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A Musical Look at Health Around The Globe

Posted by J. Paul Spencer, CPC, CPC-H in Health Care & Society

I don’t know what the typical physician thinks of the work I do, but there are times when I feel rather unimportant to our health care delivery system. I’m on the administrative side of this line of work. I don’t draw blood, I don’t auscultate the heart and lungs, I don’t perform any type of therapy and I can never respond to the cries of “Is there a doctor in the house?”, but I help physicians all I can to handle the “business’ side of healthcare.

When I try to justify the fact that when I was 6, I didn’t stare up into the sky and say “I want to be in medical coding and compliance”, I remember that at the root of this business is someone trying to help someone else and the scientific discipline of the function of the human body. So since this is an unscheduled stop in this space today (thanks to unscheduled absences last week), I’d like to take a look at health care news from around the globe as I listen to my specially-programmed music streaming service of ’80’s alternative music.

As Robyn Hitchcock cautions me about thinking I am in love, I see that Great Britain has identified only the 10th global case of coronavirus, a disease more familiar to 4-legged animal species. This particular patient spent time in the Middle East and Pakistan, which does something to solidify the belief in the medical community that the disease is transmitted to humans through bats and camels. The symptoms can parrot the respiratory indications for the flu, leading medical professionals to believe that many more cases could exist. Holding the skeptic’s heart deep within my rib cage, I have two takeaways from this, the first being that just as I suspected, getting a flu shot is at best a guess, and the second is that my belief that there is no good reason to go to the Middle East in the 21st Century now has medical science behind it.

As the Clash asks that age-old musical break-up question, the news keeps me in Great Britain, as the country deals with the sudden revelation that beef that has been imported for human consumption has turned out to be horse meat upon testing. Certain countries in Europe do consider horse meat as a delicacy, with England not being one of them. If that weren’t enough, some of the tested meat has revealed the presence of phenylbutazone, a painkiller that is strictly reserved for sporting horses. Authorities believe that the horses in question originated in Romania, a charge that that country denies.

Now, I am of the realization that the number of vegetarians in our country appears to be growing, if my friends are any indication. As long as you make that decision free of the misanthropic histrionics brought forth by PETA, I am not your enemy. Yet as a dedicated carnivore, even I find the idea of consuming the equine participants in a Carpathian steeplechase to be a new low. Britain has reached yet another crisis regarding the safety and sanctity of their food chain. The only blessing this time around is the fact that, unlike the past outbreak of Mad Cow Disease, there do not appear to be any broader health issues. If nothing else, it will make me take a second look at the next cheesesteak I consume when the opportunity arises.

Finally, as Joy Division tells me what will tear us apart, I read about the national birth rate of the United States reaching its lowest number ever, at 12.7 per 1,000 people. As a global fatalist, this is one time that I was actually proud of my country. Since the time of Thomas Malthus, we have known that human demand had the potential to far outstrip supply. Having thrown in the towel on the world’s powers wanting to do something about the situation that could be classified as a remedy, the only logical solution is to drop the birthrate. Of course, when it comes to educating people to stop procreating, we are dealing with hundreds of global belief systems that preach the exact opposite, but it is a bit of a relief to be (briefly) part of a country who appears to be getting the message, however slowly. As the world’s population rushes toward 7.1 billion, I wonder if it will make a difference.

So as the Stone Roses tell me that “She Bangs the Drums” (whoever “she” is), I remain but a small cog in the global health machine, but I continue to sit in wonder about the human body, the effect on it from outside stimuli and how long the planet will continue to tolerate the human presence, all of which is a long way philosophically from the CPT book that sits at my left hand.

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February 11th, 2013 | No Comments »

The HIPAA Tipping Point: Too Much Data To Keep Private

Posted by J. Paul Spencer, CPC, CPC-H in Health Care & Society

Among the many old television series that I have on DVD at home are all seventeen episodes of the 1967 British series The Prisoner. The show is about a secret government agent who resigns his position and plans an extended vacation, but is instead kidnapped, brought to a secure island known as “The Village” and assigned the identifier Number Six. Over the length of the series, a psychological conflict between prisoner and captor plays out, with Number Six stating that he will not be “pushed, filed, stamped, indexed, briefed, debriefed or numbered”, and the ever-changing Village leader, Number Two, trying all things possible to break his spirit and identity.

It is a curious mental quirk of the human animal that any one of us can travel to a place on Earth where there exists a large group of people and easily assimilate into it, while at the same time believing that each one of us is significantly different from one another. We are all human, yet unique. We step into the world with our left foot, having all the potential in the world and conclude our stride with our right foot having no potential at all. We are private, yet public.

