This message from Chris was sent to the BI SWG but I wanted to be sure the Testing SWG received it as well.
Marcallee
-----Original Message-----
From: Christopher Feahr [mailto:[EMAIL PROTECTED]]
Sent: Tuesday, June 10, 2003 10:23 AM
To: WEDI Business Issues Subworkgroup List
Subject: Re: Meeting Minutes - 5/22/2003 -- who pays cost of testing
Dear Group,
Just when my most trusted advisers are beginning to suggest that maybe I
should throttle back a little on the Fairness Rant... I am reminded once
again that it lies at the core of our thorniest and most contentious
issues. The more I think about these things, however, the more I am
able to reduce Fairness to a set of clear and measurable properties...
that result in a quantifiable and utterly blameless STATE of existence.
Unfairness has causes and remedies, but it need NOT have blame and
"fault" associated with it. I am ONLY interested in reducing unfairness
until it approaches zero. I accept that it will not reach zero, but if
we had a way to measure it, I believe that we could reduce it.
Fairness is not a binary, black and white state. Obviously some states
of existence are regarded [by the legendary "Reasonable Person"] as
"more fair" than others... so I believe that we will benefit some day
from a measurable, technical standard for "fairness" in human
enterprise. Until we get there, however, we must rely on basic human
concepts of rightness and wrongness... and our innate abilities to
distinguish between Shinola and that other stuff. We all know what
unfairness smells like and we generally know when we have stepped in it!
In my view, the reason that we are having this discussion about the
fairness of various cost shifting strategies is simply that there is FAR
TOO MUCH COST in our present B2B communication system. Rather than
agreeing on the most fair way to push that cost around, we should be
focused on removing it.
No small to medium sized provider feels "able" to shoulder ANY of the
cost of maintaining point-to-point EDI connectivity with payers.
Providers have adopted a generally submissive attitude toward the
insurance industry over the last 40 years, however, BECAUSE they feel
powerless to change payer requirements... and powerless to assert their
own. DDE is actually the most flagrant and damaging shifting of cost
onto the provider that I have seen in the last 30 years... and look at
providers' willingness to accept it. They just hire more staff and
purchase more internet bandwidth.
Eventually, however, providers will recall that we have had a healthcare
industry for approximately one million years and that the Health Plan
concept is relatively recent. Health Plans invented themselves only in
response to an opportunity... not so much a need. Yes there was and
remains a need to mitigate risk (of getting so sick that one would be
unable to pay for one's own treatment) but the payer doesn't want that
risk either... so it is being shifted onto the provider community and
the government wherever possible... mostly as capitated, managed care.
My point is that, in the most global sense, Health Insurance invented
itself as a marginally useful service to Employers and, in doing so, has
essentially foisted itself onto providers... who had been doing their
thing without health insurance for thousands of years. So if the Health
Insurance model also introduces new costs, it seems patently unfair to
shift even one penny of those costs onto the provider community. It is
MOST CERTAINLY unfair to shift those costs to the provider community
while it remains officially unrepresented in the discussion.
That's my $.02.
Christopher J. Feahr, O.D.
Optiserv Consulting (Vision Industry)
Office: (707) 579-4984
Cell: (707) 529-2268
http://Optiserv.com
http://VisionDataStandard.org
----- Original Message -----
From: "Kepa Zubeldia" <[EMAIL PROTECTED]>
To: "WEDI Business Issues Subworkgroup List"
<[EMAIL PROTECTED]>
Sent: Monday, June 09, 2003 10:36 PM
Subject: Re: Meeting Minutes - 5/22/2003 -- who pays cost of testing
> This is an interesting thread and I hope that throwing in my $.02 will
not
> generate too many flames.
>
> There are several issues to consider.
>
> One issue is the difference between trading partner testing and EDI
compliance
> testing. The SNIP white paper recommends that EDI compliance testing
be
> completed before trading partner testing starts. Doing so is for the
benefit
> of the covered entity that is testing its own EDI compliance, and once
EDI
> compliance testing is complete, further testing with trading partners
is much
> simplified.
>
> When using trading partner testing in lieu of EDI compliance testing
you are
> making a choice. Trading partner testing is, by definition, trading
partner
> specific. Most likely it is not portable from one trading partner to
> another. So, a provider that chooses to use trading partner testing
with
> payers, without having completed EDI compliance testing first, is
likely to
> have to repeat the testing from scratch with each payer.
>
> Of course, if the provider's EDI compliance testing also includes a
component
> of testing against multiple simultaneous payer specific EDI companion
guides
> under one testing umbrella, instead of having to repeat the entire EDI
> testing with each trading partner from scratch, then they get the best
of
> both worlds. But that train of though would deviate from the core of
the
> discussion, so I will focus back on the problem.
>
> The second issue is cost shifting. The cost shifting of the EDI
testing
> occurs in both directions. Let me explain...
>
> In some cases the providers expect the payers to provide some sort of
"free"
> EDI testing as they have done in the past. In other cases the
providers want
> to make sure their EDI systems are compliant independent of one
specific
> payer. In some cases the payers desire to provide a "free" EDI testing
> service to their providers. In other cases the payer does not want to
pay
> for the provider's EDI compliance testing. In some cases the payers
do not
> want to become the EDI trainers for the providers. In some cases they
do.
> In some cases the providers are sending test files that do not meet
basic X12
> syntax requirements. In other cases their files are very clean and
doing
> further payer testing is simple, easy, and effective. In some cases
the
> providers expect the payers to tell them what to do and how to fix the
EDI
> problems. In some cases the payers do not have the resources to do
this. In
> other cases they do. In some cases the payer specifies one payer
specific
> testing service and pays for it. In other cases the payer specifies
one EDI
> compliance verification service before starting the trading partner
testing
> and does not pay for it. In other cases the payer specifies more than
one
> EDI testing or compliance service and may or may not pay for it. In
some
> cases the provider prefers to test with multiple payers from scratch.
In
> other cases the provider prefers compliance testing prior to trading
partner
> testing. In some cases the provider can spell HIPAA, WEDI, SNIP and
X12. In
> other cases the provider cannot spell them.
>
> As you can tell from my tongue in cheek list, there are many tensions
and a
> multitude of reasons why the cost shifting is happening. Cost
shifting is,
> in theory, unfair. Some times the cost is shifted to the payer.
Other times
> it is shifted to the provider. If there was no cost shifting,
everybody
> would pay the share of the resources they consume. But reality is,
cost
> shifting is part of the nature of business. Market forces drive it.
>
> Take the clearinghouse as an example. Today, most clearinghouses are
looking
> at being Business Associates of both providers and payers. But, are
the
> costs allocated proportionately to the services being rendered for
each
> party? And, I don't mean to pick on clearinghouses. Ask a smoker and
a
> non-smoker what they think about the cigarette taxes and you will get
two
> different answers. Cost shifting is common business practice in free
> markets.
>
> Having said all this, is SNIP about to put a response in the DSMO
server
> saying that cost shifting in a certain direction is more or less fair
than in
> another direction? Is SNIP about to stick its neck and say that a
certain
> kind of cost shifting is not allowed? Or, is SNIP going to say that a
> certain class of trading partner (e.g. payer) should bear the burden
of
> testing all the other (e.g. provider) trading partners?
>
> I doubt it.
>
> But, never say never...
>
> Kepa Zubeldia
> Claredi
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