The Department of Health and Human Services "expects to release an interim final rule in the near future that will include a new compliance date that would require the use of ICD-10 beginning October 1, 2015. The rule will also require HIPAA-covered entities to continue to use ICD-9-CM through September 30, 2015."
After one month of silence, the federal government has announced that it will reset ICD-10 implementation for Oct. 1, 2015, the earliest date allowed by law.
"We are so happy about this," Lynne Gordon Thomas, CEO of the American Health Information Management Association said in a telephone interview Thursday evening.
"It gets the momentum back. Our fear was that people are going to say 'we don't know when it's going to be. We have so much going on in healthcare right now that you can only concentrate on so many things at one time.' We wanted to make sure this didn't get lost in the shuffle."
The ICD-10 delay was slipped into a larger bill that also delayed implementation of the Sustainable Growth Rate funding formula. The Protecting Access to Medicare Act of 2014 was hustled through Congress just before the SGR cuts were to take effect, and it was quietly signed into law by President Obama.
Since then, frustrated advocates for ICD-10 have been hounding the Department of Health and Human Services and the Centers for Medicare & Medicaid Services for specifics on when they planned to reset a new implementation date for the coding set.
On Thursday afternoon advocates got their answer when CMS issued the following statement:
"On April 1, 2014, the Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. No. 113-93) was enacted, which said that the Secretary may not adopt ICD-10 prior to October 1, 2015. Accordingly, the U.S. Department of Health and Human Services expects to release an interim final rule in the near future that will include a new compliance date that would require the use of ICD-10 beginning October 1, 2015. The rule will also require HIPAA covered entities to continue to use ICD-9-CM through September 30, 2015."
The fickle action by Congress to stuff the delay into a larger bill with no advance warning, and the federal bureaucracy's unwillingness to communicate on a reset date prompted the Commission on Certification for Health Informatics and Information Management to announce that it would hold off on testing for ICD-10 accreditation until the new coding set is "officially implemented."
The new implementation date provides a target for providers, many of them were left in limbo after planning for the Oct. 1, 2014 startup, which had already been delayed by one year in 2013. Gordon Thomas says many providers have been restless with the delay.
"What we are hearing is everybody wants to move on," she says. "It's been frustrating to the healthcare community because we want to move on and it's tough on people when there is indecision. So, I think people will be very pleased."
Because CMS plans to issue an interim final rule, Gordon Thomas says, it's not clear if it will ask for public comments or what other regulatory steps will be taken before the new implementation date becomes final.
The ICD-10 delay had been sought by specialty physician associations that have long questioned the value and cost of the coding set. Gordon Thomas says ICD-10 backers should spend the next year addressing the concerns of physicians and other skeptics.
"We are really developing a strategy," she says. "We've talked to CMS about working with small physician practices. We want to make sure they understand why it's important, and empathize with them and help them."
"They've been a little scared from what they are hearing, so we are going to be putting out 'mythbusters' literature telling them 'this is what you are hearing, but here are the facts.' It is a change. They are asked to do more documentation but they need to do that whether we go to ICD-10 or something else like value-based purchasing."
Otherwise, Gordon Thomas says providers should use the additional 12-months to provide.
"We want people to take advantage of this extra time," she says. "They need to continue to work on their clinical documentation improvement programs. The need to train their staff and stakeholders, whoever that may be, and at the appropriate level of training depending upon what they need. They should continue working with dual coding, and they should work with their vendors to make sure that they are ready, ready, ready."
Part of the integrated health system's strategy is to complement "clinical prevention work with environmental strategies that increase access to healthy, affordable food and safe physical activity," says the executive leading the effort.
Loel S. Solomon, PhD
Vice President for Community Health for Kaiser Permanente
The term "food desert" is not new. It's been around for a couple of decades and it succinctly describes patches in urban and rural settings where people don't have access to healthy foods.
In the past few years the term has gained usage in the United States as we come to recognize that access to healthy food is a critical component of population health management, which itself will also become a key metric for provider reimbursements.
Kaiser Permanente already supports a network of farmers markets outside many of its medical centers and clinics. So it's not surprising that executives from the giant California health system were in the crowd earlier this month to mark the grand opening of a new 40,000-square-foot, full service supermarket in a South Los Angeles neighborhood that is served by the integrated health system.
Loel S. Solomon, PhD, KP's vice president for community health, says providers can no longer improve population health without looking beyond their own walls.
"Good clinical prevention is necessary, but insufficient to help our members eat better, which is critical to addressing obesity and diabetes and all sorts of chronic diseases," Solomon says. "We know we have to make the healthy choice the easy choice and that means we have to address the lack of access to healthy food in too many of our communities. So, it's part of our strategy to complement our clinical prevention work with environmental strategies that increase access to healthy, affordable food and safe physical activity."
The April 14 opening of the Northgate Gonzalez Market was 17 years in the making and was facilitated by a $50,000 workforce development grant from the California FreshWorks Fund, which describes itself as "a $272-million impact investing fund that provides loans and grants to grocers and other food enterprises to improve access to healthy food, spur economic development, and foster innovation in healthy food retailing."
Quality Food and Jobs
Northgate Gonzalez Market will bring fresh fruits and vegetables and other healthful foods into the neighborhood and it won't sell alcohol or cigarettes. It also used the workforce development grant to recruit, hire and train people living in the neighborhood, which suffers from high unemployment.
