Community-level tobacco interventions: Perspective of managed care

Abstract

The work of the Task Force on Community Preventive Services (TFCPS) is an impressive contribution to the growing body of rigorous, evidence-based recommendations to reduce the prevalence of tobacco use and exposure to environmental tobacco smoke. As is pointed out often and in many contexts, rates of tobacco use are unacceptably high in this country, and it remains the largest contributor to premature morbidity and mortality from tobacco-related diseases. It is not surprising that rigorous evidence reviews result in comparable recommendations. The TFCPS’s health care system‐level recommendations are similar to those in the recently published U.S. Public Health Service (PHS) clinical practice guideline on treating tobacco use and dependence 1 and they address the critical elements of effective tobacco control strategies at the individual, practice, and organizational levels. 2 At the individual level, the TFCPS recommends multicomponent programs (e.g., counseling and pharmacotherapy) that include telephone support. At the practice level, the TFCPS recommends the use of provider reminders such as chart stickers and vital sign stamps, as well as provider education on how to motivate and reinforce smokers for efforts to quit tobacco use. At the organizational level, the TFCPS recommends reducing patient costs for effective treatments. Strategies at each of these levels are necessary to achieve the full promise of health care system efforts to reduce tobacco use prevalence. Managed care organizations (MCOs) are poised to be leaders in implementing these evidence-based guidelines and recommendations. A cornerstone of managed care has been its clinical preventive care focus. Although there are many different permutations of “managed care,” at a minimum, MCOs have service delivery systems with an identifiable group of accountable primary care providers to whom they can provide performance incentives and/or reimbursement for addressing tobacco use. MCOs also have centralized resources for quality improvement that include staff and systems to review and customize evidence-based guidelines and to conduct provider education. Finally, MCOs’ centralized data systems can be adapted for population-based tracking registries and to provide feedback on practice patterns. Moreover, MCOs are motivated to implement tobacco guidelines when accreditation organizations such as the National Committee on Quality Assurance include tobacco-related measures such as smoking-cessation advice as benchmarks for quality of care. Unfortunately, implementation of tobacco-related, evidence-based guidelines has been less than optimal. A recent national survey of MCOs found that less than 10% of the respondents had fully implemented the recommendations included in the 1996 Agency for Health Care Policy and Research (AHCPR; since 1999,