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If HHS Delays ICD-10 Long Enough, Could the U.S. Adopt ICD-11 Instead?

Feb 19, 2012• 1

By Tom Sullivan

The case for leapfrogging ICD-10 and holding out for ICD-11 just got a lot more curious. And though it’s not here yet, when ICD-11 is ready, it will be something ICD-10 cannot: A 21st Century classification system.

Now that HHS Secretary Kathleen Sebelius has thrown her department’s hat in the ring, saying late Wednesday that HHS intends to delay ICD-10, the most pertinent question is how long will HHS push back compliance?

“My opinion is that CMS won’t be able to announce three months or six months of delay for ICD-10,” says Mike Arrigo, CEO of consultancy No World Borders (pictured at left). “They will need to announce a delay from October 1, 2013 to at least October 1, 2014 because of CMS fiscal planning calendars.”

Others in the industry are suggesting that even one year is not enough to lighten the burden on physicians, providers and payers enough to make the transition smoother.

“I have a gut feeling they’ll go for two years, who knows?” speculates Steve Sisko, an analyst and technology consultant focused on payers and ICD-10. “Maybe January 2015?”

No more mixed signals

There it is on the Department of Health and Human Services Web site, a crystal-clear headline atop a brief explanatory statement: HHS announces intent to delay ICD-10 compliance date.

“We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead,” Sebelius said in the statement. “We are committing to work through the rulemaking process, with the provider community, to reexamine the pace at which HHS and the nation implement these important improvements to our healthcare system.”

Anytime We Consider Anything Less than Everything, We Are Missing Something.

Feb 18, 2012• 1

By J. Paul Neeley

When we design today, we isolate problems and then create solutions for them, and we then celebrate those solutions. But in reality we have no idea exactly what we’ve done, because in focusing on any particular problem we have really just ignored everything else. We have failed to engage with the complex realities of our interconnected world, and in our attempts at solutions have only created more problems, the cumulative effect of which can be devastating.

When we really understanding the implications of this idea, we soon realize that in our design of anything, we must consider everything. There is no part of the entire system that isn’t affected by every other part of the entire system. This idea became very clear to me while working in healthcare. You can’t solve for a particular condition in isolation… it interacts in complex ways with the system of rest of the body. When you consider the entire body, and you soon realize that you can’t solve for the health of the individual in isolation… it interacts in complex ways with the social systems, culture, the environment, and on and on. Changes to any part of that system can have dramatic, complex, unforeseen, unintended, and often unknown consequences in other parts of the system.

The Trouble with Treating Patients as Consumers

Feb 17, 2012• 7

By Augusta Meill and Gianna Ericson

To be a patient today is to be treated as a consumer. But treating patients as typical proactive, in control, well-informed consumers can backfire. Asked to take on increasingly complex decisions and digest ever-larger amounts of information, patients find themselves placed — often by design — in the driver’s seat. High-deductible insurance plans aspire to make the cost implications of care more transparent and implicitly shift decision-making to members. The “empowered patient” movement encourages patients to become hyper-informed and to take control over their care. But providing greater information, access and autonomy — so often successful in consumer settings — does not necessarily drive better care or experience. Consider these cases:

An unexplained black-out sent a 61-year-old Boston woman to the emergency room and set off a flurry of visits to specialists to uncover the cause. Each doctor needed records of the diagnostics from previous visits. Hospital policy, however, required that patient data be released only to the patient, meaning she had to return to the hospital prior to any new specialist visit. Requiring her to control the information flow burdened her in the midst of a medical crisis.
After years of struggling with her weight, a New York mother underwent bariatric surgery. She was inundated with information from her medical team about how she would need to change her behavior. Guidelines around when, how, and what to eat or not eat — the rules were overwhelming and constraining. Before long her weight had jumped again. For this woman, an excess of information (along with an assumption that she was prepared to absorb it) was part of the problem, not the solution.

Can the Press Save DSM 5 from Itself?

Feb 17, 2012• 2

By Allen Frances, MD

DSM 5 has suddenly become a star press attraction. In just the last three weeks, more than 100 news stories featuring DSM 5 appeared in major media outlets located in more than a dozen countries. (For a representative sample see Suzy Chapman’s post on Dx Revision Watch.) The explosion of interest started with a flurry when The New York Times published two long DSM 5 articles and three DSM-5-related op-ed pieces, all within a few days. An unrelated press conference in London then generated a widely distributed Reuters story and also many independent pieces. Several other reporters had also been working on their own DSM 5 stories that just happened to arrive at the same time.

