ICD-10 codes needed for loneliness to curb epidemic

Anne Jordan, chief customer officer and cofounder of Pyx Health will speak at AHIP 2023. 

Photo: Courtesy of Pyx

The COVID-19 pandemic highlighted the mental and behavioral health needs of many Americans, and, with social isolation rampant during that time, particular focus was trained on the health effects that can result from prolonged bouts of loneliness. Yet even with this new knowledge, loneliness doesn't have its own ICD code, so being reimbursed for treating it can be a difficult endeavor. 

According to Pyx Health cofounder and CEO Cindy Jordan, that's a problem. Pyx Health is a healthcare technology company focused on supporting individuals dealing with loneliness through member engagement and screening tools for social determinants of health. 

AHIP is tackling the issue when Anne Jordan, chief customer officer and cofounder of Pyx Health, and Dr. Pooja Mittal, chief health equity officer at Health Net, speak during AHIP 2023 in the session, "Loneliness: A Driver of Engagement and Predictive Factor in High-Utilization," from 1:25 to 1:40 p.m. Wednesday, June 14, in Theater #1: Booth1137.

AHIP 2023 is being held June 13-15 in the Oregon Convention Center in Portland, Oregon. 

Calling loneliness an epidemic, Jordan said one positive thing emerged from the pandemic: It unlocked funding for a ton of research. That research revealed that one in three adults are chronically lonely, with the most prevalence occurring in the 18-24 age group. 

"What social media has done to this generation is that connections are a mile wide but an inch deep," said Jordan. "People feel very alone, even though they're surrounded by 7,000 friends."

The problem, from a health system and payer perspective, is that feelings of loneliness often drive people to the emergency room – and are a driver for what is considered inappropriate ER utilization. Jordan estimated that about 60% of people utilizing the ER are not there for an appropriate need, and this drives thousands of dollars in Medicare spend for a given year.

ICD codes are needed, she said, because it would provide for easier reimbursement. 

"Also, instead of coming out of the admin budget, I would contract with the payers and do what we do," said Jordan. "When you come out of the admin budget, it comes out that you're a vendor, and the vendor spend is always scrutinized. When you get to ICD-9 and -10 codes, you use evidence-based screenings – which we do in our platforms – do an intervention and then get paid for it. Otherwise you're out there convincing executives, saying, 'I can show you a return if you believe in loneliness and the effect it has on the spend."

In the meantime, loneliness can be a pernicious problem for many patients. People on the high end of the loneliness scale – those who feel it acutely – can't simply feel better by getting out more and engaging with the community. Their brain is actively telling them that no one and nothing can help them – not their medicine, their doctors or their family.

That means addressing loneliness in any meaningful way requires a specific intervention. And with a lack of coding around loneliness, interventions can be hard to come by. Pyx does its part in that regard, but the lingering issue in the healthcare community is that loneliness is still largely thought of as a symptom of other ailments, not an ailment in and of itself.

Lobbying the Centers for Medicare and Medicaid Services to create a new ICD code would be an important step, said Jordan.

"CMS has a lot of power here," she said. "If you can convince CMS this is the right thing to do, that would catch on like wildfire."

Data may go a long way toward convincing CMS. Pyx's data shows a per member, per month spend ranging from between $350 and $500. Stopping just one unnecessary emergency room visit would yield significant savings, said Jordan.

One thing CMS has done is create Z Codes – one of the three primary categories under the ICD-10 guidelines for mental health, which provide descriptions for when the symptoms a patient displays do not point to a specific disorder, but still warrant treatment. 

"The focus is on social determinants of health," said Jordan. "Payers can be reimbursed if they show they've addressed SDOH. When you shake the tree of loneliness, all these other SDOH fall out. You don't have access to your medicine, you don't have enough food, etc. It goes on and on. Loneliness was included in that. This could be the first step in the dabbling of how we reimburse for that."

Right now, loneliness is tied up in the Z Codes, which is a bit of a fuzzy area. Payers don't really know how to leverage the codes, said Jordan, which is where the push for ICD designation comes in.

But while the reimbursement picture is still blurry for payers and providers, there are things individuals can do to stem the tide.

"Engage in the community, even if it feels uncomfortable," said Jordan. "Make a phone call, or engage with your church, or whatever it's going to be. For youth, there isn't a community for them in the same way. But in the end, the most solid, reliable way to move through loneliness is to rely on family, however that's defined for you."
 

Twitter: @JELagasse
Email the writer: Jeff.Lagasse@himssmedia.com