Revolt over IT requirements

Seismic pressures building within the healthcare industry to improve quality, lower costs and rapidly adopt information technology have generated a pair of regulation-related temblors.

One big shock came Nov. 14 when members of the American Medical Association's House of Delegates voted to resist the federally mandated adoption of a new set of clinical codes. The delegates also called on the AMA to rally physicians against “its unnecessary and significant burdens on the practice of medicine.”

A CMS spokesman responded to the AMA in an e-mail, saying that providers have been given adequate time and flexibility to make the transition. “Implementation of this new coding system will mean better information to improve the quality of healthcare and more accurate payments to providers.” Three days later, though, the CMS announced it would ease off an enforcement deadline for the rollout of a related set of healthcare electronic data transmission standards, known as 5010.

Hospitals, office-based physicians, health plans and claims clearinghouses will have a 90-day grace period before the CMS begins enforcing compliance with its rule to convert by Jan. 1, 2012, to the ASC X12 Version 5010 standards for electronic clams and other administrative communications. While relaxing enforcement, the CMS kept the compliance date the same. The CMS said “a majority of covered entities and their trading partners” would be unable to be in compliance with 5010 by Jan. 1, adding that it has “also received reports that many covered entities are still awaiting software upgrades.” The switch to Version 5010 standards from Version 4010 is deemed to be a needed precondition to ICD-10 adoption.

The deadlines for both 5010 and ICD-10 transitions were set nearly three years ago. After initial postponements, the final rules for both, laying out the current deadlines, were issued in January 2009.

On the final day of their interim meeting in New Orleans, the AMA delegates passed a resolution from state medical associations in Alabama, Mississippi and Texas and two urology societies to “vigorously work to stop the implementation” of ICD-10 diagnostic and procedure codes. The resolution also called on the AMA to work with other informatics organizations to find “an appropriate replacement” for the ICD-9 codes now in use. The CMS-imposed deadline for ICD-10 adoption is Oct. 1, 2013.

At the New Orleans meeting, delegates passed several pro-IT resolutions, including one supporting open competition in the development of electronic health information exchanges and another to provide practitioners with the ability to check on a patient's healthcare benefits electronically in real time.

The American Hospital Association doesn't back the AMA's stand, according to Don May, AHA vice president for policy. “At this point we're still supportive of ICD-10, but you can't move forward without 5010, so we'll have to see how that plays out.”

But it's clear the AMA's anti-ICD-10 policy is tapping the zeitgeist with a growing number of increasingly anxious physicians. The Texas Medical Association, for example, has a “Calendar of Doom” on its website listing compliance deadlines, including one entry under the headline, “ICD-10 compliance. Make the transition or your claims won't be paid.”

The Texas resolution called the ICD-10 conversion a “monumental change” that “will place a staggering increased work burden on physicians and their staff with no direct benefit to patient care.” The resolution noted that physicians “are already under much stress” from paperwork and “increased financial obligations” from the Patient Protection and Affordable Care Act.

Dr. Robert Wah, chairman of the AMA's board of trustees and chief medical officer of IT services provider Computer Sciences Corp., said the association resolution opposing ICD-10 shouldn't be viewed in isolation.

“The statement is indicative of the level of frustration with the regulatory and financial pressures on physician practices across the country,” Wah said.

Wah conceded there could be public health benefits from gathering more complex and granular data via ICD-10, but from the delegates' perspective, “This was just one more thing where we don't see how it's going to improve individual patients' care.”

And it's not just physicians feeling overburdened, Wah said. “I think a lot of people are starting to blink here a little bit.” California's Medicaid program, for example, has announced it won't be in timely compliance with the 5010 rule, he said. “The states are feeling the same pressure.”

ICD-9, released by the World Health Organization in 1975, was adopted by the U.S. in 1979. ICD-10, out in 1990, is used around the globe, but in the U.S., ICD-9 still dominates.

An initial release of ICD-11 is expected in 2015, and that should be the focus of U.S. attention now, according physician informaticist Dr. Joseph Schneider, chairman of the Texas Medical Association's health IT committee and chief medical information officer for Baylor Health Care System in Dallas.

“There is a general consensus that ICD-9 is on its death bed,” but “ICD-10 is getting old and gray,” Schneider said, adding “I'm not sure there is much love for ICD-10 in the informatics world.”

So, instead of playing catch-up with the rest of the world on ICD-10, Schneider suggests the U.S. ought to play leapfrog and be among the earliest adopters of ICD-11.

“Part of the (AMA) resolution was saying, let's spend our time in the next few years working on ICD-11 and making that what we need and working at the end of the decade to put it in place,” Schneider said.

But Sue Bowman, director of coding policy and compliance at the American Health Information Management Association, long an advocate for ICD-10 conversion, said pausing for ICD-11 is not a viable option. “I don't think we can quite wait that long,” Bowman said. “We've delayed implementation long enough, and I don't think delaying it further is going to make it cheaper and easier.” Planned quality improvement and value-based payment reforms “are all linked to better data,” she said.

Of the two conversions—to 5010 and ICD-10—the latter is by far the bigger lift, industry observers say. But the proximity of the 5010 upgrade—just six weeks away—is giving practices more stress now, according to Robert Tennant, senior policy adviser for the Medical Group Management Association.

In June, after polling its members on their 5010 readiness, the MGMA called for the CMS to create a Plan B if, a couple months out from the deadline, the picture hadn't dramatically improved. And that's what the CMS appears to have done with relaxing enforcement, according to Tennant.

Long before the AMA vote, MGMA members have been grumbling about ICD-10, Tennant said, so the AMA resolution was no surprise. Nor will it be the only act of resistance.

Tennant also noted that the challenges practices face go far beyond ICD-10. “You can't look at it in a vacuum. You have pending Medicare cuts, e-prescribing, meaningful use, large hospitals looking to gobble up their practices. It's a lot of pressure.”

While it's good that the CMS is providing some flexibility on 5010, Tennant added, it probably won't be enough. California's isn't the only state Medicaid program that will not be able to meet the 5010 compliance deadline, he predicted.

“The CMS has to look seriously about allowing 4010 claims for a considerable length of time,” Tennant said. “We strongly encourage the government to monitor the industry. If things don't improve, they'll have to look seriously about augmenting this decision they made today.”