Amidst Chaotic Healthcare Environment, WIPHL September Symposium on BSI Strikes a Chord

By Richard L. Brown, MD, MPH
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With only one month before enrollment opens for new exchanges and four months before new requirements for health plans take effect, most of us are wondering how the Affordable Care Act (ACA) is going to come together.  Although polls show a wide range of opinion about the ACA and its implementation, almost everyone agrees that U.S. healthcare must be more effective and cost-efficient.  Indeed, a Gallup poll earlier this year found that 81% of Americans personally worry either “a fair amount” or a “great deal” about the availability and affordability of healthcare.

Within the healthcare industry, many individuals are concerned about how cuts will affect their sectors and yet few dispute our collective need to work toward the triple aim. That’s improving health outcomes, enhancing patients’ experience of healthcare, and controlling healthcare costs.

Perhaps that’s why nearly 150 people in Wisconsin have already registered for WIPHL’s September Symposium on Behavioral Screening and Intervention (BSI), which is co-sponsored by the Wisconsin Collaborative for Healthcare Quality.

Our goals for the symposium are:

  • To disseminate information on how administering systematic BSI would arguably be the largest step a clinic or hospital could take toward the triple aim;
  • To highlight progress in Wisconsin and other states toward spreading BSI;
  • To identify barriers to further spread; and
  • To generate strategies and enthusiasm for overcoming those barriers.

Our keynote speaker, John Torinus, author of the new book “Opt Out of Obamacare, Opt Into the Private Health Care Revolution,” will describe why large and medium-sized corporations are increasingly voting with their feet to leave the mainstream U.S. healthcare system and what it would take for them to return.

During our free, day-long Symposium, I’ll review the need for BSI, its contribution toward the triple aim, WIPHL’s successful model of BSI delivery, and where BSI stands in Wisconsin.  In addition, Mia Croyle, WIPHL’s Director of Development, will facilitate a panel discussion among diverse healthcare professionals whose clinics are systematically and successfully delivering BSI.

Additional sessions will include more discussion on BSI delivery models, BSI-related policy issues, employers’ perspectives on BSI, coding and reimbursement and how BSI is linked with cardiovascular prevention, federally qualified health centers (FQHCs), educational settings, and mental health disorders.  Speakers from across the United States will add a national outlook as well.

The day will be full of opportunities for discussion, networking and planning next steps for dissemination of BSI.  We’re fortunate our current grant from the Agency for Healthcare Research and Quality allows for registration, lunch and refreshments at absolutely no cost to participants.

If you’ve already registered, we look forward to seeing you, and feel free to invite others.  If you haven’t, please register here.

For more information, refer to our Symposium agenda packet or email any questions and comments to info@wiphl.org.


Erroneous POEM Analysis on Alcohol Screening and Intervention

By Richard L. Brown, MD, MPH

Earlier this year, a randomized control trial by Eileen Kaner analyzing the effectiveness of screening and brief alcohol intervention in primary care settings was released. It concluded that, “All patients received simple feedback on their screening outcome. Beyond this input, however, evidence that brief advice or brief lifestyle counselling provided important additional benefit in reducing hazardous or harmful drinking compared with the patient information leaflet was lacking. “

I believe an analysis of the trial by Essential Evidence Plus POEM, which stated the bottom line was that alcohol screening and intervention did not decrease the percentage of patients drinking to excess at six months, completely misinterpreted Kaner’s study.

Kaner’s study did not assess the efficacy of alcohol screening and intervention, which is already well-established in dozens of randomized controlled trials, including Mike Fleming’s seminal study published in JAMA in the 1990s. Kaner’s study assessed the effectiveness of training physicians and nurses in primary care settings in delivering these services. And of course, the physicians and nurses did poorly, because they simply don’t have time to adequately screen and intervene.

