Reimbursement for tobacco cessation: New models for fee for service and ACO/capitation
Tobacco cessation services provided by medical practitioners do not appear to be effective. According to the most recent Surgeon General’s Report, each year only 7.6 percent of smokers are able to stop. Although smokers report that doctors advise them to quit smoking, only one third of smokers making quit attempts use evidence-based interventions such as medication or counselling. As a result, relapse rates are high, and some smokers require up to 20 attempts before they are successful. Smokers with higher burden of social determinants of health are even less likely to receive cessation services. Although many barriers to systematic implementation of tobacco cessation services have been identified, the least well studied is the role of reimbursement and overall practice income.
Clinical practice guidelines detail evidence-based interventions regardless of a smoker’s readiness to change. Thus, smokers could receive a billable service at every office visit. However medical claims data from several health plans show that clinicians rarely bill the codes for smoking cessation counselling. Models for fee-for-service environments suggest large levels of reimbursement are available when CMS guidelines are consistently applied. One study calculated the lost opportunity in a health system in Pennsylvania and Maryland at over $5 million over 3 years. pre-print Lost Opportunity in Tobacco Cessation Care: The Impact of Underbilling in a Large Health System | medRxiv
The long-term economic value of tobacco cessation is well established and should be of great interest to medical groups operating on a capitation or shared risk, Accountable Care Organizations, and health insurers. Published reports show an ROI ranging from 3:1 to 10:1. You can find a summary of this literature here. Another recent paper showed economic returns when a systems-based approach was implemented in an HMO setting. Cost-Effectiveness of a Comprehensive Primary Care Smoking Treatment Program - PubMed (nih.gov) The cost of implementing systems-based improvements in smoking cessation is modest and the benefits continue to accrue and increase over future years that members are retained.
To get a snapshot of the reimbursement potential for your practice. Follow the link to an XL spreadsheet that supports an estimate of the reimbursement based on billing every smoker for a 3 minute counselling cessation. CMS and other payors now support “incident to” billing, so the doctor need not be present int the room. Go to the XL Worksheet here to do the math for your practice.
The largest medical expense in smoking cessation is the medication, a cost that is borne by the insurer. Counselling can be provided by state Quitline’s or health plan wellness programs. Systems-based changes in smoking cessation are not costly to implement: The main effort in counselling patients can be provided my non-professional office staff as detailed by the AAFP Office Champions Program or CMS Million Hearts. The Electronic Medical Record can be programmed to make referrals to the state Quitline.
Tobacco Cessation Change Package | Million Hearts® (hhs.gov)
Details on CMS requirements for documentation, billing and coding are available here
Please share your thoughts and questions with me.
Edward Anselm, MD Clinical Assistant Professor, Icahn School of Medicine at Mount Sinai
eanselm@MSN.com