Medicare Medicaid Insurance Subsidies May Be on ‘Super Committee’ Hit List

Reprinted from HEALTH PLAN WEEK, the most reliable source of objective business, financial and regulatory news of the health insurance industry.

By Steve Davis, Managing Editor

August 15, 2011Volume 21Issue 28

As part of the Aug. 2 agreement to boost the federal debt ceiling, a bipartisan “super committee” of 12 members of Congress has until the end of November to trim an additional $1.2 trillion from the federal budget over the next decade. While reductions in Medicare spending could impact Medicare Advantage (MA) carriers, cuts to entitlement programs could make managed care models more attractive, which would bode well for health insurers.

The committee is likely to eye cuts to Medicare and Medicaid, as well as subsidies called for by the reform law, industry observers tell HPW. If the committee is unable to reach an agreement — or if Congress fails to approve its recommendations — “triggers” called for in the debt-ceiling agreement would automatically cut Medicare up to 2% beginning in 2013.

Starting in 2014, the reform law calls for federal subsidies, on a sliding scale, up to 400% of the Federal Poverty Level (FPL). A portion of the subsidy will be transmitted to the eligible member’s health insurer each month and the enrollee will be responsible for the remainder of the premium. The committee might, for example, recommend reducing the subsidies from 400% of FPL to 300%, suggests Uwe Reinhardt, Ph.D., a health care economist and economics professor at Princeton University. Such a cut would mean higher out-of-pocket costs for consumers and potentially fewer enrollees for health plans if people decide to pay a penalty rather than buy coverage.

It’s still unclear how the committee might target Medicaid and/or Medicare, if at all. A voucher program for Medicare recipients, as proposed by Rep. Paul Ryan (R-Wis.) last spring, or block grants for Medicaid, could be beneficial for health insurers, says Steve Zaharuk, senior vice president at ratings firm Moody’s Investor Service.

While Medicaid is shielded from the automatic triggers, the committee could look for ways to reduce the program’s costs. Block grants, depending on the size of the grant and how they are distributed, could be financially beneficial for some Medicaid managed care firms. While poorer southern states receive higher Federal Medical Assistance Percentages (FMAP), they typically receive lower federal subsidies (in dollars) because they have stricter eligibility criteria, Reinhardt tells HPW. FMAP is used to determine federal matching funds allocated to states for social programs such as Medicaid.

“I could see Congress arguing that block grants to generous states (e.g., N.Y., Mass., N.J., Calif.) should be lower than traditional federal Medicaid dollars sent there, and vice versa for the poorer states,” he said in an email to HPW. “It would have to be done gradually over time. But I could imagine that the redistribution would go toward states in which private insurers are more heavily present. It’s a complicated picture.”

However, former CMS Administrator Tom Scully, now with law firm Alston & Bird, says it’s highly unlikely Democratic members of the committee will agree to any sort of Medicaid block grant. “I don’t think there’s any way Medicaid will be block granted,” he says.

‘Trigger’ Would Boost MA Rates

For health insurers, Medicare cuts triggered by the committee’s inability to forge a deal could be more attractive than cuts elsewhere. Under that scenario, Medicare reimbursement to MA carriers would be reduced by up to 2% each year for the next 10 years. For the most part, insurers will either raise premiums or cut expenditures when they prepare their bids for the 2013 plan year, Scully explains. “It’s not going to be catastrophic for [insurers], but it won’t be good either. At least they’ll have enough notice to plan for it.” The 2% cut would be adjusted each year and would not be part of the base reimbursement rate.

Across-the-board reductions in Medicare payment could translate to more cost shifting by providers, which could lead to higher premiums charged by commercial plans and/or increased cost shifting onto employee-based coverage, says Jason Lee, senior partner and director of the Global Institute for Emerging Healthcare Practices at Computer Sciences Corp. (CSC).

Ana Gupte, Ph.D, an equities analyst with BernsteinResearch, says a 2% cut to Medicare for health plans and providers, for example, would impact earnings by 2% or less, because health plans are “pass-through intermediaries” that will be able to “offset the reduction in payments through lower contracted costs to hospital, doctors, nursing home and other suppliers, while also modestly adjusting the cost sharing with seniors to keep margins stable.”

