid patients that Obamacare had placed into HMOs. We had 600 patients added to our rolls. The very first day they were placed on our list, we have had up to 150 messages on our phone each day of which 100 were refill requests. These came in during each of the 24 hours of day or night. We at once realized that none of these new enrollees had jobs or worked, they all had cell phones which explain the day and night requests since these were men and women essentially at leisure without any time frame.
My wife normally would come to the office and respond to the three or four phone messages, and then get on with the day’s work. During these six-months, she spent three hours every morning to record the messages and another two hours to process the requests. Our HMO felt no obligation to reimburse us for this additional work. Thus my front desk had five additional hours of work each day for no pay. We were promised these patients would be paid on the Medicare fee schedule for the first visit and all subsequent visits would be 10 percent above MediCal rates. It took us a while to figure out why our income had dropped so precipitously. Instead of $18 for a MediCal office call, we were now paid $19.80. We were forced to terminate what we had hoped was our obligation to the poor. But we were getting poor in the process and unable to pay our taxes.
Every single function with this new category of care took immeasurable longer. Doctors that saw referrals for us would not accept this new hybrid of welfare/ HMO patient. After working for hours on one referral, my wife found a consultant in a town 50 miles away. The next time she tried to use the same consultant; his practice was closed to this hybrid. We had one specialty referral that no one of the 4000 physicians in Sacramento, would accept, and the HMO called and said they found someone in San Francisco (100 miles from Sacramento) that would see her. We actually had one patient willing to make this trip before that practice was closed to this hybrid of welfare/HMO.
Thus this monstrosity of Obamacare which was to make health care more accessible has, in our experience, made healthcare less accessible and in several cases, totally inaccessible.
Medicine during the days of the county, city and state hospitals was a two-tiered system. Unfortunately it still is. With the entitlement mindset, it will always be.
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