How Medicare Part D, Medicaid, Electronic Prescribing and ICD-10 Could Improve Public Health (But Only if CMS Lets Them)

24 Health Matrix: Journal of Law-Medicine 209 (2014)

39 Pages Posted: 9 Apr 2013 Last revised: 29 May 2014

See all articles by Jennifer L. Herbst

Jennifer L. Herbst

Quinnipiac University School of Law; The Frank H. Netter, MD School of Medicine at Quinnipiac University

Date Written: April 8, 2013

Abstract

A simple change to the Medicare and Medicaid outpatient prescription drug billing systems could improve patient safety and the systems’ long-term fiscal stability. Including diagnosis codes on prescription drug claims (codes already in use for other billing purposes) would transform the Medicare Part D and Medicaid prescription drug claims databases into powerful public health research tools – ones that could provide much-needed (and, to date, elusive) information on how prescription drugs work in vulnerable patient populations underrepresented in clinical research.

Achieving the full potential of this proposal, though, depends upon the federal agency responsible for Medicare and Medicaid (CMS) maintaining its current reimbursement policy, which is perhaps best characterized as one of benign neglect of the statutory standard for coverage. If, instead of continuing coverage for the vast majority of prescription drugs, CMS decided to deny payment for the millions of prescriptions falling short of the statutory standard (and thus avoid spending billions of federal health care dollars), prescribers will find themselves in an ethical dilemma between truth-telling and effectively treating their patients. Due to the systemic incentives to miscode diagnoses in order to get prescription drugs paid for, the decision to treat patients effectively in the short-term under a strict coverage enforcement policy would undermine the potential to more effectively treat vulnerable patients, reduce prescription errors, and properly allocate federal health care dollars in the future. Even in the midst of a financial crisis, or perhaps especially because of our current financial crisis, we cannot afford to sacrifice improved patient safety and better informed long-term management of federal health care dollars for a short-term reduction in federal spending on prescription drugs.

Keywords: Medicare Part D, Medicaid, ICD-10, electronic prescribing, outpatient prescription drugs, pharmacy, Sentinel, pharmacosurveillance, public health research, science, medicine, ethics, truth-telling, comparative effectiveness research, Medicare Part B, Coverage with Evidence Development, compendia

Suggested Citation

Herbst, Jennifer L., How Medicare Part D, Medicaid, Electronic Prescribing and ICD-10 Could Improve Public Health (But Only if CMS Lets Them) (April 8, 2013). 24 Health Matrix: Journal of Law-Medicine 209 (2014), Available at SSRN: https://ssrn.com/abstract=2246886

Jennifer L. Herbst (Contact Author)

Quinnipiac University School of Law ( email )

275 Mt. Carmel Avenue
Hamden, CT 06518
United States

The Frank H. Netter, MD School of Medicine at Quinnipiac University ( email )

275 Mt. Carmel Avenue
Hamden, CT 06518
United States

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