“Potential entitlement spending cuts are one [if not more] step removed from [managed care plans], and may actually increase the use of managed care models,” Stifel, Nicolaus & Company, Inc. analyst Thomas Carroll wrote in an Aug. 9 note to investors.

Agreement Is Seen as Likely

Goldman Sachs analyst Matthew Borsch said in an Aug. 9 note that some MA carriers could thrive. “We think fiscal pressures will drive a bigger role for [MA] and ultimately a phasing-out of unmanaged ‘traditional’ Medicare. Even without policy changes, MA is becoming the product choice for seniors as employer retiree coverage becomes increasingly rare.”

Lee says this committee could succeed where others have failed. “I think the political will is increasingly likely to be there as the consequences of not acting become clear.” The committee is likely to look at previous cost-cutting ideas as well as new ones. Those might include adjusting the eligibility age for Medicare recipients, “means testing” premiums, coming up with a “premium support” voucher for young Medicare enrollees, or expanding payment arrangements tied to the value of a health system’s performance, he says.

The super committee must submit its ideas by Nov. 23, and Congress then has until Dec. 23 to vote on its proposal, with no amendments. In a telephone interview with HPW before committee members were announced, Scully said he was pessimistic that a bipartisan group could reach a consensus, particularly with the 2013 election year on the horizon.

“The idea that Republicans are going to agree to raise taxes before an election is unlikely. And the idea that Democrats are going to agree to big entitlement cuts is also unlikely,” he says. “While I hope rational heads prevail, it’s more likely that the automatic triggers will kick in.”

The 12-person committee was finalized Aug. 11. On the Senate side, Democrats will be represented by Sens. Patty Murray of Washington state, Max Baucus of Montana and John Kerry of Massachusetts, while Republicans will include Jon Kyl of Arizona, Rob Portman of Oregon and Pat Toomey of Pennsylvania. House Republicans will include Reps. Dave Camp of Michigan, Jeb Hensarling of Texas and Fred Upton of Michigan. Democratic House members will be James Clyburn of South Carolina, Xavier Becerra of California and Chris Van Hollen of Maryland.

Medicare Starter Kit

What you most need to know

by: Patricia Barry | from: AARP Bulletin | April 1, 2011

— R.O. Blechman

You're a boomer. The milestone of your 65th birthday may be here or just over the horizon. But you know zip about Medicare. Do you need it? What does it cover? When should you sign up? Lots of questions — but don't panic. You can get your head around Medicare with this guide to what you most need to know.

Top Eight Do's and Don'ts

1. Do give yourself time to learn about Medicare: It's a system with many choices and deadlines. Being informed is the best way to avoid mistakes that cost money.

2. Don't expect to be notified when it's time to sign up: Unless you're already receiving Social Security benefits, you must apply for Medicare. But you won't get any official notice on when or how to enroll.

3. Do enroll when you're supposed to: To avoid permanent late penalties, enroll at age 65 if you're not working, don't have employer insurance or live abroad; or, beyond 65, enroll within eight months of stopping work — even if you continue to receive COBRA or retiree health benefits from an employer.

4. Don't despair if you haven't worked long enough to qualify: You may qualify for Medicare on your current or former spouse's work record. Or you may be able to buy into the program.

5. Don't worry that poor health will affect your coverage: If you qualify for Medicare, you receive full benefits. You can't be denied coverage or charged higher premiums because of current or past health problems.

6. Do remember that Medicare is not free: You pay premiums for coverage and copayments for most services, unless you qualify for a low-income program or have other, extra insurance.

7. Don't assume that Medicare covers everything: It covers a wide range of health services (including expensive ones like organ transplants), prescription drugs and medical equipment. But there are gaps.

8. Don't expect Medicare to cover your dependents: Nobody can get Medicare under age 65, except those who qualify through disability. Medicare has no family coverage.

Quote of the Day

“I think what you might finally see in some health plans is the ability to go to a generics-only formulary. You’re going to have multiple generic drugs in every therapeutics class. Certainly, you’re going to see the generic fill rate go up, a slowing of the drug trend on the [brand] side and a narrowed formulary for brand drugs.”
— George Van Antwerp, general manager of pharmacy solutions at Silverlink Communications, Inc., told AIS’s Health Plan Week.

