Almost everyone interested in public health agrees that it is a good idea to help people quit smoking, the number one cause of preventable death in the United States. Physicians may soon have further encouragement to step up thanks to proposed changes to Medicare’s physician fee schedule.
Physicians who provide counseling on smoking cessation of cigarettes and other tobacco products during patient visits will receive a 19% increase in reimbursement, according to several paragraphs embedded in a 1,592-page document released this week. The same adjustments apply to alcohol and drug abuse assessment and intervention during physician visits.
“Given the evidence supporting the role that these services play in chronic disease prevention and management (…) we believe that assessments should more accurately reflect the clinical intensity and effort associated with these time-based services,” the proposal from the Centers for Medicare and Medicaid Services explains. Comments on the proposal are expected to be submitted by September 14th.
“Prioritizing smoking cessation as a service is long overdue, and we are very excited about it,” said Anne DiGiulio, senior director of national smoking cessation and health policy at the American Lung Association.
Ned Sharpless, a former director of the National Cancer Institute and now a professor of cancer policy and innovation at the University of North Carolina School of Medicine, said the changes, if finalized, would have a “huge impact” on people with private insurance as well as those with Medicare and Medicaid. That’s because private insurance companies tend to follow the lead of Medicare and Medicaid, the giants that cover about two in five Americans.
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“We have something to offer these patients,” Sharpless said. He was in a celebratory mood after advocating for these kinds of changes in CMS policy for years during the Biden and Trump administrations. “And we need to encourage doctors to do this.”
Until now, doctors have been earning about $10 for smoking cessation counseling, Sharpless said. It’s no big deal, and given that primary care and internal medicine physicians already have so many competing demands on them, detailed discussions about smoking cessation tend to be put on the back burner. With redemptions up nearly 20%, “nobody’s going to get rich off this, but it’s going to be on par with other activities going forward,” Sharpless said.
Even if you simply try to quit on your own, the vast majority of people end up going back to cigarettes, with less than a 10% success rate. But success rates increase significantly when people receive a combination of behavioral support and treatments designed to alleviate withdrawal and craving symptoms, such as varenicline, nicotine patches, and bupropion. But 2022 data from the Centers for Disease Control and Prevention shows that only 5% of people who recently tried to quit received both counseling and medication.
Research also shows that even a few minutes of advice during a doctor’s visit can improve quit rates. However, a study of Medicaid claims in 20 states found that an average of 2.7% of smokers who recently attempted to quit received cessation counseling.
Alcohol testing and counseling in the clinic are equally important but underutilized. One study found that 70% of people with alcohol use disorder were asked about their drinking during a clinician visit, 12% of them received a brief intervention, and only 5% received a referral or were informed about treatment options.
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“Most clinicians recognize that tobacco use is an important health problem, but patients often receive little more than a simple statement like, ‘You should quit,’ rather than an evidence-based treatment plan,” Adam Goldstein, a UNC School of Medicine professor and director of the Tobacco Intervention Program, said in an email.
Ideally, doctors should have a structured conversation that discusses issues such as the patient’s motivations for quitting, potential triggers, and medications that may help ease appetite and withdrawal symptoms, Goldstein said. Frequent follow-up support is also important, but weekly or daily check-ins are not practical for physicians. So Sharpless and Goldstein would like to see tobacco treatment experts, like diabetes educators, who work with patients to manage their symptoms and receive Medicare reimbursement.
Like Mr. Sharpless, Mr. Goldstein thinks the reimbursement increase makes sense. But he said the absolute dollar increase per individual visit is not large enough for most health care facilities and providers to offer comprehensive smoking cessation services.
“The strongest impact will occur when payment changes are combined with reliable tobacco use screening, electronic health record prompts, routine medication protocols, trained nurses or tobacco treatment specialists, smoking cessation counseling systems, and follow-up,” Goldstein said.
It’s also unclear how the changes will affect alcohol testing, interventions and referrals, Tim Clement, vice president of federal affairs at Mental Health America, said in an email. Low pay is “certainly a factor” in limited recruitment among doctors, he said, and higher salaries “are a good thing.” However, other issues may also be causing the problem.
Still, Sharpless said the change is a step in the right direction.
“It’s good to have a good story every once in a while,” he said.
Isabella Cueto contributed reporting.
STAT’s chronic health coverage is supported by a grant from Bloomberg Philanthropies. Our financial supporters have no input into any decisions about our journalism.
