WASHINGTON -- Faced with the prospect of having to write Medicare prescriptions electronically, the nation's doctors protested the expense, with one group warning that the burden could "tip many practices into financial ruin."
Lawmakers working on a Medicare drug bill tentatively agreed to create a federal grant program to cut costs for physicians, who rank among the country's highest-paid individuals.
Lawmakers also deferred a decision on whether the program, designed in part to reduce medical errors, should be mandatory or voluntary.
"Ultimately, it's costly for patients. Initially, it's costly for the physicians," said Sen. John Kyl, R-Ariz. He and other critics also say a mandatory program is premature because no proven technology exists.
By itself, the issue is merely one of dozens of contested items embedded in a complex bill, still in the negotiating stage, to overhaul Medicare while creating a prescription drug benefit.
The cost of the e-prescription proposal is minor, compared with other multibillion-dollar issues. Yet as demonstrated by the response of the American Medical Association, the American College of Physicians and state medical societies, it also reflects the struggle of industry groups, patient organizations and others to shape the final bill to their liking.
Cancer patients and their doctors oppose curtailments in planned federal payments for administering certain drugs. It's a $13.4 billion item in the House bill and $16 billion in the Senate measure. Lawmakers contend Medicare overpays doctors for the drugs. Physicians say they are not reimbursed for unusual expenses associated with administering the medication.
The National Association of Home Care & Hospice is working against two House-passed items, including a new co-payment for home health care visits. The cost to providers and patients is $7 billion over a decade.
Large health insurance companies are keenly interested in the specifications for a new program of managed care under Medicare.
The electronic prescription program aims to reduce medical errors, including those caused by illegible physician handwriting. Advocates say it also would prevent the elderly from taking medicine that would interact adversely with other prescriptions they already were using.
"This technology would really do more to improve the health care of seniors than anything" in the legislation, says Barrett Toan, chairman of Express Scripts, one of a group of pharmacy benefit managers lobbying Congress for its inclusion.
Toan said pilot programs show an increase in the use of generic drugs and lower-cost brand name drugs because doctors have more information at their disposal.
"The technology is ready," he said, dismissing physician groups' claims to the contrary.
Under an electronic program, before issuing a prescription, a physician would use a handheld device to connect to a database with information about a patient's prescription history, lower-cost medicine, possible adverse drug interactions and other material.
Lawmakers on both sides of the Capitol included an e-prescription program in their original Medicare bills. The House voted to make it mandatory by Jan. 1, 2006. The Senate decided to keep it voluntary while including a program of physician assistance to ease the transition.
The American College of Physicians, an organization of more than 115,000 internal medicine doctors and subspecialists, labeled the House approach an "unfunded mandate."
"It is essential that Congress hear your concerns about the costs and hassles of having to write all prescriptions electronically," the organization's Web site informed members.
The site includes a suggested letter for doctors to send to their lawmakers. It warns of "unproven electronic prescribing technologies" and adds: "At a time when physician payment is not keeping pace with medical inflation, this new requirement could tip many practices into financial ruin."
Despite the claim, Dr. Munsey Whebey, the organization's president, said he had no available estimate of the cost that doctors would bear. Government statistics show doctors had an average income of $122,000 in 2002.
The American Medical Association, too, has urged its members to oppose the provision. "Mandating a complex system such as this with very little time and resources to implement it constitutes an unfunded mandate that could have adverse consequences on patient care," the organization says on its Web site.
Additionally, congressional aides say state medical societies have lobbied against the mandatory program.
In rebuttal, Toan countered that the cost of the handheld devices is "in the hundreds of dollars, not the thousands." He also suggested that health plans or pharmacy benefit managers might give the equipment to doctors because of the cost-saving potential and other benefits.
Lawmakers eager to show progress toward an overall Medicare bill announced agreement recently to include an electronic prescription program. Details remain to be worked out, including whether it should be mandatory.
"Discretionary grants would be available to assist providers in implementing electronic prescription programs," according to written material.
Guidelines for the grants have not been drafted. Several lawmakers suggested they would be targeted toward older doctors, many in rural areas, who have not yet brought their practices into the computer age.
"They're the ones where the errors come from," said Rep. Billy Tauzin, R-La.