CENTERS FOR DISEASE CONTROL AND PREVENTION
Volume 14 • Number 3 • Fall 2001

Return to index of articles

Reimbursement for Smoking Cessation

Insurance coverage for smoking cessation programs has been formally requested of federal health care providers—will the private market follow suit?

Large purchasers of health insurance negotiate their benefits packages with health plans, and the federal government is no exception. Recognizing the need to reimburse for smoking cessation services, the Office of Personnel Management (OPM) has requested that federal insurers provide comprehensive coverage for tobacco dependence treatment, a policy change that will affect the approximately 2.3 million federal employees and their dependents who smoke. "The request is important not only because of the large number of beneficiaries, but also because it may serve as a model for other large purchasers to do the same," said Corinne Husten, MD, MPH, CDC medical officer and chief of the Epidemiology Branch in the Office on Smoking and Health.

The OPM request follows recommendations made by the U.S. Surgeon General and the Community Preventive Services Task Force in reports on smoking, which cite findings that lack of reimbursement keeps smokers from taking advantage of effective tobacco treatment services. Since 1995, removing financial barriers to the use of cessation services has been one of the national health objectives. 

There are nonfinancial barriers as well. Data show that only half of the smokers who saw a doctor in the past year were urged to quit, even though smoking is the single greatest preventable cause of illness and premature death in the United States. Physicians doubt their ability to help patients quit smoking, and they are concerned about offending patients by discussing smoking cessation. However, even simple advice to quit increases quit rates, and studies have shown that patient satisfaction also increases when doctors discuss smoking. Physicians also say lack of time and reimbursement for such treatment keep them from recommending that patients stop smoking. 

Reducing out-of-pocket costs can be very effective in inducing smokers to take advantage of smoking cessation interventions. At the Group Health Cooperative in Seattle, enrollees who were offered full coverage for nicotine replacement therapy in combination with behavioral therapy were four times as likely to use the services and four times as likely to succeed in their quit attempts. 

People who smoke are at increased risk for heart disease, cancer, lung disease, and other smoking-related illnesses that contribute to more than 430,000 deaths a year. Nationwide, medical care costs attributable to smoking (or smoking-related disease) have been estimated by CDC to be more than $50 billion annually. In addition, the Office of Technology Assessment estimates the value of lost earnings and loss of productivity to be at least another $47 billion a year. The cost savings of prevention efforts would be seen within 3–4 years. A July 2001 study published in the American Journal of Preventive Medicine found that the clinical treatment of tobacco use was ranked second (after childhood immunization) among 30 effective preventive services in an analysis that looked at disease impact, effectiveness of intervention, and cost-effectiveness of the intervention. "This finding shows that a lot of money and additional years of life could be saved if treatment of tobacco was incorporated into routine health care visits," said Dr. Husten.

Managed Care Looks at the Bottom Line 
Managed care organizations (MCOs) are interested in preventive care. Health insurers claim that patients do not want smoking cessation services, but they also fear that reimbursement would lead to an overwhelming and expensive demand. They know that patient costs rise the first year of cessation, probably reflecting an episode of ill health that leads to quitting. But they believe that high attrition rates mean that the ultimate health care cost savings are likely to be enjoyed by a competitor. Furthermore, they worry that a good smoking cessation benefit may attract more smokers to the plan, and smokers are more expensive to insure because they use more services. However, CDC health educator Abby Rosenthal, MPH, says that health plans find that even when cessation programs are free and heavily promoted, only 5%–8% of their member smokers sign up; up to 20% might use a pharmacy benefit. 

Several cost-benefit analysts argue that cessation does have a short-term payoff, in particular when the costs of heart disease and stroke are factored in. How long before MCOs see a return on investment? Estimates vary from 3 to 4 years, but most analysts agree that cessation services are more cost-effective than preventive services like mammography, which MCOs have enthusiastically adopted.

Organizational Changes Needed 
MCOs often add requirements that result in discouraging clients from taking advantage of cessation pro-grams, according to Dr. Husten; for instance, they may offer reimbursement only for successful quit attempts or limit the number of attempts that are reimbursed. Programs may be available only at certain times of the year. Such restrictions limit members' use of cessation services, leading MCOs to conclude that the program wasn't used enough to justify its existence. Smokers may not even know about cessation programs offered by their health plan or other organizations. 

"Restricting the use of cessation services reflects a basic misunderstanding of the nature of tobacco dependence," said Dr. Husten. "Just as patients with diabetes and hypertension are monitored and their medications and dietary interventions changed depending on the response to treatment, clinicians must continue to work with smokers until abstinence is achieved." Assisted quit attempts are more successful, but most smokers try to go it alone, she said. Most smokers try to quit at least 4–6 times before succeeding. The health care system and reimbursement need to be structured to support this process. 

