Coverage of Cessation Services for Medicare Beneficiaries: An “Almost” Success Story Linda A. Bailey Executive Director, NAQC Smoking Cessation Leadership Center 2005 Annual Meeting April 6-7, 2005 * Princeton, NJ Robert Wood Johnson Foundation

The “Almost” Success Story March 22 CMS decision to cover: 2 quit attempts per year; 4 intermediate or intensive sessions at each attempt Outpatient or in-patient (not 305.1) tx No group, quitline or web-based tx Prescription-only meds covered (Zyban, nicotine inhaler and nasal spray), effective January 1, 2006

Overview Background on the CMS Decision on Coverage of Cessation Services Analysis of Final Decision by CMS Moving from “Almost Success” to a “Complete Success”

Background – CMS Decision June 2004: PFP request for expanded coverage for tobacco cessation counseling accepted by CMS and posted for 30-day comment Dec 2004: CMS’ proposed decision posted for 30-day comment period March 2005: Final CMS decision memo published

Analysis of CMS Proposal and Final Decision CMS uses science-based analysis to determine: 1.Is the service reasonable and necessary? 2.Will the intervention improve the net health outcome of beneficiaries?

Analysis of CMS Proposal and Final Decision CMS Findings: 1.PHS Guideline (2000) provides a strong basis for allowing coverage 2.Training is necessary to provide effective counseling, but national standard does not exist 3.Smoking cessation counseling by HC practitioners (authorized in Part B) will result in effective cessation

Analysis of CMS Proposal and Final Decision CMS Findings (continued): 4. Dose-response relationship exists but no evidence on best dose for Medicare pop, so CMS will use PHS Guideline on session # & intensity 5. Inpatient stay for (tobacco use disorder) is not reasonable and necessary

Analysis of CMS Proposal and Final Decision 10 ISSUES ADDRESSED: Eligible beneficiaries * FDA-app meds Qualified providers * Training & cert. Session length * Inpatient tx Group treatment* Quitline tx Web-based tx * Pay & codes

Moving from “Almost Success” to “Complete Success” What’s missing from Medicare coverage? 1.CMS did not include “all smokers” as eligible. 2. CMS excluded group tx and quitline tx from qualified service providers. 3. CMS did not allow for non-prescription FDA-approved meds.

Moving from “Almost Success” to “Complete Success” Problems/Solutions: 1.Legislative authority only allows payment of services (1) for the sick and injured; (2) by providers on Part B list; and (3) prescription drugs (2006) 2.Administrative decision to only allow payment for “in-person” tx

Moving from “Almost Success” to “Complete Success” Will a complete success happen? Flexibility under Medicare Advantage Plan CMS Medicare Stop Smoking study + Feds could use a success on Medicare Is it important to push for complete success? Group/quitlines effective, increase reach Other payers will go as Medicare goes

For Additional Information For quitline info: For CMS decision info: t.asp?id=130