March 1998

Grant Results


In 1996, the National Committee for Quality Assurance (NCQA), Washington, an accrediting organization for managed care plans, issued a "Call for Measures" inviting public participation in revising its Health Plan Employer Data and Information Set (HEDIS).

HEDIS, the most widely used performance measurement system for managed care, had not previously addressed either tobacco use prevention or medical interventions to help smokers quit.

The Center for the Advancement of Health, Washington, gathered expert advice from more than 400 leading tobacco control researchers, epidemiologists, and performance measurement experts as well as representatives of health plans, consumers, and purchasing groups (see Grant Results on ID# 029354).

Key Results

  • Ultimately, a panel of experts proposed two composite measures:
    • A clinical measure of tobacco use screening and intervention.
    • A survey measure of tobacco use prevalence and intervention.
  • As a result, a survey measure of smoking prevalence and intervention, which highlighted medical advice to quit smoking, was included in a modified form in HEDIS 3.0 and also adopted as a quality measure by The Foundation for Accountability, the consumer-focused equivalent of NCQA.

The Robert Wood Johnson Foundation (RWJF) supported the project with a grant of $49,699 between February and July 1996.

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Tobacco use by Americans is the single greatest cause of illness and death, responsible for more than 420,000 premature deaths each year, and for over $50 billion annually in direct health care costs. Over 25 percent of adult Americans smoke cigarettes or use smokeless tobacco, and this rate has not declined since 1991. There is strong evidence that even brief clinician counseling can double or triple smokers' rate of quitting.

The emergence of managed care and organized systems of providers presents new opportunities to encourage providers to: (1) increase their knowledge about the effectiveness of brief interventions; and (2) identify and intervene with every patient who uses tobacco. In 1995, however, there was no systematic way to evaluate a health plan's medical care as it related specifically to tobacco use and addiction.

In December 1995, the National Committee for Quality Assurance (NCQA) issued a "Call for Measures," for public input into revising its Health Plan Employer Data and Information Set (HEDIS). At the time, HEDIS was the most widely used performance measurement system in managed care: over 125 health plans were members or subscribers to the HEDIS User's Group, and more than 300 health plans were producing at least some HEDIS statistics. The immediate goal of this grant was to stimulate the development of non-proprietary measures of how a health plan addresses subscribers' tobacco use and addiction, and to stimulate the adoption of such measures into the HEDIS 3.0 instrument scheduled for release in late 1996.

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In January 1996, the grantee distributed copies of NCQA's "A Call for Measures" to more than 400 experts in tobacco control, performance measurement, and managed care. Their input led to the development of 17 candidate indicators of surveillance of tobacco use, prevention, and treatment by physicians working for managed care plans, which were subsequently reviewed by an advisory panel composed of researchers, epidemiologists, representatives of health plans, consumers, purchasing groups, and the leading professional and scientific societies concerned with tobacco use and addiction. The panel gave their highest ratings to three indicators:

  • Health plan screening — the routine identification of tobacco users by clinicians;
  • Health plan intervention — an assessment of whether or not medical providers are helping smokers to quit by providing advice or appropriate resources; and
  • Prevalence of tobacco use among health plan enrollees — the percentage using tobacco.

A smaller Expert Working Group of the advisory panel was charged with developing and proposing measures reflecting these three indicators to the HEDIS 3.0 Review Group. It included representatives from the Centers for Disease Control and Prevention, the National Cancer Institute, the American Medical Association, the Henry Ford Health System, the HMO Group, the Washington Business Group on Health, the Agency for Health Care Policy and Research (AHCPR) Panel on Smoking Cessation Clinical Practice Guidelines, and the NCQA. In March 1996, the working group submitted two composite measures: (1) a core measure, which would tap tobacco use screening and intervention, proposed making tobacco use a vital sign in medical charts; and (2) an adjunctive, complementary measure focused on the prevalence of tobacco use and medical advice to be collected through periodic surveys of health plan members. The advisory panel solicited and received endorsements for its proposed measures from a broad array of organizations and constituency groups.

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  • In July 1996, HEDIS 3.0 was published with the adjunctive measure of "prevalence of tobacco use and medical counsel to quit." However, due to health provider concerns about the cost of chart reviews of vital signs, the proposed core measure was ultimately rejected.
  • The Foundation for Accountability, the consumer-focused equivalent of NCQA, included a tobacco use and intervention indicator in its quality measurement process.
  • NCQA is testing two prevalence measures for inclusion in a future version of HEDIS: (1) the percentage of adult members who smoke tobacco; and (2) the percentage who quit smoking during the past year. In its recommendations, however, the advisory panel discouraged using prevalence as an independent indicator of quality, because the rate of smoking tends to be higher in low-income populations and may be similar across plans serving a given area. The panel expressed concern that smoking prevalence measures alone do not directly evaluate the performance of medical providers, nor do they provide an incentive for health plans to act.
  • Performance measures developed under the grant are non-proprietary, i.e., they are available for use by all interested health plans.
  • In March 1996, the grantee convened roundtable discussions of researchers to discuss health related behaviors. These discussions resulted in an internal RWJF report entitled "Health and Behavior."


The results will be used nationwide as NCQA and the Foundation for Accountability proceed to accredit participating health plans and measure the quality of care provided. Quality measures collected by NCQA and the Foundation for Accountability are available to payers, consumers, regulators, and policymakers in the form of health plan "report cards." Interested parties may request, from the grantee, copies of two unpublished papers describing the process of developing tobacco control performance measures.

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  • Led to the Foundation's national program, Addressing Tobacco in Managed Care (TMC), which assesses the use of measures developed under this grant in managed care plans. It seeks to encourage managed care and research organizations to collaborate in a study of system changes aimed at reducing rates of tobacco use among managed care subscribers.
  • The Foundation has offered financial support to help both accrediting organizations, NCQA and the Foundation for Accountability, analyze the data produced while developing these tobacco control indicators.
  • With funds from the California Wellness Foundation, the grantee is working on ways to assess if health plans address other behavioral and psychosocial needs of their subscribers.
  • The grantee has received funds from the Foundation to explore opportunities for wider dissemination of a number of health behavior change interventions in managed care (e.g., tobacco, diet, physical activity, risky sexual practices, behavior, and chronic disease management, ID# 028460).

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Managed Care Performance Indicators for Prevention and Treatment of Tobacco Use and Addiction


Center for the Advancement of Health (Washington,  DC)

  • Amount: $ 49,699
    Dates: February 1996 to July 1996
    ID#:  028757


Jessie Gruman, Ph.D.
(202) 387-2829

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(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)


Center for the Advancement of Health. Tobacco Control and Prevention Performance Indicators for Managed Care: Measures Recommended by the Expert Working Group and Advisory Panel Convened by the Center for the Advancement of Health. Washington, D.C.: March 1996.

Gruman J, Birnbaum M, and Orleans T. Expanding the Role of Managed Care in Tobacco Control: The Assessment and Development of Tobacco-Related Performance Indicators. Washington, D.C.: Center for the Advancement of Health, 1996. Unpublished.

Gruman J, Birnbaum M, and Orleans T. Integrating Tobacco Control into Managed Care: The Development of Tobacco-Related Performance Indicators. Washington, D.C.: Center for the Advancement of Health, 1996. Unpublished.

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Report prepared by: Carol Schreter
Reviewed by: Patricia Patrizi
Reviewed by: Marian Bass
Program Officer: C. Tracy Orleans

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