Small Problems, Big Impact

TMA Proposes a Red-Tape Reduction Bill 

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Legislative Affairs Feature – December 2012 

Tex Med. 2012;108(12):41-44.

 By Amy Lynn Sorrel 
Associate Editor 

The clock ticked down to the wire for a West Texas emergency physician last August when, days before his state license to prescribe controlled substances was to expire, the Texas Department of Public Safety (DPS) had not renewed the certificate.

Knowing the process typically took a month or two, the physician sent the paperwork in advance as required. He had received the license renewal on time in the past, albeit slowly.

Things should have gone smoother this time. After all, DPS even touted a new computer and phone system that was supposed to streamline internal operations. But the projected efficiencies apparently didn't trickle down to doctors, thousands of whom were snared in a backlog of expiring licenses last summer. The Texas Medical Association received complaints from physicians across the state about DPS delays in processing their applications for renewed permits.

Back in West Texas, the delay carried grave consequences. The physician practices in a rural hospital, and without the license, the emergency physician staffing company he works for was preparing to pull his hospital credential or place him under the supervision of another staff doctor.

"They said I could not work," said the emergency physician, who wishes to remain anonymous. Nor could he prescribe for the critically ill patients he cares for weekly at a nearby heart hospital.

A replacement doctor wasn't much of an option. For these patients, "I'm the whole show," he added. His hospital schedule is typically booked three to four months in advance, and often he's not just the only emergency physician in the underserved area but the only long-term care specialist and hospitalist.

His wife says the physician was "too busy taking care of patients to deal with the mess," so she was prepared to fly to Austin to give DPS a copy of his application and a new check because there wasn't a way to do either online. She couldn't even download the form. However, even that extreme gesture would not have done much good, she was told, because recent budget cuts forced DPS to close its cashier's window.

Twenty-four hours before the doctor's controlled substance certificate would have expired, thanks to TMA's help, his wife connected with a DPS director who reprocessed the application over the phone.

But on a Thursday at 5:30 p.m., there were no guarantees DPS would complete the background check before Monday morning, and the emergency physician was on call that weekend beginning at 6 am Friday.

Fortunately, 20 minutes later, DPS called to say the doctor was in the clear. Also, fortunately, he had a seven-year relationship with the hospital and the emergency services contractor, who took his word that the renewal went through.

"This would not have happened without that relationship," the physician said.

 No More Red Tape  

TMA wants to make sure that red-tape nightmare and others like it don't happen again.

That's the thrust behind an omnibus "red-tape reduction bill" the organization plans to take to state lawmakers when they return in January. Key features of the bill will address last year's backlog in issuing controlled substance permits; ensure that the new DPS online prescription drug-monitoring database remains a secure and user-friendly tool for doctors; and push lawmakers for other in-office conveniences that mean less time spent on needless paperwork and more time dedicated to patients.

Physicians sweat the small stuff because it can add up to big problems, TMA Director of Legislative Affairs Dan Finch says.

TMA continues to press for legislative solutions "to cut through the additional rules, regulations, and other unproductive elements that do nothing to improve quality" and everything to interfere with doctors' ability to practice medicine efficiently and effectively, he says.

Take, for example, the hassles physicians had in renewing their state controlled substances permit they must have to maintain a valid federal Drug Enforcement Administration license, Mr. Finch says. DPS cooperated with TMA to help locate physicians' pending applications, speed up processing, and give doctors more advanced notice of impending expirations. The quick fix did the job, but physicians want long-term solutions.

As a first step, doctors want to see the agency follow through on its promise to automate the current paper-based renewal process and allow doctors to submit and pay for renewals online, similar to updating their medical licenses. Because the information entered on the form every year rarely changes, automatically populating it with physicians' personal information and prescribing identification numbers also makes sense, doctors say.

A DPS spokesperson said the program is "functioning well" and the agency is "exploring options for online registration and payment services." Meanwhile, DPS has maintained the extended license renewal policy and notifies physicians 90 days before expiration of the license "to give them ample time to complete this important process," the spokesperson says.

