Concerns with Clinical Coding

Clinical coding is the process by which procedures are translated into a code which is used for proper “hospital reimbursement.” [1] Due to the nature of the job and its emphasis on recall of possibly thousands of alphanumeric codes, it would seem as though a dedicated position within the hospital would be the best person to task with carrying out coding. However, in many cases, physicians are the ones tasked with coding for their own procedures. Even when this isn’t the case, the coders that are in charge of translating chart information into alphanumerical coding are often given an incomplete picture; whether from incomplete physician notation or incorrect information, leading to errors that affect patients and institutions financially. [2]

On the surface, it would make sense to have surgeons code for their own procedures in order to maintain a high degree of precision in detailing exactly what was performed intra-operatively. However, the heavy workload that healthcare professionals face now, especially with the move to electronic health records, makes accurate and precise coding a much more challenging operation. [3] Over a sample of 30,127 patients, some 15,402 patients had at least one change made to their medical records after audit, a shocking 51%, with a further 13% and 12% respectively being changes made to primary diagnoses or operations. [4] This degree of error in a financially high stakes area raises red flags about the implications that these errors have made on patients and their financial wellbeing.

The stress that surgeons face is only exacerbated by the expectation to code for procedures on top of actually performing them. Additionally, with heightened precision in coding for physicians comes an extended amount of time required to do so, extending the already severe shift load that surgeons are expected to take on. This creates an unrealistic expectation to perform surgery, complete documentation for the patient, and code for the operations more precisely without proper downtime. Trying to remedy this is also fraught with difficulty, with dedicated coders being subject to physician error, missing information, or unfamiliar terminology without the knowledge to bridge the gaps. [2]

Oftentimes pressing issues are also the most difficult to find a meaningful solution to, and misrepresentative coding is no different. By onboarding clinical coding personnel in hospitals, and attempting to bridge the gap in communication, documentation, and accountability between surgeons and coders, hospitals can more accurately bill patients, leading to better financial outcomes on both sides of the operating table.

Reviewed by: Benji Forman

Designed by: Maziar Salartash

References:

[1] Haliasos N, Rezajooi K, O'neill KS, Van Dellen J, Hudovsky A, Nouraei S. (2010) Financial and clinical governance implications of clinical coding accuracy in neurosurgery: a multidisciplinary audit. Br J Neurosurg. 24(2):191-5. doi: 10.3109/02688690903536595. PMID: 20210533.

[2] Tang, K. L., Lucyk, K., & Quan, H. (2017). Coder perspectives on physician-related barriers to producing high-quality administrative data: a qualitative study. CMAJ open, 5(3), E617–E622. https://doi.org/10.9778/cmajo.20170036

[3] Ball, C. G., & McBeth, P. B. (2021). The impact of documentation burden on patient care and surgeon satisfaction. Canadian journal of surgery. Journal canadien de chirurgie, 64(4), E457–E458. https://doi.org/10.1503/cjs.013921

[4] Nouraei, S. A. R. BChir, PhD, MRCS*,†,‡; Hudovsky, A. BSc§; Frampton, A. E. MB, MRCS¶; Mufti, U. MB, MRCS‖; White, N.B. MB, FRCP, FRCS**; Wathen, C. G. MB, FRCP††; Sandhu, G. S. MD, FRCS‡; Darzi, A. KBE, FRS, FRCS‡‡ (2015). A Study of Clinical Coding Accuracy in Surgery: Implications for the Use of Administrative Big Data for Outcomes Management. Annals of Surgery 261(6):p 1096-1107. | DOI: 10.1097/SLA.0000000000000851 

When Governments Shut Down: More Than Just Politics for Patients

On October 1st, 2025, the U.S. federal government entered a shutdown after Congress failed to pass the appropriation bills required to fund government operations for the new fiscal year [1]. The lockdown occurred due to a partisan disagreement in spending levels for foreign aid, and most crucially, the continuation of enhanced health-insurance subsidies under the Affordable Care Act (ACA). Republicans proposed short-term funding that kept most programs at 2025 levels but excluded or pared back the healthcare provisions that Democrats insisted upon, while Democrats pushed for extensions of pandemic-era subsidies and protections for vulnerable populations. The stalemate meant the federal government could not continue funding many programs that day, triggering widespread agency furloughs and operational shutdowns.

