Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse

I support the Centers for Medicaid and Medicare Services proposed decision memo for "Screening and Brief Counseling Intervention in Primary Care to Reduce Alcohol Misuse." It is well established alcohol misuse causes many social and health consequences, exacerbates health issues and makes an individual's health conditions more difficult to treat. In addition, screening and brief counseling of pregnant women may help prevent or minimize Fetal Alcohol Spectrum Disorders.

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August 16, 2011

Thank you for the opportunity to comment on the Centers for Medicare and Medicaid Services’ (CMS’s) proposed decision memo for Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse (CAG-00427N). America’s Health Insurance Plans (AHIP) is the national association for the health insurance industry. Our members provide coverage to more than 200 million Americans, offering a broad range of health insurance products in the commercial market and demonstrating a strong commitment to participation in public programs.

General Comments

AHIP and our member plans support CMS’s efforts to ensure that Medicare beneficiaries receive access to safe and effective preventive health services, procedures, and treatments that can improve health outcomes, as determined by current and robust clinical evidence. Health insurance plans have a long-standing commitment to preventive services and provide coverage for services recommended by the U.S. Preventive Services Task Force (USPSTF). While health plans have been implementing the USPSTF recommendation on screening and behavioral counseling interventions in primary care to reduce alcohol misuse, there are some issues that CMS should address prior to determining coverage for screening and behavioral counseling interventions.

Because the USPSTF aims to update its recommendations every five years¹ and the recommendation prompting this proposed decision memo was last published in 2004, CMS should confer with AHRQ and the Task Force regarding the next evidence review for this topic and possible date when the recommendation will be reconsidered. This recommendation is currently listed as a topic in the review process² on the USPSTF web site. It is important that CMS coverage policy align with the updated USPSTF recommendation.

Data from health insurance plans show that patients with substance abuse disorders tend to have higher acuity of comorbid medical conditions, and higher rates of emergency department inpatient admissions and re-admissions with longer length of stays. Early identification and engagement favorably impacts adherence to treatment and improves outcomes for substance abuse disorders.

If implemented, our members believe that this intervention must utilize medical necessity guidelines based on scientific evidence with established thresholds for appropriate patients, including visit frequency and defined goals over a defined time frame, and criteria specifying the appropriate licensed professionals to provide screening and behavioral counseling interventions. The time frame specified in the CMS decision memo for up to four brief, face-to-face behavioral counseling interventions per year for Medicare beneficiaries, including pregnant women, is reasonable and aligns with the evidence presented in the Clinical Considerations section of the USPSTF recommendation. Primary care physicians, nurse practitioners, clinical nurse specialists, or physician assistants are appropriate health care professionals to perform the screening and behavioral counseling interventions for this population.

AHIP’s member health insurance plans have implemented and operationalized the USPSTF 2004 recommendation on screening and behavioral counseling interventions for alcohol misuse. When finalizing its discussion on this proposed decision memo, we urge CMS to coordinate with AHRQ and the USPSTF to ensure the evidence reviewed and recommendations align with the most current recommendation of the USPSTF.

Thank you for the opportunity to comment on this important issue.

Sincerely,

Carmella Bocchino
Executive Vice President
Clinical Affairs and Strategic Planning

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August 18, 2011

Dr. Don Berwick, Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
7500 Security Boulevard
Baltimore, MD 21244

Re: Proposed Decision Memos for Screening for Depression in Adults (CAG-00425N) and Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse (CAG-00427N)

Dear Dr. Berwick:

The Coalition for Whole Health is a broad coalition of national organizations in the mental health and substance use disorder prevention, treatment, and recovery communities, and we appreciate the opportunity to comment on the CMS proposals to cover annual screenings for alcohol misuse and depression for adult Medicare beneficiaries. We thank you for making screenings for alcohol misuse and depression top priorities. We also thank you for your consideration of our below recommendations.

We strongly support the CMS proposals to cover screening and behavioral counseling interventions to reduce alcohol misuse and screening for depression as Medicare preventive services. Excessive alcohol use and depression represent major, and often overlooked, public health problems among older Americans. As noted in the memos, depression and substance use problems are common in older adults, and each often co-occur with other chronic diseases, complicating treatment compliance, worsening health outcomes, and increasing health care costs.

In addition to our strong support for providing these screens annually in primary care settings by primary care practitioners, we make the following recommendations:

• CMS should cover depression and alcohol misuse screenings and interventions that occur in any appropriate setting, not just primary care settings, furnished by any qualified practitioner, not limited to primary care physicians, nurse practitioners, clinical nurse specialists, or physician assistants.
• Depression and alcohol misuse screenings should not be limited to once annually. Screenings should be provided at every opportunity or whenever appropriate.
• CMS should further expand Medicare preventive services to include screening and intervention for illicit and prescription drug misuse and screening for additional mental health related conditions.

The following is a more detailed overview of our above recommendations.

CMS should cover depression and alcohol misuse screenings in all appropriate settings, provided by any qualified practitioner, not only primary care practitioners.

According to the Proposed Decision Memos, CMS is only proposing to cover alcohol screenings and interventions “furnished by qualified primary care physicians or other primary care practitioners in a primary care setting” and only proposing to cover depression screenings “in primary care settings that have staff-assisted depression care supports in place.” The memos explicitly exclude coverage of these screenings if they occur in emergency departments, inpatient hospital settings, outpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, and hospice.

By limiting screenings to primary care settings and providers, CMS is reducing the potential of these critically important preventive health services. For example, under these proposals CMS would not cover an alcohol screening provided in an emergency room after an alcohol-related accident, nor would it cover depression screens provided outside of a primary care setting, regardless of the appropriateness of providing those screens.

In addition, we ask that CMS allow alcohol misuse and depression screens to be provided by any qualified health care professional. By limiting those eligible to provide the screens to primary care physicians and primary care practitioners, CMS is only covering screens provided by those practitioners who may be too busy to screen and follow-up effectively, without allowing them to delegate to others who are qualified to conduct these screens. The list of those eligible to screen for alcohol misuse and depression should be expanded to include any qualified practitioner.

Depression and alcohol misuse screenings should not be limited to one annually, but should be provided as frequently as appropriate.

Given the low risk, low cost, and high effectiveness of screening for alcohol misuse and depression, and the current state of knowledge about the consequences of untreated addiction and mental illness, screenings should be done often to effectively identify problem drinking and/or depression and intervene early. CMS should not put arbitrary frequency limits on the proposed alcohol misuse and depression screenings. Screenings should be provided as often as appropriate, which may include at every opportunity for individuals identified as at particularly high risk. Similarly, CMS should cover more than four brief, face-to-face, behavioral counseling interventions per year for those identified through alcohol misuse screens as needing interventions, if additional interventions are determined appropriate.

CMS should cover preventive screenings for other mental health conditions, not only depression, and screenings for illicit and prescription drug misuse, not only alcohol misuse

Substance use disorders and mental illnesses are treatable and often preventable chronic diseases, and prevention, early identification, and treatment of these diseases is highly cost-effective.

We appreciate the inclusion of the U.S. Preventive Services Task Force recommended screenings and interventions related to depression and alcohol misuse as covered preventive services. In addition to these screenings identified by the USPSTF, there are other preventive screenings for substance use and mental health conditions that have been used for a number of years and are extremely effective.

While the USPSTF has not yet determined the value of screening for illicit drug use and prescription drug misuse, a significant body of evidence points to its effectiveness. The National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism and other distinguished researchers have demonstrated that screenings for drug use are effective tools to help identify adults in need of brief interventions and treatment services. Recent research clearly demonstrates that rapid, economical screening and brief interventions reduce substance use and significantly reduce health care costs. Therefore, we ask that you include drug misuse screening, brief intervention, and referral to treatment as a Medicare covered preventive service.

Similarly, in addition to screening for depression, Medicare covered preventive services should include screenings for the full range of mental health conditions, including screening for trauma history, for bipolar disorder, and for multiple mental health conditions. Such screenings have been shown to be feasible and effective. Therefore, we ask that you include screening for mental health related conditions, including trauma history, bipolar, and multiple mental health conditions, as covered services for Medicare beneficiaries.

In addition to the above recommendations, we urge CMS to continue to collaborate with SAMHSA, given their work regarding implementation of the Affordable Care Act in identifying the wide range of services that are needed and utilized by individuals with, at risk for, or in recovery from mental illness and/or substance use disorders. Furthermore, we urge CMS to continue to collaborate with SAMHSA and HRSA to further our prominent theme of integrating general health care with care for mental health and substance use disorders.

Thank you again for proposing to cover screening and behavioral counseling interventions in primary care to reduce alcohol misuse and screening for depression for all adult Medicare beneficiaries. Please use us as a resource moving forward.

Sincerely,

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The Society of Behavioral Medicine — the only professional organization devoted to the entire range of links between behavior and health — strongly endorses the CMS initiative for Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse (CAG-00427N). These approaches are evidence based and can reach and help many individuals struggling with alcohol misuse through the primary care system. The primary care system is a crucial venue for efforts to reach and help Americans adopt and sustain healthy behaviors. It needs to be brought more fully into play in these critical prevention areas that can save billions of dollars to the US health system. The Society of Behavioral Medicine strongly endorses this current CMS initiative as an important step in this key direction.

At the same time, we also note the importance of a variety of approaches to prevention and control of alcohol misuse, both within and outside of the primary care venue. There are no “magic bullets” in prevention and behavior change. SBM calls for development and policy support of multiple approaches that include, for example, reaching people through individual behavior change efforts, group programs, organizational and community programs, and progressive policies.

Given the prevalence and significant costs tied to this important health issue, it is critical that all trained health providers with expertise in this area be supported as part of this initiative. We therefore recommend changing the following wording in the document describing the initiative from “…"whose counseling is furnished by qualified primary care physicians or other primary care practitioners in a primary care setting" to "whose diagnosis and treatment / counseling is provided by a qualified health care provider". Among the types of health care professionals trained to deliver evidence-based alcohol assessment and intervention in primary care and other relevant health care settings are mental health providers, including psychologists, psychiatrists, and social workers. As noted in at least one of the citations referenced in this document, these trained health professionals can bring expertise in behavior modification and other evidence-based strategies appropriate to primary care and related health care settings.

Finally, we recommend that CMS develop a way of providing the treating health care providers with information and the resources and support networks that may be available for their patients.

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The National Association of Psychiatric Health Systems (NAPHS) supports the action of the United States Preventive Services Task Force (USPSTF) in recommending screening and behavioral counseling interventions to reduce alcohol misuse by adults. We also support the conclusion that the evidence is sufficient to determine that screening and behavioral counseling interventions in primary care to reduce alcohol misuse are appropriate for Medicare beneficiaries.

We understand that CMS intends to limit the provision of the screening and intervention to primary care settings as defined, for the purposes of this decision memorandum, as “a setting that provides integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing sustained partnerships with patients, and practicing in the context of family and community.” The list of settings explicitly excluded includes outpatient hospital settings. We recommend that CMS consider including appropriate hospital outpatient settings that meet the definition of “primary care setting” as entities that may be reimbursed for the screening and behavioral health counseling intervention. Many hospital-based outpatient clinics function as primary care providers as per the definition, and are well-positioned to provide the “assess, advise, agree, assist, and arrange” components of the behavioral counseling intervention.

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The American Psychological Association (“APA” or “we”), the professional organization representing 154,000 members and affiliates engaged in the practice, research, teaching, and learning of psychology supports the Centers for Medicare and Medicaid Services (CMS) proposal to cover annual alcohol screening, and for those who screen positive, to cover up to four brief, face-to-face behavioral counseling interventions per year for Medicare beneficiaries, including for pregnant women meeting specified criteria. As APA indicated in comments provided during the initial 30-day comment period in March of this year, such screening and behavioral counseling services are both efficacious and needed by Medicare beneficiaries. However, we are concerned that the proposed decision excludes clinical psychologists from providing these needed services to Medicare beneficiaries and urge CMS to include a clinical psychologist as a provider of these services in the final decision.

Clinical psychologists now commonly provide services in primary care settings with physicians and other health care professionals, often serving as members of multidisciplinary teams and taking a lead when a patient has a primary mental health or substance use diagnosis. As part of treatment teams, clinical psychologists provide patient-centered mental and behavioral health services, such as prevention, diagnosis, evaluation, assessment, treatment and management services. In its proposed coverage decision, however, CMS relies on a fifteen-year-old Institute of Medicine “primary care” definition and a list of primary care physicians and practitioners in an unrelated law (regarding incentive payments) to exclude psychologists from providing screening and behavioral interventions services to Medicare beneficiaries—services which they are eminently trained to provide. We respectfully suggest that clinical psychologists be included for purposes of these services for several reasons and highlight three below—

First, more than any other health care provider, psychologists are expert at psychological testing, assessment, screening and behavioral interventions. Many of these services are unique to clinical psychologists and commonly provided to Medicare beneficiaries in a range of settings.

Second, as mentioned above, primary care physicians now rely on psychologists regarding mental health and substance use problems. As mentioned in our comments to the proposed coverage decision in March, physicians commonly fail to recognize alcohol problems in older adults or prescribe medication where behavioral interventions are appropriate. CMS should encourage interface of primary care physicians with clinical psychologists for collaborative care for Medicare beneficiaries.

Third, clinical psychologists are available throughout the country to provide these screening and behavioral services, even in rural and underserved geographical areas. From a “real world” perspective, if a clinical psychologist is already working on an interdisciplinary team in a community or setting, this coverage decision, as proposed, would exclude them from providing services to Medicare beneficiaries when they are highly trained and available to provide them.

The APA supports the proposed coverage decision for screening and behavioral counseling interventions in primary care to reduce alcohol misuse, but we strongly urge CMS to include clinical psychologists as providers of these services in the final decision. If you have any questions or would like further discussion of these issues, please contact Doug Walter, J.D., Legislative and Regulatory Counsel, Government Relations, APA Practice Organization, at dwalter@apa.org or (202) 336-5889.

