Tamper-Proof Scripts for Medicaid Mandatory in Spring 2008
CARA CLARK
Physicians and pharmacists were recently notified about a new law, which rode in on the coattails of a bill regarding accountability for expenditures in Iraq, requiring tamper-resistant medical prescription pads to be used in all written prescriptions for Medicaid patients.
In the first phase of enforcing the new law, prescription pads must meet one of three criteria as outlined by each state’s Medicaid program. According to the Center for Medicare and Medicaid Services, each pad must have “an industry-recognized feature to prevent unauthorized copying,” or “an industry-recognized feature to prevent erasure or modification” or “an industry-recognized feature to prevent use of counterfeit forms.” By Oct. 1, 2008, the medical prescription pads will be required to meet each of the three industry-recognized guidelines. The requirements do not affect prescriptions that are phoned in, faxed or e-mailed to pharmacies.
According to the Medical Association of the State of Alabama Web site, “A ‘tamper resistant prescription pad’ is a prescription pad with each blank sheet employing at least one of the following methods to discourage forgery or alteration:
- A latent, repetitive ‘void’ pattern printed across the entire front of the prescription blank, so that, if a prescription is scanned or photocopied, the word ‘void’ appears in a pattern across the entire front of the prescription.
- A security watermark printed on the backside of the prescription blank.
- A chemical void protection that prevents alteration by chemical washing.
- A feature printed in thermo-chromic ink.
- An area of opaque writing so that the writing disappears if the prescription is lightened.”
According to Cary Kuhlmann, executive director of the Medical Association of the State of Alabama, the proviso was signed into law on May 25, 2007.
Kuhlmann said the switch, which almost certainly will include Medicare and routine prescriptions eventually, is another step in preventing abuse of prescription medications.
The medical association’s primary concern with the new law and the initial deadline of Oct. 1, 2007, Kuhlmann said, was the abruptness with which it was to be enforced when little information had been disseminated to physicians and pharmacists regarding the switch.
“I didn’t even learn about the law until mid or late summer, and we were scrambling, as were physicians, to learn (the definition of) a tamper-resistant pad,” Kuhlmann said.
Louise Jones, executive director of the Alabama Pharmacy Association, says for physicians who print patients’ prescriptions from computer files, tamper-resistant paper will be available for printers, as well as in the traditional pad format.
Kuhlman said the MSA Web site, www.masalink.org, currently has a list of 13 vendors who sell the pads, and the site will continue to be updated as more vendors are discovered. While there have been objections and confusion, Kuhlman says the net effect of the change will be positive.
“The intent is appropriate, but it’s just such a short timeline,” Kuhlman said.
From the bill’s passage in May to the Medical Association learning about the change in August, it simply was not realistic to expect full compliance.
“We’re not opposed to any measure that is going to cut down and reduce fraud,” Jones said. “The problem was the implementation time allowed. Several states already had acquired tamper-resistant pads of some sort. In the state of New York, it took 18 months to implement the change.”
According to Kuhlmann, while the plan to implement the Medicaid change in Alabama is still accelerated, the information is being disseminated in several ways: through the Alabama Medical Association newsletter, on the Web site and through e-mail notifications. Details on the change have been communicated to the Medical Group Management Association of Alabama to notify office managers and practice managers of the timeline.
Jones says a compliance report form has been distributed to the Alabama Pharmacy Association and to pharmacies statewide to notify pharmacists about the need to accept only compliant prescription forms beginning April 1, 2008. Pharmacists, too, are being notified through newsletters, as well as quarterly journals and district meetings in which the new law is a hot topic.
Kuhlmann said Alabama has been active in addressing the issue of prescription drug conversion, particularly since the abuse of prescription painkillers became prevalent.
“This is a good approach,” Kuhlmann said. “It addresses the conversion problem and safety issues and the importance of understanding what is being prescribed.”
Jones said the Medical Association is working with the Pharmacy Association and Medicaid to make the transition as painless as possible. She wants to ensure that routine audits on prescriptions reflect a clear understanding by pharmacists of what complaint prescriptions should be.
