Editorials

Paying physicians to treat tobacco use disorder

It may take more

Papers BMJ USA p  519

This article originally appeared in BMJ USA

In the United Kingdom, as in the United States, discussions of health care frequently focus on payments for physicians and the impact these payments might have on patient care. Although they reimburse for any number of treatments and preventive care visits, many public and private insurers do not pay physicians to treat patients for nicotine dependence.¹ In this issue of BMJ USA (p 519), a study by Coleman and his colleagues² suggests that the promise to pay British general practitioners £15 (about $22) per smoker who quits is not enough to change the way they treat patients who smoke. The promised payments were small and were based not on the provision of treatment, but on the hoped-for results of the servicesmoking cessation and continued abstinence for at least three months. Detailed interviews with these physicians³ suggested that many of them had done the financial math and decided that the new payments were inadequate incentive to make changes to their practice organization. The physicians in the study agreed it would have been fairer to receive payments for the additional services they provided to smoking patients.

Blue Cross and Blue Shield of Minnesota recently took just that approach. In May of 2000, the health plan, which covers about two million members, announced it would routinely pay physicians for treating nicotine dependence. A diagnosis of tobacco use disorder (ICD 9 code 305.1) is now considered a chronic medical disease. This means that physicians receive payment for treating a patient with this diagnosis, just as they would for an office visit by a patient with a diagnosis of hypertension, diabetes, or other chronic condition. The number and length of visits are not limited, so physicians and their patients are free to chart a course of appropriate treatment that makes sense for them.

Blue Cross and Blue Shield of Minnesota made this policy change for several reasons. First, there is strong scientific evidence that physicians can treat nicotine dependence successfully.⁴ Second, evidence-based standards of care for the treatment of tobacco users have been produced, ^{5 6} and these standards have been widely disseminated and supported by professional organizations. Third, patients clearly benefit from this treatment, realizing decreased morbidity and mortality.

These reasons alone are sufficient to warrant payment for appropriate treatment of a disease. But there is another: investing in treatment to help smokers quit can result in reductions in health care costs.⁷ The economic issues are not simple, and have been clouded, for example, by cigarette maker Philip Morris' recent claim that dead smokers are a financial benefit to society.⁸ But healthier people require fewer health care resources, not more. Treating tobacco use makes sense for patients, physicians, health plans, and society.

Patients who smoke want and need help quitting, and appreciate their physician's advice and assistance.⁹ Smokers have higher rates of satisfaction with their care when seeing physicians who ask them about their tobacco use than with physicians who ignore the topic.¹⁰ But even with its new policy, Blue Cross and Blue Shield of Minnesota has seen only a small increase in the number of office visits for the treatment of smokers. It may be that a lack of payment is only one of the barriers physicians face in trying to treat smokers.

Medical practice can sometimes be slow to change. Thoughtful physicians base their actions on their training and may change only in response to years of consistent research findings that support new treatments. Extremely busy practices may find it hard to make systematic changes in the way physicians approach any disease, particularly one as prevalent as nicotine dependence. Clinicians struggling with difficult staffing or management issues may find it impossible to make any systematic change, no matter how well meaning they are.

It is our hope that more and more health plans and national government insurance programs will change their policies and pay for effective treatment of tobacco users. It has the potential to save lives and save money; it is the right thing to do. For a health plan, the short-term financial risks are minimal, and the potential long-term benefits are large. But it may be only one of several changes needed to achieve a widespread improvement in the way tobacco use is treated. It may require both better training for physicians and systematic support and encouragement from health care institutions.

It is important to remember that physicians can play another critically important role in reducing the toll of death and disease caused by cigarette companies. In addition to treating smokers, physicians can help their communities stop tobacco companies from addicting youth and thwarting adults' attempts to quit smoking. By actively supporting effective public policy measures such as tobacco excise tax increases and clean indoor air laws, physicians can magnify the impact of their clinical treatment and make real progress in solving the most important public health issue of our time.¹¹

http://bmj.com/cgi/content/full/323/7310/432

Marc Manley, executive director. 

Center for Tobacco Reduction and Health Improvement, Blue Cross and Blue Shield of Minnesota, St. Paul, Minnesota, USA (marc_manley{at}bluecrossmn.com)