Those of us in the health care arena have been dealing with the Health Insurance Portability and Accountability Act for 17 years since its passage. Originally conceived of in a time following the dark and nascent days of the AIDS virus, HIPAA began with the good intention of attempting to protect people with chronic diseases from employment and insurance discrimination. Thanks to insurance dollars, HIPAA “evolved” into a multi-headed administrative beast that outlined how health care data was to be saved, sent and secured. As we all pushed the HIPAA rock up the hill, we were promised that our health care data would be secure.

There were three variables that were not taken into account when HIPAA was designed: identity thieves, the internet and the amount of data that needed to be secured.

The first HIPAA violations leading to jail time were all “inside jobs”, with patients at hospitals and long-term care facilities having their identfying information stolen by employees for financial gain. This pattern continues to this day. At least one story from the many compliance police blotters that hit my inbox on a weekly basis talks about an inside identity thief run amok. As long as the motive for such crimes exists, solutions such as background checks will only temporarily bandage the problem.

The last two items on the list continue to confound the best security people in the industry. Two stories that came out in the last week highlight the challenge in rather stark terms.

In yesterday’s New York Times came a story regarding the hidden dangers of the internet. Since 2008, there has been an ongoing international research effort to catalogue genetic variations called the 1000 Genomes Project. Over 1000 DNA strands, consisting of billions of bits of genetic information from people in various parts of the world, are publicly available to researchers affiliated with the project. A genetics researcher selected five strands of American provenance at random. Armed only with the DNA strand, the age of the donor subject and the state in which they lived, the researcher not only correctly identified the five people who donated, but 50 familial relations of the test subjects who did not take part in the project. The researcher was able to do this based on Google searches and information available on genealogy websites.

If you do a search of “John Paul Spencer” on Google, the top three links you get are two to my long-abandoned MySpace page and my Facebook profile (at least until I clear my cache, and no, my Facebook profile is not open to the public). Click on ”images” and you find a few pictures of me with my guitar in my hands, as well as a bunch of random people named “John”. Thankfully, I have never taken part in such a research project as a test subject, with my mixed-breed DNA on display. Yet I go through each passing day naively thinking that the details of my life are private, while the internet quite obviously states otherwise.

The second story I am following has to do with the amount of data that needs to be monitored under HIPAA. California’s omnipresent healthcare behemoth, Kaiser Permanente, contracted with a small document storage firm in Indio, California in 2008 to clear out thousands of patient files from a recently-acquired hospital. The firm then began to receive e-mails from Kaiser employees requesting select patient records. The requests often included PHI either in the subject line or the body of the e-mail.

Kaiser and the firm are now no longer doing business with one another, as the firm brought Kaiser’s violations to light. In return, it was discovered that the firm stored two hard drives worth of patient information in an unlocked garage. Additionally, the warehouse where records were stored was shared with a party rental business owned by an outside entity for a period of time. Nearly 300,000 confidential hospital records were under the control of the storage firm.

If the ability to protect confidential information is now outstripped by the amount of data to be protected, HIPAA has reached a tipping point. At a population of over 315 million and climbing, and with virtually every one of those people expected to require health care at one point in their lives, I am reminded of Thomas Malthus’ ideas on population outstripping resources. Malthus argued that famine, war and epidemics covered up the fact that the Earth has limited resources to provide for humans on the planet.

The stories above leave a very important point unaddressed. Records can be stored electronically, but that server has to go somewhere. For the paper records still in existence, the problem is many degrees worse. We have reached a point where the storage capacity, along with the skill set of those who manage it, are no longer up to the task of organizing the information. Perhaps Number Six was right about not being pushed, filed, stamped, indexed, briefed, debriefed or numbered. Yet, rather than being a question of the strength of the individual, maybe it is because the size of his backstory is too damned big to fit into a file.

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January 18th, 2013 | No Comments »

Are You Ready For “Medpocalypse”?

Posted by J. Paul Spencer, CPC, CPC-H in Health Care & Society

My Facebook event invites have spiked lately.

In my capacity as a songwriter in civilian life, I tend to get invitations to all of the gigs in which my friends are taking part, but the latest batch of invites is something to behold. Most of them are for the end of this week, and every one of them mentions the Mayan Apocalypse. I live in Milwaukee, so it’s safe to assume that if all astronomical expertise in the field of science is suddenly proven wrong, and the calendar of a long-extinguished people actually comes to a fiery fruition, everyone in my vicinity will greet end times with a heavier-than-usual dose of alcohol. Celebratory music, at that point, would be redundant.

Instead, I’d like to talk about the end of a different world today. I’d like to talk about the oncoming Medpocalypse, which will represent the end of the American healthcare world as we know it.

The signs of the Medpocalypse will not be what we have been trained to expect from quantum physicists, desert-based religious tomes or inter-pyramidal drawings of extraterrestrial visitors possessing wisdom. It will not occur with a blinding flash of light or an asteroid impact. Rather, it is already happening, slowly, beyond the conscious knowledge of most of the public.

