December 2006
ABC codes fill critical gaps in U.S. healthcare system
Captain James R. Johnston, PhD, USNR (Ret)
Director, American Health Science University & National Institute of Nutritional Education
The United States ranks 40th among nations in overall health and is tied with Portugal in average life expectancy (77.9 years)—in spite of our medical technology being the best and most expensive in the world.
1 Why? One reason is that medical intervention, including tests and therapies, is the third leading cause of death, after heart disease and cancer.
2 Another reason is that we are not effectively maximizing care from qualified non-medical healthcare practitioners because they lack codes to document and bill for their care.
Healthcare reimbursement is based on codes in much the same way as grocery stores use bar codes to charge for items on the shelf. Can you imagine check-out at a grocery store if only 20 percent of the products you buy had bar codes? Yet, that is what is happening in healthcare. Our government mandates the codes used to electronically process claims and pay for healthcare. These codes are medical in nature and do not adequately describe non-physician care provided by nurses, alternative medicine providers, behavioral health, and many other types of practitioners—even though these practitioners outnumber conventional physicians by four to one and their care is typically less costly. This physician-centric policy results in coding gaps (see pie chart). Many non-physician providers are qualified to submit bills without physician oversight but, without adequate codes, their bills don’t make it through “checkout” at Medicaid, Medicare, TRICARE, and private insurance companies.
Even when non-medical treatment options are available through these payers, the red tape involved makes payment difficult. The coding system used by Medicare, the insurance industry, and TRICARE is developed jointly by the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS). While this system has more than 10,000 codes to describe medical care, medical devices, and supplies, it offers only four generic codes to describe chiropractic care, and those codes do not describe specific treatments or generate sufficient information to justify reimbursement. The government has contractually given authority to the AMA to develop procedure codes (for provider care). This authority introduces a potential conflict of interest and bias in favor of medical doctors and can result in insufficient documentation to justify payment for other practitioners.
ABC codes were developed to fill critical coding gaps and describe the care provided by over 3 million qualified, licensed practitioners in the United States. Together with the medical codes, ABC codes can help automate payments while also measuring the economic and health outcomes of optional approaches to care. By including ABC codes in mandated electronic code sets, military and civilian populations would find it easier to gain access to care that is less invasive, less costly, and more available in remote areas. The following test cases support the concept:
- Alaska Medicaid began using ABC Codes in 2004 to process claims for paraprofessional behavioral healthcare services to patients in remote areas of the state. Had professional services been available, these services would have cost twice as much as paraprofessional care.
- The Navy chaplains’ corps will use ABC codes to measure the impact of chaplains’ care on force readiness, retention, rehabilitation, and reintegration. The Navy will also measure the effectiveness of chaplains’ care in disaster responses such as the Asian tsunami and hurricanes Katrina and Rita.
- A Medicare Advantage in New Mexico began using ABC codes in 1999 to provide alternative medicine services to seniors. The plan determined this care was effective and cheaper than standard care. As a result, the number of seniors with access to alternative medicine grew from 500 in 1999 to 21,000 in 2005.
The need for expanded coding is evident, but even with impressive test cases and broad support, the government will not easily break its mindset that “healthcare” means “medical care.” The developers of ABC codes have been persistently moving the codes forward through a review process for 10 years and this code set has many political supporters. The ultimate adoption of ABC codes to fill critical gaps in the mandatory code sets will provide an effective solution to unacceptably high healthcare costs—a solution our nation can’t afford to overlook.
- The Economist Newspaper Ltd., Pocket World in Figures, 2006 Edition, published by Profile Books, Ltd., London
- Barbara Starfield, MD, Boston Review, November/December 2005.
