Ten states have begun to allow physicians and other clinicians to seek Medicaid reimbursement for the first time for substance abuse screening and brief intervention (SBI). Addiction-treatment advocates said they hope the move expands access to such screening in private insurance as well.

The Centers for Medicare and Medicaid Services (CMS) added two new reimbursement codes for Medicaid claims for addiction screening and for brief-intervention services at the beginning of 2007. By July 2008, 10 states had activated the codes for SBI with Medicaid-eligible patients, according to the White House office of National Drug Control Policy (ONDCP).

"These states have taken a historic step in transforming substance abuse in the United States," said Bertha Madras, Ph.D., deputy director for demand reduction in the ONDCP, in a written statement "By 'medicalizing' the detection and intervention of substance abuse, the 10 states recognize the need to destigmatize substance abuse and mainstream preventive services into general medical care."

The following nine states have activated the AMA's Current Procedural Terminology (CPT) codes or CMS's Healthcare Common Procedure Coding System codes for SBI: Iowa, Maryland, Minnesota, Montana, Oklahoma, Oregon, Tennessee, Virginia, and Washington. In addition, Wisconsin has begun to conduct SBI as part of a comprehensive package of health services for pregnant women.

More states may add SBI to their Medicaid programs later, an ONDCP representative told Psychiatric News, because the process for adding services to Medicaid takes longer in some states than others.

Research has shown that SBI activities have been effective in reducing substance abuse, while also saving health care dollars. For example, providing brief alcohol counseling to emergency department patients whose injuries are due to drinking saves hospitals about $330 per patient by reducing return trips for alcohol-related injuries over the following three years, according to an April 2005 study funded by the Robert Wood Johnson Foundation.

Personalized SBI procedures, according to the White House office, are designed to assess an individual's substance use along a spectrum and provide immediate interventions or referrals if necessary. These procedures can be performed in various locations and settings, including in doctors' offices, trauma centers, emergency departments, prenatal and community health clinics, college campuses, and even on the Internet.

The general applicability and benefits of SBI approaches have convinced policy-makers to encourage their use. The U.S. Preventive Services Task Force—an independent panel of experts in primary care and disease prevention that reviews clinical preventive services for the federal government—recommends screening and behavioral-counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings. In a 2004 review of research, the task force found evidence that screening in primary care settings, for example, can accurately identify patients whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence, but place them at risk for increased morbidity and mortality. The review also cited data showing that brief behavioral-counseling interventions with follow-up produce small to moderate reductions in alcohol consumption that are sustained over six to 12 months or longer.

Endorsement of SBI by CMS "is important because it gets the public sector to screen where there has not typically been reimbursement for it," said Alexi Greier Horan, director of government relations for the American Society of Addiction Medicine (ASAM), in an interview with Psychiatric News.

The society, which provides training to physicians in addiction screening and brief interventions, noted that such practices continue to gain traction in the medical and public health communities, including among many private and public health providers.

At the federal level, CMS initially approved CPT codes for SBI under Medicare beginning in January. The Federal Employees Health Benefits Program added coverage of SBI services for most of its beneficiaries in the spring (Psychiatric News, May 16).

Most of the largest health insurers, including CIGNA, Aetna, and Blue Cross and Blue Shield, also have added reimbursement for SBI services, Eric Goplerud, Ph.D., director of the Center for Integrated Behavioral Health Policy at George Washington University, told Psychiatric News.

Another recent change that has spurred the use of SBI was the 2007 requirement of the American College of Surgeons' Committee on Trauma that trauma centers demonstrate that they perform SBI for alcohol problems.

More widespread use of SBI has been limited by state Uniform Policy Provision Laws (UPPL), which allow insurers to deny claims if accident victims test positive for alcohol or other drugs, according to treatment advocates. Treatment of injuries related to substance abuse can be costly to insurers, say experts, and can run into the hundreds of thousands of dollars. But such laws have the unintended consequence of discouraging hospitals and other facilities from screening patients for addictive disorders.

"It penalizes physicians and hospitals for practicing good medicine," Goplerud said.

Treatment-advocacy organizations, such as ASAM, have worked to repeal UPPL laws in 10 states and the District of Columbia, which they hope will encourage more physicians to use SBI approaches. Thirty other states have UPPL laws, and the remainder never created such measures. Federal legislation sponsored by Rep. Patrick Kennedy (D-R.I.) to repeal all such laws has not advanced far in Congress.

As a result, Greier Horan said, ASAM members continue to be concerned that screening for substance abuse problems may result in private insurers' refusing to cover their patients' injury claims if their injuries are substance related. Any physician hesitancy to perform SBI for patients with SBI-restrictive insurance is worrisome in light of research that has found that drinking plays a major role in many unintentional injuries treated in emergency departments and trauma centers, but few such facilities screen for substance abuse problems.

A challenge on another front is to increase training for physicians and allied health professionals because many do not know how to provide evidence-based screening or brief interventions.

"Just because the codes exist doesn't mean that people know how to provide these services," Greier Horan said.

A number of additional measures are expected in the near future to expand the use of SBI substantially by public and privately funded health care providers.

The Joint Commission, which accredits and certifies more than 15,000 U.S. health care organizations and programs, is examining the "desirability and feasibility" of SBI accreditation standards for hospitals, ambulatory-care centers, and mental health care providers, according to Goplerud.

In addition, an SBI measure is among the proposed physician pay-for-performance measures that are under consideration by an APA-led group developing mental health incentives for the AMA.

Further SBI usage may be spurred by grants from the Substance Abuse and Mental Health Services Administration aimed at states and medical schools. Those grants, expected to be available this fall, "will really boost interest [in SBI], especially in the medical schools, around the development of curricula on screening and brief intervention," Goplerud said.

Information on CMS's screening and brief intervention codes is posted at<www.whitehousedrugpolicy.gov/publications/pdf/screen_brief_intv.pdf>.▪