BOSTON -- Larry Gentilello, MD, believes we have an excellent system for trauma care in the US. Yet, injuries - many of them alcohol-related - are the leading cause of death for Americans under 44 years of age. "Now, it's time to move forward to prevent injuries," he says. "And to change archaic laws that discourage effective alcohol counseling that has been demonstrated to dramatically reduce injuries and readmissions to trauma centers."
Gentilello, Chief of the Division of Trauma and Critical Care at Beth Israel Deaconess Medical Center and Associate Professor in Harvard Medical School's Department of Surgery, plans to do just that. With the help of an Innovators Combating Substance Abuse award from The Robert Wood Johnson Foundation, Gentilello is leading an initiative to change laws that penalize patients and health professionals by denying insurance coverage for treatment of injuries if it is discovered that the patient is under the influence of alcohol or other substances.
Gentilello and four other trailblazers in the field of substance abuse prevention, treatment and policy development were recently named Innovators, as part of a program that recognizes leaders in the field, brings attention to their groundbreaking work, and provides an opportunity for them to undertake projects they might be unable to complete otherwise.
The laws discourage the use of effective substance abuse counseling techniques in trauma centers, Gentilello says. "I've learned that many trauma surgeons don't test for alcohol because they know that if it is found in a patient's system, their insurance company may refuse to pay the medical bill. I was shocked to discover that this is due to a law that has been on the books more than 50 years."
Yet, Gentilello has found that a simple, half-hour counseling session in the trauma center can reduce the number of alcohol-related readmissions by nearly half. "Patients are highly motivated to change their behavior at that time because they can clearly see the consequences of their drinking," he says. Gentilello is Chairman of the Trauma Prevention Committee of the American Association for the Surgery of Trauma.
The law in question -- the Uniform Accident and Sickness Policy Provision Law (UPPL) passed in 1947 with the support of the insurance industry, with the intention of decreasing insurance costs -- states: "The insurer shall not be liable for any loss sustained or contracted in consequence of the insured's being under the influence of any narcotic…" This law was created before the nation's system of trauma centers was developed 25 years ago, and its impact has never been assessed. In fact, at a recent meeting of the National Association of Insurance Commissioners (NAIC), the insurance industry was unable to provide any evidence that the law was saving them money.
"Insurers are already paying for alcohol-related injuries because, as a result of the law, trauma centers do not routinely screen for substance abuse," says Gentilello. "If the doctor doesn't screen, the insurance company cannot use alcohol as a basis to deny the claim. As a result, the only effect of the UPPL is that it prevents doctors from identifying alcohol problems in their patients." This hampers their efforts to provide counseling to patients in urgent need of it, Gentilello has learned. "Since patients who do not receive help are twice as likely to be reinjured as patients who do receive it, changing the law will benefit not only the patients, but the insurers as well."
Gentilello has been traveling around the country, speaking to physicians, legislators and insurance groups. Due to his efforts, the National Conference of Insurance Legislators (NCOIL) - the association of state lawmakers involved in regulating insurance - has voted in favor of repealing the UPPL. And the NAIC, the same organization of state insurance commissioners that drafted the UPPL, unanimously passed a new model law designed by Gentilello. "It's now in the hands of the state legislators," Gentilello says. "They must repeal the law on a state-by-state basis."
Through his Robert Wood Johnson Foundation Innovators grant, Gentilello will conduct a national survey of trauma centers on alcohol screening practices, attitudes toward screening, and, if screening and counseling are not being performed, the reasons why. He will track UPPL repeals on a state-by-state basis, and notify trauma centers of the repeals in their respective states. He will then conduct a followup study in states in which the law has been repealed, in order to determine whether substance abuse screening increases after the repeal.
The physician survey results will be presented at educational meetings of NCOIL and other relevant policy groups, and Gentilello will provide state-specific results to legislators. "I believe this will give them a wake-up call about the negative impact of these statutes," he says. Gentilello and colleagues will also present survey results at medical meetings and publish the results in peer-reviewed journals and insurance-related media outlets.
