Nancy A. Rigotti, MD

To evaluate the impact on smoking status documentation of a payer-sponsored pay-for-performance (P4P) incentive that targeted a minority of an integrated healthcare delivery system’s patients.

Three commercial insurers simultaneously adopted P4P incentives to document  smoking status of their members with 3 chronic diseases. The healthcare system responded by adding a smoking status reminder to all patients’electronic health records (EHRs). We measured change in smoking status documentation before (2008-2009) and after (2010-2011) P4P implementation by patient P4P eligibility.

The P4P-eligible patients were compared primarily with a subset of non—P4P-eligible patients who resembled P4P-eligible patients and also with all non–P4P-eligible patients. Multivariate models adjusted for patient and provider characteristics and accounted for provider-level clustering and preimplementation trends.

Documentation increased from 48% of 207,471 patients before P4P to 71% of 227,574 patients after P4P. Improvement  from 56% to 83% occurred among P4P-eligible patients (adjusted odds ratio [AOR], 3.6; 95% confidence interval [CI], 2.9-4.5) and from 56% to 80% among the comparable subset of non—P4P-eligible patients (AOR, 3.0; 95% CI, 2.3-3.9). The difference in improvement between groups was significant (AOR, 1.3; 95% CI, 1.1-1.4; P = .009).

A P4P incentive targeting a minority of a healthcare system’s patients stimulated adoption of a systemwide EHR reminder and improved smoking status documentation overall. Combining a P4P incentive with an EHR reminder might help healthcare systems improve treatment delivery for smokers and meet “meaningful use” standards for EHRs.

Routine documentation of smoking status improves clinicians’ delivery of tobacco treatment and is mandated in “meaningful use” standards for electronic health records butcan be challenging to accomplish.

		A payer-sponsored pay-for-performance incentive prompted systemwide action by the healthcare system, resulting in improved documentation among both targeted and nontargeted patients.

		The effect was greatest among targeted patients, suggesting the financial incentive added value as well as prompting the reminder.

		Combining a performance incentive with an electronic reminder could help healthcare systems to improve treatment for tobacco use and enable population health interventions for smokers.

Smoking kills more than 440,000 people in the United States annually and remains the leading preventable cause of death.

Despite the availability of effective treatments for tobacco dependence, physicians assess smoking at only 63% of visits and  offer counseling to only 21% of smokers.

 Identification and documentation of smoking status are the first steps to addressing tobacco dependence and have been shown to increase physicians’ delivery of treatment.

 Clinical practice guidelines for treating tobacco dependence recognize the importance of documentation and call for routine smoking status screening and documentation by healthcare systems. The US government’s “meaningful use” electronic health record (EHR) incentive program requires smoking status identification in a coded field.

 Yet achieving a high rate of smoking status documentation is a challenge for many healthcare systems.5

Efforts to improve smoking status documentation have included electronic or paper-based reminders, performance feedback, and a simple vital sign stamp.

 Pay-for-performance (P4P) incentives have been used in some systems to promote delivery of guideline-based tobacco treatment, or as a component of broader quality improvement efforts.

 These studies have examined performance incentives for various guideline-based treatment activities, including smoking status documentation, documentation of physician-delivered counseling, referral to telephone counseling, and payments to providers for patients’ tobacco abstinence. Prior studies of P4P for smoking status documentation were limited to US physician groups or healthcare delivery  systems outside the United States.

 Relatively little is known about the effects of P4P programs in large, multipayer, integrated US healthcare delivery systems in which P4P incentives do not apply to all patients in the system. A payer-sponsored P4P incentive in a multipayer system may only be effective for the patient population to whom it applies. However, practice changes stimulated by a targeted P4P measure can have broader benefits that improve documentation and treatment delivery for targeted and non-targeted patients.

A P4P incentive that was introduced in 2010 in a large multipayer healthcare delivery system rewarded practices for documenting the smoking status of patients with specific commercial insurers and 3 chronic diseases. The organization’s multiple payers and diverse provider groups with varied practice styles and patient populations make standardized quality improvement efforts especially challenging. Our objective was to study the effect of a targeted, payer-sponsored P4P incentive payment on smoking status documentation across the healthcare system.

Partners HealthCare Inc is a large integrated healthcare delivery system in eastern Massachusetts whose provider network, Partners Community HealthCare, Inc (PCHI), represents more than 5000 primary care and specialist physicians, and works with multiple payers including commercial insurers, Medicare, and Medicaid.

