Health settings have historically not done well when it comes to addressing substance use. More often than not, medical professionals sidestep drugs and alcohol altogether, even though substance use is a significant factor in many injuries and illnesses. And when medical settings do address substance use, sometimes it’s messy.
Take columnist Anna David’s experience:
“For some reason, when I walked into his office and he asked me if I did any drugs, I decided to be honest and told him that I was regularly doing cocaine. ‘What?’ he asked, clearly horrified; I made an instant decision never to be honest with a doctor again.”
Enter SBIRT. SBIRT stands for Screening, Brief Intervention, and Referral to Treatment and it’s a strategy to create routine conversations about drugs and alcohol in health settings using scientifically-validated questionnaires. It’s a simple notion: ask everyone. If someone’s substance use appears risky, talk about it nonjudgmentally. If someone seems to need additional help, help her find it.
SBIRT is not complicated, nor is it newfangled. It was developed more than 30 years ago and has been adapted for dozens of settings and populations. However, as we’ve written about before, SBIRT practices are too-often seen as add-ons supported by grant funding, rather than a part of normal healthcare delivery.
Getting Reimbursed: A Way to Expand SBIRT?
Healthcare is a business run largely on a fee-for-service basis. That is to say, you do a procedure for a patient, you get paid. Remove an appendix; get paid. Screen for colon cancer; get paid. If we ensure that SBIRT procedures are reimbursed, can we dramatically increase the use of SBIRT in healthcare settings?
Unfortunately, it’s not so simple.
Limited Billing from States with SBIRT Codes Turned On
Oregon “turned on” SBIRT codes in 2009. Here’s a graph of the number of SBIRT codes submitted to their Medicaid program for reimbursement between 2009 and 2016.
The net effect of simply turning on the codes was pretty much nil. As the graph demonstrates, the use of a performance measure (described in more detail below) was a more effective way to increase billing for SBIRT services.
Oregon was not unique. Other states that have turned on SBIRT codes have also found that few providers are using them.
Alzina Koric works on an SBIRT training grant at the University of Utah under the leadership of Dr. Melissa Cheng. When the Utah Medicaid program expressed interest in opening the state’s SBIRT codes, Koric conducted an informal survey of states that were reimbursing for SBIRT to determine how much SBIRT services were costing their Medicaid agency. The results?
States described SBIRT billing as “pretty minimal,” “uncommon,” “underutilized,” and “low compared to what we anticipated.”
Like Oregon, these states found that making SBIRT services reimbursable was not the same as turning on a spigot—the use of SBIRT (as measured by requests for payment) did not flow freely once the change was made.
Why is that? Don’t health systems want to get paid for discussing substance use?
Issues With SBIRT Codes
In 2016, Jim Winkle presented a webinar called “How Oregon Dramatically Increased SBIRT in Primary Care,” which detailed a lengthy process of designing an SBIRT performance measure for health providers who serve Medicaid clients. Because Oregon used claims data to evaluate whether the regional teams of providers had met their SBIRT performance goal, the state came face-to-face with a number of significant limitations of the utility of SBIRT billing codes. Here is a partial list.
Brief Interventions Require 15 Minutes: A brief intervention is a conversation between a clinician and a patient whose screen reveals at-risk substance use. Although brief interventions may be effective in just a few minutes, in many states, reimbursement for SBI requires that patients receive a brief intervention for at least 15 minutes.
As Winkle said, “There’s no evidence that says you have to spend a certain amount of time for a BI to be effective. There’s some studies that suggest even three minutes can be effective for adult alcohol use. Fifteen minutes don’t reflect the realities of a busy healthcare setting.” Other states have echoed this frustration.
SBIRT Can Only Be Conducted By Certain Providers: Medicaid reimbursement requirements vary by state, in terms of who is permitted to conduct SBIRT. In some places, the list is quite short; for example, in Oregon, SBIRT may only be conducted by a physician, physician assistant, nurse practitioner, licensed clinical psychologist, licensed clinical social worker, licensed professional counselor, or licensed marriage and family therapist.
“There are a lot of people who are not on this list,” said Winkle, such as social workers who are not licensed or health educators. This has been identified as a problem in other states with open SBIRT codes, too, such as Indiana, New Jersey, and Connecticut. The best SBIRT workflows (see, for example, SBIRT Oregon’s) incorporate members of an interprofessional team, some of whom (depending on the state) are not eligible to bill for their SBIRT services.
No Code for Referrals to Treatment: Referral to treatment is indicated when a patient receives a high score on the substance use screening instrument, which indicates that his or her use constitutes a need for specialty care. Although a small proportion of patients who screen positive and receive a brief intervention will need a referral to additional treatment, this service can be time-consuming. And currently, it is not reimbursable.
There’s More To It Than Turning Codes On
Active codes are great, but states may need to work with their Medicaid Authority to make them more usable.
“The codes in Indiana are on and active, but we needed to have them expanded, “said Mallori DeSalle, Outreach Coordinator and Lead SBIRT Trainer at Indiana University. “They were only eligible to be billed by physician-level providers, so we advocated for an expansion that allowed mid-level providers to bill, which was successful.”
Other states have advocated for changes in code requirements with similar success. For example, in Wisconsin, SBIRT codes are reimbursable (at different rates) by a range of providers, including health educators.
But ultimately, according to DeSalle, the organizations in Indiana that implement SBIRT are the ones who want to do it, or recognize that they need to do it. Financial incentives are not driving the decision to implement and sustain SBIRT.
“The organizations that sustain it are those that make a mission-driven decision to do SBIRT,” she said.
DeSalle said that this mission-based decision is the jumping off point for a thoughtful implementation process tailored to each setting. Part of the implementation process is determining how to track SBIRT service delivery, and also whether (and how) to bill for it.
However, there is one state where financial incentives have played a significant role in the decision to implement SBIRT. Back to Oregon.
Lessons from Oregon’s SBIRT Performance Measure
Necessity is the mother of invention. In 2011, Oregon’s Medicaid program was broke. So Oregon kicked off a cost-control experiment with a $1.9 billion investment from the federal government. The experiment involved the formation of CCOs, or Coordinated Care Organizations, which are regional teams of agencies that are responsible for Medicaid patients. These CCOs were given a list of 17 performance metrics and offered annual incentive payments for meeting them. One of the performance metrics was the use of SBIRT.
This is when Oregon’s Medicaid authority started to see a significant increase in requests for reimbursement for SBIRT services.
As detailed in the 2016 webinar, “How Oregon Dramatically Increased SBIRT in Primary Care,” this performance measure has not been a perfect mechanism for advancing the use of SBIRT. For one, according to Winkle, there is no way to monitor whether brief interventions are being properly administered using Motivational Interviewing principles. However, according to Winkle:
To date…the biggest impact of the incentive measure may be that hundreds of primary care clinics across Oregon that likely had never heard of SBIRT before have now screened tens of thousands of patients for unhealthy alcohol use. This foundation paves the way for more thorough implementation and fidelity to the SBIRT model down the road. Oregon’s experiment may ultimately demonstrate how SBIRT can be widely implemented in primary care, and contribute to the reduction of alcohol related morbidity among Americans.
In Oregon, as in a handful of other states, simply “turning on” SBIRT codes didn’t move the needle. Incentivizing the use of SBIRT with the creation of a performance metric made a big difference.
How Oregon Dramatically Increased SBIRT in Primary Care (recorded webinar and slide deck)