Transcript The Promises and Pitfalls of the Tobacco Master Settlement

Reimbursement for
Tobacco Dependence Counseling:
Employer, Managed Care, Medicaid
ABBY C. ROSENTHAL, MPH
Office on Smoking and Health
National Conference on Tobacco or Health
November 2002
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Purpose
• Describe Tobacco Dependence Treatment Guideline
guidance about counseling
• Provide a framework for population based cessation
initiatives
• Review Community Guide Recommendations about
reimbursement
• Describe reimbursement strategies for cessation
• Provide an overview of existing state initiatives
• Identify Medicaid implementation strategies
• Discuss State based employer initiatives
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Efficacy of Different Counseling
Formats (n=58 studies)
Number
of Arms
20
Estimated
Odds Ratio
(95% C.I.)
1.0
Estimated
Cessation Rate
(95% C.I.)
8.2
Proactive
Telephone counseling
26
1.2 (1.1-1.4)
13.1 (11.4-14.8)
Group counseling
52
1.3 (1.-1.6
13.9 (11.6-16.1)
Individual counseling
67
1.7 (1.4-2.0)
16.8 (14.7-19.1)
Type of Provider
No format
Source: Fiore et al. Treating Tobacco Use and Dependence:
Clinical Practice Guideline, USDHHS, 2000
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Efficacy of Different Levels of Personto-Person Contact (n=43 studies)
Levels of Contact
No contact
(reference group)
Number
of Arms
Estimated
Odds Ratio
(95% C.I.)
Estimated
Cessation Rate
(95% C.I.)
30
1.0
8.8
19
1.3 (1.0-1.6)
13.4 (10.9-16.1)
16
1.6 (1.2-2.0)
16.0 (12.8-19.2)
55
2.3 (2.0-2.7)
22.1 (19.4-24.7)
Minimal contact
(5 min.)
Brief counseling
(>3 to ???Min)
Individual counseling
(>10 min.)
Source: Fiore et al. Treating Tobacco Use and Dependence:
Clinical Practice Guideline, USDHHS, 2000
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Cost of Counseling
Group program
(Seven 1-hour sessions over 6 weeks)
$70
Proactive telephone counseling
(Five phone calls over 1 year)
$185+
Individual, face-to-face counseling
$200+
(Four 10-minute sessions with a physician)
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Three Levels of Cessation Interventions
• Individuals
• System changes
• Populations
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Impact = Efficacy x Reach
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Methods Used on Last Attempt to Quit
• 68% tried to quit without using any assistance
– 7% used other methods (chewed regular gum, hypnosis)
• 21% used NRT
• 2% used a prescription medication
• 1% used self-help materials
• 1% used counseling
Yankelovich Partners Inc. Smoking cessation study.
American Lung Association, 1998.
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Few Doctors Counsel Patients
about Smoking Cessation
Asked by Doctors if Patient Smokes, Percent of All Patient Visits
1991
1993
1995
Doctor Provides Smoking Counseling, Percent of Smoker Visits
1991
1993
1995
Doctor Prescribes Nicotine Replacement Therapy, Percent of Smoker Visits
1991
1993
1995
30%
60%
Source: Substance Abuse: The Nation’s Number One Health Problem from Thorndike An et al.
“National Patterns in the Treatment of Smokers by Physicians.” JAMA, 1998;279(8):604-8.
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Reducing Out-of-Pocket Costs
• Measurements (4 studies):
– Use of treatment (median impact + 7 pct pts)
– Patient cessation (median impact + 7.8 pct pts)
Source: Hopkins D, Briss P, Ricard C, Husten C, et al. Am J Prev Med 2001;20(2S):16-66.
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State Medicaid Coverage of Tobacco Dependence
Treatment, 1998-2000
WA
VT
MT
MN
ND
OR
MN
ID
NH
SD
WI
WY
NV
CA
AZ
PA
IL
CO
KS
OK
NM
AK
MA
RI
CT
MI
IA
NE
UT
NY
IN
OH
WV
MO
KY
VA
NJ
DC DE
MD
NC
TN
SC
AR
MS
AL GA
TX
LA
FL
HI
Comprehensive coverage
Partial coverage
Source: MMWR, November 9, 2001.