 All PCHIaffiliated practices use one of several different EHRs. This study was restricted to the practices using the system’s predominant EHR, the Longitudinal Medical Record, a locally developed system used by 63% of PCHI practices that was first implemented in 1998. Active providers have been using the EHR for a median of 3.5 years (interquartile range, 1.4-6.7 years). It includes progress notes, laboratory results, medication lists, electronic prescribing, and a variety of clinical reminders.

Since 2001, PCHI has negotiated P4P contracts with 3 large, commercial, not-for-profit insurers who collectively cover the majority of commercially insured patients.

 Starting on January 1, 2010, the 3 commercial insurers contracted separately with PCHI to pay practices for achieving a target smoking status documentation rate among a group of highrisk patients. The incentive was implemented using a withheld amount that was returned to practices meeting the prespecified target. Selected targets must meet agreed-upon standards of care that are easy to measure, likely to improve quality of care, and involve enough patients for statistical reliability.

 The amount of payment to practices depended on revenue from P4P-eligible patients and ranged from 3% to 4.8% of practice revenue from the participating insurers for all P4P measures, and $3.8 million was at risk in PCHI for the smoking status documentation measure. Based on the preincentive documentation and the national guideline recommending that patients be screened at every visit, the target documentation rate was set at 80%.

Documentation was measured among eligible patients over a 2-year span (January 1, 2010, to December 31, 2011), with payment at the end ofthe first year for progress toward the goal and at the end of the second year for reaching the goal.

18 years old) who made a visit to a PCHI outpatient practice during the measurement period, were insured by 1 of 3 participating commercial insurers, and had a high risk chronic condition (hypertension, diabetes, or coronary heart disease). The eligible visit could have been to any PCHI specialist or primary care practice in academic-affiliated or community-based practices.

To help practices reach the 80% target, PCHI added an organizationwide clinical decision support tool consisting of a clinical reminder to document smoking status in all patients’ EHRs. The nontargeted EHR reminder was implemented concurrently with the P4P program on January 1, 2010. The EHR-based reminder was designed so that clicking the reminder linked to the coded field for smoking status documentation. Documentation could also be accessed in the EHR through a vital signs entry screen or a health monitoring grid that tracks preventive care and chronic disease management.

To measure the effects of the P4P program on prevalent smoking status documentation, we conducted an observational study before and after P4P implementation. We compared smoking status documentation between the group of high-risk patients who were targeted by the P4P incentive and (1) all non—P4P-eligible patients and (2) a subset of non– P4P-eligible patients who most resembled the P4P-eligible group by having commercial insurance and the same targeted diagnoses as P4P-eligible patients. The study was approved by Partners HealthCare System’s Institutional Review Board.

We used data from the EHR to estimate the effect of the P4P incentive on smoking status documentation. We identified adult patients (

18 years old) who had an office visit with a PCHI provider before (2008-2009) or after (2010-2011) the P4P incentive. We extracted patient data including smoking status, age at the visit, sex, race/ethnicity and primary language entered at registration, insurance, primary care proWe identified the 3 high-risk, chronic conditions included in the P4P incentive. Patients were designated as having the chronic condition if the diagnosis was entered into the EHR before the qualifying visit for that period. Hypertension was defined as a coded entry on the problem list, with the last systolic blood pressure greater than 135 mm Hg or the last diastolic blood pressure greater than 85 mm Hg. Coronary heart disease was based on coded problem list entries of coronary arteriosclerosis, angioplasty, stent placement, coronary artery bypass graft, or myocardial infarction. Diabetes was based on a coded problem list entry of diabetes or a glycated hemoglobin value greater than 7.0%.

We included provider-level demographic data (age and sex) for the primary care provider designated in patients’ EHR registration at the start of the study year. Provider-level data were taken from a master provider list maintained by PCHI. Some provider-level data were missing; for these, we included a dummy variable for missing data.

Smoking status documentation is designated in a structured field in the EHR as “active smoker,” “past smoker,” and “never smoker.” To measure the change in documentation before and after implementation of the P4P incentive, we calculated prevalent documentation of smoking status on December 31, 2009, and December 31, 2011. To match the 2-year duration of the P4P program, we pooled patients with at least 1 visit in the 2 years before (2008-2009) and the 2 years after (2010-2011) the P4P implementation. We hypothesized that documentation prevalence would not be significantly different from year to year before P4P implementation, and confirmed this hypothesis prior to pooling.

