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Tobacco Control 2000;9(Suppl I):i42–i45
Implementing tobacco tracking codes in anindividual practice association or a network modelhealth maintenance organisation Make up of PHS smoking cessation task force Oregon is an individual practice association model health maintenance organisation with capitated model and more than 360 000 mem- bers in our preferred provider model, which is a discounted fee for service structure. PHS has 12 000 employees, over 1400 acute and longterm beds, and a demonstrated commitment to programs are one of the top priorities for reducing overall cardiac morbidity and mortal- developed a multifaceted approach to tobacco ity. A regional health system task force for cessation (fig 1). The overall program starts tobacco cessation comprised of key personnel with a variety of cessation services oVered to and stakeholders was formed in 1994 (table 1).
our patients. The group support program is a The physician leader’s role was to educate 10 session behaviour modification class. The medical care providers on smoking cessation, telephone support program (“Free & Clear”, while the program development administrator Group Health Cooperative, Puget Sound) is helped coordinate activities and was instru- provided to members. The individual support mental in securing funds for all initiatives.
intervention (one on one), for highly comorbid Smoking Cessation
Health education played a critical role in and Prevention,
Providence Health

administration of the intensive cessation inter- consists of individual counselling with a highly System, Oregon, 9205
ventions and other member focused interven- trained smoking cessation counsellor for 12 SW Barnes Road,
Suite #25, Portland,

