Armed with a brand new law to prescribe therapeutics, an optometrist confidently writes his first prescription. But as the patient leaves the office, the OD's confidence wanes. Will the pharmacy fill the prescription? Will the insurance company reimburse for the prescription? Will the prescription show up on tracking records, indicating the optometrist is actively taking part in the new laws that have empowered the profession?
The source of all this woe is the lack of a Drug Enforcement Administration, or DEA, number.
In the past 25 years optometrists have made huge strides in the therapeutic pharmaceutical agent (TPA) arena. Now, optometrists in only Massachusetts and Washington, D.C., do not have TPA privileges. But the privilege to prescribe has also been accompanied by new problems, and one of the most frustrating has been DEA numbers.
Optometry's position is unusual among medical providers in that the profession has different prescribing laws in every state. Optometrists in some states can prescribe controlled substances while those in other states cannot. Traditionally, all prescribers could write for controlled substances, so the DEA number, issued for this purpose, became a standard for not only enforcement agents, but also for tracking companies, pharmacies and insurers to identify prescribers. This has left some optometrists out of the loop.
The 25 states with legislation that allows ODs to prescribe controlled substances have registered with the DEA. This represents approximately 13,000 optometrists. Another five states are waiting for approval from the DEA, representing about 9,000 ODs. The remaining 19 states, plus the District of Columbia, do not allow ODs to prescribe controlled substances, representing about 11,000 optometrists. (North Dakota granted ODs the ability to prescribe controlled substances in March and is looking into the DEA issue.)
Chris Carey, government relations council for the American Optometric Association (AOA), said not only does the DEA situation vary from state to state, but also among different insurers in the same state.
Not what the DEA wanted
Optometry's frustration with DEA numbers is shared by the agency itself, which does not endorse any use of a DEA number aside from indicating who can write prescriptions for controlled substances.
"The problem of tracking is true not only for optometrists but for MDs as well," said James Sheahan, chief, Registration Unit, Office of Diversion Control at DEA headquarters in Washington. "Doctors often write to us and ask why they have to give their DEA number to a pharmacy or to get reimbursed for a third-party claim for a noncontrolled substance, and we tell them they don't have to. The DEA number is intended only to identify them as having the authority to write for a controlled substance."
While it may oppose other uses of the DEA number, the agency does not have regulatory authority to control what it considers misuse. "We realize doctors are between a rock and a hard place," Mr. Sheahan said.
The DEA also sees that optometry is in a particularly difficult spot because of different state TPA laws. It recognizes optometrists in a mid-level practitioner category, which includes nurse practitioners, physician's assistants, some pharmacists and some health care providers in nursing homes.
Bruce E. Onofrey, OD, RPh, in practice in Albuquerque, N.M., said, "I'm sure optometrists are angry and think they're being discriminated against, but the major problem was of our own making with the patchwork of drug laws in optometry throughout the country."
However, changes are to be expected in a profession as dynamic as optometry, Dr. Onofrey continued. "For example, 2 years ago New Mexico upgraded its TPA legislation to include orals, and this year we hope to get lasers passed; you can see how quickly things change," he said. "This doesn't happen in any other profession."
Mr. Carey agreed, saying, "We're caught in a transition. It's just a matter of time, because traditionally only physicians prescribed drugs, so all the third-party plans and utilization controls sprung up around medicine as the only model. Some people think of this as a conspiracy to hurt us, but I think it's more just happenstance."
No automatic DEA license
Even once optometrists obtain privileges to prescribe controlled substances, their recognition as a mid-level provider by the DEA does not mean they are automatically registered. Only after a state's TPA legislation is deemed consistent with the Controlled Substances Act of 1970 can optometrists apply for and receive their DEA registration number.
"Our legal office reviews the appropriate regulations involving optometrists to compare them to the act we operate under," said Mr. Sheahan. "We can't issue a federal DEA number until there is proper state authority given to handle controlled substances. People may blame DEA, but it gets back to what the state allows optometrists to handle."
Once the DEA's legal office has given the green light to a state's TPA law, optometrists in that state can register just like any other prescriber for a 3-year period at a cost of $210. They are also asked to complete an addendum with their application that specifies the controlled substances in Schedule II through Schedule V they are permitted by state law to prescribe.
Optometrists then receive their DEA number, which begins with an 'm' to identify them as mid-level practitioners.
No DEA number, no service?
This process has run smoothly for some optometrists, but those who cannot prescribe controlled substances and do not qualify for a DEA number have encountered problems ranging from patients having difficulty getting a prescription filled to insurance companies refusing to reimburse. Also, if practitioners are tracked through DEA numbers, optometrists without the number will not show up in tracking statistics, depressing the prescribing numbers of the profession.
Dr. Onofrey said ODs in New Mexico had little trouble obtaining DEA numbers because so many states had gone before them. Darlene Eakin, executive director of the Kentucky Optometric Association (KOA), said the KOA had to go through the DEA to get insurance companies to stop requiring that number for reimbursement claims. "We wrote to the DEA and they wrote back that it is improper to use the DEA number for insurance purposes," she said. "We sent the letter to the state insurance commissioner, and he sent it to the HMOs and they stopped using the number in that manner."