Last year, agency officials told TMA it had "plans in place to automate the application process in the future, including an online pay function, but as with any state agency, we must prioritize based on limited funds and resources provided."

At press time, according to the DPS website, the agency offered to email doctors a renewal application form, but they still have to mail the paperwork and fees.

 Improving PAT 

In August, DPS launched a new online prescription drug monitoring database called Prescription Access in Texas (PAT). Physicians say it can be an important clinical and risk-management tool but needs some tweaking. TMA, through its red-tape reduction bill, wants to ensure protections that give doctors the flexibility to use it in ways suitable to their individual practices and that guard against mandatory use of the database.

Several years in the making, PAT is designed to rein in trafficking and abuse of prescription drugs. It allows physicians, police, and others to check in real time patients' controlled substance prescription history for the last 12 months.  

"This is a very good first step. But we need to keep improving the database as we go forward, and we need some safeguards," said C.M. Schade, MD. The Garland pain management specialist is a past president of the Texas Pain Society and represents the organization on TMA's Interspecialty Society Committee.

Physicians can use the database, for example, to educate patients on their medications and appropriately treat them based on what prescriptions they've already received from other practitioners. The tool can be especially helpful in emergency departments, where patients often come in with pain complaints but without a medical record. Emergency departments and practices specializing in pain medicine, in particular, also remain susceptible to attempts by those trying to fool the system to obtain narcotics for illegal purposes, and the database could help identify suspicious behaviors.

On the other hand, most patients have legitimate complaints, and because they often forget the names or types of their medications, they may unwittingly be double-dipping, Dr. Schade says. The percentage of "bad apples" abusing the system is so small that requiring physicians to check the database 100 percent of the time for 100 percent of patients is impractical.

"Why check the majority of patients who are doing nothing wrong? All you are going to do is overload the system and bog it down," said Dr. Schade, who pilot-tested PAT before its launch. "I do want to know when a patient is suspected of doctor-shopping. But other than that, I want to be able to use my clinical judgment."

The sheer size of the database also raises the potential for unintended privacy and safety concerns, physicians warn. As many as 150,000 users – physicians, pharmacists, police, board investigators, midlevel practitioners, podiatrists, dentists, and veterinarians – can query the system. The volume of prescription data entered could range in the millions. Therein lies the potential for errors that could adversely affect patients. To date, there is no way for patients to correct their reports, Dr. Schade says. Nor can physicians incorporate patients' prescription information in the online database into their chart or electronic medical record. Physicians can print it out, but they must store the report separately.

"That's a problem for me as a practicing physician," Dr. Schade said, especially if doctors are supposed to readily make use of the information or if investigators come knocking for medical records and that information is missing.

State regulations also bar physicians from delegating their authority to research the database and from sharing their log-in information with anyone, even a staff member. Doing so would constitute a violation of the Health Insurance Portability and Accountability Act (HIPAA).

Dr. Schade acknowledges potential privacy concerns with such delegation. But HIPAA rules already apply to similar patient activities that doctors entrust to their staff.

"There are only so many hours in a day, and all of this red tape cuts into that," he said. "For doctors to adopt the database on a widespread basis, we have to make it practical."

A Balanced Approach 

The Senate Committee on Criminal Justice in late October heard public testimony on recommendations to enhance ongoing efforts to crack down on prescription drug abuse, including the new online monitoring database. State health officials, law enforcement representatives, physicians, patient advocates, and others testified on a range of solutions: increased funding for DPS programs, a multiagency prescription drug management strategy workgroup, and improved educational programs for patients and health care professionals.

Some health and law enforcement officials suggested a more "standardized" reporting system that requires physicians to query the database could help cut down on illicit doctor-shopping before it leads to widespread criminal activity. One mental health watchdog group proposed auditing "top prescribers" within the Medicaid program.  

