"This is a very worrisome trend," Ms. Madras said. "We have fairly strong evidence that marijuana can interfere with learning and memory, so the combination of aging plus having a drug on board that targets a receptor that diminishes the capacity to learn and to memorize is not a healthy combination. We are certainly hoping that screening this cohort of people will enhance their capacity to reduce drug use that could be detrimental."
..."Screening and intervention may help identify and help people who would not respond positively to questions about alcohol and illicit substances," Ms. Madras concluded. "By screening we can identify people who are at higher risk for abusing prescription drugs, because the people at highest risk for abusing prescription drugs are in fact illicit drug users."
If Mrs. Madras had two grey cells to rub together she would realize that older people are turning to cannabis because they have had so much experience with prescription drugs, and the only people worried about it are the pharmaceutical companies and the rehab racket.
Medscape wrote:Medicaid Will Reimburse for Alcohol, Drug Screening and Brief Intervention
Laurie Barclay, MD
MedScape
September 13, 2006 — Effective January 2007, the US Centers for Medicare and Medicaid Services (CMS) will reimburse for alcohol and drug screening and brief intervention (SBI). Experts interviewed by Medscape hope that the new policy will help identify and treat people with substance use disorders, thereby improving public health.
"The impetus behind the Medicaid decision to reimburse for alcohol and drug screening services was the recognition of the number of people who go unidentified who are in need of an intervention or treatment," Bertha Madras, deputy director of Demand Reduction from the White House Office of National Drug Control Policy, told Medscape. "About 22 million Americans have abuse and/or addiction problems; of these, about 10% are in treatment, and the vast majority of the rest are not in treatment, not because there is a problem with the system, but because they don't recognize the fact that they have a problem. Most do not seek help and remain unidentified."
The new reimbursement schedule adds 2 new codes to the level II Health Care Service Procedures Coding System (HCSPCS) used by Medicaid, Medicare and other third-party payors: one code for drug and alcohol screening, and the other for brief intervention and counseling. Leading medical research groups have recommended SBI, which is known to be effective for addressing alcohol and substance abuse problems, as standard protocol. By creating these codes, CMS and the Office of National Drug Control Policy will allow SBI to become a routine addition to primary and emergency medical care.
<span class=postbold>Screening Expands to More Clinical Settings, Overcomes Obstacles</span>
"In current clinical practice, SBI does not occur frequently, at least in part due to the absence of reimbursement," Eric Goplerud, PhD, research professor in health policy and director of Ensuring Solutions to Alcohol Problems at George Washington University Medical Center in Washington, DC, told Medscape. "Currently, substance use screening and treatment is reimbursed as specialty substance use treatments. Payors fail to recognize that SBI is a primary care service that can be performed in ambulatory, emergency department, and inpatient settings."
Obstacles to alcohol and drug screening identified by Ms. Madras are lack of reimbursement and insufficient medical school education on how to screen and how to intervene. The amount of time it takes to screen and to intervene is 15 minutes or longer, depending on how many counseling sessions are needed. Because physicians' time is so restricted by coding systems, having a code that accounts for time spent will facilitate this process.
"There are many reasons that physicians do not screen for alcohol and other drugs," Dr. Goplerud said. "Lack of training, lack of referral resources, lack of time, lack of priority — all of these discourage routine screening and brief treatments for patients with alcohol and drug problems."
Yet another obstacle to drug and alcohol screening is state insurance law. In more than 30 states, the law explicitly permits insurers to deny payment for patients injured while under the influence of alcohol or other drugs, even though between 40% to 60% of all patients admitted to trauma centers meet that criterion. Dr. Goplerud noted that "the unintended consequence of these laws is that by denying payment to doctors and hospitals that render care to critically injured patients, physicians do not screen in trauma centers and emergency departments."
<span class=postbold>Factors Influencing Decision</span>
Dr. Goplerud, who helped develop the new HCSPCS codes, named several factors considered by CMS in its decision to create new procedure codes to reimburse healthcare providers for SBI:
<ul>
<li>SBI conforms to the best scientific evidence available, leading to reduced alcohol consumption among excessive drinkers, and to reductions in adverse alcohol-related health outcomes, including mortality;</li>
<li>SBI is integral to evidence-based clinical practice standards for treatment of substance use disorders promulgated by relevant professional medical societies, federal agencies, international health organizations, and national health ministries of developed nations;</li>
<li>SBI is a core feature of clinical practice guidelines used by major commercial health insurers and government agencies to determine medical necessity and reimbursement;</li>
<li>SBI is recommended by the federal agencies responsible for public health and public safety;</li>
<li>Seventeen specialty medical societies recommend training and demonstrated clinical competency in SBI;</li>
<li>Federal health services agencies and major foundations are investing substantial resources in developing SBI demonstration programs, but the current lack of accepted procedure codes jeopardizes their sustainability; and </li>
<li>The ratio of cost to implement SBI to healthcare cost savings of SBI is positive and substantial.</li>
</ul>
"Alcohol and drug screening provides a quick way to identify individuals whose drinking or drug use patterns indicate that they have a substance use problem or are at risk for developing one," Dr. Goplerud said. "Alcohol and drug screening is not the typical screening that is now routinely performed for different health conditions, such as blood pressure, cholesterol, or weight. It is screening plus immediate, concerned feedback, which serves as an intervention, tailored to the level of either illness or risk."