The intense press scrutiny of DSM 5 is really just beginning. I know of at least 10 additional reporters who are preparing their work now for publication in the near future. And many of the journalists whose articles appeared during these last few weeks intend to stay on this story for the duration — at least until DSM 5 is published, and probably beyond. They understand that DSM 5 is a document of great individual and societal consequence — and that its impact and risks need a thorough public airing.

The press coverage has been almost uniformly and devastatingly negative. The two most common themes are 1) DSM 5 will radically expand the boundaries of psychiatry, medicalising normality and leading to unneeded and harmful treatment; and 2) DSM 5 decisions are being made arbitrarily, based on narrow input and lacking sufficient scientific support. The DSM 5 proposals that have elicited the most concern are changes in the definition of autism and the expansion of major depressive disorder to capture much of normal grief.

The articles sometimes contain small inaccuracies and sometimes emphasize peripheral issues. And the most dangerous DSM 5 proposals get far too little mention. I will discuss in later blogs how DSM 5 will worsen the over-diagnosis of attention-deficit disorder and the over-prescription of antipsychotic mediation. But the press has gotten the main points just right and somehow manages to see the risks of DSM 5 much more clearly than do the people working on it.

Where Have All the Liberals Gone?

Feb 17, 2012• 20

By John Goodman

There are two conservatives for every liberal in America. That’s the message of a recent David Brooks column as well as a Gallup survey. I think the imbalance is much starker. I would guess there are four conservatives for every liberal. Maybe even more.

Here’s a test I invite you to take. Watch C-Span’s morning call-in show and listen to what people who phone in on the “Democrat” or “liberal” line have to say. When is the last time you heard a caller say, “We should all pay higher taxes so that the government can provide us with universal day care”? Or how about, “We should all pay higher taxes so the government can provide us with universal long term care”? I bet you can’t remember ever hearing that.

Here is what I suspect you will hear: Teachers complaining that teachers aren’t paid enough. Union members complaining about competition from workers overseas. Senior citizens whining about the meagerness of Social Security or Medicare benefits. Minority callers advocating more affirmative action. What is the common denominator of these comments? Self-interest.

Yes, I know. Special interests are in both parties. Why wouldn’t they be? Yet as I wrote in my analysis of “progressivism,” the left in America has elevated special interest privilege to an art form.

Here’s the point: people wanting more, more, more are just people pursuing their own self interest in politics. They are not in principle different from any other special interest group. Importantly, they have nothing in common with what we normally have in mind by the term “liberalism.”

Paving the Regulatory Road

Feb 17, 2012• 1

By Deven McGraw

The poor quality and high cost of health care in the U.S. is well documented. The widespread adoption of electronic medical records—for purposes of improving quality and reducing costs—is key to reversing these trends.[1] But federal privacy regulations do not set clear and consistent rules for access to health information to improve health care quality. Consequently, the regulations serve as a disincentive to robust analysis of information in medical records and may interfere with efforts to accelerate quality improvements. This essay further explains this disincentive and suggests a potential regulatory path forward.

The U.S. has dedicated approximately 47 billion dollars to improve individual and population health through the use of electronic medical records by health care providers and patients.[2] Much of the funding for this initiative, enacted by Congress as part of the Health Information Technology for Economic and Clinical Health Act of 2009, will be used to reimburse physicians and hospitals for the costs of purchasing and implementing electronic medical record systems. The legislation also includes funding to establish infrastructure to enable health care providers to share a patient’s personal health information for treatment and care coordination purposes and for reporting to public health authorities.

Federal policymakers also intend for electronic medical records to be actively used as tools of health system reform. The legislation directs the U.S. Department of Health and Human Services to develop a “nationwide health information technology infrastructure” that improves health care quality, reduces medical errors and disparities, and reduces health care costs from inappropriate or duplicative care.[3]The 2011-2015 Federal Health Information Technology Strategic Plan identifies improving population health, reduction of health care costs, and “achiev[ing] rapid learning” as key goals of federal health information technology initiatives.[4]

Does ICD-10 Delay Create an Easy Opportunity for Coding Improvement?

