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In 1969, psychiatrist Elisabeth Kübler-Ross created a model, typically referred to as the “five stages of grief,” which identifies a pattern of emotional stages followed by people faced with impending death or another extreme or awful fate.

I became aware of her work in one of my favorite movies (All that Jazz, a winner of four Academy Awards and the Palme d’Or at the Cannes Film Festival). The five stages of grief are: denial, anger, depression, bargaining, and acceptance. The model was published in a book, On Death and Dying, which was inspired by Kübler-Ross’ work with terminally ill patients.

Given that many providers correlate ICD-10 with an awful fate, I thought it might be interesting to plot where our clients were/are on the Kübler-Ross scale (which will be referred hereinafter as the KR scale, because typing umlauts is proving difficult for me).

KR Scale Stage 1: Denial

Denial has been running rampant for years and was exacerbated when CMS announced last year that it was contemplating moving the ICD-10 implementation data. Many of our denial-oriented clients were speculating and hoping that there would be a multiyear delay. In April 2013, the Workgroup for Electronic Data Interchange (WEDI) issued a letter to the Department of Health and Human Services describing the results of the March 2013 Provider Readiness survey. In the letter (available at http://www.wedi.org/docs/comment-letters/2013-wedi-icd-10-survey-results-letter.pdf?sfvrsn=0), WEDI expressed the following:

  • Over two-fifths of provider respondents indicated they did not know when they would complete their impact assessment, business changes, and begin external testing. This is essentially the same as in the 2012 survey, and indicates that many providers have not made significant progress towards ICD-10 implementation.
  • About a tenth of providers expected to begin external testing in 2013, while half responded that they did not know when testing would occur. In the 2012 survey the number who did not know when external testing would occur was about the same, although the rest expected it would begin in 2013.

The results of the WEDI survey would lead us to believe that a large swath of the provider community is largely still in denial.

KR Scale Stage 2: Anger

We sure saw a lot of anger from the provider community, especially before the delay to move the mandated implementation date back to October 1, 2014. The American Medical Association (AMA) and the Medical Group Management Association (MGMA) have expressed their anger repeatedly in vigorous attempts to halt ICD-10 implementation entirely.

In our opinion, most of our clients are still not happy, but not exhibiting real anger.

KR Scale Stage 3: Depression

Some of our clients are upbeat about leveraging the increased specificity in ICD-10 for various clinical (and, in some cases, financial) purposes. However, the wide majority is somewhat depressed about the workload to remediate and the ongoing operational uncertainty of an ICD-10 world.

KR Scale Stage 4: Bargaining

Bargaining involves the hope that the inevitable (in the KR sense, death; in an ICD-10 context, enforcement of the mandate) can be postponed or avoided entirely. The provider community continues to exhibit bargaining behavior (asking for delays in enforcement, seeking congressional support to postpone, requesting that CMS perform end-to-end testing, etc.). And there certainly will be a lot of internal bargaining as providers work through budgeting ICD-10 initiatives for the following fiscal year.

KR Scale Stage 5: Acceptance

A small number of our clients have achieved a level of acceptance. We met with a client this month (a senior executive responsible for ICD-10 at one of the nation’s top ten largest hospital systems) who indicated acceptance and a high level of confidence that his ICD-10 program was on track and would be fully ready by the implementation date. The ongoing remediation work at multiple other clients we are supporting also indicate that ICD-10 is been accepted as inevitable and is being embraced.

About the Author

John Wollman is the Executive Vice President of Healthcare for HighPoint Solutions, a Management and Information Technology consulting firm focused on Healthcare and Life Sciences.  John is responsible for HighPoint’s Healthcare industry group, catering to Payers and Providers.  John is a recognized expert in several healthcare business domains (Reform, HIPAA 5010, ICD-10, Platform Strategy) and technical domains (Master Data Management, Analytics).  Since graduating from Duke University, John has held executive level positions at consulting and technology companies over his 25 years in business.

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