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Executive Summary

MEDICAL Rx CLAIM "DIRECT COMMUNICATION" TECHNOLOGY is "essential" to long-term cost efficiency and to "the right of patients to guaranteed privacy," General Computer Corporation maintained in a Sept. 23 press statement. Systems for Medicare drug program communications with pharmacy terminals or "black boxes" should be "capable of transmitting electronic claim information directly from the provider to a regional processing center," GCC President and CEO Richard Pilarczyk said. "Direct communication promotes greater patient privacy than would be possible with a central switch," General Computer argued, calling it an "inherent right" that patients' pharmaceutical records not be stored at a central location with nationwide access. Direct communication also "follows the political trend of 'decentralization,'" the company said. Direct communication would further achieve "greater cost efficiency by eliminating the expense of an extra layer of personnel, additional facilities and equipment, middle-man fees, and the need for additional telephone communications," Pilarczyk contended. One observer of the electronic claims processing business, Harry Soza, president of Preferred Solutions, Inc., has predicted that the Health Care Financing Administration will adopt a system to connect pharmacy black boxes to a federal clearinghouse, or national switch ("The Pink Sheet" Sept. 5,). Both Soza and Pilarczyk state that their alternative technologies exist and are currently in use. General Computer maintains that any point-of-sale system used in pharmacies should avoid requiring the pharmacist to double-enter prescription information. Double entry -- entering patient information into the Medicare system and into the pharmacy's own files -- is avoided "when data are initially entered into a complete pharmacy system," Pilarczyk explains. He added that the system HCFA chooses also should render patient benefit information promptly, should be capable of transmitting claims directly to the private sector without change of equipment of protocol, and should be compatible with Medicaid direct communications. "This capability exists and is being used successfully today," Pilarczyk said. The company said its Cash Flow II point-of-sale system and UIPC device "for interfacing CashFlow with existing pharmacy computers "are prime examples of the technology that can guarantee success" of the Medicare drug program. The Hook-SupeRx and Revco drug chains have installed the General Computer system to handle third-party insurance claims. Philip Devolites told an Oct. 11 workshop at the NARD annual meeting that a claims processing system involving a centrally located "clearinghouse" does not jeopardize the privacy of beneficiaries because pharmacies will not have access to patient profiles through the system. NARD's RxNet pharmacy services administrative organization (PSAO) is developing an automated system for claims processing that includes a "national switch." Devolites said the system will notify the pharmacists through their point-of-sale terminals whether the patient is eligible for the program, whether the deductible has been met, and the dollar amount Medicare will pay. In addition, the system will provide "a potential adverse drug reaction indicator," he noted. "The potential adverse reaction indicator is a compromise under the legislation between the privacy" concerns and safety concerns for beneficiaries. "The system cannot, as currently envisioned, come back and tell [pharmacists] what drugs are on the patient's system files." It can tell you only whether is "a potentially adverse indication." How such an indicator would be triggered has yet to be determined, Devolites said. "Something the community Pharmacists,, the PSAOs, and everybody involved in the field needs to do is think about what the criteria should be for triggering the indicator," said. A pharmacist receiving such an indicator will have to "to contact the patient's physician or talk to the patient to find out what drugs are involved" and how to avoid drug-drug interactions.

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