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August 15, 2011

RE: Comments on Proposed Decision Memo for Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse (CAG-00427N)

The National Council for Community Behavioral Healthcare appreciates the opportunity to comment on the proposed Decision Memo for Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse. Together with our over 1,900 member organizations, we serve our nation’s most vulnerable citizens — more than 8 million adults and children with mental illnesses and addiction disorders. A substantial number of those served have Medicare coverage because they are aged or working-age disabled. We are committed to providing comprehensive, quality care that affords every opportunity for recovery and inclusion in all aspects of community life.

The National Council commends CMS for its proposal to cover annual alcohol screening and behavioral counseling interventions when indicated in the screening. This proposal recognizes the importance of screening and providing brief interventions for individuals with at-risk alcohol behaviors.

However, we encourage CMS to strengthen the proposal by expanding the types of providers who may provide counseling in a primary care setting, similar to the criteria included in a companion decision memo also released on July 19, 2011: Proposed Decision Memo for Screening for Depression in Adults (CAG-00425N).

In its proposed decision memo on depression screening, CMS proposed to cover annual depression screening in primary care settings that have staff-assisted depression care supports in place. The memo clarified that “staff-assisted depression care supports” consist of “clinical staff in the primary care office who can advise the physician of screening results and who can facilitate and coordinate referrals to mental health treatment.”

In contrast, the proposed decision memo on alcohol screening and behavioral counseling interventions restricted the types of staff who may provide such counseling and support to “primary care physicians or other primary care practitioners in a primary care setting.” The Social Security Act (SSA) defines a primary care practitioner as a nurse practitioner, a clinical nurse specialist, or a physician assistant. This definition excludes many types of clinical staff working in primary care settings who are trained and qualified to provide behavioral counseling interventions for alcohol misuse. For example, licensed psychologists and licensed social workers are experienced in providing necessary counseling and staff supports, and many primary care offices currently employ such behavioral health professionals. As more and more practices move toward an integrated approach to providing behavioral and physical healthcare, we can expect that the number of behavioral health professionals employed in primary care settings will only grow over time.

The National Council has over 10 years of experience providing technical assistance and support to integrated care initiatives throughout the country. It has been our experience in working with these practices – both in primary care and behavioral health settings – that primary care providers are frequently under significant time limitations when treating their patients. Allowing other team members who are adept at behavioral health interventions to provide these services will both alleviate the burden on primary care practitioners and enhance patients’ access to appropriate counseling.

For this reason, the proposal to restrict coverage of behavioral counseling interventions to only those provided by primary care practitioners as defined in the SSA is not conducive to ensuring access to appropriate and timely interventions. The National Council encourages CMS to use the language in the Proposed Decision Memo for Screening for Depression in Adults as a model for the Proposed Decision Memo for Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse.

Specifically, we request that CMS replace the third bullet point in the second paragraph, “Whose counseling is furnished by qualified primary care physicians or other primary care practitioners in a primary care setting” with the following language:

Whose counseling is furnished in a primary care setting.

We further recommend that CMS add the following definition of clinical support staff, modeled after the definition in the proposed decision memo on depression:

At a minimum level, behavioral counseling interventions should be provided by licensed clinical staff in the primary care office who can advise physicians of screening results, facilitate and coordinate referrals to mental health treatment, and who are trained in offering such interventions.

If you have questions about these comments, please contact: Chuck Ingoglia, Vice President, Public Policy at ChuckI@thenationalcouncil.org or 202-684-7457 ext 249.

Sincerely,

Linda Rosenberg
President/CEO

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August 18, 2011

Louis Jacques, MD
Director, Coverage and Analysis Group
Centers for Medicare & Medicaid Services
Attention: CAG-00425N
7500 Security Boulevard
Baltimore, MD 21244-1850

Dear Dr. Jacques:

On behalf of the National Alliance on Mental Illness (NAMI), I pleased to submit the following comments on the proposed national coverage determination on Depression Screening in Adults. NAMI is the nation’s largest national organization representing people living with serious mental illness and their families. Through our 1,100 affiliates in all 50 states, our members advocate on behalf of people living with illnesses such as schizophrenia, bipolar disorder, major depression and severe anxiety disorders.

NAMI supports Medicare coverage of depression screening services as recommended by the United States Preventive Services Task Force (USPSTF). We commend CMS for its proposal to cover annual depression and alcohol screening in adults as an "additional preventive service" that is reasonable and necessary for the prevention or early detection of an illness or disability. NAMI believes that this is within CMS's authority to require coverage for "additional preventive services" if it determines through the National Coverage Determination process that the service is:

• recommended with a grade of A or B by the USPSTF;
• reasonable and necessary for prevention or early detection of an illness; and
• appropriate for Medicare beneficiaries.

In NAMI’s view depression screening satisfies those requirements and CMS can improve the health and quality of life for many Medicare beneficiaries by covering this essential service. NAMI would like to offer specific comments on several elements of the proposed NCD for annual depression and alcohol screening:

1. frequency of the service;
2. the requirement for staff-assisted care supports; and
3. the requirement proposed by CMS that screening be furnished in a “primary care setting”.

Finally, NAMI recommends that CMS further expand Medicare preventive services to include screening and early intervention for additional mental disorders and provide payment for these services.

Frequency of Screening Services

NAMI supports CMS’s proposal to cover depression and alcohol screening on an annual basis. We have a long history of support for efforts in Congress to ensure that Medicare covers depression screening at least annually, or more frequently if other circumstances (including the presence of certain risk factors, such as family history of depression, or presence of chronic disease) suggest that more frequent screening is appropriate.

Requiring Staff-Assisted Care Supports

The USPSTF has recommended screening adults for depression when staff-assisted care supports are in place to assure accurate diagnosis, effective treatment and follow-up. NAMI concurs with CMS’s proposal that a minimum level of staff-assisted care supports would consist of clinical staff (such as a nurse or a physician assistant) that can advise the physician of screening results, facilitate and coordinate referrals for mental illness treatment. CMS should also consider a similar level of support as sufficient in terms of effort and personnel. Such staff-assisted care supports were referenced by one study the USPSTF characterized as demonstrating “the lowest effective level of staff-assisted depression supports.”

In this proposed NCD, CMS further notes that “more comprehensive care supports include case management by a nurse or non-physician working with the primary care physician; planned collaborative care between the primary care provider and mental health clinicians; patient education and support for patient self-management; plus attention to patient preferences regarding counseling, medications, and referral to mental health professionals with or without continuing involvement by the patient’s primary care physician.” It is unclear to NAMI why CMS chose to define “more comprehensive care supports,” unless this is intended only for illustrative purposes (or unless CMS intends to divide payment for depression screening according to whether it involves the minimum level of support or a “more comprehensive” level of support). In any case, NAMI recommends that CMS clarify the purpose of this distinction.

The proposed NCD does not address whether CMS intends to pay for depression screening as a separately billable service or as part of a bundle of services, such as those services provided during an office visit or an annual wellness visit. NAMI looks forward to CMS clarifying its intent in this regard. CMS should consider paying for depression screening in the context of an annual wellness visit or other office visit by appropriately increasing the payment for that visit. When depression screening is performed outside of the context of an annual wellness visit, CMS should make a separate payment for the service.

It is understandable that CMS does not typically address payment issues in an NCD. However, NAMI remains concerned that Medicare beneficiaries’ access to screening services may not appreciably expand — and the coverage policy would thus not have achieved its purpose — unless CMS assures that these screening services are paid for appropriately.

This proposed NCD would cover depression screening for Medicare beneficiaries in “primary care settings that have staff-assisted depression care supports,” and defines a primary care setting as one that provides “integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” The proposed Decision Memo further specifies that primary care settings do NOT include settings such as emergency departments, inpatient hospital settings, outpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities and hospices.

NAMI commends CMS for covering this service in the primary care setting. Nevertheless, this definition of “primary care setting” can easily be read to exclude some settings where screening for depression in adults may be appropriate, such as specialty health settings or other Medicare-participating providers that furnish mental health services specifically (e.g., community mental health centers). Many of these specialty providers do not typically “address a large majority of [an individual’s] personal health care needs.” NAMI is concerned that the “primary care” requirement (especially given the definition of this term that CMS proposes to use) could needlessly restrict beneficiary ccess to depression screening in appropriate settings and is not part of the USPSTF recommendation.

The USPSTF recommendation extends to depression screening in adults when staff assisted depression care supports are in place, but does not limit this service to a primary care setting. As is noted in the NCD, the USPSTF relied partly on a systematic evidence review that required all studies to be conducted in a general primary care population. However, it is likely that the USPSTF would have specified the setting if it believed this was central to its recommendation. As a result, NAMI recommends that the final NCD not require that depression screening occur in a primary care setting in order to be covered. At a minimum, however, CMS should consider expanding the settings in which screening can occur (by refining the “primary care” definition) if it adopts a requirement for a primary care setting. Broadening the settings in which screening can be covered is particularly important given the well-recognized shortage that exists of primary care physicians and other primary care providers, especially in rural areas.

Expansion of Screening and Early Intervention to Additional Mental Disorders

NAMI recommends that CMS consider expansion of Medicare preventive services to include screening and early intervention for additional mental illnesses. Medicare covered preventive services should include screenings for a broader range of mental illnesses in addition to depression, including screening for psychotic disorders (including schizophrenia and schizo-affective disorder), mood disorders (including bipolar disorder) and severe anxiety disorders (including PTSD). A growing body of research has indicated that screening and early intervention for many of these mental disorders have been shown to be feasible and effective.

Finally, to make sure that the new coverage policy is meaningful and will translate into greater availability of screening services for Medicare patients, NAMI recommends Medicare payment for these screening and early intervention services. By covering depression screening services, CMS can help Medicare beneficiaries to identify and address a serious, often debilitating illness. NAMI strongly supports Medicare coverage of this valuable service. We appreciate the opportunity to comment on this important proposed NCD and look forward to working with CMS on this important policy.

Sincerely,

Michael J. Fitzpatrick, M.S.W.
Executive Director

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Dear Dr. Berwick:

The National Center on Addiction and Substance Abuse at Columbia University (CASA Columbia) is grateful for the opportunity to comment on the Centers for Medicare and Medicaid Services (CMS) proposal to cover alcohol screenings and brief interventions for adult Medicare beneficiaries, including pregnant women.

CASA Columbia strongly endorses this proposal. A strong body of research supports the provision of screenings and brief interventions to reduce alcohol use and its associated negative health and social consequences and costs. Adoption of this proposal also would send an important message to other payers of health services that screenings and brief interventions for alcohol misuse are reasonable and necessary and should be considered essential benefits in any health plan.

We also recommend that alcohol screenings and brief interventions be age- and gender-appropriate. CASA Columbia’s work has shown that risks for alcohol misuse vary by gender and at different times throughout the lifespan. Screening tools and interventions should be tailored to these differing circumstances.

In addition to tobacco and alcohol, the risky use of illicit and controlled prescription drugs and the prevalence of substance use disorders involving these drugs is a growing problem among older Americans. We encourage CMS to reimburse physicians for screenings and brief interventions for Medicare beneficiaries for all addictive substances.

We appreciate the opportunity to submit comments on this issue.

Sincerely,

Susan E. Foster
Vice President and Director
Division of Policy Research and Analysis
The National Center on Addiction and Substance Abuse at Columbia University

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August 18, 2011

Donald Berwick, M.D.
Administrator
Centers for Medicare & Medicaid Services (CMS)
Department of Health and Human Services
7500 Security Boulevard
Baltimore, MD 21244

Dear Dr. Berwick:

The American Society of Addiction Medicine (ASAM) is pleased to have the opportunity to comment on CMS proposals to cover annual screenings for alcohol misuse and depression for adult Medicare beneficiaries. ASAM members specialize in the treatment of addiction and practice in a wide range of primary care and specialty care settings. As such, we feel uniquely qualified to comment on the public health benefits of screening Medicare-eligible patients for alcohol problems.

ASAM applauds CMS' support of screening, brief intervention and referral to treatment (SBIRT) and feels that the summary report is quite thorough in its review of the literature, the effectiveness of SBIRT and the reasoning of why these efforts should be included within the USPSTF guidelines. Furthermore, we support your proposals to cover depression and alcohol misuse screening and behavioral counseling interventions as Medicare preventive services.

We would, however, like to offer recommendations related to the CPT codes that may be used by physicians for reimbursement of the behavioral counseling interventions for alcohol misuse.

The proposed decision memo does not specify which CPT code would be utilized for these counseling sessions. If the memo intends that CPT codes 96150 - 96155, Health and Behavior Intervention, be used, primary care practitioners may face reimbursement difficulties. Many insurers restrict these codes to behavioral health providers or do not cover them at all. Also, the instructions in the CPT manual restrict adding these codes to evaluation and management (E&M) or psychiatric services on the same date of services.

Behavioral health counseling codes are also reimbursed at substantially lower rates than equivalent timed medical office visit or psychiatric codes, thereby, providing a significant disincentive for providers to use them. Few physicians would utilize these codes if the claims processes were cumbersome or resulted in denials. Or, the physician may refer the person directly to a behavioral health counselor which often results in refusal by the patient of the referral. In light of these concerns, ASAM respectfully requests that, should CMS utilize this coding, then the aforementioned specialty restrictions and reimbursement equity issues be considered.

Many of our physician members are also worried about the potential for discrimination of patients who may screen positive for misuse but ultimately do not have a diagnosable abuse or dependence problem. With the inclusion of claims information into the Medical Information Bureau database, many patients who have been screened for alcohol (and/or drug) misuse are inaccurately given an abuse or dependence diagnosis since most insurers do not allow for the use of "rule out" diagnoses. If CMS decides that behavioral health codes are the best choice, then modification of the claims database to allow for "no diagnosis given" would provide some degree of protection against this potential discriminatory procedure.