The message that I take away from Kaner’s study is:

  • If you really want to generate the improved health outcomes and cost savings that alcohol screening and intervention will yield, you need to expand your healthcare team with staff who have the time to deliver these services.
  • The same goes for evidence-based – widely-recommended, yet seldom delivered – evidence-based interventions for tobacco and depression.
  • We can increase one-year quit rates from 6% to as high as 28% if we have additional staff who can spend as much as five hours with each patient over more than eight visits, according to a metaanalyses published in the most recent update of the Federal Guideline for Tobacco Cessation.
  • We can increase one-year rates of complete remission from depression from 30% to 54% if we have additional staff who can deliver “collaborative care,” which includes educating patients, engaging them fully in treatment and in behaviors that help lift symptoms (such as exercise and socializing), tracking depressive symptom scores (PHQ-9), and alerting other providers when poor improvement in PHQ-9 scores indicates a need to reconsider the treatment plan. (See a metaanalysis of 69 studies by Thota, Am J Prev Med, 2012.)

If you have questions regarding Kaner’s study, the POEM analysis or my response to the POEM analysis, please email me at info@wiphl.org.

For more information, see wiphl.org.


WIPHL/WCHQ Symposium Planned on Spreading BSI

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By Richard L. Brown, MD, MPH

I’m pleased to announce that WIPHL and the Wisconsin Collaborative for Healthcare Quality (WCHQ) will host a day-long symposium on behavioral screening and intervention (BSI) in Madison this upcoming September 17.

The goals of the meeting are to discuss the documented improvements in health and cost savings of BSI, the current state of BSI delivery in Wisconsin healthcare settings and together, plan how to accelerate the spread of BSI all across our state.

The conference is targeted at a diverse array of audiences, including individuals and representatives of organizations in both the private and public sectors, that:

  • Purchase healthcare
  • Pay or help contract for healthcare
  • Provide healthcare
  • Influence healthcare policy – or would like to do so
  • Advocate for the health and well-being of Wisconsinites

Our keynote speaker will be John Torinus, Chairman of the Board of Serigraph, Inc., and author of The Company That Solved Healthcare. Mr. Torinus will discuss why mainstream healthcare payers and providers are losing market share among large- and medium-sized US corporations, and what can be done to win back those customers.

I will discuss BSI, its health and economic benefits, and a model for delivering BSI that has worked well in dozens of Wisconsin healthcare settings. Kevin Moore, Deputy Secretary of Wisconsin’s Department of Health Services, will provide commentary on the prior sessions.

Mia Croyle, MA, WIPHL’s Director of Operations, will facilitate a panel of healthcare professionals who will discuss their personal experiences in delivering BSI.

Throughout the rest of the day, there will be additional sessions designed to foster a rich exchange of information, experience and new ideas on various aspects of BSI, including:

  • Delivering BSI in primary care settings
  • BSI and the business case for employers
  • BSI and other models of primary care/mental health integration
  • BSI-related national and state health policy
  • BSI and the prevention of heart disease
  • BSI in schools and colleges
  • BSI and federally qualified health centers

At the end of the day, there will be a plenary discussion of ideas that came out of each session, how to move BSI forward in Wisconsin and the various roles that participants can play. There will be ample opportunities to participate in discussions in the large groups and small groups as well at network throughout the day.

This symposium is sure to be an exciting and enriching experience, so be sure to save Tuesday, September 17 on your calendar. It will take place at the Monona Terrace. Lunch and refreshments will be provided. All symposium expenses will be funded by WIPHL and WCHQ’s current grant from the US Agency for Healthcare Research and Quality (AHRQ).

There is no fee to attend the symposium but registration is required, and there will be a registration cap. Be sure to register at http://onlinecommunity.wchq.org/event/BSIsymposium, and tell your friends and colleagues.

We hope to see you there!


Spring Brings New Policy Developments in SBIRT

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By Richard L. Brown, MD, MPH

One of the exciting aspects of serving as the WIPHL’s director has been witnessing the rapid growth and depth of support for healthcare settings to deliver behavioral screening and intervention (BSI).  In just the past few months, there has been several important policy developments regarding the recommendation and delivery of alcohol and drug screening, brief intervention and referral-to-treatment (SBIRT), both on a national and state level.

