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Wednesday, June 10, 2015

Backsliding on the looming ICD-10 conversion

I am apparently now on the Healthcare IT News hardcopy mailing list. Which is fine, I guess. I didn't order it, and have not gotten a bill. Just got a second edition in the mail. Lots of good stuff in it not yet available online. This article (above) is rather bracing. I'll read in an excerpt via Dragon:
WEDI's newest survey of ICD–10 readiness among vendors and providers is out. And the progress report is not as promising as officials had hoped. In fact, it appears as the ICD–10 delay has actually had a negative impact on progress. WEDI, or the Workgroup for Electronic Data Interchange, surveyed nearly 1200 vendors, providers and health plans to gauge their readiness for the ICD–10 go-live date of October 1, 2015. But, as the organization emphasized, the results were underwhelming. Vendor readiness remained relatively unchanged since August 2014, and providers? Will there actually falling behind.

"Unless all industry segments make a dedicated effort to continue to move forward with their invitation efforts, there will be significant disruption on October 1, 2015," wrote Jim Daly, past chair of the WEDI in a March 31st letter to HHS Secretary Sylvia Burwell.  Two thirds of providers, in fact said they had slowed their ICD–10 efforts or halted them altogether as a result of the delay...
As I write, there are 113 days until the October 1st go-live conversion deadline. Does not bode well.

The Hill is busy with a number of proposed bills yet again delaying or otherwise watering down the ICD-10 conversion. From  AHIMA:
ICD-10 ‘Grace Period’ Bill Introduced in US House

A new bill introduced into the US House of Representatives proposes a two-year “grace period” for accepting codes submitted in ICD-10-CM/PCS.

The bill, H.R. 2652, Protecting Patients and Physicians Against Coding Act of 2015, was introduced by Representative Gary Palmer (R-AL-6) on June 4.

The legislation is the third ICD-10-related bill to be introduced into the House of Representatives in the last five weeks. On May 12, H.R. 2247, the Increasing Clarity for Doctors by Transitioning Effectively Now Act (ICD-TEN Act) was introduced by Rep. Diane Black (R-TN-6) calling for an ICD-10 transition period. On April 30, H.R. 2126, the Cutting Costly Codes Act of 2015, was introduced by Rep. Ted Poe (R-TX-2) seeking to outright stop the replacement of ICD-9 with ICD-10. Neither bill has gained much traction since being introduced. Black’s bill currently has only five cosponsors, and Poe’s bill has nine—much lower than the 46 sponsors this same bill had when Poe first introduced it in 2013.

H.R.2652 would create a two-year grace period where healthcare providers’ ICD-10-based claims submitted to Medicare and Medicaid would not be denied due to coding errors. Implementing this grace period would ensure physicians are not negatively impacted while ICD-10 is “fully implemented within the healthcare system,” according to a letter sent by Palmer to fellow Congressmen asking for their support of the bill...

AHIMA Against H.R. 2652

AHIMA officials have said they are against this bill since the grace period would lead to inaccurate coding, improper payments, and potential medical billing fraud. With no official repercussions for inaccurate coding, AHIMA officials said they feel it would open the door to both intentional and unintentional coding errors—improperly paid claims at best and rampant fraud at worst—since proper payment of claims depends on accurate coding. Coverage determinations and validation of medical necessity of healthcare services also depend on codes submitted on claims, and would be impacted.

Also, claims data are used for many purposes beyond payment, including health policy decisions, assessment of quality of care, patient outcomes and safety, and evaluation of costs. Allowance of miscoding on claims will render claims data useless for any purpose, AHIMA officials said...

I know, I know; the jokes just write themselves. "Top 10 Lists" of "stupidest ICD-10 codes" abound. Relatedly,
Alabama passes joint resolution to delay ICD-10
State lawmakers urge CMS to hold off on the code set conversion
June 10, 2015

State senators in Alabama passed a joint resolution calling on Congress to hold off on ICD-10.