TMA member Larry C. Driver, MD, a cancer pain physician in Houston and a professor in the Department of Pain Medicine at The University of Texas M.D. Anderson Cancer Center, called for a balanced approach.

He testified on behalf of TMA and the American Cancer Society that he was "delighted" to have access to the online prescription drug-monitoring database to "help patients stay safe." But for doctors, "this is not a matter of 'gotcha.' This is a matter of not prescribing something a patient already has."

Doctors are working "hand-in-hand with law enforcement in their efforts to curb misuse, abuse, and diversion of prescription pain medication and other controlled substances," Dr. Driver said. "At the same time, we want to look out for the best interests of people with chronic pain."

He said doctors are on board with programs to educate the public and health care professionals at all levels. Physicians also support the establishment of a multidisciplinary workgroup.

But Dr. Driver, also president-elect of the Texas Pain Society, reminded the Senate panel that some patients, including the cancer patients he treats, can have lifelong debilitating pain as a result of their disease and its treatment.

As a physician, "I have to find a balance between pain relief [for patients] and the side effects" of a particular drug," he said. Doctors "want to help law enforcement find a balance, too," in their efforts to pursue criminal activity. "I hope we can meet in the middle."

Sen. Joan Huffman (R-Houston), vice chair of the criminal justice committee, echoed that sentiment, saying whatever direction the legislature takes, "there is a legitimate place in the medical world for these drugs and we don't want to inflict hardship" on either the physicians who are legitimately prescribing pain medications or the patients they treat. Lawmakers will "keep tweaking" the prescription drug-monitoring database and other tools "to outsmart the crooks" and balance valid medical needs, she said.

Swipe Away Hassles 

A more secure and user-friendly database could help practices streamline and enhance routine patient intake. For instance, when staff check patients' insurance, they could query the prescription drug database; it would populate the patient's electronic medical record; and automatic flags of suspicious patterns could pop up versus doctors checking every patient.

San Antonio occupational medicine specialist Bernard T. Swift Jr., DO, imagines that during that process, practices could wipe out many hassles with a simple swipe of a patient's driver's license for automatic – and accurate – data entry of their personal information.

Under TMA's bill, that could become reality.

One swipe could save 30 to 60 seconds per patient registration, estimates Dr. Swift, chair of TMA's Council on Socioeconomics. Multiply that by the 400,000 patients seen annually in the dozen or so Texas MedClinic urgent care clinics he runs as chief executive officer, and "you can do the math on what that means as far as enhancing productivity. And that's just in our facility. If we expand that to the entire state, you can see the significant efficiencies that can be achieved."

Hospitals already possess such capabilities thanks to a 2007 state law. It would take additional legislation to grant doctors the same access, which TMA would pursue in its bill. Pharmacies also are permitted to swipe patients’ driver’s licenses to help enforce certain state laws that, for example, aim to prevent drug diversion and tobacco sales to minors.

Physician practices similarly could benefit from the additional risk-management applications to cut down on fraud and related costs, particularly urgent care clinics like Dr. Swift's, which see patients on an episodic basis.

Again, privacy concerns arose at the time the hospital-related law passed.

But physician practices and clinics already verbally collect and store the same personal information contained within the driver's licenses, Dr. Swift says. The magnetic stripe contains no more information than that presented on the front of the card, and existing law gives patients the right to opt out if they prefer not to have it swiped.

"I'm not the world's policeman. I'm just collecting the information," Dr. Swift said. "As physicians face declining reimbursements, we have to enhance our practices and these processes to make sure we keep costs low. Physicians are looking for efficiencies all the time, and this is one inefficiency in the system now that could easily be resolved."

 Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email. 


 Red-Tape Hotline 

 TMA wants to hear from you as part of its red-tape reduction effort. Where are you experiencing administrative hassles? Where does the red tape need to be cut and how?

Visit the TMA website to share your complaints and suggested solutions. Or light up the phones of the TMA Knowledge Center at (800) 880-7955.

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