Smoking out the incentives for tobacco control in managed care settings.

Introduction There is a widespread perception that managed care organisations (MCOs) are not particularly interested in providing disease prevention and health promotion services consisting primarily of behavioural interventions. The belief is that MCO managers see the cost associated with such interventions, but not the eVectiveness and not the cost-eVectiveness. Indeed, they may be looking for something more than cost-eVectiveness: they may want evidence of cost savings to endorse the provision of such services. This reflects the dilemma of prevention more generally: the benefits of eVective prevention measures are abstract. (Which recipients of the intervention avoided illness as a consequence of the intervention?) And they are deferred, often occurring years into the future. The costs, however, are tangible and immediate. This situation stands in striking contrast to the benefits and costs of disease-promoting behaviours: the benefits are tangible and immediate (that piece of chocolate cake is exceedingly pleasing to the palate), while the costs are abstract and deferred (will my having eaten the cake contribute to occluded arteries that will eventually result in my premature demise?). Smoking cessation services constitute an excellent example of this phenomenon as it applies to managed care organisations. If an MCO implements a smoking cessation programme, the organisation incurs the cost upfront. The cost is self-evident and, in and of itself, obviously undesirable. The financial benefit takes the form of reduced expenditures on smoking-produced diseases. However, the lion’s share of this benefit will not accrue until two or three decades have passed, the time required to realise the avoidance of smoking-related illnesses. Further, that such health and economic benefits will accrue must be taken as something of an article of faith since, reflecting the abstraction of such benefits, no-one will be able to identify precisely which of the participants in the smoking cessation programme would have become ill had they not quit smoking as a result of programme participation.