Electronic Prescribing of Controlled Substances (EPCS) is a Texas Medicaid Priority


The Drug Enforcement Administration (DEA) issued rules in 2010 that allowed for the electronic transmission of controlled substances prescriptions that included a requirement for the certification of both the prescriber software system and pharmacy software system by an independent third party auditor. Texas Department of Public Safety (DPS) adopted the same requirements and updated their rules and regulations in October, 2013, to allow Schedule II controlled substances to be transmitted electronically. With ePCS,. Paper, fax and telephone prescribing are not required.
 

In December 2015 Surescripts reported extreme under-utilization of ePCS. The National Average for provider use of ePCS is only 4% and Texas use is even lower at under 3%. This is in contrast to pharmacy readiness. In Texas 85% of pharmacies can accept ePCS transactions, which is ahead of the 80% National Average. Benefits of increased ePCS in Texas are expected to include:

  • Reduced callbacks from pharmacy to practitioner to address legibility, formulary, and contraindication issues.
  • Reduced errors in medication dispensing by eliminating illegible written prescriptions and misunderstood oral prescriptions.
  • Reduce patient wait time at the pharmacy.
  • Reduction in prescription forgery and alteration

Electronic prescriptions for controlled substances will directly affect the following types of diversion:

  • Stealing prescription pads or printing them, and writing non-legitimate prescriptions.
  • Altering a legitimate prescription to obtain a higher dose or more dosage units (e.g., changing a ―10 to a ―40).
  • Phoning in non-legitimate prescriptions late in the day when it is difficult for a pharmacy to complete a confirmation call to the practitioner’s office.
  • Altering a prescription record at the pharmacy to hide diversion from pharmacy stock.
EPCS as an Intervention
  • In 2007 Dr. Grant Carrow and his team at the Massachusetts Department of Public Health researched EPCS.  43% of Providers surveyed who participated in the project, indicated that EPCS made it easier to identify diversion or misuse of medications.
  • Dr. Tom Sullivan, practicing cardiologist notes that the single greatest benefit of EPCS to clinical prescribers is the ability to send all drugs electronically and have a single application that creates, manages, and stores every Rx, with detailed verification and safety checks at every step.
  • Of 102 prescribers surveyed, over half reported that EPCS was easy to use and improved work flow, accuracy of prescriptions (69.5%), monitoring of medications (59.3%), and coordination with pharmacists, though high prior expectations for improved efficiency were not met. EPCS users reported a significant decrease in the perceived frequency of medication errors and drug diversion, compared with controls. Barriers to use of EPCS included limited pharmacy participation and instances of unreliability of the technology.

https://healthit.ahrq.gov/sites/default/files/docs/page/forging-pathway-for-electronic-prescribing-of-controlled-substances.pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3341776/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3715357/

References are available upon request.

White House Action Plan

October 21, 2015 the Obama Administration announced a 2 year aggressive federal, state, local and private sector effort aimed at addressing the Rx and OTC epidemic in the U.S.

  • 540,000 health care providers will complete opioid prescriber training.
  • 4 million health care providers will be targeted for awareness messaging on opioid abuse, appropriate prescribing practices, and actions they can take to be a part of the solution.
  • Centers for Disease Control and Prevention (CDC) will invest $8.5 million developing tools and resources to help inform prescribers about appropriate opioid prescribing.
  • HHS launched HHS.gov/opioids as a one-stop federal resource with tools and information on prescription drug abuse, prevention, treatment, and response.
  • Centers for Medicare and Medicaid Services (CMS) will advise States on steps to reduce the risk of overdose and is testing three new Medicare prescription drug plan measures designed to identify potential opioid overutilization.

https://www.whitehouse.gov/sites/default/files/ondcp/policy-and-research/ndcs_2014.pdf

https://www.whitehouse.gov/the-press-office/2015/08/17/white-house-drug-policy-office-funds-new-projects-high-intensity-drug

Economic Burden on Society

Total US societal costs of prescription opioid abuse were estimated at $55.7 billion in 2007.

  • Workplace costs were $25.6 billion (46%) in lost earnings from premature death ($11.2 billion) and reduced compensation/lost employment ($7.9 billion)
  • Health care costs accounted for $25.0 billion (45%) primarily from excess medical and prescription costs ($23.7 billion).
  • Criminal justice costs accounted for $5.1 billion (9%) largely comprised of correctional facility ($2.3 billion) and police costs ($1.5 billion).

http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4637.2011.01075.x/full

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4273187/

Fraud and Diversion

In Texas, California, Illinois, New York, and North Carolina for fiscal years 2006 and 2007 the Government Accountability Office (GAO) found tens of thousands of Medicaid beneficiaries and providers involved in potential fraudulent purchases of controlled substances, abusive purchases of controlled substances, or both through the Medicaid program.