Again, ASAM thanks CMS for the opportunity to submit comments regarding this important issue. We look forward to a continued collaboration with the Centers for Medicare and Medicaid Services on screening and brief intervention utilization and outcomes.

Sincerely,

Stuart Gitlow, MD, MBA, MPH, FAPA

Acting President, American Society of Addiction Medicine

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August 18, 2011

Donald Berwick, MD
Administrator
Centers for Medicare & Medicaid Services
Department of Health & Human Services
P.O. Box 8013
Baltimore, MD 21244–8013
Submitted via email to CAGinquiries@cms.hhs.gov

Re: Proposed Decision Memo for Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse (CAG-00427N)

Dear Dr. Berwick:

On behalf of the American Academy of Family Physicians (AAFP), which represents more than 100,300 family physicians and medical students nationwide, I am writing in strong support of the Centers for Medicare & Medicaid Services (CMS) proposal to begin coverage for screening and behavioral counseling for alcohol misuse. Specifically we support the proposal for annual alcohol screenings and for those that screen positive, up to four brief, face-to face, behavioral counseling interventions per year for Medicare beneficiaries, including pregnant women:

• Who misuse alcohol, but whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence (defined as at least three of the following: tolerance; withdrawal symptoms; impaired control; preoccupation with acquisition and/or use; persistent desire or unsuccessful efforts to quit; sustains social, occupational, or recreational disability; use continues despite adverse consequences); and;
• Who are competent and alert at the time that counseling is provided; and;
• Whose counseling is furnished by qualified primary care physicians or other primary care practitioners in a primary care setting.

The AAFP’s policy on alcohol misuse is consistent with the U.S. Preventive Services Task Force (USPSTF) recommendations to CMS. It is our longstanding position that primary care physicians provide screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women. The AAFP concurs with the proposed decision memo that the evidence is adequate to conclude that screening and behavioral counseling to reduce alcohol misuse, are reasonable and necessary for the prevention of early illness or disability, and are therefore appropriate for individuals entitled to benefits under Medicare Part A or enrolled under Medicare Part B.

As referenced in the CMS proposal, the AAFP provides a detailed Rationale for Screening and Brief Intervention for Alcohol Problems in Primary Care. We believe alcohol-related problems substantially impact morbidity and mortality rates and that a screening can be a safe and comfortable experience for patients and physicians. In successful clinical screening trials, brief interventions have typically taken two 10 to 15 minute office visits; therefore, integrating them into daily practice is challenging. Primary care office visits are short but face complex agendas. Furthermore, physicians value a patient-centered approach to care, which will include a discussion of alcohol only if the patient initiates the discussion (which is uncommon) or there is a clear indication to do so (e.g., intoxication). Given the prevalence of alcohol use disorders and their contribution to patient morbidity and mortality, family physicians are best positioned to screen for this problem.

In the proposed decision memo, CMS refers to "qualified" primary care physicians and other primary care practitioners. CMS defines "primary care physicians" and "other primary care practitioners," but "qualified" was not defined. However, the AAFP concurs with the CMS proposal to define “physician” for purposes of this national coverage determination as physicians who are identified in the available data as a general practitioner, family medicine practitioner, general internist, obstetrician, or gynecologist. The AAFP recommends that CMS also include geriatrician physicians for purposes of the alcohol misuse coverage determination.

The AAFP recognizes that this proposed decision memo pertains to Medicare beneficiaries, yet this largely excludes the adolescent population. It is the AAFP’s position that the avoidance of alcohol products by adolescents is desirable. The University of Michigan's Monitoring the Future National Results on Adolescent Drug Use: Overview of Key Findings 2010 reports that "Alcoholic beverages have been among the most widely used psychoactive substances by American young people for a very long time. In 2010 the proportions of 8th, 10th, and 12th graders who admitted drinking an alcoholic beverage in just the 30-day period prior to the survey were 14%, 29%, and 41%, respectively." Although the evidence regarding the effectiveness of physician’s advice and counseling is uncertain, it is the AAFP’s recommendation that physicians should use their clinical judgment in determining whether or not to counsel an adolescent patient regarding alcohol use. The USPSTF recommendation, in the clinical consideration portion, includes a statement that, “Effective interventions to reduce alcohol misuse include an initial counseling session of about 15 minutes, feedback, advice, and goal-setting. Most also include further assistance and follow-up. Multi-contact interventions for patients ranging widely in age (12-75 years) [emphasis added] are shown to reduce mean alcohol consumption by 3 to 9 drinks per week, with effects lasting up to 6 to 12 months after the intervention.” As CMS and the U.S. Department of Health & Human Services make future coverage determinations for state-based health exchanges, Consumer Operated and Oriented Plans (CO-OPs) or as HHS works with states on their Medicaid programs, we recommend coverage of alcohol screenings for adolescents.

The AAFP looks forward to working further with CMS to assist in the creation of coding and billing rules needed to implement this new policy. We appreciate the opportunity to provide these comments and make ourselves available for any questions you might have or clarifications you might need. Please contact Robert Bennett, Federal Regulatory Manager, at 202-232-9033 or rbennett@aafp.org.

Sincerely,

Lori J. Heim, MD, FAAFP Board Chair

CC: Louis Jacques, MD, CMS Director, Coverage and Analysis Group

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August 18, 2011

Lawrence Schott, MD, MS
Lead Medical Officer, Division of Medical and Surgical Services
The Centers for Medicare and Medicaid Services

Dear Dr. Schott:

The UPMC Insurance Services Division (“UPMC”) is pleased to have the opportunity to comment on the proposed coverage decision for “Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse” (CAG-00427N). UPMC proudly offers Medicare Advantage (MA) Plans and Medicare Prescription Drug Benefit Programs to more than 100,000 Medicare beneficiaries in Pennsylvania, West Virginia and Ohio. Our UPMC for Life Specialty Plan is the 7th largest full dual Special Needs Plan (D-SNP) in the United States. We support CMS (the “Agency”) in its ongoing effort to identify, through the national coverage determination process, those evidence-based preventive services that are reasonable and necessary for the prevention or early detection of illness or disability and appropriate for Medicare beneficiaries. UPMC applauds CMS for its thorough review of available peer-reviewed evidence and its commitment to a transparent coverage decision process, as evidenced by the Agency’s articulation of the various evidentiary questions and decisional elements under consideration.

The U.S. Census Bureau has projected that the percentage of the U.S. population over age 65 will increase from 13 percent to almost 20 percent in the next two decades.^1; Accordingly, it is critical that Medicare coverage and treatment policies to support comprehensive and effective preventive care for Medicare beneficiaries are implemented now, so that they may be refined to appropriately protect and treat our aging population in the coming years. UPMC believes that for all Medicare beneficiaries, but particularly for dual SNP beneficiaries, many of whom suffer from multiple chronic physical or behavioral health conditions, identifying and appropriately treating alcohol misuse is critical to the overall effectiveness of patient care.

According to the 2009 National Survey on Drug Use and Health, nearly 40 percent of adults aged 65 or older report some level of current alcohol use, and more than a quarter of those users report heavy use or binge drinking.²; In addition, among UPMC’s D-SNP members, a majority of whom are under age 65, a third or more have serious mental illness and/or substance abuse diagnoses. The Department of Health and Human Services Office on Disability has also stated that “[p]ersons with any type of disability experience substance abuse at rates 2 to 4 times that of the general population,” that almost 40 percent of individuals over age 65 have a disability, and that the prevalence of disability dramatically increases with age.^3;4; Further, the 2007-2008 National Health and Nutrition Examination Survey found that almost 90 percent of Americans over age 60 had taken at least one prescription drug in the previous month, and almost two-thirds had taken three or more.⁵; The National Institutes of Health has acknowledged the danger of alcohol misuse and drug interaction among seniors, stating that “the elderly may be especially likely to mix drugs and alcohol and are at particular risk for the adverse consequences of such combinations.”^6; These findings strongly suggest that Medicare beneficiaries are at increased risk for the damaging effects of alcohol misuse. Adverse alcohol-drug interactions and other negative health effects, including the potential for reduced efficacy of treatment for an individual’s other concurrent health conditions, can necessitate the need for additional (and potentially costly) health care services, which might otherwise have been unnecessary.

UPMC has historically recognized screening and behavioral counseling in primary care as effective tools for the meaningful prevention and early detection of illness or disability in Medicare beneficiaries, and has therefore included these as covered services (at no cost-sharing) for its Medicare members. We believe that these services contribute positively to the overall effectiveness of care and improve the health and quality of life for many Medicare beneficiaries. Despite this, it has been our experience that many providers do not take advantage of UPMC’s coverage for these services, presumably (at least in part) because of their adherence to and familiarity with the general coverage policies of the Medicare program. We therefore believe that, in addition to providing Medicare beneficiaries with a valuable benefit, the inclusion of these services as Medicare preventive services will provide notice of the availability of coverage to those providers.

For all the reasons above, the UPMC Insurance Services Division supports the Agency’s proposed coverage decision for inclusion as a Medicare preventive service the named screening and behavioral counseling interventions in primary care to reduce alcohol misuse.

1 “Table 3. Percent Distribution of the Projected Population by Selected Age Groups and Sex for the United States: 2010 to 2050 (NP2008-T3).” Population Division, U.S. Census Bureau. August 14, 2008.
2 National Survey on Drug Use and Health: Summary of National Findings. Substance Abuse and Mental Health Services Administration, 2009. Available at http://oas.samhsa.gov/NSDUH/2k9NSDUH/2k9Results.htm.
3 “What is Disability and Who is Affected by Disability?” Available at http://www.hhs.gov/od/about/fact_sheets/whatisdisability.html.
4 “Substance Abuse and Disability.” Available at http://www.hhs.gov/od/about/fact_sheets/substanceabusech26.html.
5 “Prescription Drug Use Continues to Increase: U.S. Prescription Drug Data for 2007-2008.” NCHS Data Brief No. 42, September 2010. National Center for Health Statistics. Centers for Disease Control and Prevention.
6 “Alcohol Alert.” National Institute on Alcohol Abuse and Alcoholism No. 27 PH 355, January 1995 (Updated October 2000). Available at http://pubs.niaaa.nih.gov/publications/aa27.htm.

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August 18, 2011

Louis Jacques, MD
Director, Coverage and Analysis Group
Jyme Schafer, MD, MPH
Director, Division of Medical and Surgical Services
Centers for Medicare and Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244

Re:  Proposed Coverage Decision Memorandum for Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse; CAG-00427N
       Proposed Coverage Decision Memorandum for Screening for Depression in Adults; CAG-00425N

Dear Drs. Jacques and Schafer:

On behalf of the American Medical Association (AMA), we appreciate this opportunity to provide comments on the Centers for Medicare and Medicaid Services’ (CMS) Proposed Coverage Decision Memorandum for Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse; CAG-00427N, along with the Proposed Coverage Decision Memorandum for Screening for Depression in Adults; CAG-00425N.

Regarding reduction in alcohol misuse, CMS is proposing that the evidence is adequate to conclude that screening and behavioral counseling to reduce alcohol misuse, which is recommended with a grade of B by the U.S. Preventive Services Task Force (USPSTF) for adults, including pregnant women, in primary care settings, is reasonable and necessary for the prevention of early illness or disability, and is appropriate for individuals entitled to benefits under Part A or enrolled under Part B. Therefore, CMS proposes to cover annual alcohol screening and for those that screen positive, up to four brief, face-to-face, behavioral counseling interventions per year for Medicare beneficiaries, including pregnant women:

• Who misuse alcohol, but whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence (defined as at least three of the following: tolerance; withdrawal symptoms; impaired control; preoccupation with acquisition and/or use; persistent desire or unsuccessful efforts to quit; sustains social, occupational, or recreational disability; use continues despite adverse consequences);
• Who are competent and alert at the time that counseling is provided; and
• Whose counseling is furnished by qualified primary care physicians or other primary care practitioners in a primary care setting.

Regarding depression in adults, CMS proposes that the evidence is adequate to conclude that screening for depression in adults, which is recommended with a grade of B by the USPSTF, is reasonable and necessary for the prevention or early detection of illness or disability, and is appropriate for individuals entitled to benefits under Part A or enrolled under Part B. Therefore, CMS proposes to cover annual screening for depression for Medicare beneficiaries in primary care settings that have staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment, and follow-up.

The AMA applauds CMS’ proposals to provide Medicare coverage for annual alcohol screening, with behavioral counseling interventions for those that screen positive, as well as annual screening for depression. Alcohol misuse is a serious, disabling disease. Depression is also a widespread, debilitating, and under-treated medical illness, and physicians, particularly those in primary care settings, should be reimbursed for performing depression, as well as alcohol screenings. The AMA has urged CMS to provide Medicare coverage for these critical services, and we appreciate that CMS is taking steps to implement such coverage. We also urge CMS to utilize CPT codes 99408 and 99409 for alcohol and/or substance abuse screening to report the newly covered alcohol misuse services. On January 1, 2008, CPT implemented these codes, and we urge their use for these newly covered services instead of the proposed G code.

Sincerely,

James L. Madara, MD

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The proposed Medicare coverage for screening and behavioral counseling intervention in primary care to reduce alcohol misuse (CAG-00427N) is extremely important and will be of great benefit to older adults. Many studies have found that because of stigma and other factors the majority of older adults are reluctant to admit that the have an alcohol or mental health problem and don't seek services. The majority of those that do receive services access it through primary care. So covering screening through primary care makes a lot of sense.

There is a big concern, however, about limiting the screening to a primary care "setting". Since primary care "providers" are defined the actual location of the screening or counseling should not be a factor. There are many older adults that are in institutions, home bound, or lack transportation, who are unable to get to a primary care "setting". These individuals should not be denied the screening because of this. Also primary care practices frequently do screening at health fairs, senior centers, nutrition programs, nursing homes, etc. The current wording would eliminate coverage at these locations even though the screening would be performed by a qualified primary care practitioner.

