SDOH, ICD-10, and avoiding the M-word

May 6, 2019 / By Rhonda Butler

In my last blog, I recommended checking out excerpts from the March ICD-10 Coordination and Maintenance meeting. Those excerpts were written proposals for ICD-10 codes describing SDOH (social determinants of health), socioeconomic risk factors such as inability to pay for prescriptions or for transportation to medical appointments, along with a webcast recording of the discussion. I resisted the urge to indulge in my take on the whole thing, instead spending my blogcoin to get the links and summary information out there so you could review the proposed new codes and watch the YouTube snippet for yourselves.

Now that you’ve had a taste of the original topic, it’s time for the meta-topic—the discussion of the discussion. As often happens in this and other discussions of healthcare data, it was hard to ignore what was not discussed at this meeting—the M-word—money! The topic of money, the importance of money, the effect of money, was tiptoed around in the usual way. The tendency to “avoid the M-word” is so common I think it deserves its own acronym—AtMw—pronounced “at mow.”

United Health Care, the main driver behind the request for new ICD-10 SDOH codes, phrased their request in the accepted style. The written proposal contained two excellent examples of AtMw. First, and the italics are mine: “UHC believes utilizing the ICD-10-CM codes is a logical choice, as it is the standard language between care providers and payers.” In my view, no one would come out and say, “ICD-10 codes are the logical choice because providers must assign them to get paid. Creating specific SDOH codes in ICD-10 where they are more likely to be assigned is the best chance we have of eliminating some of the more pointlessly wasted money in the healthcare industry.”

Here’s the second example: “Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT) and Logical Observation Identifiers Names and Codes (LOINC) are other coding standards that have also identified some SDOH codes, however for varying reasons, they would be a substandard solution” (again, my italics). Same deal—this is AtMw for the fact that LOINC and SNOMED-CT are not “billing codes.” Journalists may be perfectly willing to use this phrase while it is taboo for the rest of us. They don’t realize that it is “not done.” Those who have not been initiated into the subtleties of discussing ICD-10 aren’t going to practice AtMw, because the “M” word is so obviously a critical difference between ICD-10 and the other candidates for capturing data on SDOH—ICD-10 is used to move money around.

Because ICD-10 codes are billing codes, they are more sought after as coded data. Because they are used for billing, they are used, therefore as data they are a larger, more representative sample. The proposed ICD-10 SDOH codes would enable the industry to more efficiently address specific sources of wasted money, like people showing up at the ER because they can’t afford to fill a prescription, or people whose chronic conditions become acute exacerbations requiring a hospital stay, because they don’t have transportation to their provider’s office for scheduled follow-up.

Sigh—is it really necessary to pretend money doesn’t matter in these settings? Can’t we do better? Can’t we be clearer and more nuanced when we talk about this stuff? Recall the Triple Aim—as in, three parts:

1. Improving the patient experience of care
2. Improving the health of populations, and last but not least,
3. Reducing the per capita cost of health care

Why does the business of healthcare have to pretend not to be a business in situations where open discussion of all aspects of health care—quality, outcomes, and cost are all equally important?

Every C&M meeting begins with the announcement that this forum is not the place to discuss reimbursement. In an ideal world, CMS would be able to say, “We are not discussing requests for DRG assignment or New Technology Add-on Payment policy, there are other forums for that, but we fully acknowledge that ICD-10 codes are used in large part to transact the business of healthcare—duh, we are CMS, and yes, we are aware that healthcare costs money—so general considerations of the relationship between codes and cost are fair game, insofar as they are essential to the discussion.”

But this is the real world. I know, it’s complicated.

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

Striving to achieve health equity by addressing social and clinical risk.