Every year in the United States, diseases linked to smoking kill approximately 480,000 people, including more that 41,000 deaths from secondhand smoke. In case you were wondering, that’s similar to COVID-19, which killed approximately 508,000 people over the last 12 months. And every year, smoking costs the nation more than $225 billion in direct medical care — and billions more in lost productivity. These annual deaths and costs have been going on for many, many years.
According to the Federal Trade Commission, in 2020, cigarette sales increased for the first time in 20 years, and smokeless tobacco sales were also up. What’s driving up sales? There are a few likely drivers. One was the uptick in cigarette price discounts paid to cigarette retailers and wholesalers. Undoubtedly, another driver was the stress caused by so many factors in 2020, including the COVID-19 pandemic. Ironically, COVID-19 may be driving up smoking rates — and smoking is also a risk factor for the most severe COVID-19 symptoms. So, what are payers doing about this?
Measuring performance
As the old saw goes, measure what you want to manage. Along those lines, NCQA has three related HEDIS measures, including: 1) advising smokers and tobacco users to quit; 2) discussing smoking-cessation strategies; and 3) discussing smoking-cessation medications. Is all that measurement, some of which started more than 20 years ago, making a difference? Looking at these three measures over time, we see performance improvement among Medicaid and Medicare plans, but performance for commercial plans has been relatively flat for the last decade. Perhaps employers aren’t pushing payers to do more. What more can payers do? Quitting hotlines (a.k.a. “quitlines”)? Of course. New digital apps? Sure. Much more is needed, but more measurement does not seem to be the path forward.
Reducing friction
Covering smoking-cessation counseling and treatment reduces friction by reducing or eliminating patient out-of-pocket costs. Payers typically cover smoking-cessation counseling and treatment, but that wasn’t always the case. As outlined in the 2020 Surgeon General’s report, “Smoking Cessation,” when smoking-cessation interventions developed in the 1980s and 1990s were clearly shown to be effective, few insurers at the time provided coverage for them. Under the Affordable Care Act (ACA), most private health plans were forced to cover tobacco-cessation interventions, including behavioral interventions and FDA-approved pharmacotherapy, for nonpregnant adult tobacco users because the U.S. Preventive Services Task Force gave such interventions an “A” rating. A few years later, the Departments of Labor, Health and Human Services, and Treasury provided additional guidance on coverage requirements for tobacco use counseling and interventions which, in turn, was based on a related Public Health Service-sponsored clinical practice guideline.
The ACA expanded Medicare coverage of tobacco-cessation counseling and required Medicaid to cover counseling and medications for pregnant women. In 2014, Medicaid programs were prohibited from excluding any FDA-approved tobacco cessation medications from traditional Medicaid coverage. In addition, the American Lung Association’s “State of Tobacco Control” report indicates that 15 states have private insurance mandates to cover certain cessation treatments.
The Surgeon General’s 2020 report concluded that FDA-approved smoking-cessation medications and behavioral counseling are cost-effective strategies. One would think that if payers knew or believed that these treatments were cost-effective, they would proactively cover them. Disappointingly, most payers started covering smoking-cessation counseling and medications only when they had to.
While lack of coverage is a significant source of friction, coverage alone is clearly not sufficient. Other sources of friction hold back people who want to quit from seeking these interventions. For example, to continue participation in smoking-cessation programs, members often have to re-enroll — an ongoing burden and, in essence, a repeated declaration of failure. Having members, instead, opt out of smoking-cessation programs when they successfully quit smoking or want to quit these programs could reduce friction and may be more effective and cost-effective. Have payers tried to identify and reduce other sources of friction?
Adding fuel
One study of CVS employees and their friends and relatives offers compelling evidence that incentives and penalties can be the fuel that motivates people to quit smoking. All participants received “usual care,” including informational resources and free access to a behavioral-modification program and nicotine-replacement therapy. Some participants enrolled in the “reward program” and received $800 if they stopped smoking; and some participants enrolled in the “deposit program” and refunded a $150 deposit and received $650 if they quit smoking. The researchers concluded that the “reward program” was nearly three times more effective than “usual care” alone. Further, they concluded that the “deposit program” — which leverages what behavioral economists call “loss aversion” — was less attractive but much more effective than the “reward program,” even after researchers controlled for selection bias. Surprise, surprise: This research suggests that a mix of incentives and penalties may be most effective.
How else can payers use incentives and penalties, colloquially referred to as carrots and sticks? The ACA allows payers to charge smokers higher premiums. Along with age and geographic location, tobacco use can affect one’s premiums in the exchanges. Beyond monetary incentives and penalties, have payers (and employers) tried other sources of fuel? For example, are there non-monetary ways payers can acknowledge or celebrate members who quit smoking (e.g., badges, certificates)? And are payers using fuel to motivate primary care providers? Reimbursement, for instance, could be tied to quit rates; upside risk should be particularly easy to implement and, if structured correctly, could be both effective and cost-effective.
Looking upstream
Payers are clearly not doing enough to reduce friction and add fuel, but this failure is not explained by economics or a lack of evidence — quite the contrary. Even though cigarette sales are up and commercial plan performance is flat, payers have not yet demonstrated a burning desire to do what it takes to help affect change. Perhaps employers’ corporate politics and their concern with optics may explain payers’ general malaise.
Most smokers want to stop smoking. Hopefully, enlightened and persuasive payers will help their employer clients support smoking-cessation counseling and treatments in a way that minimizes the friction and maximizes the fuel without igniting a backlash.
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