Alcohol Exposé

Alcohol and Healthcare

July 27, 2010

This series takes an in-depth look at one of the most socially acceptable yet problematic and destructive social elements of our society—alcohol.

Alcohol use is an evident problem in both our country and our community. In this month’s segment we will review the healthcare options available in Taos County, and the care being offered surrounding alcohol use.
In 2001, the Taos Community Action Resource Enhancement Strategies (C.A.R.E.S.) Health Council formed as a county-wide health council that assesses community needs and strengths, particularly focusing on five community identified priorities. Following the primary goal of increasing access to health services is the organization’s goal of reducing substance abuse in Taos County. The mission of Taos C.A.R.E.S. is the unification of community efforts and the coordination of resources to enhance the health and wellbeing of area residents.

As part of the New Mexico Department of Health’s “Community Health Improvement Process,� Taos C.A.R.E.S. put together a fiscal year 2009 Taos County Community Health Profile that provides invaluable information on several health-related aspects of health among Taos County residents, with a thorough assessment of factors that affect health and wellness here. This article will highlight those aspects related to the use and abuse of alcohol. Furthermore, Taos C.A.R.E.S. Health Council has put together a Taos County Community Health Improvement Plan, a four-year (FY 2011-FY 2014) roadmap for improving the health and well being of Taos County.

Community Description
The Community Health Profile points out the relative isolation of Taos County, given its lack of commercial airline service or rail service and only a two-lane state highway linking it to the rest of the state and country. Furthermore, the majority of the county population (about 84 percent) lives outside the town limits, which creates inherent challenges to accessing the majority of social and professional services that are locating in the Town of Taos.

Regarding income and poverty, the median household income in Taos County is “significantly worse� than the state average, with over 17 percent (in 2007) of Taos County living in poverty—just 0.3 percent lower than the state average yet more than four percent higher than the national poverty level. About one-third of county residents have no health insurance. Housing is among the most expensive in the state, with only Santa Fe and Los Alamos reporting higher median prices. Taos County has high rates of financial need and increasing unemployment.

Alcohol Use
These facts and very real life conditions relate to both the use and abuse of alcohol, as well as care and treatment for alcohol-related issues. According to the New Mexico Department of Health, Taos County ranks “marginally worse� than the state in alcohol-induced deaths. Between 1999 and 2003, the county death rate related to alcohol exceeded the state in every category: chronic disease, chronic liver disease, injury and motor vehicle crashes. Between 2002 and 2006, the alcohol induced death rate for Taos County was the highest in the state and more than three times the national rate.

Health-Related Services Highlights
The Community Health Profile states that Taos County trails the state in the rating of health-related professionals, including physicians, nurses and pharmacists, with the national benchmark rate for physicians being 2.42, the statewide rate being 1.54 and the rate in Taos County at 1.26. Health Disparities Highlights in the report show that, for 1999 to 2003, the “all alcohol-related� death rate for the county population was 68.8, with the rate for Hispanics at 76.6 and Native Americans at 150.6. (The white, non-Hispanic population of the county had a higher rate of smoking-related and deaths-from-suicide than the general population). Native Americans in Taos County also report substantially higher rates of adult binge drinking than other races/ethnicities, according to the New Mexico Department of Health.

Substance abuse is the second-ranked health issue in Taos County. The Community Health Profile states that, “Determinants or risk-factors include an existing culture of abuse that crosses generations and lack of awareness and community readiness to address the problem.�

The impact of alcohol abuse on the community is huge. Death and injury may be the most evident, but the toll of missed days at work, family violence, crime and illness is also faced and absorbed by the community. Chronic heavy drinking leads to chronic diseases such as liver cirrhosis, as well as physiological and emotional alcohol dependence. Episodic heavy (“binge�) drinking contributes to numerous alcohol-related injuries including motor vehicle crashes, poisonings, falls and homicides, and there is a high correspondence between alcohol and suicide. Taos County ranks high in alcohol-related hospitalizations as well as in the density of liquor licenses (a topic we will cover at a future time).

The following table compares the death rates for all alcohol-related deaths between 1999 and 2003 in New Mexico and Taos County; Taos County exceeds the state in all categories.

