Veterans Affairs/Veterans Health Administration
There are approximately 23.4 million veterans in the United States, and the Veterans Affairs (VA), also called the Veterans Health Administration (VHA), provides health care for nearly 7.9 million of them.24 The VA currently has 153 medical centers and 909 ambulatory care and community outpatient centers in the United States.24 The population of veterans who receive their medical care from the VHA has a slightly higher percentage of people who smoke (22% of approximately 7.2 million veterans, or 1.54 million people)25 than the general U.S. adult population (20%, or 43.4 million people).26 These numbers represent a significant decrease of smoking prevalence from 33% in the veterans population27 vs. 24% in the general population28 in 1999. Note that the smoking prevalence rate across Veterans Integrated Service Networks (VISNs) varies significantly, ranging from 16.5% to 27%.29
The VA offers and “encourages a comprehensive, evidence-based tobacco use screening and cessation counseling program”29 as outlined in the United States Public Health Service Treating Tobacco Use and Dependence: 2008 Update – Clinical Practice Guideline1 and the VA-Department of Defense (DoD) Tobacco Use Cessation Clinical Practice Guideline (TUC-CPG).30 The most current version of the VA/DoD Tobacco Use Cessation Clinical Practice Guideline was updated in 2004, and will be updated to reflect the revised 2008 Public Health Service Clinical Practice Guideline. The VA provides tobacco-dependence treatment in the form of advice during normal appointments, free tobacco-dependence counseling, and pharmacotherapy with co-pay to all eligible veterans. In addition, tobacco-dependence specialty clinics provide more intensive counseling and treatment.31 The VHA has required that VA physicians provide such treatment to veterans since 2007.
The key elements of treating tobacco dependence in the VA program are as follows:32
- Every tobacco user should be advised to quit.
- Tobacco use is a chronic relapsing condition that requires repeated interventions.
- Several effective treatments are available in assisting users to quit.
- It is essential to provide access to effective evidence-based tobacco use counseling treatments and pharmacotherapy.
- Collaborative tailored treatment strategies result in better outcomes.
- Quitting tobacco leads to improved health and quality of life.
- Prevention strategies aim at reducing initiation, decreasing relapse, and eliminating exposure to environmental tobacco smoke.
Tobacco-Dependence Treatment Policies and Performance Standards for VA Physicians
The VHA has taken steps over the past several years to promote tobacco-dependence treatment. The VA began systematic tobacco use screening – asking patients about tobacco use and advising them to stop smoking – as part of its performance measures in 1996.15 In 2003, the VA lifted its restrictions on tobacco-dependence medications and mandated the availability of tobacco-dependence medications so that they could easily be prescribed to veterans.15 The 2004 update to the VA/DoD Tobacco Use Cessation Clinical Practice Guideline30 recommended “offering drugs and counseling to all smokers in the most intensive setting they are willing to attend.”15 The co-payment for tobacco-dependence counseling services, but not including pharmacotherapy co-pay, was removed in October 2005, in order to decrease financial barriers to treatment.15 As of January 2007, the Veterans Administration System revised its performance requirements, mandating that VA physicians not only advise all patients to stop smoking, but also offer and provide effective treatment, including counseling and pharmacotherapy, for tobacco dependence.15
As of 2007, VA performance measures now require the VA physician to:
- Screen for tobacco use at least once per year and advise the patient who smokes to quit,
- Provide all current tobacco users with brief counseling for tobacco dependence, as described in the VA/DoD Tobacco Use Cessation Clinical Practice Guideline,
- Offer pharmacotherapy for tobacco-dependence treatment,
- Refer patients to a VA or community tobacco-dependence treatment clinic.
