ICD-10 codes you could not make up

Courtesy of good friend and esteemed colleague Alex Swedlow of CWCI, I give you the new diagnoses you do not want to appear on your medical chart.

(For a serious review of ICD-10 and workers comp, click here for CWCI’s analysis)

First up, the tragic Y93.D1: Accident While Knitting or Crocheting. Note, needlepoint and lace-making are separate and, well, distinct.  One wonders what kind of injury…burnt lip from ingesting overly hot Earl Gray?  

Known colloquially as the “Lincoln Diagnosis”, I give you Y92.253: Hurt at the Opera.  I know, technically not an opera, but hey, close enough!

Here’s one that doesn’t sound so fun – V97.33: Sucked into Jet Engine.  I think I saw something like that in an Indiana Jones movie…but it may have been a propeller, so…never mind! 

Among the candidates for most unlikely code ever to appear outside of a blog, I present V91.07:  Burn Due to Waterskis on Fire.

From Adam Fein, a candidate for the coveted “developed after coders read The Martian” award – V95.44 (“Spacecraft accident injuring occupant”)

Then there’s this, which makes one wonder if even the ICD-10 coding geniuses thought there could be a sequel – W56.22: Struck by Orca, Initial Encounter. 

From there to something that we kinda sorta always knew in the back of our heads was definitely a medical problem, but now we KNOW it ’cause there’s an actual code! Z63.1: Problems in Relationship with In-Laws.  

Our oldest daughter is getting married next summer…I’m hoping this isn’t prescience…

Steroid injections – they kinda sort work some of the time…

Thanks to Steve Feinberg, M.D. for forwarding a study on epidural steroid injections.

Here’s the brief findings:

Epidural corticosteroid injections for radiculopathy [pain radiating from the spine] were associated with immediate reductions in pain and function. However, benefits were small and not sustained, and there was no effect on long-term surgery risk. Limited evidence suggested no effectiveness for spinal stenosis.

In a follow up, Dr Feinberg provided this:

I have a 68 year old physician colleague who is highly functional both at work and recreationally. He has rather severe cervical and lumbar degenerative disease and stenosis and a very damaged left knee. He has undergone a number of injections (more than would be allowed via EBM) and takes Vicodin 10/325 3 times a day and uses some oxycodone for “breakthrough” pain. He lives on 5 acres and takes care of 10 horses and the property. He told me that working on his property makes him hurt more but that he is not going to stop being active just because of the pain/discomfort. He has been on the same opioid dose for years and has no obvious negative side-effects. He told me that without his medications, he would have trouble practicing as a physician and he certainly would not be active on his property.

Dr Feinberg closed with:

“I ask myself everyday if so little works, what are we left with to treat?”

A colleague of the good doctor provided this as well: “Could it be that Osler’s words from over a century ago continue to direct our best efforts? “The job of the physician is to entertain the patient while nature takes its course?”

I bring this to your attention as a reminder to all that medicine can be as much art as science, that we often don’t know what works for whom why and when and how.

However, make no mistake that treatment can and should be guided by evidence-based clinical guidelines. There should be a way to navigate the care management and authorization process to allow Dr Feinberg’s colleague access to the treatment that works for him, just as there should be a high standard for approval of “non-standard” care that puts patients at risk.

I’d close with this note – there is far too much use of procedures similar to ESIs, and far too little challenging of that use.

What does this mean for you?

Promote EBM, and ensure your authorization processes work well.


So what’s up with health care costs?

Actuaries are projecting health care costs will increase 5.8% annually over the next 9 years. Others think that increases will be significantly smaller.

While the 5.8% is a bit higher than we’ve seen of late, it is a heckuva lot lower than the average for the last three decades.

Currently health care is responsible for 17.4% of US GDP; if the inflation rate prediction holds true and other economic sectors also grow as projected, health care will account for one out of every five dollars in ten years (19.6% to be precise).

We do know that the prediction will prove to be somewhat wrong, and economic growth for the next quarter is hard enough to predict, making a ten-year projection the proverbial dartboard in a dark room.  So, what’s with the discrepancy between predictions?

The actuaries responsible for the 5.8% figure believe the soft economy over the last few years has been the primary driver of low health care cost inflation.  Their thinking is that now the the economy is back to steady and significant growth, demand and prices will both heat up.

