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Board-certified internist with a long-standing focus on public health, tobacco control, and preventive care Edward Anselm discusses his article “The economic case for investing in tobacco cessation.” Edward reveals that while smoking rates have hit historic lows, 19.5 percent of adults still use tobacco, with significant disparities persisting across race, ethnicity, and income levels. He analyzes why only 6.4 percent of patients receive optimal treatment involving both counseling and medication despite 80 percent of users being advised to quit. The conversation highlights the financial argument for cessation, noting that Medicare reimburses $15.50 for brief counseling, yet systems bill this for less than 2 percent of visits. Edward outlines how a systems-change approach can create a net reduction in costs and generate substantial revenue for accountable care organizations. Discover how treating tobacco use aggressively is both good medicine and smart business strategy.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Edward Anselm, internal medicine physician. Today’s KevinMD article is “The economic case for investing in tobacco cessation.” Edward, welcome to the show.

Edward Anselm: Thank you. Glad to be here.

Kevin Pho: All right, so before we talk about the article, just briefly share your story and then maybe talk about why you decided to write this article on KevinMD.

Edward Anselm: Thank you. When I was in primary care, I became very interested in tobacco treatment. That was in the 1980s when virtually no one was doing anything about tobacco whatsoever. I continued my interest in tobacco treatment even though my career has evolved significantly over the decades. I have become increasingly involved in managed care and value-based contracting. Now at the end of my career, I am able to bring my basic interest in tobacco treatment and my skills and insight in value-based medicine together.

Kevin Pho: You mentioned when you were in primary care decades ago, there was little interest in tobacco cessation. What is the context like today? How much are we spending on tobacco cessation, and are we paying the requisite attention to it today?

Edward Anselm: It is deeply disturbing to me that to this day we do not do a good job in tobacco treatment. I like to go to the HEDIS measures on NCQA and look at the incredible progress that we have made in many dimensions of primary care, but tobacco treatment has not been one of them.

Our best information about what happens when patients meet their doctors to talk about tobacco comes from the National Health Interview Survey. It shows that only one out of three patients who are trying to quit smoking get effective evidence-based treatment from their doctors. Evidence-based treatment consists of medications and counseling together. Overall, only about 6 percent of people trying to quit smoking receive optimal care. This may be why the relapse rate is so high. We have effective treatments, but we are not using them and we are not getting them to our patients.

This really motivated my article because I asked how we can change that paradigm. How can we align interests with tobacco treatment? I endeavored to show the flow of revenue that occurs in either fee-for-service or value-based arrangements when tobacco treatment is consistently delivered.

Kevin Pho: All right, so let’s talk about that article for those who did not get a chance to read it. Why don’t you summarize it?

Edward Anselm: Basically, I put together all the moving parts that allow a doctor to evaluate their practice and determine whether or not they could add to their revenue and improve their outcomes if they treat patients with tobacco use more effectively. The first issue is about billing for the 99406 and 99407 codes. I have published several papers that show that performance in billing these codes is very low.

We do know that doctors provide counseling to their patients, but in many instances, they are not bothering to bill for these services. Medicare and other payers will pay $15, which is the national fee schedule average, up to eight times a year for any patient. It is disturbing to know that doctors are performing some work in providing patients tobacco treatment, but they are not billing it. The clinical evidence shows that tobacco treatment can be offered to every patient at every visit regardless of their readiness to change. In the fee-for-service model, doctors are missing out on huge volumes of revenue. Again in the article, I show how they can do the math on that using their electronic medical record system.

Kevin Pho: So I am a primary care physician, and I have to admit, I am actually not that familiar with those codes. So the 99406 and 99407, those are specific tobacco cessation counseling codes?

Edward Anselm: That is correct. What is really interesting is that those are incident-to codes. Therefore, you do not have to be face-to-face with the patient in order for your office to bill for those services. Anyone in a white coat can do it. It does not have to be a health professional. Anyone in a white coat can document a transaction or a conversation where you refer the patient to a quitline or prescribe medications according to a protocol.

The doctor is the captain of the ship. He or she says: “I want you to talk to my office assistant or medical associate about tobacco use.” Then they carry the ball going forward. It is a few seconds on the part of the doctor, but the office is engineered to provide treatment every visit. Of course, it has a built-in follow-up mechanism where the patient is seen again and the subject is raised again, so you can track your effectiveness.

Kevin Pho: And what is the reason why most physicians aren’t using this code? Is it simply because they are not aware of it or they just do not want to do it? From your experience, what are some reasons why it is underused?

Edward Anselm: This is a great question because it has been the subject of research since the Preventive Services Task Force started coming out with their guidelines on tobacco treatment. Why aren’t doctors doing it? First thing is the reimbursement rate. Fifteen dollars seems really low unless you calculate the fact that you can do it eight times a year and that someone else can be providing the service.

The other thing is doctors generally do not feel that they are good at tobacco treatment or basic counseling. When I was a primary care physician, I measured my own performance. My quit rate for all comers was 5 percent on an intention-to-treat basis. That is not very satisfying. That was before medications were available. Medications doubled my success rate, and that is 10 percent. Again, if you are doing something at a 10 percent success rate, you are not likely to get in the habit of doing it. It is below your threshold of perception. This is where electronic medical records can really help you understand how well you are performing and how you can do even better.

Kevin Pho: All right, what other economic incentives are there to promote tobacco cessation?

