John Marcille's blog

The collective sigh heard earlier this month came from frazzled physicians and medical groups relieved that the Centers for Medicare & Medicaid Services issued a new deadline for implementing ICD-10, pushing it back to Oct. 1, 2014. Implementing the codes — about 155,000 of them, as opposed to the approximately 17,000 for ICD-9 — has been giving providers nightmares.

The ICD codes are actually two separate groups: ICD-10-CM (clinical modification) is a set of diagnosis codes to be used, for the most part, by health plans, hospitals, providers, and PBMs. ICD-10-PCS (procedure coding system) puts an additional burden on hospitals — and to some extent payers — because they will be used to describe inpatient procedures. There are approximately 13,000 ICD-9-CM codes; ICD-10-CM will have 68,000. There are approximately 3,000 ICD-9-PCS codes; ICD-10-PCS will have 87,000.

The codes add “granularity,” a vogue term for more detail, to the diagnosing process.

CMS’s notice of proposed rulemaking (NPRM) in the Federal Register notes that “ICD–9–CM has a single diagnosis code for fracture of the wrist. If a patient is treated for two successive wrist fractures, the ICD–9–CM code does not provide enough detail to determine if the second fracture is a repeat fracture of the same wrist, a fracture of the other wrist, incorrect billing for delayed healing, or non-union or mal-union of the original fracture.” Health plans should appreciate the finer level of detail for billing and care management purposes, although the billing part might recede in importance a bit as various episode payment schemes work their way into the system. 

The problem with ICD-10 is that it was published in the Aug. 22, 2008 issue of the Federal Register. Everybody has been warned for four years (more really, since the the notice of rulemaking was late in the game) that the changeover is coming, and yet the deadline gets pushed back anyway.

The best-selling biography of Apple founder Steve Jobs by Walter Isaacson quotes Jobs as saying: “I think Henry Ford once said, ‘If I’d asked customers what they wanted, they would have told me, A faster horse!’ People don’t know what they want until you show it to them. That’s why I never rely on market research. Our task is to read things that are not yet on the page.” It is uncertain whether Ford actually said the “faster horse” thing, but Jobs believed he did.

Jobs was a difficult man to work for. But I’ll bet that if he were in charge of implementing ICD-10, we’d be talking about implementing ICD-12 by now.

John Marcille is the editor of Managed Care.

Ever since I started covering health care 20 years ago, managed care companies — HMOs back then — have had little respect from the public. I am sorry to have to point you to a new report that has managed care companies at the bottom of a list of industries in consumers’ eyes. Just below Internet service providers, TV service providers, and computer makers, and far below fast-food chains, banks, and retailers. The highest rating went to grocery chains.

The information comes from the Temkin Group, which surveyed 10,000 consumers. It uses the term “experience ratings.”

Within this despised business category, managed care, some plans have a better image than others. Will anyone be surprised that Kaiser Permanente leads the list, with Tricare a distant second? In fact, Kaiser is the only one to receive an OK rating. Others are poor or very poor. Highmark is at the bottom, just below Health Net and Medicaid.

I may be the editor of Managed Care, but I am not an apologist for the industry. It has made mistakes and worse. But I do think that managed care companies are getting a bad rap. Reasons that come to mind:

—People who get upset when their plan tells them that an expensive service is not covered are generally blaming the wrong party. In employer-sponsored plans, it is the employer who made the decision. But most people think it is the insurer or third-party administrator—the name on the plastic wallet card. My company is self-insured, but the name on the card is Independence Administrators.

—People have seen some inflammatory movies and reporting and formed opinions without all the facts. Managed care has saved consumers and employers a considerable amount of money over the years, and in many or most cases, health care companies’ policies have resulted in better care than would otherwise be the case.

—Most people have never had a major problem with their health plan. That’s because most people don’t have major health problems where coverage disputes can occur. And most of those with serious problems won’t have a major conflict with their insurer.

In any event, the likely/unlikely advent of the Accountable Care Act's going live with the sale of individual policies through exchanges is sure to spawn PR efforts by the insurers that are in that market or want to be in it. When that happens, it will probably seem as though they are all headquartered in Lake Wobegon, because they are all above average.

So read the Temkin page; it won’t take long. And ask yourself whether it makes sense, for example, that banks — which charge ever higher fees that have no relation to costs and, let us not forget, extended mortgages to millions of people who were not creditworthy—should be more favored by consumers?

People are funny.

(Here's the link to Temkin: is at http://bit.ly/yG5RM1.)

Back in the 1980s, the theme song for the television comedy show Cheers had a line: “Where everybody knows your name and they’re always glad you came.” Now, clinical executives have that place, and its drawing power is not the broad strokes associated with a mammoth social network site like Facebook, but rather, a more focused perspective.

The Medical Directors Forum, found at www.medicaldirectorsforum.com, serves as a gathering place for like-minded clinical executives to share ideas, provide guidance and insight, and discuss the many things they do on a day-to-day basis that they wish they could do better. In the past, medical meetings often provided this collegial atmosphere, but now that sharing of ideas and experiences is just a mouse click away.

