About twenty percent of hospital admissions involve people with drinking problems, which is somewhat more than twice the proportion of problem drinkers in the adult population. For emergency rooms and trauma centers, the proportion is almost certainly higher; some say as much as 50%.
Brief intervention by a physician — roughly, saying “You’re drinking too much and need to cut it out,” followed by a treatment referral if the patient wants one — has been shown to be modestly effective, and, because it’s so cheap, wildly cost-effective, and in fact cost-saving on balance. A brief interview protocol turns out to be quite successful at identifying problem drinkers. Yet the health-care machinery notoriously displays an almost total lack of interest in patients’ drinking behavior.
Rachel Zimmerman, writing in yesterday’s Wall Street Journal seems to have figured out part of the reason: half a century ago, the health insurance industry lobbied a law through in 38 states allowing them to refuse payment for medical care required as a result of intoxication by alcohol or other drugs. So a hospital that runs the test and records it in the patient’s chart is setting itself and the patient up for financial disaster. Result: they don’t look.
A spokesgoon for the Health Insurance Association of America is shocked and appalled that the hospitals aren’t volunteering to let the insurers screw them out of their reimbursements. And naturally he asserts that changing the rules would drive up insurance costs, which seems grossly implausible given that the hospitals mostly aren’t testing now and that the consequence of not testing is more health-care costs in the future. I think HIAA is now so used to opposing things that are good for the country’s health that they now assume that anything that’s good for health is bad for them.
[Note to Ph.D. candidates: Great research opportunity here. Try a cross-section analysis of the frequency of tox screening in states with and without such laws, and an interrupted time series on the states that just changed over.]
[Note to libertarians: Go ahead. Tell me how the market is going to solve this one, in the face of the obvious adverse-selection problem: being the one insurance company that offers coverage for drinking-induced accidents is going to be a marketing advantage only in selling to drunks, who are lousy health care risks.]
[Note to Democrats: So what are you waiting for? Here’s a little-guy-vs.-the-big-companies issue that’s also obviously good public policy. Go!]
Glen Whitman takes up my challenge to libertarians. His answer — essentially, the creation of a special underwriting category for alcohol and drug abusers, who would pay higher insurance rates than the more abstemious — makes sense, as most libertarian solutions do, if you abstract from a few facts:
— Much health insurance is bought by employers for employees, rather than individually.
— Being an alcohol or drug abuser isn’t (1) a simple yes-or-no; (2) a stable condition over time; or (3) an easily observable condition; the usual diagnostic approach is asking the person involved, which isn’t going to work very well if the consequence of saying “yes” is having to pay higher insurance rates.
— Someone who isn’t clinically diagnosable as an alcohol abuser can still wrap his car around a tree.
— Having all the drunks and drug abusers uninsured — the likely consequence of charging them the expected-value cost of their health insurance — means that the rest of us wind up paying for their care through the unpaid care accounts kept by hospitals and passed through to insurers, unless we’re willing to have them die in the streets. The whole logic of treating medical care as an ordinary commodity falls apart once you say, “No, we’re not prepared to have people who can’t pay for care die for want of care.”
A reader notes the use of “Quite frankly” in its modern idiomatic meaning, which is roughly “The following sentence is so astonishingly mendacious that I’m going to have trouble saying it without laughing out loud. You are requested not to notice.”
February 26, 2003
Why Emergency Rooms Rarely Test
Trauma Patients for Alcohol, Drugs
By RACHEL ZIMMERMAN
Staff Reporter of THE WALL STREET JOURNAL
Alcohol-related accidents and mishaps left Alan Levine with two amputated feet, a broken back, a ruptured spleen and only four remaining teeth.
Yet in 10 visits to emergency rooms in California, Nevada, Oregon and Washington, he says he was never tested for alcohol in his blood, nor was he ever urged to get counseling. “None of the so-called professionals mentioned treatment or counseling or gave any indication there was something wrong,” says Mr. Levine, 57 years old, who stopped drinking several years ago and now volunteers as a substance-abuse counselor in Portland, Ore.
In fact, most of the nation’s emergency rooms and trauma centers don’t routinely run blood-alcohol tests or “tox screens” on patients thought to be intoxicated. Why? At trauma centers, which treat the most seriously injured patients, the first priority is generally to save lives and provide immediate care. But doctors say another big reason the tests aren’t performed is the obscure, decades-old laws adopted in 38 states and the District of Columbia that give insurers the option to deny medical reimbursements to patients under the influence of alcohol or narcotics.
Aware that health-insurance policies can contain this exclusion, hospital staff seldom run the tests or urge counseling, for fear the results will appear in claims records and reimbursements will be denied. “Doctors don’t test because they’re afraid they won’t get paid,” says Larry Gentilello, the 49-year-old chief of trauma and surgical critical care at Boston’s Beth Israel Deaconess Hospital.