While public focus is on federal workers missing paychecks, the ripple effects of the shutdown on healthcare and medicine carry equally large consequences. The Centers for Disease Control and Prevention and the National Institutes of Health have faced massive staff furloughs, while research and clinical-trial infrastructure along with regulatory reviews are slowed [2]. Although essential entitlement programs like Medicare and Medicaid are funded separately and will continue operating, other parts of the healthcare system are vulnerable [3]. Hospitals and clinics that rely on federal grants or regulatory approvals face uncertain timelines and budgets. Additionally, hospitals warn that key programs like telehealth waivers, home-hospital care and provider-reimbursement policies are at risk if funding lapses. 

From the patient’s perspective, this is more than waiting for the government to restart: it means interrupted access, longer delays, and higher costs. For example, if research funding from the NIH or approvals from the FDA slow, this could delay the development of new treatments or devices which could translate into fewer and more expensive options for patients. Meanwhile, if subsidies under the ACA aren't extended due to the shutdown, millions risk losing affordable coverage or seeing their premiums rise, which raises the out-of-pocket burden and healthcare bills. For providers, clinics and hospitals who assist underserved populations or provide preventive care may face disruptions, jeopardizing care for those who are the most vulnerable. 

Patients are already feeling immediate ripples from the shutdown, especially those who rely on newer forms of care. For example, many hospitals and health systems report they can no longer schedule telehealth appointments for Medicare or Medicaid beneficiaries because the expanded telehealth provisions that were introduced during the pandemic expired on September 30 and have not yet been renewed by Congress [4]. Resulting in older adults, rural patients, and people with mobility limitations being forced to travel in-person or skip care altogether. It also means clinics and therapists say they may not receive reimbursements for virtual visits if the shutdown drags on, which can lead to canceling services. Moreover, the shutdown threatens the stability of insurance markets and subsidy programs, which has a downstream effect on patients. If Congress does not act and the subsidies expire, the CBO estimates 3.8 million fewer people will have health insurance because of the change while out-of-pocket insurance premiums will rise for about 20 million Americans in January 2026 [5]. 

At its core, the government shutdown occurred due to political disagreements on how healthcare spending should be approached. Republicans argue that restricting spending, including setting limits on subsidies, is necessary to curb deficits and ensure that federal healthcare commitments are sustainable in the long run. They believe that without tougher terms and conditions, healthcare funding becomes open-ended and less accountable. On the other hand, Democrats believe that protecting healthcare subsidies and research funding is essential for maintaining innovation and access. In all, the government shutdown highlights that when government funding stops, the hidden economy behind grants, regulatory oversight, and subsidies collapse, with that harm ultimately falling on the patients themselves. 

While politics play out in Washington, the real consequences are felt in the exam rooms and waiting rooms across the country. When research pauses, telehealth flexibilities expire, and federal agency staffing declines, what begins as a budget dispute becomes a public-health issue. The shutdown underscores that healthcare is not only clinical care: it is built on a foundation of policy, funding and infrastructure that is vulnerable to disruption. As the stalemate and political theater continues, it is important to remember who the costs truly fall on: the patients. 

Reviewed by: Ashley Gutierrez-Torres

Designed by: Sydney Berger

References:

[1] Who Is Missing Paychecks in the 2025 Shutdown—When and Where?  Bipartisan Policy Center. (2025, October 14), https://bipartisanpolicy.org/explainer/who-is-missing-paychecks-in-the-2025-shutdown-when-and-where/.

[2] Aboulenein, A. (2025, September 29). US government shutdown to furlough 41% of health agency workers. Reuters. https://www.reuters.com/legal/litigation/us-government-shutdown-furlough-41-health-agency-workers-2025-09-29/ .

[3] Morse, A. (2025, October 1). What a Federal Government “Shutdown” Means for PAs and Their Patients. American Academy of Physician Associates.     https://www.aapa.org/news-central/2025/10/what-a-federal-government-shutdown-means-for-pas-and-their-patients/. 

[4] Feldman, A. (2025, October 8). How The Shutdown Impacts Healthcare. Forbes. https://www.forbes.com/sites/innovationrx/2025/10/08/how-the-shutdown-impacts-healthcare/ .

[5] The health insurance subsidies behind the government shutdown. (2025, October 20). Harvard Kennedy School. https://www.hks.harvard.edu/faculty-research/policy-topics/health/health-insurance-subsidies-behind-government-shutdown.

