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Health care, software and gender identity


The nondiscrimination in health programs and activities rule went into effect July 18. However (of course there’s a however), health plans have until next year to make some of the changes necessary to comply with the rule.

One area where both providers and plans will need to make changes is to their software systems. These systems will need to handle claims that would normally trigger gender-specific edits.

Here’s how one of those critters works: A doctor submits a claim for a Pap smear for a patient who is listed as male. Somewhere along the line someone’s software is going to flag that as an error and kick it back out with a little note that reads Submit with the correct code plz. That’s fine if the doctor meant to submit a code that is not gender specific or appropriate for a male patient. When the doctor needs to submit a claim for a Trans* patient who is male, the doctor will needs some sort of override. Medicare created such an override in 2009. I see other health plans have adopted it and Health & Human Services suggested the use of the override in the final rule.

However, private plans have time to make that kind of upgrade and an override on the plan’s end won’t help a provider if the practice’s system, or that of an intermediary vendor, keeps saying I’m sorry Dave, and insisting that the provider fix the non-existent problem. (Imagine an email system that won’t let you send an email unless the text of the message is formatted in a specific way. Then imagine that you need to send an email that doesn’t fit the format exactly. Then imagine your income depends on sending lots and lots of emails.)

That’s the type of scenario that a member of a list-serv I frequent was trying to avoid. List member’s practice has a trans* patient and the list member wanted some ideas for entering the patient in the practice’s system in a way that worked for the practice, the patient and his insurer.

Another member made a couple of suggestions which included asking the software vendor to add transgender to the range of gender choices, and to call the insurance company for a pre-authorization when the patient needs a procedure that doesn’t match his listed gender.

(By the way, I’m not paraphrasing to eliminate obnoxious things people said, I’m doing so to keep this thing from devolving into a giant pile of Medadmintechlish. But perhaps it is too late.)

At any rate, in my semi-informed opinion those solutions are fine, because the practice is doing whatever it needs to do to get claims processed and the patient just comes in and receives health care.

If the practice has to wrestle with its software vendor’s rep. in order to get a needed upgrade, that’s not the patient’s concern. If someone has to sit on hold for half a day to get the patient’s pelvic exam cleared, so be it. (However, I would also talk to the payer about installing the Medicare override sooner rather than later.)

My other semi-informed opinion is software upgrades could prove to be the bigger hurdle for practices. Plans have to comply with the law. Software vendors don’t.

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  • los

    My other semi-informed opinion is software upgrades could prove to be the bigger hurdle for practices. Plans have to comply with the law. Software vendors don’t
    It seems like laws have anticipated[1] when the entity of primary responsibility cannot comply due to reliance on another entity.
    The ultimate of such a predicament would be a complete software system which never materializes.

    1. or retroactive amendments of certain laws, when the law hadn’t anticipated catch-22s…

  • Captain Oblivious

    There’s the input end (the doctor’s office) and the processing end (the insurer). The input end really shouldn’t be a massively difficult software change unless the vendor’s software is a kludged-up spaghetti-mountain (always a possibility).

    The processing end is where there could be a lot of work. Not saying it ought to be difficult, just tedious. If they were smart (they’re not — health insurers are among the lowest-paying when it comes to their IT staffs, so they mostly hire crappy programmers then manage them badly), this would all be table-driven, and it’s matter of someone sitting down and updating the tables.

    At least, that’s how things ought to work.

    • On the provider end, work that isn’t covered in the contract can be really expensive, especially if the vendor has to build a new function, rather than turn on an existing one. (I’m assuming the same would apply to intermediaries like billing companies). I think kludge is a problem as well.

      I would think the payers could just add Medicare’s override codes during a quarterly update and then it’s down to the provider to submit the right information.

      • Captain Oblivious

        I see your point.

        Even so, the capability of adding new functions without having to do a major overhaul should have been designed into the software because medical care is always changing.

        But shooda shooda shooda doesn’t mean that’s how it was written.

