For example, there was a time when a consultation visit meant just that: a patient would be referred to a specialist who was asked to opine on their condition and its management and to provide the patient and the referring doctor proper guidance. The reimbursement for such a visit included payment for the consultant’s extra time and effort, a recognition of their expertise in this area. Then on Jan. 1, 2010, a non-leap year, the consult visit vanished into thin air.3 As a way of reducing payments, the codes, payment structure, even the need to send a timely note to the referring doctor, disappeared by way of a diktat, issued by the Centers for Medicare & Medicaid Services, that Julius Caesar would have thoroughly appreciated.
Sadly, this was only one of sundry edicts that regulators and payers have recently imposed on our practices that have adversely affected clinical care. Although the erosion of medical practice began much earlier, 2015 will be viewed as a watershed year when many of the incremental changes shaping U.S. healthcare began to coalesce into one huge migraine headache for all of us.
The Year That Was
2015 saw the full-scale implementation of the Affordable Care Act, better known as Obamacare. Although some commentators and physicians deride the Act as being costly, overly bureaucratic and interfering with the optimal delivery of healthcare, it has several worthy aims, including broader coverage for those individuals who were previously uninsured and widening the safety net for vulnerable members of society. Unfortunately, the Act’s imposition of the Meaningful Use mandate has turned out to be a time-consuming activity that some clinicians believe impedes, rather than enhances, patient care.
The fault for the implementation of the bewildering ICD-10 coding system lies with another legislative branch, Congress, where rare bipartisan support mandated its Oct. 1, 2015, start date. Several of its 68,000 codes may have emanated from a Monty Python comedy sketch. Pick your favorite: There are codes for patient encounters with macaws, cows, ducks, pigs, spacecraft, lampposts, roller skaters, jet engines and even in-laws.4 Of course, it does matter whether your right or left arm was sucked into that jet engine (V97.33XD2 or V97.33XD3)! There is a Yiddish word to describe all this nonsense: narishkeit!
Seriously, ICD-10 is a severely flawed taxonomy that adds little if anything to rheumatology care. For example, it remains blissfully ignorant of the use of CCP or ANCA antibody in assigning diagnoses and does a poor job distinguishing most of our rheumatologic diseases. Nonetheless, we are stuck with it through 2016 and beyond.
Disrupting Our Care
Disruptive innovation, a term coined by the Harvard Business School professor, Clayton Christensen, describes a process by which a product or service takes root initially in simple applications at the bottom of a market and then relentlessly moves up market, eventually displacing established competitors.5 Amazon, Netflix and Uber are prominent examples.