“We hereby urge Congress to delay the implementation of ICD-10 and create an impartial committee to study the problems with implementation and develop recommendations to address the many unintended consequences that have not been adequately evaluated,” according to Senate Joint Resolution 279.

What does this actually mean?

Not all that much. In reality, such a joint resolution is little more than public advocacy – though it is technically coming from a state government rather than an industry group, such as the American Medical Association, or a private enterprise. And the SJR arrived on the heels of Alabama Republican Rep. Gary Palmer’s proposed Protecting Patients and Physicians Against Coding Act of 2015 that would institute a two-year grace period during which the Centers for Medicare and Medicaid Services would be prohibited from denying claims...

Raining today here in the Bay Area. Nice. Not gonna do anything substantive for our extreme drought, but, we'll take anything we can get.


Looks like no decision in the specious King vs Burwell case this week. The anxious Beltway pundit chatter is ramping up. Maybe next week.

I may have to write a new song. This is the tune I wrote in 2012 when the ACA first passed SCOTUS muster (narrowly) on Congressional taxing power grounds.

The "Epistemic Hairball All-Star Shoe Band" is just me and my GarageBand loops (and my friend Lenny on harmonies). No actual instruments.

June 12th update:

apropos of the coming SCOTUS ruling, my latest Harper's just arrived in the mail. Featured long read article.

Wrong Prescription?
The failed promise of the Affordable Care Act

By Trudy Lieberman

In July 2009, as the Affordable Care Act moved through Congress, Steny Hoyer, the second-ranking Democrat in the House of Representatives, laughed at the idea that any legislator would actually read the bill before voting on it. If such full-body immersion were necessary to support the A.C.A., he said, “I think we would have very few votes.” In March 2010, just before the law passed, speaker of the House Nancy Pelosi made a similar point. Addressing a national conference of county officials, she declared, “We have to pass the bill so that you can find out what is in it, away from the fog of the controversy.”

Five years after its passage, the A.C.A. is not only the most hotly debated and vituperatively denounced law of the era — it is still shrouded in a fog of controversy. Many Americans have no idea how the bill works or what it was designed to accomplish. In March, a Kaiser Family Foundation study found “significant” knowledge gaps in the public’s understanding of the law. A third of the participants were unaware of the law’s key provision: offering subsidies for the uninsured.

It is no wonder Americans have been hard-pressed to learn anything about the actual workings of the A.C.A. There has been little criticism of the A.C.A. from the left, with prominent figures such as Paul Krugman, the economist and New York Times columnist, acting as cheerleaders. The right has confined itself to disinformation and risible smears, with G.O.P. presidential hopeful Ben Carson memorably defining the A.C.A. as “the worst thing that has happened to this nation since slavery.” A lack of clarity on both sides — and some deliberate bait-and-switch tactics — dogged the very creation of the law.

The A.C.A. was sold to the public on the pledge of “affordable, quality health care.” This slogan, crafted in the shop of the Democratic pollster Celinda Lake, was incessantly pushed by everyone from grassroots advocates to top government officials, even as, the new A.C.A. website, was crashing down around them in the fall of 2013. Trying to spin the disaster on Meet the Press, Pelosi grandly promised her viewers “more affordability, more accessibility, better-quality care, prevention, wellness, a healthier nation honoring the vows of our founders of life, a healthier life, [and] liberty to pursue their happiness.” President Obama, too, repeated the mantra at every opportunity. Shortly before the exchanges established by the law opened for business, he affirmed that uninsured Americans would now have “the same chance to buy quality, affordable health care as everyone else.”

Comments like these persuaded the public that the A.C.A. was a vehicle for delivering universal health care, similar to what citizens had in other industrialized nations. It was not. Instead, the A.C.A. was a canny restructuring of the American health-care marketplace, one that delivered millions of new customers to insurance companies, created new payment mechanisms for hospitals, steered more business to pharmaceutical companies, and dictated expensive, high-tech solutions for a wide range of problems...
Maybe most citizens and legislators were clueless about the content of the ACA. I was not one of them. I followed every draft of the legislation along its way to enactment. See, e.g., my 2009 post "Public Optional."