Other states have run into much bigger problems. California received its TPA privileges in February 1996 and is one of five states on DEA's "pending approval" list, which means that the agency's legal office is currently reviewing the new law.
Cliff Wright, OD, a private practitioner from Berkeley, Calif., said, "The biggest problem is that we don't have DEA numbers and, without them, the pharmacist may not fill a prescription. It's a real problem because it makes us look like second-class doctors and it makes the patient waste money [if the insurance company refuses to reimburse the cost of the prescription]."
Jim Beckwith, OD, president of the Nevada Optometric Association, said optometrists in his state have also had to deal with the embarrassing situation of patients not being able to get a prescription filled at a pharmacy. "We've dealt with this through the pharmacy association," Dr. Beckwith said. "This is one reason we're going back to get narcotics [amplification], so we can get a DEA number. It almost gives the impression that we're not licensed to give that medicine."
Addressed at the national level
David Benkle, OD, past president of the California Optometric Association (COA), said he would like to see this issue addressed more fully at the national level. He said the COA initially approached Blue Cross, the state's biggest insurer, about setting up a dummy number to allow health plans to pay for prescriptions. The COA followed that up by establishing a unique optometric prescribing number with Blue Cross that went into use at the end of 1996. Other health plans have been asked to do the same and are working on it, but many only see the need for a dummy number. Although health plans have been very cooperative, the COA is still proceeding with legislation that would prohibit plans from requiring DEA numbers as a criteria of reimbursement
This does not solve the tracking issue, however. "That's a challenge for the profession, because we can't attract the attention of pharmaceutical companies without the tracking numbers," Dr. Benkle said.
Primary Care Optometry News was unsuccessful in efforts to contact several insurers for this article.
The AOA does not assign its members an identifying number that some other national groups, such as nurse practitioners, do for the purposes of internally tracking members or to offer insurance and tracking companies a number other than a DEA license.
However, Mr. Carey said the AOA has responded in several ways to help ODs. "We try to help states that have obtained controlled substance authority work through the hoops that federal law lays out for them," he said. "This has been on a state-by-state basis as each state gets its scope of practice expanded."
Also, because of the historical trend and data collection conventions that are part of some third-party drug plans, the AOA has registered complaints with the DEA about the misuse of the registration system.
"The DEA has been sympathetic to our concerns, but they don't have a lot of recourse against plans that use its number," Mr. Carey said. "That's been a constant source of frustration with us." He also said many of the trade associations representing insurers and tracking companies are aware of the problem, but are resisting change to their existing programs.
Will a new provider number help?
The answer to optometry's DEA problem may be found with another federal agency the Department of Health and Human Services (DHHS).
DHHS is currently at work developing a National Provider Identifier (NPI) that will eventually take the place of a DEA number, Employer Identifier number and Social Security number for tracking and insurance reimbursement purposes.
The AOA is just one of many health care organizations that has supported the use of NPIs to replace the DEA number for tracking and insurance uses. Mr. Carey said the AOA's involvement has been to help develop and implement NPIs to take into account the unique needs of optometry.
"We've been active with the NPI, which should resolve this question once and for all," he said. "It should provide private parties and third-party drug plans an alternative identifier for implementing utilization control and other data mechanisms for which they've misused the DEA number in the past."
Tracking with a DEA license
Medical associations are not alone in recognizing that using DEA numbers to track prescribers is not the most comprehensive method of gathering data. Even those who gather the information realize its limitations.
Bill Bagwell, RPh, marketing director at Phoenix-based Source Informatics, said his company uses a prescriber's DEA number if one is available, but also supplements that data with its own information-gathering techniques.
"We capture about 70% of the prescriptions written nationwide and we process that information and sell it back to the pharmaceutical industry," Mr. Bagwell said. "We can tell a pharmaceutical manufacturer the total volume of its product that moved in a particular area vs. what the competition did, and at this point you're only tracking the drug and where it's moving."
Companies such as Source Informatics are also asked to gather as much information as possible about the prescribers of drugs, and this is where Mr. Bagwell said the shortcoming of DEA numbers becomes readily apparent.
"We've found that the DEA number is the best number at this time, so we request it whether or not the prescription is for a controlled drug so we can identify the doctor," Mr. Bagwell said. "We also buy a DEA file with quarterly updates. However, we've found that it's not as inclusive as we'd like, so we've set up our own prescriber database by purchasing membership listings from professional organizations, such as the AOA and the American Medical Association."
From there, Source Informatics uses its database to verify a DEA number and create a unique identifier for its own system to identify a prescriber. The company is sensitive to unauthorized use or access to DEA numbers, Mr. Bagwell said, so DEA numbers remain confidential.
Source Informatics also supports the use of a national identifier. "Giving each prescriber a unique identifier, such as an NPI, would be ideal," he said.
Drug Enforcement Administration
All mid-level providers should contact the Office of Diversion at their appropriate regional DEA office to obtain information about registration.
