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Wednesday, July 2, 2008

Healthcare Revolutions

In honor of Independence Day, I have a few rebellious thoughts on our healthcare system, and some revolutions that we might encourage. I happen to like fireworks, so consider this my contribution to an interesting Fourth of July.

Wipe out ICD for billing
Why is it that experts in the field of healthcare standards routinely comment on the fact that billing codes are not suitable for providing data useful for clinical care, and yet we are required to report care provided using billing codes. If we really want to improve healthcare, would it not make sense to use the same measures on both the clinical and billing side? One of the principles of Six Sigma (and similar process improvement initiatives) is that you need to be able to accurately measure inputs and outputs of a process in order to improve it. Furthermore, having appropriately calibrated measurements is vital to the success of these efforts.
Why have we invested so much time and effort in the US National program1 to promote reference terminologies like SNOMED CT, and yet we require the use of a vocabulary originally designed for reporting mortality statistics, and an outdated version at that so that providers can get paid? Wouldn't it make sense to require that billing be done using clincial codes? Why do we need to spend so much time dealing with two different coding systems? Why should providers be the ones who have to make the conversion from one to the other?

Here's a radical idea. Why don't we require that the values used for billing codes come from a clinical reference vocabulary like SNOMED CT. Furthermore, we could select a reasonable value set from SNOMED CT that would allow clinical users of that vocabulary to roll up their SNOMED CT codes into the billing value set automatically. If, for some arcane reason you have an absolute need to be able to map to a vocabulary such as ICD-10, then when you creating the billing value set, do so in such a way that the mapping to ICD-10 is also automatable.

One of the advantages of this revolution would be to accellerate the adoption of clinical reference vocabularies, as recommended by the NCVHS, the Consolidated Health Informatics Initiative, and ANSI/HITSP. Another potential advantage would be to increase the value of claims data to providers. A third rationale would be that the "instruments" used to measure the practice of care, and the cost of care, would be calibrated on the same scale.

Create a Healthcare Price Index
We note that consumers do not have a good way to understand the costs of healthcare, either direct or indirect. Yet we do have a way to compare fuel economy for different automobiles, and have had ways to compare the cost of living in two different cities for many years. Why can't we create a basket of healthcare goods and services that meet the needs of various healthcare constituencies, and use that as a standard measure?

Different healthcare providers could report their costs for each of the items in that basket of goods, and different insurers could also describe what the consumer's payroll deductions and out of pocket costs would be for goods and services. We would be able to easily determine which plans provided better value based on our own needs for items in that basket, and be able to compare the value given by various healthcare providers.

This may be radical, but it shouldn't be revolutionary. It just applies some of the same principles we've been applying to the economy to the economics of healthcare. I'll bet we could hire a blue ribbon panel to develop the basket of goods for the cost of say, two or three useful new terminology definitions.

Determine which jobs we need to eliminate
This breakdown shows that most of the costs in healthcare are labor. The most productive way to take costs out of the healthcare system would be to cut labor costs. Obviously it makes more sense to cut the most expensive labor costs before the lesser costs. So, the question to answer becomes, who are we going to get rid of, and what are we going to replace them with?

This question is so radical that I'd like to hear your own revolutionary thoughts...

1 You'll see me describe the ONC/AHIC/HITSP/CCHIT/NHIN/HISPC activities as the US National Program from time to time, usually when I've recently had to describe it to someone from outside the US.


  1. My daughters' primary care provider is a Nurse Practitioner. It makes a lot of sense to me that NPs could take over many of the functions that Physicians in general practice currently provide. I've been more than satisfied with the care my daughter's have recieved over the years, and would be very happy turning much of my own care over to an NP for common ailments. So, my own answer to the last question I posed is likely to replace physician hours with nurse practioner hours.

  2. About the first issue, I'd be even more controversial in my statement: if you start to use a clinical terminology for billing, the coding will change and the use of the terminology will be corrupted, rendering it less useful for use in clinical processes.

    We probably all recognize that when it comes to billing codes, coders tend to "optimize/complete" the codes in order to get a high reimbursement fee. That's the nature of things. I've seen the main and secondary diagnosis codes switched to optimize revenue. Obviously this is disasterous from a clinical perspective.

    So it's OK to have ICD for billing - just don't use it for any clinical reason. Use SNOMED for that purpose, and don't do automatic translations, because that would not allow us humans to "optimize" the translation to billing codes.


  3. One the first issue, the first thing we need to do is define precise and hard-and-fast rules for claims data. Too much variabilty exists now, and that clogs-up the revenue-cycle for providers. Then we can deal with the code sets.

    On the second issue, there are vested interests who need to be disenfranchised first. There is a lot of money to be made when it is hard to determine the actual/fair cost.

    On the third issue, we need to first get rid of the lawyers.

    And a fourth issue: Require people who smokes to pay significantly greater healthcare costs than non-smokers.

  4. Your last point is exactly why Canada is putting such an emphasis on CDM. The most expensive part of healthcare is hospital care. The most expensive parts of hospital care are ICU and Emerg. And at least 50% of visits to both those places are chronic disease not properly managed. Proper primary care, proper education, proper home care, and proper prescription levels could theoretically cut the need for expensive specialists and expensive special equipment in half.

    Now for my own inflammatory statement: The problem is even worse in the States. Not providing primary care for everyone leads more people to ignore conditions that could be managed cheaply. They then end up in ERs and are much more expensive to treat, with longer recoveries or lack of recovery meaning more lost productivity. It's the primary reason why the US government spends almost double per capita (and a much higher % of GDP) on healthcare than Canada does to provide far less service.

    So, the parts to replace are the ER and ICU. The thing to replace them with is a solid, universal, primary care and education system.

    (Hey, you said you wanted fireworks...)

  5. One of the ways to get the labor costs out of health care is to provide automated tools to health care workers. We used to just depend on the doctors in our Primary Care practice to remember what tests to order and visits to schedule for patients with diabetes. Now we have an automated decision support system that checks the lab values, advises the doctor, and even writes a letter to the patient if they need to take action.

    Ben Littenberg