We calculated the unadjusted prevalence of smoking status documentation before and after the P4P incentive among P4P-eligible patients (as defined above), among all non—P4P-eligible patients, and among a subset of the non– P4P-eligible patients who were comparable to the eligiblepatients in having had a visit to a PCHI provider and a qualifying  high-risk chronic condition, but a nonparticipating commercial insurer. We measured the prevalence of documentation among providers stratified by the proportion of P4P-eligible patients seen.

We used multivariable logistic regression modeling to test the hypothesis that P4P measures plus the EHR reminder increased rates of smoking status documentation after the contract was introduced on January 1, 2010. We compared the P4P-eligible patients with the comparable subset of non—P4P-eligible patients before and after P4P implementation using first-order interaction terms. We adjusted for patient age, sex, race/ethnicity, language, and number of visits per year, and provider age and sex. To account for clustering, we chose to cluster by provider rather than practice as the higher-level unit of analysis because changing provider behaviors was the primary aim of the P4P and the EHR reminder. We accounted for clustering using generalized estimating equation techniques.

We investigated practice-level effects by calculating the proportion of visits to each practice by patients with P4P insurance. We found no association between clinics’ proportion of P4P-insured visits and patient eligibility, so we did not include this in multivariable analyses. We calculated adjusted odds ratios (AORs) comparing smoking status documentation before and after P4P implementation among the P4P-eligible group and the non—P4Peligible comparison group. The first-order interaction terms of time (before and after) by P4P eligibility were used to test whether patients targeted by the P4P incentive had higher rates of documentation than those not targeted. We tested the difference in change in documentation by eligibility. Analyses were performed with SAS software, version 9.3 (SAS Institute Inc, Cary, North Carolina).

From 2008 to 2009, 207,741 adults had 1 or more visits to PCHI outpatient providers who used the predominant EHR system for their records. Among these, 5671 (3%) were eligible for the P4P incentive and 1209 (1%) were in the similar but non—P4P-eligible control group (

). The P4P-eligible and similar but non—P4P-eligible patients together were seen by 807 providers, who individually saw between 1 and 191 of the patients with 1 of the 3 chronic diseases and commercial insurance. In 2010 and 2011, after the P4P introduction, 227,574 adults visited outpatient clinics using the EHR; 10,236 (4%) were P4P eligible and 2120 (1%) were in the non–P4P-eligible comparison group (Figure 1).

Compared with all non-P4P patients, P4P-eligible patients were older and more likely to be male, black, and English speaking, and to make more visits (

). Providers for P4P-eligible patients were more likely to be female and were older. The subset of non—P4P-eligible patients were slightly older (55 vs 54 years) but were otherwise similar to P4P-eligible patients.

Overall, smoking status documentation increased each year among all patients seen during the study period, from 47% in 2008 and 49% in 2009 to 63% in 2010 after the P4P intervention and 74% in 2011. The relative increase in documentation from 2008 to 2011 was the largest among never smokers, with documentation increasing by 26% in this group compared with

an 18% increase in past smokers and a 14% increase in active smokers. By eligibility, the increase in documentation was greater among P4P-eligible patients than among all non—P4P-eligible patients or the subset of non–P4P-eligible patients who were comparable to the P4P-eligible patients (

). When patients were pooled into 2-year periods before and after the P4P intervention, documentation increased among the P4P-eligible patients from 56% before (2008-2009) to 83% after P4P implementation (2010-2011) (

). The increase was similar among the subset of comparable but non—P4P-eligible patients (56% to 80%) and smaller among all non–P4P-eligible patients (48% to 71%).

The mean documentation by provider among those who saw no P4P-eligible patients increased from 30% before P4P implementation (median 20%; range 0%-100%) to 59% after P4P implementation (median 66%; range 0%-100%). Among providers who saw any P4P-eligible patients, the change in mean documentation increased by the proportion of P4P-eligibile patients seen (lowest tertile: 55% before [median 67%; range 1%-100%] to 68% after [median 77%; range 15%-100%]; middle tertile: 52% before [median 50%; range 0%-100%] to 70% after [median 82%; range 13%-100%]; highest tertile: 54% before [median 59%; range 0%-100%] to 74% after [median 84%; range 17-100%]).

