Pretty much everyone who cares about public health agrees that it’s a good idea to help people quit smoking, the No. 1 cause of preventable death in the U.S. Doctors may soon get some extra encouragement to lend a hand, thanks to proposed changes in Medicare’s physician fee schedules.
Physicians who offer counseling on quitting cigarettes or other tobacco products during visits with patients would get a 19% increase in reimbursement, according to a few paragraphs buried in the 1,592-page document released this week. The same adjustment would also apply to assessments of, and interventions for, alcohol and substance misuse during doctors’ visits.
“Given the evidence supported role these services play in preventing and managing chronic disease […] we believe that valuation should more accurately reflect the clinical intensity and work associated with these time-based services,” the proposal from the Centers for Medicare and Medicaid Services explains. Comments on the proposal are due Sept. 14.
“The prioritization of cessation as a service is long overdue, and we’re very excited about it,” said Anne DiGiulio, the American Lung Association’s senior director of nationwide tobacco cessation and health policy.
If the change is finalized, it would have “tremendous implications” not just for people on Medicare and Medicaid, but for people with private insurance, said Ned Sharpless, a former director of the National Cancer Institute who’s now a professor of cancer policy and innovation at the University of North Carolina School of Medicine. That’s because private insurers tend to follow the lead of Medicare and Medicaid, behemoths that cover about 2 in 5 Americans.
“We have something to offer these patients,” said Sharpless, who was in a celebratory mood having advocated for this kind of change to CMS policy for years during both the Biden and Trump administrations. “And we need to incentivize doctors to do this.”
Until now, the status quo has been that doctors make around $10 from tobacco cessation counseling, said Sharpless. That’s not much, and given that primary care and internal medicine doctors are already juggling lots of competing demands, getting into a detailed dialogue about quitting cigarettes is often an afterthought. With the nearly 20% bump in reimbursement, “nobody’s getting rich off this, but now it’ll be more on par with other activities,” Sharpless said.
The majority of people who simply try to quit smoking on their own wind up going back to cigarettes, with success rates under 10%. But success rates go up significantly if people receive a combination of both behavioral support and treatments designed to ease withdrawal and craving symptoms, such as varenicline, nicotine patches, or bupropion. Yet just 5% of people who had recently attempted to quit had received both counseling and medication, according to 2022 data from the Centers for Disease Control and Prevention.
Research also shows that even a few minutes of advice during a doctor’s visit can improve quitting rates. But a survey of Medicaid claims in 20 states found that an average 2.7% of people who smoked and had recently attempted to quit had received cessation counseling.
Alcohol screening and counseling in the doctor’s office is similarly important yet underutilized. One study found that 70% of people with alcohol use disorder were asked questions about their drinking while visiting a clinician, of whom 12% received a brief intervention and a scant 5% of whom were given referrals or informed about treatment options.
“Most clinicians recognize tobacco use as an important health issue, but what patients receive often amounts to a brief statement such as, ‘You should quit,’ rather than an evidence-based treatment plan,” said Adam Goldstein, a professor and director of tobacco intervention programs at the UNC School of Medicine, via email.
Ideally, Goldstein said, physicians should be having structured conversations discussing matters like patients’ motivations for quitting, potential triggers, and the medications that may help ease cravings and withdrawal symptoms. Frequent follow-up support is also crucial, though it’s not practical for doctors to do weekly or daily check-ins. That’s where Sharpless and Goldstein would like to see tobacco treatment specialists — similar to diabetes educators, who work with patients on managing their conditions and get reimbursed by Medicare — come in.
Like Sharpless, Goldstein thinks the reimbursement increase is meaningful. But he said that the absolute dollar increase for each individual visit won’t be large enough to get most practices or providers to offer comprehensive services on quitting smoking.
“The strongest impact would occur if the payment change were paired with reliable tobacco-use screening, electronic-health-record prompts, standing medication protocols, trained nurses or tobacco-treatment specialists, quitline referral systems, and follow-up,” Goldstein said.
It’s also unclear what kind of impact the change will have on alcohol screenings, interventions, and referrals, Tim Clement, vice president of federal government affairs at Mental Health America, said via email. Low reimbursement is “certainly a factor” for limited uptake among physicians, and a pay bump is “a good thing,” he said. But there may be other issues contributing to the problem, too.
Still, Sharpless said the change was a step in the right direction.
“Every once in a while,” he said, “it’s good to have a good story.”
Isabella Cueto contributed reporting.
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