Medicare coverage of smoking cessation. (Featured CME Topic: Smoking Cessation).

Today's older smokers grew up in an era in which advertisers promoted smoking; the adverse effects of smoking had not yet been established. There are significant benefits to smoking cessation, even after 30 or more years of regular smoking. Older smokers may be less likely to perceive the health consequences of smoking, but are more likely to achieve success in their cessation attempts than younger smokers. It is believed that a major portion of the physical decline among the elderly is caused more by the absence of comprehensive health promotion and disease prevention strategies than by aging.

Smoking cessation is a special concern for Medicare because more smokers will be entering the program in coming years. The prevalence of smoking in the Medicare population is currently declining slowly, but the actual number of smokers will increase with the aging of baby boomers. It is estimated that between 1995 and 2015, Medicare will spend $800 billion treating tobacco-related diseases.

By law, smoking cessation therapy as such is not a Medicare benefit. In an effort to prompt Congress to consider a Medicare benefit to cover smoking cessation, the Centers for Medicare and Medicaid Services (CMS) contracted with RAND to evaluate and summarize the evidence found through a review of the literature on the effectiveness of smoking cessation programs and to make recommendations for potential Medicare policy. As a result of this report, the CMS has provided funding for the Medicare Stop Smoking Program as part of its Healthy Aging Project. In developing this smoking cessation demonstration project CMS consulted with other government agencies and organizations including the National Institutes of Health, the Agency for Health-care Research and Quality, and the Centers for Disease Control and Prevention.

The report produced by RAND provided comprehensive, science-based information on the effective and cost-effective interventions targeting the senior population. The following conclusions were detailed in the report:

1. Individual, telephone, and group counseling are all effective, with individual counseling being possibly most effective.

2. There is consistent evidence from multiple analyses that greater intensity of counseling yields higher smoking cessation rates.

3. Nicotine replacement therapy (NRT), clonidine, and bupropion are all effective as pharmacotherapy for smoking cessation, although clonidine is not approved by the FDA for this use.

4. Patients visiting physicians trained in smoking cessation had higher cessation rates than those visiting untrained physicians.

5. Health insurance benefits of 100%. for both counseling and NRT produced the greatest number of quitters in a population.

6. There is good evidence that both medical and non-medical providers are effective at delivering smoking cessation services, but conflicting evidence about the relative degree of effectiveness between provider types.

7. Interventions with follow-up calls or visits are more effective than those without.

8. There are insufficient data to support or refute variations on smoking cessation interventions among special populations.

The following recommendations based on the RAND report evidence were formulated by a panel of experts on smoking cessation, health services research, medicine, and behavior change:

1. Smoking cessation interventions should be tested as a Medicare benefit.

2. Any demonstration project should include pharmacotherapy, physician visit, and/or telephone hotline. Group counseling should not be required, as older smokers will avoid groups.

3. Primary care practitioners participating in smoking cessation demonstrations should be offered and encouraged to have training in this area.

4. There is no evidence that paying providers for outcomes will work, and there is considerable evidence that it will not. However, providers should be held accountable for their performance in accordance with the Agency for Healthcare Research and Quality (AHRQ) guidelines. The five A's (ask, advise, assess, assist, and arrange) should be documented in provider records.

5. As in any demonstration project, sufficient numbers of minorities and women should be included.

CMS has selected seven states to participate in their Medicare Stop Smoking Program. The states were selected based on their penetration of fee-for-service Medicare beneficiaries, the prevalence of older smokers, the ability to divide the state into four geographic regions, and the absence of statewide quitlines. Four of the seven states selected are in the Southern Medical Association territory; the seven states that will be participating in the program are Alabama, Florida, Missouri, Nebraska, Ohio, Oklahoma, and Wyoming. The program, scheduled to begin in May or June 2002, will be administered by CMS through each participating state's Peer Review Organization (PRO). The PRO is designed to monitor and improve utilization and quality of care for Medicare beneficiaries. It will be the responsibility of the PRO, under the guidance of Qualidigm, the Connecticut PRO, to run the program in their state. Each PRO will publicize the project in their state through newspaper and broadcast advertisements, doctors' offi ces and community outreach programs.