I urge you to reconsider the wording to eliminate the barriers to this much needed service.

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August 17, 2011

Donald M. Berwick, M.D.
Administrator, Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201

Re: National Coverage Analysis (NCA) for Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse (CAG-00427N)

Dear Dr. Berwick:

Sincerely,

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August 16, 2011

Mr. Donald M. Berwick, M.D., M.P.P.
Administrator
Centers for Medicare & Medicaid Services
Hubert H. Humphrey Building
200 Independence Avenue, S.W., Room 445-G
Washington, DC 20201

Submitted electronically

RE: Proposed Decision Memo for Screening for Depression in Adults (CAG-00425N)

Dear Dr. Berwick:

On behalf of our 145 member hospitals and 17 member health systems, the Minnesota Hospital Association (MHA) thanks you for the opportunity to comment on CMS’ proposed decision memo for screening for depression in adults (CAG-00425N).

Along with the American Hospital Association (AHA), MHA fully supports CMS’ proposal to add alcohol screening and behavioral counseling, as well as screening for depression, to the package of prevention services offered to Medicare beneficiaries.

Minnesota’s hospitals and health systems helped implement the Institute for Clinical Systems Improvement’s (ICSI) DIAMOND model of depression treatment. MHA and our members have long been supporters of bringing evidence-based health care guidelines into practice. The CMS memo is an affirmation of the important work being done in Minnesota and now across the nation.

MHA supports the use of the primary care setting for these screenings. In addition, MHA strongly supports the memo’s recommendation to provide treatment or support once the screening is completed. This next step is critical to successfully treating depression, behavioral conditions, and alcohol abuse.

Finally, MHA would like to recommend CMS expand its suggestion of what provider types are considered “clinical staff” in staff-assisted depression care support. Evaluations of DIAMOND have found certified medical assistants to be an important part of the successful DIAMOND model. Adding “certified medical assistant” to “nurse and physician assistant” as “clinical staff …in the primary care office who can advise the physician of screening results and who can facilitate and coordinate referrals to mental health treatment” will enable more individuals to receive coordinated care and successful treatment.

If you have any questions, please feel free to contact me at (651) 659-1405 or jmcnertney@mnhospitals.org.

Sincerely,

Jennifer McNertney
Policy Analyst

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Mayo Clinic strongly supports Medicare coverage of alcohol screening and behavioral counseling.

The proposed decision memo outlines only primary care physicians, nurse practitioners, clinical nurse specialist, and physician assistant as providers of the alcohol screening and behavioral counseling. We urge CMS to consider coverage of screening and counseling services delivered by a wider range of providers (Aalto). We encourage CMS to consider allowing care managers (RNs and/or trained care managers) who are given training in the SBIRT (Screening, Brief Intervention, and Referral to Treatment) model to also provide alcohol screening and behavioral counseling under the general or direct supervision of a physician or non-physician practitioner. We believe CMS should cover alcohol screening and/or behavioral counseling by other providers who are trained and who use established tools such as those outlined in the decision memo which would result in more beneficiaries receiving the service. Several implementation studies show positive results of SBIRT when delivered by emergency room RNs (Desy), mental health nurses in the role of alcohol health workers (Crawford), or employee assistance program (EAP) counselors (Osilla).

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August 17, 2011

Donald Berwick, MD
Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
7500 Security Boulevard
Baltimore, MD 21244-1850

Dear Dr. Berwick,

The American Psychiatric Association (APA), the national medical specialty society representing more than 37,000 psychiatric physicians, appreciates the opportunity to comment on CMS’s proposals to cover an annual screening for Medicare beneficiaries in primary care settings and an annual alcohol screening and four brief face-to-face behavioral counseling sessions for Medicare beneficiaries who screen positive for alcohol misuse. The APA joins CMS in advocating for the addition of each of these services to Medicare’s package of preventive benefits. The APA would like to submit the following comments on these two proposed Medicare preventive benefits.

The APA supports annual depression screenings as a Medicare preventive benefit, as it did in its March 2011 regulatory comments, which are included below, with the following additions: 1) The APA thinks that if CMS makes it a requirement that staff-assisted supports be in place for the administration of depression screenings in primary care settings, at a minimum level, staff-assisted care supports should consist of clinical staff (e.g., nurse, physician assistant) in the primary care office who can inform the physician of screening results, discuss the screening results with the patient, and who can facilitate and coordinate referrals to mental health treatment. 2) The APA wishes to emphasize the importance of psychiatric consultation following a depression screening that is positive. 3) The APA wants to ensure appropriate payment systems are in place to guarantee the physician administering the depression screening is fairly reimbursed for conducting the depression screening, discussing with the patient his or her screening results, and, if necessary, consulting with a psychiatrist, and referring the patient for further mental health treatment.

Based on available evidence and recommendations from the U.S. Preventive Services Task Force (USPSTF)¹, as well as recommendations from current clinical practice guidelines, the APA supports screening of adult patients for depression at least once per year, linked with a follow-up diagnostic evaluation and treatment by a clinician, when indicated for individuals who screen positive. Screening may be performed by any office staff and/or patients as self-screeners. Interpretation and follow-up, however, should be performed by qualified clinicians who are acting within the scope of practice permitted by their states’ licensure law.

Depression is a widespread, debilitating, and undertreated medical illness. Unipolar major depression conveys an enormous disease burden.² The twelve month prevalence of major depressive disorder has been estimated at 6.6 percent.³ Patients with depression have significantly higher annual health care costs, at a mean of $4,246, than those patients without depression, at a mean of $2371.⁴ As much as one- third of Americans’ illness-related work leave can be attributed to mental rather than physical disorders, yet only 6.2 percent of all United States health care spending is directed towards the treatment of mental disorders.⁵

It is of critical importance that physicians, especially in primary care settings be reimbursed to perform depression screenings. For many Americans, annual examinations from a primary care physician serve as their only entry to the health care system. About one-quarter to one-half of patients with depression already receive treatment in primary care.⁶ Because of continuing stigma associated with mental illness, limited availability of mental health specialists in rural areas, or disparities in health care coverage, many patients are likely to seek mental health from a primary care physician rather than a mental health specialist, and the need for detection of depressive symptoms in primary care settings is expected to increase.⁷ Most depressed patients will present to their primary care physician with somatic complaints rather than complaining of a depressed mood.⁸ Routine screening can thus be a vital tool in detecting unreported symptoms of depression.

A number of validated screening tools are available to assist primary care physicians in identifying the symptoms of depression in their patients. The nine-item Patient Health Questionnaire (“PHQ-9”), for example, is a routinely used tool for screening, assessment, and monitoring that parallels the DSM-IV symptom criteria for depressive disorders. The PHQ-2 is a two-item version specifically recommended for screening in the Department of Veterans Affairs/Department of Defense’s (VA/DoD’s) 2009 Clinical Practice Guideline for Management of Major Depressive Disorder. Advantages of the PHQ-9 include the test’s brevity, ease of administration and interpretation, and sensitivity to change over time. ⁹

The USPSTF “recommends screening adults for depression where staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up as a grade B recommendation, i.e., with a high level of certainty of benefit.¹⁰ This recommendation is supported by well-designed and well-conducted studies of the collaborative care model of depression management. Under this model, primary care physicians collaborate with mental health professionals to provide screening and follow-up including complete assessment and treatment as needed.

When staff-assisted depression care supports are not in place, the USPSTF recommends against routinely screening adults for depression, with a grade C.¹¹ This recommendation is easy to misunderstand. As defined by the USPSTF, grade C recommendations mean that “there may be considerations that support providing the service in an individual patient.”¹² The APA suggests that for depression, such considerations should include patient populations with general medical conditions that are both frequently combined with depression and highly prevalent in adult and elderly populations, including cardiovascular disease, stroke, diabetes, Parkinson’s disease, obesity, sleep apnea, HIV infection, and pain syndromes.¹³ These comorbidities are common among patients covered by Medicaid and Medicare. Because of the interrelationship between depression and general medical illness, APA has emphasized the importance of recognizing and treating depression in medically ill patients and vice versa.¹⁴ Although CMS is not required by statute to consider USPSTF grade C recommendations, APA suggests that because medically ill patients are frequently managed in primary care settings, this recommendation (when properly understood) gives additional backing to the importance of CMS reimbursement for depression screenings in such settings, even when staff-assisted depression care supports are not in place.

The VA/DoD guideline recommends that all adult patients seen in primary care settings be screened for major depressive disorder annually using the PHQ-2¹⁵ The VA/DoD Guideline describes such screening as “an important mechanism for reducing morbidity and mortality.”¹⁶ The VA/DoD recommendation does not make screening contingent on the availability of staff supports, but does recommend follow-up of patients who screen positive. This recommendation is both clinically sensible and consistent with the same evidence reviewed by the USPSTF.

The Canadian Task Force on Preventive Health Care also recommends “screening adults for depression in primary care settings since screening improves health outcomes when linked to effective follow-up and treatment.”¹⁷ The Task Force notes that in the evidence base “effective follow-up and treatment” refers to integrated screening and feedback/treatment systems which are not the norm in Canadian primary care practice and encourages clinicians to advocate for these.

In light of the above recommendations, the APA supports CMS coverage of annual depression screening of adult patients regardless of whether staff-assisted depression care supports are in place. Such coverage may improve recognition and treatment of depression in two ways: First, by encouraging physicians, especially primary care physicians, to implement evidence-based integrated care models for the management of depression, and second, by encouraging them to screen patients with general medical conditions frequently comorbid with depression. When primary care physicians lack resources to follow up positive depression screens with assessment and treatment, the APA suggests that patients should be referred to another physician (e.g., a psychiatrist) for complete evaluation and, when depression treatment is indicated, to a qualified mental health specialist.

The APA endorses CMS’s proposal to provide Medicare beneficiaries with an annual alcohol screening in a primary care setting, and for those who screen positive, up to four brief, face-to-face behavioral counseling sessions per year conducted by a primary care physician or primary care practitioner.

The effectiveness of this approach has been proven in other settings, such as for beneficiaries of the Veterans’ Administration health care system. Every twelve months, VA beneficiaries receive an alcohol misuse screening in a primary care setting. When a VA beneficiary screens positive for alcohol misuse, the VA’s health records system tags the beneficiary’s health care record with notice of a need for a brief intervention with the beneficiary’s primary care clinician, psychiatrist, or other professional staff trained in brief interventions. The practitioner or physician responds to the alert by having a brief, one-time counseling session with the VA patient.

APA members who work within the VA health system attribute even greater praise to CMS’s proposal, which would provide for up to four brief face-to-face counseling sessions between a primary care physician or other primary care practitioner and the Medicare beneficiary, in situations in which the beneficiary has tested positive in his or her annual alcohol misuse screening. APA members agree that CMS’s proposed Medicare alcohol misuse screening and counseling will particularly benefit high risk drinkers. High risk drinkers often do not satisfy the criteria for receiving substance abuse services. However, APA members identify high risk drinkers as a vulnerable population particularly responsive to brief interventions from a primary care physician or primary care practitioner. Brief interventions by a primary care physician or primary care practitioner are likely to prevent medical complications and avert the need for more intensive and expensive specialty care substance use disorder treatment.

APA members who have treated high risk drinkers acknowledge most high risk drinkers will respond well to brief alcohol misuse counseling from a primary care physician or primary care practitioner. Research by Fleming and colleagues (2002) corroborates APA members’ experiences, finding that brief interventions with high risk drinkers not only significantly reduce alcohol use but can lead to positive health outcomes several years after the intervention.

The APA strongly urges CMS to only reimburse for alcohol screenings if a structured screening test is used. The APA reminds CMS that alcohol misuse screening instruments vary in their effectiveness. An instrument’s effectiveness is greatly correlated with the population using the instrument. The APA encourages CMS to include the NIAAA’s Single Item Screen for its alcohol misuse screenings. This test has proven effectiveness in identifying high risk drinkers. The APA also supports use of the AUDIT-C test which is a 3 item test that can be given as a self assessment or computerized questionnaire.

The APA supports the 5A’s approach that has been adopted by the U.S. Preventive Services Task Force. However, it does not feel each of the behavioral counseling interventions has to be exactly consistent with this approach; iterations of the 5A’s approach should be acceptable when counseling Medicare beneficiaries who screen positive for alcohol misuse.

From our reading of the proposal, it is not clear how primary care physicians and primary care practitioners will be reimbursed for the provision of up to four brief, face-to-face alcohol misuse counseling sessions provided to Medicare beneficiaries who screen positive for depression. The APA seeks clarification regarding how alcohol misuse counseling sessions will be defined and coded. Will these services be coded under existing CPT nomenclature, and if so, by which codes? Or, is CMS proposing the development of a new CPT code?

The APA thanks CMS for the opportunity to comment on its proposal to make depression screening, alcohol misuse screening, and alcohol misuse counseling benefits available to Medicare beneficiaries in primary care settings. Primary care physicians and primary care practitioners play an important role in diagnosing incidents of depression and alcohol misuse. For most Americans with mental health disorders, primary care physicians and primary care practitioners serve as an entry way to the mental health system. The APA thinks CMS’s proposed benefits will better equip primary care physicians and practitioners to address the mental health needs of their patients. Psychiatrists stand ready to assist primary care physicians and practitioners as they provide these screening and counseling services. For questions regarding the APA’s comments, please contact Julie A. Clements, J.D., APA Deputy Director, Regulatory Affairs, at (703)-907-7842 or via email at jclements@psych.org

Sincerely,

1 USPSTF. Screening for Depression in Adults, December 2009 http://www.uspreventiveservicestaskforce.org/uspstf/uspsaddepr.htm#related .