I’ll start with a prediction of things to come, and work backward. By January 1, 2038, I predict that there will be no non-profit hospital systems left in the United States.

Now that I’ve gotten that out of the way, let’s look at the current state of hospitals across the country. Unless a hospital is affiliated with other like institutions or an entity with deep pockets, it is operating on a financial knife-edge. Those of us in the industry have had several cheap laughs regarding the curious case of Pittsburgh-based West Penn Allegheny Health System and it’s on-again, off-again sale/acquisition to/by Highmark. Basically, a well-heeled insurance company wants to buy a hospital system, but only if it first declares bankruptcy, thereby discharging debt for Highmark’s shareholders prior to purchase. The result is finger-pointing, the involvement of legal teams and, eventually, the end of the health system, with the scavengers taking the rest.

Then we have the Patient Protection and Affordable Care Act, known in some quarters as “Obamacare” in an attempt to dually place blame and hang it like an albatross around the neck of the man that shares its name. Its history as the brainchild of the conservative Heritage Foundation is for some reason a distant memory, but the gist of the plan is mandating the purchase of health insurance for those who can afford it, and expanding Medicaid (you know, that insurance with the lowest payment rate EVER!) for those who can’t. That last part is optional for states, and there have indeed been states that have said that they will not be expanding Medicaid.

The purchase of insurance seems like a simple proposition, until you read a recent health insurance analysis from The Commonwealth Fund showing that worker spending on insurance premiums has gone up 74% since 2003, with the average family premium increasing 62% within that time period. Anyone, except perhaps for the average CEO of a not-for-profit hospital system, can tell you that this percentage far outpaces wage growth in the same time period.

With regard to Medicaid expansion, the states deciding against it threaten the health of not only neighborhood hospitals in cities, but also the health of critical access hospitals, as the dirty little secret of the “cycle of dependence” is that it hits rural areas at equal or higher rates that urban dwellers. These hospitals, it goes without saying, are not for-profit enterprises. 

Remember that these types of hospitals are already fighting off RAC auditors with skeleton crews, with legislators in Washington not the least bit interested in the results. Why, you may ask? Because not-for-profit hospitals are not the ones filling their campaign coffers. Their benefactors are from insurance companies, for-profit hospitals and the pharmaceutical industry. If insurance companies are purchasing hospitals, the smaller facilities don’t stand a chance.

So far, the RAC activity has come on the Medicare side, but the Medicaid RAC program has begun in earnest in many states. Because Medicaid RAC contractors are not obligated to publish a targeted issues list, providers have no idea either what will be audited or what the financial impact of those audits will be. I shall continue to ask the following question: is it advisable, 13 months before a vast Medicaid expansion, to bring forth contingency fee-based audit activities for Medicaid providers whose continued participation in the program is vital to health care reform as it is currently written?

With the increasing shortage of primary care physicians, CMS has begun a program of bringing doctors out of retirement to fill vacancies. Yet as a recent Washington Post story pointed out, facilities are coming to grips with determining how old is too old in a climate where 42% of our nation’s physicians are over the age of 55.

The judgment of practicing physicians is already being challenged by nurses and physicians of different specialties who have thrown in the towel and have decided to cast their careers into the hands of insurance companies. With these same corporations buying hospitals, how long will it be before the desk jockey MDs with a corner office in an insurance company ivory tower begin to work again as practicing physicians in insurance-owned death camps? (Did I say death camps? Of course I meant to say ruthlessly-efficient corporate satellite offices with private rooms. That must have been a mental slip).

All of this leads back to my earlier prediction. The political and financial winds of healthcare reform are not favoring non-profit systems. Rather, they are headed in the direction of corporate interests, the budgets for which always set aside enough money for lobbying and seeing that their continuing profitable existence is the primary political objective in Washington. The public at large, all of which morph into patients eventually, suddenly appear to reap no benefits from health care reform, but given all of the invisible players in this drama, I am no longer surprised to find out that patient well-being wasn’t the objective after all.  

Contrary to statements from our government, the Medpocalypse has now begun. Unless your underground shelter has a fully-staffed ER, nothing can save you.

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December 17th, 2012 | No Comments »

Meanwhile, In Another Part Of The World…..

Posted by J. Paul Spencer, CPC, CPC-H in Health Care & Society

In the lead-in to this year’s presidential election, the major party political conventions have now come to an end. The remnants of streamers, signs and deflated balloons are swept off the convention floors while button-festooned Americans of every stripe (reeking of alcohol & carnal pleasures and with pockets newly lined with blood-stained lobbying dollars) return to their home towns to begin to rapidly delete digital photographs from their cell phones.

