Does HHS and CMS understand the impact of smoking on health and health care costs for seniors?

The most recent Surgeon Generals’ Report estimates that over 480,000 people die of tobacco related diseases each year. Most of those people are seniors who on average die ten years sooner than non-smokers. Tobacco-related diseases profoundly affect the quality of life for over 16 million people and are estimated to contribute 8.6 percent of the total medical expense in the USA. The data summarized below suggests that clinicians who care for seniors are performing poorly on tobacco cessation services and that seniors are not getting the message about the availability of resources to help them stop. In spite of much excellent work, HHS and CMS need to do more.

A recent report on the prevalence of tobacco use shows that notwithstanding overall declines in the reported use of cigarette smoking from 2011 to 2022,  among adults 65 years and older, smoking prevalence increased slightly from 8.7% in 2011 to 9.4% in 2022. Trends in US Adult Smoking Prevalence, 2011 to 2022 | Health Policy | JAMA Health Forum | JAMA Network. Most smokers want to quit, yet more than two-thirds of adult cigarette smokers who tried to quit during the past year did not use evidence-based treatment such as counselling or medication. Smoking Cessation: A Report of the Surgeon General (Executive Summary) (hhs.gov), page 4.

 Kleykamp and Kulak observing the same data raised this concern in the American Journal of Public Health over a year ago, but there has been little response. Cigarette Use Among Older Adults: A Forgotten Population - ProQuest. They argue that the intense focus on youth adoption of tobacco in all its forms may have drawn away from appropriate attention to current smokers.

 Other evidence suggesting that CMS may be disregarding the available evidence on poor performance includes:

The recently released HHS Framework to Support and Accelerate smoking cessation does not reference seniors as one of the groups with a disparate impact, when in fact most of the effects of disparities become manifest among seniors. HHS Framework to Support and Accelerate Smoking Cessation 2024. While there is extensive presentation of the many tobacco control initiatives since 1980, there is no analysis of their limitations. The new framework presented is laudable but is likely to underperform if clinicians do not provide the basic services of tobacco cessation.

 The CMS Universal Foundation for Aligning Quality Measures released in 2023 does not include smoking cessation. Aligning Quality Measures across CMS — The Universal Foundation | New England Journal of Medicine (nejm.org)

 The highly detailed assessment of the Million Hearts Program does not include measures of tobacco cessation medications or counseling, and scant reference to tobacco use status which would have the highest impact of all modifiable risk factors. Evaluation of the Million Hearts® Cardiovascular Disease Risk Reduction Model Final Evaluation Report (cms.gov)

 The annual report from the North American Quitline Association stated that 22% of the 255,372 unique calls to one of the states’ quitlines were covered by Medicare. With 65M Medicare enrollees and a 9% prevalence, this indicates that only 0.1 percent of eligible smokers called. Quitlines average a success rate of 32 percent and provide free nicotine patches and gum which are not available from Fee for Service Medicare or Medicare Advantage plans. FY23_Annual_Survey_Slides_FI.pdf (ymaws.com)

Unpublished claims data from my former employers shows that fewer than 1% of Medicare Advantage members received both smoking cessation counseling and medication. The average number of counselling sessions for seniors who receive this service is 1.1 per year, even though the benefit is up to eight per year. Data from commercial insurance plans has similar evidence of underutilization of both medical and pharmacy interventions. While commercial insurers have state of the art resources available for all members who request them, these resources are not aggressively promoted. Many smokers are thus graduated to Medicare.

Data from electronic medical records of a large health system in Pennsylvania and Maryland show that smoking cessation counseling is rarely billed, with only 4.7 percent receiving counselling over a 3 year period. eventpower-res.cloudinary.com.pptx (live.com). At a meeting with CMS, held on 11/9/2022, representatives of ATTUD presented 2019 data showing that “Medicare currently is only spending $11.3 million annually on reimbursing for the current smoking cessation codes”. If the average reimbursement for those codes is $14.00, then there were approximately 800,000 counseling sessions. With over 65 million Medicare enrollees at that time, and a prevalence of 9%, this suggests that fewer than 1/7 smokers received cessation services.