2 World Health Organization 2008: The global burden of disease: 2004 update.

3 See National Comorbidity Survey Replication; Kessler et al, 2003.

4 Narrow WE, Duffy FF, “Outcome Measures for the Treatment of Depression in Primary Care Settings,” at p. 319 in Tansella M and Thornicroft G (eds.): Mental Health Outcome Measures, 3rd edition, London: Gaskell, 2010.

5 Kessler RC, Heeringa S., Lakoma M.D., et al, Individual and Societal effects of Mental Disorders on Earnings in the United States: Results from the National Comorbidity Survey Replication. June 2008. Am. J. Psychiatry 165(6): 708

6 Narrow WE, Duffy FF, “Outcome Measures for the Treatment of Depression in Primary Care Settings,” at p. 319 in Tansella M and Thornicroft G (eds.): Mental Health Outcome Measures, 3rd edition, London: Gaskell, 2010.

7 Id.

8 The VA/DoD Clinical Practice Guideline for Management of Major Depressive Disorder, Appendix B, p. 4.

9 Narrow WE, Duffy FF, “Outcome Measures for the Treatment of Depression in Primary Care Settings,” at p. 332 in Tansella M and Thornicroft G (eds.): Mental Health Outcome Measures, 3rd edition, London: Gaskell, 2010.

10 USPSTF. Screening for Depression in Adults, December 2009 http://www.uspreventiveservicestaskforce.org/uspstf/uspsaddepr.htm#related

11 Id.

12 Id.

13 American Psychiatric Association. Practice guidelines for the treatment of patients with major depressive disorder, third edition, Am. J. Psychiatry, 167 (Oct Suppl), 2010.

14 Id.

15 The VA/DoD Clinical Practice Guideline for Management of Major Depressive Disorder, Appendix B, p. 15.

16 Id. at p. 4.

17 See MacMillan HL, Patterson CJ, Wathen CN, et al. CMAJ 2005; 172:33-5.

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I fully support the Centers for Medicaid and Medicare Services proposed decision memo for "Screening and Brief Counseling Intervention in Primary Care to Reduce Alcohol Misuse."

I am the Director of Boulder County Public Health. We just completed our community health assessment process, and alcohol abuse is one of the top three priorities for us as a community. One of the major opportunities we see is more intervention at the community health clinic and private provider level for screening, intervention, and referral. As I am sure you are aware, we hear from providers that they will be able to do more of these upstream prevention activities when they have the ability to get paid to do it - this is a step in the right direction and will help us meet our need in Boulder County!

Sincerely,

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I support Medicare coverage of screening for unhealthy alcohol use (the spectrum from use that risks consequences to dependence). I have several substantive recommendations that may improve the decision.

1. This coverage recommendation presents an opportunity to modernize terminology to use an appropriate clinical designation for what should be identified by screening. That target is Unhealthy Alcohol Use which is the clearest and most inclusive term for the spectrum of interest, from use that increases risk of consequences, through dependence. "Misuse" implies intent and is pejorative, and is an inappropriate term for dependence. Sometimes "misuse" is used to include dependence, sometimes not, generating confusion. (N Engl J Med 2005; 352:596-607)

2.FOR PEOPLE WHO SCREEN NEGATIVE: Here we have new data to inform the question. We presented this at various national professional meetings. We followed over 14,000 people who initially screened negative for alcohol or drug misuse [most, alcohol] at a healthcare visit. 12-24 months later, on re-screen, 3.4% screened positive (this proportion is about 1/5th to 1/6th the proportion that screens positive on the first screen, however, it is not “small.” And could justify annual screening in this population). Reference: Alford DP et al. "Should adults who screen negative for unhealthy substance use be rescreened? "Subst Abuse 2010;31(3):209.

3. Although the coverage decision addresses "misuse" meaning nondependent unhealthy use, the fact is that when one screens one does not know what will be identified. Screening is done to detect the spectrum of unhealthy use. Those with low risk use or risky but nondependent use receive advice or brief intervention. However, it is important that the coverage decision address dependence as well. Currently it is often the case that when a physician (nor under behavioral health contract) bills for the diagnosis of alcohol dependence only, the bill is not paid. It is critical that coverage extend to dependence since treatment of dependence in primary care is efficacious (O'Malley SS re naltrexone in primary care; COMBINE Study by Anton R et al. as examples).

4. Coverage should extend beyond physician services. It is clear that screening and brief intervention will never be widely disseminated as it should be unless it is implemented by a team or system of care. This requires staff beyond the physician and systems such as decision support (electronic). Coverage should extend to health educators. Although definitive evidence for efficacy is unavailable, a systematic review by Sullivan L et al in Am J Addictions 2011 suggests that "nonphysician" brief intervention is not significantly less efficacious than physician intervention.

5. Referral to treatment is not evidence-based, in that there is little to no evidence that referral to treatment of people identified by screening leads to completion of referrals and/or clinical benefit. As such it is critical that treatment of dependence be covered in medical settings.

6. The screening test most likely to be done because of brevity and validity (published by Smith P et al in J Gen Intern Med 2009) is the single item screening test (How many times in the past year have you had 5 or more (4 or more for women) drinks in a day?) recommended by the National Institute on Alcohol Abuse and Alcoholism. This test has been underemphasized in the coverage decision documents. The AUDIT-C is also a good choice if and only if there is electronic calculation of the score and decision support to address how to respond to different levels of the test result, and if there is ample time to answer all three questions and to sort through response options. Other tests are longer or more complicated (AUDIT) or do not detect the condition of interest (CAGE, MAST).

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The American Congress of Obstetricians and Gynecologists (ACOG), representing more than 52,000 physicians and partners dedicated to improving women’s health, appreciates the opportunity to comment on the “Proposed Decision Memo for Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse (CAG-00427N)”. Our primary concern in reviewing any proposal for new reimbursement policies is the potential impact these policies may have on access to and quality of health care for women.

We appreciate that screening and behavioral counseling to reduce alcohol misuse will be covered under Medicare. The proposal allows "four brief, face-to-face behavioral counseling interventions per year to address alcohol or substance abuse in primary care.” This number of visits is inadequate. Alcohol and substance use disorders are chronic and recurring conditions that require frequent and consistent intervention. There is no evidence that CMS should limit the amount or frequency of physician/patient interaction for alcohol and substance use disorders.

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August 16, 2011

Louis Jacques, MD
Director, Coverage and Analysis Group
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244

Re: Proposed Decision Memo for Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse (CAG-00427N)

Dear Dr. Jacques:

On behalf of the 8,000 members of NAADAC, the Association for Addiction Professionals, I am writing to comment on Medicare's proposed national coverage determinations (NCDs) of screening and behavioral counseling in primary care to reduce alcohol misuse. NAADAC thanks CMS for its strong commitment to make prevention of substance use disorders a top prevention priority in Medicare.

We strongly support the CMS proposal to cover as a preventive service screening and behavioral counseling interventions in primary care to reduce alcohol misuse. Excessive alcohol use and misuse of psychoactive prescription drugs represent major, but often neglected public health problems among older Americans, even among those who regularly receive health care from a physician.[i] These problems include heavy drinking, drinking and driving, medication interactions, depressive symptoms, insomnia, poor nutrition, congestive heart failure, impaired cognitive function, osteoporosis, and loss of balance leading to falls, the most common cause of fractures and accidental death in this age group.[ii]

More than one million patients have been screened for alcohol, drug and tobacco use and provided behavioral health counseling as part of a large SAMHSA demonstration grant program. Experience has shown that routine delivery of screening and behavioral health counseling in primary care is greatly enhanced when primary care teams are expanded with trained and clinically supervised health educators and paraprofessionals. Physicians and other medically trained primary care clinicians simply do not have time to respond to the 20% to 30% of patients who are positive on initial screens. We strongly recommend that Medicare Part B incident-to billing rules be substantially relaxed, so that primary care can be reimbursed for screening and behavioral counseling by paraprofessionals under their supervision who deliver these services (1) according to standing orders, (2) following evidence-based protocols, and (3) on the same day when supervising providers deliver other professional services. In addition, it is important that Medicare Part B prevention reimbursement be available to ALL patients, not just those with an alcohol-related injury or illness.

Evidence-based screening instruments exist that can detect harmful alcohol and other drug use in this vulnerable population. Brief interventions that can be delivered during a single primary care office visit have been tested in multiple randomized trials, including a multi-center one in the Medicare eligible age group. They demonstrate that screening and intervention significantly reduce health risks, and generate cost-savings of approximately $4 dollars for every dollar invested in providing them.[iii]

Substance use problems in this population are not uncommon. Analysis of the 2008 National Survey on Drug Use and Health (NSDUH) finds that 27.3% of men 65 years and older and 10.4% of older women report drinking 5 or more drinks on at least one occasion within the previous 30 days, levels that exceed NIAAA recommended limits[iv]. Although a small proportion of older men and women meet diagnostic criteria of alcohol use disorders (1.5% for men, 0.3% for women) [v], the much larger number of older Americans who use alcohol at unhealthy amounts that can dangerously interact with other medications that they take. As many as one in four older adults take psychoactive medications (i.e., sedative-hypnotics, anxiolytics, and narcotic-analgesics) that have high abuse potential, are frequently prescribed for common geriatric conditions (e.g., insomnia, anxiety, and chronic pain), and that interact dangerously with alcohol and other prescription drugs[vi] . Older individuals are more likely to experience adverse side effects from these medications, and their use can lead to significant drug interactions[vii].

Alcohol and psychoactive substance use are associated increased the risk of hospitalization, nursing home placement and death among older adults[viii]. A recent study of Medicare beneficiaries found that presence of heavy alcohol use more than doubles older the risk of hip fractures[ix]. Nightly use of benzodiazepines is associated with a significantly increased risk of falls among older adults, and other psychoactive medications (sedative-hypnotics, tranquilizers, and prescription analgesics) appear to also increase risk of falls in the elderly[x]. The cost to Medicare of the lack of routine screening and intervention for substance use is substantial. The annual cost to Medicare for the illnesses and injuries caused or complicated by alcohol use[xi],[xii] exceeds $1 million/1,000 enrollees ($99.51 per beneficiary per month). This cost was composed of $374,184 per 1,000 patients for outpatient services, $5,197 for emergency services, $735,671 for inpatient care, and $79,063 for time spent in a skilled nursing facility. One out of every six dollars spent by Medicare, more than $53 billion annually, goes to treating alcohol-related illnesses and injuries[xiii].

SAMHSA has projected future alcohol and drug use disorders among elderly patients.[xiv] They estimate that rates in this population will rise by 44% by 2020. Thus, it is timely and critical to introduce routine screening and brief intervention for alcohol and harmful prescription drug use problems as a routine component of clinical care for this fastest growing segment of society.[xv],[xvi] Thus, it is timely and critical that Medicare Part B cover routine screening and brief intervention for alcohol and harmful prescription drug use problems as a preventive service for this fastest growing segment of society.

Again, thank you for the opportunity to provide comments on this important topic. Please use us as a resource moving forward.

NAADAC, founded in 1972, is the primary professional association for addiction-focused counselors, nurses, educators and other health care workers. We represent nearly 8,000 members and affiliate organizations in over 50 states, territories and countries. NAADAC's mission is to lead, unify, and empower addiction-focused professionals to achieve excellence through education, advocacy, standards of practice, ethics, professional development and research.

Sincerely,

/s/
Donald P. Osborn, MS, MA, MAC, NCP, ICAC, NCC, LMFT, LMHC, LCSW
NAADAC President

[i] Dufour MC, Archer L, Gordis E. Alcohol and the elderly. Clin Geriatr Med 1992; 8: 127-141. Reid MC, Anderson PA. Geriatric substance use disorders. Med Clin North Am 1997;81:999-1016. Fink A, Morton SC, Beck JC et al. The alcohol-related problems survey: Identifying hazardous and harmful drinking in older primary care patients. JAGS;50:1717-1722. . Mokdad A. H., Marks J. S., Stroup D. F., Gerberding J. L. Actual causes of death in the United States, 2000. JAMA 2004; 291: 1238-45.. Darke S., Degenhardt L., Mattick R. Mortality Amongst Illicit Drug Users: Epidemiology, Causes, and Intervention. Cambridge: Cambridge University Press; 2007, p. 20-40.. Adrian M., Barry S. J. Physical and mental health problems associated with the use of alcohol and drugs. Subst Use Misuse 2003; 38: 1575-614.. Rehm J., Room R., Graham K., Monteiro M., Gmel G., Sempos C. T. The relationship of average volume of alcohol consumption and patterns of drinking to burden of disease: an overview. Addiction 2003; 98: 1209-28.

[ii] Yuan Z, Dawson N, Cooper GS et al. Effects of alcohol-related disease on hip fracture and mortality : A retrospective cohort study of hospitalized Medicare beneficiaries. Am J Public Health 2000;91:1089-1093.

[iii] Fleming M, et al. Guiding Older Adult Lifestyles. J Fam Pract 1999;48:378-84.

[iv] Analysis of NSDUH 2008 conducted November 29, 2009, Goplerud EN.

[v] Analysis of NSDUH 2008 conducted November 29, 2009, Goplerud EN.

[vi] Glantz MD, Sloboda Z: The elderly. In Coombs RH, Ziedonis DM (eds): Handbook on Drug Abuse Prevention: A Comprehensive Strategy to Prevent the Abuse of Alcohol and Other Drugs. Boston, Allyn & Bacon Press, 1995, p 429. Solomon K, Manepalli J, Ireland GA, et al: Alcoholism and prescription drug abuse in the elderly: St. Louis University grand rounds. J Am Geriatr Soc 41:57, 1993. Sorock GS, Shimkin EE: Benzodiazepine sedatives and the risk of falling in a community dwelling cohort. Arch Intern Med 148:2441, 1988. Sheahan SL, Coons SJ, Robbins CA, et al: Psychoactive medication, alcohol use, and falls among older adults. J Behav Med 18:127, 1995

[vii] Adams WL: Potential for adverse drug-alcohol interactions among retirement community residents. J Am Geriatr Soc 43:1021, 1995. Glantz MD, Sloboda Z: The elderly. In Coombs RH, Ziedonis DM (eds): Handbook on Drug Abuse Prevention: A Comprehensive Strategy to Prevent the Abuse of Alcohol and Other Drugs. Boston, Allyn & Bacon Press, 1995. Solomon K, Manepalli J, Ireland GA, et al: Alcoholism and prescription drug abuse in the elderly: St. Louis University grand rounds. J Am Geriatr Soc 41:57, 1993.