If you had the stomach to follow the coverage of the speeches delivered at both conventions, you heard a lot of talk about our healthcare system, and this shouldn’t come as a surprise. With the recent inevitability placed on the Patient Protection and Affordable Care Act by a narrow Supreme Court decision, we heard one side celebrating its passage and the other side swearing a blood oath to repeal the law in its entirety.

For purposes of illustration, I am now juxtaposing this ongoing battle on our shores with recent news out of China regarding their healthcare system. The government of China announced that they are dedicating $63 billion through the year 2020 into their healthcare system. The money will be directed to seven key areas in the hopes of bringing order to a chronic disease problem that has run rampant in China. It is estimated that 100 million people in the country have contracted chronic diseases since 2002, with 85 percent of deaths and 69 percent of healthcare spending attributed to this pool of patients.

While it is impossible to have an apples-to-apples comparison of healthcare systems based on the differences in the governments of the two countries, it is interesting to see a major world government at the very least acknowledge that there is a chronic health problem within their borders.

With all the arguments that have raged regarding the costs of healthcare in the United States, it is virtually impossible to get any policy maker from either party to state publicly that our country is overweight, overfed, sick and getting sicker. We are lampooned internationally for our consumption in many areas, but none may pose such a threat to our ongoing existence as the insatiable appetite for food. Type II diabetes rates have spiked, and with it the attendant miseries of the disease. The costs of treatment are going up, along with our waistlines and our need to apply Crisco to our hips in order to comfortably fit through doorways.

I have many reasons not to care for China. I snickered a little when I read the above article and saw that some of the monetary investment was going to be directed to promoting “psychological disease prevention”, as history teaches us that phrases such as this can be open-ended in a Communist country.

Yet we must read this in the context of a government like China’s never acting on any issue unless it is viewed as a benefit to the state. While dictatorships rarely let the outside world hear about their weaknesses, an announcement such as this is China’s acknowledgement that they can no longer ignore the threat that a sick population poses to their booming economy. One wonders what it would take to get the same type of public acknowledgment on this side of the world.

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September 7th, 2012 | No Comments »

The Age of the Phantom Menace

Posted by J. Paul Spencer, CPC, CPC-H in Health Care & Society

The best films classified as “psychological thrillers” usually feature a main character who walks among the civilian population in an unassuming fashion. Hannibal Lechter, as portrayed by Anthony Hopkins in Silence of the Lambs, wasn’t insane to the blind eye, but rather revealed his insanity slowly to an unsuspecting population susceptible to good manners.

We spend a lot of our time – thanks to force of habit, the nightly news and actuarial tables – attempting to protect ourselves from unseen threats. From reckless drivers, to the food and drink we consume, to pucks and balls that often leave the field of play, we like to think of ourselves as prepared for the threats that surround us. Yet the truth is, as was so eloquently stated in the famous episode of The Mary Tyler Moore Show in which a beloved clown, dressed as a peanut, is killed by a rogue parade elephant, “Somewhere, there is an elephant with your name on it”.  

There are two bits of news out today that remind me in stark terms that threats to our health and safety walk among us, invisible, until we realize it is too late. We all woke to the news out of Aurora, Colorado this morning regarding the mass shooting at a midnight showing of The Dark Knight Rises!, leaving at least a dozen dead. This story is developing, so I’d like to set this aside for a story closer to my realm of health care.

Yesterday in Massachusetts, a former cardiac catheterization tech at Exeter Hospital in New Hampshire was arrested on federal drug charges. This stems from his habit of stealing syringes full of the anesthetic fentanyl, injecting himself with same and refilling the syringes with saline. These syringes were later used on patients during procedures. The 33-year-old technician was charged while in a Massachusetts hospital being treated for hepatitis C. Since the person in question was a “floater”, doing similar work for hospitals in six additional states, authorities are just beginning to determine the extent of the damage to the health of the affected patients and those around them. It more than likely offers no solace to those who have and those who have yet to be diagnosed that the technician in question passed drug tests before working at Exeter Hospital.

When assessing threats to our well-being, we don’t tend to think of movie theatres and hospitals as hot spots that become tests to our survival, which makes these news stories all the more shocking. There is no preventive cure for a lone gunman in a movie theatre, and as we learned a few weeks ago, this country’s hospitals have a long way to go with basic infection control, far beyond the sudden threat of a drug-abusing cath tech.

Yet we know that basic peaceful interaction is integral to our ongoing planetary presence. Humankind was not designed to live in the outside world contained within a Kevlar bubble. The insane and the irresponsible rarely wear flashing name tags to warn us that our safety is threatened. The news from the last 24 hours is indeed bleak. It is sometimes painful to realize that The Phantom Menace is more than just a poorly written summer blockbuster, but if you’re reading this, you still have now. It might not hurt, as we approach the weekend, to take a moment, stand back, take a larger deep breath than normal and make sure that the minuscule moments without life-changing events are the ones worth remembering.

