Buried in a 1,592-page proposed rule is a change that reveals more about American health care economics than its size suggests. CMS proposes to raise reimbursement for smoking cessation counseling, and for alcohol and substance misuse screening and intervention, by 19.1%.
The context for that percentage: under the status quo, physicians make around $10 from tobacco cessation counseling, according to former National Cancer Institute director Ned Sharpless, who advocated for the change across both the Biden and Trump administrations.
Ten dollars, for a service that ranks among the most cost-effective interventions in all of medicine.
The arithmetic that explains the behavior
Consider the position of a primary care physician with a fifteen-minute appointment slot and a patient who has diabetes, hypertension, a medication reconciliation to complete, a screening overdue, and a new complaint.
Tobacco cessation counseling comes in two forms: intermediate, defined as 3 to 10 minutes, and intensive, more than 10 minutes. Either one consumes a meaningful share of the visit. Both pay about ten dollars.
Sharpless put the consequence plainly: that is not much, and given that primary care and internal medicine doctors are already juggling competing demands, getting into a detailed dialogue about quitting cigarettes is often an afterthought.
This is not a story about physicians lacking commitment to prevention. It is a story about a payment system that priced a ten-minute evidence-based intervention at roughly the cost of a sandwich, then expressed disappointment that it was not delivered consistently. Clinicians respond to the incentives they operate under, and the incentive here has been to move on.
The deeper absurdity is what Medicare is buying on the other end. The program covers tobacco cessation for beneficiaries with illnesses caused or complicated by tobacco use, including heart disease, cerebrovascular disease, lung disease, and blood clots, the diseases that account for the bulk of Medicare spending. Medicare has been paying ten dollars to prevent the conditions on which it later spends six figures.
Why the reclassification is the smarter part
The mechanism CMS chose is more interesting than the number, and it reflects a correct conceptual move.
In the CY 2024 final rule, CMS increased the valuation of timed behavioral health services by applying an upward adjustment to work RVUs for psychotherapy codes, phased in over four years. For 2027, the final year, CMS proposes applying the same adjustment to smoking and tobacco use cessation and to screening, brief intervention, and referral to treatment services, reasoning that similar adjustments are warranted.
That is a category correction, not just a raise. Tobacco dependence is a substance use disorder, coded as such in ICD-10. Treating cessation counseling as a behavioral health service rather than as a preventive checkbox aligns the payment with the clinical reality: it is a structured conversation about changing an addictive behavior, which is what psychotherapy codes describe. Paying it like the thing it actually is has better durability than a one-off boost, because it ties the rate to a code family that gets revalued on its own logic.
The parallel extension to alcohol and substance screening matters for the same reason and addresses a comparably neglected area. One study found that 70% of people with alcohol use disorder were asked about their drinking during a clinical visit, of whom 12% received a brief intervention and 5% were given referrals or informed about treatment options.
That cascade is worth reading carefully. The screening step works. Seven in ten get asked. The failure is downstream: identification without intervention, and intervention without connection to treatment. Which points at something the payment increase alone will not fix.
Why the increase is probably too small to be decisive
Being honest about scale: 19.1% applied to roughly $10 produces roughly $12.
For a physician deciding whether to spend eight minutes on a cessation conversation inside a compressed visit, the difference between $10 and $12 is unlikely to be the deciding factor. The opportunity cost of those minutes, measured against everything else competing for them, has not meaningfully changed.
And the alcohol cascade data suggests price is not the primary constraint anyway. The drop-off from 70% screened to 5% referred is a workflow and infrastructure failure, not a reimbursement one. Clinicians who ask the question and then have nowhere to send the patient, or no time to have the second conversation, will keep producing that pattern regardless of the RVU.
What actually moves cessation rates is well documented: pharmacotherapy combined with counseling, systematic identification of tobacco users at every visit, workflows that route willing patients to quitlines or dedicated counselors rather than relying on the physician's own minutes, and follow-up contact. Most of that is delegable, and notably Medicare rules specify that auxiliary personnel may not independently furnish or bill for tobacco cessation counseling, which concentrates the work on the most time-constrained person in the building.
There is a complementary proposal in the same rule worth noting: CMS proposes to establish separate coding and payment for shared medical appointments with multiple beneficiaries receiving support in a group setting. Group cessation programs have a decent evidence base and much better economics per clinician-hour than individual counseling at $12. That provision may do more for delivery than the rate increase does.
What patients should know regardless
Several features of the existing benefit are underused because they are not widely known.
Tobacco cessation counseling is a Medicare preventive service, which means beneficiaries pay no coinsurance. It is free at the point of care.
The allowance is more generous than most people assume: patients may pursue two quit attempts per year with four sessions each, eight sessions in a twelve-month period, with an additional eight in subsequent years. Given that most successful cessation follows multiple attempts, a benefit designed around repeated attempts is well matched to how quitting actually works.
And the population is not negligible. The CDC has estimated that 9.3% of Americans age 65 and older smoke cigarettes, and the benefit is aimed at those already experiencing tobacco-related illness, where the return on quitting is largest and most immediate.
The verdict
The proposal is correct in direction, correct in reasoning, and probably insufficient in magnitude.
Recognizing tobacco cessation as behavioral health rather than a preventive formality is the right conceptual fix, and tying it to a code family with its own revaluation logic gives it more staying power than an isolated adjustment. Extending the same treatment to alcohol and substance screening addresses an equally neglected area.
But a two-dollar increase does not change the calculus inside a fifteen-minute visit, and the evidence suggests the real bottleneck is workflow rather than price: who does the counseling, whether there is anywhere to refer patients, and whether anyone follows up. Medicare spent years paying ten dollars for the intervention most likely to prevent the diseases it spends the most treating. Paying twelve is better. Paying enough to restructure how the conversation happens would be different, and that is the change still waiting to be proposed.