Edward Anselm: The big win is in value-based care. This is totally transformative because currently about 40 percent of medical practices are in value-based arrangements. An increasing fraction of that is aligned. Your payment is based on your patient’s past medical utilization, which includes their hospitalizations, their emergency room visits, their medication use, and so on.

If you and your practice are able to engender activities that result in avoided hospitalization and avoided medical expenses, then sure enough you will make money because your capitation will be high and your utilization will be relatively low. That is how you make money in value-based care by exceeding the expectations of the patient’s future morbidity.

People have done this and have published studies. I cite the papers in my article. It comes out to $35 per member per month. It is a lot of money. Think about that in terms of the practice. If you have a large group practice, the larger that number becomes because the fraction of your population that is smoking is substantially larger. It gets to be a huge amount of money. So it is not trivial.

A couple of missing elements are that most doctors do not even know which patients smoke. They do not ask them. That is something that really needs to be changed. Every paper that I have done, I have shown that health systems, and we are talking about major academic medical centers, consistently underreport the prevalence of tobacco use relative to the general population in that county or in that state significantly.

Therefore, they are missing opportunities to help their patients quit smoking. Now that we know that there is an economic vehicle behind it, they are missing opportunities to generate revenue for their practice. Changing the practice to optimally provide tobacco treatment is not just a simple transformation. It requires what I call a systems change. There is literature on that. In my article, not only do I point to the literature on systems of change, I talk to very well-designed models that can determine whether or not there is a cost-benefit for you.

My message to doctors is: Please do the math. We are all trying to provide great service to our patients in a business environment. If there is a product line that comes along that improves quality and generates revenue, it is incumbent on us to look at it. That is why I wrote the article to put together all the moving parts to allow a doctor to do the math on their practice and determine whether they should implement a systems change approach and exactly what type of systems change they should implement.

Kevin Pho: In one of the models that you cite in the article, there was an eight-hospital system that had a potential $2 million increase in annual revenue from instituting cessation services. So if we make some of these system changes that you are talking about, the increase in revenue can be into the millions, right?

Edward Anselm: That is correct. It obviously depends on the size, as this is a multi-hospital system. But they have to make their choices. That involved every touch of the patient. In other words, the hospital would have to re-engineer their workflow so that every time a patient was met by a medical assistant, they were asked about their tobacco status and provided a documented script regardless of their readiness to change.

If they do that, well, there is a couple million dollars down the road each year. As they shift towards value-based care, since that was a fee-for-service model, they are better positioned. The population that they inherit for their value-based care will be tobacco-free. So they have actually ensured their future savings. I invite people to do the math. It is exciting to imagine that you could make these small changes that will really result in improved patient outcomes and revenue.

Kevin Pho: So given this economic context that we talked about today, why aren’t more hospitals and medical insurers doing what you say? Why are we still underdiagnosing and undertreating tobacco use? What are some of the barriers that prevent us from doing these systems changes that would benefit economically health insurers and medical systems?

Edward Anselm: I have to say that there is a form of bias involved in treating tobacco as it is with many addictions and as it is with the treatment of obesity until recently. Doctors do not feel comfortable doing this and may avoid addressing it. When you see a patient who has smoking among their dozen problems, well, there you have 11 things to take care of before you get to smoking. Smoking is difficult. That is why we need a systems-based solution. We need to overcome the cognitive biases and the inertia that people have about tobacco.

With respect to insurers, there is a somewhat different paradigm operating. This involves time to return on investment. A doctor creates a relationship with their patients over many years. So in a value-based setting, they have the opportunity to see the benefits of all their interventions over time. Insurers on the other hand tend to look at things a little bit differently. They think about member turnover and their average member turnover. So they are not willing to invest the cost of tobacco treatment, which is overwhelmingly medications, because they say that value is going to go to some other health plan.

This is deeply flawed. I have shared my opinions with them on my website and in correspondence because they have the math wrong. Tobacco treatment is one of the most cost-effective interventions we have beyond vaccination. The cost of tobacco treatment nowadays for varenicline, which had been the number one drug costing $300 a month, is now below $30 a month. It has now gone generic. It is $30 a month, and it does not cost the insurer anything to do it.

What they need to do is overcome their own barriers in thinking about this. They do not want to promote health. It has been anecdotally stated that if it wasn’t mandated by the Preventive Services Task Force, the preventive services wouldn’t be executed. They wouldn’t be included in insurance plans because insurance plans are really to cover medical expenses and not preventive services.

So insurance companies still have a long way to go in terms of understanding how they can do better in terms of ensuring the health of their populations. It is unfortunate because in reality they are the largest public health departments we have in the country. They encompass millions of people, yet they do not have public health officers and they do not aggressively promote tobacco treatment or vaccination or other things. So they have a ways to go.

We all have an educational curve that we need to go through, but the only way that can be overcome is by doing the math. I invite anyone at any level, individual practice, group practice, or health insurer, to read the paper and do the math for themselves. I think they will come up with a positive response.

Kevin Pho: We are talking to Edward Anselm, internal medicine physician. Today’s KevinMD article is “The economic case for investing in tobacco cessation.” Edward, let’s end with take-home messages that you want to leave with the KevinMD audience.

Edward Anselm: As I like to reiterate, please do the math. Once you do the math, you will find that you can delight your patients and delight your office managers with improved revenue. Let’s agree that it is satisfying to take knowledge and put it into practice to see better clinical outcomes and better economic outcomes. So the takeaway message is: read the article and do the math.

Kevin Pho: Edward, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Edward Anselm: Thanks so much.