[viii] Reid M. C., Anderson P. A. Geriatric substance use disorders. Med Clin North Am 1997; 81: 999-1016. Reid M. C., Boutros N. N., O'Connor P. G., Cadariu A., Concato J. The health-related effects of alcohol use in older persons: a systematic review. Subst Abuse 2002; 23: 146- 64. American Geriatrics Society. Clinical Guidelines for Alcohol use Disorders in Older Adults. Available at: http://www. americangeriatrics.org/products/positionpapers/alcoholpf.shtml. Geriatric Mental Health Foundation. Substance Abuse and Misuse among Older Adults. Available at: http://www.gmhfonline.org/gmhf/consumer/factsheets/substnabuse_factsheet.html. Moore A. A., Whiteman E. J., Ward K. T. Risks of combined alcohol/medication use in older adults. Am J Geriatr Pharmacother 2007; 5: 64-74. Simoni-Wastila L., Yang H. K. Psychoactive drug abuse in older adults. Am J Geriatr Pharmacother 2006; 4: 380-94.

[ix] Yuan Z, Dawson N, Cooper GS et al. Effects of alcohol-related disease on hip fracture and mortality : A retrospective cohort study of hospitalized Medicare beneficiaries. Am J Public Health 2000;91:1089-1093.

[x] Sorock GS, Shimkin EE: Benzodiazepine sedatives and the risk of falling in a community dwelling cohort. Arch Intern Med 148:2441, 1988. Sheahan SL, Coons SJ, Robbins CA, et al: Psychoactive medication, alcohol use, and falls among older adults. J Behav Med 18:127, 1995.

[xi] CDC. Alcohol Related Disease Impact (ARDI). https://apps.nccd.cdc.gov/ARDI/HomePage.aspx)

[xii] Goplerud EN. Alcohol attributable fractions and Medicare costs. Working Papers, Ensuring Solutions to Alcohol Problems. Washington DC, GWU, 2005.

[xiii] Kaiser Family Foundation. Medicare spending by state of enrollee, 2004. http://www.statehealthfacts.org/comparemaptable.jsp?ind=628&cat=6

[xiv] Han B, Gfroerer JC, Colliver JD, Penne MA. Substance use disorder among older adults in the United States in 2020. Addiction. 2009;104:88-96.

[xv] Glantz MD, Sloboda Z: The elderly. In Coombs RH, Ziedonis DM (eds): Handbook on Drug Abuse Prevention: A Comprehensive Strategy to Prevent the Abuse of Alcohol and Other Drugs. Boston, Allyn & Bacon Press, 1995, p 429. Solomon K, Manepalli J, Ireland GA, et al: Alcoholism and prescription drug abuse in the elderly: St. Louis University grand rounds. J Am Geriatr Soc 41:57, 1993. Sorock GS, Shimkin EE: Benzodiazepine sedatives and the risk of falling in a community dwelling cohort. Arch Intern Med 148:2441, 1988. Sheahan SL, Coons SJ, Robbins CA, et al: Psychoactive medication, alcohol use, and falls among older adults. J Behav Med 18:127, 1995

[xvi] Adams WL: Potential for adverse drug-alcohol interactions among retirement community residents. J Am Geriatr Soc 43:1021, 1995. Glantz MD, Sloboda Z: The elderly. In Coombs RH, Ziedonis DM (eds): Handbook on Drug Abuse Prevention: A Comprehensive Strategy to Prevent the Abuse of Alcohol and Other Drugs. Boston, Allyn & Bacon Press, 1995. Solomon K, Manepalli J, Ireland GA, et al: Alcoholism and prescription drug abuse in the elderly: St. Louis University grand rounds. J Am Geriatr Soc 41:57, 1993.

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In San Luis Obispo County (CA), only 40% of pregnant women are screened for alcohol or drug use during pregnancy. Prenatal alcohol use causes Fetal Alcohol Syndrome and a spectrum of related cognitive and behavioral disorders that fall under the term Fetal Alcohol Spectrum Disorders. These are 100% preventable. Screening and brief intervention is known to be effective at preventing alcohol use during pregnancy.

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I strongly support the use of addiction screening and interventions in primary care, especially for pregnant women. I also believe that primary care settings should receive careful, comprehensive SBIRT training so that they may maximize the effectiveness of these evidence-based practices.

Coverage for alcohol screening and brief interventions as a core medical care service will send a powerful message that identification and intervention for alcohol problems should be part of routine primary care. Screening and brief intervention have been proven to have a sustained impact on reduced alcohol use and will therefore have major benefits both for patients and for overall medical care costs, as excessive drinking often makes other medical problems worse and harder to treat.

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I am a principal author of the WHO manuals on the AUDIT screening instrument and brief interventions, as well as other works on alcohol screening and brief intervention (which I abbreviated SBI nearly 20 years ago). I have also consulted to SAMHSA on its SBIRT program since before its initiation. I am currently consulting to CDC on its work in this area. I have devoted nearly 25 years to advancing alcohol screening and brief intervention.

Based upon the last 30 years of research, I would heartedly support (with the change mentioned below) your proposal to cover annual alcohol SBI. That research provides strong evidence of the efficacy of the service, and there is growing research evidence that implementation of the service in practical medical settings, especially primary care, is effective. It works, it can be done, and it, therefore, should be done. Having CMS pay for it will contribute to its being done. So please proceed to include it among CMS recommended, covered, and supported services.

I hope you will also continue to monitor this service as implementation advances. We need new and better methods of measuring its dissemination. And we need to learn how to advance its implementation in collaboration with many other countries that are also engaged in similar efforts (some of which are more advanced than the USA in this regard). WHO would be a useful partner in such collaboration, since it has spearheaded this initiative since 1980.

Please note also that CDC has published a guide for SBI implementation in trauma centers (http://www.cdc.gov/InjuryResponse/alcohol-screening/resources.html), which is now under revision. A primary care version of this manual should be available by the end of 2011. If you can supply information for providers willing to implement SBI on how best to obtain CMS reimbursement, I’m sure it would be acknowledged in these publications. CDC will also soon be launching a program to increase awareness and demand for medical practices to provide this service.

Finally, I would note one portion of your proposed plan with which I strongly disagree. The CAGE, T-ACE, and TWEAK are NOT acceptable screening instruments for the service recommended by the USPSTF. They are fairly good at identifying alcohol dependence, which affects fewer than 4% of American adults annually. But since they do not measure alcohol consumption in any way, they are not acceptable instruments to identify the 25% of adult Americans who are not dependent but who drink in excess of recommended guidelines annually. It is the latter population that should be the prime target for screening and brief intervention. So please DELETE the mention of these instruments from your final decision.

If I can be of any assistance in your important work, please contact me at johnhb7@comcast.net or 203-393-1030.

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This proposal is basic common sense: "an ounce of prevention (and early diagnosis) is worth a pound of cure." With proper screening and evidence-based early intervention, the enormous costs (financial and quality of life/emotional) untreated abuse and addiction can be dramatically reduced.

Nowhere is this more true than for a pregnant woman and her very vulnerable fetus. And, it is true across the board for any abuser or addict. Do IT...it is the right thing on every level.

Coverage for alcohol screening and brief interventions as a core medical care service will send a powerful message that identification and intervention for alcohol problems should be part of routine primary care. Screening and brief intervention have been proven to have a sustained impact on reduced alcohol use and will therefore have major benefits both for patients and for overall medical care costs, as excessive drinking often makes other medical problems worse and harder to treat.

In addition, Medicare coverage often sets the standard for other insurance benefits. If this proposal takes effect, other insurers may follow Medicare's lead and provide the same coverage for people participating in their plans.

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Dear Dr. Schott,

The National Congress of American Indians (NCAI) is the nation’s oldest, largest, most representative national tribal organization made up of American Indian and Alaska Native tribal governments. NCAI writes in strong support of the proposed coverage decision to provide screening and behavioral counseling to reduce alcohol misuse under Medicare Parts A and B. The proposed coverage decision memo addresses a serious need in Indian Country, as alcohol abuse and dependency has plagued tribal communities for more than two centuries. Recent data shows American Indians and Alaska Natives are five times more likely than the majority population to die of alcohol-related causes.i Other data reveals that between 2003 to 2005, American Indians and Alaska Natives alcoholism death rates were 519% higher than the alcoholism death rate for all other races in the United States. ii Alcoholism is a leading contributed to other behavioral health issues in tribal communities, including additional substance abuse problems, domestic violence, and child malnutrition and neglect. NCAI appreciates the work the Centers for Medicare and Medicare Services are doing to protect tribal communities and looks forward to future work together.

If you have questions please contact Ahniwake Rose at arose@ncai.org or 202-466-7767.

Sincerely,

Jacqueline Pata
Executive Director
Substance Abuse and Mental Health Services Administration.
Center for Substance Abuse Prevention.

Fetal Alcohol Spectrum Disorders Center for Excellence. (2007). Fetal Alcohol Spectrum Disorders Among Native Americans. Retrieved August 1, 2011, from http://www.fasdcenter.samhsa.gov/documents/NI_WYNTK_FASD_Among_AIAN.pdf. ii Indian Health Service. Division of Behavioral Health (2011). American Indian and Alaska Native Behavioral Health Briefing Book. Retrieved August 3, 2011, from http://www.tribalhealthcare.org/documentlibrary/2011/08/IHS_BH_BriefingBook_072611.pdf

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I support the Centers for Medicaid and Medicare Services proposed decision memo for "Screening and Brief Counseling Intervention in Primary Care to Reduce Alcohol Misuse." It is well established that alcohol misuse causes a host of social and medical ills, exacerbates existing health problems and makes patients more difficult to treat.

I work for an agency which provides advocacy, shelter and help for victims of domestic violence and sexual assault. A huge percentage of the clients we work with have AODA issues and slip through the cracks getting help for these destructive addictions. Therefore they slip back into old patterns of behavior and ways to alleviate their psychological pain, self medication. Screening during primary care visits would identifiy many of these problems and be the first step in helping overcome the dependency. Thank you.

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It is well established that alcohol misuse causes a host of social and medical ills, exacerbates existing health problems and complicates patient care. On the other hand, numerous studies have demonstrated the efficacy and effectiveness of early identification and intervention for alcohol misuse to mitigate these negative effects.

While the evidence for alcohol misuse screening exists, the uptake of such screening and counseling interventions in primary care has been slow. Some studies, such as Saitz et al in JGIM from 2002, suggest that professional satisfaction in caring for patients with alcohol problems is lower than that for patients with other chronic health issues. Reviews have also suggested that primary care physicians may see identifying and addressing issues such as alcohol misuse as outside their scope of practice (Miller NS et al, Academ Med 2001). Historically, lack of parity for behavioral health issues and low reimbursement rates may also have contributed to the low uptake of SBIRT in primary care.

In the era of healthcare reform and focus on integrated, comprehensive care, however, such attitudes and paucity of reimbursement cannot stand. That is why I support the Centers for Medicaid and Medicare Services proposed decision memo for "Screening and Brief Counseling Intervention in Primary Care to Reduce Alcohol Misuse."

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Coverage for alcohol screening and brief interventions as a core medical care service will send a powerful message that identification and intervention for alcohol problems should be part of routine primary care. I have conducted and published in peer reviewed journals my own research on the positive effects of screening and brief intervention for pregnant women participating in WIC. Results indicated that this approach resulted in bettter newborn outcomes and lower mortality rates for those who received intervention as opposed those in the control group (O'Connor & Whaley, American Journal of Pubic Health, 2007). Screening and brief intervention have been proven to have a sustained impact on reduced alcohol use and will therefore have major benefits both for patients and for the developmental outcome of their children, resulting in reduced costs to society.

In addition, Medicare coverage often sets the standard for other insurance benefits. If this proposal takes effect, other insurers may follow Medicare's lead and provide the same coverage for people participating in their plans.

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This is an excellent move and has the potential to be very cost effective in the long run. Many people especially in the 50 - 70 year range fail to realize the dangers of alcohol consumption while taking medications. Some doctors fail to properly inform/warn their patients about alcohol use or try to keep them happy by saying "sure it is alright if you have a drink now and then". To some in this category that means several drinks every day. I say this from anecdotal observations made in my own community.

I believe that many health issues can be averted or minimized if we reduce the consumption of alcohol.

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To whom it may concern,

I am in full support of Medicare and Medicaid covering screening and brief counseling interventions in Primary Care. This would be a large step in the right direction of reducing the alarming trends regarding binge drinking and alcohol misuse and abuse. This is very important to me, especially in Colorado where I live and here the alcohol misuse and abuse rates are higher than the national average. This change would help set a standard in Primary Care and save millions of dollars and lives at the same time.

Thank you very much for your time.

Nicole E. Teel MS

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Please adopt the current proposal to provide coverage for alcohol screening and brief interventions as a core medical care service.

This is a wise investment that will pay back in many ways — better care for patients, lower overall medical costs through improved screening and providing at-risk patients with vitally important preventive care against.alcohol and substance abuse.

Emotional and physical illness, family violence, drunk driving incidents, fetal alcohol syndrome, and placing children of alcoholic parents at risk of addiction themselves and other potential health impacts of living with addicted parents — all of these harms can be reduced by early screening and care for those at risk of alcohol and substance abuse.