The percentage of Taos County mothers drinking during pregnancy is also high, resulting in a number of serious and totally preventable disorders in the child, and youth drinking is another serious issue, with more than one-third of surveyed high-school students reporting consumption of their first drink by age 13. Underage drinking in Taos County is linked to teen suicide, teen vehicle fatalities and teen pregnancy. “Underage drinking inflicts economic, social and health burdens on our community,� the profile states.

Community Resources
Given the extent of the problem, it is essential to consider the resources available to Taos County residents.

The U.S. Department of Health and Human Services has classified Taos Pueblo, Peñasco, Picuris, Arroyo Hondo and Questa as a Health Professional Shortage Area (HPSA), indicating a shortage of primary medical care. About 20 percent of the U.S. population resides in primary medical care HPSAs. The statistics align perfectly—the greatest problems resultant from alcohol use and the least amount of available care are centered among one and the same, largely within the Native American population.

To help New Mexico residents receive medically necessary services, the New Mexico medical assistance division (MAD) pays for covered outpatient services that are provided at federally qualified health centers (FQHCs). Taos County has three FQHCs: El Centro Family Health in Peñasco; Las Clinicas del Norte in Ojo Caliente, El Rito and Abiquiu; and Questa Health Center. The Questa Health Center provides alcohol treatment programs. The Town of Taos is one of only two towns in the state that does not receive services from a FQHC.

While there are private sources in Taos County for treatment of alcohol use, they can be expensive and unaffordable for many residents. There are also sources of treatment being provided as court-ordered through the justice system. But, available to anyone is the multitude of services provided by Tri-County Community Services, Inc. Tri-County has been in operation since 1975 and is accessible to all residents of Taos County (as well as nine other counties) and provides an outpatient clinic, an intensive outpatient clinic, substance abuse counseling and prevention services, and a detox unit that offers stabilization care for those going through alcohol withdrawal. Holy Cross Hospital does not have a substance abuse program and refers out, often to Tri-County. The Rio Grande Alcohol Treatment Program, Inc., located in the Town of Taos, is another local outpatient alcohol treatment program and Taos Pueblo Recovery is a federally funded outpatient clinic for Taos Pueblo.

The Taos Municipal Schools contract with the New Mexico Department of Health to operate two School-Based Health Centers, called “wellness centers,� at Taos High School and Taos Middle School, with the high school clinic open to all Taos County teens through age 18. Both centers offer counseling, including alcohol and substance abuse counseling that is available without parental/guardian consent as allowed by New Mexico statute.

The Taos County Community Health Improvement Plan
Access to health services is the most highly ranked priority and health issue in Taos County. While new medical technologies do exist, much of Taos County has trouble accessing the services because they may be unavailable where they live, they may be hard to obtain, or be too expensive.

The second priority of the Health Improvement Plan is the reduction of substance abuse.
The good news about alcohol related problems is that they are preventable and treatable. Yet the human and economic toll of alcohol-related problems drains $185 billion from our economy every year, exceeding expenditures for other drug problems or cigarette smoking, according to The George Washington University Medical Center.

National Health Care Costs of Alcohol
• Twenty-five to 40 percent of all patients in U.S. general hospital beds (not maternity or intensive care) are being treated for complications of alcohol-related problem
• Annual health care expenditures for alcohol-related problems amount to $22.5 billion.
• Individuals with a history of heavy drinking have higher health care costs.
• Untreated alcohol problems waste an estimated $184.6 billion dollars per year in health care, business and criminal justice costs, and cause more than 100,000 deaths.
• Health care costs related to alcohol abuse are not limited to the user. Children of alcoholics who are admitted to the hospital average 62 percent more hospital days and 29 percent longer stays.
• Alcohol use by underage drinkers results in $3.7 billion a year in medical care costs due to traffic crashes, violent crime, suicide attempts and other related consequences. The total annual cost of alcohol use by underage youth is $52.8 billion.

Who Pays for Alcohol Treatment?
The majority of Americans’ alcohol treatment is paid for by public funding, not private health insurance, even though the majority of problem drinkers are employed. In virtually all other areas of medical care, private insurance pays the majority of the costs. Taxpayers are the single greatest funder of alcohol treatment services, with more than 57 percent of treatment paid with public funds. (For general health care, public sources pay 45 percent of the costs). Of the public tab, state and local governments are picking up the largest portion. Problem drinking costs state budgets $9.2 billion each year. This financial burden on both state and local governments could be greatly reduced by improving private alcohol treatment benefits. For decades, alcohol has been regarded as a disease, yet insurance companies have found a way out of having to treat it as one. Parity—health insurance that provides coverage of treatment for mental illnesses and substance abuse equal to coverage for other illnesses—could enable many more people to recover from their alcohol problems while also creating significant savings to states and businesses.

