Healthcare Economy

ICD-10 is in the air. The industry have kick started its preparation. Leaders have started formulating their implementation strategies. Lots of thought are going into deciding on the "go" or "no go" facts, "tactical vs. strategic" compliance, "remediation to neutralization" approach, different testing models and so on. With all these now enough consideration needs to go into the "build, buy, and partnership" approach so as to align with the vendors at the right time for a fruitful acquiescence.

It's a fact that exclusive vendor centric remediation is a definite risk; on the other hand self reliant compliance strategy may end up in "Hits and Misses". When the biggies among the applications driving organization's core business are vendor specific, in such a scenario the best approach is to align the vendors in every step of remediation. This will be the potential way to reduce the risk and maximize the benefit. 

I don't mean "Vendor management" as a new buzz word in ICD-10 remediation; rather intend to make it a focal point for compliance. Vendor alignment is not just to understand the "when" of ICD-10 upgrades or "how" to deploy the revised technologies. It should be realized that potential business decisions are dependent on individual vendor strategies. Much business thought needs to be pooled in before the vendor strategy can be aligned in the organization's remediation roadmap; such as-
1. What if my contracts are still in ICD-9 and my vendor applications are ready with ICD-10?
2. Can my vendor help me to fit the existing ICD-9 based grouper logic to its ICD-10 upgraded system?
3. Will my vendors help me to support backward compatibility?
4. If different multiple vendors upgrade their products in different timelines, what will be the impact in my business process?
5. Even with dual code processing capability once my organization is in ICD-10, how will the vendors disable the ICD-9 in the transactions?
6. Can my vendor help me to provide a unified view of all historical and present data irrespective of the code sets?
7. Will my vendor help in training my internal resources related to their upgrades?
8. In most instances the vendors will amend systems via releases thereby requiring frequent internal integration and testing, how do I conform to that and will there be any impact in my business operation?

Apart from the above, a simple example (as follows) can help an organization to understand the gravity of Vendor alignment. A claims engine vendor will upgrade its system for converting ICD-9 claim edits for benefit exclusion to ICD-10, in this case the vendor may still consider 386.04 ICD-9 code for Meniere's disease as an inactive coverage code overlooking that in ICD-10, 8109 for Unspecified Meniere's disease is not delineated as an active or inactive code. This is simply because the output of the vendor's application is only a valid target code but it might not validate the  new business logic based on the ICD-10 codes.  Such small instances might severely impact the business of any organization and lead to unnecessary revenue loss in spite of being compliant in time.

Today, the vendor community may be in the midst of its own transition planning and may not publicize their specific transition schedules. But at the end of the day it's the responsibility of the client to incorporate the vendor's in their transition activity and sync up properly with them in every phase of the ICD-10 implementation. Thus in any organization workflow redesign, interface up gradation, testing strategies, training plans all have to be considered with the vendor's ICD-10 strategy.

Posted by Dr Suman De at 5:08 PM | Permalink | Comments (2) | TrackBacks (0)

One health plan I know has budgeted approximately USD 100M for ICD-10 implementation. Major chunk of that money is expected to be spent in 2011. That's a lot of money for a health plan of any size to spend, on a "regulatory" program - and that too between now and Oct 1^st 2013. Smaller organizations will spend less, but it will still be a significant portion of their IT budget in the next 3 years.

I'm assuming that most organizations are going to have to make cuts in their discretionary project spend to make way for ICD-10, unless the ICD-10 implementation is spread out into multiple phases. Spreading out the implementation into several phases can also help reducing the risks with the ICD-10 transition.

 

One way to spread the ICD-10 implementation can be:

Phase	Highlights	Systems/Functional Areas
Phase-1: implement by Oct 1st 2013	-   Migrate trading partner facing applications to ICD-10 -   Use crosswalks to map to ICD-9 for internal applications -   Create technical framework to transmit ICD-10 across the enterprise systems -   Store both ICD-9 and ICD-10 across all the enterprise systems	-      Gateway, Customer Service
Phase-2: implement by mid 2014	-   Create ICD-10 based rules in core applications -   Use crosswalks to map to ICD-9 for peripheral applications	Claims, Benefit Management
Phase-3: implement by late 2014	-   Migrate peripheral applications to ICD-10	Analytics, Medical Management
Phase-4: implement in 2015	-   Migrate historical data to ICD-10	Claims, Provider contracts, Analytics, Medical Management

 

Although this is a potential approach to achieve compliance in the short term, it should be kept in mind that these systems have critical dependencies between them. Making these systems interoperable on different code-sets can be expensive. Detailed assessment should be carried out to determine if there are compliance or organization specific disruption risks with such an approach.

