Laying the Groundwork for Rationing

Laying the Groundwork for Rationing

Think the rollout of Obamacare was less than smooth? To put it in the words of the classic band Bachman-Turner Overdrive -- BTO to fans -- you ain't seen nothin' yet.

Looming on the horizon is something that could be far more disruptive: implementation of the International Classification of Disease, Version 10 (ICD-10), by the Centers for Medicare and Medicaid Services (CMS). The new system is slated to go online October 1, 2014, replacing ICD-9, the current version. Both ICDs make disease names computer-friendly by converting them into series of five to seven letters and numbers.

CMS has delayed implementation of ICD-10 not once, but twice, for a perceived lack of readiness. Seeing as the change is now set to occur just weeks before the midterms, CMS will almost certainly receive "encouragement" from the White House to come to its senses and again delay this changeover. But political expediency aside, ICD-10 should just be abandoned. It is proving exceedingly difficult to implement, will reduce the amount of time doctors can spend with patients, and will promote the rationing of health care.

About two weeks after ICD-10 launches, a virtual meltdown in the system of payments to health-care providers and facilities will almost certainly occur, as tens of millions of Medicare and other insurance claims are rejected. Why? Because very few of those involved will be prepared. Indeed, how can you truly prepare for a change that is on par with asking your local library to convert from the Dewey Decimal System to the Library of Congress Cataloguing System -- e.g. from 811 to PZ8.3.G276 Cat2 for The Cat in the Hat -- literally overnight?

ICD-10 has 68,000 disease codes, as compared with the current 14,000 -- and the two sets of codes bear no similarity to one another. Thus, users must learn what amounts to a vastly expanded foreign language by fall. Truth be told, we already operate under an overly complicated billing system that many don't get right. Why would we expect a more than four-fold expansion to make that better?

Much of this effort will come at the expense of patient care. In a 2012 poll by NPR, the Robert Wood Johnson Foundation, and the Harvard School of Public Health, only 39 percent of respondents believed that most doctors spent enough time with their patients. Making the billing process dramatically more complicated will only place greater demands on doctors' time.

There's more. The American Association of Health Information Management (AAHIM) -- a proponent that is one of four "cooperating parties" for the maintenance of ICD-10 -- suggests the added specificity of the new codes is necessary because "[insurers] cannot pay claims fairly using [ICD-9] since [it] does not accurately reflect current technology and medical treatment." In particular, the group explains that under the current system, different procedures are often assigned the same code -- a nod to the 72,000 new procedure codes being implemented on top of the disease codes.

Perhaps some modest, incremental additions to address its concerns could have been defensible. But the wholesale changes involved in moving to ICD-10 are not limited to expanding the codes that need it. Instead, the new system achieves a level of detail that could make it far easier for CMS and other payers to ration care and regulate beneficiaries' lifestyles.

For example, treatment for a burn caused by mundane circumstances might be covered, while one due to "water skis on fire" -- not a joke, see code V91.07XA -- might not. In fact, ICD-10 is so specific it could allow payment for treatment in the right eye but not the left.

While these examples may be a bit extreme, make no mistake that "payment fairness" is merely a euphemism for rationing. Somehow I don't think, in authorizing this change, Congress bargained for a system that might broadly empower CMS and insurers to divvy up care in ways voters -- a.k.a. patients -- are unlikely to understand or accept.

So, what do we get here other than full-time employment for members of AAHIM and a bad 784.0 -- or R51 for the handful of you out there who have already made the leap to ICD-10? (You can look it up, but it's a "Headache.")

I'm willing to bet most Americans -- if they were actually asked -- would prefer this burdensome change go the way of the Edsel. That would allow health-care providers to instead focus, to use another throwback to BTO, on takin' care of business -- the business of their health.

Craig H. Kliger is a physician and executive vice president of the California Academy of Eye Physicians and Surgeons.

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