"Tamper-proof Medicaid Prescriptions: More Fog from Washington" by David F. Torchiana, MD

There are many reasons why healthcare costs are growing so fast. There is one set of causes that should be particularly frustrating: well-intentioned but ill-conceived regulatory changes that aim to fix one problem but inadvertently create others. A case in point is the recent Medicaid requirement for “tamper-proof” prescriptions. Designed to curtail narcotics abuse by making prescribing less prone to forgery (a good thing), the rule substantially increases costs and complexity for hospitals and physicians who have adopted electronic prescribing.

Last May, this new Medicaid rule was tucked into an Iraq war and Katrina recovery funding bill. On October 1, 2008 the use of tamper-resistant prescription pads becomes mandatory to prevent unauthorized counterfeiting, copying, erasure or modification. This is fine for those who are still hand writing prescriptions (all you need are special paper pads) but what are the consequences for electronic prescribing – the efficient, modern, safer approach to ordering medications?

Unfortunately, the US Drug Enforcement Administration (DEA) doesn’t allow physicians to electronically prescribe certain medications.

These “Schedule II” drugs are narcotic, stimulant, and depressant drugs like morphine, Percodan, Ritalin, and Dexedrine; medications with legitimate medical uses but with the potential for abuse. A tamper-proof paper prescription must be provided for these medications. More than 3.6 billion Schedule II prescriptions were written in 2005. The Medicaid program can’t change the ban on electronic prescribing of these medications; it’s up to DEA.

Doctors who are now generating prescriptions electronically will have two choices: go back to hand written prescriptions for controlled medications – a technique we know is less safe – or implement a way to print this category of prescription on special tamper-resistant paper. The special paper must be secured to protect against it being stolen and used inappropriately. This means installing special printers with locked paper trays and separate storage lockers to house the tamper-proof paper. At MGH alone we estimate a cost of about 2.5 million dollars to comply with this rule. There are about 5,000 hospitals in this country and hundreds of thousands of physicians’ offices. Do the math – upfront and ongoing costs will be massive.

Importantly, this policy imposes an additional deterrent to adoption of electronic prescribing and an incentive to stay with paper prescription pads for all the other prescriptions that doctors write. Senator Kerry and others have led a national effort to hasten adoption of e-prescribing. Medicare is also pushing it. We have asked DEA to allow electronic prescribing for Schedule II drugs and our state is conducting a demonstration project funded by the US Department of Health and Human Services to show how it could be done. But, as of now, the rule takes effect in October.

The authors of this new law were well-intentioned, but the rule further complicates the frontlines of healthcare delivery with a backward-looking, unfunded mandate, designed to address one issue, when a forward-looking regulation could have increased both the ease and safety of electronic prescriptions. Unfortunately, in their zeal to change and improve healthcare, government regulators, payers and employers rarely coordinate policies with each other and the big picture gets lost. All too often, the right hand doesn’t know what the left hand is doing and as a result providers are further tied in knots. So health care gets more expensive but no better.

David F. Torchiana, MD
Massachusetts General Physicians Organization