1. Increasing Institutional Consumer Demand: Tim McAfee, MD, MPH 206-876-2551 Tim.mcafee@ freeclear.com Healthplans, Employers (& Government)

2. Why bother with institutions? Strong evidence that –removal of access barriers –aggressive institutional promotion markedly increases individual consumer use of evidence-based services BUT: There is only fair to middling institutional demand for tobacco treatment services

3. Populations 80% of population has health insurance 70% of smoking population works 100% live in a state Special institutional populations: –Those who hold the risk long-term Union Trusts VA Medicare

4. Financing as a social justice issue: 99% of MSA and tax dollars are being spent on things other than helping smokers quit Tobacco taxes are an involuntary tax on an addiction Smokers are disproportionately represented in the poor Treating tobacco dependence should be a core, evidence-based component of healthcare

5. Tobacco Treatment

6. On Wisconsin Medical Assistants invited 4,174 adult smokers –Free patches with or without CQ or counseling –In urban Milwaukee clinics 68% of those invited accepted 1/2 re-contacted, screened & agreed Half self-selected Rx: –25% patch-only –33% patch + CQ –42% patch + CQ + Counseling “We made it incredibly easy to use with barrier and hassle-free access at time of contact” – Michael Fiore Fiore MC et al. Integrating smoking cessation treatment into primary care: an effectiveness study. Preventive Medicine 38 (2004) 412-420.

7. Population: 23K – 7,400 smokers Intervention: –Coverage for nicotine patches, gum & bupropion –Coverage for proactive phone counseling –Publicity via mailing and union meeting announcements Ringen et al. Am J Ind Med 42:367-377 (2002) Union Trust Fund: Western WA Carpenter’s Fund

8. Results Western WA Carpenter’s Fund 944 smokers enrolled (13%) –2/3 smoked >20 years –2/3 smoked > a pack a day Program usage –60% chose 5-call program –75% used a medication Outcomes –22-27% quit rate at 12 or more months Ringen et al. Am J Ind Med 42:367-377 (2002)

9. Understanding their lawn… Healthplans –Purchaser & user (providers & enrollees) pressure –Regulatory requirements –Evidence of rapid ROI or cost-effectiveness –Complex and variable other factors (KISS) Employers –ROI Healthcare costs & productivity –KISS –Why not just fire them? State Gov’t (is a healthcare purchaser) –Cost-effectiveness, not ROI –Potential impact –How it plays in Albany, Sacramento, Olympia, etc

10. Product/services Healthplans: –Interested in disease mgmt models Stratification Manage population Recruitment & effectiveness competency –Interested in integrated offerings Employers: –Show me the productivity savings! –Carve out or insist healthplans provide

11. Healthplan Coverage Estimates ATMC 2002 survey - Coverage – for patches: 8.6% –For Bupropion; 40-80% –For phone counseling: 52% –For individual counseling: 41% Limitations –Only best-selling commercial HMO product included –No ASO vs fully-insured distinction –Based on survey response – 2/3 from 3 national plans –Some answers do not jibe with experience #s improved from previous surveys McPhillips-Tangum C, et at. Addressing tobacco in managed care: results of the 2002 survey. Prev Chronic Dis (serial online) 2004 Oct: URL: http://www.cdc.gov/pcd/issues/2004/oct/04_0021.htm

12. Employer Coverage Estimates Mercer national survey of employer- sponsored health plans 2001 Limits: –21%response rate Results: –90% note increased productivity & decreased healthcare costs as reasons to cover preventive services –Biggest discrepancy between calculated impact/value and provision is tobacco treatment: Any type of treatment: 20% (29% in HMO) Prescriptions: 15% (24% in HMO) Counseling: 10% (17% in HMO) Bondi MA et al. Employer Coverage of Clinical Preventive Services in the United States. American Journal of Health Promotion January 2006

13. Barriers: Lack of perceived need & benefit –Risk is buried –Opportunity is uncertain Inertia Complexity Institutional biases The Frog Phenomenon

14. HIGH PARTICIPATION RATES 1.Full coverage of counseling and medication 2.Integration 3.Ongoing promotions 4.Incentives to enroll & engage

15. STRONG SUPPORT FOR INCENTIVES 2005 Wall Street Journal online poll* reveals: –71% of adults think employers should provide financial incentives to employees who join a stop smoking program –63% of adults favor different levels of insurance premiums for smokers *Based on sample of 2,007 U.S adults. Survey conducted by Harris Interactive Health-Care in December 2005.

16. What drives institutional demand? 1) Guaranteed and predictable impact (participation + outcomes) from known strategies 2) Comparison against other programs that are embraced with much lower proof of ROI/effectiveness (statins, mammograms, holiday parties) 3) Comparison against what happens if you do nothing: Spiraling cost and sickness

17. TOBACCO COST EXPOSURE PER YEAR: $350,000,000 TOBACCO COST EXPOSURE PER YEAR: $350,000,000 THE COST OF TOBACCO Client Population1,000,000 Adult Covered Lives 670,000 Adult Smokers140,000 Excess cost/smoker $2,284

18. NET SAVINGS OPPORTUNITY LINK TO ROI ANALYSIS TOOL LINK TO ROI ANALYSIS TOOL NET SAVINGS OVER 3 YEARS: $13,212,787 NET SAVINGS OVER 3 YEARS: $13,212,787

19. Public-private partnerships Minnesota/Oregon examples: Healthplans/employers cover meds & phone State & Healthplan mass media Quitline or phone center triage functions Integration of pharmacotherapy into treatment AND promotion Help with advocacy

20. Impact: health system & state Group Health: pop’n: 580,000 –adult smoking 15% 4,500/year use GH QL (~7.5% of smokers) –All receive proactive follow- up –70% with pharmacotherapy =540 quits (12% AIQR) WA state QL: pop’n: 5,800,000 –adult smoking 23% 9,500/year use WA QL (~0.9% of smokers) –3000 receive proactive follow-up –6,500 receive single intervention =685 quits (12% & 5%)

21. It’s a complex world ABC campaign – increased demand, right? Maybe/Maybe not: Multiple states cut back on state promotional campaigns

22. Novel Healthplan approaches HIP NY –DM vendors provided known smokers –FC called –50% of those contacted signed up Lumenos –Consumer-directed Healthplan –Provided counseling/meds as first-dollar coverage + HSA incentive –Strong education –Above-average participation rate

23. Program Participation Group Health Enrollees One-year quit rate: 25-30% (30-day abstinence ~ Intent-to-Treat)

24. National retail employer: 21% participation –$10 monthly premium differential –Continuous communication Southwest employer: 18% participation –Pre-launch web-cast to all managers –CEO launch and follow up letters Large western health plan: 8% participation –Brochures in all clinics –Frequent member communications –MD’s trained and tracked on referrals WHAT WORKS

25. What we need… Better ROI data & packaging –Chronic condition REAL ROI examination –Productivity data Better institutional trend data Bully pulpit pressure from public health Products that speak more directly to institutional needs