Posted by Vijay Kumar B at 12:47 PM | Permalink | Comments (0) | TrackBacks (0)

We have the whole provider industry gravitating towards the "Meaningful Usage" requirement. Everywhere one goes, all one hears is 'Is it doable?', 'How are we going to achieve it?' etc. Let's first try to see, what has to be done by whom all, before we start speculating on whether it is doable or not.

The 'Meaningful Usage' mandate, in a nut shell, requires the provider community to be level 6 or level 7 compliant as stated in HIMSS EMR adoption model. Readers, who are really interested in the gory details, can check the model out here . There is another picture to go with the model though, and that is what percentage of the providers is at what stage of the model. I produce three sets of numbers here for each stage, at the end of 2008, at the end of first quarter of 2010 and the corresponding numbers from Canada.

Stage	End 2008 (%)	Q1' 2010 (%)	Canada Q1'2010 (%)
Stage 7 (Full EMR, CCD based data share, DW, Data continuity with ED, Amb, OP)	0.3	0.7	0.0
Stage 6 (Physician documentation, Full CDS,  Full RAD-PACS)	0.5	1.8	0.2
Stage 5 (Closed loop medication)	2.5	5.0	0.0
Stage 4 (CPOE, CDSS (clinical protocols))	2.5	7.7	1.1
Stage3 (Nursing/clinical documentation, CDSS, PACS outside RAD)	35.7	50	30
Stage 2 (CDR, CDS, CMV, possible imaging, HIE capable)	31.4	16.5	23.2
Stage 1 (All 3 installed)	11.5	6.9	11.4
Stage 0 (Lab, Rad, Pharmacy not installed)	15.6	11.4	34.2

Source: HIMSS Analytics™ Database ©2010

Let's look at these numbers carefully and one will realize very quickly that there is not a very significant shift in the numbers across the top 2 stages (6 & 7), there is slightly higher movement in the next 2 stages (4 & 5) but the real turbulence starts below stage 4. Let's try to explore some of the other inherent trends...

• There is a significant drop in the number of providers at stages 0 through 2 and primarily that number seems to have shifted to stage 3 and 4. This shows a clear intention on the community's part to adopt electronic records.
• Majority of the financial and operational efficiencies are gained at the lower end of the model rather than the upper end, which is primarily focused on clinical efficiencies. And that is where the major churn seems to be, implying that the community is highly ROI conscious and has shown reluctance in moving up the chain beyond a certain point where short term gains usually do not outweigh the cost, though in the long term, the benefits will be tremendous.
• The inertia is much higher to go from nothing (stage 0) to something (stage 1) rather than once the provider has gotten the taste of electronic records. The largest jump is between stage 2 and stage 3 and the reason for that could be that the incremental cost and effort associated with clinical documentation and PACS is relatively lower than going from stage 1 to stage 2, i.e., acquiring the CDR and CDS in the first place and standardizing the usually non-standard EMR systems to get ready for EHR. Once the stage 2 hurdle is crossed, going to stage 3 is relatively easy.
• Almost all of stage 4 through stage 7 functionality is incremental in nature, except for the DW at stage 7; thereby implying that it should be relatively easy and possibly less costly to move from stage 3 through stage 7. Still we see very little movement there. Surely a part of it is due to the ROI issue that I mentioned previously.
• And last but not least of the observations (and I wanted to highlight it because I missed out on this comparison previously and so am assuming that a few others might have too) is the fact that Canadian healthcare system (the one that I hear about all the time about how great and streamlined it is) is after-all not doing that well with respect to electronic adoption.  But they seem to have a lower cost of care. So maybe there is something more to reduction in cost of care than simply "Electronifying"  (is there a word like that in Webster or for that matter Oxford. If not, I should put a TM in front of it) everything in sight.

Now, I know that numbers don't tell everything but here they seem to be singing quite strongly. Let's see if these trends provide us with some clear guidelines/pointers to ensure success of the initiative. From this point onwards, the text is pretty much an opinion

• Maybe it will be a good idea to split the initiative into two phases, corresponding to the lower and upper half of the above model. Yes, I know, it is already phased into three stages, but what I am saying is that lets try to achieve only through stage 4 till 2015. What are we going to miss? We will have CPOE, we will have CDSS, we will nurse's documentation. What we won't have is physician's documentation (which is a big behavioral change in any case) and the analytics. I think the benefit achieved through a much higher potential adoption with outweigh those misses.
• Maybe it will be a good idea to concentrate the incentives more on the adoption stages rather than time bound. For example it should be more beneficial to focus higher incentive to jump from stage 0 to stage 1 because that is the biggest inertia point in any case.
• Maybe it will be a good idea to align the 'Meaningful Usage' matrices with the HIMSS model much more tightly in terms of encapsulated functionality achieved at each stage rather than the incremental percent achievement across multiple functionality areas as the case is currently. This will allow the providers to tackle one thing at a time before moving on to the next, rather than fighting battles at multiple fronts.