<span class=postbold>Policy Includes Both Screening and Brief Intervention</span>
The new policy will cover screening, using 1 or more of 3 well-defined, well-characterized screening tools, namely validated, brief questionnaires about context, frequency, and amount of alcohol or other drug used. Also covered is a brief intervention consisting of 1 or 2 sessions with a clinician or with a qualified counselor, typically occurring in the physician's office or hospital emergency department, and lasting between 5 and 30 minutes.
"The healthcare practitioner, using the results of a screening questionnaire that indicates an alcohol or drug problem, expresses medical concerns about the individual's drinking or drug use, and helps the individual to develop an action plan and the motivation to act on it," Dr. Goplerud said. "Brief interventions are a low-cost, effective treatment alternative for alcohol and drug problems that use time-limited, self-help, and preventive strategies to reduce hazardous use, and for alcohol- or drug-dependent patients, to facilitate their engagement in specialized treatment programs."
Brief interventions usually take place immediately after screening, but some models of brief intervention include one or more follow-up care management contacts with patients either in brief face-to-face counseling or by telephone.
The reimbursement schedule for the SBI codes has not yet been published.
"The clinician can simply say: Perhaps [your substance use] is too much, perhaps you can cut down, and start thinking about it, because it has consequences for your life," Ms. Madras explained. "These kinds of interventions have been found to have a significant impact on alcohol and drug use, as well as on emergency room visits, on trauma, and on a number of associated or collateral issues that can interfere with the health of the individual."
<span class=postbold>New Policy Cost-Effective, Reduces Negative Outcomes of Addiction</span>
The cost savings of SBI are estimated to be approximately 2.5:1, or even 4:1 in terms of healthcare costs, according to Ms. Madras. Dr. Goplerud estimated that the net savings to the federal Medicaid budget annually would be $520 million, and that states would save nearly $500 million in Medicaid fees if injured hospital emergency department patients are routinely screened for alcohol and drug use, and those with substance use problems are briefly treated.
"This means that more money can eventually be freed up to help people with other medical conditions for which there may be scarce resources," Ms. Madras said. "Most importantly, [SBI] can have an enormous impact on the health of the individual by reducing alcohol and drug use. It can increase their general health; it can increase their ability to be employed, their functioning at the workplace or at school."
"More important than the cost savings is the reduction in reinjury, rehospitalization, and death," Dr. Goplerud said. He cited a randomized controlled study of trauma center patients showing that those who received brief substance abuse treatment were 48% less likely to be reinjured in the following 18 months, and 50% less likely to be rehospitalized in the following 3 years (Gentilello LM, et al. Ann Surg. 1999;230(4):473-483.).
For college students who are binging on drugs, SBI could increase awareness that this behavior is highly detrimental to their brain, their body, their test performance, and their ability to participate in extracurricular activities. If SBI is extended to adolescents, this could help promote good health and help reduce the possibility of addiction. Ms. Madras cited data indicating that the earlier a person begins to use substances, the much greater the risk of addiction, dependence, and use of other substances — up to a 2.5- to 5-fold increase.
<span class=postbold>Older Patients More Likely to Be Screened</span>
A new national survey on drug use and health data indicates that people aged 50 to 59 years are increasing their use of marijuana and other drugs.
"This is a very worrisome trend," Ms. Madras said. "We have fairly strong evidence that marijuana can interfere with learning and memory, so the combination of aging plus having a drug on board that targets a receptor that diminishes the capacity to learn and to memorize is not a healthy combination. We are certainly hoping that screening this cohort of people will enhance their capacity to reduce drug use that could be detrimental."
Ms. Madras also referred to a growing body of literature indicating that substance abuse exacerbates certain medical conditions. Alcohol can aggravate diabetic symptoms, sleep problems, and depression, whereas marijuana can compromise the immune system. "Reducing and eliminating substance abuse and addiction can also help the outcomes of medical diseases," she said.
<span class=postbold>May Reduce Prescription Drug Abuse</span>
Another area of concern is the increasing trend for prescription drug abuse, especially among 18- to 25-year-olds, but also in high school students. Approximately 74% of prescription drugs that are abused are opioid analgesics, which have a highly significant addiction potential if misused.
"Screening and intervention may help identify and help people who would not respond positively to questions about alcohol and illicit substances," Ms. Madras concluded. "By screening we can identify people who are at higher risk for abusing prescription drugs, because the people at highest risk for abusing prescription drugs are in fact illicit drug users."
<span class=postbold>Related Links</span>
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Laurie Barclay, MD is a freelance reviewer and writer for Medscape.
<small>Medscape Medical News 2006. © 2006 Medscape
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