Although NCQA has recognized the inadequacies of its CAHPS-based measure on advice to quit smoking, there is no haste in replacing it with a more reliable HEDIS measure. NCQA HEDIS measures and Medicare Stars measures have had a profound impact on physician practice but there has never been a STARS measure linked to tobacco. NCQA is exploring the development of two new measures related to tobacco use and lung cancer screening. These measures would potentially become part of HEDIS no earlier than measurement year 2026. CMS is considering proposing these measures for the Star Ratings pending future rulemaking. Summary of Changes in the 2025 Advance Notice (healthmine.com). Let’s make sure they adopt NQF 0028 Quality ID #226 (NQF 0028): Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention – National Quality Strategy Domain: Community / Population Health - Claims (cms.gov)

The recently released HHS Framework to Support and Accelerate smoking cessation does not reference seniors as a group  with a disparate impact, when in fact most of the effects of these disparities become manifest among seniors. HHS Framework to Support and Accelerate Smoking Cessation 2024

The key arguments for greater action are outlined by Tim McAfee Ignoring our elders: tobacco control’s forgotten health equity issue | Tobacco Control (bmj.com)

There is much more that HHS, CMS, health insurers, Accountable Care Organizations, hospitals and clinicians can do to improve cessation services to seniors.

Edward Anselm, MD Assistant Clinical Professor of Medicine, Icahn School of Medicine at Mount Sinai

Letter to the New York Times: Death statistics do not motivate change

One of the key points in the NYT article One Year, 400,000 Coronavirus Deaths: How the U.S. Guaranteed Its Own Failure (1/18/2021) is that science has been “sidelined at every level of government”. The politicization of science at the expense of human suffering is not unprecedented. The most recent data from the CDC states that there are over 480,000 preventable deaths each year due to tobacco. The 2020 Surgeon Generals’ Report shows how many evidence-based interventions to reduce tobacco use are under-utilized. Additional examples of this science denialism abound; human-induced climate change, the obesity epidemic, and gun violence, to name a few. As part of the recovery from the pandemic, we need to commit to a stronger link between science and public policy and call out those politicians who reject it.

 Smoking Cessation: A Report of the Surgeon General (hhs.gov)

Are you paying too much for your implantable defibrillator?

Health insurers and other groups that take economic risk in health care should be aware of a recent JAMA study that shows that 96.4 % of patients receiving new defibrillators had the procedure performed by a physician who had a financial relationship with the manufacturer. Patients were more likely to receive a device from the manufacturer that provided the highest payment to the doctor. Association Between Industry Payments to Physicians and Device Selection in ICD Implantation | Cardiology | JAMA | JAMA Network

IS IT TOO SOON TO LEARN FROM THE PAST? October 12, 2020

The US Coronavirus response shows that we continue to make the same mistakes as we did with tobacco. In this article, Dr. Alan Blum reviews lessons we are doomed to forget again. Money and politics will always cloud our ability to recall. At a time when people are proclaiming that ‘Black Lives Matter,’ the truth is that very few lives matter when balanced against profit or political victory.

https://cancerletter.com/articles/20200918_2/

FDA to Announce Ban on Sale of Most Cigarettes in Convenience Stores Due to Addiction of Hundreds of Thousands of Youth to Cigarettes

Michael Siegel got it right. If we were really concerned about the effect of tobacco on the health of your people, sales of tobacco in convenience stores would have been banned a long time ago. Instead we are banning sales of electronic cigarettes, especially Juul. Limiting access to Juul, and similar products is a good thing, but this move also limits access for adult smokers seeking to lower their risk of tobacco related disease. Scott Gottlieb has stated that the FDA is committed to the harm reduction approach to tobacco control. The FDA has never been able to make the distinction between youth access and adult access. See the details here. FDA to Announce Ban on Sale of Most Cigarettes in Convenience Stores Due to Addiction of Hundreds of Thousands of Youth to Cigarettes

California Tobacco 21 and equating e-cigarettes and combusted cigarettes: A New York Times editorial supported two pieces of tobacco control legislation. A closer view of the science is warranted.

http://www.nytimes.com/2016/03/06/opinion/sunday/raise-the-legal-age-for-cigarette-sales-to-21.html?_r=0

To the editor

The scientific evidence for supporting the California Tobacco 21 Initiative is strong and is based on an Institute of Medicine Report (editorial March 6, 2016: “Raise the legal age for cigarettes”). There is no similar body of evidence that would support the other bill before the governor which would classify of electronic cigarettes as tobacco products.

