Healthcare Economy

There are three types of providers currently in the market space,
1) Who believe that transition to ICD10 is not going to take place at all. Statements such as ‘Not in my lifetime’ and ‘I will see ICD11 before I see ICD10’, are commonplace among the practitioners of this faith.
2)  Who believe in the fact that the transition is very simple and it is more of a media hype rather than actual issue. Statements such as ‘My vendor will take care of it all’ and ‘It is simply a matter of replacing one list of codes with another’ are the staple of this group.
3) Who believe that there is an issue but they are helpless to do anything about it because they are absolutely resource (read cash) starved and have many fires to fight. ‘Do I pick ICD10 over meaningful usage’ and ‘I don’t have any idea what is it going to cost me’ are often-heard platitudes from these industry bellwethers.

I have a different reaction to the three groups. I usually shudder involuntarily in the company of the representatives of the first group and am reminded of the age old adage ‘Ignorance is bliss’. In the company of the second group, I am not sure why, but I start seeing the images of Titanic hitting the iceberg (obviously the James Cameroon version). But it is the third group that I really empathize with.

These are a set of people who are not only well aware of the impending doom but are also the selected few who want to do something about it. These are the people who deserve every possible break and support that they can get to overcome this potential mess. And these are the people who sleep the lightest (if they can sleep at all).

Look at it this way, we have a provider system in this country which is working at less than 3% average margins (there are people who will contradict that statement and I have seen numbers as high as 15% but I go with the multitude here and discard the outliers). More than half of these systems are actually working at less than 1% or infact in negative margins. Their reimbursement rates are already way down, close to 60%, i.e., every dollar they bill, they get around 60 cents. On top of that, if they don’t fulfill their commitments to meaningful usage, they are in line for penalties ranging up to 10% in some cases. And, please don’t tell me that the government has earmarked significant dollars for getting meaningful usage compliant and hence that should be a wash for the providers. Has anybody ever implemented a decent (or for that matter any kind) of EMR for 44 thousand dollars? Throw up the transition to ICD10 on top of that and you have the classic case of good intentions gone haywire.

That is where this hapless group finds itself. They understand the urgency of the situation. They even understand the potential impact of the transition on the quality of care. But… what do they do? Where do they get the 100-500k dollars to get an assessment done? And God-forbid, if they get an assessment consulting vendor, who charges them an arm and a leg and comes out with a 70 page PowerPoint presentation which not only states the obvious (i.e., all your processes and systems are going to be impacted) but also puts in the fear of God into them in regards to the fact that they better upgrade all their 3rd party systems at exorbitant fees and fully remediate all their custom systems, lest the wrath of God rains down on them, come 1st October 2013.

These are troubled times for this group. They want to do the right thing but face following challenges, in no specific order,
• The very top level executives are not in tune with the people who actually understand the problem. The execs still believe that the issue is either non-existent or simply vendor-driven switch.
• The struggle for limited resources between I10 transition and other ARRA mandates that actually have tangible monitory significance attached to them either through incentives or through punitive measures.
• The lack of education with respect to scope and cost of the effort, which makes them susceptible to the high level (read lacking substance), generic consulting efforts.
• Lack of understanding of where the payers are going, e.g., are they going to deny I9 based claims post 10/1/2013 or will they still entertain them? That lack of understanding directly leads to reduction in commitment.

So what is the solution?
Simple answer is nobody knows for sure. I can try to address the technical aspects of it by introducing the concept of a low-cost shrink-wrapped package to do baseline assessment (not just a high level PPT) and core scope and effort estimation, but still the process impact falls outside of it. What does one have to do to handle that sort of BPM consulting with its inherent ‘no-guarantee’ disclaimers? A crosswalk, that is much beyond what GEM proposes, is a must, not only for training purposes but also for post-transition production phase. Some kind of a tool to support contract renegotiation is a must too. In addition automated training and tools to support productivity are essential. But they all cost money, which is not there to begin with.

So whichever you look at it, it is not a situation I would fancy being in. ‘Rock and a Hard place’, anybody?