The electronic medical record system33 is used as a tool to support performance measures, establishing a clinical reminder for the physician to assess tobacco usage by simply following the steps listed on screen. The health care provider documents directly into the electronic medical record the services and treatments that were provided. However, the time spent with the patient is not documented by this electronic system. (Further information about the Performance Measurement Program can be found at the Office of Quality and Performance Department of Veterans Affairs website.34)
The VA tobacco-dependence treatment programs (also referred to in the VA literature as tobacco or smoking cessation programs) support treatment for VA patients with either the primary care or mental health services provider, because the mental health provider is often the primary care provider as well. Any VA physician, however, can now provide tobacco-dependence treatment, including prescribing pharmacotherapy. The VA also has provided nationwide training programs on tobacco-dependence treatment for VA mental health care providers to keep them up to date on techniques and pharmacotherapy and enable them to train other providers at their local VA facilities.35
Physicians and care providers can prescribe tobacco-dependence medications (nicotine gum, patch, or lozenge, or bupropion, varenicline, or Combination Nicotine Replacement Therapy (CNRT)) that are listed in the VA-approved formulary pharmacotherapy table36 and are available at pharmacy co-pay to veterans. All medications that are on the FDA approved list, and that are widely used outside of the VA, should also be available in the VA’s formulary. Local VA pharmacies, however, at their sole discretion, may over-ride the physician’s prescription and restrict the number of refills. Pharmacotherapy is also tied to the VA/DoD Tobacco Use Cessation Clinical Practice Guideline recommendations. Individual VA pharmacies may limit or restrict what medications they allow their VA physicians to prescribe for treating tobacco dependence. In such cases, the pharmacy may not provide sufficient resources to enable physicians to follow the recommended VA/DoD Tobacco Use Cessation Clinical Practice Guideline performance criteria. Therefore, although the VHA, as a health-care delivery system, is far more advanced and enlightened than private, third-party payers, there is still too much deviation from the mandated, national VA tobacco-dependence performance standards that is paradoxically dictated by the local VA pharmacy. Individual VA physicians, therefore, need to determine the pharmacological resources available to them at their specific VA and then work within their VA structure to improve those resources so that they are able to provide the level of care outlined by VA/DoD Tobacco Use Cessation Clinical Practice Guideline and this Tool Kit, and thus to fully comply with the medically appropriate and scientifically justified national VA performance standards for tobacco-dependence diagnosis and treatment.
There are two main co-pay categories that are used for the tobacco-dependence treatment programs. There are no limits on number of office visits or counseling sessions.
(1) No co-payment for tobacco screening and
tobacco-dependence counseling (individual or group).
(2) Basic $15 co-payment for a basic outpatient
primary care visit (for priority categories 7
and 8 only; no co-pay for other priority categories).
The co-payment for pharmacotherapy is $8 for a 30-day supply of medication for outpatient treatment for those patients who have a medication co-pay.37
The VA uses special categories and priority groups for veterans and provides exceptions to the co-payments for them (e.g., for POWs, those with severe injuries sustained in the line of duty, etc.). 38, 39
Computer-Based Program for VA Care Providers
The Erie, PA VA Medical Center uses an enhanced computer-based program to support tobacco-dependence treatment. The program addresses both patient support and education. It automates tasks for the medical providers and allows them to order medications, provide ongoing education and counseling services, and arrange for follow-up visits immediately, during the patient visit. The first three months of using this program resulted in a 400% increase in the number of patients given smoking cessation treatment.33 After further trial, this program could be easily ported to all other VA medical centers.
VA Summary & Conclusions
The Veterans Administration Health Care System steadily and consistently increased the level, intensity, and effectiveness of tobacco-dependence treatment for its veterans between 1996 and 2007. In 1996 tobacco dependence became a priority for the VA system, nationwide. In 1996 the VA required physicians to ask each patient if that patient smoked and, if so, advise that patient to stop smoking. By January 2007, those physician performance standards had increased so that physicians were required to provide effective tobacco-dependence treatment including pharmacotherapy, as recommended by the 2004 VA/DoD Tobacco Use Cessation Clinical Practice Guideline and the 2000 US Public Health Service Clinical Practice Guideline: Treating Tobacco Use and Dependence.
Between 1999 and 2007, the smoking prevalence rate among veterans in the VA Health Care System fell from 33% 27 to 22% 25. Also, between 1999 and 2007 the smoking prevalence rate among the US population, overall (men and women) fell from 24% 28 to 20% 40. Thus, the VA smoking prevalence rate fell 33% between 1999 and 2007 while that in the civilian population fell only 17%. This is no accident and reflects the consistent increase in depth and breadth of tobacco-dependence treatment services that the Veterans Administration provided over those years to its veterans.