Many of the recent declines in smoking are attributed to the use of electronic cigarettes. The majority of individuals who take up e-cigarettes do so in order to reduce their risk of tobacco related disease. E-cigarette use has been shown to promote additional quit attempts in smokers and half the users experience a fifty percent reduction in the amount smoked. In England, The National Health Service has recently initiated programs to dispense e-cigarettes for these purposes.

Increased restrictions on electronic cigarettes, other than limiting sales to young people, are contrary to public health and the public interest.

Edward Anselm, MD

New York, NY

Assistant Professor of Medicine, Icahn School of Medicine at Mount Sinai

Senior Fellow, R Street Institute 

Corruption in America: Take a look at health insurance

Read this book, if you want to understand health insurance in America. Health care is not mentioned in Zephyr Teachout’s “Corruption in America: From Ben Franklin’s snuff box to Citizens United” but if you have been watching the rise of costs and the continuing problems with access and quality, then the connections are inescapable.

For decades, state government oversight of insurance markets have allowed commercial insurers to rig state-specific marketplaces to favor large employers and large insurers and compel individuals with greater health care needs to buy insurance at higher rates. This defective reallocation of wealth has been institutionalized through the passage of Patient Protection and Affordable Care Act (PPACA), commonly called Obamacare.

Another example is Medicare Modernization Act of 2003 which established the Medicare prescription drug benefit. By the design of the program, the federal government is not permitted to negotiate prices of drugs with the drug companies, as federal agencies do in other programs. One would think that it is inherently corrupt to preclude competition in this country.

The congressional staff that wrote these pieces of legislation went on to high-paying jobs as lobbyists and consultants for health insurance and pharmaceutical industries.

I welcome thoughts on how to increase transparency and accountability for the actions of our legislators.

http://www.amazon.com/s/ref=nb_sb_ss_c_0_14?url=search-alias%3Dstripbooks&field-keywords=corruption+in+america&sprefix=corruption+in+%2Caps%2C149

Physicians Advice to Smokers Regarding Electronic Cigarettes

Two recent surveys of practicing physicians show similar results :

·         Fifty percent of the smokers in these doctors’ practices are asking about electronic cigarettes.

·         One out of three doctors are recommending electronic cigarettes for their patients who smoke.

While public health authorities and regulators are struggling with the policy issues with a special concern regarding electronic cigarettes and young people, adult smokers are following a harm reduction strategy with their doctors, or on their own.

We need to find ways to adapt the standard approaches to smoking cessation counselling to include quitting with electronic cigarettes as well as harm reduction interventions.

Steinberg MB, Giovenco DP, Delnevo CD. Patient–physician communication regarding electronic cigarettes. Preventive Medicine Reports. 2015;2:96-98.

Kandra KL, Ranney LM, Lee JG, Goldstein AO. Physicians’ attitudes and use of E-cigarettes as cessation devices, North Carolina, 2013. 2014. e104632. 

Can E-Cigarettes Save Lives?

Joe Nocera wrote an an opinion piece on this question:  http://www.nytimes.com/2015/10/17/opinion/can-e-cigarettes-save-lives.html?action=click&pgtype=Homepage&module=opinion-c-col-left-region®ion=opinion-c-col-left-region&WT.nav=opinion-c-col-left-region&_r=0

Here is my letter to the New York Times: 

Re: Can E-Cigarettes Save Lives 10/17/15

Concerns about the effects of e-cigarettes on young people are holding the health of 42 million smokers hostage. Fortunately smokers who want to reduce their risk of tobacco related disease are not waiting for anyone. Reuters reported that 10 percent of adults now use electronic cigarettes1. One prominent health activist has attributed the decent decline of cigarette smoking to a new low of 15.3 % to the increased use of e-cigarettes2.

