It has been my habit in the past to begin my weekly dissertations in this space with amusing anecdotes and random thoughts blurted out from a brain long since “modified” by a habit of sleeping roughly 4 hours per night for many years. Instead, in order to jolt you into the content about to follow, I shall precede the guts of today’s post with this brief but powerful musical interlude, which features Donald “Duck ” Dunn, bass player extraordinaire (easily in my top 5), who passed away this week.
Now that we have that out of the way, let’s talk about the latest in a long line of proposed rules for an ICD-10 compliance date, the comment period for which expired last night at 11:59 PM. As promised, I submitted my comments yesterday afternoon, which I have decided to post in this space as well as on regulations.gov. It is a healthy mix of seasoned opinion and “poking the bear” that states my views on the proposed, revised compliance date of October 1, 2014:
RE: CMS Proposed Rule, File Code CMS-0040-P, Docket ID: CMS-2012-0043
I wish to submit the following comment on the above proposed rule. Specifically, I would like to address the portion of the Proposed Rule regarding the revision of the compliance date of ICD-10 from October 1, 2013 to October 1, 2014.
It is with particular disappointment that upon reviewing the Proposed Rule, one again CMS is committed to a path that will lead to the United States being on a lower tier internationally with regard to symptom, disease and morphology reporting.
As was stated in the Proposed Rule, CMS rejected the idea of moving directly from ICD-9 to ICD-11, scheduled for release by the World Health Organization in May of 2015, which is notable for being only 8 months after the new proposed date for ICD-10 compliance. This two-paragraph rejection of such a move was footnoted by two recent industry articles, which indicated that a clinical and procedural modification would “take anywhere from 5 to 7 years for the United states to develop its own ICD-11-CM and ICD-11-PCS versions”.
During the original Proposed Rule comment period in late-2008, leading up to the Final Rule in January, 2009, I submitted a comment regarding the oncoming implementation of ICD-10 (then slated for October 1, 2011 in the Proposed Rule). Commenting on the original proposed date of October 1, 2011, I stated that the United States “will have finally caught up to the rest of the world in its reporting structure, only to see that disappear within three years as the world begins to use ICD-11”. With the proposed release date for ICD-11 now appearing a mere 8 months after the proposed date, I again state that I am in favor of moving directly to ICD-11 from the current outdated standard.
The industry articles cited in the new Proposed Rule under footnote 48 had arguments that fell into two lines of thought, the first being the expense and time already spent planning for ICD-10 implementation, and the processes that would need to happen to move our current system to ICD-11. I would like to address the first of these two articles, which involved the costs and time already dedicated to ICD-10. The article states that work first began in 1993, and concludes with the statement “We could have skipped ICD-10 in 1993-it’s a bit late now”. This appears to me to be a facetious argument, as the planning for the succeeding code set, ICD-11, did not begin until roughly a decade later. If the overarching argument of the article is that the amount of time and dollar investment now necessitates the country staying behind the global health care curve, I am having a hard time fathoming why CMS finds the article worth quoting, if CMS’ current mission to modernize our health care system is in earnest.
The other main argument against ICD-11 implementation appears to be the idea of being unable to bring forth a “clinical modification” acceptable to stakeholders in the American health care system. The original final rule for ICD-10 released in January of 2009 offered an implementation date of 2020. There are now estimates being put forward of ICD-11, after American clinical modification, not being released until as late as 2030. The previously quoted article in the new proposed rule offers an implementation date of 2024.
CMS has stated very clearly, both with words and with a host of payment reform initiatives that the Centers wish to connect reimbursement for services with patient outcomes. Given that ICD-11 interfaces with SNOMED-CT as part of its design, and given that a global clinical modification will be part of the ICD-11 code set upon release, I see little reason to attempt to modify ICD-11 after release in order to make it fit into the current payment models in the United States if CMS’ goal remains as stated. ICD-10 has been modified for our current payment model, and based on its design dating back to the late-1980’s, allows for better reporting for reimbursement, rather than better reporting for clinical outcome. I posit that it is time to abandon the idea of a uniquely American clinical modification so that we as a country can begin to report diseases, symptoms and morphology in a way that is conducive to bringing forward better outcomes.
I am more in agreement with another recent article on this subject, which was penned by five physicians, one of whom happens to be a member of the ICD-11 Revision Steering Group for the World Health Organization. The opinion of this article is that if ICD-10 is to be the standard for the immediate future, that a delay of one to three years in the implementation date be enacted, but with the understanding that planning for ICD-11 implementation begin immediately. I would like to go a step further and state categorically that in order to stay true to CMS’ goal of aligning payment with outcomes, the ICD-11 code set, as scheduled for release by the World Health Organization, should be accepted without further modification as the reporting standard for the United States.
I then signed off, with name, rank, serial number, shoe measurements and other pertinent information.
Originally, ICD-10/ICD-11 was going to be my only topic today, but I came across a study yesterday in my daily search for new information that is instructive with regard to one of many sore subjects in the healthcare debate. According to a joint survey by the Overseas Employment Development Board (who?) and a private company called Jackson Healthcare, physician compensation in the United States is equal to 8.6% of total healthcare spending in this country. Compared to the healthcare systems of seven other industrialized nations, only Sweden and New Zealand, at 8.5% and 7.35% respectively, had a lower percentage of healthcare spending going to physicians.
On the surface, one might be tempted to cry for the poor American physicians, until we take a closer look at the numbers, as well as the populations of the countries listed in the survey. There were eight countries measured in the survey, with data from Australia, Canada, France, Germany, New Zealand, Sweden and the United Kingdom joining that of the U. S. When we look at total healthcare spending, we see that the combined healthcare expenditures of these countries equals only 38% of the total healthcare spending of the United States. For more perspective on the numbers, I also notice that the $216 billion dollars paid to American physicians is higher than the combined healthcare expenditures of Australia, Canada and New Zealand.
Yet population differences tend to cleanse these figures somewhat. The United States is the third largest country in the world in terms of population, trailing China and India by a good distance. The closest country in terms of population in the survey was Germany, but the total population of Germany only represents roughly 26% of that of the United States. In fact, the United States is roughly ten to fifteen percent higher in population than all seven countries combined. By virtue of our size and dollars spent, the 8.6% number could almost be admirable, but the amount of waste in our system, coupled with the knowledge that 13.9% of America’s gross domestic product is spent on healthcare, makes any admiration fleeting.
As I try to gain control of these and other random thoughts, I leave you with the above points to ponder as the weekend approaches.