July 2, 2013

Anticipating and Managing Changes in Hospital/Physician Relationships Due to ICD-10

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The appropriate focus of most hospital ICD-10 implementation teams is to ensure the proper education of staff, particularly coders and clinical documentation specialists. This is done to assess the many and varied information system ramifications, to schedule and coordinate the implementation of necessary components such as clinical documentation improvement (CDI) and computer-assisted coding (CAC), and to plan for the necessary engagement and education of physicians. These are all legitimate priorities, and most hospitals and health systems are well on their way to coordinating such efforts.

In addition to these integral components of the transition to ICD-10, the healthcare industry also needs to anticipate and plan for changes in the relationships between groups and individuals as our delivery model evolves. We know the role of coders will change as the scope and scale of their work expands, requiring more assistance from technology. But will coders working in an ICD-10 world be more or less interactive with physicians, documentation specialists, and others?  The role of the clinical documentation specialist is rapidly becoming more vital, as such staffers are transitioning from simply identifying opportunities for documenting more specific diagnoses to assisting in the validation of diagnoses, interpreting data that is relevant to core measures, and monitoring patient safety indicators, medical necessity and the like.

The group I would like to focus on at the moment, however, is the medical staff of the acute-care inpatient hospital. Many leaders feel that if we educate physicians on ICD-10, purchase a few new applications, train our CDI/coding teams and test all our systems, relationships will stay relatively stable. I would challenge that assumption.

We know that, at the present, the majority of physicians have done little in their private offices to prepare for the transition to ICD-10. Health systems employing a high percentage of the physicians they use already have undergone a seismic transition toward a new social relationship with hospitals. However, many community hospitals of varying sizes still depend on a voluntary medical staff to provide referrals and manage inpatient care.

Consider the impact in 2014, as physicians begin to realize at a visceral level that their current models are unsustainable. I predict that somewhere around May or June of 2014, many physicians who have maintained private practices for decades will face the realization that they simply will not have ICD-10-compliant systems (including trained staff) in their offices by Oct. 1, 2014. That leaves them with some sobering options. They can continue to practice but prove unable to bill for their services (that model obviously cannot be sustained), or they can go another route. But the alternatives are limited. Financially secure, older physicians are likely to retire. Others are likely to seek hospital employment. However, market conditions are primed to change. Hospital CFOs concerned about making payroll during the ICD-10 transition already are arranging to obtain temporary lines of credit. With anticipated cash shortages, one easily could anticipate that future practice acquisitions and employment agreements reached during times of limited financial means among hospitals may not prove to be professionally satisfying (and physicians will have little leverage). Today, many physicians also are dissatisfied with changes in healthcare made during the last several years. Yet those changes are likely to continue occurring. Physician executive leadership should be considering how to mitigate the antagonism that is likely to arise when many physicians are forced into new relationships with hospitals.

We can anticipate and plan for IT and educational needs for the ICD-10 transition, because these are fairly well-defined and predictable. We will also, however, have to deal with some of those less apparent cultural changes accompanying the transition to ICD-10 – or we may end up with a broad spectrum of dysfunctional relationships.

About the Author

Paul Weygandt, MD, JD, MPH, MBA, CCS, FACPE, is a Certified Physician Executive (CPE) with more than 20 combined years of experience in medical management, legal counsel, and orthopedic surgery. He has served as a hospital VPMA, improving documentation across all DRG payers. Paul is vice president of physician services for J.A. Thomas & Associates (a Nuance company). He is also an AHIMA-approved ICD-10-CM/PCS trainer.

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Clinical Integration/Clinical Integrity: What is the Risk for I-10 Transformation?

Paul Weygandt, MD, JD, MPH, MBA, CPE