Two recent studies report that half of their smoking patients ask about e-cigarettes and one out of three physicians are recommending them for harm reduction or cessation3 4.

Why can’t public health authorities acknowledge what their clinical colleagues already know: Widespread adoption of electronic cigarettes by adult smokers would have a profound effect on public health?

Edward Anselm, MD

Medical Director, Health Republic Insurance of New Jersey

Assistant Professor of Medicine, Icahn school of Medicine at Mount Sinai

If you want to discuss, please call me at 917-364-1154

1.            Mincer J. E-cigarette usage surges in past year: Reuters/Ipsos poll. 2015; http://mobile.reuters.com/article/idUSKBN0OQ0CA20150610. Accessed 10-5-2015, 2015.

2.            Schroeder SA. Is Smoking Yesterday’s News? 2015; http://smokingcessationleadership.ucsf.edu/directors-corner/is-smoking-yesterdays-news. Accessed 10/5/2015, 2015.

3.            Kandra KL, Ranney LM, Lee JG, Goldstein AO. Physicians’ attitudes and use of E-cigarettes as cessation devices, North Carolina, 2013. 2014.

4.            Steinberg MB, Giovenco DP, Delnevo CD. Patient–physician communication regarding electronic cigarettes. Preventive Medicine Reports. 2015;2:96-98.

No New HIV Infections While Using Truvada

No new HIV infections have occurred among more than 500 users of the Kaiser Permanente healthcare provider system in San Francisco in members using pre-exposure prophylaxis – better known as PrEP. 

The US Food and Drug Administration (FDA) approved Truvada for PrEP in July 2012, and this past May, the US Centers for Disease Control and Prevention (CDC) recommended that people at substantial risk for HIV infection should consider PrEP, basing its recommendations on findings from the iPrEx trial and others. Patients in this study were followed for 2.5 years. (Volk, J.E., et al., No New HIV Infections with Increasing Use of HIV Preexposure Prophylaxis in a Clinical Practice Setting. Clinical Infectious Diseases, 2015.)

Harm reduction strategies are worth exploring for other major public health challenges.

http://www.newsweek.com/truvada-hiv-prevention-proves-highly-effective-368579?utm_campaign=KHN%3A+Daily+Health+Policy+Report&utm_source=hs_email&utm_medium=email&utm_content=21819800&_hsenc=p2ANqtz-9C1ow5rSAMLyZpOOPpek6kWMzjFPokbk8_bfzNQ6SWvRCWkPw2buU6WwtYzED4KQlUzELtU7RLhOi7PPebVTRAQMGJ_g&_hsmi=21819800

Health Plan limitations on contraceptive coverage are not defensible

A new Kaiser Family Foundation report released yesterday at a Washington, DC briefing finds how health insurance carriers are interpreting and implementing the Affordable Care Act's contraceptive coverage requirement varies, limiting contraceptive options for some women.

My comments at the conference: “For the most part, health plans policies limiting access to contraceptive coverage outlined in this report are not defensible and should be challenged. With the implementation of the ACA, we have made great progress towards allowing access to contraceptive services without cost sharing. With increased transparency and public discussion we can eliminate these barriers.”

Harm reduction in action

Mike Pence, conservative Governor of Indiana in facing an epidemic of HIV infections due to needle sharing in Scott County said“, I do not support needle exchanges as anti-drug policy, but this is a public health emergency,”

http://www.indystar.com/story/news/2015/04/17/indiana-hiv-outbreak-cases-rises-cases/25926807/

The Indianapolis Star has been covering the story- Here is my letter to the editor:

I applaud the decision to initiate needle exchange programs to reduce the spread of the HIV virus. To quote Governor Pence “I’m going to make a decision on the best science and the best way to stop this virus and this outbreak in its tracks.” Harm reduction strategies force us to focus on the users of drugs and treat their life situation in the broadest context. Perhaps this difficult public health challenge can serve to open a discussion of other harm reduction strategies for tobacco, opiates, and other drugs.

Edward Anselm, MD

Peering through the haze...