Lieberman continues,
...[W]hat of those middle-class Americans who were supposed to benefit from the law, and were promised that they could keep the policies and health providers they already had? They’ve already been hit with higher premiums and higher out-of-pocket costs — and people with top-of-the-line coverage from their employers will soon find those policies shrinking, thanks to a provision of the law that encourages companies to offer less-generous benefits.

It’s bad enough that the A.C.A. is fattening up the health-care industry and hollowing out coverage for the middle class. Even worse, the law is accelerating what I call the Great Cost Shift, which transfers the growing price of medical care to patients themselves through high deductibles, coinsurance (the patient’s share of the cost for a specific service, calculated as a percentage), copayments (a set fee paid for a specific service), and limited provider networks (which sometimes offer so little choice that patients end up seeking out-of-network care and paying on their own). What was once good, comprehensive insurance for a sizable number of Americans is being reduced to coverage for only the most serious, and most expensive, of illnesses. Even fifteen years ago, families paid minimal deductibles of $150 or $200 and copays of $5 or $10, or none at all. Now, a family lucky enough to afford a policy in the first place may face out-of-pocket expenses for coinsurance, deductibles, and copays as high as $13,200 before its insurer kicks in.2 Of course, these out-of-pocket caps can be adjusted by the insurer every year, within limits set by the government, and there are no caps at all for out-of-network services, which means that some providers charge whatever the market will bear. In the post-A.C.A. era, you can be insured but have little or no coverage for what you actually need.

The A.C.A.’s greatest legacy may finally be the fulfillment of a conservative vision laid out three decades ago, which sought to transform American health care into a market-driven system...
A fine, thorough (albeit firewalled) article. About national health reform policy and the ACA overall, but there is mention of P4P delivery process initiatives and Health IT.
Unable to go head-to-head with hospitals or the big drug companies, the drafters of the A.C.A. instead embraced less contentious methods for reducing costs. These included discouraging fee-for-service payments to physicians in favor of bundled payments, which would cover all the services needed for an episode of care; penalizing hospitals for too many readmissions; and encouraging accountable-care organizations (A.C.O.’s), which are supposed to allow doctors and hospitals to coordinate treatments, thereby lowering costs and improving the quality of the actual services.

These ideas are all worth exploring. But early analysis suggests that they have had little meaningful impact. Alan Weil, the editor of Health Affairs, has argued that the shift to bundled payments is flawed and insufficiently disruptive — there’s no evidence that it will achieve its goals. According to Scott Smith, the managing CEO of Medical City Dallas, a highly profitable hospital, the old fee-for-service model is “what our physicians want — and they want to maintain that for as long as they can.”

As for A.C.O.’s, the news is a little more promising. A recent report on the government’s pilot program indicated savings of more than $384 million in its first two years of operation. However, these gains were inconsistent, with some A.C.O.’s barely breaking even or losing money. And of the thirty-two organizations selected for the program, thirteen have already dropped out. One was San Diego’s Sharp HealthCare, which called the A.C.O. model “financially detrimental.”

The A.C.A. pinned similar hopes on digitizing medical records. Robert Wachter, the chief of the Division of Hospital Medicine at UCSF Medical Center and an expert on health IT, said that substantial savings may well materialize from such efforts, but not for five to ten years. A 2005 RAND study determined that health IT could eventually save $81 billion a year, but more recent research found inconclusive evidence of cost reductions so far. Record-keeping systems are still rudimentary, and the biggest problem is that the systems don’t talk to one another: in many cases, the electronic record your doctor uses cannot be read by the hospital or by another doctor trying to coordinate treatment.

