Happy holidays from WIPHL!


Patient Story: “Patient Advocate” Makes A Positive Impact

A health educator who delivers SBIRT services in a Wisconsin healthcare clinic tells the story of how a brief intervention resulted in her patient getting much-needed mental health and financial help. (Some details have been changed to protect patient confidentiality.)

A patient came in for a medical appointment, and after a brief screen, depression was identified as a potential topic that could be discussed through the SBIRT services provided at our clinic. I met with the patient, who was a bit apprehensive at first. During our initial brief meeting, further assessment was completed. We discussed anti-depressant medications, behavioral techniques that are helpful for addressing issues with depression, as well as the benefits of further mental health counseling.

The following week, I made contact with the patient via phone, and he expressed his struggle with making appointments and financial issues. I referred the patient to a social worker, who would be able to connect him with resources, and mental health counselor, who could provide more intensive counseling for his challenges with depression.

At a subsequent medical appointment, the patient made it a point to find me and thank me for my assistance. He reported that when he first met me, he was hesitant because he was worried SBIRT services were being offered due to others mistakenly thinking he had an alcohol or drug problem. The patient continually grew more comfortable with me and was able to open up freely about his concerns. More importantly, this led him to be more comfortable with making follow up appointments that I had recommended for him, which included meeting with a social worker who connected him with financial resources. This significantly helped him finally get some very serious medical issues addressed. The patient ended the conversation with me by asking what my title was. He stated that he felt “patient advocate” should be added to the title because more services than just education were provided. Lastly, he said he appreciated the positive impact it made in his life.

Even though the patient’s initial contact with me seemed fairly standard at the time, it later came to light that the SBIRT services provided to him had a positive impact in his life and greatly increased his ability to seek out further medical and mental health care.

BSI Bolstered by Clarification of Statute on Discounted Healthcare Services

By Richard L. Brown, MD, MPH

While behavioral screening and intervention (BSI) has continued to gain momentum in Wisconsin, a legal issue involving billing has hindered some clinics in delivering BSI and discouraged other clinics from hiring health educators to do so.  For years, there has been widespread perception that Wisconsin state law prohibits clinics from delivering BSI at no charge to patients who cannot afford it.  Confusion has shrouded this issue, as the specific statute could not be located, and this perception could not be tested – until now.

After extensive research and legal consultation, WIPHL is pleased to announce that all Wisconsin clinics are able to deliver BSI free of charge to uninsured patients and any patients for whom a fee would create undue financial hardship. Clinics can hire health educators and deliver systematic BSI to all patients regardless of the patients’ ability to pay.

The belief about this issue has especially hindered BSI delivery at federally qualified health centers (FQHCs), community-based organizations whose mission is to provide high-quality healthcare to economically disadvantaged individuals.  At most FQHCs where health educators systematically deliver BSI, the preference is to serve all patients, including “sliding scale fee” patients whose income determines how much they pay for healthcare services.  Because of the purported law, FQHC administrators believed that their sliding scale fee patients had to pay extra for BSI.  When notified about the fee, most patients understandably decline.

The issue has also troubled WIPHL’s clinical partners in the private sector.  Administrators and providers at many clinics would prefer to offer BSI free of charge to uninsured patients but perceived that doing so would violate state law.

Administrators, providers and staff at many of WIPHL’s participating clinics have understandably felt ethically uncomfortable about delivering inferior care to their patients of lesser economic means.  The prospect of such discomfort has discouraged some clinics from partnering with WIPHL altogether.

Dianne Kiehl, WIPHL Advisory Committee member and Executive Director of the Business Health Care Group of Southeastern Wisconsin, clearly recalled that a statute prohibiting the discounting of healthcare services was passed in the 1980s. At that time, managed care organizations became prominent and established networks of specialty physicians with whom they contracted for care at reduced rates, resulting in lower co-pays for patients when they saw those specialists.  Some out-of-network specialty physicians attempted to attract managed care patients by offering discounts to individual patients.  The statute in question was intended to help maintain the integrity of managed care organization specialty referral networks.

Despite Dianne’s familiarity with the statute, discussions with many Wisconsin healthcare leaders and calls to several state agencies, the statute could not be found.

Thanks to Jo Musser and Fred Nepple, the mystery is now solved.  Musser, a former Wisconsin Insurance Commissioner and current WIPHL Advisory Committee member, recommended WIPHL contact a healthcare attorney.  With help from the Wisconsin Collaborative for Healthcare Quality, which collaborates with WIPHL in the Agency for Healthcare Research and Quality-funded Partners in Integrated Care program, WIPHL contracted with Fred Nepple.  Nepple previously worked for 27 years at the Office of the Insurance Commissioner and is currently with the law firm, Michael, Best and Friedrich in Madison.

After quite a bit of searching, Nepple found the statute – Section 146.905.  Before reading the statute, you’ll want to know that Wisconsin state law defines health insurance as “disability insurance.”

Section 146.905, Subsection 1 reads: “Except as provided in Subsection (2), a health care provider, as defined in Section 146.81 (1) (a) to (p), that provides a service or a product to an individual with coverage under a disability insurance policy, as defined in section 632.895 (1) (a), may not reduce or eliminate or offer to reduce or eliminate coinsurance or a deductible required under the terms of the disability insurance policy.”

This statute explicitly clarifies the law does not apply to patients without health insurance.  It is also important to note that fee-for-service Medicaid coverage is not considered health insurance by the state of Wisconsin. The statute continues on to say the law doesn’t apply if payment for services imposes an undue financial hardship on the patient. The statute does not define “undue financial hardship,” and the statute has never been clarified by case law, which means clinics have discretion in interpreting this phrase.

Another interesting aspect of the statute is that it does not name a state agency to enforce it.  Since no state agency is closely enforcing the law, there seems to be little risk in interpreting undue financial hardship quite broadly as it’s hard to envision who might bring a suit against a clinic that discounts BSI.  Of course, I am not an attorney, so please check with your attorney on this if you have concerns.

Mr. Nepple’s written opinion will be distributed to WIPHL’s partnering clinics and is posted on our website here.

To read the full text of the statute, click here.

We, at WIPHL, are committed to identifying barriers and finding solutions to ensure all patients – regardless of their ability to pay – have access to critical BSI services. If there are barriers preventing you or your clinic from delivering BSI, we’d love to hear from you and discuss how WIPHL can help you overcome those barriers. To contact us, please visit our website at www.wiphl.org or email us at info@wiphl.org.

FQHC administrators, providers, and staff:  Look for Dr. Brown’s article on BSI in the next issue of Community Health Forum, the magazine of the National Association of Community Health Centers.

Four Questions That Can Help Patients Make Their Own Arguments For Change

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 of the processes in MI is to evoke change talk.  Change talk is defined as the other person’s own arguments for change.  Research suggests that helping the other person to develop and verbalize arguments for change increases the likelihood of change.  To this end, the MI practitioner may utilize many different strategies to create opportunities for patients to articulate this vital change talk.

One of the most straightforward ways to elicit change talk is to ask for it using targeted evocative open questions:

  • “How would you like for things to change (in regards to your marijuana use)?”
  • “If you did decide to cut back in your drinking, how could you do it?”
  •  “Most smokers feel two ways about quitting.  You’ve probably got some reasons to keep things the way they are, and you’ve probably considered a few reasons to quit or cut down.  What are some of the reasons you’ve considered for quitting or cutting down?”
  • “How serious or urgent does it feel for you to address your depression?”

I encourage you to try out these questions  – others like them – as a way to actively create opportunities for patients’ own arguments for change to occur.  You might be surprised by what you hear!

“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.