TM 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 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

TM 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 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

TM 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 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

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 Total Cost of Smoking to Medicaid* Estimated to be over $17 Billion in % of all Medicaid expenditures Estimated to be over $17 Billion in % of all Medicaid expenditures *Zhang et al. 1999

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 Are the specifications mandatory?

TM Key Components of the Medicaid Specifications Adults Pregnant Women Adolescents Adults Pregnant Women Adolescents

TM System Strategies Patient identification mechanisms Implementation of the 5 A's Coding (305.1 ICD-CM) —Claims Data Base —Encounter Form Patient identification mechanisms Implementation of the 5 A's Coding (305.1 ICD-CM) —Claims Data Base —Encounter Form

TM 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 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

TM Adolescents Prevention counseling Cessation counseling Referral to community programs if appropriate Prevention counseling Cessation counseling Referral to community programs if appropriate

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 Medicaid Purchasing Specifications Available at:

TM State Initiatives

TM Wisconsin Coverage —Counseling —Medication Strategies —Chart Audit —Consumer Survey-Telephone Counseling Challenges —Under utilization of benefit —Effective Coordination between state agencies Coverage —Counseling —Medication Strategies —Chart Audit —Consumer Survey-Telephone Counseling Challenges —Under utilization of benefit —Effective Coordination between state agencies

TM Oregon Coverage —Medication —Counseling Strategies —Work through State Tobacco Coalition —Office based training —Telephone Counseling Challenges —Payment for preventive services —Coordination of state agencies

TM 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 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

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 Know your current Medicaid Coverage Compare coverage to Medicaid Model Language Coordinate with state Medicaid Agency to make the case for evidence-based treatment

TM 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 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

TM Upcoming Products from the CDC Cost-effectiveness of smoking cessation Summary of Medicaid Specifications Reimbursement: Two documents Cost-effectiveness of smoking cessation Summary of Medicaid Specifications Reimbursement: Two documents

TM Acknowledgements Abby Rosenthal Office on Smoking and Health Centers for Disease Control and Prevention Abby Rosenthal Office on Smoking and Health Centers for Disease Control and Prevention

TM CDC Office on Smoking and Health