Solomon says the market created 153 new jobs, of which 111, or 73%, were new hires. Of those new hires, 74% are from adjacent zip codes and the vast majority live within two miles of the store. The workforce is 79% Latino, and African Americans predominate the remaining 21%—ratios that reflect almost exactly the demographics of the community served by the market.
"The idea is two-fold. One, we come at it from a health perspective. If we are serious about addressing people's health issues we need to create more access to healthy food," Solomon says.
"But, a good solution solves many problems. The other major driver of health and a major social determinative of health is whether people have jobs or not. So, the healthy food financing initiative and the California Fresh Works fund is an effort to create more and better employment for people who don't have access to it. It addresses health from that factor too. It is what we call a co-benefit—improving access to quality food and increasing well-paying jobs for people who often don't have access to good jobs."
A Few Questions
There is a lot to like about this project, but it also raises questions. For example, will the Northgate Gonzalez pay a living wage for its workers, or will it copy the business model used by a certain big block retailer and many fast food chains that cover labor costs with employee canned food drives and government subsidies in the form of food stamps and Medicaid?
"For this project, every job [pays a] fulltime, living wage in accordance with LA City's Living Wage Ordinance and with benefits—health, dental, vision, 401k," Solomon says.
If the demand is so great, why is a subsidy needed? Why hasn't the free market responded?
"It's called market failure and there are countless cases of when the market left to its own devices doesn't always produce the socially desirable results," Solomon says. "How else would you explain that there are large concentrations of people who are not served by a full-service grocery store and who have money to spend."
And Solomon insists that the new market is not some pie-in-the-sky do-gooder scheme that will require a permanent subsidy or go out of business.
"The important thing to understand is that there is this workforce development grant but it is a loan they got based on an economic analysis that that loan can be replayed," he says. "Those investors in the Fresh Works Fund include banks and people who want a return on investment. That is the opportunity. How can we, with a little bit of grant money and a lot of technical assistance and communications with the market operators and the Fresh Works Fund folks, create a new economically viable model that produces health and wealth for an entire community that has been left out of the economy? It's not a free lunch."
Encouragement for Other Communities
Of course, KP is not your typical community hospital. It is a massive, deep-pocketed integrated health system with resources that most providers can only read about. Solomon says that a lack of immediate resources shouldn't stop any providers from pushing for healthy food in their communities.
"It requires partnership. Nobody can do it alone. But every single hospital is an anchor institution in their community," he says. "Every single hospital is a major employer in their community. Every single hospital has important relationships with the business community. Every single hospital CEO is a civic leader. It's not about the dollars. It's really about your civic leadership and understanding the nature of the problems we confront and be willing to roll up your sleeves and be willing to address the complexity and the bigger solutions we need to bring to bear."
Maybe your community hospital can't land a 40,000-square-foot supermarket for the people you serve. But you could probably find a way to get a weekly farmers' market trucked into your food desert.
"That is the real opportunity for every single healthcare leader and every single hospital executive," Solomon says, "to think about what is really driving health and illness and work with others to find solutions."
Many states that passed malpractice caps a decade ago should expect to see judicial review because caps aren't passing constitutional muster and aren't delivering on what they advertised, says a legal expert.
The Florida Supreme Court's ruling this spring invalidating that state's 11-year-old cap on damages in medical malpractice suits marks the latest successful challenge to state laws across the nation that critics say enrich insurance companies but deny due process to grievously injured people.
"It is unfortunately a constant battle for victims of malpractice. This seems to go on in just about every state," says Richard Levin, a medical malpractice attorney with the Chicago-based firm of Levin, Riback Law Group.
"What seems to be the overriding ethos of the insurance companies and the physicians is that the premiums are too high and doctors are leaving the state and as a result we have a malpractice crisis. But the statistics bear out the exact opposite."
The battle over malpractice caps reignited in March when on a 5–2 ruling the Florida Supreme Court struck down as unconstitutional a 2003 statute that capped at $1 million medical malpractice payouts for intangible damages such as pain and suffering.
The Florida case involved the 2006 death of a pregnant 20-year-old woman who died from complications that arose during labor. The woman's family was awarded $2 million for pain and suffering, but that award was halved to comply with the state statute, which was passed into law at a time when many states were enacting "tort reform."
Florida's high court invalidated the law and ruled that it violated the equal protection clause of the state constitution. The majority ruling also challenged the validity of the purported medical malpractice crisis that supposedly prompted the law in the early 2000s and said the crisis was "not fully supported by available data."
Instead, the court majority wrote that the effect of the law was to enrich insurance companies at the expense of plaintiffs and that the malpractice caps had done "virtually nothing" to stabilizing malpractice premiums for physicians and other providers.
Astronomical Income Increases for Insurers Citing testimony brought forward by committees in the Florida Legislature, the high court said that "it is estimated that the Florida medical malpractice line of business standing alone generated a… return on surplus of 14% in 2012… This represents the ninth consecutive year of profitability."
The court went on to say that "The profits would probably shock most concerned. Indeed between the years of 2003 and 2010, four insurance companies that offered medical malpractice insurance in Florida cumulatively reported an increase in their net income of more than 4300 percent."
Levin says many states that passed malpractice caps a decade ago should expect to see new judicial review because they aren't passing constitutional muster, and they aren't delivering on what they advertised.
