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CENTERS FOR DISEASE
CONTROL AND PREVENTION
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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. |
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"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 46 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 34 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 (HEDISฎ), 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 HEDISฎ 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.
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Policy | Accessibility This page last reviewed August 10, 2004 United
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