Healthcare

Problem is that there is a significant stratum of healthcare population who are still in denial mode. Payers, especially the large ones, have moved on from the denial phase and are gearing up for the impending change. In fact some of them are even using the mandate as an opportunity to generate efficiencies, as I mentioned in my last post. On the other hand, we have a large population of providers, who for one or the other reason are not willing to accept that the new code set is coming and is coming pretty hard, let alone the possibility that the impact will be catastrophic if one is not well prepared.

Over the last few months, I have heard a variety of reasons being proffered for this laissez-faire attitude, ranging from ‘It is never going to happen. ICD11 will come before ICD10 ever gets implemented’ to ‘What do I care. My vendor will provide me with all the upgrades that I ever need’ to ‘I outsource my revenue cycle in any case, so why should I care’. In certain uncomfortable encounters people have just simply laughed at me when I brought up ICD10, as if I have just cracked a real funny joke. Trust me it has given me second thoughts about my career choice, Maybe I should have become a stand-up comic. But then the sanity prevails.

Seriously, how can anybody think on such lines, especially when we just went through a mess with NPI? One account that I read sometime ago, stated that the overall reimbursement rate for the providers dipped by 4-6 percent because of the interruptions caused by NPI. And to think that the scope of NPI was a pittance compared to what is in store with ICD10. Let’s talk about some of these objections,

• It is never going to happen because ICD11 is already defined – I have just one thing to say about this one. ICD10 was defined way back in early 90s and it is going to take only around 20+ years to implement it in USA. What makes you think that ICD11, which came into draft reckonings only in mid 2000s, is going to be adopted any sooner. By the way, rest of the developed World has adopted ICD10 and going by precedence I don’t think we are going to leapfrog to unchartered waters.
• It will be pushed back – Well, it has already been pushed back. Original date was October 2011 and not 2013. If we go by precedence, CMS is not in the habit of pushing things back indefinitely. HIPAA Admin Simplification was pushed back a couple of times, NPI was pushed back by a year and so has ICD10 been too. Also, with the spiraling healthcare costs and bigger deficits, the administration is trying its best to improve initial quality of care and hence more focus on highly granular code schemes such as ICD10.
• Vendor will provide all remedies magically – First of all, most product vendors will cover only the absolute-must requirements such as increasing field sizes to cover 7 digit codes instead of 5 digit ICD9s. Second, at the best vendors will cover only their respective products. What happens to those umpteen home-grown COBOL programs? Thirdly, who said this is just a technical issue? What about the impact on all associated business processes? Even if your contract management system covers for 7 digit codes, if you have not renegotiated your contracts with your payers for new DRGs, don’t complain about the steep reductions in your payouts.
• All revenue cycle processes are outsourced – Really. And that is supposed to help you? I hope people realize that the impact of code changes is not only on RCM and/or contracting activities. It is going to pervade every sinew of the body that is healthcare. From benefit planning to claims adjudication, from contract negotiation to fee schedules, from care considerations to life style management, from disease management to pay for performance. The list is endless. You better have outsourced your physicians too, in case you want hide behind the “outsourcing” excuse.

So what is the net result? In my humble opinion (obviously I stretch the truth here by using the word ‘humble’), the state of readiness is a typical reflection of the World that we live in, i.e., a World divided between ‘Haves’ and ‘Have-nots’. The only difference is here it is ‘Getting ready’ or ‘Going to get into trouble’. There is no third category. Nobody is completely ready yet and won’t be for some time so that excludes the ‘Ready’ category. And on the other end anybody who does not get prepared is betting against odds higher than lightening striking the same place 10 times in a row (See, I deliberately did not use the lightening-striking-twice phrase because the odds the unprepared guys are working against are much larger than that). So that rules out the category ‘See-I-was-smart-did-not-spend-a-dollar-and-came-out-smiling’. That brings me back to my two original categories, ‘Getting ready’ or ‘Going to get into trouble’.

This is a very serious situation, especially in the ‘Provider’ space. The ‘bury-the-head-in-sand’ approach is not going to work. Believe it or not, the mandate is coming and equally certain is the fact that most payers (and all the big ones, commercial and blues) are going to be ready. And that could mean only one thing: providers will find themselves on the wrong end of the stick when it comes to renegotiating payments for new DRGs and/or worse yet, challenging the payouts down the line. How can one negotiate without any information or preparation with guys that have done their homework well? How can one not get penalized for low quality of care when one does not even have systems and/or processes to support the higher level of clinical granularity?

I don’t know who originally said it but I distinctly remember Sean Connory’s character saying it in ‘Untouchables’:

Never take a knife to a gun-fight.

Truer words have not been spoken and still we do it repeatedly and provider fraternity is no exception this time around.