Sustaining SBIRT in the wild: Simulating revenues and costs for substance abuse screening, brief intervention, and referral to treatment programs
Aims To examine the conditions under which Screening, Brief Intervention and Referral to Treatment (SBIRT) programs can be sustained by health insurance payments. Design A mathematical model was used to estimate the number of patients needed for revenues to exceed costs. Setting Three medical settings in the United States were examined: in-patient, out-patient and emergency department. Components of SBIRT were delivered by combinations of health-care practitioners (generalists) and behavioral health specialists. Participants Practitioners in seven SBIRT programs who received grants from the US Substance Abuse and Mental Health Services Administration (SAMHSA). Measurements Program costs and revenues were measured using data from grantees. Patient flows were measured from administrative data and adjusted with prevalence and screening estimates from the literature. Findings SBIRT can be sustained through health insurance reimbursement in out-patient and emergency department settings in most staffing mixes. To sustain SBIRT in in-patient programs, a patient flow larger than the national average may be needed; if that flow is achieved, the range of screens required to maintain a surplus is narrow. Sensitivity analyses suggest that the results are very sensitive to changes in the proportion of insured patients. Conclusions Screening, Brief Intervention and Referral to Treatment programs in the United States can be sustained by health insurance payments under a variety of staffing models. Screening, Brief Intervention and Referral to Treatment programs can be sustained only in an in-patient setting with above-average patient flow (more than 2500 screens). Screening, Brief Intervention and Referral to Treatment programs in out-patient and emergency department settings can be sustained with below-average patient flows (fewer than 125 000 out-patient visits and fewer than 27 000 emergency department visits).