"There are 19 states that have malpractice caps, and none of them have a provision in them that if the awards are capped at a certain number when the premiums are paid then the premiums will be reduced," he says.
"In fact, the opposite has been shown, that the premiums increase. And there is nothing in the statute that says when there has been a decrease and the insurance companies will reap the benefits of that they will pass the savings on to the doctors. That has not been done. They are not, in fact, paying lesser premiums."
Defense Attorneys See it Differently
Jeff Scott, general counsel for the Florida Medical Association, which filed an amicus brief supporting the caps, blasted the high court's ruling.
"We had documented the premium increases prior to 2003 and in many instances we were seeing triple-digit increases. It was a full-blown crisis. The rates were skyrocketing. Physicians were dropping their coverage because they couldn't afford it," he says.
"For the (FL) Supreme Court to question whether there was a medical malpractice crisis was absurd. They were either living under a rock in 2003 or just plain ignorant. I cannot fathom how they made that determination."
Scott says tort caps "absolutely" work. "One needs only look at the states that have an effective cap in place, such as California and Texas, to see that malpractice rates are lower and the movement of physicians to those states," he says.
The reasoning behind the malpractice cap and its effect on premiums is just common sense, he says.
"It provides a measure of predictability for the insurance companies," he says. "They are the ones who have the authority on whether to settle a case or to take it to trial. If you have a predictable number as to what your non-economic damages are going to be, then you are able to settle claims at a lesser amount. If the sky's the limit then your costs of settling the claim increase."
Scott also predicts that malpractice premiums will increase in Florida now that the cap has been invalidated and more suits are filed.
"There isn't any doubt about that. We have heard word from some of the insurance companies that it is an inevitable result," he says. "They mandated back in 2003 when they passed the cap something called the 'presumed factor' by which the insurance companies were supposed to reduce their rates. If you take away the cap that provides some measure of stability for awards then I don't see there is any way that rates wouldn't go up."
More Suits Anticipated
Levin concedes that lawsuit filings will likely increase with the caps invalidated, but not for "frivolous" reasons.
"Malpractice cases of all fields of personal injury are the most expensive to pursue. The average malpractice case for a catastrophic injury with multiple defendants usually costs about $200,000 in out-of-pocket expenses that the attorney fronts on behalf of the client," he says.
"So, if that case is lost, the attorney has to pay for it. As a result, since the caps have been in place, attorneys won't take the cases where somebody has been catastrophically injured because they know the risks are too high. That is why the filings are going down."
"You hear a great rallying cry about 'frivolous lawsuits.' You hear that all the time. But insurance companies and corporations are not afraid of frivolous lawsuits. They are afraid of legitimate lawsuits." Levin says.
It's an easy thing to say that somebody has a frivolous lawsuit, but the people who are affected by the cap on damages are not people who have frivolous losses. They are people with serious losses," Levin continues.
"Tort reform is always going to be one of those issues that is always on the agenda because of insurance companies. They would like to pay less money and if you can cap risk at $1 million as opposed to an unlimited amount, wouldn't you do that? I understand why they are trying to do it. I just disagree with it."
A two-day summit organized by the American Health Information Management Association has ended, and ICD-10 stakeholders say they are still waiting to hear from federal officials on a firm implementation date.
A federal official involved in the ICD-10 launch couldn't give a room full of stakeholders a firm date on for the new implementation of the medical code set, but suggested on Wednesday that an announcement is imminent.
Denise Buenning, acting deputy director with the Centers for Medicare & Medicaid Services'Office of e-Health Standards and Services reportedly told attendees at a two-day ICD-10 summit held in Washington, DC, that a firm date for the implementation would be forthcoming.
"She said they are working on getting the word out and that the regulatory language is being drafted," said Lynne Thomas Gordon, CEO of the American Health Information Management Association, which organized the summit. "[Buenning] kept checking her cell phone to see if she would be able to make some sort of announcement but she wasn't able to. My guess is its going to be Oct. 1, 2015. That's when everything switches over for CMS."
The Protecting Access to Medicare Act of 2014, signed into law this month by President Obama, delayed implementation of the ICD-10 code set until at least Oct. 1, 2015. Stakeholders had hoped to get a firm date for the new implementation when Buenning spoke Wednesday afternoon.
The delay was made public just hours before the bill passed the House in late March, and since then, CMS has seemingly lowered a cone of silence over the process.
The only public acknowledgement of the delay came Wednesday in a brief release on the CMS website which read: "With enactment of the Protecting Access to Medicare Act of 2014, CMS is examining the implications of the ICD-10 provision and will provide guidance to providers and stakeholders soon. This provision in the statute reads as follows: "The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD-10 code sets as the standard for codes sets under section 1173 (c) of the Social Security Act (42 U.S.C. 1320d-2 (c)) and section 162.1002 of title 45, Code of Federal Regulations."
Risk factors that can adversely affect a patient's recovery or trigger a hospital readmission include behavioral issues. The chair of the Cedars-Sinai Department of Psychiatry discusses how screening for depression will become more widespread as hospitals adopt value-based reimbursement models.
Bysome estimates, about 18 million people in the United States, roughly 7% of the adult population, experience an episode of major depression each year. Undiagnosed and untreated, depression can have a profound effect on hospital patients who are also dealing with seemingly unrelated health issues.
