Transcript The Promises and Pitfalls of the Tobacco Master Settlement

Making the Case to Insurance
Purchasers for Tobacco Use Treatment
Coverage
Maya Vijayaraghavan, Ph.D.
Office on Smoking and Health
National Conference on Tobacco or Health
November 19-21, 2002
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Purpose
• Development of Medicaid Model Language
for Tobacco Dependence Treatment to:
– Increase standardization of contracting nationwide
– Improve comprehensiveness of coverage
– Increase access and availability to evidence-based
treatment
– Provide sample language for state programs
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Background
• High smoking prevalence among Medicaid enrollees
• % of smoking attributable low birthweight births
higher in Medicaid populations
• Tobacco related disease is a major expense
for Medicaid
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State Medicaid Coverage of Tobacco
Dependence Treatment, 1998-2000
WA
VT
MT
OR
MN
ID
NH
SD
WI
WY
NV
CA
AZ
IL
CO
KS
OK
NM
AK
NY
MO
OH
WV
VA
KY
NC
TN
IN
NJ
DC DE
MD
SC
AR
MS
TX
MA
RI
CT
MI
PA
IA
NE
UT
MN
ND
AL GA
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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Total Cost of Smoking to Medicaid*
• Estimated to be over $17 Billion in 1997
• 12% of all Medicaid expenditures
*Zhang et al. 1999
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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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Are the specifications mandatory?
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Key Components
of the Medicaid Specifications
• Adults
• Pregnant Women
• Adolescents
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System Strategies
• Patient identification mechanisms
• Implementation of the 5 A's
• Coding (305.1 ICD-CM)
— Claims Data Base
— Encounter Form
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Pregnancy
• Graded questions to reduce deception rates
• 5 –15 minute counseling
• Psychosocial interventions that exceed the
minimal advice to quit
• Provision of pregnancy specific material
• Relapse assessment and counseling
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Adolescents
• Prevention counseling
• Cessation counseling
• Referral to community programs if appropriate
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Treatment Recommendations
• 5 A’s
• 5 R’s
• Two 90 day courses of FDA-approved
medications
• Two 90 day courses of counseling (individual,
group or telephone)
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Medicaid Purchasing Specifications
Available at:
http://www.gwhealthpolicy.org/newsps/tobacco
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State Initiatives
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Wisconsin
• Coverage
—Counseling
—Medication
• Strategies
—Chart Audit
—Consumer Survey-Telephone Counseling
• Challenges
—Under utilization of benefit
—Effective Coordination between state agencies
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Oregon
• Coverage
— Medication
— Counseling
• Strategies
— Work through State Tobacco Coalition
— Office based training
— Telephone Counseling
• Challenges
— Payment for preventive services
— Coordination of state agencies
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Utah
• Coverage
— MSA funds for pregnant Medicaid enrollees
— Counseling and prescription medication
• Strategies
— Medicaid contributes to media campaign
— Medicaid matches DOH in quitline funding
• Challenges
— Match based on complicated formula
— Coordination between state agencies
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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
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Recommendations (continued)
• Coordinate efforts to create comprehensive coverage
• Promote monitoring of coverage implementation
• Provide support for coordination between plans
serving Medicaid
• Utilize WIC and other public clinics to provide services
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Upcoming Products from the CDC
• Cost-effectiveness of smoking cessation
• Summary of Medicaid Specifications
• Reimbursement: Two documents
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Acknowledgements
Abby Rosenthal
Office on Smoking and Health
Centers for Disease Control and Prevention
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CDC
Office on Smoking and Health
www.cdc.gov/tobacco
770-488-5309
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