Joe Nocera responded to recent CDC data on increasing us of E-Cigarette

http://www.nytimes.com/2015/04/18/opinion/joe-nocera-peering-through-the-haze.html?_r=0

The kids have it right. If you are going to use nicotine, then why not use a safer form? Young people will experiment with many drugs including marijuana, alcohol, and “party pills” Nicotine often becomes the drug of choice for mood modulation and self-medication because of the convenience of the delivery system.

No one is able to state with any scientific certainty that electronic cigarettes are safer than standard combusted cigarettes, but consumers may not want to wait for evidence that may be decades away. Young people who have grown up with anti-smoking messages may be more prepared to avoid traditional cigarettes entirely and it certainly appears that inhaling vapor is not the same as cigarette smoke.

The long awaited regulation of e-cigarettes will certainly make it more difficult for young people to adopt regular use of tobacco products, but in the meantime perhaps adult smokers might take a cue. For the 42 million smokers in the United States, who on average will live ten years less than their nonsmoking peers, the opportunity to reduce the burden of cigarette related diseases is profound.

What is truly required is a more public discussion of tobacco control.

The most recent Surgeon Generals Report on Smoking and Health calls for new approaches to control tobacco use and a recent article in The Atlantic, The Nicotine Fix, describes the landscape for Harm Reduction very well. http://www.theatlantic.com/features/archive/2014/11/the-nicotine-fix/382666/

Missing from any of the public discussion of smoking is the question of self-medication. The prevalence of tobacco use among patients with mental illness is almost double that of the general population. Nicotine is an antidepressant. In addition, research has shown that people with Schizophrenia, Attention Deficit Hyperactivity Disorder and Obsessive Compulsive Disorder have improved cognition and Schizophrenics had reduced hallucinations. It is certainly understandable why these smokers are reluctant to quit.

Appropriate diagnosis and treatment of people with mental illness needs to part of any solution to the tobacco control problem. Some anti-depressant medications have been approved for use in smoking cessation, so why not treat two conditions with one drug? A harm reduction approach would also recognize that current medications may be inadequate to completely treat mental illness and that nicotine substitution by lifelong use of nicotine patches or gum may help support a patient to maintain abstinence from smoking.

Many people smoke to prevent symptoms of nicotine withdrawal, with a few added puffs for mood modulation in times of stress. While we debate the regulation of electronic cigarettes, let us acknowledge that anyone using these devices is reducing the harm to themselves. Let us also promote the use of nicotine in safer forms. The British National Health Service has done just that.

What is truly required is a more public discussion of tobacco control. Our number one public health problem, one for which we have evidence-based solutions, has faded from general awareness. Why has that happened?

Health Republic Insurance of New Jersey introduces new benefit on Tobacco Harm Reduction

The choice architecture for smokers needs to change. There is a middle ground between abstinence and continued smoking-tobacco harm reduction. In order to support discussion between patients and their doctors and appropriate use of medication for the purpose of tobacco harm reduction, Health Republic Insurance of New Jersey is altering their benefit design.

LINK to Press Release

LINK to Policy

Doctors Cash In on Drug Tests for Seniors, and Medicare Pays the Bill

A recent WSJ article explored CMS reimbursement for office based drug testing in the context of pain management programs. http://online.wsj.com/articles/doctors-cash-in-on-drug-tests-for-seniors-and-medicare-pays-the-bill-1415676782

I posted the following: I have studied this issue in great detail while I was working in a Health Plan special investigations unit. In order to protect against this type of wasteful, if not abusive practice, I have recommended policies on frequency and quality of testing for patients in pain management and substance abuse treatment programs. Many health plans have adopted them. It would be difficult to implement in the context of CMS. Let me know if you need the details.

Screening for Lung Cancer

In October, I wrote a letter to the editor in response to an Op-ED piece on screening for lung cancer that appeared in the NYT. (To read the Op-Ed piece click here.) The question of screening for lung cancer in the Medicare population is very complex, however I was promted to write the letter because the Op-Ed spoke about winning the war on lung cancer with mention of the words cigarette, smoking, or tobacco. The NYT edited out this critique, but published the rest of what I had to say.

In order to read the letter, click here