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Addressing behavioral issues in the workforce

A case for behavioral screening and intervention (BSI)

The United States has a substantial problem with behavioral risks and disorders. Every year it is estimated they are responsible for 40 percent of deaths, most chronic diseases, $300 billion in health care costs and $600 billion in additional costs such as lost productivity and disability. Key behavioral issues include tobacco use, alcohol and other drug abuse, depression, poor diet, physical inactivity and obesity.

Behavioral issues are responsible for approximately $18 billion in health care spending alone annually in Wisconsin.

Twenty-five percent of the U.S. population will have some sort of diagnosable mental illness in any given year.

Due to the enormous costs and human toll they take, employers have attempted to tackle behavioral issues affecting their workforce with a variety of strategies – mostly with mixed results. Wellness programs have been successful for some employers, but participation rates, particularly in smoking cessation and weight loss programs, remain low. Utilization of Employee Assistance Programs (EAPs) for behavioral issues is very low. It is difficult to get employees to admit they need help. “Our society has created some stigma around talking to a counselor,” said Wendy Strobel, director of the Northeast ADA Center, based at Cornell University's Employment & Disability Institute.

While wellness programs and EAPs have had some success in addressing behavioral risk issues, additional strategies need to be considered to address an issue of this magnitude. The Wisconsin Initiative to Promote Healthy Lifestyles (WIPHL) is addressing this issue in partnership with and support from numerous public and private entities. A grant-funded program of the Department of Family Medicine in the University of Wisconsin School of Medicine and Public Health, WIPHL helps health care settings systematically implement Behavioral Screening and Intervention (BSI) services. Through BSI, patients are systematically screened for excessive drinking, drug use, depression, tobacco, diet, exercise, and obesity.

Wisconsin loses $6.8 billion every year due to excessive alcohol consumption.

How BSI works

BSI involves screening patients in primary care, emergency room and hospital settings for alcohol, drugs and other behavioral risks. For patients visiting their primary care provider, the screening is performed annually. Patients complete a brief screening questionnaire in the waiting room that quantifies their risks and identifies problems early, when treatment is more effective, easier and less expensive. Those patients with mild-to-moderate risk receive brief medical intervention from a health educator trained in motivational interviewing to promote behavior change. This group includes the 25 percent of patients in Wisconsin who are not alcoholic but engage in risky or binge drinking. Health educators obtain the biggest impact by delivering brief alcohol interventions. According to the National Business Group on Health, these interventions generate reductions of:

  • 20 percent in emergency department visits;
  • 33 percent in injuries;
  • 37 percent in hospital admissions;
  • 46 percent in arrests; and
  • 50 percent in car crashes.

Occasionally BSI will uncover patients with serious conditions, such as alcoholism, addiction or depression. The health educator will refer those patients back to a specialist for treatment. Since its inception more than six years ago, WIPHL has helped 44 Wisconsin primary care clinics systematically deliver BSI services to over 100,000 patients.

Employers improve their bottom lines by $771 for every employee who receives a brief alcohol intervention.

Hurdles to widespread implementation of BSI

Unfortunately, few Americans receive BSI services. One significant barrier is staff time. Given the number of residents in Wisconsin with smoking, binge drinking, depression and obesity issues, if primary care providers spent only five minutes on each of these behavioral issues, they would add two hours to their workdays.

Another issue is training. Most physicians, nurse practitioners, physical assistants, nurses and medical assistants lack expertise in providing the effective interventions for behavioral health issues.

Discussions with health care provider organization leaders have shown there is general agreement that BSI should be delivered, but a reluctance to deliver BSI services presently. One source of reluctance is inconsistent fee-for-service reimbursement. Not all payers reimburse providers for delivering BSI services, sometimes leaving providers with services rendered for which they cannot bill. Additional barriers include a perceived lack of demand for BSI services and other priorities competing for limited time and resources available to providers.

The National Commission on Prevention Priorities ranks alcohol screening and intervention fourth in effectiveness and cost-effectiveness of all preventive services recommended by the U.S. Preventive Services Task Force. That ranks higher than screening for high blood pressure, cholesterol and all kinds of cancer.

What can employers do?

Employers can assist in the widespread provision of BSI services by encouraging:

  • Their claims administrator to adequately reimburse providers for the delivery of BSI services
  • The provider community to adopt behavioral screening and intervention as a routine standard of care, not unlike routinely checking a patient’s blood pressure


The adoption of BSI services as a routine standard of care is a relatively simple, yet highly effective way to address the substantial and costly problem of behavioral risks and disorders we face in Wisconsin and in the United States. Employers, administrators and providers need to work together to make this happen.

Works Cited

Douglas, G., September 30, 2013, Employers Face Obstacles in Helping Employees with Mental Health Problems, Human Resources Report, as reported in Bloomberg BNA.

Partnership for Health Care Payment Reform grant submission to Greater Milwaukee Business Foundation on Health, 2013

Sherman, Bruce, Summer 2013 Emotional Health - a vital component of employee well-being and workforce performance, Connect, Employers Health Coalition, Inc.

Wisconsin Intitative to Promote Healthy Lifestyles (WIPHL) web site


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BHCG Monitor: Focus on Health Care Benefits - April 2012