Michael T. McCue

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AMERICANS SEE ALCOHOLIC DRINKS nearly every day-on TV, at parties and even on the family dinner table. However, they rarely talk about its addictive dark side or the toll it can take on a person's health. While alcohol-related health problems are prevalent, expensive and sometimes difficult to identify, the good news is that one of the most effective management strategies for alcohol addiction is simple and inexpensive. 

"Messages that come directly from a health plan aren't going to mean a lot to a problem drinker, so they aren't likely to have a great impact," says Robert A. Holtz, vice president of behavioral health services for Capital District Physicians' Health Plan (CDPHP). "But studies have shown that providers who have a 10-minute discussion about alcohol abuse can have a significant impact on consumption among their patients."  

But it's not just reducing the social stigmas; legislation and mandates are also having an effect on the number of people receiving help for their alcohol problems, according to Holtz.  

"I've seen an increase in the utilization of inpatient and outpatient services for alcoholics, largely due to an increase in drinking-and-driving arrests, a greater emphasis on alcohol in parole and probation departments, and various other legal efforts," he says. "So while there are definitely more people getting treatment for alcohol abuse, much of that treatment is mandated." 

The impact of alcohol abuse is magnified when combined with other conditions such as depression, especially for older Americans. 

Even those who are aware that alcohol abuse is a severe health and societal problem don't realize just how prevalent the problem is. There are nearly as many people with alcohol use disorders (17.6 million) as there are with diabetes (18.2 million)-a fact that isn't surprising given the connection between excessive drinking and Type 2 diabetes. 

Articles

Americans see alcoholic drinks nearly every day-on TV, at parties and even on the family dinner table.

Brief interventions reduce alcohol abuse and its effects

ALTHOUGH HEALTHCARE is a tough business, some issues transcend market competition. That is certainly the case with the rapidly approaching shift from ICD-9 to ICD-10, a massive system overhaul that many have underestimated. The federal government settled for a final compliance date of Oct. 1, 2013, two years later than it originally proposed because of pushback from the industry. 

Because the overhaul will have such far-reaching effects, large-scale collaboration is critical to making it work, according to Rich Cullen, managing director of interplan programs for the Blue Cross and Blue Shield Assn. (BCBSA).  

That's why BCBSA and other health plans are working with the American Hospital Assn., the American Medical Assn., and government agencies to ensure the benefits of ICD-10 conversions are realized.  

According to Joe Nichols, MD, medical director for Edifecs, a healthcare IT firm based in Bellevue, Wash., the ICD-9 code set contains a total of 32 codes for a fracture of the radius, for example. Under the new ICD-10 set, there are more than 1,700 codes for the same injury. 

Generally, industry experts agree that ICD-10 codes ultimately will deliver on the promise of greater insight into providers' decisions to perform specific treatments and procedures, and a smoother path toward automating healthcare transactions. But just because it's the right thing to do doesn't mean payers or providers are motivated to make the change. Implementation could take years, and the Department of Health and Human Services (HHS) is expecting error rates on filed claims to rise from the typical 3% seen after past updates to as much as 10% after ICD-10 conversion. 

"While we all look forward to realizing the benefits ICD-10 will bring, we first have to get the codes implemented and working for all stakeholders," says Russ Thomas, president of Availity, a health transactions network based in Jacksonville, Fla. "The migration to ICD-10 is not a simple upgrade. If we only had to expand field lengths to support the new format, that would be relatively straightforward. But that is not the case. Among many things, there are translation issues to deal with." 

Understanding the increased specificity provided by ICD-10 and applying it appropriately will require an enormous amount of training at all levels of the healthcare supply chain, he says. HHS estimates implementation costs at $1.64 billion industrywide, including $356 million in training costs. 

The rapidly approaching shift from ICD-9 to ICD-10 is a massive system overhaul that many have underestimated.

If you aren't working on ICD-10 now, you're already behind schedule

"Our biggest concern is about healthcare coverage and extending it to the maximum number of people, but that can lead to the chronic problem of potential government underpayments," says Richard Umbdenstock, president and CEO of the Chicago-based American Hospital Assn. "Medicare pays hospitals, on average, about 91 cents on the dollar, and Medicaid about 88 cents. If more of our patients are covered by those government programs, or some sort of public option tied to those payment rates, the result is going to be much greater financial instability for the entire system." 