Gentilello will work with the Insurance Legal Foundation (ILF), a nonprofit, nonpartisan research and education arm of NCOIL, in conducting and disseminating results of a survey of legislators on their attitudes toward UPPL and obstacles to repealing it. "After conducting this survey, we will present the trauma center results," he says. The legislators' attitudes will be monitored with a followup study. The Harvard Division on Addictions will also work with Gentilello on the project.
Gentilello became interested in this issue during his trauma surgery residency at the University of Texas Health Science Center, Houston 15 years ago. He observed that many trauma patients had alcohol problems, but that help was not being provided. He first led a small study involving the inclusion of an alcohol counselor on the trauma service. The combined impact of the recent major injury and the provision of timely counseling resulted in 89 percent of patients entering alcohol treatment after they recovered from their injuries. "I wanted to bridge the gap between trauma care and addiction treatment services," he says.
Next, he conducted a randomized, controlled trial of 762 patients at Harborview Medical Center in Seattle. At one year of followup, the group that was randomly assigned to meet with an alcohol counselor while they were in the trauma center decreased their alcohol consumption by 22 drinks a week, compared to no change in those who were not offered counseling. In addition, the patients were followed for three years after discharge from the trauma center. During that time there was a 47 percent reduction in hospital readmission for trauma, and a 48 percent reduction in injury-related emergency department visits for the intervention group, compared with the control group.
Next, Gentilello conducted a nationwide survey of trauma surgeons to determine current attitudes toward screening and interventions. While more than 80 percent had no prior training in detection of alcohol problems, nearly all were willing to take time from their practice to learn these skills if the provision of counseling was shown to be feasible. The surgeons repeatedly asserted, however, that documentation of alcohol or drug use in patients' charts was not feasible because it would lead to insurance claim denials. In fact, even patients who did not have an alcohol problem and drank responsibly but were nevertheless injured (through no fault of their own) would be stuck with a potentially large and devastating medical bill.
Gentilello's group next conducted a nationwide survey of state insurance commissioners, which documented that 42 states had adopted legislation allowing insurers to deny payment for treatment of alcohol related injuries. They discovered the statute was identically worded in 38 of those states, which led to the suspicion that the UPPL had a common source: a model law created by the NAIC and adopted by these states more than 50 years ago.
Gentilello petitioned the NAIC to hold hearings to consider repeal of the law. The NAIC drafted a new model law that prohibits denial of coverage for treatment of injuries or other medical conditions on the basis of intoxication, "over the vigorous objections of the insurance industry," he says. After petitioning NCOIL, Gentilello got NCOIL to hold hearings on the issue - and they subsequently passed a resolution similar to the NAIC's.
The issue now rests with the states - and this is where Gentilello's Innovators project comes in. Model legislation has passed in some states, while others have bills in the works. And Gentilello is hoping for a nationwide change. "Through my Innovators project, I hope to be able to clearly demonstrate that this is essential to reducing the burden of injuries and improving public health," he says. "And The Robert Wood Johnson Foundation is giving me the freedom to do this project, which would be unlikely to qualify for other types of funding because it is not strictly answering a scientific question."
Innovators Combating Substance Abuse is a national program of The Robert Wood Johnson Foundation that recognizes and rewards those who have made substantial, innovative contributions of national significance in the field of substance abuse. Each award includes a grant of $300,000, which is used to conduct a project over a period of up to three years that advances the field. The program addresses problems related to alcohol, tobacco and other drugs through education, advocacy, treatment, and policy research and reform at the local, state and national levels. Now in its third year, the Innovators program continues to be managed by the national program office at the University of Medicine and Dentistry of New Jersey (UMDNJ) School of Public Health.
Beth Israel Deaconess Medical Center is a major patient care, research and teaching affiliate of Harvard Medical School and a founding member of CareGroup Healthcare System. Beth Israel Deaconess is the third largest recipient of National Institutes of Health research funding among independent U.S. teaching hospitals.