No coverage
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Medicaid Coverage for Treatment
of Nicotine Dependence
• Counseling
– 11 states reimburse for individual counseling
– 10 states cover group counseling
• Prescription tobacco-treatment medications
– 31 states cover some prescription medications
– 22 states cover all products
• OTC tobacco-treatment medications
– 23 states cover OTC medications
• There are often restrictions on use of services
or products
MMWR, November 9, 2001
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Background
• High smoking prevalence among Medicaid enrollees
• % of low birthweight births higher in Medicaid populations
• Tobacco related disease is a major expense
for Medicaid
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Cost Benefit
• For every $ 1 dollar spent on smoking cessation
for pregnant women $ 3 saved (Marks, et al. 1990)
• An annual percentage point decline in smoking
prevalence would prevent 1,300 low birth weight babies
and save $21 million in 1995 U.S. dollars (Lightwood
et al. 1999)
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Medicaid Purchasing Specifications
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Treatment Recommendations
• 5 A’s
• 5 R’s
• Two 90 day courses of FDAapproved medications
• Two 90 day courses of counseling
(individual, group or telephone)
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Recommendations
• Know your current Medicaid Coverage
• Compare coverage to Medicaid Model Language
• Coordinate with state Medicaid Agency to make
the case for evidence-based treatment
• Work with Medicaid to promote benefit
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Employer/Purchaser Initiatives
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Employer Coverage of Tobacco-Use Treatment
HMO
50
Indemnity Plan
40
Percent
42%
38%
30
20
10
25%
16%
0
Cessation Counseling
Drugs and Devices
Source: Partnership for Prevention, 1998
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The Office of Personnel Management Now
Encourages Coverage of Clinical Tobacco-Use
Treatment Interventions
• “We encourage plans to provide benefits for smoking cessation
that follow the Public Health Service’s treatment guidelines.
• Consistent with these guidelines, primary care visits for tobacco
cessation should be covered with the standard office visit copayment.
• Individual or group counseling for tobacco cessation should be
covered with no co-payment.
• Prescriptions for all FDA-approved medications for treatment of
tobacco use should be covered with the
usual pharmacy co-payments.”
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Blue Cross/Blue Shield Response
• We now treat smoking cessation services the same as
other medical or mental health/ substance abuse services.
• Previously, under Standard Option, smoking cessation
services were limited to $100 of coverage per lifetime.
• In addition, we no longer limit smoking cessation drugs
to one course of treatment per year; additional courses
of treatment do require prior approval and participation
in a smoking cessation program.
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North Carolina
• Implemented North Carolina Prevention Partners
• Prevention Report Card
• Basic benefits
• Cost/ Return on Investment Formulas
• www.ncpreventionpartners.org
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Wisconsin
• State, University, Medicaid
Partnership
• Incentive/risk initiative
• State employee coverage
• Medicaid involvement
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Recommendations
• Promote effective treatment
• Work toward public and private sector reimbursement
for cessation treatment
• Develop creative working relationships with purchasers,
providers, and payers
• Coordinate with managed care and other insurers to
create effective system change in public and private
sectors
• Develop strategies to promote effective implementation
of Medicaid coverage
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Next Steps
• Identify coverage provided through health plans
• Promote online referral to the quitline
• Assess smoke-free worksite status in your area
• Explore Medicaid coverage and promote monitoring
• Determine cessation coverage by your own agency and
work to provide if not available
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© Published in the New Yorker, 10/07/2002
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Paradigm of Tobacco-Use Treatment
Higher price for tobacco
Reducing cost of treatment
Counter-advertising
Individual
Telephone quitlines
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CDC
Office on Smoking and Health
www.cdc.gov/tobacco
770-488-5705
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