Change is Constant, As Is Payment Reform



The last decade has been exciting…tumultuous…challenging...invigorating...demanding…transitional (pick your term) for stakeholders in the health care community. Providers, payers, consumers, and administrators have all been affected by the unprecedented level and rate of change in the health care delivery system in this country.

An aspect of this new landscape that has health care administrators pulling out their collective hair is payment reform. How are providers and facilities going to be reimbursed under the various models of payment with their various requirements? Will costs increase? Will revenues fall? Or vice versa?  How will providers adapt to the demands for new levels of documentation required?

Let’s look at one model - Population Health Management (PHM). PHM moves beyond the disease management model by expanding to include preventive health, chronic disease management, patient education, care integration, and the meaningful use of electronic health records, all to improve quality of care while lowering costs associated with delivering care. Providers are tasked with improving financial and quality outcomes to a defined patient population across the continuum of care.

Clearly, this model has some significant differences from a typical fee-for-service reimbursement scenario. But a diagnosis is a diagnosis, and a procedure is a procedure, so coding should not be affected that much…right? Wrong. Documentation in PHM needs to be substantially more robust than in the fee-for-service model.

While coding has been geared toward insurance reimbursement for discrete problems encountered during an office visit or a hospital admission, coding in the PHM environment needs to account for the “whole patient.” What conditions, beyond the chief complaint, does the patient have? As noted healthcare payment reform expert Harold D. Miller writes in “Ten Barriers to Healthcare Payment Reform and How to Overcome Them,” “the provider has an incentive to do complete coding of diagnoses, not just to ensure accurate payment, but to ensure that all of the patient’s health conditions are being managed in a comprehensive and coordinated way.”

The clinical picture of the patient needs to be 3-D. The provider may well take longer than usual to establish a comprehensive record that encompasses a patient’s current conditions, both chronic and acute, previous illnesses and treatments, risk factors, and patient education initiatives. The coder will have his or her work cut out to put all of this information into codes that tell the complete story of the patient’s journey through treatment to be inclusive of all patient settings. 

The health care administrator is faced with the Herculean task of assuring that the infrastructure, training, and process is in place so that the system works – regardless of what payment reform looks like ten years from now. Because we know change is the constant.

Training is key in supporting mastery of the multitude of changing demands in this…exciting…tumultuous…challenging…invigorating…demanding…transitional time in health care planning and administration. Enhance your Herculean skills today.