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I have been working at the Hanley Center in West Palm Beach, FL for close to a year now. I perform brain SPECT for our inpatients here. We look at the regional cerebral blood flow (rCBF) in alcohol and drug addiction. The most striking decreases in rCBF seem to occur in alcoholics. Opiates, cocaine, marijuana, benzodiazapines, amphetamines...none of these seem to affect the rCBF as much as alcohol.

"An ounce of prevention is worth a pound of cure."

I support the Centers for Medicaid and Medicare Services proposed decision memo for "Screening and Brief Counseling Intervention in Primary Care to Reduce Alcohol Misuse." It is well established that alcohol misuse causes a host of social and medical ills, exacerbates existing health problems and makes patients more difficult to treat.

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Coverage for alcohol screening and brief interventions as a core medical care service will send a powerful message that identification and intervention for alcohol problems should be part of routine primary care. Screening and brief intervention have been proven to have a sustained impact on reduced alcohol use and will therefore have major benefits both for patients and for overall medical care costs, as excessive drinking often makes other medical problems worse and harder to treat.

In addition, Medicare coverage often sets the standard for other insurance benefits. If this proposal takes effect, other insurers may follow Medicare's lead and provide the same coverage for people participating in their plans.

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I have worked in the Addictions field for 25 years. I believe that it is a primary illness that frequently goes undiagnosed. The consequences get diagnosed. This action would go a long way toward assisting patients and families improve their quality of life. It could save untold amounts of money in that proper diagnosis and treatment of this primary disease would help avoid the necessity to treat the consequences of this illness.

Therefore:

I support the Centers for Medicaid and Medicare Services proposed decision memo for "Screening and Brief Counseling Intervention in Primary Care to Reduce Alcohol Misuse." It is well established that alcohol misuse causes a host of social and medical ills, exacerbates existing health problems and makes patients more difficult to treat.

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Screening and brief intervention have a sustained impact on reduced alcohol use and will therefore have major benefits for patients as well as for overall medical care costs, as excessive drinking often makes other medical problems worse and harder to treat.

In addition, Medicare coverage often sets the standard for other insurance benefits. In providing this coverage, it sends a message to other insurers who may follow Medicare's lead and provide the same coverage for people participating in their plans, coverage that is vitally needed.

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Coverage for alcohol screening and brief interventions as a core medical care service will send a powerful message that identification and intervention for alcohol problems should be part of routine primary care. Screening and brief intervention have been proven to have a sustained impact on reduced alcohol use and will therefore have major benefits both for patients and for overall medical care costs, as excessive drinking often makes other medical problems worse and harder to treat.

In addition, Medicare coverage often sets the standard for other insurance benefits. If this proposal takes effect, other insurers may follow Medicare's lead and provide the same coverage for people participating in their plans.

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Coverage for alcohol screening and brief interventions as a core medical care service will send a powerful message that identification and intervention for alcohol problems should be part of routine primary care. Screening and brief intervention have been proven to have a sustained impact on reduced alcohol use and will therefore have major benefits both for patients and for overall medical care costs, as excessive drinking often makes other medical problems worse and harder to treat.

In addition, Medicare coverage often sets the standard for other insurance benefits. If this proposal takes effect, other insurers may follow Medicare's lead and provide the same coverage for people participating in their plans.

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I support the Centers for Medicaid and Medicare Services (CMMS) proposed decision memo for "Screening and Brief Counseling Intervention in Primary Care to Reduce Alcohol Misuse."

There are research-based screening instruments such as the CAGE (Ewing, 1984) and AUDIT (Babor et al., 1992) that have been tested and found effective in primary care settings. Moreover treatment services overwhelmingly support these brief assessment, screening type tools that establish targeted conditions with respect to acceptable levels of sensitivity and specificity (Bushsbaum et al., 1991, 1995; Bohn et al., 1995; Barry and Fleming, 1993; Saunders et al., 1993).

Evidence indicates that asking questions about alcohol or other drugs "primes" patients to disclose information and results in a two to threefold increase in their stated intention to discuss Substance Abuse problems with their health care provider (Skinner et al., 1985). Further, studies have indicated that screening for alcohol-related disorders is more acceptable to patients if it is part of a comprehensive health-risk evaluation that covers topics like exercise, diet, weight control and medication use (Allen et al.,1995). Also, using this approach within the larger context of preventive health care can help, including the screening of illicit drugs (Fleming and Barry, 1991).

It is well established that alcohol misuse causes a host of social and medical ills, exacerbates existing health problems and makes patients more difficult to treat. Every man, woman and child in America pays nearly $1,000 annually to cover the costs of unnecessary health care, extra law enforcement, motor vehicle crashes, crime and lost productivity due to substance abuse (Institute for Health Policy, 1993). Nearly 25% of Americans say that "drinking has been a cause of trouble in their family" (Institute for Health Policy, 1993, p.40). In addition, there was an “analysis of the epidemiological evidence, which revealed that 72 conditions requiring hospitalizations are wholly or partially attributable to substance abuse” (Center on Addiction and Substance Abuse, 1993, p.21). In short, substance use disorders are simply too pervasive and too costly to be ignored.

Fortunately, effective specialty treatment is available for problem drinkers and illicit drug users. Now there is effective brief interventions in primary care settings that studies indicate can substantially reduce hazardous drinking, a behavior that has enormous negative effects on public health (Kahan et al., 1995).

In this era of managed care, the primary care clinician's responsibility is expanding. As the gatekeeper charged with ensuring the provision of comprehensive care, the primary care clinician will almost certainly provide some type of alcohol or other drug-related service. Those clinicians who are familiar with the medical complications of substance abuse and are able to relate them to other co-morbid illnesses will be better equipped to deliver adequate, cost-effective care.

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I can not possibly support the Centers for Medicaid and Medicare Services proposed decision memo for "Screening and Brief Counseling Intervention in Primary Care to Reduce Alcohol Misuse." Although it is well established that alcohol misuse causes a host of social and medical ills, exacerbates existing health problems and makes patients more difficult to treat, there is no evidence that such screening programs are anything more than intrusive.

Attempting to demand that Medicare be used to pay for a testing program that has such a huge potential for abuse, incuding arresting mothers who test positive for alcohol and taking thier children fromthem, and even imprisonment, in far too many cases with such mandated testing regarding other drugs only shows how far such a testing system could be abused.

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I support the Centers for Medicaid and Medicare Services (CMMS) proposed decision memo for "Screening and Brief Counseling Intervention in Primary Care to Reduce Alcohol Misuse."

There are research-based screening instruments such as the CAGE (Ewing, 1984) and AUDIT (Babor et al., 1992) that have been tested and found effective in primary care settings. Moreover treatment services overwhelmingly support these brief assessment, screening type tools that establish targeted conditions with respect to acceptable levels of sensitivity and specificity (Bushsbaum et al., 1991, 1995; Bohn et al., 1995; Barry and Fleming, 1993; Saunders et al., 1993).

Evidence indicates that asking questions about alcohol or other drugs "primes" patients to disclose information and results in a two to threefold increase in their stated intention to discuss Substance Abuse problems with their health care provider (Skinner et al., 1985). Further, studies have indicated that screening for alcohol-related disorders is more acceptable to patients if it is part of a comprehensive health-risk evaluation that covers topics like exercise, diet, weight control and medication use (Allen et al.,1995). Also, using this approach within the larger context of preventive health care can help, including the screening of illicit drugs (Fleming and Barry, 1991).

It is well established that alcohol misuse causes a host of social and medical ills, exacerbates existing health problems and makes patients more difficult to treat. Every man, woman and child in America pays nearly $1,000 annually to cover the costs of unnecessary health care, extra law enforcement, motor vehicle crashes, crime and lost productivity due to substance abuse (Institute for Health Policy, 1993). Nearly 25% of Americans say that "drinking has been a cause of trouble in their family" (Institute for Health Policy, 1993, p.40). In addition, there was an “analysis of the epidemiological evidence, which revealed that 72 conditions requiring hospitalizations are wholly or partially attributable to substance abuse” (Center on Addiction and Substance Abuse, 1993, p.21). In short, substance use disorders are simply too pervasive and too costly to be ignored.

Fortunately, effective specialty treatment is available for problem drinkers and illicit drug users. Now there is effective brief interventions in primary care settings that studies indicate can substantially reduce hazardous drinking, a behavior that has enormous negative effects on public health (Kahan et al., 1995).

In this era of managed care, the primary care clinician's responsibility is expanding. As the gatekeeper charged with ensuring the provision of comprehensive care, the primary care clinician will almost certainly provide some type of alcohol or other drug-related service. Those clinicians who are familiar with the medical complications of substance abuse and are able to relate them to other co-morbid illnesses will be better equipped to deliver adequate, cost-effective care.

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I support the Centers for Medicare and Medicaid Services' proposed decision memo for "Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse." Providing coverage for alcohol screening and brief interventions as a core medical care service should be part of routine primary care. In addition, screening and brief intervention have been proven to have a sustained impact on reduced alcohol use and will therefore have major benefits both for patients and for overall medical care costs, since excessive drinking often makes other medical problems worse and harder to treat.

If this proposal takes effect, other insurers may follow Medicare's lead and provide the same coverage for people participating in their plans, allowing major benefits both for patients and for overall medical care costs as well.

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I support the Centers for Medicaid and Medicare Services proposed decision memo for "Screening and Brief Counseling Intervention in Primary Care to Reduce Alcohol Misuse." It is well established that alcohol misuse causes a host of social and medical ills, exacerbates existing health problems and makes patients more difficult to treat.

Pregnancy is an especially vulnerable time and drinking during pregnancy can lead to a host of problems in the developing fetus as well as future cognitive and other developmental problems. Please read:
Conners, N., Bradley, R., Mansell, L., Liu, J., Roberts, T., Burgdorf, K., & Herrell, J. (2004)
Children of mothers with serious substance abuse problems: An accumulation of risks. The American Journal of Drug and Alcohol Abuse, 30(1), 85-100.
Sensory processing and adaptive behavior deficits of children across the fetal alcohol spectrum disorder continuum.
By Carr, Joshua L.; Agnihotri, Sabrina; Keightley, Michelle
Alcoholism: Clinical and Experimental Research, Vol 34(6), Jun 2010, 1022-1032.

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Coverage for alcohol screening and brief interventions as a core medical care service will send a powerful message that identification and intervention for alcohol problems should be part of routine primary care. Screening and brief intervention have been proven to have a sustained impact on reduced alcohol use and will therefore have major benefits both for patients and for overall medical care costs, as excessive drinking often makes other medical problems worse and harder to treat.

In addition, Medicare coverage often sets the standard for other insurance benefits. If this proposal takes effect, other insurers may follow Medicare's lead and provide the same coverage for people participating in their plans.

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Coverage for alcohol screening and brief interventions as a core medical care service will send a powerful message that identification and intervention for alcohol problems should be part of routine primary care. Screening and brief intervention have been proven to have a sustained impact on reduced alcohol use and will therefore have major benefits both for patients and for overall medical care costs, as excessive drinking often makes other medical problems worse and harder to treat.

In addition, Medicare coverage often sets the standard for other insurance benefits. If this proposal takes effect, other insurers may follow Medicare's lead and provide the same coverage for people participating in their plans.

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We support the Centers for Medicaid and Medicare Services (CMMS) proposed decision memo for "Screening and Brief Counseling Intervention in Primary Care to Reduce Alcohol Misuse."

There are research-based screening instruments such as the CAGE (Ewing, 1984) and AUDIT (Babor et al., 1992) that have been tested and found effective in primary care settings. Moreover treatment services overwhelmingly support these brief assessment, screening type tools that establish targeted conditions with respect to acceptable levels of sensitivity and specificity (Bushsbaum et al., 1991, 1995; Bohn et al., 1995; Barry and Fleming, 1993; Saunders et al., 1993).

Evidence indicates that asking questions about alcohol or other drugs "primes" patients to disclose information and results in a two to threefold increase in their stated intention to discuss Substance Abuse problems with their health care provider (Skinner et al., 1985). Further, studies have indicated that screening for alcohol-related disorders is more acceptable to patients if it is part of a comprehensive health-risk evaluation that covers topics like exercise, diet, weight control and medication use (Allen et al.,1995). Also, using this approach within the larger context of preventive health care can help, including the screening of illicit drugs (Fleming and Barry, 1991).

It is well established that alcohol misuse causes a host of social and medical ills, exacerbates existing health problems and makes patients more difficult to treat. Every man, woman and child in America pays nearly $1,000 annually to cover the costs of unnecessary health care, extra law enforcement, motor vehicle crashes, crime and lost productivity due to substance abuse (Institute for Health Policy, 1993). Nearly 25% of Americans say that "drinking has been a cause of trouble in their family" (Institute for Health Policy, 1993, p.40). In addition, there was an “analysis of the epidemiological evidence, which revealed that 72 conditions requiring hospitalizations are wholly or partially attributable to substance abuse” (Center on Addiction and Substance Abuse, 1993, p.21). In short, substance use disorders are simply too pervasive and too costly to be ignored.

Fortunately, effective specialty treatment is available for problem drinkers and illicit drug users. Now there is effective brief interventions in primary care settings that studies indicate can substantially reduce hazardous drinking, a behavior that has enormous negative effects on public health (Kahan et al., 1995).

In this era of managed care, the primary care clinician's responsibility is expanding. As the gatekeeper charged with ensuring the provision of comprehensive care, the primary care clinician will almost certainly provide some type of alcohol or other drug-related service. Those clinicians who are familiar with the medical complications of substance abuse and are able to relate them to other co-morbid illnesses will be better quipped to deliver adequate, cost-effective, care.

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I am writing to add my name to the list of Americans who support the use of Medicare & Medicaid funds for alcohol abuse screening and brief interventions.

The reduced incidence of fetal alchohol syndrome and fetal alchohol effect by treating pregnant women with alcohol use disorders will be not only cost-effective, in the sense that it will save the cost of caring for these disabled children; it is also just the right thing to do for the health of the child in utero.