>Itai Danovitch, MD, MBA
Chair of the Cedars-Sinai Department of Psychiatry
With that in mind, Cedars-Sinai Medical Center in Los Angeles, CA announced this month that it has begun screening all adult inpatients for depression along other risk factors that could adversely affect their recovery.
Itai Danovitch, MD, MBA, chair of the Cedars-Sinai Department of Psychiatry, spoke with methis week about the need for screening, and how it will become more widespread as hospitals enter value-based reimbursement models. The following is an edited transcript.
HLM: Why did you start screening all inpatient adults for depression?
ID: At Cedars Sinai Medical Hospital the psychiatry department does a lot of consultations. That means that doctors call on us when there is a problem with a patient that they think is related to mental health and is affecting their medical care.
Depression is incredibly common and one of the things we know is that often, by the time we get called for helping a patient with depression, they have already had that depression for a period of time. If we could get calls earlier, or if the depression could get recognized sooner, there [would be] opportunities to intervene and help that patient earlier on.
That was our personal experience, and in reading the quite extensive literature on the prevalence of depression in patients with medical illness and also its impact on outcomes.
The rate of depression prevalence in patients who have medical disorders ranges from about 10% to 30% and in some diseases, such as cardiac disease, it is 30%. The presence of depression impacts basically every feature of a patient's medical care. It impacts their experience with care, their satisfaction with care, it impacts their adherence to care regimens. It impacts the disease outcomes from the medical diseases they are suffering from.
For cardiac patients the risk of myocardial infarction goes up substantially when someone also has a history of depression for reasons we don't fully understand. It also impacts their utilization of healthcare services. Having depression is associated with a two-fold increased risk of being readmitted to the hospital.
Essentially virtually every feature of healthcare is impacted in a negative way by depression. You can only address it and help somebody with depression if you first recognize it. The purpose of this initiative is to screen patients so that we can identify them more readily and give the patients information they need to empower them to be able to get help if they choose to.
HLM: What does the screening process involve?
ID: It is quite straightforward. There are a number of screening tools for depression. The ones we are using are called the Patient Health Questionnaire. There are two forms of it: the PHQ-2 and the PHQ-9 that screen for depression. They ask about the symptoms of depression and the purpose of the PHQ 2 is a broad screener. Are they depressed? Have they lost interest in things? That's used by the nurse to then ask the rest of the questions if the patient is positive.
If not, they move on with the rest of their assessment. It is easy to do and it is a measure that has been tested and validated in many different healthcare environments. It can be appropriately administered by many different health professionals.
The challenge of detecting depression in the medical setting is that there are many medical conditions that can cause symptoms or syndromes that can look like depression. So it is important to have a physician or an allied health professional evaluating the patient to disentangle various forms of depression and give the patient guidance on how to find treatment for it.
HLM: Are the screenings expensive or do they require significant time or resources?
ID: The screening cost in and of itself requires a little bit of extra labor on the part of nurses, but our experience here and in other locations is that nurses are readily able to integrate this.
It doesn't impact their work flows too much. Of course, more and more quality demands are placed upon nurses and we are very sensitive to that. But the nurses here really feel that this is a sufficiently important aspect of healthcare to make it a priority and to involve themselves in the screening.
The costly thing is actually referring patients and having them get treatment for their depression. That is a cost that ultimately patients and their insurers bear. What the literature shows is that it is even costlier not to address depression.
HLM: Many providers across the nation have problems accessing behavioral health services. Why bother screening patients if you can't get them the help they need?
ID: It should be the healthcare professionals' role first and foremost to determine what is wrong with a patient, to be able to diagnose them and refer them to the services that the patient needs in order to get better.
As a society we have a different problem, which is how do we finance the things that we know to be helpful to patients? What we are recognizing now is… that in the long-term some of the interventions that are simple and benign can be helpful in producing long-term gains for patients in reducing costs whereas in the short term it can be hard to recognize those values.
So, the closure of a lot of mental health services is a function of the fact that those services don't reimburse very well because our field and our society haven't done a very good job of recognizing the value of those services.
HLM: What happens if you determine a patient has depression?
ID: We notify the patient's medical doctor and the social worker that the patient has screened positive. Every patient has a social worker assigned to them and the social worker does additional assessments to determine if the patient is already in care.
Do they have a treating psychiatrist, psychologist, or therapist who is able to educate the patient? The physician for the patient is also asked to assess the patient, to advise them about the findings of the screening and their relevance to their medical care and to assist them with a referral if the patient wants that referral.
HLM: Do you see these screenings become more common as hospitals shift to population health and value-based reimbursements?
ID: Absolutely! When we talk about bending the cost curve, which really means trying to get better outcomes without spending more for them, some of the greatest opportunities to do that are in improving the behavioral and mental health of patients.
HLM: How will you know if these screenings are successful and a good return on investment?
ID: The worthiness of the screening has been established by a number of other groups besides us. The U.S. Preventive Services Task Force has adopted depression screenings as a best practice. That is a function of extensive data supporting the idea that identifying and screening depression is cost effective and valuable.
At Cedars-Sinai our measures are how well we identifying patients. Are we screening every admitted patient? Are we educating our allied health providers and nursing staff? Eventually we are going to look at other things such as how do positive scores on depression relate to other important features of care, such as patient satisfaction with care, readmissions, length of stay in the hospital, are we able to increase the referral rate for treatment services for patients who screen positive, etc.