Quote of the Day

“Serving Medicaid patients requires specialized expertise, and that expertise will be very helpful for plans participating in exchanges, since a lot of patients will migrate from Medicaid into the exchanges, and in some cases migrate back. As a result, health plans now doing a good job with Medicaid populations are receiving a lot of attention. There undoubtedly will be more mergers or acquisitions, but the market is competitive now, and will almost certainly be more competitive in the future….”

NY Medicaid Compliance Chief Describes Flaws; Reviews Should Stress Outcomes

Reprinted from The HCCA-AIS MEDICAID COMPLIANCE NEWS, monthly news and valuable how-to strategies for identifying and reducing today’s top Medicaid compliance risks.

By Nina Youngstrom, Managing Editor

August 2011Volume 5Issue 8

It’s not a good sign when board members have no clue what their organization’s compliance program is all about, but apparently sometimes that’s still the case. The Office of Medicaid Inspector General in New York state has run into this problem during compliance-program effectiveness reviews.

“It was kind of surprising,” Matt Babcock, assistant Medicaid inspector general at OMIG, tells MCN. OMIG conducts onsite compliance-effectiveness reviews at health care organizations, evaluating each of the eight compliance-program elements. (The Federal Sentencing Guidelines and HHS Office of Inspector General obviously put forth seven, but the state added another, for nonretaliation policies.) The boards’ obliviousness became apparent during OMIG’s evaluations of training, he says. “We look for the tone at the top and say, ‘unless board and senior management are adequately trained, how can they get behind your compliance program?’”

OMIG published compliance-program gaps it identified during onsite reviews and Babcock elaborated on them in an interview. OMIG also published best compliance practices and opportunities for enhancement. “We try to use these as an educational tool,” he says.

Compliance Deficiencies Identified

Compliance officers in all states can use this information during their effectiveness reviews, which former HHS Inspector General Richard Kusserow says should focus on outcomes. “It should be a three-dimensional examination,” he says. “The HHS Office of Inspector General states the goal of an effective compliance program is to reduce fraud and abuse.” For example, consider whether employees learned anything during compliance training — not just whether attendance was 95% versus 99%. Who cares if they went, if they didn’t learn everything, if it didn’t stick or if they don’t know how to apply what they learned? “If you are the CEO signing off on compliance-program effectiveness under penalty of law” — the law that prohibits false statements — “you want proof it is effective,” says Kusserow, president of Strategic Management Systems of Alexandria, Va.

The stakes for effectiveness have shot through the stratosphere with the health reform law, which mandated compliance programs. Providers and suppliers will have to certify they have compliance programs — and that their compliance programs have certain core elements — as a condition of enrollment or re-enrollment in Medicare, Medicaid and the Children’s Health Insurance Program. Essentially, that means proving compliance program effectiveness will soon be part and parcel of the golden ticket of Medicaid, Medicare and CHIP admission. So it’s helpful to know what’s not working in the eyes of Medicare and Medicaid watchdogs. Babcock, head of OMIG’s Bureau of Compliance, describes some of the deficiencies in several other compliance-program elements that OMIG encountered during its onsite reviews:

Sparing Managers Undermines Compliance

(1) Lack of written policies and procedures (including no compliance program, code of conduct or compliance policies/procedures): OMIG won’t have a hard time tracking down conflict-of-interest policies that are AWOL, at least at nonprofit organizations. They are required to complete the IRS 990, which contains questions that essentially cut to the chase of an organization’s integrity. Form 990 has a yes-or-no question asking whether the nonprofit has a conflict-of-interest policy. “We are looking at whether people can use their position for personal gain. So there needs to be an affirmative statement that the provider will not allow that sort of thing to happen,” Babcock says. “We want to make sure there is a policy in place.”

(2) Problems with the compliance officer reporting structure: During its reviews, OMIG found compliance officers who report to CFOs, which is discouraged by HHS OIG. For example, obviously compliance officers may clash with CFOs over repayments because CFOs are struggling to enhance revenue (legally). Compliance officers should report directly to the CEO, with dotted-line access to the board so they can go there directly if there is management monkey business afoot. Also, some organizational charts did not reflect reality. The charts made it seem like the compliance officer reported to the CEO when, in fact, the compliance officer reported to the CFO. “We said, ‘change what you are doing to make sure what is on the chart is what you are doing,’” Babcock says.