Public health professionals argue that insurers have yet to give smoking cessation interventions a fair assessment. An essential first step is to be sure that smokers are identified so physicians can discuss the need to quit; making tobacco use a "vital sign," as was is done with blood pressure, is a simple way to identify smokers and influence clinicians to counsel smokers at each office visit. The use of administrative datasets allows the plan to monitor how the physician is handling the tobacco use and include it in quality improvement efforts. Until such tracking is done, patients will continue to develop preventable tobacco-related diseases. 

"We're where we were 25 years ago with blood pressure screening," noted Ms. Rosenthal. "In the late 70s, physicians did not screen for blood pressure. A concerted effort was needed to educate the public and providers about the need. We must do the same to get health care systems and providers to screen for tobacco use and to advise patients to quit." 

Model programs such as that begun by Group Health Cooperative of Puget Sound in 1989 suggest that proper organizational support can boost the effectiveness of cessation interventions. After an aggressive recruitment effort, members were allowed to choose from a telephone counseling intervention or a group program (both included pharmacological treatment as well). Most selected telephone counseling. The program resulted in a strong decrease in smoking prevalence compared with the state as a whole. Also, the program paid for itself in reduced hospitalization costs in 3–4 years. (Smokers' health care costs increase annually, so reducing the number of smokers in a plan benefits the bottom line.) 

Public health has raised insurers' awareness of the need for cessation services by adding tobacco-related practices to quality-of-care report cards issued by the managed care industry. The Health Plan Employer Data and Information Set (HEDIS^ฎ), a set of standardized performance measures designed to enable purchasers and consumers to compare the performance of managed health care plans, includes a standardized survey of consumer experiences. The HEDIS^ฎ tobacco measure asks, if you smoke and were seen in the health plan in the past year, were you advised to quit? The strategy has met with some success, but MCOs still don't have the data that would persuade them to adopt cessation reimbursement. "It's too bad, because studies show that physician advice, counseling to stop smoking, and pharmacological aids really do increase quit rates and lower health care costs," said Dr. Husten. 

Studies show that the recommendation of a clinician or any health care worker to quit smoking increases quit rates by 30%. More than 10 minutes of counseling doubles the quit rate. Individual, group, and telephone counseling can all help patients quit. "Just handing the patient self-help materials won't work," said Dr. Husten. "Person-to-person contact is a key factor." 

What should providers say in counseling? "They need to offer patients support for the quit attempt and explain how to seek support from friends and family," Dr. Husten explained. "The provider should encourage the quit attempt, exhibit caring and concern, and help the smoker identify situations that put them at risk for relapse and develop strategies to deal with these situations." 

Tobacco dependence treatments are both clinically effective and cost-effective in comparison with other medical and disease prevention interventions. The 2000 Public Health Service (PHS) guideline, Treating Tobacco Use and Dependence: A Clinical Practice Guideline, contains evidence-based information about pharmacologic therapies, which include bupropion SR, nicotine gum, patches, inhalers, and nasal sprays. The guideline urges health care insurers and purchasers to include, as a covered benefit, the counseling and pharmaco-therapeutic treatments identified as effective and to pay clinicians for providing tobacco dependence treatment, just as they do for treating other chronic conditions (see sidebar, "Six Strategies for Systems Changes from the PHS Guideline Treating Tobacco Use and Dependence.") "We know that both counseling and pharmacologic treatment are effective," noted Dr. Husten. 

Ms. Rosenthal believes that large self-insured employers like General Motors (GM) will understand the value of tobacco-use treatment intervention sooner than some of the MCOs. That's because employers stand to benefit directly from reduced absenteeism and increased productivity, as well as reduced health care costs. GM, the nation's largest employer, is working with its top 11 MCOs to cover cessation services. Part of the impetus was that a corporate vice president had developed lung cancer. Also, GM has more retirees in its plans than currently employed workers (206,000 employees, 412,000 retirees). The health of these older members is more likely to be affected by tobacco-related illness, such as lung cancer, emphysema, and heart disease. 

"Public health professionals should view corporate purchasers of health insurance as groups that can affect policy change," noted Ms. Rosenthal. "Groups of self-insured employers sometimes form purchasing cooperatives, and such groups should be actively recruited to participate in state-level tobacco control initiatives." 

Further information about the PHS treatment guidelines may be found at www.surgeongeneral.gov/tobacco. More information about clinical practice guidelines is available at www.jama.ama-assn.org/issues/v283n24/toc.html*. Copies of Treating Tobacco Use and Dependence: A Clinical Practice Guideline are available by calling 1/800/358-9295 or writing to Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907- 8547.

Return to index of articles

Privacy Policy | Accessibility

Home | Contact Us

CDC Home | Search | Health Topics A-Z

This page last reviewed August 10, 2004

United States Department of Health and Human Services
Centers for Disease Control and Prevention
National Center for Chronic Disease Prevention and Health Promotion