American College of Physicians: Internal Medicine — Doctors for Adults ®

Friday, October 9, 2015

ICD-10 and inflation of codes

October first has come and gone. For many of us, this date had little significance beyond the promise of cooler weather, lovely autumn colors, and the invasion of neighborhoods with giant inflatable Halloween decorations. While these decorations are fascinating to me, the do cause me to ponder the enormous gulf between my taste and that of my neighbors.

October 1, however, was a huge day to the medical community. It is a day that will live in infamy. It is the object of dread, of diaphoresis, of doom. October 1 was ICD-10 day. This view was further bolstered when I went to the CMS (Government Medicare) website, there was actually a doomsday countdown timer at the top of the page. Just looking at this made me anxious.

For those still unaware (perhaps looking through catalogs for gigantic inflatables for President's Day), ICD-10 is the 10th iteration of the coding taxonomy used for diagnosis in our lovely health care system. This system replaces ICD-9, which one would expect from a numerological standpoint (although the folks at Microsoft jumped from Windows 8 to Windows 10, so anything is possible). This change should be cause for great celebration, as ICD-9 was miserably inconsistent and idiosyncratic, having no codes describing weakness of the arms, while having several for being in a horse-drawn vehicle that was struck by a streetcar. Really.

But, as Abe Lincoln may have said, better the devil you know than the one you don't. We all got used to the stupidity of ICD-9, and, like the crazy neighbor who puts huge inflatables of the Santa Maria in their yard on Columbus Day, we learned to tolerate its eccentricities. It's better than having an axe murderer or hospital administrator in that house. Unfortunately, the folks over at ICD Inc. got overly zealous in their desire for completeness, increasing the number of codes from the 17,000 in ICD-9 to over 90,000 in ICD-10. It's as if that neighbor not only added the Nina and Pinta to their lawn, but also inflatable natives infected with smallpox along with a mural depicting the skyline of Columbus, Ohio. It seems a bit over the top.

Anyone paying attention to this subject knows of the ludicrous codes now available to the medical community (being bit by a duck while wearing a thong, being bit by a duck that is wearing a thong, being bit in the thong by a duck, being crushed by a giant inflatable while eating kale, etc.), so I won't go into those now. These give health wonks hours of entertainment, for which we are all grateful. But there is a much bigger, more serious set of problems brought about by the onslaught on the medical community by the ICD hordes.

Before I go into this, however, let me state that, because I no longer live in the insurance world (doing direct primary care), I do not bear the brunt of this apocalypse. Yes, we are inconvenienced by the need to submit ICD-10 codes for consults, labs, and procedures, but that is about the extent of it. I was tempted to get snarky here and lord this fact under my suffering colleagues, but thought better of it. While this may be a boon to the growth of alternative practice models like DPC, gloating over it seems cruel. Having lived in the land of insurance and codes for 18 years, the prospect of converting over to ICD-10 even now gives me cold sweats.

There are 2 main problems with this conversion from 9 to 10. The first problem is that, as I've written before, codes are the product produced by health care businesses. Health care providers (doctors, hospitals, and the rest) are paid for producing problem (ICD) codes and matching them with procedure (CPT and E/M) codes. This is the product they sell to their true customer: the third-party payers. Submission of the wrong codes has 1 main result: no payment. Codes are the lifeblood that carry the money to medical providers, and so changing those codes threatens the financial viability of medical businesses, large and small. Get this conversion wrong, and you don't make enough money to stay in business.

Now, because there has been enough time, and with the ubiquity of EMR systems centered on billing, the ironic heroes in this may be the EMR vendors. This should minimize the overall damage to the financial survival of medical businesses. Despite this fact, the conversion of codes strikes at the very heart of our health care business model.