  • About 65,000 Medicaid beneficiaries in the five selected states acquired the same type of controlled substances from six or more different medical practitioners. Such doctor shopping resulted in about $63 million in Medicaid payments.
  • Medicaid paid over $2 million in controlled substance prescriptions written or filled by 65 medical practitioners and pharmacies barred, excluded, or both from federal health care programs, including Medicaid, for such offenses as illegally selling controlled substances.
  • According to Social Security Administration data, pharmacies filled controlled substance prescriptions of over 1,800 beneficiaries who were dead at that time.

http://www.insurancefraud.org/downloads/drugDiversion.pdf

Under-Age Prescription Abuse
  • 77% of the Texas Medicaid program is comprised of people under age 21.
  • 65% of the Texas Medicaid is age 14 or younger.
  • New York State Department of Health reports:
  • 1.5 million American kids report they have abused prescription drugs.
  • 2,700 teens per day try a prescription medicine to get high for the first time.
  • 50% of teens do not see a risk in abusing prescription (Rx) or OTC drugs.
  • Teens believe that abuse of Rx and OTC medicines is safer than street drugs.
  • Over 50% of teens agree Rx drugs are easier to get than illegal drugs.
  • 1 in 3 teens report having a friend who abuses Rx pain relievers to get high.

http://www.samhsa.gov/data/sites/default/files/CBHSQ-SR168-TypicalDay-2014/CBHSQ-SR168-TypicalDay-2014.pdf

http://www.samhsa.gov/data/sites/default/files/CBHSQ-SR168-TypicalDay-2014/CBHSQ-SR168-TypicalDay-2014.htm

http://www.samhsa.gov/data/sites/default/files/State_BHBarometers_2014_2/BHBarometer-TX.pdf

Medicaid Cost

Medicaid annual spending on opioid prescriptions tripled between 1998 and 2003 to nearly $1.2 billion. Analysis of direct costs of insured members showed that health care costs are 8 times higher for opioid abusers compared to non-abusers when researchers took into account hospital inpatient, physician, outpatient and prescription drug costs.

http://www.amcp.org/data/jmcp/3.pdf

http://www.ncbi.nlm.nih.gov/pubmed/20718646

http://www.tandfonline.com/doi/abs/10.3109/15360280903544877

Emergency Department (ED) Over Utilization

Drug Abuse Warning Network (DAWN) of SAMHSA estimates that over 1.2 million emergency department (ED) visits involved nonmedical use of prescription medicines, over-the-counter (OTC) drugs, or other types of pharmaceuticals (Rx) in 2011.  DAWN estimated there were over 200,000 ED visits resulting from drug-related suicide attempts in 2011 and nearly all involved a prescription drug or OTC medication.

  • 41% increase in drug-related suicide attempts from 2004 to 2011.
  • 46% of medical emergencies involved nonmedical use of pain relief Rx.
    • 29% were related to narcotic pain relievers.
    • 40% involved after ED follow-up
  • 132% rise in medical emergencies from nonmedical use of Rx from 2004 to 2011
    • 183% rise in opiate/opioid involvement.

http://www.samhsa.gov/data/emergency-department-data-dawn

Prescription Drug Misuse and Abuse

The Substance Abuse and Mental Health Services Administration (SAMHSA) describes prescription drug misuse and abuse as the intentional or unintentional use of medication without a prescription, in a way other than prescribed, or for the experience or feeling it causes. SAMHSA reports in results from the 2014 National Survey on Drug Use and Health indicate that about 15 million people aged 12 or older used prescription drugs non-medically in the past year, and 6.5 million did so in the past month.

This issue is a growing national problem in the United States. Prescription drugs are misused and abused more often than any other drug, except marijuana and alcohol. This growth is fueled by misperceptions about prescription drug safety, and increasing availability. A 2011 analysis by the Centers for Disease Control and Prevention found that opioid analgesic (pain reliever) sales increased nearly four-fold between 1999 and 2010; this was paralleled by an almost four-fold increase in opioid (narcotic pain medication) overdose deaths and substance abuse treatment admissions almost six times the rate during the same time period.

http://www.samhsa.gov/prescription-drug-misuse-abuse

http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm