Tag: ICD-10

‘Doc fix’ bill would overhaul health IT policy, too

The “doc fix” bill introduced Thursday to replace Medicare’s sustainable growth-rate formula for physician pay would also significantly alter federal policy on health information technology.

Lawmakers avoided making any changes to the timeline for requiring the industry to switch to ICD-10 diagnostic and procedure codes. Last year’s temporary “doc fix” included a stealthily added delay of the conversion.

But the legislation’s merit-based incentive payment system would fundamentally change the government’s program promoting the adoption and “meaningful use” of health IT. Under the current program, failure to meet meaningful-use requirements will trigger penalties beginning this year. Under the SGR bill, meeting the standards would yield a bonus.

That’s not all. The bill would also reward remote patient-monitoring and telehealth as clinical practice improvement activities. “Those are all good things,” said Joel White, the head of Health IT Now, which describes itself as a coalition of patient groups, provider organizations, employers and payers.

Lawmakers have also used the legislation to take aim at obstacles to realizing the benefits of IT in healthcare, particularly the lack of interoperability, or data-sharing, between electronic health records.

The SGR bill establishes a July 2016 deadline for HHS to develop metrics to quantify progress toward more data-sharing among hospitals and other providers. HHS would have to account for the progress by December 2018.

“The industry as a whole would benefit from a conversation” that starts because of those metrics, said Jeff Smith, the vice president of public policy for the College of Healthcare Information Management Executives.

Stephanie Zaremba, senior manager of government and regulatory affairs with Athenahealth, agreed that the industry would benefit from federal metrics on data-sharing. “We need some actual numbers,” she said. “We’ve spent $30 billion on software that in theory exchanges information. Now we need to actually do it.”

But generating such metrics could be a complicated endeavor. They could examine the technical capability of the software to exchange information—that is, whether the data could flow and whether it occurred without introducing errors into the record. Or they could assess whether data is actually being exchanged or not.

“It is a difficult task to try and develop a scoring system that would allow you to figure out performance,” Smith said, though it appears to be aligned with the goals of HHS’ Office of the National Coordinator for Health Information Technology.

The SGR bill also asks for a flurry of reports. HHS, for example, would be tasked with studying ways to help providers compare various EHR systems, such as a website aggregating surveys from physicians and hospitals that use the products.

The comptroller general would be asked to assess how private insurers are promoting the use of remote patient-monitoring and the barriers to wider adoption of the technology for Medicare beneficiaries.

The bill also requests a study on the feasibility of allowing small groups of physicians to work with independent risk managers to help them participate in risk-based payment models.

That provision has piqued Athenahealth’s interest, Zaremba said. “What we want to do,” she said, “is go to CMS and private payers and negotiate nationwide for providers to plug into.”

Last year’s version of the SGR overhaul contemplated requiring the use of clinical decision-support software—which analyzes data and gives doctors guidance—to promote appropriate use of imaging. That provision has been dropped from the SGR legislation but was added to a different bill that became law.

GAO Gives CMS ICD-10 Readiness Thumbs Up

Efforts by the Centers for Medicare and Medicaid Services to prepare providers, clearinghouses, and health plans for the October 1 ICD-10 deadline are on track, and CMS is ready to process claims using the new codes.

That is the conclusion of a just-released Government Accountability Office report on the readiness of CMS for the ICD-10 switchover.

“The transition to ICD-10 codes requires both CMS and covered entities to develop, test, and implement information technology systems that can process the new codes,” states the GAO report. “In addition, these covered entities need to educate and train staff in using these new codes, and may need to modify internal business processes.”

According to GAO, CMS has developed various educational materials, conducted outreach, and monitored the readiness of covered entities and the vendors that support them for the ICD-10 transition. For example, the agency held in-person training for small physician practices in some states and monitored readiness through stakeholder collaboration meetings, focus group testing, and reviews of industry surveys, finds the report.

GAO also reported that CMS modified its Medicare systems and policies. For example, the agency completed all ICD-10-related changes to its Medicare fee-for-service (FFS) claims processing systems. Auditors also found that the agency provided technical assistance to Medicaid agencies and monitored their ICD-10 readiness. As a result, all Medicaid agencies reported that they would be able to perform all of the activities that CMS has identified as critical by the October 1 implementation deadline.

Nonetheless, while CMS’s Medicare FFS claims processing systems have been updated to reflect ICD-10 codes, GAO states that “it is not yet known whether any changes might be necessary based upon the agency’s ongoing external testing activities.” Auditors also conclude that although CMS has worked with states to help ensure that their Medicaid systems are ready for the ICD-10 transition, “in many states, work remains to complete testing by the transition deadline.”

At the same time, GAO reports that stakeholder organizations identified several areas of concern about the ICD-10 transition and made several recommendations, which CMS has taken steps to address. For example, stakeholders expressed concerns that CMS’s testing activities have not been comprehensive. To address this concern, CMS officials said that the agency has scheduled end-to-end testing with 2,550 covered entities during three weeks in 2015 (in January, April, and July).

In response to the GAO report, Senate Finance Committee Chairman Orrin Hatch (R-Utah) and Ranking Member Ron Wyden (D-Ore.) issued a statement saying they have “confidence” that CMS is “adequately preparing to implement” ICD-10 by the October 1 deadline. “As demonstrated by this report, the provider outreach and responsiveness to stakeholder concerns from CMS have kept the agency on track to upgrade to the next level of healthcare coding,” said Hatch. Wyden added that CMS has “taken unprecedented actions to help providers prepare for this change.”

Similarly, the Coalition for ICD-10 in a statement said that the GAO report “affirms widespread recognition across the healthcare industry that CMS is well-prepared to implement the U.S. transition to ICD-10 on October 1, 2015, and that the agency has undertaken extensive efforts to help the health care industry prepare,” adding that “the U.S. is ready to move forward with ICD-10 with no further delays.”

House Committee Dangles Possibility of ICD-10 Hearing in 2015

The House Energy and Commerce Committee on Dec. 10 issued a statement that it is prepared to hold a congressional hearing on ICD-10 in the New Year.

In a joint statement, House Energy and Commerce Committee Chairman Fred Upton (R-Mich.) and House Rules Committee Chairman Pete Sessions (R-Tex.) said that they are looking ahead to the October 1, 2015 ICD-10 compliance date and will continue their “close communication with the Centers for Medicare and Medicaid Services to ensure that the deadline can successfully be met by stakeholders.”

Upton and Sessions commented on the fact that following the latest delay in the ICD-10 implementation they “heard from a number of interested parties concerned about falling behind or halting progress,” and that they “would like to acknowledge and thank these organizations and individuals for opening up this dialogue and expressing their thoughts and concerns regarding this issue.”

Physician groups have been lobbying for an additional two-year delay to the implementation of ICD-10. The American Medical Association and its regional societies and delegations are reportedly working with Upton and Sessions to extend the ICD-10 compliance date to October 2017. Last month, a letter from the Medical Society of the State of New York to Speaker of the House John Boehner (R-Ohio) was circulated to other members of Congress, requesting the ICD-10 deadline be pushed back to 2017.

Upton and Sessions in their statement emphasized that ICD-10 is “an important milestone in the future of healthcare technologies” and it is their “priority to ensure that we continue to move forward in healthcare technology and do so in a way that addresses the concerns of all those affected and ensure that the system works.”

In addition to ensuring that stakeholders are prepared for the ICD-10 code switchover in October 2015, they argued that it is “essential that we understand the state of preparedness at CMS.” Upton, along with other House and Senate committee leaders, sent a letter to CMS last June expressing concerns about ICD-10 preparedness for both providers and CMS following a one-year delay that Congress imposed in the spring of 2014.

ICD-10 Delay, Meaningful Use Changes Rocked Healthcare in 2014

2014 was an extraordinarily eventful year in the healthcare industry, punctuated by the latest ICD-10 delay, exemptions and extensions to meaningful use, and the VA’s scandalous summer of shame.  As healthcare providers look ahead to 2015 and its similarly high potential for being a roller coaster year, EHRintelligence recaps some of the biggest stories of the past twelve months and how they impacted healthcare for good or for ill.

The ICD-10 delay shocks and disappoints

Hands-down, the biggest surprise of 2014 was the delay to ICD-10.  A sneaky piece of legislation, signed by President Obama on April 1, changed the compliance date from October 1, 2014 to October 1, 2015 with barely any discussion, consultation, or warning.  Leaving CMS speechless for weeks as healthcare providers scrambled to understand the impact of the change, many organizations expressed disappointment, frustration, anger, and resignation.

As another delay scare comes and goes with the finalization of the 2015 Congressional spending omnibus, providers are encouraged to view October 1, 2015 as the real and actual deadline.  Whether or not the new year will include a new delay is impossible to say, but prepping for the code set switch is imperative for organizations that continue to lag far behind.

Meaningful use gets a little bit of a makeover

The EHR Incentive Programs have never been the most popular of healthcare reform attempts, but providers squared their shoulders and dove into Stage 2 of meaningful use with all the gusto they could muster – right as CMS extended the hospital reporting deadline.  Hospitals now have an extra month, ending on December 31, 2014, to gather their attestation data and avoid the upcoming penalties starting in 2016, which provides a little breathing room for stressed out facilities.

The extension comes on the heels of several significant changes to the program over the past year, including a relaxed hardship exemption and changes to the use of 2014 Certified EHR Technology (CEHRT).  At the very end of last year, CMS also announced that they would be pushing back the start of Stage 3 by one year until 2017, which gives healthcare providers more time to climb the meaningful use ladder.

VA is hit by electronic scheduling system scandal

As the will-they-won’t-they drama of interoperability upgrades continued to play out between the Department of Veterans Affairs and the Department of Defense, the VA was slammed with a public relations nightmare: a former physician whistleblower claimed that patients were routinely denied access to care, leading to numerous deaths, due to shady scheduling practices within the VA system.

The scandal felled top brass at the department, including VA Secretary Eric Shinseki, and prompted the passage of a massive spending bill to expand services, build new clinics, and overhaul the business practices of the hundreds of VA facilities across the nation.  New Secretary Robert McDonald has promised to continue making reforms that will eliminate the “corrosive culture” that led to the shortfalls.

Massive data breaches continue to slam providers

Millions of patients were notified that their personal health information had been compromised during 2014 as healthcare providers continue to suffer from poor privacy and security practices.  From the unencrypted data of two government websites providing AIDS resources to the 4.5 million patients whose information was exposed during a data breach at Community Health Systems, Inc. to the tens of thousands of compromised patient files in New Jersey and Los Angeles, it’s no wonder that patients remain nervous about giving their health data to their doctors.

Healthcare organizations are slated for some serious HIPAA audits by the Office of Civil Rights (OCR) in the coming months, and must prepare themselves to meet stringent privacy and security measures not only to pass the OCR’s scrutiny, but to avoid making some undesirable headlines in 2015 with an ugly and public patient data breach.

AHIMA: ICD-10 Costs Lower Than Previously Reported

New data published online in the Journal of AHIMA suggests that the estimated costs, time and resources required by physician offices to convert to ICD-10 are “dramatically lower” than initially estimated.

The evidence also suggests that physicians and their office staff, vendors and health plans have made considerable progress on ICD-10 implementation with fewer resources than previously estimated.

The article estimates that the ICD-10 conversion costs for a small practice are in the range of $1,900-$5,900. This is in stark contrast to a 2014 update of a widely referenced 2008 report by Nachimson Advisors to the American Medical Association (AMA), which estimated the cost for a small practice to implement ICD-10 was in the range of $22,560-$105,506.

The authors of the Journal of AHIMA article based their estimates on results from recent surveys, published reports and ICD-10 conversion experience with hospitals and physicians. The authors defined a small practice as three physicians and two impacted staff members such as coders and/or office personnel.

Additionally, the survey found that costs related to electronic health record (EHR) adoption and other healthcare initiatives such as meaningful use are not directly related to the ICD-10 conversion and were sometimes included in previous estimates.

“This research confirms that the ICD-10 conversion for small practices is not only highly achievable but far less onerous than many have suggested,” AHIMA CEO Lynne Thomas Gordon said in a statement. “AHIMA remains committed to helping small practices with their transition to ICD-10, a modern and robust coding system that will lead to improved patient care and better health outcomes at reduced costs.”

Why Doctors Are Sick of Their Profession

All too often these days, I find myself fidgeting by the doorway to my exam room, trying to conclude an office visit with one of my patients. When I look at my career at midlife, I realize that in many ways I have become the kind of doctor I never thought I’d be: impatient, occasionally indifferent, at times dismissive or paternalistic. Many of my colleagues are similarly struggling with the loss of their professional ideals.

It could be just a midlife crisis, but it occurs to me that my profession is in a sort of midlife crisis of its own. In the past four decades, American doctors have lost the status they used to enjoy. In the mid-20th century, physicians were the pillars of any community. If you were smart and sincere and ambitious, at the top of your class, there was nothing nobler or more rewarding that you could aspire to become.

Today medicine is just another profession, and doctors have become like everybody else: insecure, discontented and anxious about the future. In surveys, a majority of doctors express diminished enthusiasm for medicine and say they would discourage a friend or family member from entering the profession. In a 2008 survey of 12,000 physicians, only 6% described their morale as positive. Eighty-four percent said that their incomes were constant or decreasing. Most said they didn’t have enough time to spend with patients because of paperwork, and nearly half said they planned to reduce the number of patients they would see in the next three years or stop practicing altogether.

American doctors are suffering from a collective malaise. We strove, made sacrifices—and for what? For many of us, the job has become only that—a job.

That attitude isn’t just a problem for doctors. It hurts patients too.

Consider what one doctor had to say on Sermo, the online community of more than 270,000 physicians:

“I wouldn’t do it again, and it has nothing to do with the money. I get too little respect from patients, physician colleagues, and administrators, despite good clinical judgment, hard work, and compassion for my patients. Working up patients in the ER these days involves shotguning multiple unnecessary tests (everybody gets a CT!) despite the fact that we know they don’t need them, and being aware of the wastefulness of it all really sucks the love out of what you do. I feel like a pawn in a moneymaking game for hospital administrators. There are so many other ways I could have made my living and been more fulfilled. The sad part is we chose medicine because we thought it was worthwhile and noble, but from what I have seen in my short career, it is a charade.”

The discontent is alarming, but how did we get to this point? To some degree, doctors themselves are at fault.

In the halcyon days of the mid-20th century, American medicine was also in a golden age. Life expectancy increased sharply (from 65 years in 1940 to 71 years in 1970), aided by such triumphs of medical science as polio vaccination and heart-lung bypass. Doctors largely set their own hours and determined their own fees. Popular depictions of physicians (“Marcus Welby,” “General Hospital”) were overwhelmingly positive, almost heroic.

American doctors at midcentury were generally content with their circumstances. They were prospering under the private fee-for-service model, in which patients were covering costs out of pocket or through fledgling private insurance programs such as Blue Cross/Blue Shield. They could regulate fees based on a patient’s ability to pay and look like benefactors. They weren’t subordinated to bureaucratic hierarchy.

After Medicare was introduced in 1965 as a social safety net for the elderly, doctors’ salaries actually increased as more people sought medical care. In 1940, in inflation-adjusted 2010 dollars, the mean income for U.S. physicians was about $50,000. By 1970, it was close to $250,000—nearly six times the median household income.

But as doctors profited, they were increasingly perceived as bilking the system. Year after year, health-care spending grew faster than the U.S. economy as a whole. Meanwhile, reports of waste and fraud were rampant. A congressional investigation found that in 1974, surgeons performed 2.4 million unnecessary operations, costing nearly $4 billion and resulting in nearly 12,000 deaths. In 1969, the president of the New Haven County Medical Society warned his colleagues “to quit strangling the goose that can lay those golden eggs.”

If doctors were mismanaging their patients’ care, someone else would have to manage that care for them. Beginning in 1970, health maintenance organizations, or HMOs, were championed to promote a new kind of health-care delivery built around price controls and fixed payments. Unlike with Medicare or private insurance, doctors themselves would be held responsible for excess spending. Other novel mechanisms were introduced to curtail health outlays, including greater cost-sharing by patients and insurer reviews of the necessity of medical services. That ushered in the era of HMOs.

In 1973, fewer than 15% of physicians reported any doubts that they had made the right career choice. By 1981, half said they would not recommend the practice of medicine as highly as they would have a decade earlier.

Public opinion of doctors shifted distinctly downward too. Doctors were no longer unquestioningly exalted. On television, physicians were portrayed as more human—flawed or vulnerable (“M*A*S*H*,” “St. Elsewhere”) or professionally and personally fallible (“ER”).

As managed care grew (by the early 2000s, 95% of insured workers were in some sort of managed-care plan), physicians’ confidence plummeted. In 2001, 58% of about 2,000 physicians questioned said that their enthusiasm for medicine had gone down in the previous five years, and 87% said that their overall morale had declined during that time. More recent surveys have shown that 30% to 40% of practicing physicians wouldn’t choose to enter the medical profession if they were deciding on a career again—and an even higher percentage wouldn’t encourage their children to pursue a medical career.

There are many reasons for this disillusionment besides managed care. One unintended consequence of progress is that physicians increasingly say they don’t have enough time to spend with patients. Medical advances have transformed once-terminal diseases—cancer, AIDS, congestive heart failure—into complex chronic conditions that must be managed over the long term. Physicians also have more diagnostic and treatment options and must provide a growing array of screenings and other preventative services.

At the same time, salaries haven’t kept pace with doctors’ expectations. In 1970, the average inflation-adjusted income of general practitioners was $185,000. In 2010, it was $161,000, despite a near doubling of the number of patients that doctors see a day.

While patients today are undoubtedly paying more for medical care, less of that money is actually going to the people who provide the care. According to a 2002 article in the journal Academic Medicine, the return on educational investment for primary-care physicians, adjusted for differences in number of hours worked, is just under $6 per hour, as compared with $11 for lawyers. Some doctors are limiting their practices to patients who can pay out of pocket without insurance company discounting.

Other factors in our profession’s woes include a labyrinthine payer bureaucracy. U.S. doctors spend almost an hour on average each day, and $83,000 a year—four times their Canadian counterparts—dealing with the paperwork of insurance companies. Their office staffs spend more than seven hours a day. And don’t forget the fear of lawsuits; runaway malpractice-liability premiums; and finally the loss of professional autonomy that has led many physicians to view themselves as pawns in a battle between insurers and the government.

The growing discontent has serious consequences for patients. One is a looming shortage of doctors, especially in primary care, which has the lowest reimbursement of all the medical specialties and probably has the most dissatisfied practitioners. Try getting a timely appointment with your family doctor; in some parts of the country, it is next to impossible. Aging baby boomers are starting to require more care just as aging baby boomer physicians are getting ready to retire. The country is going to need new doctors, especially geriatricians and other primary care physicians, to care for these patients. But interest in primary care is at an all-time low.

Perhaps the most serious downside, however, is that unhappy doctors make for unhappy patients. Patients today are increasingly disenchanted with a medical system that is often indifferent to their needs. People used to talk about “my doctor.” Now, in a given year, Medicare patients see on average two different primary care physicians and five specialists working in four separate practices. For many of us, it is rare to find a primary physician who can remember us from visit to visit, let alone come to know us in depth or with any meaning or relevancy.

Insensitivity in patient-doctor interactions has become almost normal. I once took care of a patient who developed kidney failure after receiving contrast dye for a CT scan. On rounds, he recalled for me a conversation he’d had with his nephrologist about whether his kidney function was going to get better. “The doctor said, ‘What do you mean?’ ” my patient told me. “I said, ‘Are my kidneys going to come back?’ He said, ‘How long have you been on dialysis?’ I said, ‘A few days.’ And then he thought for a moment and said, ‘Nah, I don’t think they’re going to come back.’ ”

My patient broke into sobs. ” ‘Nah, I don’t think they’re going to come back.’ That’s what he said to me. Just like that.”

Of course, doctors aren’t the only professionals who are unhappy today. Many professions, including law and teaching, have become constrained by corporate structures, resulting in loss of autonomy, status, and respect. But as the Princeton sociologist Paul Starr writes, for most of the 20th century, medicine was “the heroic exception that sustained the waning tradition of independent professionalism.” It is an exception whose time has expired.

How can we reverse the disillusionment that is so widespread in the medical profession? There are many measures of success in medicine: income, of course, but also creating attachments with patients, making a difference in their lives and providing good care while responsibly managing limited resources.

The challenge in dealing with physician burnout on a practical level is to create new incentive schemes to foster that meaning: publicizing clinical excellence, for example (public reporting of surgeons’ mortality rates or physicians’ readmission rates is a good first step), or giving rewards for patient satisfaction (physicians at my hospital now receive quarterly reports that tell us how our patients rate us on measures such as communication skills and the amount of time we spend with them).

We also need to replace the current fee-for-service system with payment methods such as bundled payment, in which doctors on a case are paid a lump sum to divide among themselves, or pay for performance, which offers incentives for good health outcomes. We need systems that don’t simply reward high-volume care but also help restore the humanism in doctor-patient relationships that have been weakened by business considerations, corporate directives and third-party intrusions.

I believe most doctors continue to want to be like the physician knights of the golden age of medicine. Most of us went into medicine to help people. We want to practice medicine the right way, but too many forces today are propelling us away from the bench or the bedside. No one ever goes into medicine to do unnecessary testing, but this sort of behavior is rampant. The American system too often seems to promote knavery over knighthood.

Fulfillment in medicine, as with any endeavor, is about managing hopes. Probably the group best equipped to deal with the changes wracking the profession today is medical students, who are not so weighed down by great expectations. Doctors ensconced in professional midlife are having the hardest time.

In the end, the problem is one of resilience. American doctors need an internal compass to navigate the changing landscape of our profession. For most doctors, this compass begins and ends with their patients. In surveys, most physicians—even the dissatisfied ones—say the best part of their jobs is taking care of people. I believe this is the key to coping with the stresses of contemporary medicine: identifying what is important to you, what you believe in and what you will fight for. Medical schools and residency programs can help by instilling professionalism early on and assessing it frequently throughout the many years of training. Introducing students to virtuous mentors and alternative career options, such as part-time work, may also help stem some of the burnout.

What’s most important to me as a doctor, I’ve learned, are the human moments. Medicine is about taking care of people in their most vulnerable states and making yourself somewhat vulnerable in the process. Those human moments are what others—the lawyers, the bankers—envy about our profession, and no company, no agency, no entity can take those away. Ultimately, this is the best hope for our professional salvation.


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