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July 20th, 2012 | No Comments »

The Return of Liniment and Leeches?

Posted by J. Paul Spencer, CPC, CPC-H in Health Care & Society

We live in a world of hyper-progress. I exist in a country that has turned the idea of “planned obsolescence” into an art form. As a glaring example, it was only 26 months ago that Apple’s first version of the iPad went on sale in the United States. Chances are, if you still own an inaugural version of this device, there are many things that it can’t do in today’s data infrastructure, leaving you frustrated. With each passing day, things that surrounded me have disappeared completely, never to return. Some things I miss, but I chalk up not seeing them as the price of progress. I also accept it as an inevitable cloud that grows ever larger over the aging process.

The human being, as it relates to the idea of obsolescence, is another matter entirely. In a famous episode of The Twilight Zone, Rod Serling provided a coda that said “any state, any entity, any ideology that fails to recognize the worth, the dignity, the rights of man, that state is obsolete”. Coming as it did in the days of the Cold War, this could be translated as an attempt by one political side to point out the anachronistic approach of their main political antagonist, in this case the Soviet Union. Yet the aging of any organism, at some point, will reach such a point that normal function and evolution, for all intents and purposes, stops.

In human beings, life itself is not the only thing that slams on the brakes. Every one of us who is employed hopefully goes forth with the realization that the skills and tools that we have used as part of our working lives will someday become obsolete. Because I am surrounded by the world of medicine, I think about the evolution of procedures and diagnostic tools, as well as treatment methods. Technology and intensive study have broadened the horizons of medicine at a faster rate than ever before. Consider for a moment that the 1926 Nobel Prize for Medicine went to Johannes Fibiger, who believed that parasitic worms were a direct cause of cancer. It took only a few years to determine that his theory was incorrect, and looking back on it 86 years later, knowing what we now know about cancer, the thesis seems particularly outdated.

Harboring all of these thoughts in my mind on a daily basis (along with sports statistics, band lineups from the 1960’s and other random bar trivia facts), it was with particular interest that I read a piece of proposed legislation from the House of Representatives. Last Friday, the Physician Reentry Demonstration Program Act was introduced by suburban Baltimore congressman John Sarbanes. If enacted, the law would establish a demonstration project for retired physicians to re-enter the working world as primary care providers. Specifically, the law would issue grants to encourage the creation of programs that assist physicians in transitioning back into clinical practice. Databases would then be created for the programs. In addition, assistance would be offered to granted entities for assessment and credentialing of physicians reentering the patient care world. The bill focuses on physicians who have been out of their area of specialty for two years or more.

Because the country is facing a critical shortage of primary care physicians, particularly as the Baby Boom population ages, Sarbanes’ legislation can be viewed as an honest attempt to address the problem, but knowing what I know about the world of physicians, I have a couple of questions. First, after one full year of inactivity, any Medicare provider is automatically terminated from the program. If that provider wants to resume billing the Medicare program, he or she must begin the credentialing process again, with new numerical identifiers being issued to that provider. Anyone who has dealt with the wonder and the majesty of the latest version of the Medicare credentialing process can tell you that it is anything but succinct. Additionally, with identity theft being at the root of many Medicare fraud cases, what controls would need to be put in place to ensure that the retired physician coming back into the clinic isn’t actually an elaborate front for criminal activity?

Second, in a world of hyper-progress, when merged with the inevitable truths related to the passage of time and its unavoidable effects on an organism, how quickly can a reentering physician be trained and brought back up to speed with present-day clinical protocols? Suppose for a moment that a paradigm shift occurs for primary clinical practice in the interim time between retirement and rehiring. This isn’t as difficult to imagine as you may think. Prescription drugs appear and disappear with increasing rapidity and genetic testing holds the promise of fundamentally changing existing treatments for long-established conditions. The suddenly-reintroduced clinical physician may find himself or herself at a critical disadvantage at a time in his or her life that is not particularly conducive to change. Suddenly, liniments, leeches and carbolic smoke balls aren’t going to cut it.   

Sarbanes’ bill is very much a first draft, and his party affiliation, as it applies to the current political makeup of the House of Representatives, promises a rocky road for the proposed legislation. Yet even in the absence of CAS (Congressional arteriosclerosis; I just thought that up; evolution!), the realities behind Sarbanes’ modest proposal may sentence it to an eternity in the starting gate. Chalk another one up to progress.

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June 8th, 2012 | 1 Comment »

American Healthcare: Fighting Through Red Herrings

Posted by J. Paul Spencer, CPC, CPC-H in Health Care & Society

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.