The counter-argument attributes the recent happy days of low medical cost inflation to structural changes in the health care delivery system. Their view is these changes, while overwhelmed somewhat by the big increase in the insured population due to PPACA, will help keep cost growth low as they become increasingly commonplace.

At this point, we just don’t know; there is anecdotal evidence that medical homes work and don’t; that ACOs are a success and a failure; that behavioral changes are working and are non-existent. That is far from surprising; we are still pretty early into this process, a process which is massively changing almost one-fifth of our nation’s economy.

What does this mean for you?

The key message is costs will continue to increase, with health insurance cost increases somewhat mitigated by higher deductibles and copays.

What’s also very clear is the health plans that are able to deliver lower costs and sufficient outcomes will do very well.



Consolidation in the real world – implications for workers’ comp

There’s been a lot of mergers and acquisitions in the work comp arena, and certainly more to come.

But the activity in our little corner is minor indeed compared to what’s happening in the “real world” – group health, Medicaid, and Medicare. Make no mistake, these transactions will affect work comp.

You’ve probably heard of some of the activity among payers;

When these deals are completed, there will be three giant health insurers; United, Anthem, and Aetna.  All will have major operations in the Health Exchanges, Medicaid, Medicare, and employer-sponsored health insurance. Anthem, which owns many Blues plans, will have more local dominance in specific markets while Aetna and UHG are bigger players in the employer marketplace.

What you may not be tracking is the provider consolidation – which is equally frantic.  Just a few examples from the last few months:

The ongoing seesaw of market power is playing out nationally and locally – but the local scene is much more relevant for workers comp payers.  Local health systems negotiate with these big payers, with both sides coming to the table from positions of strength.  If Aetna wants coverage in southeastern PA, UPenn-Lancaster must be in their network.  For UHC to compete for employer and/or exchange business in New Jersey, they’ve got to have access to facilities and docs controlled by the two entities listed above.

The bruising battle over access, rates, and exclusivity is what’s driving the move to narrow networks. Health plans have to deliver more patients to specific health systems or those systems will not negotiate on price.

The best way to ensure increased patient volume is to make a deal exclusive – and we will see more and more narrowing of networks as competition heats up among the big three health insurers.

What does this mean for workers comp?

Work comp is incidental to Medicaid/Medicare/group/Exchange business. Health systems are going to get squeezed in these deals. Health plan execs will look to several reimbursement sources to make up margins; out-of-network care being most important but workers comp will be considered quite attractive as well. Comp is quite profitable, particularly as it drives orthopedic and ancillary revenue, services which have traditionally high margins for hospitals.

The other consideration is the care that is delivered via a health system or facility is billed under a hospital fee schedule. And, there can be a facility charge in addition to the physician fee. 

The net is work comp will be seen as a great source of very profitable patients.

The anti-vaccination idiocy

Penn and Teller profanely destroy the anti-vaccination case in a 90 second video well worth watching.

Unfortunately, many of the so-called anti-vaxxers won’t watch it, or understand it, or believe it.  No, they are willing to put their own kids – and everyone’s kids – at risk because of a completely wrong, now-retracted article in the Lancet purported to show a link between vaccinations and autism.

When, of course, there is NO SUCH LINK. As this group of parents with kids afflicted with autism eloquently shows…

And there’s any number of lunatics claiming vaccinations cause all type of horribles, e.g. whack-job, cartoon character Michelle Bachman’s assertion that the HPV vaccination can cause mental retardation

From the other side of the political spectrum, there are anti-vaxxer liberals who don’t get refuse to understand/outright deny the science – nice to know we all have morons in our midst…

Fortunately, people in third world countries are a lot smarter than these cretins 

We take vaccines so for granted in the United States,” Melinda Gates told HuffPost Live in January…

“They will walk 10 kilometers in the heat with their child and line up to get a vaccine because they have seen death. We’ve forgotten what measles deaths look like. We’ve forgotten … the scourges they used to be. But in Africa, the women know death in their children and they want their children to survive.”

The anti-vaxxers claim it is their right to jeopardize their kids – and yours. Fine.  While one could make a compelling case that their stupidity is grounds for a charge of child abuse, there’s a much bigger public health issue here, one that is all too obvious now that these idiots have allowed their kids into public spaces where they’ve infected others.

That case is simply this – if you choose to do, or not do, something that creates a significant public health risk, then you get to pay for the consequences.

Monetarily, criminally, civilly.

