What a government shutdown looks like for this cog

Note: I started this blog on Monday morning, when an agreement to end the shutdown was still being worked out. Now that government is funded, the blog looks like old news. But I think there are still things worth discussing about the experience, and I share what I learned here. RB

When the press reports on a government shutdown, as with this latest one, they tend to focus on the public attractions that will be open or closed—national parks, the Smithsonian Institution, war memorials. Understandable, I suppose, since not being able to drive down a road because there is a locked gate across it, or not being able to walk into a building because it is closed, is something everyone can relate to. But consequences such as these amount to delayed gratification—John and Joan can’t go to the museum as planned—and are rather trivial in the larger scheme of things.

The actual work done by a functioning government is harder to describe in a few words. It is an enormous Rube Goldberg contraption, cogs meshing with other cogs inside and outside government, that results ultimately in super-institutions like “the healthcare system” or “the economy.” A machine this complicated is very costly to stop and re-start, and so the interruption of government for any length of time is likely to have ripple effects that only show up later. Each day lost during a government shutdown can’t be calculated simply as one lost day of work. Of course, I am telling you something you already know, but ripple effects may be an abstract notion for some of you. For some of us ripple effects are all too concrete.

For instance, here is what is happening at work today, Monday January 22, because some of the people I work with can't do their jobs. Today is one in a succession of deadlines to comment on drafts that ultimately result in Coding Clinic—the official ICD-10 coding advice published quarterly by the American Hospital Association. In my role on the Coding Clinic advisory board under contract to CMS, I sent my comments in and copied the representatives of the four Cooperating Parties (AHA, AHIMA, CMS, and NCHS/CDC). This automatic reply came back from the NCHS/CDC member Donna Pickett:

Due to the absence of either an FY 2018 appropriation or Continuing Resolution for the Department of Health and Human Services, I am out of the office on furlough and I am not able to read or respond to your message.

Okay, so the Donna Pickett cog is not turning today. Is that a big deal? Try this: Picture the image from the Charlie Chaplin movie Hard Times showing that whole wall of cogs. Now picture that image in a funhouse mirror that replicates itself umpteen umpteen times. That’s how many cogs are not turning today. As one tiny cog that meshes directly with other government cogs, I can tell you it is one thing to say that “government is not working,” and quite another thing to experience a government in which no one is working.

Although government was back to work on Tuesday, a couple of weekly Tuesday meetings with CMS on proposed changes to the FY 2019 MS-DRGs were cancelled. Two cancelled meetings are usually cause for celebration, right? But these weekly meetings are essential to the work getting done for the next fiscal year update to the MS-DRGs. (Under contract to CMS, 3M maintains the MS-DRGs, the software and definitions manual that is the implementation of the Inpatient Prospective Payment System.) The multidisciplinary team that evaluates public requests to change the MS-DRGs—picture twenty or so people on a conference call—has been working steadily on these requests, including clinical discussions and data analysis, since the comment period ended in December.

CMS must respond to public requests to change the MS-DRGs through the rulemaking process, and the submission of draft CMS proposals to the Office of the General Counsel (OGC) at HHS for legal review is on a very tight schedule. The deadline for completion of initial segments to be included in the IPPS proposed rule was a couple of days before the shutdown. The deadline for submission of the next segment is a few weeks later.

If legal review of the segments falls behind schedule, some segments may not make it into this year’s IPPS proposed rule. What that translates to in practical terms is that even after ICD-10 implementation, the country may end up with yet another one-year delay in reaping the benefits of ICD-10. This year is the first year that ICD-10 coded data can be used to evaluate the effectiveness of the ICD-10 version of the MS-DRGs, and several important MS-DRG topics on the docket have been on hold, waiting for ICD-10 data.

That is what I mean by a ripple effect. Even one day where the cogs are not turning could ultimately cost the MS-DRGs one year. A year in the life of a payment system that governs two percent of the GDP is not trivial.

Despite the fact that we gripe endlessly about the ways in which government is “not working,” as Americans we have no real experience of what it means when government actually doesn’t work—doesn’t function at all—for any length of time. We mostly take for granted that it mostly works. So, when all those cogs stop turning, as they have in recent days, it’s a chance for us to take a moment and acknowledge what we have when we have a functioning government, and what we stand to lose if we don't.

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