        • Agreed. And yet, there were some vendors that missed the deadline for the ICD changeover, so my expectations are really very low.

  • mtraven
  • It’s posts like this that make me glad I do pediatric critical/intensive care.

    “Patient sick as stink — please pay me.”

    “OK — no problem.”

  • petemack

    Software overrides sound like a terrible idea. The hospital needs to know your physical gender more than your preferred identity, as a matter of treatment consideration. So no, you don’t want software overrides for anything. You want to specify both genders when they are different. And the doctor needs to know it when he or she is treating you. So the basic gender in the system stays the same. There is one more flag added that indicates your personal identity, if it’s different.

    • The override I mention simply says to the payer that the provider is aware of a mismatch between the procedure and the patient’s listed gender and to pay him anyway.

      The hospital (or other treating provider) needs to know the patient’s gender identity to avoid discriminating against the patient.

      As for whatever the provider does in the background, that’s fine, but it can’t result in – for example – a patient receiving paperwork that doesn’t reflect his or her gender identity.

      • petemack

        The easiest way to do that is just to leave all gender off the paperwork entirely.

        • twbb

          You mean just have “biological sex at birth”? That seems to be the best compromise.

    • hen wen

      Most of the time, doctors and hospitals don’t need to know the state of your genitals. I’ve been to the doctor many times without needing to take off my pants. It’s my right to know when to disclose. Yes, they should know if you’re on T/T blockers/Estrogen/etc, but it turns out lots of women, not just trans women and non-binary folk, are on HRT. I assume there are people on T that aren’t trans, but I’m less familiar with that.

      Further, its actually extremely important to for them to know how you identify. I know trans folk who avoid doctors and hospitals because they’re terrified of being misgendered. Being misgendered can be an extremely painful experience, its important for hospitals to avoid this. That is part of your care.

      • JL

        All of this, and also what DrDick said below.

        According to the NTDS, 50% of T/GNC folk have had to educate their health care providers about trans care, 28% have been harassed in medical settings, and 19% have been refused care because of their gender status (numbers that were higher for T/GNC people of color). Being out as trans to your health care provider was a risk factor for being refused care.

        More than two fifths of trans men, a quarter of trans women, a quarter of transmasculine GNC/genderqueer/nonbinary people, and a fifth of transfeminine GNC/genderqueer/nonbinary people, have postponed health care when they were sick or injured, out of fear of discrimination. All those numbers are higher for postponing preventative care.

        • The rule cites similar findings. One of the things that’s heartening is in the HHS noted that the non-discrimination rule has been in effect since the ACA passed in 2010 (and it has been enforcing it). This is Enforcementspeak and means that it won’t be lenient on the grounds that the rule is “new.”

          Also – the link goes back to this post, did you mean to link here: http://www.ustranssurvey.org/study/?

          • JL

            Huh. No, I meant to link back to the predecessor to the US Trans Survey, the NTDS, because I didn’t think the US Trans Survey had published more than a few preliminary results yet. If you search “national transgender discrimination survey” it should show up.

    • DrDick

      You want to specify both genders when they are different.

      Technically, only the identity/presentation is gender. The biology is sex (which is also not always unambiguous – intersex is a thing)

    • earl

      That’s a lot of work to build into software.

      I worked as a developer for one of the largest EMRs in the US. They primarily sell to outpatient with dozens of doctors and inpatient. It heavily relies on gender to deduplicate records. The problem is, women change names (marriage, divorce), use inconsistent names, lie about their age and worse yet, don’t lie consistently. (Yes, even to the records people in the medical office.) All of this results in women having duplicate records in the system. I was responsible for software that detects and merges these duplicate records. It was a mess. Allowing gender to change will be a lot of work.

      Gender is also used all over the place to provide sanity checks in data exchange between systems — eg surgery scheduling, outpatient, inpatient, and test results may all be run by different software suites that then must exchange data. Gender is hardcoded to not change, and all of that will have to be backed out of the code. This is going to keep large teams of people busy for years.