Feb 16, 2012• 4

By Al Lewis

Implementation of ICD-10s has been delayed “indefinitely.” Rather than opine on whether that’s a good thing or a bad thing, I will note that it creates an opportunity for a simple but powerful improvement in the value of the coding.

Caveat: I am not a coding expert (I don’t even play one on TV) so there might be something wrong with this idea. The specific reason for the post is to find out whether there is some reason this can’t be done, given the value of doing it. (I am so unfamiliar with coding that it is possible this is already being done and I’m the last guy to find out about it, in which case perhaps John and Matthew would be kind enough to remove it.)

Quite simply, how about adding an optional “R” for “rule-out” after the codes? For instance, today if a patient gets tested for diabetes and it turns out that he HAS diabetes, he gets coded “250” in the ICD-9s. Whereas if it turns out the patient does NOT have diabetes, he still gets coded “250.” My proposal would code that (in ICD-9s) 250R.

By contrast, giving two opposite diagnoses the same code creates a cascading set of problems, in outcomes measurement, risk scoring, registries, disease management, reimbursement, and predictive modeling, problems that will be exacerbated as risk shifts down to the provider level and payors move to outcomes-based reimbursement.

The Creative Destruction of the News Business and Other Weird Stories

Feb 16, 2012• 8

By Dave Chase

Health system CEOs would be well advised to study what newspaper industry leaders did (or perhaps more appropriately, didn’t do) when faced with a dramatic industry change. Turn back the clock 15 years and the following dynamics were present:

Newspaper leaders knew full well that dramatic change was underway and even made some tactical investments. However they didn’t fundamentally rethink their model.
Newspapers were comfortable as monopoly or oligopoly businesses allowing for plodding decisions. Their IT infrastructure mirrored the plodding pace with expensive and rigid technology architectures.
Newspaper companies bought up other newspaper chains and took on huge debt.
Owning printing presses was a de facto barrier to entry allowing newspapers unfettered dominance.
Depending on one’s perspective, it was the best of times or the worst of times to be a leader of local media enterprise.

Before they knew it, owning massive capital assets and the accompanying crushing debt became unsustainable. The capital barrier to entry transformed into a boat anchor while nimble competition dismissed as ankle-biters created a death-by-a-thousand-paper-cuts dynamic. Competitively, newspaper companies worried only about other media companies or even Microsoft, but their undoing was driven by a combination of craigslist, monster.com, cars.com, eBay, and countless other marketing substitutes for their advertisers. In addition, there were easier ways to get news than newspapers. Generally, the newspaper’s digital groups were either marginalized or unbearably shackled so that the encumbered digital leaders left to join more aggressive competitors. The enabling technology to reinvent local media didn’t come from legacy IT vendors who’d long sold to newspaper companies, but from “no name” technologies such as WordPress, Drupal and the like.

The Unfortunate Side Effect of Death

Feb 16, 2012

By Andrew Schutzbank

Peggy was in her early 70s and suffered from a terrible lung disease known as pulmonary hypertension. Her case was so bad that she had a pump infusing a medicine under her skin 24 hours a day to keep the blood supply to her lungs open. Once started, this medicine, treprostinil, was known to improve life in those with pulmonary hypertension. Unfortunately, like all continuous infusion medicines of this type, it has the unfortunate side effect of sudden death if stopped for more than 4 hours. Starting it was a difficult choice for Peggy and her expert team of physicians, but her disease had progressed to a point where it was the right decision. As you can imagine, this drug was mighty expensive. We would only find out how expensive later.

On the day that I met Peggy, she was being admitted to the Intensive Care Unit (ICU) not for her pulmonary hypertension, but because she had a bleed in her stomach, which caused her to swallow blood/stomach contents into her already damaged lungs. Once stabilized, our first challenge was to ensure that she continued on the treprostinil. It took a little magic from pharmacy and the drug’s manufacturer, but we were able to get everything together and Peggy was no worse for the wear.

A few days later Peggy was improving, breathing tube out and awake and back to herself. Due to the special nursing needs with treprostinil, Peggy was required to be in the Cardiac Care Unit (CCU), a special type of (ICU), despite her progress. Even though Peggy managed this medicine at home by herself, hospital policy prevented her from transitioning out of the ICU to the general medical floor, at a fraction of the cost. Conceding that point, the decision was made to try and transition Peggy directly to Rehab. But her progress was stalled for one simple reason: treprostinil.
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