New York State AFP Works All Avenues to Mold Legislation, Traditions

The New York State AFP (NYSAFP) couldn't stop the state's Internet System for Tracking Over-Prescribing Act (I-STOP) from becoming law, so members of the NYSAFP Board of Directors opened a dialogue to temper the bill -- and succeeded.

In brief, the legislation creates an online database that doctors and pharmacists are mandated to use to report and track controlled substances in real time. The system also is designed to provide data that should allow these health care professionals to detect potentially dangerous drug interactions, identify patterns of abuse and prevent potential addiction before it starts.

Enactment of I-STOP makes New York the first state in the nation to mandate that physicians consult a database containing patients' prescription histories before prescribing most controlled substances. It also makes New York the largest and only the second state to require real-time reporting by pharmacists when such prescriptions are filled. Finally, the legislation makes the state among the first to schedule a universal mandate of electronic prescribing for controlled substances by December 2014.

According to NYSAFP President Philip Kaplan, M.D., of Manlius, I-STOP represents a well-intentioned goal that will, unfortunately, be borne partly on the backs of physicians throughout the state. Still, he added, although the legislation is cumbersome and the technology needs to be ironed out, the new law is much more manageable for prescribing physicians than its original incarnation -- thanks, in large part, to the NYSAFP.

"About a year ago, (a group of NYSAFP Board members and lobbying consultants) had a chance to sit down with a member of the legal team from the attorney general's office," Kaplan said. "We spent several hours outlining our concerns about the original legislation and how it would affect the ability of family physicians to practice in the state.

"After that, the bill was picked up by Gov. Cuomo's office, and, surprisingly, about three months ago, we were invited to Albany to talk to his counsel team and further address our concerns. So while we didn't get our first wish -- throwing the bill out entirely -- they did listen to our concerns and make adjustments that we think will make the new regulations more palatable to our physicians."

The original bill, explained Marc Price, D.O., of Mechanicville, a member of the NYSAFP Board and chair of the NYSAFP advocacy committee, required physicians and pharmacists to consult the database and report on 15 different fields before being able to complete a prescription. That portion was deleted entirely.

In addition, the original language required that doctors and pharmacists do all of the data entry themselves, prohibiting other staff from being involved in the process altogether.

"While it still means physicians will have to pay staff to check the website and do data entry, at least that practice is no longer forbidden in the new language," Price said. "So they did listen.

"The problem going forward will be using a cumbersome system that is currently not in real time and not integrated with electronic health records. We will continue having an open dialogue with Albany to make sure the changes and upgrades that need to be made are made."

Kaplan said that because of the quick timeline set out in I-STOP -- all prescriptions are to be sent electronically in as little as two years -- he will work to open a direct line of communication with those managing the system to funnel physician complaints to the right office. He said because of the success the NYSAFP has had in past dealings with state officials, he believes that, eventually, both searching and prescribing controlled and other drugs online will become seamless processes.

"Our experiences over the last few years make us confident that our dialogue with Albany -- being part of the process of developing legislation -- is an approach that will produce a regulation that we can be optimistic about," Kaplan said. "For instance, the 2008 roll out of NYSIIS (the New York State Immunization Information System) was not easy, but because we developed a personal relationship with the people behind the system, we were able to create a much more supportive regulation, rather than a punitive one."

"The same goes for the recently adopted HIV testing law," said Kaplan. "The NYSAFP convinced the (New York State) Department of Health that requiring an HIV test at every office visit was unreasonable within the practice of medicine, and so it is only required at the first annual wellness visit and is only given after that if judged pertinent by the doctor. So, with regard to the I-STOP legislation, while we would rather have seen a different outcome, we believe we have reason to be hopeful about how the law is implemented because we have earned the respect of both the offices of the attorney general and the governor."

The chapter has been successful in other advocacy efforts, as well, including ensuring the state's physicians are able to maintain adequate medical liability coverage, given that many hospitals in New York require physicians to have a second layer of medical malpractice insurance in place in addition to the coverage the state requires.

