Editor's Note: This year, Dr. Lehman's column focuses on the ethical responsibility of chiropractors to pursue prevention and wellness care. This article discusses smoking cessation as a necessary element of that duty.
Whether chiropractors practice vitalism, spine care or neuromusculoskeletal medicine, it is my opinion that they are ethically responsible to provide prevention and wellness care to their patients.
Sobering Statistics
Tobacco use is the leading cause of preventable disease, disability and death in the United States. Nearly 40 million U.S. adults still smoke cigarettes, and about 4.7 million middle- and high-school students use at least one tobacco product, including e-cigarettes. Every day, more than 3,800 youth younger than 18 years of age smoke their first cigarette.
Annually, nearly half a million Americans die prematurely of smoking or exposure to secondhand smoke. Another 16 million live with a serious illness caused by smoking. The United States spends nearly $170 billion on medical care to treat smoking-related disease in adults every year.2
You Have the Power to Help
While employed by the Lovelace Medical Center in Albuquerque, New Mexico as a chiropractic orthopedist, I participated in a research project funded by the NIH / National Cancer Institute. Our case study was one of three that demonstrated how three communities have implemented the Community Intervention Trial for Smoking Cessation (COMMIT) standardized protocol.
The "Tobacco and the Clinician: Interventions for Medical and Dental Practice" outcomes were published.1 I learned that if a clinician merely asks a patient to cease smoking, 5 percent of patients will stop. Of course, more advanced counseling increases the success rate.
The CDC emphasizes the key role health care professionals can play in fighting tobacco use, the No. 1 cause of preventable death and disease in the United States:6
No matter what your specialty is, you know the drastic effects that smoking can have on your patients' health. You know the toll secondhand smoke can take on their children and families. Many smokers want to quit. Getting started often takes support and motivation from trusted sources, like you.
When it comes to talking to patients about quitting tobacco use, the Tips From Former Smokers® (Tips®) campaign can be a conversation starter. The campaign offers resources for you as well as your patients. With the support of CDC's materials, you can help more patients live smoke-free lives.
Treatment Options
The American Cancer Society (ACS) says there are scientifically proven ways to stop smoking, and many medical practices may already be using them. Effective treatments according to the ACS include the following, keeping in mind many people need a combination to quit once and for all:3
- Seeing the doctor for advice on quitting
- Counseling from a physician, a group or by telephone
- Prescription meds and nicotine patches
- Former smokers report that nicotine gum or candies help fight the urge
Smoking cessation is an intervention that can be performed by chiropractors in most states. Some smoking cessation programs suggest the use of medications such as Nicoderm.4 Possibly your patient would benefit from this medication, but there are nondrug alternatives. For example, auriculotherapy has been used for smoking cessation.
Cigna suggests that a good quit-smoking program can help a person quit by providing support and encouragement. Programs are available to attend in-person, by telephone or online. Look for a program led by someone who has training in helping people quit smoking.
Better in-person smoking cessation programs include:5
- Have at least four to seven sessions that include self-help materials and individual or group counseling
- Have sessions that last at least 20 to 30 minutes
California chiropractors may want to use local services to assist with smoking cessation training. The state offers free training for health professionals interested in offering smoking cessation counseling to patients, which includes online training, CE credits and credentialing.7
A Professional Mandate?
The Association of Chiropractic Colleges serves as the collective voice of chiropractic education. Through programs and services, the Association strengthens and promotes the chiropractic identity and mission of its member institutions so that all associated with chiropractic education can contribute to the world's health and wellness.
Based upon the ACC statement, it is reasonable to ascertain that chiropractors have an ethical responsibility to provide health and wellness services, including smoking cessation.
Our Challenge: The Perils of Economic Credentialing
Smoking cessation counseling codes are 99406 and 99407. Reimbursement may be possible if you bill the patient's insurance company correctly. Medicare covers two cessation attempts per 12-month period.
Although Medicare limitations restrict reimbursements to chiropractors, Section 2706 of the Affordable Care Act requires providers be reimbursed without discrimination for similar services. Hence, non-governmental, third-party insurance companies should reimburse chiropractors for smoking cessation services if the state practice act permits. Of course, interested chiropractors should pursue additional training and certification.
Unfortunately, economic credentialing limits the chiropractic profession by limiting scope of reimbursement. Economic credentialing is a term of disapproval used by the American Medical Association. The AMA defines the term as "the use of economic criteria unrelated to quality of care or professional competence in determining a physician's qualifications for initial or continuing hospital medical staff membership or privileges."8
It is unreasonable to expect private-practice chiropractors to routinely offer services that are not reimbursed by third-party payers. In addition, it is ridiculous to anticipate that health care organizations, such as hospitals, medical clinics and community health centers, will integrate chiropractic services without fair and reasonable reimbursement by third-party payers, Medicare and Medicaid.
Although a small percentage of the public will pay out of pocket for chiropractic services, it has been my experience that the majority of patients continue to expect the insurance company to pay for their health care costs.
The Solution: Advanced Scope of Practice and Reimbursement
As a chiropractor, I suggest you should recognize the negative effects of economic credentialing and counter them by expanding your scope of practice and scope of reimbursement to include recognized wellness and prevention services. I am not referring to detection and correction of subluxation, but efforts to prevent serious diseases such as obesity, addictions, heart disease, cancer and chronic pain.
First, I strongly recommend you become trained and credentialed to provide said services. Next, investigate the third-party reimbursement opportunities. Finally, integrate into the health care system. If you are interested in smoking cessation, for example, become involved with the appropriate organizations.9
References
- Tobacco and the Clinician: Interventions for Medical and Dental Practice. National Institutes of Health: National Cancer Institute. Smoking and Tobacco Control. U.S. Department of Health and Human Services. NIH Publication No. 94-3693, January 1994.
- Smoking and Tobacco Use. Centers for Disease Control and Prevention.
- Quick Guide: Billing for Smoking Cessation Counseling 99406 and 99407. Capture Billing: Medical Billing Services.
- Quit Professional. www.quitprofessional.com/?cc=000000005124
- Quit smoking programs. Cigna.
- Health Care Professionals: Help Your Patients Stop Smoking. Centers for Disease Control and Prevention.
- Free Training: The Center for Tobacco Cessation, California Smokers' Helpline.
- Economic credentialing. Wikipedia.com.
- Streipe B. "Ten Organizations That Want to Help You Quit Smoking." HowStuffWorks.com.
Click here for previous articles by James Lehman, DC, MBA, DIANM.