There is obviously no panacea for this whole initiative but if one carefully analyze the trends, history teaches a lot of lessons, even if it happens to be contemporary history.

 

Posted by Rajiv Sabharwal at 8:21 AM | Permalink | Comments (0) | TrackBacks (0)

Affordable healthcare for everyone. Most Payers are planning to offer healthplans that are basic but cheap. Most of these plans will be very basic and the benefits will not be anywhere near what current plans might offer. But the positive side is that as an individual, you get a lot of flexibility in customizing your plan for your individual needs. This hopefully will be similar to buying a new car. Consider the current scenario to be similar to buying , say a Honda Accord. You buy the car and it comes with most of the features you need. You probably never smoke, but still pay for the cigarette lighter. Maybe you don't like to eat or drink in your car, but you still get the cup holders. Consider buying a Scion, which is highly customizable. You chose what you need in your car. The options are varied, but still it is not going to cost you too much like buying a highly customizable luxury car. The new scenario should also be like this. You should be able to pick and choose what benefits you will most likely use and not get something which you most probably won't use. Say you are too young or too old to have a baby, you probably don't have to opt for the maternity package.

One of the benefits of universal coverage is that everyone will get the chance to have preventive care which is currently missing. You don't have to wait till your health condition gets cornice to go in for treatment, because you do not have healthcare. Everyone gets to do their physical checkups and do some preventive care which in the long run is going to be much cheaper, not to mention much healthier! As the saying goes. "stitch in time saves nine".

Have you seen the Windows 7 ads recently where you have people claiming that they designed it. They told Microsoft what they wanted and they did it. You will probably  see similar ads from Payers too in the near future. There is a lot of interest shown by Payers in social networking and reaching out to the individual member directly and getting their feedback using the social networking channel. Soon you will see plans being designed and modified based on popular customer demand. That would be refreshing, won't it ? This will definitely help improve the customer satisfaction scores for Payers too.

Posted by Shinju Damodaran at 7:16 AM | Permalink | Comments (0) | TrackBacks (0)

I know it is tantamount to a Berlin wall to fall, when we talk about unifying two water-tight compartments of US healthcare - The provider and the Payer. The Berlin wall did fall after a quarter century, as times changed. Times are changing for US healthcare as well. Will this healthcare wall between payer and provider fall?

Billions of dollars are spent on acquiring a billing system, training resources, healthcare billing process, submission, recovery, compliance and the whole revenue cycle management. And that's just one side of the wall.

Many billions of dollars are spend by payers, on buying, maintaining, integrating and being compliant to receiving the billing in the right format - EDI, HIPAA and many more to come.

Can we save Billion dollars, by establishing a single system that becomes a front-end for healthcare billing and front-end for claims adjudication? We are talking about same data being exchanged!

Q: Can a claims adjudication engine be modified and used as a billing system - death of a billing system!
Q: Can a billing system be modified and used as a claims adjudication system - death of a claims adjudication system!
Q: Will we save Billions, by removing intermediaries from the business landscape!

Posted by Venu Tirumala at 8:33 AM | Permalink | Comments (0) | TrackBacks (0)

I recently read a very interesting book called Selling Sickness by Ray Moynihan and Alan Cassels. The book brings to light a unique issue related to patient enablement namely disease mongering - a term coined by medical writer Lynn Payer to describe the process of widening the boundaries of illness that require medical intervention for personal gains. Patient enablement is all about educating and empowering patients to proactively manage their health but passing on improper information, educational or marketing material to patients will encourage them to seek medical help and resort to medications for conditions which can be managed much more efficiently with lifestyle changes. This is what disease mongering is all about.