A main draw will be the discussion boards. Each will be moderated by a thought leader on the topic who can tease out pearls of wisdom from the participants that might otherwise remain hidden or, at the very least, unshared.

Please do sign up for these boards as soon as you join the forum, so as to help them achieve the critical mass needed for good discussion. The forum is just starting up, and the number of participants will slowly grow.

Another area on the site that is expected to get a lot of traffic is the reference library, which will pull guidelines from various government agencies and commercial insurers and provide access in one convenient location.

John Marcille is the editor of Managed Care.

It's all about choice these days. Different routes, same destination. In this case, it's reading Managed Care when and where you like, and if you own an iPhone or an iPad, you can do that with our new app available at the Apple Store.

Search for "Managed Care," "P&T," "Biotechnology Healthcare," or "MediMedia," or just click here:
http://itunes.apple.com/us/app/medimedia-managed-markets/id496230488?mt=8

The free app gives access to Managed Care and our sister journals, P&T and Biotechnology Healthcare. You can access all the content through an online connector or, as I do, download the issue to my device and read it from there.

We still have three other ways of reading Managed Care: right here on this page (click on the "latest issue" tab above); on our digital facsimile site, and, of course, the awesome printed magazine itself.

Happy reading.

John Marcille is the editor of Managed Care.

I was just looking at the website of Newtek Business Services (www.thesba.com/), which also goes by the name of The Small Business Authority. It sells financial and administrative services to small businesses. I found more evidence that the public doesn’t have a clue about what’s going on in health care. This is goofy stuff, folks, so I'll have some fun with it.

Newtek has been conducting an online poll for about a month. I know, it is unscientific — it isn’t even clear that the poll is limited to small business representatives (I was able to vote, and was told that my vote was recorded, yet a news release describes those polled as “business owners”) — but it is interesting, to say the least. And the most interesting part is that about 5/6 of the respondents think it is wrong to force people to buy health insurance — much more than legit polls show, while at the same time, 9% plan to buy health insurance from the government. They must have heard that America’s gone socialist. I, however, thought the public option had been ditched in the negotiations leading to adoption of the Accountable Care Act.

And as if that weren’t enough, about a fourth of respondents expect the cost of health care to decrease in the next two years.

On what planet?

This is all ridiculous, to be sure, but it underscores the public’s confusion about current developments. And people should be confused! There’s even massive disagreement among health policy wonks about what’s in store. But I think the wonks could agree on one thing: Costs ain’t goin' down anytime soon.

I’d call it a sure bet.

I was amused and somewhat unsettled when I heard of Kaggle, a company with a novel approach to data analysis. As I understand it, Kaggle is a middleman between companies that have large amounts of data and are looking for certain kinds of analysis and the people or companies that can provide that analysis. But with a twist.

The companies with the data can be any kind of company. And the analysts? They could be anybody, too, and some of them might even be nobodies. Here's a quotation from the website, (http://www.kaggle.com/): "Kaggle is a platform for data prediction competitions that allows organizations to post their data and have it scrutinized by the world's best data scientists. In exchange for a prize, winning competitors provide the algorithms that beat all other methods of solving a data crunching problem. Most data problems can be framed as a competition." You don't have to be a big-time scientist to engage in the competition. You just need a big idea.

One competition, sponsored by California’s Heritage Provider Network, is to "identify patients who will be admitted to a hospital within the next year, using historical claims data." Practically the holy grail of managed care. There are over 1,000 contestants, and Heritage will hand out $3 million to the winner.

This is a pretty ingenious way to get people to work on a project that you might otherwise spend $3 million contracting with a single company and not get what you had hoped to get. Using a Kaggle competition, you could get exceptional value for your money. But if lots of jobs were done this way, there would be an awful lot of work done without being paid for, which is bad in itself, and which might shred the business of many kinds of consultants.

In managed care, I am thinking of the predictive modeling (PM) consultants who emerged 10 or 15 years ago and have been more and more accepted by health plans. Will operations like Kaggle mean the end of these vendors? Will competitions make PM consulting less lucrative and reduce the number of players? Or will it result in improved modeling with no downside for the sponsors of the competition?

This sounds like a disruptive innovation that bears watching.

John Marcille is editor of Managed Care.

Life is change. We here at Managed Care are breathing new life into our website by changing its look, but not only the look. Sure, it is more streamlined and easier on the eyes, but the change that excites us is in the content, which is richer and more interactive. Our home page is now a blog, and will feature short, pointed, readable articles by a varied group of contributors—people from many areas of health care, from present and former health plan medical directors to pharmacy experts, practicing physicians, consumer and employer advocates and representatives, and people active in many other sectors of health care.

We hope to promote dialog on significant issues among the many people in health care who visit our site. Our new format allows for many more authors and categories of information and argument than can be accommodated in our flagship, the monthly Managed Care magazine, which is the best-read monthly publication in its category. We will post current articles from Managed Care, as we always have.

This new blog is a blank slate. See an article that could use some support, or maybe a rebuttal? We are interactive: You are invited to post responses to any item. We also invite you to contribute in a more substantial way by sending appropriate submissions directly to BlogEditor@ManagedCareMag.com.

John Marcille, Editor of Managed Care