Could ICD-10-CM reduce the primary care workforce?

On the heels of primary-care opposition to the switch to ICD-10-CM comes news of a survey that shows half of primary-care doctors would quit medicine today if they could. The major reason? Insurance-company and government red tape.

Well, the switch to ICD-10-CM is a big roll of federal-government red tape. Will this additional red tape from the federal government lower the threshold for many primary care physicians to leave medicine?

For starters, we'll let them tell you themselves.

The letter by the American College of Physicians on behalf of its Internist members states: The burden associated with implementing ICD-10-CM is likely to exacerbate the crisis in the primary care workforce.

The letter by the American Academy of Family Physicians (AAFP) was somewhat less pointed but no less clear: CMS must realistically consider whether pressures to rapidly adopt the ICD-10-CM code set outweigh the importance of supporting the already fragile backbone of patient care, primary care medicine.

The survey of primary-care physicians obtained responses from an impressive 12,000 doctors, 4000 of whom took the time to provide written comments. Here are some key findings of the survey:

• 49% of physicians -- more than 150,000 doctors nationwide -- said that over the next three years they plan to reduce the number of patients they see or stop practicing entirely.
• 94% said the time they devote to non-clinical paperwork in the last three years has increased, and 63% said that the same paperwork has caused them to spend less time per patient.
• 82% of doctors said their practices would be "unsustainable" if proposed cuts to Medicare reimbursement were made.
• 60% of doctors would not recommend medicine as a career to young people.
• If they had the financial means, 45% of doctors would retire today.
• Only 6% of physicians described the professional morale of their colleagues as “positive.” 42% of physicians said the professional morale of their colleagues is either “poor” or “very low”.
• 78% of physicians said medicine is either “no longer rewarding” or “less rewarding”.

Instead of throwing these physicians a lifeline, the government is throwing them an anchor (ICD-10-CM). Many will very likely drown (leave practice) as a result.

Internists oppose the switch to ICD-10-CM, too

In yesterday's post, we highlighted the opposition of family physicians to the switch to ICD-10-CM.

It turns out that internists, too, are against the switch. Dr. Yul Ejnes wrote a letter (pdf) on behalf of the American College of Physicians (ACP) opposing the switch. Like the AAFP letter (pdf), Ejnes' letter was in response to the proposed rule to mandate a switch.

Here are some highlights from internists' opposition to the switch:

The College urges the Centers for Medicare and Medicaid Services (CMS) to suspend plans to adopt ICD-10-CM, the diagnosis code portion of the ICD-10 set, for physicians and other outpatient entities. Adoption of this diagnosis code set in the ambulatory setting is unwarranted as the collective costs far out-weigh the benefits...The burden associated with implementing ICD-10-CM is likely to exacerbate the crisis in the primary care workforce.

The administrative changes and related costs of ICD-10 adoption at this time will place a significant burden on internal medicine and all other physicians; with the burden especially acute for primary care physicians. This is at a time when physician practices—small primary care practices--are already struggling to meet:

• other regulatory requirements (e.g. other HIPAA related initiatives including implementation of the National Provider Indicator (NPI) and the upcoming adoption of the 5010 transaction standards);
• calls for increased adoption of HIT (e.g. e-prescribing and interoperable electronic health records (EHR) systems) including the recently passed Medicare e-prescribing bonus that transitions into a payment reduction; and
• expectations to participate in various pay-for-quality initiatives such as the Medicare Physician Quality Reporting Initiative (PQRI).

Providing more diagnostic code options is not guaranteed to generate better data or patient care.

Indeed, the problems with ICD-10-CM that we have outlined here make it certain that our data will not be better if we switch.

Two of the major primary care specialties, specialties on which hopes for health care reform are often founded, have weighed in. ICD-10-CM will not help them care for patients. Instead, the switch would burden them unnecessarily and impede their ability to care for patients.

Family physicians oppose switch to ICD-10-CM

Much of the opposition to HHS' proposed rule to adopt ICD-10-CM is about the timeline. They have drunk the ICD-10-CM kool-aid, as it were, and simply ask for more time to make the switch from ICD-9-CM.

However, we recently uncovered opposition to switching at all. On behalf of the American Academy of Family Physicians (AAFP), Dr. Jim King writes a letter in response to the proposed rule.

Here are some highlights of the letter:

The AAFP does not support the transition to ICD-10-CM because we do not find that there is good rationale for making such a significant change.

The purported benefits of the transition to 68,000 ICD-10-CM diagnosis codes are largely based on assumptions and not supported with any real world trial involving practicing physicians in the United States.

Our recommendation that CMS not adopt ICD-10-CM is further supported with the following:

• Enhancement and adoption of electronic health records (EHR) must come first
• ICD-9-CM diagnosis codes meet the needs of patient care
• Biosurveillance and research needs can be met through the mapping of ICD-9-CM to ICD-10-CM
• Disease management programs are not dependent on diagnosis codes
• CMS’s estimates of coding education needs are not accurate
• Changes required for adoption of ICD-10 are substantial
• Lack of resources to support physician adoption

The AAFP is the premier speciality society for family physicians. Dr. King is Chair of the Board of the AAFP.

The AAFP has been at the vanguard of electronic health record (EHR) adoption. They have been a key driving force behind the creation of health care information technology standards, including the continuity of care record and continuity of care document.

This opposition does not therefore come from a small, fringe group. Nor does it come from a group that is backwards in its thinking with respect to health care information technology.

The Centers for Medicare and Medicaid Services would do well to listen to those doctors who are at the forefront of using information technology to improve healthcare. They should drop their plan to switch to ICD-10-CM.

As a postscript, we note that in our third post, we criticized the AAFP for not opposing the switch. We hereby withdraw that criticism!

The blogosphere recognizes the pitfalls of ICD-10-CM

The blogosphere is coming to the realization that ICD-10-CM has substantial problems.

Dr. Wes, in a post on October 25th entitled "Ten Times the Fun," laments:

Imagine, 290 codes just for diabetes! Yeeeee haaaaa! Diabetes with foot ulcers on the right foot gets one code, diabetes with foot ulcers on the left foot gets another code, diabetes with foot ulcers on both feet, but not involving the shins gets another code... I mean, a new code for every nuance of disease! You get the drift! Isn't this SPECIAL? Just think of the COST SAVINGS those clever bureaucrats have found!

Meanwhile, Richard Elmore in a post on his Healthcare Technology News blog on October 29th, entitled "More painful than an insect bite? ICD-10 cost-benefit for healthcare providers," lists all 87 ICD-10-CM codes for diagnoses of insect bites. These 87 codes replace 18 ICD-9-CM codes, a 4.8 fold increase.

Mr. HISTalk linked to Dr Wes' post in his October 27th entry. Mr. HISTalk also linked to Richard Elmore's post in his October 31st entry.

Readers of Mr. HISTalk are similarly not impressed with ICD-10-CM. Comments from Mr. HISTalk readers (not including the comments of yours truly) include the following:

The lists of codes are in general a slavish enumeration of nearly every possible combination of pathology, anatomic location, laterality, and ordinality of visit.

They [NCHS] are distributing it [ICD-10-CM] in a text file to:

1. Reduce the most “arduous” task - writing an upload and deduplication routine
2. Keep a non-Government entity (3M?) on the payroll to “manage” the process for them

Disease classification as patronage?

The blogosphere isn't fooled. ICD-10-CM is a poorly designed and executed boondoggle.