Letters to the Editor

Physicians will bear the costs of the update to ICD-10; population studies need to apply their predictive value to individual patients; health care reform can cover everyone only when it curbs escalating costs.

Déjà vu and ICD-10

What benefits of ICD-10 accrue to practicing physicians? According to “Future claims: moving toward ICD-10 and new standards” [ACP Internist, July-August 2009], none are easily recognizable. Who then benefits? The health care industry, insurance systems, pay for performance, comparative effectiveness, biosurveillance, health plan eligibility, software vendors, and, in general, the payers.

But who pays? Physician practices, of course. It's estimated to cost $80,000 and way up for a small practice to update software and systems, train staff, review and modify contracts, and integrate ICD-10 into daily practice. Sound familiar?

Not surprisingly, there haven't been any complaints from the passive, timid, beaten-down medical establishment, only sympathy and an offer of instructional support to ease the pain. I guess the Department of Health and Human Services views this as chump change for both small and large practices. The large insurers will just pass the cost of their new toy on to patient premiums.

I doubt there are many internists unable to select a reasonably appropriate ICD-9 code for a patient visit from their office worksheet. My office lists about 120 separate codes, of which 25 or so get the most use. It's a widely accepted paradigm of system design that as any system becomes excessively complex, it also becomes more prone to failure. I'll speculate that the likely failure of ICD-10 to provide useful information will be attributed to inputting errors due to excessive specificity requirements. If I am unable to quickly select a code because of too many competing choices, I'm frustratingly unlikely to invest even more precious time delving through an order of magnitude more possible selections. Not-otherwise-specified codes, if they even exist in ICD-10, or “first code I can find that comes to mind” may become my selection of choice, regardless of accuracy.

Perhaps physicians will learn to “game” ICD-10, locating certain codes that are associated with higher “pay-for-performance” ratings or reimbursement. These types of physician responses can only make the quality and validity of conclusions drawn from ICD-10 suspect at best and defeat the purported purpose.

Practicing physicians were the unfortunate guinea pigs for the failed first attempt at global capitation, unproven pay-for-performance schemes, and the rush to acquire expensive electronic records, and now comes ICD-10. If past is prologue, we should all very anxiously await its rollout.

Michael E. Miller, ACP Member

Research and primary care

Regarding your article “No need to monitor bisphosphonate effects in first three years” [ACP InternistWeekly, June 30, 2009], which discussed routine monitoring of bone density for women in the Fracture Intervention Trial, from the perspective of the practitioner one cannot assume such large population research data have meaning for the primary caregiver.

What any population study needs to do is give the practitioner some idea what the predictive value of the population data is for his or her individual patient. The population data should at least show a range of responses and not only the average, which so often is the focus with the evidence-based approach. I am certain the data then would show that some patients may not need follow-up as often but some would (their bone density declines). How often this conundrum occurs is important for the practicing doctor but is unclear from the published material. We certainly can't assume this study's result based on a large population will help us decide what to do for a single patient.

Present-day medical practice needs to start focusing on how best to use any population-based result in the individual patient. Applying the conclusions from such studies directly to a patient is not helpful or is nearly impossible. Such population data are helpful if one deals with large populations such as an insurance company or a national health service.

Angelo Licata, FACP, PhD

Health care reform: know the cost

To accomplish health insurance for virtually all of our nation's population, we need to curb the escalating cost of health care. To do so through incentives rather than governmental restrictions, we need more economic participation by the patients and their families in health care expenditures. This incentive approach can be straightforward, effective, and more palatable politically.

Currently there is widespread antagonism generated by the reform proposals which add to the tax burden of wealthy persons in order to pay for the health insurance of the uninsured portion of our population. This negative reaction is intense even though we would all benefit from having every citizen with some form of health insurance. An alternative methodology could be to have a small, tiered co-pay for the patient using health care measures beyond basic primary care. A three-tiered sliding scale could be developed with the co-pay ranging from 1% to 10%. This co-pay would apply to imaging procedures, hospitalizations, surgical procedures, chemotherapy, and other measures.

To be more workable and to generate more saving, this approach would apply to all payment systems including Medicare, Medicaid and private insurance. The extent of health coverage by supplemental insurance would be limited so that the patient makes the co-pay out of pocket. The co-pay percentage calculation would be based on Medicare allowable or on the private insurer's payment schedule.

Presently many Medicare patients carry supplemental insurance such that the patients pay nothing themselves, and moreover have no knowledge of the medical costs generated. A benefit of this methodology would be to create transparency such that patients would have knowledge of their own costs for health care. Currently even diligent patient inquiries typically fail to yield accurate information regarding health care costs.

To utilize this approach would have the patient help pay the expenses for themselves rather than some persons having an increase in their taxes. Also, the patient would become aware of and concerned with the costs generated by health care that goes beyond primary care. Such patient responsibilities would provoke discussions between doctors and patients regarding costs, and would in some situations stimulate less expensive avenues for serving medical needs.

Tiered co-pays seem much more compatible with American individualism, which resents limitations imposed by an insurance company or a public agency. Small co-pays would be better tolerated by the public and would lead to a shift away from the entitlement mentality that contributes to progressively increasing health care costs.

Robert H. Bilbro, FACP
Raleigh, N.C.