The bigger issue here is the fact that, while they are the ones saddled with the expense of conversion and the ones facing the financial risk of not doing so, there is no obvious advantage to the doctors themselves to be making this transition. ICD coding is a billing nomenclature that does not give any apparent benefit to patient care. Codes don't help us make diagnoses, nor do they improve doctor-patient relations. In fact, it's very likely that this transition will lessen the ever waning focus on the patient while providers are obsessing on getting the code that will get them paid. The only positive most medical practitioners will see out of this conversion is getting rid of ICD-9.

Perhaps, like the 30-foot Santa riding a motorcycle which exploded in my neighbor's lawn last December, my fears are overinflated. The reality is that October 1 will come and go without the world caving in on the medical community. But my fear is that this is one more way our system is alienating and frustrating its workforce. This is, in my view, the more serious problem that will soon overtake all others. It is possible to still love practicing medicine, even in the screwed up system we have. But the number of doctors, nurses, and other providers who are reaching their limit is growing quickly, as witnessed by the number of phone calls and emails I am getting from doctors looking for an alternative.

Perhaps that's a good thing, as the misery created by ICD-10 may drive the system toward a better model. But I don't imagine the ICD corporation and its minions are pushing this on us with this intent. Someone somewhere thinks this makes sense.

Just like my neighbor who thought it made sense put a giant inflatable pregnant woman in front of their house for Labor Day.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

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A fundamental health disparity is reduced

When we talk about disparities in health care, there are many: access to care; the costs of care; the quality of care; and of course, the outcomes of our crazy, ill-designed, patchwork health care “system.”

Perhaps no disparity is more stark than that revealed by a regional analysis of how long people live on average, compiled by ZIP code. Our life spans, after all, are a complicated product of our health, determined as much (more!) by societal and economic forces as well as health care.

A decade ago in Tulsa county, we found that the life expectancy of people born in ZIP code 74126 was on average 14 years less than those born in ZIP code 74137.

This is not unique to Oklahoma. The Robert Wood Johnson Foundation conducted similar analyses for other metro areas and found gaps of 14 years in Kansas City, and an astonishing 25 years in New Orleans.

Knowing what we now know about the importance of early childhood in brain development, educational attainment, and health outcomes, many think that improving this fundamental disparity will take generations.

Some good news, then: the Tulsa Health Department re-did the analysis-by-zip-code and found that the gap had diminished–by 3 years!

The analysis only reports the outcome of a reduced life-expectancy gap. As to the reasons why, we can only speculate.

One editorialist looks at the community's openness about its failings and its collective investment: $46 million over the last decade from public and private sources to build infrastructure (clinics, offices, etc.) and bring health care professionals to areas that lacked them.

This is pretty heady stuff, to be honest. It shows that collective action in pursuit of a complicated goal has to be pursued on many fronts. And most importantly, that we still have a long way to go.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.

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Thursday, October 8, 2015

Is the medical profession a 'special interest'?

Don't expect this humble blogger to explain Donald Trump's broad and sustained GOP support, if our most seasoned political pundits are flummoxed. Why is this man with no prior political or governmental experience trumping all of his competitors?

Is he ahead because he is right on, or is he leading because the competitors are way off?

Like most folks, the conventional politicians are by and large an uninspiring lot who offer scripted screeds that are canned and calculated. Indeed, most political junkies like me can almost orate their stump speeches, since they vary little from speech to speech.

The conventional candidates often rail against “special interests,” a pejorative term that conjures up an evil group that is possessed by greed that tramples over the public good to serve themselves. I challenge you to identify a candidate who has not spewed vitriol against these nefarious ‘special interests'. When they do so, the audience reliably responds with loud applause.

Of course, this is pure political pandering. Here's why. Special interests are not a dark and ominous cloud hovering over us ready to thrust a bolt of lightning impaling us. We all are special interests. Every one of us either belongs to or supports one of them.
• My beloved first grade teacher Mrs. White belonged to a teacher's union. Is she a special interest?
• Is the letter carrier who delivers mail to my house a special interest?
• My accountant prepares my taxes. I pay him for this service. Does he have a special interest to resist tax reform?
• Are NRA members and gun control advocates special interests who are trying to further their agendas?
• Is Emily's List a special interest?
• Is the Sierra Club a special interest?
• Are trial attorneys who donate millions of dollars to politicians to pursue good government or are they a special interest?
• Aren't corporations allowed to advocate for their special interests like the rest of us?