HLM: Can these screenings be done at hospitals where resources are already stretched?
ID: An increasing number of hospitals, including community hospitals, are engaging in various alliances and partnerships with other parts of the health continuum to manage the lives of populations.
Whether it is with insurers or outpatient clinics, the first questions are 'who are the stakeholders in the patients' healthcare and what is the best point of service to screen the patient for depression? So, there is very little question that, from the patients' experience, they need to be screened for depression and they need to be offered services. Exactly who does that and where in the system that happens and how it is managed depends upon the arrangements of those particular health systems. It is hard to answer that question totally generically. A lot of health systems do this in the primary care setting.
HLM: Do you anticipate that this could be mandated at some point by the federal government?
ID: It is a good question and I don't know the answer. Some regulatory bodies like The Joint Commission and others have considered and evaluated some quality metrics that get to behavioral health outcomes and possibly depression. The Joint Commission has established suicide screening as a national patient safety goal and detecting patients at a high risk of suicide is accomplished in part through this measure.
Globally, if we look at trying to enhance value and improve outcomes for patients, this effort to improve value and outcomes is going to drive more health systems to be screening and identifying underlying behavioral health issues. That is an area where overall we haven't done a really great job of meeting patient needs and where the failure to meet patient needs costs us a lot in terms of financial costs, but also more importantly in terms of patients health outcomes.
It's an important opportunity because we can both potentially reduce utilization and improve their health outcomes.
On the first day of an AHIMA-organized summit, the Coalition for ICD-10 picked up a strong ally, America's Health Insurance Plans, but got no new information from federal officials about an implementation date.
ICD-10 advocates attending a two-day summit in Washington, D.C., got stonewalled by federal officials who declined Tuesday to provide a new start-up date for the medical coding set.
Godwin Odia, who is leading the Medicaid ICD-10 implementation for the Centers for Medicare & Medicaid Services updated stakeholders on the status of Medicaid readiness at the federal and state level, but didn't go much beyond that.
"He basically read a script and said 'don't ask me any other questions. I can't answer anything,'" said Lynne Thomas Gordon, CEO of the American Health Information Management Association, which organized the summit. "I kept asking 'When? When?' and he kept saying 'stay tuned.' It was very scripted."
"The intent of his talk sounded like we are moving ahead. Medicaid sometimes gets a bad rap because people say they aren't ready. Odia said 'we are ready.' He was trying to reassure everybody."
The stakeholders also heard from Donna Pickett, a medical classification administrator with the Centers for Disease Control's National Center for Health Statistics. "She also had the same line: 'I can't tell you anything,'" Thomas Gordon said.
The Protecting Access to Medicare Act of 2014, signed into law this month by President Obama, delayed implementation of the ICD-10 code set until at least Oct. 1, 2015. Stakeholders want some sense of a new implementation date when they hear from Denise Buenning with CMS'sOffice of e-Health Standards and Services.
Also Tuesday, the Coalition for ICD-10 gained a strong partner with the announcement that America's Health Insurance Plans has joined the industry's lead advocacy group.
"The implementation of ICD-10 is a critical step on the path to a more sustainable health system for consumers," AHIP President/CEO Karen Ignagni said in a media release. "We look forward to working with all members of the Coalition to help advance this important transition."
In addition to AHIP, Coalition for ICD-10 members include: American Health Information Management Association; American Hospital Association; BlueCross BlueShield Association; College of Healthcare Information Management Executives; WellPoint; Siemens Health Services; and 3M Health Information Systems.
"AHIP has always been for no delay and we are glad to have them on the coalition," Thomas Gordon said. "Everyone talks about end-to-end testing and 'are we ready?' so it's nice to make sure the payers are with you."
AHIMA and other ICD-10 stakeholders say they want to know when federal officials intend to set a new implementation date for the delayed code set.
Stakeholders and other supporters of ICD-10 are scheduled to meet in Washington, DC Tuesday with a senior official at the Centers for Medicare & Medicaid Services with the hope of learning when the federal government is going to act on the oft-delayed medical coding set.
The Protecting Access to Medicare Act of 2014, signed into law earlier this month by President Obama, delayed implementation of the ICD-10 code set until at least Oct. 1, 2015. Stakeholders want some sense of a new implementation date when they hear from Denise Buenning with CMS'sOffice of e-Health Standards and Services. The two-day summit is being organized by the American Health Information Management Association.
AHIMA CEO Lynne Thomas Gordon says ICD-10 stakeholders have been left in the dark ever since the delay was slipped in as part of a bill that delayed implementation of the sustainable growth rate funding formula for Medicare reimbursements.
"We have been trying to keep our eyes and ears attuned to what the news is and we have not gotten anything official," Thomas Gordon said Monday in a telephone interview.
"Perhaps we might hear something (Tuesday). We would like to try to pin them down because we feel it should be no later and we are just assuming it will be Oct. 1 2015. We will definitely be asking those questions."
Thomas Gordon says the delay is somewhat "understandable" because CMS has been preoccupied with the Obamacare rollout over the past several weeks, with departure of Health and Human Services Secretary Kathleen Sebelius announced last week, and with the nomination of Sylvia Burwell, the director of the Office of Management and Budget, as her replacement.