(3) Problematic communications: If there’s no way to anonymously report a compliance problem, then the compliance program lacks credibility. OMIG doesn’t care about the nature of the reporting method — it can be a drop box, emails or a dedicated phone line — but the key is the guarantee of anonymity to employees and others who want to file complaints, Babcock says. It’s not good enough to tell employees they can call the compliance officer without revealing their identity, because caller ID will do it for them, more or less, he says. It’s also important to distinguish the compliance drop box from a conventional suggestion box.

(4) Lack of disciplinary policies or letting the powers-that-be off the hook (i.e., policies don’t exist, they aren’t enforced and/or they are enforced inconsistently): During compliance reviews, he says, organizations were asked how they are expected to enforce the compliance program if they lack policies that warn employees they will be disciplined — up to and including termination — for violating compliance policies. Sometimes organizations did punish violators. They were re-trained, reassigned or fired. But guess who got off the hook? Management. “We found disparate treatment when there is a violation,” Babcock says. “Line staff gets fired but no management gets punished.” That undermines the compliance program, he says. “If ‘there’s punishment for me but not for the boss,’ people won’t talk. They know from past experience that nothing happens to [management] for failure of compliance, so they won’t report” compliance problems next time, Babcock says.

(5) Lack of a routine system to identify compliance risk areas: Babcock says some organizations still don’t monitor on a regular basis, either internally or externally. And there may be no system to log errors or complaints. Or when problems are identified through compliance monitoring, “no one pays attention unless there is clear support by the governing board or senior management,” he says. Ideally, he adds, a management committee should be involved in solving problems.

(6) No system to respond to compliance issues identified by OMIG or federal or other state regulatory agencies.

Babcock says ensuring the structural parts of a compliance program are in place is relatively easy. There’s no great challenge to putting in place a training program or disciplinary policies or a hotline. But the “process elements” — a system for routine identification of compliance issues and a system for responding to compliance issues — are where the rubber hits the road.

When health care organizations evaluate their effectiveness or hire outside vendors to do it, they shouldn’t take a checklist approach — yes or no to the presence of each element. The emphasis should be on outcomes, says Kusserow, whose firm has conducted 3,000 compliance-program effectiveness reviews. “Effectiveness is an outcome factor, not an output factor. Effectiveness is a function of outcome,” he says. “There is a huge difference between outcome factors and output factors.” Analogously, output is how many patients the physician sees, not the improvement in their quality of care. The problem, Kusserow says, is that “most people who evaluate compliance programs check process, not outcome.”

Lack of Board Interest Irks OI

If compliance-program effectiveness reviewers are focused only on how many calls your hotline received, they are barking up the wrong tree, according to Kusserow. “The number has no meaning in and of itself,” he says. Suppose there were 25 calls last year and 50 this year. It could mean more fraud, or it could mean more people have confidence in the compliance program. What matters is whether the calls were handled correctly.

Kusserow notes that there have to be concrete standards of effectiveness because of the compliance-program mandate. “You want data. You are going to have to have metrics on which you can rely that the compliance program is reasonably effective,” he says. For example, OIG says the mark of an effective compliance program is one with support from executive leadership and the board. You can tell whether that exists partly by looking at the minutes of board meetings to determine if the board even talked about the compliance program.

“One thing that frustrates the OIG,” he says, is the make-up of many board committees that are responsible for compliance oversight (i.e., audit or compliance committees). The board members typically have financial backgrounds — audit or business — and are financially literate, “but they are not compliance literate,” Kusserow says. “No one at the board-level committee has a background in compliance. When you talk about Stark, claims processing or the anti-kickback statute, they don’t know what it is and they don’t care, so they go to sleep.” It’s a big problem, he says, because it means they can’t provide true oversight of the compliance program.

To view the OMIG compliance-program documents, go to www.omig.ny.gov, and click on “Provider Compliance” under the “Compliance” bar.

Arcadian acquisition likely signals more to come by Humana, competitors

Business First - by Steve Ivey , Staff Writer

Date: Monday, August 29, 2011, 10:34am EDT

Ron Bath | Business First

Humana, which bases its headquarters in Louisville, is one of the area's largest employers.

