TM Reimbursement for Tobacco Dependence Counseling: Employer, Managed Care, Medicaid ABBY C. ROSENTHAL, MPH Office on Smoking and Health ABBY C. ROSENTHAL, MPH Office on Smoking and Health National Conference on Tobacco or Health November 2002

TM 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 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

TM Efficacy of Different Counseling Formats (n=58 studies) Number Odds RatioCessation Rate Type of Providerof Arms(95% C.I.)(95% C.I.) No format Proactive261.2 ( )13.1 ( ) Telephone counseling Group counseling521.3 ( ( ) Individual counseling671.7 ( )16.8 ( ) Number Odds RatioCessation Rate Type of Providerof Arms(95% C.I.)(95% C.I.) No format Proactive261.2 ( )13.1 ( ) Telephone counseling Group counseling521.3 ( ( ) Individual counseling671.7 ( )16.8 ( ) Estimated Source: Fiore et al. Treating Tobacco Use and Dependence: Clinical Practice Guideline, USDHHS, 2000

TM Efficacy of Different Levels of Person- to-Person Contact (n=43 studies) Number Odds RatioCessation Rate Levels of Contactof Arms(95% C.I.)(95% C.I.) No contact (reference group) Minimal contact (5 min.) ( )13.4 ( ) Brief counseling (>3 to ???Min) ( )16.0 ( ) Individual counseling (>10 min.) ( )22.1 ( ) Number Odds RatioCessation Rate Levels of Contactof Arms(95% C.I.)(95% C.I.) No contact (reference group) Minimal contact (5 min.) ( )13.4 ( ) Brief counseling (>3 to ???Min) ( )16.0 ( ) Individual counseling (>10 min.) ( )22.1 ( ) Estimated Source: Fiore et al. Treating Tobacco Use and Dependence: Clinical Practice Guideline, USDHHS, 2000

TM Cost of Counseling Group program$70 (Seven 1-hour sessions over 6 weeks) Proactive telephone counseling$185+ (Five phone calls over 1 year) Individual, face-to-face counseling$200+ (Four 10-minute sessions with a physician) Group program$70 (Seven 1-hour sessions over 6 weeks) Proactive telephone counseling$185+ (Five phone calls over 1 year) Individual, face-to-face counseling$200+ (Four 10-minute sessions with a physician)

TM Three Levels of Cessation Interventions Individuals System changes Populations Individuals System changes Populations

TM

Impact = Efficacy x Reach

TM 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 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.

TM Few Doctors Counsel Patients about Smoking Cessation 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): %60% Asked by Doctors if Patient Smokes, Percent of All Patient Visits Doctor Provides Smoking Counseling, Percent of Smoker Visits Doctor Prescribes Nicotine Replacement Therapy, Percent of Smoker Visits

TM Measurements (4 studies): –Use of treatment (median impact + 7 pct pts) –Patient cessation (median impact pct pts) Measurements (4 studies): –Use of treatment (median impact + 7 pct pts) –Patient cessation (median impact pct pts) Reducing Out-of-Pocket Costs Source: Hopkins D, Briss P, Ricard C, Husten C, et al. Am J Prev Med 2001;20(2S):16-66.

TM State Medicaid Coverage of Tobacco Dependence Treatment, Comprehensive coverage Partial coverage No coverage Source: MMWR, November 9, TX AR AZ AK OK ND WY OR ID LA KS IA NE MT UT SD NV CO WA NM MO MN CA GA TN AL KY OH MS FL PA WI IN NY WV VA NC SC NH CT DE RI MA NJ MD MN IL MI HI VT DC

TM 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 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

TM Background High smoking prevalence among Medicaid enrollees % of low birthweight births higher in Medicaid populations Tobacco related disease is a major expense for Medicaid High smoking prevalence among Medicaid enrollees % of low birthweight births higher in Medicaid populations Tobacco related disease is a major expense for Medicaid

TM 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) 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)

TM Medicaid Purchasing Specifications

TM 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) 5 A’s 5 R’s Two 90 day courses of FDA- approved medications Two 90 day courses of counseling (individual, group or telephone)

TM 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 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

TM Employer/Purchaser Initiatives

TM Employer Coverage of Tobacco-Use Treatment Source: Partnership for Prevention, 1998 HMO Indemnity Plan 42% 16% 38% 25%

TM 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 co- payment. 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.” “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 co- payment. 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.”

TM 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. 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.

TM North Carolina Implemented North Carolina Prevention Partners Prevention Report Card Basic benefits Cost/ Return on Investment Formulas Implemented North Carolina Prevention Partners Prevention Report Card Basic benefits Cost/ Return on Investment Formulas

TM Wisconsin State, University, Medicaid Partnership Incentive/risk initiative State employee coverage Medicaid involvement State, University, Medicaid Partnership Incentive/risk initiative State employee coverage Medicaid involvement

TM 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 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

TM 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 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

TM © Published in the New Yorker, 10/07/2002

TM Paradigm of Tobacco-Use Treatment Higher price for tobacco Reducing cost of treatment Counter-advertising Telephone quitlines Individual

TM CDC Office on Smoking and Health