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Some of Obamacare’s Complicated Mistakes


Stanley Feld M.D.,FACP,MACE 

President Obama appointed Dr. Donald Berwick as head of CMS during the congressional recess last August. It was my impression it was a one-year appointment. He does not seem to be leaving anytime soon.

 President Obama made this appointment to avoid congressional hearings and the publicity of disapproval.

 Dr. Berwick’s goal for healthcare reform is a single party payer. He also believes in redistribution of wealth. I believe Obamacare will be repealed either by the Supreme Court or the next election.

 CMS’s execution of their initiatives is poor.

 Dr. Berwick believes in increasing bureaucratic structures to administer central control over physicians and their patients by regulations and penalties. 

 Accountable Care Organizations are not a bad idea if they could work. They would increase the measurability of good care. There are too many organizational barriers in the way of execution of ACOs.

Physicians and hospital systems will be fighting with each other over distribution of reimbursement and quality care judgments. Family practitioners and internists will be fighting with specialist over the distribution of reimbursement. I do not believe physicians will be satisfied with a salary determined by hospital systems.

Patients will suffer as access to care decreases. Federal funds will be wasted and the federal deficit will increase further.

ACO’s are in really HMO’s on steroids. Patients were dissatisfied with HMOs in the late 1980s to early 19990s.

The Pay4Performance formula creates penalties and not incentives for physicians and hospital systems. There are no incentives or penalties for patients’ performance.

Health Insurance Exchanges are supposed to be a way to increase insurance availability for patients who are uninsured. It is in really the “Public Option” in disguise. The Exchanges will turn out to be very costly. They will increase the federal deficit as well as state budget deficits.

 The states are objecting to the Health Insurance Exchanges for two reasons. The federal government is trying to shift the economic burden to the states while decreasing state control over of their insurance policies. HHS has even threatened to take total control of the Health Insurance Exchanges. 


Electronic Medical Records remain too costly for physicians. EMRs are not completely functional despite President Obama’s $100 billion dollar subsidy. Most hospitals and physician offices are trying to comply with the government mandate. The subsidy is not enough to purchase the best EMR.

No one has acted on my suggestion to put the ideal EMR software in the cloud and charge hospitals and physicians by the click. A fully functional universal Electronic Medical Record would be available instantly at an affordable cost.

These are some of the layers of complexity. I predict these initiatives will not be fulfilled by 2013. There are too many new things to adjust too all at once. All the initiatives need a reason for total cooperation.

Making things worse is the requirement to use ICD-10 to file claims. 

ICD is a claims coding formula going into its tenth iteration in 2013. It is much more complex than ICD-9.

 “The differences between the two versions are significant. Whereas ICD-9 CM provides approximately 13,000 diagnosis and 3,000 procedure codes, the version of ICD-10 diagnosis and procedure codes to be deployed in the United States are roughly 68,000 diagnostic codes and 87,000 procedure codes.”

 In January 2009, HHS and CMS mandated ICD-10 codes be used by all healthcare plans, providers, and clearing houses for all diagnosis and inpatient procedures effective October 2013. It seems like there would be enough time to adjust. However, healthcare system adjustment will be huge.

“ICD-10 is one key piece to the overall success of the larger puzzle. More granular

Data will better reflect the patients’ condition and help us manage their care better. At least, that’s the idea.”

I do not think ICD-10 will happen in 2013. These initiatives are federal mandates. They have two things in common. They rely heavily on IT, both for transactions and analytics, and they impose significant changes on organizational workflows, specifically those of clinicians.

 Any workload changes are difficult to adjust to. Too many changes at once are lethal to an initiative.  Dr. Berwick’s timing introducing the changes will be lethal to the changes. When this change comes at physicians from so many different angles they become passively aggressive and resist change. 

 ACOs, Electronic Medical Records and Health Insurance Exchanges fulfillment is behind schedule. ICD-10 will also be behind schedule.

 CMS has declared the ICD-10 compliance date will not be moved.

 The vast majority of respondents (72%) believe ICD-10 will have a positive impact on quality in the long term.

• While they see the long-term benefit, many respondents (41%) also believe ICD-10 will strain physician relationships.

 • Most (60%) expect short-term cash flow to be negatively impacted both in terms of project resources and lost revenue. 

• Only a third of the respondents believe payers will be ready by October 2013 and most believe physician cooperation will be their biggest barrier.

 Although the knowledge that ICD-10 is coming has sparked action by healthcare leaders—most (84%) have started their ICD-10 projects—as a group, less than a third (29%) have moved beyond the assessment phase into implementation.

 ICD-10 is creating many levels of complexity to coding. It will require an increased office staff along the care continuum. The staff must learn and use the new diagnostic and procedure codes. It will also require someone to assign appropriate codes that reflect physicians’ notes. Someone will be needed to create an appropriate claim for the medical encounter. ICD-10 will increase overhead as reimbursement decreases. It is naïve to believe the EMR will automatically accomplish this

Unquestionably, ICD-10 introduces an added layer of complexity to the multitude of challenges for physicians and hospital systems that are already at hand as a result of Obamacare.

 ICD-10 puts revenue at risk for the sake of data the government might use misuse.

 I predict physicians will not participate fully. The physician shortage will intensify as more people enter the healthcare system and fewer physicians are available to treat Medicare patients.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone. 




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