tions. Health plan involvement was important months. The task force developed self help OR 97225, USA;
in changing the benefit structure of the health materials in Spanish and Russian. We have a cbentzmd
plan to broaden coverage for smoking cessation @providence.org
C J Bentz
counter nicotine patch and bupropion (Zyban;GlaxoWellcome), which is linked to participa-tion in a structured behavioural modification program. To any interested clinic, we oVer, at no cost, a tailored training program based on the 4A’s developed by the National Cancer which draws from the “stages of change”theory3 and “self determination” theory.4 Assurance, and the eVorts in tobacco cessation played an important role in that accreditation.
Specific groups are targeted for smoking cessa- tion, including patients with coronary artery disease, diabetes, and asthma. Members of the PHS task force have been involved in commu-nity activities, such as the Tobacco Free Coali- tion of Oregon, and have helped shape the state of Oregon’s preventive strategy for the Oregon We have also implemented a hospital based smoking cessation intervention based on work by Stevens et al.5 In this program, every patient Providence Health System (PHS) smoking cessation and prevention program admitted to a PHS hospital is asked about cur- 1999. TOFCO,Tobacco Free Coalition of Oregon; OMAP, Oregon Medicaid AssistanceProgram; PHP, Providence Health Plan; OHP, Oregon Health Plan; NCQA, National Committee for Quality Assurance; HEDIS, Healthcare Employer Data Information Set; department, and the smoking status of every C.O.R.E. Centre for Outcomes Research and Education; EMR, electronic medical record; patient is recorded in the hospital demographic CAD, coronary artery disease; DM, diabetes mellitus; Prov-RN, a telephone point of servicepatient advice line; PCP, primary care physicians. database. Lists of inpatient smokers are printed Implementing tobacco tracking codes Building measurement into clinical practice7 + Seek usefulness, not perfection, in the measurement + Use a balanced set of process, outcome, and cost measures + Keep the measurement simple (think big, but start small) + Write down operational definitions of the measures 0’89 ’90 ’91 ’92 ’93 ’94 ’95 ’96 ’97 ’98 ’99 2000 Smoking rates in PHS versus state of Oregon. a novel method of tracking and providing feed- each day in the respiratory care departments, back to providers on the delivery of preventive and dedicated respiratory therapists systemati- cally provide a smoking cessation interventionto interested patients as a routine part of inpa- Primary care quality bonus
tient care at no additional cost to patients.
We have developed a successful “primary care quality bonus”, which pays primary care physi- smoking cessation within the health system.
cians to deliver preventive health care. A small His eVorts led to PHS being the first health amount of the capitated payment is withheld from the primary care providers ($2 per mem- provide a financial incentive for primary care ber per month). This withhold/bonus is paid to physicians to address tobacco cessation in rou- physicians according to their performance on various measures. Physicians accrue points in this bonus by achieving certain goals in access smoking rates among Providence Health Plan to care, patient satisfaction, and selected clini- members. Smoking rates, as measured by the cal quality measures issues. The quality bonus program has resulted in improvement in meas- ures of preventive health care delivery (fig 3).
were compared with a PHS survey using the In order to build provider acceptance for the same methodology. Over the last four years, we have seen a significant decrease in self reported bonus, we have adopted a “stepped approach”.
smoking rates, down to 17% in 1998 (fig 2).
This is a process by which the quality bonus measure for smoking cessation changes over a encountered in implementing tobacco cessa- period of several years. Initially the goal of the tion in all types of managed care settings.6 We incentive is to build preventive care infrastruc- confirmed that many of these barriers aVect ture, then after we have at least 75% of our our clinics. In an evaluation of smoking cessa- clinics reporting that the infrastructure to tion in one of our primary care oYces we found deliver the preventive care is in place, achieving that physicians faced time pressures, patient the quality bonus will require attaining defined issues, paperwork, and lack of incentive. We performance targets. In 1999, to meet criteria also found that medical assistants were too for the quality bonus smoking cessation meas- ure, providers need only show that they have a frustrated by lack of provider interest. A systematic approach to smoking cessation in project of continuous quality improvement in their oYce. This approach must be based on one clinic simplified the medical assistant’s the 4A’s: asking all patients about smoking sta- role, gave them feedback on performance, and tus, and for paediatric patients, asking about provided several training sessions, resulting in exposure to second hand smoke; advising all dramatic improvement increases in tobacco smokers to quit; assisting interested smokers in developing a quit plan; arranging for follow up.
into routine primary care is needed if we expect to have improvement in the delivery of demonstrating, in a sample of medical records, preventive health care in routine oYce settings.
that the 4A’s are taking place. Initially, the A review by Nelson et al7 clearly laid out prin- quality bonus will not measure the physicians’ ciples that were followed as we have developed rates of performance of the 4A’s. This steppedapproach allows us to give an incentive for building oYce infrastructure before giving anincentive for specific performance targets. As we perfect our method of measurement we will gradually incorporate performance targets into Tracking codes for prevention
Measurements of health care performance
require chart review, which is costly and time consuming for both physicians and managed sustainable in the long run. Since most private practice physician oYces lack the infrastruc- Quality bonus performance in PHS 1996-98. ture to address tobacco use or other preventive Tracking codes dictionary, based on HEDIS 3.0 quality measures and 1999 PHP quality bonus program Influenza
Dilated retinal exam
> 8 < 9.0
Negative both micro & macroalbuminuria
> 7 < 8.0
Positive either micro & macroalbuminuria
Smoking cessation
Non-smoker/remote quitter (> 6 months)
Recent quitter (< 6 months)
>130 < 160
> 100 < 130
ACE inhibitor use
Prior total hysterectomy
Bilateral mastectomy
Measures in bold are part of the PHS system 1999 tracking codes pilot initiative.
health care systematically, a new approach is advise, assist, arrange), then it is necessary to needed. We have developed a set of tracking enable providers of health care to carry this codes, similar to the current procedural termi- + If providers are expected to ask every patient (MCOs) to measure and reimburse for delivery this possible by having a clear policy in place of these services.8 These prevention codes are documented at the point of medical care by the infrastructure to carry this out and achieve physician, captured on fee slips, and submitted to the MCO’s claims system. It is equally + If providers are expected to give cessation important to track the exceptions to preventive advice to all smokers, then the MCO needs health care. For example, diabetics who are on to create an incentive that encourages cessa- angiotensin converting enzyme (ACE) inhibi- screening for diabetic proteinuria. A prelimi- + If physicians are expected to assist interested nary “dictionary” of prevention tracking codes smokers in quitting, then the MCO needs to has been developed (table 3), which includes a provide training in smoking cessation and set of codes to track tobacco use and provider also provide the resources needed to help + If medical care providers are expected to funded by a planning grant from the Robert arrange for follow up visits for smoking ces- results of this project, being piloted in oYces using both paper based and electronic medical aspect of cessation and allow appropriate records, will be available at the RWJF’s Conclusion
work of the PHS task force on smoking cessa- eVorts to address tobacco use in our loosely tion. Teamwork has contributed to the success aYliated health care system. Everyone benefits of this task force, which has received two from improvement in the delivery of preventive health care. To make progress in this area, and again in 1999). No other group in our health smoking cessation in particular, we need to be system has won this award twice. Defining the clear about who the real customer is. While the roles of doctors and administrators has been patient is the ultimate customer, the immediate crucial to our success. If physicians are customers are physicians and the physicians’ expected to deliver the 4A’s of smoking (ask, Implementing tobacco tracking codes 7 Nelson EC, Splaine ME, Batalden PB, et al. Building meas- infrastructure. We have demonstrated that our urement and data collection into medical practice. Ann
Intern Med
1998;128:460–6.
8 Powers M. “Tracking codes” may increase compliance with delivery of preventive health care service, and HEDIS. Capitation Management Report 1999;6:17–20.
we hope it will eventually improve the health ofour patients. Doctors are benefiting from Questions and answers
enhanced revenue collections in the form of quality bonus incentives. Our health systemwill save expenditures by avoiding chart review, will benefit from improved public image, and A: It is a team eVort to provide preventive will continue to garner praise from external programs. Thus, you really need to have team reviewing organisations, such as the National Q: Most of the large health organisations are losing substantial amounts of money, thus physicians does not automatically improve incentives may be one of the first things to quality of care. It takes teamwork. But if there eliminate. Do you think that is the case? is one thing that managed care can do, and has A: In our MCO, there are several funds.
the promise to do, it is to improve delivery of There is the institutional fund, which pays the hospital, the referral fund which pays theproviders, and the PCP fund which goes to pay 1 US Department of Health and Human Services. How to help primary care. Every single major fund is in a your patients stop smoking. A National Cancer Institute deficit right now. So, there is a huge outcry and manual for physicians. Bethesda, Maryland: National Can-cer Institute, Smoking and Tobacco Control Program, it is a time of turmoil. If there are funding cri- 1991 (NIH Publication No 92–3064).
ses, what better time and way to figure out 2 Lichtenstein E, Hollis JF, Severson HH, et al. Tobacco ces- sation interventions in health care settings: rationale, model, outcomes. Addictive Behav 1996;21:709–20.
advocate and go to the chief executive oYcer 3 Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: applications to addictive behaviors.
and say, “This is a great opportunity for us to American Psychologist 1992;47:1102–14.
show what is most important about managed 4 Williams GC, Quill TE, Deci E, et al. The facts concerning the recent carnival of smoking in Connecticut and care—which is prevention, all types of preven- elsewhere. Ann Intern Med 1991;115:59–63.
tion. These bonuses are important because it is 5 Stevens VJ, Flasgow RE, Hollis JF, et al. A smoking cessation intervention for hospital patients. Med Care 1993;31:65–
how we are being measured; they demonstrate the quality of our organization”. These are very 6 Davis RM. An overview of tobacco measures. Tobacco Con- trol 1998;7(suppl):S36–40, S47–9.
Implementing tobacco tracking codes in an
individual practice association or a network
model health maintenance organisation

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