It's a perfect storm brewing across the healthcare landscape, and the economy is only one part of it, says Gary Blackford, president of Universal Hospital Services, a medical equipment outsourcing company based in Edina, Minn.  

On the bright side, some experts believe that this difficult period has helped prepare hospitals for a brighter future by forcing them to become leaner and more efficient.  

"It's not like hospitals simply closed their eyes and continued to plow forward during this down period; they made improvements in their ability to control expenses, particularly on the labor side," according to Gary Pickens, leader of the research and development group for the Center for Healthcare Improvement at Thomson Reuters.  

Without many other viable options, so far, hospital executives have largely focused on cost cutting: freezing their capital budgets and cutting into their operating budgets. For the most part, experts say they've done a good job at that; in fact, some for-profit hospitals have posted record-setting quarter-over-quarter gains. They've made a solid recovery, but there is no indication hospitals have returned to business as usual yet. However, it does appear that they've at least weathered the storm, Pickens says. 

Still, hospitals can only cut costs and put off expenses for so long, because they must continue to purchase supplies, while the clinical equipment accumulates wear and tear. They can't keep using the same X-ray machines and hospital beds for the next 20 years. Maintenance and new investments are a must. 

"The good news is that the bond market has turned around, so hospitals are now able to get long-term financing at attractive rates," Blackford says. "In addition, while philanthropy and charitable donations did drop-as expected in a tough economy-they didn't drop as far as hospital executives feared they might. The public has understood the need to support the healthcare system, especially at the community level." 

Hospitals also have done a good job of managing their labor expenses. When it comes to labor costs, the two easiest (though still painful) ways are to cut wages or decrease total headcount.  

If more patients are covered by Medicaid, hospitals stand to become unstable under reimbursement of 88 cents on the dollar

Hospitals remain unsure of future business model

As if it weren't bad enough news that healthcare costs continue to spiral upward, the benchmark quality report for 2009 from the National Committee for Quality Assurance (NCQA) reveals that quality has stalled somewhat. In fact, the report examined the link between the cost and quality of care and found little or no connection between the two. 

"The State of Health Care Quality: 2009" report examined quality data submitted by 979 health plans across the country that collectively cover 116 million Americans, a 9% increase over 2008's sample.  

"The status quo is unacceptable," O'Kane said during a press conference last month. "Overall, the [quality] gains are pretty small, particularly among the most vulnerable populations," as plans serving Medicare and Medicaid patients failed to show noticeable improvement in many key quality measures for the third consecutive year. 

Among the notable areas in which quality has stalled: 				

Despite those disappointing results, there were several bright spots. Among them were a 12% increase in the provision of beta-blocker drugs to Medicare patients who had a heart attack within the previous six months; nearly across-the-board high-quality care for asthma patients; and substantial gains in smoking-cessation efforts in the Medicaid population.  

"Sometimes, a plateau is just a place to get your bearings and figure out what your next strategy is going to be, and that's the kind of plateau I think this is," O'Kane says.  

The need to get healthcare quality back on the path to improvement is dramatic, however. NCQA says that if all health plans were able to perform as well as the top 10% of plans did, the United States would realize fewer deaths and save at least $12 billion in medical costs and lost productivity every year. If every American were able to receive care that matched the quality of that provided by those plans in the top 10%, the number of lives saved would range between 165,000 and 272,000 annually.  

Where those saved lives come from might depend on geography; the New England region had the highest-quality health plans, while the South Central region of the United States came in last.  

"Every American deserves to have quality care, and a diabetic in Alabama shouldn't get poorer care than a diabetic who lives in New Hampshire," O'Kane says. 

Decades of quality improvement now giving way to a leveling off trend in many areas

Michael T. McCue

Articles

Brief interventions reduce alcohol abuse and its effects

If you aren't working on ICD-10 now, you're already behind schedule

Hospitals remain unsure of future business model

NCQA tracks plateau in quality yet increased reporting of measures