Richard Averill readily admits to completely misjudging the amount of political opposition that manifested against ICD-10.
As senior vice president of clinical and economic research at 3M Health Information Systems, one of the lead developers on ICD-10-PCS under a CMS contract, with his background conducting DRG work since 1983, and from attempts to roll quality into payment experiencing that it cannot be done as fairly or as accurately as it should using an antiquated coding system, well, upgrading to ICD-10 just seemed like a task that needed to be undertaken, Averill said. Indeed, part 1 of this interview delved into many reasons the U.S. needs even the zaniest ICD-10 codes.
In this episode, Government Health IT Editor Tom Sullivan spoke with Averill about where the ICD-10 opposition resides, how lawmakers could potentially circumnavigate the administration and get another delay, and why all the health reform facets currently underway presuppose the use of a modern classification system.
Q: I read your piece in the Journal of AHIMA in which you address a number of ICD-10 myths swirling around the mainstream media, but which ones particular to the healthcare sector still persist?
A: In terms of the healthcare industry itself, I think you have to segregate that. If you’re talking about hospitals, hospital management, certainly coders, they’re all are very knowledgeable about I-10 and understand the benefits it will bring, know that there are some implementation challenges but, by and large, they are pretty systematically moving forward.
The vast majority of misperception is within the physician community. If you look at where the opposition or the sort of quasi-marketing rhetoric is coming from, that’s largely through the health delegates in the AMA. It’s manifesting itself through members of Congress, especially members of Congress who are physicians, being opposed to ICD-10. A lot of what comes out from that are the misperceptions, like jokes by Congressman Paul, that are articulated and stated as if they are fact and there hasn’t been any challenging of this misinformation.
Q: Which is why among the myths you present in the Journal of AHIMA, I found number 5 to be really interesting, that ICD-10 was developed by bureaucrats out of touch with the real world — if only because Texas Rep. Ted Poe and as you mentioned Kentucky Senator Rand Paul in politicizing ICD-10 are at the same time perhaps proving how distant many lawmakers are from really understanding the issue…
A: When something gets so politicized, unfortunately they take the most extreme examples and make that the sound bite. They’re just following the lead from the AMA’s house of delegates. There are a number of state medical societies that have been very vocal on this issue, like Texas, so I think Sen. Tom Coburn (R-Okla.) and Rep. Ted Poe (R-Tx.) are just taking the lead that they’re getting from their constituency.
Q: Another of the concerns I hear frequently is that tech vendors — be those practice management, revenue cycle, EHRs, computer-assisted coding — are not yet issuing ICD-10 updates, which some fear will create a last-minute scramble to update the software or, worse, switch to a vendor that is ICD-10 ready…
A: I would say to providers that you need to hold your vendors accountable. We said all our software will be I-10 ready by this October, I think most of it was actually ready last October, and we just do it as part of the normal update. It’s no different than every other regulatory update we do each year. The reality is that this October you should be acceptance testing, integrating, and so on. Of course there are going to be some stragglers out there but if you postpone it another year, it’s going to be those same stragglers there another year from now.
If it got postponed again, that would actually cause far more problems. I personally don’t think there’s any danger of further postponement from the point of view of the Obama administration. From HHS, CMS, etc., I don’t think there will be any wavering on the 2014 date. The one thing that could happen is that a bill gets passed in Congress that requires a postponement through the introduction of a Coburn bill or something like the farm bill. The reality is that it won’t be a standalone bill, it would have to be amended to something else. If there was some bill the administration really cared about and a non-germane I-10 amendment somehow got appended to it, well, the fact that there’s an ICD-10 piece it doesn’t like doesn’t mean the administration won’t pass that. So what we have to watch for is such an amendment to a bill that has widespread support and will get passed and signed. That’s where the danger lies.
Q: While not impossible, isn’t that something of a longshot?
A: For a lot of members of Congress I would agree with you but Sen. Coburn is an extremely effective legislator. He’s one of the Time 100 and in the Time 100 someone writes a story about you and Barack Obama wrote the one about Sen. Coburn — so given that it’s Coburn I think the possibility is slightly higher than it would be for someone else.
Q: And what about the AMA’s proposal of an “enforcement-free period” around ICD-10, along the lines of what CMS granted after the HIPAA 5010 deadline?
A: There’s good news and bad news of being in the electronic world. For payers, the infrastructure to run completely dual systems to accept a bill in either I-10 or I-9 and run completely parallel systems that work together would be a very substantial increase in cost of the conversion. The intent is to have one standard and if we’re going to have one standard it should go into effect at the same time. The sheer ability to manage data coded in two different systems all coming into payers and claims processing systems at the same time, I’m not sure how well our systems would be able to handle that. So it may sound like a good idea but in reality, if totally thought through, might imply some extreme difficulties to make it happen.
Q: You mentioned earlier that it's the physicians who are resistant to ICD-10. Why aren’t they clamoring for that kind of data?
A: I don't why there’s so much emotion on this issue. I don't know if medicine is becoming so complex that they’re longing for simpler times and I-10 has just been a lightning rod for complexity, or because it’s an unfunded mandate while moving to EHRs and e-prescribing were funded and there are no funds for I-10 so I don’t know if that’s what they’re upset, or if it's the Big Brother aspect — that more precise data is going to be used to evaluate performance, evaluate what’s going to be paid. At the end of the day those evaluations are going to occur so you can’t bury your head in the sand. The better question is how accurate will those be, how fair are they going to be? And with I-9 fairness is fundamentally compromised. Whether stopping I-10 will stall the progression of performance evaluation, I don't know. Again, I totally misjudged the amount of opposition from the physician community. I actually thought, naively in retrospect, that the physician community would be one of the biggest proponents.
Q: I obviously can’t speak on behalf of the physician community in general, AMA specifically, or anyone for that matter, but from reporting on this for a few years now, I can say the fact that ICD-10 is an unfunded mandate certainly doesn’t help when they’re the ones who essentially have to foot a large chunk of the multi-billion dollar bill…
A: Raise the complaint. If that’s it, make that argument. Make the argument that it should have been funded as opposed to trying to hold back time, the progression of time if you will. What people forget is that we’re trying to do all these things, enormous investments in EMRs, enormous investments in ACOs, enormous investments in value-based purchasing. But that all sort of presumes we know what was wrong with the patient and we know what we’ve done with the patient. So we’ll be able to access the laboratory data and do these nice things with the EMR. But if we have totally imprecise diagnostic and procedure information it’s very difficult, in some cases impossible, to take advantage of all that additional information.
If we’re going to do all these reforms, they have to live together — so everything we’re trying to do sort of presumes the use of a modern coding system.
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