Struck by Turtle: Anticipating a New Healthcare-Billing System

“I went to medical school to care for patients, not to fill out forms.”
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T minus 12 months and counting until physicians and hospitals must comply with the federal government's October 1, 2014 deadline to implement the ICD-10 system for classifying diseases. 

Developed by the World Health Organization, its predecessor ICD-9 has been in place since the late 1970s. It lists no fewer than 13,000 billable codes, which include such exotic diagnoses as "injury from fall while occupying spacecraft" and "exposure to fireball effects of nuclear weapon." The U.S. clinical modification of ICD-10 will include no fewer than 68,000 codes. These changes are emblematic of a plague of complexification sweeping across healthcare.

The deadline for implementing ICD-10 has been pushed back multiple times, mainly due to the time required to design and install software and hire and train coding specialists to cope with the new system. Most physicians I know are baffled by it. For example, ICD-10 distinguishes between "spacecraft collision injuring occupant," "spacecraft fire injuring occupant," "spacecraft explosion injuring occupant," "forced landing of spacecraft injuring occupant" "unspecified spacecraft accident injuring occupant," and "other spacecraft accident injuring occupant."

But this isn't all. It also distinguishes between such turtle-related injuries as "bitten by turtle" and "struck by turtle," and between "bitten by turtle - initial encounter" and "bitten by turtle - subsequent encounter," as well as "struck by turtle - initial encounter" and "struck by turtle - subsequent encounter." Under just what circumstances someone would be struck by a turtle in a subsequent encounter is left to the imagination of the coder. Similar byzantine coding subcategories apply to assaults by alligators, dogs, and even ducks.

Imagine typical community physicians, who might be a solo or small-group practice. How could they hope to cope with such complexity? Would they be able to master it on their own? Or would they need to retain the services of a small battalion of coders, billers, and information technology support staff to have any hope of putting such a system into practice? And what is the effect of such complexity on the efficiency, ease of use, level of integration, quality of communication, and overall cost of our healthcare system?

Who could blame patients and physicians for thinking that the provision of high-quality medical care is already more than sufficiently complex without adding additional burdensome layers of administration? Just look at any contemporary textbook of internal medicine. The best known runs to over 4,000 printed pages. It is chock full of information about human disease and its treatment. Then along comes a disease classification system that runs to 68,000 entries. It is not difficult to imagine many physicians hanging their heads in despair, overwhelmed by a sense of futility. 

Many innovations in healthcare that originally seemed like important steps forward have turned out merely to add complexity without offering any real benefit to either patients or physicians. For example, bolting on new information technology and increasing the complexity of medical information systems has frequently accomplished little more than turning the physician into a data entry specialist. Even worse, the goal of such initiatives is frequently not to enhance care but to facilitate billing. 

The attractive red ribbon in which such gifts originally came wrapped has often turned out to be a mummifying ball of red tape that makes it difficult to unwrap the present that is supposed to be safely encased inside. Said one of my colleagues recently, "I went to medical school to care for patients, not to fill out forms." 

Put another way, healthcare is becoming more bureaucratic, and the rate of bureaucratization seems to be increasing exponentially. More and more, bureaucrats, not physicians, are shaping how medicine is practiced by assuming control of how healthcare is classified and paid for. The word bureaucracy after all, comes from the French word bureau, meaning desk, and a bureaucrat is someone who sits behind a desk, devising rules and making sure they are followed. 

Bureaucrats both public and private frequently have little or no experience of actually caring for patients. What seems obvious from the standpoint of someone with a background in insurance or healthcare administration frequently does not make sense from the perspective of patients and health professionals.

John Stuart Mill famously wrote that bureaucracy stifles the mind, and this is exactly what is happening in healthcare. The personal dimension of the patient-physician relationship is being taken out of the equation and replaced by a series of bureaucratic guidelines and rules. Every complaint, every diagnosis, and every treatment must have its own code. Rules, not the judgment and discretion of human beings, increasingly predominate. 

Patients and physicians who thought they were acquiring a new and better range of healthcare options are discovering that such systems frequently turn out to function like huge boa constrictors, squeezing the life out of the collaboration and trust that characterize a thriving patient-physician relationship. For healthcare to thrive in the future, physicians need to see themselves not as nameless and faceless functionaries, but as personally responsible for the quality of work they do and the relationships they build.

What can ordinary people do about the growing complexity of healthcare? When confronted with such looming changes as ICD-10, we can seek answers to some basic questions and then vote accordingly with our ballots and wallets:

Why do physicians spend as little as eight minutes per day in the company of each hospitalized patient, yet spend more than 40 minutes per day interacting with health plans?

Why does the U.S. spend at least $360 billion annually on healthcare administration, more than three times what we spend each year on treating cancer?

And above all, why is my doctor so distracted, distraught, and discouraged, and what can each of us do to help all doctors devote more of their attention to what really matters most in healthcare - taking good care of patients?

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Richard Gunderman, MD, PhD, is a contributing writer for The Atlantic. He is a professor of radiology, pediatrics, medical education, philosophy, liberal arts, and philanthropy, and vice-chair of the Radiology Department, at Indiana University. Gunderman's most recent book is X-Ray Vision.

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