Medical Organizations Collaborate to Press for Private Payer Coverage of Tobacco Cessation Counseling, Pharmacotherapy

America's health insurance companies should include tobacco cessation counseling and associated pharmacotherapy in their standard benefit plan packages, and they should pay physicians fairly to provide those services.

That's the central message of a July 21 letter sent to dozens of health plans and signed by the presidents of the AAFP; the AMA; the American Academy of Pediatrics, or AAP; the American College of Obstetricians and Gynecologists; and the American College of Physicians.

The AAFP took the lead on the letter after 18 months of brainstorming discussions with the AMA and the AAP. The organizations hope to bring commercial insurance coverage in line with Medicare, which has paid for smoking cessation counseling since 2005. They're also looking for ways to eliminate children's exposure to tobacco and secondhand smoke.

According to the letter, primary care physicians are in a unique position to help patients with their tobacco addictions because nearly six of every 10 office visits in this country are made to primary care physicians.

The physician groups made their case for tobacco counseling by listing some facts about tobacco use in America:

The organizations pointed out in the letter that the U.S. Public Health Service's Clinical Practice Guideline on Treating Tobacco Use and Dependence: 2008 Update strongly recommends that clinicians screen all adults for tobacco use, provide tobacco cessation interventions for those who use tobacco products and counsel parents to avoid exposing children to secondhand smoke. The guideline recommends that both medication and counseling be considered components of a treatment plan for nicotine addiction in most patients.

The physician groups noted that the National Business Group on Health recommends that preventive health services benefits include both brief and intensive counseling for tobacco use as covered benefits. The letter also said that cost analyses show that the inclusion of tobacco cessation insurance benefits saves employers money because counseling and pharmocotherapy have been proven to double cessation rates.

The letter also noted that although some commercial payers consider smoking cessation an optional benefit, the 2008 Healthcare Effectiveness Data and Information Set, or HEDIS, measures (11-page PDF; About PDFs) include a measure on medical assistance with smoking cessation. That means commercial payers, as well as Medicare and Medicaid, need physicians to provide tobacco cessation counseling if the payers are to receive a favorable HEDIS score.

HEDIS is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service.

Jonathan Klein, M.D., M.P.H., is director of the AAP's Julius B. Richmond Center of Excellence, an initiative dedicated to the elimination of children's exposure to tobacco and secondhand smoke. He has been at the forefront of the medical organizations' collaborative efforts on tobacco.

In an interview with AAFP News Now, Klein said that months of discussions on nicotine addiction brought two issues to the forefront: Namely, that tobacco cessation counseling and pharmacotherapy work as prevention strategies, but there is a troubling gap between the ability to provide those services and the availability of commercial insurance coverage to pay for them.

"There is no routine coverage by most health plans for smoking cessation services; it's considered an add-on service," said Klein, who is a professor of pediatrics, community and preventive medicine, and family medicine at the University of Rochester in Rochester, N.Y.

Klein said if a company wants to include the services in its health plan benefits, the insurance company is more than happy to do so -- for an extra charge. Klein argued that it makes no sense for payers to cover preventive services such as mammography and prostate-specific antigen screening, but not this one.

"If all employers started saying, 'We're not going to consider any plan that doesn't include all of the preventive services,' we might make significant headway on this issue," said Klein. "Our organizations haven't approached the business community yet, although that certainly would be another way to advocate for this coverage."

According to calculations provided by staff in the Academy's Practice Support Division but not included in the letter, physicians can file a Medicare claim for tobacco cessation counseling using CPT code 99406 (behavior change counseling for 3-10 minutes) or CPT code 99407 (behavior change counseling for more than 10 minutes). Based on the 2009 Medicare physician fee schedule without geographic adjustment, the average payment for each of these codes is $12.98 and $24.89, respectively.

However, the existence of a CPT code does not compel private insurers to recognize that the service represented by the code is a payable benefit.