In the area of Medicare funding for this reason, many seniors develop alcohol use disorders in an attempt to self-medicate or reduce feelings of boredom and lonliness. Doctors often do not realize the amount of alcohol their patients are consuming and the risk of mixing alcohol with prescription medications can produce disaster. Alcohol screening and brief intervention should be a part of routine primary care for this population.

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I support the Centers for Medicaid and Medicare Services proposed decision memo for "Screening and Brief Counseling Intervention in Primary Care to Reduce Alcohol Misuse." It is well established that alcohol misuse causes a host of social and medical ills, exacerbates existing health problems and makes patients more difficult to treat.

"An ounce of prevention is worth a pound of cure."
The drain of monies and services for alcoholic related problems can be curbed with early intervention policies.
Early intervention is key.
Thanks,
Susan Rocco

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I support the Centers for Medicaid and Medicare Services proposed decision memo for "Screening and Brief Counseling Intervention in Primary Care to Reduce Alcohol Misuse." It is well established that alcohol misuse causes a host of social and medical ills, exacerbates existing health problems and makes patients more difficult to treat. I also think it will save a tremendous amount of money if the screenings can identify problems before they manifest themselves in additional physical problems resulting from the misuse of alcohol.

Thank you for the opportunity to present my thoughts on this important matter.

Sincerely,

Don Nichols

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Coverage for alcohol screening and brief interventions as a core medical care service will send a powerful message that identification and intervention for alcohol problems should be part of routine primary care. Years of research has proven that screening and brief intervention have been proven to have a sustained impact on reduced alcohol use and will therefore have major benefits both for patients and for overall medical care costs, as excessive drinking often makes other medical problems worse and harder to treat.

As a clinical psychologist with 30+ years experience in the field of addiction treatment I can attest to the importance that good early medical screening can play in getting people appropriate treatment for their problems in this regard. My own experience and research has shown that the earlier someone gets treatment for addiction and/or alcohol abuse the better the prognosis and the less costly the treatment will be.

In addition, Medicare coverage often sets the standard for other insurance benefits. If this proposal takes effect, other insurers may follow Medicare's lead and provide the same coverage for people participating in their plans.

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Coverage for alcohol screening and brief interventions are a core medical care service and identification and intervention for alcohol problems should be part of routine primary care.

Screening and brief intervention have been proven to have a sustained impact on reduced alcohol use and will therefore have major benefits both for patients and for overall medical care costs, as excessive drinking often makes other medical problems worse and harder to treat.

In addition, Medicare coverage often sets the standard for other insurance benefits. If this proposal takes effect, other insurers may follow Medicare's lead and provide the same coverage for people participating in their plans.

Please change Medicare coverage to allow for alcohol screening. The SBIRT (or screening, brief intervention and referral for treatment) model is evidence based and effective for this purpose.

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Alcoholism is a disease and my understanding is that people are genetically predisposed to it. In San Antonio, liver transplants are not granted to people who need one but drink. Is that treating it as a disease? My main concern is that in order to quit, insurance coverage is necessary. By the way, a major problem for Veterans is alcoholism as well as PTSD. If we are going to give our Veterans care for alcholism, then we should do the same for others. I had [PHI Redacted] die of liver disease due to drinking. [PHI Redacted] was able to stop but already has liver damage.

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Coverage for alcohol screening and brief interventions as a core medical care service will send a powerful message that identification and intervention for alcohol problems should be part of routine primary care. Screening and brief intervention have been proven to have a sustained impact on reduced alcohol use and will therefore have major benefits both for patients and for overall medical care costs, as excessive drinking often makes other medical problems worse and harder to treat.

In addition, Medicare coverage often sets the standard for other insurance benefits. If this proposal takes effect, other insurers may follow Medicare's lead and provide the same coverage for people participating in their plans.

I support the Centers for Medicaid and Medicare Services proposed decision memo for "Screening and Brief Counseling Intervention in Primary Care to Reduce Alcohol Misuse." It is well established that alcohol misuse causes a host of social and medical ills, exacerbates existing health problems and makes patients more difficult to treat.

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August 9, 2011

Donald M. Berwick, M.D., M.P.P.
Administrator
Centers for Medicare & Medicaid Services
Hubert H. Humphrey Building
200 Independence Avenue, S.W., Room 445-G
Washington, DC 20201

RE: Proposed Decision Memo for Screening for Depression in Adults (CAG-00425N)

Dear Dr. Berwick:

On behalf of our more than 5,000 member hospitals, health systems and other health care organizations, and our nearly 42,000 individual members, the American Hospital Association (AHA) appreciates the opportunity to comment on the Centers for Medicare & Medicaid Services’ (CMS) proposed decision memorandum for depression screening in adults. We fully support CMS’s proposal to add alcohol screening and behavioral counseling, and screening for depression to the package of preventive services offered to Medicare beneficiaries. Prevention of illness or disability only occurs when beneficiaries receive an accurate diagnosis, effective treatment and appropriate follow-up. Evidence supports improved health outcomes for beneficiaries when they receive screening and behavioral counseling to reduce alcohol misuse. We also agree that screening for depression in adults is reasonable and necessary for the prevention or early detection of illness or disability, and is appropriate for individuals entitled to benefits under Part A or enrolled under Part B. In addition, we believe that the primary care setting is an appropriate venue through which these services should be delivered.

If you have any questions, please feel free to contact me or Joanna Hiatt Kim, senior associate director for policy, at (202) 626-2340 or jkim@aha.org.

Sincerely,
/s/
Rick Pollack
Executive Vice President

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August 5, 2011

Centers for Medicare and Medicaid Services
Attention: Dr. Lawrence Schott
7500 Security Boulevard
Baltimore, MD 21244

RE: Proposed Coverage Decision Memorandum for Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse (CAG-00427N)

Dear Dr. Schott,

The National Congress of American Indians (NCAI) is the nation’s oldest, largest, most representative national tribal organization made up of American Indian and Alaska Native tribal governments. NCAI writes in strong support of the proposed coverage decision to provide screening and behavioral counseling to reduce alcohol misuse under Medicare Parts A and B.

The proposed coverage decision memo addresses a serious need in Indian Country, as alcohol abuse and dependency has plagued tribal communities for more than two centuries. Recent data shows American Indians and Alaska Natives are five times more likely than the majority population to die of alcohol-related causes.ⁱ Other data reveals that between 2003 to 2005, American Indians and Alaska Natives alcoholism death rates were 519% higher than the alcoholism death rate for all other races in the United States. ⁱⁱ Alcoholism is a leading contributed to other behavioral health issues in tribal communities, including additional substance abuse problems, domestic violence, and child malnutrition and neglect.

NCAI appreciates the work the Centers for Medicare and Medicare Services are doing to protect tribal communities and looks forward to future work together. If you have questions please contact Ahniwake Rose at arose@ncai.org or 202-466-7767.

Sincerely,

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We are writing on behalf of Rush University Medical Center Older Adult Programs. It is our professional opinion, that social workers and psychologists are in a position to provide quality screening and brief intervention services to clients. This type of screening is currently already part of a broader comprehensive service provision provided by social workers and psychologists. These behavioral health clinicians have the training and experience to assess, screen and provide treatment to a wide range of at-risk clients. These services are currently being provided in our institution without compensation. Social workers and psychologists are also in a unique position to provide this screening in that they collaborate on a regular basis with client's primary care and speciality doctors for the purpose of continuity of care. As is the case with many other professionals, if this funding is not provided for social workers and psychologists, it will become increasingly difficult to provide these much needed services.

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We are very pleased to support the CMS proposal to cover annual screening and, for those that screen positive, up to 4 face-to-face, behavioral counseling interventions per year, including pregnant women. We agree with the first 2 caveats under that proposal.

As to the third caveat: We recommend, in light of growing patient centered medical home use of health teams, that coverage for brief counseling be broadened to include other health team members. Allied health professionals can provide the brief counseling as noted in the research. The BRITE (SBIRT) Project (1)involved certified addiction specialists and mental health counselors in addition to nurses and social workers. Madras, et al.(2) noted that trained peer educators conducted screenings and brief intervention counseling in some large state SBIRT projects with behavior changes similar to those shown in the research cited in the CMS proposal. In Massachusetts trained bachelor’s level health promotion advocates provide SBI in several primary care settings. Follow-up interviews of 10% of patients with positive screening results show reductions in use. Trained health team members - including medical assistants, community health workers, patient navigators, coaches and/or peer educators – who can provide brief behavioral counseling under the supervision of a physician would save money while saving lives.

We are also pleased that CMS recognizes the NIAAA single screen question as appropriate for patients of all ages. Primary care providers often tell us there’s little time for one more screen in their busy practices, and the NIAAA single question screen can address that barrier.

It is also important that primary care sites doing SBI develop protocols and connections to make referrals for further specialized counseling for the relatively small percent of those screened who may have a dependence problem. .

(1). Schonfeld L, King-Kallimanis BL, Duchene DM, Etheridge RL, Herrera JR, Barry KL, & Lynn, N. (2010). Screening and brief intervention for substance misuse among older adults: The Florida BRITE Project. American Journal of Public Health, 100(1), 108-114. doi: 10.2105/ajph.2008.149534
(2). Madras BK, Compton WM, Avula D, Stegbauer T, Stein JB, Clark HW. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend. 2009. 99(1-3):280-95. Epub 2008 Oct 16)

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Subject: Medicare Proposes Coverage for Screening and Counseling for Alcohol Misuse and Screening for Depression (00427N)

Dear Colleagues,

On behalf of the California Hospital Association (CHA) and our 400 member hospitals and health systems, we wish to express our support for the Centers for Medicare & Medicaid Services (CMS) proposal to add alcohol screening and behavioral counseling, and screening for depression to the package of preventive services for Medicare beneficiaries. We offer the following comments for your review and consideration.

CHA concurs there is sufficient evidence to support improved health outcomes for beneficiaries when they receive screening and behavioral counseling to reduce alcohol misuse. We also believe primary care providers and primary care settings are a reasonable and necessary location for these services to occur in. Prevention of early illness or disability, can only occur when beneficiaries receive an accurate diagnosis, effective treatment, and appropriate follow-up.

Furthermore CHA supports the behavioral counseling interventions being consistent with the 5A’s approach that has been adopted by the U.S. Preventive Services Task Force (USPSTF);
Assess – Advise - Agree – Assist – Arrange.
With that said, CHA recommends CMS consider including telemedicine as an acceptable method to be used when providers “Arrange” for follow-up contacts with beneficiaries to provide ongoing assistance and support with these patient’s treatment plans. Escalating healthcare costs, an aging population, rapid increases in chronic disease, and dwindling access to health care in underserved urban and rural areas necessitated the adoption of Telemedicine. For example, in rural Yuba county, there were 2,602 residents for every primary care physician according to 2008 statistics, far in excess of the suggested 60-to-1 ratio.
Rural communities throughout California suffer shortages of licensed mental health professionals, resulting in patients having to drive long distances, and/or wait for weeks or months to access the care they need. Primary care providers in rural clinics find it increasingly difficult to fully meet their patients’ mental health needs. Patients’ lack of access to mental health care often complicates the physical symptoms doctors are trying to treat in the primary care setting. Many of the psychiatric emergencies in rural Emergency Rooms could be avoided if patients had access to regular out-patient mental health care services. Telemedicine is a critical and vital resource and should be an acceptable method for use by primary care providers.
In addition, CHA urges CMS to reconsider the exclusion of the hospital outpatient setting from its definition of primary care setting. As part of the FFY 2014 Medicare hospital outpatient quality reporting program, CMS has acknowledged the outpatient setting as a primary care setting by proposing quality measures related to diabetes care and argues that a significant portion of primary care services are provided in these clinics. In addition, in California, hospital based outpatient clinics providing primary care make up approximately 50% of the primary care clinic services available statewide. In some communities these hospital based outpatient clinics are the only primary care provider in very large geographic areas.

Currently consumers are not able to discern the difference between a hospital based clinic providing primary care services and that of a federally quality health center or community health center. These two types of providers (outpatient hospital clinics and primary care clinics) provide almost identical services. Not allowing outpatient hospital setting to provide comparable care to those of non-hospital based primary care clinics will further fragment an already complex primary care delivery system in California and lead to significant access issues for Medicare beneficiaries.

Any clinic that’s primary purpose is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community should be permitted and encouraged to offer these new screening and counseling services.

Again we very much support the proposal to add alcohol screening and behavioral counseling, and screening for depression to the package of preventive services for Medicare beneficiaries. We appreciate the opportunity to comment. If you have any questions or concerns, please do not hesitate to contact me at skruckenberg@calhospital.org or 916-552-7576 or my colleague Alyssa Keefe, vice president federal regulatory affairs at akeefe@calhosptial.org or 202-488-4688.

Sincerely,
/S/
Sheree Kruckenberg
Vice President Behavioral Health Services

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As a mental health nurse and an administrative director it is welcoming to see the proposed decision to adopt an alcohol screening and 4 sessions for treatment as part of a preventive health visit. So many disease states are compounded by the patient's inability to self-manage due to mental health and substance abuse concerns that are often missed during the "physical" assessment of a provider's visit.

The focus on prevention today is noteworthy but only when it is holistic and includes evaluation of substance abuse which impacts the patient and the family who are so in need of education and support themselves. Accountable care is also accountable care delivery which includes prevention to enhance population health.

I would also welcome CMS's consideration of the decision proposed to include Mental Health certified (ANCC) registered nurses and LCSW's and LPC's who are adept and trained to provide the screening and referral to treatment. In achieving this assessment, physician providers will benefit from patient access to an increase in licensed non physician providers to secure the preventive screening.

Thank you for your consideration and the opportunity to comment.

Linda Keenan RN-BC, BSN, MPA, NMCC

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