Will real treatment for the #1 killer please stand up.
tobacco addiction treatment as a lifestyle medicine professional
This is an example of what it looks like to be a Lifestyle Medicine professional in sustainable high-quality practice in the real world, representing a much higher level of clinical and operational expertise than is typical.
Tobacco - The Challenge of Modern Healthcare
One of the most prevalent and worst things that a person can do with lifestyle is to smoke or use other forms of tobacco. It is a huge contributor to all the major causes of death and many forms of morbidity. And yet, in our current healthcare system, we treat it like just a bad habit. Our treatment approach is haphazard, minimally effective, and very poorly reimbursed. The really, really good stop smoking programs have abysmal success rates of roughly 20%. It is one of the most important issues we can address in providing high-quality lifestyle medicine services. But how do we do it well and effectively clinically, and how do we make a living doing it so we can continue to provide quality lifestyle medicine services?
TYPICAL - CLINICALLY
What does normal care look like for tobacco addiction? How does a typical office visit go? Often the provider will be seeing the patient for something else. It has been a long term battle just to get providers and systems to consistently ask if someone is using tobacco, let alone to deal with that problem well. It has finally become fairly universal to at least record whether or not someone is smoking. And to a large degree, providers do recommend that people quit smoking. However, providers are not trained in effective counseling techniques and dynamics. Many will do their best to try to get the patient to quit smoking.
The treatment focuses around medication to deal with the chemical processes of chemical dependency. In a better than average situation the patient may be referred to a cessation program. The much more common norm is simply giving patients a card or a phone number for a quit line they can call. These efforts are usually founded on scaring patients with all the bad things that smoking will do to them physically. Sometimes this even means showing patients pictures of horrible disfiguring cancers, ugly black lungs, and other R-rated materials. There is minimal individualization of approach other than a couple medication options, and pushing for as much as the patient will do at that point. In an unusually good scenario a follow up for tobacco addiction will try to be scheduled.
TYPICAL - BILLING AND FINANCES
(Specifics taken from a PowerPoint presentation of billing professionals teaching billers how to bill for this.)
25-minute office visit. 15 minutes spent on tobacco cessation counseling. Therefore one should select the “>10 minutes tobacco counseling” code of 99407 (vs the “3-10 minutes” code of 99406). The remainder would be 10 minutes for the E&M office code for a 10-minute office visit of 99212.
Our Real-World Analysis Medicare pays the following in our area: 99212 $43 for 10-minute office visit 99407 $28 for 15 minutes of tobacco counseling (>10 minutes) Total $71
Do you expect to stay in business generating $71 per 25 minutes in a medical practice?
ANALYSIS - CLINICALLY
What is wrong with this picture clinically?
The most important issue is that it simply just doesn't work. Why doesn't it work? There are many reasons, but some of the primary ones are as follows:
It is based on the operational and relational dynamic of fear or scare tactics.
The patient is offered nothing better than something that is working for them at present.
It is a one-size-fits-all, non-personalized approach.
It uses extremely rudimentary, minimally effective tools and systems.
It is based on reductionistic chemical addiction theory.
It is a medication-based approach.
It is focused on treating a problem instead of the person.
There is no effective structure or process for real relationships for healthy living.
It is contrary to what the clinical science shows is most effective (intensity).
You can’t do effective work dealing with deeply ingrained lifestyle habits in a few minutes.
And we wonder why our success rate with this approach is in the single digits — if we are lucky.
ANALYSIS - BILLING AND FINANCES
What is wrong with this picture on the billing and financial side?
For the sake of round numbers, let’s say the cost to run a basic primary care provider totals about $200/hour (including support staff, overhead, etc). Your revenue needed per 25 minutes to break even is $83.33/hr (25 min/60 min X $200/hr). For this visit $83 - $71 = $12 loss in providing this service. Breakdown analysis shows you are generating $112/hr for the tobacco counseling portion of time — a loss rate of $88/hr — a huge financial loser. In the scenario above you just donated $12 for the privilege of counseling someone about the most important thing they can do for their health. You are in the business of going out of business doing the right thing.
How many covered “attempts” are allowed per 12 months, or “sessions” per “attempt” are irrelevant for a going-out-of-business business. Necessary modifier codes are also similarly irrelevant, though technically appropriate, if one does billing this way. We will not even mention these specifics here as someone is likely to hurt themselves with them.
SO, WHAT IS ONE TO DO?
Should we just give up and accept that we are ineffective clinically and broke financially trying to address the #1 plague of disease and death in our patients? Or is there another way to do things? Even in our broken disease care circus?
Give up? No! Absolutely not! It can be done well — clinically and financially.
LIFESTYLE MEDICINE - CLINICALLY
What does it look like clinically?
