Self-funded research

Research in systems change for tobacco cessation will pay for itself

Link to full proposal which you can adapt

Data from the last decade of National Health Interview Surveys (NHIS) show that clinicians do not routinely provide these tobacco cessation services to their patients. Two out three people who are able to stop smoking do not use evidence-based interventions to support their quit attempt. This may explain the high rate of relapse. In addition to suboptimal support, numerous opportunities to advance cessation are missed. Clinical practice guidelines for tobacco cessation detail evidence-based interventions that can be provided at every visit regardless of a tobacco user’s readiness to change. Data from medical claims from national health plans show that clinicians’ billing of the codes for tobacco cessation counselling and prescribing of medication is significantly lower than stated in the NHIS or other surveys. This is further confirmed by study of electronic medical records at several health systems.

 The economic impact of tobacco cessation is substantial regardless of the payment model (value-based, fee for service, or mixed). The long-term economic benefits of tobacco cessation are well established. The progression of tobacco-related disease is altered resulting in less morbidity and mortality, lower medical expenses and better quality of life. A recent paper showed economic returns in the first year when a systems-based approach was implemented in a capitated HMO setting. Another study calculated the lost opportunity of fee for service billing in a health system in Pennsylvania and Maryland at over $5 million over 3 years. When cessation interventions are applied repeatedly and follow-up sessions are scheduled, a larger fraction of tobacco users are able to stop.

 The performance and success of tobacco cessation interventions varies widely by state, medical practices, and among individual clinicians in a practice. Systems-based approaches have been shown to increase the performance of the medical groups where they have been applied and are likely to maximize revenue gain. Tools to evaluate the structure of tobacco cessation interventions are readily available to establish baseline process and outcomes data.

 After an assessment of organizational structure and support, and current performance, improvement opportunities can be modelled and tested, and the cost and benefits of each improvement can be estimated. Regardless of the current state of implementation of systems change for tobacco cessation in a given setting, regardless of the payment arrangement, improved performance in tobacco cessation will generate additional revenue. The magnitude of additional revenue is likely to exceed the cost of the analysis, training of current staff or hire of new staff.

Detailed review of variation among clinicians and practice locations as well as benchmarking to national data provided here can point to practice successes that could be amplified or systematic defects in workflows. With this baseline data, a variety of performance improvement strategies can be tested. The outcomes of these quality improvement initiatives are an increase in quit rates and improved revenue.

Draft PowerPoint

Tobacco Cessation: A new focus on practice revenue and systems change

Abstract: Link to full presentation is here

Tobacco cessation services provided by medical practitioners do not appear to be an effective intervention for population health. Each year only five percent of smokers are able to stop. Although smokers report that doctors advise them to quit smoking, only one third of smokers making quit attempts use evidence-based interventions such as medication or counselling. As a result, relapse rates are high, and some smokers require up to 20 attempts before they are successful. Smokers with higher burden of social determinants of health are even less likely to receive cessation services. Although many barriers to systematic implementation of tobacco cessation services have been identified, the least well studied is the role of reimbursement and overall practice income.

Clinical practice guidelines detail evidence-based interventions that can be provided regardless of a smoker’s readiness to change. However medical claims data from several health plans show that clinicians rarely bill the codes for smoking cessation counselling. Models for fee-for-service environments suggest large levels of reimbursement when CMS guidelines are consistently applied. One study calculated the lost opportunity in a health system in Pennsylvania and Maryland at over $5 million over 3 years. Another recent paper showed economic returns when a systems-based approach was implemented in an HMO setting. Many models showing the return on investment from smoking cessation have been published, but these studies need to be recalibrated to reflect the efficiencies of systems-based approaches and the availability of generic varenicline.

 There is a growing literature evaluating systems-based interventions, but these have not been widely adopted. The first step in implementation is a program assessment, and the results of the initial review of the WTC program are discussed.  By testing systems improvements medical practices and accountable care organizations can create quality improvement narratives and generate sufficient revenue to fund the research and continued program support.

 Educational Objectives:

 Learning Outcome 1: Assess the economic landscape for tobacco cessation services for their practice setting.

Learning Outcome 2: Identify the opportunities to maximize outcomes for tobacco cessation interventions.

Learning Outcome 3: Identify the opportunities to maximize reimbursement for tobacco cessation.

Learning Outcome 3: Select optimal strategies for sustainable program funding.

Detail 3

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