Humana Inc.    Humana Inc. Latest from The Business Journals Humana: Health plan costs decrease with health information exchanges Corporate giving is holding steadyCharity is ingrained in business philosophy Follow this company ’s recent acquisition of a California-based health plan will expand the company’s geographic market and is likely to add to Humana’s earnings over the next two years.

Those were among the findings of a research report released Monday by New York investment firm Sanford C. Bernstein & Co. LLC    Sanford C. Bernstein & Co. LLC Latest from The Business Journals Icahn wants to join, replace Clorox boardExpress Scripts' Medco buy prompts fears of layoffs in N.J.EMC's Tucci: takeover is an option Follow this company .

Humana (NYSE: HUM) announced Aug. 25 it had purchased Arcadian Management Services, the holding company for a Medicare Advantage HMO based in Oakland, Calif.

Terms of the deal were not disclosed, but the Bernstein research report estimated that Humana likely paid about $150 million, based on communications with Humana’s investor-relations department and Arcadian senior management’s commentary.

The report also said Humana was one of more than 10 health plans that competitively bid for Arcadian. Other bidders included Humana’s competitor UnitedHealth Group Inc.    UnitedHealth Group Inc. Latest from The Business Journals Pharmacists, YMCAs getting paid to drive down diabetes risksReal estate vet Bob Best diesReport: Antitrust fears for Express Scripts' Medco buy 'overdone' Follow this company (NYSE: UNH) and five to seven private-equity firms.

“We view this deal to be the harbinger of still more such deals in Medicare Advantage,” the report said.

With Arcadian’s 64,000 Medicare Advantage customers in 15 states, Bernstein expects the deal to add 14 cents per share to Humana’s earnings in 2012 and 21 cents per share in 2013, net of any Arcadian debt servicing and lower investment income.

Arcadian has about $622 million in annual revenue and estimated annual income of $14 million to $18 million, the report said.

Combined with more baby boomers entering the Medicare market beginning this year, Bernstein maintains its bullish outlook for Humana, the report said.

CMS Announces 2011 Electronic Prescribing (eRx) Incentive Program Final Rule

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Room 352-G
200 Independence Avenue, SW
Washington, DC 20201
Office of Media Affairs

Fact Sheet

FOR IMMEDIATE RELEASE                          Contact: CMS Office of Media Affairs

August 31, 2011                                                                      (202) 690-6145

CMS Announces 2011 Electronic Prescribing (eRx) Incentive Program Final Rule

Overview

The Centers for Medicare & Medicaid Services (CMS) today announced Changes to the Medicare Electronic Prescribing (eRx) Incentive Program for Calendar Year 2011.

Background

Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) required the Secretary to establish a new reporting program for eligible professionals who are successful electronic prescribers as defined by MIPPA, beginning on January 1, 2009.  While the eRx Incentive Program has similarities in structure and processes to the Physician Quality Reporting System (formerly the Physician Quality Reporting Initiative or PQRI), this program is a separate program with distinct reporting requirements and associated incentive payments and payment adjustments.

In addition to the electronic prescribing incentive payment, MIPPA called for a Medicare Physician Fee Schedule (MPFS) payment adjustment that will apply beginning in January 2012 to eligible professionals who are not successful electronic prescribers, as defined in the Calendar Year (CY) 2011 MPFS final rule. For eligible professionals who are subject to the 2012 eRx payment adjustment, the fee schedule amount for covered professional services furnished by eligible professionals during the year shall be 1 percent less than the fee schedule amount that would otherwise apply for 2012.  The potential MPFS reductions in the future are a 1.5 percent reduction for 2013 and 2.0 percent reduction for 2014.   

Provisions of the 2012 eRx Payment Adjustment Established in the CY 2011 MPFS Final Rule

In addition to establishing the requirements for successful reporting of the electronic prescribing measure for the 2011 eRx incentive, the CY 2011 MPFS Final Rule also establishes the program requirements for purposes of avoiding the 2012 payment adjustment. 

