“A Violation of Medical Ethics”

By Richard L. Brown, MD, MPH —

Rarely have I seen such strong words used to describe the failure of our healthcare system to address risky and problem tobacco, alcohol, and drug use and addictive disorders. The quote in the title is taken from a comprehensive, scientifically based, and hard-hitting report recently released by the National Center on Addiction and Substance Abuse at Columbia University.

The executive summary (Chapter 1) is worth a read.  It validates everything we’re trying to do to improve tobacco, alcohol and drug screening, intervention, referral, and treatment — and we can use the same infrastructure to address depression, nutrition, physical activity and obesity.

 Here is more context for the title quote:

“It is long past time for health care practice to catch up with the science.  Failure to do so is a violation of medical ethics, a cause of untold human suffering, and a profligate misuse of taxpayer dollars.”

Of course, many employer dollars are being wasted, too.

Download the report

Evocation: 6 Do’s and Don’ts for this Key to Patient Motivation

By Mia Croyle, MA —

Motivational interviewing (MI) is an evidence-based method of facilitating a collaborative conversation focused on strengthening a person’s own motivation for and commitment to change.

One key element of the style — or spirit — of MI is evocation. Practitioners of MI attempt to convey an understanding that motivation for change, and the ability to move toward that change, reside mostly within the other person. Practitioners focus their efforts on eliciting and expanding that motivation within the interaction.

Practitioners who are less successful at evocation tend to:

  • rely on fact gathering or information‐giving as a means of facilitating change
  • are likely to provide the person with reasons to change, rather than eliciting them

Practitioners who are more successful at evocation tend to:

  • follow up on person’s ideas when the person offers them
  • actively seek to explore person’s ideas when not offered
  • not rely heavily on information or education as a means of persuading people to change
  • actively create opportunities for the person’s own arguments for change to occur

One of the simplest ways of creating these opportunities is to simply ask for them:

“So tell me, what are some of the reasons you might consider doing something different to treat your symptoms of depression?”

In the next issue of the WIPHL Word, I’ll share more strategies for creating these opportunities in your conversations with patients.

Patient Story: Catch Fish, Not Buzz

By Jonathan Zarov —

A Wisconsin healthcare setting began delivering services this year with the help of WIPHL’s Agency for Healthcare Research and Quality (AHRQ) grant. One of their health educators tells this story…  (Some details have been changed to protect patient confidentiality.)


The patient indicated he had consumed 5 or more drinks in a day on multiple occasions over the course of the past year on the Healthy Lifestyles Questionnaire.  I was alerted to this screening result and met with the patient.

Brief assessment and initial brief intervention:

The patient stated that he enjoyed drinking beer daily and tended to drink beer all day long when fishing on the weekends.  He typically goes fishing every weekend during the summer months. Upon brief assessment, this patient’s drinking fell into the category of harmful use.  He typically drank about 8 beers after work during the week and about 20 beers daily on weekends when fishing.

The patient expressed some desire to cut back on his alcohol use. He stated that he often felt tired. He has a young son and wants to be more active with him and his wife. I shared feedback and recommendations with him and discussed several strategies for cutting back. He agreed to try some of these out and to meet again for a follow-up visit.


One week later I saw the patient for a follow-up visit. He had tried non-alcoholic beer in place of regular beer over the weekend while fishing. His friends gave him a hard time, but he said it didn’t really bother him. He noticed an increase in his energy levels and was pleased with that.  He didn’t really enjoy the taste of the non-alcoholic beer as much as regular beer, but was going to try some other brands.

A few weeks later, I followed up further with the patient. He had not had any alcohol in the previous week.  Prior to that there had been a night when he drank “quite a few” beers following a stressful event.  He had a headache and a hangover the following day. This episode influenced his decision to take a break from drinking altogether. He shared that he had been feeling “better” and “wide awake” since he stopped drinking and had been busy doing yard work instead of drinking in the evening. He had also begun eating more regular meals and looking forward to waking up early on the weekends to go fishing. He expressed concern for the upcoming weekend. He told me a lot of his friends would be around for a big fishing tournament, people who he hadn’t seen since making changes to his alcohol status, and he would want to drink with them. After we talked things over, he created a plan for how he wanted to handle this situation.

In a subsequent followup after his fishing tournament weekend, the patient shared that he had drunk more than the  low-risk drinking guidelines on one of the days, but still drank less than he would have in previous years.  He was proud of his successful efforts to decrease his alcohol use.

Overall, he has seen positive effects to his health and wellness, increased productivity levels, and an improved relationship with his wife and son. He also now sees that he can have fun fishing with his friends even when he isn’t drinking.

Health Care Reform – What it Means for Behavioral Screening and Intervention (BSI)

By Richard L. Brown, MD, MPH —

It’s official. The healthcare reform law is the law of the land – all two thousand plus pages of it, except for the part that prohibits the federal government from withdrawing all Medicaid funds for states that don’t increase their Medicaid coverage.

This is good news for spreading behavioral screening and intervention (BSI). The law includes requirements that healthplans reimburse for certain preventive services – those that carry Grade A or B ratings from the US Preventive Services Task Force. These services include proactive, universal screening and intervention for tobacco use, alcohol misuse, depression, and obesity, plus counseling on a healthy diet – issues that account for over 40% of deaths, most chronic illness, most disability, and nearly $900 billion in healthcare costs per year. The requirement took effect for many healthplans in 2010, and its effect for all plans in new exchanges on January 1, 2014.

But if the Republicans make gains in the coming election, might the law be repealed or undermined by defunding? Possibly, but BSI increasingly has a life of its own through requirements and incentives in the private sector. For example:

  • Patient-centered medical homes, which command higher reimbursement rates from many commercial healthplans, are increasingly required to implement population health management for behavioral issues
  • Accountable care organizations must meet certain BSI quality requirements, and ACOs get to keep most of the cost savings generated by BSI
  • Employers are increasingly demanding value when they purchase healthcare, and BSI saves $895 per employee through favorable impacts on healthcare costs, productivity, absenteeism, and workplace injuries.

With or without healthcare reform, US healthcare is moving toward payment mechanisms that reward value rather than delivery of services that may or may not improve health outcomes. BSI will inevitably be part of the value-based revolution.

Although not all BSI services are currently reimbursable, several healthcare settings have found they can more than break even when they hire dedicated health educators to deliver BSI. As reimbursement increasingly rewards value, fee-for-service reimbursement for BSI will pale in comparison to BSI’s favorable impacts on outcomes and total costs.

WIPHL is pleased to have continuing funding from the US Agency for Healthcare Research and Quality to help primary care settings implement BSI. Our AHRQ grant allows us to defray ample start-up costs by providing health educator and site training and support at no charge for Wisconsin primary care clinics. We can also advise hospitals and emergency departments.

Wisconsin primary care clinics: WIPHL would be glad to help you get started with BSI. Employers, including local governments: you’ll benefit most, so please steer your local healthcare organizations our way via www.wiphl.org. It’s inevitable – all healthcare settings will deliver BSI. The sooner, the better – for Wisconsin patients, providers, businesses, and state and local governments.