Monday, November 28, 2011

ICD-10: Regulatory Burden or Pathway to Improved Health Care Services?

Yesterday, Dr. Jason D. Fodeman penned an Op-Ed piece in the Washington Post Examiner that “Congress should stop the coming medical billing fiasco” where he opined that the coming conversion to ICD-10 will do more harm than good. I can hardly disagree more with Dr. Fodeman.

In this post, I present a few questions and comments to Dr. Fodeman. I’ll present these questions and comments in the order by which Dr. Fodeman presented his viewpoint; and that’s all this post and Dr. Fodeman’s Op-Ed really is…a viewpoint, however biased we each might be. :)

Q1: Where’s the evidence that ICD-10 ‘regulations will do more harm than good?”

C1: In fact, ICD-10’s increased specificity will mitigate the need for providers (professionals and institutions) to submit additional information. I noted these clinical data elements in a post a short while ago. See Computer-assisted coding for ICD-10

C2: There are some silly and likely unneccesary codes in the new ICD version. They’ve made for some amusing articles and posts. I believe this WSJ article started the laughs Walked Into a Lamppost? Hurt While Crocheting? Help Is on the Way and went a long way toward exposing some of ICD-10's silliness. But how many providers and payers actually believe they’ll be required to submit codes for these silly conditions?

C3: No doubt that converting to ICD-10 is a non-trivial cost – for professionals, facilities, payers AND intermediaries. And these costs will be a drop in the bucket compared to the benefits that greatly enhanced care management, administrative efficiencies, benefit design, provider reimbursement, compartive effectiveness research and other improvements ICD-10’s specificity will enable.

C4: Not converting to ICD-10 epitomize the problems facing our nation's healthcare system: fractured care management programs, administrative inefficiencies, unrealistic benefit packages, inaccurate provider reimbursement levels and the inability to perform meaningful compartive effectiveness research.  Moreover, the pay-for-performance and quality management programs needed to really make an impact to our healthcare are enabled by ICD-10.

C5: All healthcare constituents have a stake in improving healthcare outcomes in the United States: patients, physicians, hospitals, payers and intermediaries. It seems self-serving for physicians to be leading the charge against ICD-10 with the somewhat aggressive stance that they are the only ones that will not benefit from ICD-10's modern age diagnoses coding capabilities.

Q2: What is the reason that providers are not already capturing and documenting the information necessary to properly code a complete diagnosis? If not, I suggest they are largely committing malpractice. I had an Aircraft & Powerplant license and a good mechanic would never think of not over-documenting the work they did – it was just good business sense - for the mechanic, the pilot and the passengers.

C6: I totally disagree that the ICD-10 mandate ‘will be onerous and frustrating for physicians” and that it’ll be "the patients that suffer the most from diminished care.” How could more accurate, detailed clinical documents, enhanced adjudication/payment processes, and the abilty to develop new procedures and care management programs via comparative effectiveness programs – all of which will be enabled by ICD-10 – diminish pateint care?

C7: I agree with Dr. Fodeman that CMS got the cart in front of the horse. ICD-10 and HIPAA 5010 compliance should have been mandated before Meaningful Use. But I suppose they thought hanging the MU carrot out before the ICD-10/5010 stick would be more palatable. Sort of like building the master bath and bedroom of a house before laying its foundation?

In closing, I’ll say once again – like Dr. Fodeman did in his closing paragraph – one can joke all they want about ICD-10 codes for being "bitten by turtle" and "struck by turtle"  - or, my personal favorite - "sucked into a jet engine, for the second time" - but that tack, to me, is a red herring attempting to diminish the true and real value implementing ICD-10 diagnosis coding offers the U.S. healthcare system.

Comments? Retorts?

Sunday, November 27, 2011

Who says Consumer Directed Health Plans are Wrong?

I read a post by Rick Unger on today titled Consumer Driven Healthcare Proponents Finally Proven Wrong

And I tried to post a comment/reply but, for some reason, I couldn’t register – so I’m gonna post my reply to Rick Unger here.  This is a little off-topic from my usual ICD-10-related posts but I think it may be useful nonetheless.  Here was what I hoped to post on Forbes and what I did email to Rick Unger.  I welcome your comments.

= = = =

Of course “healthcare is not something that people will bargain for when seriously ill.”  Who's going to bargain when the chips are down?  It seems to me the key is for people to be aware of costs and to bargain when they are  holding some chips that others are hoping to earn/win from them.

In my opinion, your position that Consumer Directed Health Plans (CDHP) are an abject failure is way off the mark. You can’t possibly believe the population of Grand Junction, Colorado is representative of the entire U.S.? I suspect Grand Junction demographics are not even close to those of towns in Mississippi, Louisiana, Arkansas and many other states.  So, to me, your extrapolations seem suspect indeed; cherry-picking, or perhaps “reverse red-lining?” 