In multivariable logistic regression models, both P4Peligible and the similar but non—P4P-eligible patients were more likely to have a documented smoking status after the P4P was implemented. We compared smoking status documentation before and after the P4P was implemented among P4P-eligible patients (AOR 3.6; 95% confidence interval [CI], 2.9-4.5; 

<.001) and the similar subset of non-P4P patients (AOR 3.0; 95% CI, 2.3-3.9; 

 <.001) (Table 3). Before the P4P intervention, there was no difference in documentation between the P4P-eligible patients and the similar subset of non—P4P-eligible patients (AOR1.0; 95% CI, 1.0-1.1; 

= .45). After the P4P intervention, documentation was higher among the P4P-eligible patients compared with the subset of non—P4P-eligible patients (AOR 1.3; 95% CI, 1.1-1.4; 

 = .009). The differencein- differences between P4P-eligible and non—P4P-eligible was significant (

 <.001). Other characteristics that were independently associated with an increase in  moking status documentation were older age, female sex, black or Hispanic race, non—English speaking, having a younger primary care physician, and having a female primary care physician.

A targeted P4P incentive from insurers that stimulated adoption of a systemwide EHR reminder significantly improved smoking status documentation in a large multipayer integrated healthcare delivery system. Although the P4P incentive applied to only a minority of patients in the system, smoking status documentation rates increased among all patients.

Among patients targeted by the P4P incentive, the improvement in documentation could be attributable to the performance incentive, the EHR reminder, or both. That the effect was slight but statistically significant among P4Ptargeted patients compared with nontargeted patients suggests that the financial incentive added to the effect of the EHR reminder alone. Our findings are consistent with prior work in single-payer systems or physician group practices that demonstrated the effectiveness of performance incentives for improving smoking status documentation.

 In our own system, a decision support program for chronic disease management had the greatest improvement in measures that were also incentivized with a P4P contract.

 Our data suggest that combining a P4P incentive with an EHR reminder may be an effective way for integrated healthcare delivery systems to promote provider behavior change and reach meaningful use goals for smoking status documentation. However, the reminders may account for a large share of documentation improvement. A healthcare system could achieve improvement in documentation with a reminder alone.

A unique feature of this study was the opportunity to observe the effect of a P4P incentive on patients in the same practices who were not targeted by the incentive. The increase in smoking status documentation among these patients could be attributed to the EHR reminder that was implemented for all patients. Had the EHR reminder not been implemented, providers might still have responded to the targeted P4P incentive by altering their smoking status documentation practice for all patients, rather than trying to figure out which patients were eligible. While we cannot determine whether this “spillover” effect occurred in this observational study, we suspect this behavior would occur if providers believe a performance target is important.

In general, P4P programs that promote documentation improve process measures but have not demonstrated effects on quality of care or patient outcomes.

 Screening patients for tobacco use has been associated with increased treatment delivery in some settings, but increased cessation rates havenot been demonstrated.

 However, the evidence base linking brief clinician interventions with smoking cessation outcomes is strong.

 Furthermore, smoking status documentation may have additional benefits in that it enables healthcare systems to implement chronic disease management tools to help smokers achieve cessation outside the clinical encounter.

We acknowledge several limitations to this study. First, we cannot exclude secular trends as an explanation for the increase in documentation in 2010. Notably, meaningful use standards for EHRs were announced in 2010,

 which created an incentive for healthcare systems to improve documentation. During the time period of this study, our healthcare system was still engaged in planning activities and had not yet implemented interventions to meet the standard. Second, unmeasured confounders may be associated with specific insurers. Insurers might be targeting their members who smoke in other ways that prompt patients to discuss smoking with their provider, or insurers might be contacting high-volume providers to promote assessment of smoking status. Third, we used EHR data to identify patient diagnoses, whereas the P4P incentive was administered with claims data. Accurate diagnoses depend on providers maintaining up-to-date problem lists and may be underreported in our data. We chose to use EHR data, which were readily available and reflected the information available for clinicians in deciding whether to screen patients. If patients with comorbidity were identified in administrative claims but not in our EHR data, they would have been included in our non—P4P-eligible group. This would have made our groups more similar and biased our results toward no effect. A fourth limitation is that the P4P incentive mandated that smoking status be documented at the visit or at some earlier time. It was unknown whether smoking status entries from the past were still accurate. The increase in smoking status documentation also identified more never smokers than current smokers. While the utility of documenting smoking status lies in the system’s ability to identify a population of smokers who can be targeted for treatment and care management, increasing overall documentation increases accuracy of smoking prevalence estimates and encourages healthcare system action and investment.

