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Thursday, September 24, 2015

Countdown to ICD-10, and other pending developments

Well, as I write this (with the TV on as Pope Francis addresses the U.S. Congress), one week from today, the transition to the ICD-10 coding system will be required. That news may well be overshadowed by another federal government shutdown, this time over the issue of funding for Planned Parenthood.
SEPT 26th UPDATE: House Speaker John Boehner has announced his resignation, effective at the end of October. It looks like he will prevent the Tea Party hardline wing of the GOP from shutting down the government, given that he controls the flow of legislative proposals that actually get to the Floor.
Plenty of ICD-10 reporting out there these days.
Medscape Medical News
ICD-10: Countdown to a Meltdown, or a Yawn?
Robert Lowes, September 24, 2015
Government rollouts in healthcare haven't enjoyed a good reputation lately.

The website for the Affordable Care Act (ACA), called, went live in October 2013 and then went glitchy. Only after major repairs could Americans sign up for insurance coverage without pulling out their hair. The year before, the switch to the Version 5010 standard for electronic insurance claims delayed payments to some physician practices, which in turn struggled to meet payroll.

These memories darken expectations of the ICD-10 diagnosis codes that debut on October 1 after being damned, denied, and delayed the past several years, according to students of physician reimbursement interviewed by Medscape Medical News. To some, the ICD-10 jitters recall the Y2K scare, when people stockpiled bottled water in fear of civilization-wrecking computer crashes on January 1, 2000. With ICD-10, the favored survival tactic for physicians is obtaining a bank line of credit for 3 to 6 months, if not longer, to cope with interrupted cash flow.

"There's a lot of anxiety about how claims will go through," said Robert Wergin, MD, president of the American Academy of Family Physicians, in an interview with Medscape Medical News. "The experience with makes you a little nervous."

Then again, the worst-case prophecies for Y2K never materialized, and the same could be true for ICD-10...
I recall being in the air on a Delta red-eye enroute from Vegas to Florida to deal with my ailing parents at the moment of Y2K. Picked that flight deliberately.

I hope the ICD-10 transition will be another relative yawn. We probably will not really know for quite a while.

Other news:
Medical Societies Call for Delay of Meaningful Use Stage 3 

Meaningful use stage 3 is not scheduled to start until 2017, but 41 medical societies, including the American Medical Association (AMA), American College of Physicians, and the American Society of Hematology, are calling to delay the start of stage 3, especially given recent changes to Medicare. 

These medical societies are backing Senator Lamar Alexander, who believes the meaningful use program should be paused given the need to improve usability and interoperability of electronic health records. 

"Proper reassessment of the program before implementing the final stage of regulations will help avoid problematic software that physicians and patients will be burdened with for years to come," AMA President Steven J. Stack, MD, said in response to Alexander's calls for delay...
No surprise there. Most of the MU incentive money is already out the door (at ~$32 billion thus far). All that remain are the griping and looming payment penalties for non-compliance.

Also, today, Chapter 10 of the jaw-dropping Steve Brill series.


My latest read.

Yet another look into organizational culture issues of relevance to the health care space (e.g., see my "Talking Stick" post).
How Doctors Tried Not to Behave Like Economists

THE MOOD IN THE LECTURE theater at Harvard Business School was earnest and respectful. Sitting in the rows of seats, arranged in a horseshoe shape around a dais, were some of the most ambitious young people in the world. Attending Harvard Business School typically costs at least $ 100,000, and competition to win places is fierce. 1 The students have sky-high expectations of themselves and speakers who visit that famed lecture hall. And the man chosen to address the students on that day in early autumn 2006 was dazzling

A tall, imposing figure with a craggy face and big ears, Toby Cosgrove, sixty-five, was one of most famous heart surgeons in world. During the first few decades of his career, he had shot to glory in the medical world as a pioneering cardiothoracic surgeon who had operated on more than 22,000 patients and filed thirty patents for medical innovations. But in 2004 Cosgrove was appointed CEO of the mighty Cleveland Clinic in Ohio, one of the biggest medical centers in America, with an operating budget of $ 6 billion and staff of 40,000. The clinic was ranked among the best in America in numerous fields, including Cosgrove’s speciality of heart surgery. It offered cutting-edge treatments at prices that were better than those of most competitors. People from around the world flocked to use its services. It was, in short, a model of how a twenty-first-century hospital should operate, at least in the eyes of Harvard Business School. 

