After one year, Oregon’s effort to overhaul the health care system is seeing some success. The state says ER visits among Medicaid recipients are down nine percent and doctor visits are on the rise. But there is one area where the state is struggling: screening patients for drug and alcohol use.
The Oregon Health Authority is trying to slow the pace of rising health care costs by changing incentives. Rather than have doctors and hospitals charge for each service they perform, sixteen Coordinated Care Organizations have been created around the state. They’re each paid in a way that rewards them for reducing the cost of patient care over time.
The goal is to change the focus of health care from disease treatment to disease prevention.
To ensure the new system is working, the state developed a raft of measurements. They include everything from cancer screening rates to immunizations.
By most of those measures, the health organizations are seeing changes, but one measure is lagging.
“It’s trying to reach folks who drink too much or use drugs but are not necessarily dependent,” said Jim Winkle, a public health researcher at Oregon Health and Science University. “Knowing that if we reach these people and do a brief intervention we’re likely to cut down on the cost that might happen over the long term through trips to the ER and hospitalizations that happen when people become heavy users or dependent on a substance.”
Winkle says there’s strong evidence that for risky drinkers, a brief intervention — which can be as short as a five minute conversation — can reduce alcohol consumption by up to 30 percent over a year.
But the trouble is, doctors, nurses and counselors aren’t intervening any more than they were before the health reforms started.
Winkle says there may be several reasons for that.
For example, to bill for the intervention, the feds says it has to last at least fifteen minutes.
“Spending fifteen minutes is really not practical for most clinics,” said Winkle. “Most clinicians get about fifteen total to spend with a patient, who usually comes in with multiple medical complaints. And they’re reluctant to squeeze into an already packed patient visit.”
There are other reasons that could explain why intervention numbers haven’t improved over the last year. An intervention is a very different skill from diagnosing a problem and prescribing a medication, and doctors aren’t necessarily trained to do them. Many clinics aren’t big enough to have a social worker on staff to do an intervention. And finally, there’s a lot of confusion about billing.
But Winkle says it’s still early in the process. “I don’t think we’ve really given it a decent shot yet.”
Winkle says it takes time to train clinic personnel and points out that most states aren’t requiring doctors to conduct drug and alcohol screening. Oregon, he says, is pushing the envelop in this area and change can take a while.