Nearly 25% of trauma surgeons report that they have been denied payment by an insurer in the last 6 months because a patient was under the influence of alcohol or drugs when his or her traumatic injury occurred, according to Larry M. Gentilello, M.D., of the University of Texas Southwestern Medical Center at Dallas, and his colleagues.
The failure to pay on the part of insurance companies may be affecting alcohol screening and treatment practices in hospitals, the researchers said.
The researchers analyzed responses from 98 general trauma surgeons around the country and found that less than half reported routinely measuring blood alcohol concentration among their patients even though 91% of respondents said it was important to do so. The findings are slated to be published in the Journal of Trauma Injury, Infection, and Critical Care.
The barrier for many physicians is the Uniform Accident and Sickness Policy Provision Law (UPPL), a national model law that allows insurance carriers to deny coverage for injuries sustained while under the influence of alcohol or drugs. The model law was developed in 1947 by the National Association of Insurance Commissioners, and as of April 2004, it had been adopted by 38 states and the District of Columbia.
But in 2001, the commissioners amended the model law to prohibit insurers from applying the substance abuse exclusion to medical expenses. As of April 2004, six states adopted the new model law.
In general, trauma surgeons were not familiar with the UPPL. For example, only 13% reported that they practiced in a state with a UPPL in effect, but 70% of the respondents were from states with such a statute in place. However, the survey results also indicate that the general fear of insurance denials may be causing some physicians to circumvent the laws by not documenting the use of alcohol or drugs.
Dr. Gentilello and his colleagues found that only 37% of surgeons report that half or more of their patients with alcohol problems receive counseling. And 82% of the respondents said that if there were no insurance barriers, they would be willing to help their trauma center establish a brief alcohol intervention program if provided with other clinical tools.
Either physicians are not screening and documenting intoxication or insurers are not applying the law in every case, the researchers wrote, because with 35%–50% of trauma patients estimated to be under the influence of alcohol or drugs, trauma centers could not absorb the resulting cost of uncompensated care.
The researchers conducted a separate anonymous e-mail survey of state legislative leaders. Researchers analyzed responses from 56 legislators. Most were not sure whether the UPPL existed in their state but generally favored prohibiting alcohol-related exclusions in medical expense policies.
Studies specifically looking at alcohol screening and intervention among injured patients show that brief interventions can reduce future alcohol use and hospital readmissions, Dr. Gentilello, professor of surgery and chairman of the division of burns, trauma, and critical care at the University of Texas Southwestern Medical School, said in an interview.
After being treated for a serious injury resulting from substance abuse, most patients are in an ideal state of mind for this counseling. “They've had a real teachable moment,” Dr. Gentilello said. “Trauma presents a crisis we can capitalize on.”
But the existence of the UPPL means that physicians who practice good medicine by screening and treating alcohol and drug abuse are denied payment, said Eric Goplerud, Ph.D., professor at the George Washington University in Washington and director of Ensuring Solutions to Alcohol Problems, a group that provides research information on effective alcohol treatment as a part of the university's medical center.