Dr. Gentilello has been waging a grinding, three-year fight with insurers, regulators and state lawmakers to repeal the laws and make drug and alcohol tests and counseling a routine part of trauma care. He has the support of groups including Mothers Against Drunk Driving, the National Highway Traffic Safety Administration, the National Association of Insurance Commissioners and the American Society of Addiction Medicine, but progress has been slow. Maryland, North Carolina and Vermont have repealed their laws, but repeal efforts have failed in legislatures in New York, Washington and Arizona.
A three-time college dropout, Dr. Gentilello grew up in New York’s Washington Heights, drove a Checker cab and worked at a White Hen Pantry convenience store before applying to medical school. During his surgery residency at the University of Texas Health Science Center in Houston, he began to wonder why trauma care for substance abusers wasn’t automatically linked to counseling.
In a three-year, federally funded study published in the Annals of Surgery in 1999, Dr. Gentilello looked at more than 700 trauma patients admitted to Seattle’s Harborview Medical Center for alcohol-related injuries. The patient group that received 30 minutes of counseling at the hospital experienced a 47% reduction in serious injuries requiring trauma-center admission in the following three years, plus a 48% reduction in less-serious injuries requiring ER care.
With alcohol and drug-related injuries accounting for as much as half of all trauma-center visits, such reductions on a national scale could save as much as several billion dollars a year in health-care spending, Dr. Gentilello figures. But eager to cut costs, insurers are denying alcohol and drug-related claims more often, he believes.
Dr. Gentilello says insurers’ denial of coverage to substance abusers is short-sighted and discriminatory. “Do we not treat venereal disease if the person did not wear a condom? Do we not treat emphysema in a patient who will not stop smoking?” he asks.
Jeffrey Hammond, chief of trauma and surgical critical care at Robert Wood Johnson University Hospital, New Brunswick, N.J., says doctors’ awareness of denied reimbursements has led to a steady decline in testing and counseling during the past five years. Ideally, most adults admitted to trauma centers would be tested and referred to counseling when appropriate, he says. But without the assurance of payment, many hospitals and doctors can’t afford to jeopardize profits by providing such preventive care. “No margin, no mission,” Dr. Hammond says.
Philip Barie, director of the surgical intensive-care unit at New York-Presbyterian Hospital in Manhattan, says he routinely avoids testing patients’ blood alcohol because he doesn’t want to risk having their insurance claims denied. Once a blood-alcohol test is completed, “it’s in the record and they have grounds to deny the claim,” Dr. Barie says. “Hospitals are not in business to lose money, and doctors depend on the billings.”
Insurers say they can’t afford to cover everything, and the cost of claims would go up, not down, if they had to cover all the injuries of people under the influence of alcohol and drugs. But beyond economics, they say, there’s an ethical concern: Medical needs, not insurance coverage, should drive health-care decisions.
“Quite frankly, I’m a little disheartened that physicians would base their treatment decisions on whether or not they might be reimbursed by an insurance policy,” says Larry Akey, spokesman for the Health Insurers Association of America, a 300-member trade group. The HIAA has argued that doctors who won’t order tests and counseling for alcoholics and drug abusers because of financial concerns are guilty of a “shocking abdication of responsibility.” Trauma doctors don’t need permission to test for drugs or alcohol while treating their patients.
The state insurance laws at issue are based on the Uniform Individual Accident and Sickness Policy Provision Law, or UPPL, a model law drafted by state insurance commissioners in 1947. The HIAA’s Mr. Akey says a number of the group’s members have such provisions in their policies but wouldn’t identify which companies. Aetna Inc. and Cigna Corp., two of the nation’s largest health insurers, say they don’t have such provisions.
But Dr. Gentilello says Cigna recently denied a trauma-care claim at Boston’s Beth Israel because the patient was intoxicated. He says the hospital fought the denial, and eventually Cigna paid. A Cigna spokeswoman says the company can’t comment without the patient’s name; Dr. Gentilello says he can’t name the patient due to confidentiality rules.
Deana Watterson, a 44-year-old waitress in Mouton Cove, La., suffered a ruptured duodenum and other internal injuries in a 1997 car accident. Because there was alcohol in her blood, she says, her insurer didn’t cover the nearly $200,000 cost of her treatment at Our Lady of Lourdes hospital, in Lafayette. She filed for personal bankruptcy; the hospital wrote off the costs. The lesson? “Given the option, I don’t order blood-alcohol tests,” says Christopher Lee, the surgeon who treated her. “And I ask the ER docs not to order them.”
Write to Rachel Zimmerman at firstname.lastname@example.org
Updated February 26, 2003