In conclusion, a limited P4P incentive targeting only a minority of a healthcare system’s patients stimulated the system to adopt a universal EHR reminder to prompt smoking status documentation. The combination improved smoking status documentation among all patients, although improvement was greater among patients targeted by the P4P incentive than among those who were not. It appears that the P4P incentive added value beyond its prompting of a systemwide EHR reminder. These findings suggest that combining a P4P incentive with an EHR reminder could help healthcare systems striving for meaningful use goals to improve treatment for tobacco use and enable population health interventions for their patients who smoke.

 From Division of General Medicine (GRK, NAR), Department of Epidemiology (YC), Tobacco Research and Treatment Center (JHKK, NAR), Department of Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School (GRK, YC, JAL, JSE, NAR), Boston, MA; High Performance Medicine (JHKK), Clinical Informatics Research and Development (JSE), Partners HealthCare, Boston, MA; Division of General Medicine and Primary Care (JAL, JSE), Brigham and Women’s Hospital, Boston, MA; Mongan Institute for Health Policy (NAR), Boston, MA

Articles

A payer-sponsored pay-for-performance incentive for smoking status documentation prompted implementation of a systemwide electronic reminder and improved documentation among all healthcare system patients.

Healthcare System Effects of Pay-for-Performance for Smoking Status Documentation

 To use physician reports to evaluate their awareness of health plan tobacco control guidelines and cessation support coverage and to validate the extent to which health plan cessation support material had been disseminated and implemented in clinical settings.

Comparison of survey responses of physicians with tobacco control activities reported by key informants in the health plans with which those physicians were associated.

 A total of 100 primary care physicians in the care delivery organizations associated with 9 nonprofit health plans were randomly selected to receive a survey asking about their health planâ€™s tobacco cessation guidelines, coverage, and support for clinician action. Their responses were compared to data reported by the plan with which they were associated.

 Responses were obtained from 91%. Although 88% were aware of their health planâ€™s tobacco cessation guidelines, considerably fewer were correctly aware of whether the health plan covered medications and cessation classes or counseling. Physician reports of cessation supports during care bore little relationship to health plan reports of those supports.

 Physician reports may be a useful way to verify health plan dissemination and implementation of tobacco control activities. Even these relatively high-performing plans have ample room for further improvement.

Provision of preventive services has been one of the bright spots for managed care organizations (MCOs) during a time of widespread attacks on their efforts to control costs and improve quality,

especially in staff model nonprofit plans.

Some of these plans have been leaders in tobacco control,

and both governmental and private sector groups have identified MCOs as important vehicles for addressing the epidemic of tobacco-related disease in the United States.

Managed care tobacco control efforts have been encouraged by public recognition awards from the American Association of Health Plans as well as by targeted research funding programs (eg, The Robert Wood Johnson Foundation program entitled, Addressing Tobacco in Managed Care). The US Public Health Service (USPHS) Tobacco Use and Dependence Clinical Practice Guideline 

even includes specific recommendations for health plan tobacco control efforts: 

Implement a tobacco-user identification system in every clinic

Provide education, resources, and feedback to promote the delivery of tobacco cessation services by clinicians

Include tobacco-dependence treatments (both counseling and pharmacotherapy) as paid or covered benefits for all members

Reimburse primary care clinicians and specialists for delivery of effective tobacco-dependence treatments 

However, to date evaluation of health plan efforts to implement these recommendations has been scarce. Two surveys of health plan leaders about their specific policies and activities in tobacco control have been published but no documentation is available about whether these policies are really in place, other than the Health Employer Data and Information Set (HEDIS) reports of health plan rates of advice to quit.

The HEDIS ratings provide no direct information about the recommendations or about comparison with nonmanaged care plans, and the methodology employed has been somewhat controversial.

We recently completed a survey of 9 nonprofit health plans with above-average HEDIS rates of tobacco cessation advice, to learn what policies might be responsible for these rates and whether these plans followed the USPHS recommendations.

