Vermont Department of Health Vermont – Third Party partnership with private insurance Todd Hill, LiCSW, LADC January 7 & 9, 2009

Vermont Department of Health 2 In 1997 the Vermont Banking, Insurance, Securities and Health Care Administration (BISCHA) created “Rule 10” VT - BISCHA’s Rule 10 reporting includes scores they achieve on smoking cessation questions that are asked on CAHPS (Consumer Assessment of Healthcare Providers and Systems) Advice to quit, Recommendations of Medication and “Strategies”

Vermont Department of Health 3 Vermont Quit Network Established in 2001 – Quitline and face-to-face counseling at all 13 hospitals in the state of Vermont. ( Contract with QuitNet was added in In 2002 funds were dedicated from the tobacco control program budget to provide NRT to those smokers who were enrolled in Medicaid, Medicare or were uninsured. QuitBucks was developed – A voucher system where smokers redeemed them at local pharmacies. Quitline callers were referred to hospitals for the vouchers but stayed with the quitline for counseling.

Vermont Department of Health 4 3 insurance companies make up 95+% of the private market share in Vermont. (Blue Cross-Blue Shield of Vermont, Mohawk Valley Plan (MVP) and Cigna) Our face to face counseling program (administered through Fletcher Allen Health Care – VT’s teaching hospital) had a relationship with Quality Improvement (QI) people at Blue Cross and MVP The NRT subsidy developed with these three plans was based on the premise of making NRT more readily available, healthcare providers will be more willing to discuss smoking cessation and offer a referral to the Vermont Quit Network services Both the plans and hospital would provide “academic detailing” to promote this new program

Vermont Department of Health 5 $20 subsidy for fully insured members only. Because “Rule 10” is a government mandate - insurance plans did not include self-insured programs Required counselors to call in to verify type of insurance 2005 – Quitline begins to provide NRT – starts with uninsured and Medicare 2006 – VT authorizes quitline to provide NRT to all Vermont smokers 2007 – Quit In-Person program contracts with GlaxoSmithKline (GSK) to provide medication at close to wholesale price Insurance companies increase subsidy to cover the full cost of NRT

Vermont Department of Health – Blue Cross/Blue Shield expands program to self insured businesses as well 2008 – All insurance companies agree to pay for NRT that is provided through the Vermont Quitline 2009 – VT will get data from Quitline to begin to bill insurance companies for NRT they supply 2009 – Cigna drops out of plan as of January 1. Reason: The QuitBucks program is duplicative as they have their own quitline and direct ship NRT program

Vermont Department of Health 7 This measure reports the aggregate experience of the MCOs in assisting smokers to quit by combining the performance levels for the three separate smoking cessation services: advising smokers to quit, discussing strategies, and discussing medications. Evaluation of the 2008 Rule 10 Managed Care Organization Data Filing (VT BISHCA Dec 2008) Major Findings: Performance of all the plans is consistent with national average. BCBS performance from 2006 to 2008 is significant compared to the level of performance of the other plans. Absolute performance for all plans is low.

Vermont Department of Health 8 This measure is a two-year rolling average of the percentage of adults who are currently smokers, and who were seen by a practitioner and received advice to quit. Evaluation of the 2008 Rule 10 Managed Care Organization Data Filing (VT BISHCA Dec 2008) Major Findings: CIGNA’s performance level is significantly above the national average. The other plans performance levels are consistent with the national average. MVP’s and TVHP’s performances are significantly below the regional average. The levels of performance for all plans remain unchanged over time.

Vermont Department of Health 9 This measure is a two-year rolling average of the percentage of adults who are currently smokers, and who were seen by a practitioner who discussed medication options with them. Evaluation of the 2008 Rule 10 Managed Care Organization Data Filing (VT BISHCA Dec 2008) Major Findings: BCBS’ and CIGNA’s performance levels are significantly above the national average. The performance levels of the other plans are consistent with both the national and regional averages. BCBS’ performance improvement between 2006 and 2008 is significant compared to the performance levels of the other plans

Vermont Department of Health 10 This measure is a two-year rolling average of the percentage of adults who are currently smokers, and who were seen by a practitioner and received advice on strategies to quit smoking. Evaluation of the 2008 Rule 10 Managed Care Organization Data Filing (VT BISHCA Dec 2008) Major Findings: The performance levels of all plans are consistent with both the national and regional averages. The performance levels of all plans remain unchanged between 2006 and The absolute levels of performance by all plans, is low.

Vermont Department of Health 11 Conclusions Opportunity presents itself in a variety of ways. There is not one way to tackle the issue of reimbursement. While it did not provide the QI improvement they were looking for, it gave us a “foot in the door”. Program proved that offering NRT doesn’t break the bank. While imperfect, this relationship now allows us to provide NRT for every Vermont smoker who enrolls in our counseling program. Changing healthcare provider behavior continues to require a multi- faceted approach.