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March 16th, 2012 | No Comments »

OIG Report Provides Dark View of the Afterglow

Posted by J. Paul Spencer, CPC, CPC-H in Health Care & Society

Like every other person for whom the majority of his or her life exists as fading objects in a rear view mirror, I have a tendency to think about the world that has surrounded me during my existence. On the surface, I should have a very hard time thinking fondly about the 1990’s. I spent the first half working in the insurance industry and the second half ensconsed in a slow-motion traffic accident of a first marriage. Yet the one thing that the ’90s had going for it was a brief window of time when the country was seemingly free of a big threat to its existence. From the moment in 1989 when the Berlin Wall was torn down, to September 11, 2001, the United States enjoyed a time when thoughts of the sudden annihilation of a large portion of its population did not hang over every major decision.

The 9/11 attacks had the effect of changing that perception for the balance of my life. I remember having a conversation a few days after the attacks with someone I knew at the time, talking about how best to prepare for similar incidents in the future. I felt that every community should have a disaster plan similar to the air raid wardens of World War II or the nuclear attack drills of the 1950’s, which would integrate public employees and buildings, along with the local health infrastructure, to provide an organized and coordinated response to such incidents.

Instead, we received the “War on Terror”, color-coded paranoia and the Big Brother-esque overreach of the Patriot Act. I stopped being optimistic shortly after that. Perhaps it’s my tendency to watch old post-nuclear science fiction films during my late-night fits of insomnia that informs my decision making, but when I heard the head of the Department of Homeland Security tell me that my best defense against future attacks was plastic and duct tape, I was immediately skeptical about our country’s ability to handle future disasters.

It was with all of this in mind that I read a 44-page report released this week from the OIG entitled Local Public Health Preparedness for Radiological and Nuclear Incidents. The report was commissioned based on the belief of our current national security apparatus that the greatest danger to America is a terrorist attack utilizing a nuclear weapon. To assess planning and coordination in the event of such an incident, the OIG requested information from 40 localities from around the country, representing the largest metropolitan areas in and around cities in 23 states, totalling just over 50% of the total population of the United States. The findings of this report clearly show that preparedness for radiological and nuclear incidents is far behind where it needs to be.

Thirty-six of the 40 surveyed localities have conducted some type of risk assessment for a disaster. Because the OIG report did not specifically name the four localities that did not, I am unable to tell anyone specifically to begin digging holes for your survivalist bunker. Of the 36 that did conduct a risk assessment, 30 specifically identified non-power plant related radiological/nuclear incidents as a threat, with 24 of those determining the specific threat level. Taken as a whole, this means that there are 16 major population centers in the country that have not fully determined the risk of a nuclear attack in their area. Only four of the 40 localities have identified radiological incidents as a high-priority threat, but only one had a specific plan in place to respond to such an incident.

The OIG assessed the preparedness of each locality in five areas of responsibility in public health: Monitoring of the population for exposure, decontamination, planning for laboratory analysis, fatality management and communications. Only 21 of the forty had any sort of public health plan in place in case of a nuclear incident that encompassed any one of these areas, but only two localities had plans that included all five. Perhaps the scariest thing to me was that only 8 major population centers in the United States have fatality management plans to limit the amount of exposure to the surviving population emanating from those that will have already perished in such an attack. Knowing this bit of information suddenly reminds me that thoughts of a zombie apocalypse are not as rib-tickling as they were prior to the release of this report.  

When the issue of greater coordination with federal, state and local partners was assessed, only 16 localities have plans that coordinate with any one federal department, with 10 coordinating with their state agencies and 14 coordinating with local entities such as hospitals, county health departments or other emergency medical personnel.

Taking all of this information into account, I have determined that the community health plan for most population centers in the event of a nuclear event consists of three steps: hoping for survival, fitting your vehicle with a plow attachment to move the bodies out of the street, and concluding with more hope for survival. I know it’s hard to see my face in that this is written material, but it is important for you to know that I didn’t crack a smile when I wrote that last sentence.

Chances are fairly good that when you drive home tonight, you’ll pass an older public building with a faded sign that says “Fallout Shelter” on it. There was a time in America, corresponding to the existence of a country known as West Germany, when that sign was brand new, painted a bright yellow, with everyone in the community having acute awareness of what it meant. Perhaps you’re even old enough to remember a “duck-and-cover” drill, the CONELRAD system, the letters ”CD” standing for “Civil Defense” rather than “Compact Disc” or some other quaint custom that kept the idea of the dangers of radiation exposure in the forefront of your mind.