Because all of the recommendations relate directly or indirectly to physician support for smoking cessation, a survey of physicians should provide a more objective assessment of whether these policies were truly in place and thoroughly implemented. We were encouraged by the findings of Borowsky and colleagues that physicians will provide critical feedback when asked about the performance of the health plans with which they contract.

Therefore, we surveyed primary care physicians about their awareness of the tobacco control policies and practices of the health plans with which they were associated. We hypothesized that physicians could help to verify the extent to which tobacco control programs had been disseminated and implemented in medical practice settings. 

Our study was conducted by 9 of the 10 public domain research organizations associated with nonprofit health plans that have collaborated in the Cancer Research Network in order to conduct research studies of cancer prevention and treatment under a grant from the National Cancer Institute. The research project described in this paper is called Project HIT (HMOs Investigating Tobacco) and was funded to study health plan tobacco control policies and their effect on smoking cessation and healthcare costs. These 9 plans provide health insurance coverage for 8 million people in 8 states from Massachusetts to Hawaii, and deliver a full range of healthcare services, mostly through staffmodel –integrated delivery systems. In 1999, all 9 plans had HEDIS rates for advising smokers to quit that ranged from 66.7% to 81.6% and were substantially above the national average of 63.6%.

In 1999, we surveyed multiple key informants in each of these MCOs and reviewed each plan's written tobacco guidelines to verify their content.

In 2000, we repeated that survey to obtain updated information about each health plan's use of tobacco clinical guidelines, implementation efforts, incentives and supports for clinician cessation actions, coverage for various cessation services, and other tobacco-related activities. 

Soon after this policy survey update, we conducted a mail survey of a random sample of 100 primary care physicians from the care delivery organizations associated with each of the 9 HIT health plans. Both surveys were approved by the Institutional Review Boards associated with each of the participating health plans. To be included in the sample, the subjects needed to be adult primary care physicians (internists, family physicians, or obstetrician-gynecologists) who had worked for their current group for at least 1 year and who worked at least half time in a nonurgent care setting. The questionnaire was a 1-page, 19-item document that asked about the respondents' awareness and the perceived implementation of 8 important aspects of their health plans' tobacco control policies. A 5-point Likert scale was used for all responses, with 

 responses for most questions and 5-point 

 responses for questions about the availability of 5 cessation support resources at the time of a patient visit. The anonymous questionnaire was mailed to the physicians' office or home addresses with a cover letter from their medical leader and an official from the National Cancer Institute. This first mailing was followed by a reminder postcard in 1 week and by another questionnaire 2 weeks after that. To maintain anonymity, physicians responding to the survey were also asked to return a postcard at the same time that they separately returned the anonymous questionnaire. Although the postcard did include an individual identifier, the questionnaire did not. Nonresponders were contacted at 6 weeks by someone from their health plan's research group to encourage return of the questionnaire. These protocols were reviewed and approved by the Institutional Review Boards of each study health plan. 

Completed responses were summarized and compared with the relevant data from our survey of the tobacco control policies at each health plan. Where there were differences among the plan policies (eg, whether or not the plan provided performance feedback or financial incentives), we separately analyzed the responses from physicians associated with those plans that did and did not have the policy. In cases where there were multiple components to an aspect of plan policies or programs, we made decisions about what was most relevant to practicing physicians. For example, the health plan policy survey asked about a variety of approaches to training about tobacco control recommendations, but we limited the physician survey comparison to awareness of training for clinicians at their practices and the availability of central workshops. 

In addition, questionnaire items were compiled into contingency tables, along with the plan characteristics, and simple response frequencies (and range of frequencies among plans) were computed. The physician responses to the question about plans having cessation as a priority area were further investigated with logistic regression. The positive responses of physicians (

 with respect to cessation as a priority) were tested relative to their sex, age, and half-days worked per week, and to the plan characteristics (as documented in the key informant survey). 

