March 6, 2012

Trains: A Metaphoric Overview of Where We Are

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Like most people past middle age, I have certain hobbies that remind me of my childhood. I ride a Schwinn mountain bike (one of the first, and carefully maintained) and the black Harley Trike I’ve mentioned before. I also listen to classical/rock/pop/adult contemporary/country music, and play four instruments, none very well. And I am into miniature trains … “N-scale,” specifically.

Trains can be interesting metaphors for so many things:

  • The weakest link (car) can determine the success or failure of the entire train.
  • Someone/something (engine) strong enough to do the job must lead the train and follow a path laid out by those who came before.
  • The course the train follows (tracks) must be well-planned and well-executed. It is, perhaps, the ultimate strategic plan, since it is virtually unchangeable once completed, and where it leads, almost everyone goes.

Now let’s sit back and take a few moments to consider this train metaphor in the context of the entire Congress/HIPAA Transaction Rule/HHS-OCR-CMS/5010.D0/ICD-10/provider/payer/clearinghouse/consumer/beneficiary/patient” train on which we now find ourselves.

The Tracks

Back in the dark ages of healthcare management (1996, to be precise), Congress passed and the president signed the Health Insurance Portability and Accountability Act. It happened very quickly, and most senators and representatives who were queried admitted to approving it solely on the recommendation of staff – and not necessarily their own staff. That was 16 years ago, and there are aspects of HIPAA that still have not been (and probably never will be) implemented (the Payer Identification Number and the Beneficiary or Patient Identification Number come to mind). At the moment we have only four components of HIPAA in place:

  • The Transaction Rule;
  • The Privacy Rule;
  • The Security Rule; and
  • The National Provider Identifier (NPI) Rule.

For the sake of this article, let’s call HIPAA and its rules the “track.” With this in place, we are supposed to know where we’re going and how we’ll get there. On to the train itself!

The Train

The U.S. Department of Health and Human Services (HHS) has multiple subunits, two of which are the Office for Civil Rights (OCR) and the Centers for Medicare & Medicaid Services (CMS). In its infinite wisdom, HHS management decided that HIPAA and its rules could be managed by existing entities, so the Privacy and Security rules now are enforced by OCR while the Transaction and NPI rules are enforced by CMS (don’t waste time trying to understand the rationale behind these assignments; just accept them for what they are). Let’s agree that CMS is the engine for our train, which I suppose makes Dr. Berwick and Ms. Tavenner our two most recent engineers. And yes, it’s a steam engine, so there is a tender (coal car).


 

Our first cars after the tender are that big boxcar labeled “5010” and the flatcar labeled “D.0.” 5010 is a transaction standard; it specifies the code sets that can be used for various transactions in the healthcare revenue cycle:

  • ICD-9/10 diagnosis codes are required for all claims.
  • ICD-9/10 procedure codes may be used on inpatient claims only.
  • CPT (or “HCPCS Level 1,” if you prefer) codes may be used on outpatient claims only (a requirement that goes a long way toward filling the corporate coffers of the AMA).
  • HCPCS (or “HCPCS Level 2”) codes, copyrighted by HHS, can be used on any claims, but on a very limited basis on inpatient claims.

So, what’s that “D.0” flatcar, you ask? Well, that’s the pharmacy coding requirements. Think of it as a big exception for a relatively powerful segment of the economy that is so fragmented it renders the CPT/HCPCS/ICD systems unusable.

But wait … what’s this? It’s another box car, even bigger than the first, and it has a big sign on the side that reads “ICD-10-CM and ICD-10-PCS.” To quote Dorothy from The Wizard of Oz: “Oh, my!” It’s bad enough that this car is part of the train at all, but apparently it’s going to be shunted onto a spur for a while in deference to the AMA and others who think it rolls too fast (and just when we all were having so much fun getting it into use).

Finally, we come to the three tank cars, so named because the involved parties are “tanking” just trying to keep up with everything the HIPAA rules and CMS keep doing! First are the two provider tankers; these are institutions and medical professionals. Then we have the clearinghouse tanker, which holds all those companies that make “dirty” claims clean. And finally we come to the payer tanker: insurance companies, Medicaid programs, workers’ compensation, and – Yes! What’s this? – CMS! Believe it or not, the engine is actually one of the cars too. It appears that our train can only run in a circle, going nowhere and accomplishing nothing. We don’t run off the track; we just run in circles, and our engineers call that “progress.”

But wait – we aren’t quite finished. What of the consumer/beneficiary/patient? You see that caboose sitting on the siding? That’s us. If our train wasn’t forever chasing its own tail, our caboose would bring up the rear and the voyage would be complete. But the other cars in the train – especially the engine and that last tank car – are so busy pursuing their own agenda (and unilaterally deciding what’s best for us in the caboose) that we can only sit wondering when it all will end.

Next Stop

So there we have it: a train with a bureaucracy in control, we providers and vendors caught in the middle, and that same bureaucracy bringing up the rear for the majority of healthcare expenditures – while few question why we don’t get anywhere. The HIPAA track was supposed to go somewhere – protecting patients as they change jobs and simplifying the administrative burdens of claim filing, processing and paying – but regrettably, and in true D.C. fashion, a new track was laid next to the HIPAA track. The new track goes nowhere, costs a fortune to run and gives the illusion of accomplishing good on behalf of we consumers/beneficiaries/patients who are sitting in that ratty caboose, just wishing something meaningful would happen.

I don’t know about you, but if I could figure out how to get out of here, head to the station and catch another train, I would.

About the Author

Billy K. Richburg, M.S., FHFMA is HFMA-Certified in Accounting and Finance, Patient Accounting and Managed Care. Bill graduated from the U. of Alaska, Anchorage and earned his M.S. in Health Care Administration from Trinity University, San Antonio, TX. Over a career spanning more than 40 years, Bill has held positions including CEO, COO, CFO, and CIO in hospitals ranging from 75 beds to over 300 beds, and in home health agencies, DME stores, and a home infusion company. Bill is a Board Member of the Lone Star Chapter, HFMA, and is Director of Government Programs for the Revenue Cycle Technologies business segment of MedAssets, Inc. His office is in Plano, Texas.

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Read 14 times Updated on September 23, 2013
Billy Richburg, M.S., FHFMA

Billy K. Richburg, MS, FHFMA is HFMA-Certified in Accounting and Finance, Patient Accounting and Managed Care. Bill graduated from the University of Alaska, Anchorage and earned his MS in Health Care Administration from Trinity University, San Antonio, Tex. Over a career spanning more than 40 years, Bill has held positions including CEO, COO, CFO, and CIO in hospitals ranging from 75 beds to over 300 beds, and in home health agencies, DME stores, and a home infusion company. Bill is a Board Member of the Lone Star Chapter, HFMA, and is Senior Director of Government Programs for the Revenue Cycle Technologies business segment of MedAssets, Inc. His office is in Plano, Texas.