"They've had some turnover there so I can understand with a new secretary coming in she probably wants to get her feet on the ground before things are announced, but maybe we will hear something (Tuesday)," Thomas Gordon said.
The silence from HHS has fostered a growing sense of frustration and urgency among ICD-10 stakeholders. Last week, the Coalition for ICD-10 asked HHS to establish Oct. 1, 2015 as the new ICD-10 implementation date. In a letter to CMS administrator Marilyn Tavenner, the coalition said the delay has caused great uncertainty across the healthcare industry about the future of ICD-10.
"The delay is going to be disruptive and costly for healthcare delivery innovation, payment reform, public health, and health care spending, and uncertainty on the implementation date only adds to the disruption and cost," the letter stated.
The coalition, comprised of hospitals, health plans, professional associations, hospital and physician office coding experts, vendors and the health information technology community, says it would "work with CMS to identify measurable milestones on the path toward implementation to demonstrate that preparatory work is proceeding smoothly toward successful implementation."
Thomas Gordon says she also hopes to hear from ICD-10 industry leaders at the summit about what they're doing to cope with the delay. "What we are hearing anecdotally is that people are moving ahead, trying to beef up their clinical documentation improvement programs, working with their vendors, educating their physicians and training their staff on ICD-10," she says.
"We want to know if that is really true. We will take some polls. We are trying to take a pulse of the industry, what is going on and how can we help."
A Community Hospital Corporation deal illustrates the great financial strain on Georgia 's small and rural hospitals as a result of a decade-long decline in state Medicaid reimbursements, the economic recession, and the challenging demographic of older, poorer, and sicker patients.
Monroe County Hospital, a 25-bed critical-access hospital serving the Forsyth, GA area, has hired Community Hospital Corporation to provide advisory and management support services.
Kay Floyd, CEO of Monroe County Hospital, said the county 's hospital authority elected to hire CHC after considering everything else on the spectrum from loose affiliations to an outright sale of assets.
"We have a very proactive hospital board that has had their mind on strategic planning and mapping the future of the hospital for the last couple of years. It took us into a pretty extensive [request for proposal] process looking at affiliation, " Floyd said in a telephone interview.
"We were prompted by the concerns around shrinking reimbursements, some concerns that are directly related to the healthcare reform law and the shortage of physicians. We are in a community of 26,000 in the county and trying to get primary care physicians in rural communities is a significant challenge. "
In the end, Floyd says, it came down to maintaining local control.
"My hospital authority feels strongly about keeping control of the healthcare delivery local, strongly about governance, and strongly about having the delivery site be accessible in the community itself and preserving the hospital, " she says.
"Healthcare delivery should be local. We want to preserve our services. We are pretty heavy on the geriatric demographic with people who have limitations and an inability to travel very far to get their services. Transportation is a big hurdle for some of the people in our community. We serve a lot of people in our hospital who walk to our emergency room. "
The deal comes as Georgia 's small and rural hospitals are under tremendous financial strain owing factors including to a decade-long decline in state Medicaid reimbursements, the Great Recession and its continuing after-effects, and the challenging demographic of older, poorer, and sicker patients.
Established in 1957, Monroe County Hospital is located about 60 miles south of Atlanta Under its critical-access designation, Monroe County Hospital has a transfer designation agreement with the Medical Center of Central Georgia, about 24 miles to the southeast in Macon. HCA also has two hospitals in Macon.
Craig Sims, CHC 's senior vice president of operations, says many of the smaller rural hospitals that CHC contracts with want to remain independent.
"They are looking for affiliation strategies or a way where they can continue to serve that community, " he says. "What has worked best in our model is the relationship that brings in a larger or tertiary partner in that market for clinical affiliations. So, it really varies by the opportunity and what the board and the hospital and the local market have that cause us to make those decisions. "
Floyd says she will be able to tell relatively soon if the contract with CHC is a success.
"I don 't mean to be coy, but the bottom line is the answer, " she says. "We 're going to be looking for some financial improvements right away. I will also be looking for some clinical improvements where the service line that we have available would be concerned. "
The MCH deal was one of two new contracts that CHC announced this month. The Plano, TX-based not-for-profit company also signed a contract to manage 49-bed Bowie (TX) Memorial Hospital, located about 90 miles northwest of Dallas.
CHC owns or leases 10 hospitals. Bowie Memorial and Monroe County are among the 12 hospitals that CHC 's consulting arm, CHC Consulting, manages or supports.
"Our primary objective is to ensure that community-based hospitals achieve long-term success, especially as federal and state governmental mandates drive down reimbursements for both hospitals and physicians, " CHC President and CEO Michael D. Williams said in a media release.
Bowie Memorial Board Chairman Tim Winn said the relationship with CHC "will help to strengthen our hospital for future success and prepare for the myriad of changes occurring within the healthcare environment. "
VCU Health to Acquire Community Memorial Healthcenter
Virginia Commonwealth University Health System in Richmond will acquire Community Memorial Healthcenter in South Hill, VA, in a deal that is expected to be completed this summer, the two health systems have announced jointly.
The hospital, located about 70 miles south-southwest of Richmond and near the North Carolina state line, will be renamed VCU Community Memorial Hospital. VCU Health System will commit at least $75 million in new investments in CMH, including a new hospital, healthcare technologies, clinical initiatives and physician recruitment.
