Removing a Major Barrier to Treating Substance Abuse in the Emergency Department

    • July 23, 2009

Larry M. Gentilello, MD
Professor of Surgery
University of Texas, Southwestern Medical School
Dallas, Texas

The problem: Trauma surgeon Larry M. Gentilello, MD, believes that a major opportunity to treat substance abuse is lost every day in trauma centers and emergency departments.

About 50 percent of the patients who come to his trauma center and other trauma centers are intoxicated or under the influence of a drug, Gentilello said.

"When you are badly injured as a result of alcohol or illegal drug use it seems like it could be a time that could serve as a wake-up call," according to Gentilello, professor of surgery at the University of Texas Southwestern Medical School. "We found that an injury makes people very aware of the need to change. There is a moment of clarity in the trauma patient, and physicians should capitalize on that moment."

But a little-known insurance law was keeping these patients from getting the help they needed. With his Innovators award, Gentilello conducted research to prompt changes in laws that prevented doctors from using these moments to encourage people with substance abuse problems get help.

Programee background: Earlier in his career, Gentilelllo realized that state health insurance laws acted as deterrents to the detection of drunk drivers and hampered alcohol screening and intervention programs in trauma centers and emergency departments.

The 1947 Uniform Policy Provision Law allows insurance companies to refuse to reimburse physicians and hospitals for treating patients with alcohol-related injuries. The law specifies that if a patient comes to an emergency department or trauma center appearing under the influence of alcohol or drugs and a blood alcohol or toxicology screen has a positive result, the insurance company is not responsible for the patient's hospital bill.

The National Association of Insurance Commissioners pushed for passage of this model law, which was then adopted by 42 states. While intended to reduce insurance costs and hold drunk drivers responsible for the cost of their care, the law had the opposite effect, Gentilello said.

In states that enforced this law, trauma and emergency physicians stopped screening patients for alcohol or drugs in order to protect themselves financially. For the past two decades, Gentilello has worked to make it easier for trauma surgeons and others in emergency departments to intervene with patients they believe are abusing alcohol or drugs. But he did not have the data he needed to persuade lawmakers to change the Uniform Policy Provision Law.

The award: In 2002, Gentilello received an Innovators Combating Substance Abuse award and got a chance to change that situation. The Robert Wood Johnson Foundation (RWJF) created the Innovators program to nurture and promote innovation in combating substance abuse. Between 2000 and 2003, some 20 senior researchers, practitioners and policy-makers received Innovators awards. See Program Results Report for more information on the program.

The overarching goal of Gentilello's research was to promote alcohol screening and brief interventions in trauma centers. During his Innovators project Gentilello analyzed provisions of insurance laws to determine whether they inhibited health providers from screening emergency department and trauma center patients for alcohol or drug problems.

The results: With funding from his Innovators award, Gentilello conducted a nationwide study of trauma centers. He found that 25 percent of trauma surgeons were experiencing denials of reimbursement due to the Uniform Policy Provision Law. He also found that 82 percent of trauma surgeons would be willing to start an alcohol screening and intervention program in their center if their state's law was repealed.

Gentilello's study, "Effect of the Uniform Accident and Sickness Policy Provision Law on Alcohol Screening and Intervention in Trauma Centers" appeared in the Journal of Trauma in 2005. The abstract is available online.

In another study funded by RWJF, Gentillelo found that screening all adult emergency department and trauma center patients could produce a savings of $89 for every injured patient screened, or $330 for every patient offered a brief intervention, the researchers estimated. He and his colleagues estimated that for every dollar spent on screening and brief interventions, $3.81 could be saved in health care costs. The study was published in the Annals of Surgery in 2005. See Program Results Report for more information.

Advocates from organizations such as the American College of Surgeons, the American Society of Addiction Medicine and Mothers Against Drunk Driving used findings from Gentilello's research to educate legislators about the effect of the Uniform Policy Provision Law on trauma centers and patients.

Fourteen states and the District of Columbia have repealed the law since Gentilello began his Innovators project and several other states have laws pending repeal as of December 2008.

"In order to change the law, I needed the data," Gentilello said. "I couldn't study that through a federal National Institutes of Health grant. Federal agencies look for the usual science. If what you are trying to study is totally innovative, you're out of luck. So what this award really did was give me free license to pursue what was blocking screening in a trauma center."

Additional achievements resulting from Gentilello's work include a 2007 mandate from the American College of Surgery Committee on Trauma, the accreditation body for trauma centers, which requires all level 1 trauma centers to screen patients for alcohol and drugs and provide interventions for those identified as having a substance use disorder.

Cost-benefit study shows savings. Gentilello's cost-benefit study of screening and brief intervention in trauma centers demonstrated a savings of $3.81 in future health expenditures for every $1 spent on screening. Gentilello noted that this finding was key to securing passage of the screening and intervention mandate.

Findings from Gentilello's cost-benefit study were published in 2005 in the Annals of Surgery. The article, entitled "Alcohol Interventions for Trauma Patients Treated in Emergency Departments and Hospitals: A Cost Benefit Analysis" notes that interventions in trauma centers may also provide an opportunity to initiate care before problems progress and require more costly and intensive medical services.

More recent cost-benefit studies conducted by Gentilello found that when compared to patients whose injuries were not related to alcohol use, patients with alcohol-related injuries use more health resources, stay in the emergency department longer, more frequently require inpatient care, have an average hospital bill that is $1,833 higher, and add nearly $250 million annually for ambulance and emergency department care alone. Patients who were injured while under the influence were also 60 percent more likely to require admission to the hospital, rather than be treated and discharged from the emergency department. In short, screening and intervention reduces the costs of future emergency and other care, Gentilello said.

New payment provisions for physicians. Gentilello's Innovators award also supported his work as part of a team that drafted new Common Procedural Terminology (CPT) codes for the American Medical Association (AMA). CPT codes describe procedures performed by health providers who use the codes to bill for services. Once the AMA approves a code, insurance companies typically pay for services or procedures covered by that code, Gentilello said.

The codes allow physicians to receive reimbursement for screening for a full spectrum of substance use, and for delivering a brief intervention in health care settings. These codes became fully effective in January 2008.

Importance of the award: Looking back on the accomplishments of his Innovators award, Gentilello observed: "Right now, all level 1 trauma centers in the U.S. have to screen their patients and determine if they have a substance use problem. They have to provide a brief intervention to those who screen positive. Trauma surgery became the first medical specialty in the United States to mandate the provision of substance use services to patients who need it. We removed the insurance obstacles, and that enabled it to happen."

Gentilello added that the Innovators program exposed him to people in different fields whom he never would have met otherwise. He is collaborating with other Innovators on various substance use projects.

RWJF perspective: "The Innovators Combating Substance Abuse program recognized the innovation and creativity of researchers, advocates and providers who have dedicated their professional careers to reducing the toll of substance use and abuse," said Michelle A. Larkin, JD, RN, MS, RWJF senior program officer. "These individuals have had an extraordinary impact on the prevention and treatment of substance abuse, promoting the science and advocating for positive and lasting change."