Screening and brief intervention (SBI) for addictions and other behavioral problems could save billions in healthcare costs if widely implemented as a component of national healthcare reform. But experts say that the programs need to be introduced in a systemic fashion to be effective and avoid overburdening physicians.
Various research studies have shown that SBI can cut hospitalization costs by $1,000 per person screened, save $4 for every $1 invested in trauma-center and emergency-room screening. A study from the state of Washington found that SBI reduced Medicaid costs by $185 per patient per month, according to Richard Brown, M.D., associate professor at the University of Wisconsin School of Medicine and Public Health.
“All three studies showed that the savings occurred over the first 12 months,” noted Brown.
“This has the capacity to save thousands and thousands of lives and billions and billions of dollars,” said John C. Higgins-Biddle, Ph.D., retired assistant professor in the Department of Community Medicine at the University of Connecticut Health Center and a consultant on the Join Together report, Screening and Brief Intervention: Making a Public Health Difference.
The report says that use of SBI programs is growing nationally but still faces some significant hurdles, including lack of funding; reimbursement and cultural issues; and so-called UPPL laws, which allow health insurers in some states to deny payment to individuals injured in alcohol-related incidents, discouraging screening in trauma centers and emergency rooms.
However, the federal government provided $29 million in grants for SBI programs last year and is proposing similar funding in the FY2009 budget. A growing number of insurers have agreed to reimburse for SBI services, including the Federal Health Employees Benefit Plan, which covers 5.6 million federal workers. And in January 2009, Ohio became the 15th state to repeal its UPPL laws.
Advocates say that devoting even a few minutes to screening patients for alcohol and other drug problems in emergency rooms, health clinics, employee-assistance programs, and doctor's offices can identify at-risk patients and steer them into treatment before problematic substance use blossoms into a more serious health crisis.
“Most people don't use at risky levels, so for them the process takes less than a minute,” said Susan Aromaa, co-author of the report and manager of research and communications at Join Together. When a brief intervention is warranted, the 15-20 minutes required can be longer than most physicians allot per patient visit. Therefore, many hospitals and clinics employ specialized screeners to take the burden off of doctors — a setup that has become more common as reimbursement for SBI has been more widely accepted.
Research has shown that many screened patients cut down on their drinking simply because they were asked about their alcohol use; likewise, brief interventions have been shown to effectively reduce alcohol and other drug use. “Some doctors fear not having the treatment space, and that scares them away,” Aromaa said. In primary care settings, however, “Only about 1 percent of patients generally need treatment,” she said. (The rate is higher in emergency-rooms — around 3%.)
Wisconsin has emerged as a national leader in SBI implementation: the latest state budget calls for reimbursement of screening and brief intervention services under the state's Medicaid plan, and Wisconsin insurers have broadly accepted SBI as a part of the treatment continuum, according to Brown, who also serves as the clinical director of the Wisconsin Initiative to Promote Healthy Lifestyles.
Fourteen states currently receive federal funding for SBI projects, but “most [states] only [fund] one organization or hospital,” said Brown. “In Wisconsin, we decided to take on the whole state.” SBI programs are currently operating at 20 sites in the state, and Brown said he is optimistic that the programs will survive beyond the expiration of Wisconsin's federal funding thanks to the support of the state and insurers.
Noting that the U.S. spends at least $200 billion annually treating problems related to alcohol and other drug problems, Brown added that SBI is a natural fit for national healthcare reform. “It's a wonderful way to promote healthy behaviors and reduce healthcare costs,” he said.
The Join Together report spells out a series of recommendations for expanding and implementing SBI programs, including:
- Do not expect physicians to bear the sole responsibility for widespread public health implementation of SBI. Physicians tend to focus on procedure-oriented medicine and may not be compelled to shift their practices to accommodate a technique based on empathic listening. If SBI is to become a routine element in health care practice, it must be organized and delivered in a way that does not rely solely on physicians.
- Involve specialty health providers to share the responsibility for providing SBI services. The National Institute on Alcohol Abuse and Alcoholism, for example, has targeted mental-health providers as well as generalist physicians with information on screening and brief intervention. Because the prevalence of risky and heavy drinking is higher among people with mental-health disorders, efforts to integrate SBI into psychiatry practice could benefit many individuals who are seeking treatment for mental-health problems.
- Repeal state insurance laws (known as UPPL laws) that discourage screening and brief intervention services. UPPL laws remain on the books in more than 20 other states.
- Include SBI as part of medical school curriculum and residency training. Making sure that medical students have an awareness of SBI and its concepts will make it more likely that they will incorporate it into their regular practice.
- Use screening tools that emphasize ease of use, and integrate screening for alcohol and drug use with other routine preventive screenings. Physician practices will be more likely to phase routine screenings into their work when automated screening and feedback tools are widely available. The Join Together report details a number of SBI tools, including the NIAAA Single Question, AUDIT, CAGE, the Michigan Alcoholism Screening Test, and the CRAFFT questionnaire for adolescents.
- Encourage professional associations to endorse SBI as routine health care practice. The American College of Surgeons' Committee on Trauma was the first physician organization in North America to mandate that all members screen patients for alcohol problems, and the Federation of State Medical Boards has adopted a goal of universal screening for alcohol and drug problems.
- Expand SBI beyond the health care system. Use online screening instruments, EAPs, and other private sector settings. AlcoholScreening.org, a service of Join Together, has been successful in enabling individuals to anonymously screen themselves for risky and hazardous alcohol use using and online version of the AUDIT screening tool.
- Use direct to consumer marketing to raise the demand for screening and brief interventions. Much in the same way that pharmaceutical companies have succeeded in driving demand for their products by marketing directly to consumers, proponents of SBI implementation can educate the public directly on harmful use, potentially getting patients to initiate discussions with their health care providers.