CMH is licensed for 99 acute care and 161 long-term care beds and provides inpatient and outpatient services. It is one of the area 's largest employers with approximately 800 employees, 200 volunteers and 85 physicians who represent more than 30 medical specialties. VCU has an existing relationship with CMH through the Massey Cancer Center.
CMH employees join about 9,000 VCU Health System employees. The CMH board of directors will continue with local and VCU Health System appointments. Under the new structure, local leaders and CMH will continue to represent local interests on governance and strategic planning, and the CMH Foundation will continue to be a philanthropic arm of CMH.
CMH Chairman John Lee said in prepared remarks that the acquisition was the culmination of an extensive affiliation study conducted by a committee of stakeholders.
"Our committee 's charge was driven by a desire to ensure CMH 's long term sustainability, and allow it to not only continue its legacy of high quality healthcare offerings, but to expand and enhance its services, and do so from a new state of the art hospital worthy of those CMH is here to serve, " Lee said.
"We recognized that meeting those objectives would likely require the ongoing support and clout of a world class organization, and this mutually beneficial relationship with the VCU Health System very successfully accomplishes all those goals. "
In our December Intelligence Report, more than one-third of healthcare leaders (36%) said it is likely they would drop clinical services as a way to cut costs or enhance margin. What do those results suggest generally, and how is your organization handling its clinical services?
Alison Page
CEO
Baldwin Area Medical Center
Baldwin, WI
Healthcare needs to change, and it will change. The biggest challenge for healthcare organizations is going to be riding the transition to a future reimbursement model based on value, and how do you reduce costs and increase quality while designing the delivery system of the future?
How do you move from our current world in which all the revenue is based on face-to-face visits and admissions to a world where revenue is based on effective management of total cost of care? Right now if we do a group visit or health coaching, we don't get paid for that. These things are a great way to reduce costs, so the challenge is going to be moving to the new care delivery model incrementally in a way that allows you to keep your margins steady.
There are a lot of services that we offer that we don't make money on, and we are going to have to evaluate which of those we can continue to offer or other ways that we can reduce costs. We are a critical access hospital, so closing services means people have to travel further. You want to offer services that meet the needs of the people who live in your region, but you also have to have a black bottom line.
Mark Bogen
Senior Vice President and CFO
South Nassau Communities Hospital
Oceanside, NY
On balancing revenues: The hope and expectation is that there are enough profits being earned on the service lines such as orthopedics and oncology and cardiology to allow the continuation of access to things such as behavioral health or pediatrics or outpatient clinics.
We have seen that on Long Island with both the private and even the state-run hospitals for behavioral health. That has dumped a lot of patient issues on the doorstep of those of us who still have programs.
On feeling the squeeze: As hospitals feel squeezed and feel like their overall financial viability is threatened, they are going to take a look at those programs that have the least contribution margins and they may feel that it's better to close to keep everything else going. That reduces access for people who have grown dependent on those institutions to provide for those services. You see that as a microcosm when you look at those hospitals or systems that start to show the cracks financially. You cut services that aren't performing and somehow that is not enough and you continue to cut and pretty soon you don't have anything left.
On long-term implications: That may take a year or 10 years, but I have seen it all too often where it is like water going down the drain. I understand the finance guy. The survival of the organization is always at the most critical level in making these decisions. But you start to lose the identity and the mission the organization was originally founded upon.
Dennis Wolford
CEO
Macon County General Hospital
Lafayette, TN
We are a 25-bed critical access hospital. We are not-for-profit. We have to look at these services we provide and how much is in Medicare or Medicaid. We look at that closely. We can't provide services like obstetrics. That is not reimbursable and we haven't had any docs or OB-GYN services since 1984.
One thing we are concerned about is our rehab services: physical therapy and occupational therapy. The provision there is, do you need direct supervision or can you use general supervision? We got it clarified and it looks like we are exempt from that, but there are a lot of other critical access hospitals that are providing a lot of services that require direct supervision and it is going to kill them. It almost feels like CMS has got it out for critical access hospitals.
We do at least a three to five-year strategic planning but with so much up in the air—the impact of Obamacare and these other pending changes, and Tennessee has not approved Medicaid expansion—we are almost living from month to month and day to day. It's hard to project. We have been treading water for some time. Financially we are holding our own, but with what is coming down the pike I don't know how much longer we can hold on and I know all the other critical access hospitals in this state are facing the same thing.
Tammy P. Mims
COO
Effingham Health System
Springfield, GA
It is very likely that Effingham will drop clinical services as a way to cut cost. Our organization is examining each service line to determine profitability.
Any service line that is a drain on the bottom line will be thoroughly examined and may be eliminated. Or we may restructure to eliminate waste and reduce operating costs to keep the service line at a minimum. It is unknown today if any service lines will be dropped.
They generate $1.6 trillion in economic activity, but as a class, physicians are slow to upgrade and adopt technologies that would make them—and the nation's healthcare system—more efficient and less costly.
The general public is getting some mixed signals these days from physicians.
The American Medical Association came out with a report this week that says that physicians generate about $1.6 trillion in economic activity, support 10 million jobs, and are "vital economic drivers at state and national levels."
I won't quibble with that figure. Physicians are among the most highly educated, highly trained, highly respected, and highly compensated professionals in our country. It would only make sense that we trust them to have a key role in supervising the nearly 20% of the economy that the healthcare sector occupies.