The design of the program to test smoking cessation as a Medicare benefit will involve dividing each state into four geographic regions and assigning a treatment plan to each region. Medicare beneficiaries will then be told of the smoking cessation program. All Medicare beneficiaries will receive the Department of Health and Human Services publication Consumer Guide: You Can Quit Smoking. Those Medicare patients wishing to participate in the smoking cessation program benefit and living in a geographic region that is assigned reimbursement for smoking cessation treatment will be asked to identify a provider of healthcare (physician, nurse practitioner, physician's assistant). The healthcare provider will then be notified that their patient has chosen to participate in the smoking cessation project and provided with a smoking cessation CME Training Packet. It is possible for the Medicare beneficiary to be randomized into one of the following four groups:

1. Reimbursement for provider counseling alone;

2. Reimbursement for both provider counseling and Zyban or nicotine replacement therapy;

3. A telephone counseling quitline and reimbursement for nicotine replacement pharmacotherapy; and

4. Usual care (the Control Group).

The covered benefit will be limited to two counseling sessions in one twelve-week cycle, with coverage of two twelve-week cycles. The reimbursement to the healthcare provider will be for three to ten minutes of counseling. Patients assigned to the groups receiving pharmacotherapy will receive the Zyban or Nicotine replacement therapy by mail from a pharmacy benefit's manager.

Maintaining the statistical integrity of the control group is critical to the validity of the study results. It is for this reason that the patients are recruited rather than recruiting the healthcare providers. The "usual care" group will not receive counseling or pharmacotherapy reimbursement coverage. Instead the healthcare provider should answer patient initiated questions according to the content and recommendations found in the Consumer Guide: You Can Quit Smoking.

For further information regarding the Medicare Smoking Cessation Program, the Connecticut Peer Review Organization, (Qualidigm) may be contacted at:

Qualidigm

Marcia K. Petrillo

100 Roscommon Dr.

Suite 200

Middletown, CT 06457

Phone: [phone]

Fax: [phone]

Hotline: [phone]

http://www.qualidigm.org

Peer Review Organization contact information for the four states in the Southern Medical Association territory:

ALABAMA

Alabama Quality Assurance Foundation

Henry Koehler, President/CEO

One Perimeter Park S

Suite 200 N

Birmingham, AL 35243-2354

Phone: [phone]

Fax: [phone]

Hotline: [phone]

http://www.aqaf.com

FLORIDA

Florida Medical Quality Assurance, Inc.

Logan Malone, EdD, CEO 

4350 W. Cypress St.

Suite 900

Tampa, FL 33607

Phone: [phone]

Fax: [phone]

Hotline: [phone]

http://www.fmqai.com

MISSOURI

Missouri Patient Care Review Foundation

Richard A. Royer, Acting CEO

3425 Constitution Court

Suite E

Jefferson City, MO 65109-5753

Phone: [phone]

Fax: [phone]

Hotline: [phone]

http://www.mpcrf.org/MU

OKLAHOMA

Oklahoma Foundation for Medical Quality

Jim L. Williams, President/CEO

5801 Broadway Extension

Suite 400

Oklahoma City, OK 73118-7472

Phone: [phone]

Fax: [phone]

Hotline: [phone]

http://www.ofmq.com

Reference

* US Department of Health & Human Services Center for Medicare and Medicaid Services: Evidence Report and Evidence-based Recommendations: Interventions to Promote Smoking Cessation in the Medicare Population. Prepared by RAND. Available at http://www.hcfa.gov/healthyaging/2b.htm

From the Department of Practice Management Services, SMA Services, Inc., a subsidiary of Southern Medical Association, 35 Lakeshore Dr, PO Box 190088, Birmingham, AL 35219-0088.