“We’re trying to educate pharmacists and let them know that not only is there a requirement due by April 1, but what it is,” Jones said. “Pharmacists need to be very clear on what constitutes a compliant prescription — just like physicians do. The law is written as more of a burden on physicians, but it really is a burden on the pharmacy, as well.”
As physicians and pharmacists adjust to the new law, it is the patient who is of primary concern to professionals like Dr. Allan Goldstein, a pulmonary disease and internal medicine specialist at Trinity Medical Center.
“Medicaid needs to have doctors who will be available to take care of patients,” Goldstein said. “I don’t have very many Medicaid patients, but for the ones I do have, I don’t want to compromise their ability to get their prescriptions. They get caught between the medical community and the political world. That doesn’t help the patient. I don’t think we can put patients in a position where they become pawns, because then we just become politicians.”
Kuhlmann said though costs for the changeover should be marginal, many physicians will be concerned with another unfunded mandate. While telephone, fax and e-mail prescriptions will be exempt, the cost still may be a hardship on smaller practices.
“If you’re going to pay for the changeover for one set of patients, you might as well pay for all,” Goldstein said. “The problem is, who is going to pay for it? The doctor is going to have to fork out the money for the new prescription pad. People say doctors make lots of money, but there will be no one to pass that cost on to. People forget medicine is a business, and the practice of business and medicine aren’t always compatible.”
Goldstein says while the discomfort level for some physicians will be minimal, for others, the switch could mean a significant pinch.
“A friend of mine is a pediatrician in South Alabama with about 1,200 Medicaid patients,” Goldstein said. “With what she gets reimbursed for care, she has to struggle to stay open. She’s in a small town, which puts more pressure on her. A lot of doctors don’t take Medicaid, because they are not reimbursed fairly, and there is too much paperwork.”
Goldstein said a primary consideration in implementing the new law is the current situation with abuse of prescription drugs.
“We have a major problem with drugs and drug diversion,” he said. “Anything that is going to try to decrease that drug diversion is good.”
According to Drug Enforcement Administration reports from 2006 reflecting incidence of abuse of prescription drugs through 2005:
“Current investigations indicate that diversion of hydrocodone products such as Vicodin® continues to be a problem in Alabama. Primary methods of diversion being reported are illegal sale and distribution by health care professionals and workers, ‘doctor shopping’ (going to a number of doctors to obtain prescriptions for a controlled pharmaceutical), and the Internet. Oxycodone products (such as OxyContin®), methadone, benzodiazepines (such as Xanax®), and phentermine were also identified as being among the most commonly abused and diverted pharmaceuticals in Alabama.”
Like Kuhlmann, Goldstein believes the law soon will extend to cover Medicare and patients insured through other health insurance groups.
“The law says we have to (change to tamper-resistant pads),” Goldstein said. “Other insurances will do this sooner or later, so we might as well get started now. And there is a value. If we can divert drugs from kids, we are doing society a favor. And there is a problem. Anyone who doesn’t think we have one is being naïve.”
According to a report from the United States General Accounting Office filed in December 2003, a consistently abused drug is oxycodone: “Several factors may have contributed to the abuse and diversion of OxyContin. The active ingredient in OxyContin is twice as potent as morphine, which may have made it an attractive target for misuse. Further, the original label’s safety warning advising patients not to crush the tablets because of the possible rapid release of a potentially toxic amount of oxycodone may have inadvertently alerted abusers to methods for abuse. Moreover, the significant increase in OxyContin’s availability in the marketplace may have increased opportunities to obtain the drug illicitly in some states. Finally, the history of abuse and diversion of prescription drugs, including opioids, in some states may have predisposed certain areas to problems with OxyContin.”
With the prevalence of drug abuse, the switch to tamper-proof prescriptions across the board seems inevitable, and the outcome of that transition could be a boon to society.
“Drug abuse is a major problem in the United States.,” Goldstein said. “People are using illegal drugs, and people are hooked on legal drugs. The people who are getting drugs are very smart. You’re not dealing with a group of idiots. We have a drug problem. Too much money is being made in drugs for anyone to put a stop to it. We need to do whatever we can to stop the diversion of drugs. With something like the tamper-proof prescription pad, we can attack it. Is it going to stop it? Probably not, but we have to do the best we can.”
December 2007