If you carve out all of the special interests, who's left?

When politicians speak of special interests, they identify them specifically. If they were to name them, they would alienate many voters who support them. Politicians want voters to believe that the special interests being targeted are other voters' interests, not theirs.

Is the medical profession a special interest? You'd better believe it. We are gluttons feeding at the special interest trough. Physicians, pharmacists, pharmaceutical companies, hospital administrators, medical device companies, nursing home owners, home care companies and medical insurance companies all have their own interests which may collide against the public interest. For example, there may be many reasons why a particular artificial hip is used in a hospital. Why are only certain heartburn medicines available on hospital formularies? Similar questions can be asked of every medical specialty or hospital. Get my point?

Who's looking out for the patients? What special interest is advocating for them?

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

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A missed opportunity: Promoting healthier eating in the hospital

I remember the day like it was yesterday. I was a medical student, rounding with my team, and we had just talked to a diabetic patient who was recovering from a myocardial infarction. The attending looked over at the side and saw some chocolate donuts and cakes lying on the tray table, which had been brought in by the patient's relatives. The attending shook his head disapprovingly and said, “I don't think those are going to do you any good!”

Indeed, if there's 1 place in the world where we should be promoting healthy eating and addressing the real source of so many of the chronic diseases that are afflicting our society, it's in our nation's hospitals. Having been in clinical practice now for over a decade, I'm sad to say it's not just relatives that bring hospitalized patients less than optimal food. Hospitals everywhere are missing a golden opportunity to serve our patients nutritious (and delicious) meal options. And although we've made great progress over the last several years, with an undoubtedly palpable push towards healthier meals, both for patients and staff in the cafeteria, we are still nowhere near where we should be.

As an example, if we look at the standard bland food that's served for lunch and dinner, the “meat and vegetable” option, not only is it dull and boring but it also falls strikingly short of really promoting healthier eating to our patients. The world of health care really needs to put more thought into taking things to the next level. This does not necessarily have to be expensive gourmet 5-star restaurant style food, but it can be both nutritious and tasty if we dare get creative about it.

And while we are putting our heads together to come up with better meal options, why not also take this opportunity to educate our patients too? How about the kitchen staff or servers being told to provide “nutrition pearls” as they lay the patient's food out? How about some eye-catching educational material? Let's also think outside the box about other things we do to encourage healthy eating. Isn't it a disgrace that most hospitals have an abundance of soda and candy machines dotted around the building? This hardly sets a good example.

And finally, how about getting physicians in on the act? Most hospital doctors believe (wrongly) that it's the primary care doctor's responsibility to educate their patients on preventive medicine. This is another huge missed opportunity, as physicians routinely underestimate the power of what they tell their patients. I've often been pleasantly surprised by how patients and their families respond to some simple common sense advice to eat more fruits and vegetables, cut back on salt, and eat smaller portions. Just a very brief statement can have a big effect when it comes out of the respected doctor's mouth.

As we develop comprehensive strategies for hospitals to serve up better food, the approach needs to be multifaceted, involving input from nutritionists, doctors, nurses, patient advocates, and even people from the creative food industry. The old joke about bad hospital food has become so much part of health care folklore, it almost seems a rite of passage for hospitalized patients. I often joke when patients complain to me about the food (which is the second most common complaint I get after their inability to sleep) that; “We can't make hospital food too good, otherwise you will have no incentive to get better!” It always raises a smile, but hopefully 1 day in the future hospitals will start to be seen as the ultimate healthy eating establishments. The temples of healing and prevention that they should be.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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