Estimating the Short-term Clinical and Economic Benefits of Smoking Cessation: Do We Have it Right?

Joseph Menzin; Lisa M Lines; Jeno Marton

Disclosures

Expert Rev Pharmacoeconomics Outcomes Res. 2009;9(3):257-264. 

In This Article

Policy Considerations

How Well Are Smoking-cessation Strategies Covered by Insurance?

Better data on the cost-effectiveness of smoking cessation could improve coverage and access to smoking-cessation interventions. This leads to the question of the status of such coverage in the USA. Health plans have begun to use evidence-based medicine and clinical guidelines put forth by groups such as the Public Health Service and the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) to address tobacco use and cessation therapy coverage. In 2003, 88% of surveyed private health plans provided coverage for at least one pharmacotherapy smoking-cessation aid (generally the generic medication bupropion), and at least one behavioral smoking-cessation therapy was covered by 76% of health plans.[54] The most common behavioral therapy offered was self-directed online resources, which can be provided at almost no cost to the plan.[54] Unfortunately, it appears that few insurers cover nicotine replacement or other forms of pharmacotherapy, and the survey has not been conducted since 2003.[54]

Even when smoking-cessation therapy is covered, the proportion of smokers who use the benefit is fairly low historically (6-7%).[40] Considering that approximately 44% of smokers attempt to quit every year,[66] the lack of uptake among smokers may be partly the result of poor communication between payers and patients about what therapies are and are not covered.[55] Other barriers to patient access to effective therapies may include offering therapy only through the purchase of a rider, pre-authorization policies, step therapy, pre-enrollment in behavior modification programs, onerous enrollment procedures, high copayments and high deductibles.

Medicare covers two quit attempts per year. For each quit attempt, the total benefit covers up to four intermediate (3-10 min) or intensive (> 10 min) counseling sessions, covering eight total sessions annually. In order to qualify, the beneficiary must have a health condition that is exacerbated by smoking or tobacco use or use a prescription drug that is adversely affected by the use of tobacco products. Beginning in January 2006, Medicare Part D covered prescription smoking-cessation aides but not over-the-counter aides, such as nicotine patches or gum.

Medicaid coverage varies by state with respect to eligible populations, benefit type and counseling availability. As of 2006, approximately 15% of states do not offer any coverage.[72] Medicaid programs, similar to private payers, may be primarily concerned with short-term benefits, since between a quarter and a third of a typical state's caseload turns over every year.[73] According to a Washington state analysis, smoking-cessation programs would not help to lower the cost of the Medicaid program, although the benefit-cost ratio would be between 0.07 and 0.57. For example, if Medicaid spent US$332 for counseling and nicotine nasal spray per quit attempt, it would reap US$106.38 in avoided healthcare costs per quit attempt (in 2001 dollars), yielding a benefit-cost ratio of 0.32.[74]

The experience of the UK's National Health Service (NHS) regarding universal coverage of smoking-cessation treatments is promising. From April 2000 to May 2001, 127,000 people made an attempt at quitting and a remarkable 48% achieved at least short-term abstinence.[56] Previous studies of abstinence rates in untreated smokers indicate a range of abstinence after 1 year of between 3 and 5%.[57,58] For those smokers who receive some treatment, 1-year abstinence rates are still only between 4 and 13%.[58,59] In the UK, the cost to the NHS was less than GB£800 (in 2000) per life-year gained, which is an excellent value by any measure.[75] By comparison, the NHS sees a cost-effectiveness ratio of GB£4000-13,000 per life-year gained with statin therapy to lower cholesterol.[60]

The WHO publishes data on coverage of nicotine-replacement therapy and bupropion by national health systems in 53 countries in Europe. According to the latest data available, only 9% offer reimbursement for bupropion therapy as part of their national healthcare systems, whereas 11% reimburse nicotine-replacement therapy products, such as the patch.[76] The WHO Framework Convention on Tobacco Control of 2003, which currently has more than 160 signatory countries, was the first treaty negotiated under the WHO's auspices and the world's first global public-health treaty. The treaty requires that signatories attempt to address the demand for tobacco, in part, through taxation and bans on advertising; reimbursement of nicotine-replacement therapy or other smoking-cessation aides was not given high priority, but was mentioned as a potentially cost-effective strategy as well.[61]

Is Too Much Attention Focused on Short-term 'payback'?

Policymakers and payers may have conflicting priorities regarding tobacco control. A short-term focus may lead to suboptimal investment in smoking cessation from a broader societal view because of the issue of 'free riders' - employers may leave it to other firms to invest in smoking cessation and reap the benefits when they hire ex-smokers. Members of the legal community have recently devised a proposal to handle situations in which an insured person, who has received an intervention that has a long-time horizon for cost-effectiveness, switches insurers.[62] The proposal is for a mandatory insurance clearinghouse, managed by and operated by the insurers themselves, which would involve transfer payments between insurance companies. The case study described in the proposal was for bariatric surgery, but smoking-cessation therapy could have been an equally valid case. In both cases, insurers may not have sufficient incentives to cover the intervention because they may not pay for themselves within 3 years (the average tenure of a health plan member's enrollment).[62]

Might Smoking Cessation Have a Place in Value-based Purchasing for Insurers & Patients?

Value-based purchasing in health insurance is a way for public and private purchasers to influence the quality and costs of healthcare. Payers can use their purchasing power to improve the quality of health programs, especially by rewarding or penalizing plans or providers using incentives or disincentives.[77] Using coverage of smoking-cessation counseling as a quality benchmark and measure for financial incentives has been proposed for the Medicare hospital value-based purchasing program,[78] and similar measures could be taken by private employers. In addition, plans could waive copayments for smoking-cessation therapies.

Is Smoking Cessation Treated Differently than Other Preventive Strategies with Limited Evidence of Short-term Payback?

Smoking cessation has been called the gold standard of preventive treatment.[68] It is estimated that an investment of US$1 million into an anti-tobacco education program would save 7000 person-years of life. This makes smoking cessation approximately ten-times more valuable than other preventive-care strategies that receive near-universal coverage by payers, such as treatment for diabetes, hypertension and dyslipidemia.[63] Perhaps there is a connection between the perceived short-term return on investment, actual coverage of different preventive strategies and the apparent self-inflicted nature of smoking-related health problems.

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