Chasing Value Through an Imperfect Lens

Andrew L. Pecora, MD

We all know that healthcare is at a crossroads: to the left, there is rationed care, and to the right, you have economic insolvency, if we remain on our current course. Many in government and the private sector are working diligently to change these potential eventualities. However, the tools we have to do so are imperfect and truly are clouding our ability to see the correct path forward. The best example of this is our current disease classification system, ICD-10. Imagine if microbiologists were trying to categorize and organize different species of bacteria and all they had available for decades were the unassisted human senses of sight, smell, taste, and touch. We might be able to separate aerobic from anaerobic bacteria based on smell, but that would be about it.

There appear to be many fathers to the instrument we call the microscope, which enabled us to see very small objects as clearly as we would a baseball. The first compound lens microscope is attributed to Dutch inventor Cornelis Drebbel, while Giovanni Farber got credit for coining the name “microscope” (Ancient Greek: to see the small). Sight aided by a microscope allowed distinctions of bacteria by size, shape, and patterns of coalescence. With this level of detection, names could be given to the various subtypes, and each subtype could then be better defined by patterns of growth in cultures and, later, susceptibility to antimicrobials in culture. Even with this incredible advance, however, we remained limited to the external structure of a bacterium, with no understanding of how it looked or behaved internally. This all changed with electron microscopy, starting in 1931, which substituted electrons for light to describe an image. The final advance in our ability to learn more in depth about bacteria came with the development of immunofluorescence-based microscopy. Using this method, you can target a part of a bacterium with an antibody attached to a fluorescent probe to distinguish subcellular characteristics—again, to learn more about the nature of the bacterium studied.

By now, you are probably wondering what any of this has to do with our current healthcare crisis. Everything, in fact. ICD-9 coding was the equivalent of using eyesight to characterize disease. It gave us virtually no means of distinguishing disease types—never mind one subtype from another—and yet this was the tool by which payment claims were adjudicated. Everyone knew this was inadequate, but instead of moving from the bare human eye to a microscope, or—better—electron microscopy or immunofluorescence-based microscopy, we handed physicians and payers a simple magnifying glass in ICD-10 codes.

For a woman with breast cancer, ICD-10 cannot tell you if the tumor is HER2/neu positive, what the stage is, or if this a first or second progression, but it can tell you exactly where it is located in the breast. In melanoma, ICD-10 enables you to define precisely the site of origin but not BRAF status. How can this “lens” lead to knowing what the correct therapy is and, therefore, what to pay for? How can ICD-10 help eliminate adverse variance in care (too much or too little) in order to improve clinical outcomes and reduce total cost of care? It cannot. It was Yogi Berra who said that when you come to fork in the road, you should take it. How about we stick a fork in ICD-10 and give physicians and payers a coding system that provides a proper lens to see the truth?