By Lucian Newman III, MD, FACS

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From our first days in medical school, we are taught to respect the human form and learn to understand the diseases that lead to its ultimate demise. When needed, physicians intervene to impede these conditions, whether they be infectious, traumatic, idiopathic, genetic or the inevitable result of aging. “Comorbidity” can be defined as the effect of all other diseases an individual patient might have other than the primary disease of interest. We quickly realize that no single condition stands alone. Instead, each patient possesses an array of risk factors that affects the other conditions. Consider the myriad effect of diabetes or immunosuppressive disorders. We are challenged with treating the whole patient precisely because each disorder may affect another. The research done to study the effects of medical and surgical treatments often shows results that are unintended and unanticipated. Even with the level of sophistication seen in the modern practice of medicine, perfection of care is not possible, in part due to a lack of understanding of differences attributable to each individual patient and his or her comorbidities, both known and unknown.

As our society searches for the optimum way to care and pay for our population, a more intense focus on costs is natural. Generally, there are wide variations in expenditures based on the age, lifestyle, comorbidities and even geographical location of the patient. Although controlling the variables is difficult, simply knowing the variables is possible by aggregating all descriptions and treatments attributable to individuals. Accuracy in this endeavor is paramount, and this is the cornerstone of documentation and coding-improvement projects that are so important today. Payment mechanisms based on diagnosis-related groups (DRGs) reward facilities and physicians for describing the care of sicker patients generally limited to three levels of care. Newer initiatives will likely create more levels, and also will consider quality metrics and satisfaction scores to arrive at reimbursement totals. The physician’s role is paramount and increasing in these models.

Medicine is becoming increasingly complex. As physicians treat a narrower spectrum of disease, their comfort level in describing the whole patient decreases. Nevertheless, we are responsible for taking into account many variables before recommending both medical and surgical treatments. No physician is capable of knowing everything, but he or she should be capable of assembling information that is known and searching for unknowns, particularly in their respective discipline. The language of medicine does not always translate into the appropriate classification code assigned to describe the condition, or the language is not specific enough to distinguish between code options. The revision in the International Classification of Diseases [ICD]-10 codes requires greater specificity, but it is needed because our advances have outstripped our ability to describe the disorders specifically. There are many ways to criticize the move to ICD-10, but understanding that the ICD system was created to foster a better understanding of disease and death should be recognizable by all health care providers (although I’m not convinced that knowing whether an injury was caused by a raccoon or the pilot of a spacecraft is germane).

A sound argument can be made for higher reimbursement to those facilities and physicians who are responsible for higher-acuity patients. Determining what constitutes meaningful differences in acuity, and thereby justifying a higher or lower payment, would seem to be more difficult. Payment variables also now involve the level of patient satisfaction including 1% at risk for Medicare services. Satisfaction ratings are a part of Medicare plans by linking a small percentage of reimbursements to “value-based purchasing.” Comparing hospitals against their clinical performance guidelines (70%) and on patients’ perception of the quality of care (30%) will generate a basis for bonus or penalty. The Hospital Consumer Assessment of Healthcare Providers and Systems (or HCAHPS) form is the vehicle used to generate information by communicating with patients. The survey, which has 27 questions and is not limited to the discharge of Medicare patients, is conducted between two days and six weeks after discharge. (The survey and guidelines are available at www.hcahpsonline.org.)

Many physicians are frustrated by the intrusion into their relationships with their patients and the time spent with them. Each new directive, requirement or protocol requires a level of understanding and commitment, and often changes the status quo. Even the “meaningful use” set of standards has been shunned by some physicians who object to it on many levels. Clearly, the near future of medicine requires some adjustments to most health care practices. Attention to details previously ignored will be suggested, if not absolutely required. As responsibility for management shifts, the physician’s autonomy may disappear.

The ICD-10 codes will be introduced on Oct. 1, 2014. For further information, visit the Centers for Medicare & Medicaid Services at http://www.cms.gov/​Medicare/​Coding/​ICD10/​index.html?redirect=/​icd10.


Dr. Newman is founder and CMO of ComplyMD (complymd.com), a company that provides procedural documentation solutions. He is a general surgeon in Gadsden, Alabama.