So the students listened with awe as Cosgrove explained how Cleveland Clinic worked. He was a good speaker, who exuded firm, natural authority, leavened by flashes of dry, self-deprecating wit. What most people did not know was that Cosgrove was also dyslexic. In his teens and early twenties he had struggled at school. But he had battled through this handicap to become a surgeon by virtue of ferocious willpower and a photographic memory. “Dr. Cosgrove is a brilliant man, the most ambitious person in the world since Alexander the Great,” Bruce Lytle, a fellow heart surgeon at Cleveland Clinic sometimes joked. “That is good— you need those people to change the world.” 

After Cosgrove finished his speech to the Harvard students, he took questions. The first few were admiring. But then a young, slim brunette woman named Kara Medoff Barnett, who was sitting in the second row of the auditorium, stood up. “Dr. Cosgrove, my father needed mitral valve surgery. We knew about Clevelend Clinic and the excellent results you have. But we decided not to go there because we heard you had no empathy. We went to another hospital instead, even though it wasn’t as highly ranked as yours.”

There was a startled pause. Barnett pressed on, looking Cosgrove in the eye. “Dr. Cosgrove, do you teach empathy at Cleveland Clinic?”

Empathy? Cosgrove was a loss. During his decades-long battle to become a star surgeon against fierce odds, Cosgrove had spent numerous days honing his technical skills. But he had never given much thought to empathy. It sounded hippie, if not self-indulgent. “Not really,” he mumbled vaguely, and switched the subject. 

The next day he left Boston, and tried to brush the incident off. But that odd little encounter kept buzzing through his mind. Dr. Cosgrove, do you teach empathy? Ten days later, it popped into his head again, in the unlikely setting of Saudi Arabia. The top managers of Cleveland Clinic were keen to expand in the Middle East, since it had a pool of wealthy clients. So Cosgrove decided to attend the official opening of a new hospital in Jeddah. To mark the occasion, the Saudi king and crown prince hosted a ceremony, along with many local dignitaries, and the new head of the hospital gave a passionate speech. “This hospital is dedicated to the body, spirit and soul of the patient,” he declared. As he spoke, Cosgrove glanced across to the Saudi king and noticed, to his complete surprise, that tears were rolling down his face. He felt a frisson. We’re really missing something here. He was used to thinking about medicine in dry, technical terms, or a delineated bundle of specialist skills. He did not usually think about the whole “soul.” 

But were specialist skills really enough? The question kept buzzing around in his mind. On paper, Cosgrove knew that Cleveland Clinic was an excellent medical center, or at least it was if you looked at it using the type of mental map that doctors used. There were world-class surgeons, physicians, nurses, psychologists, and physiotherapists; there were divisions of Anesthesiology, Pediatrics, Medicine, Surgery, Pathology and Laboratory Medicine, Post-Acute Care, Regional Medical Practice, Nursing, and Education. To name but a few of the specialist teams. 

But was this what sick people really wanted? Was it the best, most effective, or cheapest way to do medicine? Cosgrove was starting to have doubts. Doctors visualized medicine as a collection of technical skills. Patients did not. When people were sick they did not say “I need a cardiothoracic surgeon” or “Take me to a cardiologist.” Instead they would declare “My chest hurts,” or “I am having a seizure,” or “I can’t breathe,” or “My stomach is in pain,” or simply “I feel unwell.” 