Despite efforts to assure that only eligible physicians were sent surveys, 65 respondents did not fit the inclusion criteria. Of the remaining 835 subjects, completed surveys were obtained from 761, for an adjusted response rate of 91% (range 86%-95%) among the 9 plans. Forty percent of respondents were female (range 33%-52%) and the mean age was 46 years (SD 10 years). Participants reported working a mean of 7.5 half-day clinic sessions per week. 

 shows physician awareness of health plan clinical guidelines for tobacco cessation. All 9 plans had guidelines with similar recommendations, and the vast proportion of physicians reported knowing the guideline existed and its specific content. However, in 2 plans (plans E and H), 23% and 21% of physicians were unsure whether their plan had such a guideline and larger proportions than in any other plan (11% and 6%) reported that there was no guideline. 

 display health plan tobacco control actions where there was substantial disagreement between plan key informant and physician reports and substantial variation among plans. The percentages Doctors' Thoughts on Tobacco Control for 

 responses in these tables do not add up to 100% because physicians responding 

 are not displayed. Table 2 indicates that physicians were no more likely to report having received a copy of their plan's tobacco guideline or awareness of physician training in plans that reported these implementation strategies than in plans that did not. However, physicians may be aware of performance feedback and financial rewards more often in health plans with those policies, although the proportion who were aware was not large and physicians in plans that did not have these policies were more often aware of the lack of such policies. All plans provided at least some coverage for prescription cessation medications and cessation classes or counseling. As seen in Table 3, a high proportion of physicians across plans seemed to be aware of this coverage, although almost half of the physicians in one plan (plan E) were unaware or unsure of coverage for cessation classes or counseling. Physicians may be less aware of their plan's coverage of over-the-counter (OTC) nicotine replacement therapies. 

Although nearly all plans reported that they provide or encourage various types of tobacco cessation assistance, the proportion of physicians who reported awareness of such assistance for patient care varied widely (

). Much of this variation was derived from responses of the physicians in plans E and H, who reported much lower likelihoods of each of these forms of assistance in working with their patients. 

We also compared various actions by each health plan with the proportion of associated physicians reporting that tobacco control was a plan priority. Only 2 plans were rated by nearly all their physicians as having tobacco control as a high priority, whereas only half the physicians in 2 other plans reported tobacco control to be a priority. The plan actions with the greatest difference in physician reports between these 2 extremes were: 

Supporting clinic cessation assistance systems: 90% versus 38% 

Sponsoring community tobacco control activities: 55% versus 16% 

For the other 5 plans, an intermediate level of physicians reported that their plans had a priority for tobacco control (70%-84%). Similarly, an intermediate level of those physicians reported each of the above actions. 

Finally, in the logistic regression, we assessed the effect of physician sex, age, and half-days worked per week on responses. Male physicians were less likely to report all forms of quit assistance being easily available. Older physicians were more likely to report that tobacco control was a priority for their plan, that their plan provided training, and that cessation classes and materials were easily available, but they were less likely to report that their plan provided financial rewards. Physicians working more half-days per week were somewhat less likely to report getting feedback reports, but more likely to report smoking status being identified and classes and materials being readily available. Most of these associations, although statistically significant at the 95% confidence interval level, were small, and there were no other associations between these 3 physician characteristics and their responses to these questions. 

By usual standards (eg, HEDIS measures), all of these health plans have successful tobacco control policies. However, our study showed substantial variation in physician awareness of various elements of the USPHS recommended policies, and that the level of implementation and maintenance of practice cessation supports are both variable and suboptimal. If physicians delivering an important aspect of tobacco control efforts are unaware of a health plan's elements, the best-intentioned program will not succeed. 

There are 2 ways to categorize health plan tobacco control policies for purposes of this study: 

 For example, whether a clinical guideline exists for tobacco cessation support and whether cessation therapies are covered.

Subjective and dependent on the degree of implementation:

 For example, extent of clinic system changes, training, performance feedback, and financial rewards.

For policies in the first category, very high proportions of physicians associated with most of these health plans were aware that the plans had tobacco cessation guidelines and covered classes, counseling, and prescription cessation medications. However, few physicians knew whether their plan covered OTC cessation medications, perhaps because physicians are not as responsible for the use of these medications. 

Physician reports on health plan policies in the second, more subjective, category should provide an opportunity to assess how thoroughly these policies have been implemented. Thus, incomplete implementation and alternate sources of guidelines and training probably accounts for the lack of relationship between the presence of these policies and awareness by physicians. Physicians in plans that do not provide feedback or financial rewards for cessation support rates are relatively aware of that, but the high proportions of physicians reporting that they have received a copy of the guideline or believe that their plan provides training for plans that do not do these things suggests that there may be other sources of those actions that confuse the respondents. However, the mixed responses for plans that do provide feedback or rewards probably reflect a limited distribution of this information. Although all plans reported encouraging or providing most of the various types of office cessation supports identified in Table 4, the highly variable physician reports of availability of those services is certainly a reflection of variable and incomplete implementation. The wide range of physician reports among plans for this information probably reflects this variation in distribution or implementation. 