Premium Aging: The Growing Cost of Nursing Home Care

About 0.4% of the entire population of the United States lives in nursing homes, making up one of the most high-risk medical groups in the country [1]. It is a common misconception that nursing homes are the best option for an elderly person with complex medical needs or dementia. While they are able to provide continuous care, the quality of the facilities is often poor, and many are understaffed and underfunded, causing them to crowd more patients into smaller rooms and spend less time with each individual resident. Many nursing homes and assisted living facilities in the United States are common breeding grounds for communicable diseases that put patients’ fragile immune systems at risk. To make matters worse, many high-end skilled nursing facilities won’t accept Medicaid coverage, creating a divide between those who can afford clean accommodations and high quality care and those who cannot. The transition itself can also be a detriment to an elderly person’s health, since it is often an abrupt and jarring change that may cause them to feel a loss of self and autonomy [2]. 

But nursing homes haven’t always been the only option. For centuries, people have lived in multigenerational households with parents, children, and grandparents all under the same roof, which allows elderly individuals to grow old peacefully in a familiar home, surrounded by family and friends who can provide the care and attention that they need. However, when independent societies like the United States put more emphasis on people owning their own homes away from family in the 1950s and 1960s, they started pushing the elderly out of family homes and into nursing homes [3]. Now, in the 2020s, multigenerational housing is on the rise again, as people feel the pressures of inflation and the cost of living crisis, and are turning to sharing homes with their extended family to save money on mortgages, rent, and nursing home fees. 

This idea is also the basis of the Medicaid-funded home and community-based care program that allows elderly people to live at home and retain their community connections while also being supported by a skilled medical team and receiving at-home care as needed. However, current budget cuts to Medicaid have left 700,000 on the waitlist for these home care programs and more people are being forced into nursing homes every day [4]. This problem is exacerbated by the flux of Americans returning to in-person work after the pandemic, with many opting to pay out of pocket for nursing home care for their loved ones, since they cannot take care of them any longer and the home-based care programs have decades-long waitlists. 

Additionally, many working-class Americans plan their finances under the assumption that they will be living at home for the majority of their elderly years, but many conditions, such as stroke or dementia, are difficult to predict and can have a very rapid onset. In one study, about 83% of adults reported that they would have great difficulty paying for the estimated cost of one year in a nursing home or one year of at-home assistance, which is between $60,000 and $100,000 [5]. This means that if these individuals needed the assistance of a nursing home, they would likely have to apply for Medicaid, which many higher-end nursing homes will not accept as payment, or rely on family or friends to partially fund their stay. The reality is that many elderly people are forced to enter overcrowded and underfunded nursing homes as a last resort either due to their financial situation or their family’s inability to care for them. The United States needs to amplify their Medicaid-funded home-assistance programs in order to provide the best quality geriatric care possible and allow elderly people to enjoy the final years of their lives with their family instead of being forced to live in a nursing home. 

Reviewed by: Ayan Jung

Designed by: Ariha Mehta

References: [1] Bakx, P., Wouterse, B., van Doorslaer, E., & Wong, A. (2020). Better off at home? Effects of nursing home eligibility on costs, hospitalizations and survival. Journal of Health Economics, 73(73), 102354. https://doi.org/10.1016/j.jhealeco.2020.102354.

[2] Grabowski, D. C., Chen, A., & Saliba, D. (2023). Paying for Nursing Home Quality: An Elusive But Important Goal. Journal of the American Geriatrics Society, 71(2), 342–348. https://doi.org/10.1111/jgs.18260.

[3] ​​Ruggles, S. (2007). The Decline of Intergenerational Coresidence in the United States, 1850 to 2000. American Sociological Review, 72(6), 964–989. https://doi.org/10.1177/000312240707200606.

[4] Stedman, N. (2025, July 2). How Medicaid Cuts Could Force Millions Into Nursing Homes. Penn LDI. https://ldi.upenn.edu/our-work/research-updates/how-medicaid-cuts-could-force-millions-into-nursing-homes/.

[5] Hamel, L., & Montero, A. (2023, November 14). The Affordability of Long-Term Care and Support Services: Findings from a KFF Survey | KFF. https://www.kff.org/health-costs/the-affordability-of-long-term-care-and-support-services/.