In some sense, that differences in perception exist about medicine should come as no surprise. When anthropologists first started to study non-Western cultures in the late nineteenth century, they realized that different societies view the body and define sickness and health in subtly varying ways. Then, as anthropology expanded in the twentieth century, a sub-discipline emerged called “medical anthropology,” which examines how health is perceived, experienced, and implemented in different communities around the world. This discipline, which is one of the fastest growing areas of anthropology, argues that health is not really a matter of biology, or not just science. It is a cultural phenomenon too. Our physiology might be universal. But concepts of “sickness” can vary between different cultures, and within the same society...

Tett, Gillian (2015-09-01). The Silo Effect: The Peril of Expertise and the Promise of Breaking Down Barriers (pp. 192-195). Simon & Schuster. Kindle Edition.
The author, a financial columnist for The Financial Times of London, holds a doctorate in cultural anthropology. My first boss at HealthInsight in 1993, our "Senior Analyst," Dr. Ruth Moore (our chain-smoking "Ruthie") was a PhD medical anthropologist. She was a delight. One of my all-time favorite writers is David Graeber, a respected "social anthropologist" whose book "Debt, the first 5,000 years" is a learned and witty must-read. You can do the cheapskate free online Cliff's Notes essay version here at "To Have is to Owe." I cited and excerpted his second book "The Utopia of Rules" here back in February.

Gillian's is an interesting book, a very nice read on its own terms, notwithstanding that I found her take on the financial crisis of the late 2000's (a good bit of the book, actually) excessively apologetic and exculpatory. The otherwise innocent cluelessness wrought by organizational siloing explains a lot, but not nearly enough. The FIRE sector (Finance, Insurance, and Real Estate) was and remains overpopulated with avaricious, cynical, corner-cutting, Machiavellian operatives who personify the phrase "Gresham's Dynamic" ("the Bad drive out the Good").  Google "Moral Hazard Principal Agent Problem." 

Bernie Madoff, anybody? Enron? Worldcom? These people took full advantage (some of it overtly criminal) of the lax, increasingly moribund regulatory environment that was an explicit goal of President George W. Bush and Fed Chairman Alan Greenspan and other so-called "conservatives" whose motives were as opportunistic as they were ideological. I've been a student of white collar skulduggery going all the way back to the Equity Funding scandal of the 60's, through the S&L scandal, the junk bond era, the " built-to-flip bubble" years, and, most recently, the subprime-driven Wall Street debacle of the past decade. I worked in subprime as a risk management analyst for a time as well (2000-2005). See my posts "Tranche Warfare" and "The Dukes of Moral Hazard." I read everything by the likes of respected FIRE sector writers Yves Smith, Nomi Prins, Michael Lewis, and Dr. Bill Black, among others.
"In the gap between perception and reality, there's money to be made." - convicted former junk bond king Michael Milken
apropos of the topic here, I also didn't find as much of relevance in The Silo Effect specific to healthcare workforce culture as I'd hoped (no specific mentions of or allusions to "Just Culture" principles, for example). I will have more to say about it. For now, as she concludes Chapter 7 (the only chapter focused on the healthcare space):
...“Pay matters hugely. Our system of pay is one reason we were able to break down silos. You cannot do this with a fee-for-service model,” Lytle said. “Long-held allegiances and habits only change when they have to change. Harvard doesn’t have to change— they are Harvard, with a long history and the largest endowed institute in the world. But we are a not-for-profit institution in a Rust Belt city on the shores of Lake Erie with a declining population. We have to be better and more creative.” 

