January 21, 2005
Mark A. McClellan, M.D., Ph.D.
Centers for Medicare and Medicaid Services
Department of Health and Human Services
200 Independence Avenue, S.W.
Room 314-G - HHH Building
Washington, D.C. 20201
Decision Memo for Smoking & Tobacco Use Cessation Counseling
Dear Dr. McClellan:
The undersigned patient, provider, and research organizations are writing in strong support of the Centers for Medicare and Medicaid Services (CMS) decision to provide Medicare coverage for smoking cessation counseling services. Counseling is widely recognized as contributing to the success of smoking cessation efforts, and the agency action will ensure that Medicare beneficiaries enjoy the advantages of comprehensive cessation services.
We recommend that cessation counseling be covered for all Medicare beneficiaries, rather than only for beneficiaries who have been diagnosed with a tobacco-related illness or who are taking medications whose metabolism or dosing is affected by tobacco use, as proposed by CMS. We believe this change will ensure access to cessation counseling for all beneficiaries who might be undertaking smoking "quit attempts." The data support this expansion, as the data reviewed by the agency establish the effectiveness of counseling services when utilized by senior citizens, including but not limited to those who have co-morbidities associated with smoking. The agency has concluded that cessation counseling is a cost-effective intervention, and an expansion of the proposed benefit to include smokers who may not have a smoking-related diagnosis should pose no financial burden for the program.
some evidence that older smokers, because of the length of time they have
smoked and the strength of their addiction, may require more quit attempts
and more intensive services during their quit attempts. Therefore, the proposed
coverage of two quit attempts, with four counseling services (intermediate
or intensive services) during each quit attempt, may not be adequate for older
smokers. In its decision, the agency has cited evidence that supports a dose-response
relationship between the length of time spent on each counseling session,
number of sessions, and total length of counseling (the dose) and the effectiveness
of counseling (the response), and the dose-response relationship should be
carefully monitored for the older smokers who will be the primary target for
We are gratified that CMS intends to provide well-defined and unique codes for the counseling services and to use the codes to evaluate per-capita utilization of services, as well as outcomes and patient experiences. This ongoing evaluation should allow the agency to determine whether the coverage standard is appropriate for older smokers in terms of the number and length of covered sessions.
The proposal would allow payment only for services provided by individuals trained in tobacco use cessation counseling. We recommend that training according to the 2000 Clinical Guideline of the United States Public Health Service be the standard for providers. Adherence to this clinical guideline would ensure that beneficiaries are receiving appropriate services but would not unreasonably restrict access to services.
We commend CMS for its decision to cover tobacco cessation counseling, and we look forward to working with the agency to educate beneficiaries and health care professionals regarding the availability of this new service.
Cancer Leadership Council
American Society of Clinical Oncology
American Society for Therapeutic Radiology & Oncology, Inc.
Association of American Cancer Institutes
Cancer Care, Inc.
Cancer Research and Prevention Foundation
The Children's Cause for Cancer Advocacy
International Myeloma Foundation
Kidney Cancer Association
Lance Armstrong Foundation
Lymphoma Research Foundation
Marti Nelson Cancer Foundation
Multiple Myeloma Research Foundation
National Coalition for Cancer Survivorship
National Patient Advocate Foundation
Ovarian Cancer National Alliance
Sarcoma Foundation of America
The Susan G. Komen Breast Cancer Foundation
Us Too International Prostate Cancer Education and Support Network
The Wellness Community
Y-ME National Breast Cancer Organization