It is not about fear. It is about the joy of living well.
If I can’t help them find something that works better for them, why would I take their tobacco away?
It is about the person, not their behavior. If they don’t know that I really care about them, why should they embark on something as difficult as addiction treatment with me?
A structure and process for effective relationships and connections needs to be present.
It needs to be personalized.
It needs to be what the science says works in addiction treatment (intensity).
It should not be medication-based.
Medications need to be used skillfully and intelligently, not one-size-fits-all.
It needs to be based on a real understanding of the dynamics of human living, not just a chemical addiction theory.
One needs to use tools and systems that make high quality care efficient and effective.
And yes, it will take more time than is typically spent.
In the course of an office visit I will intentionally communicate that I as a provider do not consider them stupid, bad, or weak. I express respect for their self-determination and that I am here to care about them and for them no matter what they do with tobacco. My intention is that they would have the best life possible as they choose it. I express empathy for the difficulty of dealing with the most addictive substance known to mankind.
I ask if they know why they smoke. Most do not. Many have bought into the common misconceptions and think they are just addicted chemically, that they are stupid, or a failure. I share a deeper understanding of how it works in day-to-day life, that it serves positive functions like helping one deal with stress, or control one's appetite and weight (nicotine is a neurotransmitter). How do they find themselves using it? Now they know I understand. They know I care about them and respect them. I present them with a very different and much more successful way to be free from the tobacco in a way that works for them, where they end up with something better. Primary treatment is dealing with why they smoke and filling the functions that smoking is filling with other and better things.
Our goal is not for them to be a miserable non-smoker, white-knuckling it the rest of their life. Our goal is for them to be a happy, contented non-smoker. I let them know that the science shows that the more intensive the approach, the more successful it is, so we will follow the science. We will customize it to them, their issues, their needs. We will include medication to make the actual quit process relatively painless when we get to that point. We very specifically and consciously redefine failure from an issue of them “slipping up and having a cigarette” (and feeling like they can’t talk to the doctor about it) to one of relationship and process. Failure is quitting the process, not having a smoke. If they don’t quit the process, "we"will get there. I will never get in their face or make them feel badly about themselves or their struggle. Neither they nor I should waste our time beating up on them for the slips. We need to be able to talk about them, learn from them, and determine our plan for success in the next cycle. We are creating a functional therapeutic alliance based on genuine caring.
When they are ready, we use tools and systems that allow us to assess the strength of their addiction chemistry, screen for depression (some are self-medicating for depression), and get quantitative numerical estimates on the different functions smoking is performing for them so we can tailor our efforts to their specific needs and not waste our time on all the elements of one-size-fits-all that are found in many approaches. This is done as part of a tobacco specific medical history intake that identifies all the tobacco related issues (important clinically and for diagnoses codes).
LIFESTYLE MEDICINE - BILLING AND FINANCES
On the coding and billing side, how is this sustainable?
In a quality, whole-person clinical approach we have identified tobacco related issues and problems. This may include things like a chronic cough, shortness of breath, stress-related issues, depressive conditions, etc. One may choose to code for treating multiple of these issues in dealing with the tobacco addiction.
What billing codes could or should one use? And are they financially sustainable?
The scenario of the 25-minute office visit is very workable and very common. A normal 25-minute office visit can typically be coded based on time if the majority of the time is spent in counseling. There is nothing saying that it can’t be for tobacco use. In this case it was. But in treating the whole person we are not only dealing with tobacco behavior, but are treating the whole person. I may treat “1. Chronic cough; 2. stress-related disorder; and 3. tobacco dependence” in this visit. I would appropriately bill a 99214 25-minute office visit, being sure to document the time spent and that the majority of the time was spent in counseling (and may include the basics of that counseling). In our area, Medicare pays $106 for this visit, which translates to $254/hr ($106 X 60 / 25). Even if you left 5 minutes of slack after 25 minute visits you would still be generating $212/hr. This is above our break even and keeps us providing quality, effective, sustainable lifestyle medicine services.
This illustration simply deals with the medical provider’s role and reimbursement. It doesn’t mean this is the ultimate, optimal way of doing things. There are ways for other staff to provide components. A behavioral health professional would be an excellent integral part of the services that can be clinically excellent and financially sustainable. And there should be structures and processes for creating community and peer-to-peer support, as well as education. It is perfectly OK for patients to pay out of pocket for components of an effective overall service that really can’t fit within existing reimbursement structures (please don’t bill office visit codes for group education sessions).
The unfortunate reality is that financial discrimination against treating the #1 killer in our country in the form of unsustainable reimbursement is codified into the current reimbursement structure of healthcare. Clinically excellent, financially sustainable whole-person tobacco addiction care is possible by following astute clinical and billing practices.