Moreover, you fail to address a few other important points:

1. People WILL and should bargain for healthcare services when they are not seriously ill, healthcare is elective (a want) or non-elective (a need) and should be differentiated as such. CDHP covers the preventative needs, governs the wants and protects against the needs of the seriously ill.

2. The high-deductible health plans characterizing CDHP contain strict provisions about coverage for the “preventative care” you argue for. Typically covered at 100% not subject to deductibles.  I believe that’s an IRS regulation for a qualified CDHP. So preventative services are not anathema to CDHP.

3. How do you argue that Grand Junction, Colorado health care consumers are representative of average American consumers?  I suspect that Grand Junction demographics are not even close to towns in Mississippi, Louisiana, and Arkansas.  How are you sure you’re extrapolation will work across the U.S.? Seems suspect and I say you’re cherry-picking? Or perhaps “reverse red-lining?” 

4. How would a dearth of PCP’s and local specialists impact your hypothesis?  (and that’s all you are really offering: anecdotal “evidence” and an educated guess that Consumer Directed Health Plans are a losing proposition)

5. How is it you think the physicians in the IPA you mention who “wish that patients on Medicare and Medicaid - not be treated differently than those with private insurance” are representative of the majority of doctors? Of course all physicians want the best for everyone. I suspect they also want to be paid for their efforts. Many doctors and health systems across the nation are abandoning Medicare and Medicaid enrollees due to low reimbursement levels and projected future cuts. 

6. Under the program you describe, what do you think will happen to the rates/premiums paid by private insurance customers who are subsidizing the others?  Ya think these private customers are going to be a sustainable revenue flow?

Some things I agree with you about – sort of - include:

1. Waste associated with end of life care.  [But that’s a real hot potatoe topic; especially for grandma and some who want it both ways.]

2. Physicians being subject to peer reviews where any proclivity to engage in procedures or tests of questionable value by a physician will be called out. [But that seems like a pipe dream – given current tort laws and a likely 'proclivity' for physicians to ‘protect their own.’]

3. Guaranteed pre-natal care, whether she has insurance or not. [Good idea]

In my opinion, you are selecting a microcosm of the U.S. healthcare population and extending those across the entire U.S.  Just doesn’t seem reasonable.

Steve S. (aka. ShimCode on Twitter)


Monday, November 14, 2011

ICD-10 Financial Neutrality – Questions and Comments

As someone once said: “$#!& rolls downhill and is occassionally thrown back up.” How do you think the ICD-10 mandate will impact your organization? Will you be uphill, downhill, or tossing it back and forth with your business partners?

Considerations for Both Payers and Providers

It doesn’t matter if you’re a payer, an institutional facility or a physician, you WILL BE IMPACTED by ICD-10 in less than two years. All constituents – payers, facilities and professionals have skin in the ICD-10 mandate.

1. Y’all need to understand the Medical Concepts, Clinical Scenarios, Contracting Agreements and how Patient Benefits are impacted by the ICD-10 mandate.

2. How do you independently verify and validate (IV&V) that your business processes and IT systems have been appropriately remediated?

3. Where are your vendors in their process to remediate the software you bought from them? What do you need to make yourself comfortable with their progress and official delivery dates? Assuming they’ve stated anything solid?

4. Do you have a plan to edge-test your major business processes to confirm your integration points will work as expected?

5. What does “operational neutrality” mean to you and how will it impact your financial neutrality? See here for a previous post about Operational Neutrality.

Considerations for Payers
Understanding ICD-10’s impact helps payers and large self-insured employers redesigning their medical policy, benefit plans and payer contracts; and – if payers have some level of transparency, should help providers anticipate and plan for potential shifts in reimbursement.

1. How are you going to handle translation of claims with 10-codes into 9-codes for your data warehouse and analytic reports?

2. Should you use native processing of both code sets? Or should you use crosswalk? How might a ‘purpose-built’ map based on a combination of native processing and crosswalks be your best remediation approach?

3. Whichever approach is followed, what methodologies and techniques will help ensure enterprise-wide consistency?

Considerations for Providers
The provider side is still governed by medical necessity and appropriate documentation to support diagnosis coding. Since ICD-10 allows for greater specificity - in theory - providers who care for the sickest - and do a good job - may see their reimbursement increase – if they get the coding right.

1. How can you mitigate potential revenue impact to existing contracts that include diagnosis or diagnosis-related components?

2. How will your ability to properly code your services increase your reimbursement levels under the inevitable pay-for-performance and quality-based programs being bandied about?

3. Have you identified the top 10-20 diagnoses you service? By dollar amount and volume? How might some effort to model these outliers under the ICD-10 scenario help you understand where your revenue will be impacted?

In another post I’m going to offer up some approaches and ideas I’ve learned and developed that can help payers and providers perform the financial and operational modeling to help them gauge the impact of ICD-10 on their bottom line.

For more information on ICD-10, you can follow me on Twitter @ShimCode. You’re also welcome to link up with me.

How can I help?