Identifying Risk-Adjusted Services During the Opioid Crisis

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
May 6th, 2021

Between June 2019 and June 2020, the United States saw a total of 107,750 deaths from COVID-19. The spread of this virus was so extraordinary that it led President Trump to declare a public health emergency (PHE), and we watched as individual states began implementing laws and regulations to limit social interaction in an attempt to try and control the spread of the disease.

Another PHE was declared long before COVID-19, and continues in full force today. On October 26, 2017, President Trump declared a PHE due to the opioid crisis and just like the COVID-19 PHE, waivers were put into place to help states, providers, and payers deal with this crisis in ways that were not available to them previously. As a matter of fact, data for the same time period noted for the COVID-19-related deaths, shows the opioid crisis claimed the lives of 83,000 Americans and was not nearly talked about to the same degree as COVID-19 during that same time period. 

What does this have to do with risk adjustment? Well, many patients with an opioid addiction also have a behavioral health disorder and additional risk-adjustable medical conditions such as respiratory, cardiovascular, and liver diseases, not to mention social determinants of health; all of which affect overall healthcare and costs.

Identifying these at-risk patients and guiding them to the care they need can alter their path to include opportunities for healing through treatment programs such as: 

• opioid treatment program (OTP)
• medication-assisted treatment (MAT)
• narcotic treatment services (NTS) 

One additional fact that goes hand-in-hand with mental illness is the rate of suicide in the United States. Although not officially considered a PHE, 48,344 Americans died by suicide in 2020 and it is, according to the CDC, the 2nd and 4th leading cause of death in 10-34 year-olds and 35-54 year olds, respectively. Among those who died by suicide, 90% had a diagnosable mental health condition at the time of their death.

In "Mental Health Myths and Facts," (published by the Department of Health and Human Services) it was revealed that 1 in 5 people deal with some form of mental illness; of these, only 44% of adults and 20% of children and adolescents received needed treatments. Many others did not believe that treatment would help or felt there was a stigma attached to seeking help for such a condition.  

With such staggering numbers, it is important that we identify these individuals sooner, rather than later. Services such as communication-technology based services (CTBS), virtual care, secure email and patient portal communications, as well as telemedicine services allow patients to open up in a secure setting where they can obtain the help they desire without any perceived stigma.

Providers should be encouraged to offer preventive medicine services, annual physical examinations, and include opportunities for patients to vocalize issues or concerns they may be experiencing. Identifying young patients suffering from liver, cardiovascular, or respiratory complaints may be a good place to implement questionnaires and encourage communication about potential substance abuse, reminding patients of the HIPAA laws that were implemented to protect their private medical information in certain situations. 

Payers armed with risk adjusted funds have an opportunity to make a difference by instituting programs and benefits that help providers identify, diagnose, and obtain treatment for at-risk beneficiaries. 

About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Aimee L. Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.