General Business Issues

Health Plans Support Push From Employers for Early Alcohol Screening and Intervention

Featured Health Business Daily Story May 19, 2008

Reprinted from HEALTH PLAN WEEK, the industry's leading source of business, financial and regulatory news of health plans, PPOs and POS plans.

Health plan executives might believe that medications are underutilized in alcoholic treatment programs. But the more pressing issue, according to plans interviewed by HPW, is identifying problem drinkers earlier in the cycle and getting them into treatment before their drinking becomes an addiction. The best way to do that, these plans contend, is through screening and brief intervention (SBI) services delivered in primary care offices, employee assistance programs (EAPs) and other settings.

"The fact that medications are underutilized in alcohol treatment is a substory under a larger issue," Doug Nemecek, M.D., national medical director of the CIGNA Health Solutions Unit, tells HPW. "We know that 60% of people consume alcohol with some problem. But only 20% to 25% of problem drinkers get any treatment at all, and when they do, it's about eight years after they become dependent."

According to The George Washington University Medical Center's Ensuring Solutions to Alcohol Problems (ESAP), 70% of Americans visit a primary care physician (PCP) at least once every two years. One in five men (and one in 10 women) seen by PCPs drink at levels that put them at risk for alcohol-related problems. Patients trust their health care providers and are more likely to take seriously advice about their use of alcohol when it is given during visits. Studies show that brief interventions are effective in reducing alcohol use among non-dependent patients in a wide range of medical settings.

Rhonda Robinson Beale, M.D., chief medical officer at OptumHealth Behavioral Solutions, says that introducing SBI into primary care offices parallels the recent introduction of depression screening and treatment into this setting. OptumHealth is a subsidiary of UnitedHealth Group.

"Many physicians resisted this, saying they either didn't have time or were not qualified to address depression. But once they were educated and trained, they started doing it," she says. PCPs now prescribe 80% of all antidepressants.

In January, two medical billing codes for SBI services in primary care settings were approved by the American Medical Association and CMS. Soon after, the Office of Personnel Management (OPM) announced that 5.6 million employees with federal health insurance will be covered for SBI services. On April 17, the National Business Coalition on Health (NBCH) announced that two national insurers (Aetna Inc. and CIGNA) along with seven multistate and regional health plans have agreed to pay for SBI.

Brief intervention in primary care and other settings typically consists of an initial counseling session lasting five to 20 minutes and one or more follow-up sessions. Studies show that a few sessions with a PCP or nurse can persuade people who are less dependent to cut down on their drinking and, in some cases, stop drinking altogether. While it is not designed to treat alcoholism, brief intervention can motivate alcoholics to seek out and participate in more intensive and long-term treatment options.

Nemecek says CIGNA is increasing its screening initiatives across all programs, including its case management programs, which now screen members for depression and alcohol use. The company also works with EAPs to integrate SBI into their services.

He admits that it can be difficult to get PCPs to talk with their patients about alcohol use. Many don't feel comfortable because drinking is socially acceptable. But he says this is changing. "Alcohol-use questions are now included in health risk assessments and profiles, and this is helping us identify people who need further screening and evaluation." CIGNA works with its network PCPs to help them do a better job at depression screening, so SBI for alcohol use is a natural follow-on, Nemecek says.

CIGNA's Web site includes A Clinician's Guide for Helping Patients Who Drink Too Much, a flow chart published by the National Institute on Alcohol Abuse and Alcoholism (available at www.niaaa.nih.gov) that guides physicians through the assessment process.

CIGNA Works With Employers on Coverage

CIGNA, which has mainly self-insured business, does not place many limits on its alcohol-treatment coverage, and discourages employers from doing so. "If an employer decides to put limits on its benefit plans, we discuss with them the reasons why it's important to broaden rather than restrict their coverage." Nemecek says that a few years ago, the company realized that residential substance-abuse treatment was not a standard benefit for its employer plans, although the company knew that it was effective. But because of the added cost, many employers were not including it in their coverage options. The company quickly made residential treatment a standard benefit across its plans.

Robinson Beale also sees slow adoption by PCPs. "We're working with our medical partners to help them recognize the value of SBI, knowing that many physicians are concerned about doing this," she says. "But what many PCPs don't understand is the power and influence they have with their patients, especially those who may be using alcohol in a hazardous way." She adds that just asking a few key questions about alcohol use can be effective in getting some patients to stop drinking or explore treatment options.

OptumHealth coaches EAPs on how they can work with members who present with alcohol-use issues. "We have condition-specific modules on our Web site that EAPs can access to screen and offer brief interventions," Robinson Beale says. "We know that just bringing the problem to patients' attention can get 1% to 2% of them to stop drinking without further intervention." Ensuring Solutions claims that more than 60% of people taking advantage of counseling in an EAP did not need further treatment to address their problem drinking.

In releasing the results of its annual survey, NBCH noted that the early identification and treatment of substance-use problems is an important issue for employers, and that bringing SBI services into the mainstream of health care will produce significant economic savings.

According to ESAP, for every 1,000 members, the typical health plan can identify 80 who have an alcohol problem. But when screening methods are used to identify even as few as 20% of employees and dependents who are problem drinkers, a business can reduce its benefit costs. The program is actively encouraging employers to direct their health plans to use these screening methods.

Nemecek says this is already happening, noting that employers are starting to ask CIGNA more questions about their substance-abuse benefits. "They're not so much asking us to pay for medications and treatment, but rather asking what we are doing to identify problem drinkers earlier and get them into treatment sooner." Employers know that there are significant productivity losses associated with alcohol use by employees and their families, he adds.

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