POCP Blog

By Tony Schueth, CEO and Managing Partner

The world of health IT was buzzing this week in the wake of a massive rule drop by the Office of the National Coordinator for Health Information Technology (ONC) and the Centers for Medicare and Medicaid Services (CMS). ONC published its long-awaited proposed rule on interoperability and information blocking. Simultaneously, CMS issued a related proposed rule aimed at making claims and other health information available to patients through application programming interfaces. We will be publishing our thoughts on them soon, so stay tuned.

That said, we shouldn’t overlook the guidance issued by the federal government toward the end of 2018 that will affect electronic prescribing (ePrescribing) and electronic health records (EHRs). The requirements were put forth as legislation, proposed rules or as a memorandum to Medicare Part D plan sponsors.

H.R.6 mandates ePrescribing for controlled substances covered under Medicare Part D and ePA for all covered Part D drugs requiring prior authorization.

Here’s what happened at the end of 2018.

1. Legislation mandating ePrescribing and improved interoperability for prescription drug monitoring programs (PDMPs). These are part of the bipartisan SUPPORT for Patients and Communities Act (also known as HR6). The bill mandates ePrescribing for controlled substances covered under Medicare Part D and ePA for all covered Part D drugs requiring prior authorization, effective January 1, 2021. Of note is that facsimiles, proprietary payer portals and electronic forms no longer comply with the law. The act also provides grant support to promote PDMP interoperability. (Click here for our take on the legislation and how it impacts ePrescribing and PDMPs.)
2. Proposed rule to require use of the real-time benefit check for Part D by January 1, 2020. CMS recently issued a proposed Part D rule under which plan sponsors must adopt a “real-time benefit check (RTBC) tool” by January 1, 2020. The draft regulation also indicates that if an RTBC standard is available in a year or so, it could be adopted by Part D for 2021. Point-of-Care Partners submitted extensive comments on the proposed rule, including the timeline, adoption of standards and other implementation issues. (Click here to read our comment letter.)
3. Part D sponsors to provide an indication-based formulary design beginning contract year (CY) 2020. According to CMS, indication-based formulary design is a formulary management tool that allows health plans to tailor on-formulary coverage of drugs predicated on specific indications. CMS says this gives health plans the ability to negotiate formulary coverage based on specific indications. That sounds promising, but there are many details to be fleshed out by stakeholders such as CMS, EHR vendors and standards organizations. Some of these unknowns may be addressed in the final rule:
   • How will indication-based formulary information be displayed in EHRs?
   • Will vendors have enough time to meet this implementation date?
   • Are standards needed?
   • How will payers develop the information?
   • Will physicians understand it?
   • And will physicians be required to use the data?
4. Proposed rule to rescind two HIPAA administrative simplification standards. HHS issued a proposed rule that would rescind the required use of the standard unique health plan identifier (HPID) and other entity identifier (OEID), which are part of the suite of standards named under the Health Insurance Portability and Accountability Act (HIPAA). These two standards are really oriented toward claims but payers and physicians have resisted using them. In fact, HHS has never taken enforcement actions for noncompliance with these two standards.

HHS’ action to rescind the two standards was taken in response to recommendations by the National Committee on Vital and Health Statistics in 2014 and follow-up input by stakeholders. According to HHS, the identifiers do not add value to electronic health care transactions and would be “costly, complicated and burdensome” to implement. In addition, the industry already has moved on, developing other ways to route claims and other HIPAA transactions using existing payer IDs. Comments are due February 19, so the final rule should be out in early summer. Payers and providers should be happy with HHS’ action, as they have opposed use of the standards for decades. Providers were particularly unhappy about the prospect of using HPIDs, noting that their health information technology systems were programmed to identify payers rather than plans. We wonder whether CMS’ action signals the need for HHS to update HIPAA standards and operating rules to reflect regulatory and market developments. Such a reboot would definitely have implications for ePrescribing as well as EHRs.

Point-of-Care Partners is closely monitoring these and other legislative developments. We’d be happy to walk you through them and help you with comment submission. Drop me a line at tonys@pocp.com.

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• electronic prior authorization
• ePrescribing
• Regulatory Trends