      (Note this is not an endorsement of not doing so; I’m just mentally speccing the engineering effort to do this and the bugs that will be introduced and wincing.)

      I was present for one all-hands drill when a doctor got test results back and told his patient he definitely wasn’t pregnant. That resulted in calls to eng and a team working nearly non-stop for a week to figure out test results ended up in the wrong patient’s records…

  • It took me a while to parse “Medadmintechlish” as anything other than “Me dad mint echlish”.

    • los

      med (computers)admin techlish(‘tech’ language)

    • Ahuitzotl

      better to mint Scatlish nowadays, after Brexit

  • Yankee

    What you are actually asking for is a system whereby the Humans can take over and Get Things Done when they feel it necessary. Good! … but that degrades the two justifications for having the system: efficiency, and management-by-statistics, so it ain’t gonna happen until people in charge care more about Healing the Sick than Making the Money. Industry runs on uniform procedures acting on uniform inputs.

    • OT, really, but this is the kind of thing that often is labeled “neoliberalism,” where people are made to fit numerical or statistical slots in order to make them easier to monitor and govern. Usually, though, without addressing (as S does) the fact that things can be improved, instead in a kind of defeatist-sounding way that suggests there’s nothing we can do about it. “Industry” is not a bad label but doesn’t quite get the idea.

      • Redwood Rhiadra

        How is putting people in slots “neoliberalism”? Even Communist governments do that. (Actually, I suspect Communist governments are *more* likely to do that – it’s a consequence of centralized control.)

        • Short answer: Foucault’s theories about governmentality and biopower; very long answer. I’ve always thought Foucault probably applied fairly well to Communism but is meant to apply to late 20th century France, which is also centralized and liberal more than socialistic.

  • CrunchyFrog

    If the practice has to wrestle with its software vendor’s rep. in order to get a needed upgrade, that’s not the patient’s concern. If someone has to sit on hold for half a day to get the patient’s pelvic exam cleared, so be it. (However, I would also talk to the payer about installing the Medicare override sooner rather than later.)

    My other semi-informed opinion is software upgrades could prove to be the bigger hurdle for practices. Plans have to comply with the law. Software vendors don’t.

    I have zero knowledge of this industry, but do know software. I’d be shocked if the vendors aren’t completely aware of this requirement and are working on updates – if not delivered already. It’s one of the points you are asked about in RFPs – what is your policy regarding compliance with changing legal requirements. If you make this a pain point for your customer then they will go shopping for another vendor.

    • DocAmazing

      Not so easy when it comes to medical office software. There are relatively few vendors, the health record/diagnosis program has to be able to work fairly seamlessly with the billing and compliance programs, and all of that needs to be able to send and receive records, test results and so forth with hospitals and other offices. It is not yet a buyer’s market.

      • Redwood Rhiadra

        And a crapload of medical software is still written in MUMPS, a language designed in the 60s for mainframes.

        • DocAmazing

          As always, beware cute acronyms.

        • CrunchyFrog

          Still? Wow. My first project out of college was to rewrite a MUMPS program used by customer engineers into a more efficient language.

          • earl

            One emr in particular had pushing 40m lines of mumps/cachescript back when I worked there well over a decade ago. It’s never going anywhere.

            • Ahuitzotl

              Ok, definitely time to stab that monster with their steely knives.

  • Bitter Scribe

    The elimination of gender discrimination (i.e., charging women more) in health insurance gave rise to what IMO was an even bigger distortion than “death panels”: the claim that men would be “paying for pregnancy.”

    I’m sure that the nitwits making that argument either didn’t know or didn’t care about the Rehnquist decision declaring that not covering pregnancy did not constitute gender discrimination, because if men could get pregnant, they wouldn’t be covered either. I swear to God I did not make that up.

    Sorry, slightly OT, but I had to rant.

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