Every year, the White House and Director of the Office of National Drug Policy (also known as the “drug czar”) release an update of the nation’s strategy to address its drug problems. Chapter two of the newly-released National Drug Control Policy of 2013 is titled “Seek Early Intervention Opportunities in Healthcare” and details steps the federal government is taking to promote delivery of  SBIRT. These efforts include promoting better education for healthcare professionals, enhancing fee-for-service reimbursement for services, and updating educational resources. The document cites WIPHL and its partnerships with universities and employers as a “model public-private collaboration.”

Toward enhancing the delivery of SBIRT services, the Center for Medicare and Medicaid Services recently released a plan to update its rules on reimbursing hospitals for services delivered to Medicare patients. An exciting aspect of the plan is to require hospitals to report to Medicare the proportion of Medicare patients who have received SBIRT services and to institute strong financial incentives based on quality metric reporting. This aspect of the proposal would be implemented in 2016, which gives hospitals liberal lead time to plan how they will deliver these services.

Finally, at the state level, Wisconsin’s State Council on Alcohol and Other Drug Abuse (SCAODA) is charged with making recommendations to the Governor and legislature on preventing and addressing alcohol and drug problems in our state. SCAODA will soon consider adopting its subcommittee recommendations intended to help make BSI a routinely delivered service in primary healthcare settings, emergency departments and hospital inpatient units throughout the state. Recommendations include eliciting the support of the Governor’s Office in convening representatives of private and public healthcare  purchasers, and requiring payers to publicize fee-for-service reimbursement policies for behavioral screening and intervention.

Also at the state level, the Wisconsin Department of Health Services submitted a grant application to the US Substance Abuse and Mental Health Services Administration for approximately $8 million to continue disseminating alcohol, drug, tobacco and depression screening and intervention in primary care clinics throughout the state. The Wisconsin Primary Health Care Association (WPHCA) would be a lead organization in this project. Although WPHCA serves as an umbrella organization for Wisconsin’s federally-qualified health centers, all primary care clinics will be invited to participate. Notification of a funding decision will likely come in the early fall, and service delivery will start at some clinics by early 2014.

These exciting developments are further evidence of momentum for behavioral screening and intervention. If your clinic and hospital aren’t yet delivering BSI, they will in the future. Please contact WIPHL if you have any questions on how to get BSI started in your clinic or hospital, or on what you can do to accelerate implementation of evidence-based, cost-saving BSI in your community.

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To Improve Mental Health Care and Generate Cost Savings, Let’s Focus on Primary Care

By Richard L. Brown, MD, MPH

While it has been clear for years that millions of Americans with mental health disorders have suffered terribly from poor access to services, it sadly took the killing of 20 school children in Connecticut to galvanize concern about the state of mental health care in our nation.

Wisconsin Governor Scott Walker has proposed nearly $30 million in increased funding to improve mental health services in Wisconsin.  Funds would go to a new state office for children’s mental health, community-based services for seriously mentally ill adults and children, in-home counseling for children, and additional forensic units at Mendota Mental Health Institute.  Clearly, these funds are needed.

But we should make certain we do not lose sight of the concomitant need to improve services for the majority of patients with mental health disorders who do not receive specialty-based services.

In typical primary care settings:

  • Ten percent of patients have major depression, and about one-third to one-half go undiagnosed.
  • Patients diagnosed with depression often receive suboptimal care – for example, inadequate doses of antidepressants or inadequate changes in treatment when patients do not attain full remission.
  • Diagnoses of bipolar disease are often delayed for up to years while patients’ “inappropriate behaviors” wreak havoc on their lives and the lives of their family members and friends.

Research has shown we can do much better, and a large part of the answer is collaborative care.  Dozens of randomized control trials show depressed patients who receive collaborative care for depression have quicker and more complete resolution of depression than those who only receive typical care in primary care settings.  In nearby Minnesota, Project DIAMOND has found that collaborative care doubles treatment response (from 34% to 70%) and nearly doubles complete remission (from 30% to 53%) at one year.  Some studies suggest that collaborative care can be helpful for anxiety disorders and psychoses as well.

