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This issue of Tobacco Control contains the proceedings of a conference, Addressing tobacco in managed care: partnering for success, held on 3 and 4 February 1998 in Arlington, Virginia, United States. The conference was intended to encourage the use of the Agency for Health Care Policy and Research (AHCPR) smoking cessation guideline1 in health plans and to provide an opportunity for such plans to share their experiences and best practices regarding tobacco control. A recent supplement to this journal thoroughly describes the AHCPR guideline, including implementation issues, field examples and the roles and reactions of various components of the healthcare system.2 In 1998, more than 80% of workers covered by health plans receive their care through health maintenance organisations (HMOs) and other forms of managed care.3 A basic principle of HMOs has been an emphasis on prevention, although the application of this principle has been more often conceptual than realised. Several factors have pushed managed care organisations to do better at making prevention a feature of their product. They include: consumer expectations for better performance on childhood immunisations, cancer screening, cholesterol screening, dietary counselling, and tobacco prevention and control; external accreditation—for example, the National Committee for Quality Assurance (NCQA); report card performance based on largely preventive measures, such as the Health Plan Employer Data and Information Set (HEDIS); and influence on policy makers by an increasing body of literature on the cost-effectiveness of prevention. A recent additional performance measure for HEDIS version 3.0 ascertains the proportion of smokers in a health plan who have been counselled by their physician to quit smoking.
Tobacco has been well documented to be the leading cause of preventable illness in the United States. Health plan leadership should seek to limit, if not eliminate, tobacco use among its membership, whether that plan is a federal health delivery system such as the Veteran’s Administration, a commercial HMO or internationally, a national health service. Unlike childhood immunisation programmes, which have a high benefit-cost ratio, deliver their health benefits in close proximity to the investment required, and whose population at risk is every child, smoking cessation programmes target only the approximately 25% of members who smoke, have considerable “upfront” expense, are uncertain as to the efficacy of the intervention, do not have a necessarily receptive target audience, and must deal with a longer interval from exposure until onset of major ill-health effects. In addition, current levels of plan membership turnover make it less likely that the member who smokes and is provided with a cessation programme will remain in the plan long enough for the health (and presumed economic) benefits to occur.
The survey of managed care plans described by McPhillips-Tangum in this issue4 suggests that, while most managed care plans are aware of the AHCPR guideline, over half have not implemented it. There have been some model successful programmes5 6; however, many health plans are at early stages of devising coordinated and effective smoking control policies and programmes.
Some of the more successful tobacco control programmes have occurred in group or staff model HMOs with more integrated components and other features that facilitate a coordinated prevention programme. A greater challenge exists for individual practice association (IPA) or network model HMOs with large physician panels in which each physician may be a provider for many managed care and insurance plans, each with different covered benefits and programme emphases.
These conference proceedings describe a meeting of quite different attendees who were able to share diverse experiences and viewpoints: academicians, health plan executives, practicing physicians, health educators, public health professionals from state and federal agencies, and staff from voluntary and philanthropic organisations. Even within the category of “managed health care”, there was representation from group, staff and IPA model plans, from for-profit and not-for profit plans, from large national health plans and smaller local ones, and from those with considerable tobacco control experience and those with little experience.
However, all participants shared a common belief in the importance of tobacco prevention and control and the need for managed care plans to be actively involved in the process of tobacco control and to work toward the goal of decreasing smoking prevalence in their membership and in their broader communities.
The Robert Wood Johnson Foundation, the AHCPR and the Centers for Disease Control and Prevention (CDC) have shown their recognition of the importance of improving the performance of managed care plans in tobacco control by funding the conference whose content is described in this journal supplement. In addition, the Robert Wood Johnson Foundation is sponsoring a major programmatic initiative, “Addressing Tobacco in Managed Care”, which will fund grants to promote the integration of effective smoking cessation into routine health care. We hope the conference and the information shared in it and presented here will encourage more widespread adoption of the AHCPR smoking cessation guideline and higher rates of health plan participation in community and clinical intervention efforts.
Dr Koplan is now director of the US Centers for Disease Control and Prevention in Atlanta, Georgia; email:
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