Should physicians even bother to offer smoking cessation counseling or weight-management pamphlets?
The idea of positive incentives and preventive efforts by physicians, which seems to be catching on, is wonderful in theory: Not only do preventive services supposedly prevent adverse events, but they also save money in the long run by keeping patients from receiving costly medical care to treat patient-induced illnesses.
The theory is so intoxicating that an increasing amount of money has been poured into preventive incentives, also known as positive incentives. Recently, a new state program in Connecticut that offers Medicaid recipients money to quit smoking made headlines for receiving federal grants. The iQuit program, certainly not the only one of its kind, will be fueled by a five-year federal grant of up to $10 million.
But many people who know the beast of addiction will tell you differently. There is no smoking-cessation pamphlet that is any match for cigarettes, no low-fat recipe that can singlehandedly change a compulsive overeater.
Which brings us back to the practicing physician, who is hard-pressed for time but wants to serve her patients. Is telling an overweight patient to lose 50 pounds really going to change that patient’s eating habits? Is taking five minutes to go over options to quit smoking really going to get a patient with lung issues to put down his cigarettes?
We asked a few physicians what they thought. While positively reinforcing good behavior has some merit, does it actually lead to long-term change?
“I do counsel and bill for smoking cessation counseling, however I do feel that my efforts are futile,” said family physician Scott Litton, a contributor to Practice Notes. “I feel this for a couple of reasons. Firstly, patients do not feel compelled to stop smoking because they are not able to sense the harm that smoking poses to them until they have been doing so for several years. Next, there are several handy medications for curbing the habit, but many of these medications are very expensive and are generally not covered favorably on most part D plans.” These include Chantix, patches, and certain gums.
Wisconsin-based family physician Christopher Tashjian says positive incentives are more likely to work if the physician has a good relationship with his patient, or if the patient has a compelling reason to quit.
“There is evidence that a multifaceted approach to smoking cessation works better that any single approach,” Tashjian told Physicians Practice. “One of the more successful methods to get people to stop smoking does include the primary care provider. I think this depends on the physician-patient relationship and how long the provider has known the patient. I know firsthand, I am more successful with established patients than I am with new patients.”
So this raises an interesting question: Is negative reinforcement more effective? Not too long ago, Arizona legislators came under fire for proposing a law that would impose a $50 fee to childless Medicaid recipients who smoke and/or are obese.
Tashjian says incentives such as these might have some merit.
“Fifty dollars is lot of money,” said Tashjian. “We as physicians are incented by payers to help people quit and I also think this helps. I routinely will remind patients that a pack a day costs over $2,500 in Wisconsin. Any cost to quit is small compared to this.”