"The secondary coverage market is very limited in New York," said NYSAFP EVP Vito Grasso, C.A.E. "So the state created the Physicians Excess Liability Program, which is a pool of money funded from various sources. It allows hospitals to purchase secondary coverage for physicians at no cost to the physician. Premiums are paid from the funds in the pool."

When word got out that Gov. Cuomo's 2012-13 budget contained provisions that essentially cap the excess liability pool, potentially forcing some doctors out, Grasso said NYSAFP members started to voice concerns that hospitals could apply selection criteria that put primary care physicians at a disadvantage.

"I think there is a potential for hospitals to give preference to those specialties that generate the most admissions and business for the hospital," Grasso said. "And that is not good for primary care."

NYSAFP leadership acted to clarify the situation and find alternative markets for those who stood to be excluded from participating in the pool, contacting Healthcare Professionals Insurance Company (HPIC), one of the companies that writes the secondary coverage. Kaplan said a June 19 letter from HPIC President and CEO Mark Morris should calm fears.

"HPIC is now on record as providing the option of self-pay for the excess layer (of liability coverage) without a lapse in coverage for any physician ejected from the pool, retroactive to July 1," Kaplan said. "We do not all agree on the value for such coverage, but I prefer to spend a little to protect the low-probability, high-severity exposure of personal assets.

"Those who agree will have the option of buying the protection. This binder, which guarantees the direct-pay option at a premium under $1,000 per year in many areas of the state, removes the uncertainty for those who may not know whether they are covered for months after the July 1 start of the policy year."

Kaplan said the commitment also should bear fruit with New York's five other such carriers. He said that the NYSAFP will send a letter to the other carriers requesting they issue the same or similar statements.

"The HPIC letter should be the impetus for them to respond similarly," said Kaplan. "The point here is that the access provided by being organized is exciting. As the spokesman for (thousands of) physicians, residents and students, I had access not otherwise available to an individual physician."

The NYSAFP has also had recent success influencing the licensing of international medical graduates (IMGs) -- without any legislative action at all.

Kaplan explained that the New York State Education Department, which licenses physicians, requires extensive documentation of training and experience, and IMG residents often have difficulty securing the necessary documentation from foreign sources, which delays action on their licensure applications. Thus, IMGs in New York typically cannot get their licenses until several months after completing residency, which oftentimes leads these physicians to set up shop in more IMG-friendly states, such as Michigan.

"That's great for them, but it is bad for us," said Kaplan. "We are training doctors that we need here in the state and sending them elsewhere because of bad policy."

Acting on a resolution brought by a resident member of the chapter's board and adopted by the NYSAFP Congress of Delegates in 2011, NYSAFP's leadership met with New York State Commissioner of Health Nirav Shah, M.D., M.P.H., to enlist his support for the chapter's proposed solution.

Specifically, the NYSAFP asked that the state's education department accept letters from residency program directors as early as 60 days before graduation that indicate a particular resident is in good standing and is likely to graduate on time. This would allow the department to begin processing applications while residents continue to gather documentation verifying their educational and training experiences, rather than waiting until the application is complete before processing it.

"After all of that, we were told that it was all very interesting, but that the (New York State) Board of Regents hadn't passed on the issue yet, so we thought we were dead in the water," said Kaplan. "But I just heard yesterday that the writer of the resolution -- a resident in Schenectady -- learned that several of her fellow IMG residents have their licenses before graduation, which has never happened before."

What makes this exciting, he added, is that this was not a matter of law, but one of tradition.

"So without rewriting any laws or any regulations, we were able to point out that there is an issue of fairness and health care manpower and they made a change in practice," Kaplan said. "I find that almost more exciting than seeing a law change on the front of the paper. An organized effort produced an opportunity to have access because of the rational nature of the request."

Kaplan said it is concrete proof that paying one's dues to the NYSAFP equals results.

"It makes one realize that lobbying isn't all about bags of money being dragged into a room by … folks who are (trying to) buy favor, but that there is actually a commerce of ideas," he said. "It isn't about wasting money on millions of dollars' worth of political campaigns. If you put together a cogent argument, there are reasonable, honorable people in Albany who are going to listen."