Treatment and Recovery—Screening
Health plans only diagnose eight percent of people with alcohol problems, whereas diagnosis rates for other chronic diseases are between 60 and 75 percent. Effective alcohol screening is a cost-effective methodology proven to help with the problem. Treatment for alcohol-related issues is effective and has been demonstrated to return more than two dollars for every dollar invested. So, if a methodology exists that helps the people who need it and it saves money, why is it not being used?

Screenings and Brief Interventions (SBI)
People dealing with alcohol problems face barriers to treatment and recovery. Seventeen million adults have a serious problem with alcohol, but only three million get help. Screenings and brief interventions (SBI) address risky alcohol use long before it leads to health, financial, social, employment or family problems. A brief, non-judgmental intervention by a health care professional can have a positive, long-term impact on risky alcohol use. SBI for risky alcohol and drug use is moving from research into the mainstream of preventive medicine and public health, with hospital emergency rooms in several states using the technique with patients to address problem drinking and addiction. There is no better place than the hospital emergency room for our healthcare efforts around alcohol use to be implemented—at the time of trauma center admission, 40 percent of injured patients have a positive blood alcohol concentration (BAC).

As The George Washington University Medical Center’s “Ensuring Solutions to Alcohol Problems� website states, “Imagine there’s an illness that kills 85,000 people every year. Then imagine that we know how to treat the illness, but we only find one out of every 20 people who have it. There would be a national outcry to diagnose and treat the victims.� But interestingly, the primary goal of SBI efforts is not to identify alcohol- or drug-dependent individuals for referral to treatment. Rather, these approaches are intended to meet the public health goal of reducing the harms and societal costs associated with risky drinking and drug taking.

Research shows that risky drinking causes more total accidental harm than the heavy drinking of alcoholics. Though risky drinkers are individually less likely to cause alcohol-related problems, they make up a significantly larger portion of the general population than alcoholics. The most significant amount of damage is caused by those who engage in risky drinking from time to time but are not dependent on alcohol.

With SBI, physicians or other health professionals administer simple screening tests or questionnaires to discern whether a patient has an alcohol problem. Depending on the severity of the problem, physicians may conduct brief interventions—short counseling sessions to discuss problem drinking and its health risks—with patients in the emergency room. These sessions may last anywhere from a few minutes to an hour.

Brief intervention can motivate risky drinkers to seek help and can significantly reduce the health and other risks that stem from drinking. And although SBI is not designed to treat alcoholism, which requires greater expertise and more intensive case management, it can be helpful in motivating patients with alcoholism to engage in more intensive, long-term treatment. Trauma patients who received just 30 minutes of post-screening counseling have been demonstrated to have 48 percent fewer readmissions to the hospital, and 28 fewer drinks per person per week than patients who did not receive counseling.

Studies show that SBI in health care settings, including emergency rooms and trauma centers, reduces DUIs, alcohol-related arrests and injury-related hospital readmissions, while also saving the healthcare system and taxpayers money:
• A recent study demonstrated that every $1 spent on alcohol screening and intervention for an injured patient saves $3.81 in overall health expenditures.

• If a brief intervention were offered to every eligible injured person in the U.S., the resulting savings from healthcare costs alone would be approximately $1.8 billion annually.

New Mexico could save more than $18 million a year if ER patients were routinely screened for alcohol and drugs, followed by brief treatment when necessary. Failure to identify and treat substance use in emergency services may cost New Mexico business and residents $95 million each year in extra health care expenses. Research shows that implementing screening and brief treatment in hospital emergency services could save $351 per patient by reducing re-injury and re-hospitalization costs.

Alcohol Exclusion Laws (AELs)
Despite the availability of the proven, cost-effective approach of SBI for alcohol problems, physicians and patients in many states face a roadblock to it: alcohol exclusion laws (AELs).

