January 6, 2012

The ICD-10 Tale Act I

By David Block, MD, PhD

[The scene: Crossroads Medical Center (slogan: “We’re there for you at your Crossroads”), a 250-bed hospital in the mid-sized town of Crossroads. The town is in transition socially, economically and politically. Once controlled by the medical staff, the hospital board had to bring in professional management in 1998 or risk closing the doors, and as a major employer, that would have devastated the town as well as the patients. Many older doctors weren’t sure about “transplanting these ‘suits’ in our town,” but they moved in. CMC is run as tightly as possible, a well-kept secret from the staff and community, as it always looks like there’s money for somebody’s pet project.

Working first on compliance with DRGs and HIPAA, then on MS-DRGs and now on ICD-10 hasn’t been easy. There is no tradition of collaboration among the medical staff members, let alone staff, administration, employees, local employers and the community. When the hospital CEO informed her medical staff that compliance with ICD-10 was “expected,” the staff (backed by a recent AMA decision) revolted. Staff members demanded that the hospital resist the ICD-10 directive, pleading “Use your political clout for us for once in your life!” Physicians talked about dropping privileges or “sending our people to a friendlier hospital, at least for our surgeries.” The ICD-10 threat exposed cracks in healthcare in Crossroads. But how many? And were they just cracks, or something more serious? The CEO brings in a mediator to facilitate a dialogue among the obvious stakeholders in the hospital’s Community Hall.]


ENTER: The Mediator:  (The feelings in the room make him a bit uncomfortable. He wonders if he’s telling the whole story or just part of the story. He speaks.)


Mediator: Ah, you lucky people! We’re going to have a dialogue about ICD-10! Come on. The doors are bolted; you can’t get out, but ICD-10 is coming in! I will facilitate – as a consultant, I’ve got to do something, after all. Just kidding. Now, all doctors on this side of the room – hey, look at me, I’m telling a doctor what to do! Everybody who’s a card-carrying HFMAer over here – come on, now, you’re not that shy. You’re an asset, not a liability, ha-ha. And everybody in AHIMA over here. Quickly, please. Take your coffee. Take your chocolate. We want everybody neurophysiologically energized, with enough glucose on board to sustain critical brain function. Good. Who wants to start? Ah, the doctors...


[A 50-year old surgeon, Fritz Charcuterie, working on his MBA, looking sullen, sighs and stands. He speaks.]


Surgeon: We docs don’t know what this is all about. Why does this charting and coding business have to be different now? What was wrong with the way it was? We took care of our patients, we made our money and we went home. It won’t be the same ever again. They’re telling us what to do now, and when and how to do it. I’m doing a damned MBA just so I’ll understand this stuff. Maybe I can be the next VPMA here. I don’t know. It’s not fair. The AMA says on its fact sheet that this ICD-10 is “burdensome,” that “the move to ICD-10 will not be easy.” Going to cost us docs $30,000 each. Who’s paying? Overhead’s high. We’re being nickel and dimed by every SOB out there. They’re going to make me spend my days writing in a chart when I should be operating. I’m too old. It’s not fair.


[The surgeon sits and pouts, mind churning. An attractive, well-dressed, 40-something woman stands, smiles at her people, smiles at the doctors and nods to the administrators. She speaks.]



Medical records director: I’ve been the head of medical records here for 17 years. I started here right out of high school. I learned what to do, took classes and passed every test. It’s my department now. This hospital runs on me and my coders: we get the wrong code, you get the bills wrong, the quality measures are inaccurate, the outcomes look awful, and so on. And lawyers love it. I know every doctor, what they like, who they married, who they should have married. And I’m saying, Fritz, you’re wrong.


[The surgeon looks up. The room gasps.]


Medical records director: ICD-10 is nothing different from what you did in residency. Take appendicitis. You didn’t say at morning report back then if you saw peritonitis or an abscess during the appy? Or how many abscesses there were? Pus or no pus? Why are you always prattling about Holier Than Thou Hospital and how you loved the real medicine you did there? Prove it. Prove you’re the doctor you know you are. We’ll help you. It’s a new world.


[Overcome, she sits; the coders fan her with old charts. Fritz stares ahead, whispering, “It should have been you, Marie.”]

[A gray eminence stands up representing the finance clan – the cost accountants, the managers, even IT. The poor guy just looks tired, preoccupied. Everyone melts with pity, if only for the moment.]


CFO: I, the CFO, speak for the administration. Our back is to the wall – doing more procedures trying to catch up, coping with more risk, more regulations, more competition. A RAC attack is coming, and I can smell their outdated Toshibas, their well-worn blazers. Trying – no, forced – to do more with less: that’s us. Everything that was on the horizon, ACOs, PCMHs, whatever, they’re here now. Insurers have their agents all over. Damn. Sounds like a bad country western song.


[He muses silently for a moment.]


In high school, I had a band. Where’d it go?


[Snaps back]

Look, we need ICD-10, and we’ll get it. By October 2013. No ICD-10, no money. Period. This is our baby. My office is in charge. We have a battle plan. Dr. Frootlupe will champion it for the medical staff.


[Frootlupe remembers to smile.]


CFO: Marie, I want you and your best CDI in my office at 0800 tomorrow. Finish up that coffee, people. Metabolize that glucose. Let’s get out, and get down.



[A general hubbub ensues. Then a still, small voice breaks through. It’s the neurologist, in an Orvis jacket.]

Neurologist: What does the consultant have to say? It cost plenty to bring him here.


[Just what you’d expect from a neurologist. The consultant smiles warmly at the crowd.]

Mediator: We’ve got a genuine conflict here. The facts are not at issue: we know what ICD-10 is, and we know when it’s coming. So it’s not a cognitive conflict that we could settle by going to some authority. We’ve got a relational conflict. How do we negotiate the implementation of this as a group throughout the system, with everything we feel and think about each other, so that we are engaged not only in the life of the hospital, but in each other? Sound like new-age BS? Then consider this: without engagement, without alignment, the organization and its enterprise will fail. Doesn’t matter if it’s a hospital, a medical practice, a marriage. They all fail.


[A brave family doc calls out.]


Doctor: So, what do we do?


[None too sure of himself but hiding it awfully well, the mediator responds.]

Mediator: We begin. It’s not as bad as you’re afraid of. It won’t be as easy as you’d like, but compared to what each of you had to endure just to get to this place, at this time? Well, we can do it. Ready?


[Folks look around at each other carefully, not sure why such a simple thing like this ICD-10 threatens them. “Did I trust you yesterday?” each asks. Two things they agree on: a new year isn’t necessarily a better year. And they’d better figure out a way to make things work. They agree to meet again. And they exit stage left. Curtain.]

About the Author

David Block is a physician and has a PhD from New York University. He taught linguistics and medieval literature for three years in Illinois before entering the Abraham Lincoln School of Medicine at the University of Illinois, graduating with honors in 1979. He is a registered neutral in the State of Georgia and is a founding partner of HealthCare Mediation, LLC, in Athens, Georgia.

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