Since this is a health care forum, I ask the reader to save a thought for how they believe their local health infrastructure would respond to such an attack. We find ourselves in an era of consolidation of health care resources under the ACO model that is designed mainly to reduce cost. While IT initiatives have mentioned such things as better coordination of care and improved public health reporting, all of these good intentions will crumble during a cataclysmic event without a disaster plan in place in the communities surrounding the hospitals. The OIG report shows that many areas don’t  have one that is adequate. Additionally, if the recent breakup of the band REM didn’t already drive the point home for some of you, know that the relatively tranquil and naive days of the 1990’s are an increasingly distant memory on the roadways of our lives.

Paul Spencer will be a presenter at the Fi-Med RAC Summit in Milwaukee, WI on April 16th and 17th, 2012. Go to the Summit website for further information on this unique educational opportunity. Use promo code “SPENCER” to receive $50 off the registration price for a limited time.

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January 27th, 2012 | 1 Comment »

High Tech & Health: Of Cholera, Cars and Clairvoyance

Posted by J. Paul Spencer, CPC, CPC-H in Health Care & Society

Today marks the final day of the Consumer Electronics Show (CES) in Las Vegas. For four days every January, thousands of electronics firms display gadgets of every kind for seemingly every purpose. Some of the wares are destined to saturate the market, while some return to the their makers, never to be seen again.

In the last 50 years, technology has changed the way we live. Other than what surrounds us in our homes, institutions such as aviation, public libraries and finance have seen paradigm shifts thanks to the core technologies at the heart of their operations. Perhaps no other sector has been altered quite like the world of health care.

Over the past few days, with CES’ shadow looming over the landscape, a few indicators of the changes that have either come to or are on the horizon for health care came to light.

The first was a study appearing in the American Journal of Tropical Medicine and Hygiene (now THAT’S specialized) that looked at the role of social media in the reporting of the post-earthquake cholera outbreak in Haiti in 2010. Given the ubiquitous nature of Twitter, the study looked at “tweets” emanating from the quake zone in the time leading up to when the outbreak was widely reported by the news media. What was discovered was that Twitter users were reporting the cholera outbreak and bringing forth case data to the world a full two weeks before then outbreak was widely reported.

This story teaches us that in bold terms that the news cycle is evolving to “up-to-the-minute” faster than any of us anticipated. In the case of a disease outbreak, time between identification and treatment can prevent further loss of life. With the threat of pandemics such as SARS and avian flu over the past decade, we now have scientifically-vetted proof that social media can play a very important part in shrinking that time frame.

Part of CES is what is called a “Digital Health Summit”, where a particular innovation or initiative takes center stage during the keynote address. This year was no different, with Ford Motor Company stating that they are partnering with Microsoft and two other tech companies to design a car that will monitor the driver’s health while traveling.

In reading this item, I was immediately reminded of my car trip this past summer that saw me drive from Milwaukee, WI to St. John’s, Newfoundland, Canada and back. In particular, the drive back became what I can only describe as driving between memory gaps. After setting off at 7 AM in St. John’s, I had planned to stop for the night on a Thursday in Moncton, New Brunswick after 12 hours of driving across Newfoundland, 7 hours on a ferry and roughly 5 more hours on the road from Northern Nova Scotia. What I didn’t count on was that apparently Thursday night is “Take Your Mistress Out To Dinner Night” in Moncton, as every hotel room in the town was booked. What followed was 22 more consecutive hours of driving from Moncton to Milwaukee, with stops only for gas, fast food & caffeinated beverages on the New York Thruway and moose hallucinations along the darkened roads of Maritime Canada. Somehow, I arrived safely in Milwaukee at 2 in the morning on a Saturday.

It would have been nice to have had a car that knew I was seeing antlered mirages, so it could shut off and pull over to the side of the road until it detected REM sleep. I hope that Ford follows through on their concept, not just for the exhausted, but for the drivers with health risks that could pose a hidden danger to themselves and other nearby motorists.

The last bit of technology news borrows something from the dark arts of psychic phenomena. On the heels of a study at the University of California-San Francisco which covered development of useful prognostic indicators for older adults, a new website has been created to help create a mostly accurate estimate of an elderly patient’s remaining life expectancy. While planning end-of-life care is a neglected part of the health care debate in this country, there is something about this technology that sends a shiver up my back. One of my all-time favorite short stories is “Imagine A Day At The End Of Your Life” by Ann Beattie. Someday, when my time comes and with the help of this website, I’ll not only be able to imagine such a day, but I may very well be able to mark it on a calendar. Having always believed that life doesn’t include a two-minute warning, I shall look deep within myself in the intervening years to decide how I feel about such a website.

The lightning pace of technological innovation has brought dramatic change to the science of medicine. It would be naive to think that the emerging technologies indicated above are simply novelties, as for every failed invention comes the spark of furthern imagination. Upon my retirement 25 years from now, it is very possible that one or all of these current technological leaps will be considered a quaint stepping stone to what exists at that future moment in time.

