The Story Behind Oregon’s SBIRT Incentive Measure and Its Impact on Implementation
Monday, September 12, 2016
Jim Winkle, MPH, Project Manager - SBIRT Oregon, OHSU Family Medicine
Editor's note: Jim will be presenting on this topic at the Fall Primary Care Conference in Denver on October 17
Over a quarter of all Americans drink enough alcohol to pose serious risk to their health, but few primary care clinicians address this behavior with patients. This is evident by the extremely low numbers of billing codes submitted by providers concerning alcohol use, and by surveys of patients, in which only 16% report ever discussing alcohol use with a health professional.1
Surveys of physicians, meanwhile, reveal a number of perceived barriers: fear of embarrassing or angering a patient by asking about alcohol use, the presumption that patients will not respond honestly, uncertainty about treatment options, and a general feeling of discomfort around discussing alcohol use with a patient.
Most significantly, perhaps, is the barrier of time. Providers often feel pressed for time trying to address the medical complaints a patient presents during a visit, let alone finding time to squeeze in a preventative service like alcohol screening.
The good news is that these barriers diminish after clinicians receive training in Screening, Brief Intervention, and Referral to Treatment (SBIRT). SBIRT offers a standardized, universal approach to addressing unhealthy alcohol use, and earns a “B” rating from the United States Preventive Task Force. Under this model, validated screening questionnaires can do the work of assessing unhealthy alcohol use during the check-in and rooming process. Discussions that can enhance the motivation of patients to cut back their drinking can be performed in less than five minutes when delivered by a trained provider.
Encouragingly, most physicians respond positively to SBIRT training. They report fewer barriers to bringing up the topic of alcohol use with a patient and greater proficiency in effectively discussing behavior change. Clinics that prioritize a patient-centered, medical home model of primary care, meanwhile, are well positioned to adopt a team-based SBIRT workflow.
Despite these advantages, however, widespread implementation of SBIRT remains elusive. Public health advocates hoping to reduce alcohol-related morbidity by disseminating SBIRT into health settings run into a different set of barriers. Adequately training providers and other clinical team members requires convincing a busy clinic to set aside several hours outside the patient schedule. Securing reimbursement for SBIRT processes helps ensure sustainability, but also depends upon complex and poorly suited billing codes that increase the burden of documentation. A team-based workflow means more opportunities for the process to break down, especially in clinics with high turnover. Tracking the SBIRT clinic workflow, essential for quality improvement, requires new tools built into the electronic health record and more boxes for clinicians to check.
It is notable, then, that despite these challenges, the last three years have seen a dramatic increase in the number of billing codes submitted for alcohol screening and brief intervention in primary care clinics in the state of Oregon. What happened?
The big increase in SBIRT across Oregon correlated with the introduction of a statewide performance metric. In 2013, Oregon Medicaid, also known as the Oregon Health Authority (OHA), created a benchmark rate in which a minimum percentage of Medicaid patients are expected to receive screening for alcohol or drug use, or screening plus brief intervention, at least once a year. The metric uses billing claims data to measure how often these SBIRT processes are performed.
Significant revenue is at stake behind meeting this benchmark, which is why the SBIRT metric, along with 16 other statewide metrics, are referred to as “incentive measures”. Millions of dollars have been awarded to the Coordinated Care Organizations (CCOs) in Oregon – agencies that manage Medicaid reimbursement – that demonstrate enough progress towards reaching the these incentive measure benchmarks. Three years into the metric, nine CCOs have acheived the benchmark rate for SBIRT, and all eight others have steadily progressed each year.
The metric is far from perfect, mostly because billing codes come with rules that limit their ability to capture what really happens in a clinic. Brief interventions delivered by providers, for example, may not meet the minimum length of time deemed necessary by a billing code. Many providers may be missing out on receiving credit for performing brief interventions as a result.
To date, however, 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.
A primary care clinician reviews screening form with patient
A social worker discusses alcohol use with a patient
A medical assistant administers the AUDIT alcohol screening tool to a patient
A primary care clinician reviews screening form with patient
Photos courtesy of www.sbirtoregon.org
1. Centers for Disease Control and Prevention: “Vital Signs: Communication Between Health Professionals and Their Patients About Alcohol Use — 44 States and the District of Columbia, 2011.”
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