An interesting finding about these responses was that physicians associated with plans that do not have a particular policy appeared to be more likely to report that the policy was present (ie, false-positive reports) than are physicians associated with plans that do have the policy to say it is not present (ie, false-negative reports). This observation suggests that these physicians have been made aware that their plans are interested in reducing tobacco use and that they tend to give their plans the benefit of the doubt if they are unsure whether certain specific tobacco control policies are present. 

Finally, plans varied considerably in the extent to which affiliated physicians believed that tobacco control was a priority for their health plan. In contrast, the key informants from every health plan indicated that tobacco control was a high priority for their plan. The variance between plan actions and physician ratings of the priority of tobacco control suggested that if a health plan wishes to convince physicians that tobacco control is a high priority, a useful measure might be to provide and ensure physician awareness of training, feedback, and financial rewards. 

The principal limitations of this study were that the survey was restricted to physicians closely affiliated with these health plans, all of which have relatively high performance rates for tobacco cessation support. Thus, one must be cautious in generalizing these results to other types of health plans. Also, our desire for a short survey with high response rates prevented our exploration of relationships between response items and specific physician characteristics. 

Our findings suggest that physician reports of health plan policies may be a useful way to verify the extent to which those policies have been effectively implemented, but only for policies that directly affect the physicians and their work. In general, study physicians appeared to have high expectations for their health plan as far as tobacco control policies. Nevertheless, their reports indicated that these health plans that are leaders in tobacco control are not doing a very good job of making physicians aware of most of the assistance that they provide. The plans appear to have ample room for improvement by more thoroughly implementing the policies and systems that the USPHS guideline recommends. 

We thank key informants and staff at the participating health plans (Group Health cooperative, Seattle, Wash; Harvard Pilgrim Health Care, Boston, Mass; Health Alliance Plan, Detroit, Mich; HealthPartners, Minneapolis, Minn; Kaiser Permanente Colorado, Denver, Colo; Kaiser Permanente Hawaii, Honolulu, Hawaii; Kaiser Permanente Southern California, Pasadena, Calif; Kaiser Permanente Northern California, Oakland, Calif; and Kaiser Permanente Northwest, Portland, Ore. We also thank all of the investigators and staff of the HMO Cancer Research Network HIT Project. Mikel Aickin, PhD, biostatistician at Kaiser Permanente Northwest, was particularly helpful with the statistical analyses conducted to assess the contribution of physician and health plan characteristics. The policy and physician survey instruments can be obtained from Victor J. Stevens, PhD, Kaiser Permanente Center for Health Research, 3800 North Interstate Avenue, Portland, OR 97227-1098. 

From the HealthPartners Research Foundation, Minneapolis, Minn (LIS); Kaiser Permanente Southern California, Pasadena, Calif (VPQ); Kaiser Permanente Center for Health Research, Portland, Ore (VJS, KSS); Kaiser Permanente Hawaii, Honolulu, Hawaii (TMV); Harvard Medical School, Boston, Mass (NAR); University of Massachusetts Medical School, Worcester, Mass (JGZ); and Kaiser Permanente Colorado, Denver, Colo (DPR). 

This study was supported by grant #U19 CA79689 from the National Cancer Institute to the Cancer Research Network. 

Address correspondence to: Leif I. Solberg, MD, HealthPartners Research Foundation, PO Box 1524, MS#23302G, Minneapolis, MN 55440-1524. e-mail: 

Managed care and the morality of the marketplace. 

 Does managed care lead to better or worse quality of care? 

4. Phillips KA, Fernyak S, Potosky AL, Schauffler HH, Egorin M. 

Use of preventive services by managed care enrollees: an updated perspective. 

5. Himmelstein DU, Woollhandler S, Hellander I, Wolfe SM.

 Quality of care in investor-owned vs not-for-profit HMOs. 

 Waking the health plan giant: Group Health Cooperative stops counting sheep and starts counting key tobacco indicators. 

Nancy A. Rigotti, MD

Articles

Healthcare System Effects of Pay-for-Performance for Smoking Status Documentation

Tobacco Control Efforts in Managed Care: What Do the Doctors Think?