NEW YORK – The Internet and social networking, pay-for-performance, the economic crisis and conversion from ICD-9 to ICD-10 disease code sets are among the top issues facing healthcare in 2009, according to PricewaterhouseCoopers Health Industries Group.

In its annual review of the top concerns for health executives and policymakers released earlier this month, global research and consulting firm PwC says the healthcare industry will face many challenges in the year ahead, including how to deal with more underinsured and fund new cures in a capital-starved market.

The adoption and use of healthcare IT is implicit in several categories, including pay-for-performance and the conversion to a new coding system.

"The coming year will be a watershed for healthcare in the United States," said David Chin, MD, PricewaterhouseCoopers' Health Research Institute Leader. "Severe economic conditions are placing pressure on hospitals, insurers, employers and patients alike. President-elect Obama has called for significant reform for healthcare and will have a Democratic Congress supporting him. The convergence of market and political forces will drive the greatest change in healthcare in a generation, changes that could benefit patients and make the health system stronger."

The report is an annual review of the most pressing issues for health executives and policy makers. PwC identified nine top issues for 2009:

1. The Economic Downturn Will Hit Healthcare

Although the health industry historically has been less vulnerable to economic downturns than other industries, the disrupted economy will hit healthcare in 2009. Hospitals and other providers, from family physicians to dentists, will experience an increase in bad debt and a drop in elective procedures. Investment portfolios for all health organizations have been affected. The payer mix is shifting away from relatively lucrative commercial insurers and seeing a drop in enrollment and premium revenue - a trend that will likely continue if employment drops further. Charitable donations and investment income are down, and improvement projects involving capital outlays for IT, facilities and equipment, have been put on hold. Pharmaceutical and biotech companies have seen their valuations drop, which could further affect access to additional capital. Health organizations that need to find new sources of capital will have to demonstrate that they're improving their core businesses, improving efficiencies and delivering value.

2. The Underinsured Will Surpass the Uninsured as Healthcare's Biggest Headache

The uninsured draw most of the attention, but the number of underinsured is growing even faster - an estimated 25 million adults qualify as underinsured, an increase of 60 percent since 2003. With some but not enough health insurance, the underinsured often can't or won't pay the high deductibles and co-pays for the services they need. In 2009, the nation could see more bad debts for hospitals, more cost-shifting to commercial plans and more patients delaying or foregoing care.

With growing unemployment, self-pay is becoming a major part of providers' revenue cycle processes. Many hospitals have begun to pre-qualify patients. Some are using credit card-like swipe machines to verify eligibility and estimate insurance coverage. Others are using credit cards and extending their own lines of credit. Not-for-profit hospitals must tread carefully, as they don't want to further complicate the credit for uninsured and low-income patients. Business operations will likely look to technology and processes from the retail, banking and credit industries to manage self-pay patients and the underinsured.