- Atlanta Division Office
- 75 Spring Street, SW, Rm. 740
- Atlanta, GA 30303
- (404) 763-5908/5909
- Jurisdiction: Ga., N.C., S.C., Tenn.
- Boston Division Office
- 15 New Sudbury St.
- Boston, MA 02203-0131
- (617) 557-2200
- Jurisdiction: Conn., Maine, Mass., N.H., R.I., Vt.
- Caribbean Division Office
- 2432 Loiza Street
- Santurce, PR 00914
- (809) 253-4230
- Jurisdiction: Puerto Rico, Virgin Islands
- Chicago Division Office
- 230 S. Dearborn Street, Ste. 1200
- Chicago, IL 60804
- (313) 353-1234/1236
- Jurisdiction: Ill., Ind., Minn., N.D., Wis.
- Dallas Division Office
- 1880 Regal Row
- Dallas, TX 75235
- (214) 767-7121
- Jurisdiction: Okla., Texas
- Denver Division Office
- 115 Inverness Drive, East
- Englewood, CO 80112
- (303) 784-6300 or (800) 326-6900
- Jurisdiction: Colo., N.M., Utah, Wyo.
- Detroit Division Office
- 431 Howard Street
- Detroit, MI 48226
- (313) 234-4302/4301
- Jurisdiction: Ky., Mich., Ohio
- Houston Division Office
- 1433 West Loop South, Ste. 600
- Houston, TX 77027
- (713) 693-3660
- Jurisdiction: Texas
- Los Angeles Division Office
- 255 East Temple Street, 20th Floor
- Los Angeles, CA 90012
- (213) 894-2216
- Jurisdiction: Calif., Hawaii, Nev., Trust Territory
- Miami Division Office
- 8400 N.W. 53rd Street
- Miami, FL 33166
- (305) 590-4880
- Jurisdiction: Fla.
- Newark Division Office
- 80 Mulberry Street
- Newark, NJ 07102
- (201) 645-3501
- Jurisdiction: N.J.
- New Orleans Division Office
- Three Lakeway Center
- 3838 N. Causeway Blvd., Ste. 1800
- Metairie, LA 70002
- (504) 840-1063
- Jurisdiction: Ala., Ark., La., Miss.
- New York Division Office
- 99 Tenth Avenue
- New York, NY 10011
- (212) 337-1593
- Jurisdiction: N.Y.
- Philadelphia Division Office
- William J. Green Federal Bldg.
- 600 Arch Street, Room 10224
- Philadelphia, PA 19106
- (215) 597-9536
- Jurisdiction: Del., Pa.
- Phoenix Division Office
- 3010 N. 2nd Street, Suite 301
- Phoenix, AZ 85012
- (602) 664-5736
- Jurisdiction: Ariz.
- San Diego Division Office
- 4560 Viewridge Avenue
- San Diego, CA 92123-1672
- (619) 616-4542
- Jurisdiction: Calif.
- San Francisco Division Office
- 450 Golden Gate Avenue
- P.O. Box 36035
- San Francisco, CA 94102
- (415) 556-8541
- Jurisdiction: Calif.
- Seattle Division Office
- 220 West Mercer St., Suite 104
- Seattle, WA 96119
- (206) 553-4040
- Jurisdiction: Alaska, Idaho, Mont., Ore., Wash.
- St. Louis Division Office
- United Missouri Bank Bldng.
- 7911 Forsyth Blvd., Suite 500
- St. Louis, MO 63105
- (314) 425-3241
- Jurisdiction: Iowa, Kan., Mo., Neb., S.D.
- Washington, D.C., Division Office
- 400 6th Street, S.W., Room 2558
- Washington, DC 20024
- (202) 401-7360
- Jurisdiction: District of Columbia, Md., Va., W.V.
- United States Department of Justice
For Your Information:
- Bill Bagwell, RPh, may be contacted at Source Informatics, 2394 East Camelback Road, Phoenix, AZ 85016; (602) 381-9104; fax: (602) 381-9777.
- Chris Carey may be contacted at the American Optometric Association, 1605 Prince Street, #300, Alexandria, VA 22314; (703) 739-9200; fax: (703) 739-9497.
- Bruce E. Onofrey, OD, RPh, may be contacted at 9101 Montgomery Blvd. NE, Albuquerque, NM 87111; (505) 275-4226.
- James Sheahan may be contacted at the Office of Diversion Control, Drug Enforcement Administration, Washington, DC 20537; (202) 307-7977; fax: (202) 307-8485.
- David Benkle, OD, past president of the California Optometric Association, can be reached at (209) 951-2020; fax: (209) 951-2016.
- Cliff Wright, OD, can be contacted at 15251 East 14th St., Suite B, San Leandro, CA 94578; (510) 481-2121; fax: (510) 481-2129; e-mail: firstname.lastname@example.org.
- Darlene Eakin can be reached at the Kentucky Optometric Assn., P.O. Box 572, Frankfort, KY 40601; (502) 875-3516; fax: (502) 875-3782.
- Jim Beckwith, OD, can be reached at the Nevada Optometric Association, 3311 S. Rainbow Blvd. Suite 132, Las Vegas, NV 89102; (702) 220-7444.