An eligible professional will not be subject to the 2012 payment adjustment if one of the following applies:

·        The eligible professional is not a physician (MD, DO, or podiatrist), nurse practitioner, or physician assistant as of June 30, 2011 (This determination is based on the primary taxonomy code in the National Plan and Provider Enumeration System (NPPES)) and does not generally have prescribing privileges, and reports g-code G8644 (defined as not having prescribing privileges) at least one time on an eligible claim prior to June 30, 2011;

·        The eligible professional does not have at least 100 cases containing an encounter code in the electronic prescribing measure’s denominator;

·        The eligible professional’s allowed charges for covered professional services submitted for the electronic prescribing measure’s denominator codes is less than 10 percent of the eligible professional’s total 2011 Medicare Part B PFS allowed charges;

·        The eligible professional reports a significant hardship code and CMS determines that the hardship code applies (see “Significant Hardship Exemptions” section below) and is granted an exemption; OR

·        The eligible professional becomes a successful electronic prescriber for purposes of the 2012 payment adjustment by reporting the electronic prescribing measure via claims for at least 10 unique electronic prescribing events for patients in the denominator of the measure between January 1, 2011 and June 30, 2011.

A group practice that is participating in the 2011 eRx group practice reporting option will not be subject to the 2012 payment adjustment if one of the following applies:

·        The group practice reports a significant hardship in its 2011 self-nomination letter for participation in the eRx Incentive Program group practice reporting option (see “Significant Hardship Exemptions” section below) and is granted an exemption; OR

·        The group practice becomes a successful electronic prescriber.  The group practice becomes a successful electronic prescriber for purposes of the 2012 payment adjustment by reporting the electronic prescribing measure via claims for between 75-2,500 unique electronic prescribing events (depending on the group practice size) for patients in the denominator of the measure between January 1, 2011 and June 30, 2011.

Significant Hardship Exemptions.  Section 1848(a)(5)(B) of the Act provides that the Secretary may, on a case-by-case basis, exempt an eligible professional from the payment adjustment, if the Secretary determines, subject to annual renewal, that compliance with the requirement for being a successful electronic prescriber would result in a significant hardship.  In the CY 2011 MPFS Final Rule, CMS established the following two significant hardship exemptions in the form of g-codes for purposes of the 2012 payment adjustment:

·        The eligible professional practices in a rural area without sufficient high speed internet access (report code G8642)

·        The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing (report code G8643)

In order to request consideration for an exemption from the 2012 payment adjustment via one of the two aforementioned significant hardship g-codes, the eligible professional must report the g-code at least one time on a claim between January 1, 2011 and June 30, 2011.  A group practice participating in the eRx group practice reporting option for 2011 must have requested the significant hardship exemption at the time the practice self-nominated to participate.

Changes to the Medicare eRx Incentive Program for Calendar Year 2011

Since publication of the 2011 MPFS Final Rule, CMS has received public comments raising concerns that the Medicare eRx Incentive program did not better align with the Medicare or Medicaid EHR Incentive Program as well as the need for additional significant hardship exemption categories.  To address these concerns, we are finalizing the following changes:

Modify the existing 2011 electronic prescribing measure to address uncertainties related to the technological requirements of the Medicare eRx Incentive Program: The existing 2011 electronic prescribing measure is revised to indicate that a qualified electronic prescribing system includes certified EHR technology as defined at 42 CFR 495.4 and  45 CFR 170.102.

Provide additional significant hardship exemption categories for purposes of the 2012 payment adjustment: The eligible professional or group practice must demonstrate that one of these situations applies to the respective practice:

-          Eligible professionals who register to participate in the Medicare or Medicaid EHR Incentive Programs and adopt certified EHR technology;

-          Inability to electronically prescribe due to local, state, or federal law or regulation;

-          Limited prescribing activity; or

-          Insufficient opportunities to report the electronic prescribing measure.

Extend the deadline for requesting significant hardship exemptions to November 1, 2011.  This extended reporting deadline would apply to the two significant hardship exemptions established in the CY 2011 MPFS Final Rule as well as the additional significant hardship exemption categories above.

Require submission of significant hardship exemption requests for the 2012 eRx payment adjustment via a web-based tool for individual eligible professionals and via a mailed letter for group practices that are participating in the 2011 eRx group practice reporting option.  Instructions on how to request a hardship via the web-based tool will be available on the eRx Incentive Program website at http://www.cms.gov/ERXincentive/.

The final rule can be found athttp://www.ofr.gov/OFRUpload/OFRData/2011-22629_PI.pdf.

  For more information about this announcement, read the http://blog.cms.gov/2011/08/31/greater-flexibility-in-e-prescribing-means-greater-success/