There’s a reason for this electronic babel. As part of the 2009 stimulus bill, the government allocated $35 billion to health IT, of which $28 billion has already been spent. Lawmakers declined to include any real standards or specifications — and nearly 800 vendors, small and large, rushed to cash in, swamping the market with more than 2,500 products. Each system creates its own record and may encode it differently from others, says David Whitlinger, the executive director of the New York eHealth Collaborative. Six years later, there are still no standards. “Congress has tried to direct the Office of the National Coordinator to mandate interoperability,” Whitlinger told me, “but there’s reluctance at the federal level to mess with commerce.” The market is slowly consolidating, as markets always do. In the meantime, Whitlinger says, “There’s a lot of money to be made.”

But even if the A.C.A. wrings substantial savings out of these initiatives, and even if health-care costs stop rising, the law does little or nothing to contain the price of prescription drugs. Spending on these medications rose 6.4 percent from December 2013 to December 2014, a rate not seen in two decades, and it is unlikely to dip anytime soon...
I cited Dr. Wachter's book here, back in April.

The conclusion of the Lieberman article:
[T]he fiction that people can control their own health-care destiny, and the narrative of the rational shopper, continue to delay the day when the United States will have to make real decisions about our high-priced, unequal, and insanely inefficient system. The A.C.A. didn’t invent this system, of course. But because of a failure of nerve and the immense power of health-care stakeholders, the A.C.A. has reinforced and accelerated many of the system’s most toxic features. Who should get quality health care? The poor, the rich, the vast middle in between? And how should we pay for it?

King v. Burwell, the latest legal challenge to the A.C.A., will be decided by the Supreme Court just as this article goes to press. The case hinges, absurdly enough, on a single four-word clause — “established by the state” — which, according to opponents of the law, prevents Americans from receiving subsidies on policies they have purchased from federal exchanges. The court’s verdict will determine the future of the law. But putting aside whatever decision may come down, it’s fair to ask: Is the A.C.A. better than nothing? Even with the law’s considerable defects, the answer is probably yes. It has expanded the number of the nation’s insured by 17 million, at least for now. And if the A.C.A. survives King, the decision may offer a fresh opportunity to assess the law’s shortcomings, and maybe even to fix some of them.

As I’ve suggested, the shortcomings are numerous. Too many Americans are still excluded; the process of buying insurance remains incredibly complicated; there is little regulation throughout much of the country; and millions of people are saddled with huge out-of-pocket expenses and lack the coverage they truly need. Fixing these problems would be a huge step forward. But even if that can be done, we will be left with the system’s fundamental flaw: high costs and our inability to effectively control them. The only way to fix that is to attack the stranglehold that drug companies, insurers, hospitals, and doctors have on the machinery of health care in this country — a bold move that has so far frightened away almost all contenders.

On a cold February night, New York assemblyman Richard Gottfried met with the Chelsea Reform Democratic Club in Manhattan. Gottfried pushed a new proposal for reforming health insurance, a plan he called New York Health. He argued that America rations care according to wealth, and that people are still going without. Some in the audience were skeptical. One woman worried that good doctors would leave the state, and that lines would snake around the block to see an average one. An audience member stood up and posed the question on everybody’s mind: “Wasn’t the Affordable Care Act supposed to solve all this?”
What comes down in the wake of King v Burwell is anybody's guess should SCOTUS strike the federal HIX subsidies.

Coming shortly, Lamar Alexander's Senate HELP Committee:
Achieving the Promise of Health Information Technology: What Can Providers and the U.S. Department of Health and Human Services Do To Improve the Electronic Health Record User Experience?

Date: Tuesday, June 16, 2015 
Time: 10:00 AM 
Location: 430 Dirksen Senate Office Building
I'm reviewing the four witness testimony PDF's from the latest hearing. Short summary thus far? "Usability is good." "Interoperability is good." "Innovation is good." "Collaboration is good."

More to come...

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