DWI, knowingly infecting partners with STDs, failing to keep firearms locked up, texting and driving, all are akin to the anti-vaccine movement.  And all come with legal consequences.

What does this mean for you?

Be careful, stupidity didn’t die out with the Middle Ages.

2015 health care predictions

I’ve decided to split my predictions into work comp stuff (where I do most of my work) and health care stuff not directly related to work comp.  Here’s my health care predictions…

1.  Health care cost inflation will remain low.  After five years of growth at or below 4 percent, health care costs remain relatively stable at 17.4 percent of GDP.  It is possible that health care costs for 2014 will come in below that benchmark due to increasing productivity and stable health care costs.  In the interest of setting a metric, I’ll predict costs remain at 17.4% of GDP…

2.  ACA will be less of a story.  The healthcare.gov website appears to be working well – at least on the front (enrollment/consumer) end.  Work on the back end (communications with internal governmental programs and agencies, financial links, and ties to health plans) continues but seems to be proceeding apace.  We’ll base evaluation on the volume of news stories this year vs 2014.

3.  Employer take-up of health insurance will remain stable; if it drops it won’t do so by more than a percentage point. Despite the hysteria from ACA opponents claiming employers would drop insurance en masse, it hasn’t happened.  And it won’t.

4.  Expect 11 million plus enrolled via the Exchanges this year (federal and state).  Initial enrollment in late 2013 was strong in key states, and the outreach efforts are paying off.

5.  More ACOs will close down or suspend operations, while others will grow and expand. Net is we will see more lives covered via ACO-type models.  For those of us old enough to remember the halcyon days of HMOs this is hardly surprising. The number of HMOs reached 640+ in the late eighties before market forces led to consolidation via merger/acquisition, failure of some, and expansion of the successful ones into new markets.  This is how it works – a decreasing number of ACOs is not an indication that the model doesn’t work.

6.  More hospitals will close as the reduction in Medicare and private pay reimbursement hits those unable to adapt.  While there will be pain in affected local communities, this is inevitable as a sixth of our economy goes thru restructuring.  It happened in the oil industry in Pennsylvania in the 1940s, shipbuilding in the 1960s, textiles, clothing, clothing, furniture, automobiles…

7.  More doctors will work for very large multi-specialty groups and health systems.  Currently about three-fifths of physicians are employed; expect that to bump up by a couple percent.

8.  Care extenders will get more care authority.  This is going to be contentious, at times nasty, politically charged. It is also inevitable.  PTs can do a lot of things orthopods currently do; nurse practitioners are already delivering a lot of primary care, and nurse midwives are increasing their scope of practice in many areas.

9.  Specialty drugs will continue their meteoric rise in cost and prevalence.  I know, an easy one, but absolutely worthy of note as they will become an even larger portion of medical spend, forcing payers and policymakers to make some very hard decisions about coverage.

10.  Ebola will disappear from American mass media.  If it’s not here, we don’t care, and it won’t be here. Yet another example of the American public and American media’s obsession with really bad things only when they directly affect us.


Med mal’s not a factor in health care costs – more evidence

More research indicates tight restrictions protecting physicians and facilities from malpractice suits doesn’t reduce health care costs.

Three states, Georgia, South Carolina, and Texas, essentially prohibit suits unless the physician intentionally orders care that s/he knows will hurt the patient.  A pretty very high standard, and one that would – one would think – allow docs to practice care with no concern about “defensive medicine.”

That may indeed be the case, however it is also the case that there’s no evidence that this high standard reduces cost.  The research, which focused on Emergency Department utilization and costs, found tight limits on suits didn’t reduce the “cost or volume of ED care.”

Moreover, “Legal risk does not motivate physicians as much as some previously thought.” [emphasis added]

This will not still the wagging tongues in the talking heads – nothing will.  But they’ll have less to wag about.

What does this mean for you?

Question those assumptions…

Good news is bad news – Medical cost inflation’s continued decline

Perhaps the biggest news to hit this summer is the decline in medical inflation.

Make no mistake, this is very, very important.

Important – as in huge decreases in the federal deficit.

Important – as in low-single-digit health premium increases.

Important – as in placing huge pressure on health care systems, hospitals, and other providers – because low premiums for employers equals less income for providers.

Here’s what the data shows.

Today, CBO projects the 2019 Medicare spend will be $95 billion less than it projected four years ago.  That’s equivalent to a fifth of the military budget.  Or the entire budget for welfare, Amtrak, and unemployment.

