40 percent of smokers are being left out of the conversation
A new choice architecture for quitting cigarettes: Every smoker, every visit
A literature on trial of quitting is emerging that can alter the standard approach to smoking cessation. Several recent articles show that smokers who are “not ready to quit” can be prompted to make a successful quit attempt by a trial medication and support. This approach has been embraced by the American Thoracic Society
In fact, the entire enterprise of smoking cessation counselling is due for a reconsideration. Physicians who have been trained in smoking cessation have been taught about stages of change and to focus on those who are ready to change. This excludes 40 per cent of the smokers from an effective intervention.
Read the literature review here
Substance Abuse and Public Health: Tobacco Control: Still the Number One Health Crisis January 6,2021
Presentation for MPH Students at the Icahn School of Medicine at Mount Sinai click here
Key Insights from the 2020 Surgeon General’s Report on Smoking Cessation
Empowering and Actionable information: click here
Best Practices in the Use of Electronic Cigarettes for Smoking Cessation and Tobacco Harm Reduction
Navigating the haze of information: click here
New Paradigms in Smoking Cessation and Tobacco Harm Reduction Updated February 2018 for Mount Sinai MPH students
Course outline here
Lecture Slide show here. Detailed references on request
There is an overwhelming body of evidence to support tobacco control interventions. These interventions are effective, cost-effective, and produce a return on investment. Yet there is tremendous political resistance to widespread implementation of these interventions. Those states and nations that have implemented effective strategies have dramatically altered the burden of tobacco related illness. New paradigms of tobacco control are emerging including better approaches to treatment, harm reduction strategies, and electronic cigarettes.
Health Plans and ACOs may be missing opportunities to improve health status of their members and lower costs by failing to align with the local and national tobacco control strategies. Presentation at NGS Payors Summit" Public Health Perspectives of Accountable Care Click here
The Center for the Study of Tobacco and Society led by Dr. Alan Blum presents a visual record of the marketing of tobacco marketing. For a link to this valuable archive click here. My own modest contributions to tobacco control are cited 14 times and include multiple appearances at City Hall in New York to testify about smoke-free environments. As part of my work with Dr. Blum in a group called DOC, Doctors Ought to Care, one student came to me with an idea to help immunize young people against tobacco advertising. Dr. Alan Herschenfeld produced the Ballad of McSmoke the Tobacco King and Nikki Teen a rap music video (click here) and an educational package for use in schools (click here).
Reimbursement for tobacco cessation: A new model
Although the reimbursement rate for tobacco cessation is relatively low, by initiating a brief individualized, documented reminder by clinic personnel, the additional reimbursement will be significant. One practice in Alabama estimates that its 90,000 adult medicine visits could generate over $190,000 per year.
Here is how the model works: The American Academy of Family Physicians has developed a set of tools that support non-clinicians in providing and documenting the counselling interventions in conjunction with physician advice to the patient.
The Center for Medicare and Medicaid Services (CMS) and several medical organizations provide guidelines for evidence-based interventions for every smoker at every visit. This includes those patients who are “not ready to change”.
Here are the details of the model: In the Alabama practice, there were 90,000 adult medicine visits in 2021. The distribution by insurance type was estimated. The statewide prevalence of smoking was applied to each type of coverage, taking into consideration that the smoking prevalence among Medicaid recipients and the uninsured is double the that of the general population. The reimbursement for the three-minute counseling session was obtained for the Medicare, Medicaid, and commercial fee schedules. Were a 3-minute counseling session (CPT 99406) provided to each tobacco user for every visit, the model would generate an added revenue of $190,697 per year.
Details of my ongoing review of practice improvement in tobacco cessation is here
How much would your practice generate in tobacco cessation revenues?
Please share your thoughts and questions with me.
Edward Anselm, MD Clinical Assistant Professor, Icahn School of Medicine at Mount Sinai
eanselm@MSN.com
The economics of tobacco cessation: an overlooked resource in practice success
Many medical practices are moving away from fee for service towards accountable care models where members medical expenses are capitated. Regardless of where in the transition your medical group rests, you may be missing out on significant opportunities to improve net income by underperforming in tobacco cessation. Employers value the excess medical expenses of smokers at approximately $2000 a year (1). If you estimate the prevalence of smoking in your patent population (2), you can calculate the excess practice medical expense attributable to tobacco. In order to capture this expense your clinicians can advise patients to quit, prescribe medications to assist, and provide counselling themselves or by referral to local resources. A systems approach is recommended by the CDC (3) but most practices do not perform well. Only 7.5% of smokers quit each year and when they do, fewer than one third report use of medication or counseling. The data shows that there are innumerable missed opportunities to help your patients quit. How does your practice perform?
To examine practice effectiveness in tobacco cessation, look to your EMR and billing systems. Two CPT codes 99406 and 99407 (4). These codes are often not billed even when the service is provided. For many fee for services practices a systematic approach to documenting and billing tobacco cessation can generate substantial revenue stream that exceeds the cost of implementation. A calculator that encompasses reimbursement rates, prevalence and your patient visit volume to predict your revenue is available(5). What would it cost to capture this value for your practice? Detailed approaches to adoption of systems change have been published (6,7) but the key elements are review of patient flow, alignment of EMRs to track performance and provide referrals to local quit lines, and staff training. The largest expense involved in tobacco cessation is medication, which is paid by the health insurer. Medical group practices are encouraged to look closely at their approach to tobacco cessation. Additional insights and resources are available on this website.
https://www.smokefreestjoe.org/smoking-costs-in-the-workplace/; https://www.theexprogram.com/resources/blog/smoking-and-health-care-costs-when-do-companies-see-savings/
Current Cigarette Smoking Among Adults in the United States | CDC
Quitting Smoking Among Adults — United States, 2000–2015 | MMWR (cdc.gov)
99406: Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes; 99407: Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes.
Go to the XL Worksheet here to do the math for your practice.
Published in The economics of tobacco cessation: an overlooked resource in practice success (medicaleconomics.com)