There are several conditions where the boundary of what is a disease requiring medical treatment is quite fuzzy. Depression would be a classic example. The book talks about a checklist screening test for depression that classified 49% of the people as having mental disorder! Such mis-guiding health tools will make patients out of fairly healthy people going through a rough patch in life and drive them to popping pills. Once they start on medication, anti-depressants often have side-effects and worrisome withdrawal symptoms which make them continue with medications much longer. Another example is Menopause, a natural change in women's life, which has been medicalized and dubbed as a medical condition of "estrogen loss" requiring hormone replacement therapy. Social Anxiety Disorder, Attention Deficit Disorder and the list grows for conditions where boundaries for medical condition have been stretched to draw more and more people into the net as patients. For such conditions, there are significant geographic and cultural differences in what gets categorized and treated as a disease.

It's a misconception that health conscious people need a name for everything that doesn't "feel" right and they want "a pill for every ill". This is no excuse to brand mild conditions as diseases. People only care about relief from symptoms and for some cases going on vacation or joining a hobby class can provide more enduring relief than drug therapy.

As US government is struggling to control increasing healthcare costs through healthcare reforms, it's amazing how disease mongering has been overlooked as a cost driver. In 2002, there were more than 10 million prescriptions written for teenagers for anti-depressants in US alone. Public health agencies need to play a prominent role in preventing disease mongering and ensuring that people have access to accurate and unbiased health related information.

Their two pronged approach should be to:
• Shield public from mis-information that generates health scare and drives them to seek drug therapy and medical treatments
• Encourage lifestyle, diet and behavioral changes as a means for restoring well-being for conditions which do not need medical treatment.

After years of isolated but persistent efforts, we are finally seeing a start of "green" revolution where everyone: government, corporate, schools and individuals are united in their efforts to be eco-friendly. It will be great to see beginnings of a similar health revolution where all converge in their efforts for health management through life-style changes first and medical intervention as and when needed. People deserve access to right and complete information for making healthcare decisions.

Posted by Seema Pandey at 8:02 AM | Permalink | Comments (0) | TrackBacks (0)

The diversity in the nature of ICD-9 to ICD-10 coding means that the task of developing a workable translations and crosswalks is highly challenging and complex. To my opinion any healthcare organization that tries to address all of them only through GEM is at significant risk of paralyzing itself. A thoughtful and rational approach is essential to derive the best from the out of the box maps available in the GEM. But that cannot happen without availability of reference clinical data.

Looking at the industry pulse, it is evident that providers are sluggish in complying with ICD-10 by the mandated timeline. As HIPAA 5010 also accommodates ICD-9, Providers can take this advantage to send out claims in ICD-9 post October 2013 till they are ready with ICD-10. Going with the mandate, Payers in such situation can simply opt to deny payments for all ICD-9 based claims. But that won't be a wise business decision, as in that case they might end up losing potential Provider clients.

A generic frequency based ICD-9 to ICD-10 mapping can be an intermittent solution to serve the purpose of reimbursement. But such a map may not be intelligent enough to assign an accurate dollar amount to the provided ICD-9 coded clinical diagnosis/procedures in the claim. Simply with such a frequency based crosswalk, Payers will fail to derive the financial incentives of ICD-10 that is promised by its clinical granularity & specificity. Even tackling the issues like detection of fraudulent claim would be still challenging for Payers, as before. Frequency based map will also fall short in defining precise crosswalk for all ICD-9 based historical data, that will be required to re-strategize their allied business lines e.g. Disease management, Utilization management. This is why Payers needs to look forward in creating a clinical data referenced agile crosswalk that will serve across the spectrum of their business.

It's true that unlike Providers, Payers doesn't have any in-house clinical data source, but that does not mean that it's too difficult for them to develop a clinically sound crosswalk? To best of my knowledge, there is a potential means for Payers to get access to clinical information and develop their own intelligent crosswalk. They just have to turn back and make a rational judgment in mutually mandating the existing ANSI X12 275 Claims attachment transaction with their trading partners.  Even to adjudicate claims with insufficient information, payers today do seek for an X12 275, then why can't payers make it a compulsion now with every incoming 837?

So far the considerable animosity between health plans and providers have been a bar in turning the 2005 published NPRM [45 CFR Part 162] to a final rule, which intended in mandating the EDI X12 275 transaction among the covered entities. But it's now the time for Payers to lead from the front in resolving the existing debates. Mutually mandating the EDI X12 275 with the Providers/trading partners can aid Payers to fetch adequate reference clinical data. Converting the clinical data that comes in a XML format as per the HL7 (CDA) standard or scanned images through EDI to a human-readable format and parsing them through a GEM based ICD-10 code mapping tool powered by intellectual clinical rules will certainly produce a simple, clinically intelligent, business agile ICD-10 crosswalk for payers.

Posted by Dr Suman De at 5:58 AM | Permalink | Comments (0) | TrackBacks (0)