But the crucial point about Cleveland Clinic, the doctors argued, was that it showed the value of thinking about classification systems. When people inside businesses or government departments were encouraged to reimagine the world— say, by looking at the world from the perspective of consumers, not producers— they could often become more innovative and effective. If journalists were to start organizing their work according to how readers (not reporters) perceived the world, how would that change the media? Or if manufacturers started organizing their departments based on what customers (not salespeople or designers) thought was important, would they sell the same things? The key point, in other words, was that looking at business processes or services upside-down, or back-to-front, could change an institution’s perspective. Or it could if everybody was willing to take a risk, even without knowing where that mental exercise might lead. “A couple of years ago at Cleveland Clinic we thought we could develop a consultancy business by exporting our model— but then we realized that was a stupid idea,” Modic, the head of the Neurological Institute, observed as he sat in his office in May 2013. “The point is that you cannot buy our system for breaking down silos. You have to build it yourself. It is the process of building a new system and talking about it that transforms you.” [ibid, pg 217]
In the Health IT world, we pretty much speak of "silos" in the context simply of "data" opacity -- the EHRs that won't/can't "talk to each other" (my whole "Interoperababble" mess). We give far less attention to functional opacity -- operational siloing that is really the focus of Ms. Tett's book. And, yes, without data transparency you will continue to be bedeviled with functional siloing. But the issues extend beyond data, into asymmetric and frequently toxic interpersonal power relations.

I am reminded of another fine book in my stash, of some relevance here:

The most straightforward cause of strife on the new pastures is tribalism, the (often unapologetic) favoring of in-group members over out-group members. This is going to be a very short section, because there’s little doubt that humans have tribalistic tendencies that promote conflict. Insofar as there is a debate about our tribalistic tendencies, it’s not about whether we have them, but about why. In my view, the evidence strongly suggests that we have innate tribalistic tendencies. Once again, anthropological reports indicate that in-group favoritism and ethnocentrism are human universals. Young children identify and favor in-group members based on linguistic cues. Reaction-time tests (IATs) reveal widespread negative associations with out-group members in adults, children, and even monkeys. People readily favor in-group members over out-group members, even when the groups are arbitrarily defined and temporary. People readily replace racial classification schemes with alternative coalitional classification schemes, but they don’t do the same for classification by gender, as predicted by evolutionary accounts of human coalitional psychology. And there is a neurotransmitter, oxytocin, that makes people selectively favor in-group members. Finally, all biological accounts of the evolution of cooperation with non-kin involve favoring one’s cooperation partners (most or all of whom belong to one’s group) over others. Indeed, some mathematical models indicate that altruism within groups could not have evolved without hostility between groups.
In short, we appear to be tribalistic by nature, and, in any case, we are certainly tribalistic. This is bound to cause problems— though by no means insurmountable problems— when human groups attempt to live together. 

Tribalism makes it hard for groups to get along, but group-level selfishness is not the only obstacle. Cross-cultural studies reveal that different human groups have strikingly different ideas about the appropriate terms of cooperation, about what people should and should not expect from one another...

Greene, Joshua (2013-10-31). Moral Tribes: Emotion, Reason, and the Gap Between Us and Them (pp. 78-79). Penguin Group US. Kindle Edition.
We do well to also triangulate some of these things with some of the "futurism" citations contained in my prior post, too.


My next read.

Ran across this Stanford prof here:
Jeffrey Pfeffer: Do Workplace Hierarchies Still Matter?
A professor of organizational behavior says office power dynamics are part of our DNA
In a world where a junior staffer can tweet to the CEO, the lines that traditionally delineated power and influence have been blurred. So much so, in fact, that when Jeffrey Pfeffer teaches about corporate America's hierarchical power structure, his students often push back. That model of power isn't relevant anymore, they insist. Such 20th-century thinking.

Pfeffer's students are largely millennials — the youngest generation now in the workforce, born between about 1980 and 1992. He says that they, like much of the media, think the traditional power structure in business is changing and that companies are becoming more dynamic and less hierarchical.

They're wrong. "There's this belief that we are all living in some postmodernist, egalitarian, merit-based paradise and that everything is different in companies now," he says. "But in reality, it's not." In fact, in a new paper that explores the notion that power structures haven't changed much over time, Pfeffer explains that the way organizations operate today actually reflects hundreds of years of hierarchical power structures, and remains unchanged because these structures "can be linked to survival advantages" in the workplace. The beliefs and behaviors that go along with them, he writes, are ingrained in our collective, corporate DNA...
I'll be triangulating this take with the likes of Maccoby and David Marx and others. Side note: my take on our current BS'er-in-Chief.

More to come...

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