In 1947, the National Association of Insurance Commissioners (NAIC)—the organization of insurance regulators in the 50 states—adopted the model law known as the Uniform Accident and Sickness Policy Provision Law (UPPL). The law states that health insurers would not have to reimburse patients for costs incurred when an accident is a result of “the insured’s being intoxicated or under the influence of any narcotic.� However, in 2001, recognizing advances in alcohol treatment—and with strong support from medical authorities—NAIC unanimously recommended that states repeal the Alcohol Exclusion Law and prohibit the denial of coverage for individuals injured while under the influence of alcohol or narcotics. Several groups support the elimination of exclusions, including the American Medical Association, the American Public Health Association, the American Bar Association and the National Conference of Insurance Legislators. Yet 36 states continue to allow insurers to use alcohol exclusions.

Of these 36 states, 27 have laws that explicitly allow insurers to use alcohol exclusions, and nine states, including New Mexico, implicitly allow insurers to use alcohol exclusions—meaning there is no specific law related to exclusions. Instead, courts have ruled that, in the absence of explicit laws, insurance companies can sell policies that use exclusions to limit liability. Court rulings vary by state.

More than a quarter of a million Americans seek help for an alcohol problem but can’t get it. Alcohol exclusions allow insurers to deny coverage to people injured while under the influence of alcohol. Exclusions can be used to deny payment to doctors and hospitals, discouraging alcohol screening in trauma centers and emergency departments. When benefits are denied, injured people can’t pay for medical care. To avoid bankrupting their patients, many physicians and hospital managers avoid any activity—including measuring blood alcohol levels or screening for alcohol problems—that might result in an alcohol-related diagnosis. In turn, people with insurance policies that include alcohol exclusions usually don’t know about it until a claim is denied. AELs make no contribution to deterring dangerous behavior like drunk driving. Instead, the laws prevent long-term solutions to alcohol-related problems and discourage people with alcohol problems from getting the help they need.

The Intention & Consequences of AELs
Alcohol exclusions have resulted in unintended consequences.
• Intended to discourage drinking and drug use, alcohol exclusions have actually allowed drunk drivers to escape detection. Between 85% and 96% of drunk drivers involved in a crash avoid detection if they are transported to a trauma center.

• Intended to save insurance companies money, alcohol exclusions have actually contributed substantially to the $19 billion in annual alcohol-related health care costs. At the time of trauma center admission, 40 percent of injured patients have a positive blood alcohol concentration (BAC). But, because alcohol exclusions permit insurers to deny coverage for injuries suffered under the influence, many medical providers are reluctant to test injured patients’ BAC. This limits the number of patients who receive brief alcohol counseling in emergency rooms. Individuals receiving brief interventions have 48 percent fewer readmissions to the hospital. And for every $1 spent on alcohol counseling for injured patients, hospitals can expect to save almost $4.

Alcohol exclusions get in the way of identifying and helping people with alcohol problems. The best way to prevent drunk driving and alcohol-related injuries is to prevent and treat alcohol problems. By screening for alcohol problems, emergency rooms and trauma centers can play a key role in finding and helping people with alcohol problems.

Prohibiting Alcohol Exclusions
Prohibiting exclusions would:
• Increase the likelihood that drunk drivers will be detected

• Help prevent repeat drunk-driving incidents

• Reduce the costs of health care

• Provide the opportunity for treatment of alcohol problems at the time when treatment can be most effective.

If screening and brief interventions were routinely provided in all emergency departments, it is estimated that the federal portion of Medicaid could save more than $520 million each year, and Medicare could save almost $1.1 billion annually.

Instead of encouraging personal responsibility, preventing drunk driving, and helping people with alcohol problems, alcohol exclusions do the opposite. Patients with an alcohol use problem are not identified.

New Mexico Insurance Loophole Increases Taxpayer Costs, Prevents Treatment and Denies Insurance Benefits
New Mexico courts have ruled that insurance companies can decide not to pay accident and health insurance benefits if the insured person’s intoxication due to alcohol or drug use caused the injury. New Mexico’s alcohol exclusions were intended to reduce drunk-driving by forcing impaired drivers to pay their own medical costs, but alcohol exclusions have in fact not reduced insurance payouts. Trauma surgeons have decided to not measure blood alcohol and avoid documenting alcohol use in the medical record, and without documentation of alcohol use, an insurance company has no basis to deny payment. Insurance companies still pay for alcohol-related injuries, but people who would benefit from treatment don’t get help and drunk-drivers are not detected. Eliminating exclusions in New Mexico would require a law to be passed that would prohibit exclusions. Alcohol exclusions need to be eradicated so people can get help and doctors can do their work.