How should government processes work in the digital age? What about ICD-11?

June 23, 2023 / By Rhonda Butler

The day I delivered the fiscal year 2024 ICD-10-PCS update files to the Centers for Medicare & Medicaid Services (CMS) for posting, it so happened that one of my favorite podcasts aired an episode about implementing government policy in the digital age. Specifically, why it can be frustratingly difficult to deliver high quality software and services, even when everyone agrees on the general goal. The podcast is the June 6 edition of the Ezra Klein Show from the New York Times. The guest, Jennifer Pahlka, has written a book called “Recoding America: Why Government is Failing in the Digital Age and How We Can Do Better.” She was involved in the “rescue effort” of the healthcare.gov site, among other state and federal initiatives to improve digital services. I found the conversation fascinating because it talks specifically about what happens to hamstring government in enacting its own policy, why it happens and what could be done to improve the process.

Process is a key word here. For me the podcast was a powerful reminder that, in a democracy, government is first and foremost a process—one that takes time and dedicated people to produce results. I should not have needed the reminder. This is my 20^th year working under 3M’s contract with CMS, for developing, implementing and making annual (now biannual) updates to the ICD-10-Procedure Coding System (PCS). While some days it seems like I’ve been doing this job forever, the process behind the work I do has been around for 40 years—forever times two! The milestone that defined our current use of ICD codes was the 1983 federal regulation that created the IPPS (inpatient prospective payment system), which mandated the use of diagnosis related groups (DRGs) and ICD codes for Medicare beneficiaries.

Forty years is a long time. These days, whole new digital technologies are launched and adopted, and in a matter of months human culture is changed forever. In comparison, government processes look increasingly retro. The annual IPPS rule process, by definition, requires one year to make a change, no matter how small.

It sounds like I think we should speed things up to match the speed of change in industries like social media. I don’t. Time is an essential ingredient in democratic processes and the measured, reliable pace of those processes is an important aspect. It takes time to consider the possible downstream effects of change, and while going slow can be frustrating, going too fast can be much worse. We have already seen in hindsight, for example, the harmful effects of social media on mental health, especially in young people. This kind of damage is difficult to undo and is one of the reasons why legislators are taking the possible consequences of artificial intelligence seriously, because they failed to require the social media industry to do things in a more measured and constrained way.

As Pahlka points out, most people who work in government are skilled and dedicated professionals providing the best possible service they can, given their roles and constraints. The stereotypical bureaucrat portrayed in popular media is exaggerated for effect, like most heroes and villains, real or imagined. According to Pahlka, the culture inside government agencies can prevent career civil servants from doing their jobs more effectively, to their own satisfaction and all our benefit. A “better safe than sorry” culture produces mismatched incentives for employees because it emphasizes not making mistakes rather than rewarding initiative and performance. The healthcare.gov website was a textbook case of how government processes and culture can take precedence over making something that works for its users.

Interestingly, in our little corner of the regulatory world, it is the health care industry rather than government that tends to resist upgrades when it comes to new software or processes. The years-long delay implementing ICD-10 came from private insurers and physician stakeholders rather than the federal government. It won’t be a surprise if the same thing happens with ICD-11.

My colleagues at CMS are classic examples of skilled, dedicated people who do their jobs to the best of their ability, given their roles, the constraints of the agency and the fact that they have inherited a process that is a 40-year-old running list of specifications! They work closely with every requestor that asks for new ICD-10-PCS codes, through every step of the process. They analyze proposed DRG changes and draft the proposed and final rules under tight deadlines, and they do this with legal staff scrutinizing every line for inconsistencies and inaccuracies. It’s not as fun as it sounds! And to top it off, they get blamed for things totally unrelated to the work they do.

As the new codes for Oct. 1, are released, to be followed by the final IPPS rule, many people in health care will be under pressure to get the code and DRG updates in place for their organizations and customers. It’s tempting to vent frustration with government—that it doesn’t work, that’s it too slow. We all do it at times. But at the same time, we can acknowledge that things are not that simple, and most of what supports our daily lives is the result of a complex, interconnected web of necessary processes.

Speaking of government processes in a democracy, the National Committee on Vital and Health Statistics (NCVHS) has issued a general invitation to attend its Aug. 3, meeting on ICD-11. The invitation includes a request for comments prior to the meeting. Comments are due June 30, and the public is invited to comment on any aspect of ICD-11. There are 12 questions included in the invitation as examples of topics to get the juices flowing. Here are two short ones: How should HHS implement ICD–11 in the U.S. for morbidity coding? What kinds of technical resources, guidance or tools should the U.S. federal government make available? NCVHS says they will compile responses and get input from subject matter experts in advance of the meeting.

Rhonda Butler is a clinical research manager with 3M Health Information Systems.