Paul Spencer will be presenting at the Fi-Med RAC Summit in Milwaukee, April 16-17, 2012. Go to the summit website for further information. Use promo code “SPENCER” to receive $50 off the registration price for a limited time only.

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January 13th, 2012 | 1 Comment »

The (Actual) Value of a Health Care CEO

Posted by J. Paul Spencer, CPC, CPC-H in Health Care & Society

As it pertains to the weather, Wisconsin just completed a rather mild Autumn. As compared to previous years, the usual seasonal chill was a late arrival. As unseasonably warm as it was, it didn’t appear to have an effect on the chilly relations between the two prevailing sides in our ongoing political and economic debate.

Taking advantage of this year’s strange weather window throughout the Fall, the “Occupy” movement attempted to shine a spotlight on income inequality between the 1% at the top of the ladder and the balance of America. Yet if we were to rely solely on cable news commentary regarding the optics of a billionaire mayor of New York ordering the police to clear Zuccotti Park near Wall Street, we would learn that there is nothing wrong with the economic system, no one knows what ”these people” want and the protesters were just making a mess and needed to leave.

Since the dawn of “trickle-down” economics nearly 31 years ago, CEO salaries, as compared to the employees they direct, have not skyrocketed, for that verb doesn’t go far enough in describing what has happened. Rather, CEO salaries are on a trajectory of a deep space probe to planets several million lights years from our own. We need only consider the six heirs of Sam Walton, the founder of Wal-Mart, who have as much wealth as all people at the bottom 30% of the economic ladder in the United States.

While nowhere near the level of the CEO of Wal-Mart and the salary of their aging, cat food-consuming greeters, the realm of health care is not immune from income disparity and inflated CEO pay. According to a report on 2010 CEO salaries released by the research group GMI Ratings, the two highest paid CEOs in 2010 were in the health care field. If we expand it to the top 10, we also find the outgoing CEO of Aetna and the CEO of CVS, a retail chain that makes at least a portion of its profits through its pharmacy operations within its stores.

While not in the top 10 or generally on the radar of the public at large, the salaries of hospital CEOs have been under the microscope as part of the sudden discovery of wide income separation.

The champion in this club in my region is one Dean Harrison, the CEO of “non-profit” Northwestern Memorial Hospital in Chicago, who made $10 million in 2010, $7.5 million of which was a one-time payment due to vesting of his “supplemental executive retirement plan”. When I think “supplemental”, I tend to think of the Vitamin D I take ever morning due to the cloudy weather in Milwaukee. I don’t tend to think of a hospital-bestowed lottery ticket. To further add context to this particular compensation package, Northwestern Memorial owns Prentice Women’s Hospital, a non-profit facility that lost its property tax exemption status in Illinois last year because the state Department of Revenue determined that it wasn’t providing the adequate level of charity care. Prentice subsequently increased the level of such care by over 50% from the previous threshold.

Whenever the wide gulf between the highest paid and lowest paid worker is in the spotlight, I hear the same tired refrain from those at the top, which thanks to the “folk process”, goes something like this:

“In today’s marketplace, in order for a company to remain competitive, we need to be able to attract the top talent. To not do so would be a risk to the organization’s ongoing well-being.”

One hospital CEO even added to that recently, stating unabashedly and without the slightest hint of irony, that his $3.6 million annual salary “..isn’t going to affect your health care cost.”

Do you know what else is a risk to the ongoing well-being of your hospital and its operations? Employees who can’t take a sick day because they either can’t afford to miss a day of work or their health insurance is actually only an insurance premium generator, leaving them with large out-of-pocket expenses if they actually get sick, which ends up discouraging them from seeking any care. Instead, they come to work at your hospital, which expands the risk to the patients paying health care dollars that eventually end up in the pocket of the CEO.

The very idea of “trickle-down” economics is incredibly insulting; return all tax revenue to people at the top of the ladder, then, when the lords and viscounts decide to throw a few doubloons to the peons, maybe you’ll get yours. Oh, and if you’re not working yourself up from fry cook to the executive boardroom, despite the fact that all that top-tier tax revenue was taken from your local school district, leaving you without the requisite skills to get there, you’re just being lazy and deserve your lot in life of barely keeping your head above water. That is assuming that you haven’t succumbed to the rising water already (*cough* Ninth Ward in New Orleans *cough*).

If nothing else, the idea of income inequality is now front and center, thanks to the Occupy movement. Were it not for similar gatherings across the country, this week’s tax kabuki in Congress may not have received the attention that it did. The issue of CEO pay in the health care field, an industry that odds are will be accessed by every citizen of the country sometime in our lives, is one that needs to move from the realm of idle economic curiosity to front and center of the current debate over the nation’s wealth divide.

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December 23rd, 2011 | 2 Comments »

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