Over a decade, the reduction is about $700 billion.  According to a piece in the NYTimes (link above);

much of the recent reductions come from changes in behavior among doctors, nurses, hospitals and patients. Medicare beneficiaries are using fewer high-cost health care services than in the past — taking fewer brand-name drugs, for example, or spending less time in the hospital. The C.B.O.’s economists call these changes “technical changes,” and they dominate the downward revisions since 2010…[CBO analysts say] the economy is playing a negligible role in what’s happening in Medicare, meaning that they’re more confident that the practice of medicine really is changing. (emphasis added)

That’s all good, right?  The fiscal cliff is farther away, and not nearly so steep and scary as it was even a couple years ago.

Not so fast. One person’s savings is another one’s income.  In this case, that “other one” is the healthy care delivery system – doctors, pharmaceutical companies, hospitals, device companies, health systems.

Those stakeholders are adapting as fast as they can, and making great strides.  But a big part of that adaptation is revenue maximization – making darn sure they are getting as many dollars from every patient as possible.

What does this mean for you?

Pretty obvious, methinks…

Delivery systems and workers’ comp

There’s been quite a bit of focus on alternate health care delivery methods of late, with medical homes and Accountable Care Organizations prominently noted as ways care will be improved and costs reduced.  One source indicates there are 270 ACOs currently operating with an estimated 20 million members.

While the early evidence is somewhat mixed, in general the news is positive; a Pennsylvania ACO raised quality, and decreased infections and readmission rates, leading to a year over year decrease in medical costs.  Generally, ACOs involve facilities and providers agreeing to focus on specific quality measures and reward performance instead of paying on a fee for service basis.  In PA:

Half of hospitals and physicians’ potential earnings are based on their performance improvement in hospital-acquired infections, patient experience, readmissions, surgical care, and treatment for heart attacks, heart failure and pneumonia. The other half of the earnings are based on the providers’ ability to manage costs across inpatient care, outpatient care, ancillary care, home health services and prescription drugs.

There are problems inherent in the model; patient satisfaction is a tough metric to achieve when ER patients only want narcotics for their pain, while readmission rates are going to be higher when patients refuse to be responsible for post-discharge care. Our daughter works in an inner-city ER and this is all too common; patients KNOW these are key criteria and tell care givers they will downscore them if they don’t get their meds.

Nonetheless, it’s a far better financial model than fee for service as it doesn’t incent more care and higher intensity care.

Notably, it’s hard to find any evidence of ACOs in work comp.  I’d be most grateful if readers could point me to any reports or information related to alternative delivery systems in WC; while there are some bundled payment models, and a couple episode-of-care pilots I’m aware of, there’s just not much going on as far as I can see.

Just leave a comment here – and thanks!

The revenge of the nerds

It’s about understanding medical care, cost drivers, and components thereof.

Several years ago (ok, more like ten) I was in a client CEO’s office discussing medical care cost drivers, competitors, and possible differentiation strategies.  He stepped out for a few minutes to take a call, and, finding myself with nothing to do, I pulled out the latest Health Affairs to catch up on the latest and greatest in health policy research.

Upon this august gentleman’s return to his office, he asked me if I actually read Health Affair. When I said I did, he said something to the effect of “no one reads that, they just carry it around to look smart.”

And therein lies the problem.

And no, it’s not that I don’t need all the help I can get to look smart.

It is a lack of attention to the underlying drivers, influencers, issues.  It is a failure to think about how Medicare’s physician reimbursement affects commercial rates, how Medicaid enrollment drives provider behavior, how Part D enrollment influences drug pricing, how the lack of coverage among certain populations increases facility costs to commercially-insureds, how low adoption of evidence-based medicine makes for poor outcomes, how productivity is affected by insurance coverage status, how payment reform will affect workers’ compensation medical expense ratios.

There’s also a predilection on the part of some to ignore, or more commonly discount, information that runs counter to their worldview.  I see this all the time with workers’ comp execs when discussing Obamacare; they allow their political blinders to affect their business decisions.

There is so much happening in health care delivery and financing and reimbursement and evaluation and coverage that no one can possibly keep up.

What does this mean for you?

The ones who take the time to read and listen objectively, to think about import and impact are going to be more prepared, more aware, and better equipped than those that, for ideological or other reasons, have tunnel vision.

And thus more successful.