Collaborative care requires expanding the healthcare team with individuals who can spend more time with patients than typical primary care providers.  Those trained individuals (we call them “health educators”) administer standard questionnaires to gauge the severity of depressive disorders and assess for other mental health disorders.  They educate patients about depression, explain treatment options and instill optimism.  They deliver behavioral activation interventions, engaging patients in behaviors that lift depressive symptoms, such as exercising and socializing.  They contact patients regularly to maximize engagement in treatment and reassess depression severity regularly and “pull the alarm” when insufficient improvement suggests a need to reconsider treatment plans.

A rigorous study, updated for inflation, concluded that a $900 investment in collaborative care for each depressed patient yields healthcare savings of $5200 over the next four years.  That means for every dollar spent, net savings total $4.75.  If 10% of Wisconsin’s 420,000 Medicaid recipients are depressed (most likely, an underestimation), collaborative care could save the state $180 million over four years – enough to fund Governor Walker’s initiative six times over!

That’s what WIPHL is all about – delivering behavioral screening and intervention (BSI) services that improve public health while decreasing costs.  Please see www.wiphl.org for more information on how can make BSI routine in Wisconsin healthcare settings.


Holiday Joy and Anguish

By Richard L. Brown, MD, MPH

I hope you and your loved ones had very happy holidays. Unfortunately, many Americans didn’t – and that’s because of drunk driving. During most of December, 28 percent of traffic fatalities in the United States involve an intoxicated driver. But between Christmas and New Year’s, that rate climbs to a staggering 40 percent.

According to the National Institute on Alcoholism and Alcohol Abuse, “two to three times more people die in alcohol-related crashes than during comparable periods the rest of the year.” And more than one-third of those who die are not intoxicated.

In Wisconsin, the problem is particularly concerning as we lead the nation in the proportion of adults who anonymously report driving drunk. In 2011, the most recent year in which data is available, there were 184 alcohol-related fatalities on Wisconsin roads.

What can we do about this?

Typically, one suggestion is to increase drunken driving penalties. Wisconsin is one of the few states in the country where first-time drunk driving is not a misdemeanor conviction. Unfortunately, while stiffening penalties would send a long, overdue message that drunk driving is not to be tolerated, research has shown stiffer penalties seldom deter illegal behaviors when most individuals do not believe that they will be caught. Therefore, a measure that is more likely to deter drunk drivers is to expand sobriety checkpoints, because checkpoints increase the perceived likelihood of apprehension. This would necessitate changing Wisconsin state law, which currently prohibits sobriety checkpoints even when localities would like to implement them.

Another typical suggestion is to clamp down on repeat offenders. For example, every U.S. state has some version of an ignition interlock law. Requiring ignition interlock devices does not eliminate drunk driving but does substantially reduce it. However, most drunk drivers involved in fatalities are not repeat offenders. A comprehensive strategy must also reduce drunk driving by those who have never been caught before.

The following graph illustrates the problem:

DrunkDrivingChart

About two-thirds of the differences in rates of drunk driving across states can be attributed to differences in rates of binge drinking. This finding suggests that we will not substantially decrease drunk driving and related fatalities and injuries in Wisconsin unless we decrease binge drinking.

Decreasing binge drinking may sound challenging, but all that is needed is the political will to implement policies and programs that have been proven to work in many other places across the U.S., including reducing alcohol access and raising alcohol prices through higher excise taxes. See healthfirstwi.org and collegedrinkingprevention.gov for more information.

And of course, systematic delivery of SBIRT in clinics and hospitals would also help decrease binge drinking. One study in Wisconsin primary care clinics found that brief interventions reduced car crashes among binge drinkers by 50 percent the following year.

So, as this year’s holiday season fades, let’s stiffen our resolve to prevent the deaths and injuries that we can inevitably expect next holiday season and throughout the year. Please join me in a New Year’s resolution to do whatever possible to make SBIRT routine in Wisconsin healthcare settings.