Through a combination of mass misinformation, complete lack of curiosity and laziness, I am noticing of late a tendency of blind acceptance of the way things are. I see people who pass themselves off as “experts” exposing themselves as nothing more than stenographers of conventional wisdom. Any idea that makes anyone remotely uncomfortable must have dirt thrown on it and summarily dismissed.
Let me start the St. Patrick’s Day Weekend reverie by offering a different approach, that being hard work, logic and openness to ideas. As always, I’ll help us all get started with some clarity about the (cue the fireworks, waving flags and citizen salutes to the clouds) American Healthcare System, brought to you by….AMERICA!
I begin with a news release from this week. The Congressional Budget Office (CBO), which theoretically operates in a strictly actuarial capacity, put out a report this week that stated that based on budget estimates, and taking into account our aging population, spending for Medicare and Medicaid could double by 2022. As a reasonable person who likes to discuss how to improve things, my first instinct is to think of ways to avoid this. Since my first instincts are comedic and cynical, I think of quick fixes such as Senior NASCAR, raising the military volunteer age to 85 and a new game show called Canasta for Surgery, but I quickly see the possibly unpopular nature of these ideas.
However, I could argue that at least I’m offering ideas (however twisted) as to how to solve the problem posed by the CBO numbers. What we get from the people in charge of fixing it are recriminations about how everything would be great if the people on the other side of the aisle would just do it our way, plans to obliterate Medicare and Medicaid entirely or (as has been the case for the last 15 years) punting the problem down the road for someone else to fix. You will notice that none of these options remotely resembles a workable solution. We expect a high end pork loin from our legislation, and instead we get scrapple. I eat scrapple, but only because by the time I was old enough to figure out what was in it, I was already addicted, much like virtually every other thing that has been stuffed down our throats in this country over the past four decades.
At the time of his departure, I ruminated about Donald Berwick, the immediate past CMS administrator. Because one side of the political divide decided very early on that they would use Dr. Berwick for rhetorical target practice, Mr. Berwick remained mostly silent during his tenure as CMS Administrator, which ended back on December 2nd. No longer shackled by his office, Berwick has come out in favor of finding a comprehensive vision for the agency free of constant Congressional meddling, underfunding and chronic under-staffing.
In a widely disseminated article this week, Berwick was joined by a number of past employees of the agency voicing similar concerns, chief among them the fact that the average tenure of a CMS Administrator is 14 months. Given the staffing vacuum, it’s a wonder that any CMS initiative is introduced at all. CMS has 4,900 direct employees, with the balance of work farmed out to contractors (we all know my low opinion of MACs and RACs by now, I hope). Even counting the contractors, CMS’ staffing is dwarfed by the Social Security Administration’s 62,000 employees. To pay Social Security benefits, you wait until someone gets old, disabled or insane and you cut a check. Paying a Medicare claim is significantly more complex, but the government employs fewer people to do it, which gives us the abominable payment error rate of the program. Add on the dozens of health care initiatives going on at the agency right now, and we learn a new respect for the employees of CMS for trying as best they can to keep it all straight. If only the Legislative Branch of our government was as solutions-oriented, but there are TV cameras that require their attention.
Finally, I feel I need to respond to the lazy voices in the health information management community regarding my feelings on ICD-10. Among others in our field, I have raised the issue of our health care system preparing itself to step into a new paradigm of being left behind. After two decades of waiting, ICD-10 will be the standard sometime in the next two years (remembering that CMS has decided that they are delaying the October 1, 2013 compliance date). I suggested in 2008, and reiterated recently that ICD-10 should be skipped for ICD-11, given that the worldwide release date by the World Health Organization is now May of 2015.
The popular response to my suggestion, now being widely parroted by professional acquaintances, is three-tiered, with all levels of argument being so devoid of logic, curiosity and self-awareness that I feel I must now openly mock them.
The first response I get is that ICD-11 is based on ICD-10, and we can’t introduce the former without the latter. This one is as easy to punch holes in as Glass Joe in the classic arcade game “Punch-Out“. Version 5010 of the X12 billing standard was mainly designed for ICD-10. If ICD-11 is based on ICD-10, what’s the problem with skipping? Second, the American Association of Professional Coders (AAPC) is warning coders not to become too familiar with the ICD-10 code set until we get close to implementation. If virtually no one knows how to code a claim using ICD-10 currently, than we are not faced with a Labor of Hercules to skip ICD-10 in favor of the the newer global standard. You need a better reason than perceived codependence to convince me.
The second response sounds something like “CMS has so many initiatives going that are built around ICD-10 that adapting it is now inevitable”. As I pointed out earlier in this piece, CMS is understaffed. If the cost of waiting 18 months for the latest and best disease reporting system is that over-burdened CMS employees move on to other timely tasks, the inevitability argument begins to sound a lot like a cult preacher telling you that the end of the world is a week away and that he has something really tasty for you to drink.
Finally, there’s the third argument, which I’ll again puncture like the foil top on a bottle of antifreeze. There’s this belief that an American clinical modification of ICD-11 can’t be available until 2020. Bluntly, this is a lie borne out of acceptance of the current status quo in American Healthcare being the absolute best we can do. ICD-11 will include a clinical modification upon release. What the ICD-10 Final Rule was referencing when they put this idea forth was an industry-approved clinical modification which will enable insurance carriers of all types to more effectively deny claims. Given the long-standing abuses of Big Insurance, what provider advocate in their right mind would argue waiting for that?
Going from ICD-9 to ICD-10 with ICD-11 so close on the horizon has the effect of waiting in a line for 20 years for the expressed purpose of moving to another 20-year line. It displays the quitter’s mentality of someone who has given up asking questions and accepts things the way they are. As St. Patrick’s Day approaches, I know full well how good beer should taste. To those who’ve quit trying, I’ll ask one final question: what do defeat and red herrings taste like?
Paul Spencer will appear at the Fi-Med RAC Summit coming up on April 16th and 17th, 2012. Click here for more information about this unique education opportunity.

