The ICD-10 Chronicles: How Congress Solved One Problem (For Now) and Created a Whole New One

April 1, 2014
For those of us who have been wondering when the U.S. Congress would take action on the so-called “doc fix” issue, Monday evening’s congressional action was not the way to do it.

For those of us who have been wondering when the U.S. Congress would take action on the so-called “doc fix” issue—the need to do something to forestall massive Medicare physician payment cuts, based on a 1997 law known as the SGR (sustainable growth rate for Medicare physician payment), one that has never been fully implemented because of its impossibility to fully implement—Monday evening’s action was not the way to do it.

First of all, we once again got only a temporary “doc fix,” not the long-term solution to a problem that is now calculated in the hundreds of billions of dollars (yes, that’s right, by some estimates, as much as a couple of hundreds of billions that the federal government owes itself, depending on who’s counting, and how; indeed, the Congressional Budget Office had estimated the cost of a permanent "doc fix" at $316 billion in January 2012, then lowered it to $245 billion in August 2012, and then to $138 billion in February 2013--but the numbers are constantly shifting, because of changing forecasts for future Medicare spending). What’s needed, when it comes to the “doc fix,” is a complete reworking of the SGR, something that will be difficult for a politically polarized Congress to do—though my policy sources tell me that, behind the scenes, staffers from both major parties and from the two lead committees in Congress—the Senate Finance Committee and the House Ways and Means Committee—are preparing a long-term solution to be revealed most likely in mid-November, after the 2014 elections.

But even if we get a longer-term solution to the SGR problem, the fact that Monday’s temporary “fix” came with a huge asterisk is troubling. That’s because, according to our sources on the Hill, some anonymous lobbyist for a group of medical specialty societies quietly took aside one of the House staffers putting together the House SGR doc-fix bill, and got language inserted that would delay the transition to the ICD-10 coding system from October 1 of this year until October 1, 2015. Say what?? The ICD-10 transition has already been delayed by a year—as we all know, it was supposed to take place last October 1, Oct. 1 2013.

But we also know that the American Medical Association and some of the specialty societies have continued to push for yet another delay, despite the fact that everyone in healthcare has been moving forward as quickly as possible to prepare for the October 1, 2014 deadline, a deadline that now appears to have evaporated.

It’s hard to believe that President Obama would veto the “doc fix” bill solely to force the ICD-10 issue, even as Marilyn Tavenner, R.N., Administrator of the Centers for Medicare and Medicaid Services (CMS) asserted firmly at the HIMSS Conference last month that there would be no further delays in the ICD-10 transition beyond October of this year. So now, if the President signs the legislation, as our sources predict he will, the administration is faced with a between-Scylla-and-Charybdis-type quandary, one not of its own making.

And, many levels down from the Olympus-like level of congressional lawmaking, the leaders of patient care organizations nationwide find themselves and their organizations in a ludicrous position with regard to ICD-10 preparation.

In the next few days, the situation will become clear, and most likely, all those organizations already prepared for the ICD-10 transition will find themselves prepared to go forward, even as this delay confuses and frustrates the industry. But, to be honest, this legislation penalizes the progressive, well-prepared clinicians and patient care organizations in this country, even as it was intended to tackle a different problem. Honestly, it’s situations like this that make people in this country cynical about the legislative process.

If, as we expect, President Obama signs this legislation—and honestly, the way that legislators in both the House and Senate have handled this situation puts him in an impossible situation in any case—there will have to be a major readjustment around the ICD-10 transition now, of course. Perhaps, to make lemonade out of this rather large lemon, senior officials at CMS could figure out an administrative way to smooth the ICD-10 transition going forward, perhaps by helping to facilitate some kind of dual-systems testing phase, or by creating a broad demonstration project that can help payers and providers demonstrate their readiness by early this autumn.

Either way, this whole situation brings strongly to mind that old adage about the undesirability of seeing either sausage or legislation being made. For my part, this evening, at least, I think I’d rather see sausage being manufactured.

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