Regulations & Guidelines Affecting LTPAC Practitioners
American Recovery & Reinvestment Act of 2009 (ARRA)
- This is the legislation that created incentives for the acquisition and implementation of Electronic Health Records.
The Challenge ARRA Poses for LTPAC Providers
The incentives for use of information management completely overlooked LTC facilities. There’s no statutory requirement or financial incentive for LTC facilities to implement information technology, and there’s no direction for them to interact with the LTC physician who is expected to use electronic records.
If physicians who work in LTC use technology certified as an ambulatory health record, that physician (or nurse practitioner) is eligible for various incentives. There is no incentive for the LTC facility or the LTC pharmacy – each of which manages a critical part of the record required by the physician to complete the “Medical Home” record.
Patient Protection and Affordable Care Act (ACA)
The Challenge the ACA Poses for LTPAC Providers
When the PPACA was written, no one actually thought to focus on the chronically ill people in institutions. Since the passage of the Patient Protection and Affordable Care Act (PPACA), we’ve predicted that the role of LTC physicians was destined to change. That legislation, paired with the HITECH Act, casts primary care physicians and nurse practitioners in the role of “quarterback” for the patient’s care team. PCP workloads would increase in every setting. The days of a physician following patients in multiple settings would stop making sense – both for the physician and the provider setting.
ePrescribing in the LTC Setting
e-Prescribing in the physician’s office is a long-standing practice. The workflow is simple and relatively straightforward; orders go directly from the physician’s office to the pharmacy. When the first LTC e-Prescribing models were built, the office based model was used as the base case. This ignored the regulatory requirement that Nursing Homes must follow– they are the custodians of the official record and all of the orders have to be in their medical record – whether it’s paper or electronic. That means the initial communication has to occur between the physician and the facility nursing staff. Nothing prevents the order from going to the pharmacy simultaneously, but you can’t ignore the facility.
The Challenge ePrescribing Poses for LTPAC Providers
The prescriber has no reasonable way to verify which orders were actually attributed to him when a claim is submitted by the facility, pharmacy or other provider. Nearly100 percent of LTC medication orders are managed by the nursing home. The provider issues orders by telephone or written order sheet, and the facility takes responsibility for getting those orders to the pharmacy. None of the patient information is presented to the prescriber in digital or aggregate format. Reviews are conducted every 30 days using a paper list – a tool that relies exclusively on the physician/extender’s memory for drug-drug interactions, medication history, etc.
Physicians working in LTC are exposed to a vicarious risk when they leave much of the record keeping to the facility and pharmacy – distorted performance measurements in “pay for performance” plans. Anyone paying attention to CMS reimbursement strategy recognizes that computerized claims analysis will drive future Medicare payment adjustments. Without manageable data (e.g. electronic copies of orders) the physician and their practice will be oblivious to what their alleged behavior appears to be.
How do you reconcile the two conflicting demands of efficiency and regulatory adherence?
Physicians working in “pay for performance” plans risk distorted performance measurements if they leave much of the recordkeeping to the facility and pharmacy. Anyone paying attention to CMS reimbursement strategy recognizes that computerized claims analysis will drive future Medicare payment adjustments.
Without manageable data (e.g. electronic copies of orders) the physician and their practice will be oblivious to what their alleged behavior appears to be.
“It is important that facilities, pharmacies, and their respective software vendors understand the specific regulatory and legal imperatives that govern physician practices. Without an appreciation of this, unnecessary conflicts arise that may threaten the availability of an increasingly scarce resource: experienced primary care physicians and extenders.”