On the other hand, we have another report this week about efforts to wean doctors away from fax machines. That's correct: Fax machines. I had to double check the article to make sure it wasn't a satirical piece from The Onion.
Why are some of these "vital economic drivers" still using 1980s technology? Did they get a special closeout deal on thermal paper down at the office supply store during the Y2K scare? Perhaps it was part of a package deal that came with a beeper, a mimeograph, and a rotary phone.
At many physicians' offices patients still have to fill out paper forms and medical histories every time they go for an office visit. Take-out pizza joints and auto lube shops use more sophisticated, consumer-centric IT than many physicians, because most retailers are light-years ahead when it comes to customer satisfaction and delivering value.
So far, consumers have put up with a healthcare system that treats them as an afterthought. At some point they won't. And that change will occur quickly and probably sooner than anyone expects, now that consumers are responsible for more of the cost of their care through high-deductible insurance plans.
Therefore, while physicians boast about controlling $1.6 trillion of economic activity even as some of them continue to use cumbersome, antiquated technologies to collect and share patient information, they shouldn't be surprised when the government steps in and mandates health information technology upgrades.
Yes, there are still a lot of snags and snafus associated with electronic health records systems, but this industry-wide movement toward EHR was not done in a vacuum and it didn't sneak up on us. I was sitting in the audience at Vanderbilt University in May 2004 when President George W. Bush said that EHR would be a national priority.
I don't know of any other industry or sector of the economy that has had to be forced by the government to enter the digital age, nor been given such a long lag time and financial incentives to get up to speed.
ICD-10 Delays
Technophobia was in bloom last month when specialty physician associations allegedly convinced Congress to delay by at least one year more–again–the implementation of ICD-10. History tells us that ICD-10 was ready in 1992 and that every advanced country in the world has already adopted the code set, including China, Thailand, and South Africa.
And just as with the EHR mandate, ICD-10 didn't sneak up on anybody. If you didn't have plenty of warning that this was coming, you were asleep.
The American Health Information Management Association was so certain that ICD-10 was a done deal that they nearly destroyed what they reasonably assumed were obsolete ICD-9 instruction manuals. Now, twice-burned AHIMA won't certify for ICD-10 until it is up and running. Community colleges across the country are pulling those old ICD-9 texts out of the dumpster and scrambling to retrain many of the 40,000 students who naively thought they'd have a job coding ICD-10 on Oct. 1.
Instead, they'll be learning a medical coding technology that was adopted in 1979, a year perhaps best remember for the Iran hostage crisis, and the debut of The Dukes of Hazzard. I am struggling to make an analogy here with any other huge, data-reliant industry that would advocate for a shift away from say, Windows 8.1 to MS-DOS.
Pay Data Transparency
Also this month, physicians' associations were bracing for the worst when the Centers for Medicare & Medicaid Services released Medicare payment data on individual physicians, a data dump detailing the use of taxpayers' money that the American Medical Association and other physician groups had fought for years.
Why the trepidation? So far, the data is showing that the vast majority of physicians provide competent care at a reasonable cost to a challenging patient demographic. Predictably, many of the outlier physicians who've received millions in Medicare dollars grabbed the headlines for a day or two. But even many of them have legitimate and commonsense explanations that the public will accept. The few docs who are ripping off the system should be exposed.
While a growing number of providers understand that healthcare can no longer operate under business models from the 20th century, a significant minority still do not. Payment schemes are shifting from volume to value and that shift will require a tremendous amount of data to support and verify outcomes for large groups of people.
Turf Battles
There are problems on at least two other fronts.
Physicians' associations in many states are fighting rearguard actions to limit scope of practice for nurse practitioners and higher highly skilled clinicians. This is a fight physicians are going to lose. Their best option now is to negotiate surrender on favorable terms.
And deep-pocketed drug store chains and other retailers with a long history of meeting consumer demand see the value of walk-in clinics and they will lobby hard to expand their purview. It's common knowledge that there aren't enough physicians to provide adequate access to care, and that's a problem that will only get worse in the coming decade as more physicians retire.
More importantly, this is what consumers want and it's not clear if some physicians' associations understand this. The American Academy of Pediatrics, for example, recently stated that "retail-based clinics are an inappropriate source of primary care for children because they fragment children's healthcare and do not support the medical home."
This may be true in some cases, but the AAP's nuanced arguments about the continuum of care might be lost on a wage-earning single parent who's got a bawling two-year-old child with an earache at 9 pm on a Friday and no place else to go, other than the nearest hospital's emergency department.
Instead of criticizing the proliferation of walk-in clinics, physicians' associations should ask themselves why this is happening. Clearly someone in the marketplace is attempting to meet a consumer demand. Perhaps physicians' associations should urge their member physicians to do more to expand their office hours and make themselves more available to the public after hours and on weekends.
Jump or Be Pushed
We have heard many of the arguments for why some, but most certainly not all, physicians are so reluctant to embrace change. Many docs and their professional associations may have perfectly legitimate reasons for resisting a particular policy or technological mandate.
Here's the problem: If your response to EHR, ICD-10, and other innovations or data releases or consumer trends is "no" or "not now" or "there's no value in it for me," then people are going to stop asking you. They're going to make you do it, or they're going to find someone else to do it for them.
One reason why physicians are the object of government mandates is because a significant percentage of these "vital economic drivers" often appear unwilling to take on the task by themselves.
